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Home My WebLink About1000-66.-2-12 i4f so SOWN OF SOUTHOLD Rental Permit 00 . E 1510 Owner: Molly Harris Occupied as: Single Family Dwelling Located at: 570 Hippodrome Dr Southold 66.-2-12 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: 07/10/2026 Wa49 Expiration: 07/09/2028 6de orcement Acial This Notice must be posted by the main entrance at all times TOWN OF SOUTHOLD—BUILDING DEPARTMENT f Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 Telehon C ) 2 Fax (631) 765-9502t / r clala) ltrtcy RENTAL PERMIT APPLICATION hermit Fee $300 (Application must be renewed every two years) Section A. Property Information: Rental Property Address: 9 (� ; mJ,� (�� IR4 I I q I�, l I � rJ 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) C tLl '�(- a 60' �' . ,. � 5 Telephone Number (s): Daytime Evening Emergency Property Owner Email Address: of"-c e � Page 1 of 4 so Town Hall Annex 1 t►�( 765-1802 54375 Main RoadCA " 6Lii P.O.Box 1179 Southold,NY 11971-0959 BUILDING DEPARTMENT1a " TOWN OF SOUTHOLDrw» ' r ". 55 RENTAL PERMIT APPLICATION INSTRUCTIONS Effective September 27th 2023 Rental Permit Fee: $300 (Application must be renewed every two years) The items listed below are required to be submitted with the completed application. ■ Floor plans: Floor plans of each rental dwelling unit, please show location of all smoke & carbon monoxide detectors. 1-CJ- okk • Certificates of Occupancy and Pre-Certificates of Occupancy: Certificates of occupancy or Pre-Certificates of Occupancy for each rental dwelling unit. � bp ■ Certification of Code Compliance (form enclosed): Must be submitted by a license architect, engineer or license home inspector if an inspection by Town of Southold Inspector is declined. • Rental Permit Fee: $300.00 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 555 86!� L4),,s,,C(;f&�usqk Telephone Number (s): Daytime Evening (P 31 9Emergency Email Address: CO 00(�)0 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, 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: Use and Dimensions of each room in Rental Dwelling Unit: W - t Ca sin Qom, 11 H x a3 5' I4) 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 ❑ 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 � ' , 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: � Property Owner's Signature: � Sworn to before me t4 n day of �u�- 20_cW 4-n Official Notary Public Signature and Original Notary Stamp CONNIE D,BUNCH Notary Public,State of New York No-01BU6185050 Qualified in Suffolk Count)yy.,, Commission Expires April 14, Page 4 of 4 of so ; TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 I I'mm fwi& P E(oft;T 10 N [ ] FOUNDATION 1 ST/ 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 [j,-r`RENTAL REMARKS: C��ie� pew S o f a Aw DATE �"�� R P ECTOR _ Fol Town Hall Annex ®� � '•� Town of Southold 54375 Main Road Rental Inspection Report PO Box 1179 Southold, NY 11971-1179 Tel: 631-765-1802 SCTM # Date �-q•a�o Owner HeL W Je4 S Phone Address 570 2-oµt 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 &Operational Condition of Property Heating Building interior Hot water Building exterior Electrical Property clean, maintained &safe Mechanical Handrails&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 —pelor Rental occupants: Comments: l 1 TOWN OF SOUTH .OLD PROPERTY R1 OWNER _ STREET VILLAGE DIST1 SUB. LOT Yi f F s FORMER OWNER N E ACR. S W TYPE OF BUILDING RES. Z , SEAS. VL. FARM COMM. CB. MISC. Mkt. Value LAND IMP. TOTAL DATE REMARKS t { °7 J d t z 4� 1 j AGE BUILDING CONDITION _ NEW NORMAL BELOW ABOVE of FARM Acre Value Per Value Acre Tillable 1 Tillable 2 I Tillable 3 I I R Woodland 1 Swampland FRONTAGE ON WATER /r a 1 FRONTAGE ON ROAD Brushland � � � House Plot i DEPTH E !BULKHEAD E . Total DOCK 1 F i wry/ I ' - >LOR I f . F I . 6M Y E _ s � f 4 . f � RL s I . . i 66.-2-12 2/08 z M. Bldg Foundation ` Bath = Dinette Extension w p Basement i � G Floors !a '` K. Extension 'Ext. Walls �:` ,I �, I nterior Finish LR. i j� ., _ ------------ Extension Fire Place Heat �c? 4 c DR. = iType Roof Rooms 1st Floor BR. Porch Recreation Roo l Rooms 2nd Floor FIN, B. Porch ;Dormer i i Breezeway 1 Driveway I Garage Patio O. B. i Total � �: r J✓'-- � � �� FORM NO.4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold,N.Y. Certificate Of Occupancy No. . . . .z 14 7 7 9. . . . . . . Date . . . . . . . A u gu s t .9... . . . . . . . . . . . . . 