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Home My WebLink About8538-zl~OK~ NO. 4 TOWN OF $OUTHOLD BU~.BING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at .. L:tnd&. Rm~d .............. Street Map No.~R~. ][;I,d~[.. Block No ........... Lot No.. 1~0. ..... ~;S;;l,~U~k...N. ~.,. .... conforms substantially to the Application for Building Permit heretofore filed in this office dated .............l~...2t5, 19..7.~ pursuant to which Building Permit No.. dated ...........~.~$~...2?., 19..?~, was issued, and conforms to ail of the require- ments of the applicable provisions of the law. The occupancy for which thi~ certificate is issued is .... p~;i, ya..t.e..o..n.e..f.a.~..i.~...d.w.e.~l..~, g .................................... The certificate is issued to .. Adelphi. ~nd. C~I'9 ..... c~rne~..bu~ldel' ............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . J. uly..Ri...~97~...by, lt,. UNDERWRITERS CERTIFICATE No....]l~.~.~l... ~l~Ly..~8..~.97& .............. HOUSE NUMBER ..... 1.~0 ...... Street .... ~,~ld$. ~ ...... ~$.t.~i~ ......... FOBM NO." TOWN OF $OUTHOLD 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? 8538 Z Permission is hereby granted to: ..... ~..~.~.....L..~.~!.! ............ L..a...::.t~ ....... ,C.~':.'~. to ...... [[:j..U..!..L.~ .......... .A ......... ~:..V:..a.. ~.£ ......... C.~:.~ .......... Ed..~./.~,.:r. ......... ~ ~..{f./...L..,..~. L~',* at premises lOCated at ................... ],..!...~...~.~:~ ......... ]~.[..~.J..~....~ ....... t?....~....-~.L..{...'~....~...f..!...~. ............. ................... J.~.~.-~. ............ L.P...~ ....... £~.~..*~ ........ !~.~..'.~......!:..~.;.......; ................................................ pursuant to application dated ............................... A~.~J..L.......~.~., 1~...~..., and approved by the Building Inspector. Fee $......~...~....~... Building Inspector FORM NO. 6 TOWN OF $OUTHOLD , Building Depurtment 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: l. 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 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 ..................... New Building ....~.... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property .................................................. ~. ........................................... j. ....... ~..~.~. ................. Owner Or Owners Of Property ~ ~ "~-'¢-~_ ~ J ~.-J~'"D Ca ~P, Subdivision .~.~.~...~.~.~....~.~ ...... Lot No..~.... Block No ............. House No ............. ~e~ No.~.~.;~ ...... ~. Of ~.~ ............... L.~pp,c..~ ..~.tS.~ ...... ~.....¢~.~. .... Health Dept. Approval ....... ~.;;~.;~.'~...~ ........ Labor ~pt. Approval ................................................ U.~e~w~it.~ A~o~.~ .... ~.~...~..L ..................... m,.ing ,~rd Approv~ ........................................ Request For Tempora~ Ceffificate ........................................ Fin~ Certificate ~ Fee Submitted $ ........... ~. ...................... Construction on above described building and permit meets all a' licable codes and regulations. Sworn to before me this J~O~=~" ~'~ ~" ~"> CZI:~ ~;,~//,~./7~~ ........ ~ of ....S~;......Q.../....C...c~.... (stamp or seal)~ ~,~/ Nota~ Pub,lc ~~ Coun~ ~, ? ,~ TIME'CLO~KS: 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 ~£~ r.x~s~ Phone 2.~-~t)'~Q Address ,.~ '~q~ , ~~ ~ ~.~1, ~q~ 6. Section 2. Property ~ocation ~ ~.,~ m ~, ~ ~ S~ 7. Lot Number C~ ~, 8. Private Well Village ~~ Township ~.~ 9. Public Water 3. Public Water Company Name ~ ~,~ ~~. Distance to main 4. Lot size: Width ~ feet Length ~ feet 10. Sewage Disposal System: A. 00~- llon septic tank: (For Health Services Dept. Use) Precast ~Equivalent Block__ B. Leaching pools: Number of pools ~ Precast ~ Block .Special ~---- ~ 11. If ~rivate well, fill in the fol- 1 o'~/~ n'g blanks, t.~ ~ ~r A. ~ capaci tYl_~gal 1 ons B. ,,,-'" The undersigned CERTIFIES: "Constructi~ of authorized installations will be in accordance with the Suffolk County Department of Health Services' ourrent 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 HEAETH SERVICES' USE ONLY. Based on the information presented here- wit'h, it is the opinion off 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 S-15 Rev. 4/1/73 TOWN/OF SOUT.O'D ~ BU"LDI~ DEPARTMENT ~ TOWN ~LE~K'S OFFiG~ SOUT.OLD, ~xamined ................. ~.; ..................... 19 ........ ~ ~ pp oved ................... n~l ................... 19 ........ Permit No ............ D sa roved a c '" 7~[( ~ / ~ ' ' pp / ....................... .~ ................... ~ ............... ~.....t.~.~ ........ .............................................................................. :::::=- ................. ~.~.~ ~, ~ (~ ~ ~ ~ . ....................... (Building Inspector) o. This applicotion must be complemly filled in by typewriter Inspector, with 3 sets o{ plons~ *couture plot plan to ~olo. Feo occordin~ to schedule. b. Plot plon showin0 Iocmion of lot ond of buildi~os on premises~ relotionship to ~dioinin~ premises or public streets o~ ore~s~ ond flivin0 o detailed description of I~out ofproperty mus~ be drown on the dio~rom which is part of this opplicotion. c. The wor~ covered by this opplicmion moy not be commenced be{ore issuance o{ Buildino Permit. d. Upon opproval of th~s *pplicotion~ the Buildin~ lnspoctor will issue a Buildin~ Permit to tho opplicont. Such ~ermit~ sholl be kept on the premises ~voil~ble for inspoction throughout the work. e. ~o buildin~ sh~ll bo occupied or usod in whole or in part for ony purposo whatever until ~ Certificoto of Occuponcy sh~ll h,ye been ~mnted by the Buildin~ Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to th~ 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 remove or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premise~ and in buildings for necessary inspections. ....... ....... ........................ (Signature/of applicant or name, if a corporation) ..................... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises Rob~r~ ~ Ti~r%h Rot~i~s'~n~':, ?~' ~. ~ If oppli~nt 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 ............................................. Other Trode's License No ............................................... ~/J.~l~/'; /4: ~ ~c~', J ~0 Location of land an which pro~o, sed work ~iH be done. Ma~ Nob .................................... Lot No ......................... Street and Number (,~t ~.G ~'D~ ~ ~,'¥"~ ~(.1¢.,~ ~', '"' Municipality State existing use and occupancy of premises and in.~ended use and occupancy of proposed construction: a. Exisiting use and occupancy ....................... V......~...~.~.'../~...~ ............................................................................ b. Intended use and occupancy ........................~...~.~?..P...?....~...c;:...~..~. ......................................................................... 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ..4 ............ Repair .................. Removal .................. Demotitian .................... Other Work .................................................... (Description) 4. Estimated Cost (to be paid on filing this application) Number t ~'~/o 5. If dwelling, number of dwelling units............................1~/ of dwelling units on each floor ............................ If garage, number of cars I ~ '-/AZ 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................/r~ 7. Dimensions of existing structures, if any: Front ......../~..~.k'Z....~.~.. Rear ...~ .... Depth Height ........................ .Number of Stories .................... ~ .................................................. ............... Dimensions of same structare with alterations or ad~~ ...................... Rear ............................ Depth ................................ Height ............................ Number of Stories ................................. 8.Dimensions of entire new construction: Front I='t' ............ .............. Rear ........Depth..... .... Height ...~..'~.....~...?. Number of Stories ~1 9. Size of lot: Front 40 ................................................................................................. J']¢~ ........... ............. · ;A'"_'":'-""'-"t';4'L" :.. ............ Rear .................................. .,,.~.... Depth .............................. 10. Date of Purchase .................................. ~ ..................... Name of Former Owner ......................................... ! ............... 11. Zone or use district in which premises are situated ... ~ ~,-~$ I~ (~v~,~.~ 12. Does proposed construction violate any zoning law, crdinance or regulation: ~ O 13. Will lot be regraded ......... .~.1~.,~ ........... Will excess fill be removed fromm premises: ( ) Yes ( 14. Name of Owner of premises ..., ................................................ /~aaress ................................ Phone No ....................... Name of A'rchitect .............................................................. Address ................................ Phone, No ........................ Name of Contractor ............................................................ Address ................................ Phone No ....................... 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 ¢~hether interior or corner lot. STATE OF NEW%~LY, O. RK,~ .~ ~ /'SS ................................................................................................. being duly sworn, deposes and says that he is the applicant . (Name of individual signing contract) above named. He is the ................................................................................................................................................................................ (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 kno~wle,~e and belief; and tha~ the work will be performed in the man. ner set forth in the applicati~;~f4i~;~.therewith. ' -~ __ , Sworn to before methis /~ ...,,¢ ~/¢ ~ ~ x (~-"~/1~ ........................ of ................ ...... Notary Public, ~.~ C~ou~n~ County ~ , ~ ,.~J~,~__~ (Signature of applicant) ELIZABETH ANN NEVtLL£ NOTARY pUBLIC· Sl~te o'~ New York Ne. 52.8125850, Suffolk (;o0t~t~/ Term ExDifes M~t~;~q-30 ~_~Z ~ DRIVE Lot 119 Lot 12.1 COPIES OF THIS SURVEY MAP NOT SEARING THE LAND SURVEYOR'S INKEO SEAL OR EMBOSSED SEAL SHALL NOT 8[ CONSIDERED TO SE A YAUD TRUE COP~ GLIARANTEES INDICATED HEREON SHALL RUN ONLy TO THE PERSON FOR WHOM THE SURVEY IS PREPAREO~ AND ON H~S BEHALF TO THE TITLE COMPANy~ GOVERNMENTAL AGENCY AND LENDING ~NSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. GUARANTEES ARE NOT TRANSFERABLE TO ADDiTiONAL ~STITUTION$ OR SUBSEQUENT OWNERS, JULY ~0,1976 x =MONUMENT S UBDLVI$10N MAP FI1ED'IN THE oFFICE OF THE C~E~KOFSUFFOLK cOUNTY ON ' dA~ l~ 19~9 A~F/~E~ I67~ YOUNG & YO~ 400 OSTRANDER AVENUE, ALDEN W. YOUNG SURVEY FOR: GEORGE KOUTSOUR~S g VOUL,4 AT MATTITUCK TOWN OF SOUTHOLD SUFFOLK CO., N.Y. SCALE: I" = ~0' DATE: TITLE INSURANCE CO, SOUTHOLD SAVINGS BANK MAY 12,1976 APPROVED AS NOTED 765-2660 9AM TO 4PM FOP, REQUIP~. f