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Home My WebLink About7908-zFORM NO. ~ TOWN OF SOUTHOLD BUll,DING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupnncy THIS CERTIFIES that the building located at .~.5..0..~.~4.E...'r~.~.~....~..O.~.~.T' Street Map No ............. Block No ........... Lot No .................................. conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... .~.~.. ...., 19.7. f pursuant to which Building Permit iXlo. dated ........ }.4. 6.:f .... 5.., 19..7.b. Twas 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 . .A...q~/~! ~t.h .w.( .... ~.~.{ .... ?..A..~! .L.'f .... D.~/.~-. k~,.b~, f_,-. .................. The certificate is issued to .... .~.D. .A {-.4 ..... 1-.'1..".f..~.{..~...ICY.! .~. ~ ..................... (owner, of the aforesaid building. Suffolk County Department of Health Approval .'t!~.~,~..~.-~..~...~. :.~.~.:.5..7. ..... HOUSr, NUMBER .... .~..~..0. .... Street ...~.! M.~......-f~..~.g ......~.O..0..~..W'. .......... Building Inspector FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7908 Z Date ........................ ]~' .......... 9 ............ , 19-..~I~· 'Permission is hereby granted to: ~..Jeeeb~.....A~-.A~am..l~ys.~.e~Acz .......... to .hu~d..z~e.w.. ~n~.. fm~'tl.~ ..d~e.l.l:L~g ............................................................................... at premises located at --.]~,G,lr/.,...N./l~...P~e..Tl, ee-..l~o~ ............................................................. ..................................................... C-a, tcl~o~ae ........................................ tame.-&-.~n~y..~.l~... pursuant to application dated .................... ~p~l.~ ...................... 19.~'.., and approved by the Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD ~ Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This apphcation must be filled in typewriter OR ~nk, and submitted in DUPLICATE to the Budding Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, aha unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage d~sposal--(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 s,te plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buddings and "pre-exist~ng" 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: I. 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 t/ Addition Old or Pre-existing Building Vacant Land Location Of Property .L.0.....U.: ....... Or Owners Of Property Owner Subdivision . ..~..~.~...~...~. .......... ~ .................. Lot No.....~.. ..... Block No ............. House No...~.....-~... Permit No?.?..~......~......~.. Date Of Permit ..,.~. ,..?/..~.~?..J~Applicant .... ~././/./.~....~..'...?.~.~...~....-~..: ............ Health Dept. Approval .~....~.C?.,~..~ ........................ Labor Dept Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ...~;; .................................. Request For Temporary Certificate ........................................ Fincd Certificate .......................................... Fee Submitted $~...~.....c~.. ....................... Construction on above described building and permit meets all_applicable codes and regulations. Applicant.....~...~....,~..~...~....,~¢~~ .:.. ~ ............................... Sworn to before me this /-~ ................ day of ............................................ (stamp or seoD Notary Public .................................... County SUFFOLK 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 ~YV/ilf,~ ~, ~ ,, ,'~ Phone . x~, ~ 73¥- ~r'~5'' Address D~,%? ~ - ~,'~ t99~ ' ~r~ ~a~ 2. Property Location V~llage ~ ~c~cl~ Township ~o 1~ 3. Public Water Company Name 4. Lot size: Width f-;~feet 10. Sewage Disposal System: 5. Subdiv. ' 6. Section 7. Lot Number 8. Private Well 11. 9. Public Water , ~ Distance to main kength~ feet ~ ;2.;C~r (For Health Services 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 fol- lowing blanks: ~x~)~ gallons A. Tank capacity B. Pump G.P.M. C. Total well depth '7j~ D. Depth to ground water Amount of water in well ~ E. 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 .S/~F/')~ Signed 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 ..th.i.s/l~lot. S-15 Rev. 4/1/73 ~.E.O . 0 l I / ~0 ,> Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. State whether ap~cont, is owner, lessee, agent, architect, engineer, general contractor, elect.c,ab, pJumber or builder. If applicant is a corporate, signature of du~ly.?3uthorized officer. (Name and title of corporate officer) APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Buildinll Permit pursuant to the Bud ng Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applic able Laws, Ordinances or ; 'Regulations, ~for the construction of buildings, additions or alterations, o~r for removal or. demo!it lan, The applicant agrees to comply with all appli.cable laws, o.rdinances, bui.kllng code, housing cage and regulmlanm, and to admit authorized inspectors on premises ~ ,n buildings for necessary inspections. , .. ' .............................. ..... , . ..... AYlt/mC- ~u,~Dl¥1..%l~A~ , Other Trade s License No ......................................... ~, ~ . -- - ·, .... ~e~ .~.,.~.,~,,.,T~, fl, LV~ Lot o 1, L~ahon of la~ on which p~d work wdl be done. Map No .......................... Street and Number ......................................................................................................... m~c~l 2. State existing use and ~cu~ncy of premises and intended use and ~Cu~ncy of pr~d construction: e. ~isiting use a~ ~cupancy .......... / ~--g'""~"m~Z~"'"'~"~Z~'"'~//'~ ....................................................... ...... ............ . ......................................................... ~ ~, iN~RU~i~S a. This a~l cat on mu~ ~ c~pletely fill~ in by ~ewriter ge in i~ a~ s~mi~ in triplicate ~ ~ Bui~i~ In~or, wi~ 3 ~ of p~, ~mm pl~ plan ~ ~le. b Plot Pr~ shying I~btio~.of ~t andof' bUildi~s ~remi~s, relationship ~ ~loining,premi~s or puD!it struts or areas, and ~ivi~ a detail~ d~ription of I~ ofp~ must ~ drown on the dmgmm which ~s ~ of th~s apphcati~. c. ~e work c~er~ ~ ~ a~licQti~ maY n~ ~ c~ ~fore i~ua~ce of Building Permit.. d; U~n ~al of ~is.a~licati~, ~e ~ildl~ I~tor wil~ i~ue ~ Buildzng Permit ~ the apphcant. Such permit shall ~ ~t ~ the premi~ ~allable ~ insp~ti~ ~gh~t ~e ~rK. e. No building shall ~ ~cupi~ or u~ in whole or in ~ for any pu~e whoever until a Ce~ificate of ~cu~ncy shall have ~en gmnt~ ~ the Buildi~ Ink,tar. 3. Nature of ~ (Check which applicable): New Building.. ........... Addition .................. Alteration ..., ........... o . Repair .................. Removal .................. Demolit~n~,.:.~ ............. Other Work ...................................................... f~.~ ~ / ,~ ,~.~ (D~ription) 4. ~timated Cost ..~ .......................................... Fee ...~ ....... ~; .......................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ..... ~. ................... Number of dwelling units on each flor ............................ If garage, number of ~ ............. ~ ...................... ~ ................................................................................................... ~ 6. If busine~, commercial or mixed ~cupancy, speci~ nature and extent of each ~pe of u~ ..............~ ............. 7. Dimensions of existing structures, Jf any: Front ............................ Rear ................................ Depth .................... Height ........................ Nu~er of Stori~ ................................................................................................................. Dimensions of ~me structure with alterations or additions: Front .................................... Rear ............................ Depth ................................ Height ............................ Number of Stories ................... 8. Dimensio?~ entire new construction: Front ...~...~ ...................... Eeor.~ ....... Height ..~-- ................ Number of Stories .... ~.....~.~ ............................ ; ................ ~.~: ............ [~.~'. 9. Size of lot: Fret........... ...(..Rear ..... ~.g ........................... Depth ,.~.~ .................. 10. Date of Purchase ...~.,...(.~l..t~.~.~ .................... Nome of Former ~ner ...~.~.~.~..~ .................... 11. Zone or use district in which premises are situated ........ ~ ....................................... ~ ........................................ . ...... 12. D~s proposed construction violate any zoning law, ordinance or regularly: ........................................................ 13. Will lot be r~rad~ ............................ Will excess fill be rem~ fr~pmmi~s: ( ) Yes (~) No 14. Name of ~ner of premises ~.~.~,.~.~l~(~.~.. A~mm .~~,~.~ P~ No~: Nome of Architect .............y ........................................... A~re~ ................................ ~e No ....................... Name of Contractor .~]~1~...~.~ ..................... A~ress ] ~... Ph~ ..... PLOT DIAG~M L~ate clearly and distinctly all buildings, whether existing or proposed, and. indicate all ~t~k dimensions from prope~ lines. Give str~ and bilk number or de~ription according ta d~, and show ~reet ~mes and indicate whether interior or corner lot. ........ ~.4./:t.l.~...%l,~J~.....~..]..-' .~.. ............... .... : .........' being' duly sworn, d~oses end soys ,~, he is the opplicon, tmome at mOlVlOUO signing c~tmcO above nem~. He is the ......................... ~././~ ..................................................................................................................... (Contractor, ~ent, co~orate artier, etc.) of said owner or owners, and is duly authorized to perform or h~e performed the said work and to ~ke end file this application; t~t all statements c~tai~ in this application are tree to the best of his knowledge and belief; end that the work will ~ performed in the manner ~t fo~h in the application fil~ ther~ith. Swo~om me this ...... ..... ...... .................. ' ~ , JUDITH T. BOKEN (Sign~ ~plicant) Nota~ Pubric, ~t~le of New York No. 52-0~963 Su~lk C~n~ ~mi~lon ~pires Mamh d,6~ ?O 1{41~ SU{tVEY IS A VI{:3 LA11ON O~ F 1:;2. 0 r',,,l -F VAT[ON C-'23 5" / ,_ L C, ~'T ~ i.J P Pix'lAN IN 1--1 I 'T P- C.T N N c:D, ~- -..~I '1 ~.~ _ _,.. FL- T/ 3 C__ E LL~i2. ~,hqD F'OLJN/~-i'I ON PL~,N ( 7 ,] ~NT 12.W _ I I Ni FLO O12. PLAN -E L E,. V A.7 lO N1 ,/ ~NE ~AM[I-¥ IFWELLIN~. I'& , I T , · \ f ~d6 o t) 3;LI_C_~I~.T ..:: B I DF_.- F-.L,~. V AT I 0 N ...... ZPl 0 U 5 F .. P L ~ h-,.l ,.~