HomeMy WebLinkAbout5791-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate OI Occupancy
No...Z~..~..~ ...... Date .............. 6*pt.. $3 .... , 19.~2.
THIS CERTIFIES that the building located at .. fl~x, clinerl-/~ne ......... Street
Map No..~01k ....... Block No .... lot .....Lot No. ~ ...8OItt~O].~!..N,][, .........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ........... bpr~,~,..~,., 19..~ pursuant to which Building Permit No.
dated .......... &pr~,~....~'.., 19..~ 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 .Fray&re. _~n~ ®. fara$1y .dv®Ll.~ng .......................................
The certificate is issued to . .Founderl~. ltome~. Ine ........ 0,¢ne~ ...................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval Seltt..~.~.l 9.~.. bl~..it...V$lla ......
UNDERWRITERS CERTIFICATE No..~1..lt.~.~ ........................................
ttOUSI~ N UMBER.. ~ ....... Street .... G&rd~er.~..I~Z~ .............................
Building Inspector
FO~ NO. ~
TO~N OF SOUTSOLD
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)
5791 Z
Permission is hereby granted to:
...... /.J~Jl~tlra ..1/,~ml...I~....,l~l ..................
at premises located at ........ J, ql~'-~'""~&Jr, F~"'P&'~JK .................................................................
...................................................... ~.s,~l,t..~e,J-.t~, ................... ~o~a~l~ .......................................
pursuant to application dated ................................. A~..-.~..., 19..{~1~., and approved by the
Building Inspector.
Fee $..~.~ iT. .........
I~ORM NO. 6
TOWN OF SOUTHOLD
Building Depo~tment
Town Clerics 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:
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 accupancy $1.00
D te .........
New Building ..... ~ ......... Old ar Pre-existing Building ............................ Vacant Land ............................
Owner Or Owners Of Property ..?.~.~,..z~.J~.~.~.~.......~-~e..t~.~.-,~......I.~L..~. ...................................................
Subdivision ...?...~...t...R....V...t...~...l~.......~..~....~..t~ ................... Lot No ............. Block No ............. House No .............
Nc~...~...~ J....~....
...I
Permit Date Of Permit/d~'~,..~.~^pplicant ...... ....
Underwriters Approval .............................................. nning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate
Fee Submitted $ ....................................
Construction on above described building and permit meets all applicable codes _and regulations.
Sworn to before me this
..... !.~. ...... day of ...~.~.'~.~,?~...~. 9~...~..~.~.,,,~,.
Notary Public ................. ~s~,~'~. County
TERRI L[[ ELAK
~OTARY pUBMC, State 0f New York
No. 52-6168295
Qua i[ied in Suffolk
Commission Expires Marcl,
(stamp or seal)
S-9
SCHD
SUFFOLK COUNTY DEPAHTHENT OF HEALTH
Date ,.~CF ; 1972
Bldg. Permit No.
TO WHOM IT
at
MAY CONCERN:
The sewage disposal facilities
(Give deed location)
for a structure located
have been inspected by this department and found to be satisfactory.
1972
Chief of General Eng:ineer~g Serv~ ce~
SUFFOLK COUNTY DEPARTMENT OF HEALTH
H.DoReference No ~'-/d~
APPLICATION FOR APPR0~J~ TO CONSTRUCT PRIVATE SEWAGE DISPOSAL $YSTF~S Date~
Approval to cor~truct said systems is requested,pertinent data here~lth:
Address~''~e~ ~ ~~ ~,~ ?-Section ~ ~
2-Detail~ p~pe~y locationW/~ ~,~ ~. 3KO'~ t,~. 8-Lot No. q~
~mlet &~ ~ To~ ~W~-~ '-- ~9-Private well?
3-~blic ~ter supply ~me -- Dis~nce to nearest ~in
4-~t Size: Width IO~ ft. Leggth~O~ ft. (also enter on,enter plot plan below:)
5-~elli~: Single Family ~ T~ Fa~ly? ~ /Cellar? ~l~b? ~ ~Crawl S~ce?
lO-~o~s~ ~st~: Septic tank ~ /Precast ~Cess~ols ~S~llow ~ols ~ /Other
il-Septic tank inside dimensions: Volume
12-Precast sections: / /Number~Square
Total blocks below inlet.-~
PLOT PLAN
Gals.Length. ft. Width' ft. Liquid depth___ft.
Ft. Cesspools'~lock sizeL~_incs. D ~ ins. H~_4ins.
Capacity ~ 'G%ls.
O.P.M.
Street
[
The Undersigned CERTIFIES:
Indi
No
"Construction of authorized installation
;ate
~th
Data Feet
0
2
6
8
10
12
will be in
accordance with the Suffolk County Health Departments' current Standards, Bulletins,
and amendments thereto, covering Private Sewage Disposal Systems".
