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Home My WebLink About48063-Z �O�QSUFEOtkcoG Town of Southold 8/14/2022 o �4 P.O.Box 1179 o s 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43328 Date: 8/14/2022 THIS CERTIFIES that the building OTHER Location of Property: 375 Green Hill Ln.,Greenport SCTM#: 473889 Sec/Block/Lot: 33.-2-47 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/9/2020 pursuant to which Building Permit No. 48063 dated 7/14/2022 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: "as built"pool fence as applied for. The certificate is issued to Lewis Rev Inter-Vivos Trt of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED uth ri ed ignature TOWN OF SOUTHOLD QuFFot,r�aG BUILDING DEPARTMENT TOWN CLERK'S OFFICE 'ate,• t`r 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#: 45479 Date: 11/23/2020 Permission is hereby granted to: Modern Age Blders LLC 330 E 38th St#56G New York, NY 10016 To: legalize "as built" pool fence as applied for. At premises located at: 375 Green Hill Ln, Greenport SCTM # 473889 Sec/Block/Lot# 33.-2-47 Pursuant to application dated 11/9/2020 and approved by the Building Inspector. To expire on 5/25/2022. Fees: AS BUILT -ACCESSORY $200.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $250.00 Bui di nspector �oyoSUFfot,��oG TOWN OF SOUTHOLD BUILDING DEPARTMENT 2 TOWN CLERK'S OFFICE VJ "o • � 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#: 48063 Date: 7/14/2022 Permission is hereby granted to: Lewis Rev Inter-Vivos Trt 230 Park PI Apt 4K Brooklyn, NY 11238 To: Legalize "as built" pool fence as applied for. Replaces BP#45479. At premises located at: 375 Green Hill Ln.,Greenport 'SCTM #473889 Sec/Block/Lot# 33.-2-47 Pursuant to application dated 7/14/2022 and approved by the Building Inspector. To expire on 1/13/2024. Fees: PERMIT RENEWAL $250.00 Total: $250.00 Bui6r4g Inspector SOUTyo� TOWN. OF SOUTHOLD BUILDING DEPT. `ycourme 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATIO CAULKING [ ] FRAMING/STRAPPING [ ] FINAL O Vfj*a, [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ]' RENTAL REMARKS: DATE INSPECTOR FIELD INSPECTION REPORT 'DATE COMMENTS FOUNDATION(IST) ,� y ------------------------------------- FOUNDATION(2ND) z � o J ROUGH FRAMING.& y PLUMBING INSULATION PER N.Y. (� y STATE ENERGY CODE FINAL • v ADDITIONAL COMMENTS 0 50•o Ak- MAO O n d: A�r�RF •^y�- �au-- • -�j (1) Z ®11 m �=P rY ' F k� tv ' b H. TOWN OF SOUTHOLD—BUILDING DEPARTMENT u,a�r: CLrS ii Town Hall Annex 54375 Main Road.P. O.Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631)765-9502'littl2s://www.soLitholdto-vvnily.gQv �^ -��j Date Received o{11' � �{iE+l iy 1ii}.lh dLS PE`IVIldu For Office Use Only LL r` PERIVlIFFN . tBuilding Inspector: - _ NOV — 9 2020 Applieatia5 and.forins�inust tte fcttec# t in their entirety.,Incomplete:.: _. appl�satin virHt.natbe accepted :Where the Ip►pplicaM:s.not thetoiivner,;an`•`_ atatctet'sAvthortzaYiva_few(Page2jshatl�be::coinpletecl`:,� ,°;..-. , `- .` _:• - l��T�'�,�?�i-?�l�l,�•�a, '�^.11,'i i: 'Z.rT,%3�r 3.I�+.��LW9YJS✓' Date: r: Nares � s SCTM#1000- Physkak ess: _3 7 5egrreen, 4 Phone#: 3 _ &77 Email: A0,4 modemhamebuirF6r cv Mailln&Adel 75:5- c,�a ✓y -� �S�c ¢e a.1�, y CONAL:._ Name: 0' Mailing Address: Phonelk Email: DESIGN PROFESSIONAL INFORMATI ON_. - Name: — Mailing Address: Phone#: Email: CONTRAC60R INFORMATION:, Name: Mailing Address: Phone#: Email: DESCRIPTION'OF PROPOSED CONSTRUCTION., ❑New Structure ClAddition I]Altera. ' n ❑Repair ❑Demolition Estimated'Cost of Project: ther F t:5 A C� $ 150.00 Will the lot be re-graded? ❑Yes�No Will excess fill be removed from premises? ❑Yes Ylo 1 _R01PERTY.!INF0R!WqR.,�__, Existing use of property: r Intended use of property: 7 Zone or use district in which.premises is situated: Are there any covenants and restrictions with respect to this property? [3Y!S36 o IF YES,PROVIDE A COPY. lona acid doslghp�' '1--'erie, ',q li�e-'e.6aii�dr6fi _waterk�ias-0rqWd16d:bV' a 4.respo fd' lie, S nceW,a8uM jitgee sua �!mft pu*6nt'td.t BRUdingZones ium4-6,untii*iwYcA and constriction df.buildings, ad i' �n- rermytakpai-h-irelnd6scii6i.i"heap�ica�t4r.ees6'c6mpi ii*all aopflcable'6�ordinances;- bul,Iding cde- housing code and re orts anif"-'diiwiiiifior6i imii-2e#qr_.9,wprq`m'lie� 1�'b6jidlriroe ' tb' "C""ry!7spii"ons-�Fiiiiiis"tatenieht�r6adiliereln are.,-;punishabl , p 0& aC i �dimii4nor-purs--Ua'nt"to-�'siittlo1OAs-6f,thiNdW.VikS Peial M6 Bern LLC— Appftai0�Submitted,ByL(prIntna OAuthorized Agent wrier Signature of Applicant. Date: STATE OF NEW YORK) SS: COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)-above named, (S)he is the o(J nez (Contractor,Agent;Corporate Officer;etc.) of said awnerwownws,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 04).day.of 20 ��?�� 1 L CONNIE D.BUNCH Notary Public Notary Public,State of New York N 0.0 IBU6185050 Qualified in Suffolk Cou�@7y,' Commission Expires April 14,2WMre the.applicant is not the-owner) A- - residing at do eby authorize to apply on my behaWtotheTown of Southold Building Depa nt for. val'as described herein. Owner's Signature Date Print Owner's e 2 DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/28/2020 THIS CERTIFICATE IS ISSUED ASA 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 rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME C Cole Lahey PF Northeast Brokerage Inc PHONE Ext: (845)223-8107 FAX AIC No: (845)227-8816 LAIC,No.1035 Route 82 ADDRESS: clahey@pfnortheast.com iNSURER(S)AFFORDING COVERAGE NAIC B Hopewell Junction NY 12533 INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Ohio Casualty,Ins Co. 20701 Bukowski Homes Inc. INSURERC: Travelers Casualty Ins.Co ofAmerica 19046 P.O.Box 291 INSURER D: INSURER E: Holbrook NY 11741 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2031211441 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 MAYBE ISSUED OR MAY-PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT MALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL 51.0511 POLICY EFF EXP LTR TYPEOFRMRANCE INSD WVD POLICYNUMBER MIDD M POLICY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 300,000 X Contractual Liability MED EXP(Any one person) $ 15,000 A BLS59538207 03/15/2020 03/15/2021 PERSONAL&ADV INJURY $ 1,000,000 _ GEN'LAGGREGATE LIMRAPPLIES PER: GENERALAGGREGATE- $ 2,000,000 POLICY❑X j�T' FLOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT $ 1,000,000 Me accident ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BAS59538207 03/15/2020 03/15/2021 BODILY INJURY(Per accidem) $ AUTOS ONLY AUTOS X HIREDX NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOSONLY Peraccident $ XUMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS,Lu►a CLAIMS-MADEUS059538207 03/15/2020 03/15/2021 AGGREGATE $ 1,000,000 DED I X1 RETENTION$ 10,000 $ WORKERS COMPENSATION X SPER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTEI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 C OFFICER/MEMBEREXCLUC M NIA UB-2J303967 03/14/2020 03/14/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) Provided it is required by written contract,the following are named as additional insured as respects general liability with regard to the insured's ongoing operations under form CG8810 0413,to the extent provided therein:Town of Southold. 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. 54375 Route 25 AUTHORIZED REPRESENTATIVE Southold NY 11971 &4- 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks ofACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured (631)767-4807 Bukowski Homes Inc. 346 S Sunrise Highway lc.NYS Unemployment Insurance Employer Center Moriches,NY 11934 Registration Number of Insured Work Location of Insured (Only required if coverage is 1d.Federal Employer Identification Number of Insured specifically limited to certain locations in New York State, Le., a or Social Security Number Wrap-Up Policy) 20-5300333 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Travelers Casualty Insurance Company of America Town of Southold 3b.Policy Number of entity listed in box"la" 54375 Route 25 UB-2J303967 Southold,NY 11971 3c. Policy effective period 03/14/20 to 03/14/21 