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Home My WebLink About7336-z FOBM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT CI'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NV 7336 Z Permission is hereby granted to: ~ ,..~bueehe ae .....~J¢.... J~e~ ..~l~a ......... ~e.....a~-.~A ..................................................... · ..~..l.l.e~..P.taee.-..,.-. 4-1.76~. ........................... ~o ~i~..~v..o~m...£~m ~34r..~v~ l~.lz~ ..................................................................................... at premises located a~[aat..~l~........O~t&~..~l::e~ ........................................................................... ......................................... ,..~uv~..~a~t ........... .Or~ent..-..N..~.~ ............................................ pursuant to application dated .........................,Tt~e...~ ............. , 19~...., and approved by the Building Inspector. -~v,- Bulld:ng In's~:~ctor ~ORM NO. 6 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 19§7), No~-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 Dote ...g. :..~.....-~......~.....-...?......~... ........ / NewBu dng V' Addton OdorPreexistin Buil&n ' a n ' ' o, .... ..... ............... .............. Owner Or Owners Of Prope_.~, ....... .~'~ ~ ~'~i~'~ ..................................................... Subdivision .j~/~...~...~....~..~.~.'.'i'.~.'i:i~..~..~i ; '~i N:i'~'~'.'.':'~ ~ii"~ .............. i'~i'~"~: ............. Permit No~.x.~.~..~..... Date Of Permit .~--~'..Z..~.~..Z.~...Applic;nt ~..'. ~/.~.c~P~"~/~ ..~.....~. ~'".~.'.'~4~_ ,~ Health Dept. Approval '. ........................................... Labor Dept. Approval ................................................ Underwriters Approval .............................................. Panning Board Approval Request For Temporary Certificate ........................................ Final Certificate Fee Submitted $ ........ ~).:...?...0.. ............... Applicant ............... ~.~ :... :...-~......:~ ......¢/~' ......... :.T..~ ................................... (starnp or seal)~~ Nt P ' ~~~ o ary ubhc .......... County SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY ' ' '~ ~ ':¢~Y 5. Subdiv. 1. Applicant ~i " / Phone /, Address ' ~ , '-:, ,~ ~.. ~/ /. ~ '~ ,, ,: ~,.~.,~ 6. Section 2. Property Locatlon ~, ;,. ~,Y.L ~ ~' · ,~,,<~/ ~ : ~ ' 7. Lot Number ~llage ' ' "~' ' ',, ,,~ ~,.,~ / ~ ~,~,~,, (~ ~ ~, ,~ 8. Private Well V Township % ~., '7/z~,~ ~ 9. Public Water 3. Public Water Company Na~ Distance to main 4. Lot size: Width /~.,' feet Length ~ ~,~' feet 10. Sewage Disposal System: A. O~gallon septic tank: Precast .Equivalent Block~ B. Leaching pools: Number of pools Precast'~Oq) Block __~pecial ll. If private well, fill in the fol- lowing ..b_~a_ n ks: A, Tank '¢~tpacity ~B. Pump: G_. P.M. C. Tot~ well depth D. Dep~d~_ to ground water E. Amount of water in well gallons (For Health Services Dept. Use) The unders~'gned CERTIFIES: "Construction of authorized installations will be in accordance wi th 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. FOR THE DEPARTMENT OF HEALTH SERVICESm 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 Cy('..,~(~'· SIGNED ~ -__ ~ - S-15 Rev. 4/1/73 EXCAVAII:-G REQUIRED INSTRUCTIONS q a. This application must be completely filled n by typewriter o~..in in~ and submitted in tripli~x~te to the Building Inspector, .with 3 sete ofplm~ accurate ~ plan to scale. Fee according to schedule. b: Plat plan ~Wing location of lot and of buildings on premises, relationship to adjoining premises or public streets ox areas, ar~dgi~inga detailed cl~s~rjptio~ of 10yout ofpra~erty must be drawn on'the diagram which is part of this appticatibn. c. The work covered.by :th. is applLcation- may not be commenced before issuanCe of Building Permit. d. Upon approval of lJll~'applJ~ati~, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on the pmmises 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. · ~ AP..PLI_CATIC~I_ IS HEREB. Y MADE to the Building Department for the issuance of a Building Permit pursuant to the ~uild!ng Lane Or~. Ina~nce ot ~.he Town of Southol.d..,.Suffolk County, New York, and other applicable Laws, Ordinance~ or Kegulati..ons, for the,~-'onstructlon of buildings, additlOe~ or alterations, or for removal or clemotiti..~, as herein described. ~ ..appl'.m. an~ ag~..~r~ ~fo comply wJth?l applicable, ,.k~s, o,rdlnances, building _c~e, housing code, and reg~lations, and to aamlt aumoflzedinspectors on premises and in bultdmgl tot nace~ary impactiom. .... ............................. · (Signature of applican}; or name, 'if a corparatioe). State whether applicant is owner~essee, agent, architect, engineer, gen. eral 'contractor, electrician, plumber o~ builder. .............. ................... : ........................................................... / I .// ........................ ~ ........ "ame o~ ow.er of ,~m s. :/Z~',,,,.~. < ,'WU Z./.-,~.,~/ n p ............. rS,KA-.~/, :1.~...~,..... ,w .. ~ ........................................................................................................ If applicant is a corporate, signature of duly authorized officer. (Name 'and title of corporate officer) Builder's License No ..................................................... Plumber's License No ....... ~...