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Home My WebLink About1000-34.-5-19 C) .U) U) c r 0 O CO 5 Q- ,-- a��i w M Im •6 .0 , O Q + o U M s OE 4 -0 � O to U o [a c U bA US Co L • 4 N U) = •0 E o0 N U cu a a' ca EL a� CIS C7 � � z u _� Vol �-- U O O C� O L Q o o �y �.-� 4-1 F- > .L v 0 O n Z CaO O O_ z �' O 0 U 0- 0' o E 41 {r- O O _U Y_ C 0 •� F- •x NM CD o o is U cu Co O � o q 4-+ a) (o O N 00 _ Q — N •� 4-1E \O 0 (0 J r--+ V� 105 (P 5-u � 38O sof S , Oe,+ 1(2-44A- Town Hall Annex Telephone(631)765-1802 54375 Main Road a °" P ,3I)765-9502 P.O.Box 117911 41 Southold,NY 11971-0959 M 5 2023 BUILDING DEPARTMENT TOWN OF SOUTHOLD J 1'nING TIP71". RENTAL PERMIT APPLICATION Rental Permit Fee $200 (Application must be renewed every two years) Section A. Property Information: Rental Property Address: Tax Map Number: 1000 SECTION ��-BLOCK -LOT SECTION B. OWNER INFORMATION: Property Owner Name: Property Owner Legal Address: Property Owner Mailing Address: Telephone Number (s): Daytime </&40/Vwening., Emergency Property Owner Email Address: � '"' � ' Page 1 of 5 Town Hall Annex Telephone(631)765-1802 54375 Main Road �� Fax (631)765-9502 P.O. Box 1179 Southold,NY 11971-0959 X 410 1971-0959 ` BUILDING DEPARTMENT TOWN OF SOUTHOLD Mailing Address of ManagingAgent: � __ Telephone Number (s): Daytime ening Emergency . .,,�........w_ Email Address: - -�jr✓� . c� 'rj\t v)<- ` ,�' e . .,_ 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, Q 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: A- Number of rooms in Rental Dwelling Unit: "_ _ Use and Dimensions of each room in Rental Dwelling Unit: z Page 3 of 5 S"0 ° Town Hall Annex Telephone(631)765-1802 54375 Main Road r Fax(631)765-9502 P.O.Box 1 179 Southold,NY 11971-0959 ,e 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. ❑ I 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) I , 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 i° Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 � el � 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: — . Z) _w....... Property Owner's Signature: Sworn to before me this day of e>&oJe ` 20_0;?j Offi I N ry Public Signature and Original Notary Stamp Jacqueline Anernon Notary Public-County of&�� state of New York Notgornrnlss pan Expires: Page 5 of 5 Town Nall Annex Q1 Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1 179 � ' Southold,NY 11971-0959 � BUILDING DEPARTMENT TOWN OF SOUTHOILD RENTAL PERMIT APPLICATION ADDENDUM Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: so TOWN OF SOUTHOLD BUILDING D 831 -765-1802 IN PECTION [ ] FOUNDATION 1 ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION/CAI [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY IN! [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (T11 [ ] CODE VIOLATION [ ] PRE C/O [ I DATE 0- ~ 3 INSPECTOR Town Hall Annex TUWn Of Southolden 54375 Main Road Rental Inspection Report PO Box 1179 Southold, NY 11971-1179 ► Tel: 631-765-1802 SUM # r/ _ Date /0-lef a _... Owner GGA Phone rt e Address 'Visible _.. ._ l . . .m . .. �...... Hamletns pector 'Floor Level Quantities µ _. . . .. .. ............ __�.....� .._...._._�..,. ......�.._..� ,.� _._ ....._..,.. a . Sub . 1.,,.... 2 3 C Smoke Detectors (not located in bedrooms) . __ . 1..._.. ..... . Carbon Monoxide Detectors Fire .. ..,., _.., , . ..w...,. ..�..._ .... .. ., .. Extinguishers Exits �., ... ti.., Bedrooms 1 2 3 4 5 6 m� Smoke Detectors Egress Occupant Count Building Systems Maintained &Operational Condition of Property Heating Building interior Hot waterBuildin g exterior _....... ...�.. ....._.� .� _�..... ._�.... .. Property clean, maintained &safe Electrical Hand... .. Mechanical Handrails &guards installed &secure Pool Safety J.Po.ol-on.,.Site- Surface water alarm .. Date of CO issuance Door alarmsPool completely enclosed � i Pool fence to code requirementsI Selfclosing/�latching.,.._._g gates ... ._._.. ., . for all items present Prior Rental Comments: n W' . � r'�Y - W � w ) r�m'•n^ M ywx�r I ��.� n' r q � a b r � k µ° u ap wa oa r All a 77 ; LL- 7 a Dr � ......'.., .. .. �._ m .. ( y a, I W 6' _,. Wsa„ae »u At- 1 I 4 y �� rq I��mmq �ry� � -9x EE ( 4`l. n j ail c I r % f r l i' 04 r`G Www � j [ o W S LIJ 00 LU J LU cd j C I l A 0Lij LU {n 1 ( f f W W I c }� - k 1.. I c Cp m LL i w. j ( � � I' r I � rrr r � ' I � m j {W o f < r LL u f .µ 1 } (U i m m 1 P� pp ! � C. G7 i Q a � � o pp off y -� w o v a 6 o Vd a �C C n. 0 a v b < o o u' F- .......... - 1- `� I y I i. . . ,,,.. �» ,,,„w, , .., ,..,�.,� FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-28476 Date: 0 "30 02 THIS CERTIFIES that the building NEW DWELLING Location of Property: 870 CHAMPLIN PL GREENPORT (HOUSE NO.) (STREET) (HAMLET)Mm County Tax Map No. 473889 Section 34 Block 5 Lot 19 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 7 2001 pursuant to which Building Permit No. 27424-Z dated JUNE 21, 2001 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 FRONT DECK AND ATTACHED TWO CAR GARAGE AS APPLIED FOR. The certificate is issued to THOMAS MARZANO (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-00-0221 ..... 01 3 02 ELECTRICAL CERTIFICATE NO. 56761 05/01/02 PLUMBERS CERTIFICATION DATED 02 24 02 THOMAS MARZANO ... Authorized Sig. ture Rev. 1/81