The URL can be used to link to this page

Home My WebLink About8184-zFOBM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Ot~ice Southold, N. Y. Certificate Of Occupancy No.3688~ ....... Date .............. ;:~.eb....9 ..... , 1976 THIS CERTIFIES that the building located at . .~ ./8. ~.~: .~.a.g..~ ........ Street Map No. ~ ........ Block No...~t~; .... Lot No, . .~.~....I?~..~.O.~.i.~... ~:~: .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated .J~ep.~..~1-19 ~.~pursuant to which Building Permit No. 81 dated ........... $.~p.~...8 ...., 19..~.~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is .. Eri.vate. O~e. I~,~Y..~.e..~.~.;14a. g ..................................... The certificate is issued to . i F~.ar~..& .lg~..~.~o~'..R.~&~. ~.~.~ .~ .............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .~.~.a....~ 1971~ l~t R, UNDERWRITERS CERTIFICATE No...~.~,~?.~.8.~. .~..1~.. 28 1976 HOUSE NUMBER ... 21.0 ....... Street ...$pr. iz~g..~.e .......................... ~OI~V~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S oFFICE SOUTHOLD, N~ Y. BUILDING P,ERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 818 Z Permission is hereby granted to: ~'~.~r~-or-"~c,~O.'-'~'Z'O.~"~o~"--'A~"~z-~"~'~ea~ey .......... ~ ;'-' [{'o~ -' {~ e.~ ............ C~ r~'"" ?~' ~'~' ~'" at premises located at -.-,.~/~.-&p~'-~...~,e)~ ................................................................................... ..................................... :; .............................. .~e~ .......................................................................... pursuant to application d~ted ............................. ~e.p~ ....... .~ ....... , 19~..., and approved by the Bui{ding {nspector. Fee $.~-i6.~2.~ ........... 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 f~, ~/~, Phone ~-q~ 5. Subdiv. Address ~ ~ ~, ~,~ ~ 6. Section 2. Pr~p~rt~ 'Lo'cation /~ ~'~ ~ /~/~/~ ~. Lot Number ~ ~ ,~/~ '~ 8. Private Well Village Townshi~~' 9. Public Water 3. Public Water Company Name ~ Distance to main 4. Lot size: Width ~feet Length ~ feet 10, 11. Sewag~ Disposal System: A. ~O~allon septic tank: Precast m~'Equivalent Block B. Leaching pools: Number of pools ~ _ Precast ~lock__~pecial__ I_~ privet, well, fill in the fol- :~owing ~-~nks: ~?Tan k~--c-'~ p a c i ty ~, ~/.~i ? To ~a~'~w e 11 depth. ~ Dep~' to ground water ~'~E~ Am of water in well (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. ===================================================================================== 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 ~d Water Supply can be installed on this plot. SIGNED __~ S-15 Rev. 4/1/73 ~/ 1_/~ ~(~'c~'~ ( ~f(l~_~. ..................... ~e ............... .~. ..................... , 19.~ ~ IN~I~ ~uild~ Z~ O~i~e of the T~.of ~, ~lk C~, N~ Yo~, a~ ~er ~ ~,~ ~i~ or~- K~ulat*~s, tar t~ c~st~i~ of ~ddi~, ~it~ or a~mtl~s, or ~r m~l or ~th~, ~ ~mln ~d~ ~ ~e apphcant ~s to c~ly wi~ all ~licable I~, ord~, ~lldi~ c~, h~i~ ~, ~ ~l~i~, a~ ~ admit au~Hz~ in~ ~ pmmi~ ~ in ~l~l~ ~ ~ff I~ti~. ................... (Signature of applicant, or name, if a corporatlo~) (Address of applicant) / State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ....... ............................................................................................................................................................ Name of owner of premises ....~,.Z~'~.~/. ,~.,,...'~.. If applicant is a corporate, signature of duly authgrized officer. .... (Name and title of corporate O~1cer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............... 1. Location of land on which p~ work will be done. Map No.: ........................................ Lot No ......................... Street and Number ..~'.~,~/~..~... ...... ~/~./~..~. ............................................. ~ .................. ................ : ...................... 2. State existing use and occupancy of premises and intended use and occupancy of propaeed camtru~Jon: a. Exisiting use and occupancy ......... /~..../~1~..~..~ ...... ..~..~.~. ................................................................ .......... use and occupancy ...... ~.~.~.. ........ .~.j~.~..A..~.. ........ ~)...~...~..(.,f~.Z' .~...~.,~...., ............................. b. Intended 3. Nature of work (check which applicable): New Building. ....... /........... Addition ......... ...... ... Alteration ................. Repair .................. Removal .................. Demolition .................... Other Work ..................................................... .,,-~ ~ . ~ ~'~' 70 (Description) 4. Estimated Cost ...... ~.~...:~,~a'.. ............................... ~-ee ....... ~"~'ii'i'~"~'l~i~"~i~i .................. S. If dwelling, number of dwelling units ....~.4~..*C.. ......... Number of r~welling 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 .......... arum ......Number of Stories ....... ~ ..................................................................................... Dimensions of same structure with alterations or additions: Front...~. ....................... ~ Rear ............................ Depth ........... ~ ............. Height ............................ Number of Stories ................................ ~j~l~ens,ons of entire new construction: ~Fro~t .~llp,j~..~%~... Rear "'~'tl~"~ .......... Depth "~"~r'~r ......... ~g~ .~...e.~.~l~r of Stories ...... al~,~... .............................. : ................................................................. ~%~of at' Front ~, Rear ~ ~ Depth . # . ...... ~ .~ ............................................. ~ ............................ ..~.¢ 6~ ............... 10.- Date of Purchase " ~ ~" ..~ffr~z~4......~.~..~:~ .............~ame of Former Owner ....................................................... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... ~le~~. ....................................... ]3. Will rot be regraded ....~,T:~ ............ Will excess fill be removed from premises: ( ) Yes ~ 14. Name of Owner of premises ~,e~,~.~,/~e~q~t~6~(~....~e~~~t.~ ............ Phone No. Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor PLOT DIAGRAM (_~A~ · .~ ,.,.~' 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 whethe~,d~Lq~ br corner lot '~TATE OF NEW YORK, ~ ' ~:OU~TY OF ............... ., ...... ~ ...... ~.S.S ~....~.~.~~~~ .............. being- ~g'y,~rn, ~q~ says t~, he is the applicon, ~NO~ o a' ~oual s~g i~g c~tmcr) ' ' ' , .e ........ ........... .................... (Cont~tor~ agar, c~at~ affirm, etc.) of said ~ner or owners, and is duly authorized to perform or have performed the ~id work and to ~ke and file this application; that all ~ate~ts con~in~ in.:th~ application ar~,t~ to the best of h~s kn~ledge and belief; and thor the ~ork will ~ ?~fo~d in t~ manner ~t fb~h in the applic~[o~ f~ t~r~ith. Swom~fom meth,s /1~ ~ ~ ~ .......... ...... ................ 1 / N~oW ~lic, ..... ~~ ....... ~ ........... ~n~ ... ~~..~T. t.~,~~ ................. LINES ARE FOR A SPECIFIC PUR- PARED, AND ON HIS BEHALf T0 PROPERTY OF UNAUTHOMZ~O ALTERATION OR OWNERS. fH~ NEW YORK STATE ~DUCAT'ON SURVEYOR'S GUA~NTEED~~NLY tO~ -- bOOk &'Page ~R 0 N -T Y/.£ V,-) t¢4 ~ z.