HomeMy WebLinkAbout7996-z FOR~4~ NO. 2
TO'WN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
$OUTHOLD, N. Y.
· BUILDIING PERMIT
(THIS"~ERM1T MUST BE KEPT CN THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 7996 Z
Permission is hereby granted to: ~~.~, ~
B&~..C.on~tr...COrl>....~/~ ............................ Y.
....... ~th~.t~ .....................................................
to .B....'~..,$..cL ..~.~.~.....o. lg.e... £.~ml,;l,:z ...ct~. ~.,1~ ~.~', ...................................................................................
at premises located at ..L0~..~...22 ................... Fom. dham..Ac~s ..... sac..~I ................................
............................................. l~igg~t_ns...LanE, ......... .a~e r~p o~f~ .....~r.,y. .........................................
pursuant to application dated ........................~T. tAlle ....... ~..~ ......... , 19.~..~..., and approved by the
Building Inspector.
Fee $.!.O..?..,~J.~. ........
Building Inspector
TOWlq OF SOUTHOLD
~ Building Department
Town Clerks Office
Southold, Iq. Y. 11971
APPLICATION FOR CI~RTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled ~n typewriter OR ink, and submitted in DUPLICATE to the Building
Inspector with the following; for new bu Idings 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 farm or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buddings, Multiple Residences and simdar buildings and
installations, a certificate of Code comphence 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 buddings 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 cwner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buddings 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,...z.....E../.~.z::.
New B~ilding ................ Addition ................ Old or Pre-existing Bu,lding ................ Vacant Land ..............
~o~o~,o~ o~ ~o~ ............. ~...~...;.~.~.~.,.~..~..~......9..~..~.~.~.~.. _ ............
Owner Or Owners Of Property, ..........~'------ "-- -- ...~...~....~...~.~.A..7..~....~-~.:..~.. ......... ..~....~...~..~..~. ...............................................
Subd,v~s,on .k..4~.zL..4>/.~5.. ...................... Lo, No....Z..~. Block No ............. House No ......... ,..
Permit No..Z~...~ Date Of Permit ..~...~../.~.~..7....~plicant ~.~.~....~..~..~.~.~.~.~...~.~..~..~
Health Dept. Approval ....~./~.~...~./Z.~-- ............... Lobar Dept. Approval ..............,~'..../...~t:.. ......................
Underwriters Approval/~.~'..~..e..7..~......'....,~...~..~.~..'~.... Planning Board Approval ...... ~.~...~... ......................
Request For Temporary Certificate ....................................... FinaJ Certificate ........~'..~
Construction on above described building and pj~cm~ meets till ~Ipplicali~codes and regulations.
Applicant
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Notory Public ..~.,~ County ~:~c,~' [ i~
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Health Services
Reference Number ~--~0 - ~
APPLICATION FOR AFPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
Address ~¢ Kd~f~ ~[(/~Ly~ ~Y.~.
2. Property Location ' ?/~,~t~_~-~ /~_x/~ '
Village~~ Township_~U~.~
3. Public Wa~er C~mpany~ame ~c~:F
4. Lot size: WidthY~Z~ feet LengtY./~J~feet
5. Subdiv.~44'~'~5
6. Section
7. Lot Number
8. Private Well
9. Public Water
Distance to main
10. Sewag~Disposal System:
A.~allon~ septic tank.'
,,~,,) Equivalent Block
B. Leaching pools:
Number of pools
ll. If private well, fill in the fol-
lowing 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
(For Health Services Dept. Use)
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
FOR ~H~D~ARTMENT OF HEALTH SERVICES' US~N~. Ba~n 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 this plot.
S-15
Rev. 4/1/73