HomeMy WebLinkAboutZ-10260 FORM N0.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
210260 November 17 SO
No . Date ..................!.............,19...
THIS CERTIFIES that the building .
Location of Property 9r=5 Middleton Road, Greenport, N.Y.
House No....... 04O Stre~~ 025 Hamlet
County Tax Map No. 1000 Section ............Block ...............Lot .
Subdivision ...............................Filed Map No. ........Lot No. .
reqquirements fora 0ne-Family Dwelling built rior to
conforms substantially to th2'Apglit'atlait70'1"B1x4fdift~P817iif['ft€tftfb78Yft"tfted'Yh ttiis'8t't~ft~Ce3'-'
A ril ?_3, Certificate of Occupancy
p . 19 . 57pursuant to which BtriiBirtg']~tR'R11t'idtf' , ,#Z 10260
dated November 17, , 19~. ,was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .
Private One-Family Dwelling with Accessory Structure (One-Car Garage)
The certificate is issued to ...Athena Keeria and An0.
(owner, ~
of the aforesaid building.
Suffolk County Department of Health Approval , NCR
UNDERWRITERS CERTIFICATE NO.. ,NCR
Building Inspector
Rey ans
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
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 Inspec-
torwith 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 equall.
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, acertificate 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 peoperty 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 informa-
tion 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 ../.11d'll~l~~:... / 7
New Building .............Old or Pre-existing Building ~ Vacant Land .
Location of Property /F'~rP d!~/Cl ;v.. _ , , , , , , , , , , , G~ .
House No. Street ~ Ham/at
Owner,orOwnersofProperty ...,1`\/.•:L/.~ t~U.4t~..~
County Tax M~ap-/No. 1000 Section . Block ~ Lot ....0 Z:~.... .
Subdivision L.-.~ .l . ..............Filed Map No. ..........Lot Na .
Permit No. Date of Permit ..........Applicant .
Health Dept. Approval ,~~r~ ............Labor Dept. Approval ....~.~G .
Underwriters Approval ...~.//`............Planning Board Approval ~l~~C:.......... .
Request for Temporary Certificate .....................Final Certificate .
CYG
Fee Submitted $ .
Construction on above described building and permi s all cable odes and regulations.
Applicant(.. ~
i I'I'~~fl~(;~D' ~bO
Rev. 10.10-78 ~ ~ 1~
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