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HomeMy WebLinkAbout47087-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#: 47087 Date: 11/8/2021 Permission is hereby granted to: Rohrbach, George PO BOX 1155 Mattituck, NY 11952 To: install window replacements to existing single-family dwelling as applied for. At premises located at: 1620 Grand Ave., Mattituck SCTM #473889 Sec/Block/Lot# 107.-3-9.2 Pursuant to application dated 10/25/2021 and approved by the Building Inspector. To expire on 5/10/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 i )ddir'g actor 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 :, n- ¥ww so l: I :, y ,. Date Received � L A For Office Use Only j l i PERMIT NO. Building Inspector: - IBU LI IN' U- >I Applications and forms must be filled out in their entirety.Incomplete T0'10,0�0 r S0U:rH0 D applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 9/17/21 OWNER(S)OF PROPERTY: Name:Adriana and George Rohrbach SCTM#1000- 10 — '3— C] D,Project Address:1620 Grand Ave f Phone#:(631) 949-1089 Email:ag ,525@yahoo.com e Mailing Address: 1620 Grand AVe CONTACT PERSON: i Name: Lisa Einsidler I Mailing Address:ggg South Oyster Bay Rd, Bethpage, NY 11714 Phone#:888.736-6335 Email:llsa.einSidler@powerhrg.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: ' CONTRACTOR INFORMATION: Name:Power Home Remodeling Mailing Address:ggg 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 Estimated Cost of Project: EJ Other Remove and replace 5 windows.U factor 0.27,SHGC 0.25.No structural changes. ? $10,896.00 Will the lot be re-graded? ❑Yes *No Will excess fill be removed from premises? ❑Yes ONO 1 PROPERTY INFORMATION Existing use of property: Residential i 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? ❑Yes No IF YES, PROVIDE A COPY. Check Box After Read Ing: 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 210AS of the New York State Penal Law. Application Submitted By(print name): Lisa Einsidler ligAuthorized Agent Downer Signature of Applicant: Date: 9/17/21 STATE OF NEW YORK) SS: COUNTY OF 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 17th day of September 2021 Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) Adriana and George Rohrbach residing at 1620 Grand Ave Power Home Remodeling do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. See signed contract (attached) 9/17/21 Owner's SignatureDate SLALAdriana and George Rohrbach cI * -m4y, My Col22b Print Owner's Name C-ammission Nun"r 12t-2 2 E(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE DAT3/26/2021 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 policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endorsements. PRODUCER 'CONTACT Lacher&Associates insurance Agency _ NAME-- JAX Lacher Insurance Group g_ 215-? 3 437 4 21 ?23 577 632 East Brad Street E-MAIL Souderton PA 18964A 6/ . cult: @�e6gIapherinsurance corn __ -. SNSURER(S)AI`IsOROING CO _, E - NAIC# INSURER A a Pennsylvania Manufacturers 12262 INSURED POWERCL-01' iNsuRER a,Market American Ins CO --- - � � Power Home Remodeling Group, LLC 2501 Seaport Drive;4th Floor [INSURER C.Endurance American Specialty 41718 Chester PA 19093 IasuRRt . 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lNR -I DLImAntSU84 POLICY NUMBER F_POLICY EFF --POLICY TYPE OF INSURANCE - - LIMITS AMERCIAL GENERAL LIABILITY LX M302175-66-20-96-7 4/1/2021 , 4/1/2022 EACH OCCUR€ NC-F S Z000JG00 CLAIMS-MADE {{x OCCUR - - j .O A* iO_RENTEOI - L OR�Mc LEq�—� caL S 1=OM;0 0 I _ Mn EXP(A $10,000 _...... I (PERSONAL ADV INJURY S1000,000 -_ GEWL AGGREGATE LIMIT APPLIES PER. NE s ATE X PROP GE RALAGGR 134 I;3- U0 POLI L€C 3 El LOC :PRCJUC-`S-COWDIOP AGG S 4.000.30 OTHER: $ A 'AUTOMOBILE LIABILITY152075-66-20-96-7A 10/1/2020 10/1/2021 =CBtr�DStaC€EL'MIT X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED .— AUTOS ONLY AUTOS BODILY INJURY(Per accldent),$ HIRED I NON-OWNED ) PROPERTY -4GE - - )-. AUTOS ONLY _.,.. AUTOS ONLY I #�On,l $ $ B i UMBRELLALIAe X !OCCUR MKLM7EUL100369 4/1/2021 4/1/2022 EACH OCCURRENCE 13.COO,D00 X EXCESS LIAB C' lMS-AiAfiE' _ _ - - - AGGFW ATE ,3 3 000,000 t z ....EO X RsYTI01- A WORKERS COMPENSATION 202175-66-20-96-7 1/1/2021 1/1/2022 X PEP OTI., , -ARID EMPLOYERS'LIABILITY YIN -- dv { ET tiEEY GJ roe ' FEI&+ EaSE.lttl<-'_€10�.Lt NIA; .E. .iHA..,�ssOENT S1,OOf},UvL? (Mandatory In NH) � E.�.03 E-E<A EMPLOYEE'S'.000 000 #fes d ,—I under I 'O P:,O-. OF OPERA-IONS ---§ec°vf <,'MSEASF-POLICY,-IMI T $1.000 C EXCESS LIABILITY ELD30000834203 4/1/2021 4/1/2022 ;EACH OCCURRENCE 5,000,000 OVER POLICY# ;AGGREGATE MKLM7EUL100369 _ 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) 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. 53095 Route 25 P.O. Box 1179 Southold NY 11971 AUTHORIZED REPRESENTATIVE USA I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:69CE59B0-3C40-4D03-9D13-D99EAD69t3D67 YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE I 1a Legal Name&Address of Insured(use street address only) 1b,Business Telephone Number of Insured I 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 j Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security 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 13b.Policy Number of Entity Listed in Box"1 a" 53095 Route 25 Southold NY 11971 202175-66-20-96-7 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 above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York Siaie Wor e Compensation Lave.(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 erlit,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 the:cancel the policy or eliminate the insured from the coverage indicated on this Certificate, (Thee notices me,,,be sent by regular trail.) 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 o1 `ofauthorized represerratm or liclerSotl agent nt of insuranns Carner) Ji 12/17/2020 j 3:26:24 PM EST Approved by: Ls - - — 'A- –, (Signature) (Dale) Title: Underwriter Telephone Number of authorized representative or licensed agent of insurance carrier:434-530-8392 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 NLW Ir S CERTIFICATE OF INSURANCE COVERAGE .` tvn DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW d PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Power Home Remodeling Group LLC2501 Seaport Dr. 4th Floor 610-874-5000 Chester, PA 19013 Work Location of InSU (Only muif coveragslsspecificallylimited 1c.Federal Employer Identification Number of mcanair bcations in Now Yo star&,=,a.,i< p- p Po cy Insuredor Social Security Number 233030708 2.Name and Address of Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Arch Insurance Company 3b.Policy Number of Entity Listed in Box"l a" Town of i Southold53095 11 DBL9519600 Route 25 3c.Policy effective period Southold NY 11971 to 4. PPkpy provides the following benefits: LX]A.Both disability and paid family leave benefits. r]B.Disability benefits only. C.Paid family leave benefits only. 5. Pofi y 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 cove as describeve. 12/24/2020 Date Signed By S (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number 201-743-3937 Name and Title James lannicelli,AVP Accident& Health IMPORTANT: If Boxes 4Aand 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 NYSDisability 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 sox 4C or 5B 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. III IllllDiiuigii�iidmqiiupi�giiii�i'iiiisll� D8.120.1 (70-17) National Headquarters AJri9na ,d ; ,r-e hr-a,--[- 2501 Seaport Drive,Chester,PA 19013 _e 888 736-6335 WWW.POWERHRG.COM PRODUCT SPECIFICATIONS ' Buyer(s)'Information and Description of the Property: Project Number:35-37094 September 10,2021 Adriana Rohrbach Date of Agreement George Rohrbach (631)298-4782(Roma) age525@yahoo.com 1620 grand ave (631)949-1089(Adriana's Cell) E-Mall Address 1 MATTITUCK,NY,11952 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 9/22 between 9:00a and 10:00a. Windows-Inspira Inclusions: Includes composite reinforced meeting rails, night time safety lock on double hung windows and two part window sliders only.Welded corners,foam injected frames,concealed tilt latch on all double hung windows.total protection spacer, Heatshield, Duraglass, exterior custom capping, installation,clean up and haul away of all job related debris. Windows-Elegance-Architectural Inclusions:Fully welded frames with Duraglass, installation,clean up and haul away of all job related debris. Doors-Dynasty Series Inclusions:Includes all new hardware,ball bearing hinges,foam core, reinforced wooden lock block, installation, clean up and haul away all job related debris. 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 3 page agreement. Power Home Remodeling Group Buyer(s) Buyer(s) /09/10/21 �109/10/21 -- 109/10/21 Signature of Remodeling Consultant Signature Signature Justin Costantini Adriana Rohrbach George Rohrbach 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. September 10 2021 14.03 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Page 1 of 3