HomeMy WebLinkAbout48103-Z 4�0�0 coGy Town of Southold 8/12/2023
P.O.Box 1179
o _ 53095 Main Rd
4,, 'Aao '4�' Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 44430 Date: 8/12/2023
THIS CERTIFIES that the building ALTERATION
Location of Property: 1392 Park Ave.,Mattituck
SCTM#: 473889 Sec/Block/Lot: 123.-8-2
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
6/21/2022 pursuant to which Building Permit No. 48103 dated 7/22/2022
was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
"as built"alterations, including in kind and in place window and door replacements and porch repairs,to existing
accessory garage with attached storage as applied for.
The certificate is issued to Beckstead,June
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED 17
th e Signature
osufFocK. TOWN OF SOUTHOLD
BUILDING DEPARTMENT
y 2 TOWN CLERK'S OFFICE
"may • � ,{{ 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#: 48103 Date: 7/22/2022
Permission is hereby granted to:
Beckstead, June
548 3rd St
Brooklyn, NY 11215
To: Legalize door and window in-kind replacements and porch repairs to an existing
accessary garage with attached storage room as applied for.
At premises located at:
1392 Park Ave., Mattituck
SCTM # 473889
Sec/Block/Lot# 123.-8-2
Pursuant to application dated 6/21/2022 and approved by the Building Inspector.
To expire on 1/21/2024.
Fees:
AS BUILT-ACCESSORY $400.00
CO-ACCESSORY BUILDING $50.00
Total: $450.00
Building Inspector
FIELD INSPECTION REPORT DATE COMMENTS
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�gOFFOLrNeq, TOWN OF SOUTHOLD—BUILDING DEPARTMENT
H Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtowmy.gov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only p I i
1 V � V� �Ol � L� o
PERMIT NO. Building JUN 2 1 2022
Applications and forms must be filled out in their entirety'..Incomplete
applications will not be accepted. Where the Applicant is not the owner,an 1?MJu .,T)ZI a IaF'TrYT,
Owner's Authorization form(Page 2)shall be completed: a °'[';1,,^;_„ ;, T;i r.>01f,�
Date:
OWNER(S)OF PROPERTY:
Name: ��(1�� � f� �� SCTM#1000-
Project Address: ) RIP—K #VEf`J Ur__ __F/
Phone#: �� �S �� Email: _1��,e��G(c s/ cQ�61( Ohec, /, c
Mailing Address: fi �� � D�� �( NY 112/_
CONTACT PERSON:
Name:
Mailing Address: 74ff V17 P-051fZ-ffeiq
Phone#: �jSs `7�(�2 Email: v�� beGl
DESIGN PROFESSIONAL INFORMATION:
Name: r)e—
Mailing Address: VA&v-
Phone#: (�3 6,0 -- r Email:__J
CONTRACTOR INFORMATION: I
Name:
Mailing Address: k 3
Phone#: IJ - tiVb �) 6 OrJ 1 n h 3ap
DESCRIPTION'OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration tpl�epair ❑Demolition Estimated Cost of Project:
❑Other $
Will the lot be re-graded? ❑Yes VXO Will excess fill be removed from premises? ❑Yes No
' 1
PROPERTY INFORMATION
Existing use of property: t!DTrFl�/ Intended use of property: 27 Dt'I_r1/-LJ
Zone or use district in which premises is situated: Are there any covenants an restrictions with respect to
M f TW/K this property? ❑Ye No IF YES, PROVIDE A COPY.
Check Box After Reading: The owner/contractoj/desigri 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 corriply.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 misdern,ianor pursuant to Section 210:45.of the New York State Penal Law.' ,
Application Submitted By(print name): U Ne" � L ��-�+✓._ -._.. ..._...[]Authorized Agent J�tlr>ner
Signature of Applicant: Date:
STATE OF NEW//'YORK)
COUNTY OF S/ . Ir )
:TU n e, Aec ks' a�"" being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)Jabove named,
(S)he is the do Ole"
(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 r W
v` I day of20
Notar P Ii
c
JONATHAN D. F®OAR
PROPERTY OWNER AUTHORIZATION Notary Public-State of New York
(Where the applicant is not the owner) NO.01 F06241421
Qualiifed,in Suffolk County
My Commission Expires May 23,2
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
I ® DATE(MM/DD/YYYY)
,4�oieo CERTIFICATE OF LIABILITY INSURANCE
04/06/2022
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 NAME CT Katie Jackson
Brian Micena PHC No Ext• (631)821-2200 aC No):(631)821 2296
45 Route 25A suite D2 AD
AIL Katie.Jackson@American-National.com
Shoreham, NY 11786 INSURERS AFFORDING COVERAGE NAIC#
INSURERA: Farm Family Casualty Insurance Company 13803
INSURED INSURER B:
Gabrielsen Builders LLC INSURERC:
PO Box 317 INSURER D:
INSURER E:
Jamesport NY 11947-0317 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.
