HomeMy WebLinkAboutZ-10317FORM NO. 4
TOWN OF SOUT~OLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. Z 10317
Date December 22, 19 80
THIS CERTIFIES that the building ................................................
Location of Property ........... .H.e..d.g.e..S..~.r.e.e.~..~ .......... F..t.s.h.e.r..s..I.~.1. ?.d. .........
House No. Street Hamlet
01
County Tax Map No. 1000 Section ...?:'?. ..... Block .... .ur ......... Lot
Subdivision ............................... Filed Map No ......... Lot No ..............
Requirements for a One F_a~_tly Dwelling Built Prior to
conforms substantially to the
Cer~ificete of 0ccupencyzl0317
·..A.p?.l. 1.. ~.~.~. ........, 19 .5.7. pursuant to which B'a/kti~-t~rm'it-N~ ......................
dated . . D..e.c.e.m.b..e.r..2: 2. t ............ 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 .........
....... ?r.~ya..i.e..o.n..e..F.~.m..~.~y. p..~.e.~!~..ng .........................................
The certificate is issued to John G. Schr~mm
..................... ?o¥,,'~',.,~2~----~~ .....................
of the aforesaid building.
N/R
Suffolk County Department of Health Approval ..........................................
UNDERWRITERS CERTIFICATE NO.. N./.R. ...........................................
Rev 4/79
FORM NO. 6
TOWN OF SOUTHOLD
Building Depaffment
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 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 ali 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: I. 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 Building ................ Addition ................ Old or Pre-existing Building ......~ ........ Vacant Land ..............
Location Of Property ..... ..S..~..u..~..b..w...e.~..e..~..1.~.1.J:.~..e.~.~.~.~..e.~.d.g.e.~..~..:~.~..~.~.~.~.~:~ ................
Owner Or Owners Of Property ..... .j..o...b...n....J.:....L.~.o,,n...s. .....................................................................................
(former owner Frances M. Farley, Executrix of Estate of John G. Schramm)
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No ..................... Date Of Permit .................... Applicant ..................................................................
Health Dept, Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ............. .~. ...........................
Fee Submitted $ .b.,..O...O. ...........................
Construction on above described building a~nc~ per~igL~ets all opplica.ble cod~s and regulations.
Applic .~..Y. ..... ' .........................................
Sworn to before me this.--~-'~/ / / - / ~, - ~
.... ~.$.1;.h. ..... day/ (stamp or seal)
Notary ~'UDliI[~....I..:...Z....,~...,ZT.V.~.f (~ggnty Notary Pm:Hc. SMte e,f New Yo~ . L' ~' J~ ~J/~
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