The URL can be used to link to this page

Home My WebLink About7785-z FOR~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE SOUTHOLD, N. Y. BUILDING prERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7785 Z Permission is hereby granted to: ...?.~.:.~.~ ......... ~.?..~Z .......... ~e~ ................. ................ ~.~?.~......~.~.~......~,.~:~.~..~....~. ~ ~ ~,~ .) ~o ...~.~.L~.P. ....... ~ ........ .~.~.ZJ~ ......... ~.~. ........ .~.~..~.~..~.~ ....... ~.~..~.~.~.~.~ ...... pursuont to opplicotion doted ............................... ./~..?...'.~.!...~......,~.., 1-~.-~....., and opproved by the Building Inspector. Building Inspector FORM NO, 6 TOWN OF SOUTHOLD Building Department Town Hall 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 Inspec- tor 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 featu res. 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 Underv~riters. 4, Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, 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 peoperty 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 informa- tion required to prepare a certificate. C, Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land,use 3. Copy of certificate of occupancy $1.00 Date ......................... New Building ~J . Old or Pre-existing Building ........... Vacant Land ............. Location of Pr~it~ '.~. ~. '~.'..0. ,'.~. '.~ F.J.'~. ,~Y. ~. ~. ?T, · · .' -~..~4'.~. ~?, ,J~..0. · .~. · .~-/· ./('~' ?' '/' · House No, ~ , / , Stree~ Hamlet ~l~f~ ~ I ~A ~/.~. Owner or Owners of Property .,.,,--. ....................... r ~ ...................... ,000s.,,o. :: .... .... ......... ...... )~/~H~~/'~ lv/~ ~ -- Ma-No~'~:Z,~. LotNo - ~u~.ws~on ..................~ .......... /..~ ~ ....... ~ .... , ,Z/ ............ .......... .: ...................... U~r~e~ ~,,ro~,... ~Y~Z~ Z.q ....... ,,a..,.~ ~0.~ ~,,~o~., ...................... Request for Temporary Certifica[~ ..................... Final Certificate ,, ~ ................ Fee Submitted $ ....... ~ .............. Construction on above described buildinfl an~permit meets all a~licable codos and re~uladons. Applicant /~.. ~4, . .................. SI~FFOLK COUNTY DEPARTMENT OF HEALTH SERVICES 3. 4. 10. Health Services Reference Number APPLICATION FOR APPROVAL TO coNSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY Applicant ~.<' ~:" ,, 7 ,,~ (~ ~"L?~, ,' ,~¢"P~ne 5. Subdiv. ~z~/~- f;/f./)9 Address ~ .... .> -~-, , <., ..""~ ~/~1~/~, ~, 6. Section Property Location~ ,, ....... ' - ' 7. Lot Number ..... ~' , ~- ,'~ ,-~ ~'~ 8. Private Well Village ~ -,,, -.,,. , ~ Township 9. Public Water Public w~ter cb~n~m~',/,~ ' Distance to main Lot size: Width feet Length feet (For Health Services Dept. Use) Sewage Disposal System: 11, A. 900-gallon septic tank: Precast ~Equivalent Block B. Leaching pools: Number of pools ~ Precast ~J Block Special__ If private well, fill in the fol- lowing blanks: A. Tank capacity B. Pump G.P.M. C. Total well depth D. Depth to ground water E. Amount of water in well ~/~-' .gallons 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 <',~z?/~//~_r. Signed ~' ~ ~/r~l ~¢,~----~ ~ ===================================================================================== 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 a~,equate and satis- factory Sewage Dispos~al System and Water Supply can be ~ns~al~e~on ~j~)s plot. S-15 Rev. 4/1/73 O .% ~r~OSET ~'Y//' NOTIFY BUILDING DEPARTMENT AT 765-2660 9AM TO 4PM FOR REQUIR- ED INSPECTIONS: 1. BEFORE BACKFILLING POUNIDA,. TION OR START FRAMING 2. BEFORE COVERING PIPELINE 3. FINAL WHEN JOB COMPLETED NOT RESPONSIBLE FOR DESIGN OR CO{~- ~iTRUCTION ERRORS 4.¸