HomeMy WebLinkAbout1000-103.-7-22 TOWN OF SO T OLD
£.
Rental Permit
Permit No. 0232
Owner Christine Tan
Occupied as Single Family Dwelling
Located at 955 Pequash Ave Cutchogue 103-7-22
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.
11/20/2019 John Jarski
Date of Issue Code Enforcement Officer
This Notice must be posted by the main entrance at all times
i
To"Han Aft
54375 Mato Road '7 ( 1)765-ISM
PA.Box 1179 �( 1)74S"5M
Sm thOK NY 11971-0959 "
i
E J
BUILDING DEPARTMENT
TOWN Oil souTHOLD
RENTAL PERMIT ADPLICA7"1ON
o
Rental Permit Fee$200(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
cJ3S �ZLQJP -A ►tVC 11q3 Y
Tax Map Number IM SECTION 0 3 BLOCK LbT
f o
SECTION B.
OWNER INFORMATION:
Property Owner Name: 1
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
�114-111, r
Telephone Number(s): ;43— 1 6 Z
Property Owner Email Address: re Ya 400w
Page 1 c f 4
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: w
Address of Authorized Agent no P.O. Boxes
Mailing Address of Authorized Agent:
/ .
Telephone Number (s):� �.�,�
Email Address: "µ
Section D.
Managing Agent Inforirri Lion®
Name of Authorized Agent of dwelling unit, if
Address of Authorized Agent(no P.O. Boxes):
Mailing Address of Authorized Agent: ___M �__
Telephone Number(s):T _
Email Address:
SECTION .
SITE MANAGER INFORMATION: (required for rental properties containing 8 or more rental units)
Name of Managing Agent of dwelling unit, if any:_ m
Address of Managing Agent no P.O. Boxes ;
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:
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 r
l Identifier: 10
Requested Maximum number of persons allowed to occupy Dwellin
g Uw,rt.
Number of rooms in Rental Dwelling Unit:_.
Use and Dimensions of each room in Rental Dwelling Unit: ,,)Ilu, Joe
060
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 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.
1C I am requesting a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold.
Page 3 of 4
11 1 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: S!gnature mu notarized and MUST be the owner of the dwelling unit
STATE OF NEW YO )
COUNTYrOF SUFF )
l. 1 1 i� under penalty of perjury,thefollowing:
1. 1 am the owner of the property identified In"Section "of this application.
2. The property owner's legal address set forth In"Section e of this application is my legal
address and I understand the Tort will use the address for service pursuant to all
applicable laws and rules. I further acknowledge that I will notify the Town of Southold
a
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.
. 1 will notify the Town Wthin five(5)business days s to any change to the information
regarding Authorized Agent,Managing Agent,or Site Manager.
Property Owner's Name:
Property Owners Signature,
w n to before e hls day f 141mb
2C p
O cial Notary l)u lic Signature and Original Notary
Page 4 of 4
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INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING /STRAPPING [ INAL 404�
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE`RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ _] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
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