HomeMy WebLinkAbout1000-97.-3-2 TOWN OF SOUTHOLD
Beata) Permit
4
1160
Owner Route 25 LLC
Occupied as Single Family Dwelling with Business Office
Located at 36570 Route 25 Cutchogue 97.-3-2
Maximum Permitted Occupancy 4
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.
6/26/2024
ode fo e e t Official
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 Fax(631)765-9502
P.O.Box 1179 �
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Southold,NY 11971-0959
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BUILDING DEPARTMENT AUG 2 -��
TOWN OF SOUTHOLD
BTU"D": (Ir T)EFIT.,
RENTAL PERMIT APPLICATION 11)W 'SOVrTr f,I
Rental Permit Fee $200(Application must be renewed every two years)
Section A.
Property Information:
Rental Pr'o ertyAddress;
Tax Map Number: 1000 SECTION 1 --BLOCK� `LOT Z
SECTION B.
OWNER INFORMATION:
Property Owner Name: V tt
Property Owner Legal Address: Property Owner Mailing Address:
o a � � A
Telephone Number (s): Daytime Evening Emergency
Property Owner Email Address: o c �- » 4-Ma,c fig ►
Page 1 of 5
` ' SOO °.
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
a
P.O.Box 1179
Southold,NY 11971-0959 �
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any:
Address of Authorized Agent (no P.O. Boxes): 7 s D N1 t
Mailing Address of Authorized Agent: ._.._. -T *1 t
e .7/- 371 711�-
Telephone Number (s): Daytime____,.._ Evening Emergency
Email Address: e fp o tc. 1, c --
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)
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 Hall Annex �e
Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O. Box 1 179
Southold,NY 1 1971-0959 .`
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BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Mailing Address of Managing Agent: f v M q I y ,. dt b/
S11 - 3 / 77- 11 q 21
Telephone Number (s): Daytime Evening_Emergency -
Email Address: • mot +► r _ �� !w.-.... - -' --
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: �__ ._. _ ww....
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 Dwelling7Unitj: A
IL—
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
Page 3 of 5
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Town Hall Annex
Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1 179 ,
Southold,NY 1 1971-0959 4,
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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.
'q/l 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
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Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
A.
P.O.Box 1179
Southold,NY 11971-0959 µ
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: 0 ✓ tC .
Property Owner's Signature: 4c/tC.
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Sworn to be re me is day , 20?
Official Notary Publi riginal Notary Stamp
SANDRA V. SAIEGH
NOTARY PUBLIC-STATE OF NEW YORK
No.02SA6407223
Qualified in Suffolk County
My commission Expires 06-1Q-2024
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Page 5 of 5
INSPEC ION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ I UL
LFRAMING / STRAPPING [ INAL
FIREPLACE & CHIMNEY [V FIRE SAFETY I
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
L ] ELECTRICAL (ROUGH) L ] ELECTRICAL (F
[ ] CODE VIOLATION [ ] P [ I
REMARKSMI
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DATE Yl(VY INSPECTOR