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Home My WebLink About7779-z TOWN OF $OUTHOLD BUILDING TOWN CLERK'S SOUTHOLD, N~ Y: N? BUILDING PERMIT · · ~ (THIS PERMIT MUST BE KEPT ON THE PP'EMISES uNTtL I~ULL :: :' Permission is hereby granted to: ........... ~la.tti.t~e~...: ........ ~ ...... . ........ ~ ................. to ..~ ~..1~ ..t~ e~ .. One...~. e~a.~.l.~.. ~.~ 5.1..:L~g ...................... ,.....:....., ............................................... at premises located at .~l/l ..,~d~..~.~.~va.t®..~oaxL..(.oe~l~,t~;L~.ob,,.p,,eac[) .......................... ........................................ 0~.i,~ ..~ t... ~..;~. o ........................................................ : .................................. pursuant to application dated ............................. Feb-,-.-.~.~ ........ :., 19...~..~., and'approved by the Building Inspector. NO~J~s Roa~ay ~0 be imp~'~v~d as ~'eqtli~ed b~ ]~ Appealso Fee $...l/~.elal~ ......... Building Inspector / FOlg~ NO. $ TOWN OF $OUTNOLD , Bui[dln9 Deparement Town Clerks Office Sou~hold, 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 X..~...~. ~ _' Date .................. ~ ....................... 4; New Building ......... Addition ................ Old or Pre-existing Building ................ Vacant kond .............. Owner Or Owners Of Property ....... ;..,...-..:.,;.:.-....~';....4...~..~.: ............................................................ Subdivision ................................................................ Lot No ........ ..... Block No ............. House No ............. Permit NoT~..Z.~..~... Date Of Permit ..~.~..~...-,~...//..Zl~cant ..~'--~L'.~..,,~..~...~....(,-~..~.,,s. ....... ~.. Health Dept. Approval ......................... ~bor ~pt. Approval .......... ~L..[.~ ...................... Underwriters Approval ~.~.~.~ ........... ~ ........ Planning B~rd Approval .... ~..~ .................... ~;;;~j~;e]~e~ificat] ....~ ..................... ~in~ Certificate .......................................... Construction on above described building and p,.~Fmit meets all applicable ,~odes and regulations. Applicant .................................. Sworn to before me this ,___----. .... /%,,.L day of ............. 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 5. Subdiv. Address 6. Section 2. Property Location /"' ,' - ~ / /7. lot Number 8. Private Well Village ~ ~ ~ '? Township - 9. Public Water 3. Public Wa~er Company Name Distance to main 4. Lot size: Width ~' feet Length ~ feet lO. Sewage Disposal System: (For Health Dept. Use) A. 900-gallon septic tank: Precast-~ Equivalent Block__ B. 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 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 .......... ~ ..................................... 2~ ...................................... :.__ FOR HEALTH DEPARTMENT USE ONLY. opinion of the Health, Department that an adequate and satisfactory Sewage Di and Water Supply can ~be i~stalled oo this pl,ot. Rev, 4/1/73 Based on the information presented herewith, it is the System FOE~ NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOI. D, N. Y. Application No.. 7 7 ~ .~. APPLICATION FOR BUILDING PERMIT Date ..................... ~.~......./.....~...., 19..7..~.~.... INSTRUCTIONS o. This application must be completely filled in by typewriter or in ink end 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 or areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Building 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 o 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, os herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for nec~x~,ary inspections. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ......... i'~ ......... ....~..~ .............................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No. -- , Plumber's License No ........ .~...~....7......(~.. ................ Electrician's License No ...... ..~x.....~,4..::....~,,~ .............. Other Trade's License No ............................................... t~-,,~~ . ,~ r .... Municipality 2. State existing use and occupancy of premises and iht'ended use and occupancy of proposed construction: o. Exisiting use and occupancy ............................................................................................................................. b. intended use and occupancy ................. l..~.....i~~.....~,~~~ -- ............................................ 3. Nature of work (check which cl~caNe): New Building Ad Alteration Repair .................. Removal .................. Demolition .................... Other Work ...................................................... .~. ~ ~ ~ (Description) 4. Estimated Cost ......... .O.~..~...o..~. ................................. Fee .......................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of 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 of existing structures, if any: Front ............................ Rear ................................ Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front ..... -----~/...~..:. ................... Rear ........ .~J...~. ........... Depth ..~.....:~.. ............ Height ...,/...~. ........... Number of Stories ......... /. .................................................................................... .~ ..................... ....................................... ...... ..................... .................. 9. Size of lot: Front ....... /..~ Rear ..~....~..c)... ~,~,Lh_~ 10. Date o'f Purchase ....:...../..~..~...~. .................................. Name of Former Owner .......... ~ .............................. 11. 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 from premises: ( ) Yes ~,~) No 14. Name of Owner of premises ....~..~:~ ............... Address ................................ Phone No ....................... Name of Architect ......................... ~'~" ('J I ~'_~"~'~.~ ....... Address ................................ Phone No ....................... Name of Contractor ...,.~..~......~.~.~: ....... Address ................................ Phone No ....................... PLOT DIAGRAM Locate clearly and distinctly ail buildings, whether existing or proposed, and indicate all set-back dimensions from propeTty 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 Y~'~,.I~ ~ S ..................... ~_..~.~ ............... being duly sworn, deposes and says that he is the applicant (Nqme of individual signing cont~i~cf) a'bove named., He is the .i:i .................................. ~ ..................................................................................................... (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 file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work wJJl be performed in the manner set forth in the application filed therewith. ..................... MAP