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FORM NO. 4
T WN OF . SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, X-X.
,
Certificate Of Occupancy
:Jan 1+ 19. .'��
THIS;CERTIFIES that,.the btulding.iocated at �- g +a � Street
Block No 4 _ Lot No Qient R
e Uil remez-t fo b saes bu . .d :
conforms substantially,to thewag
t d be b re Air .3. 9 � e fi f ea-U ,' cupMCY
pursuant to which
was issued, and conforms to all of the require-
ments of the.applicable provisions of,the.law The:_occupancy,for- whichahis,certificate is
issued is s e .b ld�x tore Postmf'm apa exit
The certificate is issued to M. ?gorfte . 4 hsr9 tt to BC3'�tZ.`
owner seeu or tenant)
of the aforesaid building. ,
Suffolk Count De artment of Health Approval
Y P px� :Elx ,S:tYtP
UNDERWRITERS CERTIFICATE No, pre est �a f:`
HOUSE NUMBER .J4 Street 0 �'� $ zm
'tt?2Q n (idle xa )
Attache 9/25/ 8 ~
Building Inspector
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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 disposal—(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences rand :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 I
Date . ..............�.`�.........6.....
New Building ................ Addition ................ Old or Pre-existing Building .X........... Vacant Land ..............
LocationOf Property ....... � .........4 ................. ................... .....:.............
Owner. Or Owners Of Property ...(.. .....................
Subdivision ..... .........................:...................L,ot No. .�?�/�,. Block No. use No.............
Z
64)Permit No. Date Of Permit .......Applicant ...�G`::".................... .. "
n
Health Dept. Approval ...t-Z" .... ........Labor Dept. Approval ............ :....`.'.......................
Underwriters Approval .....�1. :...... ......Planning Board Approval ..../ .........................
Request For Temporary Certificate ........................................ Final Certificate ....... ......................
60
Fee Submitted $ . ...................
Construction on above described building an p rmit meets all applicable codes and regulations.
a
Applicant ........ ... ................ ..................... ... ..... ........................ .. ..........
Sworn to before me / y`�Z
.. . .....,f�clay of ........... . ..�:6 (stamp drr eal � $'2--
Notary Public ... ..... ... .. . unty
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