HomeMy WebLinkAbout9730-z FOI~M NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N9 9730 Z
Permission is hereby granted to:
...~.~:.!..!~ ......... ~. .........
,o ....... ~:.?~.!~ ........... ~'N. ~ ... ~. .~'~;~ .... :?':'. ~ ~': ... ~',.~ ~.~.~ ,~,.:~..
at premises located et ........... ~.:~.:.....~:'..~.~:=~: ......... C.::.:.~:./.~: ......... :~:[:.~.:.~,: ..............................
pursuant to application doted tM/X '/ 16
................................................... ~.-., 1 .., and approved by the
Building Inspector.
......
Building Inspector
TOWN OF $OUTHOLD
, Building Depmtment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This applicatior, 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 dispasal--(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
New Building ................ Addition ...~. ......... Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property ..... ~..~..~......j~.>.~..~..~ ....... ~./~.V~...4~,,.~......~....~.~. ..................................
Owner Or Owners Of Property ....... ..~.../~..~.~....d,:....~.......~,.~.~:...,.,.~...~ .................................
Subdivision , ..,.~.t.s~.../~m ~ . .~..~ .............. Lot No..~.,'~,..... Block No....~.. ....... House No...~.~.~....
Permit No, ....~'..?..~...o., ..... Date Of Permit ..~'.//.~.l.'/..?..,....Applioant ..~/...~..,.~..:..?....~..c....~....~..Jj~. ......................
Health Dept. Approval ............. ../g..i//~ ....................... Labor Dept. Approval .............~/./~.. ............................
Underwriters Approval .............................................. Planning Board Approval .......... ..~../6. ......................
Request For Temporary Certificate ............ .,~,./,~.. .................... Final Certificate ..........................................
Fee Submitted $ ....................................
Construction on above described building anc~t 7e(~%applicab, le codes and regulations.
Applicant .......... ~J(.~/.~ ...............................................
Sworn to before me this
................ day of ............................................
Notary Public .................................... County
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