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Home My WebLink About5985-zFOKM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office , Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located a~..°~n.,d. , .V?.w...A.v.e. ............ Street Map No.$~1..t...A~.r..e..El~ock No ........... Lot No. ~. .... .F~..t~.~t..u.c.k... i/.,.~; .......... conforms substantially to the Application for Building Permit heretofore filed in thin office dated ...........~'.u~e. ~0.., 19 ~.2. pursuant to which Building Permit No..~.~8 dated ........J..u~.. y.... 3. ..... , 1~.2..., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this cert'fficate is issued is..P..r.i.?a.~..e. ,o,n.e,, ,f.~,m,l., ,]..y, ,d.,¥.e.l.]:i..n~. ...................................... ~he certificate is issued to . ....... .......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .qcl;...2~...1.973...bY. ~,...V~..Z.]~e... UZ DERWRZT , S C ,R IFICAT , No. ................................... HOUSE NUMBER . 3.~.C)0 ........ Street .~ee.v.e. ~o~l. l~.~un~..V.~.es¢..Ave) ......... FORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.. Y. BUILDING prERMIT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5985 Z Permission is hereby granted to: ~,mt~o~..~..~.p~. .......... .9.....6.~. o~.....*..~.~. ........................................ ............. ~'~'~ll~ ...................................... ~o ...~L~!...~..e.~....°.?..~...~.m...i.l~-...~):~.e..l!L~.~.~ .................................................................................. at premises located at "fl~C"~ ....... ~-~aiTe'"Es%a%e~ ................................................................. ........................... &ett~...¥i~w..aye l~et~%~ct~ t~.Y~ pursuont to opplicotion doted ...................... ~l'~-e..-..-~ ............. , 19~...., ond opproved by the Building Inspector. Fee ~.~ ............ Building Inspectork FORM NO. 6 TOWN OF SOUTHOLD Building Depo~tment 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 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 ail 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 Date ................................................ New Building .....~...~... ........ Old or Pre-existing Building ..........~ ............. Vacant Land .........~. ................ / ~' Location Of Property ...~.......~....o...~...~....~;~......~..~..~...~... ........... ..~...~.?....~ ............. ...~..~l.~..-~..../2...c..)....r~. Owner Or Owne~,rs Of Property ....~...t.f..[~....Q..~../.9..R...~ ................ ~..,~....c~...j..~...~ ............ ? ............................. Subdivision ...~...~..J..~../~J.i..~...~C....~...~.T/~..?...%~....kot No.....(~ ..... Block No .....t ....... House No~...~..Q....O. Permit No....).~..~..~.~..... Date Of Permit ..'~..].~.~..~../~.7~(~plicont ..... J ~..-~..'--~..~.~.J~..~.......~.'..(.~..'.~..~.-..~..) ....... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ /o Underwriters Approval .... .~...~.. ......... /.. ..................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and permit meets all appJj,cable codes and regulations. Sworn to before me this Applicant ............. ,~,~.,...,.,,--,.,-7.....----7/-.... .............. ~.~.....~-~ ..Z~ ......... day of .....~.~ .......... ~.~. ............. ~amp or seal) ~/~07 Noto~ Public .... Z~....~.~.~.~.~... Coun~ ' ~~ ~~ NO. 52-3953501 5aiio,~ Count~/ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference No ~ i?~'2j'~ APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to construct said systems is requested,pertinent data herewith: 1-Applicant ~~ ~ ~ $~ ~;~ ~ ~ 1'~ Phone ~; ~ ~* ~ 6-Sub div Address~.*~ ~ ~ ~ ~ ~ ~,'~ ~' ~ ~ ~ 7-Section 2-Detailed property location /A ~ ~ ,~ ,~ U ~ ~ ~ ~ ~ =' 8-Lot No. Hamlet ~ ~ ~, % w ¢ ~ ~ Town '~ ~ ~ ~ ~ ~ ~ .9-Private well? 3.Pablic water su~j~ly name ----- Distance to nearest main 4-Lot Size: WidthS% &~ft. Length;~'* ft. (also enter on center plot plan below:) 5-Dwelling: Single Family ~ ~ Two Family? ~ /Cellar? /~/oSlab? ; ~Crawl Space? 10-Proposed system: Septic tank .~w~Preca~st ~_.~Cesspools ~__~Shallow pools / yOther il-Septic tank .inside dimension~: Volume~Gals. Length ft. Width ,ft. Liquid depth ft. 12-Precast sectzons: / ;Number~_~Square Ft. Cesspools: Block sizeL incs.D ins. H ins. Total blocks below inlet: ~1 $2 ~3 PLOT PLAN · ade Capacity ¥~Gals. G.P.M. ~ No~th T.at H ~le Data ~ee~ 0 2 6 8 10 12 14 18 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-,t,~,~ ~ ~-,, Signed ~ ~ , Owner or ilder FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the Health Department, that an adequate and satisfacto~ewage Disposal System can be installed on this Plot. (10/65 Revts.) S-15 APPLICATION 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 distance to nearest intersection of ~ain 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 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, il, & 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 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 "Vacant" on the plot plan. Streets adjoining applicant's lot to the righ%~, 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-lO feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Welt-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-lO 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 Approved ................ ~ .... ~., .......... m't No .................................. Date ............. , .............. ~., ~ INSTRU~IONS ~. T~is ~pplic~tion must ~ completely filled in by ty~writer or in ink and submitted in tripliCate to t~e B~il~in] InjeCtor, wit~ 3 s~ts of plans, ~ccur~te plot ~lan to scale. Fee ~ordin~ to sChedule. b~ Plot plan s~owing Io~tion of lot ~nd of buildings on premises, relationship to ~djoi~in] premiss or publi~ ii,in] ~ detailed description of I~?out of property must be dr~wn on diagram which is ~rt of t~is ~li~tiom ~. The work covered by this ~ppli¢~tion m~y n~t be commen~d ~fore issu~n~ of Buildin] Permit. d. Upon ~pprowl of thi~ ~ppli~tion, th~ Building Inspector will is~u~ ~ Buildin~ Permit to t~e ~ppli¢~nt. the premises ~il~bl~ for ins~ction throughout the work. e. No buildi~ shill ~ occupied or u~d in whole or in p~rt for any purpose whatever until ~ 0~rtifi~t~ of O¢~u~n¢~ ~nte~ by the Building In~ctor. APPLICATION 18 HEREBY BADE to the Building Dep~rtment for the issu~n~ at ] Buildi~ P~rmit Ordinance of t~e Town of 8outhold, ~uffolk County, New York, ~nd ot~er ~pli~ble L]ws, Ordin~n~l buildings, ~ditions or alterations, or for removal or demolition, as ~erein described. T~e ~ppli~nt {Si~n~tur~ of a~ic~nt, or 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.: .~Ig,L,.'~.~$.~...~.~.'I~'~ Lot No....~ ..... Street and Number .............~I.M.~I[...~.LIE,v~I......(~.~.I~... ...................................... ~]l~..~.l~l~.J~, .......... ~ ..... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ......................... ~ ....................................................................... ~ ............................. b. Intended use and occupancy .... 3. Nature of work (check which applicable): New Building ........ L ........ Addition ..................... Alteration...~..?..:..'..~..'. Repair ............. · ............ Removal ......................... Demolition ........................ Other Work .................................... ~ Description) 4. Estimated Cost ........... ...~....~.,~.~....~.......,,. (to be paid on filing this application) 5. If dwelling, number of dwelling units ....... ,L..,.. 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 ........... ~m ...................... 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 .....~L ......... Height ..... ., ........ ,,~,~....,:. ............ Number of Stories ........................................ 8. Dimensions of entire new construction: Front ....... ~,.~...; ......... Rear ....... ~..1...~ ........... Depth ..c~..~........~...,L.% ....... Height /..~'.. Number of Stories ~. 9. Size of lot: Front ........ ?..~.~...~...~...i ............. Rear ........... .~...~..~...~..~ .............. Depth ......41..~..~......A-& ....................... 10. Date of Purchase ..............: ...................... Name of Former Owner ............................................................................ 1 1. ZOne or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ......... ~..o. .......................................... 13. Will lot be regraded ........ ~.~.~1 ................... Will excess fill be removed from premises: [ ~4Yes [ ] No 14. Name of Owner of premises .../J/'.s.~..!~.~../..~..'~ .......... ~..~.;~...(~...~ ..................................... .~..9..4~.....o4~4.~ ...... , ..... ' A ~ ~ ( A~d'clFe~ / (Phone reo4 PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed,~and indicate all set-back dimensionsfrom p~0perty lines. Give street and block numar Or description according to deed, and show street names and indiCate wheth- er interior or'corner lot. STATE OF NEWYOR~. "~'~ ) COUNTY OF ........... ~%.~....k~... ............ , SS .......................................................................................................... being duly sworn, deposes and says that he~ the applicant above named. (Name o,f individual signing contract} He is the ................. i ................................... ~ ................................................................................................................. {Contractor, agent, corporate officer, etc.} of said owner or owners, and is duly aut, huor, iiz~c~.t[~,,l:~,~r~prm or have performed the said work and to make and file this application; that all statements contained in this applicq~&~a~truest~a~tlae ~ae~t ~frkh s knowledge and belief; and that the work will be performed in the manner set forth in the application filed thetevai~hp344~3 Suffolk Cn~mmission_ Expires M~m.h 30, Notary Public, ~J...~.~.. ~.. C~nty ~ ........ ~..~....~...~:~.~ ........................... ~' ' ~ -- ' (Signahtre o/ appltcm~[t] I ~TOlf Y' $1 I:d. Mon (-or 7 LOT <~ SUFFOLK COUNTY HEALTH DEPART~tENT ~1o./9 'DATE The sewage disposal and ~ater supply facilities for t~is location have been o~nspected by %hi~ department.and found tO be satisfactory. ~~ ~.~ ~'/5./7' Chief of General Engineering Services N / F H ¢ K HARgEN 6URVEY OF PROPERTY Situated of M A TTI TU C I4, TOI/VI~ OF SOU TI/IOI.._D ,,SUFFOLK COUNTY NEW YORK 5urve~ ,quar~ntecd to: "I ~: I I ~¥ § ~ 130 ~l, DATE,,5 SURVEY£O: JUiNI~ g~, I'D7g /VOI/. ~,197~. J ~.~T .8 ALL- COT /~/UM~S SHOWN HEt~OI~ A CA DIA k/ 7~° 5o'3o" E EL ~.oo 75'50' 3o"W 201.27E4L¢ Eo I. fO7. ~'/' L.o T <~ ~1~. 17' J 0 N / F m ¢ ~ HA RN£N 6URVEY OF PROPERTY $/toctcd u! Surveyed bu~ MA'TTITUC I~ SM/TH ¢ JUNO SURVEYED JO~ E~ /0 ~,~ ~ ACADIA TO VVIV OF $ O U T f 5urve~ DA TE5 7:$~ //.'-la ' >