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Home My WebLink About1000-51.-3-20 } s3¢ TOWN OF SOUTHOLD Rental Permit 1220 Ai Owner 475 Clark Road LLC Occupied as Single Family Dwelling Located at 475 Clark Road Southold 51.-3-20 Maximum Permitted Occupancy 3 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. J 1O128/2024 *ode C Official This Notice must be posted by the main entrance at all times TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY ,.R 9Telephone (631) 765-1802 Fax(631) 765-9502 htto ://wNvw. ou holdt.own AUG 1 9 20 24 Bullding Department RENTAL PERMIT APPLICATION Town of Southold Rental Permit Fee $300(Application must be renewed every tiro years) ��' �N Section A. Property Information: Rental Property Address: 475 Clark Road ,Southold NY 11978 Tax Map Number: 1000 SECTION 51 -BLOCK 3 -LOT 20 - SECTION B. OWNER INFORMATION: Property Owner NameAlexis Moore(475 Clark Road LLC) Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) 211 east 53rd street, 9D 1854 Montauk Highway, PO BOX 276 New York NY 10022 Amagansett, NY, 11930 5166412940 Telephone Number (s): Daytime Evening Emergency Property Owner Email Address: amoore724@gmail.com Page 1 of 4 Town Hall Annex r°, Telephone(631)765-1802 54375 Main Road? Fax(631)765-9502 P.O.Box 1179 Southold,NY 1 1971-0959 UK' , Vfay��° 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: 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 U $'M OL4faC�� a� w " Ina 7 A It Page 3 of 5 SECTION F. PROPERTY DESCRIPTION: 1 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." unit 1 � � . .. � Rental Dwelling Unit Identifier: Requested Maximum number of persons allowed to occupy Dwelling Unit: 5 Number of rooms in Rental Dwelling Unit: " see floor plan Use and Dimensions of each room in Rental Dwelling Unit: 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. �-Ot I 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. Page 3 of 4 SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) ) COUNTY OF SUFFOLK) I alexis moore , 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: Alexis Moore Property Owner's Signature: a4xx� State Florida County Okaloosa Sworn to before me thisl4th day of August 20 24_ by Alexis Moore provided NY State DL for ID - Mom_ O f` al Notary Public Signature and Original Notary Stamp OZELLA MAE MOORE '410 b';4 qx y"r OZELLA MAE MOORE Notary Public-State of Florida w *r� Commission#HH 391505 Expires on done 19.2027 Page 4 of 4 Notarized remotely online using communication technology via Proof. �061 �oa&o <1--- TOWN OF SOUTHt'T .D BUILDING DEPT. r► 765-1802 I N S P E T 10 N [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAUL ING [ ] FRAMING /STRAPPING [ ] NAL [ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECT ON [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O a R ARKS: S,�✓� rem. -U",, ov-*fl DATE Y � INSPECTOR Tat ° CA 4�00 W TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] NAL [ ] FIREPLACE & CHIMNEY ( FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PEN TRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL. (F AL) [ ] CODE VIOLATION ] PRE C/O [ RENTAL RE PIKS: 0 co t h 1 � - i s Y DYV - - ---_ t CCI IRK x Y �. g" F'M+L l DINING 67'x ` " ACCESS F ROOM KITCHEN - BEDROOM TO 4 x114 CLOSET REF a° CLOSET g r4A x 2T ENTRY BATH /7'r x 4-1 - TUB � fr LIKING ROOM 14°4" x 1 7°9„ BEDROOM } 14'8" x 11'5" r IN r^ od i...... I, A FiunIm-w' w°.m y . vv"a rx .x�i=�_7 r. ri ihc�r navy.�hr;odic-s 475 Mark Road, Southold t'�`,��r"0 �� O O DVV _ ELECTRIC .` is L- UNDpy �i DINING 6'7"x s 4 , 7 ROOM KITCHEN BEDROOM 7'8" x 9'8" 8'4" x 11'4" 9'8" x 11'3" w � °4 (HW RE closer CLOSET \� 4'4"x 2 4" ENTRY ' 3-11"x 3'8e BATH \0 77°x 4'1{'� TUB x1'11° LIVING ROOM 14'4" x 17'9" f BEDROOM 14'8" x 11'5" ¥ Sale In feet Indicative on y.Dlmenelons are approximate.Ail Information contained herein Is gathered from sources we be'ieve to be re lab e.However,we cannot guarantee its a=mcy and Interested penwns should re y on their own enquiries. 475 Clark Road, Southold corecoran ;t TOWN OF SOUTHOLD PROPERTY Riv f - - LL�i STREET VILLAGE DISTRICT SUB, LOT "MEOWNER N E ACREAGE I ' Li P/i S I W TYPE OF BUILDING I s- RES. 'o I SEAS. VL. FARM GOMM. IND. CB, ! MISC. LAND IMP. TOTAL DATE REMARKS All s / 7 No _ � _ _ �s 0 d0 v- 4�"77ff z F AGE BUILDING CONDITION — - �NEW NORMAL BELOW ABOVE Farm Acre Value Per Acre Value Tillable 1 Tillable 2 � Tillable 3 Wcodland Swampland Brushland House Plot Totn I t s € — _ i € 1 t € — i a,c ' V ` M. Bidg. 3O X 3 p j p( Foundation Bath Extension = J Basement Floors Extension )tt. Walls _ �� . = Interior Finish _ n Extension t Fire Place /y O Heat ! , q'A Porch - Attic I Porch Rooms 1 st Floor Breezeway= Patio Rooms 2nd Floor Garage F � � Driveway Q. B. I € i J' FOSK mm a TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z6621 . . . . . . Date . . . . . . . . . . . . .Au9. . S. . . . . . . 19.?V?. THIS CERTIFIES that the building located at .00. Clark .Road . . . . . . . . . . Street Map No. . . . . . . . Block No. . . xxx. . . .Lot No. . .Southold . . .N..Y.. . . . . . . . conforms substantially to the r t ' a � it 1 "k 1n cods to t. . .Deyare. Apri�.. .23 19. 5.7. +r +srt i, ca„ oi~' occu aney d pursuant to which o. Z6al . . dated . . . . . . . . . .04ust. . . .8., 19. .75, was issued, and conforms to all of the require. ments of the applicable provisions of the law.The occupancy for which this certificate is issued is tirlVate .one Samlly•dvellwag . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . The certificate is issued to Sstata. of.Li lliaa .Totten .te. Joseph .gyd U. . . . .Own•r of the aforesaid building. (owner, lessee or tenant) Suffolk County Department of Health Approval prep.*xi sting. . . . . . . . . . . . . . . . . . . . UNDERWRITERS CERTIFICATE No. . pmrs►xIsst . . . . . . . . . . . . . . . . . . . . . . .. . . . . HOUSE NUMBER . . . . . ?+75. . . . . Street . . .Clark.Road. .. . . . . . Southold. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . , . . . . . . . . .((fgjr.. ., . , . . a . ., . . . . Building Inspector .. M HOUSING CODE INSPECTION August 8 , 1975 #475 Clark Road Southold, N.Y. Tax Roll: Samuel & Lillian Totten Unoccupied Upon receipt of an application for a Pre-Existing Certificate of Occupancy, I ,made an inspection of this one story framed dwelling. I picked up key from Arnold Larson, realtor, North Road, Southold, New York, and began inspection at approximately 1:25 P.M. The building consists of two bedrooms, a kitchen, dining room, living room and full bathroom. Heat is furnished to all rooms from an oil fired warm air furnace located in crawl space of cement block foundation. I found no violations of The Housing Code, Chapter 52 , Town of Southold, N. Y. The building and grounds are in good condition. Inspection completed at approximately 1:40 P.M. Key was returned to Mr. Arnold Larson. R ectfully sub fitted, EH:mm Edward Hindermann Building Inspector NOTE: Hallway light was left on as it was found. Fj 4 lJ iJ °uu IT