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Home My WebLink About8133-z"FORNI NO. 2 TOWN OF SOUTHOLD 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? 8133 Z Permission is hereby granted to: .. ~l.elL~-~...~.~.t. ~;[~; ............................ ............ ~.....~emo~..~.~ ......... H~u~to~.. pursuant to application dated ........................... ~..~.....~. .............. , 19.~..~..., and approved by the Building Inspector. Fee $... ~.3..e...~. · ........ SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services ~ .4_~ Reference Number . APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY In Applicant,' Address~ 2. Property Location=~/~ 3. Public ~-~-6r Co~pan~i-N~-~-~ 4. Lot size: Width , feet Phone 10. 11. Township, , Sewage Disposal System: Ap~e~g~EquSi~Paiie~ttank:Block B. Leaching pools: Length :,~_feet 5. Subdiv. 6. Section 7. Lot Number 8. Private Well ~. Public Water Distance to main / Number of pools f Precast___~O~ Block ~pecial __ If private well, fill in the fol- lowing~blanks: : A. Tank capacity ~(,.~ gallons B. Pumt~ G.P.M.__ ~' C. To~l well depth. (For Health Services Dep_t~ Use) D. Depth to ground water E. A~o~nt of water in well The under~'~gned 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. Date " Signed 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 installed on this plot. APPROVAL DATE ~//~.~/~ ~ SIGNED ~~ ........ _ 5-15 Rev. 4/1/73 FOI~,M NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE SOUTHOLD, N. Y. Approved ................ :.Z......2....., Perm,t .... Application No. Oc~ / ~' ~ Disapproved a/c ..... ~ ........................~,~,, ...................... ~'"~ ....... ..................................................................................... :" ':' ': ............... ~(Bbilding Inspector~[ APPLICATION FOR BUILDING PERMIT Dote INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, with 3 sate of pla,ns, accurate plot plan to scale. Fee according to schedule. ' b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will 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 part for 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 o 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 described. 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. (S g~x~ture of appl cant, or name, ~f a corporat on) (Address of applicant) ~ ................ Stq.te whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ~-~//'/6'/~Z7- ~? ~'~1,14.- '~ ........................................................................ : ...... ......................................................................................................... ~ame or owner o~ premises ..................................................................... T ................ ~ ..... '.. ~ '4~ z-- d:6 ~l~/Z/~ If a~plicant is a~r~orate, ~i~nat~Z~)of duly authorized officer. ======================= .................. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which proposed work will begone. Map No.: ................. , ...................... Lot No ......................... Street and i~umoer ......................................................................................................................... $.~...J...~ Municipali~ State existing use and occupancy of premises and in~ended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................. b. Intended use and occupancy 3. Natur~ o~ ~v~rk (check which applicable): New Building ......~. ....... Addition .................. Alteration ................. Repair .................. Removal .................. Demolition .................... Other Work .................................................... (Description) 4. Estimated Cost .......... ..,~....).~ ~-3 ,~---- ' 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 construction: Front ........ ,~......~.. ............ Rear ........ ~ ...... ..~... ..... Depth ........................ Height ........ ,~. ..... Number of Stories ............................ ~ ........................................................... ~.~.~; ........... 9. Size of lot: Front .............. ~..~..~. ................................. Rear ........... ./ ..................... ~ ...... Depth ....... >~ ...................... 10. Dote of Purchase ...~'~C..~ ...... ~..~.~. ............... Name of Former Owner .~.~'.<~........~..'.....-f.~.....~.,...~.~.. ........ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning Iow, ordinance or regulation: ........................................................ 13. Vv~ill lot be regroded' . ........................... WiU excess fill be removed from premises: ( ) Yes ( ) No 14. Nome of Owner of premises .~'~,~'~'~'..~'~l~..Q~./,.~.~,..*~..C'Address .~/~',,¢~....~.~.: ..... Phon,,~ No..~.~., ,~...'.~.,'~,,.,~... . , Name of Architect .~.~/.~)¢,~,~.~... ~.~.~-~. .......................... Address ..¢~¢~;..~.~.. Phone No .................... Name of Contractor ..,~.,,~,~..~..~/:1~./,..~.~¢ .............. Address ..6Z~./;,~ .~......C.~.'..... Phone No. ~',~',~,,~ ~'~'~,o'~l' PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate oil 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. STATE OF NEW Yx~ti~K,_ .... "¢~6me ~'i~lvidual signing contracf) above named. of sold owner or owners, and is duly authorized to perform or hove 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 knowledge and belief; and tha~ the work will be performed in the manner set fo~h in the application filed therewith. Sworn to before me this Noto P bhc,. ......................... ......................... ~ /% ~/~ g - / ~ ~Signature of applicant) 8LiN ,/ , I ,, NOT