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HomeMy WebLinkAbout49224-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 APPRO"V"ED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 49224 Date: 5/10/2023 Permission is hereby granted to: Williams, Leonard 46 Washington Ave ....._. Garden City, NY 11530 To: Construct an accessory garage to an existing single family dwelling as applied for. Must maintain a minimum setback of 15 feet. At premises located at: 6925 Great Peconic Bay Blvd, Laurel SCTM # 473889 Sec/Block/Lot# 126.-10-16 Pursuant to application dated4/6/2023 and approved by the Building Inspector. To expire on 11/8/2024. Fees: ACCESSORY $388.00 CO-ACCESSORY BUILDING $50.00 Total: ....... .. 43 8.00 Building Inspector wr -4 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 ://www.sotith l(lto.ryrincro—y Date ary APPLICATION FOR BUILDING PERMIT For Office Use Onlyr/ n I f t PERMIT N0. Building Inspector: a w' 2DZ2 Applications and forms must be filled out in their entirety. Incomplete + •wa applications will not be accepted. Where the Applicant is not the owner,an `)VV I OF Owner's Authorization form(Pr,; )shall be completed. I Date: OWNER(S)OF PROPERTY: Name: �� VD SCTM# 1000- �ZI..- Op- ©l(e Project Address: (.16 Phone#: 9I'1- q2� _ Email: Mailing Address: CONTACT PERSON: Name: Mailing Address:AZZ3� Phone#: (e?✓'I- Zj- I .. ���l�l. k�i� �i DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address; Phone#: �?J�_Zg�j_C � Email: ��- CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: 73`' AlJ:kil� NIIJJ' -424 1 DESCRIPTION OF PROPOSED CONSTRUCTION 'New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑OtherQ 2 q removed from, premises? ❑Yes I�Vo a i Will the lot be re-graded. ❑Yes�,No Will excess fell be i APP-IL5-901 J, M` �o 4 1 ` r PROPERTY INFORMATION Existing use of property: 6-9;4� TAMT-1-�A Intended use of property: A � Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to _ this property? ❑Yes )eNo 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): f '4Authorized Agent ❑Owner Signature of Applicant: Date: 7-ZI -Z6; STATE OF NEW YORK) `SSS:,_, ,J 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 064 (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 P O. 1 day of Q 20 �tlz ry flublic : '.fit: MW4 PROPERTY OWNER AUTHORIZATION ,` " ,*" (Where the applicant is not the owner) �r� i N�E\N, `' residing at 1"4 rt do hereby authorize to apply on my behalft ti o f old Building Department for approval as describ h7in,, Owner s- Ignature Date Print Owner's Name 2 ,.pp DAT (9/ YY17 /22 0 21 00 CERTIFICATE OF LIABILITY INSURANCE 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. certificateIMPORTANT:If the holder is an INSURED, YcrpADDITIONAL INSURED provisions be endorsed.If SUBROGATION IS WAIVED,subject the terms and conditions of the policy,certain policies may requirean endorsement.A statement on this - certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 'p NAME: Aon Risk Services Central, Inc„ pi F (866) 283-7122 ..�..._.._._. FAX (800) 363-0105 d Chicago IL office QAC ate.Ex IAS,No _____________________� v 200 East Randolph ADDRESS: _ Chicago IL 60601 USA INSURER(S)AFFORDING COVERAGE NAIC# ...._. .......... ......._...� '.INSURED INSURER A: Zurich American Ins Co 16535 'Morton Buildings, Inc. INSURER B: American Zurich Ins Co 40142 West Adams Street Great American security InCo 31135 Mor INSURER C: Morton IL 61550 USA s _,. Mor _ INSURER D: INSURER E: .._.. ...... ................_. .... .._. INSURER F: COVERAGES CERTIFICATE NUMBER:570089614952 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. Limits shown are as requested I7'li TYPE OF INSURANCE INSO yq/VO POLICY NUMBER MMIIICY DIYyyy. MMpDD YyYPY.. LIMBS A X COMMERCIAL GENERAL LIABILITY GLO 3 EACH OCCURRENCE ',. 52,000,000 �._ . L. _ CLAIMS-MADE OCCUR SAPREMISES(E�.occurrence ...... M N 'rL $1,000,000 MED EXP(An one person) $50,000 PERSONAL&ADV INJURY $2,000,000' w LO �....... a.... ..........� ........