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Home My WebLink About7864-zFOB, M NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. TEMPORARY Certificate Of Occupancy No.~..~,-.9.8. ...... Date ............ ~.~e. 3Q ...... , 19. THIS CERTIFIES that the building located at Na~'l~ne. ~ne ............. Street Map No. ~ .......... Block No..~ ...... Lot No, . ~.. ~~...~ ~.* ......... confor~ subst~ti~ly to the Application for B~g Permit heretofore f~ed ~ t~s office dated ............ Ap~. ~ 19.7~. p~su~t to w~ B-~lding Pe~it No..~6~. dated ......... Apr~... ~Q, 19.7~, was issued, ~d co~o~s ~o nl1 of ~e ~q~ ments of the applicable provisio~ of ~e law. The occup~cy for w~ch ~is certificate is suea is ..................................... ~e certificate is issu~ to ~b~ .g,. ~0. ....... ~e~. ......................... (owner, lessee or ten~t) of the aforesad b~ld~g. , S~o~ Co~ty Dep~ent of He~th Ap~y~ .J~. ~2~,~.~1.. b~ f~.Z'-~ill~ · · UNDERWRITERS CERTIFICATE No ............................................. HOUSE ~ER ...22~. ...... Street . ~:1~..~: ..... ~tl$~ek ............. ]FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at .. ~$11.~ ./0. On.~ ............ Street ~-~..,~ap No..:I:~.. ........ Block No. ~ ..... Lot No,~ 14attitu~k N,][, '~-"~2onforms substantially to the Application for Building Permit heretofore filed in this office dated ........... Apr~L~,.. 3,019 ?.~.. pursuant to which Building Permit No.. ?.8.6.~$. dated .... .~p?.~.l.. ~Q. , 19.7.~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is P.r$¥t~O..o~o.. $~..~.~.y..d.~.e..~.~..~.g ................................ The certificate is issued to .~q~.~. ~:. $..k~...o ...... . .0X~..~.~' .......................... of the aforesaid building. Suffolk County Department of Health Approval UNDERWRITERS CERTIFICATE No. ~.~3~. ?.~. (owner, lessee or tenant) z~..e...~...~7.~., ~...~....v..~?.~ .... ... ~ .~'...1 ~...1.97~. ............. HOUSE NUMBER ~,2~ ...... Street ...~41s.~.~,..t..,~.e..L. 8~u.e. ' .... .... B~d~g Inspe~ FO~ NO, 2 TO~VN 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) Ne 7864 Z Date ..................... ~.~.;~ ;l,......~O ............. 19..~..~. Permission is hereby granted to: .......... ............................. ................. ~.~..~.....~.~ .............................. ...................... ~f~.C.~£~k ............................... to ...~.~ ~,3,¢1 .. ~ e~.. ~e... ~:~,-~.~.~.. <~r.e Z.Z. ~.~g .................................................................................. at premises located at ..... ]~-~-]3e...~u~ ............................................................................................... ................................................................. ~.ti.t~ .......................................................................... pursuqnt to application date(:] ...................... ~IDlei~,l,....,2C~ ........... , 19....~.~, and approved[ by the Building Inspector. Fee $. ~.~,,.Lj: ~. .......... I~RM NO. 6 TOWN OF SOUTHOLD ~ Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instrucfioas 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 Arch,tect 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 inspechon 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 ...... New Bu, ilding ...J~.~.... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property .................................................................................................................................... Owner Or Owners Of Property ..,j.Z/.~.~ ................................... ~.~'.~.! ..................................................... Subdivision ..~: .......................................................... Lot No~ .... / Block No ............. House ~ ...... P rm,t No ..................... Date Of Permit .................... p,i a,t ............ Health ~pt. Approval ............................................ ~bor ~pt. Approval ........... ~'~ ....................... Unde~ritem Approval .............................................. Planning B~rd Approval ...~: ........................... Request For Tempom~ Ce~ificate ........................................ Fin~ Ce~ificate .......................................... Fee ~bmitt~ $ ....... ~:. ........................ Notary Public ..: ...... ~.~./4~.L~County Construction on above described building and p~J~ ~eets ,,RI.J~ apxplic/able codes and regulations. .......... ./.. /./. . ........... '7 '>." .......... Sworn to before me this · -:q _ THE NEW 'YORK BOARD ,C)F_ F.!RE UNDERWRITERS ~ ak -:~ ~!'- i, -"~i:- .- BUREAU OF ELECTRICITY I 8 Da,e July=15 ~= 1975 APP~ic""°"'~°'°~'l" 79679i THAT THIS CERTIFIES - ~ ~ --. ' only ~he electrical ~q~ip~e~t__ ~ ~scribed be~w and ~ntroduced by t~pplican~-~medn on t~e a~ove appHc~tlo~ nu mbe~ ~ the prem~sez of _ -' --'Johh S~r6, Jr., Marlene Lane, . s~ff~Main Road, L. I. ~so~.~i.odo. July 10, t975 a'taf°undt°~einc°ml'hance"iratherequirements°fth~sB°a;d' FIXTURE FIXTURES OUTLETS FLUORESCENT 10 - DRYERS FURNACE MOTORS OIL FUTURE APPLIANCE FEEDERE ~ R/~NGES - s NO OF CC OVENS J DISH WASHERS =, EXHAUST FANS TIME CLOCKS MULTI.OUiLET DIMMERS SYSTEMS NO OF FEET R - ':- V I _ C--- ' E ,~ _ ^wa NO?i~UTR^LSj__ A W O NO OF HI LEO J OF HI LEG OF OF NEUTRAL OF CC COND OTHER APPARATUS Water heater: ~l-4.Skw Motor/s: 1-1/3bp : -.,_: _ _ _ ~j- ~ - r___ ':____, ._:: Box 417, i.. - ,~._ ~ ~' ~N~ /?:__Southpld, Th~s certificate must ~ot ~e altered ~ff~%~ manner; return ~o lhe office Board ~ incorrect inspectors ma~ ~e Jdenh~ed ~y their ¢redenhals ~FFOL~ 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.)~¢l ~, ~K~)/~r~ P.hone ~- ~/~.~- 5. Subdiv. ~ Address ~ i ~ ~ '~/~p ~. ~,~c/~ 6. Section - 2. Property,Ldcatibn~ S~ ~1~, ~N,'~n~'~ ~ 7. Lot Number~ ~r~$~ i~ ~q,~' 0 ~ ~ ~-~. - , 8. Private Well ~ ~ill~ge '~~c/~ ' ToWnship' ~ut~m~ 9. Public Water'~a~A+~ 3. Public Wa't6r'Co~Pahy Name / ' Distance to main / ' 4. Lot size: Width~fee~ ~ 10. Sewage Disposal System: (For Health Services Dept. Use) A. 900-gal~/on septic tank: / Precastz// Equivalent Block B.Leaching pools: Number of pools Precast__Block , Special__ 11. If private well, fill in the fol- OO lowing blanks: A. Tank capacity .~)Z~ gallons B. Pump G.P.M. ~5~ C. Total well depth D. Depth to ground water E. Amount of water in well C_ The undersigned 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 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. ======================================== ==================================== 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 APPROVAL DATE ~ ,.~¢-~x~ S-15 Rev. 4/1/73 INSTRUCTIONS 7 a. This ~,,~i~ion must be, completely filled in by typewriter or. in ink and submitted in trlpiicg~ ti) tl~ ~lJdi~ ~ scale. Fee according ~ Inspector, ~ 3~ of plans, accurate plat plan to . to ~t~clule. . r b. Plat ~ slJi~wing location of lot and of bull.dings on premi.ses, .relationsl~.ip t.o. odjoini .rig..prem~es or..1~_ ~olSl~ o, . areas, and giving Qdetalled description of layout atproperty must.be drawn on the aJagram which iS prat at this ~ ca on. · c.' 'Thq work ceverecl by thLs application may not be commenced before issuance of Building Permit. Ui~n appravai of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit premises available for inspection throughout the work. e. No building Iholl be occupied or used in whole or in port for any purpose whatever until a Certificote of Occupency~.. shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building ~:rmit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New .York, and .other applicabe I.a~s., .O~li.nanceeOr, .~ Regulations, for the construction of buildings, additions or alterations, or tar re~. ,m or. demol, ition, .as ne.mm The applicant agrees to comply with all applicable laws, ordinances, building ecae, housing caae, ami mgulatiom, and to State whether applicant is owner, lessee, agent, amhitect, engineer, general contractor, electrician, plumber ~r builder. ....... .................... L.L / ' ........................... : ........................ ...................................................................................... Name of owner of premises .~.I~....~J~L...-J../.~./~.~/.~..'.'...~JLI~r~: ................ ,..' ............... ' ..................................... If applicant is a corporate, signature of duly authorized efficer. (Name and title of comorate officer), Builder's Liconse bio ........~.. ............................. Plumber's License No. ' ? Electrician's License No .................. : .......................... Other Trade's License No ............................................... 1. Location of land on which prop--d work will bj~j~/~No.: ..~j~-.'~- ............ Street and Number ....................................... ,,~x~.w.r~w;..:..-.. .................... l~ ......... ~1~~ ,~.... 2. State existing use and occupancy of premises ~::d:c__.use and occupancy of prop°seal ¢anstruction: a. Exisiting uS~ and occupancy ..................../1~.~ ...................................................................................... b. Intended 6second occupancy I 3. Nature of work (check which applicable): New Building...~ ....... Addition .................. Alteratiofi Repair .................. Removal .................. Demolition .................... Other Work ................................................ . .... (Description) 4. Estimated Cost ............... .'. ........... ~ .................................................................................................................... (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 ............................ f7. 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 ..........,.~....; ............... · /O /8. Dimensions of .e~tim new construction: Front .~..~...(. ....... . ............... Rear ..~...../. .............. Depth .~..?...~.~/.~. Height o~(,~ . Number of Stories ....{~1~.: ............................................. .,-~-.,-.~..~.~,. .... ............. I ' ' -~ ~--~ j~ ~9..Size of lot: Front ...~.~..,~..~...O. ..................................... Rear ..... ~....~._!..I..~ ............. ~...~ Deptl]b:./...~.~,.~ ............ /10' Date of Purchase ,~.../....~....~ ................ Name of For~0er Owoer~4~)......~'~(~./~.(~..: ................. 11' Zone or use distric;"/n'~;~'p~;;;;:;re situated ...................... ~..~.1.: ....................................... '~/12. Does proposed construction violate any zoning law, ordinance or regulation: ..~.~;~.. ...................................... /13. Will lot be regroded ....~',/~ ...............,.,,W!II excess fil be removed from premises: (~'Yes ( ) No 14. Name of Owner of premise~...~.'.~.~...~.~..'~' J~ ................. Address~./...~...~..~.;.~, Phorm No...~..~ .~....~./.~ ' Name of Architect .................'~ ...................................... Address .....,~.~/: .................... Phone No....,~. .... -. Name of Contrac~0r ...................... ~..-. ............................... Address ............ .~...~.. .............. Ph°ne No...;...~ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from _ property lines. Give street and block number or description according to deed, and show street na~n~ a~l indicate whether interior or corner lot. STATE OF NEW YORK, I c ¢. ........ · ~/-~'/'~' '/'e'~~"'"'L ....... : .......... being duly sworn, dep~es and says t~t he is the applicanl He is the ...~.~ ...................................................................................................................................................... (Contractor, agar, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke and file this application; t~t all statements contained in this application are tree to the best of his knowledge and belief; and th~ the work will ~ perform~ in the manner set fo~h in the application fil~ therewith., ....--.... ........ ...... ...... ....... , · ( ~oto~ Publi .n ........ ~.-.-~2..~ .......................... y pUBLIC 3~ rio. 52'°'?~ ,,L.,h 30 19~ ' . . , ~j I ® IL//,~ r r/n, vc,~:, ,V,