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HomeMy WebLinkAbout47814-Z �o�SUFFa o TOWN OF SOUTHOLD ay BUILDING DEPARTMENT x TOWN CLERK'S OFFICE oy • 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#: 47814 Date: 5/16/2022 Permission is hereby granted to: Vavas, James 152 83rd St Brooklyn, NY 11209 To: demolish existing dwelling as applied for per DEC Non-Jurisdiction letter and Trustees approval. At premises located at: 3165 Bay Shore Rd., Greenport SCTM #473889 Sec/Block/Lot# 53.-6-7 Pursuant to application dated 4/13/2022 and approved by the Building Inspector. To expire on 11/15/2023. Fees: DEMOLITION $619.30 Total: $619.30 Building Inspector 'OUfFOI,t�oGy�S TOWN OF SOUTHOLD—BUILDING DEPARTMENT N Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy�Ol yao�� Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownnygo_v /;Date Received . APPLICATION FOR BUILDING P RMIT For Office Use Only ® E C PERMIT NO.JJ1K] Building Inspector: APR 3 2022 ;Applications;and forms must be filled out in their,entirety. Incomplete BUILDING DEPT. applications'will not be accepted. Where the Applicant isnot the owner,an TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed.. Date: April 7, 2022 OWNERS)OF PROPERTY: ; Name. James and Vicky Vavas ____-_-- SCTM#1000- 053.00 - 06.00 - 007.000 Project Address_ 3165 Bayshore Rd, Greenport.__ Phone#: 917-848-5246 _ _ _ _ Email: 'ames vavas vavaslnsurance.com Mailing Address: 152 83rd Street, Brooklyn, NY 11209 CONTACT PERSON: . ; Name: Stacey Bishop -East End Construction Services LLC Mailing Address: PO Box 63, Southold, NY 11971 Phone#: 631-905-4382 _ Email:__ modu-larg.all@aol.com DESIGN PROFESSIONAL INFORMATION: - Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION:: Name: Ken Rousell Inc Mailing Address: PO Box 499,-Speo9k,. NY 11972 Phone.#:_63_1-2_887_2.545-__-- Email: Kristin@rousell DESCRIPTION,O.F PROPOSED CONSTRUCTION . 1:1 New Structure ❑Addition ❑Alteration ❑Repair ®Demolition Estimated Cost of Project: ❑Other $ 22,000.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes 8No i 1 PROPERTY INFORMATION. Existing 9_- use of property: Sin le a--- lmil home Intended use of property: New Modular Home - --.. -- - - _f Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R4O _ this property? ❑Yes ®No IF YES, PROVIDE A COPY. B Check Bok" After Reading: The owner/contractor/design professional is responsible for all drainage and storin water issues as provided by, Chapter 236 of the Town Code. APPLICATIOMS HEREBY,MADE to the Building Department for the issuance of a Building Permit pursuant to the,Building Zone . 0rdinance.of the ITTo. Wn of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, ' additions;Aterations 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 buildirig(s)for necessary inspections.False statements,made herein are punishable as a Class A misdemeanor pursuant to Section 2'10.45 of the New York State Penal Law. Application Submitted By(print name): Stacey Bishop BAuthorized Agent El Owner Signature of Applicant: Date: April 7, 2022 STATE OF NEW YORK) COUNTY OF 1K ) I S)Aac e &Shor-) being duly sworn, deposes and says that(s)he is the applicant (Name of individu I signing contract) above named, (S)he is the (Contrac r,Agent, orporate Officer,etc.) of said owner or owners, and is duly authorized to 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. I Sworn before me this t'" day of Al2 ri � 20 22 tary Public TRACEY,L LYER N@TANY PW§L10,OTP V-OF NEW YORK PROPERTY OWNER AUTHORIZATION IED IN BUF OLK I�(��l611=l�@ 1[V������K COUNTY (Where the applicant is not the owner) @9MMIQ1IQN 9-XI'IREA JUNIZ 00,OU" I, residing at Separate ' Attached do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 I Building Department Application � AUTHORIZATION (Where the Applicant is not the Owner) I i I V GyC,.