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Home My WebLink About7739-zFORM NO. ~ TOWN OF $OuTHO~D ~ BUILDING DEPARTMI~NT TOWN CLERK'S OFFIGE SOUTHOLD,-N. Y. BUILDING PERMIT: (THIS PERMIT MUST BE KEPT ON THE PI~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7739 Z Permission is hereby granted to: !.~t.~ ituck at premises located at Building Inspector. Fee S~..;~ ............... Building Inspector TOWN OF SOUTHOLD , Building Deportment 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, 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 Date .... .H...~.~.....8.., ... ~..g..7...5. ................. New Building ..... .~.. ........ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ~B/.~..M~.~.a.~q.o.~.~...i~.o.~.d.~....M,~%.~.~..~.~g..k.~.....~.~W...Y..o..z.~ ...................................... Owner Or Owners Of Property ...,~,~.,~.z...1..e.§....~..:...-~.~..s..~..a.~...,.~,~.*. ................................................................. Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..7..7...3..9...Z. ........ Date Of · Mar, 4,75 INLAND HOMES, INC. Permit .................... Applicant .................................................................. Health Dept. Approval ...5. r..7...-.7...5. ............................ Labor Dept. Approval ................................................ Underwriters Approval .....4..-.~.T'..7...5. .......................... Planning Board Approval ..~ .............................. Request For Temporary Certificate , no ................................ Final Certificate .... .y.e,s .............................. Fee Submitted $,~....0...0. ......................... Construction on above described building and permj, tcn~eets a_ll applicable,codes and regulations. Applicant ......................... [~enneth W. Thuzbez, Sworn to before me this ........... . . oyof ....... ....... Notary Public ..... ~/~.~.~.. County INLAND HOMES, (stamp or seal) ~UFFOLK COUNTY DEPARTMENT OF HEALTH Health Department Reference NUmber APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant ~ '"'~ ~. I,-! Phone Address 2. Property Location Village '~ ~ ~ 3. Public Water Compa~y,Name 4. Lot size: WidthJ,>,,S feet lO. 11. Townshin ' ~-', Length :.: (.:- ,~ feet 5. Subdiv 6. Section 7. Lot Number 8. Private Well ~9. Public Water Distance to main Sewage Disposal System: A. <~?gallon septic tank: Precast~ Equivalent Block__ Bo Leaching pools: Number of pools Precast,/,~ ~ Block _Special If private well, fill in the following blanks: A. Tank capacity :/ -. gallons B. Pump G.P.M. ,.~ C. Total 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 ~n accordance with the Suffolk County Department of Health's current gtandards 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~ · /-' Date 2 /" / ~,~ Signed ~ / ~ ' ~ FOR HEALTH DEPARTMENT USE ONLY. Based on the informa]ti~n presented herewith, it is the opinion of the Health Department that an adequate and satisfactory Sewage Disposal System and Water Supply can/be i~qstalled on this p~oto /~ /~ ,¢~ Examined .... ~ ............... ~ ......... , proved ................. ......... ...... , p,,rm,, No. Disapproved a/c ............................................................................................ (Building fnspectorJ / APPLICATION FOR BUILDING PERMIT INSTRUCTIONS '~- a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building~ Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. -, b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets o~/ areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this oppiication.~" c. The work covered by this application may not be commenced be(ore issuance of Build ng Permit. ~. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit~ shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. ~,/ APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or/ Regulations, for the construction of buildings, additions or alterations~ or for removal or demolition, as herein described./ The applicant agrees to comply with oil applicable laws, ordinances, building code, housing code, and regulations, and to/ admit authorized inspectors on premises and in buildings for necessary inspections. / (Signature of applicant, or nome, if o corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nome of owner of premises .............. ~ .................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ..... ~...~.,..'.~.........J~... ................... Electrician's License No...r~.....¥..h;~....~.~: ................. Other Trade s License No ............................................... I cat.on of land on whmh re osed work dl be done Ma No ...~¢,.~ ..%..~ L t 1. ~o ' '~ p p w' .,, p .: ............. :~Lo No ......................... Street and Number .. ...... ....................... ...... ............ .............................. 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: Exisiting use and occupancy ............................................................................................................................. Intended use and occupancy .............................. 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ................ Repair .................. Removal .................. Demolitiar. .................... Other Work ................................................ . (Description) 4. Estimated Cost .........~::Z.~..,....°...°...q .............................. Fee .......................................................................................... (to be paid on filing this application) 5. [f dwelling, number af dwelling units ........ ~.', ................ Number af dwelling 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 af existing structures, if any: Front ............................ Rear ................................ Depth .................... Height ........................ Number af Stories ................................................................................................................. Dimensions af same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height .......................... .;Numb~er of Stories ............ ~ ................... 8. Dimensions of entire new construction: Front ..... .~....~, ................ Rear ..,,,,~'T~.,. ............. Depth ....'.~-...~.. ............. Height ...~/..?.. .......... Number of Stories ...... ~ ........................................................................................................... 9, Size of lot: Front ....... -- ~'/...'.~... ................................... Rear ...... ,J....~...~ ....................... Depth ....8....O.....~. .............. ]0. Dote of Purchase ........................................................ Name of Former Owner ........................................................ l ]. Zone or use district in which premises ore situated ..................................................................................................... 12. Does proposed construction violate any zoning law~ ordinance or regulation: .~ .............................................. 13. Will lot be regraded .....~ ........ Will excess fill be removed Cram premises: ( ) Yes ¢X~ No 14. Name of Owner of premises ..,~..[~ ....... Address ..~,~....-~..... Phone No ....................... Name of Architect ........................................................... ~,, ...,..,~..-..-..- Address ................................ Phone No ....................... Name of Contractor ..'~.~,¢,~..~ ............. Address ~ ..... Phone No ....................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions frarn property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW/~QRI~,/,,///~ ISS COUNTY OF~~......~.../.%¢ ' ................................................................................................ being duly sworn, deposes and soys that he is the applicom (Name of individual signing contract) above name. He is the ................................................................................................................................................................................. (Contractor, 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 fife this application; that all statements contained in this application are true to the best of his knowledge and belief; and thor the work will be performed Jn the manner set foRh in the application filed therewith. Sworn to b~¢~e me this ~ ~ ~ ............ ....... ....... ........... - (Sig~m~ o~li~ ,,, ri" '~-'-"UED AS I',O 14.d 1¢].4''