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Home My WebLink About9108-z August hs !977 Joe Gold~ 8 Fz~he~mans ~ e~.,~,~ August ! [ , '-,9 , - . / -,:Z--i Gusta~ B~wtra "'~ 227E Breo~ate? Rd: Matti~uck~ M,Yo ~2952 FORM NO. 6 TOWN OF SOUTHOLD Building Depa~tment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: ]. 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--($-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 P[anning Board approval of completed site plan requirements where applicable. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: ]. 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: 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 $5,00 Date ..~.7,.../..~ZZ ..... New Building ....~ ............ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .......... ~ .................................................. Owner Or O ners v v Subdivision ................................................................ Lot No.../~.. Block No ............. House No ............. ,~,~,~ ~,,~. ~,,~o~ .~::.~'2 .................. ~o~ ~,,,.~,,ro~ ................. :..~., ..................... ..................... ........................................ Eequest For Temporo~ Ce~ificete ........................................ Finel Ce~ificete Fee Submitted $ .................................... Construction on above described building and permit meets all applicable codes and regulations. Ap p Iic ant .~'...~/~..~ ..., ............................. Sworn to before me this ........... /.. tdo of ...... Notary Public ............~~County C.OUNTY OF DEPARTMENT OF HEALTH SERVICES August 3, 1976 MARY C. McLAUGHLIN, M.D,, Mro Joseph Gold 250 Park Avenue Freeport, New York Dear I'Ir. Gold: 11520 Re: Application to Construct a Private Sewage Disposal System s/s Haywaters Road, 715' w/o 'Landing Road, Southold Town At the hearing held on July 2l, 1976, in the office of the Suffolk County Department of Health Services, H. Lee Dennison Executive Office Building, Veterans Memorial Highway, Hauppauge, New York, you had an opportunity to present your appeal of the department's ruling on the subject application. In accordance with the provisions of subdivision (c), Section 7, Article I of the Suffolk County Sanitary Code, the determination of the Board of Review is as follows: Based on the infom]ation submitted, that this application not be approved until the owner of the property upon which the well pi% is located is determined and legal permission obtained from the owner. Since the determination of the Board of Review submitted to the Commissioner's office on July 28, 1976, has not been reversed or modified by her, it is therefore deemed to be the determination of the Commissioner. Very truly yours, H.W. Davids, PoE. Chief Bureau of Environmental Heal th tlWD/gpb cc Robert A. Villa, P.E~ Board of Review File ~Southold (T) Bldg. Dept. 3. Nature of work (check which applicable): New Building' .....¢~'. ........ Addition .................. Alteration .............. . Repair .................. Removal .................. Demolitior~ .................... Other Work ..................................................... (Description) 4. Estimated Cost ......~....~..~..3~...~..:.~..(.J. ..................... Fee ~ (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 ............................ 7. Dimensions of existing structures, if any: Front ............................ Rear ................................Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or oddifions>.Front .................................... Rear ............................ Depth ............................ Height ............................~um~er of Stories ................................ 8. Dimensions o~ entire new construction: Front ...~...../~ ............... Rear ...~. ........ /.~ ........Depth ..~.~ ............. Height ..~.~/. ...... Number of Stories ...... ~.~ .............................. ? ................................................................... 9. Size of lot: Front ........ ~..~ ..................................... Rear ....... ~ ......................... Demh ..ZT~.~ .......... 10. Date of Purchase ........................................................Name of Former Owner ..~.l.~..~.~..~..~.~ ......... 11. Zone or use district in which premises are situated ........... ~ ..................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ I3. Will lot be regraded . ........................... Will excess fill be removed from premises: ( ) Yes (~) No 14. Name of Owner of premises J~,..~,...~ ........... Address ~.~..~[~; ..... Phone No~e..~.~.. N~me of Architect .............................................................. Address ................................P~one No ....................... Name of Contractor ~...~.~/~.~,.Z~,. Address~...g~.g..~: Phone 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, Qnd show street names and indicate whether interior or corner lot STATE OF NEW YOI~.K, [ c c COUNTY OF ....... Suf f.ulk ........ f .... ......................... ..~..~.~D.~.....~. ~.~..!~.9,~q .................................. being duly sworn, deposes and says that he is the applicam (Name of individual signing contract) above named. Fie is the ....................... ~g.~..~O~...~q~Q~ .......................................................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make ~nd file this application; that all statements contained in this application are true to the best of his knowledge and belief; and tha~ the work will be performed in the manner set fo~h in the application filed therewith. Sworn to before me this ~ 9 ~ W ............... 2~ day of .................. ~ .Ch ............. , 1 ..?~.. .............................. Co,, .... ..................... (Signature at apmicant) ~seph R. Oold Telepfi~6e{ 370 3230 The l~t~p su-p~ 2~0 ~a~ Avenue ' ~ ~o~ t~ ,ear. ce wt~-o~fo~ ~ ~ o,47' ~o~1It ~ ~/~F~ I ~ ~.0¢ ~S~ff$o%/o MAP OF PROPERTY % SITUAteD IN I HEREBY GERT FY ~ ........ THAT THE ABOVE SHOWN ....... fin ACTUAL FIELD SURVEY * SU~VEYED BY /~ :~::~ AND THAT THERE ARE No O GRADY-K~EEGER ASSOCIATES DE TA I L 'A" ?1 Z or Z~ ~ Hu~ Sa~t .~'.,e · cone. plo' ~ 6540so'/o"z:' IoI ,s Lop- MAP OF PROPERTY SURVEYED BY OGRADY-KLEEGER ASSOC!ATES CONSULTING ENGINEERS-- LAND SURVEYORS ] SEP The ~e~ facll£t~e: inspected Unauthorized alteration or addition to this storey is a v/olaffon of section :7209 of the New York Store Education Law. Cop~es ~ th~s survey map not bearing the I~nd ~u~eyor*s ~nked snal or el~lJ)OS~lOd seal shall not bo conCpdorod to be a valid copy, ',r ¢. J~t.~ffJons ind cared hereon ~haff run only to the pc , , ~.,r ,/, Ch1 tho survey ~S prepared, and on his behaff to the ~H~ ~ (~mpany, governmental agency and lending institution listed her~.or~, cma fo lhe assignees of the lending institution. Guarantee~ or certifications are not trans~e~ble to additional insfilutJoni el ~ubsequent disposal ~nd water supply , fo~' thi~ location hav~ b~n by thi~ dep~rtment ~d .~d tier of Gen, eral~n~ln~rl~ Services / %' '~ ?~y bcatbn from house ewners and field ~ .:pools ar~t visiblo thoso dimensions AT NASSAU' POINT scAcz. AUG. 31,1977 INC, 4P NO. 786