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HomeMy WebLinkAbout47203-Z » rt s TOWN OF SOUTHOLD BUILDING DEPARTMENT 00 ar 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#: 47203 Date: 12/8/2021 Permission is hereby granted to Harned, Richard PO BOX 212 Laurel, NY 11948 To: install generator as applied for. At premises located at: 1090 Laurelwood Dr., Laurel SCTM # 473889 Sec/Block/Lot# 127.-7-9 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 3 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) 765-9502 i t ps , A, „� QCIV Date Received APPLICATION For Office Use Only =_# r PERMIT N0. �`� Building Inspector: __ t Applications and forms must be filled out in their entirety.IncompleteEi , 1 applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization formPag e 2 shall be completed. �SULCI NN p - .HO-D Date:November 18, 2021 OWNERS?OF PROPERTY: Name:Richard Harried SCTM # 1000- 7 Project Address:1090 Laurelwood Drive Laurel NY 11948 Phone#:631-298-8640 Email:leearthar@yahoo.com MailingAddress:PO Box 212 Laurel NY 11948 CONTACT PERSON: Name:Se n O'Neill Mailing Address:PO Box 64 Jamesport NY 11947 Phone#:631-722-3595 Email:oneilloutdoorpower@hotmail.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR II EOR ATION, Name:Laurel Lighting Inc. Mailing Address:1977 Main Road Laurel NY 11948 Phone#:631-457-3363 Email:kfcelectric@aol.com DESCRI[PTION OF PROPOSED CONSTRUCTION , ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $10,000 Will the lot be re-graded? ❑Yes El 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/contractorldesign 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. O'Neill Application Submitted By(print name:Sean= XAuthorized Agent ❑Owner Signature of Applicant: -� Date: November 18, 2021 STATE OF NEW YORK) SS: COUNTY OF i , ) Sean O'neil I 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 day of 1 V Q V ' , 20 otary Public IJ TPA ' , A _ A R NaOy PROPERTY OWNER AUTHOR17ATION (Where the applicant is not the owner) ,2Dad I, Richard r residing at 1090 LaurelLaurelwood Drive kil Laurel NY 11948dohereby authorize Sean O'Neill to apply on my behalf to the Town of Southold Building Department for approval as described herein. a November 18, 2021 Owner's Signature Date Richard Harned Print Owner's Name 2 DAT C ® E(MMIDD/YYYY) CERTIFICATE LIABILITY INSURANCE 11/09/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 Leri irate holder is an Ai}OMONAL INSURED.the policy(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 endorsemettt(s). PRODUCER tdAM CT Carol Losquadro Roy H Reeve Agency,Inc. PHONE (631)298-4700twc'No 631 298-3850 PO Box 54 E-MAIL ADDRE closquadro@royreeve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INsURERA: Maxum Ind Co 3 26743 INSURED INSURER B Eastern LI Gas Services LLC ?INSURER C: I PO Box 1134 INSURER D INSURER E E Mattituck NY 11952 1 INSURER F! [ COVERAGES CERTIFICATE NUMBER: CL219115163 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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. WNW—, ---_ JAUDIL sL15Ri POLICY EFF POLICY Exp ] LTR I TYPE OF INSURANCE '-INSD WVD 1 POLICY NUMBERLIMBS MMIpD/YV1'VI. MMIDD/YYYYI, I COMMERCIAL GENERAL LIABILITY ? I I EACH OCCURRENCE 1,OQO,DUO CLAIMS-MADE ®OCCUR [ i ;,PREMISESAn o,.