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HomeMy WebLinkAbout8276-zFOBM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certi[icate O[ Occupancy THIS CERTIFIES that the building located at ~.~ ~. ~l.~l: ~X ~... ~}~ ~. Street Map No. ~ ~ ~ ~ Block No...~.. conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ ~'., 19~ ~ p~suant to which Building Permit No. ~.g7~ dated ........... .~.. ~.., 19.~., was issued, ~d conforms to all of the require- ments of the applicable provisions of the law. The occup~cy for which this certificate is The certificate is issued to .q ~.~1~..p...~...~?~ ~.~: ~...~... ~ ~.~( .......... (owner, of the aforesaid building. Suffolk County Department of Health prrova UNDERWRITERS CERTIFICATE No. Bffilding Inspector FO~ NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8276 Z Permission is hereby granted to: at premises located at ~ ~ /- L .k -cc E ~.~ : ~-~ ....... (~.J .4. i~ ~ o ~ ..... .k...o..~ ............ .~., ....... .~.~...fl.~t ..... ~ ~..~t~q ......... r....~L~ ~.~..~.o.~.... ~ ... pursuant to application dated ~ .... ~..L.., 19..~..., and approved by the Building Inspector. Fee .................... FOI~ NO. $ TOWN OF $OUTHOLD , Building Department Town Clerks Office Southold, N. ¥. 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 e certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or lend use $5.00 3. Copy of certificote of occupancy $1.00 New Building ~' Addition ................ Old or Pre-existing Building ................ Vacant Land Location Of Property .................................... Owner Or Owners Of Property .~,~.JJ.~.~[...~ ...... l..~...~ ..~'..~..~..(.~......~..~... ...... ~..~...~C_/.~:;?~.~..~. ............ Subdivision .~..~.~.~.~.,/.~.] .~.......o~'~f:~:bM~?.~.-.~. No. ~ %'''' Block No. House No ............. .............. Lot' ' :> ........................ .,/, Health Underwr ters Approval ................................... /..'/.?~,..Plannmg Board Approval ........... ~/.~.~.. .................. Request For Temporary Certificate ,..'.~.!...0.. ............................. Fin~ Certificate ........... .~/..~.~,.,~. .................. Fee Submitted ~ -~'I o~ Construction on above describedApplicantbUilding..~;....~....~~and~p§rmit meets all applicable ........ codes~:~ulotions. Swam to before me this ~/-'~' ~ ....... ~ ....... ................ day of ............................................ Notary Public .................................... County THE NEW: ,yORK'BOARD- OF FIRE r UNDERWRITERS ~ , aU'~S^U OF £'~CTRICIT¥ CgRTIFIES THA~ Joseph Dooley, 22~0 Gille~tte D~tve, East MariOn, L.I. ...~.,.~,,od o. Mar ch ,~ t 19 ? 6 and found to be in compliance With the requirements of th~s ~oard, 19 '"" t~it ek; . ~, , Ma u L: This cerfi{icale must not be altered in any manner; return to the a{Jice o{ 1he Board if incorrect. Inspectors may be idenfJfie Lie. 2~2E G~,:K~L m~N~GIm D credentials. SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services Reference Number ~.~-J APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY 1. Applicant~-~o~) ~ ~ Phone 7~,~--~e~ Address ~ / ~ ~:i~,~ ~'/~-~/~) 2. Property LO~ation ~/~ ~d/~ ~ ~/~ ~ '~ ?illage ~ ~ Township ~~ 3. Public w~ter Company Na~e 4. Lot size: Width /~o feet Length /m~--feet lO. ll. 5. Subdiv. 6. Section 7. Lot Number 8. Private Well 9. Public Water Distance to main Sewage Disposal System: A. O~gallon septic tank: Precast ~<' Equivalent Block B. Leaching pools: Number of pools ~[ ~._ Precast/~ Block _Special__ If private well, fill in the fol- lowing blanks: A. ~&~k capacity_ Y/61)'~_gallons G.p.M. C. ~al well depth, ,D. De~th to ground water E. AmOqht of water in well (For Health Services Dept. Use) The undersighed CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Heal th ServiCes' current standards thereto." This application will be valfd for one year from the date of approval indicated below and may be renewed if a current local Building Department Permit is in effect. FOR THE DEPARTMENT OF HEALTH SERVICES' USE ONLY. Based on the ~nformation 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 this plot. APPROVAL DATE ,/~/?f SIGNED ~. __ __ --~.. S-15 Rev. 4/1/73 TOWN OF $OUTHOLD BUILDI~ DEP~RT~ENT TOWN ~LERK S OFFICE ~. ~UTHOLD, N. Y. Examined .................. ~r ................. , 19......... z.Appli¢~ o~ ]:~Lo~..o_.::... ......................... proved ............... ...... ...... ar<lc ........ ~ ('~'~'i'lding Inspector) '¢~2 Date ................................................. J~ ............ INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Buildin~ Inspector, wlt~ 3 set~ of plans, accurate plot plan to ~aJe. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets areas, and giving a detail~ description of layout ofproper~ must be draw~ on the diagram w~ich is pa~ of t~is application. c. The work covered by this application may not be commenced before Jssuanc~ of Building d. Upon approval of t~is application, t~e Building Inspector will Jssu~ a Building Permit fo t~e applicant. Such permit s~all be kept on the premises available for inspection throughout the w~rk. e. No building shall be occupied or used in w~ole or in part for any purpose w~otever until a Ce~ificate of ~cupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit p~rsuant 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 ~lterations, o~ for removal or demolition, as herein described.~ The applicant agrees to comply with all applicable laws, ordinances, ~uilding code, housing code, and regulations, and admit authorized inspectors on premises and in buildings for n~ess~ inspections. ....... ....... ..................... (Signature of applicant, or name, if a corporation) S~ate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .............. .............................................................................................................................................................. Name of owner of premises ...... .~,..o,,.~.~.~.,...P.,......~.......~D..~..I,,L.~,.~...~.,,..~..~..~. ....................................... If applicant is a corporate, signature of duly authorized officer. ,, (Name and~aroora~tit e at corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which p, roposed work will be done. Mop No,: ...;.~....O,.....'~..~.. ................. Lot No ..... J.....'~.. ............. Street and Number ,,,~l..~.~...sC~.~.J,,J~...-~..I=.....~.~.~,~.JE,......~'~..I~.N~L...J'~/~.~.~, ...... Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy .~,/,~..~.J~..~.. .................................................................. b. intended use and occupancy ..... .~..~l.'~...~.l.J~.'~........~ ..~.~,/~l.~kl~ ................................................ 3. Nature of work (check which applicable): New Building....,~, ........ Addition .................. Alteration ,r..:: ....... ,. , . Repair .................. Removal .................. Demolitior ..................... Other Work .................................................... (Description) 4. Estimated Cost~°--~7..-~.......I..6.~ ................................... Fee ........... ~'~ ~C),.~.~<...t.;...... ............................................................ (to be paid on filing this application) 5. If dwelling, number of dwelling units ........... ~ ................ Number of dwelling units on each floor ............................ [f 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 ..... ...~..~ ............... Depth .....~/~ .............. Height ..... (,4~.,~. ......... Number of Stories ........ .~ ............................................................................................................ 9. Size of lot: Front (OS-t . Rear ~ .................................... I..O....~.. ................... Depth ..... .~..~..O ................. 1 1. Zone or use district in which premises are 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 2(. 1- 14. Name of Owner of premises ..~...o..~.~.¢..~.~.~.H~J.~l.~...~)..c,.c.~.~.¥Address ................................ Phone ~o. Name of Architect .............................................................. Address ................................ Phone No ....................... Nome of Contractor .'~./~r~-(~.~.~l.l~....~.~.~......~t4~.... Address ~w"~..(..?~..~..~..~.~-.¢~ Phone No. Z'~.~-.=./.~..~.', PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate oll set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STA-I;E OF NEW,-~'O~ ~[/ COUNTY OF ...~.~......~.--~'I;¢¢...(:~. ........ f.-'-,~ ,,. ...... ?.'..,.'........~....~..~./~. .......... ~ ...... ,,~o~.~f...U.! ......... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ............................................... .~..¢~..~~..d~.,.L~.. ........................................................................................ (C~-'. ' , -:~;-::~, corporote officer,4~ of said owner or owners, and is duly authorized to perform or hove performed the said work and to make and file this application; that ail statements contained in this application ore true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ........................ of ......... Notary Public,. ................ ..q~.~TT~...{/{~ .......... County ..~-w..~....,~ ...~~~ ............... ~/.~J~ ~,/¢L/~J /~~'~' (Signature of appHcont) ELIZABETH ~NN NEVILLE e.e pLoT' .F::L..A~ OF L o'"~' ~'2, 9 TO~N OF $OUTHOLD Building Inspector's Office Town Clerk Building Southold, N.Y. 765-2660 APPRO. VED ,AS NQT-ED REQUfR. BEFORE B~CKFILLING FouND~ )N OR STAR~ FRAMING BEPORE COVERING PIPELINE P~AL WHEN JO~'COMFLETED T ~ONSiBLE FOR DESIGN OR 1 (.