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HomeMy WebLinkAbout46297-Z �SUF�at�: X00 1pGy Town of Southold 10/9/2021 o - P.O.Box 1179 53095 Main Rd kyljpl �ao�}Yy�i Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42413 Date: 10/9/2021 THIS CERTIFIES that the building ADDITION/ALTERATION Location of Property: 100 Victoria Dr., Southold SCTM#: 473889 Sec/Block/Lot: 78.-9-63 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/5/2021 pursuant to which Building Permit No. 46297 dated 5/24/2021 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: two stoop additions to existing single-family dwelling as applied for. The certificate is issued to Lawlor Susan Revoc Trust of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46297 9/15/2021 PLUMBERS CERTIFICATION DATED th ize SV nature �SUFFiK� TOWN OF SOUTHOLD po aye BUILDING DEPARTMENT C 2 y TOWN CLERK'S OFFICE 4o, SOUTHOLD, NY ol 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#: 46297 Date: 5/24/2021 Permission is hereby granted to: Lawlor Susan Revoc Trust 100 Victoria Dr Southold, NY 11971 To: construct front stoop additions to existing single-family dwelling as applied for. At premises located at: 100 Victoria Dr., Southold SCTM #473889 Sec/Block/Lot# 78.-9-63 Pursuant to application dated 5/5/2021 and approved by the Building Inspector. To expire on 11/23/2022. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $216.00 CO-ADDITION TO DWELLING $50.00 Total: $266.00 I nspector rjv so Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 sean.deviinCa-town.southold.n us Southold,NY 11971-0959 y' COU BUILDING DEPARTMENT TOWN OF SOUTHOLID CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Lawlor Susan Revoc Trust Address: 100 Victoria Dr city-Southold st: NY zip: 11971 Building Permit#: 46297 Section. 7$ Block. 9 Lot. 63 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Boxer Electric License No: 60137ME SITE DETAILS Office Use Only Residential X Indoor X Basement X Service X Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel 200A A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures 11 Pump Other Equipment 200A Panel 30 Circuit/ 13 Used Notes* Service Inspector Signature: I Date: September 15, 2021 S.Devlin-Cert Electrical Compliance Form 80Hp # * TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 a INSPECTION - [ ] FOUNDATION 1ST ' [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] SULATIOWCAULKING [ ] FRAMING /STRAPPING ] FINAL �5. P� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION' [ ] FIRE RESISTANT CONSTRUCTION [ ' ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: voh DATE Zg INSPECTOR FIELD INSPECTION REPORT DATE GOMMEN'FS• FOUNDATION(IST) �H ------------------------------- FOUNDATION(2ND) ROUGH FRAMING& - H PLUMBING r INSULATION PER N.Y. H STATE ENERGY CODE FINAL ADDITIONAL COMMENTS o V � z 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 h s//www.southoldtownn ov P � ) � ) ttP � X-�__ Date Received APPLICATION FOR BUILDING P MITMAY _ 5 2021� r`' �_.. Ls For Office Use Only � ,•,/ 1 PERMIT NO. Building Inspector. -Applications and forms must be filled out in their entirety.Incomplete lig# °11'�T �• s 'applications"will not be accepted. Where the Applicant is notthe.owner,an` - Owner's Authorization form.(Page 2)shall be`completed.' Date: OWNERS)OF PROPERTY: ` Name: Sus Ara LAW L.o k SCTM#1000- -7�_ q - �3 Project Address: 100 V 1(TO 21A 'NZVVE , SOV-F4 0 Lb , N y 11 �� I Phonet31,_,1105- SOD Email: Mailing Address: I0o V1(,�pP-4A 1>94�VE60UUT1-IOILt�,, Ny_ 10-11- CONTACT PERSON: " Name: KEITH N 0-L-A (:j N LI Mailing Address: p 0. G"OX Phone#: ( 31 , F31- 234- Email: (�AAI,6,0Q-1(Z LTl4 L -1(00 . com DESIGN PROFESSIONAL'INFORMATION: " Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: ` Name: KMIC L��1'I"IZIk(,TI�G LLC Mailing Address: p U X q p SUS �1;1�U-1 IS I��q Phone#:X31 - 931-2b 9 Email: ICltllt;�b lJTP�pr( I tJCa LLCcOM VA44 'DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition %Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other Will the lot be re-graded? ❑Yes VNo Will excess fill be removed from premises? ❑Yes $No 1 PROPERTY INFORMATION Existing use of property: ggb 1bE1MA.L Intended use of property: SI IE�TI A-L_ 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 Mg: 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 Newyork State Penal Law. Application Submitted By(print name): �6 ITI4 M C LA Ai H IA t� UrAuthorized Agent []Owner Signature of Applicant: Date: STATE OF NEW YORK) COUNTY OF k/el'fk 2.,.. tI 1,-n being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the CCii� T 4C-�o V-- (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 dary y of r' ° 20 + Ot,qT,y1P1,Ubj it, z -JE.ANjN HOLIAND ZORRATON.' E YorkrsG°�r�®G°�[ R1f�Y ®WII�CI� ,NotaryPcub0N061451 3�=;• ns °' Where the applicant is of r ) �;�Y'�, Quafified in Suffolk Coun I ( pp n the owner rr Expi es May. i � ��k�Aj:;tom„`-'f-`bt".a�t.W''w �• i t AA I,-%510 y' residing at V , GEL 04LIQ do hereby authorize4<%")M(� ��Gjr L /� d to apply on my behalf to the Town of Southold Building DepAtment for approval as described herein. Owner's Signature Date yS_+_PA� � Print Owner's Name 2 T7NG DEPARTMENT- Electrical Inspector 44�y�� ®may t TOWN OF SOUTHOLD SEP - g 2b�1wn 1-Lall'Annex -54375 Main Road - PO Box 1179 ® 'u Southold, New York 11971-0959 ®�dTelephone (631) 765-1802 - FAX (631) 765-9502 TOV, ; f ,,.,.� r(C" southoldtownny.gov -seand@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: r oxe, Name: LAZOJ " License No.: ���c _ 6� 3 email: j3,we,r fir- �®° e ®lr Phone No: ;-q -91®5s ❑I request an email copy of Certificate of Compliance Address.: JOB SITE INFORMATION (All Information Required) Name: iSIA&AM L IOW L.o Address: in jC,-r0 j \b&IVE So�TI-lolb ll°l"1 Cross Street: ft! A VtE\AI KOR6 Phone No.: 611--Ib5 _ C05() Bldg.Permit#: If 69 q-1 email: Tax Map District: 1000 Section: Block: Ot Lot: (�3 BRIEF DESCRIPTION OF WORK(Please Print Clearly) (�0(�Q��IF 66ZV I c.,t= 1t Check All That Apply: Is job ready for inspection?.- DYES QNO ❑Rough In ❑Final Do you need a Temp Certificate?: DYES ONO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground F]overhead # Underground Laterals ❑1 2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION tom- Electrical Inspection Form 2020.xlsx Y workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation 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 that Carrier 1 a.Legal Name'&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured KMK CONTRACTING LLC (631)831-2348 24 ROCKHILL LANE ROCKY POI T,NY 11778 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required ff coverage is specifically limited to Number certain locat i ns in!New York State,i.e.,a Wrap-Up Policy) 861344224 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) TOWN of SOUTHOLD New York State Insurance Fund(NYSIF) 54375 MAIN D I 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD,NY 17971 DBL 7477 25-1 3c Policy effective period i 03/06/2021 to 03/06/2022 4.Policy p ovides the following benefits: ® A.Bothl disability and paid family leave benefits B.Disability benefits only F] C.Paid family leave benefits only 5.Policy covers: ® A. "of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law E] B.Only the following Gass or classes of employer's employees: I I I ( Under penalty of,per)ury, I certify that I am an authorized representative or licensed agent of the insurance camer referenced above and that the named insured has NY i Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signe 5/5/2021 gy ��-� (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number (866)697-4332 Name and Title Melissa Jensen,Director of Disability Insurance Unit IMPORTANT:' If Box 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 513 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, DB 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 56 of Part 1 has been checked) State of New York Workers' Compensation Board Accordingto 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) I Telephone Number Name and Title I 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-920.