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Home My WebLink About8174-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at ~'~0~ ................ ~[£NN ~ C0. W ...... btam. .... Vk- Street Map No .... ?./~..~)..~. Block No ........... Lot No...~...~ ............................ conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ ~. ~?X...~., 19~..~.. pursuant to which Building Permit No. ~..t.V. ?...~_ dated ............ .~..~?.T... ?~., 19~.' .fi'., 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 . .~ ...."i~W.I.~. .~?..'ff.... O.N..~ .... .~..~ ~ I. ~.'(....~. ?...~.L..L.( .~., .~.. .............. The certificate is issued to ~'1~ ~]) ~ ~"~f~U ~1[~ V,~N · .............................................. ( owner, t6s~e-e~wa~c) of the aforesaid building. Suffolk County Department of Health Approval . ~.~../?~. ....... .~..-..~. ~.'-. ! ! .~. ........ UNDERWRITERS CERTIFICATE No ..... ~....~..~...'.~.~.. ?.'7. ....................... HOUSE NUMBER ~ 0~ Street ~ENN 5:C~0-1T Sou Building Inspector F01~I NO. :~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTH'OLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8174 Z Date .............................. ,~3e~¢ .......... ~...., 19~... Permission is hereby granted to: ~ a,,.m.v.~.~..-~ui.~.l.n~...~.....A/~..~e.~nerd--.~ran~og~: ing& .'~. ........ P-a't;c i-~o g~e .................................................. to ~rL'td..~,~:~; .~no., .~'4~-l.~._:~r...d~.]..~,i-~g .................................................................................. at premises located at .*,~-t~ ~' .~;r:~e¢~¢...;-~:rk- ......... ~ ...................................................... .............................................. .t~/~...~,~n~¢.o:~.t...~,,~,~.ve .... ~,~.'~%-he.].~ t, ~¥~ pursuant to application dated .........................~.~. ....... .~ ........... , 19.r/.,C,.., and approved by the Building Inspector. Fee :~.~.. ~C) ............. TOWN OF SOUTHOLD , 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: ]. 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 U~derwrlters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, o 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 sur~ey.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 B~ilding ................ Ad~b~ti~n ................ Old or Pre-existin~ Building ................ Vacant Lond Locotion Of Property .................................................................. u~ .~ ....................................... ~.~ o~ ~"~, ~ ~xm~ ,,,,,, ~., .........~ ~..~,~. ........................ ~ .............................................................. P~rmit N~ ........... ~t~/Of P~rm t ~. Apa i¢~t ............. L.. ............... · R/-/~ ~ ~ o -- I ~'~ '"~:'-- ' ......... Healtk ~ept. Approval ..... ~ ..................................... ka5or ~t. Approval ................................................ Unde~riters Approval .............................................. ~l~n~ing B~rd Approval ........................................ Request For Temporaq~icat~ ........................................ Find Certificate .......................................... Fee Submitted $ .................................... pa .................. ....................................... Sworn to before me this ............... . . .C : : :17;':; '; '; (stamp or seal) i/~/7~ ' 77~_~ THE nr ~ December HIS CERTIFIES THATI Southold~ L- I-' 2Z , I r = ' 'iii BUREAU OFELECTRICITY:: ~Mlc~h' MUL'TI-OUTLET , DIMMERS :SYSTEMS } ;ERVICE DISCONNECT HER APPARATUS: l~. Special receptacles: 1JSO, ~ Furnaces Oil: 2-1/8, .2~1/~15h Shirley~..L;I. 1196.7 ?. certificate ~bst not be'& tersed ,n any mom return to the o. ce MANAGER TOWN OF SOLTTHOLD Building Inspector's Office Town Clerk Building Southold, N.Y. 765-2660 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Re~erence Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE ~EWAGE DISPOSAL SYSTEM AND'A WATER SUPPLY 1. Applicant (<~!U\~W,,, :~t4 5. Subdiv.~_~_____ Address I~ ~ ~l~. ,,~'.,L.~ ~ Z"' ~,)~ ,1~'~?_6. Section ~_~ 2. Pro ert~ k~a~tio~ .~ 1® ~"'~ -~v, ~7. Lot Number ~,~ P~dl~ ~u~ % 8. Private We~ : ~illage ~.~v, ~ ~,~o~n~)~~X-~ 9. Public Water ~ 3. Public Water CompQp~ame '~'~"' ~'~f~ ~ Distance to main ~ 4. Lot size: Width IT) feet Length ()~feet lO. 11. Se~ge)Disposal System: AYe-gain septic tank: Precast Equivalent Block B. Leaching pools: Number of/pools / Precast )"/Block _Special If private well, fill in the roi- blanks: lowing A. Tank capacity gallons B. Pump G.P.M. C. Total well depth, D. Depth to ground water E. Amount of water in well (,Fo? 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 fQr one year from the date of approval indicated below and may be renewed if a current local Building Department Permit is in effect. Date _~ ~__~ [t]~ 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 Dispos~)q~)Syste~ and Water Supply can be installed on this plot. APPrOVAl DATE SIGNED S-15 Rev. 4/1/73 BUILDING DEPARTMEHT TOWN CLERK'S OFfiCE SOUTHOLD, H. Y. ..................................... , . / 7 9'Z_- ~ o ~..,, . v ~ ~,~o..