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Home My WebLink About1000-31.-15-6 CD w , <<All r.+ fD � (D lu N 0- (p• - cn O o Cn m r+ Pk " �r lD O S CD sv a oo w, N o .� =r CD w m ocn w r 0 cn ccl ch �• z CDCD O QCD 3 CD =r � 3 CD0 0 � 0O _ m X � m cD z oCD 0 Er `° 3 It O CL o rte+ V1 �. r--f IQ o N CD ~ VJ 3 =' :v O (7 CD OQ -0 rDEP a �• =3 CD d �* c� 0 LUN m 51 1 O o =3a) • Q Q r CD W cn Q N -� 0v 3 CL W o CD C_-1 Q r.+ Q � O CD =r H, .0 0 o W z 1-� CD LA 1 O 0 cc :3 t+� CD 1 < ca O w O A [D c Fn O� Town Hall Annex "� y, Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 k BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION Rental Permit Fee $200(Application must be renewed every two years) Section A. Property Information: Rental Property Address: c� 8 Wr est L ,—I - n.S i�l A 13 1�y✓ ke-1,/ Ya It Tax Map Number: 1000 SECTION 031 BLOCK ISS LOT SECTION B. OWNER INFORMATION: Property Owner Name: Pe-lox Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) CwSi �l�N� e fe _V li r 36 8 l .. ' - . $ Telephone Number(s): Ge Property Owner Email Address: l- A4 C,k i co i It Page 1 of 4 Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: Address of Authorized Agent (no P.O. Boxes): ji Mailing Address of Authorized Agent: S r-�r-►m e_ Telephone Number(s): Email Address: � �✓d "u .��/ i , rm �° Section D. Managing Agent Information: Name of Authorized Agent of dwelling unit, if any: Address of Authorized Agent(no P.O. Boxes): Mailing Address of Authorized Agent: Telephone Number(s): Email Address: SECTION E. SITE MANAGER INFORMATION: (required for rental properties containing 8 or more rental units) Name of Managing Agent of dwelling unit, if any: Address of Managing Agent (no P.O. Boxes): Mailing Address of Managing Agent: Telephone Number(s): Email Address: Page 2 of 4 SECTION F. PROPERTY DESCRIPTION: Number of Rental Dwelling Units on property: For each Rental Dwelling Unit set forth the Rental Dwelling Unit identifier(for example, Unit 1, Unit 2, Unit 3 or Apt A, B, C);the use of each room in the Rental Dwelling Unit (for example, Kitchen, Bedroom 1, Bedroom 2, Living Room) and the dimensions of each room. For properties with multiple Rental Dwelling Units use "Rental Permit Application Addendum." Rental Dwelling Unit Identifier: j Requested Maximum number of persons allowed to occupy Dwelling Uni . Number of rooms in Rental Dwelling Unit: o l . ° Use and Dimensions of each room in Rental Dwelling Unit: .9e,e, I v o v- i, SECTION G. INSPECTION: Pursuant to the Town Code of the Town of Southold Chapter 207 (Rental Properties), a safety inspection by Code Enforcement Official is required. If the owner chooses not to have said inspection performed by the Town, a certification from a NYS licensed architect, a NYS licensed professional engineer or a home inspector who has a valid New York State Uniform Fire Prevention Building Code Certification is required stating that the property which is the subject of the rental permit application is in compliance with all of the provisions of the code of the Town of Southold, the laws and sanitary and housing regulations of the County of Suffolk and by the laws adopted by the New York State Fire Prevention and Building Code Council. ZI m requesting a fire safety inspection to be performed by a Code Enforcement Official from the Town of Southold. Page 3 of 4 ❑ 1 am submitting a completed Town of Southold certification form from a licensed architect, a licensed professional engineer, or a licensed home inspector who has a valid New York State Uniform Fire Prevention Building code Certification. SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) ) COUNTY OF SUFFOLK) 1 , certify under penalty of perjury,the following: 1. 1 am the owner of the property identified in "Section A" of this application. 2. The property owner's legal address set forth in "Section B" of this application is my legal address and I understand the Town will use the address for service pursuant to all applicable laws and rules. I further acknowledge that I will notify the Town of Southold Building Department of any changes of address within five (5) days of any changes thereto. 