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Home My WebLink About7371-zI~ORM NO. 4 TOWN OF SOUTHOLD ltUTLI~IN(~ DEPARTMENT Town Clerk's Office Southold, BI. Y. Certificate Of Occupancy No. Z~tSB ..... Date ............]~tOb~.. ~..., 19...~. THIS CERTIFIES that the building located at B~S. Jaokmon .La~uB ~. Street Map No. g&o~sm~n. ~l~Block No ...........Lot No...~.0 ..... l~l~.~.t.~..t~...~... ~.o.Y.: ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............Jul)'.. 2., 19.?.~,. pursuant to which Building Permit No..737.1.Z.. dated ..........J.~.....2 .... , 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 Private ~ne family dwellinf The certificate is issued to . Th~. Pet, el. lan ..... 0wnalt ............................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .(~..~.. 3.0.. ~. 9..~... b~...R.,..V.~..1.1.a. .... UNDERWRITERS CERTIFICATE No. P~5~I~ ................................... HOUSE NUMBER ..... t~20 .....Street ...J&~)~q~...I~....~.~..R..o~.5. ............... .... .......... TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING I~EBMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby grclnted/to: ~ ~ //~ .~.:.~...~..~./~. ........ . ....................................................... '~'""~t ............................. ~ ......... "~ ......... ;/": ............... : ~, prem,ses Iocoted ~, ........~..../~...~. .......~..~.~ ............ ...~ ........................ . .................................... ~ ...... ~~..-.~.q.... ....... ...... pu uo t to ~ppli¢~fion dot~:l ..................................... ~. ................. , 19 ........ , ,,nd opproved by the Buildin~ In~:tor. FORM NO. S TOWN OF SOUTHOLD Building Department 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 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-ex'sting" 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: l. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 Date ..J .......................... New Building ~' Addition Old or Pre-existing Building ................ Vacant Land Location Of Property .~.../.~...~..~.?...~.~.~.~.~.~....~..~.~....~..$.~.~....~:.....~.~...1:.~.J:..~.~.?.~..~.....~..~..~.Z ........ .~..!..0. .............. Owner Or Owners Of Property .~.o.~...~..e...C..C..e...~..~..e.~ ................................................................................... Subdivision .~.~.?...~.?...O..~..~.~...~...~,.,C~.~..~..~. ..................... Lot No....J.0.... Block No ............. House No ............. Permit No.?.~.?.?....~ ....... Date Of Perm t ?../..~.../.~.~ ...... App cant A.'....~..e.~..]:..l.,,~....~,...~.....~..°,..~.~..s...,~.,~,°..*. ......... Health Dept. Approval ..~.0./.,~.~./.~.~. ...................... Labor Dept. Approval ................................................ Underwriters Approval ...?...e.~.~.~...~. .......................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ~ Fee Submitted $ ~o00 Construction on above described building and permit meets all applicable codes and regulations. ^pp,icant ......................................... : ...... Sworn to before me th. is / ~'~ /~/'~ ~ ..... .~'../.. day o f ......~..../~/..../..?..~../~.. ........... (stamp or , le I~/~' ~/~, 75 .~ z~ Notary Public ...~/~-~. ...... County ~d~ SUFFOLK COUNTY DEPARTMENT OF HEALTHjFJ~I~ES Health Services Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant4~Phonem~'~ ~'~'~' 5. Subdiv.~¢~$'m~s Address -~ ~' ~ ~ 6. Section Lot 2. Property Lo~L~ ~e ~.~ ~~ ~' Number ~ ..... ~,~,~, ~. Private Well Village ~/~.Township J~o ~ 9. Public Water 3. Public Water Company Name ~m~ Distance to ~in 4. Lot size: Width /~ feet Length. ~ feet 10. Sewage Disposal System: (For Health Services Dept. Use) A. 900-gallon septic tank: Precast ~.