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Home My WebLink About7723-z FOI~M ~0. 2 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE $OUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~,E~ISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 7723 Z Permission is hereby granted to: ................. ~:t.e,~t; ............................................... ro .................. at premises located at .......~.Z'.~...[':;~;],~,..~Q&..~t, ..................................................................................... ............................................................ ~J.:e £:.¢~t~ ...... ~.,~.,~,~ ..................................................................... / pursuant to application doted ...................... .~f.~. ....... .~.~.ff: .............. , 19.~.~..., and approved by the Building Inspector, Fee ~'.',:t *. ~.Q ............. Building Inspector FORM NO. $ TOWN OF $OUTHOLD , 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 natural or topographic features. 2. Sworn statement of owner or previous owner as to use, accupancy 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: i. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or rand use $5.00 3. Copy of certificate of occupancy $1.00 Date New Building ................ Addition ..... /~'. ....... Old or Pre-existing Building................~ Vacant Land .............. Location Of Property ......~Z~.......:~...~ ....... ..~...~~...,..~..:...~_~: ...................... Owner Or Owners Of Property..~.~..~.~...~. ........................................... Subdivision ................................................................ Lot No .......... ... Block No ............. House No...~.....~....~.. Permit No. Z ~...~'....~.....'.~:.. Date Of Permit ...~.Z.//Zz.Z?.).-Appllcant ..~ ..~....~.....~...~...~ Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ FinQI Certificate Fee Submitted $ .................................... Construction on above described building and permit meets all applicable codes and regulations· Appl,cant ................... .(,~.¢ ...... ... ,.~y4 ....~. ~dc~cff~¢~.~ ....................... ,...:... ~, ~*~00 Su~l~ Count~ SUFFOLK COUNTY DEPARTMENT OF HEALTH Health Department Reference Number APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY t. Applicant~il~',~?}//? ~,,~, ~,~P~one 5. Subdiv. ........ · '~'~ 6. Section Address ,-~ ~, , ~ ~, ~. ,~, 2. Property Loa~6tion c ~ /,/$~,,q ~?j_~ ~x~,o ~. ~ Fj~ y~; ~ /. Lot Number ,.~ ~ ~ ~fJ .... ~. ~ ~ ......... / 8. Private Well~,~S ~f~l 1 a~e/ ~ ~)~'r, ~ ;.,; '~ ~ ~' 3. Public Wat6r Company Name 4. Lot size: Width~feet Length~feet 10. Sewage Disposal S9~: '~ (Fur Health Dept. Use) ll. Precas~fEquivalent B. Leaching pools: Number of pools L~ Precast_~ck .fipecial 900-gallon septic tank: Block If private well, fill following blanks: A. Tank capacity B. Pump G.P.M. in the gallons C. Total well depth ,i~ /x D. Depth to ground water E. Amount of water in well The undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Health's 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 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 canfbe/"installed on this plot. E~D"~'---)/t~~ /q UJ~ APPROVAL DATE ~ /~ '~ .~ SIGN ~- S-15 Rev, 4/1/73 ~