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Home My WebLink About1000-73.-1-1 TOWN OF SOUTHOLD Rental Permit 'Al 0797 Owner 15105 Oregon Rd LLC Occupied as Single Family Dwelling Located at 15105 Oregon Road Southold 71-1-1 Maximum Permitted Occupancy 12 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. 12/22/2022 ode for erg Official This Notice must be posted by the main entrance at all times Town Hall Annex ° Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1 179 � j a 64N '4 V 1 tl 1 1�. tWl'ry Southold,NY 11971-0959 DEG 2 2 2022 BUILDING DEPARTMENT TOWN OF SOUTHOLD Bi �L -80)( HO OE��O��Ot ) RENTAL PERMIT APPLICATION Rental Permit Fee $200 (Application must be renewed every two years) Section A. Property Information: Rental Property Address: 0 r2 Tax Map Number: 1000 SECTION a -BLOCK SECTION B. OWNER INFORMATION: Property Owner Name: IS C-0 Sv, e q1 Q d Property Owner Legal Address: Property Owner Mailing Address: i 10 S C'e I ori Telephone Number(s): Daytime Evening_Emergency Property Owner Email Address: Page 1 of 5 Town Hall Annex Telephone(631)765-1802 54375 Main Road Pax(631)765-9502 P.O. Box 1 179 Southold,NY 11971-0959 coin BUILDING DEPARTMENT TOWN OF SOUTHOL D Mailing Address of Managing Agent: _� -.----. Telephone Number (s): Daytime ln& Emergency Email Address: SECTION F. PROPERTY DESCRIPTION: r Number of Rental Dwelling Units on property: Heti 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: ,s Page 3 of 5 14f son Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1 179 Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOL D 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. ❑ 1 am requesting a fire safety inspection to be performed by a Code Enforcement Official from the Town of Southold ❑ I am submitting a completed Toed6' ,of SoujHolfte'rf Watton form from a licensed architect or a licensed professional engineer. r SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) ) COUNTY OF SUFFOLK) I1rdL%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 Halt Annex hone(631)765-1802 �" � Telephone 54375 Main Road Fax(631)765-9502 P.O.Box 1 l79 Southold,NY 11971-0959 BUILDING DEPARTMENT TO OF SO .SOLD 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. 1 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. OW{ Q�, Property Owner's Name: are lm Rd Property Owner's Signature:__t:::27 .4 " Sworn to before me this 0)4*'' ay of "L-e � 20 ' Official Notary Public Signature and Original Notary Stamp .` CONNIE D.BUNCH Notary Public,State of New York No. 01 BU6185050 Qualified in Suffolk County Commission Expires April 14,204 7 Page 5 of 5 , r 191, so Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 VE P.Q.Box 1179 POS Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION ADDENDUM Rental Dwelling Unit Identifier: _ `tJ �._. Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: ,r Rental Dwelling Unit Identifier: r.,lcC)t'' 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: vI Requested maximum number of pWX1sjj5,4owed to occupy a ch dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: tf-1 W "T"I WN 0 Std THOLD BUILDING ING D PT. 631-765-1802 lomm'SPEC 1010' [ ] 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 (FIN [ ] CODE VIOLATION [ �] PRE C/O RENTAL DATE '" INSPECTOR - Y z 1 r Specht - _ E 1. e KA Irl I b waa .'X:A _ t3t SF .tea Y r _ N i a w A. 1 1MIS,- NOT FOR REGULATORY APPROVAL,PERNHMNG, OR CONSTRUCTION - t _ IN PIIOSAESS-1— m. ' � e tFFI—M. to-.a _ r;a�=t•-a Al W N�l Specht t] McM.-i lK NOT FOR REGULATORY APPROVAL,PERMITTING, ON CONSTRUCTION Wal Arvdma i Specht i � I= s =WIT { n z NOT FOR REGULATORY ---� APPRGVAI,PERNVTRNG, — pR MRSTRUGTiGN �1 ea�Pxasxras-WiAif ,6< 3F FM1ro�}XaA PYe A102