•s residing at 15 A (Print property owner's name) (Mailing Address) e E FW0 d 4444 �jj 116109 do hereby authorize -FnnC ,I (3/,5 400 Fromm to apply on my behalf to the Southold Building Department. E rwner's Signature) (Date) J V 61 CLs (Print Owner's Name) ► i t 1 APPLICANT/OWNER TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart of town officers and employees The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. FOUR NAME :—I�t S"i/-?I 2.� SUc-c— LLC (Last name,fust name,middle ini 'al,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) TYPE OF APPLICATION: (Check all that apply) Tax grievance Building Permit Variance Trustee Permit Change of Zone Coastal Erosion Approval of Plat Mooring Other(activity) _ vLc> 10cn.,ucT- aL=c,o inc— Planning Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold?"Relationship"includes by blood,marriage,or business interest."Business interest"means a business,including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee. Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply) A)the owner of greater that 5%of the shares of the corporate stock of the applicant(when the applicant is a corporation) B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation) C)an officer,director,partner,or employee of the applicant;or i D)the actual applicant DESCRIPTION OF RELATIONSHIP Submitted this Co day of &Aj 20 620- Signature Print Name i i APPLICANT/OWNER TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. _ YOUR NAME: VC(.\) C4- 5 (Last name,first name,middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) TYPE OF APPLICATION: (Check all that apply) Tax grievance Building Permit Variance Trustee Permit Change of Zone Coastal Erosion Approval of Plat Mooring Other(activity) Planning Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold?"Relationship"includes by blood,marriage,or business interest."Business interest"means a business,including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee. Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply) A)the owner of greater that 5%of the shares of the corporate stock of the applicant(when the applicant is a corporation) B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation) C)an officer,director,partner,or employee of the applicant;or D)the actual applicant DESCRIPTION OF RELATIONSHIP i Submitted this day of MIC""tL► ,20.IL.2— Signature ✓� Print Namlv cc"q-e—.� ,. Gcy t1 i I NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY @ Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-03651 F:(631)444-0360 www.dec.ny.gov LETTER OF NO JURISDICTION TIDAL WETLANDS ACT James D. Vavas September 22, 2021 8423 Third Ave Brooklyn, NY 11209 Re: Application #1-4738-04276/00005 Vavas Property, 3165 Bay Shore Rd, Southold SCTM # 1000-53-6-7 Dear Applicant: Based on the information you have submitted the Department of Environmental Conservation (DEC) has determined that the portion of the subject property landward of the substantial man- made legal structures (bulkheads) with the combined length greater than 100 feet, constructed j prior to August 20, 1977, and have remained functional, as shown on the survey prepared by Angelo Joseph Cecere L.S., last revised 1/29/2021 and as verified on the 1960 Historical Aerials document and Tidal Wetlands map# 720-550, is beyond Tidal Wetlands Act (Article 25) jurisdiction. Your proposed project consisting of the removal of the existing single family dwelling, accessory structures and construction of new structures. Also, to abandon the existing and install a new I/A OWTS sanitary system is located landward of this jurisdictional boundary. Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6NYCRR Part 661) no permit is required for this project. Be advised, no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary, as indicated above, without a permit. It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Article 25 jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and your project (i.e. a 15' to 20' wide construction area) or erecting a temporary fence, barrier, or hay bale berm. There is no application fee required for a proposed project that meets the criteria for no jurisdiction. Your application fee check (Suffolk Environmental Consulting check# 2574- copy attached) has been voided. wExrvORK Department of OPORTI NfiY (Environmental Conservation .,. TERMS AND'CONDITIONS The Permittee,James D.&Vicky Vavas,residing at 3165 Bay Shore Road,Greenport.New York ;,.. as part of the consideration for the issuance of the Permit does understand-and prttcribe:.to'tlie�;il.=�. }� "-'_:=,-� : - .'-, following: That the-said Board of Trustees and the Town of Southold are released from any and all damages,or claims for damages,of suits arising directly or indirectly as a result of any operation performed pursuant to this permit,and the said Permittee will,at his or her own...., expense,defend any and all such suits initiated by third parties,and the said Permittee assumes full liability with respect thereto,to the complete exclusion of the Board of Trustees of the Town of Southold. 2. That this Permit is valid for a period of 24 months,which is considered to be the estimated time required to complete the work involved,but should circumstances warrant,request for i an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely,or as long as the said Permittee wishes to maintain the structure or project involved,to provide evidence to anyone concerned that authorization was originally obtained. 4. That the work involved will be subject to the inspection and approval•of the Board or,its - agents,and non-compliance with the provisions of the originating application may because for revocation of this Permit by resolution of the said Board. 5. That there wil I be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along the I beach between high and low water marks. 7. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized,or if,in the opinion of the Board of Trustees,the work, shall cause unreasonable obstruction to free navigation,the said Permittee will be required, upon due notice,to remove or alter this work project herein stated without expenses to the Town of Southold. 8. The Permittee is required to provide evidence that a copy of this Trustee permit has been recorded with the Suffolk County Clerk's Office as a notice covenant and deed restriction to the deed of the subject parcel.-Such evidence shall be provided within ninety(90)calendar days of issuance of this permit. 9. That the said Board will be notified by the Permittee of the completion of the work authorized. 10. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit,which may be subject to revoke upon failure to obtain same. 11. No right to trespass or interfere with riparian rights. This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights,title, or interest in real or personal property held or vested in a person not a party to the permit. i i i Please. note that this letter does not relieve,you of the responsibility of obtaining any necessary permits or approvalsfrom other agencies or local.municipalities. i Si c rely, I san ckerman Regional Permit Administrator cc: Suffolk Environmental Consulting; BMHP; file I I I i i i I I I I I r BOARD OF SOUTHOLD:TOWNTRUSTEES SOUTHOLD NEW YORK" C r. PERMITWO,:9995 DATE: SEPTEMBER 15,2021 s ISSUED TO: JAMES D.