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HomeMy WebLinkAbout5701-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No.. ~ ..... Date ............ .~..~ ....J ~ ....., 19. THIS CERTIFIES that the building located at . .0~-'~oo~. I)~, .............. Street Map No. ¢~5a~. ]~e&e~li~[~lo ........... Lot No. ~.~>~l~l~OJ.~ ..... ]~.w.~., ..... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... ~'~... ~..., 19'~.. pursuant to which Building Permit No..~0.~I~.. dated ........... ,1~1~... 2.~ · ·., 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 . .~.I':1..~..~. ~,~.. :~.~l~r...~.~. ].J..~ ...................................... The certificate is issued to . ~l~e' & '$®81~ 8~:~ffi~'~fll~ ...... 0~'8 ................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . ~..~.~...~...~.~)'~.~..~.~. ~.'..¥~'.J-.~.& ...... UNDERWRITERS C[RTIFICATE No .... ~ .~. ....................................... HOUSE N UM B E R... ~ ...... Street .... 081~ · 1)~-~, .¢~,~. 1~11 · 1~ ............ Building Inspector FOEM NO. 2 TOWN oF $OUTHOLD BUILDING DEPARTMENT! TOWN CLERK'S OFFICE SOUTNOLD, N, Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISF..S UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5701 Z Permission is hereby granted to: ..... ~e~a. J~amUL ~IL..A/-~..i!E/aea ..&..l'ea~ lite~.~a~ ........................................... eal~-~me~..~,~ ............. ~a~am~ ....... ~,~, ................................... pursuan~ to application dated ........................ ~ ...... ~ ........... ~....., 1~...~, and approved by the Building Inspector. Iding IrTspector' / FO]~.~I NO, 6 TOWN OF $OUTHOLD 0 Building Department Town Clerks Office $outhold, N. Y. 11971 APPLICATION FOR CERTIFICATE O1~ OCCUPANCY Instructions A. This oppi[cotim~ ~us~ be (ilied {n typewriter OR ink, and s~bmi~ed in DUPLICATE to the Building Inspector with the following; ~or new buildings or new ~e: 1. Final su~ey of property with accurate IocQtion of ell ~buildings, property lines, streets, end unusual natural or top~rephic features. 2. Final epprowl of Health Dept. of water supply end sewerage disp0sol~(5-9 form or equal). 3, Approval of electrical installation from Bo~rd of Fire U~de~riters; 4. Commercial buildings, Industrial buildings, ~ultiple ~esidences end similar buildings end installations, e certificate of Code compliance from t~e Architect or Engineer responsible for the building. 5. Submit Planning Board approval of complet~ site pla~ 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, ~0ccupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pe~inent in- formation required to prepare ~ certificate. C. Fees: ]. Certificate of occupancy $5.00 2. Certificate of ~cupancy on p~lling or land,use $5.00 3. Copy of certificate of ~cu~l.00 : D~te .......................... New B,ilding ..~.~dditi°n~ ................ OId~or Pre-existing,~ ~~ding'..'~' ...... Vacant Land .............. Owner Or ~ners Of Prope,y ..~.~..~...~.~..~/~.~ .................................... ..; ............................................................... ........................... R~quest For Tempor~ Ce~ificote ........................................ Fin~ Cs~ifico~o .......................................... Fee Submitted $ ...l...~. .................... Construction on above described building and per'it meets oll~plicable c~es and regulations. ....... Sworn to before me this / ................ .~ o, ............................................ TOWN OF SOUTHOLD Building Delmftment Town Clarke Office Southold, No Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY I nstructJons A. This application must be filled in typewriter OP, ink, and submitted in triplicate to the Bullding Inspector with the following; for new buildings or new usA: 1. Final survey of property with accurate location of all b~ildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewer~age disposal--(S~9 form or equal). 3. Approval of electrical installation from Board of Fire Unc~erwriters. 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 p~an 'requirements where applicable. B. For existing buildings (prior to April ]957), Non-conforming u~es, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, s{reets, 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 New Building ...... ..~.- ........ Old or Pre-existing Building ................ Location Of Property .... ..C.~=.~.~..~......~...~,.4~.....~......'~..~.~ ................... $5.00 Dote ...... ........ ........... Vacant Land ............................ Owner Or Owners Of Property ~F~g -{- ~-¢'~ ~,. Subdivision .................... ~ ........ ~ ............................................ ?. Block No ............. House No ............. Permit ..... Date Permit A t. .. . ..Applicant-- .......... Health Dept, Approval ...