HomeMy WebLinkAbout6453-zTOWN OF SOUTHOLD
BUILDING DEPARTMIENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE P~,EMISES 0NTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N? 6~53 Z
Permission is hereby granted to:
.......... ~hag~ze .................................. :. .............
to ...:]~d.. ne~.. ~:me... fam~..dt~e 3.iL ~g ............................. ; .....................................................
~t premises Iocot*d at ..I,o.~...~'t.....~J~,,e~..gg.....~e~..~l:.....I .....................................................
........................................... Qsl~e~...&e~t..l~oad .............. O~.~enl~.t ............ : .............................
pursuant to application d~t~d .........................A_DZ~.I.~.. ....... ~ ........ .., 19:...~/.3, and approved by the
Building Inspector.
Fee $.~,.~g. ..........
Building Inspector
APPLICATION
TOWN OF SOUTHOLD
Building Department
Town Clerks Office
Southold, N. Y. 11971
FOP, CERTIFICATE OF; OCCUPANCY
Instructions
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 u~e:
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 fram Board of Fire Ufiderwriters.
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, ~treets, 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 buildiogs or premises, or other 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 $I.00
Date .................................
New Building ....~ ....... Addition ................ Old or Pre-existing Building ................ Vacant Land ..............
Locaton Of Property J~..~.~, ' ' .~ ~.' ~ In ' Z<~. -
...... ..... .........
Owner Or Owners Of Property.....~.~..!..J~."..'
Subdivision ..~C~....~..~,..~...~.....~...~..' ' ' .......... Lot No.....~.../..~' Block No.._~. ~...~../.. House No .............
Permit No ..................... Date Of Permit Applicant .... ' .............
Health Dept. Approval../;~...~--.~.:../..}~l..~.....~. ............ Labor Dept. Approval .......... Z.......~..':[.~...: ..................
Underwriters Approval ....... ..2:...?./..~...~.....Planning Board Approval ........... ~ .........................
Request For Temporary Certificate ................... ~. .................... Final' Certificete ...~.. ......................
u i ~.
Fee S bm tted $ .....-~. .............................
Construction on above described building and,_~errrpit meets all applicable codes and regulations.
Sworn to before me thi,~ ~,,~
....... .~..;~ day of ...... ~:..~.....!..~...:?..~ ..... (stamp or seal)
Notary Public .................................... County
BEFORE BACKFILLING FGUNDAi OR START FRAIv, ING
E COVERING p~pELINE
~AL WHEN JOB COMPLETED.