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Home My WebLink About6312-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy THIS CERTIFIES that the building located atJT~..~.[}...DR .~.....~.0..~ .~. .... Street Map No.~q~g/.~~]Ia. ~.~..Lot No...~. ~... ~.Z.~'.~.~ .~ conforms substantially to the Application for B~lding Permit heretofore filed in this office dated ............. (.~ ...... , 197.~ pursuit to which Build~g Pemit No.~ 3. [.~ dated ...... ~. ~.~ ..... , 197~, was issued, ~d conforms to all of the require- ments of the applicable pro~sions of the law. The occupancy for which this certificate is issued is. ~.~.~ ~ .~ .~.~ I.C .y .... ~ .~ &~. I .~ .~ ............. The certificate is issu~ to .~ .~...~.~ ~ ~ ..... ~.~. U. ~. ~ ................ (owner, lessee or ten~t) of the aforesad building. Suffolk Co~ty Department of Health Approv~ .~.~'/.. {~.~ ~ ~ S...~. ~: .Vl .C a ~ UNO~WRIT~RS C~RT~CAT~ ~o.. ~: Q !.7.( ~ ..... ~. ~.~../.~ ?3 ...... ~ous~ NUM ~...(7.~...st~t. ~.~ ~. ~.~.i .... ~.9 ~ ~ ........................ Building Inspector FORM NO. ~ TOWN OF SOUTSOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 6312 Z Date .................... .D.e.9.....~.7. ................... , 19...72 Permission is hereby granted to: Inland i .... ~omes Inc ~'~/C oam Kupeeki ...... · ~.S2 ....... ~ddl e...G~un~ r.~..i~d ........... ................ ;~alcte~ ...... }i4-Y.~.1.~. 7~ ..................... to ~uil~ ne~ op.e ~..~,;l~..~.~.,.~,;~f~ .................................................................................... at premises located at ... %.....2.2.....~q,~,~e~...l~,r~D.]:l.s...I.~ ............................................................. ..................................... ~.t.~r~l, fty...~.d ............ ~a.t.t 1.tuck ....... ^.~:~ ............................................ pursuant to application dated ............................ .D...~.~ ........ .1..be.. ........ , 1~.~...., and approved by the Building Inspector. Fee $..~.,!.*,.1..,O. .......... FOBM NO. 6 TOWN OF $OUTHOLD Building Depoffment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions 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: 1. 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 3. Copy of certificate of occupancy $1.00 $5.00 Date ............ .2..~..~...e.Sf.... ~ 9.7. ~. ......... New Building ........ X ......... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ................... ~..~.~1;~..~.1;~`[~.~1`~S~1;a`~e`~.~c~.~3'~c~ Owner Or Owners Of Property .... S,...a~......~_~,e.,c.~,~.. ............................................................................... Subdivision ......~..u:.~..~..~...~9,,1..~,~ ........................... Lot No.....;~2,... Block No ...... TT.. House No ............. Permit No......(3..3..3....2..Z...... Date Of Permit ...~.~.~.~.7./..7.~,pplicant Health Dept. Approval ..... ..~./.~.7.~..7.,3. ...................... Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ............... ~..e..s. .................... Fee Submitted $ ............... 5,DO ............ Construction on above described building and~it~, a~ppZ~.?es~.~ regulations. Applicant ......... ~ ......... .~.~ .......................... Sworn to before me this ....... ~. ...... day of ..... ~m'~ ..../..~..,~.....?. .... SUFFOLK COUNTY DEPARTHENT OF HEALTH H.D.Reference No~/~-/J~) APPLICATION FOR APPROFAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date Approval to construct said systems is requested,pertinent data herewith: 1-Applican~ ~ ~ Phone 6-Sub div Address ' 7-Section· 2-Detaile~cationproperty '~ im*-~,~ la 8-Lot No. ..... 9-Private well? Hamlet ,*-e,~ ~--.a. Town - ~ 3-Public water supply name Distance to nearest main 4-Lot Size.. Width_~ft. Length_.~ft. (also enter on center plot plan below:) 5-Dwelling: Single Family ~ Two Family? ~ /Cellar? ~.Slab? / I Crawl Space? 10-Proposed system: Septic tank ~..~Precast ~_/Cesspools ~_I~Shallow pools / /Other ~_/ il-Septic tank inside dimensions'. Volume~Gals.Length ft. Width ft. Liquid depth__ft. 12-Precast sections: ~ /Number~_/Square Ft. Cesspools: Block sizeL incs. D .ins.H_...ins. Total blocks below inlet: ~1_.__$2 ~3 PLOT PLAN ,G ~ad9 G .W.L. Street Capacity Gals. -'1 G.P.M. Indi e No ~th "Construction of authorized installations will be in Data Feet 0 2 6 8 10 12 18 The Undersigned CERTIFIES: accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". ~ or Builder · /.~ ~%2 FOR ~LTH DEPA~ USE ONLY. ~s~ on the info~tion present~ here~th, it is the opinion of the H~lth De~ment, that an ad~te and satisfacto~ S~ge Dis~sal System can be installed on this ~ot. Date / ~ -/~ -> ~ SSgn~~ SUFFOLK COUNTY HEALTH DEPARTMENT ~T~AY 1:7 lg/~ ~. D. REP. The sewage disposal and ~vateP supply fae~.lit~es for this location have be~n inspected by this depaF%men% and found vices . III DEC. 5,197~ ~0 0~?NAN~N AV~E, NIVMNHffAO ~ N. F, ' FEB. 8, 1973 A~ ~ 'YOUN; SZYMON KUP~CKI 8 ~LIZA~TH ,... _., o.~. $C4LE~ I "= 40' O~E:NOK 19, 19?0 ~0 DEC. 5, 1972 ~00~?NAN~ AVENUE, NIV~ffAO ~ N. ~ ~N · FO~N~ H~ARO ~ ~N~ S~YMON KUP~CKI lO ADDITIO~L INStiTUTIONS O~ ~tQUil JCALE; : ~1 TOWN OF SOUTNOLD ~,,~..,::%~., BUILDING DEPARTMENT TOWN CLERK'S OFFI~E~ ...... ................... ........ ~ro~ ........................................ , ,~ ........ ~ ,,~ ....................... ..................................................... ........ ~L ....................... ~~-':-'~'-'"'t-: ............. '_'F":~/- J__ _ ' -~ _ -~ --..h. (Building Inspector) [ ~n ~1~-~ .... ~.