HomeMy WebLinkAbout7692-zFOEM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnte Of Occupancy
~(.,:-:'~. ,,A,/_~i e' 2~~
No ............. Date .. ',~K ~' ~0'(.,' ' 'If '~ [);:' '" 19 ....
THIS C~TIFIES ~at the b~ld~ located at . . ~: .... ~ .,.:~. ~,. Street
Map No ............. Block No ........... Lot No ..................................
conforms su~%an~all~ to the Applie~t~n fo~ B~lding Permit heretofore filed in this offiee~
dated ....................... , 19 ...., was issued, ~d conforms to ~1 of the req~e-
ments of th~ ~p~c~!~. pro~i~ns ,of the law/~e occup~cy f~ which this certificate is
................. :'~P~ i ~" ~ ~'~'; i '~ ~ .........
The certificate is issued to ........................................................
(owner, lessee or ten.t)
of the aforesaid building.
Suffolk County Department of Health Ap~rov~ ....................................
UNDERWRITERS CERTIFICATE No ...... ~ ....~ ......~ ............ ~ ...........
HOUSE NUMBEB .............. Street ..........................................
Building Inspect;;
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
'BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? ,7692 Z
Permission is hereby granted to:
~.ug~..~a~ ........ ~.~...~ ~,~...C.~b~L a.uc ~ .......
.................. ,..~'~. .........................................
to ]~uild .. ~ e.~., ~c c.e, ,~.~o ~;~..-~u£1d.ir~ ........................................................................................
at premises located at ..~z~d.D$..L.~e. ...............................................................................................
.................................................... 2.e~o~ie.....}.~ · Z~ .............................................................................
pursuant to application dated ........................~.~,~.~.....1.~1-. .............. , 19.~..~..., and approved by the
Building Inspector.
Fee t..~..,~.~..Q ..............
Building Inspector
I~OR~VI ~0. 6
TOWN OF SOUTHOLD
, Building Depu~tment
Tow, Cie,ks Office
Southold, N. Y. 1197'I
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 topographic features.
2. Final approval of Health Dept. of water supply and sewerage dispQsal--(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.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
formation required to prepare a certificate.
C. Fees:
1. Certificate of occupancy $5.00
]: :rpt fioCFtc;r?iffi:; o? c % rc;-;i.s;7 dwe,,in or land use $ .00 _ ?
e B~ Date~......~.~.~,/,~ ........... :~ ..........
Location Of Property ......... /...~.~..~ ................ ~/. ......... ~.~.../~../..¢.z,. ...............................................................
Owner Or Owners Of Property ...~.~.z.~../...~.~Z~.......~.~.~.~..~./..~:..'~..'.r.~...~! ..........................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No~....~.~...~...f.~.... Date Of Permit ./..T../,..~.'.Z .~...Applioant ~...~.././. ...... ,..~.~ ~:....c(,~... ..........................
Health Dept. Approval .,;......~...~.~ ...................... Labor Dept. Approval ................~...J.~.. ......................
Underwriters Approval ....~...~.....~...~.../....'~....~.. ................ Planning Board Approval ..... .~(.,../...~., .......................
Request For Temporary Certificate ........................................ Fin~ Certificate /'/'~'-~
Fee Submitted $ ....................................
Construction on above described build,ng a~.~r, mit. ~.et, ~a~ a~._~2~ ~d regulations.
Applicant ...._~~~..... x ..., .....~ ~r..~ .....................................
Sworn to befor~
(stamp or seal)
.