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HomeMy WebLinkAbout48936-Z TOWN OF SOUTHOLD rt 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 #: 48936 Date: 2/21/2023 Permission is hereby granted to: Blair-Hudson Liv Trt 4560 Vanston Rd Cutcho ue, NY 11935 To: Replace windows at existing single family dwelling as applied for. Additional certification may be required. At premises located at: 4560 Vanston Rd, Cutcho ue SCTM # 473889 Sec/Block/Lot# 111.-10-16 Pursuant to application dated 2/9/2023 and approved by the Building Inspector. To expire on 8/22/2024. Fees: AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $400.00 CO-ALTERATION TO DWELLING $50.00 Total: $450.00 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 httl?s://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. ��J Building Inspector tJUILUIIUh Utf 1. Applications and forms must hp filled out in their,entirety. Incomplete TOWN OFSnII Phlnt ppGcatlons will not be accepted„Where,the Applicant 1s not the owner,an OwneF's'Authorization f(irrn10agej shall be compileted. Date: -z- OWNER(S) OWNERS)OF RO OTY* Name: ( �(,iSSDN j �ST SCTM #1000- l Project Address: t4 V//-,w Phone#: - 2j ��- �2j �'v Email: ���/' , 4iU©C 0� 6,141 Z-. doff Mailing Address: Cv T e) (:� O C AN 0 � CONTACT PERSON: Name: Mailing Address: -f 6 0 V ''"';, -rz- I” /&4 U z� Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name:. Mailing Address: Phone#: Email: 'CONTRACTOR INFORMATION: Dpi Name: �� U f Mailing Address: / Av5 (o L-T, u— 1....17 S`z Phone#: Emai . DESCRIPTION OF PROPOSED COINS RUC`I iON Witw Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estu ated Cost of Project: her W(/JbDU) 2L C�9c�� $ OHO Will the lot be re-graded? ❑Yes 21ko Will excess fill be removed from premises? ❑Yes o 1 PRdPERTY`iNFORMATfON Existing use of property: �S �J c-E Intended use of property: lEez-s( G176C Zone or use district in which premises is situated: Are there any covenants d restrictions with respect to this property? ❑Yes . o IF YES, PROVIDE A COPY, 0 Check Box After Reading: The owner contractor deli n rofessional Is res oinsiblefor all d ratna 'e and storm water issues as'rovided b g / / g P P g � Y Chaote;236 of the Town Code. AppWCAT10PF IS HEREBY MADE to the Building Department for the issuance of a Bulding Permit pursuant to the Building Zone ,� �arr �� ��Y ,. Ordinan�s of the Town b#Ssiuthol�,Suffolk,County,NeWYork and Ether applicable lays,Ordinances or Regulations,for the construction of buildings, additions; Iterations or fgr removal or demohtton as herein deseri¢ed The applicanYagrees to comply with all applicable laws,ordinances,building code, housing i e and i"J Nation apd� admit aut 4,A inspectors on premises and in building(s)'for necessary Inspections.False steteniedts made herein are punishable as a das's A misdemeanor pursuant to Section 210.45 of the New York State Penal,Law, Application Submitted By(prin '"ame): r7lAuthori2ed Agent (lOwner M Signature of Applicant: y - �2r � Date: CONNIE D. BUNCH STATE OF NEW YORK Notary Public,State of New York No. 01BU6185050 SS: Qualified in Suffolk County Commission Expires April 14, 2 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 (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 d � day of f f i, �,L j 20 �'� � " ps Imo '' �r� �" -""rt�d�,-✓� Q� Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) 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 DATE(MMIDD/YYYY) ACCOR"' CERTIFICATE OF LIABILITY INSURANCE 02/03/2023 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(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 to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT UTICA FIRST INSURANCE COMPANY NAME. PHONE 315-736m8211 315-768-4408FGI RISK INC Cei 1007 GLEN COVE AVE MAI GLEN HEAD, NY 11545 INSURERSIAFFORDINGCOVERAGE NgIC# INSURER A: UTICA FIRST INSURANCE COMPANY 15326 INSURED INSURER 8: DOOR DUTCHMAN, INC INSURERC. 194-6 MORRIS AVE INSURER D: ....... m ._. ... �._�.-a HOLTSVILLE, NY 11742 INsurtEg E....,.,..��......._............m....,_._..... , . __ ....... .... e. .. INSURER F COVERAGES CERTIFICATE NUMBER: 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. I TR.TYPE"OFINSURANCE 6151 POLICY POLICY NUMBER POLICYEFF ME DIYYYY) MPOLDI© LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 OOO 000 _ CLAIMS-MADE ® OCCUR PREMISES(Fa c�Lurrgpcel $ 50,000 ---..µ.------ XP(Any one person) $ 5,000 ,.An� A � Y ART5097323 02/05/2023 02/05/2024 PERSONAL&ADV INJURY $ 1,000,000 GE N"L AGGREGA'T'E LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 7-1I RC. POLICY PROSJECLOC PRODUCTS-COMP/OP AGG $ 2,000,000 _ ........ ,. OTHER' AUTOMOBILE LIABILITY I COMBINED SINGLE(LIMIT $ LE a apcl_vitnl) _. ., ANY AUTO BODILY INJURY(Per person) $ ... OWNED SCHEDULED _,.�,-,...w� AUTOS ONLY „„„„„„„ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED R{'1PERT'Y6,EAPkr1A(E $ AUTOS ONLY AUTOS ONLY ,1FerI,„r.iueMwl1,,, UMBRELLA LIAB M_____ EACH OCCURRENCE $ .. 4 1 CLAIMS-MADE -- ....AGGREGATE $.. ........... _....... ... .... EXCESS LIAB � OCCUR � a DED RETENTION$ $ N ,.,.$TATUTF '..,,,,,,,,......ER... .. WORKERS COMPENSATION r AND EMPLOYERS'LIABILITY -� ANYPROPRIETOR/PARTNER/EXECUTIVE YIN EL EACH ACCIDENT $ OFFICER/M EMBER EXCLUDED? N/A ”"` (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) ADDITIONAL INSURED:ARNOLD BLAIR CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ARNOLD BLAIR ACCORDANCE WITH THE POLICY PROVISIONS. 4560 VANSTON RD AUTHORIZED REPRESENTATIVE CUTCHOGUE, NY 11935 I ©1988-2015 ACORD CORPORATION. 11 rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD AC CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNY-YY) 02/09/2023 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(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 to the certificate holder in lieu of such endorsement(s). PRODUCER c N AcT Automatic Data Processing Insurance Agency, Inc Automatic Data Processing Insurance Agency, Inc. SP NAME ExI) 1-800-524-7024 _w _ 11 FA . AM•MYAIL AOOR[ss P Insurance Company ... INSURER A: INS ) DING COVERAGE NAIC# Roseland NJ 07068 Phoenix In R .�...,�....�� �_. � 25623 1 Ad......Boulevard �.....�...........�_. � —_ .... . . ... INSURER(S)AFFORDING.. ... ,._. � ..w...,�. ..�. �... l.. ........... INSURED Door Dutchman Inc INSURER B:..__ _ ....... .. INSURER C .................................._. ... .... . _.,. _......._. 51 New Lane INSURER D: INSURER E Selden NY 11784 INSURER F: COVERAGES CERTIFICATE NUMBER: 2857224 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. TNSRLTR DG. N# ._.... POLICY NUMBER ....,._.._.._.__._—... ._ ... . .�.�.,,,,,, ......._ ........... .......... .,�,,,,.�,..,,,._..,_. WVQ, TYPE OF INSURANCE R POLICY EFF POLICY EXP LIMITS MM/DD/YYYY MM/CID/YY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE ��OCCUR PREMISF.S(E, crllrrPnre), $_, MED EXP(Any one person) $ , _.. ..�..o.....a..,.. ._....,,� PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT �P E LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY VE:S�"1 LOG � � PRODUCTS COMP/OP AGG $ 11-7 OTHER: AUTOMOBILE LIABILITY Ea aCOMBINED SINGLE LIMIT $ ANY AUTO BODILYNJURY Pe� ( r person) 9$.v....—, ...,,�.,,. ._ . OWNED SCHEDULED .(Per accident$ AUTOS ONLY AUTOS BODILY Pe ( HIRED NON-OWNED Pr1(7PFRTYD'A-MAOI' $ AUTOS ONLY AUTOS ONLY t )�....._......m.. .w m..._.... ... UMBRELLA LIAB EACH OCCURRENCE $ ... �. . EXCESS LIAB � LAlMS-MADE —....�.............,.-..�____ ...,.......... l�OCCUR AGGREGATE $ DED RETENTION$ 99 $ WORKERS COMPENSATION /N 24 STATUTE ,,, f OTH E L EACH ACC ENT , AND EMPLOYERS'LIABILITY ER ANY PROPRIMBER EXCLUDED? /EXECUTIVE Y""""" N $ 1,000,000 A OFFICER/MEMBER EXCLUDED? N N/A N UB-1 N714082-23-42 01/01/2023 01/01/20 � 1,000,000 ... (Mandatory in NH) E L DISEASE EA EMPLOYEE $ EL,.DISEASE-POLI _ If yes,describe under POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/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 Arnold Blair ACCORDANCE WITH THE POLICY PROVISIONS. 4560 Vanston Road AUTHORIZED REPRESENTATIVE - Cutchogue NY 11935 )�— .4-)"-- a- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Suffolk County Dept of \ \ _ \ \ Name �\ J CHARLES VIA! ESE u _ i . .. t ' " ,. yr Utonse `_ mbec H-53697 1"I u- sd M- 23120,14 0 � -11*2024