HomeMy WebLinkAbout1000-114.-12-13.1 TORN OF SOUTHOLD
Rental Permit
0423
.
Owner Niloy Banerjee
Occupied as Single Family Dwelling
Located at 400 Ole Jule Lane Mattituck 114.-12-13.1
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.
4/24/2024
Code E or ent Official
This Notice must be posted by the main entrance at all times
I
� 631 78551802 //�
INSPECTION
[ FOUNDATION 1ST [ ] ROUGH PL13G.
[ FOUNDATION 2ND [ ] INSULATION/CAt
[ FRAMING / STRAPPING ] FINAL
FIREPLACE & CHIMNEY [ ] FIRE SAFETY INS
1 FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (TI
[ ] CODE VIOLATION [ ] PRE C/O [
REMARKS:
ok- "r-hnve-W
DATE
,, INSPECTOR
Town Hall Annex
I've
Town Of Southold 54375 Main Road
w` �w
Rental Inspection Report PO Box 1179
p p
ZL-
4W� Southold, NY 11971-1179
PR,
Tel: 631-765-1802
5UM# /a — �• Date
�...�, �. „��m...w , ,....,.. � ... �... _... ... �................... �.,.,. ._. .� ....
Owner
"Phone
.�,n.�� ��.9,. . ... . .. ..,.mAA-n .-_.. _ .... .... _�. _.... .........m........
Address j/ Visible
Hamlet �� .. ..... ... .._.. w.... ... .�..........�Inspector ......'
�..
Floor Level Quantities Sub 1 2 3
Smoke...R.w .. . .... .,,.... . .µw _. ..... . M...,. _ .... ...
Detectors not located in bedrooms
�....� .....
. ... „a.� � � ,.... . .......R. ...��.�.m�...�..�. .
Carbon Monoxide Detectors
, . . I
Fire Extinguishers
Exits
Bedrooms 1 2 3 4 5 6
� ..,
Smoke Detectors �.. ... .... ......�._. .w�. ., .
I I {
Egress � µ_..._...�� ...f �.�..w...... �.. ...._....... � .......µ,. .. I ..... ......
t.� Occupant Count __� �... ..� a. ... . '..... ..... ,._......... .........1 . .w. ._ . hl..
., .... e..e,,.,.W. ..�..u., w ...�.�,,.,.............� ...... e,., ...,o,.a.,, ,,,,, ...,...„. ..w.. ...... .......,.,� ,,.��..,.....,
BuildingSystems Maintained&Operational
y nal Condition of Property
Heating Building interior
........,, _ A... �.. �.... . �n .......� ... . _ ..,..�. .... . .��,, .
Hot water Building exterior
�m... . ........ .mRm..� ... , . ,
Electrical 'Property clean, maintained &safe
..�. !�I w �.. . .��.... . � �.�
ails&guards installed &secure
Mechanical �.,_....�, rya_. ... ..... Handr ..�... ......... . ........ ....� ,. .._ .....�.... ..,..�.
Pool Safety Pool on Site
... ti......w_. . �..,� ,.. �.y ..ro.���,ww �..... ... �a. .... .. �.....,.
Surface water alarm Date of CO issuance
....w. . �Ro..w. _ a. . w... ..... ._u.�. ��. . ,......,.�.�..�..��.��..,�
Door alarms Pool completely enclosed
latching gates Pool fence to code requirements
Self closing/��.a�._ ... a ......�N ,, ...�_.. ...__m� .... ......... . ....�.M . ,,a .�........... ... ...,. .. ... ..
�,C...�. items
O s for _..a�.._.��....�. sent..... Prior Rental ...�W ....�. . .,.�� ...� �.� .��
Comments:
_.....,. ... .., .. . .. ..,.,... ..,,,,,,.. .... ............ . . ........
1
............
.................. .. ........ ... ........,..,., ... ,,. .. ..........., .,., , ..,. . ....
