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Home My WebLink About1000-115.-14-5 of so TOTNN OF SOUTHOLD Rental Permit 1511 Owner: Carlos Sainz , Sainz B Trust, Sofia Sainz, Acdez Gonzalez Occupied as: Single Family Dwelling Located at: 1782 Theresa Dr Mattituck 115.-14-5 Maximum Permitted Occupancy: 6 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: 07/06/2026 Expiration: 07/05/2028 cod info meat ill This Notice must be posted by the main entrance at all times 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 WIL.//yyN so pldt� � �.� 0 E JUN 2 4 2026 RENTAL PERMIT APPLICATION Building Department Rental Permit Fee $300 (Application must be renewed every two y°I arsw of Southold Section A. Property Information: Rental Property Address: Tax Map Number: 1000 SECTION 3 _ --BLOCK 14 -LOT 5 SECTION B. OWNER INFORMATION: Property Owner Name: 5A( N Z- Property Owner Legal Address: Property Owner Mailing Address: (Cannot be the same as Rental Property Address) Telephone Number (s): Da time Evening 6 Emergency Property Owner Email Address: 6A6'L&6 I:zc LAN DO'�Pgt-17_&h5t-4'60m Page 1 of 4 Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: A SLL'2 -2- Address of Authorized Agent (no P.O. Boxes): 5-15 Mailing Address of Authorized Agent: A Hk Telephone Number (s): Daytime Evening t Emergency Email Address: GrkAZ LC iZ 0 L-A tA 0 0 6 A i t4 Z- CE17 1-15 N - <�O t-1 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: Use and Dimensions of each room in Rental Dwelling Unit: Do lz 0".-11" ..,` De k2` rc� 1 `i 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 afire 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. 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 JZL06 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: ,At �AIi�C Z Property Owner's Signature: d Sworn to before me this�� day of w1� _, 20—,2& t Official ignature and Original Notary Stamp - - - - - - - - - - - - JIE ZHEN FENG Notary Public-State of New York N0.01FE6276583 Qualified in Queens County My Commission Expires Feb 19,2029 Page 4 of 4 1 i 14f SO TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 I No zS' P E%ChT 1 (36� N [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ RENTAL REMARKS: O IL �� jo .......50r\ oc�uw DATES INSPECTOR Town Hall Annex � `ea Town of Southold 54375 Main Road Rental Inspection Report PO Box 1179 Southold, NY 11971-1179 � Tel: 631-765-1802 SCTM# Date Owner SOUiA Phone Address a Sf- 2- Visible Hamlet Inspector Floor Level Quantities Sub 1 2 3 Smoke Detectors(not located in bedrooms) Carbon Monoxide Detectors Fire Extinguishers Exits Bedrooms 1 2 3 4 5 6 Smoke Detectors Egress Occupant Count Building Systems Maintained &OperationaHHandrails.& Condition of Property Heating Building interior Hot water Building exterior Electrical Property clean, maintained &safe Mechanical guards installed &secure Pool Safety Pool on Site Surface water alarm Date of CO issuance Door alarms Pool completely enclosed Self closing/latching gates Pool fence to code requirements CO s for all items present Comments: a } p Flo S us to E) VIEW t 1611 Ai 1_0 v � � u v,, _ tot ( f4 ` f • . � v € -- _. a = -Lii AMEXE } �' SID vw _ s i O GLb. MCp, yMOKE1G0. OETEGTOR TOWN F S UTH LD PROPERTY RECORD ,I a OWNER STREET %' r` VILLAGE DIST I SUB. LOT f 3 FORMER OWNER N E ACR. a , _ S g W TYPE OF BUILDING 3 RES. J - SEAS, VL. j FARM COMM. CB. MISC. MI<t. Value LAND IMP, TOTAL DATE REMARKS f� , _ j g f ; •� f f� "yam li 16, a NEW---` ��L � V =`E FARM Acre Value Per Value C'-0'?�b� Acre [ " a l-_ � s Tillable 1 - Tillable 2j f '_ -7to 61 Tillable 3 3 C,c7 LID, Woodland Swampland FRONTAGE ON WATER Brushland FRONTAGE ON ROAD l House Plot iDEPTH 'BULKHEAD Total DOCK 1 t 3 O;`_ s y COLOR ; c � i ' 3 TRIM 4 _ \\ems �� o. - aa _ e Q = I 115.-14-5 3/2014 _ x B M. Bldg Foundation B e ath Dinett r= 3 �Extension . Basement c Floors � �° K� , w r _ t = _ r Extension .. a _ Ext. Walls „ Interior Finish r , LR� _� Extension Fire Plac Heat DR. % �_ _ ;' £Type Roof £Rooms 1st Floor = BR. v i Porch - _,, ; Recreation Room =P.00ms 2nd Floor FIN, 4 Breezeway Driveway I - - — Gargt? — Patio_ [ O. B. ' Total I C � a FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z5050. . . . . . Date . . . . . . . . . . . . .Maroh . . .29 . . ., 19 73 . THIS CERTIFIES that the building located at . rasa.Dr. .Wt .44. ). . . . Street Map NoDeep.Hole.C eoOgck B ta.tes. . . . . .Lot No. 4. . . MattitucY. . .N.Y.. . . . . . . . . . . lo Io. . . . conforms substantially to the Application for Building Permit heretofore filed in this office dated . . . . . . . . .Oct. . . .3Z. . . ., 1972. . pursuant to which Building Permit No. .622--tZ dated . . . . . . . . . . .MOV . . . . 3 . ., 1972. ., 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 . Private .Me 10itUy.ftelUxt, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The certificate is issued to .John. vap. • • . • • • .Owner. • • • . • . • . • • • • . . • . . . . . . . (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval Mar.., .16,. .t973. . . . . . . . . . . . . . . . UNDERWRITERS CERTIFICATE No. . 3177453 . . . . Mareh. . .129- 1973. . . . . • • . . . . . • . HOUSE. NUMBER. .1.782. . . . . . .Street. . . - They"rssa•Dr3, t. . . . . . . . . . . . . . . . . . . . . . . . . . Biiildiiib Inspector .......... Town of Southold Annex 10/25/2013 P.O.Box 1179 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36581 Date: 10/25/2013 THIS CERTIFIES that the building DECK .............. ...Location of Property: 1782 Theresa Dr,Mattituck, SCTM#: 473889 See/Block/Lot: 115.-14-5 ... .............. Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 10/18/2013 pursuant to which Building Permit No. 38420 dated 10/18/2013 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; deck addition to a Lq�pijq_famj y dwell% applied for. -i — plAs a_ The certificate is issued to Savage,Alice .............. (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED ............................ re Au �ed S' tP0l,�� Town of Southold 4/16/2019 P.O.Box 1179 re 53095 Main Rd wa a Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40323 Date: 4/16/2019 THIS CERTIFIES that the building WOOD STOVE Location of Property: 1782 Theresa Dr., Mattituck SCTM#: 473889 Sec/Block/Lot: 115.-14-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/28/2019 pursuant to which Building Permit No. 43593 dated 3/28/2019 wYWmmW„ 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: W0017l3" 1N0 S COVB'1N AN B ISTiNC101111 1 AMILY DWELLING AS APPLJ8171'Qjk The certificate is issued to Sainz,Carlos&ors of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED _._...... _m ,... ................... hor`,- Signature