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Home My WebLink About8177-zFOJLM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No, .~.~.~.~.~ ...... Date ............ .J.a~..~.~..~...~ .... , 19..~.6. THIS CERTIFIES that the building located at . R,~.W-, .S/8..Ba~lew. ~a~treet Map No.~ .......... Block No. ~ ....... Lot No, ~... R~l~.. ~,Y, ......... conforms substantially to the Application fo~ Building Permit heretofore filed ~ this office dated ............ AUg...2~.., 19.7~. p~suant to which Building Permit No..~1'7~.. dated ......... ~e~l...3 ..... , 19.7~, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is The certificate is' issued to .H~F~ .~d~b~ .... ~F ............................. (owner, lessee or ten~t) of the aforesaid building. Suffolk County Department of He~th Approval . ·. ~. ~..]-976.: .by B,. V~lla ..... UNDERWRITERS CERTIFICATE No..~6~0....Q~...~...~97~ ............... HOUSE NUMBER .... 265 ...... Street ... ~et~ .L~e ...................... Building Insp~ TOWN OF 5OUTHOLD 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) 8177 Z Permissio~ is hereby granted to: ....... l~.3....~,...~,..a~..,,v~....C, ea~e.~.eaob ..... m bg.;LL~,..~e~...o~...~a~LL~...dwalli~g ...................................................................................... at premises located at .~Le.~.n.....~.~..,~te~...~n=~. ................................................................ ................................................................ &o~tl~et~l-...-~,-r ~., ............................................................... pursuant to application dated ..........................~.l~g....~.br. ............ , 19~.~..., and approved by the Building Inspector. Fee $.1.0,.,Q.~. ,,~.Q ......... Building Insflector ~ FORM NO. 6 TOWN OF SOUTHOLD , Building Depa~tment 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 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 oil property lines, streets, buildings and unusual natural or topographic features. 2. Sworn ~tatement 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: ]. 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 ..... .: ......... O d or Pre-ex sting Building Vacant Land Locaton Of Pro er, {~ ..~..,' ¥..~.Z ~~_~5,~---~ ~,~/- py .... ..................... , · ........................................ Owner Or Owners Of Subd v s on xj · ' ' ' ......................................................... Lot No ...........Block No ............. House Nd~.[.~.,...~'~ Permit N~./...~....~Z~ate Of Permit .................... Applicant ~.. ~.~..~...,~?~..~ ................... Approval ..~ ............... Labor Dept. Approva Health Dept. Underwr ters A rova ~ · PP .... .~ ................................... Planning Board Approval ..... Request For Temporary Certificate ........................................ Finczl Certificate Fee Submitted $ ...... ..~....~... ..................... Construction on above described building and permit mee_ts ~111 ppplica~le codes and regulations. Applicant Sworn to before me this ............ d , o .\:,... .............. ~ ....................... -, (stamp or seal) THE NEW ,YORK~ BOARD.'OF FIRE, UNDERwRILEI'<b"? ,' 85 JOHN STREET NEW,YORK NEW YORK 10038 the el~trtcal equtpment ~ ~scrtbed be~w a~ introduc~ by ~ appJtcant ~ed on ~ above appl catto~umber Jn t~e prem~es of Gr~l Homes~ e/s/o E~z~et~ E~O~,m 20O~s/o ~n ~y~ew ~.~, .. RECEPTACLES SWITCHES 3o SUFFOLK COUNTY DEPARTMENT OF HEALTH Health Department Reference Ntimber ~_3~ 6 - / / ~ APPLICATION FOR APPROVAL TO~CONSTRUC~ A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant ~ ~ Address 2. Property Location Phone Village Public Water Companj Name Lot size: Width feet Township. Length ' feet 5. Subdiv. 6. Section <7. Lot Number 8. Private Well 9. Public Water Distance to main lO. Precast .Equivalent Block B. Leaching pools: Number of pools ~-~, ~, Prec a~ ,~B1 ock Special ll~!~:f private well, fill in the }~.~ol 1 ~ng blanks: ~.~. T , capacity gal 1 OhS ~ B. G.P.M. :'; C. ~al 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 Standardslthereto. 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 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 pl, ot. APPROVAL DATE ¢/'~'/~'~,/~ S!GNED S-15 Rev. 4/1/73 rl If. ~/~"~ x~ ~ . This a~lic~i~ mu,, c~ple, ly fill~ i~pewriter oc.~ i~ a~ a. In~or, wi~ 3 ~ of pl~s, accu~ pl~ plan ~ ~le. F~ a~.~ to ~h~ule. b. Plot plan shying I~ation of lot and of buildings on premiss, relationship to ~joining premiss or p~lic stree~ ar~s, and givi~ a detail~ ~ription of I~ ofpr~ must be drown on the diagram which is c. The work c~r~ by ~is a~licati~ ~y n~ ~ commenc~ before i~uance of Buildi~ Pe~it. d. U~ appr~al of ~is a~li~ti~, ~e Buildi~ Ins~tor will issue a Building Permit to the applicant. Such permit shall be kept ~ the pmmi~ ~le for In~i~ th~h~t t~ ~rk. e. No building shall be ~cupi~ or u~ in ~ole or in pa~ for any pu~e wh~er until a Ce~ifica~ of ~cupa~y shall have ~en granted ~ the Building In~r. . APPLI~TION IS HEREBY ~DE to the Building ~ment for ~e i.uance of a Buildi~ Pe~t pum~t Building Z~e O~i~nce of t~e T~n of ~hold, ~lk Count, New York, and ~her apphc~le ~, OMt~nc. or R~ulations, for the constru~on of buildi~s, oddities or altemti~s, or for m~al or ~moliti~, as ~min d~ri~. ~e applicant ~r~s to comply with .all a~licable I~, ordina~.~lldi~ c~, h~sl~ ~e, a~ ~latl~, a~ admit authoriz~ in~o~ on pmm,~s ~ i~ buildl~ ~~s.. ........................................ ...... (A~bf applicant) State wh~th~r ~pplic~nt i~ ~n~r, I~*, ~nt, a~hlt~, ~n~in~r, Oen~ml c~troctor. ~lectrici~! plumber ..... ..................................................................................... I{ ~pplicont i~ a co.orate, ~i~n~tur* o{ duly ~uthori~ed officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No. ~.~.....~........~... ....................... Electrician's License No....~...~..L...~.. ..................... Location of land on which prolx2se_ d work will be done..Map No.: ....................... Street and Number~l~..-,,~.~/.~i~.C~.'.~'~',d-~.C~..J..~//....o~.~2.c~..~. 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 ..... ,.~.A~_,41~ ...................................................................... 3. Nature ~f work (check which applicable): New Building .......... Addition .................. 'Alteration ................. Repair.~ .................. Removal .................. Demolition .................... Other Work ..................................................... (Description) 4. t,m ed Cost ..................................... ............................................................. (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 ~ ..... ~ ................................ ~ ......................................................................... ~ ....................... 6. If business, commercial or mixed occupancy, specify nature and extent of each ~e of u~ ............................ 7. Dimemsions of existing structures, if any: Front ..~ ....... Rear ................................ Depth .................... Height ........................ Nu~er of Stori~ ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................R~r ............................ ................................ Stories ................................ ~___ e~~ ~ Depth Height ............................ Number of 8. Dimensions of entire new construction: Front .~ ...................... Reor~ ................ D~t ........................ Height ..~../. ...... Number of Stories ..~ ......................................................................................................... ~ 9. Size of lot: Front ...~.~ ........................................... Rear ..... ~.~.~ ......................... Depth~.~.~..~..~.~.~ ..... 10. ~ote o~ ~urchas~ .... ~ .......... ~om~ o~ Fom*r ~n~r ........................................................ 11. Zoneorusedistrictinwhichpremisesaresituated ..... ~. 2;~i~;;2~ ................................................. 12. Does proposed construction violate any zoning law, ~;~' ~, ......................................................... 13. Will lot be regraded ....~: ....... Will ~cess fill ~e removed from pmmis~s: ~Y~. ~ ~_ ~ Name of ~ner of prem~ ~ ..... A~m,~...~ ..... Name of Architect A~re~ N~e of Contractor i..g.~...~.: .... ~ ....... , .......................................................... PLOT DIAG~M Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all ~t~k dimensio~ from prope~ lines. Give street and bilk number or description according to d~, and show street names and indicate whether interior or corner Jot. STATE OF NEW.~..R,J(.~, - ,- - ~.SS COUN'n' ' ....................................... ~3(~...~',~,~,~',(;.~. ........................ being duly sworn, deposes and says t~t he is the appJicam~ (Name of i~ividual signing c~tra~ a~ve name. He is the .................................................................................................................................................................................. (Contractor, ~:~t, cc~:r:t; ~f;~,, ~;~.) of said owner or owners, and is duly aut~rized to perform or have per~ormed the said work and to ~ke 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~erewith. Sworn to ~fore me this ~ ..... ................... ........ ... ....... ..................................... ~ ~- (Signature of applicant) NOTARY PUBLI~. St~e of New No. 52-~522026 - Suffolk CounW~ Cemm~ssie~ ~xpire* March 3~ ./ ~c~ ¸AT