HomeMy WebLinkAbout1000-86.-4-3 � I F11141T -WN OF SOUTHOLD��41 0
ar Rental Permit
�#
0221
Owner Rachel Rushforth-Worrell
Occupied as Cottage
Located at 1200 Indian Neck Ln Peconic 86-4-3
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.
z� All
11/23/2021 `f
Code Enforcem t Official
This Notice must be posted by the main entrance at all times
Town Hall Annex
OUTOLD TOWN
54375 Main Road
Rental Inspection PO Box 1179 Southold,
Qr NY 11971-1179
Tel: 631-765-1802
t, Fax 631-765-9502
[(o
zoo - �=
SCTM _ ® l 2
Owner old ( U Co fl Phone -Za
(Address Zip
Hamlet _ Inspector
Address visible from street?
LEVELS SUB .,��
Smoke Detectors (#-bedroom detectors excluded)
Carbon Monoxide Detectors (#)
Fire Extinguishers (#)
Exits(#)
BEDROOMS1 2 3 4 5 Y.
Smoke Detector Alarms
Carbon Monoxide Alarms (#)
Egress(windows) (Y/N)
BUILDING YT CONDITION OF PROPERTY
Heating system maintained/operational Building Interior is clean/maintained
Hot water system maintained/operational Building Exterior is clean/maintained
Electrical system maintained/operational Property is clean/safe/maintained
Mechanical system maintained/operational Handrails &guards present
POOLS POOL BARRIERS IN
Pool present Pool is completely enclosed
Pool surface alarm and/or door alarm Barrier is a min.48" high
resent
POOL GATES All openings in barrier less than 4"
Self-closing, self-latching Max. 2"clearance @ bottom of barrier
Latch on pool side of gate, meets height Barrier capable of being locked &child-
requirements proof when unattended
COMMENTS:
TOWN OF SOUTHOLD
Rental Permit
=�
- Permit No. 0221
Owner Rachel Rushforth-Worrell
Occupied as Single FamilyDwelling elhng (cottage)
Located at 1200 Indian Neck Ln
Peconic 86-4-3
Address
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 housingregulations
the County of Suffolk and by the laws adopted by the New York State Fire Prevention and Buildin Co Exiraion of
two (2) years from date of issue. The operator is responsible for arranging for the bi-annuald inspection.
Expiration is
11/13/2019
Date of issue John Jarski
This Notice must be posted by the main entrance at all times Code Enforcement officer
Town Hall Annex 'iG
/ l' � `II"ele lone(6,31)^q65....1&102
54375 Main Road �
Fax(631)765 9502
P.O.Box 1179
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOILD
RENTAL PERMIT APPLICATION
LJ
Rental Permit Fee (Application mus a renewed every t Oyer r5)
SEP 9' 2019
Section A.
Property Information:
Address:
RentalProperty ..Jq �. l,,J_.._.61 t�i'� p e C., o isf i L
Tax Map Number: 1000 SECTION � -BLOCK -LOT
SECTION B.
OWNER INFORMATION:
Property r e: r-6 a c #_L_s -
Property Owner Legal Address: Property Owner Mailing Address:
/ I Yj t lA ri Kr(c j Zoo i Ni 0 i L
.........
o 14
I .....
N \1. .... 1 1 C-q
Telephone Number(s): Daytime Evening,_,_,__,,,,, er ency
Property Owner Email Address:_ ,aAl tF " C
Pae lofSVO
�e'.�
Town Hall Annex Telephone(631)765-1802
54375 Main Road `� '�� Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959P� �
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: .. _�.,. �.... _..�.�.�......._..m. _, ..r..........�.�_�. ....n..
Address of Authorized Agent(no P.O. Boxes):. ....................... ................................. __._..............._. .
Mailing Address of Authorized Agent:_ w ... . _.
Telephone Number(s):Daytime ,,,__ ,__Evening_Emergency
Email Address:
Section D.
