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Home My WebLink About1000-69.-3-18 Rental Permit 1268 Owner: Maia Khutsishvili Occupied as: Single Family Dwelling Located at: 95 Apple Ct Southold 69.-3-18 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: 03/06/2025 Expiration: 03/06/2027 cEnf rcement official This Notice must be posted by the main en- nc t i es katI Gr to� "w TOWN OF SOUTHOLD—BUILDING DEPARTMENT ` Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, N 1, 11 );j Telephone (631) 765-1802 Fax(631) 765-9502 I'lt / �� iq�) 1 1 �w �w E 99 1 6 25 RENTAL PERMIT APPLICATION Building Department Town of Southold Rental Permit Fee $300(Application must be renewed every two years) Section A. Property Information: Rental Property Address: 95 APPLE COURT SOUTHOLD,NY 11971 1 1000-069.00-03.00-018.000 Tax Map Number: 1000 SECTION -BLOCK -LOT SECTION B. OWNER INFORMATION: Property Owner Name: MAIA KHUTSISHVILI Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) ii7� Telephone Number (s): Daytime 631-276-4942 Evening Emergency Property Owner Email Address: makuna1963@gmail.com 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 I TION: (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 Identifier: Requested Maximum number of persons allowed to occupy Dwelling Unit: 6 Number of rooms in Rental Dwelling Unit: 3 Use and Dimensions of each room in Rental Dwelling Unit: Reference floor plans attached, 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. R I am requesting afire 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) p 1' 77,0 .S�� , certify under penalty of perjury,the following: 1. I 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: di Property Owner's Signature: TIFFANY.pJ nc EZNY....W .. Sworn to before me this E day of „ G 20� Notary Public-Stuie of New York No.01BHK4112 Official Ori Expires 06/17/202 al r blic SI aturc a My Commission g glnal Notary Stamp Qua ifed in 6ufiolk � 6 Page 4 of 4 w Town Hall Annex Telephone(631)765-1802 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 Sy BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION ADDENDUM Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit. Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit:. Use and Dimension of each room: Rental Dwelling Unit Identifier: Requested maximum number of persons allowed to occupy each dwelling unit: Number of Rooms in Rental Dwelling Unit: Use and Dimension of each room: c vwv TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 t— 3 19 INSPECT1,0N [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING / STRAPPING [ ]�FINRE AL FIREPLACE & CHIMNEY [ SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (F AL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL DEMARC oq . ..... bA- vi DATE INSPECTORIX `h TOWN OF SOUTHOLD PRI )RD CARD OWNER STREET VILLAGE DIST, SUB_ LOT ACR. ' 7 REMARKS TYPE OF BLD_ ,. I - - - 1e PROP, CLAS LAND IMP_ TOTAL DATE 04 r � �. 4'' e•`� Zit s pipe- 003 _ E - T FRONTAGE ON WATER TILLABLE FRONTAGE ON ROAD WOODLAND DEPTH MEADOWLAND ,z BULKHEAD HOUSE/LOT - _�s TOTAL i ®` \\�\\\ 2 }- 2 69.-3-18 3/5/ZD20 I ; T r r�( pQ 1� p Foundation P Bath / .. .o- �1(a0 � T-� C`� � Dinette Extension p Basement aAw� Floors Kit. SLAB Extension �- �(� �i � — (� Ext_ Walls Interior Finish ._ L.R. Extension �! Fire Place 7 Heat D.R. f , t Patio Woodstove BR. Porch aC "--- � (� Dormer � I Deck xdj � - Attic Breezeway Rooms 1st Floor ! GAL— C X�� Driveway Rooms 2nd Floor I O.B. _ y L ROOM 18'5"x IT2 1 , =s '= SWIMMING POOL SMOKE ACM 71 FAMILY ROOM 18'5"x 197 'I W.I.C. BATH BATH i KITCHEN SAfiH LDININGAREA HALL .x 11`-, SMOKE DEIECfOR - . t#`/` LIVING ROOM ` 15'6"x 137 TOTAL:2705 sq.ft BELOW GROUND: 606 sq.ft,FLOOR 2: 1302 sq.ft,FLOOR 3: 797 sq.ft EXCLUDED AREAS: ELECTRICAL ROOM: 119 sq.ft,BAY WINDOW: 9 sq.ft,FIREPLACE: 8 sq.ft Si+flM.l.1:4'O POOL tY RCM y 185'.14'T I s W.I C ..--..« BATH 47" IV « yr,x rl' - IT—N v- i5'S'z`:t'tt' TtTa PRIMARYBEOROOM f mmmY ` F 98'dxTB'1ff BEDROOM 1T8'a11T (_ LIVING ROOM DINING AREA I - 956'z 132' «- 98'e' 1rr,s8' - AUNORY IT11' RECREATION ROOM Wa',1 lw gu-- €R*w 91'd'x 18'd" 1. < BATH - STORAGE ROOM ' - 9a ` 67.3'9B' apt "✓�5 e/'i ,'�' W TOTAL: 2705 sq.ft BELOW GROUND: 606 sq.ft, FLOOR 2: 1302 sq.ft, FLOOR 3: 797 sq.ft EXCLUDED AREAS: ELECTRICAL ROOM: 119 sq.ft, BAY WINDOW: 9 sq.ft,FIREPLACE: 8 sq.ft BATH 97" x 7'1„ MOKE DETECTOR ' HALL ' 711011 x 3'8" PRIMARY BEDROOM 18'8" x 23'10" BEDROOM 12'6" x 221' W.I.C. 415" x 10'1" TOTAL:2705 sq.ft BELOW GROUND: 606 sq.ft,FLOOR 2: 1302 sq.ft,FLOOR 3: 797 sq.ft EXCLUDED AREAS: ELECTRICAL ROOM: 119 sq.ft,BAY WINDOW: 9 sq.ft,FIREPLACE: 8 sq.ft ROOM 1114" x 513" LAUNDRY 5'8" x 10'11" RECREATION ROOM 14'8" x 22'10" ELECTRICAL ROOM 11'4" x 16'0" BATH ' 519" x 714" STORAGE ROOM ' SMOKE DETECTOR 9 0 x 101 W.I.C. ► 51 9" x 3'10" TOTAL:2705 sq.ft BELOW GROUND: 606 sq.ft,FLOOR 2: 1302 sq.ft,FLOOR 3: 797 sq.ft EXCLUDED AREAS: ELECTRICAL ROOM: 119 sq.ft,BAY WINDOW: 9 sq.ft,FIREPLACE: 8 sq.ft . .........., i r"n"fly 1 /»%iJ�1 Y�hu»y fYl ll i t�/'fill'�� r ��1/i/�l rf�urx✓� 1, (I�f IJ � 1 fi) �p9Yrr�mrJ��ar'��ryi�/r(�j�y�l ��y��I�WYIyI j 0.H�I,4 �� r ('✓1lY%I/flfl(lj(N i�✓.�wHtN« �� 1 f , / r j` r j k 1% t� 11 ("f/J