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HomeMy WebLinkAbout49219-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#: 49219 Date: 5/9/2023 Permission is hereby granted to: QJSG Properties LLC 333 Central Park W Apt 106 New York, NY 10025 To: construct additions and alterations to existing single-family dwelling as applied for. At premises located at: 38015 Route 25 Orient SCTM #473889 Sec/Block/Lot# 15.-2-15.7 Pursuant to application dated 3/29/2023 and approved by the Building Inspector. To expire on 11/7/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $1,056.00 CO-ADDITION TO DWELLING $50.00 Tidal: $1,106.00 Building Inspector � TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold NY 11971-0959 41 Telephone (631) 765-1802 Fax (631) 765-9502 htt s://www.southoldtownn .)ov Date Received APPLICATION FOR BUILDING PERMIT p 1. For Office Use Only PERMIT NO. Building IrYgpdc'tpr. � a f Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,anb'"/ Owner's Authorization form(Page 2)shall be completed. Date:03/21/2023 OWNER(S)OF PROPERTY: Name:QJSG Properties LLC, Chad Gallant scTM # 1000-15-02-15.7 Project Address:38015 Main Road, Orient NY 11957 Phone#:646-734-3579 Email: Mailing Address:333 Central Park W, Apt 106, New York, NY 10025 CONTACT PERSON: Name:Gary Steinfeld/West Creek Builders Mailing Address: PO BOX 256, New Suffolk, NY 11956 Phone#:631-334-9205 Email:gary@westcreekbuilders.com DESIGN PROFESSIONAL INFORMATION: Name:Condon Engineering, P.C. Mailing Address: 1755 Sigsbee Road, Mattituck, NY 11952 Phone#:631-298-1986 Email: CONTRACTOR INFORMATION: Name:West Creek Builders Mailing Address: PO BOX 256, New Suffolk, NY 11956 Phone#:631-334-9205 Email:gary@westcreekbuilders.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure RAddition RAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $150,000 Will the lot be re-graded? ❑Yes WNo Will excess fill be removed from premises? Eyes RNo 1 PROPERTY INFORMATION Existing use of property:Single Family Residential Intended use of property:Single Family Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R80 this property? ❑Yes ®No 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 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):Gary Steinfeld, West Creek Builders BAuthorized Agent ❑Owner Signature of Applicant: Date: 3/z y/O-Z STATE OF NEW YORK) SS: COUNTY OF ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is they ! (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 hi " know and belief;and that the work will be performed in the manner set forth in the application file that uvi Sworn before me this day of 20 Notary Public Richard m.Noncarrow Notary Public,State of New II Rol-')IIC g ry OWNI1E]R Au rHORIZA rigim No.01 N06 4106 ounr (Where the applicant is not the owner) tin r�issieon i�pi es Jur 2 2C Chad Gallant, QJSG Properties LLC 38015 Main Road, Orient NY, 11957 I, ,residing at do hereby authorize Gary Steinfeld, West Creek Builders to apply on my behalf t he Touu of bout d Building Department for approval as described herein. 3 Owner's Signature ate Chad Gallant, QJSG Properties LLC Print Owner's Name L, 2 Scott A. Russell STORIMMA\'7[']EIK SUPERVISOR NIA NAGIEMIENT SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold d CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) - - - - - - - - - - - - - - -- - - - - — - - - - - - - - - - - - - - - APPLICANT: (Property Owner, Design Professional, Agent, Contractor, Other) NAME: Gary Steinfeld/West Creek Buicilders, Agent Date: ,rpus�lt"'� �, 04/03/23 Contact Information: gary )+l, st reekbui@ders.com IE-Mail&Telephone Numhei9 631-334-9205 Property Address / Location of Construction Site: 38015 Main Road, Orient NY 11957 S.C.T.M. #: 1000 District 15 02 15.7 Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT Area of Disturbance is less than 1 Acre. No S.P.D.E.S. Permit is Required! - Project does Not Discharge to Waters of the State. No.13RD.E.S. Permit is Required! Area of Disturbance is Greater than 1 Acre&Storm water Runoff Discharges Directly to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit DIRECTLY From N.Y.S. D.E.C. Prior to Issuance of a B ildin Permit. Area of Disturbance is Greater than 1 Acre&Storm-water Runoff Flows Through Southold D Town's MS4 Systems to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit through the Southold Town�Enineerin Department Prior to Issuance of a Build in Permit, L/ Reviewed By: Date: / Fnpm * CM('P-T0q nrtnhPr?n i n J W-3 i� � �' E'iVCd / ACOI�O" CERTIFICATE OF LIABILITY INSURANCE 07� /E2 °°"""'' 02.2 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 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 Nicholas Zulkofske Brookhaven Agency,Inc. PHONE 631' 941-4113FF— Ax 61 941-4405 100 Oakland Ave,Ste 1 E-MAIL certificates brookhavena enc .com IN URER S AFFORDING COVE AIC Port Jefferson,NY 11777 IN • Southwest Marine&General Ins Co INSURED West Creek Builders,LLC INSURER C PO Box 256 INSURER New Suffolk NY 11956 8. 