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HomeMy WebLinkAbout7142-zFOBM NO. 4 TOWN OF SOUTHOLD BIJII'.~ING DEPART}dk'NT Town Cle~k'~ Office Southold, N. Y. Certificale Of Occupancy No ............. Date .............. .~....~..~.7. ..... , ~9~... S that the b~g locat~ THIS~~ ............................ S~t Map No ............. Block No ........... Lot No. / co~o~ subst~ti~ to ~e App~ea~on for B~d~ Pe~t heretofore ~ ~ ~ o~ dasd .......... ~ ~ ........ , 1~.... p~t to w~ch B~d~g Pe~t dated ....................... , 1~...., was ~su~, ~d conforms men~ of_~e appBcable pro~io~ ~'"~ ' ............. '~'~ ~ " :' ~/ " ,~ ....... ~"~ ~'~'~ " '~v,~ K ............. '~ne ce~mca~e ~ ~su~ ~ ........................................................ S~o~ Oo~7 ~e~e~ o~ ~e~ UNDERWRIT~ CERT~ICA~ Ho ............................................. HOUSE ~ER/ ~ ~ f' S~t I~B~ NO. ~ TOWN OF ~OUTHOLD BUILDING DEfARTMENT TOWN CLERK'S O~FICE ~OUTHOLD, N~ Y. BUILDING PERMIT trillS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7142 Z Permissio~ is hereby granted to: at premises located atL~...l~ ....... :l~.13Z'~3J~oc~J...E~I:~ ..................................................................... pursuant to application dated ................ ~,......~.~ ...................... , 19~..., and approved by the Building Inspector. Fee $.6..~. ,,.~. ............ FORM NO. 6 TOWN OF $OUTHOLD 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 disposol--(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: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 ,.00 Date ................................ New Building ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ..... ..~'.~..'~.~. ........... ~.~!..L'.!~.'.-~...~.....I~....O.,..~. ........ .~..~'..:.~./...~.. ............................................. Owner Or Own.ers Of Property .....~....~..'....~........~...(.'~. ........ ...~....o....~...~...~...!'~. ........ .~.....O...C...~,...../Y~.....(I.. ........................ Subdivision ..~.~.:r...~..~.'.~......~.~.~,._~Lot No.../.Y..... B,ock No ............. House No ............. Perm,rNa ?~4a ~ate~rm,t~./..~?~Applicant ~:' a~'O* ~0~ '~. Health Dept. Approval ........ .~. .............................. Labor Dept. Approval ................................................ Underwriters Approval .............................................. Plannin~ Bo~rd Approval ........................................ J Request For Tempo~,r~ry Certificate ........................................ Final Certificate .........t~..... ............................ Fee Submitted $ ...: ................................ Construction on above described building ai~p.~rmit meets all apl~icable Fode~a~z~gulations. ~ppmmcon~ .................................. ~ ................................. : ............................. ................ ~ ~ ,,~ ..... ~,,~,~ ............... Not~ Publ~ .:...~...../~..~/Cou.~r , ,~r~, SUFFOLK COUNTY DEPARTMENT OF HEALTH Health Department Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant ~. y~Y~)k'F'~m/ +~?O~'~hone ~Z~/-~'?---5. Subdiv. ~/~,"~ Address ~ ~1~ ~ ~"/, 6. Section 2. Property Location ~ ~ ~ ~]~ 7. Lot Number 8. Private Well Village ~ ~T~ Township ~o~4o~ 9. Public Water 3. Public Water Company N~me Distance to ~in 4. Lot size: Width /~feet Length ~ feet 10. Sewage Disposal System: A./~O90~-gallon septic tank: ; Prtc'~ V/~Equivalent Block B. Leaching pools: Number of pools Precas ~B1 ock Special 11. If priva~'e well, fill in the fol 1 owi ~g- blanks: A. Tank capacity. ~/~allons Pump G.P.M. 7 B. C. Total well depth D. Depth to ground water E. Amount of water in well (For Health Dept. Use) The undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Health's 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 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 and Water Supply can be installed on this plot. APPROVAL DATE ~/"~//~"~ SIGNED ~- ~ .~ __ S-15 Rev. 4/1/73 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITYi;, . ES JOHN STREET, NEW YORK, NEW'YORK 1003S 8mpCmmbGr 25,197& ztpplicationNo, onfile ""'" N 184312 THISCERTIFIES THAT in the/oiling ~a~ ~ ~ erami~ on andfou~ ~ ~ in compl~an~ w~th t~ r~uirements of th~ ~. UANOES S R DRYERS FURNACE MOTORS FUTURE AI~JANCE ~ ,~V~T. ' K.W. OIL H.P. OAS H.P. A~T. NO. ,~ W. o. I 2O0 CB Elm:. roea he, st:eros 2 G.F.Z. I..8'2W 1:3W 3~'3W 3~'4W NO, C~C~.COND. EXHAUST FANS DIMMERS 210 6'10, 1-1.5, 1'1.0, 2'.75, iht cer boaters/z COPY l~ BUILDING DEPARTMENT. THiS COPY OF CERTIFICATE MUST [lOT BE ALTERED IN ANY MANNER. ~UILIIIN~, DEPARTMENT TO~N CLERK'S OFFICF.~ .~/~o/'?,~- ~'/~.O. E amined .................................. .?...., ', ........ " z__. Approved ................ ~ .............. , 19 ....... Permit No ..................................... Disapproved a/c ............................................................................................ (Building InspeCtor) APPLICATION '0' 'UILD~N' PI:~VUT. , / ~'~ ate ......................... , 19 INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Buddi Inspector, with 3 sets of plans, accurate plot plan to scale. Feq according to schedule:. 'b, · 'Plot pl(3n showing locatiOn of Io~ and of buildings on premises, ~'elationship to ~ljoining premises or public streets ~ol. ~ areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application. c. The wo.rk covered by this application may not be commenced before issuance.of Building Permit. d. Upa approval of th~s apphcat~on, the Budding Inspector wdl 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 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 Building Departi~nent 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 buildings, additions or alterations, or for removal or demolition, as herein clescHbed. The applicant agrees to comply with all applicable laws, ordinances; building code, housing code, and regulations, and to admit authorized inspectors on premiSes and in buildings for necessary inspections.. (~gnature of applicant, or name, If a-corporatlon) .. /f~..~ ..... .......................... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................................... ............ ....................................... Name of owner of pram ses , ,~.,..~..e.~ ~,~, .~. ~. If~ant is a cor~'at,( ~'gnat. ature of ~luly autll~rized officer. ....... ~'l~i~nd'-'"~i~'le of corporate of'--'"~'"'"'"'"'"~i;:'~';i'''v' .... Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... and on wh ch ro osed work be ' n AAa ' o ~'~' ~ ''/~ ' ' ~ Location of :,np p w' aa e. - p r,4 .~ ................................... .... Lot N0. ...~...~ Street and Number ........../'~J~.~-~.~l~).,~ ....... ,L~.~'..,~ ................................... /~.~..~...~......e~.... - Municipality State existing use ~ond occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ~...~_~---~ ...... _ ~`~;./~.~............~...............~......................................~....... ~..z. ..... .........t 3. Nature of work (check which applicable): New Building ..: ............. Addition .................. Alteration ................. Repair ................. Removal .................. Demolition .................... Other Work ........................................... ( riptlon 4. Estimated Cost '. ~ .. Fee (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 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 construct on: Front ... ~j~.l R~,~. H,~ght ....~.gl ...... Number of S~r~es ..... ~L ...................................................... ~. S,ze of ~ot: .Front ................ ./..~...'. ......................... .ear .......................................... Depth ....2. P...O...~ ............ 10. Date of Purchase ........................................................ Nome of Farmer Owner ........................................................ 11. Zone or use district in which premises are situated ..~'~....~. ............................................................... ...................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... .~.¢~. ........................................ 13. Will lot oe regraded ............................ Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises .J~l~..... ~-.~t~t~. ........ Address J~rR~.~/~ ..... Phone No~...~....',.~..~ Name of Architect ............................................................... Address ................................ Phone No. ~ ~.b~ ~ ...................... Nome of Cont=tor...~ ...... .*....~. ............ Address. . Pho~ PLOT DIAGRAM Loca,t.e clearly and distinctly all buildings, whether existing or proposed, and ind cate all set-beck dimens ons from property hnes. Give street and block number or description according to deed, and show street names and indicate whether Interior or comer lot. STATE OF NEW YORK, ~¢ c COUN~F ..............................~[~'?'1~ , · (Name of individual sigming contract~ - ' above named. ~_... OV,/. ~ He is the .................................... ~...~..~......~....~.~ .............. ~. S.~,,..~ ................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, end is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in~J~a .¢L~p!ication or~. true to the best of h s know edge and be el; and that the work will be performed in the manner set forth m the al~llicafiqn filed therewith. Swam to before me this ........................ day of ............................................ , ]~ ........~ ~ __.. \ J ,, Notary Public,. ................................................... County ..... bot 16 TEE £OC./[TIO/T OF WELLS ~'D CESSPOOr-,~ SHOWI~ HEREIN ARE FP, OM FIELD OBSERVATIONS AI'¥D/OR FROM DATA O~T.&I~ED FROM OTHERS 5'6~O/V/~N MAPFILED IN TNE OFFIGE REVISIONS YOUNG & YOUNG APR. 15~1974 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK SEPT. i2,1974 ALDEN W. YOUNG HOWARD W. YOUNG . SURVEY FOR: ROBERT A, LOCK MAN ::,,. o. co. so~-,-.o,_,~ I" 40' = MAY 4,1972 IN°' 7~- ~22 DIETZGEN 135 1l$46 'F~LL ,I ,t t lC> ©0~ Locktv~^~l m