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Home My WebLink About8974-z FOBM NO. 6 TOWN OF SOUTHOLD Building Delm~tment 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 triplicate 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 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 requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey aT 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: 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 ....~. g.~.9 ~.f~r....4., J. ~.~. ~. ........... New Building ..... X ............. Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ................~.5.~.~.~..~.y.~.L.~.q.e..~.~.?'.~.9~..~.i~e...~.d"~.~.~.~.~9~!~x~ Owner Or Owners Of P, roperty ....... Go.~.~.i.~..~n~l,..J~.art~e.t;.~: .................................................................. Subdivision .~IT..e..e..n..~.i..e..I...d.~......E...8.~.~..e.~ ............... Lot No.....L6..... Block No ............. House No......5....6..5... .................. I I ~/22,[7~ Ii ant Permit NoS~..~, Z Date Of Permit ..................pp c .................................................................. Health Dept. Approval ...~,-.S..0.:..2..0..~. ...................... Labor Dept. Approval ................................................ Underwriters Approval .N,~,~,~,.0,,O,~, ............................. Planning Board Approval ........................................ Request For Temporary Ce~rtificate ........................................ Final Certificate .......~( ................................ Fee Submitted $ .;~.~.. .............................. Construction on above described building and permit meets all applicable codes and regulations. Annlicant ~~L~L~,~ . ~.g. en~; .~o.r,. Fr',nk Bor'n . ................................. ¥2. ............... .......... Sworn ,o before me ,his . "~l, - , THE, NEW?¥O'~K BOARD OF :FIRE UNDERWRITERS i . '-', i' - ;' .[--7 ' THIS CERTIFIES THAT ' G0witz '& Barnett~;w/s '"Barley Southo,ld, L.I. ,-- - in th~ follotrlng l~ation; ~ August 21 1GFCI' smoke detector J. Crocombe~ Box 1175 Center Horiches, L.I.t1934 This cedlficate must not be altered in any manner; return to the office of the Board if incorrect Inspectors may be ~dent[fled ~ir credentials. FORM NO, 6 TOWN OF SOUTHOLD Building Department Town Clerks Office $outhold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate 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, end 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 plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buJJdJngs 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: 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 ....0~m~.~.. ~ t .I.~. .......... New Building ..... ~. ............ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ................ Owner Or Owners Of Property ....... ~.~l~lej~lj~.il~ll~t..~l~r~l~ ................................................................. Subdivision .............. Lot No ..... [6.... Block No ............. House No,.....~..6,.~;. Permit No~I~4..Z ....... Date Of Permit ...J.l./~31~.~pplicont ...F.~#~...~..~ ....................................... Health Dept. Approval ...~-,~t~.~ ...................... Labor Dept. Approval ................................................ Underwriters Approval N.~,~{~.3 ............................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ........ [ ............................... Fee Submitted $ .................................... Construction on above described building and permit meets all applicable codes and regulations. ....... ....... Applicant Sworn to before me this ................ day of ............................................ (stamp or seal) Notary Public .................................... County or J. J. oonOl~Oo for (vocontl THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND/OR FROM DATA OBTAINED FROM OTHERS THE WATER SUPpLy AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE SUFFOLK CO DEPARTM T HEALTH SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES FOP, APPROVAL OF CONSTRUCTION ONLY i~ ot 15 NOTE: · = MONUMENT SUBDIVISION MAP FILED'INTH[OFFICE OF THE CLERK OF SUFFOLK COUNTY, ON NOV. YOUNG & YOUNG 4-00 OSTRANDER AVENUE, RIVERHEAD, NEW YORK ALDEN W. YOUNG HOWARD W YOUNG SURVEY FOR: GORWITZ 8~ BARNETT LOT 16 "GREENFIELDS AT SOUTHOLD" AT SOUTHOLD j GUARANTE:ED TO: TOWN OF SOUTHOLD SUFFOLK CO., N.Y. SCALE: I"= 40' I DATZ:0CT. 25, 1976 J NO. ~'6-924 .j. J- erlY or f°rlv°c°¢) THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND/OR ROM DATA OBTAINED FROM OTHERS THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE SUFFOLK COUNTY DEPARTMENT OEHEALTH SERVICES APPLICANT ADDRESS -- TEL -- -- - NOTE: I = MONUMENT SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY ON NOV. I0~ 1975 AS FILE N0.6~1;5. UNAUTHORIZED ALTERATtON OR ADDITION TO THIS SURVEY TS A VIOLATION OF SECTION 7209 OF THE NEW YOpK STATE EDUCATION AUG. /1~ 19X? YOUNG & YOUNG 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK ALDEN W. YOUNG HOWARD W. YOUNG SURVEY FOR: GORWITZ & BARNETT LOT 16 "GREENFIELDS AT SOUTHOLD TOWN OF SUFFOLK CO., N.Y. SCALE: I" = ~0' IDATE: OCT. 25, 1976 J NO. 76-924