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Town Hall Annex y Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
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COUNSouthold,NY 11971-0959
d j ".
TOWN NG WNOF SOUTHOLD ' , a EF, J 0 2 2 s
RENTAL PERMIT APPLICATION
Rental Permit Fee $200 (Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address: /�
�3 C9iGl��� .00'e'V.01G/
Tax Map Number: 1000 SECTION �.3--� -BLOCK 3 -LOT 3 -
SECTION S.
OWNER INFORMATION:
.��property Owner Name: /'Zig "/G�
Property Owner Legal Address: Property Owner Mailing Address:
.moo
Telephone Number(s): Daytime �IEvening s Emergencyw„�.. _
Property Owner Email Address:
Page 1 of 5
Town Hall Annex m14,n Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 COM-
� i
Southold,NY 11971-0959 �S `
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 nit 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: /
Requested Maximum number of persons al d t occup Dwelling Unit:
Number of rooms in Rental DwellingUnit:
Use and Dimensions of each room n Renta Deo 'ng Uni
Page 3 of 5
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 u
Southold,NY 11971-0959 .
�"q a.y y
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.
/? 1 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)
`oZ.,1Godle 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
Page 4 of 5
Town Hall Annex a"° Telephone(631)765-1802
54375 Main Road ; Fax(631)765-9502
P.O.Box 1179 '
Southold,NY 11971-0959
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:
Sworn to b fore me thi day of
Official Notary Public Signature and Original Notary Stamp
r-
Page 5 of 5
o�sarrr
�!'r/' $OVA%
0 TOWN F SOUTHOLD BUILDING DEPT.
765 1 2 ��j�l" � , Z�
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.,
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ]
FRAMING / STRAPPING [ ] FINAL
[ ]
FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
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