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HomeMy WebLinkAbout5880-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~1~9~6 ...... Date ............ 1~.. ~ ........ , 19.72. THIS CERTIFIES that the building located at (~oi~klJ~ .Iki. & .0~k. l~.~t ..... Street Map Nc~&I'5., .l[~;[.e. Block No ........... Lot No.. ~ .&. ~-~ .... ]~;tl.~l~k.. conforms substantially to the Application for Building Permit heretofore filed in this office dated .............. M~. - 6, 19..?~ pursuant to which Building Permit No.. dated ....... M~.....~6 ...... , 19~2.., 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~.~va~;o .o~. $~]r .d~J,~Lt~g ...................................... The certificate is issued to ...Jol~ .&. J~ l~].o~r~ ............................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ...I)~ .2~v .]~72. · .b~'. I[, UNDERWRITERS CERTIFICATE No ..... ~. ~,,~ ·. O0~,. 6 .~-9~2 ..................... HOUSE NUMBER... Jl, O0 ...... Street...{J{iJlJl~.],.,~ll. ~ .................................. Building Inspector NO. ~ TOWN OF SOU~THOLD BUILDING DEP~RTMENT TOWN CLERK'$~OFFIC:E $OUTH~LD, ~.\Y. BUILDING (THIS PERMIT MUST BE KEPT ON THE COMPLETION OF THE WORK UNTIL FULL N? 5880 Z Date Permission is hereby granted to: at premises located at ..... ~..~Jl~.&.~J~ ........ ;J~ll~l~d~, ............................................. .........................................- --- -'--r,,elslr, l,~..~..~,lX~:..ll~.i~..:.....l~t,,tAtm~~ · ....................................... pursuant to application dated .......................... ,.~JJ~..:i!;.,~ ........... , 19...~...., and approved by the Building Inspector. . ~, Fee $*...~,y~ ....... PERMIT INCLUDES APPROVAL TO REMC, VE EXCESS FiLL FROM ABOVE PREMISES BY RFGP, ACING LOT :.~ '/EW ?,¥ CONSTRUCTfO~'4 ~",OL CONSTRUCTION -~ .~ 'SNS' RUCTION Building Inspector IPOB, M NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, N. ¥. 11971 APPMGATION 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 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), 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 .......... ( .,~,...~ ...~....( ..'..,'7., ..,'~. .......... New Building ~/ Old or Pre-existing Building Vacant Land Location Of Property ..../...~.C ....... (~/~.......~.. ......................... I......~./.~.....~.~ .A'/////~'~.....~...~..' ................. Owner Or Owners Of Property . .~..q ~.~. ,~....~...~.. A/.~..~.....~..~ ~...~. j~..,,~.. Subdivision ................................................................ Lot No.....~.....O.~'.. Block No ............. House No ............. Permit No. ~'~0 ~. Date Of Permit ..~..".!..~'..?....~...Appllcont ~J *~'Le i~/ ~'~' ..... Health Dept. Approval .... ..~,.,O...T././...~'.....'Z ................ Labor Dept. Approval ................................................ Underwriters Approval ....#.....~'....~.e~.D....~.. ............... Planning 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 Notary Pp~blic ......... ~ounty // (stamp or seal) SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference NO ~ -//~/ APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to construct said systems is requested,pertinent data herewith: 1-Applicant ~m ~ ~ ~ La wo ~-Rs Phone AgF-~//~? 6-Sub div Address ~,d~ iA~ ~7-T,T~C~ 7-Section 2-Detailed property location C~K~ ~o-o~ P~c~- 8-Lot No. Hamlet Town /~-ru-,T~¢~= .9-Private well? 3-Public water supply name Distance to nearest main S-Lot Size: Width/o ~ ft. Length/-~ft. (also enter on center plot plan below:) 5-Dwelling: Single Family I~l Two Family? ~_~Cellar? ~ /Slab? ; /Crawl Space? 10-Proposed system: Septic tank f~fPrec~'~-_~_/Cesspools ~_/Shallow pools il-Septic tank inside dimensions: Volum4g~ ,J;als.Length ~ ft. Width oc ft. Liquid depth 12-Precast sections: /~/Number~_/Squar~. Cesspools: Block sizeL incs.D___ins. H Total blocks below inlet.'*' ~1 !~J~2 ~3 PLOT PLAN Street . / ins. Capacity~%Gals. ,G 'ad~ Data Feet 77 , 0 ~' 2 5A~o ~ 6 ~' 8 lO ~2 Indi e No ~th The Undersigned CERTIFIES: "Construction of authorized installation~ will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". ~owner or Builder FOR HEALTH DEPART~NT USE ONLY. Based on ~ 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 (10/65 S-15 Signed APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEM~ 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. b. 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 " " " " "~ a 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 LO~t 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 pl~t plan aIso. 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-4 feet 6 ins. minimum below grade to well head and lateral water pipe CESSPOOLS LOCATION: Upon determina¥ion of the Sewage & Waste disposal "type of systems" reqUired, the follo~ng 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 1 food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of I foot FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ........................................ , 19 ........ Pemit No .......... Application No ............................... Disapproved a/c ...... ~~ ............................ . .............................. ............................ APPLICATION FOR BUILDING PERMIT 1NSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building ~ Inspector. 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 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 _,>4 shall be kept on the premises available for inspection throughout the progress of the work. ,r~ e. No building shall be occupied or used in whole or in part for any purpose whatever unt!ka 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, 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. (Signature of applicant, or name, if o corporation) ................... .......... ............................... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................... ..................................... Name of owner of premises ........... ...'~.....O..,~...~(.........~...Zr.~..~...~.~..~.. ..................................................................................... ..%.. If applicant is a corporate, signature of duly authorized officer. ]. Locotion of Iond on which proposed work will be done. Map No.: ....... . .,~....~...?... ............ Lot No...~...~..~..~'-~' r 0.o~Ll,~J i~D- 0 ~'¢ LAC~ /~1T""/"17"(./6 ........... Street and Nombe ........................ ........................ ~ ....... .~. ....................................................... ..~r.,6~.:..~. .............. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: Exisiting use and occupancy ................................................................................................................................ Intended use and occupancy .....O.../~.....~......~..~..~l.l~.y.....~.....~.....~...~.~..L./~....~ ........................................................ 3. - Nature of work (check which applicable): New Building I/~ Addition Alteration Repair .................. .R.~noval .................. Demolition .................. Other Work (Describe) ....................................... ....................................................................................................................... 4. Est mated Cost ....... ~ -~ 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 ....................... .~'...9..~....~ 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 .............. '-T ................. Depth ........ '~. ........... Height ........................ Number of Stories ............. ~ ................................................................................................... Dimensions of same structure with alterations or additions: Front ................ "'. ................... Rear -- Depth ............... '~. ................ Height .............. .-T.. ........... Number of Stories ~ Dimensions of entire new construction: Front ........... .~.~....~ ............... Rear ....z~..../. ............... Depth .~...~..;..o..~..~.s.Z~.£ Height ....Z ...........Number of Stories ......... /'"7 ........................................................ ; .............................................. Size of lot: Front .......... ~...0..1~...~ ...... Rear ..~..~..~...;'....0....~. ............. Depth .......... .~...~. ~....; ........ Date of Purchase ........................................................ Name of Former Owner ........................................................ Zone or use district in which premises are situated ..................................................................................................... Does proposed construction viola~te any zoning law, ordinance or regulation? ............ ~.....D. Name of Owner of premises ..... .o.~/~.....~..~.~.J~...E'..~..~......Address ............................................ Phone No...~.~...'...~...~.~..ff Name of Architect ..~.~.~t/g,['..~-.~...J'..?.../:~'.~/.R..~.... ......... Address ....{~.~..°..~..~...~...~..~.i.V.~'... Phone No../~.~...~.Z..Z.../.{~' Name of Contractor ..Z.~.~../~.....~.'...~..~...~...~.. .................. Address ..~'.~/..~...~.~...~..~.~.~...~..../~...(...~.. Phone No. ,~.~...77.~...~..~./ 10. 11. 12. 13. 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 N~,~/Yb,l~,~ ~, ~ '~ ¢ ¢ COUNTY Of~..~~-'' ........................ "'~'~...~~ ................. being duly sworn, d~oses and says that he is the applicant (Na~ of individual signing application) above named. 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 ~ke and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and thor the work will be performed in the manner set fo~h in the application filed therewith. 5wo~ to befor~e this ............. of .................... ........ , Nota~ Public, E JOHN FLOWERS IX/Imp OF LAND ~T ©H hJ FLOWERS Am ~U F~oLK CoN NT~, Lo'r Nos. $~OWN ~.F.P~R '~O NOTE..:' HIS SU~VE~ IS A VIOLATION OF I rob PIP~. · ~F~OLK COUNTY HEALTH DEPAET.~EN~ ~ ~ewage d~osat and water ~acil~ti~S for this loca~icn hav~ been ~ief of ~,c~:-a! L:Lii;~ tine 7 ,'i¸