~-~ , ,c.~ ~ I' ~i .~'"' ' ~ ~ ~" "£_ --- , §, ~fw ' ~ APPLICATION FOR IUILDING Pli~VIIT ~ ~.., ·L _ .,.~ ~ _L r '.4 '~( :' ~.,. 14 December 197z ,, ~ a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wight 3 sets of plans, accurate plot plan to scale. Fee according to schedule. ~. b. Plot plan shbwing location of lot and ~of buildings on premises, ~'elationship to adjoining premises or public streets or areas,~a,~ 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 wh, at,e~er until a ,Certificate 9f Occupancy shall have been granted by the Building Inspector. ~ ~ ~::?/~//C_ ~, ~ ~ APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zdlne Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the c°nstructiorf of buildings, additions or alterations, or for redloval 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. ............................................................. , ............. .~r~a~;i~..C. gGl~;~,~ ~.~;~,....; ................................................................... Sam Kupecki Name of owner of premises ,..~. If applicant is a corporate, signature of duly authorized officer. ~ ................ ~.~/~..~ ~..~/.....:~J...~...: ...................... I Name and title of corporate officer) Builder's License No .......................................................... plumber's License No, .............. : ......................................... E ectr can's L cerise No . ~ ~ ~ . · ................................................... ~,~ S~ . Other Trade s License No ............................................... '"' I~o ~1~"'~ I''/~-~;...~..~.....~ 22 1. Location of land on which proposed work will be done. Map ....... ..'~...:.:~./..; ...... : .... Lot No.., ........................ Street and Number .................................. ..S..t....a~...1..e.,~...~.o..e....d. ......................................................................................... Municipality 2. State existing use and occupancy of premises and intended use and o~cupancy of proposed construction: a. Existing use and occupancy ............................ ~...~.~..~:~:...:::kC~.~.~D..g. ............................................................... b. Intended use and occupancy .......................... ..3....~..a~...J....l~...~.]....~..a.~. ............................................................... 3. N'-{~m ~f work (check which applicable): New Building.. . X . ..... Addition . .................. .. A terat on .....~: Repair ......................... Removal ......................... Demolition ........................ Other Work (Description) · $3o ooo.oo - /0 4, Estimated Cost .............. ~, ............................... ~ee .......................... ~ ................................................................ (to be pa~ on filing this application) · 1 Number of dwellin units on each f oor .................. 5. If dwelling, number of dwelling umts .............. g ............ 14 X 20 If garage, number of cars .................................................................. ~ ......................................................................... 6. If business, commercial or mixed occuoancy, specify nature and extent of each type of usa ..................................... 7. Dimensions of existing structures, if 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 59 t 8" Rear ...... ..5..9..t...8..~ .......... De-'~ 26 Height ................. ~.~ ............................ Number of Stories ............... ~, ....................................................................... 111.11 De th 180 9. Sizeof tot: Front 111.1.1. Rear .......................................... p 10. Date of Purchase ..................................... Name of Former Owner ......S.~.s..e...t......K~...°...1..1..s.....D..e..y-e-1..9~.:....C...°...~ ........ 1 1. Zone or usa district in which premisas are situated .................................................................... 12. Does proposad construction violate any zoning law, ordinance or regulation: no 13. Will lot be re~jraded .............................. Will excess fill be removed from premises: [ ] Yes [ ] No 14. Name of Owner of premises ........................................ (Address) (Phone No.) Name of Architect .................Xg%l. g143.0...blg:B.~.~ia. ];lX~a ..... ~.9..1..d...e,~..a..33]~' ................ ..7..3...2..-.~..1.7.7. ............ (Address) (Phone No.) Inland H~mes, Inc. Selden, NY 732-2177 Name of Contractor ................................................................................................................................................... (Address) (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-beck 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. I/I. II STATE OF NEW YORK..J ) COUNTY OF ............ ~; .......... ) SS ......................... [~.~...~.~.~..l~.~....[~...~,.....~..~l,..u~....b...e..~..a......'~... .................... being duly sworn, deposes and says that he is the applicant above named. (Name o/individual signing contract) He is the CoD,1;~a,c~;or ............................... (Contractor, agent, corpon~te o/J~cer, 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. DOLORES SCHOMBS NOTARY PUBLIC, State of New Y~rk -- ,// ~ fllo. 52-884~.~00, Suffolk County/ ............... .............. dayo, ........ ....... ..... . Notary Pubhc, . ........ Cou ................................ /'~ /' / · ' {Signature of applicant} J tl 1