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Home My WebLink About7640-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificnte Of Occupnncy No. Z6~4~ ....... Date ...............,Tal~..~9 ..... , lg..~.~ THIS CERTIFIES that the building located at., JBe_~.~ltt. P.o~d. l~ ....... Street Map No..~ .t.t..P.o. li~loek No ........... Lot No...1. .... .M~l~.t.~.t;~k...~.,.Y.: ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated ...........lion,...18..., 19.. ~. pursuant to which Building Permit No...?[~1~ dated ............ IlO.~...~..., 19. ~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is .. P:e~,~'&~. olsa .fa~L~y. ¢h~ell~n~ ..................................... The certificate is issued to . .Igal, ter..~alak.~ ...... ~te~ ............................ of the aforesaid building. Suffolk coUnty Department of Health Approval (owner, lessee or tenant) .. o~t.. ~.. ~9~. · b~ .a...~lla.. UNDERWRITERS CERTIFICATE No..l12.f~.~'l 8 ..... Jlala.. ~ ~.. 19].6 .............. HOUSE NUMBER ...32~. ....... Street ...B.e.~..~.t.t. ?.o..n~l., ~ ................... · '' ' ' '~--g Inspector ~uildin ........ FOB~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PEIUvtlT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N°. 76 10 Z \, Permission is hereby granted to: "~ Wal~ar...Oaz~co .................................................... ...2O....~..Z,~ne ..................... [,~ ........................ ...... ~t,v~r.l~a~ .................................................... Build z~ev (me fmall~.d.,vel%~,p~g ... at premises located at ...~k, Ot...$ ............ ]~,e~it'~e~.~"Pol~t"'d~lb ........................................................... pursuan~ to application dated ......................... Bi~V' ......... ~ ......... , 19.~.., and approved by the Build? Inspector. Building Inspe~fr FORM NO. 6 TOWN OF SOUTHOLD , Building Depmtment Town Clerke 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. 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: t. 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 .....~ .......Addition ................ Old or Preexisting Building ................Vpcant Land .............. Ow,er Or Owners Of ,ro rty Subdivision ...... .~.~.R.~.~....~.~.~ ................. Lot.o ..... t ...... B~oc~ ~o..~ ...... .ouse.o.:d...Z.~. Permit ~a.'2..~..~.~,~. Date ~f ~erm~t ~ ..Applicant ,.,...-..~...--~. .--...--------~ '.....,...,....,.,.. Health Dapt, Approval ..... I,/. ......... T~, ...................... I-~bor D~pt. Approval .......................... : ..................... Underwriters Approval .............................................. Planning Bo~rd Approval ..... 'i"" ........... : ................. 'V Request For Temporary Certificate ........................................ Final Cert' 'cate ....... ~ ........................... Fee Submitted $ ,,,.,..~..,~,., ................ Con st ru ct ion on ab ove descri~:p i:::::n .:. :~C .t ~~.:...7 .t:...: .: .:..'~ .r~..,.~.g ...... / SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant~-}//-~-/~t/~ Phone-~Z] (J~.~7,., 5. Subdiv. Address 7-.0' ~C~/~ ~fl'~.~-- /~,~-/C/;~"'-/~'~T- 2. Property Location- ~/~-;, /-tgtJ ~ Village /iA ~ ~1 ~ ~ ~,-~ Township ~Ou-~O~a 3. Public Water Compaq, Name -- Distance to main 4. Lot size: Width/~(~feet Length/~,~feet 10. Sewage~J~isposal System: (For Health Services Dept. Use) A. O~9~gallon septic tank.' Precast ~/~Equivalent Block B. Leaching pools: Number of pools Precastj~ Block Special If private well, fill in the fol- lowing blanks: A. Tank capacity, c/~/ gallons B. Pump G.P.M. Y C. Total well depth D. Depth to ground water E. Amount of water in well 11. 6. Section 7. Lot Number 8. Private We~ 9. Public Water The undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Heal th Services' current standards thereto." This application will be valid for one year from the date of approval indicated below and may be renewed if a current local Building Department Permit is in effect. Date ///c~/~7 (-?/ Signed,~Y~ ~~ . FOR THE DEPARTMENT OF HEALTH SERVICES~ USE ONLY. Based on the information presented here- with, it is the opinion of the Department of Health Services that an adequate and satis- factory Sewage Disposal System and Water Supply can be installed on this plot. APPROVAL DATE ////~ ?/~' SIGNED ~-~--.--- ~ S-15 Rev. 4/1/73 INSTRUCTIONS ~ F ~ ~' ~'c~ ~. m. c{,, ~ '/~,/?~, a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Building Inspector, with 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, and giving a detailed description of layout ofproperty must be drawn on the 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 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 been granted by the Building Inspector. APPLICATION IS HEREBY/V~DE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of bu Id ngs, add t OhS or alterations, or for removal or demolition, as here n described. The applicant agrees to comply with oil applicable laws, ordinances, bu Iding code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. ...... (Address of applicant) ........... Sto{e whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........................... ..................... Nome of owner of premises .......... '"~"'~i[[~?~'i[iiiiii[i[[iiii[[iiiii[[[i[[iiii[[[[[i"i[ .............................................. If applicant is a corporate, signature of duly authorized officer. (Name end title of corporate officer) Builder's License No. ~).,,~.~-,o- Plumber's license No .................. Electrician's License No ...................~..~....~....'~ ......... Other Trade's License No ............................................... ~ ~; ~"a Street and Number ....... ~.~., .,~..~..~,.....~..~....,~....~.....~.~..~..~, .............................................. :::::::::::::::::::::::::: Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ......... /Z,~..~..~.~_,~,~. ............................................................................................... 3. Nature of work (check. which applicable): New Building. ................. Add' 'o .................. Alter~' 'o ................ Repair .......... ~ ....... Removal .................. Demalitia~ .................... Other Work. ...................... ~'.-.t .................... , ,/ :P -- ? ~) _ ([~scription) 4. Est mated Cost ...........~..:'Z../....~Z.......?.. ..................... ,.Fee ..... l..!. .............................................................................. (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 ~'~. ..................... 6. If business, commercial or mixed occupancy, specify nature and extent of each ~pe of use ............................ 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 ................................ Height ....................... ;~.N, umber of Stories ......... =~.....; ............... 8. Dimensions of entire new construction: Front .....~..('~.- ....................... Rear ...~..~. ................. Depth .~..~'. ............ Height .~...~..' Number of Star es ................. ~ ................. ~,~. 9. Size of lot: Front ........ :~'.~..~... ......................... ~ ........ Rear ........ ~.~..... ....................... ~epth ....1..~...~.. .............. 10. Dote of Purchase ............ L.Y................... Name of Fgrmer Owner ,,., ~ ~.~..~... 11. Zone Or use district in which premises are situated .................. ~.~./~../.~.......~/~.....~...!...~......Z.. ........................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .... ~..~... ........................................... 13. Will lot be regraded .....~.~.~/.~.....::: ...... Wgl exce. ss fill be removed from~prem, ises: (,) Yes No 14. Name of Owner of prem,se~?:.. ................. ................... Add ........................... .................. Name of Architect ...... ~ .................................................... Address ................................ Phone No ....................... Name of Contractor ...~..~....~. ~.~.?.'.'.~ ~.~z~..~ Addres~.~..~!.t..../~...~..~... ........... Phone N~.~.L./...~.~....~... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fram .property lines. Give street and block number or description according to deed, and show street names and indicate ' whether interior or corner lot. 1 "15'7' COUNTY OF ..~:~'~,./.~-~.-~......f ' ............ '... ~( J ,t~*t,~,~.....~..~i~'~.~,~ ................. :~ .................. being duly ~"-' ~(Name~o~ in'dual signing contrace above named. He is the ....................... ~V~*,:,,.L.,~....~ .......................................................................................................................... (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 thor the work will be performed in the manner set fo~h in the application filed therewith. Sworn to b~fo~ me this .............. o, ....... . Nota~ Pubhc, . ................ ~=~./~;...~. Coun~ ...~. ................... ;:.I ............. : .............................................. ~ / ~/~,~, '. ~gnature O* applicant) sworn, deposes and soys that he is the applicam ;~ MAP OF PP..OPEP...TY V,/ALTEP.. G .~ATTFrUcK ,5our~, N_.Y MEN r 1