The URL can be used to link to this page

Home My WebLink About5876-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at .l~t~.elr. Raa4 ............... Street Mat, No..~~t;' .......... Block No ........... Lot No.. 32..&. 3~ .... l~a.t, tit~t.ck,, !~.,X,.. conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... l~.a~.. ].5[ .... , 19.~. pursuant to which Building Permit No. dated ........... .M~'...IS..., 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 . .pleS,~.a.~;~..¢~te. ~.am$-~...d~r..~l.ll~g ...................................... The certificate is issued to . .~t~ave. & ~iar~or/e. Lellmalm ...... q .~. er.a. ......... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ~.e.D.t...~.9... ?.9.7.2....D.Y..R.~. UNDERWRITERS CERTIFICATE No~....~'..~.~..67~.....~'.~.~.t... ~',~.t .~97~. .................. HOUSE NUMBER.-365-. ~F.~r~. ................................................ ..... FORM NO, 2 TOWN OF SOUTHOLD BUILDING DEPARTM£N~ TOWN CLERK'S OFFICE SOUT.~O~-D, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL CQMPLETION OF THE WORK AUTHORIZED) N°. 5876 Z Pate Permission is hereby granted to: ........ ~~ ..................................... to ...~.t~...~.. ~,. ~,. ~.~,~ ........................ ~ ............................................. ~: .......... at premises locater"at .~;~.~.,~..~.:,~,~:,;~ ~ ~, .............. : .................. ...... .... ........................................... · ~e,.-~,~,~',: ...... ~0t ?h'~-,~'.t ...... : .............................. ,.. ~ ~ 1, .~ and cpproved by the[, pursuant to application doted ........ Building Inspector. [** ,....~g~. ....... TOW~ OF $OUTHO~O Building Department ~own ~lerks Office Southold, H. Y~ 11971 APPLICATION FOR CERTIFICATE OF~CUPANCY Instructions Sworn to before me this/ ~ ..... dayof ....... A. This application must be filled in typewriter OR ink, and s~bmitted in triplicate to the Building Inspector with the following; for new buildings ar new ui~e: I 1. Final survey of property with accurate location of all ~uilj:lings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sew~tagi~ disposol--(S-9 form or equal). 3. Approval of electrical installation from Board of F~re Urlderwnters. 4. Commercial buildings, Industrial buildings, Multple R~sdences and similar buildings and installations, a certificate of Code compliance from th6~ A{chitect 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 ~ses~ or buildings and "pre-existing" land uses: 1.Accurate survey of property showing all property lines, ~tre~ts, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, ~cupancy and condmon of bm drags. 3. Date of any housing code or safety inspection of buildir(gs br 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 us~ 3. Copy of certificate of occupancy $1.00: .,.~. _--~--~-- : Date · / ..... ,,.... ./...~.~,...A/...ff~. New Building ....... .~.. ....... Old or Pre-existing Building ................ ':,'"'i ...... Vacant I~nd ............................ Location Of Property ..~l./.:~ ........ ~.~.,~.~.>'.J ........ ~..~.:......~...5'"~"L:...!!~....b.....,.j,~..~-?.......~.~..'.~.: Owner Or O ners Of Property ...... .................. Subdivision ................................................................ Lot No..,.~.~...!... Block No ............. House No ............. Permit No. ''('~ '?~ DQte Of Permit .~'..Applicant ................................... Health Dept. Approval ............................................ Labor Oept, ~pp~oval ................................................ Underwriters Approval .............................................. Planning t~oa}d ~pproval ........................................ Request For Temporary Certificate ........................................ Final Ce~'tificate ..~ ..................................... Fee Submitted .................................... Construction on above described building and permit' meets al~ al~i~able codes and regulations. (stamp or seal) TOWn1 OF $OUTHOLD guilding Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF !OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and su'J~m[tted in triplicate to the Building Inspector with the following; for new buildings or new us~: 1. Final survey of property with accurate location of oil bud~mgs, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewe~rag~ disposal--($-9 form ar equal). 