HomeMy WebLinkAbout1000-4.-5-5.16 TOWN OF SOUTHOLDRental Permit
3 Permit No. 0123
Owner Samuel S Polk Rev Trust
Occupied as Single Family Dwelling
Located at Private Road Fishers Island 4-5-5.16
Address Village 5/B/L
Maximum Permitted Occupancy 8
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.
7/25/2019 Mike Verity
Date of Issue Code Enforcement Officer
This Notice must be posted by the main entrance at all times
a,
Town Hall Annex
Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 i
Southold,NY 11971-0959
Q
IRpI ,
BUILDING DEPARTMENT nDD .
TOWN OF SOU TTHOLD �
RENTAL PERMIT APPLICATION
Rental Permit Fee $200 (Application must be renewed every two years) " ..,
Section A.
Property Information:
Rental Property Address:
0 -Ing r is' .b Zs r (A-.
Map S. 16
Tax Ma Number: 1000 SECTION —BLOCK—,5' ,LOT,
SECTION B.
OWNERINFORMATION:
Property Owner Name: so ""._\ _S'
• �b�i�
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
FL �- rs
L�5
Telephone Number (s): -11 Z- 5`4-6, 3 a 3i'
Property Owner Email Address: S c 6-D ti rv\w:1t c6w.
Page 1 of 4
Section
C.
Authorized Agent Information:
Name of Authorized Ili i , if any: Ae-
Address
Authorized ):
Mailing re riz :
Telephoner (s): ._........ __.�....
Email Address:
Section D.
Managing Agent Information:
Name of Authorized Ili i , if any:
Address of Authorized ):
Mailing r riz ........�..........................................
...._._.._
Telephone r (s : _.......................p
EmailAddress:
SECTION E.
SITE MANAGER INFORMATION: (required for rental properties containing8or more rental units)
Name of Managing Iliunit, if �l
Address of Managing ( ):
Mailing i :
Telephone Number( ...__.
Email Address:
Page 2 of
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: ""
For each Rental Dwelling Units o I Dwelling Unit identifier(for example,
Unit 1, Unit 2, Unit 3 or Apt A, B, C);the use of eachroom in the Rental Dwelling Unit
(for example, Kitchen, r r , Living ) and the dimensions of each
room.
For properties with multipleental Dwelling Units use "Rental Permit Application
Addendum."
Rental Dwelling nit Identifier:
%�m%uw-
Requested Maximumt of persons allowed to occupyDwelling nit:
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit: _�wwwwwww_
SECTION G.
Pursuant to the Town Code oft the Town of Southoldter 207 (Rental Properties), a safety
inspection by CodeEnforcement icil is required. I r chooses not to havesaid
inspection rmed by the Town, a certification from licensed architect, licensed
professional it or a home inspector who has a validr it Fir
Prevention Bit i iici is required stating at the property whichis the subject
of the rental permit applicationis in compliance withall of the provisions of the code of the
Town of Southold,the laws and sanitaryhousing regulations Suffolk and
by the laws adoptedthe New YorkFire Prevention and BuildingCouncil.
I am requesting fire safety inspection to be performeda Enforcement ficial
from the Town of Southold.
Pae
1am 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)
I YA1 ,x ,( S. ?ML-V, 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" oft i lication 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
Property Owner's Signature:
Sworn to before metis/112 dayof 20Z3
-IG-AAA
Official N6tary PU Signature and Original Notary Stamp
Page 4 of 4
so
TOWN OF SOUTHOLD BUILDING DEPT.
Vol 765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING /STRAPPING [ ] F'I L
[ ] FIREPLACE & CHIMNEY. [ FIRE SAFETY INSPECTION
{ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
pig et
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FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. . ZZ.235.7. . . . . .. . . Date . . . . March„ .1.4' . ,1,984. . . . . . . . . . ., 19 . . .
THIS CERTIFIES that the building . . .0r1e. .£ami-]..y. .dwall insj . . . . . . . . . . . . . . . . . w . ,
Location of Property fast End, Road,, Chocorggv;i - 131.;1.1, , . , , , , , , , , . X> shQxs. J.jland
ila ise No. Street Hamlet
County Tax Map No. 1000 Section . . . . . . . . .Block . . .5 . . . . . . . . . . .Lot . . . .$.9. . . . . . .
Subdivision . . . . . . . . . . . . . » , , . . . . . .Filed Map No. . . . . . , , .Lot No. . . . . . . — . —
conforms
,
conforms substantially to the Application for Building Permit heretofore filed in this office dated
May , 2 7, . . , , . , . . , 19 P.2.pursuant to which Building Permit No. .115 0.0-Z
-datedl a 21' . . 19 8?. ,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 . . . . . . .
construct one family dwelling amended to include deck
The certificate is issued to Isabel Du Bois. . . . . . . . . . . . . . .
(owner,�lessee�or�tenantl
of the aforesaid building.
Suffolk County Department of Health Approval . . .117507-119, , , , ,
UNDERWRITERS CERTIFICATE NO. . . . , . . , . , ,6,23930. . . . . . . . . . .
Building Inspector
Rev. 1/81
qk
Town of Southold Annex 6/10/2013
P.O.Box 1179
w:w
54375 Main Road
w; Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 36252 Date: 6/10/2013
THIS CERTIFIES that the building ADDITION/ALTERATION
Location of Property: Private Rd, Fishers Island,
SCTM #: 473889 Sec/Block/Lot: 4.-5-5.16
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this officed dated
5/13/2013 pursuant to which Building Permit No. 38015 dated 5/13/2013
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:
additions and alterations, hicludingy deck and coNr red.Sg h,,,,cgA_,exi ting one famil!yisrg..-s Ap l� for.
This
Certificate of t} gi. _ cy has been crected for�to i1 a lid,tL dzt ,..w�aGcl��snt�r s�aa�e datc as tlr l rn-utmmrenewal.
The certificate is issued to Polk, Samuel
(OWNER) ...
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. Joseph Hirschfeld 4/8/09
PLUMBERS CERTIFICATION DATED 9/25/09 3061826
__ _....._ .........
Aa.. t a�d �igrmalt � _...
Town of Southold 4/17/2018
P.O.Box 1179
53095 Main Rd
V Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39606 Date: 4/17/2018
THIS CERTIFIES that the building ALTERATION
Location of Property: Private Rd.,Fishers Island
SCTM#: 473889 Sec/Block/Lot: 4.-5-5.16
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
9/1/2016 pursuant to which Building Permit No. 40950 dated 9/1/2016
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:
PARTIALLY FINISHED BASEMENT WITH BATHROOM IN AN EXISTING ONE FAMILY DWELLING AS
APPLIED FOR
The certificate is issued to Polk,Samuel
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40950 11-17-2017
PLUMBERS CERTIFICATION DATED 01-31-2018 M"a W bolo " iii
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