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Home My WebLink About5995-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~. ~.2~..~. ...... Date ............... ,l'gne. 26 .... , 19. THIS CERTIFIES that the building located at Balt~l~d. Coul, t ............ Street Map No~l~'O~[ .P,~ck No ........... Lot No. ~ ..... .~.$.~....t3~.....~:.~.~. . conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... Jll~.... 7 .... , 19. ~ pursuant to which Building Permit No...~9.~.~ dated ....... ~l,~ ..... 7 ....., 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 . P.l'ivat~. al~e. fa~l~'. Mlltnl ...................................... The certificate is issued to JO]~. Nll,~.~l'. ....... 0~.~: . ........................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval J~e.. 2~...19~'.~..b~..R.,. ?.il..1~ .... UNDERWRITERS CERTIFICATE No.. J.. 0~.~ .... ~. · .I~A~...~.1 ,..'1.~3 ................... HOUSE NUMBER..~1'.~. ....... Street... BII'L~.a~'~.. {~.0~1~ ............................. Building Inspector I~O~*M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFI~.~ SOUTHOLD, N~ Y. BUILDING PEltrY, IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 5995 Permission is hereby granted to: ........ Je,~,r,..~,s~e;'. ........................... ~ .............. ............. ~a~t~.tu~ ............................................. to .~u~<~..~e~.. ~e ...£aud:..~..4~e...~.~.t~ .................................................................................... at premises located at ........... ~4...,~..i....~e.~wa.~e~..~4A,~o4~ ............................................................ ................................................. l~;~...~sW&?el" I~mn-t .............. ~la~t~le ............................... pursuant to application dated ................... ev.~. ......... ~ ............... , 19..1'/~., and approved by the Building Inspector. Fee $~l,v.~. ........... FORM NO. $ TOWN OF $OUTHOLD Building Delm~tmoet 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 duplicate 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. $. 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-ex'st'ng 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 $5,00 3. Copy of certificate of occupancy $1.00 New Building ................... Id or Pre-existing Building ............................ Vacant/and ............................ Location Of Property .....~...~...~.~...~....%..~...~.........~....~...~..~.~....~.....~..~....`~.~....-~..~....cm.~..~. ................................ Owner Or Owners Of Property ..... .~..~,,,~,~...~ .................... .~. ~ ~..~..~...~...~. ........ ...~...~.~.~...~....~. ................................. Subdivision .~..~....~..~....~....o...q...~......~....~..~....o..~ .......... Lot No..:~. ....... Block No ............. House No ............. Permit No ..................... Date Of Permit .................... Applicant ..~l~,.~%..~....~.~tL~.~....%~... Health Dept. Approval ..~/..'.,o.~%,....?~.~,....L~..?...~......Labor Dept. Approval ................................................ Underwriters Approval /~..~..c[...]..c],?~.~ ...... .~/..-~..1.~.... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ....~ .......................... Fee Submitted $ .,.~:.:...~....~.. ..................... Construction on above described building aTid I~rmit meets all applicable codes and regulations. . ~msio~ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference No APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date Approval to construct said systems is requested,pertinent data herewith: i-Applicant / - / , Phone_ ~, ~ , /6-Sub div ~ _ Address /, __/.~. / /~ ~ ~ - ---- - , ,, ? 7-Section' 2-Detailed property location 8-Lot No.' Hamlet Town/,,'/ f--/-.~- '~ 9-Private w~ll? 3-Public water supply name Distance to nearest main ' 4-Lot Size: Width ft. Length ft. (also enter on center plot plan ~below:) 5-Dwelling: Single Family ~_~ Two Family7 ~ /Cellar? ~_~Slab? ~ ~ Crawl opace? / / 10-Proposed system: Septic tank ~ /Precast J /Cesspools / /Shallow pools / /Other / ii-Septic tank inside dimensions: Volume /___Gals.LenEth ft. Width ft. Liquid depth Cesspools: Block sizeL incs. D ins. H 12-Precast sections: / /Number~'/Square Ft. Total blocks below inlet: ~1__~2__,~3 PLOT PLAN / ins, Ta .Grade GW.L. Capacity Gals. -'1 G.P.M. I ;ate No ~th Data ~eet 0 2 4 6 8 10 12 ~6 18 Street ' -, , ,_%, % 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". Date /~/~ Signed ;% ~/ //Y~//. ' ~Z , ~ Owner(.//' or Builder FOR HEALTH DEPART~NT USE ONLY. Based ~n 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 ~ ~ · ) L-- Signed -, ~ ./ (10/65 Revis. ) S-15 E×om~ned Approved ........................................ , Disopproved o/c ............................................................................................ ~%o TOWN OF BUILDING DEPARTMEN'I~'~, TOWN CLERK'S OFFICE ~UT~D, H. ~ 19...~.. APPLICATION FOR BUILDING PERMIT ~' ............ Ly.. ........ ........ INSTRUCTIONS ~I~ a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wit _~ 3 sets of plans, aCCurate plot plan to scale. Fee aCCording to schedule. ~ b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas anc~ giving a detailed description of layout of property must be drawn on 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 inspeGtion throughout 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 HEBEBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of SO.hold, Suffolk County, New York, and other applicable Laws, Ordinances of 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, and to admit authorized inspectors on premises and in buildings for necessary inspections. (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 ....... .~.1~.~.. ....... ~.L..~....~...Z~..~'.~,~ .............................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Location of land on which proposed work will be done. Map No. ot No ................. Street and Number ....~.~f......~......./.~.~ ................................................. 4-/_~ _~ ~- Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: ao be Emsttng use and occupancy .,...~... ....................................................................................................................... Intended use and occupancy .......... ~.....~...~ ......................................................... ! 3. Nature of work (check which applicable): New Budding ........ ~ ............ Addition ..................... Alteration .............. Repair ......................... Removal ......................... Demolition ........................ Other Work ......................... (Description) 4. Estimated Cost . ./...~ ...O....O....O........~.. Fee ,.,..~....~.,...!....0. .......................................................................... (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 .........i.~.....~ ...................... , ........................ ;.~. .................................................................. 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 ~tories ~.., ........................................................................ Dimensions of same structure with alterations or additions: Front ...... ~ ................... Rear ......................................... Depth ............................................. Height ......................................... Number of Stories ..... ~ .................................. 8. Dimensions of entire new construction: Front .......... ~..~..~... Rear......,.~.................~ '/' Depth ~'..~l....~..,..'~. ......... ~ .... Height ........ ~ ............... ......................... Number of Stories .....~ ................................................................. "Iotl\ 1~'4'?~ · :.l.~..~) .............. De th ~-~0 9. Size of Front ..~,,~...~..:...., .................... Rear ................. . p ............ ,~.. .................................. Height ......................................... ; .......... Number of Stories .......................................... ~. .......................................... 10. Date of Pumhase ..................................... Name of Former Owner ............................................................................ 11. Zone or use'district in which pram see are situated .~.~.....~.... ~....f...~...~.. .............................................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ~ O 13. Will lot be regraded ...........~..~ .......... Will excess fill be removed from premises: [ ] .Yes, [~ No 14. Name of Owner of premises .....~-:~f~.......~....~ ...................... ~ .......................... (Address) (Phone No.) Name of Architect ..................................................................................................................................................... ~ ~ ~,~ ~,.~Address) ~/~~ (Phone No.) Name of Contract~r ;.:~;. .......................... t ................... ~, ....... ? .............. '.'/".~."~.. .................................... (Address) ......... '~rj~ ....... (~;l~ne No.) ..... V PLOT DIAG RAM 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 wheth- er interior or corner lot. .............................. ofindivldual signir~COntract) '"'"'"~(Name .being duly sworn, deposes and says that he is the applicant 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 make 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 forth in the application filed thert~ith,n Notary Public ...................................................................... County ~' ~/ ( /gna ofappltc~;) .................................... 73S-?0226 LoT 4 SURVEY FOR EUGENE ~ DIANNE AT MATTIT~CK TOWN OF SOUTHO£D SUFFOLK COUNTYw N.Y. SCALE 1"'30' JUNE 5, 1973 GUARANTEED TO ~ CHICASO TITLE INSURANCE COMPANY RIVER~AD SAV~NeS BANK EUDEN~ · DIANNE PEARSON N.Y..~ LIC. NO. NIl?RS NIVERHEAD f N.Y. Id,4cLe'~, C