HomeMy WebLinkAbout7780-zFOR~V~ NO. 4
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the building located at i~/~. 1~[~.. ~ s. · .: · · · Street
Map No. ~621 ....... Block N~ ......... Lot No, .i0 ..............................
conforms substantially ~o the Application for Buildin~ Permit heretofore i~ed in this office
da~ed ...~oh .31,, ......... , 19~g. pursuant to which Building Permit No.
dated ...~oh. ~l.l .......... , 19..~, was issued, and conior~ to a~ oi ~e req~e-
ments oi the applicable ~rovisions oi the law. The oecup~cy for which this certificate is
The certificate is issued to . ...¢~a~as .~pa~sas ..................................
(owner, ~)
of the aforesaid building.
Suffolk County Department of Health Approval ........ ~ ........................
UNDERWRITERS CERTIFICATE No ..... .~ ....................................
Building Inspector
FORM NO. ~
TOWN OF $OUTHOLD i
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Yo
BUILDING PERMIT
(THIS PERMIT MUST 'BE- KEPT ON THE PREMISES UNTIL FULL
coMPLETION OF THE~WORK AUTHORIZED)
N? 7780 Z
Permission is hereby grented to:
...9. ~..s.~.~.~... ~ ~r.~.~.~.~. .........................................
...~3.9....-.... ~J. ~.~ .......... ~.o..~.~z~. .......... : .............
to .b...q~.l!l.. ~;c.i,.'/~];~... g~ r~g~ ........................................................ i ................ ~,~;: .................. ~ ..........
ot premises Iocoted ot .......L~t;...$a....}lal~.....~6a.1 .............................................................................
....................................................... C~d a~..D.~,i.~ ......... ,Ea.s~..~.~n ....................: ......................
pursuant to application dated ............................... ~]~q.~ ...... z,.~.l..., 19~..~'..., and approved by the
Building Inspector.
Fee $.?l~aO, O .........
TOWN OF $OUTHOLD
, Building Department
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 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--IS-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:
I. 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 $].00
Dote ... ~.a~.l~.~.3~ ~....! ,Q e....17~.~ ......
New Building ...~.'~ ....... Addition ................ Old or Pre-existing Building ................ Vacant Lend ..............
. . ion Y.
Location Of Property .......................................... ~.. ....... .1 ....................................................
Owner Or Owners Of Property .....C~o.s.t~a..~ap.aa~a.a ..............................................................................
Subdivision ...~.~.62.~. ................................................. Lot No. 3.9 ....... Block NO ~ ....... House No...~..~.~...
Permit No..~..~..~.~.. ....... Date Of Permit ..~./..~..1.../.~.~.Applioant ..... .C.o..s..l;..~....~..a...~.~..~.s..~?. .........................
Health Dept. Approval ..... ~./.~, ................................ Labor Dept. Approval ......... ~/..,~. ................................
Underwriters Approval ....... ~./.~ ................................ Planning Board Approval ...~.,~. .............................
Request For Temporary Certificate ........................................ Final Certificate .......... ~. ..........................
Fee Submitted $ ..~..e..O...O. ........................
Construction on above described building and per,nit n~et~ oll ~pplicable codes and regulations.
App cant ~' ~ . . ......................
Sworn to before me this ......... '~' '~ ~b ......... :',' ;~'~ "~'~' ~ ~ ~'~
............... V ............................................ (stamp or seal)
Notary Public .................................... County ///~/77