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HomeMy WebLinkAbout48550-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT 4 r TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 48550 Date: 12/1/2022 ww Permission is hereby granted to: Moran, .Susanne.�_..�� .......... _— Ae__ __ _ .... ........ ....� .. .....�m_ .... .._.. .�.� 11_1 Autumn Dr _ . pHau au.gNY 11..7.88.............�....._......�... --�...............................___ w.....................�........�___ ..............................� �.u �. ..�a, ��.e...._ To: Install a new boiler converting oil to propane gas to a single family dwelling as applied for per manufacturer specifications. At premises located at: 506...Azalea yRd,,, Mattituck�.�� ........................�. _ _....�......�.�......... --.aa........................... SCTM #473889 Sec/Block/Lot# 115.-6-8 Pursuant to application dated 10/3/2022 and approved by the Building Inspector. /1/2024. To expire on 6/1/2024. Fees: AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $200.00 CERTIFICATE OF OCCUPANCY $50.00 ............................................m...................� Total: $250.00 Building Inspector '" rav 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 https://www,sotitlioldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. q55 0 Building Inspectorsy R E)) 0 CT 3 2022 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUILDING DEPT. Owner's Authorization form(Page 2)shall be completed. TOWN OF SOUTHOLD Date:9/26/2022 OWNER(S)OF PROPERTY: ®®�� Name: SCTM# 1000- I I rJ• ' IP Project Address:505 Azalea Road, Mattituck, NY 11952 Phone#:631-304-8855 Email:tmoran1277@ Mailing Address: 15prie CONTACT PERSON: ' Name:N/A Mailing Address: Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name:N/A Mailing Address: Phone#: Email: � ti' CONTRACTOR INFORMATION: Name:NH Ross Inc. Mailing Address:120 Middle Country Road, Middle Island, NY 11953 Phone#:631-924-0677 1Email:service@nhross.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: E10ther Oil to Propane conversion of Boiler System $14,850.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes 9 No 1 YSIF 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 Nlew York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A 112233200 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE X HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER N H ROSS INC TOWN OF SOUTHOLD 120 MIDDLE COUNTRY ROAD 54375 ROUTE 25 MIDDLE ISLAND NY 11953 SOUTHOLD NY 11953 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 824 595-3 838584 11/01/2021 TO 11/01/2022 09/23/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 824 595-3, 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. 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 �rrw AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 591639204 1111111111111111110 0 0 0 0 0 0 0 0 0 0 IIIIIfl000000000000 Forth WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-8245953] U-26.3 17 ronononnnnnnne7insasmrnnni-ononnR?4s953lr**G1r75777-vuc rt Nov-CERT nrm-nnonrn 710/20/2021 DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME.... UNFCU Financial Services LLC d/b/a Industrial Coverage PHONE FAX 62S Ocean NY11772I D ss„ cert 1 m?ndu 500 ,Np) 631-736-7619 mm �tAl� tI�.�X1k)Patchogue - strialcoverae.conn __. mm_.. INSURERS AFFORDING COVERAGE_ m NAIC# mm INSURERA: Merchants Mutual Ins Co 23329 _.�..................... _--.�___....................-.................A,.,.,... -�...........................-_.....,,,...� __..----....._...�m.,,..._ .......--..--................-- .,...... INSURED NHROSS1-01 INSURER 8: N H Ross, Inc. w�.... _....... -.�,,... .... 120 Middle Country Road INsuRERc, Middle Island NY 11953-2519 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1608147899 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .LTR ...� TMP.................. -.. �_ .............. ... E OF INSURANCEm AODI. 'U8&f_.._ �-POLICY NUMBER IuP1'NOIf1} �rYY POLICY EXP LIMITS Y MM/DD A X COMMERCIAL GENERAL LIABILITY BOP1061411 10/17/2021 10/17/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE ..X OCCUR PREMISES Fa ) �cqurrence $500,000 ..-...- MED EXP $15,000 000 PERSONAL&ADV INJURY $ GEN'L,AGGREGATE LIMIT APPLIES PER: GENERAL A � $2,000,000 POLICY[v P( LOC PRODUCTS-COMP/OP AGG $2,,000,000 OTHER: $ A AUTOMOBILELIABILITY CAP9265309 10/17/2021 10/17/2022 C YMBtlNE( SINGLE V.IMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ ._ X AUTOS ONLY X AUTOS nPar,ac ...0fb DA $ HIRED NON-OWNED PROPERMAGE AGE AUTOS ONLY -�-� AUTOS ONLY 0M cidU__ .. A X UMBRELLALIAB X OCCUR CUP9139060 10/17/2021 10/17/2022 EACH OCCmURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED X RETENTION$......................... �.. $ WORKERS COMPENSATION PER OTN- AND EMPLOYERS'LIABILITY YIN ":_A!,V.j ...... .qI` .. . "" """11 ANYPROPRIETOR/PARTNER/EXECUTIVE E!ED EA EACH ACCIDENT $ OFFICER/MEM BEREXCLUDED? N/A (Mandatory In NH) E.L.DI EMPLOYEE $ SEASE . ..................A ......_. .-............. If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE FOLDER 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 Southold NY 11971 AUTHORIZED REPRESENTATIVE USA 01_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD