HomeMy WebLinkAbout8312-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
THIS CERTIFIES that the building ................................................
Location of Property .... 'j..6.2~.....Y.~.r~. ~.~.O.~;~;. ~.~,¥~ ................ S~'~hO~l,d ~. I'L,.Y,
House No. Street Hamlet
County Tax Map No. 1000 Section .... ~5 ...... Block ....... ./4 ....... Lot ..... 22 ..........
Subdivision....~ez~.~O~;~. P.e~k ........... Filed Map No....518'~.Lot No .... 30 .......
conforms substantially to the Application for Build]ng Permit heretofore f'fled in this office dated
· 2~ove;bez' .... 21 .... ,19. ?Spursuant to which Building Permit No ...... .8~.1.~Z. ..........
dated ...... No~real~,.. 2.i ........ 19.7~, was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
The certificate is issued to .Ralph. Glazier.. (Ne~ .Owg, a~.s..Steve~ .&. lnla .Mandala.).
(owner,~
of the aforesaid building.
Suffolk County Department of Health Approval ............. N/I~ .........................
UNDERWRITERS CERTIFICATE NO .... .N.2.9.7.? .2.0 ......................................
Building Inspector
Rev 4/79
l~"Ol~.,~ NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N9 8312 Z
Permission is hereby granted to:
Fees ............
to .. ~..lin.. adfl~tt4mn..e~, .. ex~t~u~, d,ell:tnlL..(~atle). ........................................
at premises located c~t .... ~.~.:~.....~I~..J~OOJ~..~-~JI; .......................................................................
................................................... ~e~t..!~ ......... a~a~l~ ....................................................
................................................................................. ?. 2.....~.L: .......... ; .......................................................
~pu~u~nt to application dated ]Jl]~ 2~J , 197~ , and approved by the
B~u!idin~g ~ Inspector.
I~ tic-- Buil,ding Inspector
FO~l~ NO. 6
TOWN OF $OUTHOLD
, Building Department
Town Clerk~ Office
Southold0 Iq. 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 use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and
unusual natural or topagraphic 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 af 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, 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 $5.00
3. Copy of certificate of occupancy $1.00
New Building ................ Addition ................ Old or Pre-existing Building ..... ~ ........Vacant Land ..............
Location Of Property ~C~p~g~T~TX~g~'~k~Z~2~~q~~~¢ N.~
Owner Or Owners Of Property .8.%~.y.~..~...T,~..~....~.~..~..~.~..~.~. .................................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No ............
Permit No .................... Date Of Permit .................... Applicant ~.~,e,~,e.~,.,~,,~,,c].,,,,Z,.~.~,,~,a,,~,.~,a...1,~ ..............
Health Dept. Approval ............................................ Labor Dept. Approval ...............................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ FinaJ Certificate
Fee Submitted $ ..5.~.0.0 .........................
Applica [~.~]~ & B heys for 'Xpplican~' .............
Sworn to before me ~is by: Rudolph H. Bruer
.... ~.~b ..... day of ....... J~.~.,....%.~2.~. ............. (stomp or ~al)
Nota~ Public .... ~.~.~Q.~ ............... C~nW O.C ~ ~fS'~