Date~ m~;~ Signed~er
FOR HEALTH DEPART~E~NT 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 ~/,~7 )-'~
(10/65 Revis.)
S-15
TOWN OF SOUTHOLD ~ ;-4 .o · n ,~. ~'~ /.,~
TOWN CLERK'S OFFICE ~ ~ v~ ~,.~ ~
S~THOLD, N.Y. ~ ~.0 ~
............... , Applicati~ ~6.' ................................
........................................ , ]9 ........ Pemit ~o .....................................
INSTRUCTIONS
o. This.application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
b. Plot plon showing location of lot on.d of buildings on premises, relationship to adjoining premises or public streets or
or~s, and giving a detoiled description of layout otpraperb/must be drown on the diogram which is p~rt of this opplication.
c. The work covered by this application may not be commenced before issuance of Building Permit. ·
d. Upon approval of this appJ]cation, the Building Inspector will issue a Building Permit to the applicant. Such perm t
shall be kept on the premises 69ailable for.in~pection throughout the progress of 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 hove 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, buil~.ng ;-ode, housing code, and regulations.
(Signature of applicant, or name, if a corporation)
, .(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer,, ge, neral contractor, electrician, plumber or builder.
Name of owner of premi~e~ ..... .~..?..Y..~..P.~.~.~...~.e .~-....~....~.....)..1~...~-.: .... . .....
........ .......... :, --f
(Name c~d title of Vorporate officer)
1. LOCation of land on which p.rpposed work wifl be done. Map NO.: ........ ; ............................... lot Ne.....~.~: ...............
Street and Number :C?..e.A.I~.~ i~ ~8...,.~/~ ,....~'.~..i ~..~..1 ..~.......~..~...&....~. ..... .3..~...~ :...~,~., .~/,i~l..m.-..~..~....~. ~: ........
2: 'State existing use and'~u~nW of p~is~ and intended use ~d ~cuponcy of p~o~d ¢onsfmction:
a. Exisiting use and OCcupancy ................................................................................................................................
b. Intended use and OCcupancy ........ ~....~...l~.......~.~j~ .~..!.~....~'. ...... ~..~...~....Lt..~....~...~..: ....................................................
3.* NatUre of work (check which applicable): New Building ........... Addition .................. Alteration ..................
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................
4. Estimated Cost ........~.~....~. ....................................... Fee ~"/' ~ ~
(to be paid on filing this application)
5. If dwelling, number of dwelling units ........ ~.. ................. Number of dwelling units on each floor ..~-.~.~9..~...~. .......
If garage, number of cars ...........J. ................................................................................................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each h/pe 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 ............. ~ .................. I
8. Dimensions of entire new construction: Front ...... .~....~. ...................... Rear ..~'.0. .................... Depth ...~...~. ................
· ,.ti ~'o~__ _
Height ....I ........ ~ Number of Stories ...... ~. ................................................. ~ ....................................................... ...~
9. Size of lot: Front ........ /.§.0. ............ Rear ...... /.~.~. ...................... Depth .....~.O....O. ..................
10. Date of Purchase ........ ................. Nome of Former Owner ,~.e..~..'T'..~.....°....~..A~.'.~.....~/~...~....~.....c~....~*
11. Zone or use district !n which premises are situated .....................................................................................................
12. :Does proposed construction violate any zoning law, ordinance or regulation? ..... .~...0.. ...............................................
13. Name of Owner of premises .~...".l~J~,,~.$...J~.e.s...IN¢.Address ~e~-~-(-I?~...-.~..--.~v~'/---Mqt~ Phone No.~.~..~..'.~...,~...~....
Name of Architect ................... .~..~ ................................ Address .............. .~..~. .......................... Phone No...~..! ...............
Name of Contractor .................... k...~ ...................... ~ ...... Address .......... .~..~. .............................. Phone No..L..k. ..............
P~OT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate oil set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate
whether interior or comer lot. ~'nt&,l~ ~P,~.e~.
STATE OF ~"
u/s , .3So'
!being auty swo~oses and says t~t he is the applicant
( , a~lication) ~
above named. He is the C*~.~.~ ..~ ~L~.- ~.~,~..~.iF
(Contractor, agent, co~orate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke 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 fo~h in the applicatJ~ filed therewith~
Swomt~ me this . ~
...... o, .......................
Nota~ Pu~..~.~~oun~~~r~ ~[;; )
Notary Pub[iq Sia~e of New ~a~k
No, 52-0344963 Suffolk County ~
Commission Expirei March 30, 19~
W
5.'75 O0 ~D E..
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MAP OF PP._OPF_P. TY
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FOUHDE1E,~ HOI~E,8,
AT.
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TOWN Ol::~SOJmOLP.N.¥
ING.
CTli~EI:) TO TI4.~ O4~ T'IT'LF-,
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