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Home My WebLink About5938-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. UPDATED CERTIFI~CUPANCY No Z17959 Date APRIL 18~ 1989 THIS CERTIFIES that the building Location of Property 940 CASE'S LANE House No. County Tax Map No. 1000 Section 109 Subdivision ONE FAMILY DWR. TJ.TNG CUTCHOGUE Street Hamlet Block 05 Lot 11 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 6~ 1972 pursuant to which Building Permit No. 5938Z dated JTJNE 12~ 1972 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ONE FAMILY DW~T~.ING WITH FRONT PORTICO AND REAR DECK. The certificate is issued to THEODORE & RENA POLASKI (owner, ~{~) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL JULY 5~ 1973 by R. VILLA UNDERWRITERS CERTIFICATENO. PLUMBERS CERTIFICATION DATED UPDATE OF C0. Z5341 JULY 7~ 1973 by J. KUBACKI N/A Building Inspector Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z..~.~.~J. ...... Date ............ R..~.$~..~.t....~ ...... , 19..7.~. THIS CERTIFIES that the building located at . .1~/.S..C$~.$...L.~..n~.. ........... Street Map No. ~ ......... Block No.. ~ ...... Lot No..XX. .....C~t..t.e.h.o. kin..~....N.o.~.; ......... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... June .. 6 ..., 1972. pursuant to which Building Permit No. ~9~S.. dated .......... Jll~t...~2..., 19.7.2., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is P~lva.~.a. o1~..fal~,ly, d.~llll~ ....................................... The certificate is issued to ...~...°d.°?.~...P.°.l.~..sit..I. .... .~..wll.~.~. ......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . July. ~.. 19.7.3.. b7 .R,..V. lll~ .... UNDERWRITERS CERTIFICATE No..J.u.!Y.. 7..~.~3..b.y..J....K..~..a.~.k.! .............. HOUSE NUMBER .~ ......... Street . .~aa~..l,,i~ .............................. Building Inspector FO~ NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5938 Z Permission is hereby granted to: at premises located at ........... .................................................. Gmt~eh®l~e ......... g.~., ...................................................................... pursuant to application dated ........................... ~.t~$ ........ ~ .......... , 19....~..., and approved by the Building Inspector. Fee $...~,.)~.~ ........ ! ' Building Insp~-ctor / !~0~,~ NO. 6 TOWN OF $OUTHOLD Building Delm~tmont 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 duplicate 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 in§tallation 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 June 8s 1973 New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ~.w../..S.~?..a..s..e.?.~?.'~`~e.~.~..~..~.t~.c.~.~...~...e~.s~..~ .................................................................. Owner Or Owners Of Property ..... ~,e.,°.,d.°.~.e...~.°..Z..a..s...~.'....T....,~.,~a..~...o.~,.a..s...~. ................................................... Subdivision ........................... .....~.. ........................... Lot No.....~.. Block No.......~...... House No ............. Permit No. ~.~...~....~....~.. Date Of Permit ....6../..1.~./.?..2....Applicant Theodore ?olaeki Health Dept. Approval ............... Labor Dept. Approval J~J"~ Underwriters Approval ................... 2.~. ............... Planning Bo~rd Approval ~l{~- ........................................ Request For Temporary Certificate ........................................ Final Certificate ~- Fee Submitted $ 5.00 Construction on above described building and per.~it meets all applicj:d~le-,,codes and regula, tions. (stamp or seal) PubliC, State al New Y~ R~i.~ in ~fl~ C~ No. 52-71353t5 ~ ,/ ~mm~s~ Expires ~h ~, 1~ Sworn to before me this ..... /..~/..~... day of ...~...../..~..~..._~. ...... Notary Public ....... County ~/L~'~TOHN OF SOUTHOLD BUILDING DEPART}lENT TOWN HALL SOUTHOLD, NEW YORK 765 - 1802 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY DATE.-~/>.'~h.. ...... NEW CONSTRUCTION ....... OLD OR PRE-EXISTING BUILDING ...... VACANT LAND ........ HOUSE NO. STREET HAHLET Uouaty Ta, ,ap No. ,000 Se.tion Z~... BIoc~ ~ Lot ..X../ ..... Subdivision ....................... Filed }tap ........ Lot .......... Permit - -~-' ....... Date of Permit . .Applicant ~--~..~...J~..~... Health Dept. Approval .................. Underwriters Approval .............. Planning Board Approval ................ Request for Temporary Certificate ....... Fee Submitted: Final Certificate ................ APPLICANT.~ ........ . ....... rev. I0/14/88 SUFFOLK COUNTY DEPARTHENT OF HEALTH H.D.Reference No 3~-/13/ APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to construct said systems is requested,pertinent data herewith: Date · 1,Applicant Theodore ~ol~ski Phone Y55-2977 6-Sub div 2-Detailed p'roperty lOc~ti6h Hamlet ~u,+~ ..... Town ~.~+.~.~ 9-Private well? ;eH 3-Public water SUpply name nO - Distance to nearest main S-Lot Size: Width ft. Length ft. (also enter on center plot plan below:) 5-Dwelling: Single Family lO-Proposed system: Septic il-Septic tank inside dimensions: V$1ume ~Gals.Length ft. Width f.t. Liquid depth ft. 12-Precast sections: /./FNumber~Square Ft. Cesspools: Block sizeL' lncs.D ins. H ins. Total blocks below inlet: PLOT PLAN Capacity_~_~als. G.P.M. ~' rade ,W.L. T.at H,i~ Data ~eet 0 2 4 6 8 10 12 18 The Undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". l /f Owner or Ba-iQ~ r 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. ~, ~ J~-~- Signed ~ '- ~ Date (10/65 Revis.) S-15 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate 1-Means Owner or Builder. Address to ~_ich 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. ~-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 Nnmber 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 IV " " " " " " 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 50 feet of Applicant's LOt 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-lO0 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-lO feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point We]l-DJ) feet minimum into ground water for well point Well-4 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-lO 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 1 food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of 1 foot 9 ,Scale: 50'= I"" ~ : e "woll MA~ OF PI?.OPEI?.TY TH£ODOI?.E POLA,SKI NO. 1 TO~N OF $O~JTHOLD TOWN CLERK'S OFFICE ~.~ /~ ~r~ ~./~'. -'~ · · SOUTHOLD, N. ¥. Examined ..~. ....... ~...~......., 19..~...?'?.. Application No..~..,.~..~.~... ................ Approved ...........~:.., 19 ........ Pemit No.~.....~.~......~...~ .......... Disapproved a/c ............................................................................................ ~ (Building I~spector) APPLICATION FOR BUILDING PERMIT '~ -, ............. ............ , .... INSTRUCTIONS ~ a. This application must be completely filled in bv 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. Plot plan showing' location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on diagram which is part of this application. c. Thd work covered by this application may not be commenced before issuance of Building Permit. ~ d. Upon ~flroval 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 use~ in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been g.ranted 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~ 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, ordinancea, 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) o/o #. ~m~ 275 o.v (Address of applicant) S~ ~her applicant is owner, I~e, a~nt, archit~t, engin~r, ~neral contr~tor, electrician, plum~r or builder. Na~e of ow~r of premi~ ~ Po~t If appli~nt is a cor~ra~, signa~re of duly authorized officer. (Name and title of corporate officer) 1. Location of lan n i h k '1 · d o wh.,~/c ~ p[oposedfaf~or w~ I be done. Map No ...................... ,, ,~ ,~L°t No .................................... ; ........ Stree, and Number ..... L~J../.,w~ ......... ~....~...~ ............. ~~~...,,~.::;;;';,;..__ ............ '. ....... ~ MUnicipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed ~'bnstruction: a. Ex~st~nguse and occupancy ............. ~...~ ............................................................... b. Intended u. and occupancy ........ gR~..~lR~..~R~,~,,,~fl.. .............................................................. ...... ~ ..... ~,~ ~. aNature of work (check which applicable): New Building ....... .'.. ............. Addition ...... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) {to be paid on filing this application)/ each" 5. If dwelling, number of dwelling units ....... ~ ........ Number of dwelling unit~ on rmor ........ ,.,. ............................ If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................................... 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 ....................... ................. Height .................................... ~ ............ Number of Stories ................................................. ~ ........................ t ............. Height .................................................... Number of Stories .................................................. .................................... 11. Zone or use district in wl~ich premises are situated ........... ,..., .......... , .......................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .................. ...l~.. .................................. '... 13. Will lot be regraded ..................................... Will excess fill be removed from premises: [ ] Yes [ Iii No 14. Name of Owner of premises l']~,,-4ot*e t'o:Leekl 1~1 k~e~ .Wee~ R~lmZt (Address) (Phone No.) Name of Architect ..................................................................................................................................................... (Address) (Phone No.) Name of Contractor ............ ~..i~ ................................................................................................ ' ............... (Address) (Phone No.) PLOT DIAGRAM .Locate clearly and distinctly a!l buildings, whether existing or proposed, and indicate all set-beck dimensions from property lines. Gi~e street and block n~mber or description according to deed, and show street names and indicate wheth- er interior or corner lot. STATE OF NEW Y~ll ) COUNTY OF ...................................................... ) SS being duly sworn, deposes and says that he is the applicant above named. (Name of individual signing ,contract) He is the ................................................................................................................................................................... ; ............................................. [Contractor, agent, corporate officer, etc. of said owner ar 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 mamleF* set forth in the application filed therewith. /~P OF' PR. OPER. TY THEODOeE PO£A~SKI ,.eeo/e: SO'= I,, = .well ~[~v. P.O.o CuT-c/4o~u£, ~. M The se,?aEe dis~osa! s',d ~'.'~i er s~nply fac"![t~ec for th"~ ]oc,-~1~cn Y:ave been inspected, ky thi~ t~art!2cn% and found Chief of ~e.n.qral Engineering Services MAP OF P~OPE/~TY' THEODORE POL,tISKI CuTc~o~u~ ~.~ C9 . ~e ll .% OF' ,Ol2_.OPE P_..TY 7-t4 0D0 £ -G = cessb°°/ ~ =well e/~v. zO.O oP--N, W. Jr~cn/z~, t; ,,z g. '9 S E¢.¢_/©~1 60' 04" /8' /4-' Po,eT/co 33-1o