HomeMy WebLinkAbout7770-z I~ORM NO. 2
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BUILDING DEPARTMENT
TOWN GLERK'$ ' 0FFiGE
$OUTHOLD, N~ Y.
BUILDING PER/v~!T
COMPLETION OF THE WORK AUTHORIZED)
N? 7770 Z
Permission is hereby granted to
pursuant to application dated ...................... MttT'""2~ .................. 19~.~'..., and approved by the
Building Inspector.
Fee $6 ~'.-?0 ...........
Building InspectorI
FORM NO. 6
TOWN OF SOUTHOLD
, Building Department
Town Clerks Office
So.thold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, end submitted in DUPLICATE to the Building
Inspector with the following; for new buildings or new use:
l. Final survey of property with accurate location of oil buildings, property lines, streets, and
unusuo[ noturol or topographic feotures.
2. Finol opprovol of Heolth Dept. of woter supply ond seweroge disposol--(S-9 form or equol).
3. Approval of electricol instollotion from Board of Fire Underwriters.
4. Commerciol buildings, Industriol buildings, Multiple Residences ond similor buildlngs ond
instoHotions, o certificote of Code compliance from the Architect or Engineer responsible for
the building.
5. Submit PIonning Boord opprovol of completed site plon requirements where opplicoble.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings ond "pre-existing"
Iond uses:
]. Accurote survey of property showing oil property lines, streets, buildings ond unusual noturol
or topogrophic feotures.
2. Sworn stotement of owner or previous owner os to use, occuponcy ond condition of buildings.
3. Dote of ony housing code or sofety inspection of buildings or premises, or other pertinent in-
formotion required to prepore o certificote.
C. Fees: 1. Certificote of occuponcy $5.00
2. Certificote of occuponcy on pre-existing dwelling or lond use $5.00
3. Copy of certificote of occuponcy $1.00
Date July 8, 1975
New Building ...x~.. .......... Addition ................ Old or Pre-existing Building ................ Vacant Land ..............
Lo~ #21 Rosewood Estates, W/s Rosewood Drive~ Mattituck,N.y.
Location Of Property
Owner Or Owners Of Property Philip. $chmitt
Subdivision ................................................................ Lot No. 21 Block No. House No 275
Permit No....?.7..?..O..Z.. .....Dote Of Permit ...~.~.2..7.~.~..5...Appli,c~nt ~N'[JkND HOMES~ INC.
Health Dept. Approval .7. ./_ .8. .'(. .7. ~. . . .5. .-. . .S_O. . .~ .2. ?. . .......... Lobar Dept. Approvol ................................................
Underwriters Approval .7./...1./..?..5....]J....2..3.~.5..2..~ ..........Planning Board Approval ..~.e$. ..............................
Request For Temporary Certificate ....n...o. ................................ Final Certificate ..y...e..~ .................................
Fee Submitted $ 5,00
Applicant .............. ,'7 .................................................................
Kenneth W. Thurber, INLAND HOMES, INC.
Sworn elate m~/~ ,?,..~.. '2~'''
....... L ............ (stamp seal)
................ day of ./~ 7]~//_]~. or
Notary Public ..... ~~../~.~ County
THE NEW YORK BOARD OF FIRE UNDERWRITERS
~dl BUREAU OF ELECTRICITY
I 85 JOHN STREET, NEW YORK, NEW YORK 10038
o,,...~ul~- ~, ~ ~,,,,~.,,o.~..,,~,,~?~ N 233526
THIS CERTIFIES THAT ~
_ . Philip ~c~ltt, w/s~Rose Wood'~Dr., Mattituck, L.I.
:in ihe/otlowln}'loeatton; ~ B~ement' )st FI ~ 2nd ~l. ' '" aU ide Section .. Block Lot21
w~examtnedon June 27 1975 , , - andfo,~natobeihcompllancewiththbrequlremenrsofthlsBoard,
not be altered In any manner return to the o~ce O[ the ~ord tf incorrect. Inspectors may be',~denhfted by the r credenfi
~J
SUFFOLK COUNTY DEPARTMENT OF HEALTH Health Department
Reference Number~
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
1. Applicant - Phone~Im~k~5. Subdivl~l:~ll~:#~
Address m ~ 6. Section ~
2. Property Location . Lot Number~
8. Private Well_ Y~8
Village~ Township_t~llilt~litl~ __9. Public Water_]~l~
3. Public Water Company Name ~ Distance to main_
4. Lot size: Width~ _feet Length__~l~{l~k~feet
lO.
11.
Sewage Disposal System:
A. ~2~-gallon septic tank:
Preca~t X Equivalent~ Block
Bo Leaching pools:
Number of pools.~f'
Precast~'~OV°~lock ~ Special__
If private well, fill
following blanks:
A. Tank capacity IB{}
B.
C.
D.
E.
in the
_gallons
Pump G.P.M. __~
Total well depth ~
Depth to ground water~
Amount of water in well ~
(For Health Dept. Use)
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.
Date ~/'1~ Signed
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 can be installed on this pl~ot.
APPROVAL
DA
TE
S-15
Rev. 4/1/73
The sewage dfspoBal and w~te~' suppI~'
.... f-ae~-l%~ie~%~nlk-t~iS lo~c~t.!on hav. e~b~_n.
inspected by thi:s department ~ ~o~
S~v~ceS -
OP
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