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HomeMy WebLinkAbout48673-Z rr .aTOWN OF SOUTHOLD BUILDING DEPARTMENT 4 TOWN CLERK'S OFFICE 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 #: 48673 Date: 12/30/2022 Permission is hereby granted to: McNab Glenn 665 Arrowhead Ln PO BOX 176 Peconic, NY 11958 To: Construct addition to existing single family dwelling as applied for. At premises located at 665 Arrowhead Ln, Peconic SCTM # 473889 Sec/Block/Lot# 98.-3-4.1 Pursuant to application dated 11/1/2022 and approved by the Building Inspector. To expire on 6/30/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $322.40 CO-ADDITION TO DWELLING $50.00 Total: $372.40 Building Inspector IaG� � 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.southoldtowLipy.iiov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only g r4 + �� ` e PERMIT NO. Building Inspector: V�!;,�V r,.3.1:Y Applications and forms must be filled out in their;entirety.Incomplete T applications will not be accepted. Where the Applicant is not the owner,an Qwners Authorizati6i'hI (Page 2)shall'be completed. Date: OWNER(S)OF PROPERTY: Name: � Z�jl� N� SCTM# 1000- $ �3 Project Address: �.� � '��H/f � ,�"„A Phone#: C-31- 7(0 r73'-Id Email: Mailing Address: P� �o9L 1'1di✓!C // g��j CONTACT PERSON: Name: Mailing Address: 00"`av x lq U Phone#: (o31, .��7' 17-�Vo Email: Y 00 , ('-'vru DESIGN PROFESSIONAL'INFORMATION: Name: Mailing Address`P(O, - Phone#: �J ( � /r %.' / Email: �d t h 0tie t4S 6�� a.ti c coin F( 'ATI IlN* Name Mailing Address. O _T> ifs( l%/'lGi ' /'t-,1 y �[ Phone#: 31" 7-_;`f `z Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition C�Klteration ❑Repair ❑Demolition Estimated Cost of Project: [--]other $ ' Will the lot be re-graded? ❑Yes ZNo Will excess fill be removed from premises? ❑Yes ❑No 1 PROPERTY INFORMATION Existing use of property: t�!�6 / Intended use �� 0 of property: Zone or use district in which premises is situated: Are t'hiere any covenants and restrictions with respect to this property? ❑Yes "o IF YES, PROVIDE A COPY, ❑ Check Box After Reading: The owner/contractor/deslgn 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 New York State Penal Law. Application Submitted By(print name): 111N L,< ❑Authorized Agent tier Signature of Applicant: C 1 n/i ,.� -- Date: STATE OF NEW YORK) ' J/ COUNTY OFA C5 6,gA ./ 1G/U� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the hDlvtOwlitr (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 � � ID "0 ZC day of NN6-04�-f" �*, N t P b I c w" "",� � '� ` CIoC MO,M 491 PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) N t oN� N, residing at 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 NYSIF York State Insurance Fund PO Box 66699 Alban New Y ,NY 12206 Y 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 0 C!7 r A A A A A A 208229707 OLDWOOD INC PO BOX 1461 MATTITUCK NY 11952 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER MCNABB RESIDENCE OLDWOOD INC TOWN OF SOUTHOLD PO BOX 1461 PO BOX 1176 MATTITUCK NY 11952 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12387982-8 426404 04/0112022 TO 04/01/2023 10/28/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2387 982-8, 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. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRES ARNOLD R GOLZ JR VP AMANDA GOLZ OLDWOOD INC TWO PERSONC CORP 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. NEW YORK STAT 4 71*1 NCE FUND DIRECTOKIN URANCE FUND UNDERWRITING VALIDATION NUMBER: 341880656 U-26.3 OLDWINC-01 CBES CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 10/31/2022 ^ 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 .. _... a certificate holder is an CERTIFICATE HOLDER. MPOR : REPRESENTATIVE EN ATIf the PRODUCER AND _..� _...... an ADDITIONAL INSURED,the policy(ies)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 tot the certificate holder in lieu of such endorsement(s). PRODUCER MVP a„e,,,_. TACT Roers Insurance Services PHONE FAX (+ ,No,EXIq:m� ?5)365-3201 ?Town and Country Drive0 }. A/C Na Suite B A %F,$$; . Danville,CA 94526 ®.... .,..,,,_ INSURER A;Ohio security, Corn an �2!�062 . ,®.... INSURED ,9NSUIM B, Oldwood,Inc. JRSgKR C. ®,a I'll, "I'll 7280 Sound Ave PO Box 1461 I_NSUFtE­RD: Mattituck,NY 11952 INNSUAErC E INSURER P COVERAGES _. ._._. CERTIFICATE NUMBER _._ .... _ REVISIgJ N+IUMBER ....... 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. I AR X COMMERCIAL GENERAL LIABILITY I"" '' "� 'LICY EXp 1 LIMITS ,,... p , TYPE OF INSURANCE u $ POLICY NUMBER y yI P �'+f LACH OC CURRENCIE, CLAIMS-MADE X OCCUR SLS63963666 10/11/2022 10/11/2023 DAI A E 10 RENTED 300,000 _1?R�Mtl.S,E;S.iEAar�.�aV�,e1 �5 m, MED LXPPAny game mrrs rm) ...,e ,.... 15„000 _,. PFR,QNA�L�.,Py NJURY $1. 1000, 4f1 ' " $_ p . 0® . I GEN'LAGGREP,AjELIMIT APPLIES PER: �EfkRALAGO� ¢tiTE X . LOC D4CTSC MPR]PALG 2k0L0„)OO .DTHER ....... COMBINED SINGLE LIMIT AU MOBILE LIABILITY (Ea a%,iden+t)e, ...... _..... .®,.....a.......,,. ANY AUTO BODILY tN,)VRY(Per`ppyscl , ...,.. OWNED SCHEDULED AUTOS ONLY AUTOS 130DILYIN,4p$Y(peraccrdetll) S PROPER'fV DAMAGE � 4HIM (} ONLY A1ONO N leer ar I V E W _._..... ...... . . UMBRELLA LIAB OCCUR EACH O�!� EXCESS LIAB CLAIMS�uIADE�� i AGORi"GIIRRENOE ...,., �+ . , �, DED RETENTION$ , WORKERS COMPENSATION STATU"pE 1 I E � - ....., ... AND EMPLOYERSLIABILITY ,),/N O'EI'uPROPEn OR/PAR NERIE ECUTIVE N/A Ed Efttl"HACI"9CEN1 5 .. ANY PROPRIETOR/PAR P L IJV a' 15E-POLICY im y I)YEE If C s,describe under I7, ORIPTION CP OPIA'fiATIONS_tR�v 0" DISEASE--LA EI L t4T ............_. �., DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule, ... ... _ maybe attached if more space is required) Certificate holder Is named as additional insured'., ................ ................ ...� CERTIFICATE HOLDER ��.. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Glenn&Yvonne McNabb ACCORDANCE WITH THE POLICY PROVISIONS. 665 Arrowhead Ln Peconic NY 11958 ..... -_ AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/0303) _ The ACORD name and logo are registered marks of ACORD i i w q ° i 1 h � N a W IV „� �,,,, Suffolk County Dept. of Labor, Licensing Consumer Affairs HOME IMPROVEMENT LICENSE k Name 1 1ff t ARNOLD R GOLZ JR 1 Business Name I fZic rortifioc that tno ,parer is duly licensed OLDWOOD INC. ;' fhe County of suffolK License Number: H-37816 Rosalie Drago Issued: 09/27/2005 Commissioner I I Expires: 09/01/2023 2