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) Certificate Number 642036 YIS I F New York state Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEWYORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE i A A^AAA 861344224 KM I CONTRACTING LLC 24' OCKHALL LANE RO KY POINT NY 11778 0• SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER 2� K CONTRACTING LLC TOWN OF SOUTHOLD ROCKHALL LANE 54375 MAIN RD ROCKY POINT NY 11778 SOUTHOLD NY 11971 i OL16Y NUMBER CERTIFICATE NUMBERPOLICY PERIOD DATE 1542 071-2 497819 03/10/2021 TO 03/10/2022 5/5/2021 i TI- I IS 'TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUN UNDER POLICY NO. 2542 071-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUI SID i OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF Y OU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW Yd K STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THI POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS i ERS OF A LIMITED LIABILITY COMPANY. I THI CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. i i f I I I NEW YORK STATE INSURANCE FUND f DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER. 453468306 U-26.3 A C - I CERTIFICATE OF LIABILITY INSURANCE DAT3/24/2021 Yj �'"� � 03/24!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 REPRESENTp TIVE 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 SUBROGAITION 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 CONTACT NAME, Howard M Lane Howard M.Lae j PHONE 845-738-8801 (AI .No): 845-395-0011 500 Route 32 E-MAIL DDREss• Highlandmillsoffice@amedcan-national.com PO Box 1014 INSURE S AFFORDING COVERAGE NAIC# Highland Mills i NY 10930 INSURER A: Farm Family Casualty Ins Co 13803 INSURED j INSURER B: mkContracting LLC INSURER C: 4 Rockhall Ln INSURER D INSURER E Rocky Point NY 11778 INSURER F. COVERAGES1- CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO C RTIF,Y 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 ND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR i ADDL SUBR LTR PE OF INSURANCE POLICY NUMBER MMIDDY EFF POLICY M DDNYXYY LIMITS X COMME CIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CU IMS-MADE71 OCCUR DAMAGE TO RENTED A 31031- PREMISES[Ea occurrence) $ 100,0007251 3/17!21 3/17/22 MED EXP(Any one person) $ 5,000 I PERSONAL&ADV INJURY $ 1,000,000 GEHLAGGREGATE�LIMITAPPLIESPER. GENERALAGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMPIOPAGG' $ 2,000,000 OTHER' I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANYAU O BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS C NLY AUTOS BODILY INJURY(Per accident) $ HIRED! NON-OWNED PROPERTY t DAMAGE AUTOS NLY I AUTOS ONLY Per acad $ I $ A X UMBREL LIAR X occuR 3101E4572 3/17/21 3/17/22 EACHOCCURRENCE $ 1,000,000 EXCESS IAB GEMMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ 10,000 $ WORKERS gQ4PENSATION PER OTH- AND EMPLOYERS'LIILpRBILITY YIN STATUTE ER OOFFCEOR/PRlETDRJP EMI3 REXCLUDEDCUiIVE F—] N/A EL EACH ACCIDENT $ (Mandatory In H) , E L DISEASE-EA EMPLOYE $ If yes,descnbe under' DESCRIPTION OF OPERATIONS below I I E L DISEASE-POLICY LIMIT $ I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) In the event the insurance policy is cancelled(not renewed),lapses or is changed,at least fifteen(15)days prior written notification shall be given to the Licensing Review Board. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are realstered marks of ACORD t/D`)/N /Ac L<IWLOR Sd $usa/v LAWGOR PROPERTY Loeareo or BAy ✓lew rEaR SovrHoco) 7'owN of SOIVA10t0 6UACOIK e0chVry, AIEW YORK Aft,-,o=16 55go 1'0 11kautdcuzsd a!a aaan a addition to this wryey is p otolanon 0(Seet=SM4olilremewYork State Fducatan Law. 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AID. �YZ2,�f y� 9/?/,0Q A?PrOA1,f ( ( .SAyy1LLE,All. f'�vac 6uR✓6ya5-5-94 r - 4OTo,BER/9, /9 93 . �C s. 5 r-d 7ou6lt APR® ED AS NO ED DATE: S B.P.- 02 FEE: o BY: COMPLY WITH ALL CODES OF OCCUPANCY OR NOTIFY BUILDING DEPARTMENT AT NEW YORK STATE & TOWN CODES USE IS,UNLAWFUL 765-1802 8 AM TO 4 PM FOR-THE AS REQUIRED AND CONDITIONS OF WITHOUT CERTIFICATE FOLLOWING INSPECTIONS: _ 1. FOUNDATION - TWO REQUIRED C FOR POURED CONCRETE BOARD OF,OCCUPANCY 2. ROUGH - FRAMING & PLUMBING 3. INSULATION S UTH0_LU0WN4ISTEES 4. FINAL - CONSTRUCTION MUST �i Y S nor BE COMPLETE FOR C.O. " ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEWs L I,� T RETAIN STORM WATER RUNOFF YORK STATE. NOT RESPONSIBLE FOR T Y l a.n d �� PURSUANT TO CHAPTER 236 DESIGN OR CONSTRUCTION ERRORS. OF THE TOWN CODE. E. y