...,... ........... ...,..................., .._.. ... ......., . ....,.,,........................................., ...,.,. .._.... .., .,....
...,...,,,,,_.....,_ _....._ .. .,,..,.. ..v.,,.,..,....
......,,,.,w�
TOWN OF SOUTHOLD
Rental Permit
0423
Owner Niloy Banerjee
Occupied as Single Family Dwelling
Located at 400 Ole Jule Lane Mattituck 114.-12-13.1
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.
10/26/2022
Code End ent Official
This Notice must be posted by the main entrance at all times '
° SOUTHOLD TOWN Town Hall Annex
54375 Main Road
PO Box 1179 Southold,
Rental Inspection
NY 11971-1179
Tel: 631-765-1802
Fax 631-765-9502
ri/iii//i Z-2
b � D t 0
ii/ /%/r
%
r,
111/3r jW/ //// /��i/�/�//�/r�i
Ad(�rBSS61A
/ rr i%lrl ' �, a i,�.,. Me ���/irr 0%j�%� �. .
NOrVO,%�//r
s-r
,%rt
IT
////J /,bf
Ini
/, / //, /,r rrii
LEVELS " ., UB,,/; / /` /,
Smoke Detectors (#- bedroom detectors excluded) '
Carbon Monoxide Detectors (#)
Fire Extinguishers (#)
Exits ( `
BEDROOMS
Smoke Detector Alarms (#)
Carbon Monoxide Alarms (#)
Egress (windows) (Y/N) f
BUILDING SYSTEMS N CONDITION OF PROPERTY CIN
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 Lo Y 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:
TOWN OF SOUTHOLD
g Rental Permit
Permit No. 0423
Owner Niloy Banerjee
Occupied as Single Family Dwelling
Located at 400 Ole Jule Lane Mattituck 114-12-13.1
Village
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.
4/29/2021La.e_��
Code Enforcei!feffi Official
This Notice must be posted by the main entrance at all times
YF)TownHallHall Annex R` Telephone(631)765-1802
5
54375 Main Road t` Fax(631)765-9502
P.O.Box 1179 ^
Southold,NY 11971-0959
BUILDING DEPARTMENT =
TOWN OF SOUTHOLD '
RENTAL PERMIT APPLICATION JAN 1 3 2021
Rental Permit Fee$200(Application must be renewed every two years) F. TT.
Section A.
Property Information:
Rental Property Ad ress: Lam— fflafh44 c�
Tax Map Number: 1000 SECTION _i L _-BLOCK
SECTION B.
OWNER INFORMATION:
Property Owner Name: 1 �u ,!_SC e �-1
Property Owner Legal Address: Property Owner Mailing Address:
74 v. --L-- -
Lx�
0STel7�i (p4la -Wo- 10S-
Telephone
ephone Number(s):Daytime Evening_"aiM-2_Emergency ot�►�-2-
Property Owner Email Address: u`^� S U X13�0 I�a'LI` Cd�M
e
f�4e �r\d�, 0
Page 1 of 5
� 16141
Phone(631)765-1802le
Town Hall Annex ��' "� � Te
54375 Main Road ` Fax(631)765A502
tA
P.O.Box 1179
r
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF S)OUMOILD
Section C. 9.0 .
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, any:
Address of Authorized Agent(no P.O. oxes): o� �OL�k (DD__
Mailing Address of Authorized Age t: N L1 /qLJ ( U U 1
1�5
Telephone Number(s):Daytime (Q � �� Lvening.Sar�.2_ Emergency Sc N`'e.
Email Address: � , cu��
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 Emergency -
J
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
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
hel
P.O.Box 1179 i
Southold,NY H971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Mailing Address of Managing Agent:
Telephone Number(s):Daytime Evening Emergency
Email Address:
SECTION F.