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"W' 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"T'. The Insurance Carrier will also not6 the above certificate holder 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 array be sent by regular mail.) Otherwise,this Cet'tificate is valid far 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. Please Note: Upon the 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 perjury,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: Joseph W.Pires (Print name of authorized representative or licensed agent of insurance carrier) Approved by: /� 1�'�/�� 10/28/2020 .(Signature) (Date) Title: President—PF Northeast Brokerage Inc. Telephone Number of authorized representative or licensed agent of insurance carrier: (845)223-8107 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form.-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us roEW Workers! CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PARTY.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 BUKOWSKI HOMES INC 631-569-4513 P.O-BOX 291 HOLBROOK,NY 11741 1c.Federal Employer Identification Number of Insured Work Location Of Insured_(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-up Policy) 205300333 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Torml'aof Southold 3b.Policy Number of Entity Listed in Box"1 a" 54375 Route 25 OBL617449 Southold, NY 11971 3c.Policy effective period 06/25/2020 to 06/24/2021 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. Q B.Disability benefits only. 0 C.Paid family leave benefits only. 5. Policy covers: Q A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. Q B.Only the following class or classes of employers 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. Date Y Signed 10/28/2020 B �X ,4t (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 5=16=82131'011; 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 46,4C 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 ss of Part 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. 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) �IIIIIP°°u1ii2i0�i1iiiii(i1i0iiii17)°i�ll9 OCCUPANCY OR SURVEY OF PROPERTY LOT 124-MAP EASTERN WITHOUT CERTIFICA EASTERN SHORES AT OF OCCUPANCY 130.00 RESIDENCLOT125CWATER GREENPORT,SEC.5 FILED:DEC.31,1968-MAP NO,5234 LOT 126 SITUATE N69°02'10 E MONFNp O.3'N SC/WNWXFENCE 0.21NI GREENPORT �B, II;w on TOWN OF SOUTHOLD K) 4 SUFFOLK COUNTY,N.Y. TAX MAP NO.:1000033.00-02.00047.000 SANITARY SYBTEM LOCAnON sze �' w"""�NZE LOT AREA:19,500.00 S.F.(0.447 ACRES) A Q p O 56.0' =35.0' d n DATE SURVEYED:NOV.15,POI 9 LE�aa POOLI(LP./) 3s ea WIN�A 4_7 °I p� m ' FINAL SURVEY:AUGUST 27,2020 LEACN.POOL2a-P.2) 23 +e N �� in zA Ys'I LPI m 3 m �ggm�a to I % m o C -ELEVATIONS REFER TONAVD88L07124 O. �y > lli 20 .� I $ n D31 NN n9 ( —� > D mo _ _ _ _ O m 3 i 1 2 1 I L LOTCOVERAGE O -- ------ _ _-- - • J _21 RESIDENCE=1988 S.F. 90&,3 �Ryy/� pC rl. TOOL=7245.F. Ld 9 )/„� 1 TOTAL=2712 B.F.tl 3. _/l V�j tll APPROVED AS NOTED �Sj 17� C 'by O.FFL^2-71 Ip eeryi O m 41.7' o DATE: ' B.P.# I m IAD C I � 6 .41 m ! § m FEE;",. -1 BY: y� z g z NOTIFY BUILDING DEPARTMENT,AT o � a N cruvELDwEwar n r 765-1662-1 6,AM- TO. 4 PM FOR THE 24.9' FOLLOWING•.INSPECTIONS: o � �°P N 0 j D 1. FOUNDATION = TWO REQUIRED FOR POURED CONCRETE' _=4 °� 'QUI m CHAIN P.M-0. 2.. ROUGH =:FRAMING & PLUMBING REHFND, N LWE 6'PV CE - 3: INSULATION 130.00 S691021 1 011ww RESIDENCE•PUBLIC WATER 4-'FINAL - CONSTRUCTION MUST LOT 123. - SCDHSUSE ONLYBE " O��;� ALL^ICON6TRUGTIONP-,SHALL•',=MEETw�THE"1':-» 8 a .�:-x��YO,RKY°.STATEtt,.-NO.T-zR-ESPOuS1B4Z,f@R— CON M— COMPLY WITH ALL CODES OF NS U, 10 `HDESIGN;�R:o�C. TT ,;�� 1 NEW YORK STATE &TOWN CODE AS REQUIf * 1DI f VS OF c s. °(AJG,L: ND SURVEYItV6 PLLC �, L AND.SURVEYIING'y&aPL.ANNING`'`, .: I' I. S.COLEMNROAD,;CENTEREACH,F1.72�I` IIN.GBOARD o 30 so Fet t i :E` -PHOtdE:631.846.9973 -,u,1, 4 u � Ni_•,,,,;,•... �/ ANOELO J06EPH CECHRE SCALE: 1 wcN v 3 O FEET ry tt PROPFSSIONALL.ANDSURVEYOR SpyT}I NTEES , JC246CPOPTOLJNE.NET AI R TQJ�IN TR I s ccs Coff) y )OV5 ��0�nhal OdCk_