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HomeMy WebLinkAbout43250-Z Town of Southold 4/12/2019 ti P.O.Box 1179 '= 53095 Main Rd ��✓�jZ01 Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40315 Date: 4/12/2019 THIS CERTIFIES that the building ADDITION/ALTERATION Location of Property: 6105 Wickham Ave, Mattituck SCTM#: 473889 Sec/Block/Lot: 107.-4-2.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/15/2018 pursuant to which Building Permit No. 43250 dated 11/28/2018 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: PORCH/LANDING ON AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to White,Laurie of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED A t ' ed Signature o�S�FF TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE Py • SOUTHOLD, NY dol � Sao BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 43250 Date: 11/28/2018 Permission is hereby granted to: White, Laurie Tuthill Ln Mattituck, NY 11952 To: reconstruct an existing porch/landing as applied for. At premises located at: 6105 Wickham Ave, Mattituck SCTM # 473889 Sec/Block/Lot# 107.-4-2.2 Pursuant to application dated 11/15/2018 and approved by the Building Inspector. To expire on 5/29/2020. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $209.60 CO -ALTERATION TO DWELLING $50.00 Total: $259.60 uil nsector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets,and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial building,industrial building,multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. " 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957)non-conforming uses,or buildings and"pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy- $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 1e Date. lam'OJ t J tit 2c)( 0 New Construction: l/ Old or Pre-existing Building: (check one) Location of Property: b (0 5 W `C V_t QF L) House No. Street Hamlet LOwner or Owners of Property: _lA'/'V2 (Cri -r Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary CPrtigcate Final Certificate: (check one) Fee Submitted: $ AJ Applicant Signature v �� Of SO(/lyo # # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm, 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION ,. [ ] FRAMING /STRAPPING [vilINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECT ON [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: � N k tfu Cwvti al 01 ✓ � � "m bak - - a A� �69J kL ND/> W 7� u v,J k - TO n Aw blo� DATE 3 a INSPECTOR 4 OF SOUTy�� # # TOWN OF SOUTHOLD BUILDING DEPT. °yi'ouff 765-1802 INSPECTION ' [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [" ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE INSPECTOR -�� � � - � r� 1 -- o � ; r — __ w __.�... © � t , � t��� r � � �,• is .t ' 1 � 2 # ' y �.3 a -.. �•`� - ��t- ,, ��:� . � .. ��a r. 's .+JiY V 9 w Y� ♦ V -*Prim a. A ry r r ski �����.� '..a +ry.{ '�1f:��� �} �„ �, �" :, ; �, _- 1 i � �, � ; ��, �, r a � .....� � t� f . i. �!.^ �' � _ _ * - A � � I FIELD INSPECTION REPORT DATE COMMENTS ' b FOUNDATION (1ST) -----------=------------------------ 'FOUNDATION (2ND) �- O ROUGH FRAMING& PLUMBING ® r y INSULATION PER N.Y. y STATE ENERGY CODE ` u®o ` FINAL JAV t ADDITIONAL COMMENTS - � - z _ rn �. d 5 , 0 z d b y TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST r .i BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX: (631)765-9502 Survey Southoldtownny.gov PERMIT NO. 7Check Septic Form MY S D.E.C. Trustees C.O.Application Flood Permit Examined 20 Single&Separate Truss Identification Form Storm-Water Assessment Form 2 �� ontact: Approved 20 Mail to: STVV(K - Disapprove a/c — rr Phone: ira4iI Building Inspecto ,NOV 1 9 2018 APPLICATION FOR BUILDING PERMTT 3� Date P Gil T' ,20 i i�te ' � ;1 INSTRUCTIONS TOWN OF SOUT OLD a.This app ication MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant.Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. A (Signature of applicant or name,if a corporation) /Ze o wk14svi15 f 11S"/ MAI tJ RD I l2\yc---Q"C--A to �J-/e f 1q0 r (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer, eneral contractor,electrician,plumber or builder Name of owner of premises W(-} ( 7-F-- (As '+`(As on the tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) Builders License No, S f l-G 1$ 14 Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will a done: G)O S "1C, VA.ta,-y - 1 '-f�J �t i tet. L ct NC- 11A 140- 'I 7 -(tie L¢ House Number Street Hamlet County Tax Map No. 1000 Section (0-7 Block Lot 2-1 . Z Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and oc pancy of proposed construction a. Existing use and occupancy. �C &a.,,\no_� \r-CJv -p - b, Intended use and occupancy 3. Nature of wor check which applicable):New Building Addition Alteration Repair Removal Demolition Other Workcoc e_ (`cc)vvk tp o rC� —dKD (Descnption) C_V'.b.c.•.�2 4. Estimated Cost �'Z a� Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9, Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO 13 Will lot be re-graded?YES_NO Will excess fill be removed from premises?YES_NO_ 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?*YES NO *IF YES,PROVIDE A COPY STATE OF NEW YORK) SS: COUNTY OF_____) f%C>NNIE D. 1311NC1-I being duly sworn,deposes and saW;flM' York (Name of individual signing contract)above named, 0.0113496155050 Qualified in Suffolk County (S)He is the Commission E)fnirpc Ar)r1l 1 n nr11 r l (Contractor,Agent,Corporate Officer,etc.) ' of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief;and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me thisp _day of t)Uy 20 Notary PubliC Signature of Applicant OF SOUTgQI � o Town Hall Annex Telephone(631)765-1802 54375 Main Road cn Fax(631)765-9502 P.O.Box 1179 G.c1 • Southold,NY 11971-0959 Q lyc®UNTY,'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD STOP WORK ORDER TO: Laurie White 6105 Wickham Avenue Mattituck, New York 11952 YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: 6105 Wickham Avenue, Mattituck S.C.T.M. 1000-107-4-2.2 Pursuant to Section 144-8 of the Code of the Town of Southold, New York, you are notified to immediately suspend all work and activities until this order has been rescinded. BASIS OF STOP WORK ORDER: Bounced check for BP 43250 issued 11/28/2018. The Building Permit has not been paid. CONDITIONS UNDER WHICH WORK MAY BE RESUMED: When the Building Permit has been paid for at the office of the Town Clerk. Failure to remedy the conditions aforesaid and to comply with the applicable provisions of law may constitute an offense punishable by fine or imprisonment or both. I�TE 24/ 19 J n J. r i e for uil In pector (Ce . Bunch, Connie From: Rudder, Lynda Sent: Thursday, January 24, 2019 9:59 AM To: Bunch, Connie; Silleck, Mary Subject: returned check ti Importance: High AMS Home Improvement has NOT paid. Please put a stop work on the building permit immediately until this matter is taken care of. 4,0V,z //W RW, Lynda M Rudder Principal Account Clerk `UA o o Southold Town Clerk's Office j�0 53095 Main Road,PO Box 1179 Southold,NY 11971 -D 631/765-1800 ext 210 631/765-6145 ru Certified Mad Fee _ Irl EaFa Services&Fees fcheck box,add tee as appropriate) ,+4" 6 � 0 Ratum Receipt(hardcopy)' $ r-q []Return Receipt(electronic) $ O Post", 1 Q []Certified Mail Restricted Delivery $ M []Adult Signature Required $ C3 ❑Adult Signature Restricted Delivery$ Postage Total Postage and Fees C3 U1 Sent To 0 ,';' ^�� Wk `�\ i r-9 ---------------------------------- --------------------------------- C3 Street and t No.,or EO B N + ------ ------ - l ---r City,State P 4® , �/ + p i e� t sECTON ON DELIVERY, ® . ETH . • A. Signature ', i ■ Complete items 1,2,and 3. ®Agent m Print your name and address on the reverse ,( ;�, - ®Addressee i so that we can return the card to you. B. Received by(Printerd Name) C.Date of Delivery ■ Attach this card to the back of the maiipiece, or on the front if space permits. i 1. Article Addressed to: D. Is delivery address different from item 1? Cl Yes ~ � If YES,enter delivery address below: ®No x rjAvt i j3. Service Type ❑Priority than 8PW I II II II III I II it I II II �I� ❑Adult Signature ❑Registered Medi°' �I II I I II I I ❑Adult Signature Restricted Delivery ❑Der ery�Mall Resti9ctedl [Q Certified Mail® �Detum Receipt for 9590 9402 2925 7094 3429 26 ❑collect Mau leeryRestrted Delivery Men handise 0 Collect on Delivery ❑Signature conal mation-A ❑Collect on Delivery Restricted Delivery (3SI®nature Corrfirmatlon' I I 2 Article Number(Transfer from service label) ❑Insured Mall Rd DelNery s-1®S g `, ¢1 91 1544' l� , 1 ❑`Insuied Mall ResUlcted Delivery t io—�,� 'a.�l�4.J a UU over$500 ' 7,530-02-000-9053 _ Domestic Return Receipt Ps Form 3811,July 2015 PSN , i tF0t�r ELIZABETH A. NEVILLE,MMC Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 �,��• �, " Southold,New York 11971 REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER Fax(63 1)af, . Telephone 1)'7676 76145 145 5-6 5-1800 RECORDS MANAGEMENT OFFICER �Ol ;tic: �`�� www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK t TOWN OF SOUTHOLD December 26,2018 CERTIFIED MAIL ' �U'.12N '��II'T"REQYJEI�TED, t i AMS Home Improvement LLC 249 Hubbard Avenue Riverhead,NY 11901 z Dear Sir: z The bank returned your check no. 146 in the amount of$259.60 due to insufficient funds. The check was payment to the Southold Town Building Department. This office is required to collect the money for the check and a$20.00 returned check charge for each check. Payment must be cash, money order, or certified check. The s total amount due is $279.60 ($259.60+20.00). Payment must be received be close of business on January 4,2019. Failure to pay this amount within the specified time will result in the referral to the Town Attorney's office for collection and the building permit will be voided. Thank you for your anticipated cooperation. Sincerely, Lynda M'Rudder Deputy Town Clerk encs Scott A. Russell °Su m STO]RI��J WAT]E)E, SUPERVISOR �} z hM A�N A\\,GJEN11EN T SOUTH53095 ain RLD O 9 Road-SOUTHO D NEW YORK 11971 WN HALL-P.O.Box 1179D �o �-,- Town of,Southold CHAPTER 236 - STORIMIWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) -------------- i DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING: YesVA. (CHECK ALL THAT APPLY❑ Clearing, grubbing, grading or stripping of land which affects more t an 5,000 square feet of ground surface. ❑ B. Excavation or filling involving more than 200-cubic yards of material .-Within any parcel or any contiguous area. ❑ C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. t. ❑ Site preparation within 100 feet of wetlands, beach, bluff or coastal E erosion hazard area. ❑[y. Site-preparation within the one-hundred year floodplain as depicted op.