9R_9 IN§URERF 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. ADDLSUBR,' POLICY EFF POLICY EXIP LIMITS INSR TYPE OF INSURANCE '.IC'Y NUMBER GENERAL LIABILITY EACH OCCURR NC 1 O00 000 A x MCLAIMS-MADEGENERAL X OCCLIABILITY UR X X GL2022LHB00168 05/09/2022 05/09/2023 MED EXP A n son 100 000 OAMAGE TO RENTED 5,000 PERSONAL&ADV INJURY..... $1,00 000 GENERALAGGREGATE _§_21000,00 EN"L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $2,000,000 XPOLI YPRO. LOC $ 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 1.0001000 AEXCESS LIAB CLAIMS-MADE X EX2022LHB00045 05/0912022 05/09/2023. AGGREGATE $1,000,000 RDEQ I I RETENTIONS WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETDRfPARTNEFV'EXECUTIV YIN E L EACH ACCIDENT $ OFFIC!ERJMEM'SER EXCLUDED N/A See NYSIF certificate (Mandatory in NH) E L DISEASE EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OREOMQNS b low E ...DISEASE-POLICY LIMIT $. DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION ***PROOF OF COVERAGE*** SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD /Vak\ NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE IT ^^^^^^ 205334771 BROOKHAVEN AGENCY INC 100 OAKLAND AVE STE 1Iffil N-05 PORT JEFFERSON NY 11777 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER WEST CREEK BUILDERS, LLC TOWN OF SOUTHOLD PO BOX 256 53095 ROUTE 25 NEW SUFFOLK NY 11956 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12403219-5 100242 05/12/2022 TO 05/12/2023 7/21/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2403 219-5, 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 THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 SUR NCE FUND 4 �/ DIRECTOR„INSURANCE FUND UNDERWRITING VALIDATION NUMBER:617550544 I I_7R'2 vo K Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation I Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier la. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured WEST CREEK BUILDERS, LLC 631-334-9205 P. O. BOX 256 NEW SUFFOLK, NY 11956 1 c. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e„Wrap-Up Policy) 205334771 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 53095 Route 25 3b. Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL371008 3c. Policy effective period 01/13/2022 to 01/12/2024 4. Policy provides the following 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 1 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 . Date Si ned 7/21/2022 By Vd 9 (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard Whitt Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's 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 5B 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 emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (only if Box 4B,4C or 513 have been checked) State of New York Workers' Compensation 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(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature 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 of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 111 Jill DB-120.1 (12-21)°111111 'e Suffolk Court- Executive's Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 8/27/2007 No. 41503-H SUFFOLK COUNTY - Home .improvement Contractor License This is to certifv that GARY M STEINFELD doing business as WEST CREEK BUILDERS LLC having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules � and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. Additional Businesses NOT VALID WITHOUT DEPARTMENTAL SEAL AND A CURRENT CONSUMER AFFAIRS ID CARD Director I Town Hall Annex n` Telephone(631)765-1802 54375 Main Road U. Fax(631)765-9502 P.O.Box 1179 Southold, NY 11971-0959 nTr s k y I0 BUILDING DEPARTMENT NOTICE OF UTILIZATION OF TRUSS TYPE CONSTRUCTION PRE-ENGINEERED WOOD CONSTRUCTION ANDIOR TIMBER CONSTRUCTION Date: 03/21/2023 Owner: QJSG Properties LLC, Chad Gallant Location of Property: 38015 Main Road, Orient NY 11957 Please take notice that the (check applicable line): New commercial or residential structure X Addition to existing commercial or residential structure Rehabilitation to an existing commercial or residential structure to be constructed or performed at the subject property reference above will utilize (check applicable line): -X_ Truss type construction (TT) X ........_._... Pre-engineered wood construction (PW) Timber construction (TC) in the following location(s) (check applicable line): Floor framing, including girders and beams (F) Roof framing (R) Floor and roof framing (FR) Signature; '' � Name (person submitting this form): Ga rY Steinfeld, West Creek Builders � Capacity (check applicable line): Owner X Owner representative TrussRegl5.docx Effective 1/1/2015