PROPERTY DESCRIPTION: i
Number of Rental Dwelling Units on property: �(��60�t P_ [ R7t Ia _
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: 1 I
Requested Maximum number of persons allowed to occupy Dwelling Unit: I� � 1� ovJy
Number of rooms in Rental Dwelling Unit: I
Use and Dimensions of each room in Rental Dwelling Unit:
'-�hsio��vy r+�s � � .��'�,ruU•rvLS ��� ti w� r c`� ✓�� �����
Page 3 of 5
Town Hall Annex .�` , Telephone(631)765-1802
54375 Main Road {� Fax(63 I)T6.5-9502
P.O.Box 1179
Southold,NY 11971-0959
h �
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.
V1 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 SUFFOLK)
I
r'fify 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
yF r #
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 +
Southold,NY 11971-0959
arze?:�
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
t'e.qarding Authorized Agent, Managing Agent,or Site Manager.
Prop rt Owner's NamL-
Property Owner's Signature:
Sworn to before me thiJ Clay of 20,;Q.
Official Notary Public Signature and Original otary Stamp
CONNIE D.BUNCH
Notary Public,State of New York
No.01BU6185050
Qualified In Suffolk County
(;OMMisslpn Expires April 14,20
Page 5 of 5
SOUTHOLD TOWN Town Hall Annex
54375 Main Road
y Rental Inspection PO Box 1179 Southold,
n' NY 11971-1179
d •
Tel: 631-765-1802
Fax 631-765-9502
SCTM # L — 3 Date ,Z
Owner 1110 o fL,� Phone 6� -10
Address qdo ® I� tu Zip
Hamlet Inspector
Address visible from street?
LEVELS SUB 1 2 3
Smoke Detectors (#- bedroom detectors excluded)
Carbon Monoxide Detectors (#)
Fire Extinguishers (#)
Exits (#)
BEDROOMS 1 2 3 4 5
Smoke Detector Alarms (#)
Carbon Monoxide Alarms (#)
Egress (windows) (Y/N)
BUILDING SYSTEMS Y CONDITION.OF PROPERTY Y N
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 YA1 POOL BARRIERS Y&
Pool present Pool is completely enclosed
.Pool surface alarm and/or door alarm
Barrier is a min.48" high
present
POOL GATES Y/ 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:
SCREENED PORCH
12'11"x 1118"
Ivv,
4 10 01 1
Rte, KITCHENT J
16'2"x 12'0"
RECREATION ROOM * DINING ROOM
18'2"x 23'9" 11'10"x 12'0" BREAKFAST
STORAGE F 91
10'5"x 22'10" 19110"x 1410"
GARAGE
1916"x 27'9"
i
LIVING ROOM
FLOOR 1 17'10"x 12'5"
i
i
FOYER
10'3"x 12' FAMILY ROOM
8" 14'9"x 1615"
FLOOR 2
'4�• BEDROOM
15-9"xy,6
C �4n
J14'10"x 3 0"
J �
MASTER BEDROOM BEDROOM
/ p ✓l z'i 0 Y.s 16'5"x 1717" 11'10"x 13'5"
BEDROOM
818"x 12'9"
y. f�
.
FLOOR 3
`51�
SIZES ARID DIMENSIONS ARE APPROXIMATE, ACTUAL MAY VARY,
TOWN OF SOUTHOLD PROPERTY RECO
OWNER I STREET e VILLAGE DIST. SUB. LOT
"s
F,ORMER OWNER UX N, E ACR.
yp-
S gg W TYPE OF BUILDING
ZAI
RES. 21 n1 SEAS. VL. FARM COMM. CB. MICS. Mkt. Value
LAND IMP. TOTAL DATE REMARKS
3o g
� 716
. . . f
Gi s9:� t..�, T�C'e...'� �v^ �`'fl �-r'<'l""_@ ^_i 64,
'Cn ' { ?'i
m AE ids
nc
51077- Lig'a-S71ap ra 4--
Tillable ( FRONTAGE ON WATER W
Woodland FRONTAGE ON ROAD :3 >> >
Meadowland 5,C) 6EPTH
House Plot / t BULKHEAD
Total :"
r
:1
i
r
:OLOR TRIMx
•
114-12-13.1 3/03 -
_
Extension
1 rj Y P
Extension ,t.
