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TOWN OF SOUTHOLD BUILDING DEPT.
o 631-765-1802 /,j-a—7. 7
1 ofmm S mrw& E C T I u"alk 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 (FIN )
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS: &4ew 9 5e3
C olli owl o u
DATE `� �� INSPECTOR
Town Hall Annex
Town of Southold 54375 Main Road
' Rental Inspection Report PO Box 1179
Southold, NY 11971-1179
� Te1: 631-765-1802
SCTM # .01 .7 Date .,
Owner G V11S LG Phone
Address J)tfM41ZeSP4 Visible
Hamlet Inspector imeZll
Floor Level Quantities Sub 1 2 3
Smoke Detectors(not located in bedrooms)
Carbon Monoxide Detectors
Fire Extinguishers
Exits
Bedrooms 1 2 3 4 5 6
Smoke Detectors
Egress
Occupant Count
Building Systems Maintained&Operational PCondition of Property
Heating Building interior
Hot water Building exterior
Electrical Property clean, maintained &safe
Mechanical Handrails&guards 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
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CO's for all items present ��" ��+�����//��/%%/ %�1�/%��,� � tq '���,��/�,
Comments:
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TOWN OF SOUTHOLD—BUILDING D&A T NT ��r:. � j` c, C)Lo S-t+Cp
Towp Hall,annex 54375 Main Road P.0. Box 1179 Southold,,NY 11971-0959 -,k&
Telephone(631)765-1802 Fax(631)765-9502 ti� �° /r v� ��i a c�Lomrm L�r
RENTAL PERMIT APPLICATION
Rental Permit Fee$300(Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address:
La
Tax Map Number: 1000 SECTION 13 -BLOCK .� -LOT - - 7
SECTION B.
OWNER INFORMATION:
Property Owner Name:
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
n
Telephone Number(s): Daytim vening_,_,,,, _,_,,,_,_,EmergencyGUG�_--3LULj 93 QQ
Property Owner Email Address: " G
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 ening Emergency 3e
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
Telephone Tele 631 765-1802
Town Hall Annex P )
54375 Main Road
P.O.Box 1179 ;
Southold,NY 11971-0959
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 ofeach room:
G�x to
10 V 3
L
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l 9 6X Ia9
tental'Dwefltng Unit ldentifer:
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 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."
rU
ental Dwelling Unit Identifier:
equested Maximum number of persons allowedh to occupy Dwelling Unit:
umber of rooms in Rental Dwelling Unit:
se and Dimensions of each room in Rental 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 whohas 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 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
��° �� 'A Telephone(631)765-1802
54375 Main Road
P.O.Box 1179
Southold,NY 11971-0959
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: 44
Use and Dimension of each room: 4 # 9.
a or. &Lf— Gsx �p
� 3
9 �Ala9
� x 6 : a crQ. 2o0�1 x 3
ante 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 inust be notarized and MUST be the owner of the dwelling unit.
STATE OF NEW YORK)
)
COUNTY OF SUFFOLK)
t" 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 Iegar 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 Signature:
ate,...,,.•"
Swor o befog thM- dayojP(ML� 20` ` I'
Official Notary Public Sin ture and Original Notary Stamp
DEBORAH A,WOJCIK
Notary Public,State of New York
No.43 0tb
Qualified in Suffolk Counp w
Co niis�sion Expires Dec, 0„ � Page 4 of 4
SECTION H.
DECLARAYION: Signature inust 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: AC—�
Property Owner's Signature:
Swor o befoMr�pt
�
Official Notary Public Sin Lure and Original Notary Stamp
EBORAH A.WOJCIK
Notary Public,State of New York
No,4990159
Qualified in Suffolk COUn
"Onims ior�Expires I eo. Q, Page 4 of 4
(4f s 0 4 - ---H- ortlz,�t—
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* ' TOWN OF SOUTHOLD BUILDING DI
o, 631 M85 18 2 !- . _ ).-
INSPECTION
] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ ] INSUEATION/CAl
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY IN!
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FII
[ ] CODE VIOLATION [ ] PRE C/O [ I
REMARKS:
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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
No. . , 1512 3 . . . . . » • . Date . . . . . . . . . . .November. . . . . . . . . . . . . . . . . . .. 19 8 6
THIS CERTIFIES that the building . . . . . . one family ,dwelling. . . . . . . . . . . . . . . . . . .
Location of Property Demarest R.O.W. off Main Road Orient
House No. µ . . . r . . a µ ,Street flamlec
County Tax Map No. 1000 Section . . . . 0.13. . . .Block . . . . . . . . . . . . .02 .Lot . .p�° r . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
„ Aug,., ,21• I9 .$ pursuant to which Building Permit No. . . 15 4 2 7 Z. . . . . . . ..
x ,
dated . .Oc.t' 217 . . . . . . . . x . . . . . . 19 .$ , 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 . . . . . • . . .
One family dwelling including deck. w µ a
The certificate is issued to . . .CON5TANTINOS & HED[�ITG 2ERVOS . . k .. . . . . . . . . . . . . . . (owner � a •
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . .85-SO-131 Nov,.. .21,,, 1986r . «
UNDERWRITERS CERTIFICATE NO. . . . • . . . . . . . . . ?17 5 0 5 4 8. . . . » . . . . . . . . . . . „ . . . . . . .
Plumbers certificate Nov. 24, 1986
wl'
• m « r .'. ♦ • • . ♦ a . « x x . m m . n • . a . . . a x . . . .
Building Inspector
Rev.1/81
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold,N.Y.
Certificate Of Occupancy
No. . Z15424 . . . . Date . November 24. . . . . . . . . . . . . . . .. 19 86
THIS CERTIFIES that the building . . . G ar ac1e. . , , , , „ „ . . . . . . . . . . . . . . . . . . . . .
Location of Property A.=arP-Ati.F.•.O.,W, off,Main,Road , , , , , , Orient . . .
House No. Street Hamlet
County Tax Map No. 1000 Section . . .013. . . . . .Block . . .a 2. . . . . . . . . .Lot . . .p1 Q. .7 . . . . . . . .
Subdivision . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
. . .. 21 . . . . . . . . . . 1.9 85 pursuant to which Building Permit No. . . . 114 2 77. . . . . . . . . . .
dated „ , Oct. 27 . . . . . . . . 19 . $6 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 . . . . . . . . .
Accessory two car garage.
The certificate is issued to CONSTANTINOS & HEDWIG ZERVOS
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . . . . . NSA. . . . . . . . . . . . . . . . . . . . . . . . . .
UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . . . . . . . 4 3 0 8 0
4 N 9 . . . . . . . .
Building Inspector . .
Rev. 1/81
1WtCP
Town of Southold 2/1/2024
P.O. Box 1179
53095 Main Rd
u , Southold,New York 11971
'CERTIFICATE OF OCCUPANCY
No: 44916 Date: 2/1/2024
THIS CERTIFIES that the building ADDITION/ALTERATION
........ .... .. ...... ... ........ ..... .............
_—..... ---
_...... . ............ ...... .... ......... ,. ....... .... ..........
.. .........
Location of Property: 1390 Demarest Rd, Orient
SCTM#: 473889 Sec/Block/Lot: 13.-2-7.7
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
5/24/2021 pursuant to which Building Permit No. 46799 dated 9/9/2021
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:
additions and aalt r twcaa, ri ludzolg�c c�Ntc�flct�r„cr�I��ng .e�M1 1���c�c� l?�ar 1R� e�a�t �����..�l�a��v �_ar�c� INraxi ��cr�r�c�r1 I i1rg
tlt .lcat e,W ?w titlg ,111g l lrtNly...c t lwl�rtg �1pl lied for p t, C3 _7 d r c c1_ /4 / 023...
The certificate is issued to CVJB LLC
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 46799 9/8/23 & 1/3/24
PLUMBERS CERTIFICATION DATED
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