INS. TYPE OF INSURANCE ADDL SUBR POLICYNUMBER MM/DD1 LICY EFF MML/DDS LIMITS
LTR
A COMMERCIAL GENERAL LIABILITY 3152X2148 11/03/21 11/03/22 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X❑OCCUR DAMAGES C RENTED 100 000
PREMISES Ea occurrence $
X Contractors Advantage MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
PRO- PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY❑JECT 7 LOC
OTHER:
CO
A AUTOMOBILE LIABILITY 315207227 02/06/22 02/06/23 COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE Per accident $
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
ElEXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ _ $
A WORKERS COMPENSATION 3152W8527 11/28/21 11/28/22 X STATUTE ERH
AND EMPLOYERS'LIABILITY Y/N
ANYPROPRIETORIPARTNER/EXECUTIVEN/A E.L.EACH ACCIDENT $ 100,000
OFFICERIMEMBEREXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/.LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Residential Carpentry
RE: Huguenin /Ciompi Residence - 153 5th Street Greenport, NY 11944
CERTIFICATE HOLDER CANCELLATION
Village of Greenport Building Dept. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
236 Third Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Greenport, NY 11944 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE ;� n
//�` //L_,
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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&WATED A MATTITUCK I re_o 17'
room-SOUTHOLD KENNETH M WOYC1IUK LAND SURVEYING,PLLC
SUFFOLK COUNTY,NEW YORK Professional Lnnd Surveying end Design THE WATER SUPPLY,RMS DRYMIzc AND MigOX
P.O.Box 153 Agve6ogue,Ne York 11931 LOCA DONS SNOBN ARE FROU FIFLO OBSERVA nO
ru.c 1220-132 uuEa"=40' DArE:10-15-2020 RY.S=Na osoeaz PRoxB IsBgsB-lsae rAr(esq zue-Esse AND OR DATA ORTAWED FROM OTRERS
S.C.T.M.# DISTRICT 1000 SECTION 123 BLOCK 8 LOT 2
WATER M74N
PARK AVENUE
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UPa 15 15 MON -----
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UNAUTHORIZED ALTERATION OR ADDIT70N TO THIS SURVEY/5 A WOLA77ON OF SEC71ON 7209 OF THE NEW YORK STATE EDUCATION LAW COPIES OF THIS SURVEY BRO
SW FINEWN ® I'1(vll^
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ONLY TO THE PERSON FOR WHOM THE SURVEY/S PREPARED AND ON HIS BEHALF TO THE TIRE COMPANY GOVERNMENTAL AGENCY AND LENDING INSTITUTION
L157ED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. SAND 4.7' JUN 2 20?2
THE OFFSETS OR OIMENS/ONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE BROWN
NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES,ADDITIONAL STRUCTURES OR AND 07HER IMPROVEMENTS. EASEMENTS MEDIUM
AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE RME OF SURVEY SW COARSE
SURVEY oF:LOT 13 CERTIFIED T0: JUNE BECKSTEAD; SAND
GRavEL BUILDING DEPT
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MAPOF:MARRATOOKA PARK, BAY LOTS & BUN ALOW SITES TOWN OFSODEPT ®
FILED: NOV. 1, 1905 No.19 .1 WATER EL 0.9
—17'
SITUATED AT:MATTITUCK SEPT. 18,2020
TOWN OF.SOUTHOLD K.WOYCHUK LS
SUFFOLK COUNTY, NEW YORK KENNETH M WOYCHUK LAND SURVEYING, PLLC
Professional Land Surveying and Design THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL
P.O. Box 153 Aquebogue, New York 11931 LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS
FILE#220-132 SCALE-1"=40' DATE:10-15-2020 MY.S, LISC. NO. 050882 PHONE(831)298-I580 FAX(831)298-1586 AND OR DATA OBTAINED FROM OTHERS.
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APPROVED AS NOTED
22'-0"
DATE a"aa B.P. # 1 S 103
FEE 54 b 00 BY
NOTIFY BUILDING DEPARTMENT AT
765-1802 8 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1 FOUNDATION-TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH-FRAMING.PLUMBING,
STRAPPING, ELECTRICAL&CAULKING
3 INSULATION
4. FINAL-CONSTRUCTION & ELECTRICAL
MUST BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
ALL CONSTRUCTIOA SHALL
MEET THE REOU",IE1!"NTS OF THE
N CODES OF N'�*j YOR't STATE.
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anncshcrryarchitcct6dgmail.com