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HomeMy WebLinkAbout46772-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#: 46772 Date: 9/212021 Permission is hereby granted to: Geitz,Susan 1580 Leeton Dr Southold, NY 11971 To: Replace sliding door at existing single family dwelling as applied for, and with Flood Permit. At premises located at: 1580 Leeton Dr., Southold SCTM#473889 Sec/Block/Lot#58.-2-5 Pursuant to application dated 812312021 and approved by the Building Inspector. To expire on 31412023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Flood Permit $100.00 Total: $350.00 Building Inspector c 0f u`,*- TOWN OF S UT L —BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 P ) ) _ .. ��oN Telephone 631 765-1802 Fax 631 765-9502 I �? e �Vy VV V� SOUthO1Cl1O�y ni1� Date Received II[)IIIR1" 101'4 1 C' 11- 'jII" VII I' " �w For Office Use Only t PERMIT NO., '� Building Ins�ecltc+r;� ,,,, _ e AUG 2 3 "021 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 8/6/21 OWNER(S) OF PROPERTY: Name: =CTM.. 1000-Susan & Charles Geltz8� Project Address:1580 Leeton Drive Southold, NY 11971 Phone#: 914 329-3165 =maiksgeitzgaol.com � ) Mailing Address: 1580 Leeton Drive Southold, NY 11971 CONTACT PERSON: Name:Lisa Einsidler Mailing Address:999 South Oyster Bay Rd, Bethpage, NY 11714 Phone#:888.736-6335 Email:lisa.einsidler@powerhrg.com DESIGNFSI L INFORMATION: Name: Mailing Address: Phone#: 7Emaik CONTRACTOR INFORMATION: Name: Power Home Remodeling Mailing Address:999 South Oyster Bay Rd, Bethpage, NY 11714 Phone#:888.736-6335 Email:lisa.einsidler@powerhrg.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition Alteration ❑Repair ❑Demolition fr0,5) V- Estimated Cost of Project: ❑0th e r Remove andreplace 1 sliding glass door U-lector 0 27,SHGC 0 25 No structured chnnnes. •---I � � $3,090.30 Will the lot be re-graded? ❑Yes i0l No Will excess fill be removed from premises? ❑Yes El No 1 PROPERTY INFORMATION Existing use of property: Residential Intended use of property:Residential Zone or use district in which premises is situated, Are there any covenants and restrictions with respect to this property? Dyes No IF YES, PROVIDE A COPY. ii 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. 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,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(s)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By (print name): Lisa Einsidler WAuthorized Agent Downer (� Signature of Applicant: � �� �,�,a .a��a ` Date: 8/6/21 Pennsylvania CONUDMEALTHOFP~,In.AMA-w TAfaa i STATE OF illEW eORfo) *Ofiver Laird,NOTARY PUBW Daia,vara caunky SS: My Ownavm au on Evpoos(MrAdr2a25 dun Wn mirnber 121 COUNTY OF Delaware ' Lisa Einsidler being duly sworn deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the AGENT (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 6th August 21 20 � day of � . Notary Public , Where the ... ... ......... ( applicant is not the owner) I Susan & Charles Geitz residing at 1580 Leeton Drive Southold, NY 11971 _do hereby authorize Power Home Remodeling to apply on my behalf to the Town of Southold Building Department for approval as described herein. See signed contract (attached) 8/6/21 � � Owner's Signature .�" Date Susan & Charles Geitz Print Owner's Name 2 National Headquarters Susan and Charles Getz � 2501 Seaport Drive,Chester, PA 19013 35-29895 888-736-6335 August 03, 202 1 WWW.POWERHRG.COM 1440776-F)CA rGe Project Specifications na5ss " FFY00 FL!GG uwLuuuu Windows: Master 1 60.0!!x80,0" m- WINDOWS: Model Elegance Style Sliding Glass Door Type 2-Panel Config 5' ��F OPTIONS: Color White/White: Grid Pattern : None I Additional Details Special Options(ie. Full Screen, Obscure Glass,etc) Full Screen No I Obscure Glass No I Specialty Color No I Different Color Capping No I ! �� Trim Options No I Frame Options Yes Frame In for Vent or A/C unit No I Build U No I Build Down No I P P p Pack-In No I Buck Frame/Stops/Casing Yes I Remove and Reinstall No 0 C LJ NV APPROVED AS NOTED S 1IS N[ F1. 1,, DATE:9 B.P.