HomeMy WebLinkAbout6243-z FORil~ NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTN'OLD, bl., Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE Pt~EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 6243 Z
Permission is hereby granted to:
.(~.~.~.sal. t lx ..l~.cm.t~ sb.~p....Ime ..........................
..... lqatr~..~a~d .....................................................
.......... ~o=tix~la.....l~ ,,~.~ ........................
pursuant to application dated .................... I~t....:J~. ............ :......, 19,~J~.~,, b~/ the
Building Inspector. ' /
Fee $.~Q *.qO ...........
f
FORM NO. $
TOWN OF $OUTHOLD
Building Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions. ~-~9~.~ ~ ~,~
A. This application must be filled in typewriter OR ink, and submitted in ',*~l~Jete 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 ?equirements 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 ail property lines, sireets, buildings and unusual natural
or topographic features.
2. Sworn statement of owner or previous owner as to use, o~cupancy 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 o certificate.
Fees:
1. Certificate of occupancy $5,00
2, Certificate of occupancy on pre-existing dwelling or land use:
3. Copy of certificate of occupancy $1.00
$5.00
Date ....& .~..~.... !..~...... ( .?...~....'~.. ........
New Building ../.¥.~'.~.~.. ..... 01~ or Pre-existing Building ...., ........... .~ .......... ; ,VaCcmtlLand ............................
Locaton of Proper,y ...................
Owner Or ~ners Of Prope~y ..Ce~..l..4..~.'.'~.'..tl~..~,...~
....................
Subdivision ................. ~ ......................................... Lot No ..... ~;.. Block No..~ ....... House No .............
Permit No ~,~'~,~ ~ate Of Permit .~.~.l.~,..~plican, ~..I.J.S~i.t~.p~}.~.~.~..~I.GL~,.?~] ~
Health D~p* A~ro~:, ...... ~'~ ........................ Labor Dept. Approval ...~/~..~'~...~1~ J, '~
' . - I / . r
,o. d ......... ......................
Request For Tempora~ Ce~ificate ........................................ Final Certificate ....... ~ ....................
Fee Submitted $ .~.~ ..................... :
Construction on above described building and permit m~et~ all a~plic~le c~es an~regulalions.~
..........................
Sworn to before me this ~ I~'/~ ~
.... l..~d ...... aa× or ....~.~.~ ............. ~ ................
Notary Public '~,xrm~......:~.....'~...:~,¼~.~-County
(stamp or seal)