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Town Hall Annex �� �� Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 ,
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BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION IO)ING b j,�Pr,
CD4, °
" Off` u�"1 1....1
Rental Permit Fee $200 (Application must be renewed every two years)
Section A.
Property Information:
Renta
Property Address: �tL� � � � �.. .., (1
Tax Map Number: 1000 SECTION _ -BLOCK
SECTION B.
OWNER INFORMATION:
Property Owner Name: >r i _
`7C
Property Owner Legal Address: Property Owner Mailing Address:
2 7s �3
Telephone Number (s): Daytime Evening Emergency —, ___
Property Owner Email Address:
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Page 1 of 5
Town Hall Annex Telephone(631)765-1802
54375 Main RoadFax(631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959
4r d�.dG,d
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
oe
Mailing Address of Managing Agent:--AA
Telephone Number (s): Daytime Evening Emergency
Email Address:
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property:
AW;-r
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:
Requested Maximum number of persons allowed to occupy Dwelling Unit
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
��e �' x /Z. T�,� /��
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Page 3 of 5
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 µsq yaa
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 Owners Signature:
Sworn to before me this �'bt y, f C:k" 20�'
Official No ary P "blic Signature and Original.. +at.gvtamp
�. Notary Public, State Of Now Ybrk
No. 46151C*
Qualified In Nassau
Gomm aloe Expires May 27,
Page 5 of 5
1
"N OF SOUTHOLD BUILDING p
831 -765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ ] INSUTATION/CAl
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY IN!
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (Fil
[ ] CODE VIOLATION [ ] PRE C/O [ ] I
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, .. May 8, 2022
Telephone 631 765-1802
Town Hall Annex "� P ( )
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 w � 411
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
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
lro essionui seal re aired for Architect ora ineer licensed Horne ins ctor must provide
cogy of valid current cerci cation
Rental Property SCTM Number: 0D® - K 117-
Rental Property Address: 1380 Grathwohl Rd., New Suffolk NY 11956
Owner/Name: BI y —
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.)
Bedroom #1 380 sqft Bedroom #3 160 sqft
Bedroom #2 140 sqft
Property Description (Include all improvements indicated on survey)
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.
Victor Cornelius III CEO Inspector �IA k (� Pv"
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Print Name and Title ceo# 1216-0283 Original Signatu e
Please place professional seal:
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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-29009 Date: 10/23/02
THIS CERTIFIES that the building NEW DWELLING
Location of Property: 1380 GRATHWOHL RD �. NEW SUFFOLK
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 117 Block 4 Lot 6
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated OCTOBER 23, 2002 pursuant to which
Building Permit No. 28851.-Z dated OCTOBER 23, 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 ONE FAMILY DWELLING WITH FIRST AND SECOND FLOOR DECKS AND ATTACHED ONE
CAR GARAGE AS APPLIED FOR.
The certificate is issued to BRIGITTE GIBBONS .w___......_�
�w..._..w (OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-96-0016 0 1802.
ELECTRICAL CERTIFICATE NO. N 483249wgq 03L22/9-9
PLUMBERS CERTIFICATION DATED .2.9110/02 P CONIC PLUMBING & HEAT
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C orized Signature
Rev. 1/81