HomeMy WebLinkAbout7694-z FOEM 1~O. 6
TOWH OF SOUTHOLD
Building Department
Town Clerks Office
Southold, N. ¥. 11971
APPLICATION FOK CEKTIFICATE 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 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,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 ...... ............................... ----":'1 .......................................................................
Owner Or O ners Of Property .............................
Subdivision ........ -.~..':~...~...~.L'C.~..cz....,~..e~.....~r~.......~..,..~T.,..Lot-- No, ~-~..........,, (~ Block No. ............ House No .............
Permit No. ,./..-.~....~..,,,..'7. Date Of Permit .................... Applicant ...........................................................
Health Dept. Approval ........... ~ ............................... Labor Dept. Approval ................................................
Underwriters Approval ....~.?....~...~.~......~:...~..t..t:?..?...~....,,....Planning Board Approval ........................................
Request For Temporary Certificate ........................................ FinoJ Certificate ............... ..~ .....................
Fee Submitted $ ,~ ......................
Construction on above described building and permit meets all applicable codes and regulations.
Appl icant .......... ...~..~.~ .nF~ ......~ ..............................................................
Sworn to before
..........
Notary Public .....
(stamp or seed 0
/ol3
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES 'Health Services
~, Reference Number~J~'~'
APPLICATION FOR APPROVAL TO CONSTRUCT
A PRIVATE SEWAGE DISPOSAL SYSTEM AND A WATER SUPPLY
10.
Property Lo'cation /~/~ %,,~ ~'~-~ ~"~d~
~/~ 11 age' f~:' ~ '-~'~"( Towns, hip
Public Wat~'r Company~Name
Lot size: Width ~ ~ ~feet Length ~ ~'~ feet
Sewage Disposal System:
Ao~,~[.~/~J~O~' gallon septic tank:
Precast Equivalent Block
B. Leaching pools:
Number of pools
Precas t ~'~ B1 ock__.Spec i al
ll. If private well, fill in the fol-
lowing blanks:
A. Tank capacity. ~ 9allons
B. Pump G.P.M. ~
C. Total well depth
D. Depth to ground water
E, Amount of water in well
6. Section ~
7. Lot Number ~(:,
8. Private Well w,:,,~
9. Public Water ~-
~tance to main ~
(For Health Services Dept. Use)
The undersigned CERTIFIES: "Construction of authorized installations will be in accordance
wi th the Suffolk County Department of Heal th Services' current standards thereto." This
application will be valid for one year from the date of approval indicated below and may
be renewed if a current local Building Department Permit is in effect.
=========================================================================================
FOR THE DEPARTMENT OF HEALTH SERVICES~ USE ONLY. Based on the information presented here-
with, it is the opinion of the Department of Health Services that an adequate and satis-
factory Sewage Disposal Sy~t~em and Water Supply can be installed on this plot.
APPROVAL DATE
S-15
Rev. 4/1/73
7 7~
NOillY BUILDING D~P^i~TM
INSPECTIONS:
BEFORE BACKFILLING F Lrr I'
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