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HomeMy WebLinkAbout48879-Z x�t TOWN OF SOUTHOLD '+ xw BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SI=T OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 48879 Date: 2/8/2023 Permission is hereby granted to: Cleaq, Brian 101 W 86th St A t 1 E New York, NY 10024 To: construct deck addition to existing single-family dwelling per DEC & Trustees approvals with flood permit. At premises located at: 5875 Main Bayview Rd, Southold SCTM # 473889 Sec/Block/Lot# 78.-7-7 Pursuant to application dated 1/23/2023 and approved by the Building Inspector. To expire on 8/9/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $340.00 CO-ADDITION TO DWELLING $50.00 Total: $390.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631)765-9502 Date Received For Office Use Only qq PERMIT NO. - Building Inspector: i rr i JAN 9 3 "" Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUILDINGDEK Owners Authorization form(Page 2)shall be completed. 4111 I�I Date: `i + Lot 2O 'LZ OWNERS)OF PROPERTY: 52i MJ C:.LZK_JZY Name: SCTM#1000- 07 y 00 Orf , 00 '-007 .000 Project Address: T97 S-_ t-A p`i'k� ZN_I V i EL0 'rl,>. 500 T F+O i-D , I,JY 1\9 '7( Phone#: u, irl Zil.p gLi(®S- Email: 1pi-ka-r ak �� Mailing Address: 1 Oi LL) &U'tt' CONTACT PERSON: Name: 1&Z i h� cj_cr�•CZ'Y Mailing Address: 11,011, LL) S(a"" S-T. Phone#: 1`7 21L Email: �r�a-net ~fes ,C,0t-f DESIGN PROFESSIONAL INFORMATION: Name: a'_r t T MAtJ S-ruv t© E��- Wi,►J-13P-Tlz Mailing Address: -2..$Q S i. EST t-A i t-`- �Zb `1- i\TT i T, C< QY W?5�7 Phone#: Y10 $13 119,'-I Email: c:l 1 ee.r` C cA""NS-Vu960• CONTRACTOR INFORMATION: Name: C01J-poll C-"6I ..1f` rG(2/Q G Mailing Address: 1'7 6-5- 5i6sBcE lziz> , t'-'AT ri-ruc.4< } OY 9 S Phone#: 10 7-S-K 1 9tO Email: cvrJ0A° ee-* DESCRIPTION OF PROPOSED CONSTRUCTION ®New Structure IgAddition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other Qty '► _tom $ Will the lot be re-graded? ❑Yes WNo Will excess fill be removed from premises? XFYes ONO 1 PROPERTY INFORMATION Existing use of property: Intended use of property: 1ZES.0 07,J T I f L T 'IP0e:e.K Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ANo IF YES,PROVIDE A COPY. The owner/contractor/design 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 210AS of the New York State Penal Law. W Application Submitted By(print name): 'pati A0 C.'sp m []Authorized Agent 220wner Signature of Applicant:" ,rte' Date: /W PZc 2 Z STATE OF NEW YORK) SS: COUNTY OF Slk 'dIK ) ig ibeing duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the, W (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 h zo 2 2— day of f�T Y�If �— otary Public TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW61306900 QUALIFIED IN SUFFOLK COUNTY (Where the applicant is not the Owner)COMMISSION EXPIRES JUNE 30,2-PRLp I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owners Signature Date Print Owner's Name 2 x NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY r Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-03651 F:(631)444-0360 %VwW rleC.ny.gov August 1, 2022 Brian Cleary 5875 Main Bayview Rd. Southold, NY 11971 Re: Application #1-4738-04854/00001 Cleary Property: 5875 Main Bayview Road SCTM# 1000-78-7-7 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, EGL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please carefully read all permit conditions and special permit conditions contained in the permit to ensure compliance during the term of the permit. If you are unable to comply with any conditions please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Sincerely, lyssa Scott Environmental Analyst cc: Cole Environmental Services BMHP File 'WH Department of Environmental Conservation AM mama NF.W YORK STATE 1)1-;1'AR'i'Ml'.N'1'OF GNVIRONMF.N'1'Al.CONS@RVATION Facility DISC ID 1-4738-11=1854 PERMIT Under the Environmental Conservation Law (T.....CL) �. .. .._ . ... ..................... -.