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Home My WebLink About1000-107.-6-12 TOWN OF SOUTHOLD Rental Permit = 1021 Owner Piotr & Alison Uklanski Occupied as Single Family Dwelling Located at 55 Knollwood Lane Mattituck 107.-6-12 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. 11/6/2023 Cod n ce ent Official This Notice must be posted by the main entrance at all times Town Hall Annex Telephone(631)765-1802 j�' P 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 4 MAR 2 7 2023 ry � BUILDING DEPARTMENT , � •: TOWN OF SOUTHOLD RENTAL PERMIT APPLICATION Rental Permit Fee $200(Application must be renewed every two years) Section A. Property Information: Rental Property Address: SG hoiiwood Lane A4aM fvcA� l/95.2 Tax Map Number: 1000 SECTIONBLOC 6 SECTION B. OWNER INFORMATION: �1 Property Owner Name: Property Owner Legal Address: Property Owner Mailing Address: 6 ;5 1<kiall►vood Lake5 eh,edlw6Qe�' 34T ci 3 b36S" (eel 1 Telephone Number(s): Daytime Evening Emergency Property Owner Email Address: CL-/ i h 61,e,YA d 1'i�tR r C 6Y� Page 1 of 5 Town Hall Annex Telephone(631)765-1802 54375 Main Road ;% Fax(631)765-9502 P.O.Box 1179 , y Southold,NY 11971-0959 �v A � BUILDING DEPARTMENT TOWN OF SOUTHOLD Section C. Authorized Agent Information: Name of Authorized Agent of dwelling unit, if any: C 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: Address of Managing Agent(no P.O. Boxes): Page 2 of 5 Town Hall Annex 0, Telephone(631)765-1802 54375 Main Road ( r Fax(631)765-9502 P.O.Box 1 179 �r } Southold,NY 11971-0959 cou BUILDING DEPARTMENT TOWN OF SOUTHOLD Mailing Address of Managing Agent: Telephone Number(s): Daytime Evening Emergency Email Address: 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: I q Use and Dimensions of each room in Rental Dwelling Unit: < � c � V, 13,1 x 22 D Ik) t . T ° � � 2-9 WA Ltd 1N Ct oSCT 11e -!- >t !� � �� ' �I V 11J6 A1'6 6,, 21'7" UbkooM 2. 1`4) 5. x 5 A.f' 3 uj P t 66P 4,00 3 0 b P e3of5 A V- r; Town Hall Annex '�'; Telephone(631)765-1802 54375 Main Road F� Fax(631)765-9502 P.O.Box 1 179 m� A� Southold,NY 11971-0959IOUN 4^ A�rl BUILDING DEPARTMENT TOWN OF SOITTHOLD 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 I am submitting a completed Town of Southold certification form from a licensed architect or a licensed professional engineer. SECTION H. DECLARATION: Signature must be notarized and MUST be the owner of the dwelling unit. STATE OF NEW YORK) ) COUNTY OF SUFFOLK) I WW 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 Page 4 of 5 Town Hall Annex Telephone(631)765-1802 54375 Main Road �� Fax(631)765-9502 P.O.Box 1 179 Southold,NY 11971-0959 o BUILDING DEPARTMENT TOWN OF SOUTHOLD 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. I 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 as to any change to the information regarding Authorized Agent, Managing Agent,or Site Manager. r Property Owner's Name: DTA 14 K-L4'N Property Owner's Signature: .._. .."" Sworn to before me this)T -day of Me-tcsn , 2003 Official Notary Public Sig 'ature a ginal Notary Stamp a � � M wty pow-!