HomeMy WebLinkAbout1000-4.-5-17.2 t TOWN OF SOUTHOLD
Rental Permit
0219
Owner Stephen & Cynthia Cook
Occupied as Cottage
Located at Private Road Fishers Island 4.-5-17.2
Maximum Permitted Occupancy 2
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.
4/19/2024
Code Enfo went offi�ia
This Notice must be posted by the main entrance at all times
ell
Telephonc(631)765-1802
Town Hal I Annex
54375 Wain Rtwd Fpx(f�i1)7b4 9502
P,Q.Box 1179 F. "
Sautlwld,NY 11971•i] 9
JN r0
BUILDING; UEPARTMEW
TOWN OF SOUTHOLD
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
iPro ssi an al al re tri ed ► chitect tame�rlg nee^r ll ens or1 _msp—entorm ast ror '
cqy a lrali�l c �a �r crtl rya
Rental Property SCTM Number: oop."
Rental Property Address:
Owner/Name:.....
Rental Dwelling Unit Identifier:
Number&Square footage of each bedroom as depicted in the attached floor plan:
i.e. Bedroom#1-100sq., Bedroom#2-90 sq., etc.)
rope Description(Include all irnroverne is indicated on survey)
I 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 Conservatl Con5tructio Code of New
York State.
Pot "7
�,rint Name and Title •kW; f
r1a ure
P Or
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Please place professional seal: ,�
TOWN OF SOUTHOLDRental Permit
Permit No. 0219
Owner Stephen & Cynthia Cook
Occupied as Cottage
Located at Private Road Fishers Island 4-5-17.2
Village S/B/L
Maximum Permitted Occupancy 2
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.
11/13/2019 Mike Verity
Date of Issue Code Enforcement Officer
This Notice must be posted by the main entrance at all times
Iu. C 'd' 10 -:3,
ppmI 0th
Town Hall Annex ;a �, Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 ��
"
Southold,NY 1 t971-0959
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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:
Tax Map Number: 1000 SECTION / -BLOCK -LOT
cuak ouT T x 8 ILL 7"Ax )44p 7 7j . "T— 17
SECTION B.
OWNERINFORMATION:
Property Owner Name: 5'6P P . cote( Cy'j7"*g P, cook
Property Owner Legal Address: Property Owner Mailing Address:
_ ...... .. .�.
w _ sola N yap k N�t rvl
Telephone Number(s): Daytime 117-7°1?,/013Evening _SPrML ---Emergency
Property Owner Email Address: �'� t ' t1o�/7)Q��, COln
. •., .. ._ ......... ..........................
Page 1 of 5
Town Hall Annex Telephone(631)765-1802
54375 Main Road �, 1d� Fax(631)765-9502
P.O.Box 1179 '
Southold,NY 11971-0959 ;'
lei
BUILDING DEPARTMENT
SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any:
Address of Authorized Agent (no P.O.
Mailing Address of Authorized Agent:.
Telephone Number(s): Daytime Evening Emergency
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 Emergen �_m,_,__
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):
Page 2 of 5
/
F
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179 �
a
Southold,NY 11971-0959 �
101
/
m
BUILDING DEPARTMENT
TOWN OF SUTL
Mailing Address of Managing Agent: . 1i
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, 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: - UNIT
Requested Maximum number of persons allowed to occupy Dwelling Unit:
Number of rooms in Rental Dwelling Unit: w_IT
Use and Dimensions of each room in Rental Dwelling Unit:
Pimm M ' "� ly'� KiTCI�>r�l (8' '' q'8
Page 3 of 5
�I
4
01P
Town Hall Annexilii r' Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959y, C',V
0
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.
❑ 1 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)
S?'tiPM / R •
co
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
I
Town Hall Annex1Telephone(631)765-1802
loo54375 Main Road Fax(631)765-9502
P.O.Box 117915
e
Southold,NY 11971-0959
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. p
Property Owner's Name: ��� r - Cook
CZ7
�P
nl Cook R�'� Y
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Property Owner's Signature:
Sworn to b fore me this,, day of p 20fl
ZZ
Official Mary lic Signature and Original Notary Stamp
Page 5 of 5
Town Hall Annex �� �� Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOLFMOILD
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
pro ssional seal required for,Architect or Enineer, licensed Horne Itis ector must provide
c_ooy o valid current certif
ftcation
Rental Property SCTM Number:
Rental Property Address:
Owner/Name:
Rental Dwelling Unit Identifier: UN IT t
Number&Square footage of each bedroom as depicted in the attached floor plan:
(i.e. Bedroom#1-100 sq., Bedroom#2-90 sq., etc.)
Property Description (include all improvements indicated on survey)
'
I 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 a �. „ `" Original bignature
Please pla fes i al-"
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TOWN OF SOUTHOLD BUILDING DEPT.
765-1802INSPECTION1
] FOUNDATION IST [ ] ROUGH PLBG.
] FOUNDATION INSULATIOWCAULKING
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FIREPLACE & CHIMNEY -FIRESAFETY INSPECTION
FIRE RESISTANT CONSTRUCTION FIREI T T PENETRATION
ELECTRICALI L ( I
CODE VIOLATION [ PRE C/O
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DATE INSPECTOR
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TOWN OF' SOUT'HOLD
BUILDING DEPARTMENI"
"rown Cler,k's Office
Southold, N.Y.
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Certificate O Occupancy
µ
January 23, , 1
No. . . . .Z. .1035.9 . . . . a � a �� . �. o . . � o- , . ,� . ,:r
THIS CERTIFIES that the building A . . . . .
Location f ropy rty Road;. moa a 'i s p �� . ,I e . . . , . . W .
Stieet
County Tax Map No. 1000 n ection ��. . . . Noc
Not A
Block 1
. .
Subdivision .Fisher s Island. Club
Requirements fo:r a Pr'.JLvate One Family Dwelling Bu
confornis substantially 't the
Prior ° o Certificate cf Occupancy
r . ).,. w 1 . 7pumia t t ichild-ink P . • I.- ° . Z.1.0359. . .
dated . . . . . January. , . : . . . .,. . . . 19 -81 . was issued. and conforms to all of fine requirements
of the applicable provisions oaf the law. The occupancy f6r which i s certificate is issued is
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M rsT . 1 E' TRUCTU.E - A ONE FAMILY LI G
HOIJSE,�,
6 A TOILET, SINK,
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UNDERWRII ENCSRTIFI ATF.,
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In the Matter
of
AFFIDAVIT
Sale of Premises on Fishers Island,
ew York, by H. RICHARD DIETRICH, JR. ,
to STEPHEN A. COOK and CYNTHIA P. COOK
- - - - - - - - - - - - - - - - -x
TATE OF PENNSYLVANIA)
OUNTY OF CHESTER )
I, H. RICHARD DIETRICH, JR. , having been duly sworn,
To depose and say:
I am over the age of twenty-one (21) years and n-ow
reside at Chester Springs, Pennsylvania.
The main residence of the above mentioned premises
as constructed in or about 1926 and has been used for resi-
ential purposes only.
The Cottage on said premises was built at the same
LLime and contains a small kitchen with cooking facilities, a
bathroom, one bedroom and a living room and has been used since
.ts construction as a guest house .
The garage, which was also built at the same time.,
contains in addition to car space, a small bathroom with toilet
and sink and one bedroom, which has been used as servants
quarters since its construction.
CHARD ICH, JR
Subso bed and S ,orn to before me
tit rs � dayof J a y, 981
IOTA AT Pn _..._
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CO.