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HomeMy WebLinkAbout49670-Z o�S�Ff01 � TOWN OF SOUTHOLD ,� oy BUILDING DEPARTMENT s TOWN CLERK'S OFFICE ��,n• �y 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 #: 49670 Date: 9/11/2023 Permission is hereby granted to: Peconic Land Trust PO BOX 1776 Southampton, NY 11969 To: Demolition of an existing accessory shed to an existing single-family dwelling as applied for. At premises located at: 22600 Route 25 Cutchogue SCTM #473889 Sec/Block/Lot# 109.-1-39 Pursuant to application dated 8/8/2023 and approved by the Building Inspector. To expire on 3/12/2025. Fees: DEMOLITION $229.60 Total: $229.60 Building Inspector �o,\OF SOUTyOlo # # TOWN OF SOUTHOLD BUILDING DEPT. courm��'' 631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION _ [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: Aze-5-5.6jew -4xtw xyy DATE — INSPECTOR 1 �p�5yPF0�rCOG TOWN OF SOUTHOLD—BUILDING DEPARTMENT x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631)765-9502 haps://www.southoldtoLvmy.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only D E C E Y E PERMIT NO. 4900 Building Inspector: AN 6 223 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. where the Applicant is not the owner,an Building D@partment Owner's Authorization form(Page2)shall be completed. Town of Southold Date:8/8/2023 OWNER(S)OF PROPERTY: Name:Peconic Land Trust SCTM#1000-109-1-39 Project Address:North Fork Stewardship Center,, 22600 Main Rd. Cutchogue, NY 11935 Phone#:631-506-1210 Email:jwilson@peconiciandtrust.org Mailing Address:296 Hampton„Road, Southampton, NY 11968 CONTACT PERSON: Name:Dan Heston Mailing Address:296 Hampton Road, Southampton, NY 11968 Phone#:516-381-4489 all:dheston@peconiclandtrust.org DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Coastline Cesspool and.Drain Service_ Mailing Address:4225 Bridge Lane, Cutchogue, NY 11935 Phone#:631-734-6585 Email:coastlinecesspooi@gmaii.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ODemolition Estimated Cost of Project: ❑Other $4,500 Will the lot be re-graded? Dyes *No Will excess fill be removed from premises? ❑Yes RNo 1 PROPERTY INFORMATION Existing use of property:Residential,., Intended use of property:Residential . Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R80 this property? ❑Yes BNo IF YES,PROVIDE A COPY. 8 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 authorizedinspectors 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): L ij ❑Authorized Agent ❑Owner of Signature , g Applicant: 17 Date: STATE OF NEW YORK) SS: COUNTY OFt��-K r ) �r'Etiu�G— W 17y`� being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (Contractor Agen Corporate Officer,etc.) of said owner or owners,and is duly authorized to pe orm 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 D day of 07"— ,20 a A. l�- Notary Public PROPERTY OWNER AUTHORIZATI •'':��°'s: Reg1*a5a ttl01lKU420n5 BMW (Where the applicant is not the owner �t0 .''' My coQuallffed mmission idExpira `• h°' MOM 16.20 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 Demolition Permit Shed Pictures and Dimensions West Side a' .r T 1, F� fs Tl .�.r �1�°"jr¢"4 1!6 ^'.1,.ld' ry{...',.�,! � Ddu• 4 , G,s r v .�.i"j ice. �s;,k�r"r•2/,� r.?� �^i al� �:.��i�4 �i ,. .Y },�• rr ,t.+„t t,� �'�'s� r. '?�p• c ..M'''� , �4.�' �h;+�4 +C'a '�`n x�� 1. , �. South Side ur r' �s North End a. -�w r r w wa� ACC);I? CERTIFICATE OF LIABILITY INSURANCEDATE(IAWDDIYYYY) `� 1 08/03/2023 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 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 Ileu of such endorsement(S). PRODUCER NANIB: EILEEN CUSHMAN GEORGE FORMES Pare-M E....631-722-4100 IANE Nei:631-722-4500 1116 MAIN ROAD SUITE A2 aDORLsa•EILEEN.CUSHMAN(&AMERICAN-F= P.O. BOX 2336 INSURER(Sl AFFORDING COVERAGE I NAIC d AQUEBOGUE,NY 11931 I INSURER A:FARM FAMILY CASUALTY INS. CO. i INSURED INSURER 6: I ARTCO CESSPOOL&DRAIN SERVICE INC COASTLINE CESSPOOL I INSURER C: 4225 BRIDGE LANE INSURER0 CUTCHOGUE, NY 11935 INSURERE: 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 ADDL SUER POLICYEFF POUCYEXP LTR TYPE OF INSURANCE lNSLI POUCYNUMBER IMMMOIYYYYI ISIMMDI nffl LIMITS A XXCOMMERCIAL GENERAL LIABILITY X 3102X4631 04/13/2023 04/13/2024 EACH OCCURRENCE S 2,000,000 CLAIMS-MADE FXXI OCCUR PR S a o S 10.000 MED EXP(Any ene person) 5 5,000 PERSONAL 8 ADV INJURY S 2,000,000' GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4.000.000 XX POLICY�jECT F7LOC PRODUCTS•GOMPIOp AGG S 4,000,000 OTHER. $ A AUTOMOBILE LIABILITY 3101C7928 04/13/2023 04/13/2024 rEa n WNGLKI!IMIT $ 1,000,000 ANY AUTC BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Por acudont) S AUTOS X AUTOS PROPERTY DAMAGE- X HIRED AUTOS X AUT SWNED TPM Rr�,,d_a_ntl 5 .S UMBRELLA LIAB OCCUR EACHOCCURRENCE S EXCESSUAB H CLAIMS-MADE AGGREGATE S _ OED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVEE.L.EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? �NIA (Mandatory In WWI E L.DISEASE•EA EMPLOYEEI S It Yes,dotonbe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMB I S DES'RIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Sehedulo.may ba mt achod It more space Is raqulrod) CERTIFICATE HOLDER AS ADDITIONAL INSURED 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. PO BOX 1179 SOUTHOLD,NY 11971 AUTHORD.EOR RESENTATRIE ©Igb.2014 ACORD CORPORATION. All rights reserved. ACORD 26120141011 The ACORD name and l000 are realstered marks of ACORD f0TATN �( Workers' CERTIFICATE OF E Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured ARTCO CESSPOOL&DRAIN SERVICE INC COASTLINE CESSPOOL 4225 BRIDGE LANE 1c.NYS Unemployment Insurance Employer Registration Number of CUTCHOGUE NY 11935 Insured Work Location of Insured(Onlyrequired if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) FARM FAMILY CASUALTY INS CO TOWN OF SOUTHOLD POB 1179 3b.Policy Number of Entity Listed in Box'1a' SOUTHOLD NY 11971 3104W6403 3c.Policy effective period �13r�n�a to ndui ii9n�a 3d.The Proprietor,Partners or Executive Officers are included.(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'1a'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". 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? YES ANO 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: GEORGE FORMES (Print name of auth ' d representative or licensed agent of Insurance carrier) Approved by: ?I3 o'0a3 (signature) (Date) Title:AGENT Telephone Number of authorized representative or licensed agent of Insurance carrier. 631-722-4100 Please Note:Only Insurance carriers and their licensed agents are authorized to Issue Form C405.2.Insurance brokers are NM authorized to Issue It. C-105.2(9.15) www.wcb.ny.gov • 1 i ETOFSURVEY OF PROPERTY � SUFFOLK COUNTY CnEPkRTFN T OF HFA_TH SFRNICES LAN05 OF &INaR6 FAMILY G ii-ri !1� 1 i UATE: GUTGHO6U I Hauppauge New York 5 _ TOT: 5OUTHOLD -- 5UFFOLK COUNTY, NN- ,� � This is to certifythat the proposed Pe...ty uN.,ivis.on or Geve�op, -nt L SURVEYED 05-31-qa /' �� Pr ; a_ in the I ,� • . AMENDED O 09-�t9 for\�,.� +� _ ---- SUFFOLK COUNTY TAX # ` with a tote' of l is a,as t 1000 - 116 - i - 2 /`` h approved L P L'; ,ge p a roved on 'he above date. t^iat2r Suo li s and rr Disposal FaC11it1eSr:ILSL Conform '0 Cp'1Sti'lC Lori ,taneardS In effect at the titllc G I r i CERTIFIED TO: ry� �o�' i construction ono are subject to separate perruts pursuant to those o standards. This approval shell be valid only if the realty PEGONIG LAND TRUST I 5UFFOLK COUNTY / :;�,,� subdivision/development ;aap is duly filed with the County Clerk within RUSSELL McGALL t f one year of this date. Censers is he given for the filing p this I„ p on which this endorsement appears in the Office of the County Clerk in accordance with provisions of the Public Health Lara and the Suffolk 61011(` y 'c, � 1 County Sanitary Code. ,S),�/ e �� - � � b '_''-' :, V�,"' � ,�..•: tr'1�• r� Jpseph H. Baler P.E. , y Cyd h �'Pa Cirector• Divisiun of Environmental Quality } ��• ~tel ..." l+ ... ✓.+_, .�•.. 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LIG # 502C C.I 1I 't �„a4� W9� � vo°iPaoec�hoenrno aa:zact,terN-,aeatlon �a. izoJnaar atlrae,t an tP a ]oi,s t z I '� ork 5[ace Ee"cat len L NOTES: ... µI ! j' 1'� staztd'eel hall Ce , oiCeretl to 6e valitlatrue ' only scales from cne s=nal r this vey rn .atn an original f the lan0 surveyor s I _ ' s cats caPies 13 MONUMENT �� r d� Cartificatiana intlicatea hereon signify that this 1 i V py tUev Ne wrYork tate _cation f Profess Nona: i O PIPE ay PraParatl,n a a aanae its une �j sting Caoa a. of Practice fer Lartl Surveys e o te: F® /��� Land Sorveycrs. set cert iflcatfons shall r only to the person for u m tna s vey is Preaa-ea. and an his oenalf to tneP title company, governmen- AREA = TOTAL 52.2 AGREE tad agency antl tootling that it i-t lietaa sareah. a to the ass lgnees of the lerair,g institution Cert ff is a�- tions are not transferaale to a]aitiona3 Snst itUtions (TO NEW TIE LINE ALONG GREEK) JOHN C. EHILEIR S LAND SURVE YOR I GRAPHIG 56ALE n I°= 100' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 I F VERHEAD,N.Y. 11901 �' 369-8288 Fax 369-8287 REF.-ETROS\99-237