HomeMy WebLinkAboutZ-4523FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Cerli[icale O[ Occupancy
No. Z. If. ~.2~ ...... Date ............. ;[an..20 ....... , 19.~.
THIS CERTIFIES that the building located at R,0,M .. o~.f .8/~ .l~lekol'y. ~
Map No. y~ .......... Block No. ~[~ ...... Lot No.xxX. S.~. Goose- ~ay. Est,. SoutholS,
conforms substantially to the ZO r q r en aS ~ red . ~ .A eals
dated .. i~ept.. 40 .......... , 1970.. pursuant to which I~,U~I~,P~..Approval
dated ...... ~p~ .... ~'0 ......, 1970., wasg~,dand conforms to all of the require-
ments of the applieable;~e~llo~goih~l~[~ ~[~l~ccupancy for which this certificate is
issued is . P~'iv~te 'one .fa~±ly. ~i~teili~ .......................................
The certificate is issued to .. l~rron~-ze, i~e~']t~~ · -Co~-p' -. 0~;~I'- c~£ .record ......
(owner, lessee or tenant)
of the aforesaid buildiz~g.
Suffolk County Department of Health Approval · ~;.ot~, ..............................
ouse
Hicko~ Ave
Building Inspector
POEM ,NO. 6
TOWN OF $OUTHOLD
Building Deportment
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 triplicate 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:
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.
New
Building
Location Of Property ..o..a.....M~..~...q..f...C~.e.e.~i~..~at&tea.~hg~m~.oim.&[t~hed.m.~p .........................
Owner Or Owners Of Property ~*.~*~*~*~.t~.~*~*q~.*~*t*X~.~.~p*~i~.~*b.~.~9[~.~.t~.~.~~~g)~
Subdivision ......... ~J. Ctrll~ ............................................. Lot No ............. Block No ............. House No .............
pre-exieting building
Permit No....~..q..rl,~..[ ...... Dote Of Permit .................... Applicant ..................................................................
Health Dept. Approval ...-o.[.~.-..~.~[L~:.i,~g. ................ Labor Dept. Approval ................................................
Zoning
Underwriters Approval ............................................. ~ Board Approval ..~..e.p~.e...~...~.~.~...1..O.,....1..9..?..O
Request For Temporary Certificate ........................................ Final Certificate ........ ~ ...............................
Fee Submitted $ ...5.,..0..0.. .........................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant ...... .H...A...~...~..O...~....T..I .~...E.....~..F~.....L...T...Y....C...O...~...P..:. ....................................
·
Sworn to before me this By _/'/'2~~~. (~ ~-~/
...... .~..9. ...... day of ...~.a...n.~i~X ......................... Attorney fol' AppIJ(~nmtp or seal)
Notary Public ...... . .~...6/...~.~....~...~. ~/~ ..... County
N BABEiTE C. CO}~=,OY /
OTARY PUBLIC, State of New Yozk
Su~{olk County No. 52-5792800
Commission Expires l'v2arch 30, 1972