HomeMy WebLinkAbout7423-z~0~ NO. &
TOWN OF $OUTHOLD
BUN.BING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the building located at .B~.,I,~I...RO~. ............ Street
Map No. ~ ......... Block No. ~ ...... Lot No..~...~o,~ho~.. }i.,]~, ........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .............. ~ll~... 1~19..~ pursuant to which Building Permit No. ~..
dated .............. J~Y... 1 ~, 19.7.1~., 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~.~,YS.t.~.. ~.~.. ~'~]~r..d.~e~.~l~g .......................................
The certificate is issued to . .~.,l,e .MI..~,. H~l~fJI!~. & .8~:~. ~B,~I....0~..?.~/.b..~...3,.5.~.~....
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ].o.?.. $.~..]9 .~... b~..1~..,..?~].].&. .....
UNDERWRITERS CERTIFICATE No. ~..~ ~9.0.~.. ]~.o.~.. 1 ~... ~ 9.~. .................
HOUSE NUMBER.. ~ ........ Street .... ~ll&~ .Roa~ .......................
(THIS PERMIT MUST BE I(EI~/QN THE P~EMISES UNTIL FULL
COMPLETION OJ:, THE WORK 'AUTHORIZED)
7423 Z
Permission is hereby gt~mntmd tO:
O3,em~.~.....~te4d.lma~..e...~l~tL ..~... ........
,o ...~...~...o.~.,....~..~.~ ...................................................................................
I~ORM NO. 6
TOWN OF $OUTHOLD
, Building Deportment
Town Clcrks 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 end 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 .~....~..., ........ ..~.....~.. ........
New Building ....~..... Addition ................ Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property ..~Q'~Od~....~..~.'.....~......~.......~. .: ...............................
Owner Or Owners Of Property ...~. ....... .~>..~. ................................................... ' .................................................
Subdivision ................................................................ Lot [No ............. Block No ............. House No .............
Permit No. ~..~..~'~.;..~..... Dote Of Permit ./.?. Applicont
I~0 u o~ \ c~ '1 ~ I nh,~r Dept. Approval
Health Dept. Approval ..................... ~ ...........................................................................
Underwriters Approval ............................ r a n ng Board Approval ........................................
Request For Temporary Certificate ........................................ FinoJ Certificate ..........................................
Fee ~ubmitt~ $ ,,~,.. .............................
Construction on above described building and permit meets all appli.oable cod~es and regulations.
.................
Sworn to before me this
.... day of
Notary Pub ic ~~.~.....~.... Co.,unty ,~ ~ ~t~ ~ ~ ¥o~,
~'~ ~'~-~--~ ~ Commission Expires Morch 30, J ..~
(stomp or seol> /~.~.- ~'~--
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/~/~yg~x~)~-~.5~,_ Phone ~.~
Address ~ o~ ~oy ~ ~'~ ~'~ ~o~, ~
2. Property Location ~,1/~¢o Y~o ' /70 '~y. ~_ ~,~
Township
5. Subdiv. ~,I)AR
6. Section
7. Lot Number
8. Private Well
Village ~-c~oi~- 9. Public Water
3. Public Water Co~(pany Name Distance to main
4. Lot size: Width /77 feet Length,.2~y feet
10. Sewage Disposal System:
(For Health Services Dept. Use)
11.
A. 900-gallon septic tank:
Precast /~Equivalent Block__
B. Leaching pools:
Number of pools
Precas~tj Block__~pecial
If private well, fill in the fol-
lowing-blanks'.
A. Tank~ capacity ~ gallons
B. Pump G.P.M.
C. TQtM well depth
D. Depth to ground water
E. Amount of water in well
The undersigned CERTIFIES: "Construction of authorized installations will be in accordance
with the Suffolk County Department of Health 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.
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~JJ~s~talled on this p~
S-15
Rev. 4/1/73
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
~ 85 JOHN STREET, NEW YORK, NEW YORK 10038
..te~lovember 13, 197h A..,ic.t~o. No.o./i,. 757778 N 193902
THIS CERTIFIES THAT
only the eleC~ea.l ~e~uipment as. des_cr~bed below and introduced by the applicant named on the above application number in the premises of
elu~mann ~ ~on Bldrs., Lupen Drive, & Bi/lard ~d., Cutchogue, L.I.
in the following location; [] Basement [] 1st FL [] 2nd FL OUt Side $~t~o. S~o~ rot
was examlned on November 11S 197h and found to be in compliance wlth the requirernents of this Board.
FIXTURE RXTURES RANGES COOKING DECKS [ OVENS DISH WASHERS EXHAUST FANS
OUTLETS ~ECEPTACLEE SWfTCHES NCANDESCENT FLUORESCENT ,~E~C RY
DRYERs FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT. TIME CLOCKS BELl. UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
~ 1 ~0 1
SERVICE DISCONNECT NO. OF S E R V I C E
METER
1 I00 CB x 1 2 1
~Furneces: Oll 2-1/8h~, 1-1/~hp
Robert A. Ooodale, l
fir #1, Box 15A, ~'!ain ~d.,
~attituck, L.I. 11952 em~ M~NAOEt
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. ,
SOUTHOLD, N.Y. ../ ,. ,/,,~. ~,",', ,--,--" x ~
Examined 19.'?...~... £ A,oplicol~on 1'4o...~...~.....~"~. ............... ~
, ra ed ......