Managing Information:
Name of Authorized Agent of dwelling unit, if any:
Address of Authorized Agent(no P.O. Boxes) _ .n.�.w........
Mailing Address of Authorized Agent: �w w..........�. ..,h �__ ...................meemm�......
Telephone Number(s):Daytime Evening Emergency
Email Address:
SECTION .
SITE INFORMATION:(required for rental properties containing 8 or more rental units)
Name of Managing Agent of dwelling unit, if any: .. _.._ mew... -
Address of Managing Agent(no P.O. Boxes):,-----
Page 2 of 5
r
Telephone(631)765-1802
Town Hall Annexe � �' ��� „ Fax(631)765-9502
54375 Main Road
P.O.Box 11791,
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SO 'OLD
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 vabd New York State Uniform Fire
Prevention Building Code Certification i:srequired stating that the property which is the subject
of the rental permit application is in compliance withall 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)
j
COUNTY OF SUFFOLK)
g
"cHEL � µ m under penalty of perjury,the following:
� �.1�.
certifY
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
P.O.Box 1179
k'
Southold,NY 1 197 1-0959"
BUILDING DEPARTMENT
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
Pry essian l seal re uired r Architect or Fn ine „ml nsed'Home lns actor must p a yic
!copy�valid currektertl r1-r1o0
Rental Property SCTM Number: _ + —3
Rental Property Address: l
Owner/Name: IC .. h _.
Rental Dwelling Unit Identifier:
Number&Square footage of each bedroom as depicted in the attached floor plan:
(i.e. Bedroom#1-100 sq., Bedroom#2-90 sq., etc.)
_..""".
Property Description (Include all improvements indicated on survey) L),.)17-
t
W S - 941 J 0 L L f,��_ WE �wl 1M^" 1.1»�4 Vr..)l'T
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 C�aservation Construction Code of New
York State.
� RED ANIGEL
SD
Print Name and Title Or
I I S n
Please place professional seal: s -fi
` TOWN OF S
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING /STRAPPING [ ] I AL
�ttvYlf
[ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
[ Pr
INSPECTORJV06WA
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FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. . . . 9810 , . . . . . . . Date . . . . December 28 . . . . . .. . . . . . .�., 19 .79
THIS CERTIFIES that the building , . . . . . . . . .. . . . . . . . . . . . . . . „ . . . . . . . . . . . . . . . . ., » . . . .
Location of Property 1200 Indian» Neck ,k Lune Peoonior, N.Y.
House No. Creet Hamlet
County Tax Map No. 1000 Section . . . .86. . . . . .Block . . ,4. . . . . . . . . . .Lot
Subdivision . . . . . .. . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . .Lot No. . . . . . . , . . . . .
requirements for a one illellin built prior to
conforms substantially to th11:10111 11110911OPWAUMM
Occupan
-April 23 . . . . . . . . . , 19 !7 pursuant o whic1P4FCertificatec;f�1. t No. . . .. . .Ml-p. . . . ... .
dated . December, 28. . . . . . . . . . . . . 19 79. ,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 . . . . . . . . .
.4.onePoRtly.Pwo?.lig,P . A .$tu.Uo. / notched. dK lin .=it 1'. A .11tor4ge
building and A two car garage
The certificate is issued to . . . . . . . . . . . . . . . . . . . . R G..•. .R . .4C.W1, . . . . . .
fa�r�ner,
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . . . . .N� . . . . . . . . . . . . . . . . . . . . »
UNDERWRITERS CERTIFICATE NO. . . . . . . . . .NIR . . . . « , . . » . . . . . . . . . . . . . . .. . ,
. . . . . . . . . . .
Building Inspector , . . . .
Rev 4/78
BUILDING DEPARTMENT
TOWN OF SOUTHOLD, N. Y.
HOUSING CODE INSPECTION REPORT
Location r� fi Tian
number & street -(Tacna capal :tY
- Tiap No.
