HomeMy WebLinkAboutZ-9671FORM NO. 4
TOWN ~OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. Z 96-f I Date ,,JUNt" ~/~ 19'77..
THIS CERTIFIES that the bufld~g
~tion of ~ope~y ~ ~: .......................
II ~ Il
Co~ty T~ Map No. ]000 ~ction ............ Bloc~ ............... bt .................
Subdi~sion ~ ............... .Filed Map No... ~ ~...Lot No. ~..
confo~s subst~t~ly to ~e Ap~vahuu Iu~ B~dmg ~lml[ llvzvtulb~v l~d In ~ u~i~ ~d
dated ~ ~jE ~ ~ l-'9~ ~ , was issued, ~d co~fo~s to aa of the requ~eme~ts
of the app~cabie provisions of the law. ~e occupancy for w~ch t~s ce~ificate is issued is .. ~ .....
~e ce~ificate is issued to .................
~.w ..............................
of the aforesaid buildi~[.
Suffolk ~ounty Dcpa~me~t o~ ~¢a]th Approval ..........................................
UNDERWRITERS CERTIFICATE NO ..................................................
Building Inspector
Rev 4/79
,,ooo- ¢~- I-ii
FORM NO. 6
TOWN OF $OUTHOLD
, Building Deportment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
I nstructlons
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: ]. Cerfificote of occuponcy $.5.00
2. Certificote of occuponcy on pre-existing dwelling or Iond use $.5.00
3. Copy of certificote of occuponcy $].00
Date ,, ,J. ,u,, .n. ,e,, ,];, .8, :,...]., ,9, .7. ,9, ....................
New Bqilding ................ Addition ................ Old or Pre-existing Building ....x, .......... Vacant Land ..............
Location Of Property ~?..~r~a.~r.~e~.a~..~?~;~.~h..e~£~.~`~"~`~~C~[-~¢~ ......................
Owner Or Owners Of Property . .N,..a,n.,c.~, ~onE ~.o~d, ,a.n.d,.,.~,,[.,i.z,.,a,,b,.e.,t.,h...,b.,.o,.n,E..,C,,,h,,e,.,~.~;~.~ ................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No ..................... Date Of Permit .................... Applicant .................................................................. ~
Health Dept. Approval ............................................ Labor Dept. Approval ................................................ \
Underwriters Approval .............................................. Planning Board Approval ........................................ I~ ~-
Request For Temporary Certificate FinaJ Certificate ~3
Fee Submitted $ ........ .~,..9.~. ................... ~'
Construction on above described building an~_pe_r.~~l[I opp.~C~I~ ~onl:l~u'at'o~s.
/ /~, ~ ( t ~// ~/ ' No. ~-298~0S ~' -
~ ~ ~ ~/~ ~/ Qualified in Suffolk Co.~y ~, ~