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Home My WebLink About1000-107.-1-2.6 g� � p TOWN 0 SOUTHOLD loo Rental Permit 1-5 0616 Owner Bruce & Leigh Ann Bergen Occupied as Single Family Dwelling Located at 3965 Grand Avenue Mattituck 107.-1-2.6 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. 4/11/2024 )A�n _ Code Erg rc went Official This Notice must be posted by the main entrance at all times So TOWN OF SOUTHOLD BUILDING DI 531 -755 1802 107, 1 INSPEC-UION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION/CAl [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY IN; [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FII [ ] CODE VIOLATION [ ] PRE C/O [ REMARKS: Llza0 4 4 a 4/ - L< DATE - INSPECTOR � � Town Hall Annex ' r Town of Southold 54375 Main Road a, Rental Inspection Report PO Box 1179 r Southold, NY 11971-1179 Tel: 631-765-1802 mif» W f Date .� ..�. SCTM # � a ......... . .. .... .... .�.�_.. Phon 11 e .. . , ... . Owner ��. . .� .�. ._. ........... .. ... ww .w,'�� ...� Ad dress � ... .. '�` _! _.. . . ... ... ..... .... ........ ,Visible Hamlet / .. ..Inspector Floor Level Quantities.��..�......�,..� .._, � ,... �....��....�._. ......��.��.... ...�Sub 1 2..... w .. .�Ro �. — ........WR�..��w............ .e.�.....�.,�au., . � � ..` ........ Smoke Detectors(not located inbedrooms) Carbon Monoxide Detectors r �. w . ...�....RR...�w...,. .�. �..�...... ��. � R..�.�R,.. . _.. ,,,oa....,.. .._..... ! ..... .�.... Fire Extinguishers Exits edrooms B� 1 2 3 4 5. . Smoke 6. ...... .. ... ... .� . �.W. . .��, .... �... .�. �..w.. .. � .. Detectors .....Occupant Coun.t.... ..e.. m�.. _...._. �.. _ m .....: ....... . ... �.., ..., �... �...,� _.1 FIC'on Building Systems Ma intained &Operational_. _ md�.iti o.n of Property " � Heating Building interior { Hot water Building exterior Electrical Property clean, maintained&safe�... ...�. Handrails&..,vuards installed �wa �..�..., .,.. . �......... . .._..._ echanical f g d &secure �M ._ Pool Safety Pool on Site , Surface water alarm Date of CO issuance ��....��.. ....� � ..,,., ® �� ..a �,.,. �aa , ... . . wa... ..... ��, .R��,,. .......aR.... .a.�. �� ... Door alarms Pool completely enclosed elf closing/latching gates Pool fence to code requirements ... . �_....... p.�,�,.._ �. _...w �. l. ...e..�_. ......I {IrCO s for for all items pre sent i Prior Rental Comments: .a�w ._.... ... .... w. _. �wm.-..... .........�...�.. . _-..�.. . �.. . .............. . .. ... ... .... _... �......... �.... .. �_ww,_, �. _.rv. _ .....,_ _ ........ �..�.,�� i TOWN OF SOUTHOLD Rental Permit 0616 Owner Bruce & Leigh Ann Bergen Occupied as Single Family Dwelling Located at 3965 Grand Avenue Mattituck 107-1-2.6 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. 4/11/2022 o _or nt ficial This Notice must be posted by the main entrance at all times n� �e✓Town Hall Annex w Telephone(631)765-1802 , � �, ��+ , 54375 Main Road Fax(631)765-9502 F.O.Box 1179 Southold,NY 11971-0959a � p,'�ppgp� per,gyp, r .o- BUILDING DEPARTMENT TOWN OF SOUT `OLD Y a ..�,.. RENTAL. PERMIT APPLICATION Rental Permit Fee$200 (Application must be renewed every two years) Section A. Property Information: Rental Property Address: /111 �� Tax Map Number: 1000 SECTION -BLOCK 107 -LOT'� L SECTION B. OWNER INFORMATION: z Property Owner Name: . Q V1 1�C Property Owner Legal Address: Property Owner Mailing Address: -30 . 15 � qQ-034 ' Telephone Number(s): Daytime g Emer ensEvening g y Property Owner Email Address- ry (V_5 ,r Page 1 of S r 7 f ' Town Hall AnnexTelephone(631)765-1802 Fax(631)765-9502 54375 Main Road P.O.Box 1179 Southold,NY 11971-0959 , mel ,rti ' BUILDING DEPARTMENT TOWN OF SOUTHOLD Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any. OA _ww.. ... Address of Authorized Agent(no P.O. Boxes); Mailing Address of Authori15i W11b.�—((k.— - &7�'4, , sed Agent: ��« _ , Telephone Number(s): Daytime Evenin _.0 COO Emergenr Email Address: Section D. Managing Agent Information: a Name of Authorized Agent of dwelling unit, if any: Nf 0 Address of Authorized Agent(no P.O. Boxes):��_� ,._wWww_..... .w .._ Mailing Address of Authorized Agent:Telephone Number 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: a Address of Managing Agent (no P.O. Boxes):,_,_. Page 2 of 5 'fes Town Hall Annex P yr `�`w hone(631)765-1802 � Tele 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 1 1971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD Address of Managing Agent: 100 E Mailing g g g �.�... 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, 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." i — 3 1 �5 6—" Rental Dwelling Unit Identifier. T Requested Maximum number of persons allowed to occ py welling U*nit-. - ivic 1 V1 Number of rooms in Rental Dwellin Unit: lV' C Dwelling i Use and Dimensions of each room in Rental Dwelling Unit: VL-anal11 _ µ WW1 I�Oduv1 �7a x 132 � �f � 75 Page 3 of 5 Telephone(631)765-1802 Town Hall Annex At „ 1 z Fax(631)765-9502 54375 Main Road ii " P.O.Box 1179 Southold,NY 11971-0959 44k G n 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. -0/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) COUNTYOF S(JFF01.K) � . i [J- l ","certify under penalty of penury,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 Hall Annex yTelephone(631)765-1802 �� '� 54375 Main Road r! Fax(631)765-9502 P.O.BOX 1179r ",` Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOOOLD 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. L Property Owner's Name: Property Owner's Signature:" -- �- Sworn to befog me this �T day of , 20-2 Official Notary Public Signature and rignal Notary Stamp CHRISTINE ZAWESIQ Notary Public,State of New Yak Ouaffied In Suffolk County No.6247911$6 MY COnmission EWM Am 30,20.L4?. 0,Z0b 4?. Page 5 of 5 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 1 1 Q c. INSPECTION' , FOUNDATION 1ST ROUGH . FOUNDATION 2ND INSULATIOWCAULKING FRAMING /STRAPPING NAL �R*� 5rA �vv FIREPLACE & CHIMNEY /FIRE SAFETY INSPE.�HTION FIRE RESISTANT CONSTRUCTION r ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION PRE C/O w .w _ ......... ftA r Jlgf, v CO,2- 0 F( P)E A LAA H .................. ............ IS its VIL Ti I All TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREETVILLAGE DIST - SUB_ LOT ACR. _ REMARKS £ TYPE OF BLD g — _ PROP _ . CLASS - _ LAND iMP TOTAL DATE 1171 . 71F _ f F E FRONTAGE ON WATER TILLABLE FRONTAGE ON ROAD s WOODLAND DEPTH MEADOWLAND, BULKHEAD HOUSE/LOT ------------ _ i I TOTAL i -Te g COLORel \yv wv v yAvyAvv \\\ I s p i'7i r rS it I 'h t i i TRIM Z i - MMUM ao 107-1-2.6 10/01 _ fug\ Foundation Bath Dinette M. BldgISR rt = Zza Floors Kit. Extension F {3 �5 Basement S �{ 0o S J _ SLABF`s -, Extension 3 10 Ext Walls Interior Finish L-R 470 D.R. xtersor ` { Fire Place Heat Patio WoodstoveBR_ Porch Dormer Fin. B. Deck A Attic eze yRooms 1st Floor Garage - `� Driveway Rooms 2nd Floor i O.B. I ' 3 s r i FORM NO 4 g I ��c TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27726 Date: 06/05/01 THIS CERTIFIES that the building NEW DWELLING Location of Property: 3965 GRAND AVE MATTITUCK (HOUSE NO. ) (STREET) (HAP$LET) County Tax Map No. 473889 Section 107 Block 1 Lot 2.6 Subdivision _ Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 22, 2000 pursuant to which Building Permit No. 26639-Z dated " JULY 7, _2000 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 A ONE FAMILY DWELLING WITH WRAP AROUND PORCH AS APPLIED FOR. The certificate is issued to BRUCE D & LEIGH ANN BERGEN (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-00-0080 05/24/01 ELECTRICAL CERTIFICATE NO_ 1744 04/16/01 PLUMBERS CERTIFICATION DATED 12/13/00 H. RONALD VAN DUYNE SR aori• ed Si nature Rev. 1/81 FORM NO. 4 GAWE TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hail Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-32044 Date: L21.21 06 THIS CERTIFIES that the building ACCESSORY Location of Property: __3965 GRAND AVE MATTITUCK (HOUSE NO.) (STREET) (HAMLET) County Tax Map No_ 473889 Section 107 Block 1 Lot 2.6 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 24 2001 pursuant to which Building Permit No. 27801-Z dated OCTOBER_17w2001 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 ACCESSORY GAP-!3E WITH STORAGE ABOVE IN THE RE IRED REAR YARD AS APPLIED FOR. _ ..... www_..._- ._ ._.w�� _ ......... The certificate is issued to BRUCE D & LEIGH ANN BERGEN (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N A ELECTRICAL CERTIFICATE NO. 3006694 025 06 PLUMBERS CERTIFICATION DATED N/A A ori ed Si/nature Rev. 1/81 FORM NO. 4 NOL TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33326 Date: 10808 THIS CERTIFIES that the building ACCESSORY Location of Property: _ w 3965 GRAND AVE MATTITUCK w (HOUSE NO. ) (STREET) (HAMLET) County Tax Map No_ 473889 Section 107 Block 1 Lot 2.6 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated SEPTEMBER 18, 2007 pursuant to which Building Permit No_ 33427-Z dated SEPTEMBER 27, 2007 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 ACCESSORY IN GROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR. The certificate is issued to BRUCE D & LEIGH ANN BERGEN www ��_._.............n.._._ww(-OWNER) __....w_. of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/Aggqqwwmmw- x�........... ELECTRICAL CERTIFICATE NO_ 789412/15/007 PLUMERS CERTIFICATION DATED w._. �._......... N/A _w_........................ .. __...........�w_w_..� u:(.wi.izetl siyiid.Lurc Rev. 1/81