Di~pp~ a~ .... ~ .............. [ ........... ,2 ...... ~~_ ~ ~ ~ K
.............. ................................. ........................
APPLI~TI~ ~ ~I~G PE~IT - ~
~ ~ ~Qfe ~.~.....~.~ ...... · i~ ...........
. INSTRU~IONS
a. This a~licati~ must ~ complete~ fill~ in by ~writer ~ in i~ and s~mi~ in tri~ ~ ~ BuiMi~ ~
In~tor, with 3 ~ of pl~s, accurate p~ plan to ~ale. F~ acco~ing to ~h~ule. ~
b. Plot plan showing I~at~ of I~ ~ of ~ildi~s ~ premiss, relationship~to ~joining premi~ or ~lic'str~ o~
ar~s, and givi~ a detail~ d~ripti~ of I~ ofpr~ mu~ ~ drown on ~e~i~mm which is ~ ~ ~ ~l~ati~. ~
c. ~e wo~ c~er~ by' this a~lic~ion m~ n~ ~ c~me~ before i~u~e ~ Buildi~ Pe~it. ~
d. U~n approval ~ this a~ati~, ~e Buildi~ In, tot will issue a Building Permit to the ~plica~. ~h ~rmit
shall ~ ~t ~ the premi~ ~ailable ~r in~t~ ~h~t ~e ~rk.
e. No building shall ~ ~cupJ~ or u~ in whole or in ~ ~ for any pu~e wh~er until a Ce~ffic~ of ~c~ ~
shall have ~n gmnt~ ~ ~e Buildi~ In--or.
APPLI~TION IS HEREBY ~DE to t~ Buildi~ De~ment for the i~uance of a Building Pe~lt ~t to ~e
~uild~ Z~e O~i~e of the T~n of ~ld, ~ffdk C~n~, New Yo~ and o~r ~licab~ ~, ~ or
- IRegu ati~s, ~r the co~t~ti~ of buildi~s, ~it~s ~ altemti~s, or for m~al or ~litl~, ~ h~n ~n~.
~e appli~nt agr~s to comply with a a~ ic~le ~s, ordina~, buildi~ ~, h~si~ c~e, and r~l~i~, and ~
admit au~oriz~ in,tom ~ premiss ~d in buildings ~r ~es~ i~tio~.
t~,lgna~Jre OT applicanT, or name,
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ........ E~,~I{~I~"~ ............... ................................................................................................
If applicant is a corporate, signature of duly authorized officer.
Builder's License No .....................................................
Plumber's License No.
Electrician's License No. {~(Nlil~el..~lC~;l~i:~d~t ......
Other Trade's License No ...............................................
1.
Location of land on which proposed work will be done. Map No.: ........................... : ............ Lot No...~ .................
Street and Number ....... m']~Elql~"~.~'~'"""~ ........................................................ ........
State existing use and occupancy of premises and intended u~e. and'occupar~cy 6f proposed construction:
Exisiting use and occupancy ......................... ~i"~ ................................................................
Intended use and occupancy ................................................................................................................................
3. Nature of work (check which applicable): New Building. ....... ~. ....... Addition .................. Alteration ..................
Repair .................. Removal .................. Demolitic~ .................... Other Work .....................................................
'7 ~-' (Description)
4. Estimated Cost ...~"~.(3OO.,~)(~ .............................Fee ..L.LL.:...~ .................................................................
(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 c~rs .................. ~. ...........................................................................................................
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 ......... .~[.c) ...................... Rear .......... ~.c~ ............. Depth .....~.7. ............... 8
Height .....~.~..! ........ Number of Stories . ~ :~
9. Size of lot: Front .............. .~d~L~e ................................ Rear ...... 1..?~.1; .......................... Depth .....~L! ..................
11.Zone or use district in which premises are situated ..................... ~e,~,, ......................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: .......... bT~ .........................................
13. Will lot be regraded ....... ~e~ ............. Will excess fill be removed from premises: ( ) Yes ( ) No
14. Name of Owner of premises ..... ~e~e ..................................... Address .......................... .. .. .. Phone No .......................
Name of Architect ............... ,.~a~.e ..................................... Address ................................ Phone No .......................
Name of Contractor Sa.tree
............................................................ Address ................................ Phone No .......................
PLOT DIAGI~M
Locate clearly and distinctly all 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 ~ow street names and indicate
whether interior or corner lot.
l¥8
STATE OF N~'Wr~O~,./~ lc ~
.
..................... ........... , ose ond
(Nam~f individual signing contrac~
above nam~. ~ ~ ~
He is the ................................... ~ ...................................................................................................
(Contractor, agent, co~orate officer, etc.)
of said owner or ~ners, and is dul~ authorized to perform or have performed the said work and to ~ke and file
this application; that all state,s contained Jn this application are tree to the best of his knowledge and belief; and
t~ t~owb~r~il~rform~ in Jhe m( / ~ anner set fodh in the application filed therewith.
~ota~P/;,~ dayof . ' ...... C~9~
~~~ (S'~notur~ or ~pp~ic~nt)
SUFFOLK COUNTY HEALTH DEPART~U~N~
facilities ~'or this ~ccnt%o: kayo b$sn
inspected by %his department ~d i'ound ~
~ Se~lces
~,W YO,t~K
'o . ~ '"' -~ .............................. ::-~-. '- ~ , -
~. ~ . 4~ ~q_~O~]~ J NOTIFY BUILDING DEPARTMENT
I/4 = 'J ~ 0" "