_ _ . .--
Extension 4"
- _— -- —
_ j < � Foundation Both
-- -- - Finett
e -
Por&l . _a Basement - Floors
Porch �.r
1 Ext, Walls �� >� Interior Finish �� C LR.
Breezeway - -� � -t-- -----, __
Fire Place .r Heat DR.
Garage t Type Roof / Rooms 1st Floor BR. t�
Patio Recreation Room Rooms 2nd FloorEd
O. B. Dormer Driveway i t -----
Total ��
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-28656 Date: 08/06/02
THIS CERTIFIES that the building NEW DWELLING
Location of Property: 400 OLE JULE LA MATTITUCK
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 114 Block 12 Lot 13 .1
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated FEBRUARY 5, 2002 pursuant to which
Building Permit No. 28168-Z dated MARCH 12, 2002
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 SINGLE- FAMILY DWELLING WITH GARAGE UNDER COVERED FRONT PORCH AND
REAR WOOD DECK AS APPLIED FOR.
The certificate is issued to ANTHONY ALIPERTI
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF EEALTH APPROVAL R10-01-222 07/28/02
ELECTRICAL CERTIFICATE NO. 62904H 07/24/02
PLUMBERS CERTIFICATION DATED 07/15/02 SHOREHAM PLUMB.&HEATING
9 ;��_
A or' ed Si ature
Rev. 1/81
Town of Southold Annex 7/31/2011
4`�� 54375 Main Road
' Southold,-New York 11971
CERTIFICATE OF OCCUPANCY
No: 35099 Date: 7/31/2011
THIS CERTIFIES that the building RESIDENTIAL ADDITION
Location of Property: 400 Ole Jule Lane,Mattituck,
SCTM#: 473889 See/Block/Lot: 114.-12-13.1
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this offiiced dated
7/1/2010 pursuant to which Building Permit No. 35714 dated 7/16/2010
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:
roof over deck with stairs on an existing one family dwelling as applied for.
The certificate is issued to Myers, William&Myers,Marie
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
horiz Sign re
///
r
Illll ,
Neer York State Bar Association
New York Statutory Short Form Power or Attorney,8/I8/10,Eff.9/12/10
POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
(a) CAUTION TO THE PRINCIPAL: Your Power of Attorney is an important document. As the
"principal,"you give the person whom you choose(your"agent")authority to spend your money and
sell or dispose of your property during your lifetime without telling you. You do not lose your
authority to act even though you have given your agent similar authority.
When your agent exercises this authority,he or she must act according to any instructions you
have provided or,where there are no specific instructions,in your best interest. "Important
Information for the Agent"at the end of this document describes your agent's responsibilities.
Your agent can act on your behalf only after signing the Power of Attorney before a notary
public.
You can request information from your agent at any time. If you are revoking a prior Power of
Attorney,you should provide written notice of the revocation to your prior agent(s)and to any third
parties who may have acted upon it,including the financial institutions where your accounts are
located.
You can revoke or terminate your Power of Attorney at any time for any reason as long as you
are of sound mind. If you are no longer of sound mind,a court can remove an agent for acting
improperly.
Your agent cannot make health care decisions for you. You may execute a"Health Care
Proxy"to do this.
The law governing Powers of Attorney is contained in the New York General Obligations Law,
Article 5,Title 15. This law is available at a law library,or online through the New York State Senate
or Assembly websites,www.senate.state.ny.us or www.assembly.state.ny.us.
If there is anything about this document that you do not understand,you should ask a lawyer of
your own choosing to explain it to you.
(b) DESIGNATION OF AGENT(S):
NILOY BANERJEE 7 Jalan Merchu,Bukit Tunku,Kuala Lumpur 50480 Malaysia
(name of principao (address of principal)
hereby appoint:
Kathryn J.Thompson 246 East 4611 st,Apt 7N New York NY 10017
(nanie of agent) (address of agent)
(naine of second regent) (address of second agent)
as my agent(s).
