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Home My WebLink About47564-Z � 0 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 104 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 #: 47564 Date: 3/18/2022 Permission is hereby granted to;. D_io_. u_ar i Vincent. . Garden Ci , NY 1153 ------- ................._.......... .._.._ 0 ..............____...................__......I........_...... ......__.....................__........_____ ..._ ._._............................. ...__ To: Install window replacements at existing single family dwelling as applied for. At premises located at: 4890 Sound Ave., Mattituck SCTM # 473889 Sec/Block/Lot# 121.-3-7.3 Pursuant to application dated 2/17/2022 and approved by the Building Inspector, 7/2023. To expire on 9/1... Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: ---—--��$250.00 Vow. . .............. _._... Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. d. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 : �w� �mr wal:IiC: IIm„ : : Date Received APPLICATION FOR BU11 DING PERMIT For Office Use Only EC 6! r° nDJ . .I . PERMIT NO. Building irtrtcr.. PT Applications and forms must be filled out in their entirety. IncompleteV� ° ra '� L ..� applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:1/20/22 OWNER(S)OF PROPERTY: Name:Maria Dioguardi scTM # 1000- I r-7 ProjectAddress:2445 Kirkup Lane - }�C, , - CC tc.; kVe Phone#:(516) 313-8076 Ermail:mloredioguardi@gmaii.com Mailing Address:2445 Kirkup Lane CONTACT PERSON: Name:Jessica Schiff Mailing Address 105 Buttonball Ln, Glastonbury DT 06033 -Phone#:860-952-4112 Emall:permits@gopermits.org DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Home Depot USA Mailing Address:2455 Paces Ferry Road, Atlanta GA 30339 Phone#:347-541-5613 Email:permits@gopermits.org H DESCRIPTION OF PROPOSED CONSTRUCTION ❑New structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: 20therRemove and replace 1 window, like with like, no structural changes ..... . .. _ . mmµ. $4380 Will the lot be re-graded? ❑Yes *No Will excess fill be removed from premises? ❑Yes � No 1 It �...D� lot License, � a the �niost�.," mmt�nt li. ttlt ...v. m".wwm�t� rwu wmrN .�� .. � ......... ��..a�� .aaa��. L——----------- . .......�.... ..., .� ------. ... ._.. ........... �. ...�.. ........... _.. ...m ...... �.. �.. ....� florae Depot U.S,Aja c ("Home Depot") pmt- Autlim m mz (:N Nmw n,ice Pmvider named Nm:will fitmish, Nm suitmtmcN/t'r service the emNuipinen NNht �N belovv at the fly e, terms an rwt°uli(ions ,,:ks ( mm fined on this fonn, ..�........... heNr�rwur� hrret i h HGF) w poo ®,,. ,. _. „w,a.. Nr m. tm��e Provider Contact N Ntm m Service �iVidet Company N'mHtm N6 Nwmm1mm ..10 c. .� .... �r rtto� w r rr�r NN tN . _. . A w m raw ider Eimlil Address Seivice Provicler License fl(s) [� e. k � � �.:�_. ....". ....... .. .. ..�....... � �w......... � Cusumner 1,ast Name Custmmmm.mem ist Name Stf)re -/ tmtmch °Name ( P .......w 2445 hrth Lane CattitU 952 CWvO.hstffi"m.e$. dk.(hh'ee.:Vs j :'it Suite Zip p . _ I..... ........ .aa.� � N�� ) tth ; �� I��rrt�� m��arcfimsm� �.w�-... ..--a _a_...... Home N°m�rne W6 N'��ttmne# N mwm,�N N�N'm.mmm NN Customer Email Address N. NOTICE CIE RJC11TTO CA:NCIIIIK, " IIIICt "V' IIIIIE '° OR T '" " ...'A''- . ',"MAILING S PROVIDER AT: .... { . Nim m��ri r � �a�� ,.. .._ e .,.,...e� .,e...... . �G ,��flppauge ��8 ®,.1 Wi .., Address, City Stme Zip BY MIDNIGHT ON °NV"VVIVIIlTHIRD BUSINESS Y AFTER SIGNIN1,1G, UP111d,ESS THE . " ".E PROVIDES � DIFFERENT ��m 'N w1 IIIII�IIIIC.,XrIO�n" PERIOD.�� D. ��"HE � ATE SI..J ��..n�EI EINI�fl „ VN.N ).' 'VVI�VVIN � �" " CONVY.&INS A FORM TO USE IIF OXIIIINN IS SPE(l."IFICALLV RESC UIII]E ,Y LAW IN YOUR STATE. '111V'O�UR PAVEI VN11'('S�) WILL BE RE �UN IIIIC�D V' I:TH I lI IIIIEN 101) ffIU S VNIII SS DAYS All"TERFIDkIE DE11 1"" RECEIPT e 1,10111 NOTICE. YOU NluST ImAKE AVAILABLE FOR 1 1 K .N IIII!13Y 1 II " POT OR SERVICE PROVIDER, r T VOUI SERVICE ADDRESS, AND IN SUBS NVV" L'LY "THE N OP11 MITI NN AS 'WH NmN DELIVERED,IVERED, t .N'°N` IERCI Al" IIIIDISE OR VVIXIMIIItl,ALS DELIVERED TO YOU. OR YOU " CONTAcr.. i lOME VVI I ,1110T N, INSTRUCTIOP16 KEGARDPQG RETURN "°'U R SHINkIENTAT HOME DEPOT'S EK�:!)ENSE. THE LANk"" E VN.TRE �m THAT THE HOME DEPOT GIVE " N A NOTICE E XPLAINING YOUR WIII mnH T To CANCEL. PLEASE &ICN BELOW TO AC KNOW LEDGE 'I'll ., "OU HAVE BEEN GIIIIIVEN 0lll .AL AIS . r ' "' " " N ' „ w: OF NirH, O Cr N E Acknowledged byt N . 01, r rt ®. , fiuwLkl»rrreAxtudB orm�INAjNJaa8NN(;&;Y Dsae ZI/2212.f).'p,,,w .... dvad110,6 1 lYTI OM 'v �1 r11&line im p hili ovenmit g�r-��eeiiine : Page °' 4. Description s o rk trr be Performed .pr "ark rk to be pear °rrrrmss is included in theparagraph� nfitl Sc of �IT� ,,„ � iiificat n, Custarrs s�S srmrm°ssrpr 'mpnm;r� �mrQuuote [`oars,„ Esthnaw, Ims°smmke sr. a nue mmnprich ms included mrr this Agreement, . Anticipated eliv �ry Dais Ins�ialls�i;�i � s�GV�redul d �mpm�r..mmsprrmu��to Start llf atet �rr '11112022 .] Approximate tmmm�psh Date: m�m�J."m�� '� m��m��s ��mui rm��°��m�m��s�m��mmmm�m�� arm! sulLm ect iR) cl urri as based mmrm mmmui "' � ,�. mrmsu.usn�� u'�s mm� ' mmmmsss mpmsm�mm�m@ ��r��ms�r�. rw�m��rsmmr�m delays, �rsmw� rmm m �mm'ms sr�srr�� imam;p�,.umpmmrp.��prmsms�msmmi� rr��r�� III �. � � �' � ��"� � m��s� ��m��,�m`�µ �mm.�m m mrsp �m�rmm m;r'�rssm�mg mmmm fb-r any repair, r mm°msmmrm ; �. !Ilsc �rmoomrm Ikecords A.u�thsm�sr�ss�ti�on bu amra entitled d u:m s papei m o� Ir� w of grrasrmmen i ��.: you m�.onsss�i�fw�W ain s-mmmumpp mrd r m�mp y rrur w,wmmsnueni�fw s m�pwss to �:�°mu, Agrm�e mrrm�mms and idl subsequent m�rmm m pmmmsm�s p� rn'r Unnum stpm.mrms reµlaated to this Agreement. By � � � �sms� mpmwm°mrnmum�n�n�,°�� sir �un��dun�u r��mrnm m orrwhag y muur Service Prmmm pxp.e�;you uray mmp dme ,our email adds yaw, "ki r aa% your consent, mems mrbmmndnn mm paper copy of the Agreernern or sspawd d.omwm�mmsnts at no mmlll w1e. By p.aaFs�pmpnnng your m:raaunaent and veril�ying, ym.lr tnssppaddress above, you con ruii.mrm that you Nave access to s com�p ater° Out m�°smm receive and mmlllven srnads and PDF m:pocsmmre s. 7. Contrad Price Payment shsdsrllllrm Plyinant of the Conuact Price is due upon Mgnhg unless a chMent paymort sd°mss 'We is rsmpspsed by QW, s orsa iRer] below or in rr payment meet mamdrpemmdumrm. "mrm�m rrrr: llrm.cer 1; mrm hulmrs mm.'�ll umpppmam ble Mm s, Excluder finance charges.* SalesTar ps ppp �m 'prpmsum�mps� �.mrllPrlm� mmrm°mm''mrmmm�.mr °�ssm�s m .��w........... �� msm.inimm�r�;.m�p Contract Price) A "If o:drsa"amma�m�nu manor^pwtio if p,pa/'npp''.,1}' a apyrrpa`D.awnble in 3111), 41A �hi�°�'°,° (33%), /ms's, HrY (^9Y(j , s, ssli p . ...��....�� IIIiosm� r�msorn. � unrrmsrBmlmmm $ 8. Finance 41,g."ss tnw u.G Any mrmn'Leires�it payments o ober Arr mr t�.-barges will. lbe determmrpmned IQ, (�w umsi��omr�'s ssprssa to mmrm�dhslder. arm hmxa��Rn apasssmrmest., u), which Home IllII)eprwr�t is, (�)T nm pma�ity, and will t.me ilii ME% lo C�must m er's lmrio�r s�t m.mrrspss this msemsment Ustos:msm is subject to Ore t r..m.ns, arr.rr: cmrmr&�Pipm' ms of Ne cardhoMer norm.. llloan agreement, as sp.r prmnaW �No hmmmds sh mild be made payable oma em r mm,mr III I:"rmm�sprpsm i hover ev, Ssms�isrm Provider may Wma :lswn r% paymsmm^:w s mrmnrnp psary�amis p.:psms Depot m A.rmr,rmllllm trace and m rrthor° s l:w,on By signing )Gnaw pavan, you rrnnuRnorize p prwnmme Depaaur gar (im) aanmanap,s, Ar Service [Ovider to p:nsn°paDrnn°n any " a n m nwa,a,s worn, (gym) amnaRr aund emnarrys Rwr Te delivery a f'spmm:m°psp Wer nu enmtauuappsas, including g sprmashp order msn�channdise thaam may be amwasroruu