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Home My WebLink About5931-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z~0.10 ...... Date ......... Fab.. 2.1 ........... , lg.~3. THIS CERTIFIES that the building located at .Lit.tie. l;ack. Road ........ Street Map No .... xx ....... Block No ...... xx...Lot No...xx ...Cu.tchog~Aa .. N.,Y. ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... June.. 7...., 1972. · pursuant to which Building Permit No. dated .......... June. ? ...... , 19.7.2., 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 P~.iva.t.e. one..£al~d,l~. ~l~.ellillg ....................... ................. : .~F'--~-~T~certificate is issued to . H~len. J~'~dru~ki ....... /~n61~ ......................... __~ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. J~n. 3.1.~ · ~ 9~,~.. by~ .¥~1..1.a ...... UNDERWRITERS CERTIFICATE No., ~ .37.~.2.~... Aug...~.7.. ~ 9.7.2 ..................... HOUSE NUMBER..$7.7~. ...... Street ......L~.~tXe. l~elz. Road ........................ .... FORM NO. 2 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? 5931 Z Permission is hereby granted to: EL Ell/ ' ...... ~ ...... ~ ..................... ).,.>/.Z~.~.u_~.~..~. .... at premises located at ...................... ~...l...-~.../...).~ ........... /L/.E..~..~;~ ........ ~..Z~l~.~ ......................... .................................................................................... .~.. ~...~..~..~..~.~.~.~.-. ............................... pursuant to application dated .........................~.......'~'..~./~ ....... , 19~....~., :nd approved by the Building Inspector. Fee $.....~.?...~ FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerb Office Southold, N. ¥. 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: I. 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 build~ngs 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 New Building .¥.~,~ .......... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .J~,i..~..~e.....~.~tJr~....~..~.~.~.,...~.~.-~.e.~.(~.~.,...~.~ .................................. Owner Or Owners Of Property .['~,~.~x~.....)~.c[(.f,~..,~ .......................................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..~.~..~/.~-~.... * -7 Date Of Permit ./~':~ ........... ~pp ~ca t .................................................................. Health Dept. Approval ...~.......~. ...... ~..~..'~.. .......... Labor Dept. Approval ....... ../~......~.. ............................... '> . . ........ ................... Underwriters Approva~.[.~/c~....?../~...~...~. ........ Plann,ng Board Approval Request For Temporary Certificate ........................................ Final Certificate ......~.. ................................ Fee Submitted $ ..~....~ ................... Construction on above described building and permit meets, oil applicable codes and regulations. Applicant7 ........................................... Sworn to before me this ........ doyof .......... ...... Notary Public .................................... County (stamp or seal) ~/~'~- :SO / ~ FOB~ NO. 4 TOWN OF SOUTHOLD BuildEng D~qm~tment Town Cle~.l Office So,WaM, N. Y. ~1971 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: I. Final survey of property with accurate location of oil buildings, property lines, streets, and unusual natural or topographic 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 Resic~ences and similar buildings and installations, o 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. Swam 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 o 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 New Building N.~.~, ...........Old or Pre-existing Building ............................ Vacant Land ............................ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..,-~..~...~'Date Of Permit .~........~,~..~..)f~pplicant ......... ~ ........................................ H~olth Dept. Approval .~.......~../.......?...~.. ............... Labor Dept. Approval .......... ..~....:.~?.: ........................ Underwriters Approval .....~...I..-/.....~....'~......~......-'~....~..S.~anning Board Approval .......... ..../~......~... ................. Request For Temporary Certificate ........................................ Final Certificate .......... . .~... .......................... Fee Submitted $ ...~....~ .................. Construction on above described building and permit meet, s~all applicable codes and regulations. p,,cant .......... ........................................... Swam ,o before me this ///~'~1~c~/ ......... ~..../. day of ......~....~.... ....... ./..~...~......~... ......(stamp or seal) /,~_ Notary Public .................................... County ~ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Rererencc No 3 --113b APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date~e. 7 ;qTa~ Approval to construct said systems is requested,pertinent data herewith: - 1-Applicant/~ 2\ ~ ~ I-~ ,-~-~ ~'-tu'~'~ '~ Phone '7~-5~-Sub div Address ~-~¢m,~ ~n~ O ~%J~ ~- ~'~. ?-Section 2-Detailed property 16catlon ~r% ~ ~.~ {~c{ 8-Lot No~¥~{kn~A -~3acc~% Hamlet ~ ~ ~%,- ~ ~ To~ '~u ~ ~ ~2 9-Private well? ~ a =~ 3-~blic ~ter ~ply ~me ~ ~7~%f. Dis~nce to nearest ~In ~ ~ ~-Lot Size~ Wtdth%~'7 ft. Len~th~ft. (a%so enter q% center plot plan below:) 10-Pro~s~ ~st~: Septic ta~ ~/~ecast ~ /Cess~ols ~S~llow ~ols / /Other ~ il-Septic ~ inside dimensions: Vol~e~Oals.Len~th ft. Width ft. Liquid depth ft. 12-Precast sections: ~N~ber~Square Ft. Cesspools: Block sizeL incs.D ins. H ins. Total blocks below inlet: ~t ~2 _~3 PLOT PLAN Street ,G apacity~ Gals. .P.M. /~ 'ade Ind~ Nc ate th Data ~eet '(~. ~,--~, ~ % 0 k ~c, m 6 -,,.1 ' ~" 8 18 The Undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, coverin~ Private Sewage Disposal Systems". Owner or Builder 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. Date ~/F/~-- Signed (10/65 Revis.) S-15 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INsTEuCTIONS: Applications must be submitted in triplicate 1-Means Owner or Builder. Address to which mail should be directed. 2-Means detailed description of property location, together with street name and distance to nearest interSection of main thorofare, also Hamlet/Village & Township 3-Enter name of Public Water Supply District, together with the distance to their main. 4-Enter Length and Width of Lot under appropriate heading, also enter these dimensions on center plot plan shown on the face of this application. 5-Dwellings: Check-mark "V" items applicable to the proposed new dwelling. 6-Name of sub-division ?-Section Number 8-Lot Number 9-Private well: Enter "No" if Public water supply is available. Enter "Yes" otherwise. PROPOSED SYSTEMS: Answers to Items number 10, 11, & 12 please consult the Suffolk County Health Department's Standards, Bulletins and Amendments for Sewage & Waste Disposal Facilities. i.e., Part II-Residential Sub-surface Disposal Systems covering Cesspools Part III " " " " " " Septic Tanks Part l~ " " " " " " Unusual soil conditions Part V " " " " " " Shallow Leaching Pools PLOT PLAN: The following information is required concerning the Applicant's Lot: Lot size-Length and Width in feet to be indicated at the Lot lines of the heavy lined square in the center of Plot Plan shown on face of this application. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of ~0 ~ feet of Applicant's Let lines, must be shown on the plot plan also. Wells and Cesspools now on adjacent lots must be shown on the Plot Plan together with the distance to the Applicants proposed Sewage Disposal Systems and Well. Where no Buildings exist on adjacent lots, state "Vacant" on the plot plan. Streets adjoining applicant's lot to the right, left or rear, enter street name. WELL LOCATION: To locate the well & sewage disposal systems on Applicant's lot, the following Standards must be observed: Well-100 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-10 feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Well-40 feet minimum into ground water for well point Well-~ feet 6 ins. minimum below grade to well head and lateral water pipe CESSPOOLS LOCATION: Upon determination of the Sewage & Waste disposal "type of systems" required, the following Standards must be observed for the location of same: Cesspool-10 feet minimum distance from lot lines to center of cesspool Cesspools exterior must be 100 feet minimum distance from nearest well Septic tank exterior must be 75 feet from nearest well Cesspool "Center" must be 12 feet minimum distance from nearest water line Cesspool "Center" must be 15 feet from house foundation Cesspool exterior must be 50 feet minimum distance from surface Waters, Streams, Lakes & Bays, etc. Cesspools must be 20 feet minimum distance from large trees Cesspool center to Cesspool center must be at least 16 feet Cesspool cover top to grade must be held to minimum of I food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of I foot 3'-~0L E N.89' $0' 50'W. - 150.O DUNWUBER MAP OF PROPERTY SURVEYED FOR, i-IELEN ANDEUSKI SITUATE AT PECONIC TOWN OF SOUTWOLD,N.Y. · N OTES: I. DATUM ,~ ASSUMED ~$.0 £LEYATION OF NORTW\VEST CORNER OF ~EMISE$ 2-NO EXISTING WELLS ~,ND/01Z CESSPOOLS 01,4 PEOPE:ETIE$ |00 FEET FROM PREMISES UNAUTHORIZED AL?ERATIC I OR &~)~ TO THIS SURVEY 15 A VIC ~,TION O~ SCALE · 4-0'= 1" O= IEON PIPE In= MONUI~4 ENT · SURVEYED ' JAN. t~, 19't'3 ~.,CEUS~ L,~.o su~v~7o~s 'hmo,., ~.^~.~,~s ~,::~ ,~o, T~^NSF~,~ GREENPOIZ, T. NEW YOR. K s.3'-'140 LE ~$ N.89' 50' 50'Wo - 150.O DUNNUBER MAP OF PROPERTY 5URn/EYED FOR' ° ELEN AI',jDP. USK'I- 51TUATE AT PECONIC TOWN OF 50UTNOLD,N.Y. · TEST HOLE eNOTES' l- DATUM '= ASSUMED 23.0 ELEVATION 2- NO EXISTING WELLS AND/OD. CESSPOOLS ON p~.OPEIZTIES lDO FEET FROM PREMISES SCALE · 4-0'= 1" 0= IRON PiPE El= MONUMENT · SURVEYED ' JUNE I, 19'/?.' VAN TUYL ~ SON LICENSED LAND SU~VEYOi(5 GIZEENPOET, NEW ¥OlZK Be~rm. Nm I Dlnln~ Rn~ ' ~z- "~ 'Jo' BO:.8-. TOWN CLERK'S OFFICE SOUTHOLD, N. Y. No. Disopproved o/c ......... .~.__.~... .... ~ .................. (BuiJding Inspector) 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, with~,_ 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Pict plan showing location of lot and of buiJdings on premises, relationship to adjoining premises or pubJic streets or areas, and giving a detailed description of Jayout 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 Zone~'-~ Ordinance of the Town of Southold, Suffo|k County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of£~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. ....~.~.~..,.~ ~.C.. .......................................................................................................................................................................... Name of owner of premises ...~,~,~.....~,%~:~u~.~.~- ' "' .................................................................................................. If applicant is a corporate, signature of dulv authorized officer. 1. Location of land on which proposed work will be done. Map No.: ~'~.E.,k¢,~. Lot Street and Number ..~,,..~.~.~....~..~(_...~r~ ................................................. ~.~.~ · .~u~.....~['~..~ ............ k; . ~ Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ....~.,.'~P.~ ................................................................................................................ b. Intended useandoccupancy :.~"~.~,.~..~;~.{,x~g,~. ............................................................................ · 3. Nature~f,[ ~ (check which applicab(e): New Building v/' Addition Alteratior~'...,.~.. ..... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. E~imated Co~ ...... }....~..~ ......................... Fee ................................................................................................. (to be paid on filing this application) 5. If d~lling, number of dwelling units ~.~ ...... Number of dwelling units on each floor ~[ ~ ' ~J.~C ..... If gara~, number of cars ...~ ........................................................................................................................... 6. If busine~, commercial or mixed occupancy, specify nature and extent of each Wpe of u~ ;...~ ................................ 7. Dimensions of exi~ing structures, if any: Front ..................... Rear ........................... Depth ................................... Height ........................................................... Numar of Stories ............................................................................. Dimensions of ~me structure with alterations or additions: Front .......................... Rear ......................................... Depth ............................................. Height ......................................... Number of Stories ........................................ 8. Dimensions of entire new construction: Front ..~..~.~.'.~ Rear ..~.~ ...... ~. ........ Depth ~.~ ....... ~..~ ....... He ght ......... ~. .................................. Number of Stones ..~.¢.{Z~/~ ...................................................................... 9. Size of lot: Front .4.~,.~ .................... Rear .Z~.~..4.~ ..................... Depth ...5.~.~.~ ................................ Height .................................................... Numar of Stories ...................................................................................... 10. Date of Purchase ....... .~.....z.. .......... Name of Former Owner ....... ~ ....... ....p~ ........................................ 11. Zone or use district ~hich premiss are situated ......................... ~.:~..~ ......................................................... 12. Does propped construction~violate any zoning law, ordinance or regulation: ..~.~ ........ ~.~ ................................. 13. Will lot be reCeded ........ ~~ ....... Will excess fill be removed from premiss: [~ Yes _ [ ] No 14. ,ams of Owner of ,rem,~ ..}~..~.~.~.~.-~.l~&.~.~.,,.~.~.} m~.., ~.~ ........... ~...~.~.~.~.. ......... ............... (Address) ~ (Phone ~od Name of Contractor. .L~...a.~ .... ~.~.~.~ ......... .~.~... w- ~.O..~ .~...~.~.~ ~ (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 corner lot. STATE OF NEW YOn,K, ) COUNTY OF .~...~..~-.~.~..~.4~,. ............................ ) SS .............. ~.¢~1~.~....;4..~.~.£..~-~.~, ............................................... being duly sworn, deposes and says that he is the applicant above named. (Name of individual signing contract) ,~-Ie is the ...... .~.~.3.~.~. ........................................................................................................................................................................................ (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 bestJ~ ~r~1~ge and belief; and that the work will be performed in the manner set forth in the application filed therewith. ?,ol~_rv Public, s~e Yo~ ................. .............. . ................................................... ;;; ....................................