&VICKY VAVAS PROPERTY ADDRESS: 3165'BAY SHORE ROAD,GREENPORT ' � SCTM#1000-53-6-7 ;. Pursuant-to th ;. UTHO ZA I - A RI TON e prov�s�ons of Chapter 275 of the Town Code of the Town of:Southold and in accordance with the Resolution of the Board of Trustees adopted at tlie'meeting I{eld'on September 15,2021, and in consideration of application fee in the sum of$250.00 paid by James D. &Vicky Vavas and subject to the Terms and Conditions as stated°in the Resolution, the Southold Town Board of.,Trustees authorizes and permits the following: Wetland Permit to demolish existing dwelling and construct a new 1,400sq.ft.two-story,single - - ,family dwelling'fuither landward than the existing dwelling with a 151x20'(300sq.fL)attached garage;construct a 200sq.ft.landward porch;construct a 7.51x22'(165.Osq.ft.)seaward side deck;and to install a new WOWTS septic system;establish and perpetually maintain a 8' wide non=turf butler landward'of the`balkhead; and as depicted on the survey=prepared by AJC Land Surveying PLLC,last dated on September 9,2021,-and stamped approved on September 15,2021; and on the site plan prepared by Joseph FIschetti,PE,dated July 27,2021 and stamped approved on:September 15;2021, _ IN WITNESS'WHEREOF,.the said Board of Trustees hereby causes its Corporate Seal to be.affixed,and these it -f presents to be subscribed by a majority of the said Board as of the 15th day of=September,2021. f 4 , —AS FtII,�' ¢ l ' tt7 IL P, t k ;.�k�iwtr:2n»W6+:.....v<.. - .ate.. •'iwn....sw..uJ _ -/ga .e--..- ..-.-+.--�---...--�-`--' - ....t..w.. - - w,.r_'.+�+,'.s+a1 NYSI F New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 .E AAAAAA 112980169 KEN ROUSELL INC P.O. BOX 499 SPEONK NY 11972 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER KEN ROUSELL INC TOWN OF SOUTHOLD P.O. BOX 499 TOWN HALL ANNEX SPEONK NY 11972 543 MAIN RD-PO 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 1322 013-2 791648 01/0112022 TO 01/01/2023 4/7/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1322 013-2, 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 OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU 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 YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS 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 NEW YORK STAT S70* NCE FUND 4 DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 516329896 U-26.3 YORKATE Compensation Workers' CERTIFICATE OF INSURANCE COVERAGE ST Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS 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 KEN ROUSELL INC 516-668-2023 7 WINDEMERE CT SPEONK,NY 11972 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 11-2980169 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America Town of Southold 3b.Policy Number of Entity Listed in Box 1a Town Hall Annex 543 Main Rd-PO Box 1179 00984602-0000 Southold,NY 11971 3c.Policy Effective Period 09/01/21 to 09/01/22 4. Policy provides the following benefits: Q A. Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5. Policy covers: Q 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 insurae coverage as described above. Date Signed 04/08/21 By (Signature of insurance carrier's authorized representative or NYS licensed insurance agent of that insurance carrier) Telephone Number 1-888-278-4542 Name and Title Michael Prestileo,Head of Group Benefits Strategy,Product&Underwriting 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 413,4C 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 emailed to PAU@wcb.ny.gov or it can 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 413,4C or 5B have 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(Article 9 of the Workers'Compensation Law)with respect to all of their 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 (12-21) 1111111111°°°1°°°°1°°1°°°1°°11°1°°1111111 DB 120.1 (12-21) 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 NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)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 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 NYS 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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. DB-120.1 (12-21)Reverse r q Client#: 11482 KENROU DATE(MM/DD/YYYY) ACORM CERTIFICATE OF LIABILITY INSURANCE 1 4/07/2022 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 terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Commercial Support Edgewood Partners Ins.Center PHONE 631-390-9700 FAX 631-390-9790 40 Marcus Drive E-MAIL Ext: A/c,No 3rd Floor ADDRESS: certificates@cookmaran.com Melville, NY 11747 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Greenwich Insurance Company 22322 INSURED INSURER B: Ken Rousell Inc. PO Box 499 INSURER C Speonk, NY 11972-3830 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY Y NGL100038602 05/24/2021 05124/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE a OCCUR PREMISES(ERENTED occcu ence) $300,000 X PD Ded:1,000 MED EXP(Any one person) $10,000 PERSONAL$ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY[ X1 ECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY NBA100038702 05/24/2021 05/24/202 (CEO, OEaMBINED ccident $SINGLE LIMIT 1,OOO 000 a , X ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED AUTOS ONLY X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ST TUE E ANY PROPRIETOR/PARTNEWEXECUTIVE YIN N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Certificate holder is Included as additional insured for general liability coverage as required by written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall Annex ACCORDANCE WITH THE POLICY PROVISIONS. 543 Main Rd-P.O. Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S3540256/M3087169 TKNO1 MORRIS CESSPOOL SERV/CE INC. | P 0 BOX 2130 ! GREEyJP[]RTNY11q44 | 6317653300 | LICENCE L\N1O7 ' March 12022 i Towhom itmay concern: I Douglas Morris pumped out two cesspools at 3165 Bay Shore Rd Greenport NY 11944, totally dry. The work was performed for James Vavas. Thank You Douglas Morris President From:kristin@kenrousellinc.com, To:modulargall@aol.com, Subject:Licenses Date:Fri,Mar 4,2022 4:45 pm Attachments: Hi Stacey, Our license numbers are listed below: Southold: 0111 Suffollc County:HI-60912 Suffollc County Health:LW-175 Regards, Kristin Rousell Ken Rousell, Inc. P.O.Box 499 Speonk,NY 11972 Phone: 631-288-2545 Fax: 631-288-2546 www.keizrotiselliize.com Like us on Facebook: https.-Ad.fa cebook.com/kenrousellinc Follow us on Instagram: @kenrousellinc 3 ANNIVED&APY 0 PSEIG 1491?ljlk�NC*D 3/22/2022 JAMES VAVAS Service To: 3165 BAY SHORE RD, BX304 3165 BAY SHORE RD, BX304 GREENPORT,NY 11944 GREENPORT,NY 11944 Customer Project#:900000145677 Dear JAMES VAVAS: This is to advise you that the PSEG-LI electric facilities at the above referenced location have been disconnected and removed off the building structure that is located on the property. Please note that there may still be PSEG LI facilities located within the property boundaries