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HomeMy WebLinkAbout46719-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 #: 46719 Date: 8/23/2021 Permission is hereby granted to: Schein, Alvin 21~45 Little econic Ba Ln Southold, NY 11971 To: construct interior alterations to existing single-family dwelling as applied for. At premises located at: 2145 Little Peconic �ay Ln. ~Southold ~_..._._.__....................... w..._w_ ........... as SCTM # 473889... ... . .......................... ........... _...... --_w_,,,..... �...__ _.__ ..... Sec/Block/Lot# 90.-1-15 and approved by the Building Inspector. Pursuant to application --- ........................._ To expire on __...2/22/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $396.00 CO-ALTERATION TO DWELLING $50.00 Total: $446.00 Bild 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) 765-9502 Date Received APPLICATIONI LPERMIT C, .. " For Office Use Only e eIf- PERMIT NO. _ � _ Building Ins ectoi Applications and forms must be filled out in their entirety.Incomplete Pf 1tL11° DEPT. applications will not be accepted. Where the Applicant is not the owner,an E P�. .. L Owner's Authorization form(Page 2)shall be completed. tl I L .......m__. ....... . ......�._��..ww_�_. .��....�...............�..._......._.. ___�.....,...�....... � Date:August 1st 2021 OWNER(S)OF PROPERTY:...................- .... .�__�_.._.....mmm_.. _.._..._.�.__. _....--------- _.�. � _.........__.w....� Name:Alvin & Lisa K Schein - [SCTM"# 1000-90-1-15 __ .. Project Address:2145 Little Peconic Bay Lane Southold NY 11971 Phone#:516-606-0399 Email:alschein@gmail.com Mailing Address:2145 Little Peconic Bay Lane Southold NY 11971 ...._..........._...........�............................... __����.M.M.M...................w_w_.._�.....�..�..._...._wwwww.........._�w � .......ww �.�.�... -.......... CONTACT PERSON: .........._ _ _ww ... _._________..... ..._.._.._...._— Name:Alvin Schein Mailing Address:2145 Little Peconic Bay Lane Southold NY 11971 Phone#:516-606-0399 Email:alschein@gmail.com _M -_ -a......_...__._............... DESIGN PROFESSIONAL INFORMATION: Name Stromski Architecture, p.c. - Mailing Address:400 Ostrander Avenue Riverhead NY 11901 Phone#:631-779-2832 JEmail:robert@stromskiarchitecture.com CONTRACTOR INFORMATION: - m� _.,,,,,,_,.,._... .....�..-_.._._.............o_.........m..............-.__........ ..._._. Name:Stromski Architecture, P.C. Mailing Address:400 Ostrander Avenue Riverhead NY 11901 Phone#:631-779-2832 FEmail-robert@stromskiarchitecture.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition FAAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $10,000 Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? Dyes - No 1 I� FF 1 [' (y%y�vti;`rf�li�� s 11"�.J,im4 1 i ✓, �i � 11 ' ,,r. f q. Existing use of property:��r)��e FC�rrt�� Intended use of property:Sl �� Faml�" Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R-40 this property? ❑Yes No IF YES, PROVIDE A COPY. f M1 1 B r.f Y r 7 f ' 4 I� 1 o � 1 ui X C �''*TP� �M�i ll -�y�i, `' R IYI�OF�„I,l'6 fly( � J� 777=7, _ name,.RoberStromskiAppIicationSubmitted By(prin Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) S : COU NTY O F ., being duly sworn, deposes and says that(s)he is the applicant (Name of individ al igning contract}above named, _ Mhe is the .,.i' 17— (C ntractor, Agent,C rporate Officer,w 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 they h. Sworn before me this day of ,9 �' . . .. 20 a Not a�r PubI NE E GTrj()M0rjq NOTARY PUBLIC PROPERTY OWNER AUTHORIZATIONQUAUF1MV40852 (Where the applicant is not the owner) LTi MITA S DE-CEMBER 31, residing at �do hereby authorize�0 �d to apply .._- •-. on my behalf t e ; w f Southold Building Department for approval as described herein. Owner's Signature Date z41V 1)k lv�� C Print Owner's Name 2 - STROARC-01 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°°IYYYY) ..... ............ _ 8/10/2021 THIS CERTIFICATE CERTIFICATE DOESS ISSUED AS A NOT AFFFIRMATIVELYTER OF OR NEGATIIVEINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS NEGATIVELY D, EXTEND OR ALTER THE COVERAGE AFF _ _....... ...____..... 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 . __..... __ �....____:.:_ '....... p.... .....y(__). ...._.. ... ADDITIONAL INSURED provisions _.. ......... .. If this certificate SUBROGATION n p e certificate holder is an ADDITIONAL INSURED the olic les must have or be endorsed. ON IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on of confer ri phts to the certificate holder in lieu of such ondor ement(s). 79 ........... _............. PRODUCER CONTACT Neefus Stype Agency PHONE FAx A uebooue,NY 11931 M info nsa�rlsLiroOoo � ("vc Nol(....631)722 3591 q9 _ .......... ........_...�....... . .. _.... ... INSURERISj,AFFORDING COVERAGE NAIC# ............ . .. ........... ........_ ___,..... ........ _..._. ...... ............ INSURERA:Utica National Ins.CO..Of,OhiO ..........____ _ ._._. ... 1.3998 .._._.._, INSURED R B:Utica Mutual Insurance Company_ _,,,,,,,,,,,, w,25976,,,,,,, INSURE„w. Stromski Architecture PC INSURER C PO BOX 1254 INSURER D Jamesport,NY 11947 ............____.. _. ..._. ___.... .. INSURER E; INSURER F .,....... .,,,,, .. ....... .,,, .... ......_.__. .,.. .. .. .._.... ...... .......... ....,. ........_...,. ___.. _......._... ........... ..... COVERAGES.....w... CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NIAMED 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, EXCLUSIONSSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN'.. _ G IOLIC lb V_ _... _...... AND CONDITIONS OF _ TYPE OF DDi Svs _POLICY EFF POLld Y f t4P LIMITS POLICY NUMBER dWy UA X COMMERCIAL GENERAL LIABILITY ~ INSURANCE URRENCE 1,000,000 CLAIMS MADE X OCCUR fk � f'f7 RCNGI N°9 CQ 4519654 3/12/2021 3/12/2022 a a r H, li i _.. ._.. ....... ... 10,000 w .. _. A❑.. ..... CEN1 ADGREGAP LIMIT PLIES PER _ ... PINFI tf4fbt:GENERALAG, f�4IWCRPiwN,Ik�/@AuWl 1,000,000 X POLICY ElLOC JECT AUTOMOBILE LIABILITY .. C G)891U6NCLd SliWdd tl& LI ---.... .- .... ....... .................. LIMIT tr to#rol�tl.2......... .... i ANY AUTO �L re�C7JVMB iIdRa _ ........OWNED SCHEDULED dx f AUTO HIRED S ONLY NCD AUTOS �fiJfIFO 4rvRS1G ERTY,UR AGET f' _..... AUTOS ONLY AIJPIA, „r¢daaro . ................. ........... _........ —— ....... .. UMBRELLA LIAB OCCUR EAt W# R f 4kdu1 G IeVN I EXCESS LIAB CLAIMS-MADE AND-EMPLO ERS'RETENTION$ ANY P ED LIABILITY Y./.N ..... .... 4740Ii65...... _._._ __.. .....4/2/2021 4/2/2022.... .. 1 [:glii I n ...B WORKERSCOMPENSATIONENSATION L d NtP'aI�IN,Af B{Cif.NT rJP�Y ...,a ......... .. .......".. _f /PARTNER/ExI CUTIVE 500 000 t7CFfR' EXCLUDED N/A If ar describe axu(ko, k.I Uk C V. f Dti I Y K IC lltlE1,DISFASE-EA EMPFF, 500,000 !�w_,,�_r IPTION crtlw}_�xPERAl ONS bnelaw..... ..._. .. arwdereta in NH k _. ... 101,Addltlonal Remarks Schedule,may be..attached..if .......ac ..........M .........._ ....._...._.,........_....� ..... �„�.......,�...... ....... _.., DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD �. if more space is required) I �w........_ ........................... ......... _. .... ..,.._.............................._--------—` .„ .................... „ .......,...,...................... ... ...,,,..... ....... ........._....................................................,__ CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g p ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 Southold,NY 11971 __ ____...._ ..................... AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Workers 744 Cl)fn� ens t;io in 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 tat Carrier la. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Numberµof Insured STROMSKI ARCHITECTURE PC 516-380-3276 PO BOX 1254 JAMESPORT,NY 11947 1c. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e, Wrap-Up Policy) 271728181 2. Name and Address of Entit ..............._._ ....... _. ___....._.,,,........ ..... ........ y Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold Building Department 54375 Route 25 3b. Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL442299 3c.Policy effective period 04/02/2021 to 04/01/2022 4. Policy provides the following benefits: © A, Both disability and paid family leave benefits. ❑ B. Disability benefits only. F1 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 penalty4ofmperjury, certify that I am an authorized representative or 1.................. ......wwwwww__.................... licensed a ent of the insurance career referenced above g � e and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. i r Date Signed 8/10/2021 By ............................(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Ageuran .. ..... nt of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard Whlte,,—Chlef„uExecutive 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. Mail 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 513 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 E mployee) Telephone Number Name and Title --- Please Note:Only insurance carriers licensed to write NYS disabi ty and aid family leave benefits insurance policies and ^FFFFFFFF^ 'li n p 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. DB-120.1 (10-17) III 11 1111°°!111°°°°°�IIIIII NEW Workers' YORK CERTIFICATE OF STATE | —Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Stromski Architecture PC (631) 779-2832 PO Box 1254 1 c.NYS Unemployment Insurance Employer Registration Number of Jamesport, NY 11947 Insured Work Location of Insured (Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.e.,a Wrap-Up Policy) Number 27-1728181 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Utica Mutual Insurance Company Town of Southold Building Department 3b.Policy Number of Entity Listed in Box"l a" 54375 Route 25 4740865 Southold, NY 11971 3c. Policy effective period 4/2/2021 to 4/2/2022 EJ included. (only check box if all partnerstofficers included) [] all excluded or certain partners/officers excluded. This Gertifies that the insurance carrier indicated above in box"S' 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 3A 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 1Odays |Fmpolicy iscanceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpaymentufpnemiumutha 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 isvalid for one year after this form isapproved bytheinauranoenanierorita|icensedagentorunti|thepo|icy expiration date listed in box^3c^.whichever isearlier. 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 mmdepicted onthis form. Approved by: Peter Sabaf name of authorized enmnontauve�rnoena�xuoemmmourunceoar'/e� Appmvodby: 8/10/2021 (a|onumm) (Date) Tlda: ��2Oi�7 ��8�fO�[ Te|ephuneNumberofauthorizadepeeentativeorUoansedagentofinaunonuamanier 631-722-3500__­11­­ Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized boissue it. Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 11 The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE