CERTIFICATE OF RE-OCCUPANCY

CERTIFICATE OF RE-OCCUPANCY
Date of Application *

Month Day Year
Permit # *
Addition to Permit # *
Parcel # *
Date *

Month Day Year
FEES: $100.00 Commercial, Industrial and Office / $50.00 Residential *
Amount Paid
1. I (we) do hereby request permission to occupy the building or propert listed for purposed indicated. To the best of my (our) knowledge all work will be completed and will confirm with all ordinances of the Village of Somers. Further, it is my (our) understanding that the buildign or property shall not be occupied or used until a Certificate has been certified by your department.
Building Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Present Owner *

First Name Last Name
Present Owner Phone # *

Area Code Phone Number
Present Owner Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
New Owner *

First Name Last Name
New Owner Phone # *

Area Code Phone Number
New Owner Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Present Tenant *

First Name Last Name
Present Tenant Phone # *

Area Code Phone Number
Present Tenant Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
New Tenant *

First Name Last Name
New Tenant Phone # *

Area Code Phone Number
New Tenant Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Corporation Name *
Corporation Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Principal Officer *

First Name Last Name
Principal Officer Phone # *

Area Code Phone Number
Principal Officer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Former Use or Occupancy *
Intended Use of Land and Building(s) *
Please state in detail
Floor Levels *
Stories *
Total Floor Area Sq. *
Hours of Operation *
Maximum Number or Employees *
Maximum Number of Patrons *
Number of Apartments *
2. If certificate of Occupancy will not be issued unless repairs or alerations are performed who will be responsible for work?
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
3. Applicant's Signature *

Clear
Date *

Month Day Year
Date Signed
Applicant's Phone Number *

Area Code Phone Number
Applicant's Email *
example@example.com
Office Use Only
Change of Use Change of Occupancy Multiple Occupancy
Building Inspector

First Name Last Name
Date

Month Day Year
Electrical Inspector

First Name Last Name
Date

Month Day Year
Plumbing Inspector

First Name Last Name
Date

Month Day Year
Fire Inspector

First Name Last Name
Date

Month Day Year
Should be Empty: