HomeMy WebLinkAboutZ-6852FO]~M NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnte Of Occupnncy
No..~-68.~2 ..... Date ............... ,va~ ... ~..., 19.
THIS CERTIFIES that the building located at . ¥/8..~.~,l~e. L~ ....... Street
Map~ No. ~ ......... Block No..~ ....... Lot No.. ~ .~e~.. [.,~, ............
~ ~. ~..~ .... , 19. ~. p~su~t to which ~-~-~-~No.~S~..
dated ........ ~ .... ~ ..... , 19. ~6, was issued, ~d conforms to ~1 of ~e req~
ments of the applicable provisions of the law. The occup~cy for wMch this ce~ificate
issued ~ . ~eas .b~.. [store, & ~oatoffie~) .~th. a~t ......
The certificate is ~sued to .Ma~arte .~g~- &. ~s --~ .l~. ~. ....
(owner, lessee or ten,t)
of the ~oresaid building.
S~olk Cowry Department of He~ Approval .p~ .e~t~ ....................
UNDERWRITERS CERTIFICATE No.. P~..e~.~i~ ............................
HOUSE NUMBER ..... ~ .... Sffeet . ~illage .~.. ~. ~,0.,.). ...............
10~ . - (Idle ~)
Bffild~g ~spee~or
FOI~M NO, $
TOWN OF SOUTHOLD
, Building Deportment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Ins~rucfions
A. This application must be filled in typewriter OR ink, end submitted in DUPLICATE to the Building
Inspector with the following; for new buildings or new use.'
I. 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 end "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
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 ~1
Dote ................... ~.~ !.~......~.....~. .....
New Bclilding ................ Addition ............... hOld or Pre-existing Building **~.. ........... Vacant Land ..............
Location Of Property ......~./.~.. ...... ...~.~ .~.... ~-* . ~...
Owner Or Owners Of Property ../...~,.(~,~......~~.~.~..~_~/,~ __ __~ ~...-..- ......................
Su vislon ..... ............................................. V, otB,ock No. ....... H use No .............
Permit No..~ ........ Date Of Permit .~......,~p'ic~nt ......~.....~.....~ ....... ~...~....~.. ff-~
Health Dept. Approval ...'..~..~...~'"' '~ ~ ........ Labor Dept. Approval ............ °' ~'..~...:.../...~...........~'¥~ ............
Underwriters Approval ..... .~ ...... ~ ...... Plonning Board ,ag:~provol
R~:luest For Temporarg Certificote ........................................ [in~ll Certificote ....... ~ .......................
Pe, S bmi,,d $ .................
Construction on above described building an~ plprmit meets all applicable codes and regulations.
Applicant ....... -~~-~- .................
Sworn to before me/l~ _ ~ C///Y/7~/
............ .././"/day of~_....~..~...~...~.. (stamp r~,~',~' ~