Subdivzsa�on Lots)
Name of Owner(s) Richard G. Rath & wf.
Occupancy R 1
type Darner-tenant
Admitted by: Mrs. Rath Accompanied by: Mrs. Rath
Key available Suffolk Co. Tax No_1000-86-4-3
Source of request " Wm. H. Price Jr: Esq. Date Dec. 20 1979
DWELLING:
Type of construction Wood framedstories 2
Foundation Brick Cellara.r�tiaY1 Crawl space rest
, 6 2nd. FI 4 3rd. Fl
.
Total rooms l�zt. �
Bathroom(s) 2 Toilet room(s) 1
Porch, type-roof v ' m eck, 'type Patio, type cement
Breezeway Garage Utility room
Type Heat '",farm Air Hotwater -
Fireplace(s) 4 No. Exits 3 Airconditioning
Domestic hotwa-teryea Type eater off joil burner
Other
ACCESSORY STRUCTURES:
Garage, type const-.Wood/2 car _Storage, type const. Wood
Swimming pool Guest, type const.
Other Large studio w/attached 3 room cottage
VIOLATIONS: Housing Code, Chapter 52
Location Descri ton. Art. Sec.
Rear steps
aap No hand rail 52-27 B
Cellar
steps Not even & level _- _ 1I2-.2:L h
Front pch.
- woo II
sec" ion 3)ec.k_an.d
Side poEcl
& deck Cement cracked - badl 5 -7
Wood shed Very bad shape . ji T • C
Remarks:
Date of Insp. Dc„�,� (2 _
Inspected by= tisHoxton Time start 1 :20 end 2.00
Town of Southold
P.O.Bog 1179 12/31/2018
53095 Main Rd
Southold,New York 11971
CERTIFICATE OCCUPANCY
No: 40140
Date: 12/31/2018
THIS CERTHUS that the building AS BUILT ALTERATION
Location of property:
pro e _ Neck omc
P 1200 Indian N k Ln Pec
Sec/Bloc
SCTM#: 473889 _,...�.�_.—�..�._._._..�..�.....—.. �.
k/Lot: 86.-4-3 �, �...._ _......_.,.....
Subdivision:
..
Filed Map No. ..��...
� Lot No.
conforms substantially to the Application.�..�
PP for Building Permit heretofore filed in this office dated `..—
_.w .. �. pursuant to which Building Permit No. _ 42531
27/2018 � dated 4/5/2018
was issued, and conforms to all of the
which this certificate is issued is: r uherneuts of the applicable provisions of
the law. The occupancy for
ilt
as haratious to a.0 eaiStiin cotta e as a lied tri.
The certificate is issued to Rushfoi-t -Worrell,Rachel
of the aforesaid building.
SUFFOLK COUNT
DEPARTMENT OF HEALTH APPROVAL R10-18-0076 12/20/2018
D
ELEC
....�.
TRICAL CERTIFICATE NO.
2
PLUMBERS CERTIFICATION DATED �,.531
11/20/2018
2/4/2018
Ma "t k f"hi�ln g... .._,m.,_...�.......
A th Signature
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town !-fall
Southold, N.Y.
Certificate Of Occupancy
216902
No. . . . . . . . . . . . . . . . . . Date . . . . . . May. 1988 , . . . , . . . . . . . .
THIS CERTIFIES that the building . . . . addition . . . . " #
Location of Property1200 Indian Neck Road Peconic
House No, Street Ham%t
County Tax Map No. 1000 Section . . . . , .86 . " „ .Block . . , . . .4 . . 3
Subdivision . . . . . . . . . ,X. . . . „ , , Filed Map No. Lot No.
No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
March 2� 1988 pursuant 167932
p to which Building Permit No. . . . . . . . . . . . . . . . . . . . . .
dated . . .March 1 1; I988 . , , , was issued, and conforms to all of the requirements
of the applicable provisions of the Iaw. The occupancy for which this certificate is issued is . . . . . . . . .
An addition to an existing one—family dwelling.
Tile certificate is issued to . . . . . . . . . . BRUCE & BARBARA GEORGI
of the aforesaid building.
Suffolk County Department of Health Approval
UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . . . . . . .. . , , N/A „ r . , , . . . . . . . . , , . ,
PLUMBERS CERTIFICATION DATED : NSA
Building Inspector
Rev. i/81 "�
n �-t
cLIF(1
Town of Southold 11/13/2019
P.O.Box 1179
53095 Main Rd
01 Southold,New York 11971
CES TIFICATE OF OCCUPANCY
No: 40854 Date: 11/13/2019
THIS CERTIFIES that the building ACCESSORY ALTERATION
Location of Property: 1200 Indian Neck Ln,Peconic
SCTM#: 473889 Sec/Block/Lot: 86.4-3
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
4/18/2018 pursuant to which Building Permit No. 42602 dated 4/24/2018
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:
"AS BUILT"SOW REPLACEMENT TO AN EXISTING STUDIO AS APPLIED FOR
The certificate is issued to Rushforth-Worrell,Rachel
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
u ho re i Signature __—
fat Town of Southold
P.O.Box 1179 6/24/2019
53095 Main Rd
Southold,New York 11971
F
CERTIFICATE OF OCCUPANCY
No: 40463 _ Date: 6/24/2019
THIS CERTIFIES that the building IN GROUND POOL
1200 Indian Neck Ln P
Location of Property: econic
SCTM#: 473889 Sec/Block/Lot: 86.-4-3
Map M
Subdivision: Filedp No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
_..� 112018.„—
pursuant to which Building Permit No. 42575 dated 4/16/2018
was issuedand conforms to all of the re, quirements of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
Cl�S. OR IN C"r1I LTD �11”Sl [N POOL
FOR
The certificate is issued to Rushforth-Worrell,Rachel
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
42575 10-03-2018 ^ -
PLUMBERS CERTIFICATION DATED
�...
At 1i riz Signature
Town of Southold Annex 9/22/2014
P.O.Box 1179
54375 Main Road
?^= Southold,New York 11971
------
CERTIFICATE OF OCCUPANCY
ANCY
No: 37169 Date: 9/22/2014
THIS CERTIFIES that the building DECK
Location of Property: 1200 Indian Neck Ln,Peconic,
SCTM#: 473889 Sec/Block/Lot: 86.4-3
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this officed dated
11/19/2013 pursuant to which Building Permit No. 38544 dated 12/3/2013
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:
SIDE PORCH ALTERATION TO AN EXISTING-SINGLE FAMILY RESIDENCE AS APPLIED FOR
The certificate is issued to Rushforth-Worrell,Rachel
(OWNER ........ ....
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
d Signa ur
.....
TOWN OF SOUTHOLD
Rental
Permit
0220
Owner Rachel Rushforth-Worrell
Occupied as Single Family Dwelling (Main House)
Located at 1200 Indian Neck Ln Peconic 86-4-3
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.
11/23/2021 a
Code Ener nt Official
This Notice must be posted by the main entrance at all times
� Town Hall Annex
SOUT L- TOWN 54375 Main Road
Rental Inspection
PO Box 1179 Southold,
NY 11971-1179
f" Tel: 631-765-1802
w Fax 631-765-9502
` se- <I-
SCTM # _ D 2
owner v5 r� Phone
Address oo - rc_ ode_ Zip I Ll ST
Hamlet eC0/LI C_ Inspector
Address visible from street?
LEVELS SUB 1
Smoke Detectors (#- bedroom detectors excluded)
Carbon Monoxide Detectors (#) 7
Fire Extinguishers (#)
Exits (#)
BEDROOMS 1 2 3 4 5
Smoke Detector Alarms (#)
Carbon Monoxide Alarms (#) Loo, 'Ile
Egress (windows) (Y/N)
BUILDING SYSTEMS W CONDITION OF PROPERTY
Heating system maintained/operational Building Interior is clean/maintained
Hot water system maintained/operational Building Exterior is clean/maintained
Electrical system maintained/operational Property is clean/safe/maintained
Mechanical system maintained/operational Handrails&guards present
POOLS POOL BARRIERS
Pool present Pool is completely enclosed
Pool surface alarm and/or door alarm Barrier is a min. 48" high
resent
POOL GATES All openings in barrier less than 4"
Self-closing, self-latching Max. 2"clearance @ bottom of barrier
Latch on pool side of gate, meets height Barrier capable of being locked&child-
requirements proof when unattended
COMMENTS:
TOW. :...... OF SO THOL
Rental Permit
Permit No. 0220
Owner Rachel Rushforth-Worrell
Occupied as Single Family Dwelling (main house)
Located at 1200 Indian Neck Ln Peconic 86-4-3
Address S/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.
11/13/2019 John Jarski
Date of Issue Code Enforcement Officer
This Notice must be posted by the main entrance at all times
g �M1d}E
G'
YI�IvIGEUI�I Y�n T
Town Hall Annex �� ,� °� 1 � " Telephone(631)765-1802
54375 Main Road r Fax(631)765-9502
P.O.Box 1179 ..
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOV47N OF SOUTHOLD
RENTAL IT APPLICATION
Rental Permit Fee $200(Application must be renewed every two years)
Section A.
Property Information:
Ren Property Rental Pro ert Address:
e 5"
m o
Tax Map Number: 1000 SECTION _—BLOCK .L0T
SECTION .
OWNER INFORMATION:
Property Owner Name: R, A E'r
L "2- H 02 0 A
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
I 2, e.) ci i '1: pPQ � ,� "� �., V L-A N cf
Telephone Number(s): a i )
Property Owner Email Address: .,.� � ' i-L ( t /�'-i k6l
Page 1 of 4
Section C.- A e,ti 6.:.L f2-US i T-ti -0 0 IL �
Authorized Agent Information:
L,J - ice
Name of Authorized Agent of dwelling unit, if any:_ yt A iQ A
Address of Authorized Agent (no P.O. Boxes):
Mailing Address of Authorized Agent:
Telephone Number(s):
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):
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):_... w_..
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: 04F—
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: "x11
Requested Maximum number of persons allowed to occupy Dwelling Unit
Number of rooms in Rental Dwelling Unit: H
Use and Dimensions of each room in Rental Dwelling Unit: L-rvi 1 ...
ew
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 Piniform 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
7 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.
Page 3 of 4
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)
I � �� . �,� a'a. Imo, 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: H t5, � J- .. ..i f o- r-L 1
Property Owner's Signature: ""
Sworn to before me this day of 20 19
DAVID J.JANNUZZI
NOTARY PUBLIC,STATE OF NEW YORK
-•- Registration No.02JA6052586
Official Notary Public Signatd iginai Notary Stamp Qualified in Suffolk county
rorrmmission Expires February 13,��
Page 4 of 4
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Town Hall Annex v " Telephone(631)765-1802
54375 Main Road r
Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF S017 OLD
RENTAL PROPERTY CERTIFICATION
Form to be completed by a NYS licensed architect, NYS licensed engineer or licensed home
inspector
Separate form is required for each individual Rental Dwelling Unit
profs orlal seal re wired or arc itec „ Engineer, licensed Na a L to ustrav d q.
_...w__
coov of o valid New York Stab Un� rna irM+ l re en i waw rldin Code Oewl l ati n.
Rental Property SCTM Number:
Rental p Y � i:A FkL
Owner/Name,
cess: -
Rental Dwelling Unit Identifier: 2 -Sr r
Number& Square footage of each bedroom as depicted in the attached floor plan:
(i.e. Bedroom #1-100 sq., Bedroom#2-90 sq., etc.)
74
Property Description (Include all improvements indicated on survey)
ma "
I certify that I have done a physical inspection of the subject rental dwelling unit and find that
the unit 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.
