HomeMy WebLinkAboutZ-9572FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No..'~. 9. -% .~. ~-- ...... Date ................ .-.J{J.N].F~... ~ b .... 1'~..
THIS CERTIFIES that the buildMg .. ~.~ ...........................................
Location of Property .......................................... ~ff ~e. Z...~t$ ~
Hou~ No. Strut Hamlet
County Tax Map No. 1000 Section ..... ~, ~ .....Block ........ ~ ..... Lot .... ~ ~ ..........
Subdivision~J~6, .b~. ~S~ ~.~, ~h~led Map No. ~.~.~..Lot No. ~. ~ .~-t. · · ·
.......... .fl~x~.~..a~, 1~7. pursuant to wmcn ~?,qm~re~:,~o ................... :~
dated .............. ~ U~t8 .... ~ L~ · · 1977. , w= issued, and conforms to all of the requirements
of the app~cable provisions of the law. ~e occupancy for wMch tMs ceNificate is issued is . .~ ......
............ -~ t v &~ ~ .... & N t~ ....F ~ ~'~ ~. k~ ( ..... ~ ~. E 4..~.~ ~ ~ ......................
~e ce~ificate is issued to . :~.~)< ~.. ~.. N ~.l~.l.l~sd.~l .... ~.L~SF ~ $~ ~ ~ .............
t ~ ' fowler, ieee or teDs~]
of the aforesaid building.
Suffolk County DepaNment of Health Approval .. ~g .... EY.,6.~.-N .~ .....................
U~ERWRITERS CERTIFICATE NO .... ~8. · eg~ c7., ~ c ..............................
Rev 4/79
{ 000-10- 3 -1.3 ,
FORM NO. 6
TOWN OF $OUTHOLD
0 Building Depo~tmont
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 disposol--(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, hAultiple 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: 1. 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 ..... × ......... Vacont Land ..............
Lots 50 and 51 ma entitled "l:)lan f P ' '
Locot on Of Property .............................. ~ ......... ~. ............................... .~ ....... ~.T3X~fi.~,l. fi..~.t..~.;j~.hfi.~.~..lfi[a~3d,
N. Y., owned by Cha~le~. ~dg~, fil~ in Su~fol~,~o Clerk's Office on 5/11/~3, ~223'~
n ~enne~n W, analrene ~ ~n 'en
~ er Or ~nem ~ Pr~e~y ......................... , ................................... L~g~ ....................................................
Subdivision ................................................................ Lot No ............. Bilk No ............. House No .............
Permit No ..................... Dote Of Permit .................... Applicant ..................................................................
Health ~pt. Approval ............................................ Labor ~pt. Approval ................................................
Unde~riters Approval .............................................. Planning B~rd Approval ........................................
Request For Temporaw Ce~ificate ........................................ Fin~ Ce~ificote ..........................................
F~ ~bmitt~ $ ..~:.~.~. .........................
~nstruction on above described building and~er~s ~11 a~~s o~ r~ulatJons.
Applicont ~.,~.~~: ........................
~ifip ~/Malth~s~tior~ey ~
Sworn to before me this // ~ /
//
~/~
..... ~ dayof .... .......... .~...~9.~ / ...... ~ (stamp or s~l) '~~ ~
/1/I/
No ~-208~0S