nanramd.m as sprsw GRed in Us Agrem.n wwrsnu pews not sign if bink or Wo mmp k te d' sr%ice Prw umparrrs w,an prdsn�nuuaa�mpr�rs nnrp n a:mrrrtmorn rrnamy need to be [wovided to You l ansn%.p By snpflnnuunG,p, y muu awa°kuuamsledg e tham (p) You have ramaarrp., nmrm .mn��u�nunm.p�. anrnap �,,wcejx " grssnnum,,num nnu is arnnu:Gnm p, umnm.p uln g the General m, awmnwppuna.un arump Swa aup;ipnprmu:•u enun., of tiny; rap) You firm: uaacek,,inu r, �a r.rrmvpmpsms copy amp dris gmrmmmrursnntm pmrmp Sapp ruyhm and urmmsnw sts under thr s Alpecalera drrm3 solely ve mal in the perspy lk Aid as -Cnusuwnrnra.,r ma sorb: and (iv) Elecironrc srp nsnunvs a011 be deeTned originals IN all pmsgioses. k ,d I Y@lam tmrm sers suumnalnrrsE�mmts� �._..... .. .....�. ....waaaa..�... .. ,. ./s/ "ass horns p.�a Eof 5epA��t INgital Signature Date 1&r qrrsmo:rrras rellated to yr°mrr�� russinHado , con�tn ill er�srce llk�rr'rviderw at (631) � 01 MO Masa,Lwd N amtd R�aVrD q"B 7u�� :^&,N',Rik 0:;Cn mwd wDa w 0112212022— V ead['a Art I 1 T a W P 'Woiii,kers' CERTIFICATE OF INSURANCE COVERAGE $t I Coqnperisation At( Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW IFF PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier ;F -. -.-.........Name a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured HOME DEPOT U.S.A., INC. 446-807-7093 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1 c.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) 581853319 2.Name and Address of Entity Requesting Proof of 3a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD HARTFORD LIFE AND ACCIDENT 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 LNY713657 c Policy effective period 01-01-2022 to 12-31-2022 ..................-.......... ........... ......... 4.Policy provides the following benefits.- A.Both disability and paid family leave bensfits. B.Disability benefits only. C.Paid family leave benefits only. 5.Policy ovem: NA6,All of the employees employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employees employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carder referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 12-29-2021 (Signature of Insurance carrilees authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello-Assistant Director,Statutory Services 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 5B of Part I 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 Y........_... ............ (Signature of Authorized NYS Workers'Compensation Board Employee) TelephoneNumber Name and Title Please Note:Only insurance carriers licensed to mite 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-120.11 (10-17) 1� IH Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first,two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. .......... NEW Workers' YOFIK CERTIFICATE OF C(NMPeU-1Sa1J0l1 Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Home Depot USA,Inc. 770-433-8211 2455 Paces Ferry Rd.,C-20 Atlanta,GA 30339 1c.NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Only required ff 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 58-1853319 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"l a" Southold,NY 11971 WC 058240268 3c.Policy effective period 03/01/2021 to 03/01/2022 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'T'insures the business referenced above in box"1a"for 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 pedury,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: Michael Price (Print name of authorized representative or licensed agent of insurance carrier) 02/27/2021 Approved by: (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 Please Note: Only insurance carriers and their licensed agents are authorized to issue Fonn C-105.2.Insurance brokers are NOT authorized to issue it® C-105.2 (9-17) www.web.ny.gov