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Home My WebLink About5972-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Of Occupnncy THIS CERTIFIES that the building located at PA ~:.,~$~ ~.'r'.....~/../~-.- Street Map No... ~...~.~../... Block No......'--'7 .... Lot No ..... .~../. ......................... conforms substantially to the Application for Building Permit heretofore filed in this office dated ....... .~...~...~.l! .~f.~..., 197. ~-pursuant to which Building Permit No..~...~. ? .Z dated ........ .~..7... ?.(,?./~.., 19.'?.Z-;.,-was issued, and conforms to all of the requ/re- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is .... ~ ..... ~ ...... C.~.,..~. :.,..,,: ....... .D./.,:..~.~:~..,.;..~/..~:.... .............. The certificate is issued to ...... ./~../..~ fl..A..~..~ .... ./,..A..O7.~.~' .~:..~T.L.~ ............... (own, er, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval UNDERWRITERS CERTIFICATE No ....... .~.,(...q..Z..~..~...~. .......................... HOUSE NUMBER../..~/...'~..~....Street.../--, l.,,.zy.~. .V. ! ~. !,,./: .... ~. ./7). ...................... ...................................... ~.~.u...T.~-~..t! .~.t~ ........................... Building Inspector gOl~l NO. 2 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5972 Z Date ~T~IT~e ~ 19 ~ Permission is hereby granted to: ..... 3J~ 5.6 ...~;.. 3. 3 .'.Z. ................................................ to ~.~, ..~w...or~...£a~$;~.. e. wa~.;1J~r,g ..................................................................................... at premises located at .......~..,~......~.~-'~'.~..]~&:~BZ'~. .................................................................... ....................................... l, ang~. ~.ea4.. ~. r. X~. Mt,.. I?~..~.~ .......... ~ .~.t~o~,. ................................... pursuant to application dated ........................... .~'.;J:r; ...... ~.~ ......... , 19..~.'.g..., and approved by the Building Inspector. Fee $..5.~...'t .~ .......... Building Inspector FOltM NO. S TOWN OF SOUTHOLD Building Deporfment 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 dispcsal--(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 aT 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 Date ................................................ 7 ~'~ ~ Ol~d or pre-existing Building .............. ~ ........... Vacant L~d ............................ New Building ..... '""~'~'~' Lo,~. vie ~u /.fi. '~ ~'./E~A~,r Location Of Property ................~.~.~.~ .......... '2'~'~"~' ................................................................ Owner Or Owners Of Property ....................................................................................................................... T,,.x~ ~.'re~ 2 ~0 / ,5'/ Subdivision ...;.....'/ .................................................... Lot No ............. B,oc No ............. House .o/'Y. ....... ermir Pqo ..................... a e u ermit ....................ppi .................................................................. r /O"/.Z-?~- Health Dept. App oval ,: ........... ~.~,x ........................ Labor Dept, Approval ................................................ Underwriters A royal N /"/11~ 6~ Planning Board A royal PP .............................................. PP 7 .................................. Request For Temp~ary Certificate ........................................ Final Certificate .,...,,- ................................... Fee Submitted .?...0....0.. .................... on,,ruc,,o. on *ow · Zkppl icant ....... ; ./.;., .~,, _ ,, ,~, .~'....v~..~, -....,.........."~'"'~ '...,r~..~, ............................... Sworn to before me this J*'~ day of oC~' ~ (stamp or seal) Notan/ Public ..... '.~[ ;;;;'..~.~....~;....-7.;;:..?-County T~.RRT LEE ELAK NOTARY pUBLIC, State 0t New York No 52-6[6~295 e4!''' ¢, SUFFOLK COUNTY HEALT~ DEPART~'ENT The sewage disposal and water ~upplF facilities ~r tho ,structur~ loc~t~ have been ~nspect~a by this Department found to be satisfactory. 4 i ~ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference No EASTERN DISTRICT, RIVERHEAD,N.Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Oate~'~q /~7~ Approval t~ construct ,said systems is r~equested,pertinent data herewith: ~ 1-Applicant /~ ' ~r~ /~__C L-- L/~ g~6~ O Phone 6-Sub div 7~ Address ~ ! /~$~/-~f ~_~c~ ~.-~7~ Hamlet ~3 ~ ~, / ~ ~ Z d Town,3~ F-M ~ Z, C 9-Private well? 3-Public w~ater supply name ~-/~'~--~-' Distance to nearest main .~' 4-Lot Size: Width× ~ ft. Lenzth/~ ft. (also enter on center plot plan below.) ~0-?o~s~ syste~. Septic tank { /~recast ~.~Z~Cess~ols ~Shallow ~ols ! /Other ll-oeptic ta~ inside dimensions. Vol~e~ uals.Length ft. Width ,ft. Liquid dept~ft. 12-Precast sections: / /Number~/Sq~re Ft. Cesspools: Block sizeL incs.D ins.