_. m GEN'L AGGREG�LIMITAPPPER:El _ v X .POLICY ,,,w(LOC PRODUCTS GENERALA� ACOMPOPAGG TE $10E0x0C10Uded � PR". J,EGT m 0 OTHER: o A AUTOMOBILE LIABILITY BAP 9376314 18 10/01/2021110/01/2022 COMBINED SINGLE LIMIT $3,000,000 '..X BODILY INJURY(Per person)ANY AUTO C Z OWNED SCHEDULED BODILY INJURY(Per accident) r AUTOS ._ ...... ................ to AUTOS ONLY PROPERTY DAMAGE HIREDAUTOS NON-OWNED V ONLY L AUTOS ONLY Per acadentl d C X UMBRELLALIAB X OCCUR UMB4033493 10/01/202110/01/2022 EACH OCCURRENCE $2,000,000 U umbrella Liability aGG EXCESS LIAB CLAIMS-MADE REGATE $2,000,000 _....... 'DED FRETENTIIN B WORKERS COMPENSATION AND WC93763111 1070172021 1,10/01/202' X PER STATUTE OT,W A OFFICER/MEMBER EXCLUDED' AOS ""'"" '""""" EMPLOYERS,LIABILITY ANY PROPRIETOR I PARTNER/EXECUTIVE Y 8 E.L.EACH ACCIDENT $1,000.00 0 NIA Wc937631218 10/01/2021.10/01/2022 (Mandatory in NH) ""' '..MA,WI E.L.DISEASE EA EMPLOYEE $1,000,000 It yyes,describe under """"""'"""'""'"" "..... 1 DESORIPTION OF OPERATIONS below E,.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACOAD 101,Additional Remarks Schedule,may be attached It 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Southold AUTHORIZED REPRESENTATIVE PO BOX 962 Cutchogue NY 11935-1146 USA ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board ....... ............... _. 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (309)263-7474 MORTON BUILDINGS, INC, 252 WEST ADAMS 200 1c.NYS Unemployment Insurance Employer Registration Number of PO BOX 399 Insured MORTON IL 61550 Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 37-0347310 .._..... ........ _ w.... 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AMERICAN ZURICH INSURANCE COMPANY Town of Southhold 3b.Policy Number of Entity Listed in Box"l a" WC 9376311-18 54375 Main Road Southhold,NY,11971 3c.Policy effective period 10-01-2021 to 10-01-2022 3d.The Proprietor,Partners or Executive Officers are Qincluded.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. ... This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". _. u...._._ .............._.. _....... ... _._. Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? 7YES E N0 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation 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 Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. 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 the coverage as depicted on this form. Approved by: Roger Levine (Print name of authorized representative or q,8t: res,gd a1 qt of psgt n va�fl, Approved by: date Title: SVP Midwest Region Casualty Telephone Number of authorized representative or licensed agent of insurance carrier: (847)605-6914 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-15) www.wcb.ny.gov ��P r ram -4 X05 Scott A. Russell � 1JFFQ SC O�][Zl��l WA\T]E]k SUPERVISOR MANAGEMENT SOUTHOLD TOWN HALL-P.O.Box 1179 oSouthold f 53095 Main Road-SOUTHOLD,NEW YORK 11971 �r Town CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT tf ONLY FOR PROPERTIES ONE ACRE IN AREA OR LA 1" APPLICANT: (Property Owner, Design Professional, Agent, Contractor, - — . _ — _ _ — _- -. — .� _. — — Other) i° NAME: " Date: � Contact InfosAt ;^ iC-11ad R relephnne Numhei) PropertyProp-Lrty Address / Location of Construction Site: �� � ► S.C.T.M, 1000 District LAO Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT i - Area of Disturbance is less than 1 Acre. No S.P.D.E.S. Permit is Required !. No S.P.D.E.S. Permit is Re aired [3 - Project does Not Discharge to Waters of the State. - Area of Disturbance is Greater than I 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 i. DIRECTLY From N.Y.S._D.E.C. Prior to Issuance of Buildil Permit. - Area of Disturbance is Greater than I Acre & Storm-water Runoff F lows Through Southold Town's MS4 Systems to Waters of the State of Ne\,• York, THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit thrm 10,h the Southold Town Enaineerin De rtti ent Prior to Issuance of a Building Permit. c Date: 13 '' Reviewed By: + ,. FlIR M � CM('P-T(1C()rrnhar 7n I c) Alec � � �� j