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HomeMy WebLinkAbout5912-zFORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Cerlificale O~ Occupancy 7_- 4~-/ No ............. Date .~~ .~. ~.., lg .... T HI~T~ that the builTxding located at ........ ~ ~~~.~../~S~'et Map No ............. Block No ........... Lot No .................................. conforms~u_bstantially to the Application for Building Permit heretofore filed in tl~_office__ dated....C~...~....~., !. , , .., 19. ~)~pursuant to which Building Permit No ......... dated .... ."..'~....~...?. ! .....,19 .... ,was issued, and conforms to all of the require- ments of th~plicable~Lq_visions of the l~h~_e o~cu~ancy ~6i~whic_h~h~s certificate is (owner, levee or ten.t) oE the ~ores~d b~ld~g. ....... Suffolk Co~ty Dep~tment of He~th Approv~ UNDERWRITERS CERTIFICATE No...~ .~ ......................................... Building Inspector FO~M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, H. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N.o 5912 Z Permission is hereby granted to: ..~.....~......~.,...~~...*..~.......~..~...~,~, ~ ~o '"'~'l~"~"~e"f~l~"4~:ti~ ........................ ' ......................................................... at premises located at ...... ~,~.IIL..e~I ....... ~e4~lF,.[aet~e~ ..................................................................... .................................................................. I~$t;l.t~lr. ...... .11,.~, ........................................................ pursuant to application dated ............................ #1~.....~ .......... , 19~...., and approved by the Building Inspector. Fee $.....~.!~,~.: ...... pE~.I, AIT iNCLUDES AppRoVAL 'TO p,.Ei',AO'VE ExcESS F~LL FRoM ABOVE pR£MtS[S BY R£Gp, AC, u.4G LOT CON~..T p..U cTION -- - C~_LLA~L C"~ NS~ ~'LJC'~ JO N IaORM NO. 6 TOWN OF SOUTHOLD Building Delm~tment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCC:UPANCY 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), No~-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 Dote .......~,.~.....~./.. * .!. ~..~..~, ............. New Building ........ ~ ...... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ....~J-.......~..~....'~.....~./~i/~...~.....t....~)..~.F-~......~..~.~t.~ ...... ~.....~.~)~.~.~.~.~.~(~ ~ner Or ~ners Of Prope~y ...~.~.~.~.~ ...... ~.:....~.~.~.~ ............................................................. Su~ivisJon ................................................................ Lot No..J.~ ........ Block No ............. House No ............. /~ Permit No.....~4~.~ Date Of Permit~.~K.~ ........ Applicant ~.~.ff.~..~.:..~.~3.~.~..~.~..~.~ Health ~pt. Approval ~...~.~.,..~.~.~ ............. Labor ~pt. Approval ................................................ ~ ~ ~ 3 ~ Planning ~proval Unde~riters Approval ..~ ............................. B~rd ........................................ Request For Tempora~ Cedificate ........................................ Final Ce~ificate ~ ****************************************** Fee Submitted $ .................................... Construction on above described building and(~/~it. _?eets all~c.ab~le~.es and regulations. Applicant ~.....~...,~'m ......... '. ..... ~ .................... Sworn to before me this .... ......... day Notary Public ........... ~ ...~...?...~. ........... County EARL T. '41LF-S NOTARY pUBLd.S, S,, ' ~*' ~ ow York FORM NO. 6 TOWN OF SOUTHOLD Building Depaitment 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 topocjrophic features. 2. Final approval of Health Dept. of water supply and sewerage disposol--(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. Dote 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 Sept., 4 1972 X New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................ Lot 11 Deer Park~ Mattituck N.Y. Location Of Property ..................................................................................................................................... Owner Or Owners Of Property......Al£red................. ~......... & ..... Ja~e ...._...... Dautert ..................................................................... Subdivision ..D~.~t3?~.¢,~.~ .......................................... Lot No..1]. ..... Block No ............. House No ............. 1972 Permit No.~91~, ........... Date Of Permit .~¢,,&~..y.~G....Applicont .C~3.e~,_.-1....]~,...[-[~J,d. tme,~..~,..S~...Z~c. Health Dept. Approval ...~/d~f,....,~./...~,~/lw~ ............ Labor Dept. Approval ................................................ ..% --~ ~ IC~ 1 ~ P ann ng Approval Underwriters Approval ~ ............................ Board ........................................ Request For Temporary Certificate ........................................ Final Certificate .......~ .......................... Fee Submitted $ .................................... Construction on above described building on, permit meets all .applicable codes end regulations. Sworn to before me this ...... ~.. ....... day of ......'~¢.?..-'~......~.......(-~.~.~.. ...... 'Notary Public /Y'¢~-~ ~ County (stamp or seal) ,~PM~i~ATIoN__ FOR APP~OFAL. TO CONSTRUCT PRIVATE SEWAGE.DISmSAL 'SYSTEMS · · &~nroval to construct said systems is requested,pertinent data herewith.~ t.Aopltcan~.k~m ~' ,~<IOT~ R~.,~ ,~-So~ Phone'_~%~(~__6 .Sub div -' A~dress - 7-Section 2-Detailed property location ~/~ C%r '~T~q~ e ~ ~)e~ ~ 8-Lot No. Hamlet ~a.'~ ~ ~- Town~FA ~ / ~ 9-Private 3-Public water supply name Distance to nearest main O ~-Lot Size: Width ft. Length ft. (also enter on center plot plan below:) ~-Dwetling: Single Family ;)('J Two Family7 ~;(/Cellar? / /.Slab? / 10-Proposed system: Septic tank ;XYPrecast ~/Cesspools /~(/Shallow pools./ /Other ~_/' il_Septic tank inside dimensions: Volume ~ Gals.Lengtk ft. Width ft. Liquid depth 12-Precas% sections: ~_/Nu,m, ber/7~)Square Ft. Cesspools: Block sizeL incs.D.__tns. H___ins. Total blocks below inlet: ~1 ~2 ~3 - PLOT PLAN  caPacity_k._~Gals. · G~.P.~ 3' ,'" Grade Nc "C~nstruction of authOrized installations will be in Data Feet 0 2 4~ 6 8 10 18 The Undersigned CERTIFIES: accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". . '~ ~' ' - Owner or - BUilder FOR HEALTH DEPARTMENT USE ONLY. Based.on the information presented he~ewith, .it is the opinion of the Health Department~ that an adequate and satisfactor~ Sewage Disposal .System can be installed on this Plot. Signed~ Date ~'/~ ~ Ind~ (10/65 Revis.) S-15 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ~UTHOLD, N. Y. Examined ................ .~ ................. , 19.~.~ ~pr~ed ~t '( 19..~.~ Pemit No. ~/ ~ ~ Disapproved ~/c ..~......~.....~.. (Building Inspector) APPLICATION FOR BUILDING PERMIT ~J~ ~ Date .~.J~..~.....~.../. ..................... ,19...~..~.~.~.~ a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector,,~with~j 3 sets of plans, accurate plot plan to scale. Fee according to schedule. ~ ~ b. Pict plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or area~T/and~ 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 onl 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 Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of 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 inspectior,~ -~ (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. 1. Location of land on which proposed work will be done. Map No.: ~.R'~...('....~e.~..~ Lot No ....... /.~. .................................. Street and Number ............................................................ ~.~.T,~,~.~.~..~.. ........... r,~../~..~...~...o../...~... ................. 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 ............... ...~...~.....~.~......~ .................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) o o 10. 11. 12. 13. 14. Nature of work (check which applicable): New Building ............. Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) fistimated Cost .....~.., ................ .t ................ Fee ................................................................................................. {to be paid on filing this application} If dwelling, number of dwelling units ..... ~ .......... Number of dwelling unit~ on each floor ......................................... If §arage, number of cars ............................................................................................................................................ If business, commemial or mixed occupancy, specif¥ nature and extent of each Wpo of use ..................................... Dimensions of existing structures, if an¥: Front .....................Rear ........................... Depth ................................... Height ........................................................... Number of Stories ............................................................................. Dimensions of same structure with alterations or additions: Front .......................... Rear ......................................... Depth ............................................. Height ......................................... Number of Stories ........................................ Dimensions of entire new construction: Front ....~..[..,..~ ........ Rear ....h.L,...~. ......... Depth ....~....~..'....~.. ............. ~ ~'~- O' % Number of Stories ...... .I ................................................................................. Height ................................................. Size of lot: Front ...!...~'..~.1.~....~., ............. Rear ....... [...~...~..?....~..~.. .......... Depth ...... L.~....~...L..'~.. ........................... Height .................................................... Number of Stories ...................................................................................... Date of Purchase ..................................... Name of Former Owner ............................................................................ Zone or use district in which premises are situated ..................................................................................................... Does proposed construction violate any zoning law, ordinance or regulation: ............................................................ Will lot be regraded ....... ~[t ,,~-, t ~-Will excess fill be removed from premises: [~] Yes [ ] No Name of Owner of pram ses"......~...O~...~...~...~...~...~ ..................................................................................................... {Address) {Phone No.) Name of Architect ..................................................................................................................................................... ~ _ , ~ -- (Address) (Phone No.) Name of Contractor ~.[.~...'~..T..~..~.~J..~.[.~I[~.~.}.~.~.} ..~......, ........................................................................... {Address) {Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-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 corr~er lot. ~_u~ ~ATE OF NEW YOR~ COUNTYpF ........... ~E..~.~......) w ................. b~in~ dulg ~orn. depo*~ ~nd sa~* that he i~ th~ a~plieant ~bo~ n~m~d. con~actJ ~ i~ th~ ..................................................................................................................................................................... ~ Contmctor, agent, co.orate officer, etc. J of ~aid owner or owner~, and i~ dul~ authoriz*d to ~rform or ha~* ~erform~d the ~aid work and to mak~ ~nd fil* thi~ ~lic~tion; that all stat*m~nt~ contained in thi* a~lication ar~ true to th~ best of hi~ knowledge and belief; and that the work will bo ~r~orm~d in th~ ~nn*r ~t forth in th~ a~lieation filed therewith. -~ day of ................. ............. .......... ........................ ~ ~ ~ [Si~ture of appl~cant~ SURVEY FOR ALFI~F_D E. ~ ~IAY£ DAUD£F~T MATTITUCK TO~N OF $OUTHOLD SUFFOLK COUNTY~ N.Y. LOT~UMEENSREFERTOMAPOFOEEIfPANKAT ] SCALE: I#* 40* ~ MATTITUCK, Iq&EOIN?NEOFFIGEOFTHECLENKOF AI:)RII 25, 1972 GUANANTEED TO: CHICAGO TI?'I.E IN~URANC~ COMPANY ALFRED E. · JA YE E. DAUDERT i. AND SURVEYOR N.Y.S. LIC. RIVERHEAD~H.Y. Unauthorized alteration or addition to this survey is a violation of section 7209 of the New York State Education Law. Copies of this survey map not bearing the land surveyor"s inked seal or embes.'ed seal shal~ not be co~.,ide~ed to be a vafld copy. person fm whom t,~,e ~rvey is prepared, and on his behalf to the title company, ~.overnr,-*tc:l agency and lending institution li~ted hereon, and to the as,.~guees of the le~ding institution. Guarantees or certifications are not tmnsfe,eble le additionaJ institutions or NOTE: SUFFOLK COUNTY ON JULY.,8, I~O AS FILE NiX ~lO~4 .,MOHUMEN~ SURVEY FOR AI_F'RED E. ,JAYE DAUDERT MATTITUCK TOWN OF SOUTHOL D SUFFOLK COUNTY, N.Y. SCALE: 1% 40, AI:~IL 28, 1972 AU6. 4, 1972 'GUARANTEEDTO: THE TITLE GUARANTEE COMPANY AL FRED E. f~ JAY'E E. DAUD~RT FLORAL PARK FEDERAL ~ ~ LOAN ;.AND SURVEYOR N.Y.S. Ll¢.NO.~8?g~ I RIVERHE~ OCT $1. 197~ ..,). ~,~. ~-//~:~.~ The sewage disposal and water supply facilities for %ha structure located at ~ have b~on lnspec%ed by this Depar%ment axed found to be satisfactory. Th~ w~ter ~" ~ ' ~ t' ~ /2 : at Lane 0 Deer ]rive, " ~ ~- '~ m,(r ..... ~a that the wster is not to be used for ';~,,,,~ .o fo~:ula since tn'~ n[t,r,t~: ~r( in e%cess of ay~row:d ~:~'- ' ~- ~n? futuz'~; o~mcr or occupant is to ;:( _aA~ormed the hifd~ nitra%{ i~ve! ¢~f t~e wall w~t~r anl forewarned about i%s yro ~ibitJmn in the prepsration of Ve:v tru v y..urs, General Lngineering !~rvic~s 'F -- --/oC o'L I ii, j_L III .................. ~ ..........