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HomeMy WebLinkAbout49390-Z d-g, TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE r` 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 #: 49390 Date: 6/15/2023 Permission is hereby granted to: Whiting, Trac 3960 Ole Jule Ln Mattituck, NY 11952 To: construct exterior basement stairway as applied for. At premises located at: 3960 Ole Jule Ln Matituck SCTM #473889 Sec/Block/Lot# 122.-4-26.1 Pursuant to application dated 5/16/2023 and approved by the Building Inspector. To expire on 12/14/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 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) 765-9502ll�t�.� :�"�"www. oimiliolcttoNaui.� Date Received APPLICATION F"OR BUILDINGPERMIT For Office Use Only PERMIT NO. Building Inspector: MAY 1 0 2023 LD Applications and forms must be filled out in their entirety.Incomplete rJUILUM&UEPT applications will not be accepted. Where the Applicant is not the owner,an OFRni -D Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: t-Vt1i Ce,�lZ-7—'e ac � r SCTM#1000- „ Project Address: L e— L� —Vl-J Phone#: G1� �'I�Z s� 3 Email: i&-PA-tJCL �eyC1v",AeL Mailing Address: CONTACT PERSON: Name. 5 �� � vp,c c J5 �vv�� Z c-tJw Mailing Address: `��-� Vw �" Z L VZ,'c-r i2\-JKK�A 0 Phone#: 6'11 Email: C 1�T sTk-j av Ck Cc,L""' DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: V6�Cr �� G to C." Li u'n Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition Iteration ❑Repair ❑Demolition Estimated Cost of Proiect: ❑Other" ^"0C(�.X—i �,, / _lG . � � $_f.1/ Will the lot be re-graded? ❑Yes " d ' Will excess fill be removed from premises? ❑Yes F970 1 u d� PROPERTY INFORMATION Existing use of property: �� Intended use of property: IZE-s Zone or use district in which premises is situated: Are there any covenants aqo restrictions with respect to this property? ❑Yes 9<o 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 15 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): �� '/� �c1� M46thorized Agent ❑Owner Signature of Applicant: "" Date: 05116125 STATE OF NEW YORK) S: 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 A (Co actor,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 day of _ 20 )3 N t ry 4blicu Erin Murphy-Apicello Notary Public State of New York F)ROPERTY OWNER Atri QRS , FIQIY County of Suffolk � REG#01iMU60903s (Where the applicant is not the owner) 91/_11 ��,�/� Expires April 14,20� Ses- r`T,� e( Iz�-=� 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 x 'Y A, IMIS PROPERTY RENOVATIONS Tel 631-276-3334 www.amsrenovations.com Letter of Authorization To whom it may concern , I Kieran Collings allow Stuart Daccus of AMS to act on my behalf at the building dept for our upcoming project at our property located at Signed Printed Kieran Collings Date 05/12/23 SRK I Certificate of Attestation of Exemption sir T Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage "This form cannot be used to waive the workers'compensation rights or obligations of any party." The applicant may use this Certificate of Attestation 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 form 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 Ams Home Improvements LLC From:Southold building Dept 54375 main road Southold 1549 Main Rd Riverhead,NY 11901-6006 PHONE:631-779-3727 FEIN:XXXXX1541 The location of where work will be performed is 3960 okle jule lane,mattituck,NY 11952. Estimated dates necessary to complete work associated with the building permit are from January 19,2023 to April 28,2023. The estimated dollar amount of project is $10,001-$25,000 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'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 or members,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Partners/Members: stuart daccus Disability and Paid Family Leave Benefits Exemption Statement: The above named 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 MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) 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. (Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law.) I,stuart daccus,am the Member with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I 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 I 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 disability and aid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers'Cvpns and a the gover ent entity listed above. SIGN Signature: Date: " 2G 2 3 I HERE J,,,.✓//rJl✓/.pn,,,,✓/1/1'/l/1111-111/y"�✓i�// ✓O✓r✓Jv;M Jll✓�,i/./l ��AS,✓!/ /,J//IJi.�/✓✓T✓✓/ 1 /✓/Le ✓ll/„/✓,�L/ ,,,../, ✓: w✓„/ .✓U.J f/r✓r.:.. i ,,.Y✓/.i/ "' Exemption Certificate;Number ; 3 C e Jd 20.23 003764 2 NVS WorkeW+Dompfiob rd" ,,.. ,. ,.anP. ,✓,., ✓✓,✓ rr„✓.«.;✓ ✓„e✓✓✓a� er✓�r✓✓✓ri ✓✓✓✓�✓✓✓ ✓ ,✓.�-✓a✓ ✓�✓� ✓a�✓i✓ i✓ ✓� i i ,�✓ ✓ri✓o✓mr ✓ar.✓r�✓✓�'or✓✓i vi,✓rra✓r.✓✓w eoveeo✓ wvPmma/ M"✓ .,✓✓✓✓�, CE-200 01/2018 �. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD111,n"61"y 2.1YY13 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 NAME: SPECIALIZED INSURANCE&SERVICES PHONE 1531` 58-67110 -----.................... 531- 'ib 204 RTE.112 �S. tst i ....m........ JAJC,,No ADDRESS. SRU@SPECIALIZEDINSURANCE.COM PATCHOGUE,NY 11772 __K_......... _.. Auto-Home-BUSiness-Cycle-etc. _ INSURERS AFFORDING COVERAGE NAIC l INSURERA:ATLANTIC CASUALTY INSURANCE CO 42846 INSURED .._.......-..-._...-.. ... INSURER B: AMS HOME IMPROVEMENT LLCINSURER C; .............................._._................... _.__._.._.___.. 1549 MAIN RD ENSURER D: RIVERHEAD, NY 11901 INSURER 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. INSR A 1rML SITBAk POLICY EFF POUCY EXP LT TYPE OF INSURANCE POLICY NUMBER i' Y' M010050 YYYY LIMITS A COMMERCIAL GENERAL LIABILITY Y N L266000944-0 11/08/2022 11/08/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR 1$ N(t 100,000 MED EXP(An one arson X000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- JECT F—]LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMYT $ �IaP.�mAWTIl ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ �- HIRED NON-OWNED PROP 'DAMAGE­ RTYDAMAGE­$ AUTOS ONLY AUTOS ONLY Par acrlBi)m,m__ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER O '- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE -mX mmm^ mmm OFFICERIMEMBER EXCLUDED? NIA E,L EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,descn"be under DESCRIPTION OF OPERATION below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) DRY WALL OR WALLBOARD INSTALLATION, PAINTING-INTERIOR BUILDINGS OR STRUCTURES AND REMODELING CERTIFICATE HOLDER IS ADDITIONAL INSURED AS PER WRITTEN CONTRACT OR AGREEMENT CERTIFICATE HOLDER CANCELLATION SOUTHOLD TOWN BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NY-25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 54375 N -2 LD, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTAUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD