HomeMy WebLinkAbout1000-69.-3-10.3 TOWN OF SOUTHOLD
Rental Permit
0486
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Owner Scott & Linda McKay
Occupied as Single Family Dwelling
Located at 150 Blossom Lane Southold 69-3-10.3
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.
6/29/2021 U" V
C de nfor e e t Official
This Notice must be posted by the main entrance at all times
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Town Hal n ex } Telephone(631)765-1802
54375 M i ad Fax(631)765-9502
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P.O.Box 1179 JUN 2 8 2021 y
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Southold,NY 11971-0959 cDU
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:
Mo
Tax Map Number: 1000 SECTION -BLOCK =LOT -
SECTION B.
OWNER INFORMATION:
Property Owner Name: fie«
Property Owner Legal Address: Property Owner Mailing Address:
64!.o oe
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Telephone Number(s): Daytime�S �� Evening,?�7 a?Y3z Emergency 6.3�'�S^-� 'Lf
Property Owner Email Address: L 4U.0-(6 ® 4'y `'U
Page 1 of 5
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Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
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P.O.Box 1179 ® Q
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: �c-® c_Q,G
Address of Authorized Agent(no P.O. Boxes):
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: �t� �-
Address of Authorized Agent(no P.O. Boxes):
Mailing Address of Authorized Agent:
Telephone Number(s): Daytime Evening Emergency
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
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SO
Town Hall Annex Telephone(631)765-1802
54375 Main Road Jr Fax(631)765-9502
P.O.Box 1179
H 1
Southold,NY 971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Mailing Address of Managing Agent: .5A-W4 f✓' ���•4��'4 C-(.L
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Telephone Number(s): Daytime 1-��.!^ Evening6-;rj^ Emergency 63`—,'R_fsr-q-4r-
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: /•2 /caa s
Requested Maximum number of persons allowed to occupy Dwelling Unit: g
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
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3 �ti qr �loor l51CS — �.3� /
Page 3 of 5
SOU
Town Hall AnnexE Telephone(631)765-1802
54375 Main Road "' Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
c®UN11
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.
❑ I am requesting a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold
E? 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)
certify under penalty of perjury,the following:
4
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
i
Page 4 of 5
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Town Hall Annex l� l Telephone(631)765-1802
54375 Main Road °' Fax(631)765-9502
P.O.Box 1179 ® O
Southold,NY 11971-0959 Q
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:
Sworn to b ore met isZ'Fr day of ,-114 , 20�7--/
Of ' ial Notary bl c Signature and Original Notary Stamp
gI�PTEYpii� Dawn-Johnson
` =Notary Public,State of New York
i NOTARY':t a
aU'•. PUBLIC '`=No01J06349053
Qualified in Suffolk County
Commission Expires 10!11120
Page 5 of 5
Town Hall AnnexE Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 ''
BUILDING DEPARTMENT
TOWN OF SOUTHOLDD
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
Professional seal required for Architect or Enc ineer,-licensed Home Inspector must provide
copy of valid current certification
Rental Property SCTM Number: 1000 10 , 3
Rental Property Address: / <a :3 t c2s c o r_,. La -
Owner/Name:
L a Owner/Name: c o!C d— t_ek k olA V4oQ—t.-s!1
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.) Sg f%
MR ar# 41
Property Description (Include all improvements indicated on survey)
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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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