HomeMy WebLinkAbout1000-114.-11-16 of so TOWN OF SOUTHOLD
Rental Permit
1491
Owner: NF Envrmmntl Council Inc
Occupied as: Apartment
Located at: 12700 Route 25 Mattituck 114.41-16
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-annual inspection.
Issued: 06/06/2026 Q� �6
Expiration: 06/05/2028 c° �� official
This Notice must be posted by the main entrance 0all es
�LLnS f� r E .
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12e C �-
s� 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 l tp.�-//nmr so tholdtoW,.,ti ,m p-y
RENTAL PERMIT APPLICATION
Rental Permit Fee $300 (Application must be renewed every two years)
Section A.
Property Information:
Rental Property Address
Tax Map Number: 1000 SECTION -BLOCK . , _ --LOT
SECTION B.
OWNER INFORMATION:
Property Owner Name.
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
Telephone Number (s): Daytime .2v> E v e n i n Emergency f `�
i t4 � r- e.n
Property Owner Email Address:
k
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:
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: IV ' A
Address of Managing Agent (no P.O. Boxes):
Mailing Address of Managing Agent:
Telephone Mumber (s): Daytime Evening Emergency
Email Address:
Page 2 of 4
SECTION F.
PROPERTY DESCRIPTION:
Number of Rental Dwelling Units on property: �ww.
For each Rental Dwelling Unit set forth the Rental Dwelling Unit identifier (for example,
Unit 1, Unit 2, Unit 3 or Apt A, B, C); 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:—ww
Use and Dimensions of each room in Rental Dwelling Unit:
w,,�A 0 0
`7
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
C=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 NEW YORK)
COUNTY OF SUFFOLK)
1Solsctn AL��►rl�i�, certify under penalty of perjury, the following:
A
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: 0K-VCKT '. 0 U��
Property Owner's Signat re,
Sworn to before me this)` day of 20
rx
Official Notary Public Signature and Original Notary Stamp
CC7NNiIM D.BUNCH
Notary Public,;state of New York
No.01BU8185050
1 uaiifled in Suffolk County 1
Commission Expires Apr11 14, 2 dad
Page 4 of 4
2 �
TOWN OF SOUTHOLD BUILDING DEPT.
631-765-1602 - ,
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lNmop =CTl0h' N
[ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS LATION/CAULKING
[ ] FRAMING /STRAPPING [ ] NAL
[ ] FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PEN TRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (F AL)
[ ] CODE VIOLATION [ ] PRE C/O [ RENTAL
R MARKS.
DATE INSPECTO
4
20 /a X P.0 Box 1444. WOO Route 25
matbtuck, NY 11952
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TOWN OF SOUTHOLD PROPERTY RECORD CARS_
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OWNER. STREET I VILLAGE DIST SUB. LOT
E E WNER N E ACR _
vi-3 1 oc, _
jeg
S W _ TYPE OF BUILDING
- 71 -.
RES. . SEAS. :V T ;FARM OMM CB. MISC.� Mkt. Value �6 c
LAND IMP, TOTAL DATE REMARKS
_ i
uof
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3
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xn
NE'<V NORMAL BELOW ABOVE
FARM Acre I Value Per I Value =ate=
Acre
Tillable 1 -
>.
Tillable 2 a
E
Tillable 3 5
I
3
Woodland ° _
Swampland ,# FRONTAGE ON WATER - z
Brushland E FRONTAGE ON ROAD :
House Plot DEPTH
e
41
BULKHEAD
Total DOCK
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COLOR
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TRIM —
e
A RUN
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114.-11-16 4/09
g
M. Bldg a = Foundation
1 F Dinette
F o 1 to
Bath
Flo_ t{= Basement r ors s .F�.
r
I�
Extension
ok
Interior Finish s LR�
!Ext. Walls -4
3 i
4 Fire Place - �, DR.
Extension - f r
Heat
t
I I
T e Roof I FTRooms 1st Floor x BR.
t
yP
Porch Recreation Room! 'Rooms 2nd Floor FIN. B
Porch i Dormer
� I
Breezeway I Driveway
3
E
Garage
Patio
Total
Of SOU� Town of Southold
P.O. Box 1179
53095 Main Rd
° %Nr Southold, New York 11971
PRE-CERTIFICATE OF OCCUPANCY
No: 47118 Date: 06/06/2026
THIS CERTIFIES that the building PRE-CO
Location of Property: 12700eRoute 25 Mattituck,, NY 11952
Sec/Block/Lot: 114.-11-16
Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 05/22/2026
Pursuant to which Building Permit No. 53052 and dated: 06/06/2026
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:
Brick and wood frame commercial building with two offices, apartment and attached
carport.
Comments:
BP 1703 addition/alterations for living room in existing apartment CO 1387
Violations:
None
_w..�.._ �rm......w. t w_,... Inc _._...... .w..................................... .
The certificate is issued to: NF Envm�tl Council mmmm_w_w,�w_IT -.µ.
Of the aforesaid building.
Please see attached Housing Inspection Report.
