HomeMy WebLinkAboutZ-4894FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte O[ Occupnncy
No. Z.~i591+ ...... Date ...... November...6 ........ , 19.7.2.
THIS CERTIFIES that the building located at .R,0,!d... }1/~ .Be;'gCr~. i, ve.. Street
Map No .... ~ ..... Block No... ~ .... Lot No ~ ~.a,t; .t;]l.~uck...I~ ,.¥., ..........
conforms substantially to the e me t o e i"" i ',~el ' buill;
·Cer.~ificate o~ unit. fi te. oce ancy
~1~ l~.fOt'. &pr.i.l.25..., 19. ~.~. pursuant to wh~ch~~tNo.z1+~4...
dated ......... No~.ember..6.., 19.7.2., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . .Private. one. lazaily..al;welling ......................................
The certificate is issued to .. ~o.~':.'_.s..~.~ ~. $~o.;:m ........ .ow?..e.r. ........................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . ~r.e-. e;~J. stiag ...................
UNDERWRITERS CHRTIFICATE No. ~1~. ~X;l,$$.J-~%g ..................................
ItOUSE NUMBER..31+0(1 ...... Street.. 1%~. ~OZ~d. ~;..t2 .;,la.~;tituck.. ~,Z. ............
,
Building Inspector
o
FOBM NO. S
TOWN OF SOUTHOLD
Building Department
Town Clerks Office
Southold, N. ¥. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted
inspector with the following; for new buildings or new use:
1. Final survey of property with accurate location of all buildings,
in triplicate to the Building
property lines, streets, and
unusual natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage dispcsal--(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
D te ?..?..2. .......
New Building .................... Old or Pre-existing Building ....~ ................. Vacant Land ............................
Location Of Property R.0.W. N/S Bergen Ave Mattituck N.Y.
Doris K. Brown
Owner Or Owners Of Property .......................................................................................................................
Subdivision ................ ~ ......................................... Lot No.....37,. ..... Block No....~.... House No,,~,..~.~?,.,?
Permit No .......~ ......... Date Of Permit ...~ ...........Applicant ....0...l~....e..~.. ..................................................
Pre- existing , - N.R.
Health Dept. Approval ............................................ LaDor Dept. Approval ................................................
Underwriters Approval ...]~..~..e..-...e.;~.~.~.~..g .............. Planning Board Approval ...... ..~..'..~...'. ........................
Request For Temporar~ Certificate ........................................ Final Certificate ~
Fee Submitted $ .~.~...0..0.. .........................
Construction on above described building and ~er~mit meets oll.~3plicable codes and regulations.
Sworn to before me this
6 day of November 17.72 (stamp or seal)
Notary Public'~,-~ ....... ~ County
TERRI LEE ELAK
NOTARY PUBLIC, State of New York
No. 52-6168295
Qualified in Sulfclk
C0mm[ssion Expires March 30, 19 ~/