~ins. ~T P~N Ca~cit~als. G.P.M. ~ rade Street Indi Data Feet /b 0 ~'~ 2 ~ 6 ~ ,h The Undersigned CERTIFIES: "Const~ction of authorized installat will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, andamendments thereto, covering Private S~wa~e D%~posal Systems". 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 , ' Signed (10/65 Revis.) C0~50~ TOWN OF $OUTHOLD BUILDING DEPAI?~TMENT . ~WN CLERK'S OFFICE ~UTHOLD, N. ~/~ Examined .... ~...~.~ ........ , 19~.~ .............................................. . ............................ Di~pproved o/c ........................... ~ .............................. ~ ~ ............. .................................. ............. .............. ....... .................. /~:.....:...~ ................ ~ (Build~nspector) a Th s a cat n mu t c I'NSTRUCTIONS ~)~'~ · ' pP' 'o s be omp ere y filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, ~i.th~: 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 areasLa~nd~, 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 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 I~een~ 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 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 o~ ............. ........ ...... ........ ................... Name of owner of premises ..... ~.~..~.~x~..~....~..~... ........ ~'~..~.~....~....~.~.. ................................................................... If applicant is a corporate, signature of duly authorized officer. ..................... i i~'~i~;;';,',:;d"~i~i;F~;~-';;~;'~;~';;~'~' ~;:~'~;~:~;i ............ ' ........ ~. Location o~ ~and on w~ch~ ./' ~',;:'.,~ ~~ ^pr°p°sed wor~ w~be done. ~p No.: ~.~~ ................. dot ~o. ~ .... Str,t and Numar ~ ...... ~.~..~~......~~..~.~ ............. ~.~ ................ /~5'~ ~ - ~ ~ ~ Municipaliw 2. State exi~ing u~ and occu~ncy of premi~ and intended u~ and ~cupancy of propo~d con~ructibn: a. Exi~ing u~ and ~cupancy ........................................................ ~ ...................................................... ~ . . ................ b. Intended use and occupancy ............ ...x~....~..~'......~r.~.L~.g~..,~..~.....~m~. ................................ ~ .................. , 3. 'Nature of work (check whlc~h applicable): New Building ~ Addition Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. Estimated Cost ..... ...~....-.~....~..o......~.. ................. Fee ................................................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ...~.. ........,. Number of dwelling units on each floor ......................................... 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 .................... 8. Dimensions of entire new construction: Front ...~.....-~....~... Rear .....~..~ ................ Depth ...~....~....~.....~...~.. ...... Height ............................. N mber of Sro les ..................................... 9. Size of lot; Front ....... .?...~....¢~.. .................. Rear ............... ~...~ ..................... Depth ................................................ 10. Date of Purchase ..................................... Name of Former Owner ............................................................................ 11. Zone or use district in Which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........ ZI~..~. ........................................... 13. Will lot I~e regreded .................................... Will excess fill be removed from premises: [ ] Yes [ ] No 14. Name of Owner of premises ~'~..c...~..~....~../....~..~'.~C.~..~..O......~.~.~.~....~..q~.~.....~......~~C~ ...... (Address) (Phone No.) Name of Architect .............. ; ................................................................................... ................... . . . ........ ...... · · .....o...... · . (Address) (Ph ne o.) Name of Contractor .~ .~'.¢~......~/.~../....~'~. ~.,~....~.. .................. ~"~'/'.~'... ...................... ~..,~..~.....~.X./.~....~e.~..~.o~ .~..~..., ...... (Address) (Phone No.) PLOT DIAG RAM 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. .sw ¥o.. ) cou. ¥ ........... .......... ) = .......................................................................................................... being duly sworn, deposes and says that he is the applicant above named. (Name o£ indivbt,,~t signing contract) He is the .................... ~ ............................................................................................................................................................................................ {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; aqd that the work will be performed in the manner set forth in the applicaton fled therewth ~ ubic Soecf I~e~ ~c. ubl .............. ,-J ~.., L J a'-l" J '-- - II:d" ,I -//- 5" ~2-11 ~'-t o" 7L 4" t