HomeMy WebLinkAboutZ-11291FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. 2.9.1 ......... Date ......November .3 ............... 1982
THIS CERTIFIES that the buildings...2.). 1 ........................................
Location of Property ;i00 New Suffolk Avenue Mattituck
House No. Street Hamlet
County Tax Map No. 1000 Section .. > > 4 ......Block .1 ?............Lot .. 0 0.6
Subdivision .... X ..........................Filed Map No. . X ...Lot No. X . .. ....
Requirements for a private one -family dwelling built prior to
conforms substantially to the AAppitcatiort -fer- Banding- Permit- be jmtvfarre-fiied- irr this -offlm- fisted
Certificate of Occupancy
..Agri 1 .2 � .......... 195 7. pursuant to which J5Wtd1ffgPem1t No. Z.1.1.291 ..............
dated ..November 3 _ .. _ ...... 10 ? . , 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 .........
a private one -family dwelling and accessory garage.
.................................................................................
The certificate is issued to E d w a r d Edna M a y e r
(owner Tessa orW79M)
of the aforesaid building.
Suffolk County Department of Health Approval .. n / a
UNDERWRITERS CERTIFICATE NO.......... n/a
........................................
Building Inspector
Rev. 1/81
FORM NO. 6
TOWN OF SOUTHOLD
building Department
Town Hall
Southold, N.Y. 1 i971
APPLICr,TION ,FOR CcRT1F1CATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec-
tor with the following; for new buildings or new use:
1. Final surrey 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 buildinas and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible fior 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 peoperty 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 informa
tion 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 / / p
Date . . !_� �3l 4 '. . .
New Building . . . . . . . . . . . . . Old or Pre-existing Building(Y) . _.V _ Vacant Land . . . . . . . . ... .
Location of Property
House No. Street Hamiet G
Owner or Owners of Property
County Tax Map No.-1000 Section . . .f !.`I. . . , . . . , Bloc!c . . .1. . . , , . . . , Lot . . �/C1.10. . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . : . . . . . . ..Lot No. . . . . . . . . . . . . .
Permit No. . . • . • •1:. . . Da.e of Permit
-^lic�nt
Health Dept. Approval . . . . . (X. . . . . . . . . . . . . . . . .Labor Dept. Approval . . . , , . , . , ,
Underwriters Approval . . . . ... . . . . . . . . . . . . . . . .Planning Board Approval . . ./: , . , , , , . , , , , ,
Request for Temporary Certificate . . . . . . . . . . . . . . . . . . . . .Final Certificate . . . . .` \` , , , , .
Fee Submitted S . . . . , " .
1
Construction on above described building aid p.arr�.ic,wets all appt{cabl codes and regulations.
AN:piicZnt .r•-• - .. . .
Rev.10-10.78
STATE OF NEW YORK )
COUNTY OF SUFFOLK ) ss. o
EDWARD MAYER, being duly sworn, deposes and says:
That I am one of the owners of premises known as no #, New
Suffolk Avenue, New Suffolk, New York,
That upon information and belief, your deponent verily
believes that the subject premises have existed in their present
condition for more than 30 years.
That since April, 1957, no structural or other alterations
have been made to the subject premises which would require the
procurement of a building permit, use permit or a certificate of
occupancy from the Town of Southold.
That -the survey is an accurate representation of the
premises as they existed in or about April, 1957.
That this affidavit is made to induce the Town of Southold
through its appropriate officials, to issue a pre-existing use
certificate with reference to the premises herein referred to ; and
knowing and intending that the said Town and its officials will rely
upon and be induced to act by reason of the representations made
herein.
Sworn to before me this Edward Mayer
02�7Aay of October, 1982.
Notary P lic
PHYLLFS ATKINSON
NOTARY PUBLIC, State of New York
No. 52-4665676
Qualified,in Suffolk County
Commission Expires March 30, 19 Be/