~....~.....'~.....~... ................ Electrician's License No .... 1~-.,,,~,,,.~.,.~,....,~...'. ............... 1. Location of land on which pj$)pased work will be done. Map No.: .......... ....... Lot No. '....u ................. Street and Number ....... ..~. :..~...~:..~..~/.....~J~..~..~'.......~.....~...~ ............................... ..j~.~/...~,..../~...~ Municipality 2. State existing use and occupancy of premises and intended use and occupancy of praposed construction: a. Exisiting use and occupancy ...~..~ ~j ~ "7"- ~-~,~- AJ' p .................................... .... tc, cc ~. ~ntended ~se a~ occupancy .p. ....................................... .,,. .. .L/~ .. 3. Nature of work (check which applicable): New 'Building .................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition ................. Other Work .................................................... " 5' ~o 4. Estimated Cost ............................................................ Fee '~ (Description) (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 ccrs ............................. .~'.. ............................................................ 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' ~f ~Sfies .............; .................................................................................................. Dimensions of same structure with alterations or 'additions: Front ....................................Rear ............................ Depth ................................ Height ............ ~.....; ...... [...Number, Of Stories ...................... 8. Dimensions of eptire new c(~nstruct on Front .~...~..../. ' Rear .~.~... ........... Depth ...... ..~...(4::~ Height ...~,~.. ........Numbe, r,,~ ,-- ,al Stgries ............... C~ ................................... ,--~ ~, 7 .................................................. _ ~_._ ,'~ ......... 0. Size of lot: Front .......... ;.~,J..:??.....- ........................... Rear .......... ~.~1'.~.. ................. d.. Depth ...... ../..~......~.....'....~ .... Date of Purchase ././.,o~...~.. ~.. Name of Former ~er , ....................... .--'-t ................. 1 1. Zone or use district in which premises are situated ........................................................ ;'7 ........................................ 12. Does proposed constr~tion violate any zoning law, ordinance or regulation: ......... ~..~ ................................... 13. Will .lot be regrad~ ..... ~.., .......... Will ~xces~ fill be rem~ fr~ p~i~: ( ) Y, (~No ]4. N~of~nerofprem~s ~ ~ ~r~'~.~..:..Ph~ ........... ................................. ,.. ........... Nome of Archit~t ...~....~.~.~ ........... ...... A~re~ ..~~ ....... Ph~ No. Name of Contractor ~ ~.~ [~ J ~res*~ ...................................................................... h~ ~o. ~..~ ................ PLOT DIAG~ Locate cl~rty and distinctly all buildings, whether existing or proposed, and indicate all ~t~k dimensions from prope~ lines. Give strut and block number or description according to de~, and show street nam~ and indicate whether interior or comer lot. 175, o STATE OF NEV~'OP~I~, . , ( S S couN ....... · . _ (Name'of individual signing contracf) above named. He is the .................................................. .../'~..~.~...~.....'~.....?.. ....................................................... (Contr6ctor, agent, corporate officer, etc.) ......................................... of said owner or owners, and is duly authorized to perform or have performed the said work and to n'~ke and file this application; that all statements contained in this application'are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth Jn the application filed therewith. Swam ~.bgfore me this " ..... ~ .............. day~~ ......................, 19.?...Yf ..~...-~..~ ................ COUnty .... ,...~..-.: ................... ~.........~....~....,~ ...................... ~N~ (Signature of applicant) PATRICIA WYNK~ Notary Public, Stateof New York No. 52-9758835, Suffo kCoen, ty Comm. Exoi~es March :g), THE NEW YORK BOARD OF FIRE' UNDERWRITERS BUREAU OF ELECTRICFf~' [~ ~k 85 JOHN STRErr, NEW YORK, NEW'YORK 10038 THIS CE~IFIEE THAT ~ly the ~ ~u~nt ~ ~cH~ ~ ~ int~ ~ t~ ~t ~ ~ t~ a~ ~o~ ~r in ~ p~ of 3~es ~llen, e/side of ~e~ay E~t, 2~5.93' s/o Nor~ Sea ~ive, O~ient, L~ w~ erami~ ~ ~ovembe~ 7, 19 7~ a~/o.~ ~ be in ~mplia~ with t~ r~ui~ments of th~ ~. HXTURE tECEPTACLES SWITCHES INCA,DESCENT FIXTURES v'v'v'v'v'v'v'v'v'~' OUTLETS FLLK~ESCENT 1 2 12 ~AN~ES SPECIAL REC'P1 COOKING D(CI(~ I OVENS I DISH WASHIRS t ' TIA ~ SYSTIMS A~?. ~PS. NS. H.P. NO. OF Iq~"r R V I C EXHAUST FANS DIMMERS ,A/IA L ~'~" Chlof oz' Co~?,ral Engfneerin~ .~VLP Au f O.E THOMAS E, TULLY L~UFJ,~SE NO. 22914 J'l. '(. STA~E : . ' co: ='1 ~'4'c; ,4% ~4'~ = It- O*l ..-- THOMAS E. ~BLLY Llu~,L,E ilO. 22914 N. Y. STATE .~MEDFORD, N. Y. 'P-..OD JC K CO~'.IgTRUCTiO N CO, I '"' ~ ' NL, 92,8 s44o THOMAS E, TULLY .ICZNSE IlO. 22914 N. Y, STATE GO. ,14t~. --1' THOMAS E. TULLY LICENSE ilO. 229].4 N. Y. ST^TF,, d O. i N~,C. 928- 5~4o ',-'-,* :,, ',