HomeMy WebLinkAbout9114-zFO~V~ NO, 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupnncy
THIS CERTIFIES that the building located at 5. ~.5...~.~ .~.~..ff. 0.~..'[ .... .~.~..-[..k/.. Street
Map No...-~..~. ~.0... Block No ........... Lot No .... .~. ............................
conforms substantially to the Application for Building Permit heretofore filed in this office
dated............ .~.~ ~?...2..[, 197.~. pursuant to which Building Permit No.
dated .............~.~. '.~.. ~.~.., 197. 7, 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 . ,~..~..~..V/~.'~. [...(}. ,~! ~, .... !~-?..~..~.~. .... ~ .P)..E..k.k..t.~,. [ .g~.... ............
The certificate is issued to....,J..0.~..~.l .... .C. ?! ~ ?. ?...~. ~ .5.....,1~.. ...................
of the aforesaid building.
Suffolk County Department of Health Approval ./~.P. ~.. !21. !~.-/?.....~.~.~., .7.-..5.?. ~.{.
VNDERWRITERS CERTIFICATE No ........ ?.~..~'.9. ~.~ ~. .......................
HOUSE NUMBER .... .~.~. '~ .... Street .....~.~ .~.~.~...~!qo..~. ..... ?..~.'~.r.~. ..........
CuT
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Building Inspector
FOI~M NO. ~
TOWN OF SOUTHOLD
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)
9114 Z
Permission is hereby granted to:
.............. ~outl~l~ ..............................................
~o ~t~L~ .. ne~.~, ona..fmnL~.,.d~l~ L~ ......................................................................................
at premises located at .~lL~ ....... ~I. O0~...(~ID, t~I ...............................................................................
........................................ D~e~.~'~o.t ..l~t~ ........ ~t~tc&eeue .........................................................
pursuant to application dated ..................... ~ ....... ~.~1 ............... , 19.~.~..., and approved by the
Building Inspector.
Building Inspectlr
FOBM NO. $
TOWN OF $OUTHOLD
Building Depeffment
Town Glerks Office
$outhold, N. ¥. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building
Inspector with the following; for new buildings or new use:
]. 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 o'f 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
Do,e ............ ................
New Building ....... V..... ...... Old or Pre-existing Building ............................ Vacant Lond ............................
Location Of Property ................................. .~...~. ....... C.~d.t~. ........ .~..~.....~ ................ ~ .....................
Owner Or Owners Of Property ...... .....O..,~,:. ...........................................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No...~.~./..~....~,.... Da, Of Perm t ..~.....~..."~.~...?/~ ) cant ..~...?.~...~. ~ .~...~ /~" ~
)c~]e ~ ~T~ ,~ ,~ ': ........ PP ............. ~ ........ }' '"~'"'"~'" ........
Health Dept. Approval ~./;.~..~'[/.:~:Z.../(./.~.......?.~.~.:Z./.Labor Dept. Approval ........... ~ ..............................
Underwriters Approval ..... : :':.~ .................... Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ~
Fee Submitted $ ....... ~.~Q~k ..:. ...............
App,,cant ................... '- :'" .......
Sworn to before me this
................ day of ............................................
Notary Public .................................... County
(stamp or seal)
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JNAUTHORfzm ALTERATION OR AODlTlotl'
TO' THIS SU~VfY IS A VIOLATION Of
S~CTION 7209 Of THE NEW YORl( STATE
EDUCATION LAW.
COPies CF HilS SURVEY MAP NOT BEARING
THE l,l>."D SU;:V~Y;)R'S IN;:m SEAL OR
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