HomeMy WebLinkAbout1000-63.-6-6.3 (North side) !Df so TOWN OF SOUTHOLD
Rental Permit
1539
Owner: Unitarian Universalists of Sth
Occupied as: Single Family Dwelling (North side)
Located at: 51970 Route 25 Southold 63.-6-6.3
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: 09/01/2026
Expiration: 08/31/2028 codr Enforcement t�cial
This Notice must be posted by the main entrance at all times
3o v /9�(
� k 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 ht.t,as//wwaw.sotztl ooidtow�iit .��,ov
RENTAL PERMIT APPLICATION
Rental Permit Fee $300 (Application must be renewed every two years)
E E
Section A.
Property Information: JUN 2 6 2026
Rental Property Address: "11'd Opa � n
To1rm of ow�� ��o8d
Q a&�
Tax Map Number: 1000 SECTION . ......-BLOCK
SECTION B.
OWNER INFORMATION:
Property Owner Name: On ntan Ili, f
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
(" Z
7l
C-*7i- 745
Telephone Number (s): Daytime '4q!J Evening Emer ntc 0?
Property Owner Email Address: 5,0 d
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: Vlotkte�loat�a
Address of Authorized Agent (no P.O. Boxes):
--�&o ............
Mailing Address of Authorized Agent: �� �'j G +
Telephone Number(s): Daytim �' �'5VELL"ng
Emergency
Email Address: v ` O n
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: Z
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 UniV ���'
Number of rooms in Rental Dwelling Unit: 3 - -
Use and Dimensions of each ro m in Renta 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 a fire safety inspection to be performed by a Code Enforcement Official
from the Town of Southold
❑ lam 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 �-- certify un Qr 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: 01 µ I( ") l
Property Owner's Signature
4��,�Jdr
Sworn to before me this day of 20C�G
Official Notary Public Signature and Original Notary Stamp
CONNIE D.BUNCH
Notary Public,State of New York
No.01 BU6185050
Qualified in Suffolk County
Commission Expires April 14,2 .. Page 4 of 4
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Town Hall Annex ` " Telephone(631)765-1802
54375 Main Road P
P. O. Box 1179
Southold, NY 11971-0959
F
�Y
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL. PERMIT APPLICATION DDEND C D L
Rental Dwelling Unit Identifier:
Requested maximum number of persons allowed to occu y e ch dwelling unit:
Number of Rooms in Rental Dwelling Unit: -1- t
^� User and D'mensionro�f, eac room: ,(`
( Aa
Rental Dwelling Unit Identifier:
Requested maximum number of persons allows o 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:
r
TOWN OF SOUTHOLD BUILDING DEPT.
� COY 631-765-1802 w 3_ 6_w,3
I N S O' E(00;` 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 [ q-1-RENTAL
REMARKS: 27w&� i
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DATE — INSPECTOR
Telephone Tele 631 765-1802
Town Hall Annex P ( )
54375 Main Road ZZ) "nf Fax(631)765-9502
P. O. Box 1179
Southold, NY 11971-0959
P
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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 En ineer Licensed Home Inspector must
Provide coov of valid current certification
Rental Property SCTM Number:
Rental Property Address: `? t " f
Owner/Name:
A Rental Dwelling Unit Identifier: pnw�> e,
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)
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:
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