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Home My WebLink About1000-125.-1-13 of so TOWN OF SOUTH LD Rental Permit Ic 1504 Owner: 14065 Main Road LLC Occupied as: Single Family Dwelling Located at: 5075 Route 25 Laurel 125.4-13 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 ins tion. Issued: 06/24/2026 Expiration: 06/23/2028 de€nfo ern t ial This Notice must be posted by the main entrance at al tim ' TOWN OF SOU'rHOLD—BUELDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax(631y'765-95021111p w w r. o tholdtr wetly. ov RENTAL PERMIT APPLICATION Rental Permit Fee $300 (Application must be renewed every two years) «�SB9 Section A. M Property Information: Rental Property Address: 5075 Main Road-Laurel,NY 11948 My �km r Tax Map Number: 1000 SECTION 125 -BLOCK1 -LOTS'- SECTION B. OWNER INFORMATION: Property Owner Name: Benjamin Doroski Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) 830 Monsell Lane 830 Monsell Lane Cutchogue,NY 11935 Cutchogue,NY 11935 Telephone Number (s): Daytime 631.484.6481 Evening 631.484.6481 Emergency 631.484.6481 Property Owner Email Address: aos5170@gmaa.com om'sV%�. C"E'_A+ t r� Page 1 of 4 Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: Benjamin Doroski Address of Authorized Agent (no P.O. Boxes):830 Monsell Lane Mailing Address of Authorized Agent: Cutchogue, NY 11935 631.484.6481631.484.6481 631.484.6481 Telephone Number(s): Daytime Evening Emergency Email Address: �e,A-\ (6 C�AA A-i 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: 1 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: 1 Requested Maximum number of persons allowed to occupy Dwelling it: Number of rooms in Rental Dwelling Unit: 2 Bedrooms Use and Dimensions of each room in Rental Dwelling Unit: Ground Floor: Bedroom 1, Bedroom 2, Bath 1, Bath 2, Living Room, Kitchen Second Floor: Finished Storage - Non habitable 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. 0 I 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 SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) COUNTY OF SUFFOLK) I Benjamin Doroski 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: Benjamin Doroski Property Owner's Signature: Sworn to before me this "day of 20 Offici Notary Public Signature and Original Notary Stamp jOHN A,MAKi Notary Public-stag of New York No,OIMA6164838 oualified in Suffol Cnty y Commission Exp Page 4 of 4 TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 �; INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING / STRAPPING [ ] INAL [ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL F AL) [ ] CODE VIOLATION [ ] PRE C/O ] RENTAL RE7 C vi- c - ZW............... DATE INSPECTOR 52 SQ,FT OF NEW- EI?IiSNEO SPACE, R 21 WALLS R-30 CEILING -.2}_` ,. a ZEN DES' t s POST OFFICE I PHONE 53151 01 CUT 0 ,. € EDRO P 1 ..vim. BA 2 , - g NO ISSbs 3 SEASON �, SCREEN >3j ' I 01 s01 - _ €ORCH M 02 PERMITSET r z k s 03 REV Y a [ 9NIH I, i I - z - 1 i MIW04Lj REPLACE SOLID POOR —i r- l �f�hrMt . Irl scrE DO z I w; IL CONVFRT EXISTING ATTI ACHIEDSTORAGE SHED INTO 3 SEASON K'T uE- _ _, I SCREE';PORCH er [ M� S I ftQO -0444- SE-tiy a C'SLIDER,N F)XtS H f-3 Ro 6 0- STEP RESIDE , _- W75 MAIN E WALL TYPE EEG€i4'D vYMB01-L�GEV'LNY Ps�_ s SCfMa 1000 1 4E4 S;v4QKE CO2 DETECTOR 81 COUCH AF - — — NEW u ExiS I IQ POOR � FLOC Ai A®1 � 2- TOWN OF SOUTHOLD PROPERTY RECORD CALww --NER STREET VILLAGE DIST.1 SUB_ LOT i w, s FORM • ER OWNER N a ACR- s C = STING . -1U -- s SEAS. VL FARM l C �a C . MIS', Mkt Value LAND I MID. TA- DATE REMARKS tn- �An } t - s t AGE BUILDING CONDITION � NE V NORMLAL BELOW ABOVE = FARM Acre Volue Per vc�lue Aces F To"able Tillable 2 Tillable 3 Wcodlond Swampland i 1 �RON T AGE ON ROAD BsI — - - TA � � E ;louse Plot E � a a, L HE<AI T otol I DOCK b = s i = ' 4 COLOR - I I } - I : 1 7— TRIM 3 y r I i _ � c I t t : i ^ .as 1FF [ � 1 1 Bldg. ? , tFaundation _ -� Bath Dinette ,� " {� '_ � Extension �2ssm ®, x€ Basement r Floors K. AL fn f f i a r r ) Extensionfl t �� l t f E< Ext. Walls Interior i I to 'or Finish LR E Extension = !Fire Place Heat < , DR. Q.� F (Type Roof s Rooms ist Floor 1 BR. I Porch 3 Recreation Roo ,' Rooms 2nd Floo ; FIN. B. g, - Porch ( 'Dormer s I I Breezeway Driveway Garage I Patio 3 I I 0. B. _ Total A&A717 2 \\ C' FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. PRE EXISTING CERTIFICATE OF OCCUPANCY No: Z- 27923 Date: 0 07 fY . THIS CERTIFIES that the building _DWELLING Location of Property 5075 MAIN RD LAUREL (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 125 Block 0001 Lot 013 Subdivision Filed Map No. Lot No. conforms substantially to the Requirements for a ONE FAMILY DWELLING built prior to APRIL 9, 1957 pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z- 27923 dated SEPTEMBER 7, 2001 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 WITH ACCESSORY SHED The certificate is issued to HAROLD AVENT (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL NfA ELECTRICAL CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A *PLEASE SEE ATTACHED INSPECTION REPORT_ Aut �ized Si nature w Rev. 1/81 BUILDING DEPARTMENT TOWN OF SOUTHOLD HOUSING CODE INSPECTION REPORT LOCATION: 5075 MAIN RD LAURE;L SUBDIVISION: pw NO.: LOT (S) NAM OF ONNER (S): HAROLD AVENT OCCUPANCY: A-1 RESIDENTIAL HAROLD AVENT ADMITTED BY: HAROLD AVENT �. ACCOKPANIED BY: SAME KEY AVAILABLE: SUFF. CO_ TAX MAP NO.: 125.-1-13 SOURCE OF REQUEST: HAROLD AVENT 1�„211„01 �. DATE: 4D9 0" R) DWELLING: TYPE OF CONSTRUCTION: WOOD FRAME # STORIES: 1.5 # EXITS: 2 FOUNDATION: STONE & BLOCK CELLAR: PIT CRAWL SPACE: 50% TOTAL ROOMS: 1ST FLR.: 5 2ND FLR_: 1 3RD PLR.: 0 BA (S): 1.0 TOILET ROOM(S): 0.0 UTILITY ROOM(S): PORCH TYPE: DECK TYPE: — PATIO TYPE- BREE20DMY: FIREPLACE: ....a....,_......._._. GARAGE: DOMESTIC HOTWA YES TYPE HEATER: KEY SPAN GAS AIRCONDITIONING: TYPE HEAT: GAS MARK AIR: BO"TINATHR: _XX ...... OTHER: ACCESSORY STRUCTURES: GARAGE, TYPE OF CONST.: STORAGE, TYPE CONST_: WOOD FRAME, .._._.�, SWIMlQNG POOL: GUEST, TYPE CONST.: OTHER: �w .. _ __..w .........._.... ,w_..... ... VIOLATIONS: CHAPTER 45 N.Y. STATE UNIFORM FIRE PREVENTION & BUILDING CODE LOCATmN ..... _. _ T?SCFC'1�'PTION.... �� _� ART. p SEC". N N Q A � V d d REPAIR FLOOR) _......,___.._.REMARKS: BP g27598—Z—COZ-27922 (__....M_STRUCTURAL.. eim 9/4/01 ol INSPECTED BY: �,... INSPECTION- 0'1 29/_Gl MICHAEL J. VERITY TIME START: 9:45 AM END: 10:15 AM FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27922 Date: 29 O7 O1. THIS CERTIFIES that the building REPAIR Location of Property: 5075 MAIN RD LAUREL (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 125 Block 1 Lot 13 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 22 2001 pursuant to which Building Permit No. 27598-Z dated AUGUST 17 2001 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 STRUCTURAL, REPAIR TO EXISTING PARTIAL FLOOR SYSTEM IN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to HAROLD A"VENT (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N/A, PLUMBERS CERTIFICATION DATED NIA 2-�V-- Autho zed Sign ure Rev. 1/B1