~ ............................... Labor ~pt. ~pproval ...~ ...................................... Underwriters Approval .............................................. Planning Board Approval Request For ~emporary Ce~ificate ........................................ ~inal Certificate. ......................................... Submitted $ ................ ConstrucHon on above described building ~nd ~rmit meets all a~plJcable c~es and regulations. Apphcont ..................................................... Sworn to before mo this ................ day of ............................................ (stamp: or seal) Notary Public .................................... County TOWN OF $OUTHOLD Building Delm~tment Town Clerks Office Southold, N. Yo 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instrucfiofls 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: ]. Final survey of property with accurate location of all ~uildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewei~ge disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Remdences and similar buildings and installations, a certificate of Code compliance from ~heArchitect or Engineer responsible for the building. 5. Submit Plannfng Board approval of completed site plan tequlrements where applicable. B. For existing buildings (prior to April 1957), high-conforming u?s, or buildings and "pre-existing" land uses: I. Accurate survey of property showing all property lines, s~reets buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, o,~cupancy a~d condition of buildings. 3. Date of any housing code or safety inspection of buildin{is or premises, or other pertinent in- formation required to prepare o certificate. C. Fees: I. 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 j (.~. ~/.~. Date ..... · .~.. -/~...~. ........... ]...~.. ....... New Building ................ Old or Pre-existing Building ........................... ¥o¢ont kand ............................ Location Of Property ..~...E..P...~....~.....I~.~...o:....~. ...... ~.~...~.~. ................. .................. i ........................................... Owner Or Owners Of Property ~ m ('~ $ '~...~ ~-./'k/..>~....~..J..~.l ~..~..u'....~....%,.. ~ :~(~ t)~,o,a. Ai. p~¢/c ...O...~...j.. BlockNo; ............ House No ............. Subdivision ..~.. ..................... Lot No. Permit No '~.?..(..~.. ...... Dote Of Permit ~/~/ .,~..~..,?.."/..Applicant ]-¢;~'r~/~ir'~/~ '¢ Haalth Dept. Approval ..~:...~ ........................... abor Dept. , ~' ~ */ Z,~ L ~pproval .... ;~-~ .................................... Underwriters Approval ..... J~...I./.'~...~)~,,~,.~ ......... Planning Boatd Approval ....... ~ .............................. Request For Temporary Certificate ........................................ Final ;Certificate Fee Submitted $ .......................... Construction on above described building anfJ permit meets all a~plicable cd)des and regulations. Sworn to before me this ................ day of ............................................ (stamp or seal) Notary Public .................................... County SUFFOLK COUNTY DEPARTMENT OF HEALTH 50- H.D.Reference No /~) APPLICATION FOR APPROVAL TO ~NSTRUCT PR~ATE ~AGE DI~S~Lq~STE~ Date j Approval to const~ct said systems is requested,pertinent data here~th: 1-Applicant ~.' ~ ~ ~ ~e~ ~,~ Phone ~6~2~6-Sub div.,~< Address /~ . ,~ ~ ~ ,q~ ~ .... ~, , ~ ~ ~ F 7-Section 2-De~il~ p~e~y location ~,,,~? ,~- ~ ~;, ~' ~L 8-Lot No. Hamlet ~ ~ ~ ,~ ~ ~ ~ To~ ~ ~ ~ r ~,~ ~ ~ 9-Private well? 3-~blic ~ter ~pply ~me - Distance to nearest ~in 4-Lot Size: Width ~ ft. Length ~$ ft. (also enter on center plot plan below:) 5-~elling: Single Family ~/~ T~ Family? ~,/Cellar? ~ /~lab? ~Crawl S~ce? lO-Pro~s~ system: Septic tank F yPrecast ~ /Cess~ols / /Shallow ~ols /~Other / / il-Septic ~ inside dimensions: Vol~e Gals.Length ft. Width--ft. Liquid depth ft. 12-~ecast sections: / /Number/ /Square Ft. Cesspools: Block sizeL~incs. D~s.H~' ins. Total blocks below i~et: ~1 g~ ~2/~3 ~T PLAN ~th Capacity ~-~als. Data Feet 0 2 6 8 lO 12 ~6 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". · ' Owner 6'r ~uilder 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 A~.,PLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate i-Means Owner or Builder. Address to which mail should be directed. 2-Means detailed description of property location, together with street name and ~stance to nearest intersection of main thorofare, also Hamlet/Village & Township 3-Euter 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 7.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 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 wabers-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. WEI~ 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 Well-40 feet minimum into ground water for well point Well-$ feet 6 ins. minimum below grade to well head and lateral water pipe CE__SSPOOLS 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 minimumdistance 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 S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date, JUN S, TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure (Give deed location)/ located / have been inspected by this department and f~und to be satisfactory. Chief of G~ ner~l Engineering JUN 8 1972 OWN OF SOUTHOI.D~/ ~ ~ ~,~'~ ~, ~ BUILDING DEPARTMENT_ _ TOWN CLERK'S OFFICE~/~/?~- ~/~/~ ~ ~ ~:1~ ~ S~THOLD, N. Y. ~ ~* ~ [~ed ...~. ~.~ ......... , ~ .......................... ~ · .. 19 ........ ~ppl~Qti~n ~....~ ~ /~ ............................................... ............... 7 .................. ................................. APPLICATION FOR BUILDING PERMIT Oote ......................... , INSTRUCTIONS ~ a. This application mu-~t be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plat 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 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 any purpose whatever until a 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 Perm t pursuant to the ~'~ Building Zone Ordinance of the Town of Southold, Sulfa k County, New York, and other applicable,~aws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition,,~S herein described. The applicant agrees to comply w th 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, gene~l contractor, electrician, plumber or builder.~ Name of owner of premises ..~..~P....~....~...S...,~ .~...~.....~..~..R..~.....~..~..~.J~ .~.l/~ ~ ' ....~'~[ If ~ppl~ont is a corporate, signature of duly authorized officer. ....... , ..... - (Name and title of corporate officer) Location of land on which proposed work will be done. Map No.: .C...E..g,~...~.I~...~:'....~....~p,~'Lot No...~'.~.. ................ Street and Number ...~..,~./t~...~...q.p....~......./~./~/..u...~'.. .......................................................................... ~ ........................ Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................ b. Intended use and occupancy ....... ~.~.~......~..~..~..~..~...'~......~..~....~..~...~..I..~...~. ................................................. 3. Nature of work (check which applicable): New 'Building ...i ...... Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost ..~.q..o....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 ............................ Num..ber of Stories ................................ 8. Dimensions of entire new construction: Front .....~.~e.,~ .................... : Rear ~..~....Z~. ................ Depth .~?~.(.s. ........ Height ...~, .......... Number of Stories ..e~, ................................................................................................................ 0' .... .~.~..~ ......................... Depth .../~..~ .................. 9. Size of lot: Front ......~. .................... Rear 10. Date of Purchase .))~e..u.. ....... I..~..z'J.! .............................. 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? ...~l~.O. .................................................. 13. Name of Owner of premises'J.l:l.~.~.~...S.~J..Re~....~.~..tf...i~.-.--/~ddress J.I~.e...~..~IJ~..~.~.tLi~D..:..., ..... Phone N .o~_0..°../.?..6..~..~-/..-].q{ Name of Architect ...................................................... ^a~ress ............................................ Phone No ..................... Name of Contractor .~..?..~...O..~..~..~....J~.9...~..~..J..N..%...Address ~9. A~.~...~.~?....../~.-..~-....~...T'.~Phone No.~.~.-.~',~.,$. ,-~...... PLOT DIAGRAM Locote clearly ond distinctly all buildings, whether existing or proposed, and indicate all set-beck dimensions from property lines. Give street ond block number or description according to deed, and show street nomes and indicate whether i~terior or comer lot. STATE OF NEW YORK, 1 c c COUN'P~OF ........ ~ ................... :..~'~ , ........ ~.~-,~':~....~1~,,~....~,..~. .............. being duly sworn, deposes and says that he is the applicant (Name of individual signing'application) above named. He is the ........................... C~t:'J.~.~.~...~..°..x'~...-.......C..°....R.?.~.(~.~..~.-l~....~.~'-~..(~.~.~ ....................................... (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 Jn this application are true to the best of his knowledge and belief; and that the work.will be performed in the 'manner Set fortl~4n the'application filed therewith. Swam to before me this Notary Public, . ........................................................... County i~ignature of ap nt)