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HomeMy WebLinkAbout51235-Z 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#: 51235 Date: 10/03/2024 Permission is hereby granted to: FI Lookout LLC 238 Curwen Rd Rosemont, PA 19010 To: alter unfinished attic to living space (to include new dormer addition) to existing single- family dwelling as applied for. Premises Located at: 1153 Treasure Pond Rd, Fishers Island, NY 06390 SCTM#8.-2-3.2 Pursuant to application dated 07/19/2024 and approved by the Building Inspector. To expire on 10/04/2026. Contractors: Required Inspections: Fees: Single Family Dwelling- Addition&Alteration $495.00 CO-RESIDENTIAL $100.00 Total S595.00 Building Inspector 44 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 hi s://'ww �&r. o titli oldto liii ,p Date Recelved BUILDINGAPPLICATION FOR I For Office Use Only PERMIT NO. Building Inspector: 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: June 17, 2024 OWNER(S)OF PROPERTY: Name: Carol Bradbeer SCTM#1000-008000200003002 Project Address: 1153 Treasure Pond Rd. Phone#: 610-316-3997 1Email:boymom4@verizon.net MailingAddress: 414 Old Lancaster Rd. Apt. 401 Haverford, PA. 19041 CONTACT PERSON: Name: Mailing Address: Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: HP Broom Housewri ht Mailing Address: P.O. Box 70, 162 Fer Rd. Hadlyme, CT. 06439 Phone# '��i Email: 'ulie@h broom.cm DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition RAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $_ Will the lot be re-graded? ❑Yes 1@No Will excess fill be removed from premises? ❑Yes ONO i PROPERTY INFORMATION Existing use of property: residential Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes NNo IF YES, PROVIDE A COPY. ❑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 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 210AS of the New York State Penal Law. Application Submitted B {., pp y(print name): Ik ��� ` � NAuthorized Agent ❑Owner M. .. Signature of Applicant: """�" Date: June 17, 2024 STATE OF . 9K)Ct1rNTNXVt.Gtw* SS: 616 Ly 14� COUNTY OF SWAW4 William A. Bartlett being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)heisthe Contractor- HP Broom Housewright (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 20 9 Notary Pu RYN S Lam. NOTARY Pusuc State of Connecticut T_ ER AUTHORIZATIONy Commission Expires (Where the applicant is not the owner) September 30r 2024 ,, Carol Bradbeer residing at 1153 Treasure Pond Rd. do hereby authorize William A. Bartlett to apply on my behalf to the Town of Southold Building Department for approval as described herein. 6/18/2024 Owner"s� g Signature Date Carol Bradbeer Print Owners Name 2 DATE(MMIDDNYYY) ACOPR& CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE FICATE HOLDER.THl CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AF 0 BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING RER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i , P1 IMPORTANT. If the certificate holder is an ADDITIONAL INERED,the poliby(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 endorsement(s). PRODUCER CONTACTAnn Archer NAMV6 AssuredPartners Northeast LLC DBAThompson and Peck PHONE (203)389-2156 t N,c (475)234-6921 C Na,�r+fl s 1412 Whalley Ave. ADrtiR aarcher@thompsonandpeck.com ESSa INSURER(S)AFFORDING COVERAGE NAIC M New Haven CT 06515 INSURERA: Republic Franklin Insurance Cc 12475 INSURED INSURERS: Admiral Insurance Company 24856 H P Broom Housewright Inc INSURER C: Utica Mutual Insurance Co 25976 162 Ferry Road INSURER D: Hartford Fire Insurance Company 19682 P O BOX 70 INSURER E: Hadlyme CT 06439-0070 INSURER F. COVERAGES CERTIFICATE NUMBER; CL2461789708 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. _r L F LIMITS LTIR TYPE OF INSURANCE p POLICY NUMBER MM/DDIY ID MMD/YYYY X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR PREMISES'Eso rmnse $ 100,000 MED EXP(Any one person) g 5,000 A 4559787 06/16/2024 06/16/2025 PERSONAL&ADV INJURY $ 1.0001000 G,EII'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 r^w POLICY JECT ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED'SINGLEELI'.MIT $ 1,000,000 Ea aces r'X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 4546432 06/16/2024 06/16/2025 BODILY INJURY(Per accident) $�� AUTOS ONLY HIRED 'NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB BEX0960158009 06/16/2024 06/16/2025 AGGREGATE $ 5,000,000 CLAIMS-MADE DED RETENTION$ $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY YIN 500,000 ANY PROPRIETORIPARTNEfKXECUTI'IVE E.L..EACH ACCIDENT $ C OFFICERRMEMB'ER EXCLUDED N NIA 4444698 06/16/2024 06/16/2025 I Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 III yes,desr�rao radar 50()000 DESCRI"MON OF OPERATIONS,below E,L DISEASE-POLICY LIMIT S ' NY Disability&Paid Family Leave Act D Coverage DBL5520995 05/10/2024 05/10/2025 Statutory Coverage DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Project site:Residence of Carol Bradbeer, 1153 Treasure Pond Rd,Fishers Island,NY 06390. 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,Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 AUTHORIZED REPRESENTATIVE PO Box 1179 _1 _ Southold NY 11971 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD (MMIDDIYY ACOO CERTIFICATE OF LIABILITY INSURANCE � 6/2012024 Y) osr2olzoza 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 pollcy(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 endorsement(s). PRODUCER CONT Ann Archer AssuredPartners Northeast LLC DBA Thompson and Peck w11CNE E (203)389-2156 Noll (475)234°6921 1412 WhalleyAve. A earcher@thompsonandpeck.com INSURER[ AFFOAIDING COVERAGE NAIC q New Haven CT 08515 INSURERA: Republic Franklin Insurance Co 12475 INSURED INSURERB: Admiral Insurance Company 24856 H P Broom HDusewright Inc INSURER C: Utica Mutual Insurance Co 25976 162 Ferry Road INSURER D: Hartford Fire Insurance Company 19682 P O BOX 70 INSURER E: Hadlyme CT 06439-0070 1NSU ERF COVERAGES CERTIFICATE NUMBER' CL2461789708 REVISION NUMBER: THIS IS TO CERTIFYTHATTHE 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. I LTR TYPE OF INSURANCE POLICY NUMBER 'MMf0DIYY MMIDDIYYYY. LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE �OCCUR FRg EXP(Any one perm $ 5,000000 YED A 7 4559787 06/18/2024 06/16/2025 IPERSDNAL&ADVINJURY s 1,00%00D GENLA4GOREGAATE LIMIT APPLIES PEW GENERALAGGREGATE S 2,000,000 _PRODUCTS S 2,000,000 POLICY OTHER: S AUTOMOBILE LIABILITY 0 t I S 1,000,000 a a wen ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED 4546432 08/16/2024 06l16/2025 BODILY INJURY{Per acadenq S� AUTOS ONLY AUTOS Y S HIRED NON-OWNED PROP R DA AGE AUTOS ONLY AUTOS ONLY accklann S UMBRELLA LIAB OCCUR EACH OCCURRENCE S 5,000,000 B X EXCESS LIAB CLAIMS-MADE BF-XO960158009 06/16/2024 06/16/2025 AGGREGATE s 5,000,000 DEC) RETENTICN S S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE R YIN ANY PROPRIETORIPARTNEWEXECUTIVE E.L EACH ACCIDENT S 500,000 C OFPICERIMEMBEREXCLUDED N/A 4444698 O6/16/2024 06/16l2025 500000 .�.- tManllatmy in NH) E L,DISEASE-EA EMPLOYEE S If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E L,DISEASE-POLICY LIMIT $ NY Disability 8 Paid Family Leave Act D Coverage DBL5520995 05/10/2024 05/10/2025 Statutory Coverage DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Project site:Residence of Carol Bradbeer,1153 Treasure Pond Rd,Fishers Island,NY 06390, 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,Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 AUTHORIZED REPRESENTATIVE PO Box 1179 Southold NY 11971 01988.2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD V RECEIPT C pY k SUFFOLK COUNTY GOVERNMENT DEPARTMENT OF LABOR, LICENSING, AND CONSUMER AFFAIRS 11agg at ACTING COMMISSIONER JENNIFER CABRERA P.O. BOX 6100, HAUPPAUGE, NY 11788 (631) 853-4600 Today Date: 10/26/2023 Application: H-1 3061-REN02 , License #: H-13061 Application Type: Home Improvement License Renewal Fee Allocation: Fee Item Description Fee Amount Amount Paid Amount Paid Total Balance Due License Renewal $400.00 $400.00 $400.00 $0.00 .Total. * . __--------_.,...... ....�_._.. ..... _....... .._ .__. $400.00 $400 00 $400.00 $0 00 Receipt No. 514129 Payment Method Ref, Number Amount Paid Payment Date Cashier ID Comments Check 25253 $400.00 10/26/2023 LSALVAG Total: .... ...... . . . ....,...__... . -_....$400......._..---- ---------- ... .. . ....... .......------ - ....,... ..... .. 00 Contact Info: HP BROOM HOUSEWRIGHT INC HARRY P BROOM PO BOX 70 162 FERRY RD HADLYME, CT 06439 Work Description: Suffolk County Dept. of Labor, Licensing&Consumer Affairs ` HOME IMPROVEMENT LICENSE Name �a.., HARRY P BROOP,I Business Name This certifies that tie HP BROOM HOUSf-WHIGH i INC hearer is duly licensed License Number H-13061 ty to cot,my of Suffolk Issued: 1 1'01•1986 � . 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