..........,�..._............_....._.. _ ..A � ��`��r` c 'ignature...�ww._._._........__._..__._.__............_,
Housing Inspection Report
Property Info
SCTM # 114.-11-16
Property Class: 484 ONE STORY SMALL STRUCTURE
Address: 12700 Route 25 Hamlet: Mattituck
Owners:..... NF Envrn....m_.._........ _ , ...._..... _w w .....-._....www .................. _._.. .........-.....................-._........._..w.............._
mntl Council Inc Condition of Property:
Structure
Type of Construction: Brick and wood frame Number of Stories: 1
..__........�.........................._... __....._w..w._._................. ..... .. _..w_w.ww........W...._..www......_.... _.. _.. .._
Foundation Construction: Brick Number of Exits: 1
F' Partial _ Ce I l a r: _.........Ct...... .._....._.._..._. _.�...�...................................................---
....finished Basement____...._.�..w._.___.__............................_........ ... ........ _,,,.���..... awl Space:.
Garaa _.w_........_.�........ ._......__w_....................._ _ w.ww.._.....................B _..........._.�,ww. � w_.......wwww...wwwww..wwwwwww.wwww_....
_..._.._._ __ wwwwwwwwwww_w_www.
Breezeway: Deck Type:
_�.. ......._..........www.
Porch Type: Patio Type: Mudroom:
Building Systems
Type of Heater: Baseboard Fuel Type: Oil
Hot Water: ............Electric ......w....__......mm..�...m_..._..................... ._.._._.._........._.__.....__..._... _._._._._._..... � __.........._ww_w_w
Electric Panel:
:... .w ........._mm_ w_ ....www_..........._.._............m.�._._._. ...... �_ _....................�. w. ...,. ...,.,.
Air Conditioning: Fireplace: Yes
Dwelling Components
Levels Floor Rooms/ Lev Additional Items:
_.... __._....... __... Sub ..'. ._.1 . '_.w_2__.. _ _._3 _.._ __ _.. ..... ._.................. .. ,
Kitchen 1
Living Rooms
Dining Room 1
__.__........._........_w�._. _........_..._n ........ w_.w_.....M. _www _......w.w.w_...._ ...�....... .. _.......................................__ _�.. ..............
Bedrooms 2 _
............ .........w_._......
Bathrooms 1
Toilet Rooms ..__...w _ .__ _.._........w.
Utility Rooms
Entry Areas
____......._......................_............__. w_....................
Other Attached carport
Accessory Structures:
Foundation:
Garage _.—
.._.._ww..................... �...."""...�...................._. Constructio.n:....�..k...w--._._._._._._._._._._._._.. w._.___._._...........___........�............................_ _.......... �M....._......
�
Foundation
Ba..rn .. ...__......ww.............._._.___._...._..... ...w..............ww..........Constructio�n�..._.._�. ..._._._._._._...� w_...____.........._._.�_�_�_. w�._..... _ .. _�........... ........._.
Shed: Construction: Foundation:
--------
Sleep ................_...__www...�.........................�w..... Kitchen F.�.�.�m�_...m...._._._..�. w____.._....._............_...._ww� __.....................,.,..�.......w�_���. ..
p Facilities: Plumbing:
.._.�...w.w__. ....................._�.M,--
Swimming Pool:
Othmer:......._.
Comments:
Violations:
None
p y�ww_..w �...._._._........_.......... ww_.w ...... ........p Date: Ilf�/CJ5025
Inspected B John J Jarski Inspection „am � 5 .µwwww _w....
F61M NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
No, -Z ..1.387............ Date .............................o7=4—.29......... 19-42.
THIS CERTIFIES that the building located at .-OV-&-a-lide Street
Map No j=............ Block No ...3=........... Lot No. .,%=.......Mattktwk............. ...........--
conforms substantially to the Application for Building Permit heretofore filed in this office dated
......... .....................AW 3.1..........13..... .. 1962... pursuant to which Building Permit No ..Z..1703
dated ---- - --- ..........A-Pr-11- ..... ..1-3...... 19,-62,, 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
......... ....Duadmass..Vt-f-j40(?--j&..Regidelwa .......11----.........I--.............. ...........
This certificate is issued to ....AjbP-r.t..8.J.jkWW.th.................... ..01jnj4aV.......... ..........
(owner, lessee or tenant)
of the aforesaid building.
6u�i U`n-� I nspector
FORM NO. 2
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)
No 1703 Z Date ........ 1962....
Permission is hereby granted to•
A. .. ..Son.. ,.lb*rt..S11kv0rth.,..,,
ttn�k................ .. .... ......................
to Build."an..addit-Im.A.Aake••a. ratit " -on- ...........
at premises located at F,M..... , ..BoeA.i...)%tt4—tuck'v llage.... ... .•..... ......................... ..
....... ..........#a k....9.-T...... .... ....... .........,..,........,.,...................,.........,.
........... .................... .................................. ........."......... ,.. ...._. ............. .....,,..........,.....".. ....
pursuant to application dated . ..,, .,•.......... ...... ...........196a. ., and approved by the
Building Inspector
Fee $• .............
Bui Id ing`.I nspector........ ...............