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Home My WebLink About8200-zFOEM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office South&d, N. Y. Certificate Of Occupnncy No..Z69~7 ..... Date ............. March.. ] 9. .... , lg.76. THIS CERTIFIES that the building located at .3u~; .3~..~tanZey. ikt .... Street Map No. ~.~'~e~..~0~l~l~ck No ........... Lot No,~.~....l/~;,~.~.~.u.c..k...~.~.Y.,. ......... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... ~cp~c .. ~ O..., 19. ~.~ pursuant to which Building Permit No.. dated .......... ~]ep.~ .. ] 8... ~[ff ...., 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 . P.r.~va.~. aha .:~Ca~::~.~y. c~al~ng. ...................................... The certificate is issued to ....Roce.t~ .~. ~.ezla. G~ga~o .... ~qo~a ................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval · ~I~.. $9...].9~.~...by. R~..~.l& · · · UNDERWRITERS CERTIFICATE No. I~$~7.~e~2 .................................... HOUSE NUMBER . .. 2.~.2~ ...... Street..~an2,ey. l~.e.~cl .......................... Building Inspector~ TOWN OF SOUTHOLD BUILDING DEPART/~ENT TOWN CLERK'S OFFICE SOUTHOLD, N~, Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLF~TION OF THE WORK AUTHOR~Z£D) Permission is hereby granted to: ..~.~0. ....... ~;~.~...~L~y. .............. Se:yv.i.i.~e- to ....;.z: 6 3.;~...~ ~:~,. ¢~e.. · ~%~.~:fr...~h ee ~kl. ~..~ ~ .................................................................................. at premises located at .f~.~¢...~3. ....... ~Zi~'~'~'"?[t'O'Z2'~'"[f~'"~ ..................................................... ................................................. ~.~ e.¢...~,...~.~a ~ ~e?...~d ............ .i,~a.~ f~.i.'~e~ ................................ pursuant to opplicotion doted ............................ ~e~.....~ ....... :, 19..~[~.., and cpproved by the Building Inspector. FORM NO. S TOWN OP ~ Bul]din9 Department Town ~Cierks 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 fallowing; 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 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 '%'-~ ?- Permit Of Permit .................... t ............. ............................... Health Dept. Approval ........................................... Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Finaj/ Certificate Fee Submitted $ .................................... Construction on above described building a~ permit meets all~.plicable codes and regulations. Applicant .... ~.l~~...~'~ ~.~ .......... ~..~;..~. ............. Swo~n~)efore me this ~ ~/~// ........ o, Notary Public.~j~?_ ~., County~ FOR~ NO~ $ TOWN OF SOUTHOLD , Building Dep. rtment Tow. Clerks Offiee 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), Nan-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 i/ Date ................................................ New BHilding ~ Addi 'on -, Old or Pre ex'sting' Building .Vacant Land , ' ............... ........ Location Of Property ...... 7¢ ................ L..:..; .......... .: ........................ , ............ 7¢_...:. ..................................... . . ....................... ......... ': ......... ~uoaivision .............................. ~ ................................. Lot NO ............. Block No ............. r~ouse Permit No. Of Permit .....f..~:.X...L.~,Applicant ,:)/.:::,'.'.~:.LL....:..:..'.L....~.~L: ...................... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate Fee Submitted $ .................................... Construction on above described building and,permit meets all applicable codes and regulations. Applicant ....... %// ~. t~ .~;L~. ;:L...~C~.~. tZe~ .......... ~ .~¢w~,..~' .............. Sworn to. ~e~ore me this ...... l.~.,~ay of ..~.~....~.~. (stamp or seal) ~ ~//6 Notary Pub~;~ cNo°. ~? ".4~25264, Sn£~Olk County THE NEW YORK BOARD OF FIRE UNDERWRITERS C~]. ]~UREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 10038 THIS CERTIFIES THAT Hr. ~mrs. baxgano,mou~= bxae 5t~leX Roa~-s}w/cor. Stanley Road S~et Drive, Mattituck, L.I. .,....,,,.i..~,,. March 11. 19 7 6 a~dfou~ to be in ,.omplia~ with the requirements qf th~s Board, ........ [ ........ ~ ~XTURES RA~ OVENS H WA~S ~A~ ; : l 2 . 1 4 1 100 CB : x~ SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number~-/~<~G/ APPLICATION FOR APPROVAL TOCONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY Applicant ~/~ ~/~ Phone .5'~P-P.o~ 5. Subdiv. _~.>~ Address ~J~~,~ /~ .~o~//~,_~ 6. Section~ Property Location ~ ~ ~~~. Lot Number / ~ :-"'~8': Private Well Village /~y~, ~,c ~ 3. Public Water Company Name 4. Lot size: Width tz~feet 10. 11. Township '..~ ,,0 Length /~'! feet Sewage Disposal System: A. ~gallon septic tank: Pre~ast / Equivalent Block B. Leaching pools: .~ Numar of pools ( Precast~ Block__~pecial__ ~If private well, fill in the fol- ,lowing blanks: 'A': Tank .~Capacity/~?gall0ns B. Pump~ .P.M. ~'~' /depth C. Total" well D. Depth to ground water E. Amount of water in well 9. Public Water~% Distance to main (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 SERVIOES' USE ONLY. Bas:ed on the information presented here- with, it is the opinion of the Department of Health Services %hat an adequate and satis- facto~ Sewage Disposal System and Water Supply can be installed on this plot. S-15 Rev. 4/1/73 ~ FOjM NO 1 ~ ~f" ~ -- TOWN OF SOUTHOLD -,.'1.~ TOWN oLmc's OFFtC[ ~///-~'- ~,~-/~,T ........................... i ......../. Applic~tio~ No ................. .............. ................ ................ - ............................. ~~-~ ..... '~?~ '~'~%~ ~" "~%" '~% ~ ' ~ATIOH FOR BUILDIHG PEM~ ~, a. ~'b)~~ ~mpt~itte~i~ ~r or injnk ~ m~i.od ~ia~to the Building Inspector, ~3 ~tS of plans, accura~ plot plan to scale. Fee a~Qrding to schedule. ~%~-~pl~sh~at~ ~ot ~ ~gs ~s~r~&~ip to~i~i~s or public str.~ or areas, ~vi~ a detail~ descr~tion of~yout of pro~rW must be drawn on diagram which is pa~f'thi~ appli~tion. ~c. ~ wo~ ~vered by this a~lication may not ~ commen~d ~fore i~uan~ of Building Permit. ~d. U~n approval of this ~pli~tion, ~ ~ilding Ins~ctor will issue a Building Permit to the appli~nt. Such ~rmit .shall be kept ~n~ the premiss available for ins~ction throu~ut the work. e. No building shall ~ oc~pi~ ~ ~in whole or in ~rt for any pur~ whatever until a ~ifi~te of O~u~ncy shall have ~en gran~ by the Building Ins~or. APPLICATION tS HEREBY MADE to the Building Depa~ fo~'the is~n~et & ~ding Permit pursuant to the Building Zone~ Ordinanm of the Town of ~uthold, ,uffg~ CounW, NeW yor~,)an~ther a~e~-~n~ building, ~ditions ~ alterations, or ~or removal or demolition, as herein descried. ~'appli~nt agree to complyJwith all applicable laws~ ordinance, building co~, housing ~ , and r~ulations, and to admit authorized ins~ctors on ~mi~s and in ~ildings f~r ne~ary ins~ctions. (Sig~ture~ of a~li~nt, or na~, if a ~rporation) ............... ~ ~' %'. ' ~ (~dm~ ofappJ~nt) $mm wh~th~r a~lieant i* ~r, I*~, a~nt, are~it~, ~n~r~ ~tr~tor, ~l~triei~n,~ ~lum~r or builder. Name of owner of premi~s'c., r.~.~.....~ ................. , ..................... ~J .................................................................. If appl' nt is a corporate, sig ~ ure of duly authoriz[d officer. "J IName and title of ~~j~r) . Builder's Licen~ No..., ...................................................... P~umbor', Uce.. No ...... ~.~. ................................. Electrician's Li~n~ NO ..... ,~;~.~.~ ........................... Other Trade's Licen~ No...,...,,;, ........................................ 1. L~ation of land on ~ich pro~ w~k will ~ done. Map No ...... ,..~. ......... :..,...4~ot ~,., ............. Str,t and Num~r ...... ~.~'....~.~.~....~..~..~.~..~ ~...~..."...~~'~".-- ~ ~ -- ~'"~ -- ~ ' ~ ~~P~-- ~ ~ ........... ' ~ ~; ~ ~ ,/:; ' MunicipaliW 2.Stat exi~ing u~ and o~u~ncy of premiss and intended use an~ ~cupancy of propo~d '~onstruction: a. Exi~ing u~ and ~u~ncy..., ....................................................................... : ........................................................ -. ............... b. Inten~d u~ and ~u~n~ ...............................................................................~..~.. · I 3. Nature of work (check which applicable): New Building ....................... Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work (Description) ... Fee . Z. t:.. .................................................................................... 4. Estimated 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 cars ........................................... ; ......................................................................................... 6. If business, commercial or mixed occuoanc¥~sl~ecify ~at[Ire'and extent qf each Wpe 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 .............. '. .............. .~.....¥..L Number of Stories ........................................ 8. Dimensions of entire new construction: Fr0~t .:...~..~.'~ ....... ?.. Rear .....Z...~. ................ Depth ...... · , t/ Height ........... /.~. ................................ .Z'....~1~. Number Rear°f Stories J /....../. ":~: .................................................... Depth _4'- ' .............................. 9. Size of lot: Front ....... ................... ....... ...... .................. ...... ....~..~... ............................. of Purchase ..,...~.....4~.....~....../.~.~....~..... Name of Former Owner ...~..~.~'......~...~T......~.~...~'~.~.~]a~.~.~.,~'~V~. 10. Date 11. Zone or use d s?ict in w,h~h premises are situated ..................................................................................................... ! 12. Does proposed cons~ru~ic~n violate any zoning law~ ordinance or regulation: ........ ~....~. ........... 1 ........... ~' ............... 13. Will lot be regraded ./~...~......,, ............ Will excess fill be removed from premises: [ ,] Yes [~] No 14. Name of Owner of premises ...... ~.~..~..~;.~......~...~.-O~c,.~;~.~.~. ,~..~.:.......~..~'.~..!.~...~.~.~ ........... __ . -- .-- (Ad{Iress~ ~ ~ il'none mo.~ Name of Architect /~....~././.~ ....... .~.R.~'_Zx?.~ ........... ..~.~.~.~.4¢~.~..~.~......~--~.. ....... ...~..e...~...~.~.~ .~......~.. ........ ~ (Ac[dress) · _ [Phone No.) Name of C~o~ntractor ...7.~.~.~.~.~.........~..~[~..~..~....~.~,,~....(Ad~dress~.).4..~f~....~...~.....~E.h~.i~_ _~'~ __ ~/ ~._]z~ , ~ PLOT DIAGRAM ~)~ U Locat~ ~arl¥ and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. G~ve street and block number or description according to deed, and show street names and indicate wheth- er interior or corr er lot. COUNTY OF ....;[....~....) ........... ~~ .......... being duly sworn, deposes and says that he is tt~e applicant above named. He is the ................ .~,~---Z..~1~..LZ.~..J~,.~......~ ............................................................................................................ {1 ~U~ntractor, 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 all statements contained in this application are true to the best of his kno.wledge and belief; and that the work will be performed in the manner set forth n the ap~ cat on f ed therewith ~ '. \ ~ ~-~ ............. o, Notary 1~~~.~...~.2..':.~l~t3fi~,..Suf~/k ~ey . ...~....[.~ .................................... .'~.........~..//. ............. -/.. ................ ~ ~ ~ ~ M~a ~0, I976 (Signature o.f applic F~O'Ap %0 ~=MONUMENT sue~/ws/o~ M~ ~tco /s ru~ osRc~ o~ AND/OR FROM DA~A OBTAINED FBO~ OTHERS :THIS SURVEY IS A VIOLATION OF LANO ~V~;~[&~I~.~I~O~ . ,CaT~ ~W, ~ffg~ ~0~ '~'"' sU~ co,..~ - ~m~ ' u~j/..~- , ,_ .,' ~ ~. .. . .... ,I AppROvED AS NO~ED- DATE: ~ ( ~ "~ ~ EEE: 7'7 ~ BY ~ 765-2660 9AM TO 4PM FOR REQUiA- ED INSPECTIONS: 1. 'BEFORE BACKFILLING FOUNDA- TION OR START FARMING 2. BEPOAb COVERING PIPELINE 3. FINAL WHEN JOB COMPLETED NOT RESPONSIBLE FOR DESIGN OR ~ STRUCTION ERRORS :1 ~rOMARK CONSTRUCTION INC. 5250 SUNRISE HIGHWAY S~YVILLE, IqEW "fORK 11782 LT 9~2030 '$uN~tsg · OMA~I< CONSTRUCTION ]NC ~AYWLL. r:, NL'W YORN 11782 ET 9-2D30 , / 52~0 sUI~RI CF',4D f::L5 i i ,, LAY /~ L/©, t TOMARI< CONSTRUC'FiON INc 5250 SUNRISE HIGHWAY SAYVILLE, NF~W YORK 11782 LT 9-2030 il'-B"t 5;0. 8532 I