HomeMy WebLinkAboutZ-4625 FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. .. . . . . . . . . . Date . . . . . . . . . . 1`7a .. .9 19. . . .
THIS CERTIFIES that.the building located at Ia/S.11PIr1ins .sane . Street
Map No. : . :'' . . . . . . . Block No... ...7a . . . . ..Lot No.
re uirements- for one f amp 14 dwel?in and Housing Code
conforms substantially to-the '
t b®gate 2 19 ,57. pursuant to which C./O'Z)+6'2gi
dated ,. . . . Mawr. . . .2. . . ., 19, .70', 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 . pr.f.vate one. •f artily d.aajljhg. . . ... . . . . .. . . ... . . . . . . . . . . . . . . . . . . . . . ... . .
The certificate is issued to JPmes .Lambert .&.To lf-e . : . . . . . . . . . . . . . . . . : . . . . . . . . . . . ,.
(owner, ,lessee or :tenant)
of the aforesaid building.
Suffolk County Department'of Health Approval e—XiStf.zl'g. . . . . .
UNDERWRITERS CERTIFICATE No. . 0. . . . . . . . . . .. . . . . . . . . . . . . ... . . . . . . . . ... . . . . .
HOUSE NUMBER. . ry�-�� . . . . . .Street. . . . . . . . . . . . . . . . . . . . . . . . .'.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . : .
Ir
Building I»spector
• 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 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 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 April 28, 1972
Date ................................................
New Building .................... Old or Pre-existing Building .......g.................. Vacant Land ............................
Locution Of Property ..........................................
Owner Or Owners Of Property .James E. Lambert & Anne Lambert, his„wif e
.........................
Subdivision ................................................................Lot No. ............ Block No. ............ House No.............
PermitNo. .................... Date Of Permit ....................Applicant ..................................................................
HealthDept. Approval ............................................Labor Dept. Approval ................................................
Underwriters Approval ..............................................Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ..StQQ.........................
Construction on above described building and pe e I a lic a 06es-oond r gulations.
Applicant ......... . . . . . . . . . ..... .. .. .. . ... ...............................
Wi li I
Sworn to before me this v A
...28.t a... day of ....Lpzil.j...I.g'-2............. (stamp or seal)
r
Notary Public ...... A91.1, OIX.......... County JOAN
No-rARY PUBLIC, Sate of Ncea York
No. 52-6905650,
''u ( Qualified in SOW![ County
Term E,�Pims M-reh 3% 197�
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