19 86. THIS CERTIFIES that the building • ,One fami ly. dwelling . . .. . . * .. . . . 4 .* . . . . . . Location of Property 570 Hippodrome Road . . . . . w Southold, N.Y. Ao" IVo. . 066 06�i 12 . Hamlet County Tax Map No. 1000 Section . . . . . . . . . . . :Block . . . . • . . . . . . .. . .Lot . . . . . . . . . .. . , . . M/o Biexedon Ests , p 14,72 Subdivision .. . o . . . . . . . . . . • . . . . . . . . . . .. . . .Filed Ma No. . . .Lot No. . . . . . . .. . , ,. . conforms substantially to the Application for Building Permit heretofore filed in this office dated . . .N Q,v a'a0 P r. .1 Q,. . . . , 19 71.pursuant to which Building Permit No. , , .5 6 2 8 z . . . . * . . dated .November. 15!.. µ . , • ., 19 . 7�,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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . .: . . . . . , , . . . , The certificate is issued to . . . . . . . . . . . . . . • • ,Roger. Roth µ . M . » + (o •, r y . . .. . . . of the aforesaid building. Suffolk County Department of Health Approval .. JUri9. 2 7,, , �9.7.?. , AY ,R;. V i 11a w . . .... UNDERWRITERS CERTIFICATE NO. . .• . . , . . . . . 1802,4! . . . . . ,, , , . . ., , , ., ,. .. . . . . .. . . .. Corrects CO z4707 0000, Building Inspector Rev.1181 t FORM NO.Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. k BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N° 5628 Z Date ........................ . ...' :...., 19... . Permission is hereby granted to - ......`..fly��..............................�................... ................................................................................. t0 ....................s......................................+.................... ..a.ass...............................s..............o- .I ............ ................ s..................................................................... at premises located at .. ... .�.., ... ....� . .............................................. ..... ........................ . ......... « ......................................... .........................................I....................w...................,...............,............................................................... pursuant to application dated ........................... .:........S#1........... 19.... and approved by the Building Inspector. Fee $..... lt�....... ..... .. .. ....... .'�.. Xldin .. .. .. .. . .................... ..Buig Inspec FORM NO 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. .Z4707 . . . Date . . . . . . . THIS CERTIFIES that the building located at PVT-Rd .off. Zippadrme Rffitreet Map No. Bejxedon L mock No. . .tt . .Lot No. 10 . . . /v conforms substantially to the Application for Building Permit her fo �t`n this office dated Noy,r, 10 ., 19. ?1 pursuant to which Building Permit No. 56:2FZ dated . . . . . . .NOV 15 , 19. 71, 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 ptivr.we owe fain-41.,,' d ell-;reg . . . . . . . . . . . . . . . . . . . . . . . . . The certificate is issued to Roger Roth . . . . 0Imcr. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval 2.7 .1972. .by. R. Villa UNDERWRITERS CERTIFICATE No pe--ic'zL ig. . . . . . . . . . . . . HOUSE NUMBER .570 Hjpp &e Td, BLUldln 6 Inspector ! S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH JUN re_' 7 1972 Date Bldg. Permit No . TO WHOM IT MAY CONCERN: The sewage disp�osal facilities for a structure located + at 0-t (Give deed loc ion) have been inspected by this department and found to be satisfactory. ��;�a � F 1372 � ��• �s�� Ohief FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY NO: Z-33387 Date: 11/14/08 THIS CERTIFIES that the building ADDITION/RENOVATIONS Location of Property: 570 HIPPODROME DR „. ._........... mS„OUTHOLD (HOUSE NO.) (STREET) (HAMLET) Section 6 6 Block 2 Lot 12 County Tax Map No. 4"7' 9. . ,_ ........,..___�._ Subdivision _ .................__......._...._ Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated FEBRUARY 3 2006 pursuant to which Building Permit No. 31800-wZ dated FEBRUARY 16 2006 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 SCREENED PORCH ADDITION AND RENOVATIONS TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to KATHRYN A CAMPBELL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF BEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 108340C 06/30/06 PLUMBERS CERTIFICATION DATED 09/15/06 MATTITUCK PLUMBING Au, orized Signature Rev. 1/81 �z �n - to AL s e 10 E -. 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