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HomeMy WebLinkAbout47201-Z .:jA TOWN OF SOUTHOLD BUILDING DEPARTMENT ti TOWN CLERK'S OFFICE 10 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 #: 47201 Date: 12/8/2021 Permission is hereby granted to: HSA Hldgs II LLC 108 Remington Rd Manhasset, NY 11030 To. install generator as applied for. At premises located at: 4985 Great Peconic Bay Blvd., Laurel SCTM # 473889 Sec/Block/Lot# 128.-1-16 Pursuant to application dated 11/18/2021 and approved by the Building Inspector. To expire on 6/9/2023. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $235.00 A `buil n pector 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 llitpti://www.southo ,£ ,. Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only j 1 -Iln� PERMIT NO. Building Inspector � � I � � t 3 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUIM i�� Y s. Owner's Authorization form(Page 2)shall be completed. TOWN 0r Sou`HOLD Date:November 8, 2021 OWNER(S)OF PROPS Name:Joseph Peters t — ��, —L / SCTM# 1000- a Project Address:4985 Peconic Bay Blvd. Laurel NY Phone#:631-298-8113 Email:jhpehp@gmail.com Mailing Address:4985 Peconic Bay Blvd. Laurel NY 11948 o CTPERSONS Name:Sean O'Neill MailingAddress:PO Box 64 Jamesport NY11947 Phone#:631-722-3595 Email:oneilloutdoorpower@hotmail.com DESIGNPROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Universal Electrical Services LLC Mailing Address:151 First Avenue Massapequa Park NY 11762 Phone#:516-242-9204 1 Email:gebhard73@gmail.com DIESCRAPTION OF PROPOSED CONSTRUCTION - ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Othergenerator $12,000 Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes ! 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? ❑Yes ❑No IF YES, PROVIDE A COPY. ❑ 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 New York State Penal Law. Application Submitted By(print name):Sean eill Xuthorized Agent ❑Owner Signature of Applicant: Date: -1 -21 STATE OF NEW YORK) SS: COUNTY OF 5 �� ) Jean ONeill 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 I 1 day of L6e m , 20 2—1 Notary Public TMM iL l FIR NOYMYPU13=STAM OF N YCFl!< PROPERTY OWNER AUTHORIZATION N(I 010W830%W (Where the applicant is not the owner) MOAM 04 WFFOLX COUNTY 2L�-), I, residing at Joseph Peters 4985 Peconic Bay Blvd. Laurel NY Sean eill do hereby authorize to apply on my behalfAo the Tow"f Southold Building Department for approval as described herein. 11 -B-LoL Owner's ignature Date Joseph Peters Print Owner's Name 2 y0 o o y t H w 3 ° O = 1- i W OXY V) O�� Z SJa iY gs m �s 0- -- - Z t -' _ w -- SES'- rn it C-) w� m 2 w j O wn �" W z t „ co7 0 it II W O WF W f 0 O T o Z0z cr Fc OJo �m Q d d 0 � Z> U-Q 1 J j - }° OC w V) W w l w O 3 p Z J E J � Z O j W <z� S Ln ` , p ' - - if, ✓����- _. �' 310 r a _ Y CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 11/09/2021 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(ie )mast have ADDMONAL INSURED provisions or 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 ICo NTACT Carol Losquadro NA Roy H Reeve Agency,Inc. PHONE (631)298-4700 r (63=)298-3850 'A}C No,FXt- AIC,Not. PO Box 54 ADD ESS' closquadro@royreeve.com 13400 Main Road €NSL1RERtS)AFFORDING COVERAGE NA.# Mattituck NY 11952 suRFRA: Maxum Ind Co 26743 INSURED I INSURER B: Eastern LI Gas Services LLC INSURER C PO Box 1134 INSURER D; INSURER E Mattituck NY 11952 INStlRER F COVERAGES CERTIFICATE NUMBER: CL219115163 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. RISR TYPE OF INSURANCE `ENS.=WVO POLICY NUMBER - L#CYEFF •MI OMYYYY)1 LIMITS -- COMMERCIAL GENERAL LIABILITY = EAC-i OCCURRENCE $ 1,D00,000 :CLAIMS-MADE �OCCUR - " 50,000 j q a SSS 7 .v=I --- II R4>=_EXP�A-y oneyamson I S 5,000 i BDGD082594-081 09/18/2021 09/18/2022 1 s 1,000,000 € PERSONAL&ADI. � _� EN-LAG REG.ATE LIMIT APPLIES PER: € €GENEPUAL AGGREGATE .000.000 POLICY 0 PRO JECT F�LOG E -ROUC"s_CO..PICPAGG Is 1,000,000 OTHER: a AUTOMOBILE LIABILITY _.. ,-._... _.'. COMBINED SINGLE LIMIT t6 2- dt3 I ANY AUTO € BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS 1 BODILY INJURY(Per accident) 1$ HIRED NON-OWNED - AUTOS ONLY _ AUTOS ONLY I i`ROPERT` ue =$ I_ $ I UMBRELLALIAB OCCUR I-- I EACH OCCURPENCE $ EXCESS LIAR 'LAI�r1 -4, E FE FATE $ IDE/ <€_N-1' WORKERS COMPENSATION _ E �ItT1:� ANY PROPRIETOR/PARTNER/EXECUTIVE AND EMPLOYERS'LIABILITY Y I N OF=iC.EWMEMBER EXCLUDED? � N/A E i E.L.EACH.ACCIDENT (Mandatory 1n N}#} E.z_DISEASE EA EMPLOYEE €S 1t yes,de r- oar € _.._ _... —... OPSCRiPTIQN OF OPERATIONS below I I E.L.DISEASE I ICY LIM1 T $ , DESCRIPTION OF OPERATIONS I 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 Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Main RD PO BOX 1179 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 vo or ers' CERTIFICATE OF INSURANCE COVERAGE iE I Com, ertaion Nil Boa 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 EASTERN LI GAS SERVICES LLC 631-603-5687 1622 MAIN RD JAMESPORT, NY 11947 1 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,wrap-Up Policy) 463076153 2.Name and Address of Entity Requesting Proof of Coverage 1 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southhold 53095 Main Road 13b.Policy Number of Entity Listed in Box"1 a" P.O.Box 1179 DBL615307 Southhold,NY 11971 3c.Policy effective period 04/19/2021 to 04/18/2023 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 described above. i 3 11/15/2021 /' Date Signed By 4- . , U u I (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. 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 sB of Pan.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. j 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. DB-120.1 (10-17) 1�1 11 1111111111111111111111°111111111111111111111111111