[quivalent Block B. Leaching pools: Number of pools Precast ~Block__ ~pecial ll.. If private well, fill in the fol- lowing blanks: A. T~k capacity ~t~ gallons B. P~m)p G.P.M. ~:~iC. l~al well depth ~ ~i3~::D. [~th to ground water '~, ~-![. ~t~nt of water in well Tr~_~.under~ned CERTIFIES. Construction of authorized installations will be in accordance wi'~ th~S~i"'f~lk County Department of Health Services~ current standards thereto," This application will'~e valid for one year from the date of approval indicated below and may be renewed if a current local Building Department Permit is in effect. Date ~ .. Signed /~~-,~ FOR THE DEPARTMENT OF HEALTH SERVICES~ USE ONLY. Based on the information presented here- with, it is the opinion of the Department of Health Services that an adequate and satis- factory Sewage Dispos~al System and Water Supply can be installed on :his plot. S-15 Rev. 4/1/73 · = MONUME"Nr 5~01¥1510N M,41~ FILE'IN 1"14.~ OFFICE' OP rN£ CL_~NK O~ .~Ui~FOLK COUNTY ON IW4R¢~ ES~ I~ ~9 .45 A~4P NO. Lot II Lot 9 Area = 20,800 sq. ft. 160.00'- - / ,'2I,/ .EWS~ON$ YOUNG & YOUNG 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK THOR B. PETTERSEN & MARY A. m¢t~ LOT NO. IO "JACKSONS LANDING ~ MATTITUCK ~0u~ T~T~'~~ · ow. o~ SOUTHOLD T~T~/ J=AT== APRI~ 2, 1974 J NO. 74-- I"= 50' 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 planshowing location of lot and of buildings, on premises, relationship to adjo ning pram sas or pub c streets areas, and giving a'detailed description of layout ofpraperty 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 permil shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pa rt for any purpose whatever until a Certificate of Occupancy~, shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Build ng Department for the issuance of a Building Permit pursuant to thek~ Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other aPPlicable Law~, Ordinances or~~,~ ~egulati.o. ns, for the construction of buildings, additions or alterations, or for remOval or demo ti~ as her~in ,4~,~.a~,,4 ~ ~ ne applicant agrees to comply with all applicable laws, ordinances, bu'd ng code, housing code, a~l regulatlons,'-~'~t~ admit authorized inspectors on premises: and in buildings for necessary inspections. ~ ...................... ............... /. r (AddreSs of apphCOnt) ..................... State whether applicant is owner~ lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .............. Illllll~..]~llllRl~l .................................... :. ............. ................................................. If applicant isa corpora~t_e_, signor'ute of duly authorized officer. (Name and title off'corporate officer) Builder's Liconse No ..................................................... Plumber's License No ........ Electrician's License No ............ ~.~....~...~....4~.....~ee Other Trade's License No ............................................... 1. Location of land on which proposed work will be done. Map No..S/~.e..~....~ Lot No....*~... .................. Street and Number~ ..... ~ ............. ~ ........... ~ ........... ... ~ //~O .................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of~ol:~se~ d construction: a. Exisiting use and occupancy .............. ~ ...... .~~~1~) .~..~../-~"~ .......... :..: .............................. b. Intended use and occupancy ... 3. Ncture of work (check which applicable): New Building ........ · ....... Addition .................. Alteration Repair .................. Removal .................. Demolition ....... ~K. ........ Other Work .................................................... ~"/~ ~.. (Description) 4. Estimated Cost ................... .~...~e~t~(~D ............. FeeI,~,...~c. ..................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ........ .7 .................. 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 ............................ 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 ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front ........... ~(~ .................... Rear ............................ Depth ...... ~a ............. Height ...~1~ ............ Number of Stories .... .'1 .............................................................................................................. 9. Size of lot: Front ...... $.~ ........................................... Rear ...... ~.~ ............................. Depth ..1~ ....................... 10. Date of Purchase ................ ~.~.~..l~ ............................... 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: ...~!*~1 ........................................... 13. Will lot be regraded 1~ ...................... Will excess fill be removed from premises: ( ) Yes ~ ) No 141 N. ame of Owner of premises ...~ll~'..._~e~,.~l..l~ .............. Address ................................ Phone No ....................... Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor ~.?.....~..175'1...~'...~...~.......?.~...~.~...~.~.~.~ Address ...~...l~...~..t'..~....t~....~.~:.~....~he No. ~....~......~...~.~... PLOT DIAGRAM Locate clearly and distinctly oil buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, I.¢ ¢ COUNTY OF ................................ ................. ~...~l,~..~,~.~' ..................... : .................. being duly sworn, deposes and says that he is the applicam (Name of individual signing contract) above named. He is the .......................... ~.~ll.~:/t~t.~ ............................................................................................................................. (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 tl-,a~ the work will be performed in the manner set forth in the application flied therewith. Sworn to before me this ........................ day of ............................................ , 19 ........ ~.~,/ , /? ~:~:;~ ,,~ Notary Public,. .................................................. County ./..~.~..~ ?..~?..~..~. ~ (Signature of applici~t) ................... / /. SUFFOI~ COUiq~Y H~ALZH DEPARTMENT. // / The sewage disposal ¢,n~ supp-.y / i~2sFected by ~his department and foun~ /, / facilities fo~ this location hav~ b~en / to be satlsfactory~ -- ~~"n Chief of General Engzneer~ / ~'~. ~._ Services /GO. O0 ' - - Lot I0 A rea-- ~qg, BO0 sq. lt. IGO, Lot 9 LOCATION OF W£U.S ~ND CESSPOOLS OBSERVA-~ONS TO BE A VALID TRUE COp'[ e[V,S,ONS YOUNG & YOUNG ,4U~.~,/97~ 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK OCr. I, 1974 ALDEN W. YOUNG HOWARD W. YOUNG SURVEY FOR: THOR B. PETTERSEN 8~ MARY A~ ,_o-,- ,,,o. ,o ..,,,,c,,,o,,,s MAT T ITUCK HeME1TITLEiI:~I.$:I~OFCl II~l~ 0 T ~I'LE~INSUR~). TOWN OF ~UTHOLD SAV~$ BAN~ SOUTHOLD \ co., .. SCALE: I"-' 50' DATE: APRE. 2, 1974 197 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTR!C!TY , . [-- roteN°vember l~J, 1978ff JOHN STREET, NEW YORK, N~.':~O~RK 10038. .,,.,,.o,,o.~,o.o,,/,,. ?59.;,3. N 194659 THIS CERq'IFIES THAT o~/y the e/eFlt~ ~.~e4~ t ~ ~b4M~q~ ~ ifl~t G~I~I~/~' t 41*~p4~i~ M n~l~l pl. t he~.Jkl~e inthe/ollo~ingl~glofl; ~ ~.t~is~ FI. ~ 2~ FI. ou~llde w~exami~don ~ovemoev ~q, l~Tq~ flick and ~ou~ ~ be in ~mplia~e with the r~uirements o~ th~ DRY~RS IqJRNACE MOTORS K.w. S~,aAL IEC'PT ;" COOKING DECKS OVENS DISH WASHERS TIME CLOCKS [ ~U.~UNIT HIATEIS MULTI-OUT~TNo. OF FEET ,A~T. [ A~S. TRANS. H.P. sYST'IMS :,: ,.i'. SERVICE DISCONNECT [ NO. OF I S E R * V ! '100 CBre'mE X 1 AMT, AMP. TYPE ~4~UIP. 1~'2W 1~'3W $13W $~'4W NO.(~RCC.~COND. OF CC. CG~ID, 2 OTHER APPARATUS: · Furnaces: Oil 1-1/Shp, 1-1/12bp Motor/s: 1-1/2bp C EXHAUST FANS DIMMERS Joseph D. Mazzoni, 227 Waverly Ave.s_ Medford, L.I. 11763 COPY FoR .BUILDING DEPARTMENT. THIS COPY OF CERTIFICATq*:MusT NOT mE ALTERED mN, ANY ~NNER. ! ,, ,¸% NOTIFY BUILDING DEPARTMENT AT ~65-2~60 9AM TO 4PM FOR REQUIP,: i ED INSPECTION$~ ' 1..BI, FORE BACKFI.LLING FOUN~DA--~ TION OR START FRAMING:. , .. ~ 1. BEFORE COVE~INg PIPELINE i 3, FINAL-W~EN JOB ~OMF[~TED:~' -j ~' Lj [[ 'I ',4