Loading...
HomeMy WebLinkAbout49581-Z "drat 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#: 49581 Date: 8/15/2023 Permission is hereby granted to: Powers Kristen M 2013 Trust C/O Kelley Drye & Warren LLP 175 Greenwich St FI 67 New York, NY 10007 To-, Replace windows at existing single family dwelling as applied for, with flood permit. At premises located at: 220 Park Ave Ext, Mattituck SCTM #473889 Sec/Block/Lot# 123.-8-26.1 Pursuant to application dated 7/7/2023 and approved by the Building Inspector. To expire on 2/13/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Flood Perini/ $100.00 Total: $350.00 Building Inspector TOWN ON SOUI'HOLD—BUILDING DEPARTMENTr� Town Hall Annex 54375 Main Road P, O. Box 1179 Southold, NY 1 1971-0959 ! i ,.� �'tO!% I� Telephone (631) 765-1802 Fax (631) 765-9502 hII_���. I) , .... .. w.._. . Date Received For Office Use Only l PERMIT NO. � !.. _..�.�—. Building InspcCor: —.-. _—_..._.. ......__ Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 07/05/2023 OWNER(S)OF PROPERTY: Name: Kristen and Steven Powers _ SCTM# 1000- Project Address: 220 Park Avenue Extension Mattituck, NY 11952 Phone#: (631) 298-0090 Email: steve.powers37@gmail.com Mailing Address: 220 Park Avenue Extension Mattituck,NY 11952 CONTACT PERSON: Name: Alison Shumway Mailing Address: 121 Express St Plainview,NY 11803 Phone#; (631)742-4955 Email: alison.shumway@powerhrg.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email; CONTRACTOR INFORMATION: Name: Power Home Remodeling Mailing Address: 2501 Seaport Drive Chester, PA 19013 Phone#: (888)736-6335 Email: alison.shumway@powerhrg.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure [--]Addition ❑Alteration ❑Repair []Demolition Estimated Cost of Project: ®Other Remove and replace 7 windows(same size/location).U-factor 0.27;No structural changes . $ 16,1m13.16 Will the lot be re-graded? ❑Yes ONO Will excess fill be removed from premises? ❑Yes END 1 PROPERTY INFORMATION Existing use of property: Private (one family) Intended use of property: Private (one family) Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES, PROVIDE A COPY. O i,@': 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. M..». w Application Submitted By(print name): Robert Ciskanik ®Authorized Agent ❑Owner Signature of Applicant: rtw Date: 07/05/2023 STATE OF NEW YORK) SS: C0 U NTY O F Robert Ciskanik ._ mmmmmm -..._being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the Contractor (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 -day of L420 _ Notary Public MARIA HERNANDEZ NOTARY PUBLIC-STATE OF NEW YORK No. 01 HE6076686 i Qualified in Nassau Count! Commission Expires December 28,2026(Where the applicant is not the owner) 1, .,,,,_Steven/Kristen Powers residing at 220 Park Avenue Extension Mattituck' Y 11952 do hereby authorize Robert Ciskanik _. .„- _._mmmm to apply on my behalf t he Town of o old Building Department for approval as described herein. O per's Signature Date Print O ner's Name 2 �" R" AC DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/29/20.23 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T HE 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 endorsements , PRODUCER CONTACT Lacher&Associates Insurance Agency NAME . 9 Y PalomaErAz Lacher Insurance Group (A/C,N0i,Exi:. 