HomeMy WebLinkAbout1000-79.-4-17.5 TOWN OF SOUTHOLD
�i 43 Rental Permit
0848
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Owner Terence & Margaret Kelleher
Occupied as Single Family Dwelling
Located at 1075 Clipper Drive Southold 79.4-17.5
Maximum Permitted Occupancy 10
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.
4/4/2023 µ
C� e ` for.ee pit fficial
This Notice must be posted by the main entrance at all times
so
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
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:
Tax Map Number: 1000 SECTION ' -BLOCK �� -LOT �' - -
SECTION B.
OWNER INFORMATION:
Property Owner Name: � � l
Property Owner Legal Address: Property Owner Mailing Address:
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Telephone Number (s): Daytime Everting Emergency __
Property Owner Email Address: �� �" A 6V iq
&C,
Page 1 of 5
Soltp-
Town Hall Annex
Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
. ,
=t
BUILDING DEPARTMENT
TOWN OF SO . HOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: � (
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:
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)
i
Name of Managing Agent of dwelling unit, if any:
Address of Managing Agent (no P.O. Boxes):
Page 2 of 5
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Town Hail Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179
Southold,NY 1 1 971-0959
cou.
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Mailing Address of Managing Agent:
Telephone Number (s): Daytime Evening Emergency___
Email Address:
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: �� 4 �
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:(
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
S� S v L �-
Page 3 of 5
of s
Town Halt Annex ? Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179
Southold,NY 11971-0959 11
cour~m
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.
`6 I am requesting a fire safety inspection to be performed by a Code Enforcement Official
((�� from the Town of Southold
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)
%J, 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 Telephone(631)765-1802
54375 Main Road
Fax(631)765-9502
P.O.Box 1 l79
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 -
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Property Owner's Signature* _' £
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Official
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Sworn to be re me this�day of
Official Notary Public Signature and Original Notary Stamp
Notary Public-s
York
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2026
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Page 5 of 5
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631 .765.1802
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] FOUNDATION 1ST [ ] ROUGH PLBG.
] FOUNDATION 2ND [ ] INSULATIOWCAI
] FRAMING / STRAPPING [ ] AL
] FIREPLACE & CHIMNEY [ FIRE SAFETY IN:
] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FII
] CODE VIOLATION [ ] PRE C/O [�
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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-26608 Date: 08/03/99
THIS CERTIFIES that the building NEW DWELLING
Location of Prpperty: 1075 CLIPPER DR SOUTHOLD
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 79 Block 4 Lot 17.5
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated SEPTEMBER 24, 1998 pursuant to which
Building Permit No. 25338-Z dated NOVEMBER 18, 1998
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 COVERED FRONT ENTRY, REAR DECK AND ATTACHED
TWO CAR GARAGE AS APPLIED FOR.
The certificate is issued to ESTHER PILLES
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-98-0132 06/23/99
ELECTRICAL CERTIFICATE NO. N 492371 06/24/99
PLUMBERS CERTIFICATION DATED 05/28/99 PECONIC PLUMBING & HEAT.
Building spector
Rev. 1/81
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-28557 Date: 06/28/02
THIS CERTIFIES that the building ADDITION
Location of Property: 1075 CLIPPER DR SOUTHOLD
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 79 Block 4 Lot 17.5
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 18, 2001 pursuant to which
Building Permit No. 27613-Z dated AUGUST 20, 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 SUNROOM ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to ESTHER PILLES
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N580024 01/02/02
PLUMBERS CERTIFICATION DATED N/A
11
Z46thqofized Signature
Rev. 1/81
Town of Southold 11/16/2018
P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 40055 Date: 11/16/2018
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1075 Clipper Dr, Southold
SCTM#: 473889 Sec/Block/Lot: 79.4-17.5
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/2/2017 pursuant to which Building Permit No. 42029 dated 10/5/2017
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:
ACCESSORY IN-GROUND SWLAIMING POOL FENCED TO CODE.AS APPLIED FOR.
The certificate is issued to Kelleher,Terence&Margaret
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 42029 08-01-2018
PLUMBERS CERTIFICATION DATED
nut mature
Town of Southold 10/16/2018
P.O.Box 1179
ca 53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39972 Date: 10/16/2018
THIS CERTIFIES that the building ELECTRICAL
Location of Property: 1075 Clipper Dr, Southold
SCTM#: 473889 Sec/Block/Lot: 79.-4-17.5
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/1/2018 pursuant to which Building Permit No. 43107 dated 10/9/2018
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:
electric for accessory shed.
The certificate is issued to Kelleher,Terence&Margaret
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
Authorized Signature
Town of Southold 4/4/2023
P.O.Boz 1179
53095 Main Rd
�g r Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 43981 Date: 4/4/2023
THIS CERTIFIES that the building ADDITION/ALTERATION
Location of Property: 1075 Clipper Dr, Southold
SCTM#: 473889 Sec/Block/Lot: 79.4-17.5
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
3/3/2021 pursuant to which Building Permit No. 45961 dated 3/19/2021
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:
additions and alterations including"as built"finished basement,to existing single family dwelling as applied for=
The certificate is issued to Kelleher,Terence&Margaret
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R-21-2396 5/4/2022
ELECTRICAL CERTIFICATE NO. 45961 10/14/2021
PLUMBERS CERTIFICATION DATED
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Southold,New York 11971
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