HomeMy WebLinkAboutZ-7021FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte Of Occupnncy
No. Z7.0.2.1. ...... Date .............. .HAY... .7 ......., 19.?.6.
THIS CERTIFIES that the building located at .... . .I~a.y~..a.t.e..r.s..H.o..a.d. ...... Street
Map No. Na$~.o.p.t..,..PBi~k No ........... Lot No, l).t...~.7. & 268 Cutehoi~. e NoY
q renents for one
conforms substantially to the ........
built before certif$cate of occupancy
dated ......... .Ap.~..2..~ ...... , 19.5..7. pursuant to which ~~,~No.
dated ......... l~laI... 7 ......., 19.~..6., was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
The certificate is issued to .~. ~.~9.n.C..H.e..:l~. 0ruler of record
of the aforesaid building. (owner, lessee or tenant)
Suffolk County Department of Health Approval P..l~.-.e.x~..8..t.~..g ......................
UNDERWRITERS CERTIFICATE No..I~U$-...e.~s.t.~.n.g ............................
HOUSE NUMBER ..... ?~. ...... Street ....H.a..yy..a.t.e.r..s..H.o.a..d ......................
N0..T~. ~..T.12~,$..C/.Q. ~.o.v. qr.~..t.h.e...~.i.n...b.l~..i .1.d.~..g..n.o.t...un..d.e.r...C/.0...~..~.7.0...f.o.r.. ,~1...addit.
Building Inspector
FORM NO. 6
TOWN OF $OUTHOLD
, Building Deportment
Town Clerks Office
$outhold, 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:
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
New Building ................ Addition ................ Old or Pre-existing Building ..~. ........ Vacant Land ..............
Location Of Property .... ..~.~/.~.~...y..j:(~....~....~-..~'.~.~.....~.~..~......~. ..........
Owner Or Owners Of Property ....... ~..,,~/./,~.~'.~, .~..,.....~.........~,,~,/..,,..,~.~, ................................................
Subdivision &(...~..~..-'~.'./. ......... Lot No..:~..~.8... Block No....."~. ....... House No....~....
Permit No ..................... Date Of Permit ..... ~ .............. Applicant
Health Dept. Approval .... ./.Z/~.'~. ......................... Labor Dept. Approval .... ..,/Y(...~..Z..~. ............................
Underwriters Approval ....... ~.Z~2..'~..: ........................ Planning Board Approval .....~'.Zx.~..:./..,~..: ......................
Request For Temporary Certificate ........................................ Find Certificate ....... x~.' . ................
Fee Submitted $ .......... ';.....~' ...................
Construction on above described building and~rmit meets all,~licable/cod~s and regulations.
,x'~ day of /
............................... .........................
Notary P~ JOHN L. MOLLOY
....... ~ ....... ;~ .... County
~"-~ ~' ~7 NOTARY PUBLIC, State of New Yerk
' No. 30-79~6500
Residing in Nassau County