3. Approval of electrical installation from Board of Fire UnderWriters. 4. Commercial buildings, Industrial buildings, Multiple Rqs~dences and similar buildings and installations, a certificate of Code compliance from the ArChitect ar Engineer responsible for the building. . 5. Submit Planning Board approval of completed site plan :reqt~rements where applicable. B. For existing buildings (prior to April 1957), Non-conforming ~ses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, s.tre~ts, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, O~cupancy 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 .....~.~ ./....~.......c~..,~.~.'. Z...'~' New Building .......~ ......... Old or Pre-existing Building ................ ,....:~ ..... Vaca,pt Land ............................ Owner Or Owners Of Property .,..~../,~.,.~.;...?.,...~..~..~..~.~.~,;,....~,.~,7~...~.~.~/M-~ d //,~ .......... Subd v sion ................................................................ Lot No .......... ;;. B~ock No ...........Hous No .......... ................ Health Dept. Approval ............................................ ~bor ~Ph ~ppr?al ................................................ Underwriters Approval .............................................. Planning Boa~d ~prova~ ........................................ Request For Tempora~ Ce~ificate ........................................ Final ~Ce~ificate ......... ~ ............................. Fee Submitted $ ~..'J~] ........................ Construction on above described building and~er~it meets ali a~li~oble c~es and regulations· ........ ................................... Sworn to be~ore me this ................ day of ............................................ (stamp or seal) H.D. Re£erence No~]~//~/~ WESTERN DISTRICT, COMMACKi N~. Y. ,, PRIVATE SEWAGE DIs~S~L SYSTEMS APPLICATION FOR APPROVAL TO CONSTRUCT Approval to construct said sYs'tems is requested,pertinent' data herewith: Date ~ 1-Applicant ~ ,,, Ph ,~ ~ 6-Sub div .~ ..... · Address ...... $. ~ 7-Section 2-Detailed"pr°p~{y location '~ - ' ~ ', ~ 8-Lot No. ~ Hamlet To~ '~ ~, /~ I 9-Private well? 3-~blic ~te'~ supply name DistahcO to n~arest main 4-Lo% Size~ Width - ft. "'"'~ength "/ f~,' (~iS'o onted o~ center plot plan '~elo~:) 5-~elling. Single ~mily ~;' I Two Family? ~ ]Cellar?l ~lab? / gCrawl S~ce? lO-Pro~sed system: Septic tank ~ /Precor ~Cessp~ol~ ~Shallow pools / /Other il-Septic ta~ inside d~menslons. ~glume~Oals. Leng~h~ft. Wldt~ft. Liquid dept~ft, Total blocks below inlet: ~1~2 PLOT PLAN Capacity ! ,'~Gals. --1 G.P.M. ' ,~ :ade , G ,W.L. Street The Undersigned CERTIFIES: "Construction of author~ ate th Test H .le [ Data ~eet 0 2 6 10 1£ ~6 i Indi ' ~ Nc ,ze~ installations will be in re~t Standards, Bulletins, (10/65 Revis.) S-15W accordance with the Suffolk County Health Departments' cu] and amendments thereto, covering Private Sewage Disposal ~ys~ems". Date ~"~ ~? ~' Signed /'~["?~'~-/, ' O~d~ or ~ Bqilder FOR HEALTH DEPARTMENT USE OhLy. Based on the mnformatmon ~rgsented 'hereWith, 'it is the"' opinion of th'e Hea'l'th Department, that an adequate and sa~is£actory Sewage Disposal System can be installed on this Plot. Date ,>~/7 ~-- Signed APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: 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 IV " " " " " " Unusual soil conditions Part V " " " " " " Shallow Leaching Pools P__~T 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 myacant" 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-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-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 t5 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 I foot ,~ --, - -"" TOWN O' sOuTHOLD ~~K') g ](- ' "~f'~i~a~d' d '~ 3¥ /' BUILDING DEPARTMENT~ ~ ~ ~.-/~ ~ TOWN ~LERK'S ~FICE / ~z ~ ~ /~ ~ -~ ~ ~ ~UTHOLD, N. Y. -~ ~ --~"~ - ' '~- . ~ ~m~ed ..... X~.....Z ............ , ~G .... ~,,:~No ...... ~...Z ................ ~ ............. ............ ,,, .... PP / / · .................................................................................. : ................... ~....