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HomeMy WebLinkAbout7490-zFORM NO. i TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No..Z..622.2. ..... Date ............... Ds.c..3 ...... , 19..~1~ THIS CERTIFIES that the building located at ...I~/S .Gin .L~ns ........... Street Map No. Bay..Itav~iL Block No ........... Lot No..9 .... ~out~hold...Il oY.~ ......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ Au[.. 22., 19.71+. pursuant to which Building Permit No. dated .......... Alii...23 ..... , 19. ?.1% was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . Pr;I, lra~& .olde..fiLthy. d~.~ll~l .... (. firmt;..floox, only. eomple ~;ad) The certificate is issued to .~. Oh~ .&. ,~1~$...l~grray .... .O~ers. .................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .D~C..3..~9.~.. ~.~.. R.,.V.~,l~& ........ UNDERWRITERS CERTIFICATE No... P~mt~.~[ .................................. HOUSE NUMBER ...~.~.0~.. ...... Street ...~.~n.. ~..~,~ .............................. Building~Inspecte~ TOWN OF 5OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7490 Z Permission is hereby granted to: at premises located at .~j,ly~..I). ...... ~..J~l~lJ.~..~itlJle.~t~ ....................................................... .............................. ~.l/~.4~li..l~lle .......... It~tbetJ..--.lh,~, ...................... ': .................................. pursuant to application dated .......................~ .........~, .......... , 19~..., and approved by the Building Inspector. Fee ]JJl~J~ .............. ..... /....'w,., ........ ~ui'"~ing Inspec ~"'1 .............. FORM NO. 6 TOWN OF $OUTHOLD Building Deportment 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 ]957), 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 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 D. J~...Ct....... ,~..... [ .~.~...~. ......... New Building ....... · .~...... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ~.~/~j~-~.~.~j~:~/~?~ ...................... # Owner Or Owners Of Property J.~...l-~..~........~l....9....~....~....~..~.V.. ................................................................ Subdivision ~.(.~...~.~......_1~ .......... ~/ ~.--~'~ .............................. Lot No....~ ...... Block No ............. House No/.~..~..~.- Permit No~..~...~...,~.~...~Oate Of Permit 2./~...~...~...~,~.Applicant .E.~....~....~...~.,I~..~...~......J~J.~....~..~.~..../..../~....~... Health Dept. Approval ......... z..~'~'....r...;~. ................ Labor Dept. Approval ................................................ Underwriters Approval ..~..L~...~..~/...~..~.: ....................... Planning Board Approval ....... ..~...~.1..~:... ..................... Request For Temporary Certificate ........................................ Final Certificate Fee Submitted $ ..... ~.~....--~... ................... Construction on above described building and permit meets all applicable codes c~ld regulations. Applicant ~~~..:.: ........ . ,~.~.; .................... Sworn to before me~thi~). ......... day of Notary Public ......... County (stamp or seal) APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM 1. Applicant F.:~ ~,}~ ~_.~,~5 !N£ Phone~. Subdiv.~ ~.~,, ~,'T ,,~,., Address .'~ ~ ~ .... ~ ~,~ ~'~.~,~ ~ ~ 6. Section , , 7 Lot No. ~ 2. Propert~~'6~atio~ -,~ ~ .... ~ .... ;~ ' 8. Private well ~.~ Village 2.~, ~ ~ ~u,3 -'Township ~ ~.~,) 9. Public water 3. Public Water Company name ,N~ ~L Distance to main 4. Lot size: Width i~O feet Length f3'~' feet (Enter on center plot below) 10. Sewage Dispos~-~ystem: Precast//E~uivalent¢ A. f/gOD/ gallon septic tank: Block__ B. I~3-e'aching pools: Number ~Freca~--.~Block Special If private well The undersigned fill in blanks below: Tank capacity ~'Gals. Pump G.P.M. ~ Total well depth__ Depth to G.W. Amount of water in well Test Hole Data 0 2 4 6 8 10 12 14 18 :ERTIFIES: be in accordance with the Suffolk County aras thereto." ! Omu~m~--e~ Builder Feet "Construction installations will Department of Health's current stand- FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the ~Health Department, that an adequate and satisfactory Sewage Disposal System can~ ins/t~led on this plot. Date /~~ Signed ~"~ '~__ ~ S-15 Revised 4/]/72 BUILDING DEPARTMENT SOUTHOLD, N.Y. ,;Y,,'/.,~',~,,,,~'s' . ............. '~" ,'; .......... ~r;; - __ ,~/~ ........................................ , ,,rm,t D ~pproved a/c ..~'~ .................. ~ ....................................... ~ ............................................................................ ';,'"'?" ............. '. ................ ' -~ .~.~.~ ,~ ,~ II _ .~.~ .,. ,, . .-.-..t ,,.~'.~ · ....................... 1....I, ............ =T.,.....~.- ............ ,l.....~,..~,'~m,~ ...... I~ ~ . ., /VO/~- ~,~/C'/v /'-~'/[.. , (Buildit~ Inspector) I ~'~- ~.~,~,,'"~ g'~/..~/,,~PP,.~.~I~ION FOR BUlL"lNG PERMIT a. This _~.p/ication .must be c_omple.tel.y fil!