Print Name and Title ture
NIGEL R013ERT
uq
" ILLI �YwMm.
Please place professional seal:
'9557-1
'F N
kllltv So TOWN OF' SOUTHO,LD BUILDING DEPT.
765-1802
iiimiiiiii�
CTION
[ ] FOUNDATION 1ST [. ] ROUGH PL13G.
C '] FOUNDATION 2ND [ ] I SUL _ TION/CAULING
[ ] FRAMING/STRAPPING [ ] I AL
C ] FIREPLACE & CHIMNEY [V/1 FIRESAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ], ELECTRICAL (FINAL)
[ ] CODE VIOLATION
' [ ] PRE C/
REMARKS:
i
DATE INSPECTOR
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FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. . . .Z9810 . . . , Date . . . . December. 28 . . a . . . . . . . . : . 19 79
THIS CERTIFIES that the building . . . . . . . . . . . . . . . . . . . . . . . , , . , . . . . . . . . . . . . . . . . . .
Location of Property 1200 Indian Neck{ Lanes Peoonie,. N.Y.
House No. Street Ham/et
County Tax Map No. 1000 Section . . . .86„ . , .Block . . . „ . , . . , _T . . , . . , . . . . . ,
Subdivision . . . . . . . . . . . . . . , , .. . . . .Filed Map No. . , . .Lot No. . , .. . . , . . .. . . ,
requirements for a one family dwelling built Prier to
conforms substantially to tla w
April 23 57 Certificate ofOccupancy . .29810
. . . . . . . . . . . . . . . 19 pursuant to whicl t
dated Deaner. 28 19 79. ,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 . . . . . . . . .
A, .S .0Q 1�
one ` . PWO.U.49P P . A . /. Ustobed. cite lln .unit. . A .storage
buAYilding and A two car garage
The certificate is issued to . . . . . . . . . . . . . . . . . . . . . . . . . . R
(owner,
of the aforesaid building.
Suffolk County Department of Health Approval . . . . , .
UNDERWRITERS CERTIFICATE NO. . .1VR . .
Building Inspector
Rev 4/79
...
BUILDING DEPARTMENT
TOWN OF SOUTHOLD, N. Y.
HOUSING CODE INSPECTION REPORT
Location 12 'r.a: . a e Fta3 _
number & street dunic.ipati- y
Subdivision Map No. Lot(s)
Name of Owner(s) Richard G. Rath & wf.
Occupancy R
,type ow�a er-texxan
Admitted by: Mrs. Rath Accompanied by: Mrs. Rath
Key available Suffolk Co. Tax N0.1000-86-4-
Source of request ' Ift. H. Price . Jr.' Esq, Date Dec. 20 1279
DWELLING:
Type of construction Wood framed #stori.es 2
Foundation Brick Cellar artia7. Crawl space rest
Total. rooms, 1st. F1 6 2nd. F1 4 3rd. F1
Bathroom(s) 2 Toilet room(s) _ 1
Porch, type-roof vmieck, type Patio, type cement
Breezeway
Utility room X
Type Heat "Warm Air Hottilater X
Fireplace(s) 4 No. EScits_ 3 Airconditioning
Domestic hotwater yes Type heater off oil burner
Other
ACCESSORY STRUCTURES:
Garage, type const Wood/2 car_—_Storage, type const. Wood
Swimming pool Guest, type const.
Other Large studio w/attached 3 room cottage
VIOLATIONS: Housing Code, Chapter 52
Location t. 1 Sec.
_Rear stews
up No hand_rail 52-27_B
Cellar
steps Not even & level - _ II -�2--27 A
Front pch. _
sec on
Side porc4
& deck Cement cracRed
Wood shed
Very bad shape C
Remarks:
g�
Inspected by: Cl ,i, yr -- Date of Insp.w :�c �
Curtis s Horton Time start 1:20 end 2:00