~ .............................. ~/~ a/c .......................... ~ ................................................ ~a~--/-'~ ~ .......... ~ ........ ~;,;;~ ................................. · APPLI lNG ~te ................................ ,..,., ~...7.~ ..... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, with 3 sat~ of plans, accurate plot plan to scale. Fee according to schedule. b. PI0t plan showing location of lot and of buildings on premises, relationship to adjOining premises or public streets o~ areas, and giving a detailed description of layout ofpraperty 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 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 cnde, and regulatiom, end to admit authorized inspectors on premises and in buildings for necessary ir~mpectiont~ ..................... ......... i~i~natud';~';'~.,¢on..';; .... . ~f_ o*o~on> .... ......... 1~..~ ....... .~.~...~..&g ........ ~..rc...~..~.~.~ (Address of applicant) State whether applicant is owner, lessee, agent, architect, enginee electrician, plumber or builder. ""L"~'"~ ........... ;L' ................ ' ~4'~';'"":;· ....... ;'~'~3.'- .............. ;~, ...... '.?..~'~"~',";;~' ...................................... N ......f_.. erofp mses~ ................... ~ ......................... ~ ........................................................................... If,appjl'cant['~'""~i~'~ corl~rate, signature r.~..i..~ii..~.of~'iJly quthorized officer. '"~"~'"'iName andtitle of c%'~'r · o1' icerJ ......... ' Builder's License No .................................................... Plumber's License No ............................................... Electrician's License No....~...~~ .......... Other Trode's License No ............................................... ~1~',,"~. ~'- ,'""- //J,'/~k'~"-~" Location of land on which proposed work will be done. Mop No.: .'~.g/~/!.~:~.~..'. .......!..;.:~...:. Lot No. ?...'. ................... Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisitin. use and occupancy ....~.~..C-..~..~....~... ....................................................................................................... b. Intended use and occupancy ............ ~<....J..~.~. ................................................................................................... 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ...... .~.....,...i~ Repair .................. Removal .................. Demolition....! ...... : ........ Other Work ................................................ . .... 4. Estimated Cost ..........~.[.~..~..~..c~(~ ............................................................................................................. ' (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 ............................................................................ J .................... , ........................................... 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 .................... ~....TNumber of Stories "7 .........t .................. I 8. Dimensions of entire new construction: Front ...~ ........................... Rear ..(e.~ .................... Depth .~ .~..: .............. Height ..~.. ............. Numbqr of Stories ...... j .................................. ........~.../. ............................................. , .................. 9. Size of lot: Front ...~.~.~... .......................................... Rear ..... ~.~ ........................ Depth ]..~../~. ..................... 10. Date of Purchase ........................................................ Name of Former 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 be regraded . ........................... Will excess fill be removed from premises: ( ) Yes ~) No 14, Nome of Owner of premises ................................................... ~ Address ................................ Phone No. ...................... Nome of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor'~.U!~k)....g~......~. ................ Address Jl~.~j~,,~./l~orm No...~.~..~.~'.~L~ 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 s~reet names and indicate whether interior or corner lot. /\ STATE OF NEW ~6RK~J.,, COUNTY ~Of:~ ~.: ....... i.....~.~....°~/~(~'-~..-~.4~. ........................ being duly sworn, deposes and says that he is the applicon, (Name of individual signing contracf) above named. ~_ He is the ....... ~.~.O_H(~:I~...~... ..................................................................................................................................... (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 oil statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in thexnanner set forth in the application filed therewith. Sworn to before me this _~' Notary publ~~~*.t ·~ ................. ?'"'"~"'"i~Jn~ ....................... c, State of New ¥o~ No. 52-0344963 SuFfolk Coun \ ri ' 5C.~LE ~0~ Chief of C~:neral Engineering Services