HomeMy WebLinkAbout1000-15.-5-24.13 TOWN OF SOUTHOLD
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Rental Permit
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Owner Anne Burkard
Occupied as Single Family Dwelling
Located at 370 Uhl Lane Orient 15.-5-24.13
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.
4/18/2023
Codeof r ment O ' c°
This Notice must be posted by the main entrance at all times
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Town Hall Annex Telephone(631)765-1802
54375 Main Road 6 765-9 0
P.O.Box 1179 ,` hp
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Southold,NY 11971-0959 -
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APR
BUILDING DEPARTMENT 31'61ULD
TOWN OF SOUTHOILD
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 6— -LOT
SECTION B.
OWNER INFORMATION:
Property Owner Name: A191? r,
Property Owner Legal Address: Property Owner Mailing Address:
Telephone Number (s): Daytime Evening Emergency -f-lol 7,e5;7l
1
Property Owner Email Address: � � ��
Pagel of 5
%�X-
Town Hall Annex Telephone(631)765-1802
Fax(631)765-9502
54375 Main Road
P.O.Box 1 179
v
Southold,NY 11971-0959 = �
BUILDING DEPARTMENT
TOWN OF SOUMOLD
Mailing Address of Managing Agent:
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: r`
Requested Maximum number of persons allowed to occupy Dwelling Unit: —
Number of rooms in Rental Dwelling Unit: 4� _
Use and Dimensions of each room in Rental Dwelling Unit: ff
'ti ? �
Page 3 of 5
Town Hall Annex Telephone(631)765-1802
5 -t Fax(631)765-9502
4375 Main Road
P.O.Box 1179
Southold,NY 11971-0959
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.
❑ 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)
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
Ar vuh
ley
Town Hall Annex Telephone(631)765-1802
54375 Main RoadFax(631)765-9502
P.O.Box 1179 {
Southold,NY 11971-0959
tV"
BUILDING DEPARTMENT
� 023 1
TO OF SO OLD ��� � ,
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 t _
Property Owner's Signature:
Sworn to before me thi� day of � , 20a 3
Official Notary Public Signature and Original Notary Stamp
CONNIE D.BUNCH
Notary Public,State of New York
No.01BU6185050
Qualified in Suffolk County ,r�
Commission Expires April 14, 2� y
Page 5 of 5
fso-
-- TOWN OF
SOUTHOLD BUILDING1
631 -765-1802
INSPEC ION
[ ] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ ] INSULATION/CAL
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] TIRE SAFETY INc
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (Fit
[ ] CODE VIOLATION [ ] PRE C/O [ F
REMARKS:_
DATE INSPECTOR
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TOWN OF SOUTHOLD PROPERTY RECORD CARD
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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No E-23468 Date JANUARY 23, 1995
THIS CERTIFIES that the building NEW DWELLING
Location of Propert 370 UHh LANEORIENT NY
House No. Street Hamlet
County Tax Map No. 1000 Section is Block 5 Lot 24.13
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JULY S, 1991 pursuant to which
Building Permit No. 20006-Z dated JULY 9, 1991
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 A ONE FAMILY DWELLING WITH A7MCHED GARAGE & FRONT AND REAR
PORCHES AS APPLIED FOR.
The certificate is issued to ANDREW & ANNE BURKARD
(owner's)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 88-SO-123 JANUARY 19, 1995
UNDERWRITERS CERTIFICATE NO. N277379 MAY 28, 1993
PLUMBERS CERTIFICATION DATED DxcEMBER, 22, 1994 ROBERT KOWALSKI �
Building Inspect
Rev. 1/81
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