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HomeMy WebLinkAbout46646-Z TOWN OF SOUTHOLD ' BUILDING DEPARTMENT TOWN CLERK'S OFFICE � . 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 #: 46646a Date: 8/2/2021 Permission is hereby granted to: Domanico, Noreen 17 rk.. _._.. _ ... _. . 55 YoAve _ _....__....._ ........w__ __. ...... _ .... _.. .. _ ._. New York, NY 10128 .. _.ww__..,.. To: Replace windows at existing single family dwelling as applied for. At premises located at: 905 Nokomis Rd. .Southold SCTM # 473889 Sec/Block/Lot# 78.-3-26.2 Pursuant to application dated 7/ pp 23/2021 and approved by the Building Inspector. To expire on 2/1/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 ....................... _. .. Total: $250.00 Building Inspector 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) 765-9502g!)V Date Received APPLICATION FOR BUILDING PERMIT C>1 ' PERMIT NO. For Office Use Only Building Inspecton J fjl, Applications and forms must be filled out in their entirety. Incomplete ' applications will not be accepted. Where the Applicant is not the owner,an IT V c ( Owner's Authorization form(Page 2)shall be completed. yy Date: OWNER(S)OF PROPERTY: Name: "i , SCTM# 1000- �'va Project Address: 0( 0 5AJ _ov, Z,r, Phone#: - ('0 OrL Email: 60vv,�a V Mailing Address: 905 A10 ic oo VC41 ((c, CONTACT PERSON: Name: Mailing Address: QCs nx-� o i Phone#: 9 E rn a i 1: f'Vl jkk DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: CONTRACTOR INFORMATION: Name: Mailing Address: 0-m Phone#: U hl - Email: V'W Vv%V-h,,c)(avi CC,aa 0A DESCRIPTION OF PROPOSED CONSTRUCTION E]NewStructure ElAddition ElAlteration E]Repair ElDemolition Estimated Cost of Project: Z ? oLiu .qqo Other i61""�60W 'e"'V')k0L0UVV W" )A c" Will the lot be re-graded? E:]Yes C No Will excess fill be removed from premises? E]Yes El No ............. PROPERTY INFORMATION Existing use of property: Intended use of property. Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to .1 �5007/1040this property? E]Yes No IF YES,PROVIDE A COPY. ........... El Check Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code.APPUCA-nON IS HEREBY MADE to the Building Department for the issuance of a BuNding 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,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 an premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210AS of the New York State Penal Law. Application Submitted By(print name): DAuthorized Agent ner Signature of Applicant: Date" 7- /1 Z STATE OF NEW YORK) SS: COUNTY e-K'f'(2 e 77— being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the ................... (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/her knowledge and belief,and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this C day of 20C�21 -----------d ................................- Nctt'-�' u i CAMILLEAVERDI Not-,sty Public-St�ttj of New York NO.OIW.6362769 PROPERTY OWNER AUTHORIZATION surfdk C001ty .1-1--.1.1............ My C�,rurr r; trtu L,xptteska#g t,2021 (Where the applicant is not the owner) 1,_Ald rtes lb 0 vv) o-,(\ &c) residing at 905 A/c,K 0 Y'"; A-I-Aa cA< do hereby authorize ��Q'Y\ %A, to apply on my behalf to the Town of Southold Building Department for approval as described herein. .......... wne gnCture Date 'sspcmt:4' CZ Print Owner's Name 2 � k v °! Ct � L „,..: wf it X totF SUSAN, klACK5NZIE LOT a '. 