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Home My WebLink About5706-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 ...Ble$~tnt~n® .DF .......... Street Map No. ilbl' .I,~;~ ... Block No..~eOl[. .... Lot No..~.: ......... .~.Ol[.th.o],~[.. ~.,.¥, .... conforms substantially to the Application for Building Permit heretofore fi]ed in this office dated ........ ~.~b ....~ ..... , 19. ~2 pursuant to which Building Permit No..~0~Z.. dated .......... FoB .... ] ...., 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 ...~l~te. ~®. la,kilt. 0,wel].l~[;- ..................................... The certificate is issued to . l~lalTy. &. ga~;h.].e..eh..~.~O.l~ey ....... . .0k~..0.r~. ............. (owner, lessee or tenant) ,,~.~- a~¥esaid building. _Suffolk County Department of Health Approval .. Jun~...~9.. · .~972. · bit. IL,..Tt.].~ UNDI~RWRITERS CI~RTIFICATI~ No.. 1~ .~3 ....................................... HOUSE NUMBI~R...~ ~ ..... Street .....~l'~.ga~lt:~lO. DF ............................. Building Inspector FO~,~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. N: BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 5706 Z Permission is hereby granted to: at premises located ct ........~J,~;...~J.....JJlL~JJI~.. ~JJ~.....I~J~ ..................................................... pursucm¢ to application doted ............................... jll~l....~ ............... , 19..~1~., and approved by the Building Inspector. :'~'"OVE EXCESS fiLL F~,'J,,', ABOVE p?-,EMISES DY ~ ~: ".ON TP, UCTION I~OBM NO. $ TOWN OF $OUTHOLD Building Depo~tmont 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 oil 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), NomconformJng 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 ~ .g..~. · · .~.... ~'~,.~.t .. · ~...~..~- .~. · ...... / New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .~.4 ~ L~"~"-'-//'"O'I:~ ~ ~'~'~'/'-~"~'"'J~'"?"~'"~'l"~'""t~'"" ............... Owner Or ~ners Of Prope~y .~.~..~..~.~...-.~.~.~'~'~'~ .................................... Su~ivision ~.~.~.~.~.....~.~.~j....~S~.....Lot No...~.( ..... Block No ............. House No ............. Permit No. ~.~.~.~...~.. Date Of Permit ~..~.~.Applicant ..~.9.~.~...~g.~.~....L~..~.: ...... Health ~pt. Approval ....... Labor ~pt. Approval ................................................ Unde~riters Approval ~ u~ ~..~.~..~..~ ...... P ann ng Board ~proval ........................................ Request For Tempora~ Ce~ificate ........................................ Final Ce~ificate .......................................... Fee Submitted $ described building an4 permit meets all applicable c~es and regulations. Construction on above Applicant ....... : ........... Z · Sworn to before me thi~ ................ day of ..,.~;~;:..' .................... ,-. (stamp or seal) SUFFOLK COUNTY DEPARTMENT OF HEALTH ~//~/? ~. H.D.Re£erence No APPLICATION FOR APPROVAL TO ~NSTRUCT PR~ATE S~AGE DIS~SAL SYSTE~ ~ ~ . Approval to const~ct said systems is requested,pertinent data here~th: ~te~ , 1.Applicant~ ~.~,'~ ~ ~ ;~C Phone~;~ /3~6-Sub div~m~,~ Address ~ ~ ~ =w~,,~,, ~ ~ 7-Section"~ 2-Detail~ p~pe~y location~w~ ~,., .~,~: ,~, ~; ,i ~, ,~ ~,~.~-~t No. Hamlet ~,~ ,7~1,~, ~ To~ ~,~w9 9-Private well? 3-~blic ~ter ~pply ~me ,-'~ .r,~ Distance to nearest ~in 4-Lot Size: Width~g ft. Le~th~ ft. (also enter on/enter plot plan below:) 5-~elling: Single Family ~/~T~ Family? ~ /Cellar? ~//~l~b? ~Crawl S~ce? 10-Pro~s~ system: Septic tank F fPrecast y /Cess~ols ~Shallow ~ols ~ /Other / / 11-Septic ~ inside dimensions: Vol~e Gals.Lengt~ft. Width ft. Liquid depth ft. 12-Precast sections: / /Number/ /Sq~re~. Cesspools: Block sizeL incs.D ~s.H ins. Total blocks below inlet: ~1/~2~3 PLOT PLAN a_ pacity:~Gals. Indi No ~th Data Feet 0 2 6 8 10 12 14 16 The Undersigned CERTIFIES: "Construction of authorized installatio~W~will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". Date~_~ Signed.,~'~Z~,-~./~-/ ~ ~--~-~ ~'~'~-J'~ '~ Owner ~r / Bu'ilder 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 (10/65 Revis.) S-15 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. ~-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 '~es" 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 heav~ lmned square in the center of Plot Plan shown on face of this appli~cati~j~ urface wa~ers-Streams, Lakes, & Bays, etc., located within a distance of~ 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. 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 lO0 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 I 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 Date Bldg. OF HEALTH JUN 1 9 1972 TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located ~' J ' (Give deed lo~atton) have been inspected by this department a d found to be satisfactory. Chief of General E~]ginear~ Services dUN ~ 9 1972 ,- TOWN OF SOUTHOLD / ~ BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ~o~ ........................................ , ~ ........ p~ No ........ ~..~..~ ........... ............................................................................................. ....................... .... (Building Inspector) A..ucAt O. INSTRUCTIONS 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 o Building Permit to the opplic°nt. 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 o Certificate of Occupancy shall have been granted by the Building Inspector. ' HEREB. Y.,MA~DE to ,t~e B.,uil,di, ng~ D.e.p,a, rt~en, for, the issuance of a Bud ng Permit pursuant to th~] Duiming Lone vrdinance at me/own or ~ourno,a, ~urto~K ~ounty, ~'~ew York, and other appl cable 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, ord~na ces, bulli~,ng cede, housing code, and regulations. (Signature of applicant, or name, if a'c0rporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer~ general contractor, electrician, plumber or builder. ......................................... .~.~./......¢,~. ~..~.~ ~..~,.-L.~. ~, ............ ~ .................................. .'.: .................. : ............................ Name of owner of premises ..~....E'..I~..~...~...~...~.-['..~.L,~.~J...~,...~...~,..~..~..'~'.. ................................... ....... 'u'-'""...............--~... If apRlicant is a corporate,,signature of duly authorized officer. (Name and tit e otq:orporate officer) 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No....~../.. ............... Street and Number ..,~....E.~.?...~....4~. ....... ~',',',~.~..~.......~.L.c?..~..T.,,~...~...~[.'~..~...~...~ ..................................................... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. ExisitJng use and occupancy ................................................................................................................................ b. Intended use and occupancy ...~../~JE, ...... .~'.E~..f~...!..L...'~......~.JF4'.~.~..~.. .................................................... 3.~ N tu~e of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost ...... .~.~..O...O...O. ...................................... Fee .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ......... ~. ................ Number of dwelling units on each floor ~..:.?..~..~..xc..../~g~. 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 ..J.~ ............. 'Number of Stories .../.~,....-..j..~..E.~.3'..~.~..N. ................................................................................... 9. Size of lot: Front ..... j.~...O..'. .............. Rear ...cj..~.~.~... ...................... Depth .~=~.o....~.. .................... ]0. Date of Purchose ....~k~'.,,~.r........./.~..~../. ..................... N~me of Former Owner ~r~/~.b..e.~.....L..(.~...~..¥5'......~..~..~.~..~..~c; ...... ) ]. Zone or use district in which prerhises are situoted ..................................................................................................... ]2. Does proposed construction violate any zoning law, ordinance or regulation? ....H0. .................................................. 13. Name of Owner of ~remisesj~`?~..~.~j~B~.~Y~..~..~.~.~ddr~s~...~.~....~...N.~"~h~ne No.~.~.. ~..:/,~.. ~.. Name of Architect ..~,,.~,.~...O...e.~..S...~.~.E..5...~.C..:.....Address ~..~.t~..(...~...n..~....G..u..E'..: .-9~....T.....l~hone No.~.#.~-..~..~...~.,.. Name of Contractor .................................................... Address ............................................ Phone No ..................... 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. /-or ~ STATE OF NEV~O,I~J(,~ ' ....... ~..~ ........................................ being duly sworn, d~oses and says that he is the applicant (Name of individual s~ning application) above named. He is the ......................................... ====================================~ ~ , ~ 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 conta:ined in this application are true to the best of his knowledge and belief; and thor the work will be performed in the ~anner s~t fo~h in the application filed therewith. Sworn to before me this ........ ............................. NOT~ p~LIC, State of Ne~ Yor~ No. 52-8125850, Suffolk Co~ Term Expires ~arch 30,