and that NYS law (NYCRR Part 753)requires all contractors to call for a utility locate (NY 811)prior to performing any ground excavation or regrade activity. The call to the 811 Call Center must be done at least 2 business days prior to the start of the work and confirmation of utility marks having been identified must be received from all the facility owners prior to any site work. You must also contact National Grid at 631-348-6150 to procure a letter of demolition associated with natural gas service,whether or not your home or business uses natural gas. If you have any questions regarding the above,please contact Building&Renovation Services at 1-844-341-6378 or via email at BRSLI@PSEG.com. Very truly yours, Katherine Gianeelllii DQ �CCG(72fJGf/I2fi �GCJ/J2fiULG Building&Renovation Services PSEG-LI pOLK COU1VTj, ER AUT140 4060 Sunrise Highway, Oakdale, New York 11769-0901 March 28th, 2022 15283 RD ST Brooklyn NY 11209 RE: 3165 Bay Shore Rd Greenport NY 11944 To whom it may concern: On March 22"d, 2022, our representative confirmed that the water services were physically disconnected at the above referenced location. Please advise your contractor that care should be taken not to damage the existing vault and / or curb box, as the cost of any repairs would be billed to the premise and no service initiated until the balance is paid. Sincerely, �W" k (: *' I �h Lisa Cetta New service manager LC/ Ih Evan T.Steffens Nationalgrid Senior Supervisor Gas Customer Connections,NY March 30, 2022 James D. Vavas 152 83" Street Brooklyn,NY 11209 E-Mail: VAVASJD(a?GMAIL.COM ; MODULARGALIIAOL.COM National Grid WO#: T102468117 Service Address: 3165 Bay Shore Road Greenport, NY 11944 To Whom it may concern, This Letter is to advise you that National Grid investigated your request and confirmed that the subject property does not have an active gas service line. New York State law requires anyone planning underground excavation work to notify local utilities by making one call to a toll-free number to get your underground lines identified for you prior to doing any digging. This phone call needs to be made at least 2, days but not more than 10 days prior to starting work, not including the date of the call. The number to call is either the nationally sponsored "811", or the local number for NYC/ LI area, 1-800-272-4480. This confirmation letter of no active gas service line to the subject property does not relieve the excavator of making this"811" call. If you have any further questions, kindly contact me at 833-359-0645. Respectfully, 4L7/-,*I Evan T. Steffens Senior Supervisor Gas Customer Connections NY 1650 Islip Ave,Brentwood NY 11717 T:833-359-0645 evan.steffens@nationalgrid.com ngridlirudprocessinp nationalLrid.com C2, APPROVED AS NOTED/ DAT*� UILDING �e B.P.#1�7�l FEE; 3U BY: NOTIDEPARTMENT AT COMPLY WITH ALL CODES OF 765-1-62'--S ANEW YORK STATE & TOWN CM To 4 PM FOR THE � FOLLOWING INSPECTIONS: ODES I. FOUNDATION. - TWO REQUIRED AS REQUIRED AND CONDITIONS OF FOR POURED CONCRETE. 2.. ROUGH - FRAMING & PLUMBING 3. INSULATION SOUTNOLD TOWN PLANNI G BOARD 4. FINAL'- CONSTRUIC T ICN MUST BE COMPLETE F;, SOUTHOLD TOWN TRUSTEES ALL CONSTRUCTic.N 3'-{ALL MEET THE N.Y.S.DEC REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE, SURVEY OF PROPERTY LOT 55&PART OF LOT 56 m AMENDED MAP"A" OF c o 16 PECONIC BAY ESTATES �Z 50.0'WIDE RESIDENCE-PUBLIC WATER I FILED: MAY 19, 1 933-MAP NO. 1 124 m PUBLIC LOT 54 SITUATE y RIGHT OF WAY 75.00 TO M.H.W.AS PER FILED MAP PROPOSEDARSHAMOMAQUE (GREENPOR[) m e N66°09'00"E RESIDENCE– I i4cJ•38TOCURRENTM.H.W. E UTIL. xg9 hh I BULKHEAD NAIL RETURN SET TOWN OF SOUTHOLD g 19 �x�1p p�£ POLE E MON.FND. U N{ �p,L 5.5' gg� g°'1 G9 X O — SUFFOLK COUNTY, N.Y. �I I U7 ASPHAL7DRIVEWAY l9° n 243 NG K I N // WITH CONCRETE CURB Z G.FL.