HomeMy WebLinkAbout8840-z~'ORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No..~:75~81 ...... Date ............ gat* .... L~", 1O. ~?
THIS CERTIFIES that the building located at . 8o~_~d .V~ .AYe..W/. gold~r~t
Map No. X~ ....... Block No... :z~ ·" Lot No.. xx "'8oatt~old' · 'N~¥', .........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .......... Allg' ' 2(~' 19'?l~' pursuant to which Building Permit No..881,(~.
dated '- -Sep~ -. 3 , 19 r]6, was issued, and conforms to nll of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is Private one. family, .dwelling. {rebuilt-& Tes~ored') ..............
The certificate is issued to Ma:~in. Q,~_~n.~' · 'Wif~ 0w~ers .....................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ·-N,R, ....................
UNDERWRITERS CERTIFICATE No. Kubact~$ .3f7/77...(pending.) ...............
HOUSE NUMBER -- · 22100 · Street ., ~ral~l?~ew. Ave ..... Sott~hold ..........
·-/~.~ B~uii~in~'''
FORI~ NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
N9 88 0 Z
fi.HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED) ~,, ~
Dote ............................. ~.e.~.~. ....... 3..[..../.,' 19.....~.6
Permission is hereby granted to:
...................... g..~.J~.g.~. ...................................
~gnt.~ , . ~o application dated ........................ .~.~g.....~ .............. , 19.~.J~.., cnduopproved. , by the
~ ~uildi~ Inspector.
FORM NO. 6
TOWN OF SOUTHOLD
, Building Department
To~n 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 DUPLIC. ATE 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, ond
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 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 plon 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, streets, buildings and unusual naturol
or topographic features.
2. Swom 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: 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
.....
New Bqilding .... ~t ......... Addition ................ Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property. '..~/~~....~__~.~.~..~,~t~ ...... ...~..:....~.. ........................
Owner Or Owners Of Property .... .'.~.4...~~ ....... ~ ...................... ..~.......(~.
Subdivision ................................................................ Lot No ............. Block No ............. House No ............
Permit No. ,,~.....~.4~.. .... Date Of Permit ,..~../~, ,/.~.'~...Applicant ~,.~'~,,.,..~.~.~,.; ....
Health Dept. Approval ....~.. .................................... Labor Dept. Approval.. ...............................................
Underwriters Approval So rd App ovo, ........................................
Request For Temporary Certificate ........................................ Fined Certificate ..~.. ...............................
Fee Submitted $ ....................................
Construction on above described building and permit meets all applicable codes and regulations.
Ap p I i c ant ~~.... ~,-~:~......-~/..--'~ ............................................
Sworn to before me this
Notary Public~... County