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Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959
VI � ;
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
RENTAL PERMIT APPLICATION INSTRUCTIONS
Rental Permit Fee $200 (Application must be renewed every two years)
The items listed below are required to be submitted with the completed
application.
ff"�Floor Plans: Floor plans of each Rental Dwelling Unit, please show location of
all smoke &carbon monoxide detectors.
i/Certificates of Occupancy and Pre-Certificates of Occupancy: Certificates of
occupancy or Pre-Certificates of Occupancy for each rental dwelling unit.
❑ Certification of Code Compliance (form enclosed): Must be submitted by a
license architect or engineer or license home inspector if an inspection by Town of
Southold Inspector is declined.
8" Rental Permit Fee: $200.00
D D�
NOV
TOWN OF BUILDWG DEPT.
i
r J
So
P
Town Hall Annex
Telephone(631)765-1802
�
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 "" ,, r '
BUILDING DEPARTMENT
TOWN OF SOUTHOLD NOV0 2022
RENTAL PERMIT APPLICATION
Rental Permit Fee $200 (Application must be renewed every two years)
Section A.
Property Information:Rental Property Address: 353S A, yAa/A velwe
j/ // 9 a
Tax Map Number: 1000SECTION / -BLOCK //3 -LOT 03 - 2C
SECTION B.
OWNER INFORMATION: &cI e .L ..
Property Owner Name:
Property Owner Legal Address: Property Owner Mailing Address:
/oaa Pc Ag lee Ave.
a
Shay
Telephone Number(s): Daytime 7-,54-S324Evening 5aA e Emergency -570/qif
Property Owner Email Address: Andrew
. -T Z �"" k j 0 451112 'BOA
Page 1 of 5
jf so
63l Telephone Town Hall Annex P ( )765-1802
54375 Main Road CA Fax(631)765-9502
P.O.Box 1179 AF
Southold,NY 11971-0959 ��' `�) "
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Section C.
Authorized Agent Information:
Name of Authorized Agent of dwelling unit, if any: 5
40
Address of Authorized Agent (no P.O. Boxes � 9 �-o� i of�old #ekoAe
Mailing Address of Authorized Agent: JaM
a960
Telephone Number (s): Daytime 0131-301- Evening. 4A Emergent:
Email Address: f4 C `
Section D.
Managing Agent Information:
Name of Authorized Agent of dwelling unit, if any: Sct A P S Gt 0✓-e—
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: Sa vtt C 6t5 ,a, oJe—
Address of Managing Agent (no P.O. Boxes):_
Page 2 of 5
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax (631)765-9502
P.O. Box 1 179
Southold,NY 1 1 97 1-0959a
� O
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.
NZ—'-
Number of rooms in Rental Dwelling Unit: /4-
Use and Dimensions of each room in Rental Dwelling Unit: leiaj:'1.d'W
c
Page 3 of 5
QF $ IJ2. '
Town Hall Annex Telephone(631)765-1902
54375 Main Road Fax(631)765-9502
P.O.Box 1 179
Southold,NY 1 1971-0959 �Co
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
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 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.
SECTION H.
DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit.
STATE OF NEW YORK)
)
COUNTY OF SUFFOLK)
kk'....., 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
S0114
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
coo -ur
P.O.Box 1179
Southold,NY 11971-0959
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 get, or Site Manager,
,-Ile 6w (�q+ r ' / .C
Property Owner's Name: l �'w
Property Owner's Signature: X- W
Sworn to before me this day of (jpVo-b. & , 20 zt
Official Notary Public Signature and Original Notary Stamp
Kathryn Palovick
NOTARY PUBLIC,STATE OF NEW YORK
Registration No.OIPA6352796
Qualified in Westchester County
Commission Expires Jamwy 3,2025
Page 5 of 5
" 'q o f 3w w lor �e - &W&L--
TOWN OF SO►U'"1'HCILD I8UII� D. ING DEPT.
631-765-1802 till
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING /STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FI L)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS:
k/-)",(c/bAywl
RATS INSPECTOR .
p S0C�T� 7,)��<,��
TOWN OF SOU �L[htJ1LDING DEPT.
631-765-1802 k[j, t)_y
INSPOECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING / STRAPPING [ ] FI L.
[ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FI L)
[ ] CODE 'VIOLATION [ ] PRE C/O I[ RENTAL
REMARKS: �•
DATE D 17/91- I SPEOTOF ...,-
a so -,000�
TOWN OF SOUTHOLD BUILDING DEPT.
co 631-765-1802
INSPECT10" N
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION/CAULKING
[ ] FRAMING / STRAPPING [ ] F AL
[ ] FIREPLACE & CHIMNEY [V FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETR TION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FI L)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
REMARKS:
A ex
DATE ( '� 741e3 INSPECTO
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Town of Southold
P.O. Box 1179
53095 Main Rd
Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 46917 Date: 03/18/2026
THIS CERTIFIES that the building AS BUILT ALTERATION
Location of Property: 3535 Westj2halia Rd Mattituck, NY 11952
See/Block/Lot: 113.-13-20
Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 01/22/2025
Pursuant to which Building Permit No. 51594 and dated: 01/29/2025
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:
"As built" habitable third story and fire protection system to an existing single-family
dwelling as applied for per ZBA#7935 dated 9/19/2024.
The certificate is issued to: Belle &Bean Ventures LLC
Of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL:
ELECTRICAL CERTIFICATE: 25-103040 8/21/2025
PLUMBERS CERTIFICATION: Jared Zinna 1/14/2026
Au on d ig ature
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT 116VI
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. . .$.3552. . . Date . . . . . . . . . . . . . . .JUG'. . . . . 22., 19. 69
THIS CERTIFIES that the building located at jg3S. - -Westpbalia.8aa&. . Street
Map No. .XI . . . . . . . . Block No. . . .ZZ . . . .Lot No. ZZ. . . Uttitne. . .50Z a . . . . . . .
conforms substantially to the Application for Building Permit heretofore filed in this office
dated . . . . . . . . . . $ap* . .26. ., 19.6$. pursuant to which Building Permit No. .
dated . . . . . . .jia91. . 27 . . . . . .. 19.6$, was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . .fifrato .aaCassery .buM- 1m. . 4-Ar'+or i. . . . . . . . . . . . . . . . . . . . . .
The certificate is issued to willioa.A .Lois. . Xiswisga . . . . . . .QW0111. . . . . . . . . . . .
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Building Inspector
FORK NO.2
TOWN OF SOUTHOLD
BUNA1NG DEPARTMENT
TOWN CLERK'S OI1FICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N° 4069 Z IA{o ...................u.w •f•w ••.• ...•........... 19...b•:
Permission is hereby prate to:
................•bitu.«.. ,.........................................
...............................:................................................
to .... ........».. «...»..,www....».»..a,».»w..
...............................................»..................................................................................................................
at premises,located at ...... .....................................00................w ......:...w
.................................. .............. ...........................................................................
................................................................................... .........................................................................
pursuant to applkotlon dated ..................... ........... �i.._.. ..., 19AA and approved by the �
Building Inspector.
Fee �.. ...........
w. 1(
,..............
Buil�aw
n �
FORM NO. 4
TOWN OF SOUTHOLD ' „ m
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y. k I ,�V1
I�j
CERTIFICATE OF OCCUPANCY
No .Z. 22a6.... ....... Date ....... ... ... .............jQyepE eP.... 19 b5
THIS CERTIFIES that the building located at ..W,I.S.....W.estphalia...Roan...... ......... . Street
Map No ... .......... Block No ....2=...... . Lot No ..=m.......MattitualC* ....N.,.Y.....I........
conforms substantially to the Application for Building Permit heretofore filed in this office dated
• ••••• • ......................iUtdber•..30•••••..•. 19.&.. pursuant to which Building Permit No . .250..Z
dated .... . .... . . ... ......QA.. ..... 30 ...., 19 6.4, was issued, and conforms to all of the requirements
of the applicable provisions of the low. The occupancy for which this certificate is issued is ........
.........private•-one• irml .y• dwe•1.1ing.... ...... . .. ........ ......... ........ I—... ...... .. ...........
The certificate is issued to .....Willism.S..Harrison..&..Wife...... ........ Aq;r.p........ ....... .....
(owner, lessee or tenant)
of the aforesaid building
H.D.Approval NOV- 3t 1965 by R. Yf11a
Building
FORM NO. z
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
2568 Z Date .....,.................$etoj)i ... .A"....... .. 19&-f..„,
Permission is hereby granted to:
lu i„1,��rt.. .... �, Qn•aF.. jfo.................
bQZ„..20— .. ......... ..................... ......... ..... —.
...........actut);wk• .............................I..............
to ...JIU .3A.•now..On,&..f , y.4well.ift.... ...................... ....... ..,..................................
..........
atpremises located at ......y/V....W46s .14.....R4D&&d.. . ............ .............. ...................................
......................................................... xt1.t kt. ...H.X.................................................................._
pursuant to application dated .., .......... ...................^ -tObftr...30., 19. ,.., and approved by the
Building Inspector
Fee $.10.00..........
.
,......... .Building Inspecto .... .........»...
......... ....
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ADDITION TO'THIS SURVEY IS
132 CLYDE STREET/SUITE 16 VIOLATION OF SECTION 7209 OF
WEST SAYVII.LE,NY 11796 NEW ram STATE EDUCATION LAW.
'FFL.-631-5630400 FAX-631-363-5908
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COMMONWEALTH LAND=E INSURANCE COMPANY r"YRtk!'1•»C r NO�24)15-21
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'DRA'4W"N:PM CIJECIC�P.,D11'Y:PM SCALE:1'-50' DIS7RI7r:1000 SECT10N:113 Ilf, &.N 13 _[.f3T(S):20