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Home My WebLink About1000-73.-5-1 TOWN OF SOUTHOLD Rental Permit 1535 Owner: Elino Dena , Joseph Goldstein Occupied as: Seasonal Dwelling Located at: 4625 Blue Horizon Bluffs Peconic 73.-5-1 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-ann inspection. Issued: 08/26/2026 4n Expiration: 08/25/2028 code nfor ,e ent official This Notice must be posted by the main entrance at all times ECE0IC rZA z TOWN OF SOUTHOLD—BUILDING DEPARTJIT J U G 1 0 2026 4375 Main load P. }. Boy 1179 Southold,N 0 9 !0V Torn Hall hex 5 hwara partment Town of Southold Telephone (631) 765-1802 Fax(631) 765-9502 hopsf/_VN1WW.southohjto3Nmny. o RENTAL PERMIT APPLICATION e e-Cc I l Ztp$S Rental Permit Fee $300(Application must be renewed every two years) Section A. Property Information: Rental Property Address: 4625 Blue Horizon Bluffs, Peconic, NY 11958 Tax Map Number: 1000 SECTION 73 -BLOCK 5 -LOT-1--- SECTION B. OWNER INFORMATION: Property Owner Name: Joseph Goldstein; Elino Dena Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) _44 Gramercy Park North #10E _44 Gramercy Park North #10E_ _New York, NY 10010 _New York, NY 10010 Telephone Number (s): Daytime_917-406-4219_Evening_917-406-4219 Emergency_917-406-4219_Property Owner Email Address: _joseph.goldstein@jgarc.com Page 1 of 4 SECTION F. PROPERTY DESCRIPTION: Number of Rental Dwelling Units on property: ONE 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: UNIT Requested Maximum number of persons allowed to occupy Dwelling Unit:_4 Number of rooms in Rental Dwelling Unit: 4 Use and Dimensions of each room in Rental Dwelling Unit: Bedroom#1: 12.5' x 17.0' Bedroom #2: 10.0' x 16.0' Living Room: 20.3' x 24.1' Kitchen: 8.5' x 12.3' 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. ❑ 1 am requesting a fire safety inspection to be performed by a Code Enforcement Official /from the Town of Southold �1 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 NEVI YORK) COUNTY OF SUFFOLK) I Joseph Goldstein , 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:_Joseph Goldstein Property Owner's Signature: - Sworn to before me this day of , 20 ab Official Notary Public Ignature and Original Notary Stamp MELISSA ARAGON E-,my- Pageotary Public- e of New York NO.01 o177 Qualifled In K County Commission Expi s May 18,2030 4 of 4 TOWN OF SOUTHOLE) BUILDING DEPT. .� 631-765-1802 INSPECTION [ ] 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 [ PE C/O [ RENTAL RE1I ARKS::2 _ AA--od vlo/a f'o5 DATE ��l �� INSPECTOR Town Hall Annex �� Telephone(631)765-1802 54375 Main Road �F Fax(631)765-9502 P. O. Box 117946 Southold, NY 11971-0959 j 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 Home Inspector must provide copy of valid current certification Rental Property SCTM Number:_1000-73-5-1 Rental Property Address: _4625 Blue Horizon Bluffs, Peconic, NY 11958 OwnedName: _Joseph Goldstein; Elino Dena Rental Dwelling Unit Identifier: Unit#1 Number&Square footage of each bedroom as depicted in the attached floor plan: (i.e. Bedroom#1 —100 sqft., Bedroom#2—90 sqft., etc.) Bedroom #1 -212.5 sqft; Bedroom #2: - 160 sqft Living Room - 489.2 sqft Kitchen - 104.6 s� Property Description (Include all improvements indicated on survey) one story framed cottage; framed garage and studio; wood deck 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. SE D XA G i ,,..- _Joseph Goldstein, Architect Print Name and Title _ inef' ature Please place Professional Seal• ,a OFN ��1 TOWN F SOUTHOLD PROPERTY RE Ci u swAnu STREET ..,.,_. _.�..... ....._ VL.:_,_�°� LLAGE DISTRICT 8 SUB. LOT FORMER OWNER N E ACREAGE TYPE OF BUILDING S RES. SEAS. .rv_rvVL._......._.. _.FARM comm IND CB MISC..._°M_ ..... ._,..__.....__. _. r _ _m ......._ ..... .. ........ ........... �m .....,.. _.._._..._ _w....... . LAND IMP. j TOTAL DATE REMARKS } D f ��,� ' �� '', , d ' 61 r �Y i / l f l� P y Y f en AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE _' .... _._,,.,. ._ . ......._ . _.. . ..._W,. _ _ _. Form Ac re Value Per Acre �.... Value Tillable 1 Tillable 2 i Tillablemm.3'_._.,m , . ,,.�_... ,. . .._._.. ,... ......, .. _ w,f __ . ..,.... m�........... ..._ �, .__ 1 _ Woodland Swampland Brushland House Plot . c dX .. Cntal r :r, N „gyp �trmi i . u m 1 T. /? 4da r M. Bldg p /� �� Q Foundation a . Bath Extension Basement Floors '[ Extension i e Ext. Walls :Interior Finish / s ,2/6 . ._ w,._._...... _.. ._..._ _ _----------------- -- ---- _........ ._.........._ e � I Extension ` � . .. . v .__...._ ......�_�..�.., .._ Fire Place.........,.. seat �� . Porch Attic J Porch Rooms ]st Floor .............Breeze... . ...... wciyl Patio Rooms 2nd Floor Garage f ( � Driveway _ ..rc .w. _. .. _.............. .......__ ..... O B SD SMOKE DETECTOR CO CARBON MONOXIDE DETECTOR INDICATES AREAS NOT AVAILABLE TO RENTERS SCREENED-IN PORCH _._.__._ _........_ SD BEDROOM #1 �JCU 'J LIVING ROOM KITCHEN FOILET ROOM _..._.... SD IY :P '--SHOWER STUDIO BEDROOM #2 �:::.-. .:----:--- ��._ :m:='' --'UTILITY /f 4625 BLUE HORIZON BLUFFS FLOOR PLAN PECONIC, NY 11958 SCALE: 1/8"=1'-0"