HomeMy WebLinkAboutZ-4640FORM NO, 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. ~.~.61~0 ....... Date ............. lOt~ .....a6 , 19.
THIS CERTIFIES that the building located at B~...][0W..8 .~f.f~!k...]b~..d.
Map No... ~-~ ...... Block No....~. ...... Lot No.. ~ .... ]IOV SGff~.k... Il,Z,..
conforms substantially to the ~~ ~B~dl~.~l~,~=~i-
dated ~p~. ~ *p~.~., 19.~7. pursuant to which ~~;~ ~.
dated ....... M&~.-~6 ....... , 19.~., was issued, and conforms to all .of the require-
ments of the applicable provisions of the law. The occupancy for which t~s certificate is
issued is . .~e~ .~ld~l .&. ~t~lee ..,. ~fll.."~-~ .lM..~
The certificate is issued to ..-~ehaet. ~lle~ek ....... ~e~ .....
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ..... l~re- ................ eXlBt~.g r..\... ......
UNDERWRITERS
CERTIFICATE
NO
Building InspeCtor
f
I~OB1VI ~TOo 6
TOWN O~ $OUTHOLD
Bnil,lln9 Depar~ment
Town Clerkl Office
Snuthold, N. ¥. 11971
APPUGATION FOR C:ERTIFICATE OF OC:C:UPANGY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building
Inspector with the following; for new buildings or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and
unusual natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage disposal--($-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, JV~ultiple 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 completecl 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 ..... 4./..x.m,:./.../...: .............. ; .......
/ r
New Building .................... OW or Pre-existing~uildin~-....~.../.... Vrqcqnt Lanrd~/.....././../...~./....J
Location Of Prope,y .~....~...~.'~.....)~~/~... ....... ~......~.~..~.~......~.. ~
Owner Or Owners Of Property .....~..~.~~~*.~.~.~.!. .....................
Subdivision ................................................................ Lot No ............. ~e~ock No ............. House No .............
Permit No ..................... Date Of Permit .................... Applicant ..................................................................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Tempora~rtificate ........................................ Final Certificate ....~i ...........................
Fee Submitted $
Construction on above described building and .j~,t meets ~c .~o~ and ~reg~detions.
........................
..~: ...... d~ o, ............. ~..~..~.,.. ~ ' ~ Imp or seal)
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