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Town Hall Annex 1, �a Telephone(631)765-1802
54375 Main Road ^` Fax(631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959 ap
�J
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION
Rental Permit Fee$200(Application must be renewed every two years)
Section A.
Property Information:
Rental Pr erty Address: Cfp p y
Tax Map Number: 1000 SECTION -CiLOCIf,
SECTION B.
OWNER INFORMATION: L /
Property Owner Name: StS r " IXQQf SGI�
Property Owner Legal Address: Property Owner Mailing Address:
eSt q iT lac Z,
Telephone Number(s): Daytime
3en�i
ng Emergency
Property Owner Email Address: CO
Page 1 of 5
Town Hall Annex pay ,n Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179 t@w
Southold,NY 11971-0959Cou
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized 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): Daytime Evening ner en y�
Email Address:
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): Daytime. Evening mergen.cy. ..
Email Address: .
SECTION E.
SITE MANAGER INFORMATION: (required for rental properties c taining 8 or more rental units)
Name of Managing Agent of.dwelling unit,,if any: _.. .
Address of Managing Agent (no P.O. Boxes)':
Page 2 of 5
Town Hall Annex ty Telephone(631)765-1802
54375 Main Road �� Fax(631)765-9502
P.O.Box 1 179 a As�
Southold,NY 11971-0959 ws
" cDUM�I �� Il
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."
F�}
Rental Dwelling Unit [dentifer: �01,
Requested Maximum number of persons allowed to oc y Dwelling Unit:
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
my
tKsi- (10M z
Page 3 of 5
Town Hall Annex A, Telephone(631)765-1802
54375 Main Road $ Fax(631)765-9502
Y.O.Box 1179 t7 l
Southold,NY 11971-0959 A\����o
BOUNTY� r
W �6
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.
Jp 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 OF SUFFOLK)
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
a x •
Town Hall Annex ' a w Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 rY
Southold,NY 11971-0959h
OUN
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
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 as to any change to the information
regarding Authorized Agent, Managing Agent, or Site Manager.
Property Owner's Name: NIS
J A)AINCIL&
Property Owner's Signature: _ q.,..._
Sworn to before meth" day of _ •.....
. 0
Official Notary Public igna ure and Original Notary Stamp
Cheryl Simons
'VOIary Pudic,Efate of New tibrk
Qualified InISOblk County
Commission Expires February 4,
Page 5 of 5
o �nov"
DEPT.TOWN OF SOUTHOLD BUILDING
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING /STRAPPING
-- [ ] NAL
[ ] FIREPLACE & CHIMNEY [ FI E SAFETY (INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
TE - INSPECTOR
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�w t Town of Southold 7/24/2019
53095 Main Rd
Southold New York 11971
A�06o
PRE EXISTING
CERTIFICATE OCCUPANCY
ANCY
No: 37971 Date: 12/18/2015
THIS CERTIFIES that the structure(s)located at: 675 Champlin PI
SCTM#: 473889 Sec/Block/Lot: 34.-3-30
Subdivision: Filed Map No. Lot No.
conforms substantially to the requirements for a built prior to
APRIL 9, 1957 pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z- 37971
dated 12/18/2015 was issued and conforms to all the requriements of the applicable provisions of the law.
The occupancy for which this certificate is issued is:
Two slory wood fa°aine one familydvrcl:lia�g�w5t�t ra�rap �u'd.! ov�rgoxarcli wa1h.4��ews�b4:a°da*
*barn is in ne ( o r
The certificate is issued to Ebeling, John
_.
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
*PLEASE SEE ATTACHED INSPECTION REPORT.
Authorized Signature
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
HOUSING CODE INSPECTION REPORT
LOCATION: 675 Champlin PI
....................................................... _„....... ..._ _.
SUFF.CO.TAX MAP NO.. 34.-3-30 SUBDIVISION:
...... ......... ...........................................................
NAME OF OWNER(S): Ebeling,John _
OCCUPANCY:
_. ......
ADMITTED BY:
......... ....__..,_ ...... ......... _..,.,....
SOURCE OF REQUEST: Ebeling, John DATE: 12/18/2015
......... ......... .........
......................................... . ......... ...... ........._ ..............................................
DWELLING:
#STORIES: 2 #EXITS: 2
�,.... ............................................................_
FOUNDATION: Stone CELLAR: Small/Parti CRAWL SPACE:
.._..........................................._...................... .......
BATHROOM(S): 1 TOILET ROOM(S): 1 UTILITY ROOM(S):
PORCH TYPE: Yes DECK TYPE: PATIO TYPE:
... ..................................................... _ .,.m.m. .... .....
BREEZEWAY: FIREPLACE: GARAGE:
e„ - _.............. . _......
DOMESTIC [JO”
I WA"I;ER Yes TYPE HEATER: Oil AIR CONDITIONING:
TYPE HEAT: 4 WARM AIR: HOT WATER: Yes
#BEDROOMS: 3 #KITCHENS: . BASEMENT TYPE: unfinished
.. m... _
OTHER: ...........
�tr
ACCESSORY STRUCTURES:
GARAGE,TYPE OF CONST: STORAGE,TYPE OF CONST:
..... ........................ .......
SWIMMING POOL: GUEST,TYPE OF CONST:
.....,_ ..._....,
OTHER: Barn
VIOLATIONS:
REMARKS:
......... .................... . --- ...................................................... ......... ......... .........
INSPECTED BY: GARYF DATE OF INSPECTION: 11/20/2015
TIME START: END:
... ......... .............
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P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CERTIFICATE CC CY
No: 40480 Date: 7/3/2019
THIS CERTIFIES that the building ADDITION/ALTERATION
Location of Property: 675 (aka 220)Champlin Pl, Greenport
SCTM#: 473889 Sec/Block/Lot: 34.-3-30
Subdivision: Filed Map No. Lot No.
conforms,substantially to the Application for Building Permit heretofore filed in this office dated
4/1/2016 pursuant to which Building Permit No. 40692 dated 5/11/2016
was issued,and conforms to all of the reuiremet is of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
ADDITION TO AN EXISTING ONE FAMILlY D'U'ELLING AS APPLIED FOR
The certificate is issued to Pinkwater,Susan&Searby,Sally
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40692 01-24-2017
PLUMBERS CERTIFICATION DATED 06-28-2019 Io hitecava. ;e
Signature
tEa�, Town of Southold 5/22/2019
-* P.O.Box 1179
53095 Main Rd
AP Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 40400 Date: 5/22/2019
p
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 675 (aka 220)Champlin Pl, Greenport
SCTM#: 473889 Sec/Block/Lot: 34.-3-30
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
9/14/2018 pursuant to which Building Permit No. 43057 dated 9/21/2018
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,FENCED TO CODE,AS APPLIED FOR
The certificate is issued to Pinkwater,Susan&Searby,Sally
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 43057 01-02-2019
PLUMBERS CERTIFICATION DATED
11
l or-,e Signa tiro �,-_