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HomeMy WebLinkAbout44761-Z �o�suF o K TOWN OF SOUTHOLD �y BUILDING DEPARTMENT a TOWN CLERK'S OFFICE co o • SOUTHOLD, NY 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#: 44761 Date: 3/4/2020 Permission is hereby granted to: 80 Love Lane Assocs LLC 44-02 Frances Lewis Blvd Bayside, NY 11361 To: Erect a wall sign as applied for. At premises located at: 80 Love Ln., Mattituck SCTM # 473889 Sec/Block/Lot# 140.-3-42.3 Pursuant to application dated 1/27/2020 and approved by the Building Inspector. To expire on 9/3/2021. Fees: SIGN PERMIT $75.00 Total: $75.00 Build in Inspector SO(/T�OI 0 Town Hall,53095 Main Road P.O. Box 1179 Fax(631)765-950 G�' Telephone(631)765-1802 Southold.New York 11971-0959ell Q BUILDING DEPARTMENT �a� 2 7 2�Zo TOWN OF SOUTHOLD APPLICATION FOR SIGN PERMIT Date: ZZ ZdZo Application# SCTM# 1040` -- � ''` -=�-��3=�-�- -`-•^_--� � -�•�%��•' Zone District: At A rip atm-U jryr�,R-j} q �{{�^ q Fee: $At00 perj.? 11 0rt 1j Type of Si&(s)t�p--,ound�[ ]4 Rogf[ �.F �.; Wall /'Other: I L1 Applicant: tClCj Phone # tj I6- ?03 -odd y Business Name: S." v� �� � ce-- Pee- �s Sign Property Location: D Z-a� � P162 ., Property Owner: �D -Fjl/� "1 /7��de� � 1,�c-- The following items are required along with the completed application. (1) Survey or accurate-plot plan showing location of existing and proposed sign(s), building width facing streets: ' (2) Colored drawings with sizes and types of material of proposed sign(s), or photos of existing signs. Signs cannot be installed until the applicant receives align permit application approved and signed by the Building Inspector. After the sign(s) have been installed, the applicant shall request an inspection by the Building Inspector. If the sign(s) are in compliance, a sign permit will be issued and mailed to: S�'nr1 5 NA q Cmp6 l A)Y STATE OF NEW YORK) COUNTY OF / v {,L4 Applicant { } Agent for applicant, hereby agree to.abide by the conditions and requirements of Article XIX SIGNS of the koning Code of the Town of Southold and other applicable laws, : i rules anu,reg-glations pei<aining to such signs. Signature Applicant Sworn to before me this `^I day of JG n V i , 20 ZDNOTARY PUBLIC STATE OF NEW YORK (QUEENS COUNTY UC.#01AB6347712 - - -- - - - - - - -- -- - - - - - - ---- - - - - -- - - - - - - - - - -- --- - -- - - - - - - - - ----- - - -- - - Examined: 20 Approved: 2 Disapprove a/c: - Buil�g• s ectoz . Buiildin = De artment A g!ilcation AUTHORIZATION TION (where the Apphcant is not thz 0-pnol) >> LOV-e-(,4A!A;t i `1'Svi✓residing at -®p is I��Vn, (Print property owner's name) (Mailing Address) - S(. _► - do hereby authorize V t✓ : ,1 1. 0 (Agent) v a to apply on my behalf to the Southold Building Department. i (Owner's gnature) J m {Dale /� (Print Owner's Name) .eco CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YY Y) 8/30/2019 THIS CERTIFICATE It ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER 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(ies)must be endorsed. If SUBROGATION IS WAIVED,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 NAME DEBBIE L. GROBER—IMBEY AGENCY INC. PHONE (516)872-9500 FAX tsiale�z-zazi C ..EAIC No ONE SUNRISE PLAZA ADDRESS:DLEWIS@GIAINS.COM VALLEY STREAM, NY 11580 INSURER(S)AFFORDING COVERAGE NAIC ff INSURERA:TRAVELERS IDEMNITY CO. OF CT 25682 INSURED INSURERS:NATIONAL UNION