HomeMy WebLinkAbout1000-76.-1-21.2 TOWN OF SOUTHOLD
Rental Perm"t
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Owner Richard Robbins
Occupied as Single Family Dwelling
Located at 455 Smith Dr N Southold 76-1-21.2
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.
9/15/2022 VIL
a e'I�n � erg� ��t fGial
This Notice must be posted by the main entrance at all times
soy
Town Hall Annex � - Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 F
Southold,NY 11971-0959 =4"
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION
Rental Permit Fee $200(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
119
Tax Map Number: 1000 SECTION -7 -BLOCK-BLOCK 0 ( -LOT '2
SECTION B.
OWNER INFORMATION:
Property Owner Name: _V-kCkWb
Property Owner Legal Address: Property Owner Mailing Address:
e� � O � I
Telephone Number (s): Daytimeci -131 E ening 5aV'V'4� Emergency �` 'T �
Property Owner Email Address:-3�3ajj-t::� ANfle q N AjL. SIM
Page 1 of 5 �( /
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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
�UN
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: t" p'
Address of Authorized Agent (no P.O. Boxes):
Mailing Address of Authorized Agent:
Telephone Number (s): Daytime Evening Emergency
Email Address:
Section D.
Managing Agent Information:
Name of Authorized Agent of dwelling unit, if any: N-
Address of Authorized Agent(no P.O. Boxes):
Mailing Address of Authorized Agent:
Telephone 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:
Address of Managing Agent (no P.O. Boxes);
Page 2 of 5
S ,9
;y_
Town Hall Annex
Telephone(631)765-1802
54375 Main Road Fax (631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959
t
�• � M 10�'
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Mailing Address of Managing Agent: NIA
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."
Rental Dwelling Unit Identifier: -
Requested Maximum number of persons allowed to occupy Dwelling Unit
ME
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
S2211
f '6 -024 y -5 -45
Page 3 of
Telephone(631)765-1802Tele
Town Hall Annex P
631
54375 Main Road Fax� _` ( )765-9502
P.O.Box 1 179
Southold,NY 11971-0959ick
,1
�Con,
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.
19 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)
1
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 - Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
gc
P.O.Box 1179
Southold,NY 11971-0959 £�'
jry
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 Nameti:
�I Y1�� lil
Property Owner's Signature:
Sworn to =reme s day of ` a 20
Official N 4ary Public Signature and Original Notary Stamp
REBECCA A LUCAK
Notary Public-State of New York
No.01LU6386882
oualified in Suffolk County
My commission Expires Feb.04,2023
Page 5 of 5
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TOWN OF SOUTHOLD BUILDING .
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631-765-1802 �-
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 [ ] RENTAL
REMARKS:
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TOWN OF SOUTHOLD PROPERTY RECORD CARD
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Town of Southold
7/21/2022
P.O. Box 1179
53095 Main Rd
S 4P
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 4327$ Date: 7/21/2022
THIS CERTIFIES that the building SINGLE FAMILY DWELLING
Location of Property: 455 Smith Dr N, Southold
SCTM 4: 473 889 Sec/BlocltifLot: 76.-1-2!.2
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/9/2020 pursuant to which Building Permit No. 45352 dated 10/20/2020
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:
sin le-family`d ° 111n l'tti li inidh d b i] nt. front }orc11 rear s r n � a r €11u atta.hed imratee as
applied for.
The certificate is issued to Robbins, Richard
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL RIO-14-0080 2/10/2022
ELECTRICAL CERTIFICATE NO. 45352 6/28/2022
PLUMBERS CERTIFICATION DATED 6/17/2022 Plumbing
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