���. .. Permittee and Facility_. .�a.... Information Permit Issued To: Facility: 13IZIAN CLFARY CLEARY PROPERTY 5875 MAIN BAYVIEW RD 5875 MAIN BAYVIEW RD SOUI'I IOLD, NY 11971 SOUfI IOLD. NY 11971 Facility Application Contact: COLE ENVIRONMENTAL SERVICES 425 MONTAUK HWY FAST QUOGUE,NY 11942-0471 (631) 369-9445 Facility Location: in SOUTI-IOLD in SUFFOLK COUNTY Facility Principal Reference Point: NYTM-E: 716.245 NYTM-N: 4546.618 Latitude: 41'02'31.5" Longitude: 72'25")9.1" " Authorized Activity: Construction of a deck and the establishment of a non-disturbance buffer. All wo►-k must be done according to the plans prepared by Cole Environmental Services Inc.. last revised 4/22/2022. EES. .. ..... .. . ....m.. a __ _..�.w.. .. ._........... Permit Authorizations Tidal Wetlands - Under Article 25 Permit ID 1-4738-04854/00001 New Pei-mit Effective Date: 8/1/2022 Expiration Date: 7/31/2027 YSDEC A proval By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, and all conditions included as part of(his permit. Permit Administrator: KEVIN A KISI'ERT, Deputy Permit Administrator Addh-ess: NYSDEC Region 1 Headquarters SUNY (ci), Stony BrookJ50 Circle Rd Stony Brook. NY 11790 -3409 Authorized Signature: Dale Page I or 6 NEW VORK STA,rE DEPARTMENT OI, E,NVIRONNIENTAL CONSERVATION Faciuty DFIC rD 1-4738-04854 Distribution List COLE ENVIRONMENTAL SERVICE'S 131.1rcau of Marilee I Iabitat Protection };lyssa E Scott Permit Components NA'T'URAL RESOURCE; PER CI' CONDITIONS GFNERAL, CONDI`T'IONS, APPLY 'TO ALT, AUI'I10RI%I:D PERMIT'S NOTIFICATION OF OTHER PER ITTEI OBLIGATIONS .... ,,,,,,,,,,._. .............................. .. ..... ..,,... ,,� NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: TIDAL WETLANDS 1. Post Permit Sign The permit sign enclosed with this permit shall be posted in a conspicuous location on the worksite and adequately protected fi'am the weather. 2. Notice of Commencement At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form eertifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of conepletion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 3. Conformance With Plans All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of elle permit application. Such approved plans were prepared by Cole Frivironmental Services, last revised 4/22/2022. 4. Concrete Leachate During construction, no wet or fresh concrete or Icachate shall be allowed to escape into any wetlands or waters of New York State, nor shall washings from ready-mixed concrete t'UCICS, mixers, or other devices be allowed to enter ally wetland or waters. Only watertight or waterproof forms shall be used. Wet concrete shall not be poured to displace water within the 1-01,111s. S. Materials Disposed at Upland Site Any demolition debris, exCCSS COl1StrUCtlUl1 Iletltel'lal5, and/or excess excavated materials shall be Ininic(llately and completely disposed or in an authorized solid waste management facility. These materials shall be suitahl-v stabilized as not to re-enter any water body. wetland or wetland adjacent area. 6. No Disturbance to Vegetated Tidal Wetlands '['here shall be no disturbance to vegetated tidal wetlands or protected butler areas as a result of the permitted activities. Page 2 of 6 NEW YORK STATE DEVARTIM ENT OF ENVIRONIV]ENTA1,CONSERVATION Facility 1 EX, II) 1-4738-048.54 7. Storage of Equipment, Materials The storage of construction e(ILIIpI11CIlt and materials shall be confined within the project work arca and/Or upland areas greater than 75 linear Icct frons Lhc tidal wetland boundary. 8. No Unauthorized Fill No fill or backfill is alltllorized by this pumit WithOLit further written approval front the department (permit, modification, amendnicnt). 