HomeMy WebLinkAboutZ-5181FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. 745181 ...... Date ..............
Juae
..1►......
, 19.73.
THIS CERTIFIES that the building located at
.$/S .M43 .AQad .(RT?.5)
...
Street
Map No. XX ....... Block No.. xx...... Lot No. XXX ..P90CAU .... N.Y.•...........
A Housing
conforms substantially to ther�QW� ode
Bucfaled .before . April 2 19 .. er ti ats_ o occupancy
Apr 3 .. , 73 . pursuant to which pkv o. Z518I . .
dated ........ Jure • • • • .1+.... , 19.73. , 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 ..private. -one. family .dwelling.. do .2. accessory. buildings....... .
The certificate is issued to . Katherine. .Skwar.a .....Owner .........................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval Fre.. e-xisting....................
UNDERWRITERS CERTIFICATE No..pre-..ex1Ating.................................
HOUSE NUMBER... 1+2100. ... Street .... Main .RAad . (RT25) ..........................
Exceptions .to. housing .cod,as................................. .
..................
1' Main Houses Kitchen, no shutoff at gas range 508b .------
Front enterance - no light switch529b
n J
Bedrooms 2nd floor = 7'+ ceiling Cee 101 �� A
2 Cellar = broken window glass 302b
Root = needs repair & chimney Building Inspector
flashing needs repair 302c
2. Accessory buildinges garage needs repairs 301c &6039302b,e.
potato storage has broken glass 302b
C rORM N0.6
At" % i A k" 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 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:
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 June 4
Dote........... ..... ........ ..1973......................
New Building .................... Old or Pre-existing Building ..... ............ Vacant Land ............................
Location Of Property ..... a/a..4aiX1..RQ&dj..... Reo.QT ic... N..y.....................
..........................................
Owner Or Owners Of Property ..Katherine....Skwara..
........................................................................
Subdivision ...............XXX ......................................... Lot No. .?R; ...... Block No. X?�....... House No ...... 1.21DO
Permit No. ...= ........... Date Of Permit ... = .......... Applicant ... FAM1.1Y..�..
Health Dept. Approval ..... P.?;e.-eX.i,;.=9.......... Labor Dept. Approval ........... NAR .............................
Underwriters Approval ..... px.Q- ... eZisting.......... Planning Board Approval ...... N...R...........................
Request For Temporary Certificate ........................................ Final Certificate..........................................
Fee Submitted $...S..QQ........................
Construction on above described building and per it meets all app icable codes and, regulations.
Applicant�............ ...........
Sworn to before me this ly7 j
........... Y.. day ..June.....1.97.31.97a ................. (stamp or seal)
Notary Public fir.. County J3S S�
TERN LEE ELAK
NOTARY Fdn'.I
Is
commission Expres 'r"'Cil ss, 19 "74
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