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Home My WebLink About1000-9.-10-9.1 TOWN OF SOUTHOLD $ Rental Permit $ 0931 Owner Town of Southold Occupied as Single Family Dwelling Located at Whistler Avenue Fishers Island 9.40-9.1 Maximum Permitted Occupancy 8 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 6/14/2023 Code Enforce fficil This Notice must be posted by the main entrance at all times 4 01 Town Hall Annex � Telephone(631)765-1802 54375 Main Road � � � Fax(631)765-9502 P.O.Box 1179 � o 1,NY 11971-0959 f a J UN 5 2019 BUILDING DEPARTMENT TOWN OF SOLYMOL D T. 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: Property Owner Legal Address: Property Owner Mailing Address: Telephone Number(s): Daytime Evening Emergency Property Owner Email Address: Pagel of 5 T. Town Hall Annex �� Telephone(631)765-1802 54375 Main Road �h } Fax(631)765-9502 P.O.Box 1179 � w a" Southold,NY 11971-0959 BUILDING DEPARTMENTFD) TOWN OF SOUTHO D RENTAL PERMIT APPLICATION JJ'l 2 4 2019 " Rental Permit Fee $200 (Application must be renewed every two years) Section A. Property Information: Rental � Property A ress: S J Tax Map Number: 1000 SECTION I -BLOCK -LOT - SECTION B. OWNER INFORMATION: Pro Owner Name: Property Property Owner Legal Address: Property Owner Mailing Address: " oK " Telephone Number (s): Daytime Evening_,Emergency s Property er Email Address: Page 1 of 5 Town Hall Annex r '; Telephone(631)765-1802 54375 Main Roads Fax(631)765-9502 P.O.Box 1179 Southold,NY 1 197 1-0959 °k F BUILDING DEPARTMENT TOWN OF SOUTHOLD Section C. Authorized Agent Information: /t/k 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: klj F / Name of Authorized Agent of dwelling unit, if any. Address of Authorized Agent (no P.O. Boxes): ITW ✓ '� �� 1�` Mailing Address of Authorized Agent: it Ud Telephone Number(s): Daytime Evening Emergency Email Address: /�Gi I �1 ►,; � 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 � Town Hall Annex Telephone(631)765-1802 Fax(631 54375 Main Road )765-9502 P.O.Box 1 179 ti Southold,NY 11971-0959 N � 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: 0/ 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: e L-'L� Page 3 of 5 Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1 179 Southold,NY 1 1 97 1-0959 a � � 4 Ulm 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 laves adopted by the New York State Fire Prevention and Building Code Council. I' lam requesting a fire safety inspection to be performed by a Code Enforcement Official q g 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. I am the4w4w of the property identified in "Section A" of this application. 2. The property rer'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 fig" Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 c Zz Southold,NY 11971-0959 Coll ` stir BUILDING DEPARTMENT TOWN OF SOUT 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. �b Property"° es Name: V Propertyh's Signature: --- Sworn to before me this ay of �.� 2019 Offi4No blic Signature and Original Notary Stamp Page 5 of 5 E e r f i z ti i a 1 - ALI I _ k t Q r It - } E air - - E g s r - - E -, E E LIL - - - - - a i � 1 .. „_ �_. t r r i ! 1 t i ...... ...... u 1 L. .. ... i..... . �....... .. . ..I _. d. �.... �. ..�.... . ti e 1 .. _ . P a ( _ l 1