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Home My WebLink About1000-6.-1-4.2 4 o M c c O O U (B •i O N a) UJ ur c OO O CU O Q C3 N L U N Q a O (a w (B C O O QI co = cu a cu N a CO m O Z m `o v N � N CU00 `� E a) C > L v _� CIO Ncu u 0 3 O 0 - C) 1. Q w c � c ?l Y N T ~ N v O C �i N O Q '+— Z Co v NOW i O O O LL COO) 0 T O g L v �AO"lki p Q Z y E cn Cl) c _ 0 .N c (� ~ •X Cl) O cn Co CO_ a -» cu c o Q bm TOWN OF SOUTHOLD-BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax(631) 765-9502 1 S / yry .:.lct 1 n „zly L � z ��-� �� ° 7 R NT PERMIT APPLICATION Rental Permit Fee$300 (Application must be renewed every two years) 4t1 � ( Section A. Property Information: Rental Property Address: 1- C' Tax Map Number: 1000 SECTION --BLOCK-1 -LOT SECTION B. OWNER INFORMATION: Property Owner Name: Property Owner Legal Address: Property Owner Mailing Address: (Cannot -7be the same as Rental Property Address) 1�1 D - ',?1,`-�- 00 Telephone Number(s): Daytime Evening Emergency Property Owner Email Address: � Spy 6� Page 1 of 4 Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: Address of Authorized Agent (no P.O. Boxes): 31 ; " 1�1Mailing Address of Authorized Agent: µ M Telephone Number (s): Daytime Evening Emergency Email Address: �A- 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): Mailing Address of Managing Agent: Telephone Number (s): Daytime Evening Emergency Email Address: Page 2 of 4 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 Identified Requested Maximum number of persons a1, e o occupy Dwelling Unit: Number of rooms in Rental Dwelling Unit " Use and Dimensions of each room in Rental Dwelling Uni 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. XI 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. Page 3 of 4 SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. 'e h yk-i, L, STATE OF~ EW ) COUNTY OF 5blfK" 1 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 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 s to any change to the information regarding Authorized Agent, Managing Agent, or Site Manager. Property Owner's Name: " Property Owner's Signature: Sworn before me thi (ray of 20J Z- Official Notary Public Signature and Original Notary Stamp Commonwealth of Pennsylvania-Notary Seal THECLA A BENE-Notary Public Chester County My Commission Expires June 14,2026 Commission Number 1224620 Page 4 of 4 BUILDING* TOWN OF SOUTHOLD u � 631-765-1802 -- INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INS ,,kATION/CAULKING [ ] FRAMING /STRAPPING [ ] AL [ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL ( ; NhL) [ ] CODE VIOLATION [ ] PRE C/O RENTAL REMARKS: / Op�( ovi o rD, 4� DATE INSPECTOR 9 '�" z, , ., - r �I r , 1 f f 1 q YM i .. _._ . „,,J, r x f a 1 � . i r j 4 1 h, d .1. r � . i m I r y I r � V i e r Lworm4 � aur., e a„ p ............ 311ry an Z., uj L LLJ < Ali LLI LLI LU ag (D L9 > LU Z Z III Aft LLJ LLI LL LL m LLI < U- L16 0 17,ED V) Ln LU zp _0 _0 c .0 cr 0 Q) �z vi ......... LU ttl 0 r O c\j r °e 1 4I ;Cc; ❑ Y J ❑ m mLL a3 t7, V I ra C ti O 0 y f a as ai a a m _ = 3 sk IIuNI m441 I g¢ i J F u U m r I a E ° m °' W 0 m t O a &yp p LLL W 1, lL ❑ N ❑ 1 1 y � fl r OD o a o c a c04 LU m ccs o g ix� ta` as ❑ Q C7 a f µ� o E , s } LL c LL c L r cu co E . .. co LL SJ tT✓ 4 w � � d + cu f0 Ca X R7 X �- CJ N L l"d W 1 R, II � I r'g x CD 0 0 0 w m `" cu L �a ...� w w w a Gl co (7 O FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY i No Z-22573 Date SEPT EMBER 8 1993 THIS CERTIFIES that the building NEW DWELLING Location of :Property CRE'S "T AVENUE FISHERS ISLAND N_Y. House No. Street Hamlet County Tax Map No. 1000 Section 6 Block 1 Lot 4.2 Subdivision Filed Map No._ Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated_ JUNE 1, 1992 pursuant to which Building Permit No. 20767-Z dated JUNE 26 1992 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 ATTACHED WOOD DECK AS APPLIED FOR The certificate is issued to SAMUEL L. GORDON, JR. (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 91-90-82 - SEPT_ 2 1993 UNDERWRITERS CERTIFICATE NO. N-2S45B7 _ JULY 30 1993 PLUMBERS CERTIFICATION DATED JULY 21 1993 - MAYNARD PLUMB.&HEAT.INC. ildir�g Inspect-tor 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-31220 Date_ 10 13/O�u " THIS CERTIFIES that the building ADDITIONS ALTERATIONS Location of Property: CRESCENT AVE FISHERS ISLAND (HOUSE NO.) (STREET) (HAMLET) County Tax Map No_ 473889 Section 6 Block 1 Lot 4.2 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 25, 2003 pursuant to which Building Permit No. 29693-Z dated SEPTEMBER 3, 2003 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 & ALTERATIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to SAMUEL R & LAURA MARSHALL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 2012594 08/11/05 PLUMBERS CERTIFICATION DATED 09 13/05 THOMAS G. RAVINO ........... *R;r' nature ................. Rev. 1/81