HomeMy WebLinkAbout6450-zFORM NO. 4,
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupnncy
No.Z~.~0 ....... Date ............A.~r$.l.....~ ..... , 19..~..
THIS CERTIFIES that the building located at ~. l~d. ~.~ ~..P~.t.~*~. ~ Street
Map No ..... ~ ... Block No...X~ ..... Lot No. ~ .... 0.~,~..e.~$...E....~., ...........
conforms substantially to the ApPlication for Building Permit heretofore filed in this office
dated ...........~r...30..., 19.73. pursuant to which Building Permit No. ~.0~..
dated ............~.~.. 3.1..., 19..7.3, was issued, and conforms to 'all of the require-
ments of the applicable provisions of the law. The occupancy, for which this certificate is
i~.~s~ed is P~Xvate ~e family dwelling
The certificate is issued to . ~.,.L.,. ~.t.r.a.c..h.a.n. .... ...0p~e...r. ..............................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval N. ,~,. ................... ; ...........
UNDERWRITERS CERTIFICATE No. N..lL~.~9. ..... J~'...1~...~.973..' ...........
HOUSE NUMBER .2~0 ........ Street P.v.t. P~l .~. ~,... P. eter. a .~ec~ .8oad ....
FOl~I NO. ~
TOWN OF SOOTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N*. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE P'REMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
Ne 6450
Date ...................................................... ..., 19 ........
Permission is hereby granted to:
pursuant to application dated ....................................................... '., 19 ........ , and approved by the
Building Inspector.
Fee $...!....~.......2 ....
Building Inspector
TOWN OF $OUTHOLD
Building Department
Town Clerks Office
Sou~hold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF: OCCUPANCY
Ensfructlons
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 U~derwriters.
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), Nomconforming ~ses, 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: I. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land :use $$.00
3. Copy of certificate of occupancy $1.00
Date . ~..~.:d.. ~.../..../...~. ~.~,..
Mew Building ................ AddiHo? .....~..2 ...... Oldgr Pre-existing BUikting ................ Yaeont kand ..............
Location Of Property ...f,~,~.r~/"~"~'...).~.,~:z.:...Jj~.~....~....~~:~!~ ....................................
Owner Or Owners Of Property ..../~j~r~4~.~..~,~..~.......~..~......~L~.~.~/
Subdivision ............................................ ~: ................... Lot No ......... ~....., Block No. g,~ ......... House N,,p .............
Permit No...~....?...~.i~... Date Of Permit ...~.~i.~..Applicant
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval ,. ./.,.~.~,,,.:.~..~. ............. Plonnlng BoOrd Approval ....................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $'--
Sworn to before me this
......... ~ day of ..... .~... ..............................
Notary Public .................................... County
(stamp or seal)