*~ ~ ~ ~ ~ I~~ ~ ' (Building Insp~tor) ~ ~/ ~ ~ ~ zo'.l~V~ ~ ~~, _~ , ' /.. '~, J~l INSTRU~IONS ~~ ~ ~ ~ a. '~plication must be completely fimm~ in by ~peWrit~r ~r'in i~nd sullied i~ du~lig~e to ]he~uilding ~ Inspector. b. Plot plan showing Iocation, of lot ond of buildings on premises, relat~n~'~ip to ~'~nirng ;r~'misles or public streets or areas, and giving a detailed description of layout ofproperty must be drawn on the 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 progress of the work. e. No building shall be occupied or used in whole or in part for a. ny purpose whatever until a Certificate of ,Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of o Building Permit pursual~t to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable L~ws, 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. (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. Name of owner of premises ..~.~..zl~ld'~.....~.....~J~'~.~;....,.~%~ ................................... ~ If applicant is ° c°rplrate' si~notur~°f duly auth°rized °fficer'V .~._/ (J~:> .~ .............. i~;;;;;";;;;Z '~iT ;' ';i' ';;';~';;;'i; ' ;¥ii;;;;i ..... ~ 1. Location of land on which proposed work will be done. /ytap No.:,.../....~....~.. ......................... Lot No. ~...,~.....~..~,~.....~, Street and Number ....l~./.~,.....~..~.d,¢~........~......,~ff..~...~...~ ....... .g~~ .......... c.,]~/~ Municipality 2. State existing use and occupancy of pr~mises and intended use and occupancy of proposed construction: Cl. Exisiting use and occupancy ................................................................................................................................. Intended use and occupancy ..... ~ ....... ~n~q ~' ......~ (~ ................................................ ~ 3. Nature of work (check which applicable): New Building ..........~... ..... Addition .................. Alteration ............ ..~.... Repair ................ .:~ Removal ................. . Demolitior .................. Other Work (Describe) ........................................ 4. Est mated Cost ..... ~r..:l~t~z.~.. ......................................... 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 .~9..~..~ ............. Height ....... /..~'....'.... Number of Stories ............. /. ........................................................................ 9. Size of lot: Front ....... /..~.....e. ........... Rear ..... /...~..~ .................... Depth ...... ../....'~'....~. ............... 10. Date of Purchase ....~..~....~.J~.....Z..~..~..~. ..................... 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? ...... Z~..~. .............................................. 13. Name of Owner of premises .~..'..~..~7//.J~.~../t~4/ ......... Address ...~/~4~'~...~..~..~..'~... .......... Phone No ..................... Name of Architect ...................................................... ~ --__-- Address ............................................ Phone No ..................... Name of Contractor ...~.~..,~.~..I'~.~....:/~.~'.Z.~...~..$ ........ Address ../~.~.:~...../~.......~.~Z'.~..~...~.... Phone No. ~...~..~..~..~'~..~.X~ 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 whether interior or comer lot. STATE OF NEW ~ORI~,, ~ j~, ~S¢ .......... .............................. . ~ (Name of individual sign~g application) ~om, d~s and s~e t~ he is the applicant a~ve named. He is the ................................................................ ~.~ ................................ (~ntm~or, ~t, co~rote officer, etc.) of ~id ~ner or ~ners, and is.duly authorized to perform or h~e pe~o~ed the ~id work and to ~ke ~d file this.application; that all statemen~ cont~n~' in this a~pli~i~ am t~ ~ the best of his knowl~ge and belief; and that the work will ~ perfo~d i~ the manner ~t fo~h in the ~plic~l~ fil~ ther~ith. Swam to ~fom me this . . ....... ......... Nota~ Public, '~':':'m:'~'"'"~e~-*e~'""'""~'~ ~B~c.~. ,~e~----- -s"~ ~ ~ ~ ..... Coun~--/ (Signa~re of~pplicant) .................... / ~E ~ L~ b ~H Io0.o ~i~OREI~T Y ow~,~. , '~USTAVE ~,AA/P /V/Ai~dO,~IE ~ AT AIIA T T"'/ -f'I,.IC /,( , N. .... R,O ul,~ R ? '.9 ,PE/,P ELEV,4TIOlV T t: L (.,I,fvI : I N G _ D/G/qT' SIDE ELEV,4TIO/V d'ECTIOIV, I 3 ? ~-o.uIvDA TION PL,4N