9. Install, Maintain Erosion Controls Necessary erosion control mcasLINS, i.e., straw bales. silt fenclllb, etc., are to be placed on the downslope edge be put in place before any disturbance ofthc g►'ollne ofany disturbed area. This sediment barrier is to d occurs and is to be maintained in good and ILIIlCtlonal C011dlti011 Lllltll thick vegetative cover is established. lo. Tidal Wetland Covenant The permittee shall incorporate the attached Covenant (or similar Department-approved language) to the (Iced for the property where the project will be conducted and file it with the Clerk of SIJFI'01_,K County within 30 days of the effective date of this permit. This deed covenant shall run with the land into perpetuity. A copy of the covenanted deed or other acceptable proof of-rccord, a1011g with the IlUmber assigned to this permit, shall be submitted within 90 days of the effcetive date of this permit to Marine Habitat Protection NYSDI'C. Region 1 Headquarters SUNY fir), Stony BrookJ50 Circle Rd Stony Brook, NYI 1790 -3409 Attn: Compliance I1. Contain Exposed, Stockpiled Soils All disturbed areas where soil will be temporarily exposed or stockpiled for longer than 48 hours shall be contained by a COIltilILIOLIS lute of staked haybales/ silt curtains (or other NYSDEC approved devices) placed on the seaward side between the fill and the wetland or protected buffer area. 'tarps al-C authorized to supplement these approved methods. 12. Maintain Erosion Controls All erosion control devices shall be maintained in good and functional condition until tile project has been completed and the area has been stabilized. 13. Eastablish Vegetated Buffer To protect the values of the tidal wetlands, a permanent vegetated buffer zone shall be established as shown on the approved plans. "there shall be no disturbanee to the natural vegetation or topography within this area. 14. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of ally wetland or waterway by suspended solids, sediments, fuels. solvents. lubricants, epoxy coatings, paints. Concrete, leachate or any other environmentally deleterious materials associated with the project 15. State Not Liable for Damage The State of New York shall in no case be liable for any damazge or injury to the structure or work herein authorized which may be caused by or result front ILltUre. operations Undertaken by the State Im the conservation or improvement of navigation. or Im other purposes. and Ilo claim or right to compensation shall accrue Irons ally Such damage. Page 3 of 6 Aft NEM YORK STATE DEVARTMEN'r OF ENVIRONNIE.NTAI,C ONSEAVATION Facility DECID 1-473H41054 IG. State May Order Removal or Alteration of Work If lulurc operations by the We of New York raWhv an altel'atlon in the posh on Of the mructure of\vork llcl'clll authorized, or it, in the opinion of the Department L11 l;nviro11mental Conservation Il shall cause unreasonable obstruction to the free navigation ofsaid Waters or flood flows or endanger tic health. safety or welfare of the people of the State, or cause loss or destruction or lite I Mural resources of the Statc, the owner may be ordered by the DCpart111ent to remove or alter the structural work, obstructions. Or hay.ards caused thereby Without expense to the Slate. and T upwi lite expiration or revocation Of this perllllt, the structure, till. excavation, Or other modification elf[he Watercourse hereby authorized Shall not be Completed. elle owners. shall, without expense to the State, and to Such extent and 111 such tulle and manlier as the Department of Environmental Conservation may require, remove all of any portion of IIIC uncompleted StrLICtUrc of fill and resmrc to its former condition lie navigable and flood capacity ol'thc watercourse. No claim shall be made against the Slate of New York on account of any such removal or alteration. 17. State May Require Site Restoration If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant Shall, without CxpCI1SC to the Stale, and 10 SLIC11 extent and In such time and manner as the Department Of l',nv1ronniental Conservation may IaWfully rccjuirc, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of Ncw York on account orally such removal or alteration. GENERAL CONDITIONS - ...... .....� w .. �m, Apply to ALL Authorized Permits: I. Facility inspection i)y The Department "rhe permitted site or facility, including relevant records, is subject to inspectloll at reasonable hours and intervals by an authorized representathm of the Department of lalvironniental Conservation (tile Department) to delerlNne Whether the perinittee IS complying Willi [his permit and the ECL. Such representative may order the work suspended pursuant to 1?CL 71- 0301 and SA PA 40](3). 'rhe pert iucc shall provide a person to accompany the Depal'tment's representative during all inspection to the permit arca when requested by the Department. A copy of this permit, including all referenced neaps, drawings and special conditions, must be available for inspection by the Department at all times at the project she or facility. FailLu-e to produce a copy of [lie permit upon request by a Department representative is a violation of this perllllt, i Relationship or this Permit to Other Department Orders and Determinations Unless expressly providcd 161- by the DepartillCul. ISSL1a11CC of this permit (toes not modlly. SLII)CI'Sede of rescind any order or determination pl'cviouSly issued by the Department of any of the Lerills. CondltlonS Or rCCJUirCI11C1l[S contained in such order or determination. ioge 4 or 6 do,IN dbk=d NEWYORK STA` EDEPART MENTOF` ENVtIIONMl-.N'I'At,('ONSEIZVAI'ION maw Facility DEC it 1-4738-04854 3. Applications For Permit Renewals, Modifications or`Transfers The PCrolittCe IIIUSt submit a separate written application to the Department for permit renewal, modification or transfer of this permit. Such application must include any forms or SUI)PICIIIental information the Department requires, Any renewal, modification or transfer granted by the Department Must be in writing. Submission of applications for permit renewal, modification or transfier are to be submitted to: Regional Permit Administrator NYSDEC Region I Headquarters SUNY @b,Stony BrookJ50 Circle Rd Stony Brook,NY 1 1 790 -3409 4. Submission of Rencival Application The permittee must Submit it renewal application at least 30 days before permit expiration for the following permit authorizations: Tidal Wetlands. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to exercise all available authority to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate -statements in the permit application or supporting papers; b. failure by the permittee to comply with any terms or conditions of the permit; c. exceeding the scope of the project as described in the permit application; cf. newly discovered material information ora material change in environmental conditions,relevant technology or applicable law or regulations since the issuance of the existing permit; e. noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transrer should be submitted prior to actual transfer of ownership. Page 5 of 6 Aft ' leftwo NEW Y()KK SrAT[ D[ Cl)MS[&YAr|AM [xxUi\yU) 1'4738'04854 NOTIFICATION OF OTHER PER MITTEE OBLIGATIONS Mcum A: Pcrujitn:cAcuep1x Legal Responsibility and Agrees bm Kudonuohfioutiwo llic purrniUec. cxoc[Kingu(oio or Kx|cru| ugc/xoiox, expressly agrees to indomniFvond hu|d hxnn|uxs the |}cpurion:nio[[nvivonnoon(u| Conservation or the State n[NowYork, its rcpruxontuiivus, uoop|uycus. and uounb ("D[l`") for ail cloinun, suits. actions, and duo}ugus iotile extent oLih6utah|u to tile purnniKuu's acts orumisxiu/u in connection with the poondtec`x uodcdukingo[uc1ivi|ius in connection v/i(h, oroperuiiunundnnuin0ununuou[ \hcbci\iiyurCcUi(icsuuUhorizedhv (kepcnni| whe|bcrin cunop|ixoccur /voiincomp|iunnxeniih |hckzoixunduondiiionuu[tx: pcnmiL ThisindcuiniDcu|iondoes no{ ox\und (onnyc|uinnx. xuiis, uuiionx, nfdumogcxiotbecxk:o| uUributoh|c (oD[ C'xovvnncgUgcn( ur intentional acts oroolisxions. or|oany c|uirnn, xuiks, nractions naming tx: DFCand arising under /\riic|u 78 o[ihc No�v York Civil Puu(�u l'av� and Qo|ux or lily ciiixzn suii or oivi| hubtx pn`vixioo Under fcx|cru| orstate laws. Ubcmu B: Purmittee'w Contractors to Comply with Permit Tbmpernmittcc (nrusponmib|e [orin[bomingi\uindeooudcntounbuo|ons, cmp|oyutu, uguo\sunduxxi&nxn[ their responsibility hocomply with dbiupuunk, iuoludioBo|\ special conditions while acting Lis ibo pconiikze'sagent with respect 1ntile permitted activities, and such persons shall boou6iuuihothe xonnc muooiiuou lx violations oFthe Environmental Conservation Lavvoo those prescribed for the pcnnittmc. Item C: Permittee Responsible for Obtaining Other Required Permits The pnnnd(u: iaresponsible |lorobtaining any other peuni|o, approvals, lands, uoscnneuisand ri�h1x'o� v/uy that may be roquirod |ocarry out tho activities that are authorized bvthis permit. Item 0: NoRigh� � ���� o� Um������ ���m ��� This punlitdocx not convey to the punniikeoouy right to |rcspnxx upoo the kinds urin{cr[crcvviibtile riparian righto[others inorder|operform the permitted work nor does ituudhmizc (lie ino ionenio[ any duhix, (iUc, or I interest orin rcn| or personal property held orvested in person not o party to dhc yuoniL 1'ugc6o[6 i YORK Department of OPPORTUNITY Environmental Conservation NOTICE The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation Lawfor work being conducted at this site. For further information regarding the nature and extent of work approved and any Departmental conditions on it, contact the Regional Permit Administrator listed below. Please referto the permit number shown when contacting the DEC. Regional Permit Administrator i SUSAN ACKERMAN 1-4738-04854/00001 Permit Number _ Expiration Date 7/31/2027 Note: This notice is NOT a permit s I74 ITITITITm WINGISCALE:1"=30' � BA CCNU HILGI OLIA SPACING DRAWING INFORMATION k ,,,,_ .mmmmmmm_IT_ mITITIT,,, MORELLA PENSYLVANICA TOC CUETHRAALNIFOLIA TOC PHOERA T NOIA MELANCARPA OC ..•.-....••.,,._—.—. ` .. PANICUM VIRGATUM"SHENANDOAH' 12'OC R`A'PII@C SCt�"'7 htih UATRIS SPICATA 12'OC " I EASCE PIAS TUBE OSA 12 OC 9h ,h ei��o y �'g. �, AQUILEGIA CANADEN515 ;2 OC I NOTE:CAGES TO OEYA BE USED AS E HED. NEEDED ISOTECs PLANTS UNTIL 'yrom CmwCtatim�to Comyfetion" 631-369-9445 LOT CLEARING AREA 31.884.05 S.F. = 0.73 ACRE(S) �1i 12,238.57 S.F CLEARED 38% LOT CLEARED W14 AFvie wEiw o BRIAN CLEAR^/ X12 5875 MAIN BAYVIEW ROAD 9 SOUTHOLD,NY 11971 FIAG 1 SCTM NO:1000-07800-0700-007000 KrIN:G FUG 11 wrnARo vt za THIS IS A SITE PLAN BASED ON A SURVEY PREPARED BY: ° JOSHUA R.WICKS FtA�10 14 TRAINOR AVE CENTER MORICHES,NY 11934 WETUNG LAS I UPUA IFD 08.U9.21 cv,Gn SITE PLAN DRAWN BY CES ON 04.22.22 'x°" ni WLG S 5100'00" E 992.00' MG% WEtUN° FLAG 22 Mn J���tl JI 0 V i D IITII II' Mill II"IH Q, I NA,,I d VIL,P401N I � I V I C V`II IL G"✓w;P2 �. P ti LI II ulfllr III t..,, 1'�^,P.IPaYIIlry tL�G l CD e. v\ I 9 �1 I RAG A W216 vr1 C�6k�� uPPb4w .... Fvszs D IvV� RAI IPI'Id�VPVEL II IIVII� .......... �..._.�. p' o wErL" VIIV PVu Iv P y :; ffES� w¢nu o V 11 V l llC II V I'."wl� s 1 RAO 2 I <r k_ Nr I P d o �.y I —FLAG � �s y I ' GRAVE'GRP&VAYd �$ mo G s.z Fuz 611.11EAD WES 1 UGL PCLE N 59°00'00" W 992.00' NYSDEC MAIN B_AYVIE'W R 0 A], iPROVEDAS ERTERMS 1 LOT AREA AND COr«DMONS OF 31,884..05 S,F. PERMIT NO 'k.. 0.73 ACRES) DATE " s Town Hall Annex Glenn Goldsmith,President �.� 54375 Route 25 A.Nicholas Krupski,Vice President � l P.O. Box 1179 Eric Sepenoski ° Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples " ) Fax(631) 765-6641 OOUNTi,° BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD November 17, 2022 Brian M. Cleary 5875 Main Bayview Road Southold, NY 11971 RE: 5875 MAIN BAYVIEW ROAD, SOUTHOLD SCTM# 1000-78-7-7 Dear Mr. Cleary: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, November 16, 2022: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Wetland Permit#9754, issued on November 18, 2020. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, G:� 16 Pr&cadent, B d of Trustees GG:dd 'V R1 V BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD,NEW YORK W r � DATE: NOVEMBER ll 2020 PERMIT N0. 