9Ey I Otl.69' � p � m O CL 'y C C° oil S3 � Pd � N44M � .•'” .�•• � 'r4 4469 L a o e NOKOMIS ROAD Ff L8 cak Cr 4 Nih „,.Wlrrrr+' uurororv"yW�o^ "`"m+,,, ,✓,,... 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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 pollcy(Ies)must have ADDITIONAL INSURED provisions or 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 Jeff Radovicil NAME Edwards and Company PHCspVe' _ (6 t1i 472-8400 -8486 P O Box 428 a Arc°bra L -- .472472 ADREs; certs( edwardsandco.net 140 Greene Avenue - Sayville NY 11782 UNsuRERgsy Arr oRDINCI COVERAGE NAM# ...w - VER �. _. ..._n _ ..._ ._-_......_ rN q ERAm Admiral Insurance Company 24856 ,.,.�...._._.w�..... www ,..,.�..................w. ..__.,..M ,,,m.._____w.M.. ...._____. _.... .- INSURER B: Restoration Energy Inc.Dba RW Mulligan INSURERC: __wv.,.........._. ___... _.......... w,,,,._....... P.O.Box 1727 ...,,, __w._m......... .w_..,,.. ... .. ... _ .�.. ._..__........, INSURER D: INSURERE: Riverhead NY 11901 ''..INSURER F,. COVERAGES CERTIFICATE NUMBER: 21/22 CGL Master 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. IN TR TYPE OF INSURANCE „ ...,,,.. ( [l . G %' '.-.-.•-__w__..,..._,. "" IN WV' POLICY NUMBER IC4G0i0DNYYYL,,,,J„rr44'rP/DDPCLYY`� LIMITS XCOMMERCIAL GENERAL LIABILITY E/^L,CFgOCCURRENCE 1,00O,OOfY mm CLAIMS-MADE ®OCCUR 300,000 3••"E,00 'mm C�REMBSES Ea occurrend $ ^•^---- .. MED EXE A one Iaarswio $ 5,000 A Y CA00003880702 06/29/2021 06/29/2022 PER,S0NAL&ADVft1rrRY $ 1,000,000 OEN`LAGGREGKI'E LIMIT APPLIES PER: GENERAL AGG3REGATE E 2,000,000 POLICY JET D LOC ..PROS UCIS•Cr P1OIs''AGG $ 2,000,000 O"9 HERr AUTOMOBILE LIABILITY � 0-95Ard ED alr4wt7El•4'Et�ff ANY AUTO Era ¢ '.,BODILY INJURY(Per person) $ — OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED ^- RrY-- ••••— ._... ... AUTOS ONLY AUTOS ONLY P'ae zrar§dprmw@ $ UMBRELLA LIAB OCCUR EACH(X;C':URRL�rr&CE '.',$ EXCESS LIAB CLAIMS•-MADE ACLRL:&DFwII"E ...N -,.$ . DED RETENTION$ WORKERS COMPENSATION PER O'I"H. AND EMPLOYERS'LIABILITY YIN a TA"I'U"PE ._. . -"P � .. ANY PROPRIETOR/PARTNER/EXECUTIVE ^� OF"FBG"oEWMEMBER EXCLUDED? NIA E EACH ACCIDENT mmM N 3 (Mandatory in If yes,describe under E.-L...-D--ISEASE-EA EM,...PLO._Y-E-E $ _..,..„„,...... ''..... DESCRIPTION OF OPERATIONS below NNN ww ....MN E .DISEASE-POLICY UrAff� 3 '..DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ......-NNN ..__. As respects to General liability if required by written contract the following are included as additional insured per policy form CG2010. Town of Southold 54375 Main Rd Southold NY 11971 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd. AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NYSIF New Yorlk State Msurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A^^A A^ 462932269 % LEVITT-FUIRST ASSOCIATES LTD ' 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER RESTORATION ENERGY INC DBA TOWN OF SOUTHOLD R.W. MULLIGAN 54375 MAIN RD PO BOX 1727 SOUTHOLD NY 11971 RIVERHEAD NY 11901 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2314 468-6 714265 06/29/2021 TO 06/29/2022 7/20/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2314468-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/M/WW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSU RANCE FUND UNDERWRITING VALIDATION NUMBER: 583451757 U-26.3