HomeMy WebLinkAbout1000-123.-7-3 TOWN OF SOUT OL
Rental Permit
Permit No. 0047
Owner 100 Park Ave Corp
Occupied as Single Family Dwelling
Located at 100 Park Ave Mattituck 123.-7-3
Address Village s/B/L
Maximum Permitted Occupancy 6
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. Expiration is
two (2) years from date of issue. The operator is responsible for arranging for the bi-annual inspection.
5/8/2019 John Jarski
Date of Issue Code Enforcement Officer
This Notice must be posted by the main entrance at all times
IPJ
F A
Town Hall Annex Telephone(631)765-1802
54375 Main Road i Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
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BUILDING DEPARTMENT Y 01
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION TOWN 01,SO
Rental Permit Fee$200 (Application must be renewed every two years)
Section A.
Property Information:
Rental Propert ddress:
�A_ZI
;" BLOCK LOT
Map _ "
Tax Ma Number: 1000 SECTION �^ �� � -
� A
SECTION B.
OWNER INFORMATION:
Property Owner Name:
Property Owner Legal Address: Property Owner Mailing Address:
Telephone Number(s): Daytime Evening__e,,," Emergency
Property Owner Email Address:;� � _ "
Page 1 of 5
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Town Hall Annex V Telephone(631)765-1802
54375 Main Road �^ Fax (631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959
BUILDING DEPARTMENT
\TOWN OF SOUTHOLD
Mailing Address of Managing Agent:
Telephone Number(s): Daytime Evening Emergency_ _
Email Address:
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, Q 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:
Requested Maximum number of persons allowed to occupy Dwelling Unit: P�4
Number of rooms in Rental Dwelling Univ _........��°
Use and Dimensions of each room in Rental Dwelling Unit:
Page 3 of 5
Qr0,0
Town Hall Annex �' Telephone(631)765-1802
54375 Main Road � H� Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 IU
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
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 licensed architect, a 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.
❑ I am requesting a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold
I am submitting a completed Town of Southold certification form from a licensed
architect or a licensed professional engineer.
SECTION H.
DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit.
STATE OF NEW YORK)
COUNTY 1= SUFFOU
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
Page 4 of 5
Town Hall Annex , Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
Y
i
P.O.Box 1179 k "
Southold,NY 11971-0959 "
A ri �f
BUILDING DEPARTMENT
TOWN OF SO OLD
applicable laws and rules. I further acknowledge that I will notifythe 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 as to any change to the information
regarding Authorized Agent, Managing Agent, or Site Manager.
Property Owner's Name:
Property Owner's Signature:.
Sworn to before me this day of 020/9
Official Notary Public Signature and Original Notary Stamp
CONNIE Dm 13UNCH
Notary Pub6c, to of Now yo*
No.Of Bmssoso
Qualified in Suffolk County
Commission Expires April 14,
Page 5 of 5
r
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
w
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUMOLD
OLD
RENTAL PROPERTY CERTIFICATION
Form is to be completed by a license architect, licensed engineer or licensed home inspector
Separate form is required for each individual Rental Dwelling Unit
Professional sealre uired or Architect or Fn ineer, licensed Home Inspector must rovide
copy oL valid current certl lcatlarl,
Rental Property SCTM Number: 125- 7-3
Rental Property Address: 1-42A? zfiez
Owner/Name:
Rental Dwelling Unit Identifier:
Number&Square footage of each bedroom as depicted In the attached floor plan:
(i.e. Bedroom#1-100 sq., Bedroom#2-gD sq., etc.)
's-j�Q
Property Description(Include all improvements indicated on survey)
1 certify that I have done a physical inspection of the subject rental dwelling unit and find that it
fully complies with all the provisions of the Code of the Town of Southold,the Residential Code
of New York State,the Building Code of New York State,the Plumbing Code of New York State,
the Fuel Gas Code of New York State, and the Energy Conservation Construction Code of New
York State. =
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Print Name and Title
I u re
tia Ar
d
Please place professional seal:
TOWN OF SOUTHOLD BUILDING DEPT.
765
1802
INSPECTION
FOUNDAI-ION 2ND INSULATION
FIREPLACE CHIMNEY FIRE SAFETY INSPECTION
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Town of Southold 12/21/2016
P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 38721 Date: 12/21/2016
THIS CERTIFIES that the building SINGLE FAMILY DWELLING
Location of Property: 100 Park Ave, Mattituck
SCTM#: 473889 See/Block/Lot: 123.-7-3
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
7/14/2016 pursuant to which Building Permit No. 40946 dated 8/31/2016
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 DWELLING WITH REAR COVERED PORCH, FRONT AND SIDE C OVERED ENTRIES
ATTACHED GARAGE AND UNFINISHED BASEMENT AS APPLIED FOR
The certificate is issued to 100 Park Avenue Corp
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-16-0069 12-09-2016
ELECTRICAL CERTIFICATE NO. 40946 12-07-2016
PLUMBERS CERTIFICATION DATED 12-07-2016 Campeon Plumbing
nit�t
le eSignature. m
Town of Southold 12/21/2016
" P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CE RTIFICATE OF OCCUPANCY
No: 38722 Date: 12/21/2016
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 100 Park Ave, Mattituck
SCTM#: 473889 Sec/Block/Lot: 123.-7-3
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
8/29/2016 pursuant to which Building Permit No. 40947 dated 8/31/2016
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:
ACCESSORY IN-GROUND SWIMMING POOL FhN.C..I D TO CODE AS APPLIED FOR
The certificate is issued to 100 Park Avenue Corp
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40947 12-07-2016
PLUMBERS CERTIFICATION DATED
u. rued Signature