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Home My WebLink About1000-98.-4-1.1 'OWN OF SOUTHOLD Rental Permit Alf 1224 'V Owner Carole Ackerman Occupied as Single Family Dwelling Located at 105 Smith Road Peconic 98-4-1.1 Maximum Permitted Occupancy 5 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. 11/1/2024 Cock Enf r ement Off" 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 11971-0959 Telephone (631) 765-1802 Fax(631) 765-9502 httas- w.south ldt:o)NM RENTAL PERMIT APPLICATION C lob 9q3 Rental Permit Fee $300 (Application must be renewed every two years) Section A. Property Information: Rental Property Address: Tax Map Number: 000 SECTION .LJ* -BLOC _-LOT SECTION B. OWNER INFORMATION: Property Owner Name: Gem' Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) tr Telephone Number(s): Daytime 103, 7-2A Evenings .1 Emergency 1-q� Property Owner Email Address:. .' 1 C� 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): Mailing Address of Authorized Agent: Telephone Number (s): Daytime Evening Emergency Email Address: 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: hi PC 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 Identifier: Requested Maximum number of persons allowed to occupy Dwelling Unit: CQ _ Number of rooms in Rental Dwelling Unit: Use and Dimensions of each room in Rental Dwelling Unit: drA xl r XI ,J o rn - 2i x 1 I I Y 1 -2- A&A � Z lox 1 1 3 to x l (-S � c 51 / � *7 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. Page 3 of 4 SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) ) COU STY OF SUFF LK) a I v CPS , 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: XGk1<-!14J1 "" Property Owner's Signature: Sworn to before me this ft day of��Cl--) _ 20 c7 7 l ) Official Notary Public Signature and Original Notary Stamp CONNIE D.BUNCH Notary Public,State of New York No.01BU6185050 Qualified In Suffoik County Commission Expires April 14,20�9 Page 4 of 4 TOWN OF SOUTNHIOLD BUILDING DEPT. 631-765-1802 q'�7- �/- /- / INS" PECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ j INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ )"RENTAL ANDS: �Amt0 Nit �g__p } s M DATE INSPECTOR, ° _. 0 FF Town Hall Annex ee Town of Southold 54375 Main Road 4 """ Rental Inspection Report PO Box 1179 P P Southold, NY 11971-1179 Tel: 631-765-1802 SCTM# Q Date . TM _ ....� _w _ ....... �..��.�. ...�RR .. .....".�. �..�� Owner Phone Address _ �D S ( /( _ Visible ,. Ham�letw ...,. `! «.._.......... . ... ._ ... .w....... _..... . .... Inspectorµ ..WW.µ w..... . HH. . Floor Level Quantities Sub 1 2 3 ... . Smoke Detectors (not located in bedrooms) / M .o. w.v m � ,. .. ,., , .......... ... .,.. Carbon Monoxide Detectors � .. ��w.. R wA ............... .....R a.... w � �...�. Fire Extinguishers Exits .�........�..... .,.'. ..w.� .. � ......... ....... ..... .. Bedrooms 1 2 3 4 5 6 �.. ....... ... �.,, �.b ....a ......... _ _ ...�. .... .. m. _..�... Smoke Detectors s�,�,�.,.. .... .. .a� .... ...... a �.�. ...... .. .. ... ress � a�,ti.Rmo�.,�............ ,.. � a.� ...... _ . ._ _.. Occupant Count BuildingSystems._ ..,..._.......��,.,.. µw� .. ,.� ,..�...................... .............. ......�.._. ..�._..._............._�..._. � .. Maintained &Operational Condition of Property Heating Building interior .....�..... Hot water Building exterior ... ... e..,. .....0 .., ��.,� .... „�.a .. ..�� _ .. �_�. ,.�„�Rn ... .. ... ..a_ . .... Electrical Property clean, maintained &safe .. ,. a.W��.�.a.. ....... a led u &secure �� ...�....�. echanical Handrails &guards installed P, ool Safety � Pool on Site . .. ...r,. ��.ro ....� . ......,.�.... Surface water alarm Date of CO issuance Door alarms Pool completely enclosed �mw R..R,on . S��...�..R..� �..:.... ....... . .�...... �._.w l fe nce to code re uirements ...,elf clossing/latching gates Pool fe ...�.......�.�.. .......�.. ..�.... �....,,...m._. . ...� . � .�.. _..,....... C O's for all items prese nt 1 Prior Rental h.... ww. ... ..... .. . ...... .... _. . .... ...... _. ...Rental ... .a . , ,.,. ..,_. ... Comments ....,, ............. ....,.,,,,.., ......,.,,_...._..._.....m ........... —. ...., .,,,... ..,,......,,...._......—------------- .. ......,_....�......,.. ....,,,... .....,..... ......................... .,......... _ ...�........,..... ... .. .. ...._ ......_. ..._, ,,,, �, ..e.,.. .... ...._ ........� .........�. ._ ...� ..... .,,,, e ..... ...�w .... e. .__ ..,,,.... _..._,,,.....®_, f i ........ ................. .... ..,,,,,......,................. ..,, ........ .... .... .,...,.......,,.,........,.,..,.......,, „.,. ,..w......wN. .....,.,,,,.....�....�........w....,,,,,,..w..,.,,,.....�.,. ....... STREET �VIL1I..A(3E iCT ' SUB, LOT J „ a� � f r MI,ILR E ACREAGE TYPE OF BUILDING Efi 2 SFAS, � 1P . FARM � C� C V.AJL V,P, � l . P.a "d Mll a ERP kV V° P)PVP7Pk =i dm hk� w d ,a �a^ r. �... L usuu Are Votu.re; Pr".r Acre Vcilr.e Pr d 6,1164 , dWbke 3 war „ r 1 ruwaa�a a^uPa V�.�r w�!f vdt 7 r v r I I TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET 44W,... FORMER OWNER N E ACR. S W TYPE OF BUILDING RESSEAS v..._„.,_ _.,. ........_�..„„..„ „,„, .,,..... . _._ ..... .. _ . ^. fix ._.,._.i_..L FARM COMM. CB. MICS Mkt Value. ._....,.._._._...w.,. ......�,.,�,._......,....... ... _...,,,_,._.,._..___..._. � � .,. LAND IMP. TOTAL DATE REMARKS E E _w.. AGE BUILDING CONDITION _ NEW NORMAL BELOW ABOVE FARM Acre Value Per Value Acre Tillable FRONTAGE ON WATER _,_...........w Woodland.. FRONTAGE ON Meadowland DEPTH .w _w..,... .,_.., ..,._,._..w.. .. ...... .._ ., ., .,.House Plot .... .. .m BULKHEAD ......,,_ ...�w..._.._., ....._.....__..._....��.__...,.�.__w .._�...__ww._ ...,... .w_.......ww_._ w..ww_.... Total DOCK I I , 'Y') r - I � ry r l ww p 4 7 ?fr i M. Bldg. Fou BathtMw Extension Basement Floors l. � f ` _.,.... _...,,......__ In Extension ` � r� „ Finish i Fire Place .... Interior F..n i _.. .....;_ Ext. Walls / .. Extension e°� � ' R „F a^ 'k Parch Attic Porch Rooms 1st Floor ... 1 @ .rr Patio i Rooms 2nd FWooa Garage 1 . L Driveway _... _ _, _ ... ..... ...,. _.. ..._ _. a a O B J � 1 P ,,. .. .,,,_.... ..m._.. FORM NO. 4 TOWN OF SOUTHOLD,: BUILDING DEPARTMEA Town. Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z .36L2 . . . . Date . . . .06taber. . . .21,. . . . . . . . .. 196.9 . " THIS CERTIFIES that the building located at $mit x .Road&Indian.Ised A. Street Map No.Indian.Ne kBlock No. . . . . . . . . . .Lot No.Uplart, of.4. •Peoonio,. R..Y.• . . Pax 4 conforms substantially to the Application for Building Permit heretofore filed in this office dated . . . . J-Une. . .20.. . . . . . .. 19.69. pursuant to which Building Permit No. 4352Z. . dated . . . . June. . .24.. . . . . . . .. 19.69., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occul ancy for which this certificate is issued is . . .Private. .one. Xamily.dwelling. . . . . . . . . . , . • • . . . . . . . . . . . . . . . . . • . . . . The certificate is issued to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (owner, lessee�.ar_tenant) of the aforesaid building. Suffolk County Department of Health Approval ..October. 2.0. .1969,. Robert .Villa 'Building Inspector Rouse # 105 Smith Road 5000 Indian Neck Road FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. 2 .361.2 . . . . Date . . . .06taber. . . .23,. . . . . . . . .. 196.9 . THIS CERTIFIES that the building located at Omith .Roa,d&Indian.Wed Street Map No.Indian•Neo CBlock No. . . . . . . . . . .Lot No.2&part. of.4 •Beconic,. N..Y. Par conforms substantially to the Application for Building Permit heretofore filed in this office dated . . . . June. . .20. . . . . . . .. 19.69. pursuant to which Building Permit No. 4352Z• . . dated . . . . June. . .24. . . . . . . . .. 19.69•, 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 . . .pr.ivate. .one. .family.dwel1 ing• • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The certificate is issued to . !Ge0-'9:e .M0X 1x. . . . . . . . . . . . . . . (owner, lessee.or-tenant) of the aforesaid building. Suffolk County Department of Health Approval .October. 2.0, .1R69, . Robert .Villa Building Inspector House # 105 Smith toad ' 5000 Indian deck Road 51-1Af-rtn- CrAtA--WAY ` �- t4LC 7- 3 �f r tAkddsgr i'v �-- JA iz I i Oq ��` -