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Home My WebLink About1000-78.-1-15 (D o � cn c N 0 •- 01 d- o d- CY) CU E F7 Uj L: 0 ... ry. (D CU V 40. o LU Cam.„ L C 0 cu Q E "-i .= J — O � o �o C C D c . . � � o O 0 E � LZ o oL� LL 2 C .� 0 Z Z � o 0- o � �. CU CU � z a O o o c- �. � � a) 0 0 L U) z U) V) Q a • CO U) -oZ E o 00 CU ct3 =3 � N - a) E rq _o _o N •� (Q i O cc CD N G Y O t� CO _O E 0 0 'Q O 0 +-j v o O O 0 c) N �CL "' w Town Hall Annex Telephone Telephone(631)765-1802 54375 Main Road 4 Fax(631)765-9502 P.O.Box 1179 �� Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION Rental Permit Fee$200(Application must be renewed every two ye J U L 1 9 2021 Section A. Property Information: DTM,DING DE PT, TOI 'or, i1ol7rPTOL. D Rental Property Address: Tax Map Number: 1000 SECTION 1000 _ -BLOCK � -LOT- __- SECTION B. OWNER INFORMATION: Property Owner Name: Property Owner Legal Address: Property Owner Mailing Address: 31-03'_WY-7 Telephone Number(s): Daytime '` �vening Emergency kA Property Owner Email Address: Page 1 of 5 w� Town Hall Annex i Telephone(631)765-1802 54375 Main Road ��`, Fax(631)765-9502 P.O.Box 1 179 Southold,NY11971-0959 � BUILDING DEPARTMENT TOWN OF SOUTHOLD Mailing Address of Managing Agent: Telephone Number(s): Daytime Evening__Emergency . Email Address: 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:_/ Number of rooms in Rental Dwelling Unit: A _ _ Use and Dimensions of each room in Rental Dwelling Unit: N. Act ' I I S- 1, Page 3 of 5 �I Town Hall Annex Telephone(631)765-1802 54375 Main Road wFv Fax(631)765-9502 INC P.O.Box 1179 „ g Southold,NY 11971-0959 � �kaar BUILDING DEPARTMENT TOWN OF SO HOLD 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 ®' I am submitting a completed Town of Southold certification form from a licensed architect or a licensed professional engineer. SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit STATE OF NEW YORK) ) COUNTY//OF SUFFOLK) I _ h i► 1Ar&W1t , 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 Page 4 of 5 n �daifi ' Town Ball Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1 l79 n Southold,NY 11971-0959 5 BUILDING DEPARTMENT TOWN OF SOUTHOLD 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 as to any change to the information regarding Authorized Agent, Managing Agent, or Site Manager. Property Owner's Name: _ cl Property Owner's Signature: Sworn to before me this L day of U L _, 202 Official Notary Public Signature and Original Notary Stamp CAROLINE M MACARTHUR NOTARY PUBLIC-STATE OF NEW YORK No.01 MA6384635 Qualified in Suffolk County My Commission Expires 12-17-2022 Page 5 of 5 5�� )� t 50AVN4-td� Va" T OUTHOL� BUILDING 631-765-1802 0 1 NSPEC�l Ago""' 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 (F AL) [ ] CODE VIOLATION [ ] PRE C/O [ RENTAL REMARKS: ...... DATE INSPECTOR X4 rrY 1 a 0 Town Hall Annex Telephone(631)765-1802 54375 Main Roads Fax(631)765-9502 P.O.Box 1179 M Southold,NY 11971-0959 kh � � �" BUILDING DEPARTMENT TOWN OF SO'U T HOLD RENTAL PROPERTY CERTIFICATION Form is to be completed by a license architect, licensed engineer or licensed home inspector Separate form is required for each individual Rental Dwelling Unit Fro essional seal re aired or rcllitect or Fn ineer licensed home l actor must pLovide LoploLvalid current certi cation Rental Property SCTM Number: 1000-78-1-15 Rental Property Address: 55 SHEPARD DR, SOUTHOLD Owner/Name: STEVE KONDAK Rental Dwelling Unit Identifier: Number& Square footage of each bedroom as depicted in the attached floor plan: (i.e. Bedroom#1 -100 sq., Bedroom#2-90 sq., etc.) BEDROOM#1 - 179 SF, BEDROOM#2 - 189 SF, BEDROOM#3 - 116 SF,BEDROOM#4- 133 SF Property Description (Include all improvements indicated on survey) TWO STORY FRAME HOUSE 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, and the Energy Conservation Construction Code of New York State. ANTHONY PORTILLO,RA f Print Name and Title !frig S ure Please place professional seal: N r" i � J o � J r� w H � Q wLu O a w w D I d J ' Q w > `0 c ►— _ „ '� z Y 0 LL 0 cc m V�9 Lu Q " LL to o D O mco Z _ U- r1l I J ?� w 0 O -. � � m J° r F- n- �. F � w IL ,- a CD Q .. z "" 1S 4 I J a " p m OLU „x ° . c us og CO � e arr � y t4 9 ➢ # m w w Ln rFes- = 2 Z Z ........ ........ �" �� .. e.� U w � �, Ll- � m O } mow. .. w n Iw— ( Z O (3) Limµ.._ . _. ...„_.. . _ .._, ..... .._... w O W f ^ 9 JCL O °S ._ �. sf) 1 ti � U t'w m Q w � E S LL "µ,B O U FL Q d, O Q o 0 0 0 0 Ln � 0 `. U- ��, Z u. 0 �I b � � m i „ � w y C O C 2 •— LL LL � 6�,.. .. _.,.... '...... ...... ...,.. ,....., Jw. ..,. o E � 0 c o °o °� a°, °o °o 4' . ....... _ ..— IY cj� o tC ry 11 k a a u o o Q� o N u.. m w ii I— cY 0 d Ay �� iT;, I � . rie l r� errl "D O N C C .S S p� N O O CC �} CL O O C W W LLI d m x FORM Ma t TOWN OF SOUTHOLD BUILDING DEpARTMENT Town Clerk's Office Soudiold, N. Y. Certificate Of Occupancy No. 26-36. . . . . . Date . . . ., 1Pab . THIS CER unary. THIES that the building located at Olenn •&• Shepard•D . . . .. , Street Map No. WON t9re ek. R k No. . . . . . . .Lot No.44. .. . . . . .8auth0l,d. .N. Y.. . conforms substantially to the Application for Building permit heretofore filed in this o• . - dated . . � • AprSl 24 , 19'gi�, . pursuant to which Building permit dated . . . � No. ��3z. . a . . . . .Apr1l • 21� .. ., 19 74., was issued, and conforms to all of the menu of the applicable require.P of the law. The occupancy for which this issued is . �'r�YiltQ.qpA .r �Y.aK41�: to is g . . . . . The certificate . . . . . . . .. . . .. .. . . . .. . . .. . is issued to .�wronc•.& •Tharssa•Bttabla• . . . '0• • of the aforesaid building. . ..._(owner, lessee or ` �t) . . . . . . . . Suffolk County Department of Health Approval Oc.t. .31. . .19.74 . . by. .R.. Y321a , UNDERWRITERS CATIFICATE NON. 2Q$�. . . . . .. .Fab. . f� , .1975.. 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