The URL can be used to link to this page

Home My WebLink AboutZ-4679FORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerli[icale O[ Occupancy No. 5..1~.~ ..... Date ........... ~l~lO · 22 ........ , 19. ~ THIS CERTIFIES that the building located at . I/~. Cox. I~e(~k. ~ ...... Street Map No.. ~ ........ Block No .... ~ .... Lot No.. ~'' ~t~0k~' '~,~ ........ . q t f . f~ ~ e . . conforms su bstan t,ally to the ~~ ~~ ~~ ~ ~~ dated ...... ~e.. ~. ........ , 19. ~,~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is .. Pr~Vat, O -oete -fau4.l~'. &vol~ ....... ~. not/~, o~e/p~$o~ ....... The certificate is issued to .C~OI ~, .~a.~e ..... ~eF .......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval · .~. -OXi*~ ................... UNDHRWRITERS CERTIFICATE No .... ~. ~g .............................. HOUSH NUMBER....]~ ..... Street..~. ~eek' ~ ................................ . I. ~r~er~ l~o - fenced area ~Jo~g ga~gO .... ~'" .... "" ;' O~QF~t Building Inspector ' /~ ~, ~ 8, p~erty l~e = ~ve~ dr~ve~ay ~ Earago o~f on ~Jo~f lot STATE OF NEW YORK ) :SS.: COUNTY OF SUFFOLK ) CHARLES J. ZAJIC, being duly sworn, deposes ~nd says: That I reside at 3040 Cox Neck Road, Mattituck, New York and I am one of the named owners of record of the said premises since July 22, 1950. That the said premises were improved witha one.family dwelltng in 1951 and have bee~ used and occupied solely as a one-family dwelling since that time by myself and my family. That the building has been maintained in goo~ condition since the time it was built. Sworn to before me this l th ?f tddlil~ ~ll~ State of N~ ~ ~o. 3~57t~ ~u~lifJed ~n Suffolk Coun~ Term Expires March 30, FORM NO. $ TOWN OF SOUTHOLD Building Department Town Clerk* 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 disposol--(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 3. Copy of certificate of occupancy $I.00 $5.00 Date ...~I~..~,9. ,...~c).?.P- ................... New Building .................... Old or Pre-existing Building ....... ~. .................. Vacant Land ............................ Location Of Property .~...~...~z..~e,~c..Ro~d..~-tt~_t~.,..~7, ................................................................ Owner Or Owners Of Property ...~&~:~.es..~l',..&..]~.~.~J3,Y..Z~,~;:[.o .................................................................. 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 ..~[;~,~Ir,;Ll~..~Be. ............... Fee Submitted $ ..,5..,.g.0. ......................... Construction on above described building and permit r~eeiy~/~o~licgble~o~es ?ndApp icont ~,~..~ ~" ~' ~ 14-~C~ regulations. Sw;rn]~obefore methis ~/ //'/' L/ ~/ ~ .... ...... 2.~, ...... day of ....~i4¢1~....'1(J2~ .................... (stamp or seal) ~. t-/G Notary Public ..,.%,fEa].k ................... County ~o~- i I