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Home My WebLink About1000-117.-9-2 TOWN OF SOUTHOLD Rental Permit Permit No. 0240 Owner Robert Lupton Occupied as Single Family Dwelling Located at 295 Jackson Street New Suffolk 117-9-2 Village S/B/L Maximum Permitted Occupancy 7 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. 12/5/2019 John Jarski Date of Issue Code Enforcement Officer This Notice must be posted by the main entrance at all times Nov 164- U Town Hall Annex id Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 ' Southold,NY 11971-0959 BUILDING DEPARTMENT RentalRENTAL PERMIT APPLICATION Permit Fee $200(Applicationmust be renewed every two years) i Property Information: Rental Property Address: 11� m qi GcxS®*' S u1/aW � u �a1C Map 9 Tax Ma Number: 1000 SECTION I � � � IImO� _ )1�, SECTION B. OWNER INFORMATION: Z ° Property Owner Name: Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) a„ Telephone Number(s): 0 3 — ®� — y `� °'WUU ° Property Owner Email Address: Page I of 4 Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax (631)765-9502 P.O.Box 1 179 Southold,NY 11971-0959 M p� 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." Rental Dwelling Unit Identifier. S Requested Maximum number of persons allowed to occupy Dwelling Unl Number of rooms in Rental Dwelling Unit: Use and Dimensions of each room in Rental Dwelling Unit: Page 3 of 5 t TOWN OF SOUTHOLD BUILDING DEPT. 7654802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [( ]] IS L TI C L I FRAMING /STRAPPING AL FIREPLACE CHIMNEY FIRE F INSPECTION TIO ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ECTRICAL (FINAL) [ ] CODE VIOLATION PRE / f I[ DATE INSPECTOR 7 Town Hall AnnexC� Telephone(131)765-1802 S.M uif,101,3(l,` I Fax(631)765-9502 So9jQ old,NY 1 1971 09.9 JUL 3 2019 BUILDING I.7EPAR"C°MI'R`;T TOWN OF sourtioLD SECTION G. INSPECTION: ., " Pursuant to the Town Code of the Town of Southold Chapter 201 (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. I am requesting a fire safety inspection to be performed by a Code Enforcement Official from the Town of Southold ❑ 1 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�`o� ,/ SUFFOLK) �J I T r L Lyd z " , certify under penalty of perjury, the following: 1. I am the,ownrof earoerty identified in "Section A" of this application. 2. The propeily o rN er`s'1 c1p 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 L54375Maiin Annex Telephone(631)765-1802 Fax(631)765-9502 S ",)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. " Property Owner's Name: / Property Owner's Signature: _eel Zin Swor1l to of re me this LT day of 'R._ 201 u" r, w 0, icia otary P iic Signature al d original Notary Stamp ASHLEY M HENDERSON NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20134072138 MY COMMISSION EXPIRES SEP.18,2022 Page 5 of 5 .tl N 0 �m 1 S Sy.d ICS, l Ir_ e 62 STUN l V' OD N ": ✓ ,sem WOOD a n � q i a . PORCH 7 R ........... cj7 CjlCD s m Ln 0 0 1 c c 0 V) a 0 Ln CID 0 rb co 0 rn —Z, :2 Mm G) ;3 ;�J m m Ln UN Ln lig IM IIMn m 0 0 G) (n -n rl ID o .......... > IW ro CID m M CF IS )� - A z z > DO W G) G) In m m 0 0 Z -LIN 01 m All) m > 0 m 4F &Z Ln IOU LO m �17 )' 'C4, 77 1`7z, < O r� rn 1 CD co co W CDof y m a 4 - O O O 4 rJnI k Y i VJ dM � 4, r . r p 7lrn j 0o -n � L ID y � � 1 4" �� P p 0 ( r 3 g En o• W,M , CD a - i 0 0 t C F / e k _ ` n, FORM NO.4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. . . .Z 12 5 A . . . . . . . Date . . . . . . . . . June. 5 . . . . w . , . . . , . . . ., 1984. THIS CERTIFIES that the building . -,11,-prat;ion. , . , . Location of Property 295 Jackson Street New. Suffolk House No. Street Ham/et County Tax Map No. 1000 Section . . . 1.1.7 . . . . .Block . . . . 0 9. . . . . . . . .Lot , 0 0 2 Subdivision . . . .X. ... . . . . , „ „ . . . . . . . . . . . .. . . . .Filed Map No. .X. . . . . .Lot No. X , . . . . . conforms substantially to the Application for Building Permit heretofore filed in this office dated . . . . . . . P,P.K i 1. 2.2 . . . . , 19 .$3 pursuant to which Building Permit No. . . 1.23351 Z . . . . dated . . . . . . . . K-E lY. . . . . . . . . . . . . . 19 .q3,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 . . . . . . . . alteration, from clarage (attached) to bathroom & living facilmities . The certificate is issued to . . . . . . . . . KFiV�Ig. RF,AFN JQN, . . RQBERT JONES of the aforesaid building. Suffolk County Department of Health Approval , . .Nle , „ „ „ , , , , , , , , , , , , , ,. . . . , , , , , . , . , , UNDERWRITERS CERTIFICATE NO. . . . . . . . . . .R .0 4 315 . . . . . . . . . . . . . . . . . . . . „ . Building Inspector Rev. 1/01