HomeMy WebLinkAboutZ-30076FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building InspecTor
Town Hall
Sonthold,
PRE EXISTING
CERTIFICATE OF OCCUP~/~CY
No: Z- 30076
Date: 03~11/04
T~IIH CERTIFIES t~at t_he building DWELLING
Location of Property 2520 ACKERLY PD LA SOUTZIOLD
(HOUSE $0.~ (STREET) (FJ~4LET)
County Ta~ Map No. 473889 Section 069 Block 0003 Lot 008
Subdivision Filed Map No. Lot No.
conforms substantially to the Requirements for a ONE FAMILY DWELLING
built prior to APRIL 9, 1957 pursuant to which CERTIFICATE OF
OCCUPANC~f I~t~4BER Z- 30076 dated M~RCH 11, 2004
was issued, and conforms to all of the requirements of the applicable
provisions of the law. The occupancy for which this certificate is
issued is ONE FAMILY DWELLING WITH ACCESSORY WOOD FR3LME SHED*
T~e certificate is issued to ZOFIA FURMANKIEWICZ
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF ~IEALT~ APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
*PLEASE SEE ATTACHED INSPECTION REPORT.
N/A
N/A
th zed Smgnature
Rev. 1/81
BUILDING DEPAd{TMEHT
TOWN OF SOUTROLD
HOUSING ]ODE INSPECTION REPORT
ZOFZA FUHMAMKIEWECZ
ACCESSORY STRUCTURES:
VIOLATIONS: CHAPTER 45 N.Y. STATE L~IFORM FIRE PREVENTION & BUILDING CODE
LOCATION DESCRIPTION ART. SEC.
D~Z ON I~SPECTEON: 02/Z9/04 f~inspected 3/9/04
TOWN OF SOUTItOLD
BUILDING DEPART~IENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Tins application must be filled in by typewriter or ink and submitted to the Building Department with the following:
For new building or new use:
1 Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or
topograpinc features.
2. Final Approval from Health Dept. of water supply and sewerage<l/sposal (S-9 form).
3. Approval of electrical: installation from Board of Fire Underwriters,
4. Swora smtemen~ fi.omplumber certifying that the solder used in system contains less than 2/10 of 1% lead.
5. Commercial building, industaqal build/ng, multiple residences and similar buildings and installations, a certificate
of Code Compliance fi.om arcintect or engineer responsible for the building.
6. 8ut~mi~ Plafin~n~ Board Approval of completed site plan requirements.
For existing bqi!dlngs (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses:
1 Accurate survey of property show/ng all property lines, streets, building and unusual natural or topographic
features.
2. Aproperty completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is
derffed, the Building Inspector' shall state the reasons therefor in writing to the applicant.
1 Certificate of Occupancy - Ne~v dwelling $25.00, Ad~drttions to dwelling $25.00, Alterations to dwelling $25.00,
Sw/mming pool $25.00, Accessory building $25.00] Addilions ro accessory building $25.00, Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Building - $100.00
3. Copy of Certificate o£Occupancy - $.25
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00. Commercial $15.00
Date.
New Construction:
Location of Property: ~2. ~"lO
House No.
Owner or Owners of Property:
Suffolk County Tax Map No 1000, Section
Subdivision ~ ~ ~
Permit No. \~x~- ~ Date of Permit
Old or Pre-existing Building: (check one)
Street Hamlet
O (:,% Block
Filed Map. "~
xx \~\~ Applicant: ~o~
Health Dept. Approval:
Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate
Fee Submitted: $
Final Certificate: _ (checkone)
/~' -- ~plicant-Si'~g~t~e
CONSENT TO INSPECTION
Owner(s) Name(s)
., the undersigned, do(es) hereby state:
That the unders/gned (is) (are) the owner(s) of the prcuuises in the Town of
Southold, locatedat ~.c~ ~:x,c~-~ ~'~,~ ~.~7 ~ ~-,a~,.~
which is shown and designated on the Suffolk County Tax Map as District 1000,
Section O~% ., Block c~% , Lot oc~
That the undersigned (has) {lm~)--filed, or cause to be filed, an application in the
Southold Town Building Inspector's Office for the following: eaz. c,,,,~a-r,~ ~
That the undersigned do(es) hereby give consent to the Building Inspectors of the
Town of Southold to enter upon the above described property, including any and all
buildings located thereon, to conduct such inspections as they may deem necessary with
respect to the aforesaid applicat/.on, including inspections to determine that said premises
comply with all of the laws. ordinances, roles and regulations of the Town of Southold.
The undersigned, in consenting to such inspections, do(es) so with the knowledge
and understanding that any information obtained in the conduct of such inspections may
be used in subsequent prosecutions for violations of the taws, ordinances, roles or
regulations of the Town of Southold.
Dated:
(Signature)
(Prim Name)
(Signature)
(Print Name)
76So1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ]FRAMING [~AL//~ ~C~
[ ] FIREPLACE & CHIMNEY
DATE