HomeMy WebLinkAbout9150-z FORIVI NO. 2
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)
Ne 9150 Z
Permission is hereby granted to:
W~ndsway ~mildXn~ Oorp A/C Robt Wende~
8outhold
to ...~la ne,,K..~..n.e
at premises located at .....W.~...~.9.~.tl;~..~,~&O,...t~..~lli'iel~' ....... ~.,~.~e...l~eek...R(E ..................
.................................................. ~.o.u.~a~l~ ...........................................................................................
pursuent to opplicotion doted ..........................~..a,T. ......... ~0. ....... , 19~..~...., and epproved by the
Building Inspector.
~OBM NO. $
TOWN OF SOUTHOLD
Building Del)ailment
Town Glerks Office
Southold, N. Y. 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:
1. Final survey of property with accurate location of oil 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 ~./~.. ,~. ~...'
/' Date ...... -- --~ ~.,~. ........
V
New Building .................... Old or Pre-existing Building ................... ~ ......Vacant Land ............................
Locat,an Of Property ...... ............ ......................
Owner Or ners Of Prope,y ....
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
' .l:"
Permit No. q/~'~,l Z Date Of Permit .../~'.e.?.Z.~pplicant .. '..~.'.Z~... ..~. ., .........
Health Dept. Approval .... .~./....~-...~./...../'./... .............. Labor Dept. Approval
Underwriters Approval ........ ~..... .............. '~ ................ Planning Board Approval
Request For Temporary Certificate ........................................ ' Final Certificate /
Fee Submitted $ ...~....z.z:.....?. .................
Sworn to before me this //''z¢'~'
....... .~..~. day of ......~: ...................... (stomp or seo~
Nota~ Public ........ ~. County ~/~>,~
~$PH~LT
FR 0 ° r L, r_V AT I 0
O'
II