1 5-723-43'78 , _ (Air„No);215-723-5757 EMAIL 632 East Broad Street ADDRESS; car ificate@lach,erinsurance corn Souderton PA 18964 INSUREIR(S)APFORDING COVERAGE NAIL# INSURER A 1.enn,ylvaniaManlafactE.irers'Ass(.)ciatlorIInsurance 12262 INSURED POWFRCL-01 INSURER B: Harleysville Insurance Co of New York 10674 Power Home Remodeling Group, LLC I - 2501 Seaport Drive,4th Floor INSURER C Markel Arnericarl Ins Co 28932 Chester PA 19013 ONSUREyR D: INSURER E: bNSuar--.N,F COVERAGES CERTIFICATE NUMBER:555221946 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 ADDL'SBF# ,. .v., ,, .,, ._ f POLICY EFF POLICY EXP ,,,_TYPE OF INSURANCE c, y jrD POLICY NUMBER (MM1DpM/YY1,(MMIDD LIMITS A ' X COMMERCIAL GENERAL LIA80ITV 302375-66-20-96-7 4/1/2023 41112024 rpA{:II 04 C4}ffP1d NCL? $2,IJRI(1 0000 AWnAfiP tO RUNTO) y;1,041 TOO CL AINNIS-MADE X I OCCUR pRI r'"81',f,ip occu<ra,NRtCO ) S 1Gi,+„b00 M1Ib r Axx ,��^iyin vt�©i"� nxs _ 4I M ASG'REGAtlu?:l.lIMII AP'INI I r'V.PR: C41RFR I,AGGRRI GAH ,4A,(1W,4100 ,}L':CT 11.00 PRODUCTS.Cr)f�Ar'fJfa d,a, 1a4,P,1ClGl, Cl%,1 owl f1411:i6R A AUTOMOBILE LIABILITY 152375-66-20-96-7C MA and NY 111 2023 1/1/ � X ANY AUTO . SCHEDULED BODILY INJURY INCE k-LIMIT $2,000 000 2024 ^��MBIIWLU S 1/1/2024 (E i ac id-t . A I I RY(Per person) $ AUTOS ONLY AUTOS f i BODILY INJURY(Pa acr.,idr.nt) $ " a HIRED ED f FiRDdC°6tTY E}AMAGr: AUTOS ONLY AUTOS ON $ B X UMBRELLA LIAB X OCCUR CRA0000027 4(1(2.023 4/1/2024 m�EACI I OCCURRENCE $3,000,000 EXCESS LIAB CLAIMS-MADE AGGREGA”["F $9,v(00 000 _ .�,a- Y t a Gdkit _... _.._b° .. _- k d r ra rurs ""99}r9Burzu..__ �1(k6 J tiro P"ME1T PRN"'%"U1N0tlON,�."° ........... .._ ...,._.._. 4 .__ _._. _.. °.-...-,,._.. ..�.. ...- ..., ....... A WORKERS COMPENSATION 20237566-20-96-7 111/2023 1/1/24724 ,X IAIh�6lfl 4�P@Ii- AND EMPLOYERS'LIABILITY -- - - ANYPROPRIETOR/PARTNER/EXECUTIVE Y P N E L EACH ACCIDENT $'1,000,000 OFFICER/MEMBER EXCLUDED? Y NIA (Mandatory In NH) E L DI S IASkI'',i F A EMPL`kYL I„ $1,000,060 If describe under �� A W --- --- - __.... .... DESCSC RIPTION OF OPERATIONS!?slow F I DISEASE�ASE L POLICY LIMIT 6100(},000 „mmmIT ITITmm��„ C EXCESS LIABILITY '.... MKLM7EUE101009 4/112023 4/1/2024 'EACH OCCURRENCE 5,000„000 AGGREGATE 5,000,000 Excess oP 3,000„000 _ _ _ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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. 53095 Route 25 P.O. Box 1179 Southold NY 11971 AUTHORIZED REPRESENTATIVE USA S, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1'''� CERTIFICATE OF INSURANCE COVERAGE NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insuranceagentof that carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Power Home Remodeling Group LLC 1660 Walt Whitman Road 610-874-5000 Suite 140 Melville,NY 11747 Work Location of Insured(Onlyrequired if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 233030708 2.Name and Address of Entity Requesting Proof of Coverage3a.Name of Insur-anee Carrier (Entity Being Listed as the Certificate Holder) Arch Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box 1 a 53095 Route 25 P.O. Box 1179 Southold NY 11971 11 DBL9519600 3c.Policy Effective Period 1/1/2023 to 12/31/2023 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 I 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. 12/19/2022 l.�,F - Date Signed {31iµ„uil�iii c>A ws. ,ti , ,,,th ,i i .a,e, �7,.,.r:a;mh:v5littru=�rY n� rr�na.e.sC'�cvrtwhthrtni:�ur:rru¢.cre.�i¢ha�rl Telephone Number 201-743-3937 Name and TitleAVP Accident& Health James lannlcelli, e 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 513 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 5B have been .....-..n�..) ' _� � en 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 ........ ,U . ............ - -._ W.,. ., �., 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) DB-120.1 (12-21) DocuSign Envelope ID:BBF351D8-5CB6-40E0-AFFF-FADD73EBD481 �u(dW K f rid "�Rite° :w:u CERTIFICATE OF °vlAld li bra R^I,n r[.Iit,t 1 NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a Legal Name&Address or Ins wed(u:c.stree(addre..:a --- -------- m.._ ._ ._ q<a �;only) dla.l.;rs,ierlr„,�, V r,lo,paitz"oT¢!!;PIrrriilarao•raf 0 r I�rc,el I'O\A/cf I....101'11c: Remodeling C',iI I LC:; 610 874 5000 25101 'roe apof t Di ve, 41h I lour 1t; N"IS Ijrourrployi~noW lwmr arico i nplr„a4gar IRe gisIrsaririr I'rP mIII,ror of Cheslr.!i. 13A 190113, Insarrlod wry"1 rx;.(Alan of In meet(Olvy re cpurrrod rjvcrrrfir /S,,pc(occtN,rfrtr°rPrW W lit 1-r,.;doI7 al t'.mpiny,r I le_hwl,lciraliraei prrntr,rr,r 0 In^ri,arrsrl ar ,n,-ilori irnl; :.rf.rwr(r Ca,frr,ra°,are fV ,o,Ywk e)I •a '.A/mp) Up rloh(,.f; doririrr r 23-30"R)708 hdanuvca and Ardrlie ;>taf i.rdilly ,r,tlisw Beer, Proof ul(4rr,n:r.ar,,, 0 Ins uinairc.ra af y rt hrr;lr!G1 ,IIic crfilIv,,n[c I-IcpeI:) (8nWHciii CidL +:�rnr••,;allarsnil;i� ��vl;airiaf,lcirsocl 'I1Oion Iia A11,11v (rml:a;rIn}` Town of Southold ali 53095 Route 25,P.O.Box 1179 eay Ni in 7r,r;e Of i';nluirr r (a.ar'�6 ri Iii¢:r "1,a " Southold,NY 11971 202,375 66 20 .96....7 Se 1.:meta r e f,,Ca([Ve Ile,r; JIp/7 A,a ° In 1 .. P._..-...... ... /1/24 _ it .l P'r l r ;Iriiralii lr irlr'ii i i �, li rr;.afl , ire't IIP ude"wt P e:n :h. i� 1 a)i+';C; .r ld r',r 11, l:7dr0 ', 0 .l -CI iris cortiflas that the* ii suiance carrier Indicated above in box Ileswren's the business, ... referenced about: In box la" fo for workers° carr perisation under the New York State 414/oike::r,' ColTIpensation I....aw. (era use this forrn, New York (INY) must I:)e listed under I,tern 3A on the INFORI'MA TIION IPAGIl:: of the workers"conTpensation insurance policy), The Insurance Collier or Its licensed agent will :send this Certificate of Insurance to the entity listed above as the certificate Molder in box"2". fhe Insurance carrier rnr..ist notify the above certificate hholder and tfhe Workers'Compensation Board within 10 days lig ea policy is canceled due to nonpayment of prF:iniums or wifh7in 30 days IF there:are reasons other than nonpayment of prerniurris that cancel the policy or eliminate the, insured frorn the e,overaage, Indicated on this C;e Nificate,. (These notices may be,sunt by rcdulerr maail,) Otherwise,this Certificate is vallid fair one year after this fforirn is alaproved by the insurance carrier Or its licensed agent, or until the policy expiration date listed in box '°3c", wlhichevezr is earlier. This c,ertific;a[e is Issued as a Moiler of III rrnatian only and confers rlo ricltats u,ae>rr [tae cerlificate holder. I hIs ce.riificatea does not amend, oxtesrad or alterth ;Coverage afforded by the polfcay listed, rror docs; it confor ony cighlo;or ressponsiiI I')L'yC7nC1 thos,o coiateainc,c.! In the; referencec:t pc::alicy. This certificate iI be used as evidence of ra Workers'Compensation contracl ofinsurance only while [lie 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: Marian Bell iniiri1 ri uir JI'' uil i i 1^.1 a rh91 n r li rur,r f i o- il 1 i i• i, +� riri , �W. Ct�ruSE�mnd fry ApIsroved by: 12/19/2022 1 11:01:16 AM EST �._., r,c r atr�ra,ae.l pp;Wr;�b..or°er'p Qr.afrVG:,a Tlf(: IIder•1Ur eI- Te,Ccl.ahroric; f°lurrik>er of authorized repre,.,rrrtativc:;or licensed ragcrTl:of irisurararcx can 101 609-413-2017 Please Note: Only insurance carriers and their licensed agents are authorized to issue Foran C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov