HomeMy WebLinkAbout7454-zFORM NO, 4
TOWN OF SOUTHOLD:
BUILDING DEPARTMEN;T
Town Clerk's Office
$outhold, N. Y.
Certificete Of Occupency
THIS CERTIFIES that the building located at /)/'~P ~ ................/~/Ut/itk'~//]¥/~. .... . .... ~ .. Street
p ............. Block No ........... Lot No.. ~.~. ..........................
conforms substantially to the Application for Building Permit heretofore filed in this office
dated
...................... , 19 .... pursuant to which Building Permit No.~ ~/~Y~ .......
dated ....................... ~(~ ~ / , 19~, was issued, ~d conforms to all o~ the requ~e-
merits o~ the applicable provisions o~ the law. The occupancy for which this certificate is
The certificate is issued to
(owner, lessee or ten,t)
of the aforesaid building.
Suffolk County Department of Health Approval ....... ~ .~ ........................
UNDERWRITERS CERTIFICATE No ..... ~f ~ .
Building Inspector
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~. Y.
BUILDING PER~IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
cOMPLETION OF THE WORK AUTHORIZED)
N? 7454 Z
Permission is hereby granted to: ~
........... ¢~a~;¢ho~ae ............................ ~ ..................
to .[..~...$.~....~f ~.~.e~.Y .b~i3~iz~g ............................ ...........................................................
...................................................... Ff..~.6. ............................ ~ ..........................................................
at premises located at ...~;~..~. ................ ]~,~g~a~i,"]~O:~ll"l~''''''' ..........................................................
........... : .................... ..r~.. ~g.~ .eL .p.£~....~le~et~a...F,o.a~L..I .......... Outcho&ue ...........................
..................................................................................................... i~ ................ ~ .........................................
pursuant to application dated .................... ~.11~ .......... J ......... 'i ....... , lc)..~,~.., and approved by the
Building Inspector.
Fee $. J..O..,.~. ..........
FORM NO. $
TOWN OF $OUTHOLD
Bu;Iding Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR 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 from Board of Fire Uriderwriters.
4. Commercial buildings, Industrial buildings, Multiple R~sidences 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, 6ccupancy 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: 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
Date ........ C~-ff~-.. ~ ./~...../. ,C~ Z~Z...
New Building / Addition Old or Pre-existing Building Vacant Land
Location Of Property y~.~ li/05Vttlk'.l~.~TA
Owner Or Owners Of Property ........................................................ : ......... ; ....................................................
Subdivision ...~...~.~..~....~... ...... ~..J..~.!.7.. ...................... Lot No~c/~ ~ Block No. House No.~./.~.~..'...~.
Permit No. 7 Y..'~../'/...~Dote O f Permit
Health Dept. Approval .............. .................... Labor Dept. Approval ............ ../~...=/.~.. ........................
Underwriters Approval ...................~....~ .................. Plonning BoaJ'd Approval ......~..:'..'.~ .......................
Request For Temporary Certificate ........................................ Final Certificate
Fee Submitted $ ........~ ........................
Construction above
on described building and perm~ ,~,)e? all olbplicabl,~,odes and regulations.
......................
Sworn to be~this
................ d~y~ (stamp or ,ea')c~
............................ z
Notary Public ..~ ........ ~ .............. County