=1 .96 TAX MAP NO.: 1000 053.00-06.00-007.000 � r�� I O 35.0' N 10.ON I j 25.0'R.YSB. = W 01 /'� 0 ' V l rD. O B. . W'� LOT 55 = (xj 1 ! ° LOT AREA TO M.H.W: 10,888.24 S.F. (0.250 ACRES) o e w ;," 53.h' g I o 0 m gg D_ p D V D O DATE SURVEYED:JAN.27,202 i n f w— 7 „N o I A m a IT ADDED FLOOD ZONE:JAN. 29,2021 m O WATE � PL. �D� o= °, :< � y I tri Z N SERVIC C 0ro 20.0 v m= x� ' x g2xr 1m \ �' = 1 STORY z e. 6oI ^-ELEVATIONS REFER TO NAVD88. �2 gy, hn zSANITARY57 ww FRAME 01 < m !n 13 < N ESIDENC 100 .m r 0 •o -NO WELLS WITHIN 150'OF SUBJECT PROPERTY. I m _ _•_ . _ I rn _z -� — #'31-65— -- - 1 _- D -N = -r - -D Ul ` s—mss 44.3 g9 �I o0 30 60 j rL.._. G .. 9_„_PAJPT OFFeet Z1 0 °� °. 'No RA CE � , LOT 56 N m IOSCALE: 1 INCH= 3O FEET o UI L P.J/ >O 20•OJho?/ °0 DN TANK Nxg1� xgp° krO�O x°1h - -- —' v x k �" o BULKH A NAIL ro ,ISI g9 of g8 PILLAR STAKE HEDGE ROW ON LINE STAKE w OC��� h' I N0 0.2'S o\/ FND. FND. RETURN FND. O 0• 9' Z'a o�� S66°09'00"W 175.00 TO M.H.W.AS PER FILED MAP I v o m UTIL. ` 145.00 TO CURRENT M.H.W. fA POLE oa ART OF I v m0 LOT 56 56-15 o or n RESID CE-PUBLICWATER olo I w 1 m ('� O p _ I c� O '� ml m o r 0) �c—+ m CERTIFIED TO: �S®99� In � W JAMES AND VICKY VAVAS L' FIRST AMERICAN TITLE INSURANCE COMPANY � AND � ■"�� �� WELLS FARGO BANK,N.A.ISAOA } LEGALNOTES', m �l 1.COPYRIGHT THORIZED LTEAJC LANOSUR EYINGADDITION PN T THISALL SURVEY MAP SURV OR'SS A ALTERATLONLATI OR AODITIONT 7209.SURVEYMAP 2.OF NG AEW LICENSED LANG SURVEYOR'S SEAl15A VIOLATION OFSECTION 7209.SUBDIVISION 2,OF NEW YORK STATE EDUCATION 'O LAW. 3.ONLY BOUNDARY SURVEY MAPS WITH THE SURVEYOR'S EMBOSSED SEALARE GENUINE TRUE AND / CORRECT COPIES OFTHE SURVEYOR'S ORIGINAL WORK AND OPINION. U 4.CERTIFICATIONS ON HIS BOUNDARY SURVEY MAP SIGNIFYHATTHE MAP WAS PREPARED IN ACCORDANCE WITH THE CURRENT EXISTING CODE OF PRACTICE FOR LAND SURVEYSADOPTED BY HE �1_ /'���•• /� NEWYORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS,INC.HE CERTIFICATION 15 C SURV..�YfN-GJ DI �■ THEO TOPERS°AL AFOR GENCY. ATHE ND BOUNDARY SURVEY INSTITUTION ISPREPARED.ON TOHETITLARY SURVEY > 11 Y rl 1 l♦IYy V ) HEGOVERNMENTAL AGENCY.AND TO HELENDING INSTITUTION LISTED ON THIS BOUNDARY SURVEY "Vv. -'�a":- Fk �r.:J„-4'y'�-r ,,_.,,,�.5' � ../-s•?r..*,,ffi'�a,. b„'�.�� T".'4w 1/`�-. MAP. � -}.(�. VI- �/I���^` /ice 't ■■ (�I.►�\' `�J f ][ 5.THE CERTIFICATIONS HEREIN ARE NOTTRANSFERABLE. 04V _'V' ;�,l�;�i,-� P �1� �1 V- _ V/�.r//�'•f\J 6.DOFTEHE MUSTION OF UNDERGROUND IF UNDERGROUNDMENTS OR IMPENCROVEMENTS O ENCRE ROACHMENTS TS OUST 11 Y ANO OFTEN MUST BE ESTIMATED.IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMEMSEXIST OR OR ENCROACHMENTS ARE NOT COVERED S SURVEY. `ha^4�1�v ,',��/pJ ^A/ �/j 7 THE OFFSETS OR DIMENSIONS)SHOWN HEREON FROM HE SHUCTURESTO HIE PROPERTY LINES ARE m f 7�7 S CO EMAN ROAD, CENTIE RE�ACIH(t [N ■��i�10 r rIr FOR A SPECIFIC PURPOSE AND USE AND HEREFORE ARE NOTINTENOEDTO GUIDETHE ERECTION OF 'x- - �,.� S . (_'I FEN CES.RETAINING WALLS.POOLS.RAMOS PLANRNG AREAS.ADDITIONS TO BUILDINGS,AND ANY OTHER 3 '7 `QQ.../�Y 4 TYPEOF CONSTRUCTION. / :PHONE:G3:I'..'846iVti/l 4 L /VX`a ■ B.ONLY SURVEYS BEARING THE MAKERS EMBOSSED SEAL SHOULD BE RELIED UPON SINCEOTHERTHAN ` `.CY�lnt•.-+*.L I J\) EMBOSSED-SEAL COPIES MAY CONTAIN UNAUTHORIZED AND UNDETECTABLE MODIFICATIONS. %-IE=MAIL: C2 f�#@OPTONLINE.NET `1(� 9. ROPE TY CORNERDCH D 9.PROPNS.ADDRIONS.A MONUMENTS NOT SETAS PART OF THIS SURVEY UNLESS OTHERWISE NOTED. 10.ALL MEASUREMENTS REFER TO U.S.SURVEY FOOT. / U