FIRE INS. CO. 19445 JEM SIGN CORP INSURER C. T/A TEE PEE SIGNS INSURER 470 SOUTH FRANKLIN STREET INSURER E: HEMPSTEAD NY 11550 INSURER F: COVERAGES CERTIFICATE NUMBER:000OVMASTER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR TYPE ADDL SUER POLICYEFF POLICY EXP LTR D WVO POLICYNUMBER MMIDDNYYY) (MMIDDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 166051BX2363TCT 06/01/2019 06/01/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ X MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JET F—] LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accadent ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident) ccident $ B UMBRELLALIAB X OCCUR EBU043089035 06/28/2019 06/28/2020 EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? Y❑ NIA (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ A INSTALLATION FLOATER 166051SX2363TCT 06/01/2019 06/01/2020 JOBSITENEM STORAGE 50,000 PERSONAL PROP OF OTHERS PERSNAL PROP OF OTHERS 50,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) TOWN OF SOUTHOLD IS INCLUDED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN HALL ANNEX BUILDING ACCORDANCE WITH THE POLICY PROVISIONS. 54375 ROUTE 25 PO BOX 1179 AUTHORIZED REPRESENTATIVE SOUTHOLD, NY 11971 Aaron Grober/DEBBIE —< ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD INS026(201401) volc ® kers' CERTIFICATE OF STATI Co�pee�sat°®n NYS WORKERS' COMPENSATION INSURANCE COVERAGE Beard la Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured JEM SIGN CORP 516-203-0004 T/A470 TEE PEE SIGNS 1 c.NYS Unemployment Insurance Employer Registration Number of 470 SOUTH FRANKLIN STREET HEMPSTEAD,NY 11550 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Securit certain locations in New York State,i e.,a Wrap-Up Policy) Y Number 113215360 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) TRAVELERS PROPERTY&CASUALTY CO TOWN OF 3b Policy Number of Entity Listed in Box"1 a" UTHOLD TOWN HALLL ANNEX BUILDING B 54375 ROUTE 25 UB2J144509 PO BOX 1179 SOUTHOLD,NEW YORK,11971 3c Policy effective period 06/10/2019 to 06/10/2020 3d The Proprietor,Partners or Executive Officers are ❑X Included (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the Insurance carrier indicated above in box"3"insures the business referenced above In box"1 a°for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3 on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate Is Issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by- AARON L.GROBER (Puntname of authorized representative or licensed agent of insurance airier) Approved by. _41411601(l)IL 421 3(� p�l�� (Signature) 61ate) Title PRESIDENT OF AARON L GROBER AGENCY Telephone Number of authorized representative or licensed agent of insurance carrier: 516-872-9500 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-103.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcbny.gov Yo Workers!STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) lb Business Telephone Number of Insured JEM SIGN CORP. D/B/A TEE PEE SIGNS 516-203-0004 470 SOUTH FRANKLIN STREET HEMPSTEAD, NY 11550 1c Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically binned to or Social Security Number certain locations in New York State,i e,Wrap-Up Policy) 113215390 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold Town HallAnnex Building 3b. Policy Number of Entity Listed in Box"1a" 54375 Route 25 - po Box 1179 DBL107946 Southold, NY 11971 3c Policy effective period 01/01/2020 to 12/31/2020 4 Policy provides the following benefits ® A Both disability and paid family leave benefits B Disability benefits only C Paid family leave benefits only. 5. Policy covers © A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B Only the following class or classes of employer's employees, Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has NYS Disability and/or Paid Family Leave Benefits Insurance coverage as describe,, U, ht d�abbovee Date Signed 1/22/2020 By V CG (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE Mall it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200 PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 56 of Part 1 has been checked) State of New York Workers' Compensation Board According to Information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. D13-120.1 (10-17) 111111111°°°1°1°1°°1°1°�11°!�°�!°!�!°1111111 �� ��Q•'4 71 / f ,I N69'Oq•vp��; ay -.ter:->-r->. � � y •,,L f� '•� �'s4 sa •�' - aQ , L.,f L. Food Merkdt -- / to �/ 3 _ E W T,�rad/s� 3riU • , a � , - -- is G 0.b' `tl Sle S ee/ Pluevb l 0 y \NA. - - — - MAO O1✓ �lZoo62 rY F � 0 SUIZVEY�Q;FOlZ. M.A.XEZ-,5EY PQOPERT1E.5, INC. Tow,vof Sourlf-loLo,A/.Y Cb J Q` J P Sca/nf Z0'-/" f11 t]n rronurtreH-f ' \ �leVal�fi°Hs JHovJH arQ rL�lo1'iVB '�o TE/Ye assumod a/ev.a f/SO'aAovC leu level '74 HorHrwes/e-e"c✓of:laYre/of Vy'be, = \A;V A� Guaranteed to _Sacr/rity '�}�'/d � Guoranty C.O. 4,yW Fork Bang # - r*ruatCc. ad 5urveyW4i dilly.99,!971', / r VdN YL 4 SON NAU UTHORIZED ALTERATION OR ADDITION A ���• \( �-� ' TO THISSURVEY IS A VIOLATION OF ;ACTION ...p OF THE NEW.YORK STATE i EDUCATION IAW "I �• 1P^/ A , LizaH$ed Lzx dl.:rcjA"yi)r3 CC 115 OFTHIS SURSEIMMAP SNOT EAL p,RINO TRI'LAIMEOSSED SEAL SHALL NOT BE QONAIDFRED I� `,�' 1 G✓�aHp ort Nllu YorJte TO At A VALID TSUE COPY. f'V �' /1L dri if kola !• ONLY fS INDICATED HEREON SHALL I,ON' V,JSI ONLY' TMC P3Rt011 FOR V11fOM''fNf,EURYE�,�++ .'EJB' 15 TIOAEFARED• Y–1 OEL'NIS IEHI,LF,r01NE `A •J 1 IIIIF•COIAFANY„GOVEJUIINTA4 A4.IIC'/ 'j }� `� 1 'L[NDWG'I'ItT1TlIS�ON ST. H'11eOf.,•ANP,• E t}ry TO tgEASsi NEE;OF-TH d2DiI°DisE f? .4 ;;�•1 TUTict"e.A-ZSTuuTN)NS A@ Not tlarltl{F.AW%'-.,;:4jF 4 r \CY l0 ADDn u7F •�t�.7 rl ' �o � � -. _ ....._• -. _•-------•- r _- {---__tom. _.- .._ J � - _..-----..+-._..-._- �'__ `r.l._r�•'+.Ty�.'��:�C J.e.�._t YJ✓; l�: F ~ �•�- 1. t `.II Attn: Allison S. &Abby S. Customer: Daniel Gale-Mattituck Address: 70 Love Lane., Mattituck, NY �. f.. _ K _.. 4 , - + - 1'h'Alum Angle TOVB Builem — '/.'MOO Bkgtl Sothebys I've G I leg F.'Alum.Argle E Frame - E � c Y' Lag ShIdd, It 8 Anchors BncWW—Frama lea.Single Sided MDO Board Sign 2 Blank ACM Laminated Digital Blue Panels (BluSize: 3'(36")h x 11'8"(140")w X 3/4" MDO Board mounted Match Bfront b) mounted on store front behind the Sign to cover existing conditions Aerial View Copy: 18"h X 133.375"w Colors: Background painted BM#2061-10 Deep Royal Blank ACM Laminated Digital Blue Panels 6 ank AGM Laminated Digital Blue Panels Copy: 1st surface applied white vinyl graphics B� Well adokw.0 Installation: Lags&Shields DigitalFront Layer Panel With I st.Surface Applied Laminated Overall Sign Size: 36"h x 140"w=35 Sq. Ft. February 13,2020 08:25 PM J:\Daniel Gale RE\Mattituck-70 Love Lane\2019\DG Love Lan eMattituck MDO—Double Storefront-Sign Elevation-Rev#3.cdr