HomeMy WebLinkAbout359-zNO. 4
/ TOWN OF SOUTHOLD
BUILDING DEPARTMENT
: TOWN CLERK'S OFFICE
SOUTHOLD, N. Y
.i ',.
CERTIF'ICATE'0F OCCUPANCY
No. ,~..-198
September 2~ I o5~
of the Oforesaid building.
THIS CERTIFIES that the building located at W/.S VillaEe La , :' Street
Map No.
Block No. XXX'~. ~ ~rien~..:..~..~t...
conforms substantially, to the Applicalion for BuiJdlng Permit herelofo[& .filed In this office dated
,~e.....~....j ........... 19 .~., pursuant to which Building Permit Nb .~..~...j ....... ~.~
-
doted .~e.....~ ................. 19 .~8../ was mssued, and con'arms to al of the requirements
4~ ~'~,. (owner lessee or lenont) :~ '
FORM NO. $
TOWH OF $0UTHOLD
Building Department
Town Clerks Office
Southold, lq. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This oppllcation must be filled in typewriter OR ink, and 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 dlsposal--(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 b'uildings (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 olher pertinent in-
formation required to prepare o 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 ..~:..../. ......................................
New B~lildlng ................ Addition ................. Old or Pre-existing Building ........ ~..~ .... Vacant Land ..............
Owner Or ~ners Of Prope,y . _....:.~.4,~'....~ .......... ~1~ ....... ........ C{ a.,..F .......................
Subdivision ..... ~ ...................................................... ~ Lot No..~ ~ ....... Block No. ~ ......... House No .............
' ~ ' Date Of Permit ~ ........... Applicant
Permit No..:r ........ ::7. .....
Health Dept. Approval ..~z~....~.~.~ ......... Labor ~pt. Approval ........ :..~.:..~Z ...... Z ..............
Underwriters Approwl .... ~'..' ........ :2~:..:.:~v.tA ........Planning B~rd Approwl ........................................
Request For Temporal. Certiflcote ........................................ Final Cartfficole ...... .~ .........................
Fee Submitted $~..=.~:~ ..................
Construction on above described building and p~r~it meets a~l applicable F~s ~nd r~ulatigns.
Applicont ......................................