HomeMy WebLinkAboutZ-7284 coax xo. a
TOWN OF SOUTHOLD
BUII.DING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
;7284 Oct 7......, 19.7.6
No Date
THIS CERTIFIES that the building located at N~3 Main Road Sh.~
Map No.. xa Block No...?~...... Lot No.. Southold, , l? .Y , , . , , . • .
~~nt~_,~ c~e__family awellin¢ i,.1io• tg coQe
conforms substantially to the 3' -
b~tilt befare A r ? Cer ft~. 3 occupancy
dated P 3 , 19.. pursuant to winch iReltd o. Z•7284. .
dated 4 L...7...... , 19.75. , was issued, and conforms to all of the require•
ments of the applicable provisions of the law. The occupancy for whie4? this certificate is
y~u~ yQ .Private. one, family •direlling , • rgmodg~.pd) , , • , , , , , , , , , , , , , , , , •
The certificate is issued to ...fast • I slander •Hgme~ , ink, , , ,Q,~e,~ , , , , , , , , • , , , • ,
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .pre-..existing, , , , , , , , , , , , , , , , , • ,
UNDERWRITERS CERTIFICATE No.Pre- existing . (update. N2Q~124, , kt}Q, 6, . 196
HOUSE NUMBER ......5681.5.. Street Jiain.l~oad.... ~puthoL3 .
AL4te.; .front .ate~s . to..be. coxrect~d .
Building Inspector
FORM NO. 6
TOWN. OF SOUTHOLD
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 equoU.
3. Approval of electrical installation from Board of Fire Underwrit@rs.
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 loud use $5.00
3. Copy of certificate of occupancy $1.00
Date ..~..5...~,~ 7.~......
New Building Addition Old or Pre-existing Building Vacant Lond
Location Of Property ~6~~QA/.!/.1...~........
Owner Or Owners Of Property ......L~1*iC-~••.. ........~~~~L2'c(c~..~/f....4~
Subdivision ...........................................Lot No. Block No. House No....r~..'~~~~
Permit No Date Of Permit ....................Applicant
Health Dept. Approval ............................................Labor Dept. Approval
Underwriters Approval z 9 ~ ~ 2 .Planning Board Approval
Request For Tempos C~r~{jcate Final Certificate ......~i:~......-..
Fee Submitted $
Construction on above described building a d pe it me all applicable code regu tions.
Applicant
Sworn to before me this ~D~ ~ l 7-6
............day of ~ (stamp or seo~
Notary Public aunty
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IW~ JNAVTHORIZED ALTCRATiCN OR ADDITIpN
_ 1 r0 TMIS SURVEY IS A VIOLAPON OF
^f ~ J :SEiTION 72D9 CF THE NEW YORK STATE
1 L~ 1 J ~ ~EDUCATICN IA W. 1
I ~ ~COi1ES OF THIS SURVEY Il OF NOT E:ARING
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4 ~ TITLE COIL A n, .~Y AN
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A-~~~TO THE ASSi,.'..:5 Cf S.u i.iDi:14 INq^fb
7 I ~ TUTION. Gl1ARAl<Tk ES ALC i•iO7 IeAF;SFEBABEJ
TO ADDITIONAL INS7GUTI(iN5 OR SUdS~QUF!
F ~ OWNERS.
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