HomeMy WebLinkAbout1000-117.-4-1 � s=�t - a TOWN OF SOUTHOLD
a
Rental Permit
Ql ��a 0734
Owner James & Denise Balzaretti
Occupied as Single Family Dwelling
Located at 60 George Road New Suffolk 117-4-1
Maximum Permitted Occupancy 4
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.
8/30/2022
ode f rce nt fficial
This Notice must be posted by the main entrance at all times
a
Town Hall Annex Telephone(631)765-1802
54375 Main Road ss� 'f Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 ,' x,
AUGLN
18 2022
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
TO',—
RENTAL PERMIT APPLICATION
Rental Permit Fee$200(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
•6`0 dco2c4� 126A8
Tax Map Number: 1000 SECTION l -BLOCK �- -LOT _
SECTION R.
OWNER INFORMATION:
Property Owner Name:.
N Y
Property Owner Legal Address: Property Owner Mailing Address:
Fro e&L PACr , IVY' l ov ( v
Telephone Number(s): Daytime 516-22D-(GQq Evening Emergency
Property Owner Email Address: yPj �� �►V e • G01�1
Page 1 of 5
Town Hall Annex � ,`� Telephone(631)765-1802
54375 Main Road �} . Fax(631)765-9502
P.O.Box 1179s 0
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOL THOLD
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.
411 am requesting a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold
❑ 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)
A /FS T� ,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
i
Page 4 of 5
Town Hall Annex ,�, ,� ', Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 11.79 G ti
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: 2/ �J�
Property Owner's Signature. ' 4X'C_k�
Sworn to before me this day of OUV St , 2022
Official Notary Public Signature and Original Notary Stamp
KYLEE S DEFRESE
NOTARY PUBLIC-STATE OF NEW YORK
No.01DE6420156
Qualified in Suffolk County
MY Commission Expires 08-02-2025
Page 5 of 5
Of SOUTyolo �O Cf ✓�p/ V ,� ,V Y/W So l y
# #
TOWN OF tOUTHOLD BUILDING DEPT.
`ycouKn N 631-765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS LATION/CAULKING
[ ]
FRAMING/STRAPPING [ ] AL
[ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FI AL)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS:
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Extension Basements Floors �1
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'Breezeway Patio Rooms 2nd Floor
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ERTIFtCA'i"E OF°Q `� =
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No ��,�.fi ''' Date �.... .1 l� � 1g
~ TH.tS, CER71F1'ES'mthat the buitdi fccated at.. ! '' .:��::',..rr. 'ptalg,� ;ILtsas]
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conforms substan#ially to the Ap ilication for Building Rerm�t`,, eretafore' filed'iii #his 'office;'°`acted '
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;;ill¢! }14 151.,': 4, •puasuanYta which BulktIng Permit.
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dated ,:..:..:...... ..... R+�4 ,: :::.:.^i.9 '}.;was issued,:and conforms to"a{I of the requirements
.y,, of the applicgble provisions of the iaw:The occupancy;forwhich this.certificate js'issued is .
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This certif�cafe is issued to . 1ri.7s:4ar� ,Banahiist�d, , Ete ..,.. ..:.. .
towner;�lessee or.:renant);'
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