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TOWN OF SOUTHOLD—BUILDING DEPARTMENT u
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 htt, s://www. outholdtownrt ,gv MAY 1 2026
RENTAL PERMIT APPLICATION
Rental Permit Fee $300 (Application must be renewed every two years)
Section A.
Property Information:
Rental Property Ad ress:
2 � l` �l
Tax Map Number: 1000 SECTION �� -BLOCK -LOT__
SECTION B.
OWNER INFORMATION:
Property Owner Name: Uji "o
Property Owner Legal Address: Property Owner Mailing Address:
(Cannot be the same as Rental Property Address)
T
Telephone Number (s): Daytime Evening Emergency
Property Owner Email Address: �7 D r(U �G( L4 10 ��Aa
Page 1 of 4
Section C.
Authorized Agent Information:
6r-1
Name of Authorized Agent of dwelling unit, if any:
Address of Authorized Agent (no P.O. Boxes): e' el—TZ P6�—W
Mailing Address of Authorized Agent: 1 `7 - 7
/ 2 e
Telephone Number (s): Daytimeql 7' �- Eve i�3`� � Emergency
Email Address: ti/ , SI D ( M.Q- '
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
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: 2
Use and Dimensions of each room in Rental Dwelling Unit: 3S
I le' 0
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
frorh the Town of Southold
0 lam 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)
i Mar P, jJ1 g,�Q 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 a bid e'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:
s�
Sworn to k e me thi day o 2
Offid I Notary Publi nat and Original Notary Stamp WERDY 1C1 A. '"l
T" 1" 7
u " in Sum t �
pis Eras A, ' .,�,..
Page 4 of 4
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Town Hall Annex � ^� ( Telephone (631)765-1802
631
54375 Main Road � Fax( )765-9502
Cz
P. O. Box 1179x
Southold, NY 11971-0959 '
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 En sneer Licensed Home Inspector must
rovide copy of valid current certification
Rental Property SCTM Number: �O —
Rental Property Address: ✓" ..-
Owner/Name: 6dao 0
�! 5
Rental Dwelling Unit Identifier:
Number&Square footage of each bedroom as depicted in the attached floor plan:
(i.e. Bedroom#1 —100 sqft., Bedroom#2—90 sgft., etc.)
Property Description (Include all improvements indicated on survey)
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.
Print Name and Title Original Signature
Please place Professional Seal:
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Of ° Town of Southold
P.O. Box 1179
53095 Main Rd
forr Southold, New York 11971
PRE-CERTIFICATE OF OCCUPANCY
No: 46907 Date: 03/12/2026
THIS CERTIFIES that the building PRE-CO
Location of Property: 51970 Route 25 Southold NY 11971
Sec/Block/Lot: 63.-6-6.3
Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 01/12/2026
Pursuant to which Building Permit No. 52755 and dated: 03/12/2026
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:
Wood frame single-family dwelling with an unfinished basement.
Comments:
Violations:
None.
The certificate is issued to: Unitarian Universalists of Sth
Of the aforesaid building.
Please see attached Housing Inspection Report.
A.ut o . ed Si Tue
Housin Ins ection Report
Property Info
SCTM# 63.-6-6.3 Property Class: 620 RELIGIOUS
Address: 51970 Route 25 Hamlet: Southold
Owners: Unitarian Universalists of Sth Condition of Property:
Structure
Type of Construction: Wood frame Number of Stories: 1 1/2
Foundation Construction: Block Number of Exits: 2
Finished Basement: No Cellar: Crawl Space:
Garage: Breezeway: Deck Type:
Porch Type:, Patio Type: Mudroom:
Building Systems
Type of Heater: Gas Radiators Fuel Type:
Hot Water: Boiler Electric Panel: Original
Air Conditioning: Fireplace:
Dwelling Components
Rooms/Floor Levels Sub 1 2 3 Additional Items:
Kitchen i
Living Rooms s
Dining Room i
Bedrooms 2
Bathrooms s
Toilet Rooms i
Utility Rooms i
Entry Areas 1
Other
Accessory Structures:
Garage: Construction: Foundation:
Barn: Construction: Foundation:
Shed: Construction: Foundation:
Sleep Quarters: Kitchen Facilities: Plumbing:
Swimming Pool:
Other:
Comments:
Violations:
None.
Inspected By: Inspection Date: