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Home My WebLink AboutZ-10221FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Sou(hold, N.Y. Certificate Of Occupancy Date ...... 0. C..~.o.b. er., .2.8.~. .............. 19.8.0. THIS CERTIFIES that the building ................................................ Location of Property ... 6. 55..0.1r.$.l;.e.l?..P.o.qd....IaAO..~' ~ .......... 0..~.~.e.n.~. ~..N. ~.Z..~ ........... House No. Street Ham/et County Tax Map No. 1000 Section . . .0..2~[ ...... Block . .0.1 ............ Lot ...0.0.3 ........... Subdivision ............................... Filed Map No ......... Lot No .............. requireraents for a one-family dwelling built prior to conforms substantially to Certificate of Occupancy ,,~0o21 · .A.p.r.i.1...23., .......... 19 ~.~. pursuant to which l~~i~-Ne, ......... ~.:..~. ........ dated ..... .0.C.t.o..b.e.r...2.8.~ .......... 19..8.0, 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 ......... ... p.v.~.v..a.t.e..o.n. ?.-~a.~.~.~ .d..v.e.Z.~..~.ng..,%.~.~..o..rig..a.e..e 9.s.s.o. r~r..s.t.r.u.e.t.~..r.e., ......... The certificate is issued to . . .~.~ .~9.n.e.. a..*..&.. ~.o%.~. e...Iq.,..}Jg.r.k.l..1~. ...................... (owner, ~ of the aforesaid building. Suffolk County Department of Health Approval ...N/.R. .................................... UNDERWRITERS CERTIFICATE NO..~./.R. ........................ .../. ............... / Building Inspector Rev 4/79 FORM NO. 6 TOWN OF SOUTHOLD , Building Department Town Clerks Office 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 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 disposalm(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 "pro-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: ]. 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 B~lilding ................ Addition ................ Old or Pre-existing Building ~/ Vacant Land Location Of Property ......................................................... ~ ......................................... . ............. Owner Or Owners Of Property ..~./.O..~..~.~.~.'~ ..... ...~...*. ..... ..~........~'../p..~.~..~......./?..;......./~...o..~../.4.../..~...,?. ............................ ~ /_~ Subdivision q.°...~..~.'~..~......~.~....~.....~....../..d....~..~..~....E....~..Lot No ............. Block No ............. House No...~...~.~-...~'.. Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ..... ..~ff.~ ............................... Labor Dept. Approval ................................................ Underwriters Approval ....... ~/(...~. ............................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate .......z:. .................................. Fee Submitted $ ..... ~..,..0...0. ..................... Construction on above described building and I;~rmit meets g. ll~applicable codes and regulations. Sworn to before me this ................ day of ............................................ (stomp or seal) Notary Public .................................... County ~,, ~/~/J.j. BUILDING DEPARTMENT TOWN OF SOUTHOLD, N. Y. Location Subdivision HOUSING CODE INSPECTION REPORT (number & §treet) (Municipality) -- Map No. -- Lot(s) Name of Owner(s) Occupancy /~-- (type) Admitted by: ~o/~7- Key a~ailabl e (owner-~a~z~t) Accompanied by: ~t~ Suffolk Co. Tax No. /o~5--O~-oo~ Source of request ,A/,~z,,~, C c~ DWELLING: Type of construction Foundation ~_--/-~7- .~/~ ~_ Cellar ~-~/ Total rooms, 1st. F1 ~ ~- ~ m~ 2nd. F1 Bathroom(s) ~ ~ Toilet room(s) Porch, t~e~ ~. Deck, t~e Breezeway. ~ Garage ~pe Heat ~~ Warm Air Fireplace(s) ~d No. ~its Domestic hotwater #stories Crawl space 3rd. F1 Other Patio, type Utility room Hotwater ~z~ .~L~-~ Airconditioning Type heater ~c~ ACCESSORY STRUCTURES: Garage, type const. Storage, type const. Swimming pool . Guest, type const. VIOLATIONS: Housing Code, Chapter 52 Location Description Art. Sec.