HomeMy WebLinkAboutZ-7672FOKM NO, ·
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. ~767~ ...... Date ..............l~y ..... ~..., 19 7.~"
THIS CERTIFIES that the building located at 14:tnehaha. B~d ............ Street
Map No.. ~ ........ Block No...~ ..... Lot No.. ~ ...a~Ol~ · .N,~, ......
conforms substantially to the ~ ~ .~ ~
~lt ~ oo~p~e7
dated ..... ~fo~e. Ap~.. ~, 19.. ~7 p~suant to which 'Z~6~' ' '
dated ....... ~y... ~ ...... , 19. ~., was issued, ~d conforms to ~1 of the req~
ments of the applicable pro~sions of the law. The occupancy for which this certificate is
~u~d ~. ~r~W~..~. ~!~ .~.~!~ ......................................
The certificate is issued to . .Ro~rt. · .&. J~. F.,..~rk ..... ~ ...............
(owner, lessee or ten~t)
of the aforesaid building.
S~olk County Department of Health Approval ~re...e~s.t~g ....................
UNDERWRITERS CERTIFICATE No...p~..e~ng ...........................
HOUSE NUMBER ...... ~... Street .... M~. ~ ....... ~o15 .....
Building Inspector
i~Ol~bi NO. 6
TOWN OF SOUTHOLD
, Building Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR GERTIFICATE OF OCCUPANC:Y
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, /V~ultiple 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 surveyor property showing all property lines, streets, buildings and unusual naturol
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 lend use $5.00
3. Copy of certificate of occupancy $1.00
.....
New Building ................ Addition ................ Old or Pre-existing Building ....~'~ ...... Vacant Land ..............
Proper ......... ..................
Location
Of
Owner Or Owners Of PropeRty .. ~,~..~.. .... .. .......... ..~......~.~...~.....~.......'~......~...~..../~. ................ :..
Subdivision ................. .."~ ....................................... Lot No ..... ..~.... Block No......~ ..... House No....~...~...~...O
Permit No ....... ~--~.... Date Of Permit ........~. ......... Applicant ....... ~ ....................... ..
Health Dept. Approval ...... ~....~..~ ........ Labor Dept. A,~rova! ............ -- __ ..~.........,~.~ .r ...................
Underwriters Approval ....... ~.....~.......~.~..~ ......... Planning Board Approval ........................................
Request For Temporary C_e~'ificate ........................................ FinaJ Certificate ............. ~....
Fee Submitted $ ..... ..~)....'. .........................
Construction on above described building and per, it ,~neet~ all applicable codes and regulations.
Applicant ........ ~~/.~~ ..............................................
Sworn to before me this
..... .....
Notary Public ...... ...... · .~.~unty
(stamp or seal)/,~/~ /~ <~ ~-