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Home My WebLink AboutZ-11965FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. ~..~ 3 .9.6.5. .......... Date ........ Q¢ t o.b.~C. 5 ............... 19 .8.3. THIS CERTIFIES that the building ................................................ Location of Property Main Road Mattituck - H~use No. Street Hamlet County Tax Map No. 1000 Section .... 1. .2.2 ..... Block 03 .Lot 0 01 . 1 Subdivision X ............................... Filed Map No...X. ..... Lot No .... .X ......... Requirements for a private one-family dwelling built prior to conforms substantially to the APlflh:m~t-fi:n'-B~lflinlg-Permff-treretofoteq'fle~-ha-tflis-off'mede~d Certificate of Occupancy · . .~ p?.~. 1...2.3 .......... , 19 .5.7. pursuant to which Buikling-Permit No ........ Z. ~. ] .9.6.5. ....... dated October 5 ........... :. .... . ........... 19 ~.3., 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 ......... a private one-family dwelling. The certificate is issued to ALICE PANTALEO & JOHN W. BOUTCHER, JR. ..................... /o;;,n'o'r, '~i,~'~' dr'tb;a'~'O ............ ' .......... of the aforesaid building. Suffolk County Department of Health Approval .... n o..n e c p?.cl ..................... . ...... UNDERWRITERS CERTIFICATE NO. no record Building Inspector Rev. 1/81 FO~ NO. S TOWN OF ~OUTHOLD , Building Depa~ment Town Clerks Office Southold, N. ¥. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Inltmcfions 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 unusaa~ 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 pertlflent 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 $1.00 New B~ilding ................ Addition ................ Old or Pre-existing Building ..... ~,...*..... Vacant Land .............. Location Of Property .......... p..~.~.u.~..h..e..~.~.s.~.s.~..d..e.~..~.~.~.~..~"a.~.~..n.~.~..~..~.~.d.~.~~Y Alice Pantaleo and Owner Or Owners Of Property ...~.°..~.n....~.:....~...°..u..~.c...~..e...~.z...~.~..: .................................................................. Subdivision ................................................................ Lot No ............. Block No ............. House No. ............ Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate .......................................... FeeSubmitted$..1..5..:..0..0' ........................ Suffolk Co. Tax Map #1000/122/03/001. *SEE ATTACHED AFFIDAVIT Construction on above described building and permit meets all applicable codes and regulations. Sworn to before me this ~, .......... y .... P. · .~...~.~.~ ..... (stamp or seal) Nato,,, P~li- Suffolk County WILUAM WICKHAM ' · .................................... Notary Public, Stere Of New Ymk Commission Expires March Pefeco Healty Co. STATE OF NEW YORK) COUNTY OF SUFFOLK) SS.: York, 1. She side of Main Road, Boutcher estate. 2. Situated on the premises £s the was constructed long before 1900. ALICE PANTALEO, residing at Main Road, Mattituck, New being duly sworn, deposes and says: is the co-owner of the premises on the southeast Route 25, Mattituck, New York, known as the (Suffolk County Tax Map No.: 1000/122/03/001. residence which 3. Deponent further says that no alterations or additions have been made to the residence since April of 1957. 4. Deponent makes this affidavit to induce the Building Department of the Town of Southold to issue a Certificate of Pre-existing Use for the premises. ALICE PANTALEO ;worn to before me this