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Home My WebLink About6444-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupancy No, . .~.~.2..~2 ..... Date .......... ~.Url®.. 29 ........ , 19.73. THIS CERTIFIES that the building located at .l)eltllal,. l)~tV® ............. Street Map No. ~.1. C~Block No ........... Lot No. conforms substantially to the ApplicatiOn for Building Permit heretofore filed in this office / dated .. ~.. a~ .., 197~{i.,pur~ant to which Building Permit No. 6~I~Z .. dated .......... 0~.~... a8..., 19 ~3 ~, was issued, ~d conforms to all of the require- ments of the: ~pplicable provisions of ~he law. The occu}ancy ior which this certificate is issued is . ~ri~ate. orte .$~ly. ~lling .............................. The certificate is'issued to Ba~y. Fo~e. & .~ife .... 9~e~8 ........................ (o~ner, lessee or tenant) of the aforesaid building. ' Suffolk County ~ePartment of He~lt~ Approval .~e .[e~,. A97~,, ,by. ~, .V~la .... UNDERWRITERS CERTIFICATE N~..1.0188~ ........... : ............................ HOUSE NUMBER., .~ ...... Stre(t.,.; ~G~a~ .D~i~o .' ............................. TOWN OF SOUTHOLD BUiLDiNG DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, Nm. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE,WORK AUTHORIZED) N? 6~44 Z Permission is hereby granted to: v..~.v..t,~.~...~..q~.e...~ ....... A/.C.~.~.~......~.°..~.e.. ...... .......... ]Ax~d.~3...~,~ ............................................... ............... .t~s~...Q~ogue ...................................... Fo ....~.u..$.Z0.:.. ~.~w...p. ~ .e....~ ~..~.y... ~w..e..]~.z..~..~ ............................ i ..................................................... at premises located at ...... ~,g.~..~7.....~Jg,~3X. fJ~k gg.~]l~t.~..~...~.~..~.t'..9, fi ....................................... .............................................. ~.~3,~:.. ~.~. ................ :E. ~r.~.:L..~.:..Z.. :. .............................................. pursuant to application dated ............ ~.~..~..e...~.......~...8. ........ , 19..7~.., and approved by the Building Inspector. Fee $..?r..~ ?...~.~.. ......... -- E~uilding I.~:~ector [ ~ . I~OR~ NO. ~ TOWN OF $OUTHOLD Building Department Town Clerks Office Southald, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and s~bmitted in triplicate to the Building Inspector with the fallowing; for new buildings or new usage: 1. Final survey of property with accurate location of al~ ~)uiJdings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewe?age dispcs.al--(S-9 form or equaD. 3. Approval of electrical installation from Board of Fire UnblerwrJters. 4. Commercial buildings, Industrial buildings, Multiple R~sidences 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 complefed 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, ~treets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, qccupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildin~gs 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 New Building / Old or Pre-existing Building ................ ............ Vacant Land Location Of Property .......... [~..~./..'m~. m ./~......~.....~...t~..~..~E~..I.....~...~.~....~...~../~_ ....... .~...,./~. ........................ Prope y ...... ......... ........-- .................... Owner Or Owners Of Subdivision ..~..~,~..~.~5~.~.~.~.~,.~...s.A:...~.Lot No. ,...~...~;.. Block/No ............. Houkse No../....~....~/.~ Permit No. ~..~..~J..~..'..~.. Date Of Permit ..~..~....'~....T.?.~kpplicant ...:.......~.....~r...~.~ ...... .~..~...%.~....~...~....~..~. .... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Boa~'d Approval ...................................... Request For Temporary Certificate ............ '~ ........................... Final' Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and permit meets oil a~plicable codes and regulations. Applicant Sworn to before me this . ....... d y_of Notary TERRI LEE EL/~i{ NOTARY pUBLiC, State o! New yo~k (~uahhed in Su~l'~,, County SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference No. ~ ' APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE S~WAGE DISPOSAL SYSTEM Phone 1. Applicant ~ Address 2. Property location VillJge Township , Public Water Company name ~ 4. Lot size: Widt~_~ ,~ feet L~ngth ,~ ~ 10. Sewage Dispos~ ~ystem: A. ~ gallon septic tank: Precast '5. Subdiv.,: ~ / ,,- 4 / j ~,~ ~;'!-0. Section ~/ ; 7. Lot No. ~ _~_8. Private well J 9. Public water ,, Distance to main ~ feet (Enter on center plot below) ~l~quivalent Block__ B. Leaching pools: Number..9_~_ recast{~f, Block Street The undersigned CERTIFIES: be in accordance with the Suffolk County ards thereto." Date Special If private well fill in blanks below: Tank capacity,,' Gals. Pump G.P;M.. Total weil depth_ Depth to '~G~.W. Amount of water in well Test Hole Data Feet 0 2 4 6 8 10 12 14 16 18 "Construction of!authorized installations will current stand- Department of Health's FOR HEALTH DEPARTMENT USE ONLY. Based is the opinion of the ~Health Department, that an adequate and satisfactory Disposal System can be installed on this plot. /~wn ' or Builder the information presented herewith, it Sewage S-15 Revised 4/I/72 : , ', .. 21i07 · Are° 141 Lof I~ IREA~ E~-EVA liON I FROL~T ELEVATtOtd APP~oVd~, >,o ~?OTED -/ i 4"~ 4" ¢- To~LE1~ NO GcAL~ II T,iP~ 4k