HomeMy WebLinkAbout1000-74.-1-40.2 of so r� 'OWN F S UTHOL
Rental e rm it
1331
Owner: Smith L Revoc Trt
Occupied as: Single Family Dwelling
Located at: 29635 CR 48 Peconic 74.-1-40.2
Maximum Permitted Occupancy: 8
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: 06/12/2025
Expiration: 06/12/2027 de 6rcement OfIvial
This Notice must be posted by the main entrance at all times
r 1g I d
A�
� DPS� tA
TOWN OF SOUTHOLD—BUILDING DEPARTMEN, o11�1�
rt I Southold
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 1.11111-0959
Telephone (631) 765-1802 Fax (631) 765-9502 ht�t:a / t! 'ti .s a't t1 oldtow in Xoy
S-�L-aS
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RENTAL PERMIT APPLICATION
Rental Permit Fee $300(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Add re :
Tax Map Number: 1000 SECTION
SECTION B.
OWNER INFORMATION:
Property Owner Name:
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
o
Telephone Number(s): Daytime s _ tvieni " `` Emergency -
Property Owner Email Address: N l
Page 1 of 4
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any:-A- _ _..m...,.
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:
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: 2L
Number of rooms in Rental Dwelling Unit:
Use and Dimensions of each room in Rental Dwelling Unit: ,
5l ,gy m 1W V -4
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SECTION G. '1) `b0AWdcm + tt X l z ` �g� �" 3b` 6\%
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.
1i 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 I (,.)CO A. c i� , 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:
Property Owner's Signatu e:
Sworn to before me this 1 day of , 20x�
Official Notary Public Signature and Original Notary Stamp
T ,
;Exp. 02/28/2030' _ ADAm mICHAEL
Notay Pudic,Di ,oiD rAW of 4
MY
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A-W-�
TOWN OF SOUTHOLD BUILDING DEPT.
631-765-1802
INSPE(C"TION
[ ] 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 (FINIAL)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS: 5 t 0-,L L
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DATE
IIINSPECTOR
Town Hall Annex
Town Of Southold 54375 Main Road
Rental Inspection Report PO Box 1179
Southold, NY 11971-1179
Tel: 631-765-1802
SCTM# Date Sr-�v-
Owner i Phone
Address 3 157 Visible
Hamlet L%�?rG Inspector
Floor Level Quantities Sub 1 2 3
Smoke Detectors not located in bedrooms) /
Carbon Monoxide Detectors
Fire Extinguishers
Exits �I
Bedrooms 1 2 3 41 5 6
Smoke Detectors
Egress
Occupant Count a .
Building SysWrns Maintained &Operational Condition of Property
Heating Building interior
Hot water Building,exterior
Electrical Property clean, maintained &safe
Mechanical Handrails&guard►installed &secure
Pool Safety Pool on Site
Surface water alarm Date of CO issuance
Door alarms Pool completely enclosed
Self closing/latching gates Pool fence to code requirements
CO's for all items present Prior Rental
Comments:
1
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TOWN OF SOUTHOLD_ PROPERTY REC, qRD, CARD
L OWNER 5 STREkT` VILLAGE DIST. SUB. LOT
FORMER OWNER an, N E ; ACR.
S 1N TYPE OF BUILDING
ff tt
3
RES. SEAS, VL. 1 FARM COMM. CB, MICE_ Mkt. Value
LAND IMP, TOTAL DATE REMARKS _
7
3
mr ,f x �
k
i
i
Tillable FRONTAGE ON WATER
---,,. 4
Woodland FRONTAGE ON ROAD f
Meadowland I DEPTH -
_
House Plot iBULKHEAD
Total E
s
pp��''Y f�` t
! 1'
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Foundation `'i Both Dinette
Porch f � 1 Basement �� IFioors K.
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Porch ! — Ext. Walls a Interior Finish SLR.
Breezeway Tire Place Heat £DR, --
Garage I'Type Roof eams lst Floor R
,. ba
Patio _ Recreation Roam 'Rooms 2nd Floor > IN. B
0. B. lUor er Orivewov F
Total
541
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(sreent cr+ ^- New York
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy "'"
No. . . .Z,�QIZ. . . . . . . . . Date . . . .Dsceaaaber 31. . . . . . . . . » . . . . ., 19 79
THIS CERTIFIES that the building . . . . . . « « . . . . . . . « . « . . « . . . . . . . • . » • . • • • w • • . . . •
Location of Property . . .2957.5.County. Road. 27A. . . . . . . . . Peoonio, N.-7G.
House No. Street Hamlei
County Tax Map No. 1000 Section . . . .074. . . . .Block . . . . .1 . . . . . . . . .Lot .ptr -of 40. . . - .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
re a r w nta for a on* fsaalily dwelling built for to
conforms substantially to the ,
. . . .Agril. 23 . . . . . . . . 19 57 pursuant too dh � alas o. . . .ay. . . 298.12 . . . . . .
dated . . .Decaawmber. .31 . . . . . . . . . . . . 1979. , 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 ... . . . . . . .
. . . . . . . . . . , « . . . . . . .Private• One•Fsmily. DW011ing. . . . . . . . . . . . . . . . . . . . . . . . . . . .
The certificate is issued to . . . . . .Clan once .F. . nillor. A.ors . . « . , . . • • « • • • • « « • «
(owner,i
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . . . . . . . . K/.R. . . . . . . . . . . . . . • . . • . . . . .
UNDERWRITERS CERTIFICATE NO. . . « . . . . . . . . . . . . . « . . • . .X/.R. . . . . . . . . . . . « . • . . . . . . . •
Building Inspector
Rev 4/79
BUILDING DEPARTiMEI�
TOWN OF SOUTHOLD, N. Y.
HOUSING CODE INSPECTION REPORT
Location 2 Count Road 2 N
number & scree nicipay
Subdivision Map No. Lot(s)-- �
Name of Owner(s) Clarence F. Diller & ors
Occupancy unoccupied
.type owner- enan
Admitted by: -Mr. Diller Accompanied by:_ Mr. Diller
Key available Suffolk Co. Tax No.1000 O?4 1- t.of40
Source of request ' ohn C. Diller Date Nov. 28 1
D11EC.LING:
Type of construction Wood framed stories 2
Foundation P Ce12ar full Crawl space
Total. rooms, 1st. Fl 3 2nd. Fl 4 3rd. Fl
Bathroom(s) 1 Toilet rooms)
Porch, type glassed-in 'Deck, type Patio, type
Breezeway G ge Utility room X
Type Heat oil fired `"Farm Air Hotwater X
Fireplace(s) No. Exits 2 Airconditioning
Domestic,hotwater yes Type heater electric
Other
ACCESSORY STRUCTURES:
Garage, type const. 2 car/wood Storage, type con`st.
Swimming pool. Guest, type const.
Other
VIOLATIONS: Housing Code, Chapter 52
rt�
L cation • Descri tion Art. Sec.
Bathroom Floor needs r a 4
Cellar No rail on stairway; also, steps
very steed 2_ A, B,
Garage(2) Needs repairing badl ,___ C
Remarks:
Inspected by:.� _hate of Insp. Dgr., 11 1
Curtis Horton Time start 9.30 end 10:00
FORM NO.6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink,and submitted in duplicate to the Building Inspec-
tor with the following;for new buildings or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets,and unusual
natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage disposal—(S-9 form or equal).
3.Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible for the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or
topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa-
tion required to prepare a certificate.
C. Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use $5.00
3. Copy of certificate of occupancy $1.00
Date . . .IiQvembgr; A. .1979 . . . . . .
New Building . . . . . . . . . . . . . Old or Pre-existing Building . . . . . . . . . . . . Vacant Land . . . . . . . . . . . . .
Location of Property Nar.th .Road .C.A.. .27.A .(north .si.de, .approxi.ruately .29001. .west .of. .Henry .Lane)
House No. Street Pecon i c, New York Ham/et
Owner or Owners of Property . . John C. Diller . , . . . . . . , . . . . . . . . . . .
County Tax Map No. 1000 Section . . .074 . — 1 . . . . Block . . . . .I. . . . . . . . . . Lot .40 See Below', .
Subdivision , ,See Below; Filed Map No. . . . . . . . . . .Lot No.
Permit No. . . . . . . . . . . Date of Permit . . . . , . . . . .Applicant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Dept. Approval . . . . . . . . „ . . . . . . . . . . . . . . .Labor Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . .
Underwriters Approval . . . . . . . . . . . . . . . . . . . . . . . .Planning Board Approval . . . . . . . . . . . . . . . . . . . . . .
Request for Temporary Certificate . . . . . . . . . . . . . . . . . . . . .Final Certificate . . . . . . . . . . . . . . . . . . . . . . ,
Fee Submitted $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Construction on above described building and permit me I appl' ble codes and regulations.
Applicant . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
Rev.10-10-78 t CofO relates to aprt of prop ty which is subject of pending subdivision
application to Southold Town Planning Board �7/1
n
1 t�
STATE OF NEW YORK )
) ss. .
COUNTY OF NEW YORK )
JOHN C. DILLER, being duly sworn, deposes
and says:
1. I aia the owner of a dwelling with detached
two-car garage located on the north side of North Road (CR 27A)
approximately 2 ,900 feet west of Henry' s Lane at Peconic,
New York.
2. Said dwelling and garage, upon information
and belief, was built in the period 1918 to 1920 and have been
used continually from that period to date as a one-family
residence and storage area.
3. Said dwelling and garage are today in good
condition and are in all respects fit for use as a resi-
dential dwelling and storage building respectively.
Y
Sworn to before me this
2Sth day of November, 1979
GRAMW
c t sy Pu ir, "A'Aft all '400 YesM
No* 31VAM'S
d. Q#iified in Sew YOeK County
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