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Home My WebLink About7765-z ~oa~ ~o. ~2 TOW. oF SOUT' , BUILDING DEpARTMent TOWN CLERK'S 0FF!GE SOUTHOL:D, hi:. Y. BUILDIhiG PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: .......... S~uth~l~ ................................................ .~. to ~til~l ..maw...one.. ~ily... ~w~.l lir~g .................. ................................................................... at premises located at ~l;~,,.~..~.,~(~.~.9..~/.~r~.....~.l~.h~'ir$1t ......... ~ ............................................ .............................................. .~ .~...S.~..~..v..~ ............ .qr.~.e~.~.~.t. ...................................................... pursuant to application dated .........................~?.. ......... .~,.~....~....., 19.?..~..., and approved by the Building Inspector. Fee .~12 ~. ~..Q ............. BUilding inspector FOEM NO. $ 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-ex'st'rig ' 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: 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 .u.L '.{. ...... 1.9. New B~itding ....~... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ..... .~..~..~Z Z ~)./.~..~..~. Owner Or O ners Of Property ...... .L ......................... Subdivision ._..O....~.._~..~..~.~ ...... .~.(.~?....~r..~.....:......Lot No.,~.~.~..~.. Block No ............. House No..~.~.~... Permit No. ~../~.~.~...Z Date Of Perm ~/~,~'~...Applicant ~.~.?...~..0...~.&g ~.e.~..~ . ~..~.~..: ....... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval ...~.~J.~...~.......~,....~.~ .............. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fin~ Certificate ....~ .............................. Fee Submitted $ ....,~......~.~(. ................ C°nstructi°n °n ab°ye described building~lpermit meets ~DP~-Iica~le c°d~gulati°ns'Applicant ~.,~/--~/,.~ S,¥om to before me Notary Public ......~~..;~...'fi-';/'~;~ County (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 1. Applicant]:o~,)~ ~m~5 ~)h~r.,Phone~b~~,~.)~eO , 5. Subdiv.$~ Address.!~ ~,~m ~ ~-i'~, I~,,,~t'~ 6. Section 2. Property Locatlon~/j ~/~y~ ~.~ ~_.~ .5/~ ~.~, Lot Number~Q~j~?q~t~ F~'/- ~$~1~o~~'~ ~1- 8. Private Well Village~mmiPl~llllli~ ,~ ', Township £~u(O 9. Public Water 3. Public Waten Company Name ~ori~ Distance to main 4. Lot size: Width~'~O feet Length J/.~" feet 10. Sewage Disposal System: (For Health Services Dept. Use) ll. A. 900-gallon septic tank: Precast /Equivalent Block B. Leaching pools: Number of pools J Precast v/ Block Special 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 E. Amount of water in well 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. Date ~)~-)O.'.t-to ~ ~)b-' S~gned~_~..' "~ ======================================================================================= 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 t. bri~i plot. SIGNED ~ S-15 Rev. 4/1/73 EIr, AVATIOI( INSl F. CTIIm REIglB[D