-FIRM Map of any watercourse. I ❑ stallation of new or resurfaced impervious surfaces of 1,000 square t feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tag Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. --- -- - ----- ------------------ ----- --- --- -- - - - - --- - - S.C.T.M. 0: 1000 Date: APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) District - NAME C (P Section Block Lot FOR BUILDING DEPARTti-IENT IISE OINL Contact Information: .Ta,ph...L W) Reviewed By: Date: Property Address/ Location of Construction Work: — — — — — — — — — — — — — — — — — ❑ Approved for processing Building Permit- Stormwater Management Control Plan Not Required. ❑ Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review-) FORM ' SMCP-TOS MAY 2014 ' eoFFO4dao Town Hall Annex ��: Telephone(631)765-1802 54375 Main Road Fax(631) 765-9502 P. O. Box 1179 coo x Southold, NY 11971-0959 _—_ B_U LDING DEPARTMENT NOTICE OF UTILIZATION OF TRU.S&TYPE.CONSTRUCTION, PRE-ENGINEERED WOOD CONSTRUCTION AND/OR:TIMBER CONSTRUCTION Date: Own 6r:' Location.of Property: G;I� Pleasetake otice that the-(check•-appli64"Ie�Jine): ;. ;.;. "orreside;ril'strNew commercial uctare .a Addition to.existirig'commerctal'or residential steucture Rehabilitation fo``an existing,=.commercial or residerifialatructure to be•constructed or performed at the subject�property reference above will,utilize (check* applicable line): Truss type;construction (TT) r Pre-engineered:'wood-construction (PW) Timber construction (TC)b in the follow i g location(s) (check applicable line). Floor framing, including girders and beams (F) Roof framing (R) Floor,and roof framin R) --- __ . Signature: S ' r Name (person submitting this form): rN Capacity (check applicable line): Owner Owner representative TrussReg15.docx Effective 1/1/2015 6" DIAMETER REFLECTIVE RED I law REFLECTIVE WHITE PANTONE #187 1/2" The construction type STROKE designation shall be 9777 461177y gJ177I qV"or ccV17 to indicate the construction classification of the structure under DESIGNATION FOR STRUCTURAL section 602 of the BCNI(S COMPONENTS THAT ARE OF TRUSS TYPE CONSTRUCTION ■ 46F99 FLOOR,FRAMING, INCLUDING ■ ■ GIRDERS AND BEAMS R ROOD FRAMl-N-G "FR" , FR FLOOR AND ROOF FRAMiNG STANDARDS AND CODES Letter of Authorization IW )+-, 7-6- allow Stuart of AMS to act on my behalf at the Building Dept for our upcoming project at our property located at AfT" Ix S'2— e P Signed 1 Printed Date B l I A�coRD® CERTIFICATE OF LIABILITY INSURANCE DATE(A6112120 8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS'CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER CONTACT SPECIALIZED INSURANCE&SERVICES PHONE - FAX MleNo_ INC.No 204 RTE.112 ADD e PATCHOGUE,NY 11772 , SRUQSPECIALIZEDINSURANCE.COM Auto-Home-Business-cycle-etc. INSURER(S) AFFORDING COVERAGE NAIL 9 INSURER A:ATLANTIC CASUALTY INSURANCE CO 42846 INSURED INSURER B: AMS HOME:IMPROVEMENTS LLC INSURERC: 249 HUBBARD AVE INSURER D: RIVERHEAD NY, 11901 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL R TYPE OF INSURANCE DI. B POLICY NUMBER POLICY EFF PapArym MODN XP LIMITS COMMERCIAL GENERAL LIABILITY L088023038 EACH OCCURRENCE $ 11000,000 A N N CLA1M5-MADE P9 OCCUR 11/05/2018 11105/2019 p SES ERENTE a orcumPREMISES $ 100,000 MED EXP(Arty one person) $ 5,000 PERSONAL$ADV INJURY $ 1,000,000 GEHLAGGREGATE LRRMrrAPPLIES PEP. GENERAL AGGREGATE $ 2,000,000 POLICY 1-15MOTT ❑LOC PRODUCTS-COMPIOP AGG $ 2.000-000 OTHER: $ AUTOMOBILE LIABILITY COMBINEDt INGLE LIMIT $ ANYAUTO BODILY INJURY(Per person) $ �3OSCHEDULED BODILY INJURY(Per aced l) SA0ONLY AOS HIRED NON-OWNED PROPERTY OAMAGE AUTOS ONLY AUTOS ONLY Per I $ $ UMBRELLALIAB HOCCUR EACHOCCURRENCE $ EXCESSLLdB CLAIMS-MADE AGGREGATE $ DEO RETENTION $ WORKERS'COMPENSATION PER TH- ANDEmO oYERs,LIABILITY YIN 3TA E E ANYPRI]*ETORIPARTNERlEXECUTNE E.LEACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? N/A (Mandatory 1n NH) E.L DISEASE-EA EMPLOYEE $ II yyge5�describe under DESLWPTIONOFOPERAT10NSbelow E.LDISEASE-P'OLICYUMR $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached Itmmespace is required) REMODELING-INCLUDING ONLY THOSE CLASSES SHOW ON REQUIRED FORM AGL-REM 0117,DRY WALL OR WALLBOARD INSTALLATION PAINTING-INTERIOR BUILDINGS OR STRUCTURES CERTIFICATE HOLDER CANCELLATION SOUTHOLD BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 NY-25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE THE POLICY PROVISIONS. SOUTHOLD NY, 11971 AUTHORIZ SEN yy 0 1988- 15 CORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Jr+...- _•__ ------ i 35U1�F, 1j �7:3:-t11Li A�-fl1S.i�Ll.tti�!NOI9.50 .. . l.,. .,:,, rr . �T ;fA9�.2 g Sg85 �. D. R}�.�#�3. The mane= dioyoi�eI aad Tater auPP Y 1 ; : /Te; ,.y-, �: A;� i faollitt" for this loaatio2 have been lnspectod by this dopartm4at a;}d To=d I ARCA, 40.C)00 ,. to be satiafastar7� :` a. ,cl;�, r Chief of floneral Engineeripg I•:L:j° cubo: G, 808-t P, 27l 'L' Services 4J55unr�rafcrV.I, Is' i Xi I '•.. .� � � 1V it � j 4 r'' �I i '� ( '.�'' LlJ td%% • V � It, I � % I'j' � � •f,••R- i ,( NTlito 46 . 38 SGALXg • - .'r9 _� -" j e+.AwnO�eta nRitan�.t•n Ua„swq� [O inti%uVief 15 A 1,6)LA11014 Qf yq j•' i , J i L a�n¢,gv or xrr c�jopc gt�s ''' r Yt•-' .7� ; to✓C.Rp ruW.- ;1 r? i 6I F-+�/e~• j wrr of rips st:i:is wrioxfirAdC elr , SIL lrR:97•�L.S:vC:.k1-WRAI p0. ,,J13 Copmm e 11}i°;av�` r,!>,� 3 2J„ VV�L-K:Yf �Z�!a U� -Y _� !4 u A vnlc,,F�t ru+7_�,• '+ j VI a l� ! �i✓�+ _ e•t)r.„{e%ql,.vrAllM tt}G� Y - I' 'x ID}.�.•:••i.rC:WIIOM MIG _ .._ .-• 4;' U P."s'�°�,:�•_ .,rl,a.5 rq-IALF rp}}Itl ,nTLR CERTIF. 2cev;.S c NOV.27, , ;��I IAV INI•i:/�I,'Y U•J1i%(IGWPIh Sn -J C4 W X910hI s UF)or L{Pane o-,+ ti uG Y47 JY Y'w a 1,D MAI,*ct.M urtts mMAP cv-r oj 4 - A7 tfiic/.:lpo of%e ltJsllYQiICcY uPJ�"'�se cSEAL. ,7iJl! rr'O .5aur1l.0Id 5aA,,e ; T77TllCK o� Sr vc�c,rsL1 .JiJ!y ?7.rt t <; RODEFUCK.VAN TUYO P. C. 7Sw"a'= U JlJ?'1 fC�LL7,N.Y. I 1 LIC,LAND SURVEYoJttY•GREhI RT.N.Y. r o)k Co.Tax Ma Qe9( !lafiaWrr Dist-.1.000,5*c-t,107,$roci��� 7E1T HOLFc 3U FF.CO DEA7. OF HEALTH SYRYICE6�' 3TAYE1.4ENT OF IN7Jir7'�~" Y f f01,S,pj/ FOR APPROVAL OF CONSTRUCTION ONLY " J /W7xt r THE WATER SUPPLY ANb S9WA4;E �t�Jid DATE: "DISPOSAL SYSTXMS,Votj;-mis F}E;i}. l D iNGE WILL CONFORM To TH1E rlgitf H.S.REF.NO: f S'GO 1041 � STANDARDS OF SUFFOLK' CO' DLPT. gqYYJ'!Pr f �r - �l_`—'--" 11' OF� HEALTH. SP:RVIGES ,- i APPROVED: I .' •'I fi,rq � f • � 1 7' — A PF+LI CANT ' -- •�-----••Rya , APPROVED AS NOTED �Ur2FbACVv er-�- GE f DATE:L'?`'��I B P.ri ® Z607- GeP2 lZ9�t2f� cj�J rnnCSt�(-v eCu t i�� F F E . D •__ �yOTIFY �11ILUING DEPARTMENT AT f _ f 766-1802 31 TO 4 PPA FOR THE n y.t^t ��-� �2 C,,t-r-y� FOLLOWING INS, T;ON�S- -- - --------- ccs---- FOUNDATION - TV EQUIRED d '. ROUGH - FRAI ING & PLUMBING OSS 0o S 3. INSULATION AGO NG 1. FINAL - CONS -RUCTION MUST BE COMPLETE FOR C 0. 4LL CONSTRUCT ON SHALL MEET HE REQUIREMENTS DF THE CODES OF I IEW YORK STATE. NVT RESPONSIBLE � DESIGN OR CORSTRUCTION ERRC �. oe CCCUPACY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY TRUSS PLACAR®ING REQUIRED IU i2�rR I� (� sin U ccV\cv--e-�� �-�S