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HomeMy WebLinkAbout6289-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No..~. ~.09~... Date ............ &pl*~.~...~0 .... , 19..73 THIS CERTIFIES that the building located at . ~e&~h .~ood .I~ ........... Street Map NoBOllthwo~.. Block No ........... Lot No...19 ..... lio~thol~..ll,Y., ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... l)eo ..1]..., 19.72: pursuant to which Building Permit No...6289Z dated ........ D®o .... 1 $ ....., 197~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is ... l~.~&t~. Ozxe. fa~ly clv~:~:lJ~ .................................... The certificate is issued to .. R.o.b.e~*$;..&..HO~,~. ]~r.~x ...... 0vllo~ ................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .g~l*.~ .2~...]97~...by. Ro .¥~.].1~ .... UNDERWRITERS CERTIFICATE No.. ]I..~66~$,... bin,*oh...~... 'J 9.'~.~ ................... HOUSE NUMBER...~00 ....... Street ....]5.o&l~lll~XlOd. ~. .............................. Building Inspector ~ FOR~ NO. :~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N,. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6289 Z Date .......................... De C~ez'......1..1., 19..~/~.. Permission is hereby granted to: .......... ~thol4.....~.,'~.~ .................................... to ..... b~i,lA..~o~ one i,e~i4.y +~.e.~img ........................................ at premises located at ..Lo~;...$~ ....... ~Og.*o~qwa~od ............................................................................... ................................ k~aa~h~ood.....Laae ......... ~hot4.....,,.~Y.~ .................................... pursuant to application dated ......................De~ ........ 1.s~ ............... , 19r~..., and approved by the Building Inspector. Fee $'~..~wO .~ ........... FORM NO. 6 TOWN OF SOUTHOLD Building Depo~ment Town ClerKs Office but. hold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Ind'rucflons A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: !. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 Rte ........... New Building ...... .~.... ........ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .~,~...J~.~c~...?...~.~...~,./~..~.~.?.~....~...u.~.~ .................................................................. Owner Or Owners Of Property .~.°..b..~..~-~....J..,..~..~.~.?...~....~...~...E...L...~...~.....~..~.9...~.....~..; ................................. u ~' "' "' ............ House No....?....O~.,,. Subdivision ...~ .......... I~. ...... ~..~.. ................................... Lot No....)..°t ..... Block No. Permit No. ~.~..~....~... Date Of Permit~.~'..~..l~.J.~.Applicant ..~...u..~..~...o..~...~S.......~:~.o...~...~..~...J..~..C..: ......... ~L6.~ ~ r- ~ "r .............. .~...!...~.. ..................... Health Dept. Approval ............................ ~.. ............ Lab~ Dept. Approval Underwriters Approval ~ '~ ~'(o ..~..~ '~'Planning Board Approval ....... j~.../.~- .................... Request For Temporary Certificate ........................................ Final Certificate ....... ~ ................... Fee Submitted $ ..~.. ............................... Construction on above described building~ermit meets all applicable codes and regulations. Sworn to before me this ~ '~0 (stamp or seal) ................ day of ............................................ Notary Public .................................... County SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference No EASTERN DISTRICT, RIVERHEAD, N. Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval tn construct said systems is requested,pertinent data herewith: Dat 3-Public water supply name ~ Distance to nearest main S-Lot Size: Width ~u~ft. Len~th.~ft. (also enter on center plot plan below:) 5-Dwelling: Single Family ~Two Family? ~__~Cellar? ~ ~Slab? ~ ~Crawl Spac~ lO-Proposed system: Septic tank ~ ~Prec~_JCesspools Y /Shallow pools ~_~Other il-Septic tank inside di,mensions. Volu~$~$Sals. Length ft. Width ft. Liquid depth ft. i2-Precast sections: /~;Number/ /Squa~. Cesspools: Block sizeL incs. D ins. H ins. Total blocks below inlet: ~i ~2 PLOT PLAN ,~ 'ade G ,W.L. Street Ind~ Nc Capacity_y__~als. ,~te Data ~eet 0 2 6 8 10 12 ~6 18 Date //"A/,/~ Signed (10/65 Revis.) s-15 The Undersigned CERTIFIES: "Construction of authorized installatio~will be in accordance with the Suffolk County Health Departments' current Standards,~lletins, and amendments thereto, covering Private Sewage Disposal Systems". - ' ~ Ow~ee~---- BuiIder /¥~ FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the Health Department, that an adequate and satisfactory Sewage Disposal System can be installed on this Plot. Chief of Ceneral Engineering Ser~'i ces '" 4 OR ADDITION A VIOLATION OF Disapproved .o/c ..~ ............................ ...~ ..........~ ................................... i(Building Inspector) ( ..................... FORM NO, 1 ,,~ TOWN OF SOUTHO'~LD BUILDING DEP*RTMENT TOWN CLERK'S OFFICE -/ / MUTHOLD, N. Y. ........ ~ppucaTion ~o. ~ ........ ~..~. .............. . . '~~. APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wit~,' 3 sets of plans, accurate plot plan to scale. Fee according to schedule. ~. b. Pint plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, an~ giving a detailed description of layout of property must be drawn on diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zo Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction ~f buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant, or name, if a corporation) ............ (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .~$~..(~.~'.~.,.'~..,~.ff.!~.....W.~.~.~....~.~..~,~.i~. .................................................................... (Name and title of co~:porate officer) 1. Location of land on which proposed work will be done. Map No.: ...,,~..,~,,,.~,,.!.~.,,'~.,,~.~.!~ ................. Lot No. ~,~ ....... Number ~GP~c-,J~,,~,;,,O L . o~,T'HoLC:> Street and ............................................ ..~. ..................... .~. ............................................................................... ~t 0 Municipality 2, State existing use and occupancy of premises and intended use and occupancy of proposed construction: a, Existing use and occupancy ................................................................................................ b. Intended use and occupancy ....O....~....~......E~..~..?...~...'~. ...... ..O....~/..~..L...C.!...N..C~., ....................................... -q 3. Nature of work (check which applicable): New Building .............. ,~....... Addition ..................... Alteration ............... Repair .............. · ............ Removal ......................... Demolition ........................ Other Work .................................... 4. EstimetedcoSt......~....~.~...O....O. ........................ (Description) : (to be paid on filing this application) -~ 5. If dwelling, number of dwelling units ..... .~. ....... Number of dwelling units on each floor ....t..~..[.?..~..~.. ................ If garage, number of cars ..... ~ .................................................................................................................................. 6. If ~-atiness, commercial or mixed occupancy, specify nature and extent of each type of usa ..................................... 7. Dimensione,of existing structures, ~f any Front ..................... Rear ............. , ............. Depth ................................... Height ... ......................................................... Number of Stories ............................................................................. Dimensions of same structure with alterations or additions: Front .......................... Rear ......................................... Depth ............................................. Height ......................................... Number of Stories ........................................ 8. Dimensions of entire new construction: Front .....~../. ...............Rear ...~.../. ................... Depth .~..~. ........................ / . Height ....~.~. ............................. Number of Stories ..../.. ................................................................................ Size of lot: Front ....~....~... ....................... Rear ..... ~..~.. .......................... Depth .~......~. ...................................... Date of Purchase ...~..~....~...E....-....!5.?...~.. ..... Name of Former Owner ............................................................................ 10: 11. 12. 13. Zone or usa district in which premises are situated ..................................................................................................... Does proposed construction violate any zoning law, ordinance or regulation: ....~....0. .................................................. Will lot be regraded ........ ~.0. ...................... Will excess fill be removed from premises: [ ] Yes [I/~No 14. Name of Owner of premises .~..9..~..~..~...~....T...~....L..e...~.. ...... ~..~..~.?:'...!,~,. ........................................................................ ,,. ,~Address_) ~ (PhoneNo3. Name of Architect ....... J;..9..~,..~..o...~.~..,S.......~....~....~..~...~(..A'.I..~.. ....... ~..U..~.l;.~..W..~...~,...~.u..~.....~...°~, .,~,t~.~:/~........~.~...~.--..~..ff..~. ~ %. · · ~. *. (A~[ress) ~. · ~ (Phone No:)L. ~ Name of Contractor ................................................................................................................................................... (Address) (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all sat-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate wheth- er interior or corner lot. STATE OF NEW YORK, ) SS COUNTY OF ...................................................... ) .................... ~.~.~.~ .................... sworn, deposes says He is the ......................................................... ~..~.~'..<~.L~..~J:~..~... ...................................................................................................................... /Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. ...................................... day of .................................................. 19 ............. Notery~ Public .......................................................... '~",:..... County '~''~'-"c~'~)*''~'~ppu ...................