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Home My WebLink About8170-zFOEM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No..Z67.~. ..... Date ............. .N.~' .... 't.~ ..... , 19.~. TttlS CERTIFIES that the building located at . .H.~.~ .~ .............. Street Map No. Pea.onto. I4~Block No ........... Lot No..]~0 .... Peeo~ie.. I~,Y, .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... AUg...29..., 19.7~. pursuant to which Building Permit No..O]7.0.Z. dated ........... A~lg ....29..., 19.7~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy ~or which this certificate is issued is .. Pr. iva.~.e, one, ,flt~l~y. d.w. elltng ....................................... The certificate is issued to .M,~.,,.~,. ~.~a~l~;~.~ ~t~l. CD~I~..... ~ae~ ............... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . . N~.~... ~,.. ] ~[ .. b~..R,.V, ill~ .... 'UNDERWRITERS CERTIFICATE No .... ~.~,~.~j~.8~.. .... . .~q.~....~.~...~,~.~. ~ ............ HOUSE NUMBER .,. ~ ~..l+~. ...... Street ....H.e. tlNy..~,~l~.e. .......................... Building Inspector 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? 8170 Z Permission is hereby granted to: .~ ,~.~)..: ~L ...~.~.~.~..~ r....~.q.~: 1~ ...................................... ................... ,Z~,I.~'.£ ~:~ck. ...................................... to .~.~..~.% i~...l;.~.h'...~ .. ,[:~l~i~.:~:.. ~.~:~.i 1.i~ ..................................................................................... ,at premises Iocated~ at _...~.0.~...1.Q.....~.~D~;L~..~Q~ ..................................................................... ................................................................... ~er~.~J. ~...~na .......... ~.ee~rcLe ...................................... pursuant to 0pplication doted ................. .~..~.~.....~.~. ...................... , 19.7.~..., and approved by the Building Inspector. Fee ~.~.e.?..O,. ............. FORM NO, 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted ~m ~ to the Building Inspec- tor 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 featu res. -- 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 installa- tions, 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" ~and uses: 1. Accurate survey of p~operty 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 informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling $15,00 3. Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 5. Updated C.O. $15.00 NewConstruc tion ...... Old or Pre-existing Building ............ Vacant Land ............. Location of Property ...,Z',~.'~'~'.'~. ........... ~ ,'/,~,-~:/f,,,<~,~c'..~,~. ........ ,~. ~.C~J<7~Z~'; ..... House No, Street Ham/et Owner or Owners of Property . .~ .~.c~'.E'~F,/?. ,~./~..~.,4/~_, ~ ,~w.,,,'~¢'.. '~ ~.~. '~..~. .......... County Tax Map No. 1000Section ...~.z~'.. ....... Block .... ./f, ......... Lot ~.l.~.. ...... Subdivision ........ ,&%C. ....... Filed Map No ........... Lot No .......... Permit No ........... Date of Permit .......... Applicant .................................. Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ Construction o n above described building and per,~ mee~~des and regulations. Apphcant .~ ........................... Rev. 10-10-78 s. · Betty, Henrys Lane, dead end & New tIway, RT.27 eco~ic, ~L.I. ...... October 27, 1975 ~'~dfau~:dtob*ineomp~e~ith~he~q~ire,~n~of~h~rd. ~~ ~T~ ~:~- :' ,~ . E ,.' ,( TE -V I C 1-i/Shp, I-[/!3hp - : : _., , -,. - _ - ,,'.- Mattltuck r..I. 119 2 ~ ~~.~ ~.~.. ~t,,. oJ,ce of the 6oord ,f *ncorre~. I~pect.rs ~a be FORM NO. 6 TOWN OF SOUTHOLD , Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Ins~ruc~ons 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 3. Copy of certificate of occupancy $1.00 Date .....~.gZ.e...r~...b.,e.z...~..0.,, ..[..9..7..5. ....... New BHilding ....,X. ......... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ...... ..~...e..~.?.Sr.!~...~...~..~...e~...?..o..q~.~.c.~..~,..~ ................................................................... Owner Or Owners Of Property ......~..~..'~...~..o.~.s..t,.z..~..c.~.9.~....C..9.~g~, .................................................................. Subdivision ........?..e..c..o...~.~..c...~,o. tTLe..s. ........................... Lot No.....~.g..... Block No ............. House No ............. Permit No...~.1..~.O.. ~ ...... Date Of Perm it $./. ~ .c)./. ?..5...... Applicant ...+~..~...Q.9.~.~: ~.¢.tiO.~..<.Q ~¢ p~ .............. Health Dept. Approval ...... .5..~.O.~..~.~. ...................... Labor Dept. Approval .......... ~.]~ ............................... Underwriters Approval ...~....~..5.~.9.8.0. .......................... Planning Board Approval .....IxT.~ ............................... Request For Temporary Certificate ........................................ Find Certificate ...... ~ ................................. Fee Submitted $ ..5.,..0..0. .......................... Construction on above described building and~t meets all applicable codes and regulations. Applicant ........... ~ ..~..~.... ~~j~~ ............. Sworn to before me this ~ //Z///_~/ ./..~..~.. day of .~.~..'i~.~.4~_~.~., ............ (stamp .ota Pub,,c ........... cou. I~IOT~¥ ,U~LIC, State of ~w ¥~ T~rm Expl~ Uar~h ~0, 19_/_'~ SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number 2 APPLICATION FOR APPROVAL TOCONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant ~k~l' Address ~ ~ ~ ~ ~.~,~ ~'~z. 2. Property Location jqv~,~ ~ _ ~illage ~ Townshi~ 3. Public Water Company Name 4. Lot size: Width )~ feet Length 10. Sewage Disposal System: A. 9010 gallon septic tank: Pre~ '~q~i'valent Block B. Leaching pools: Number of pools''1~ Precast {~BI~ c k Speci al ll. If private well, fill in the fol- lowing blanks: A. Tank capacity B. Pump G.P.M. Co D. E. ~'J~. gallons Total well depth S~j~ Depth to ground water / J- Amount of water in well 5. Subdiv. 