�of ow Yo*Noa 010002054U"" w11h 1�rRN In EOW'Wro Page 5 of 5 �&UILDING w TOW OF SOUTHOLD D 631-765-1802 0 • INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN LATIOWCAI [ ] FRAMING / STRAPPING [ ] INAL [ ] FIREPLACE & CHIMNEY [ FIRE SAFETY IN: [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (F,l1 [ ] CODE VIOLATION [ ] PRE C/OAM [� REMARKS• t -1 1) ( .............. ((e VI/i (1 c Poky, I x DATE Q Y� INSPECTOR BATH Q� IL fyO BEDROOM S dL 1219"x 257 ;f _ x 5'7 x T I BEDROOM 1 T6"x 19'8" r BALCONY 7'6'.21-5- G�V3 L.•v1 OPEN TO BELOW 2 MONA GROSS INTERNAL AREA FLOOR 2: 1820 sq.R � FLOOR 3:775 sq.ft EXCLUDED AREAS: DECK:2466 sq.ft,PORCH 59 sq.ft BALCONY 162 sq.ft << , aim 0/4-r- � � 1'` BWIMMWG POOL DECK 5B'B'%43'11' t BATH 57xlo'2' 3 - �� PRIMARY BEDROOM 11'5x19'1' !" „� G H.•'� - KITCHEN - DFORC.M w� 19'1' 220' vr.l7 9'1'x IBB' ,f _ - _. DECK DINING ROOM LIVING ROOM iTSz283' ITB'xry pp FOYER 11'lo•%BF 7'B•xTB• gg GROSS INTERNAL AREAr � FLOOR 2:.1820 sq.ft FLOOR 3:775 sq.ft EXCLUDED AREAS: DECK:2468 sq.ft,PORCH 59 sq.ft BALCONY 162 sq.ft air „ Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 a P.O.Box 1179 ° Southold,NY 11971-0959pl BUILDING DEPARTMENT TOWN OF SOUTHOLD RENTAL PROPERTY CERTIFICATION Form is to be completed by a license architect, licensed engineer or licensed home inspector Separate form is required for each individual Rental Dwelling Unit ero egslonal seal Lecluired for,Arcilitect or En ineer licensed Home Inspector must rovide gggy oI valid current certification Rental Property SCTIVI Number: "q v 10 - Z' Rental Property Address: '055 o&-L— Owner/Name: _ o -v v Rental Dwelling Unit Identifier: CAS -J i T i_ Number&Square footage of each bedroom as depicted in the attached floor plan: (i.e. Bedroom#1-100 sq., Bedroom#2-90 sq., etc.) iia n,,o,-L-, 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, and the Energy Conservation Construction Code of New York State. /A Print Name and TitleOrlgi aj Signature Please place professional seal: OF Nei TOWN OF SOUTHOLD PACIPERTY RECORD 1�► OWNER _ STREET VILLAGE DISTRICT SUB LOT vivv ACREAGE FORMER OWNER _ ` TYPE OF BUILDING S e S T t l SEAS. VL. FARM COMM. IND. CB. MISC. Est. Mkt. Value _ _ LAND IMP: TOTAL DATE R-NAA KS en !SoltLi t ILJ _ i 3 s, 0 t � a.m.. c, e� " BUILPING,CONDITION r , f NEAff- RMAL �� ABOVE I FRONTAGE ON WAXER a _ E — r Farm :�r ,�)4olue Perk Acr e FRONTAGE ON ROAD - Tillobte— ® BULKHEAD Tillable DOCK Tillable 3 _ _ -y - � s A/ _ _ _ - - Woodland � � ofet4 Swampland B sl 41 -- - - House PI& Tota I I o v 107.-6-12 2105 aONOWN 0 M. Bldg. y _ e ? Foundation . Bath f. Extension nsior C' Bosement Floors - - Ext nsio � 0 3 Ext. Walls interior Finish Extension K Fire Place , Neat _ — - - - e- - ........ r/ r Porch, Roof Type Porch Rooms i st Floor Breezeway Patio Rooms end Floor17 _ Garagerr/rr Driveway e E .- SCO } FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERIC'S OFFICE t �� ^'� SOUTHOLD, N. Y. I V I�+ CERTIFICATE OF OCCUPANCY No. .» w. 5.9.4..,...w.w», Date ...w......ww...ww................4 ....11 w, 19. .. THIS CERTIFIES that the building located at Street Map No. .=X.......... Block No. .......YJ=.... Lot No. A=....... ..............I.... conforms substantially to the Application for Building Permit heretofore filed in this office dated ..........•QOtokketr....28......... 196P.... pursuant to which Building permit No. .119P.7. dated ..........................CO.tObOr.....29.., 19.62.., 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 ........ .....ftVate...ox o—fammily...dmet 111ae....... ...................w. .. ....,...............wee .......w.....................- The certificate is issued to ....fix .. L'bUe1~1.eTIIlan—................DMC33lJ~.T:.........w. .........e.w4.............. (owner, lessee or tenant) of the aforesaid building. H.D.Appxoval MY 311 1963 by P. X jkowski ew '#...# ## W �#.#.�#.tw ....#w........... Building Inspector # FORM 1110.4 TOWN OF SOUTHOLD 41 ' BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy Z 1 2398 Date . . . . . . ARCH. 2.g . . . . . . . . . . . . . . . .. 1984 No. . , . Z Aaaztion THIS CERTIFIES that the building . .2 . . . . . . . . . . , • . , . . . . • . . . . . . . . . . . • • . . . Location of Property 2555. .GTKXC! ,Aye,., , , , . . . , , . 1"Iatta,tuek . , , . , • „ , House No. Street Hamlet County Tax Map No. 1000 Section Q.7 . . . . . . . .Block . . Q6 . . . . . . . . . .Lot . . . 01?. . . , , . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . .Lot No. . . . . . . . . . . . . . conforms substantially to the Application for Building Permit heretofore filed in this office dated Dec.Qtbox .25. . . , , 19(51.pursuant to which Building Permit No. . . . . . 1,1.5377. . . . . . . . . dated . . . . .J61XU8ry. .7. . . . . . . . . . . . . 19$2. ,was issued, and conforms to all of the requirements of the applicable provisions of the Iaw. The occupancy for which this certificate is issued is . . . . . . . . . For an addition to existing dwelling The certificate is issued to , John & Aur. . .+_ . Stack . _ . . . , M . . (owner ,lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . . . . . . . . . . . . . UNDERWRITERS CERTIFICATE NO. . . 5 9.9.3 6 9. . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . �,� -. . . . . . . . . Building Inspector Rev. 1181 R-w--1 Plov,ta tarp. 1, Box V-- ,& 16at t 1 tia c �!-Y. 11952 ,,qril 18, 1933 ,ir. Cu, Lis Horton ;;L)ijdi)i , hispoctor Town 11a.11 Dour Ml . flortor—, In vo Uio lmipeect.t()n o-J' U-10 'addition to av 4ouse, I roco-pizo the reason l'or tho fair-railin- requiremont, In, I 1� our ruse, 11ol-jovor, ,',ay I point out that tho stairway_;loads only to my studj,oin which I Imint* The :,Wirway is in a 11ouse occupiod onl� by two adults an(!' Cie PA,vd,lo is wlorsru.»Ily us only by enysolf. ji railtag, would be an "':Wipo'etimont to lcaver caymksew# For Urlese reasons, I reopootfully reapest a vrAriance of this re,;ujation and, do hereby absolve the building aepart-1--lent of any responsibility in this Witter. Thank yov for your intorost. Sincerely, o dolln I Stack FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: 2-30667 Date: 03 0i 0 THIS CERTIFIES that the building REPAIRS Location of Property: 55 nTOLLWOOD LA MATTITUCK (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 107 Block 6 Lot 12 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated SEPTEMBER 1 2004 pursuant to which Building Permit No. 30613-Z dated SEPTEMBER 2, 2004 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 REPAIRS TO EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to AURELIE D STACK (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED N/A c hor" ed S` nature Rev. 1/81