HomeMy WebLinkAboutZ-4668FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. ~ ...... Date ............. ',Tl~e' ·
THIS CERTIFIES that the building located at ' .l~eigela .Ave .............. Street
Map No. X~ ......... Block No..~ ....... Lot ~o~... ~ti~U~' · ~,~, .........
~ ~n e~ ~ ~e . .
conforms substantially to the ~~:-1
Ce~ifieate of
~a~e~a~eA~ax. a3 ...... , ~s. ~. pursuant to wnicl~)~,~l~~...
dated ........... ~..~$..., 1~.., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate
issued is .. ~l~ · ~ .f~.ly. ~ll~g ......................................
The certificate is issued to · '~a~ 'V~~M(owner,~eeO~' or .................. tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .Pre. ~exis~g ....................
UNDH~WR[THRS CERTIFICATE No ............. ~..e=is~g .......................
HOUSH NUMBER. ~ ........ Street ....~g~' Ave .................................
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 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:
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 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
Date ....~. ~./X/~.....~.~:: ..../../~..,~'..~. .....
New Building .................... O~'J_ _-r Pre-existing Building ..~.. .................... Vacant Land ............................
Location Of Property .~i.~-..~../.~.~....x~.A:4r. ..... x~.~..~..rZ~/.-~.~C' ....... ..~.,~.~'~...~-...~.4p.~Z~z'..c~./.,..~.. .........
Owner Or Owners Of Property .~.4?.~./.£~...~./,/~.../.....-,~'.~.,x/~..,f./. ..... .~..~....xY....z~.../..~./-~.Y.~'.
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No ..................... Date Of Permit .................... Applicant ..................................................................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ....................................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant .....~,42/~../.~..//.~..~......~'...~. zY....~...7.~, t~'../.('~. ......................................
Sworn to before me this
................ day of ............................................
(stamp or seal)
Notary Public .................................... County
- E-O/OM
Po/2er! ~. Mc Grath
~95.01'