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Home My WebLink About6030-zFORM N'O. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No. Z~31} ...... Date ............. ,TI~....~. .... , 19.~. THIS CERTIFIES that the building located at . .~ A~e ............ Street Map No..~. ...... Block No ........... Lot No..1.. ~~.. ]e~, ........... conforms substantially to the Application for BuildMg Permit heretofore filed M this office dated .......... ~.. ~.., 19. ~ p~su~t to which BuildMg Permit No..~. dated .......... J~... ~.., 19..~ was issued, ~d conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which th2 ee~ifieate is issued is . .~i~. ~. f~y. d~ ...................................... The certificate is issued to ...~l~ .~ ..... ~ .......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of He~th Approval ~.~. (..(~ 7. } ..... .~.~. UNDERWRITERS CERTIFICATE No ~.'~?~ ~ .... .... Building Inspector FOuM' NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No. 6030 Z Permission is hereby granted to: at premises located at .........T~.t~...~ ............. P.O. qlx~sl~..~..,e~& ......................................................... ................................ l~,~,Jk .A.,~e .............. .~uteho6ue ........... ll~l,.. ........................................... pursuant to application dated ..................... .~...t!~.~'. .......... ~..6. .......... , 19..~...., and approved by the Building Inspector. Building Inspector PERMIT iNCLUDES APPROVAL EXCESS FiLL J~P, OM ABOVE pREMt%ES R!~ ~ , LOT ~ . ~ CN~TRUCTION C~p,_,,.,~~ LJ, qllCTlON C~LI. AR CONS1 ~,~ ~ iON OTHE~ TOWN OF SOUTHOLD Building Depalement Town ¢ledm Office Southold, N. Y. 11971 APPUCATION FOR CERTIFICATE OF OCC:UPAN~'~' Indmcfloee 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 buildings, property lines, streets, and unusual natural or topographic features. ~ Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). L,~../Approval of electrical installation fram Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Cede 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 in.~ection of buildings or premises, or other pertinent in- formation required to prepare a certiticate. C. Fees: ~Ic"~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 ......~..7....-~...o.:T....?. ~. ................ New Building ....... ~ ........ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Praperty ....... ..~..~(~.A'/~..~..e/.~.~,......~....~...~...~...~.-.~.~.~'-.~.-/-...~..'...~-.&/.~ ..................... Owner Or Owners Of Property ..,~.~.4:~.~....~...~....~....~...~..,z...~K~..,~..,....:~.~.~..d..4.~. ..................... Subdivision ..~,~/,¢,~.,r~.../~.~T~f~,~ ...................... Lot No ..... /.. ..... Block No ............. 'House No ............. Permit No. ~.~.~.~i"~"'.. Date Of Permit ,.~..:..~..?.~.~...~..:Applicant .~./.,&',~.4~zrzl.../..,~...~/2~.~.~'~/-~ ............ Health Dept. Approval ............................................ Labor Dept. Approval ........ ;..:: ........ ~ ............... Underwriters Approval .~...2.~.~...-~..~.. .................Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ......~... ......................... Construction on above described building and p~rmit meets all appl, j~able codes/enc~r~ons. Swam to before me this ....... ~...... day_of ...~....~......~.........7-.Z.~* ........ (stamp or seal) Notary Public~,~,~~ TERRI LEE [LAK ,~I~TARY PUBLIC, State of New Yo~ NO. ' led in bu,;.,, County ~n Exp:res i~13rch 30, ]~ TOWN OF SOU'THOU) Building Dqmetment Tm CbdLB Offlee Sodhokl, N. Y. 11971 AFPLJCATION FOR CERTIFIGATE OF OCCUPANCY Instmctiom A. This ai~plication 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 buildings, property lines, streets, and unusual natural or tppographic features. ~.. Final approval of Health Dept. of water supply and sewerage dlsposal--(S-9 form or equal). 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: I. 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 houslng code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: L.-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 Date ........ ..~....T....'~....~..= ...7...~· ............... New Building ....... ~... ........ Old or Pre-existing Building ............................ Vacant Land ............................ at on Of Prope / ................... Owner Or Owners Of Property .~./..~.'~.../.'~:t~1......~.r.......?.....~.../~.~..~.~..,~.~....~.~.6T.~.-~....~. ...................... Subdivision .............. ....... Lot No ......Z ..... Block No ............. House No ............. Permit No..~'..~..-,T..~.....~:.... Date Of Permit ~.~...~.....~.:..?..~...Applicant .~../.~.&..~......~......~.~...~.d?~.4.A ........ 14ealth Dept. Approval ......................................... r Dept. Approval ................................................ Underwriters Approval ...~...."~..~...~..~.. .................... Ionmng Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ......X .............................. Fee Submitted $ .............................. Sworn to before me this ...... day of .... Notary Public,-.%..~.~. ,..'~-~,,~,~ C~y (stamp or seal) PUBLIC, State of New SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to constr~ct~s~id sys~em~is reqUested,pertinent data herewith: ~te 2-Detailed Dromm~tv locati6n- ' - ~ ..... ~3"~'*~-4''' · . 8-Lot No. f , Hamlet . C~<ALU~ ~ Town _ ~'~;w'~"~-x--4 9-Private well? 3-Public water suppl~%ame -{a . Distance to nearest main ~ 4-Lot Size: Width ;~ft. Length &-~t~t. (also enter on, center plot plan below:) 5-Dwelling.' Single Family ~ Two~amil~ ~ ~Cellar? ~ Slab? ! ~ Crawl Space? 10-Proposed system: Septic ta~ I r~preca~ ~9~"--'~L~Cesspools Y ~S.hallow pools Il-Septic tank inside d~ensions.%~ll~lu~ '-W, alsoLength fro W~.d. th' fro Liquid depth £to 12-Precast sections: /_.~Numb~r~'~'~quar~'~o Cesspools: Block sizeL incs.D ~mSolt ir~o Total blocks below inlet: ~1 ~2 PLOT PLAN Street Indi No Capacity~%als. Data Feet '0 ~ 6 ' ~ 10 The Undersigned CERTIF]2~S: "Construction of authorized installation will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, S~stems". and amendments/th%rets, covering Private S 1 Owne~ or Builder FOR HEALTH DEPART~NT 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. 8-15 APPLICATION FOR APPROVAL TO CONSTruCT PRIVATE sEWAGE DISPOSAL SYSTEM~ 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. 4-Enter Length and Width of Lot under appropriate heading, also enter these dimensions ' on center plot plan shown on the face of tkis application. 5-Dwellings: Check-mark *V# items applicable to the proposed new dwelling. 6-Name of sub-division ?-Section ~,mber 8-Lot Nnmber 9-Private well: Enter *Non if Public water supply is available. Enter 'Yes" otherwise. PROPOSED SySTEMS: Answers to Items number 10, tl, & i2 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 PDOT 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 showa on face of this application. Surface waters-Streams, Lakes, & Hays, 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. W~.T.?. LOCATION: To locate the well & sewage disposal systems on Applicant's lot, the following Standards must be observed: Well-lOO 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-~0 feet minimum below grade for well point Well-~O feet minimum into ground water for well point Well-$ 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 mi~tw~un 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 ~ainiw.,m 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 1 foot t- 'A'N 'C]W4H~3AI~I SUFFOL~ COUNTy ~{EALTH DEPARTMENT The sewage disposal and ~,;at~r supply facilities for this location have been inspected by ~his department and fo~d Services TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined .~......~......~......., 19..~.......~ ,~ ~ Application ~..,~ ........... Approved ~....~. ........... ~..~.l *t. .. 19. ~I... PemitNo . Disapproved a/c ..... ~ .................................................... APPLICATION FOR BUILDING PERMIT ate .... C ' 19.~......~X...~J~ INSTRUCTIONS a. This epplication must be completely filled in by typewriter or in ink end submitted in triplicate to the Bud ng nspector, witl~ 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, an~ giwng a detailed description of layout of property must be drawn on diagram which is pert 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 Permt to the app cant Such bermit shall be kept the premises available for inspection 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 beene' 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, Suffotk 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, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant, or name, if a corporation) (Addres~f applicant) ~' State whether ap 'cant is owner, I , nt, architect, engineer, general contractor, electrician, plumber or builderz Name of owner of premises ..~,x~,.~ . .~... .............................................................................. If applicant is a corporate, signatu re of duly authorized officer. (Name and title of corporate officer) Location of land on wh~h proposed work will_be done. Map No.:~....~....~.....~... Lot No .............................................. Street and Number [./.. ~ ....... ...................................... · ~) ~.1 Municipality 2. State existing use and occupancy of premises and~.te~ ~ and occupancy of proposed construction: , a. Existing use and occupancy ..... ~..~ .................................................. ~....,~. ....... ' .~. .... b. Intended use and occupancy ....... .~......~.~~ ............ ~..~"~i'"i"iii ..... 3. Nature of work (check which applicable): New Building ..... ~ ...........Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) . ?e' 4. Estimated Cost ...... .,~..~='~.,/ ............................ (to be paid on filing this application) 5. If dwelling, number of dwe ling units ...... ..f. ........ Number of dwelling units on each floor ......................................... If garage, number of cars ............................................................................................................................................ 6. If business, commercial or mixed °CCupency, specify nature and extent of each type of usa ......'~... ............................ 7. Dimensions of existing structures,'if any: Front.....................e'~ 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 ...... ~ ...... ~ ...................... 2 Number of Stories 9. Size of lot! Front ..!..'./.,.~...'.~. .............Rear., ...... e/...~..~.2...' ................ Depth ~,,..~.....~.....?......~-=....~:'...~.. ............. Height ........... 5,% , ,-n.-,,, ................................. Number of Stories .............':~.....t, . , /~/' ~_ _ ~~;''' ~:.......~:,.~ ...................... 10. Date of Purchase ...~.[..2..~.:...~TName of Former Owner ...~.~..,LLL.~ ........................ 12. Do~ propo~d construction viola~ any zoning law, ordinancaorregulatlon:....~r?......*..'-'';~ ....................................... Will lot be regraded~_ ~ ~_ ~ ,.~.~.;~ ................... ..... Wi~i~l ca fl II /,~ ex_ss ~101 excess fill be removed%_. _ ~'~_. o ofr°m premisas:o/~, ,,[ ] Yes --~ No 13. 14. Name of Owner of premises . .~....~..~.....r~r,~:~t..~ ................................................. (Address/ v - (Phone No.) ' Name of Architect m ddt s) (Phone No.) , Name of Contractor ..~ ...... ,(.~..'.~........~ ~ . PLOT DIAGRAM Locate clearly and distinctly ell buildings, whether existing or proposed, and indicate all ~et-beck dimensions from property Iine~. Give street end block number or description eccordi~ t~o deed, and show street names and indicate wheth- er Interior or corner lot. [ ~ ~ 8TAT~OF NEW YORK, ~ COUNTY~QF .................... : ......... , ...................... ) ..~,...~~..: ............................. being duly sworn, deposes and says that ha is the applicant above named. He is the ............................................................................. ~./. ............................................................................................................ (Co~trecto~, ~t'~h corporate oJ~ce~, etc. ) of ~ald owner or owners, and is duly authorized to berform or have performed the said werk and to make and fide this application; that statemant~ ~ontainad in this application.are true to the best of his kl.q, owladga and beliaf;:and that the work will he performed in the manner sat forth in-the application filed therewith.. ...................................... day of .................................................. lg ............. No~ Public ...................................................................... ~ounW ........................................................................................................... '7'