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HomeMy WebLinkAboutZ-4861FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~'8~. ...... Date .............. 0ctobe~'. 1.~..., 19..72 THIS CERTIFIES that the building located at .l~'lva.t® .Road ............. Street Map No. F...I. ,Es.~atel~lock No..12 ....... Lot No. ~..Fi~ho~s..Islam.. N.J~, ..... eon o m u s ant,.l ,. , ~.t~f~te .o~, occupanc~ ~t. before 19. ~ pursuant to wmcn~t~o. ~$61' dated .......... ~c~ber.- .1~, 19..72, 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 . Pz'ivr.i:e ' on~ 'f?.mi'12 · !we. _.._~,s', ~ * ~ ~ ........................................ The certificate is issued to .. Eartha- 'B i' R'ob~so~ ...... O~e~ ................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ..... ~re-..cz:is.ting ................ UNDERWRITERS CERTIFICATE No .... pre-- .ex].s.ti~g ............................... ~tO U S E N U M B H R.. 'NO~ ......S ~reet ..... Priva'te - r~d,. ~o -Ba~e ................... Exception~ two private accessory buildings in front yard area~(non-conforming use) 3 <:; k .... q:..,c'-~ ;-',.' .... Building Inspector FOBM NO. S TOWN OF SOUTHOLD Building Dejmr~ment Town Clerks Office Southold, N, Yo 11971 APPMGATION 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 dispcsal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences end 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: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date ....Q.~ ~.,o..~...e.T..' .~ .7.. ,.....1.,9, .7..~ ..... New Building .................... Old or Pre-existing Building .~,l,..t....[~,5..2.... Vacant Land ............................ Location Of Property ......... .~...~.~..v.~..t..e...~.g..~..d. ............................................................................................... Owner Or Owners Of Property ....... .~...~..~...'g..~..~.....~..:...~.o...b..~..~..§.o...~. .................................................................... Subdivision ..F..i...s..h...e..r...s....l...s..l..a...q.d.....E...s..t..a...t..e...s. .......... Lot No .....3. ...... Block No .......1...2... House No ............. Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ~,-c~ ~.~ ~ Labor Dept. Approval (%' ~ ~ Underwriters Approval .............. ;; ....... ;.'. ........ .~..,..Planning Board Approval .... /~'.~'...~. ..... ~ ............. Request For Temporary Certificate ........................................ Final Certificate ~ Fee Submitted $ ..5.,..0.Q ........................ Construction on above described building and permit meets all applicable codes and regulations. · . ......... Applicant Anthony B. Tohill, Es~'J'[ '~'~"i~'I~:~'~ '~6~' ....... Sworn to before me this Martha B. Robinson ~ /~7 z-- [ '1 ~ ~'' day of ..... 2 ........ Notary Public ............... ~.g.~ ~.9.~.~.. .... County ~'A E. FITZ LiC, State of New York NO. 52-177677(3, ~,"~'".:' County Term E;:! r: M~rch.-,,'~ 1973 (stamp or seal) -0- ,C /J'J. o 7 '