~d in by .typ_~writer or in ink and subm~l~cl in triplicate to the Buildln~~' · m~ector, ,with 3 ~ or pistil,, I~ccu~ll,pl~ plan to Sccll~, F~acc,orc~irlg, to ~ch~e. b. Plot plan showing Ioc~atic~r~ o~ 1~fand 6f building~ on premises, relationShip'to adjo n ng prem ses or public streels o~ areas, and giving a detailed description of layout ofpraper~/must be drawn on the diagram wh ch is ~art of this aoolication c. The work covered by thai~ ,qpp!Ic~on may not be c~.mmencpcl,befpre, is~gance, of Bq~ling P~rmit. rr ' d. Upon approval of this application, the Building Inspector will issu~ o 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 fo~r~ any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE 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 applicab · Laws, Ordinances or Regulations, for the construction of buildings, additions Or alterations, or for remova or demolition, as here n described. The applicant agrees to coml~ly with:all apali.cable laws, ordi_nances, building code, hous ng code, and regulations, and to admit authorized inspeetors on premises ahd m builaJngs' for necessa~/inspections. .......................... ..e.,,s ...................... .s.......L .N.. ............................ (Signature of applicant, or name, if a corporation) (^ddt. of opp,,cor [ I'/7/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............ G,,~-6~,.L,.,. .~-o ~ ~-~'o~. ...................................................................... o .~1 ~/ .......... Name of owner of premises ....J.....~'.~ ..J'~,.....;..~...~j..~,.~,.....~......~...~....J~,..y.. ............................ If cLpplic~ant is a corporate, signature-of duly authorized officer. ?~ ,, - (Name and title of corporS'te cjffice~') -- - ~ [ ~' Builder's License No...:'.~ ............................................... Plumber's License No ................................................. Electrician's Licent No .................. .~ .......................... · Other Trade's License No .............................. Location of land on which proposed work will be done. Map No.: ...~ ........... ~ ............ v: ...... u~ J-or N~. s,~ ... Str.t a.d Number ~/.~ ..~..,.~...L~..- 1.~. ~..~. Municipality State existing use and occupancy of premises and intended use and eccupancy of proposed construction: a. Exisiting use and occupancy ............................................................................................................................ ..... b. Intended use and occupancy ~~?~&~y~t~~;~ ................................................. Nature of work (check which applicable): New But di .. ..... Addition .................. Alteration ............. Repair .................. Removal .................. Demolition .................... Other Work ................................... ' .................. · '~" -'~'~J~'~e' ~'/~ ~ (Description) O O ~.4 · · 4. Estimated Cost .............................................. tee .......................................................................................... ~..... / (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 type of use ............................ 7. Dimensions,no.f_m~jsting structures, if any: Front.;.~ll,. .................... Rear ................................ Depth ....... .......... ,. Height ....Imray. ............. Number of Stories ....~m' ...................................................................................................... Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Num. ber of Stories ............... v ............... · 8. Dimensions of ~ntire new construction: Front, z ........ 6"~""#' ................ ,,.., ,,,, -mRear ...~..~....: ........... ,.. Depth .~..¢~. .............. Height ..~0. .......... Number of Stories ....(.~, ...........--......~...~..ff.!...~...*..e.~f.~.~,......~....L..~...L.~...L.~. ~...'. ................. 9. Size of lot: Front ......... ~.~...O. ...................................... Rear ..../.~ ............................ Depth ...~..~ ................... 1~i' Date of P~se ~..~.--'~..~.~ .................................... Nome of Former Owner ....-~... ................................................. Zone or us~ d.istrict in which premises are situated ..................................................................................................... Does proposed construction violate any zoning law, ordinance or regulation: ..... ~.~.' ........................................ Will lot be regraded ..../~.~. ................ Will excess fill be removed from memLses: ('1~ Yes (X') No Name of Owner of premises J~all~..L~.~.~.J~m~"..~.'.~...'~.YAddress ~&'~... Phone No.~.. ............... Name of Architect. ~ ............................................................. Address ................................ .Phone No ....................... 11. 12. 13. 14. PLOT DIAGRAM 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 show street names and indicate whether interior or corner lot. IOo. el ST6TE 9F N~.- ~,,.[~-, ¥ ~, -, ............... ~ ..... ~.....'~...'.'.'.'.'.'.'.'.'~...~..~..~.:..b~ng duly sworn, d~es ~n~ seY~ t~t he i* the oppHcam above name. He is the ................................ .~.~.~.6~...~.~.~.~.~.~ ...................................................................................... (Contractor, ag~t, co,rate officer, etc.) of ~id owner or ~ners, and is duly aut~riz~ to ~Horm or h~e performed the said work and to ~ke and file this application; t~t all stotem~s ~n~ ~ t~ ~pl~ar~ the be~ of his ~ledge a~ belief; and that t~ work will ~ perfor~d i~ fha man~er" ~ fo~fl m~ the' '~p~m'~' fiF~ t~. ,.om,o.fo. t., ............. o, ........ . ............. ..... ............................ ~DITH T. BOKEN Nota~ Public, State of New Y~ ~ . No. 52-0344963 Suffolk Coun~ Commission Expires Ma~h 30, 19~- 41' A .~,/^~.r4 PE-~? 0(:% Z;~, ;974 LOT · ~L W~'LL APP, J~VED AS NOTED DATE ~/,~? .~- 1. BEFOBE BACKFILUN(; FOUNDA. TION OR START FRAMING 2. BEFORE COVERING PIPELINE ' 3. FINAL WHEN JOB COMPLETED NOT R~SPONSiiLE FOR DE,SIGN OR COJq.