6. Section 7. Lot Number 8. Private Well 9. Public Water Distance to main feet (For Health Services Dept. Use) The undersigned 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. S-15 Rev. 4/1/73 BUILDING DEPARTMENt/ Ex,mined ....... pp o ................................. APPLIGATION FOR BUILDING PERMIT Date ~-~( ~ , INSTRUCTIONS a. This application must be completely filled in by typewriter orr in ink and submitted in triplicate to the Building~ Inspector, with 3 sets of plans, 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 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 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 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. (Signature of applicant, or name, if a corporation) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............................................... · ........ .- ................................................................................ Nome of owner of premises .......... ..J~....~..~.......~Lt~...~.~.~.~...'.'~':J..~...,'~.~.. ........ ~..~....~...~ ................................................ I f applicant is a c°rp~c~ture of duly aFhlorized ~fficer. ~title of corporate officer) Builder's License No ..................................................... Plumber's License No ..... .~..~...~.....~....~,..~.....V~)..i~_)..~...C~ Electrician's License No...~..~....l~....~.......~.;~.J~j~. Other Trade's License No ............................................... ..~..~ Location of land on wh ch proposed work w bedone MapNo ..~.?.~.....~...~LotNo Street and Number ....... ...~.... ~. ......... [~...~f...~..~.~.....~....~....t~...~...~ ........... ..~..~..~ff.~...~. ............................................. Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: ' .. a. Exisiting use and occupancy ............................... b. Intended use and occupancy .............................. ~..~..~...~ ......................................................... 3. ' ~qc~ure of work (check which applicable): New Building ........ t/. ...... ... Addition ..... : ......... ,~. Alteration ............ : .... Repair .................. Removal .................. Demolition .................... Other Work .................................................... (Description) 4. Estimated Cost ..... .~......2~..j..~ ......... ..-~.. .................. Fee ....~.....'~......~ ............................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ........... '.1. ............... Number of dwelling units on each floor ........... ~ ............. If garage, number of cars ........................ ..t~..~...~....~.. ................................................................................................... 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 ................ :.........'l~z.. ....................................................................... I ................. 9. Size of lot: Front ............ )l....'~'..! .................................... Rear ............ k.~...~ ...................... Depth ...L~. ....... .~....~.. ......... 10. Date of Purchase ..... ~ ................. ', ...... ~..~... .............. Name of Former Owner ...................................................... 11. Zone or use district in which premises are situated .............. ~..~.lD..~'...~,...~...I...~...~.. .................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ....... ..b~......~... ...................................... 13. Will lot be regraded ........~.%~. ............. Will excess fill be removed from premises: ( ) Yes (~'"~o 14. Name of Owner of premises .....~....~...n~......C~...~..~..T..!.~.. Address .~..~....~'..~.....~..~....H:..~?. Phone No..~..~..'...~...'~..?.~ I~ame of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor ............. ..~....~....w~....~ ......................... 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 whether interior or corner lot. STATE OF NEW,,,YOR~/, ~_~' COUNTY OF/~~..~~'~ . ~' ..~'~..~.?.~~..~....~..! .~. be ng duly sworn, d~oses and soys that he is the applicam (Name of individuai signing contracf) above named. He is the ................................... ~:.....~.~.~..~.~ ....................... ~ .................................. ~ .............................. (Contractor, agent, corporate officer, etc.) of sai~ owner or owners, and is duly authorized to perform or have performed the said work and to make and this application; that aH statements contained in this application are true to the best of his knowledge and belief; and thaz the work will be performed in the manner set foffh in the application filed therewith. Sworn to ~o~e this _ , ....... . Notary Publi~~_~~ounty ~ ............................................... ~ / JUDITH T. BO~N - (~ure of applicant) Nolaw Public, State of New Yo~ NOTE: ~' = MONUMffNT S~IBDIIIISION MAP FILED IN TH~ OFFICE OF THE ~LE~K O~ ~O~K ~YON ~EVA TIONS A~E R~F~RENC~D T~ ' "°OM DATA OBTAtE ......... ~ gOCA~OR OF WE~S AND ~D/OR FROM DATA -- flUV l 191~ ~he sewage disposal and ware , facilities For ~hi~ ~ , r Supply A inspected by t~ ~oo~t~on have been YOUNG & YOUNG 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK ALDEN W. YOUNG HOWARD W, YC PROFESSIONAL £NG~EF.R AND LAND SU,R¥~R SURVEY FOR: MST COIVSTffUCTION CORP. LOT IVO. I0 "PECOIVIC AT PECOIVlC TOWN OF SOUTHOLD SUFFOLK CO., N.Y. DATE: APRIL $, 1975 ,i NOTIFY BUILDING DEPARTMENT AT 76E.2660 9AM TO 4PM FOR REQUIR~ ED INSPECTIONS: 1. BEFORE BACKFILLING FOUNDA- TION OB START FRAMING 2. BEFORE COVERING PIPELINE 3. FINAL WHEN JOB COMFI.ETSD