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HomeMy WebLinkAbout51308-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#: 51308 Date: 10/23/2024 Permission is hereby granted to: John A Ardito 122 Wilson St Garden City, NY 11530 To: legalize "as built" HVACcondensers and new windowsto existing single-family dwelling as applied for. Premises Located at: 480 Grissom Ln, Southold, NY 11971 SCTM# 78.4-10.3 Pursuant to application dated 09/06/2024 and approved by the Building Inspector, To expire on 10/23/2026. Contractors: Required Inspections: Fees: As Built Addition/Alteration $500.00 ELECTRIC -Residential $200.00 CO Single Family Dwelling-Addition /Alteration $100.00 Total $800.00 Building Inspector �� a -4 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) 765-9502s:� www.sottltt )dltwtsa Date Received APPLICATION FOR BUILDING PERMIT E P 4 E For Office Use Only 01 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 taa Soot eta Town Owner's Authorization form(Page 2)shall be completed. 1"ovenf Southold Date: 9.5.2024 OWNER(S)OF PROPERTY: Name: John A. Ardito SCTM # 1000-78.-1 —1 0.3 Project Address: 480 Grissom Lane, SOUTHOLD, NY 11971 Phone#: 51 6.31 7.3923 lEmail:johnardito@arditolaw.com Mailing Address: 122 Wilson St. , Garden City, NY 11530 CONTACT PERSON: Name: Same as Owner Mailing Address: Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name. N/A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: WithPride Air Conditionin & Heatin Inc, Mailing Address: Phone#: 51 6.731 .2573 Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ®Other New windows and HVAC condensors $ 7,500.00 Will the lot be re-graded? ❑Yes 11No Will excess fill be removed from premises? ❑Yes KINo 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 Residential this property? ❑Yes NNo IF YES, PROVIDE A COPY. M 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 TownCode. APPLICATION 15 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 By(print name): John A. Ardito ❑Authorized Agent ®Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTYOF John A. Ardito being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, ( ) Owner S he is the (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��-o .,1a �L- 202'4 r, C)NotAy Public JOSEPH URSO Notar Public, State of New York F) F)E T OWNER 'Tl,,,,� RV T1 0. 02UR6050061 (Where the applicant is not the ow000plified in Nassau County Commission Expires October 30, 20z. 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 F A'C DATE(MM/DDIYYYY) A410"R" CERTIFICATE OF LIABILITY INSURANCE 05/07/2024 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 oN ArT Tracy Anziano HAM AssuredPartners Northeast,LLC. PHONE 1 (631)465-4000 No INC 100 Baylis Road ADDRESS: tracy.anziano@assuredpartners.com Suite 300 INSURER(S)AFFORDING COVERAGE NAIC p Melville NY 11747 INSURERA: Merchants Mutual Insurance Company 23329 INSURED INSURER B: Transverse Specialty Insurance Company 41807 With Pride Air Conditioning&Heating Inc INSURER C: ShelterPoint Life Insurance 81434N INSURER D: 77 Marine Street INSURER E: Farmingdale NY 11735-5604 INSURER F e COVERAGES CERTIFICATE NUMBER: CL244124706 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 CONTRACTOR 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 ADULIbUt5K POLICY EFF POLICY EXPLIMITS LTR TYPE OF INSURANCE IN POLICY NUMBER MM/DD/YYYY MMIDDlYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,400 CLAIMS-MADE �OCCUR PREMISES(Ea occurrence) ._$ 100,000 Contractual Liab MED EXP(Any one person $ 10.000 A CMP9155979 04/04/2024 04/04/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY h PRI �LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHERt $ AUTOMOBILE LIABILITY COMBINED SINGLE..LIMIT $ Ea ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED P 0DAMAGE $ AUTOS ONLY AUTOS ONLY 'Par accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS UU�AB CLAIMS-MADE TSCEEX000194-00 04/04/2024 04/04/2025 AGGREGATE $ 5,000,000 DED a+"w RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN 7ATUTE ER. ANY PROPRIETOR/PARTNER/EXECUTIVE r NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Statutory NYS Disability C [TD427069 11/21I2023 11/21/2024 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The following are included as additional insureds if required by written contract,subject to the terms and conditions of stated policies:Suffolk County Department of Labor,Licensing&Consumer Affairs,P.O Box 6100,Hauppauge,NY 11788-0099. General Liability and Umbrella Liability apply on a primary and non-contributory basis with a Waiver of subrogation in favor of the Additional Insureds. Duct work&HVAC Unit Installation and service CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Suffolk County Department of Labor,Licensing ACCORDANCE WITH THE POLICY PROVISIONS. &Consumer Affairs P.O BOX 6100 AUTHORIZED REPRESENTATIVE Hauppauge NY 11788-0099 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NEW Workers' CERTIFICATE OF INSURANCE COVERAGE w arCompensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that Carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured WITH PRIDE AIR CONDITIONING&HEATING INC. 516-731-2573 ATTN: MICHAEL DOLAN 77 MARINE STREET FARMINGDALE,NY 11735 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 461358965 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Suffolk County Department of Labor, Licensing &Consumer Affairs 3b.Policy Number of Entity Listed in Box"I a" P.O Box 6100 DBL427061 Hauppauge, NY 11788-0099 3c.Policy effective period 11/21/2023 to 11/20/2024 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits.. B.Disability benefits only. C.Paid family leave benefits only.. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: 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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. r Date Signed 5/7/2024 By �" (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit,PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4B,4C or 5B have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issueII this form. II p p DB-120.1 (12-21) 111 Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name MICHAEL DOLAN Business Name WITH PRIDE AIR CONDITIONING& 'Ths art fires thAt the HEATING INC bearer is ddy We nsed by:he C 6nly cl suffolk License Number HI-60153 �nlay►,aw 1 ,"eep Issued: 08 OW018 Commissioner Expires; 08l01i2026 M1 U a Suffolk County Dept.of Labor,Licensing&Consumer Affairs RESTRICTED PLUMBING Name MICHAEL DOLAN Business Name This certllles that the With Pride Air Conditioning&Heating Inc bearer is duly licensed License Number RP-60154 by she Couinty of setrolNs Issued: 08/08/201 B t T. 4,1 Expires: 08/0112026 Commissioner t 0 a This license is the property of Suffolk County Department of Labor,Licensing S Consumer Affairs. Possession of this license does not guarantee its validity. Additional Business Name r License Category RP1—HVAC YNEW Workers' CERTIFICATE OF SPATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a_Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured With Pride Air Conditioning and Heating Inc 516-731-2573 77 Marine St 1c.NYS Unemployment Insurance Employer Registration Number of Farmingdale, NY 11735 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 461358965 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company, Inc. Suffolk County Department of Labor, Licensing 3b.Policy Number of Entity Listed in Box"'Ia" &Consumer Affairs WWC3698547 P.O Box 6100 Hauppauge, NY 11788-0099 3c.Policy effective period 2/10/2024 to 2/10/2025 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"Ila"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". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. 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: Owen F Callaghan (Print name of authorized representative or licensed agent of insurance carrier) �6 „R� 05/07/2024 Approved by: (Signature) (Date) EVP Title: Telephone Number of authorized representative or licensed agent of insurance carrier: (781)455-6664 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov