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Home My WebLink About1000-104.-7-4 of so TO'W- - N OF SOUTHOLD Rental Permit ur 1264 Owner: Richard Blair Occupied as: Single Family Dwelling Located at: 900 Mason Dr Cutchogue 104.-7-4 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. Issued: 02/28/2025 Expiration: 02/28/2027 c de En meet ;a This Notice must be posted by the main entrance at all times a r 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 11t �//wow ci�holclt'ownt . RENTAL PERMIT APPLICATION Rental Permit Fee $300 (Application must be rene e1" es A 21 2025 Section A. Property Information: BuildingDpPartmOnt e Town of Southold 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: (Cannot be the same as Rental Property Address) /r e w Telephone Number (s): Daytime / '. ~ wIvening Emergency SGC/ne Property Owner Email Address: rlG w l / "/e k . COm Page 1 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: NIA Requested Maximum number of persons allowed to occupy Dwelling Unit: D 0 Number of rooms in Rental Dwelling Unit: 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. I am requesting afire 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 C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: Address of Authorized Agent (no P.O. Boxes): 3 Mailing Address of Authorized Agent: Telephone Number(s): Daytime 7 '/ ening "� Emergency Email Address: Cne-fsVare A uS�< <� 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 H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) COUNTY OF SUFFOLK) I A A//, _ , 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 Cade 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: XIAOSHUAI LIU NOTARY PUBLIC,STATE OF NEW YORK fL Registration No.01 LI6427438 Sworn to before me thisday of bp 20 Qualified in Queens County Commission Expires December 27, 0._ "l.. Official No6rypublic Signature and Original Notary Stamp Page 4 of 4 Town Hall Annexes �; ,q Telephone (631)765-1802 54375 Main Road s � P. O. Box 1179 " Southold, NY 11971-0959 .r 4 BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION ADDENDUM Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: 5— Number of Rooms in Rental Dwelling Unit: S Use and Dimen ion of each room: ` 1 ' e .. Rental Dwelling Unit Identifier: Requested maximum number of p rsons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: Rental Dwelling Unit Identifier: 0,'j Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: OFot Town Hall Annex �� Telephone(631)765-1802 54375 Main Road °� "; Fax(631)765-9502 P. O. Box 1179 c `' Southold, NY 11971-0959 „- �X� BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PROPERTY CERTIFICATION Form is to be completed by a licensed architect, licensed engineer or licensed home inspector Separate form is required for each individual Rental Dwelling Unit Professional seal required for Architect or Engineer, Licensed Dome Inspector must provide copy of valid current certification Rental Property SCTM Number: Rental Property Address: Owner/Name: Rental Dwelling Unit Identifier: Number& Square footage of each bedroom as depicted in the attached floor plan: (i.e. Bedroom #1 — 100 sqft., Bedroom#2—90 sgft., etc.) Property Description (Include all improvements indicated on survey) K . I certify that I have done a physical inspection of the subject rental dwelling unit and find that it fully complies with all the provisions of the Code of the Town of Southold, the Residential Code of New York State, the Building Code of New York State, the Plumbing Code of New York State,the Fuel Gas Code of New York State, the Fire Code of New York State,the Property Maintenance Code of New York State and the Energy Conservation Construction Code of New York State, Print Name and Title Original Signature Please place Professional Seal: pk 517& TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 1 N � op"PhE%C'T 10 N [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 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 REMARKS: DATE INSPECTOR