HomeMy WebLinkAbout9313-zFORM NO. 4
TOWI~ OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificate Of Occupancy
No. . Z9095 ... Date ..... June . 50 ........... , 19.78.
THIS C~RTIFIES that the building located at . . ~50. ~Tm~'c. B~ad ......... Street
Map No ........... Block No .......... Lot No ........................... · .......
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ... J. tme. '17 .... , 19. ~ pursuant to which Btam]ding Permit No .... .95~5Z
dated . June . .'~? ...... , 19..7.7, was issued, e~d conforms to ~11 of the reqt~_~re-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is ..... PRZ~rATE .ONE FAMTLY. DN~T,LING..~ITH. ADDITION..(DECIC) .........
The certificate is issued to ... John. JE.. C~rnel~ ............................
er:
of the aforesaid building.
Suffolk County Department of Health Approval ........ .N./R. ....................
UNDERWRITERS CERTIFICATE No. N%R
HOUSE NUMBER 950 .... Street ....... ;Eas.t. Road. .......................
.............................................. Q~A~cchQ gue,,~,.New..York ...........
.......
Building Inspector
1~0~ NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COA4PLETION OF THE WORK AUTHORIZED)
N? 9313~ Z Dot~ ............................. ..V..~.'. ...... ~Z, ~
Permission is hereb~ ~'~6nted to: ' {, ~
................................. !.~ ......... :..._....,...: ...... , ........ ...:.~..: ............... c..~.~..c~.~.~...~.~., ..... ~.:~....:. ~
pu~uant to application doted ............................................................and oppFoved by the . ~,~ ~
Building Inspector.
Fee $:.:.t'...~,.:~ ......
Building Inspector
FOF,~ ~0o ~
TOWN OF SOUTHOLD
, 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:
I. 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), 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 ...... ..~..~.. ..... ~....~....~.: .~.......~..~.~...., ................. ~ ......................................
Owner Or Owners Of Property ..... ...'~....~.....~..~./.......~...........~-~..~..~....'~...~./...~-~....~....~ ..............................................
Subdivision ................................................................ Lot No ............. Block No ............. House No ............
Permit No...,~,~.~/.,~, ..... Date Of Permit 6/,/.7/,Z .7,,.Applicant ...................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ....... ......~ .......................
Request For Temporary Certificate ........................................ FinoJ Certificate ......... ~ ............................
Fee Submitted $ ...~.~.~...~.. ...................
Construction on above described building/o~it r~eets ollsa:~icob~"~c, xxJes and regu_lo.t~s.
Sworn to before me this . '~ ~
................ day of ............................................
Notary Public .................................... County
(stomp or seal)