2010 N.Y.Laws ch.340 Page 1 of 6
illll
New York State liar Association
New York Statutory Short conn Power orAuornty.8/18/10.Eff.9/12110
If you designate more than one agent above,they must act together unless you initial the statement below.
(_) My agents may act SEPARATELY.
(c) DESIGNATION OF SUCCESSOR AGENT(S): (OPTIONAL)
If any agent designated above is unable or unwilling to serve, I appoint as my successor agent(s):
(nanze of successor agent) (address ofsuccessor agent)
(name ofsecont successor agent), (address ofsecond successor agent)
Successor agents designated above must act together unless you initial the statement below.
(___)My successor agents may act SEPARATELY.
You may provide for specific succession rules in this section. Insert specific succession provisions here:
(d) This POWER OF ATTORNEY shall not be affected by my subsequent incapacity unless I have
stated otherwise below,under"Modifications".
(e) This POWER OF ATTORNEY DOES NOT REVOKE any Powers of Attorney previously
executed by me unless I have stated otherwise below,under"Modifications".
If you do NOT intend to revoke your prior Powers of Attorney,and if you have granted the same
authority in this Power of Attorney as you granted to another agent in a prior Power of Attorney,each agent
can act separately unless you indicate under"Modifications"that the agents with the same authority are to
act together.
(f) GRANT OF AUTHORITY:
To grant your agent some or all of the authority below,either
(1) Initial the bracket at each authority you grant,or
(2) Write or type the letters for each authority you grant on the blank line at(P),and
initial the bracket at(P). If you initial(P),you do not need to initial the other lines.
I grant authority to my agent(s)with respect to the following subjects as defined in sections 5-1502A
do4gh 5-1502N of the New York General Obligations Law:
( �y,"j ) (A)real estate transactions;
(`) (B)chattel and goods transactions;
(C)bond,share,and commodity transactions;
( (D)banking transactions;
( ) (E)business operating transactions;
(F)insurance transactions;
2010 N.Y.Laws ch.340 Page 2 of 6
II
: • Ncw York State Bar Association
New York Statutory Short Form PowerofAttomcy,8/I3/10,EIl:9/12110
(_) (G)estate transactions;
(� (H)claims and litigation;
(� (I)personal and family maintenance: If you grant your agent this authority, it will allow the agent to
make gifts that you customarily have made to individuals,including the agent,and charitable
organizations.The total amount of all such gifts in any one calendar year cannot exceed five
hundred dollars;
(_) (J)benefits from governmental programs or civil or military service;
(_) (K)health care billing and payment matters;records,reports,and statements;
( ) (L)retirement benefit transactions;
( (M)tax matters;
(N)all other matters;
�) (0)full and unqualified authority to my agent(s)to delegate any or all of the foregoing powers to
any person or persons whom my agent(s)select;
(� (P)EACH of the matters identified by the following letters:
You need not initial the other lines if you initial line(P).
(g) MODIFICATIONS: (OPTIONAL)
In this section,you may make additional provisions,including language to limit or supplement
authority granted to your agent. However,you cannot use this Modifications section to grant your agent
authority to make gifts or changes to interests in your property. If you wish to grant your agent such
authority,you MUST complete the Statutory Gifts Rider.
This power is limited to the purchase and financing of the property known 400 Ole Jule
Lane,Mattituck New York 11952 and including the execution and delivery of any documents,
including but not limited to mortgage documents,related thereto with the United Nations Federal
Credit Union, under loan number 7010148372, and to sign any and all documents necessary in
this transaction.
(h) CERTAIN GIFT TRANSACTIONS: STATUTORY GIFTS RIDER(OPTIONAL)
In order to authorize your agent to make gifts in excess of an annual total of$500 for all gifts
described in(I)of the grant of authority section of this document(under personal and family maintenance),
you must initial the statement below and execute a Statutory Gifts Rider at the same time as this instrument.
Initialing the statement below by itself does not authorize your agent to make gifts. The preparation of the
Statutory Gifts Rider should be supervised by a lawyer.
(__) (SGR) I grant my agent authority to make gifts in accordance with the terms and conditions of the
Statutory Gifts Rider that supplements this Statutory Power of Attorney.
(i) DESIGNATION OF MONITOR(S): (OPTIONAL)
If you wish to appoint monitor(s),initial and fill in the section below:
2010 N.Y.Laws ch.340 Page 3 of 6
H
11111
-••• New York State Sar Association
New York Statutory Short Fonn Power of Attorney,8/18/10,EIr.9/12/10
�)I wish to designate ,whose address(es)is(are)
as monitor(s). Upon the request of the monitor(s),my agent(s)must provide the monitor(s)with a copy of
the power of attorney and a record of all transactions done or made on my behalf. Third parties holding
records of such transactions shall provide the records to the monitor(s)upon request.
0) COMPENSATION OF AGENT(S): (OPTIONAL)
Your agent is entitled to be reimbursed from your assets for reasonable expenses incurred on your
behalf. If you ALSO wish your agent(s)to be compensated from your assets for services rendered on your
behalf,initial the statement below. If you wish to define"reasonable compensation",you may do so above,
under"Modifications".
My agent(s)shall be entitled to reasonable compensation for services rendered.
(k) ACCEPTANCE BY THIRD PARTIES:
I agree to indemnify the third party for any claims that may arise against the third party because of
reliance on this Power of Attorney. I understand that any termination of this Power of Attorney,whether the
result of my revocation of the Power of Attorney or otherwise,is not effective as to a third party until the
third party has actual notice or knowledge of the termination.
(1) TERMINATION:
This Power of Attorney continues until I revoke it or it is terminated by my death or other event
described in section 5-1511 of the General Obligations Law.
Section 5-1511 of the General Obligations Law describes the manner in which you may revoke
your Power of Attorney,and the events which terminate the Power of Attorney.
(m) SIGNATURE AND ACKNOWLEDGMENT: .000, �)
y ort9
P
In Witness Whereof I have hereunto sig d m name on th`�� day o 20]e1D
Malaysia PRINCIPAL signs hera� >
City of Kuala Lumpur ) NILRA JEE
Emba6& ftbe United Stat )ss:
of America ) ss:
On the'',b day of .s') fl� ;20'40 ore me,the and rsigned,personally appeared Allegra
NILOY BANERJEE personally known to me or proved to me on the basis of satisfactory evidence to be
the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity,and that by his/her signature on the instrument,the individual,or the
person upon behalf of which the individual acted,executed the instrument.
V �
Notary Public !_a Lira A. Schierhoff
(n) -IMPORTANT Ii4FORMATIONFOR THE AGENT: Notarizing Officer
U.S. Embassy Kuala Lumpur
When you accept he authority granted under this Power of Attorney,a special legal relationship is
created-between Vou and thy:principal. This relationship imposes on you legal responsibilities that continue
until you resign or the.Power of Attorney is terminated or revolted. You must:
2010 N.Y.Laws ch.340 Page 4 of 6
a
IIIII
New York State liar Association
New York Statutory Short Eorm Power of Auomey,8113/10,Efr:9112/10
(1)act according to any instructions from the principal,or,where there are no instructions, in the
principal's best interest;
(2)avoid conflicts that would impair your ability to act in the principal's best interest;
(3)keep the principal's property separate and distinct from any assets you own or control,unless
otherwise permitted by law;
(4)keep a record or all receipts,payments,and transactions conducted for the principal;and
(5)disclose your identity as an agent whenever you act for the principal by writing or printing the
principal's name and signing your own name as"agent" in either of the following manners:
(Principal's Name)by(Your Signature)as Agent,or(your signature)as Agent for(Principal's
Name).
