HomeMy WebLinkAbout9201-zTOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, BI. Y.
Certificate Of Occupancy
No...Z.~..~.~.8. .... Date ....~.e.p.~..~.be?..2..7 ......... , 19...7.8
THIS CERTIFIES that the building located at . .~..8.~.~ .... ~.a.~...R. 9.a~ ...... Street
Map No ............ Block No .......... Lot No .................................
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .. Ap.~.~-..2.3. ..... , 19..7.7 pursuant to which Building Permit No..
dated .. Ap~.$~-..2! ......... , 19.??., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is ....... P~l~ra~e..One. F.~ily..D~e~-3.~'qg wl~h. A.~dt~l.on ...............
The certificate is issued to ........ Henry. B, .&. Dnr'othy..~/,. Fauoon .............
(owner, ~t)
of the aforesaid building.
Suffolk County Department of Health Approval ....... NfR ....................
UNDERWRITERS CERTIFICATE No .................... .N.~. .....................
HOUSE NUMBER . ./~6~45 ..... Street ........... M~n. Ro~d. ...................
................................................ . ~a~hc~ld,. N,Y, ..............
Bt!!!ding Inspector
FO~M NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 9201 Z
Permission is hereby granted to:
$o~thold
at premises located at~../...~...~..~....:~..~.....H..o...~..d.. ..............................................................................................
................................................. ~.t.~..o.~.....~.,. ~.: ..............................................................................
pursuant to application dated .......................... .~.~..~.. ....... ~..I. ............ 19~.~....., and approved by the
Building Inspector.
FOP,~M NO, $
TOWN OF SOUTHOLD
, Building Deportment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This apphcation must be filled ,n typewriter OR ink, and submitted in DUPLICATE to the Building
Inspector with the following; for new buddings 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 s~te plan requirements where applicable.
B. For existing buildings (prior to April 1957), Nomconforming 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 buddings 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
Date ...... ..9 ./~.~../.'[.~. ...........................
New Bqilding ................ Addition ...~. ...... Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property ..... ~'~..~..~..b:~.~.'/..~:.e.~..~..~'.~.~8:~.S.9..u:~.~9.~]:~.`t~}~? ...... .]'..]'..~..~.]'. ..............................
Owner Or Owners Of Property ..... .~..e...z~..~...~.?..~...D..°.~.°.~.b...~..?..*...~.u:.°..?.?. .........................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No..~.0..3:.....~ ..... Dote Of Permit ..~'.~/..?..8. ..... Applicant .... .D..°..~..°..~..~.,Y...?.?i.[e....u.°..9..~. ...........................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval ............................................ Planning Board Approval ........................................
Request For Temporary Certificate ........................................ F~n~ Certificate ..........................................
Fee Submitted $ . .5. ... ~ .0. ...........................
Construction on above described building~0d permit r79ets all applicable codes and regulations.
Sworn to before me this Applicant C.6.~..~..: ...... 7~, ........................
................ day of ............................................
Notary Public .................................... County
(stamp or seal)