9754 ISSUED TO: BRIAN M.+CLEARY E � OAD PL3 SOUTHOLD G PROPERTY ADDRESS. 5875 MALI BA W g SCTM# 1000-78-7-7 AUTHORIZATION Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in p ,� M�i accordance with the Resolution of the Board of Trustees adopted at the meeting held on November 18. 20213 1 r' r and in consideration of application fee in the surra.of 250,00paid by Brian 1 A_, Clea 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 convert cleared wetland area(f 2,100sq.ft.)to non-fertilized grass area; G remove six(6)trees as indicated on survey; construct new 25.01x14.0' (350sq.ft.)deck withx i, landing and staircase; and driveway area to be improved with pea stone and/or gravel 600 } sq.ft.; and as depicted on the survey prepared by Joshua R.Wicks P.L.S.,received on November 18,2020,and stamped approved on November 18,2020. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,and these presents to be subscribed by a majority of the said Board as of the 18 day of November,2020. F04 r a:, +'3 m X r v � �"" � M,rw.^utWra ��+ � 6 +.anxuu,.wun� .d.+oaw�M A�,.nlr. d�f,..r.4,'�w,u �✓r&z�"�+�h -,r>' t ,� y, Lo ® eN x ° a Awl y- w LU Z.6- 0 a a N _ 0011 O Nile 000 -'0041dk�n 66'99L sal «OS,66.06 S p vp Cn 419 9 Lo � Q aha w I ':.ary uel7.zI11L.jwoµ, r O � �p:� HIP rr^^ V, � Pa , S p rF- 0 `tl d IIII �w I JYV1771A f 79V3 Jo JIN ONV7 i,.., { � 600 600 ,L07 dVN XV,L ! r n.996 9 110-9,66.06 N . Sim I-ILLAOE 7AIYU HJINS Suffolk County Dept. of Labor, Licensing & Consumer Affairs � HOME IMPROVEMENT LICENSE Name t5v EBER M PALENCIA PORTILLO Business Name bor-er is ul`y lies Palencias Painting and WindowClear��ng xnr by the County of sUffi:pk License Number: HI-66942 Rosalie Drago Issued: 07/29/2022. Co mission r Expires: 07/01/2024 NYSIF t4ew Yarl<State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysii,cam CERTIFICATE OF WORKERS' COMPENSATION INSURANCE Emil No A A A A A 6 882442167 m"'..... C;RANDLE AGENCY INC 44655 COUNTY ROAD 48 PO BOX 1345 SOU FHOLD NY 1197'1 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER PALENCIA'S PAINTING AND BRIAN CLEARY WINDOW CLEANING;INC 5875 MAIN BAYVIEW RD PO BOX 324 SOUTHOLD NY 11971 MATTITUCK NY 11952 ..m . ..... ..... �.�.. �. ............... ...... POLICY � CF RTI zr��s NNUMBF_F. ...�... ��......,, POLICY PERIOD IaDAiE 12485 558-7 4� 09(20/2021 TO 09/20/2022 9/6/2022 mw...._ .__�..�....� THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE: FUND UNDER POLICY NO. 2485558-7, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION CINDER THE: NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT 1-0 ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT 1-0 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 ATH PS:t WW.NYSIF.CO /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. PRESIDENT EBER MISAEL PALANCIA PORTILLO PALENCIA'S PAINTING AND WINDOW CLEANING INC 1 OF 1 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, BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY NEW YORK S T demi. 4NS4MIR \BICE r l)ND T DIRECTOR,INSURANCE FUND UNDERWRITING VAI IF)ATIrne.i hlf INA4CCI AnA477 �Y®R� Workers' CERTIFICATE OF INSURANCE COVERAGE � ATe BBooarpdensation DISABILITY AND PAIDFAMILY LEAVE BENEFITS PART 1.To be completed by Disability and Paid .. L �� r �Insurance p Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name Address of Insured(use street address only) Ib.Business Telephone Number �ns of Insured 'PALENCIA'S PAINTING AND WINDOW CLEANING,INC. (631)745-1243 PO BOX 324 MATTITUCK,NY 11952-0324 1 c.Federal Employer Identification Number of Insured or Social Security Work Location ofInsured(OnCyrequired ifcoverage isspecifrcallytirn0edIo Number . certain locations in Now York State,i.e.,a Wrap-Up Policy) :882442167 2.Name and Address of Entity Requesting of Coverage Proof rage 3a,Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) BRIAN CLEARY 5875 MAIN BAYVIEW RD 3b.Policy Number of Entity Listed in Box"1 a° SOUTHOLD,NY 11971 DBL 7294 32-6 3c,Policy effective period i 09/20/2021 to 09/20/2023 m..._ — 4.Policy provides the fallowing benefits: ,,.-— --, ® A.Both disability and paid family leave benefits [� B.Disability benefits only [� C.Paid family leave benefits only 5.Policy covers: ® 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 insurance coverage as described above. 64- ..... ,.... Date Signed 9161.2022 By e (Signature of insurance carrier's authorized representative or NY5 Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 _ _ Name and Title Kristin Markwica,Head of Disalo tiity Insurance Unit IMPORTANT: If Box 4A and 5A are checked,and this formis ._._ ra authorized is signed by the insurance carriers 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 58 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, DB Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200 PART 2.To be completed by the YS �tlA�Workers'Compensation ��� � -.....of Pa.._ .,as ed)� � ��� Board(OrAly if B®x 4C or SB off Part 1 has been checked State of New`for Workers' ense i n 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 ............. -_. ............ g ..S,.„-_ _._.....v. _..,.,F< ,,,_ �,.,.-„-.....�....,... (Sig namtu(e 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 g nts 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) Certificate Number 703336 Additional Instructions for Form -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 Worker's 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 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. ubd. 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 (10-17)Reverse r" CAT E(IM M111 TI J!VY'Yfl CERTIFICATE OF LIABILITY INSURANCE 09/DB/2022 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION CRANDLE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 44655 COUNTY RD 48 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW PO BOX 1345 ........— SOUTP ica9.D NY 11971 INSURERS AFFORDING COVERAGE NAIC ff ............"I'll"I ------------------ ® ........... INSURED EVANSTON INH RANCE COMPANY PALENCIA'S PAINTING AND WINDOW C1 EANING INC U DO BOX 324 MATTiTUCK NY 11952 ............... ..................... ................. 'EOVERAGES — 7T��,P9LICIES W"INSA RA �LYSIEE)DFLOWHAW'.BEEN 5§7U, LIRED 1',iAMEDASOVE PUP C -" ANY R�E6 ENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR '7 7A R9EQUIREM MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE I IMITS SI IOWN MAY HAVE BlIwEN REDUCED BY PAID CLAIMS WSR'AD0'L TYPE OF INSURANCE POLICY NUMBER pSjC",y IE qFrFL_CTIVE POLICY'EXPIRATI0,14 LIMITS DATIE OAVOWYVY'yJ DAIC MINVOOfyYyyl GENERAL.LIABILITY 09/13/2021 09113/2022 1,000 000 3FB7274 A 100,000 xS 5,000 P!HSONA[ &bl W PIIJIJ'�1 1,000,000 NI QAI P1 , nfilDA I r 2,000,000 1,000,000 H�I IN'lly AI I PICI l�11 PRO- AU 70MOBIL Im i'IAHILI'ryL.P. IM,(T ;INV kUICY Id 30D� 10PE 0 Al ,GARAGE UABIL.1 T-Y ANY AUTC; '�NPCIH N�AH u "T I AGG 'I EXCESS I UMBREL LA L.IABILI TY C C j 10 C C I I 1 11 1c I S M:;ITAD�- A(,�GM GAIL Nk"[- CN Vji)RIQA$COMPENSATION AI'M YQR'�'"T� 1.'j, Ll',IPUPQR�,LIAIW1T'( , M I'V'j I"0'd I ........... SI:ASE FAFJWary it PI Ar'[UY',E; .......... pq DEECII OF OPF.RA flMI;F,d LOCAIMNS l VEHY CLEq EXCLWL^t049 AI-Qt�D BY C[AL ICw' 4h ,UY4 s CERTIFICATE RUL—DER ...................... —C A—K C--E-'L–L A T I—ON ........................ BRIAN CLEARY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRAI ON IDA LIE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30 DAYS VVRIITI::N 5875 MAIN BAYVIEWR:D NQTICu VQ THE CERTIFICATE HOLDER NAMED TO HILLEFT,BDIFPAfl,u�a::roDOSOSHALL SUUT�IOLD NY 119 71 IMPOSC�l NO OBLIGATION OR LIABILITY OF ANY K11 I W�'0%THE REPRESEN rA TIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009101) 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), 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) DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101)