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HomeMy WebLinkAbout48930-Z ° TOWN OF SOUTHOLD BUILDING DEPARTMENT 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#: 48930 Date: 2/17/2023 Permission is hereby granted to: Innamorato, Michael .._ ....... ..__........................... ... 2145 Oaklawn Ave Southold, NY 11971 To: Construct an accessory garage to an existing single family dwelling as applied for. Must maintain 15 foot setbacks and shall not exceed 1,200 square feet. At premises located at: 2145 Oaklawn Ave, Southold SCTM #473889 Sec/Block/Lot# 70.-3-22.3 Pursuant to application dated 2/6/2023 and approved by the Building Inspector. To expire on . 8/18/2024. Fees: ACCESSORY $580.00 CO-ACCESSORY BUILDING $50.00 Total: $630.00 .. ._.... .....w......w.... .............................�. 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 littps://www..southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Insectae FEB E B U 6 2923 Applications plications will not be accepted. lWhere the Applicant ed out in their s the e owner,an rety.Incomplete l'S0U PT a wT Owner's Authorization form(Page 2)shall be completed. Date: C, OWNER(S)OF PROPERTY: Name: l« c, ISCEM #:1000- /70 --3 —� , 3 Project Address: Oik5`� � r . �,�" //I'-- 5 u14k �0 N i� /'/' S 7/ Phone#: /r Email: V411V C0 Mailing Address:Qz '/ C�/1/fc: �• r+ X71 CONTACTPERSON: Name:/A Mailing Address: , Phone#: 11, 231f- Email: .. DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION:, Name: R Mailing Address: it° aft, Phone Email: ca v/o'7 1 ou u6 #� .3 .�' ' 3� ma �''� �� - �f �� , U,-r-, DESCRIPTION OF PROPOSED CONSTRUCTION New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other G 44-& $-5 `J Will the lot be re-graded? ❑Yes IXo Will excess fill be removed from premises? Dyes o 1 PROPERTY INFORMATION T Existing use of property: Intended use of property: . Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes E* IF YES, PROVIDE A COPY. Check BOX After Reading: 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 m demolition as herein described.The applicant agrees to comply with aR 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):/ /%6/lne( _l�tJ�V�I/Kbr17"� ❑Authorized Agent ❑Owner Signature of Applica n Date: /Z STATE OF NEW YORK) SS; COUNTY OF T II V-- ) r C '� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the 6VAe4 (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 applicationg 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 7 day of 7 riJ ! 20 Z 3 Notary Public JAIME RODRIGUEZ Notary Public-State of New York PROPER iUTHORIZATION No, 01 f'06 1 Qualified in Suffolk County (Where the applicant is not the owner) Ivry Commission ion E?plre Nov.02,2023 I, 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 2 411, 34 L IG; E FEB 0 ,1 2023 13UILUINU DEPT � . TOWNOFSOUTHOLD Scott A. Russell � r�� STORMWATER SUPERVIS03t MANAGEMENT sovilJOU)7 i.rK\HALL-P n.Ile. 11'91 Ve5 K Town of Southold CHAPTER 236 STORMWATERNMNAGEMENT REFERRAL FORA 1 _ APPLICANT INFOR.,%-t �TIDN TO BE CONIPLETF.D RY THF. _APPLICANT O%-I—Y FOR PROPERTIES ONE ACK IN AREA OR LARGER APPLICANT; (Pro>� rt 0%,.ner. Dr_3gn Pr tessiona] APent- Contractor, I. w.� Other.) A AAtE_ t� bate: � Comtaet hof orma'irm: � r r „ ® �,�! .. ..m_.. ..�. _ ,e�, d...� __. . -` i Pri rte° Address ! f.,rxatt::>r� c,f C:�y'C!trUCt--.n Site: 1000 UiM,icr TO 8F COMPI-L-FI_D M --4')CTH0L1)TOWN ENGI`EERIM, DEPARTMENT \ .c P 7 E Permr: R ,,rrrd I f A1-.d . _-.C.t 1 S' _ n �.-tC I F?u��tt��7ucharg�DtF�i�J, Arta--I DiE,urLzr o: . s1 _.�' i " ,�S i".11E.5.permlG [t.R�'c;��.frhe�.m.r-.'�:. c.ri. ?11�?, AI�'I� Pt,.4 aIY� rdb I �„�" P 1. a�^."� (]- SD hold Pe 7°t 141`14. u. .. . a 3 .� .. r.-M.V vor I.+ ReCe, ved a3 0 DATE(MWDD/YYYY) C " " CERTIFICATE OF LIABILITY INSURANCE �,.. 01131/2023 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 Elizabeth Lenz NAME..: Ext:,Inc. Devine A enc PHONE (845) Anc Nei 255-7806 FAX (845)255-8101 Agency, ArC No 58 N Chestnut St E-MAIL lisa@devineinsurance.com ADD,RESS:. PO BOX 879 INSURER(S)AFFORDING COVERAGE NAIC# New Paltz NY 12561 INSURERA: Mid-Hudson Co-Operative Insurance 35866 INSURED INSURER B: RP Fabrication LLC INSURER C: 16 Youngs Avenue INSURER D: INSURER E Calverton NY 11933 fNSURERF: COVERAGES CERTIFICATE NUMBER: CL2313130619 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR �ADDLSUURi POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD "" "".COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE:f55-9E-W7ffU CLAIMS-MADE OCCUR PREM SES Ea occurrence $ MED EXP(Any one person) $ 2,000 A 91013488 09/01/2022 09/01/2023 PERSONAL BADVINJURY $ GEN1AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 �, POLICY E PRO LOC PRODUCTS COMP/OPAGG $ 1,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LINT $ Ea ocdAent ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY .Per accident. $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB '...CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ 'WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTF ER ANY PROPRIETOR/PARTNER/EXECUTIVE N IA E.L.EACH ACCIDENT $ D? OFFICERIMEMBER EXCLUDE (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 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 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 MAIN ROAD PO BOX 1179 AUTHORIZED REPRESENTATIVE SOUTHOLD NY 11971 .'61 . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD "' `""'Ap" '°`'"""""" VGI LIIIL C1LG VI 11LLGJLCILIUI I VI LACI IIVLIUI STATX C ' ell from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage "Tkisform cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate ofAttestation of Exemption ONLY to show a government entity that New York State specific workers'compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this forum to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Building Permit RP Fabrication I.I.0 16 Youngs Ave From:Town of Southold Calverton,NY 11933-1429 PHONE:631484-7239 FEIN:XXXXX8762 The location of where work will be performed is 2145 Oaklawn Ave,Southold,NY 11971. Estimated dates necessary to complete work associated with the building permit are from February 2,2023 to July 31,2023. The estimated dollar amount of project is 525,001 -$56,0010 Workers'Cont ensataion Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WO WY COMPENSATION INSURANCE COVERAGE for the following reason: The business is a LLC,LLP, PLLP or a RLLP,OR is a partnership under the laws of New York State and is not a corporation. Other than the partners orcg family ,there ons employees, day labor,leased employees,borrowed employees,part-time employees, unpaid than the artnars or taaetaalalrs dtcre arc,no ern s. Partners/Members: Robert 1'elis Disability and Paid FamiIX Leave Benefits Exemption Statement: The above narrated business,.is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business WST be either: 1) owned by one individual'; OR ) is a partnership(including LLC, LLP,PLILP,RLLP,or LP)under the laws.of New York State and is not a corporation; OR ) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation lite a two person owned corporation each individual must be an officer and Lawn at least one share of stock); OR ) is a,business with no NYS location. In addition, the business does not require disability and paid family leave benefits,coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York.State. (ltadcpendent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law) 1,Robert Pelis,am the Member with the above-.named legal entity. 1 affirm that due to my position with the above-named business 1 have the knowledge, information and authority to make this Certificate of Attestation of Exemption. 1 hereby affirm that the statements made herein are true,that 1 have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that 1 understand that any false statement.,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability and paid family leave benefits coverage is required„the above-named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disabilityand paid family leave benefits coverage and also immediately famish proof of that coverage on forms approved byL_nL_:_ Cee by«<t uau o:ale Workers'Cone nsatio 1loa o the go emment entity listed above. IIE Signature: Date: //3 D i Exemption Certificate Number lke eived 2023=006329 January 31t, 2023 NYS Workers' Compensation Boa S'04 } w I� O fwl ci CD C3 CID ci 9 '71 <co c) FN OKLA, 24-Ou uj 375,00' L N 2,T2Y50,-W OAMAWN AVENUE NOTE' CESWOOJ_ SEM TANK A VATIM SORY" UXAMM fff 07k%ft 5-6-MM Fk& WRVEY AV aw or w xmo*k W ow.M**xjb,two 0-21-2004 0WjWMG CINDER CONSTRUCTIOW LOMTION *A own""am"mom ff"w mmool joel No. 01-617 FILE No. pFCoNvc DEVEL CORP. wwbm=4RA=awt==z:=v=w"w ft*M Of&&Aomm to VAMM an ow WM,omwm"=K SURVFYED FOR UWAMMPM XAMWAO ON''Won VAM 0 A M40 Or MOW U)T MUMMM 3 7M OF YF6 WM VM MM MOOM US Wp OF pECONjC DMLOPMENT CORP. AT SOUTHOLD SNOW=mMom MW WWL a*JWY V,**PWA00 VM MW IW SMUATM AT SOUTH= VAM It0=AM ON M OW 10 IM IRA--- oo,'W=* AMW 4M 1p, 110 UM"loNft)a jvjj7a joililflill"l:! TOWN OF SOUIHW - SUFFOLK COUNTY N.Y- w"o omwom am tmj� z= on SCALE 1* - 50' DATE 12-20-2001 oomm aaar VOL=.rj%"mpwM"w a F&M MAP Na. DAM CERTIFIED ONLY TO: M ISM p No.(OW amLy) 1000-70-3-P/022 DISK SM HAROLD F. TRA14CHON JR. P.C. LANG SURVEYOR q;ww*QiiNG RIVER-MANOR RD. WADING RfVER, NEW YORK. 1VQ2 iM2 -40" No. 6;iaM -113 A 631--929 H4 LD F. TRANCHON JR. mD. 2