�__._,§ z ;$ 50,000 ` MED EXP(Any one nerson) $ 5,000 A BDG0082594-08 09/18/2021 09118/2022 !PERSONAL&ADV INJURY 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: i I2,000,000 I GENERAL AGGREGATE S POLICY PRO!ECT LOC j ' PRODUCTS-COMP/OPAGG =-$ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY "OPI-INIED SINGLE LIMIT `$ ANYAUTO ` €E ;) BODILY INJURY(Per person) $ OWNED iSCHEDULED I AUTOS ONLY 'AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPES DAM C—E AUTOS ONLY AUTOS ONLYI € ,Pe,a -da"t) $ I 1 r a i K r $ UMBRELLA LIAR OCCUR _ EACH OCCURRENCE $ ;EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ € $ !WORKERS COMPENSATIONH I EMPLOYERS'LIABILITY R Y/N F STATUTE O iANY PRr°:'fU--TOP-' fie----N '*.>XEC-JTIVE DE-L EACH ACCIDENT $ OP£ICEPOMEMBER EXCLUDED? N/A (Mandotsry In NH) € `E.L DISEASE-EA EMPLOYEE S it - be umdo € DESCRIP a rO OF OP RATII 'S below 1 E DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 P 7 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD M I ntin YORK Iworkers' CERTIFICATE OF INSURANCE COVERAGE 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 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 =3a.Name of Insurance Carrier j (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southhold 53095 Main Road 3b.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. rl B.Disability benefits only. I 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: i 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. t r F Date Signed 11/15/2021 By a (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. i PART 2.To be completed by the NYS Workers'Compensation Board (Only if Box 4C or 5B of Part 1 has been checked) State of New York i 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. DB-120.1 (10-17) IDB-120.1 (10-17) hl y gats' -AREA 41, _ . - - MAI 1N EXCESS OF 500 10 1 rq L v` s c65tx c \ 17, fil tj,6, roY> S;R7 TK, CS t oil -4 'yI t AP 1 d I 4V € 4 -4 JUA d ( v 0 � r 'VELI i N.21109'50­w1!000' ED-PIPE LAURELWOOD � A,4 � �..,° FINAL SURVEY 3-12-77 J OLT THE WATER SUPPLE SEWAGE SAE ; � ARKM ADISPOSAL THIS RESIDENCE KQVAL` WILL �ONFORM ` O THE STAND— ADDRESS � � TUf L As THE SUFFOLK COUNTY T EF O. T. F HEALTHSEr VIDES. TELEPHONIE n� 'o t: JOB C3. 7-3 3� LE iC7. S URELWOO? ESTSRUN - S?It TitR S '..Te1 THE' �F °"ft'Y f�R ViCi THE S 58 Y IS SURVEYEDpFOR y` E R., &^EOIFI i CR-HIS S SEML P€R- RAE F TO - h4 USE Af FIt T7 s , YA R _ ][ csHv; r v r 1. s,I. LOT NUMBER 29 i s t saTIT s AP OF LAUELi�dUGl3 ESTATES r a x�a cqs, rc: c o „ � €Txc€z5aw T of° s s _SSEQUE! SITUATED AT LAUREL ALIT t11s TD. HIS,`56RY Y is A . I tlLzdsrlc ...c ID .2e c= COPIES rH�s s; vEv I�aR.Not Tt'.,WN vF SOU THOLt}- SUFFOLK COUNTY .Y, � vt YQR SFT :LDU Atlas �eax�ac e -AND SU?YEVOR'i F E SE OR EMBOSSED SEAL SCALE 11" _ 50° DATE 6-17- 3977 SH,tlL NOT BE CONSIDERED TO 6E _ VALID TRUE COPY. FILED MAP NO, 5595 DATE 5-17- 1917 BOOK NO- LOOSELEAF PAGE ( R EAD lky!WOS BANK HAROLD F. T:RANCHON JR. PC. TSE TILE LAND SURVEYOR d SUCCESSOR TO WILLIAM G €lE ER � NORTH COUNTRY ROAD WADING R z t Y, LIC, N , 0148992 NEW YORK 11792 TR Ka ' .r�•, .LIC�N ,29 ,§5-E (51611929-4695 ALT 473- 3626 A e