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° r TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, 1449
Telephone (631) 765-1802 Fax(631) 765-9502 https://www south Idt
7 202
Buildin
RENTAL PERMIT APPLICATION ro" f S I
3 1'1 .
Rental Permit Fee $300 (Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
�255 DutJWS APTAA " ►����
Tax Map Number: 1000 SECTION . Ito + --BLOCK -LOT
SECTION B.
OWNER INFORMATION:
Property Owner Name: OACISAIJJ�n,A- n�
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
r_V06-:51 IePS t� � �`� s
tj ew Ya VU(_ N ek1 4 DA4(_ ►Up t ca ��
Telephone Number (s): Daytime aV—d 303 Evening•'-f O Emergency 10 —0 3
Property Owner Email Address: SAVA-S,
Page 1 of 4
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: t4 �1-► ��l
Address of Authorized Agent (no P.O. Boxes):
Mailing Address of Authorized A ent� 1 a, PI l "
e I , �
�6
3 a aa�
,4elephone Number (s): Daytime . � Evening j-4 Emergency - �t
Email Address: 1 2?i Utz' CVKA—�-
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 F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: J
For each Rental Dwelling Unit set forth the Rental Dwelling Unit identifier (for example,
Unit 1, Unit 2, Unit 3 or Apt A, B, C); 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: Z4
Requested Maximum number of persons allowed to occupy Dwelling Unit: 02
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit:
/47T47-77;i; .11�
`I vl 2vvx1 let—a ! 0>Re3vx,,— ✓ — !�—
ECTION 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.
ZIm 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
Town Hall Annex Y °'� Telephone (631)765-1802
54375 Main Road `h`t
P. O. Box 1179
Southold, NY 11971-0959 a
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:
5 r—I.-U®1— i, 7
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:
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. 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:
Y s �
Property Owner' Signature:
N
Sworn to before me this 7 day of Mo-rc� _, 20
Official Notary Public Sig ature and Original Notary Stamp
Robert CeFrese
Notary Public State of Now York
Registration No,01 DE5035111
Qualified in Suffolk County
Commission Expires October 24,2026
Page 4 of 4
TOWN OF SOUTHOLD BUILDING DEPT.
631-765-1802
1 N Smr"h` E Cm;6T I0 N
[ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING /STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FIN )
[ ] CODE VIOLATION [ ] PRE C/O [ ENTAL
ECG po►2 Sa n Orc u
DATE 3/ -ate_ INSPECTOR �.
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FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold,N.Y.
Certificate Of Occupancy
Noz1.3399. Date . . . . . . . April. 30. . . . . . . . . . . . . . .. 1985.
THIS CERTIFIES that the building . . . ,MULTIPLE DWELLING . . . y .
Location of Property 2555. .YOUNGS AVENUE. SOUTHOLDm w
House No. Street Hamlet
County Tax Map No. 1000 Section 0 6 3 _ _ . . . _ . .Block . . . . . . .0 0 . . . .Lot . . . . 8 . . . .9. . . . . .
Subdivision . . . F 0 U H P 9.R S .V T L L 9 E, . . . . „ . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
-Jan... b 104.pursuant to which Building Permit No. 12 8 49z.
dated . . . . .Jan,., .1 7. . . . _ . . . . . . . . i9$4 . ,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 . . . . . . . . .
BUILDING #2 APT . 2—A Unit in Multiple dwellingw„ „ „ * w µo- „ „ „ + * „
The certificate is issued to . . . L I Z D A REALTY LTD.
fcrw►*ner.* a91'.tati . . . . . . . . . . . . . . . . . . . . . . .
of the aforesaid building.
Suffolk County Department of Health Approval . . . . .54„ „ „ .
UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . M 6$7 2 4 . . . . „ w . . . . . . . . . . .
PLUMBERS CERTIFICATION April 25 , 1985
G.�
„ „Building Inspector
Rev.1/81