# W1 I . rile R : ° C ATE FEE:` 5" . BY: 0 . ('111 ' I 1 NOTIFY BUILDING DEPARTMENT AT C .; 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS; 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBINGIN 1 I ktV 1IAf....L C 01'3" C)I' ` & INSULATION 4. FINAL - CONSTRUCTION .MUST 11 uAVV A ,1..A V u ck J 0Wi C 0 1'')� BE COMPLETE FOR C.O. AS EQIIJ IIi D A N D ',( )t,Jr.. II �',JS C)II: ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW .........Y... p! 1 0�i D Tr";,,A R 1m r"��w YORK DESIGN ORE CONSTRUCTION TBLE FOR ERRORS. �.. �)I p 11 l l l..11 ^P'w I A�l ll'� BUD em w S01111 OLD 70011 T USTEES DEC FLOODm.. FLOW ml, PREVENTIM ..ate. III", ,.A I c . .. August 03, 2021 18:16 1111 1111111111111 6 /f DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/26/2021 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 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 ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lacher&Associates Insurance Agency P HONE... _......_ Lacher Insurance Group .c„N a.Fit),215-723-43..78......... _ (ASG gq)1 215-723-5757 Broad632 East _m. m SoudertonPAStreet E-MAIL18964 4�t?� �s c'rCl tc NSURER(S)AFFORDING99yfflAps. �.__ NAI" -------- .. ._..w. . -_. __ .INSURER A:Pennsylvania. .Manufacturers 12262 INSURED Hopme Remo 4th Floor P OWERCL-01 INSURER B Markel American Ins Co 28932 ort Drive, Remodeling Group, LLC ......- 2501 ChesterePA 1 013 INSUREINSURER D: Endurance American Specialty 41718 R, .....— —... ...........................__ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1393063149 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. - �—EFF - I (NSR TYPE OF INSURANCE iNgn wvn POLICY NUMBER MM/DPOLIDNYYY MfOJl/Da YYY LT LIMITS A X COMMERCIAL GENERAL LIABILITY 302175-66-20-96-7 4/1/2021 4/1/2022 EACH OCCURRENCE $2,000.000 DAMAGE 10 RENTL _ ( CLAIMS-MADE X] OCCUR p)3EMI'SF5 PEP ti =roar j $1,000,000 �I — ---- -- ----- --------- I MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X. POLICY JEC LOC PRODUCTS COMP/OP AGG ! $4,000,000 OT'IIE'.R: 1 f$ A AUTOMOBILE LIABILITY 152075-66-20-96-7A 10/1/2020 10/1/2021 f0MMNED,1PNGL'ELIMIr, ' $1,000,000 .... P Ea�c1r(f rrl) X ANY AUTO BODILY INJURY(Per person) $ OWNED _ SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROP R1'v"dTWAGE AUTOS ONLY _ AUTOS ONLY rt fv r,d n1) $ $ B UMBRELLA LIAR X I OCCUR MKLM7EUL100369 4/1/2021 4/1/2022 EACH OCCURRENCE $3.000.000 X_ EXCESS LIAB m0, 1 l CLAIMS-MADE AGGREGATE �$3'.000,000 .............— X._. ........... ,.... ®,,... DI=D RETENTION$ $ A WORKERS COMPENSATION 202175-66-20-96-7 1(1(20211/2022 XTpRTA IF ER AND EMPLOYERS'LIABILITY Y/, ®,�, ..- �-- ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $1 000 000OFFICE (Mandatory in ER EXCLUDED? I N/A E L.DISEASE-EA EMPLOYEE. $1 000 (Mandatory in NH) 000 If yes,describe under ` ... DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 C EXCESS LIABILITY ELD30000834203 4/1/2021 411/2022 EACH OCCURRENCE 5,000,000 OVER POLICY# AGGREGATE 5,000,000 MKLM7EUL100369 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWrI Of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 P.O. BOX 1179 Southold NY 11971 AUTHORIZED REPRESENTATIVE USA . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:68CE59B0-3C40-4D03-9D13-D99EAD698D67 O Workers' CERTIFICATE OF .- STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a Legal Name&Address of Insured use street address only) 1 b. Business Telephone - ( y) p Number of Insured Power Home Remodeling Group, LLC 610-874-5000 2501 Seaport Drive, 4th Floor 1c.NYS Unemployment Insurance Employer Registration Number of Chester, PA 19013 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 23-3030708 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Pennsylvania Manufacturers'Association Insurance Company Town of Southold 3b. Policy Number of Entity Listed in Box '1 a" 53095 Route 25 202175-66-20-96-7 Southold NY 11971 3c. Policy effective period 1/1/21 to 1/1/22 3d.The Proprietor, Partners or Executive Officers are ❑ included.