HomeMy WebLinkAboutZ-6880FO'n.M NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnte Of Occupancy
No..Z.6.8..8.0 ...... Date ........... Feb.,...g ......... , 19.7g,
THIS CERTIFIES that the building located at B.,.0, ~,. F~/$. f.~akla~. Ave. Street
Map No..Xx ......... Block No...xx ...... Lot NoXxx... $o.uth.ol.cl. ~..)~, ........
......... r~eq~Ir~-:~ent~f~, one fe~nil_v A~re]l~ng.&.j~ou~j~.,~, code
conforms suos~antm~y ~o ~ne~ , , , ,- .... ~ .... ~
built
Ee2t~fi_cate Qf occu;.ancy
dated . .bef. oce. ~r. 2~ .... , 19.~?. pursuant to which s~,i~dm~ po~,,~i* No. ~zob^
dated .......... F. ebo...~ .... , 1~6.., was issued, and conforms to all of the require-
ments of the applicable provisions of the ]aw. The occupancy for wMch this certificate is
issued is .P. ri.v. ate..one, f~u~ily..dwefCLing, with. a.c.c.e $~.o. ry. g.qr. age.~ .dC.ck ~. ~..pilings
some chain 1Xuk fencing in rear yard, vost & rail fencing on waterfr:~
The certificate is issued to .Abram .Berti~ge-r .&. E.tane · 0-'~ulti.va~. owner~..Bullchead~J~g
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .pr.e-exist.lng .....................
UNDERWRITERS CERTIFICATE No...pre.-.exis.t.±ng ............................
HOUSE NUMBER . ~,~.~ ........ Street .. 0e, kl~ .i,¥e ...........................
FO~.M NO. 6
TOWH OF $OUTHOLD
, Building Department
Town Clerks Office
Southold, hi. 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:
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 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 pertirmnt 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 /I
New Bu,ld,ng Add,t,on Old or Pre ex,sting Bu,ld,~te ~:n~'L~:
Owner Or Owners Of Property .............. ~..
Subdivision .........~ .................................................. Lot No......~.. ..... Block No...~','. ........ c'~-~ ~ House No..,~,,,~.~,.. ~
Permit No ......... ~ .......Date Of Permit .....'~:~... .......... AppI cant ~ ......... ..~ ..............
Health Dept. Approval ..... ~..~...~.....'.......~...~ ....... Labor Dept. Approval
Underwriters Approval ..................... ..../.. .................. Plonmg Board Approval .... ................................
Request For Temporary Certificate ........................................ Fincd Certificate
Fee Submitted $ .....~.....~ ..............
Construction on above described building and pe]'mit meets all applicable codes and regulations.
Applicant ..,..~,~ ....... ~./~.~. ............ ~ ...........................
Sworn to before me this
.......... ;Z... day of ..... ~--..~::U. ,,'. ? .C ~. ..~. ........... (stamp or ~eal)'
Notary Public ....~.~ounty /~/~C~- ~/~
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