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Home My WebLink AboutZ-4566FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certi[icate O[ Occupancy Date .......... l~.eJraxar~...~..., 19.. THIS CERTIFIES that the building located at I~11~0 .. No, th. Riley. An... Street Map No.. ~1~ ........ Block Noll~ ........ Lot No.. ~,~ ... l~ttt.t~Ok l. .N .Y, ....... conforms substantially to the ~J~J~]~l~-'JJ qJ.~jr~11~J~j~JJi~jlt~l~ d~°.r. .to. &'prll' '~ ...... , 19 .~.~.. pursuant to which ~1~]-'~.,~][. No... ZI)~(~ dated ....... l~elF~.&ry ~.., 19..~, 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 is . Priv~ce. or~ -family- d~el~ln.g ...................................... The certificate is issued to .. ¥.iote'~ .¥- l~llter -.. Owner .......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval pre · ex-i. stir,~ .,. I~.,R, ............. House ~ 120 FOI~M NO. $ TOWN: OF $OUTHOLD Building Department Town Clerks Office So.thold, 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 .................... Old or Pre-existing Building ........ ~ ............. Mocant Land ............................ ......................................................... ~...,..~.~ ~x..}....~..~...~ .......... ~ ........~..?~..~... Owner Or ~ners Of Prope,y ~t~.~ ~ ~ JLL~-~ Permit No Date 0 t pp .................................... Underwriters Approval .............................................. Planning Board Approval ~ J~' Request For Tempora~ Ce~ificate ........................................ Final Certificate ~ Fee Submitted $ ~ ~ Construction on above described building and permit meets all applicable codes and regulations. Sworn to before me this No'tory Public ................................ ~... County~ Elizabeth Ann' ~eville"~' ELIZABEIH ANN NEVILLE ~ NOTARY PUBLIC State of New York No 52-8125850. Sulfolk Cou~.t'~ Term Expires March 30, 19,~0~,~ REV/$1ONS YOUNG a YOUNG ~100 OS~'RANDER AVENU£, RIV£RH£AD· N Y ~LD~N ~ YOUNG HOW~ ~ YOUNS . P....-: ~'-.:L E.,.':',z~: ,t':." LA',.O S'... :',.: NIA T T I TUCt~