HomeMy WebLinkAboutZ-5189FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. 009 ...... Date ............. JIM- .13..... , 19.73
THIS CERTIFIES that the building located at M21. C"ek .DriV , ........ Street
Map No. X=........ Block No. 3= .... Lot No.j=... Southold.. N.Y,......... .
Paw conforms substantially to the ade
bat be 'ore Apse - - 23 .. , 19. ...V- pursuant to which o. z 51t
Oesu
dated ... �.... J=W... 13....... 1973.1 was issued, and conforms to all of the require-
ments of/ the applicable provisions of the law.. The occupancy for which this certificate is
issued it ....Private- 4one • f4milyr
The certificate is issued to . Frw*. &
of toe aforesaid building.
County Department of Health
Leto .... Owners ........................
( owner, lessee or tenant)
)val ... pre.. existing .................
UNDERWRITERS CERTIFICATE No... r®]CiatiAQ ................................
HOUSE NUMBER. .660 ........ Street.
..Mi11..Creek .Dr .............................
Zxception to 'housing codes ....r
1. No li,ht switch at point of entry 529b
2• Light fixtures wired with light `
lamp cord — porch, 2 bedr,00ms' attic 528a BuildingInspector
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FORM NO. 9
TOWN OF SOUTHOLD
Building Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instruction
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.
S. 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.
Date....... .�. ...........................
New Building .................... Old or Pre-existing Building ........ �....... Vacant Land ............................
Location Of Property ............................. ./.�11.�✓.....(�.�.�.�'..C.C............. P.r.L. ............................
Owner Or Owners Of Property ......................... ry..-a.n.ae.............. 4.Cr. l�......................................
4-1
Su ivision – T..�.. Block No ............. House No.............
�d .._ ..... Q.1~ ...... .. `f �..4i 2 ...Lot No:. k n
Permit No. ..AIlly...... Date Of Permit
./y/A........ Applicant ............. 411/1.......�.J........�.y.....................
Health Dept. Approval .................A...!... . <�.............Labor Dept. Approval............./.��(s///1.......................
Underwriters Approval ............... lK.................. Planning Board Approval...../..C./�.....................
Request For Temporary Certificate ........................................ Final Certificate...........x.........................
Fee Submitted $ ,cO..G?...................
Construction on above described building and per ' eets all app ' able. a and regulations.
Applicant............ ... L.- .....................
Sworn to before me this
A//...... day of ..\//.G.CJ1-.e......................... (stamp or seal) °� 1� s( r
Scd. t/
Notary Public .v .!1........... County 7,V �.1 L
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MAP OF PROPERTY
S/rZIATd*D /he THE
TOWN 0.#c- SOuTNO L D
S!/FFOLl( COUNTY, N.Y
SURVt'YEO NAY 16., /!73
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