C1i 0 1y Gt PO 1r1 Q��,/� P� Cv " v� TOWN OF SOUTlOLD 3ULDL DEPT. 631-765-1802 (p q % T_,q INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ]�FIRE L FIREPLACE & CHIMNEY [ SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANZ(FAL) ATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICALCODE VIOLATION [ ] PRE C/O [ TAL ` (50 d1 REMARKS: � l � I L DATE INSPECTOR = MASON DRIVE LOCATION _ 900 MASON DRIVE CUTCHOGUE,NY 1111035 i { e _ 3 uL�uc i r l Q _ - f,,..,� - 3 {{ 117RA�:T(1R RE R J\::16LE � y . _ qLl II\I Vnll II YI Y a a 0 HFk` E LA E 3 = EXISTV /DEMO F IS D101 1 I TOWN OF SOUTHOLDP E TY RECORD OWNER I STREET 'j� VILLAGE DISTRICT SUB. E LOT FORMER OWNER_ _ - - a N - E ACREAGE S W� _ fYPE OF BUILDING — COMM. ( IND, CB, MISC. . -_ l RES. _ SEAS. VL. FARM I l LAND IMP. TOTAL DATE £ REMARKS i �� a %✓��`�—/ _ v -AfsE BUILDING CONDITION -, — �s �?RMAL -£ ELOW ABOVE Farm Acre Value Per Acre Value �� Tillable 1 Tillable 2 , . s r 46 Tillable 3 Wcodland 9a Swampland ()-qti1 RZETt Brushland House Plot Tcta 1 I 3 C) �� ,- � -�_ a I _ s 104,74 3/05 €�- -- K Bldg Foundation Bath _ Extension X 1 as � � sement i Floors R 'i EExtension � � � 3 �� E/Xt. WaIIs�;},� f�( Interior Finish r Extension T Fire Place / Heat Porch 1 Attic Parch Rooms 1st Floor 4 Breezewayi Patio Rooms 2nd Floor ; Garage Driveway I �1 71, : a V_ C FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. PRE EXISTING CERTIFICATE OF OCCUPANCY No: Z- 27716 Date: 05/29 01 THIS CERTIFIES that the building DWELLING �... Location of Property 900 MASON DR, CUTCHOGUE (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473869 Section 104 Block 0007 Lot 004 Subdivision Filed Map No. Lot No. conforms substantially to the Requirements for a ONE FAMILY DWELLING built prior to APRIL 9, 1957 pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z- 27716 dated MAY 29, u2001 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 * - The certificate is issued to KAREN A & JESSE F SKELTON � _ (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. m-N/A www. PLUMBERS CERTIFICATION DATED N/A *PLEASE SEE ATTACHED INSPECTION REPORT. �.... .� Aut red Signa re.. __ Rev. 1/81 TOWN OF SOUTHOLD LOCATION: 904m,m,mMASON DR_.__.._.... CUTCHOGUE SUBDIVISION: MAP NO.: LOT (S) NAME OF OWNER (S) : KAREN A & JESSE F SKELTON OCCUPANCY: A-1 RESIDENTIAL KAREN A & JESSE F SKELTON ADMITTED BY, JESSE SKELTON ACCOMPANIED BY: SAME KXY AVAILABLE: . SQFF. CO. TAX MAP NO.: 10 4.-7-4 ...... SOURCE OF R19QUEST: GARY FLANNER OLSEN, ATTY 5/16 Ol DATE: 05/29 01 DWELLING• TYPE OF CONSTRUCTION: WOOD FRAME # STORIES: 1,5 # KMS: 2 FOUNDATION: CEMENT BLOCK CEMJ.AR: PIT CSAML SPACE. TOTAL ROOMS: 1ST FLR.: 3 21RD FLR.: 2 3RD FLR.: 0 BATSROOK(S): 1.0 TOILET ROOK(S): 1.0 UTILITY ROOM(S): ONE_ PORCH TYPE: www.w DECK TYPE: , PATIO TYPE: BREEZEWAY: FIREPLACE: ONE GARAGE: DOMESTIC HOTMATER: YES TYPE BEATER: OFF BOILER AIRCONDITIONING: TYPE HEAT: OIL MARK AIR: HOT WATER. XX OTHER: ACCESSORY STRUCTURES: GARAGE, TYPE OF CONST.: STORAGE, TYPE CONST_: SWIIXITG POOL: IT GUEST, TYPE CONST.: OTBSR: VIOLATIONS: CHAPTER 45 N.Y. STATE UNIFORM FIRE PREVENTION & BUILDING CODE ART. V V l n I P U p l I I I � I A l I I � N C I C REMARKS: BP #27338-Z-CO Z-27715 (DORMER AD(1S) - _M- sk INSPECTED BY: DATE ON INSPECT WW m µ ION: OS 22 01 GARY ISH 7I3M START: 10:00 AM END: 10:20 AAM FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27715 Date: OSZ29101 THIS CERTIFIES that the building ADDITION & ALTERATION Vocation of Property: 900 MASON DR CUTCHOGUE (HOUSE NO.) (STREET) (RAMLET) County Tax Map No. 473889 Section 104 Block 7 Lot 4 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 16', 2001 pursuant to which Building Permit No. 27338-Z dated MAY 25,E 2001 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 FRONT DORMER ADDITION & COMPLETE REAR DORMER ADDITION & WINDOWS AS APPLIED FOR "AS BUILT,s . The certificate is issued to KAREN A & JESSE F SKELTON (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE MO. N/A PLUMBERS CERTIFICATION DATED N/A tho zed Signature Rev. 1/81