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HomeMy WebLinkAbout50071-Z w. 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 #: 50071 28/2 3 Date: 11/ .®._. -......_ee.. Permission is hereby granted to: Wells. James 96 Clay St Apt4A Brooklyn, NY 11222 To: Construct a rear deck addition to an existing single-family dwelling as applied for. At premises located at: 240 Cedar Dr S SCTM #473889 Sec/Block/Lot# 31.-3-11.19 Pursuant to application dated 1 1/2/2023 m and approved by the Building Inspector. To expire on .....5/29/2025.... ..._.. . Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $525.50 CO-ADDITION TO DWELLING $100.00 Total: $625.50 .�... .. .................. ��� _ . .. � ...... �_ 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) 765-9502 Iltt :/" rNVW.SOLII�hoidto rn l '.Gov Date Received APPLICATION „r For Office Use Only PERMIT NO., Building Inspector. �A Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an e�'° 3:na� °"�° '4- e Owner's Authorization form(Page 2)shall be completed. Date: CCU rD Z02— OWNER(S)OF PROPERTY: ) I Name: SCTM#1000- 3 �_ Project Addre r Phone#: 90�— L+ l — It 7 Cj Mailing Address: p�� CONTACT PERSON: Name: STV VW?l V-1 CC<J Mailing Address: 154c( M 01 iJ \CCL^ ; ✓C-'Z I+CLA ' t'J I Phone#: �S 2�6r� Email: Cfr TV@ aWtG�iC,. CLit^^ DESIGN PROFESSIONAL INFORMATION: C-PT ST U Name: Mailing Address: ZC G- I A-,CC.L "J le f UC72 ffe—A'/--'0 Phone#: C✓ �' 2 —2 Cl q 2 Email: C D i I-rOWA S G 3 V-)cL C CONTRACTOR INFORMATION: Name: A\/\,.s Mailing Address: \'�'4 0--� V\/\, 1 RCA 6 Phone#: 63/ --2- (; --lAL Email: CVlK S—kA)t 4f` CG✓` DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair PDemolition Estimated Cost of Project: leer 2 e P� oz IBC L $ 4— 0 Will the lot be re-graded? ❑Yes ER To--- Will excess fill be removed from premises? ❑Yes CQfyo. 1 PROPERTY INFORMATION Intended use of property: Existing use of property. � p p rty. 2 P� Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes C?W6-1-F YES, PROVIDE A COPY. ❑ Check Coy 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 inspector:on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.4S of the New York State Penal Law. Application Submitted By(print name): C—C„.10$ QAuthorized Agent ❑Owner Signature of Applicant: Date: 2G23 i STATE OF NEW YORK) SS: COUNTY OF Spa 4041�. ) A"8,Y b&L,uA6 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the +hv)r\' 4l ( tractor,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 lj! day of U 60LI ' 2013 NA�N� N uhl Erin Murphy-Apicello Notary Public State of New York 1410PERIFY OWNER At 1 11 '°'F1I01 County of Suffolk REG#01MU6090387 (Where the applicant is not the owner) Expires April 14,20 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 + DATE(MMIDDIYY �"�" ,O CERTIFICATE OF LIABILITY INSURANCE 1l16/2oz3 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 CONTACT AME: SPECIALIZED INSURANCE&SERVICES PHONE 631 756750 Faux ST�aS SRU SPECIALIZEDINSURAN4N ,d�s). 204 RTE. 112 E-MAIL CE COM PATCHOGUE,NY 11772 ADDR � ^ ......._.°� -- _ _ . . ... Auto-Home-Business-cycle-etc. INSURERIS)AFFORDING COVERAGE c _INSURER I# ATLANTIC CASUALTY INSURANCE CO� 42846 � INSURED INSURER 8 AMS HOME IMPROVEMENT LLC 1549 MAIN RD I INSURER YTT.-TER0 � D RIVERHEAD, INSURER E NY 11901 ..............__. .... : ...�.., ._.�,_..�...... _................. 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. w.............. _, __ ........ _... Ae— iLSR w AI bl'.5—u R POLdcy E'FF POLICY EXP LIMITS R TYPE OF INSURANCE POLICY NUMBER iMWD 1YYY'Y MM)DDfYYYY'. A ._ Y N 11/08/2022 11/08/2023 ACH OCCU RRENC 100,000 0 �4�t L266000944-D EF EMISES �®©cc�rrreez� $ 1,000,00„ CLAIMS-MADE ��" VIABILITY C .... _�, mmM D EOXP(Anyone person) $.. ._. OCCUR („ .__ 5 000 ....._,..�... .. ,... ,.a......... PERSONAL B ADV INJURY $ 1,000 OOO f ._E . $ 2 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGA! T POLICY JECO'q LOC PRODUCTS-COMPIOP AGG $ (QQ()QQ OTHER: $ AUTOMOBILE LIABILITY COMBINED$INCL6 LIMI r $ .,_ RIAdcntl.... ...... . ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED NON-OWNED _.....- AUTOS ONLY AUTOS PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (for aresdrn() $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED F I RETENTION$ $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY YIN UTF R EACH TT ANY PROPRIETOR/PARTNERIEXECUTIVE E,L, TACCIDENT $ OFFICERIMEMBER EXCLUDED? �...__..�.w .. (Mandatory In NH) L.DISEASE- 'EA EMPLOYE $ if yes, de L scribe under . ...m. DESCRIPTION OF OPERATIONS below .DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 54375 NY-25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD, NY 11971 AUTHORIZED REPRESENTATIVE ©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 Attestation of Exemption STATE 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 1549 Main Rd From: Southold building dept 54375 main road Southold NY 11971 Riverhead,NY 11901-6006 PHONE:631-779-3727 FEIN:XXXXX1541 The location of where work will be performed is 140 Maple Place,East Marion,NY 11939. Estimated dates,necessary to corn fete work associated with the building permit are lfom December 1,�023 to April 10,2024. The estimated dollar amount of project is $25,001-$50,000 Workers'Coln ensation 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 PajdFamily 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 paid family leave benefits coverage and also immediately fumish proof of that coverage on forms approved by the Chair of the Workers'Compensation Board to tl vernment entity listed above. SIGN_ ..., .. Signature:gnature: '"" �': -- . ate: �� 2��12 Exemption Certificate Number Received 2023-076064 October 241 2023 NVS Workers' Compen atiol,Boaird CF- 00 01/'018 AISMIS PROPERTY RENOVATIONS Tel 631-276-3334 www.amsrenovations.com Letter of Authorization To whom it may concern , I, Juv►.,es be-115 . 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 / ' /� JA►MeS h eA G✓ if Date 74/a 3