You may not use the principal's assets to benefit yourself or anyone else or make gifts to yourself or
anyone else unless the principal has specifically granted you that authority in this document,which is either
a Statutory Gifts Rider attached to a Statutory Short Form Power of Attorney or a Non-Statutory Power of
Attorney. If you have that authority,you must act according to any instructions of the principal or,where
there are no such instructions,in the principal's best interest.
You may resign by giving written notice to the principal and to any co-agent,successor agent,monitor
if one has been named in this document,or the principal's guardian if one has been appointed. If there is
anything about this document or your responsibilities that you do not understand,you should seek legal
advice.
Liability of agent: The meaning of the authority given to you is defined in New York's General
Obligations Law,Article 5,Title 15. If it is found that you have violated the law or acted outside the
authority granted to you in the Power of Attorney,you may be liable under the law for your violation.
(o) AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the agent(s)sign at the same time,nor that multiple agents
sign at the same time.
Uwe, ,have read the foregoing Power of Attorney. I am/we are the person(s)
identified therein as agent(s)for the principal named therein.
Uwe acknowledge my/our legal responsibilities.
Agent(s)sign(s)here: _> _
STATE OF NEW YORK )
ss:
COUNTY OF )
On the day of ,20,before me,the undersigned,personally appeared
,personally known to me or proved to me on the basis of satisfactory evidence to be
the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity,and that by his/her signature on the instrument,the individual,or the
person upon behalf of which the individual acted,executed the instrument.
2010 N.Y.Laws ch.340 Page 5 of 6
p ,
'AM.;
• \ctt YorkStatc liar Association
Ncw York Statutory Short Donn Power or Attorney,8/18/10.E0:9/12/10
Notary Public
(p)SUCCESSOR AGENT'S SIGNATURE AND ACKNOWLEDGMENT OF APPOINTMENT:
It is not required that the principal and the SUCCESSOR agent(s),if any,sign at the same time,nor
that multiple SUCCESSOR agents sign at the same time. Furthermore,successor agents can not use this
power of attorney unless the agent(s)designated above is/are unable or unwilling to serve.
Uwe, ,have read the foregoing Power of Attorney. I am/we are the
person(s)identified therein as SUCCESSOR agent(s) for the principal named therein.
Successor Agent(s)sign(s)here: _>
STATE OF NEW YORK )
ss:
COUNTY OF )
On the day of ,20_,before me,the undersigned,personally appeared
'personally known to me or proved to me on the basis of satisfactory evidence to be
the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity,and that by his/her signature on the instrument,the individual,or the
person upon behalf of which the individual acted,executed the instrument.
Notary Public
2010 N.Y.Laws ch.340 Page 6 of 6
January 13, 2021
Susan Pontino
Building Department
Town of Southold
Town Hall Annex
54375 Main Road
P.O. Box 1179
Southold, NY 11971-0959
Re:400 Ole Jule Lane Rental Permit Application
Dear Sue,
Thank you so much for your help earlier this week with collecting information needed for the rental
application for our home.To recap: My husband is the U.N.Ambassador for Malaysia,Singapore,and
Brunei Darussalam.We recently purchased our home at 400 Ole Jule Lane in Mattituck.
Niloy has had to return to Malaysia, and I will be joining him in the next few months when the borders
are re-opened.We would like to rent out our home when I have joined him in Malaysia.
I have enclosed the following:
-Rental Application
-Power of Attorney for real estate transactions
-Both C of O's(that you so kindly provided)
-Floor plans with the smoke and carbon monoxide detector marked on the floor plans
-Check for$200 for the application fee
Please let me know what else needs to be provided. I am always available by phone or email.
Thanking you again for all of your kind assistance,
Kathy Thompson
646-660-1685
Kathythompson136@gmail.com
JAN 1 3 2021
BUY L- IFI-1-ISI TG' "_T"I
T'LB Y't 1': �y C: .,.