(only check box if all partners/officers included) ®all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated abovefor In box"3' insures the business referenced above in box"1 a" ' 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 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: Ashley Madormo@pmagroup.com �,. oaf aUt ipreesentative or licensed+� t�t5r4nt t��;�rizad r� agent of insurance carrier) 12/17/2020 I 3:26:24 PM EST Approved by: _E tt �e .t ......a_..._� �� (Signature) (Date) Title: Underwriter Telephone Number of authorized representative or licensed agent of insurance carrier: 484-530-8392 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov National Headquarters �md ','hw k 2501 Seaport Drive,Chester, PA 19013 888-736-6335 A.,l,t::7f i, " WWW.POWERHRG.COM PRODUCT SPECIFICATIONS Buyer(s)'Information and Description of the Property: Project Number: 35-29895 August 03,2021 Susan Geitz Date or Agreement Charles Geitz (631)765-2811 (Home) sgeitz@aol.com 1580 Leeton Drive (914)329-3165(Susan's Cell) E-Mail Address 1 Southold, NY, 11971 County:Suffolk Township: Buyer(s) listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets, in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date: Your pre installation inspection is tentatively scheduled for Wed 8/11 between 11:30a and 12:30p. Windows-Elegance-Sliding Glass Door Inclusions: Includes fully welded frames, Heatshield, Duraglass, Extruded locking screen, exterior key lock, and foot latch, installation, clean up and haul away of all job related debris. "Sliding Glass Doors including blinds are not available with argon gas and are not Heatshield. They include Low-E only. It is agreed and understood by and between the parties that the Product Specifications, along with the Custom Remodeling and Improvement Agreement, constitutes the entire understanding between the parties, and replace any and all prior negotiations, representations, or agreements, either written or oral. The Product Specifications may not be changed, modified, or varied in any way unless such changes are in writing and signed by both Buyer(s) and Contractor. Buyer(s) hereby acknowledge that Buyer(s) has read the Product Specifications. I have read and received each page of this 2 page agreement. Power Home Remodeling Group Buyer(s) Buyer(s) p /08/03/21 /08/03/21 l J08'f0 / '1 Signature of Remodeling Consultant egnature Si ature Stephen Panno Susan Geitz Charles Geitz YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Aiagiast 0.3 2021 18:16 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIII YOM: a TAI corilwlio�u���a�tt.ua °' �Workers' CERTIFICATE OF INSURANCE COVERAGE t � j Boa rd 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) 1b.Business Telephone Number of Insured red Power Home Remodeling Group LLC 2501 Seaport Dr. 4th Floor 610-874-5000 Chester, PA 19013 Work Location of Insured(only required ifcoverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 233030708 _...�. ............_ 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Arch Insurance Company Town of Southold 3b, Policy Number of Entity Listed in Box"I@" 53095 Route 25 11 DBL9519600 Southold NY 11971 3c.Policy effective period 1/1/2021 to 12/31/2021 4. Policy provides the following benefits: DA.Both disability and paid family leave benefits. F] B.Disability benefits only. ❑ C. Paid family leave benefits only. 5. Policy covers: [X_J A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. n 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 described above. Date Signed 12/24/2020 B of insurance,mi ri,,Vs authorized representative or NYS Licensed Insurance Agent o .. (Signature �r P g fthat insurance carrier) Telephone Number 201-743-3937 Name and Title James lannicelli, AVP Accident& Hearth 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'Compensationmmm 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 ................m Please Note: Only insurance carriers _ licensed to write NYS disability aa..ndpaid family leave benefits insurancepolicies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are Nor authorized to issue this form, DB-120.1 (10-17) IIII DB-10. 1 (10-11;