HomeMy WebLinkAboutZ-7219FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificate Of Occupancy
No. Z..~.~$ 9. .... Date .............. ~.e~t .... ~ .... , 19.
THIS CERTIFIES that the building located at . ~1~..l~lal~. R~. ~. ~P!~..~et
Map No...~ ....... Block No .... ~ ..... Lot No, . ~.. S~oXd.. N.,.Y, .........
conforms substantially to the t ~ ~r~nt ~f~l b~ld~
~ .b~t .be~o~. Apr. ~19..~7 p~suant to w cn ~~'9 ....
dated ......... ~.pt.. 8 ..... , 19.7~., was issued, and conforms to a~ of the req~
ments of the applicable provisions of the law. The occup~cy for which ~s ce~ificate
issued is .off'ce. b~ld~g .....................................................
The certificate is issued to . ~ph. ~r .... ~er. {. F~aer~. ~ho~) .......
(owner, lessee or ten,t)
of the aforesaid building.
S~olk County Department of Health Approval .pre,..e~s~g .... ~ ...............
UNDERWRITERS CERTIFICATE No...pre,..ex~s.t~g ...........................
HOUSE NUMBER .... ~ .... Street ... ~. ~ad ..... S~o~ .............
Building Inspector
FORM NO, 6
TOWN OF SOUTHOLD
, Building Depo~tment
Town Cle~s Office
Southold, N. 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 Cede 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
_/,~.
Date ......... .~./~...... .........................
New Building ................ Addition ................ Old or Pre-existlr)g Building .,~..~.,..;... Vacant Land ..............
Location Of Property .../~.(~..~..~I......ECI~A.,,.~...~......,.~.~)..~..~.../...~... ........................................
Owner Or Owners Of Propertyt ...~........~..{,~.~./~Z),~....../~........~...~.....l~........~.....~....
Permit ,o ..................... Dote ~ Pe,,t .................... ~p',c~, ........................ ./...r./../...,.., ........................
Health Dept. Approval ......... ""~'/~'"~//~l .................... Labor Dept. ,~q:~proval .............. ,~/,s~./~..~ ...................
................ ...... ......... ..................
R uest For Tem ora Cert f ' ~//~ '
eq p ry ''cme .......... ~...~/...~ ................. Fined Certiricate ..........................................
Fee Submitted $ .....~.... .........................
........... .....
Sworn to before me ~,~'~ ...d ~'"/'~ ~/ //~///~/~(stamo o~.~
"~'~i~" day °~~'~" tstamp or seaJl/~
%County st;re of New York
Public . ~.~.~..~.County ~o~p,~, ~u~,
~ O~ .No. 52-3302~20 . SuIlolk County
· Commission Expi~os March 30, 1977~