3. 1 have read and received a copy of Chapter 207 of the Code of the Town of Southold and agreed to abide by the same. 4. 1 will notify the Town within five (5) business days s to any change to the information regarding Authorized Agent, Managing Agent, or Site Manager. Property Owner's Name: =e i-- Property Owner's Signatur tb Sworn to before me this day of r 20L1 J Official [ ay Public Signat r and Original Notary Stamp TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK Page 4 of 4 NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,209'k;�. Town Hall Annex ��- Telephone(631)765-1802 54375 Main RoadFax(631)765-9502 P.O.Box 1174 Southold,NY 11971-0959 �� "' k BUILDING DEPARTMENT TOWN OF SO OLU RENTAL PERMIT APPLICATION ADDENDUM Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling un Number of Rooms in Rental Dwelling Unit: tv Use and Dimension of each room: Ir e, F,>_orx � Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: go TOWN OF SOUTP40LD BUILDING (IIIIIIII II 8 .. � wr4` -® IIIIIIII MSPEC'lllllllllllllrio IIIIIIIIII „ I11POUN111DAIII1IIII(IIII III4 °°1 ST IlPlOUGH IIIII°� IIIIIIIIIIIIII113G, IIII°°°! IIIIIIII °°IrIIII IIID2II4(ILIA VIII IIID IIS IIIIIIIIIIII, IIII (IIII IIII` > (V III IIIN IIII IIID III "'SII°"'H (IIII!!!)IIID[IIII% IIIIIIIN(IIII IIID III (IIII IIIIIIIIIIIACE & GlIH111111KIqllEy C;; IIII°°°IIIIIIII° Illfl°° IIII! IIIA IIS' T II °II IIIDs rIIIIIIII� °°rIII III "' II SIII!IIE MINT P G Imiiim llllllmIVI" IAV III1ryVIII°10UlI° SII wIII °nni lIIIIIIII IIIF CGII0Ei V11101IIIIIIIII lll1ION CAUllIIIIIIIII 1IIID unll '1111111 °Hill �iOb )�pp � v, 111 00 ARTO u � l ( � � rr nV21m� �� r a`� — f lWar ; " Dy 7 mild 71 0-1 f � � triwx��,� — Jrfjry� JI d 7� II S d 4 '� 4 4 F4 / �b, ur �pa I Y � r �*IUM �� w �� ........... ... rr mw u C r I�w�>M��Wa' �I°�.... �� v"• ISA. � � .�,.�� r '.� ��"",I I �"��Cs� «� F a q y�g p � .��y� y A� r � fW d � n ^✓N. r ^ r A"..:��• ,.,. �' ' �M:pry e.J. .. .... Ci a? b x 4 r 1,6• F y y ll I r p� .m� CIS p C C ✓' .+"'� r , y a" r C h t J aM d C. '�1 7 M A bM° 1&»r 5 i ar Irv_ �C M X- �Mu21' s a a j � - � $3 kw `m l 3 o wv � p1 4\ z� 8' 191°ti.M... �x s fi o 3 0 ➢ , � }� x w� � I rt 5 �n „ 5 R� n a 4, 4 �¢ric r >ti a a pq t1 ,y r y, 12 Jr fl 1 RA r n �o� pNrw „ y ,yq'�� yre•—� P" Pm � �..h4 ...si {p{r 7-7^ WI F�. 0 vA'w,. 0 FORM NO.4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold,N.Y. Certificate Of Occupancy No.Z 14 3.,5,5 Date . .. .A P r i l 1 . .? 3. . . . . . . . . . . . . . . . . . . 19 a.6 THIS CERTIFIES that the building . . . . PAQ .F.A.M11_Y. .c1Wg;,l.�n9. . . . . . . . . . . . . . . . . .. . . . Location of Property 8*0 West Lane . . . East Marion House No, Stree[ *Ha,m*/e County Tax Map No. 1000 Section . 03A . —Block . . . . .1.5, . . . . . , ,Lot . . . .6 . , . . . . .. . . . . Subdivision . . , SEC : TWO GAR NERS BAY .Filed Map No. ?75. . . . .Lot No. 6 . .. . . . , . . . . . 13-9T . conforms substantially to the Application for Building Permit heretofore filed in this office dated , , , , , , , , , , , , 105.pursuant to which Building Permit No. J 4 2 4 6 Zw , , dated . 3 e P. . 9. . . . . . . . . . . . . . . . . . . 19 .8 5,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 ..., . , . . . . . One, family ,dwe,llin4y. including.de.Q4. . . . . . . . . . . . . . . „ , . . . .. . . . . . . . . . . . . . . . The certificate is issued to , , Ronald & Elsie Kennedy . . . . . . . . . . . . . . . . (owner,� ' 7G�DiIfIK/K of the aforesaid building. Suffolk County Department of Health Approval . . . . 8 5-S 0-.145. , , , , , , , , , , , , , , , , , ,, , , , , , , , UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . X7499.0 . . . . . . . . . . . . . . . . . . . . .. . . . . PLUMBERS CERTIFICATE April 11 , 1986 Building in pector 1` Rev.1/81 -I r 0 > m (D (D -n z ml f a m F'r Cl- w N m (D F- uj 6 zil r ................ (D (b 0 C) 0 Ion -n jQ 4 CD m m .00 rr low m -TI G) Lo In ............. 00 -+ CSD G N tA9 �s"�,, .' ® rno�w ., �a owig i �. .._�_--------_'. �.. . w...... �� , ...�.. .® �..e..� 1 (D' CD ® -2 y „� � 4 , 'n� J d I I -- _C 7i ... ` 1 1 SW _ �,... CD m r Ln Ln in -1- f �� u ,.. i i E