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Home My WebLink About7679-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's O~fice Southold, N. Y. Certificate Of Occupancy No. ............ Z6380 Date ............. .March .........26..., 19.?~. THIS CERTIFIES that the building located at .The.~esa. ~. Rinhard ....... Street Ck Est Map No. D¢:~, iL~le Block No. ,Lot No, 6 conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ .J.~n. .... 6.., 19..7.~. pursuant to which Building Permit No....7.679Z dated ........... .~'?..n. ..... 6.., 19..7..~, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is Private one family dwelling The certificate is issued to .. Nichloas. l~M. tha.v~u ....... .~nea~, .................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . ~f~.~.. 2.6..19Z~ .by. ~,. ~r;Llla ...... UNDERWRITERS CERTIFICATE No. ~.o~d.$r~g .................................... HOUSE NUMBER .... .~ .6.~.Q ..... Street..T.l'te.~'.e.s.2 ...D~,. ............................ ...... ..... ........ Building Inspector FORM NO. 6 TOWN OF SOUTHOLD , Building Department 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 all property lines, streets, buildings and unusual nature[ 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 formation required to prepare a certificate. C. Fees: l. 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 ......... ~.l~/.1~.?.~ ................. New BHilding ....~ ......... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property .... .'l~h~ce.sa...D~r.~.~z~,..~a.t,£.£~ei, r..~e.~..¥.a~ .............................................. Owner Or Owners Of Property ....... Bl;t~.ho.],a~...F,...l~..].~,e~,..N~tb.v~n ................................................... Subdivision ...~a~...~Z..,,Qe~.~..~m[e...~'.e. ek,..~.s~.et No.....6...../B~oL~N~o.°.;.....4...2..?~ouse No ............. Permit No ..................... Date Of Permit .................... Applicant Health Dept. Approval .......... ~c ................................ Labor Dept. Approval ................................................ Underwriters Approval ............ ~. ............................... Planning Board Approval ........................................ Requ,~st For Temporary Certificate ........................................ Fined Certificate ............. ~. .......................... Fee Submitted $ .*.~)~.O0 ........................ Construction on above described building and permit meets oil applicable ¢pcles and regulations. Geor~.~. ~ ,., Ablera~t)~ l~er, .thc, Applicant ......... ~.... ~:~ Sworn to before me this 26th ................ day o~~,...~,9~ ............ (stamp or seal) SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services . Reference Number 'APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY .... lrbepho~e 1. Appl icantG~e ~b,~e:~s ~de~. Phone 5. ~u~a~v.~ Address2~ ~x l~m~mt ~e 6, Section 2. Property Locat/,on.~e~,mma ~'~v~,~, ~,. m~ ~m~,~j~7,. Lot Number ~ 8~ Private Well_~k~ Village ~e~ --~~9. Public Water_~_ 3. Public Water Company Name ~ .... ~~tance to main 4. Lot size: Width I0~ fee~ Length~,,~feet -- 10. 11. Sewage Disposal System: A. ~O~-Qallon septic tank: Precast ~ ~quivalent Block B. Leaching pools: Number of pools ~ Precast ~ Block ~pecial__ If private well, fill in the fol- lowing blanks: A. Tank capacity. ~ .gallons B. Pump G.P.M. ~ C. Total well depth D. Depth to ground water Eo Amount of water in well 4O (F,or Health Serviles ~i~t, Us_~e) The undersigned CERTIFIES: "Construction o~authorizediinstallations will be'in accordance with the Suffolk County Department of Heal th 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 Permi~ 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. APPROVAL DATE //,~.,///~ ? _ SIGNED (~- ~ S-l~ Rev. 4/1/73 ,[ APPR(;~/ED AS NOTED D^'~: ~ ~,.,"~ ,~-"" FEE: ~:~,Y'li~ ~ NOTIFY BUILDING DEP~ATM~NT AT 755-2660 9AM TO 4PM FOR ~EQUIR. ED ~NSPECTION~: ~. BEFOR~ BACKFILLING FOUNDA- TION OR START FRA~',ING 2, BEFOR~ COVERING pIPkLINE 3, FINAL WHEN JOB COMPLETED NOT RESPONSIBLE FOR DESIGN OR STRUCTLON ERRORS