HomeMy WebLinkAboutZ-7499FOB,~ NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No..Z...7~.. ...... Date ............ ,/an...2~. ...... , 19.77.
THIS CERTIFIES that the building located at .. EY.8..~..~!.eY..1..~. ......... Street
Map No... ~x ....... Block No.. xX ...... Lot No.X~X..~[re~r~!~oT.t.....lt.o.Y.: ........
,. er tflc l'
l~e~ . before .~p~..~ .... , 19~.. p~suant to wmen,~ ,~. ~o. Z~'
dated ....... ~ .... 25 ...... , 19.[~., was issued, ~d conforms to ~1 of the req~
ments of the applicable provisions of the law. The occup~cy for which this certificate is
issued is ...Private. o~e. f~llY. ,dve~,li~e .~.~h. ~e~e~. ~g ........
The certificate is issued to . R~ber~. ,&. ~aa~e.. Wg~re~ ..... ~ .............
(owner, lessee or ten,t)
of the ~oresaid building.
S~olk County Dep~tment of He~th Approval p~e,. e~$~}~g ....................
UNDERWRITERS CERTIFICATE No. p2~. eXiSglgg ............................
HOUSE NUMBER ... 72~ ....... Street ...~ey. A~ ....... ~ee~orZ .........
..... .........
Building Inspector ~
FORM NO. $
TOWhi OF SOUTHOLD
, Building Depu~tment
Town Clerks Office
Southold, hi. Y. 11971
APPLICATIOhi FOR CERTIFICATE OF OCCUPAhiCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in DUPLICATE 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, Ntultiple Residences and similar buildings
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), No~-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 canditlon of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent
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
Rte ....
New Building ................ Addition ................ Old or Pre-existing Building ...~.. ....... Vacant Land ..............
Location Of Property .....~,/..~.. ....... ~.~./~.4~'.~.....~...~..~..~...~.~.~......~.)t/.~..~.~[i~..~..)...~./...~..,..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 ........... --~ ............................ FinaJ Certificate ..........................................
Fee Submitted $ ...~.......~./..~...~., ...........
Construction on above described building and pern)~l~ets_all ppplicable cos~ and regulations.
Applicant ...... ...1~..~~~ ........................................
Sworn to before me ' '
...~..~.... day of .. .~11~.../~.,..../..~..?.~.... -- ,~v~r~ L pR, C £!s~mp ol~'seal,. . .
~OTARY PUB£1C, STATE OF NL"W Ye~K
Notary/ PubJic ....... ./~.~.~.,~.....~,~ i~.,.. County {esiding ill S.,~,,k I~o. at tine cf
My Commission Exi;ires March 30.
Af' /