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Home My WebLink About50870-Z Eernt � TOWN OF SOUTHOLD BUILDING DEPARTMENT �� py 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 #: 50870 Date: 6/26/2024 Permission is hereby granted to: Roeser ,, Douglas 50025 Main Rd Southold NY 11971 To: construct interior alterations to existing single-family dwelling as applied for. At premises located at: 50025 Route 25, Southold SCTM # 473889 Sec/Block/Lot# 70.-5-1 Pursuant to application dated 5/7/2024 and approved by the Building Inspector. To expire on 12/26/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00 CO-ALTERATION TO DWELLING $100.00 Total: $350.00 Building Inspector TOWN OF SOUTHOILD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 � Telephone(631) 765-1802 Fax (631) 765-9502 h p. Hwww o thnldtow-ni v. ov Date Received " BUILDINGAPPLICATION FOR y or Office Use Only . . r " PERMIT NO. 5606Building Inspector: Y Applications and forms must be filled out in their entirety. Incomplete ; `''° , r r applications P lira ions will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 6111 �A OWNER(S)OF PROPERTY: Name: e SCTM#1000- Project Address: :°" N�►`oti o gay , , " �( . Phone#: Email; A Mailing Address: 4 .;I, VA O,,, o s, (—A CONTACT PERSON: Name: ,.. " r " Mailing Address. a ° Ik p c m Phone#: � � � � p ��- Email: 4, 4AV •� � esri h> (' DESIGN PROFESSIONAL INFORMATION: Name: ------ . Mailing Address:',-- Phone#: '�"'"� Email: ■� CONTRACTOR INFORMATION: Name: . C Mailing Address: Phone#: 6..St � 47 Email: "user- � a �-) rl'F 1 . e 004 DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition (916teration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $ , Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? ❑Yes ❑No 1 t I., 41 PR INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covena s and restrictions with respect to this property ❑Yes o IF YES, PROVIDE A COPY. GKIleck Box After Reading: The owner/contractor/deslgn 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. Application Submitted B (print name): `,, ` []Authorized Agent Owner Signature of Applicant: STATE OF NEW YORK) Notary Public,State of New York SS: No.01 BU6185060 COUNTY OF Qualified In Suffolk County j Commission Expires April 14,2 OD 2 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the �•�-� iI'll - (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 therew'. Sworn before me this day of 20 �66 1, Notary Public PROPERTY OWNER AUjIl-ORIZATION (Where the applicant is not the owner) residing at do hereby authorize to apply on m behalf to the Town of Southold Buildin Department for approval as described herein. Y g p Pp . I Owner's Signature Date r Print Owner's Name 2 CERTIFICATE OF LIABILITY INSURANCE DATES° MD 04/20/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. Tift 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 ri hts to the certificate holder in lieu of such endorsements. PRODUCER NB ,:, Enc Kirk Kirk Associates LTD �° �p 631 727-7767 Ne a 631 727 7941 ....... 18 First Street p�I irk. ssoCBvcamefiCan-national fxm ISJAFFORDINGCOVERAt3E _,_„_,,,,,,, NAICX INSURER, O Riverhead w_NYwwww11w901 mmmmmmmm_IT INSURl7t A: Farm Family Casualty Insurance Company ......_ 13803 INSURED _INSURER B North Fork Home Maintenance Inc INSURERC: �.....,.,... .... ............... Po Box33 INSURERD: INSURER E: Mattituck NY 11952 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. ILTR TYPE OF INSURANCE POLICY NUMBER �...._....-- NSR �� ODLSUBR POLICYEFF POLICYEXI' LIMITS MMERCIAL GENERAL LIABILITY X X 31031-7975 06/29/2023 06/29/2024 EACH OCCURRENCE $ 1,000,000 DAw,1Ad c i i FBI a CLAIMS MADE OCCUR PR m $ 100 000 R CONTRACTUAL LIABILITY MEDEXPAnvoneperson $ 5,000 PERSONAL&ADV INJURY $ 11,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 m POLGCYJECT LOC PRODUCTS COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SNGLE UMIT $ mm ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED IN .r accident) AUTOS ONLY AUTOS (Per accident) $ mm.mm HIRED NON-OWNED PROPERTY DAMA mmmmmmm BODILY AUTOS ONLY AUTOS ONLY i er -nl $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ...... ...... EXCESS LLAB CLAIMS-MADE AGGREGATE $ DED RETENTION � $ WORKERS COMPENSATION OTH- L.AND EMPLOYERS'LUIBILITY YINANYPROPRIE-rOTATlTE„„ , _ ER 6 OFFICER/M EMBER EXCLUDE[ H AC----- mmmm $ NIA (Mandatory In NHR)/PARTNER/EXECUTIVE EL SC SE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION Suffolk County Department Of Labor, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Licensing & Consumer Affairs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Po Box 6100 ACCORDANCE WITH THE POLICY PROVISIONS. Hauppauge, NY 11788 AUTHORIZED REPRESENTATIVE Kirk Associates Ltd 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD F A �7c" '� Scope Of Work: Roeser Residence 50025 Main Road Southold, NY 11971 Den&TV Room: -Remove ceiling tiles,trim, exterior wall(interior side)sheetrock, interior wall panels and sheetrock in TV Room. -New electrical wiring to new recessed lighting. New electrical wiring brought to outlet and switch locations(where necessary)to be code compliant. -Electrical Inspection. -Air sealing,fire caulking, and batt insulation installed (peF eneFgy tab where alteration has occurred. -Insulation Inspection. -Drywall Installation. -New trim and paint. Total Square Footage is approximately 450 Square Feet. F ►. OLD rn` s� . M , r t i i j f II f I t ----------- 4-1 7-1 if -L-A