HomeMy WebLinkAbout6054-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No ............. Date ............................ , 19 ....
THIS CERTIFIES that the building located at ............................ Street
Map No ............. Block No ........... Lot No ..................................
conforms substantially t~4thCpplication for Building Permit heretofore filed in this office
dated ........... q 'A 'U'~" 19. ?~su~t to which Build~g Permit .........
dated ....................... , 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 ........................................................................
The certificate is issued to ........................................................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ....................................
UNDERWRITERS C ~P4~ kC. aTE~..__.., No ..... :P',' ki ~--'''' k)~-: 'd')~ .... ~'d ~' ~ ...............
[~U. SE UMBER ~Street .................................................
........................................................
Building Inspector
FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 6054 Z
Permission is hereby granted to:
l~ouncter~..J~o~e ~..Inc..A/f:L.l~oae.. ~c.ckLo
to...~.d....~.?..'....~?.....t.~.Z..~...d.Y~..Z..Z..~.~ ..................................................................................
at premises located at .......... l(~lc].l~[II..k~.~.~..~;..l~Jn~..N.eck..B.o~4~. ..............................................
........................................................ .s..~,.v...t.~.~.~.4 ......... ~.~f.,. ..................................................................
pursuant to application dated ................................... .A....~ ........ ~....., 19.....~.., and approved by the
Building Inspector.
Fee $..~t~.~5 ..........
FORM NO. S
TOWN OF SOUTHOLD
Building Depa~tment
Town Clerks Office
Southold, N. ¥. 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 dispcsal--(S-9 form or equal).
3. Approval of electrical instaUafion 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 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
Date ..L~..O..t~......./a ...... ~..~..'7...~, ........
New Building / Old or Pre-existing Building Vacant Land
Location Of Property .~.......~...R..~...i.~..~L~.N.I~K~...~.-~.e~L~-~./~w.~/....-...~..~.~a. LO ..........................
Or Owners Of Property Af.S.l~....~.~j,,.~.e,.Lcm~.~.~..O. .................................................................
Owner
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No. ~...O..~..~.. Date Of Permit .~:~......~.~2..Applicant ~.9..~..~.~.~.~....~....e~....g..-~...).l~.~,. .............
Health Dept. Approval ,~/,~..c~../.~.~'~. ...................... Labor Dept. Approval ................................................
Underwriters Approval .../././..~../..~i~. ....................... Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate
Fee Submitted $ ......~ ..........................
Construction on above described building.and.~oermit meets alJ~applicable_ codes and regulations.
Sworn to before me this
.... /J......¢~. day of ....~C)..'o~t~'~¢,~i%,..~..~-. (stamp or seal)
Nota~ Public ~..~9~_~ Coun~
RRI LEE ~
~,m State at New york
SUFFOLK COUNTY DEPARTMENT OF HEALTH
H.D.Reference
APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS
Approval to construct said systems is requested,pertinent data herewith: Date ~'~
1-Applicant FJ~ ,~d.~ ~lg~ ~w~. Phone~~6-Sub div
Address ,~ ~,, ~ ,~ g~,, ,.~,~ _% ~, ~.,]'~,,~. ,~ ,~ ¥ 7-Section
2-Detailed property location/F/~- C~,v~ ~ ,~._= ,-~ ~,~ ~,- ,~.'~t No..
Hamlet ~,I~L,) ' Town .~¥q'~,) 9-Private well?
3-Public water supply name ~,,,% Distance to nearest main
4-Lot S.ize: Width ~ ;~ ft. Len. gth~._ft. (also enter on center plot plan below:)
5-Dwelling: Singl.e Family ~_~ Two~amily? ~_./,Cellar? ~_~.Slab? ; ;Crawl Space?
lO-Proposed system. Septic tank .~/,~Precast ~_~/Cesspools / /Shallow pools / /Other / /
il-Septic tank inside dimensions. Volume {~Gals. Length___ft. Width ft. Liquid depth ft.
12-Precast sections: /~ ;Number/~Square--~. Cesspools: Block sizeL incs. D ins.H ins.
Total blocks below inlet: ~1
PLOT PLAN
Street
Wa¸
,G ~de
Capacity ~als.
Y
Indi ;ate
No ~th
The Undersigned CERTIFIES: "Construction of authorized installation will be in
accordance with the Suffolk County Health Departments' current Standards, Bulletins,
and amendments thereto, covering Private ,S~ge Disposal Systems".
' ~ Owner or Budder
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.
(10/65 Revis.)
S-15
Data ?eet
0
2
4
6
8
lO
12
~6
18
A~PLICATION FOR APPROVAL TO CONST~CT PRIVATE SEWAGE DISPOSAL SYSTEMS
INSTRUCTIONS: Applications must be submitte~ in triplicate
i-Means Owner or Bn41der. 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 d/mensions
on center plot plan shown on the face of this application.
~-Dwellings: Check-mark "V~ items applicable to the proposed new dwelling.
6-Name of sub-division
?-Section Number
8-LOt Number
9-Private well: Enter "No" if Public water supply is available. Enter '~/es" oth~rwise.'
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 ~ ~ ~ ~ ~ e Septic Tanks
Part IV " " " " " " UnUsual soil cor. ditions
Part V " " " " # ~ Shallow ~.eaching Pools
PLOT PLAN: The following information is requmred concerning the Applicant's Lot:
Lot size-Length and Width in feet to be i~dicated at the Lot lin~s of the
heavy lined square in the center of Plot Pla6 shown on face 9f this a~plication.
Surface waters-Streams, Lakes, & Bays, etc., located within a distance of ~0
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 ~o the Applicants proposed Sewage Disposal Systems and
Well.
Where no Buildings exist on adjacen( 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-lO0 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-SO 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-lO feet minimum 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 ~0 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 groundwater must be held to minimum of 1 foot
· ~ ~_~ ..
............. ....... ,,, ........ _ ............. .r.7 ...........
........................................ . ,, ........ ..... .............................
~i~p~o~ed ~1~ ......... ~, ~-----~ ....................... ,,,.
.......................................................................................................... ,
(Building In~
APPLICA~ON FOR B~ILDING PE~IT-- --
' ., ~te .~.~,....~ ........................., 19..~...
INSTRU~IONS
*. lhi* ~ll~tion mu*t ~ eompl~t~l~ fill~d in b~ W~writ~r or in ink and ~ubmi~d
~t~ of pl~n~, ~ur~t~ ~lot ~lan to ~eal~. ~ ~ordi~ to ~h~dul~.
B. ~lot ~l~n ~m~ location of lot ~nd of buddm~ on ~r~m~,
~i~in~ ~ d~tail~ ~ri~tion of I~out of ~o~rW mu~ ~ dr~n on di~r~m ~hieh i~ ~a~ of thi* ap~li~ion. '
o. Th~ ~ ~r~d b~ thi~ ~lie~tion m~ not ~ ~mm*n~d ~for~ i~u~n~ of Buildin~ ~rmiI.
d. H~n ~ro~l o~ Ihi~ ~pli~tion, th* 8uildin~ I~eto~ will i~u~
th~ ~r~mi~* ~il~ for in~ion throughout th~ ~ork.
~. ~o buil~'~ '~h~ '~ ~u~i~d 'or u~d in ~ol~ Or in~ for ~n~ ~ur~ ~a~r until ~ C~ifie~t~ of Oeeu~ne~ ~h~ll h~
gran~ b~ the BUilding~lg~or..~~ .~--
APPLICATION IS HEREBY MADE to the Building Depan~nt for t~ issuan~ of a Building Permit pursuant to t~ Building Zone
Ordinan~ of the Town of ~uthold, Suffolk County, New Yo~, and other applicable ~, Ordinaries or Regulations, for t~ ~nstru~ion of
building, additions or al~rations, or for removal or demolition, as herein descried. The appli~nt agrees to comply with all applicable laws,
ordinaries, building ~de, housing ~de, and regulations, and to admit authorized ins~ors on p~mi~s and in buildin~ for ne~ary ins~ions.
(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.
.................................................... C~ r.~ ~L.....~e.~..T.~ a~..~-~ ................................................................................
Name of owner of premises .~.~, ....... .~...L'l.~.~..~..~.~.l.t:~ ............... ~ .....................................................................
If apl~lica~is a corporate, signature o.~f dulY authorized officer.
-" (Name and title-ot'corpora~e officer)
1. Location of land On which proposed work will be done. Map No.: .................... Lot No ..............................................
Street and Number,/.~.....~....L.~a.e..t~a~......A~...~...Oa.~.~e
.............. ...........................
,~ .~ '~Z~-- ~ _~ ~ ~ 0 -~ 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 ...~.J~J.J~m...~'.~J~l.f.~.~.......J,,~J,~[/fM.~ ................................... 'c~r ............
Nature of work check wh ch a ca ~ '
3. ( pp ' b e) New Building ....................... Addition ........... .......... Alteration ......... ~...
Repair
......................... Removal ......................... Demolition ........................ Other Work ......................... ..~.~.~...~,,
(Descrlption~
4. Estimated Cost ........,,~,i~.~.~...~.. .................. Fee ........................................................................... ;"" '"-"'~'"~'i
(to be paid on filing this application)
5. If dwelling, number of dwelling units ..... .~[. ....... Number of dwelling unl~l on each fl~°~ ..~..,,~..r..o.~l.~. ..........
if garage, number of cars ~ ·
6. If business, commercial or mixed occupancy, specify nature end extent of each type of um .....................................
7. Dimensions of existing stm~c~tes, If afiy: Froht ..................... Rear ..~,..; ........ : ........... Depth ...................................
Height ........................................................... N6'mb~rof Storle! ?.;......, ..................................................................
Dimensions of #me gtructure with alterations:or additions: Front ......, ............ ' ....... Rear .........................................
Depth ............................................. Height ..,, ................................... Nu~ber?f Storlag ........................................
Height .,., ~/~. ........................................ Number of Storlag ,,,,~.~, ................. ~ ........... , .......................... ,,,,,,,.,, ..........
Height .................................................... Number of Storl,g ............... ,,, ............................................. ....., ............
of O ,,of
.... . .............
of ~id owner or ~wn~r~, ~nd i~ dgl¥ ~g~h~ri~d t~, mrf~rm 9r h~v~ ~rf~r~d ~h~ ~i~ wg[l~ ~nd ~9 m~kp ~nd fil~q ~hi~ ~Bl~li~ip~n; t~t~t
~?lmment~ ~n~tei8~ in tchi~ A!DRli~ie~ ~e ~ruP t~ ~ hP~ ~f hiq kn~wl~ find ~tip. fi ~nd' ~hqtc tch~ wgrk will ~ B~Ff~r~ iR ~hq p~JnnP, r
m! fe~h in ~tha {Ippli~l'~iep~ fil~ thPrPwi~h.
(~
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~ 3 ~ 3' 'k~f -
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THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK. NEW YORK 10038
,b,,,. November 9, 1972 .Ipp,i,..t,.,,.,'o..,,.~b. 60~030 N [~ ~
,.dy. the electrical eq~tipment as described below and introd~ced by the applicant named on the abo~ application n~mber in the premises
R. Pullchichio, Pine Neck Rd., Southold, N.Y.
~,,~,,. ,,u,,,,,~,,./,,,'.~i ..... [~i .. ........ .,. ix] ~l.'a ~] ~,,d Ft. outside .s~ti,,. ~t,,~ ~.,,,
,,.~,.,..,i,,edo,, November 6. 1972 .,,dfo.,,dto r, 'o. II ,,'owlththereq,,irer,,eats¢~[thi~Board.
saav,ca o,~cb..ic; ~.% OF [ S t . V C E
Water heater: 1-4.5 kw
Eleo Poom heater: 2-2.0~ 2-1.5~ 2-1..25~ 1-1.0, 4-.75, ~ 2-.5 kws
Notors: 1-1/ 2
Charles H. Hall
~ox 417
Southold, N.Y.
11971
. I
~! Th,s certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors'may be identifie~ 6Y their ~:redentiols. ~{
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