HomeMy WebLinkAbout1000-78.-3-42.3 �Q � �a TOWN OF SOUTHOLD
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� Rental Permit
0720
Owner Peter & Maryse Bransfield
Occupied as Single Family Dwelling
Located at 1780 Hiawathas Path Southold 78-3-42.3
Maximum Permitted Occupancy 6
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.
8/4/2022
(CTde Enf c me fficial
This Notice must be posted by the main entrance at all times
g SUUT�oI
Town Hall Annex ~ O Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 G Q
Southold,NY 11971-0959
COUNT{,� n p
® E C E � 1�! E --
BUILDING DEPARTMENT i
TOWN OF SOuTHOLD MAY 3 12022 D/
BUILDING DEPT.
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION
Rental Permit Fee $200(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
jig 0
Tax Map Number;1,000 SECTION
SECTION B.
OWNER INFORMATION:
Property Owner Name:!L�14C(Z �� na � ELIE
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
JA
Telephone Number (s)': ( c3 l� o
Property Owner Email Address: - .rJ0n' 6A P' S l ��[ aTc )4wm M Ar p Ca
�� Page'1 of 4
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: !
Requested Maximum number of persons allowed to occupy Dwelling U
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room
�l 1
in Rental Dwelling Unit:
c�e,40 s,(P-A--,- 6-e-V
f�)e464oq45- OAf C-Q—n-�+CP6-1-0'N
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 NYS licensed architect, a NYS 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.
Page 3 of 4
I am submitting a completed Town of Southold certification form from a licensed
architect, a licensed professional engineer, or a licensed home inspector who has a valid
New York State Uniform Fire Prevention Building code Certification.
SECTION H.
DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit.
STATE OF NEW YORK)
COUNTY OF SUFFOLK)
I .-,in Pyyo Gaa-f dS oro(-, 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 fdrth in "Section B" of this application is my legal
address and I understand the Town will use the address for service pursuant to all
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 s to any change to the information
regarding Authorized Agent, Managing Agent, or Site Manager.
Property Owner's Name: / / !n AJ Lc 73(t A-n1
Property Owner's Signature: nL�p�
Sworn to before me this day of Maw , 20 22
Zu si 4s;�U'Vo
Official Notary P69lic Signature and Ori i al Notary Stamp
TRACEY L. DWYER
NOTARY PUBIC,STATE 0r tJ1=W YC)RK
Page 4 of 4 NO.OIVW6306900
QUALIFIED IN SUFFOLK COUNTY
COMMISSION EXPIR96JUNE 00,202
pFSOUTy�� � �M "0
# #
TO WN OF SOUTHOLD BUILDING DEPT.
��ycourm e�' 765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ j INSULATIOWCAULKING
[ ] FRAMING/STRAPPING [ ] FINAL
[ ] FIREPLACE &CHIMNEY .C,. ] ,FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] 7;clO
REMARKS:
C Si
DATE 7'O INSPECTOR rr N-001
,
AN
Town Hall Annex Telephone(63U7*5'|Vos
54J?5Main Road Fax(68D?65'9zO%
p.O.Box /179
Southold,NY 1197/-0959
BUILDING DEPARTMENT ~ ��
TOWN OF SOUTHOL0 &��
�� 8K /m/�« 3 � �D9�
` �u��
RENTAL PROPERTY CERTIFICATION8..,
rOk��^~''^uDEp
r ~~--
vr8OU7�O/D
Form/sbmbe completedbymlicense architect, licensed engineer mrlicensed home inspector
Separate form brequired6nreach individual Rental Dwelling Unit
#rofessional sea?requiied for-Architdci,orEhQineer,-licensed Home.-Inspector musi provide
'copy of valid..current certification
Rental Property SCTNYNumber: 1000-78-3-42.3
Rental Property Address: 1780 Hiawatha's Path Southold
owner/Name: Maryse Bransfield
Rental Dwelling Unit |dent|fier:
Number&Square footage of each bedroom as depicted in the attached floor plan:
(ie. Bedroom#1 -2OOsq., Bedroom#3-90sq~ etu)
Bedroom 1- 12OSq
Masier Bedroom- 311 sq
Bedroom 2: 293 sq
Property Description (include all improvements indicated on survey)
2 story frame house and one story frame
'
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
mfNew York State,the Building Code ofNew York State,the Plumbing Code ofNew York State,
the Fuel Gas Code ofNew York State, and the Energy Conservation Construction Code mfNew
York State.
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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-19610 Date DECEMBER 21, 1990
THIS CERTIFIES that the building ONE FAMILY DWELLING
Location of Property 1780 HIAWATHAS PATH SOUTHOLD, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 78 Block 3 Lot 42.3
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 15, 1990 pursuant to which
Building Permit No. 19324-Z dated AUGUST 15,• 1990
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 ATTACHED PORCH AS APPROVED
BY ZBA 02256.
The certificate is issued to PETER BRANSFIELD
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 90-SO-47-DEC. 10, 1990
UNDERWRITERS CERTIFICATE NO. N-166496 - DECEMBER 21, 1990
PLUMBERS CERTIFICATION DATED DECEMBER 21, 1990 - MARK BAXTER
'eel D..�►... �x.ra.a ail.
Building Inspector
Rev. 1/81