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FOEM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnte Of Occupnncy
No.. '.Z.~.I.?.~ ..... Date Nov 6 19.
THIS CERTIFIES that the building located at .~.~.n.n.y. ~.o.~.d..~..~qqd..~Street
Map No. ~ ......... Block NoFXZ ....... Lot No... ~... ~q~$~...N t~.. .......
~ r me ~s .o f lv d el & om
conforms subst~tially to the~ r ~_ ts ~ f ~ d e,~,. ~ ,~.
~u~t before Cer~f~ea~ of 0equ~aney
dated ............. ~T~i
...*~, 19..~ p~su~t to which ~~o. Z.
dated ........... ~V .... ~..., 1~.2~., was issued, ~d conforms to ~1 of the req~
ments of the applicable provisions of the law. The occupancy for which tMs certificate is
issued is E .C, Private one famil~ d~e] ].lng '
The ce~fficate is issued to . .Jo~t..~,. ~;~Ck ....... ~,~ ~ ...........................
of the aforesaid building.
Suffolk County Department of Health Approval
(owner, lessee or tenant)
ore-exi sti~g
UNDERWRITERS CERTIFICATE No..~u Z'o-..e ~ ~ ~ J .n.g .............................
HOUSE NUMBER .... ~20~) ...... Street ... ~:.e.~.~,.~.y..:!.?~.d. .........................
/
· -/.~.. '.~':~- ( .". ·. .... - .C~. :.. :~-'-'~'~'~ ::1' ............
Building InspectOr
HOUSING CODE INSPECTION
November 6, 1974
#80 Dogwood Lane & 3200 Kenny's Road
Southold, N. Y.
Tax Roll: John R. Buck & Wf.
Occupant: Owner
Upon receipt of an application for a Pre-Existinq Certificate
of Occupancy, I made an inspection of this one story ~ramed
dwelling. I was admitted to the building by Mr. Buck and began
inspection at approximately 3:00 P.M.
The Building is built on a slab and contains a kitchen,
dining room, full bathroom off hallway, two bedrooms with one
having full bath. Forced warm air heat is supplied to all
rooms by oil fired furnace located in utility room. An electric
hot water heater is located in this utility room, this room has
access from kitchen and hallway. On the northwest corner of build-
ing there is an unheated sunporch.
The following violations of Housing Code, Chapter 52, Town
of Southold, were noted.
Outside entrance to sunporch, no means of controlling
light in room on entry. Article V, Section 52-56,
B.2.
2. Kitchen- cold water line to kitchen sink has leak.
Article V, Sec. 52-51, A.2.
Exterior of building and grounds in good order. Inspection
com~pleted at approximately 3:20 P.M.
EH:mm
Re~s~ctful~ submitted,
Building Inspector
FORM NO. 6
TOWN OF $OUTHOLD
Building Department
Town Clerks 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 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:
l. Accurate survey of property showing all I~roperty 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
.....
New Building ................ Addition ................ Old or Pre~-existing Building ....~ ...... Vacant Land ..............
Location Of Property ..~.....~.....~........~.Z....~...~....~.......~..~ ...........................................
Owner Or Owners Of Property .... ~..~: ....... ~..~.C,,,~.....~....f. Ly~.~.. .................................
Subd v s on ~ - , ~ ,;J' V '~C~"'~D~oOI
............................................................... Lot No ..... .<.~..... BIocF, No .... ..~. ..... House
Permit No ......~ ..... Date Of Permit ~ Applicant
Health Dept. Approval ..... ../~...../~....2.....~....~.....~... ......... Labor Dept. Approval ....~...'L.~.~. ..................
Underwriters Approval .............................................. Planning Board Approval .... ~ .....................
Request For Temporary Certificate ........................................ Final Certificate
Fee Submitted $ ....................................
Construction on above described building and,~ it meets all applicable codes and regulations.
..................
Sworn to before me this g~
............ · (?. day of .......... ~... ,~,., ,~.,27 (stamp or seal)
Notary Public .......... ~County