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HomeMy WebLinkAbout51360-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#: 51360 Date: 11/06/2024 Permission is hereby granted to: Anders Cap Group LLC 121 West View Dr Kalispell, MT 59901 To: legalize "as built"alterations to existing single-family dwelling as applied for. Additional certification may be required. Premises Located at: 535 Middleton Rd, Greenport, NY 11944 SCTM#40.-5-14 Pursuant to application dated 09/24/2024 and approved by the Building Inspector. To expire on 11/06/2026. Contractors: Required Inspections: Fees: As Built Alteration $500.00 CO Single Family Dwelling-Addition /Alteration $100.00 Total $600.00 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 ', +v ?: l�aatalw r�r APPLICATION FOR BUILDING PERMIT � �� � 60,0" ice Use onlyPERMIT NO. 3....�� _�. Building Inaga:�k'or� Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an ti t µ d 11a'fl' 11731C.01 Owners Authorization form(Page 2)shall be completed. Date W 1..� ..� ... OtdwriMiER{ 1OFP OPERTh": L L (,(T CE)Y,MVV\ hveSkV+�'r,,k Name SC i'M#1000 . _. . . . .. . . ...... _ .. ... . .�.......... ._.w_._� ... . ._.............. .. Project Address: S S /U\ e#: g S l 2 �.� Email: P aili mmg .—_.._._.--......... _w..ww _ J a Mn C e c .� W..._. .. . _ _ ..�..._......_ .....`. __1�_ w _ ........Address..._.._ .......W _ L(u�,r✓ �/`�U S V Q �- CONTACT PERSON: 75 Name: V (' M it-�c» C✓ www._.............,....._ ..._._.�...__._ ,. ._..(_"..�...wwww. ._._ ..._.._._...w..w___�._�..�...., ..��...�.�.._.. _www_,.._www._.�......M.w..,..._, Mailing Address. G u�1 Y,� r` ` a \ rnn L /V Phone# ...� S l '`�l. Email: yr� 1rT .L_ <(`{�`CS.... -` � DESIGN PROFESSIONAL INFORMATION: Name: M`� �rLe S (,P) Mailing Address: Se Y r1 Af Y If 760V Phone#� r Email:!"\ Cam✓�L�(G ri c� CONTRACTOR INFORMATION: Name:wwv__ ..5.. Mailing Address: i 1 /� NY ��S Phone#:C 3( I A (V(1 Email: a t 'fit DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition N14eration �Re air .._. w.._._ ..._� w� p emolition Estimated Cost of Project: []Other- �051M��...w.�__w..._,..... _ W_ _........._ ..._..� _. Will the lot be re-graded? E]Yes o Will excess fill be removed from premises? CIY s 7No ....w...._ µ... ._._......._.. .wwM__.w..,..... .—.�.........w...._... ..M.. ,......... ........ 1 �PROPERTY INFORMATION f:xisting use of property: ©�t � Iia intended use of proper[ 0 f'\C f" 17�e1�,h Zone or use district in which premises is sltuated: Are there any covenants and restrictions with respect to this property? Wes ONE) iP YES,PROVIDE A COPY, Checit floe After Rvading: The ownar(eantraetar(des[¢n proflm!andlts resporslbtu taralldralmp arr4itorm*riar12tuaswpr47A6d by chapltr 23S orlheTown CuJa_APPLls7i',IOp}ISH¢REbYlNd4E to ehc tlWldrrtt uapsrtma ntfa the lett+annroraBWld'ute irastnit pursu�nr ro U10 9u1lE:rK 2arte ordlnjn cr tho Town of seY9iold,Sufrok county,New Park and other appsmble lawe&ore i,—esOe pr3Watlow,for am con"malon ofID4M[RSs, ndditlons,arteratlani or for rkm meal or dematlon as herein dtwtr ed.The appHem alme to comply Yrlth Ailappllrahk Tam4 erdm0ce!,Wdln[ead., nousl"Coda Ar4(et uttlkm and to'44mit avihaeEtd lnipaeton on pranlfras and ioa a dint(s)rcr neceasary nspeeh¢rts FON statarnonb mado hareth we puni3habk as a t6leo A anRwdtMtAftw pu nor'rat tnktdon 2114s or the wow Yarle S'Wa Peril Lela_ i l Application Submitted By(print name): (JAuthorizedAgent 170wner Signature of Applicant: Date: STATE OF NEW YORK) COUNTY OF _ fipBng daffy svuown,deposes d says.that C,C) tl is apiaR ant (Name of individual sighing contract)above named, Whe is the - (Contractor,Agent,Cbrporate officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the slid 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 . Notary Public PROPERTY tTY ifs ER AUTHORIZATION (Where the applicant is not the owner) residing a: i. ipac U a 6t2 do hereby authorize to apply on my behalf to t own or Southold Building Department for approval as described herein. _ � 9 - 17 - ?aZy Ownet's5ignatur«e� _ Date Print owner's Name 2 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy,or validity of that document State of California County of Orange On _ ) fore me,Qa°in i l blic° personally"appeared who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, exectured the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. =GUERTINCO0 " Notaia eCom ,2lJ2fi Signal �" (Seal). Description of attached document: r V � Title of attached document: ko,WdAd' Document Date: Number of pages: AC RV CERTIFICATE OF LIABILITY INSURANCE DA09�M20224 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 CONT:ACT Ralph Fiumefreddo NA Admiral Insurance Brokerage Corp. PHONE xt^ (718)241.8500 � aeq f �N_ca1: (718)241-8520 6833 Shore Road D IL INSURER(S)AFFORDING COVERAGE NAIC# Brooklyn NY 11220 INSURER A: Western World Insurance Company 13196 INSURED INSURER B: Daylight Properties LLC INSURER C: C/O Justin Lapadula INSURER D: 73 Half Mlle Road INSURER E c Middle Island NY INSURER F: COVERAGES CERTIFICATE NUMBER: CL2491120081 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LTR TYPE OF INSURANCE POLICY NUMBER MM�D M/DD CYEFF LIMITS "X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ©OCCUR PROEM SE a ocarr0ence,) $ 50,000 MED EXP(Any one erson $ 10,000 A NPP6082188 04/06/2024 04/06/2025 PERSONAL 8ADVINJURY $ 1,000,000 GEN'L.AOGRFGATELIMIfAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 ❑PRO- 0 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECT Employee Benefits $ OTHER: AUTOMOBILE LIABILITY CONK� TJ INN LpMN $ Ea am�Ialoeat ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY D RO E TYD E $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN TATUTE.L__t ER ANY PROPRIETORIPARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $ OFF'IC:ERAMEMSER EXCLUDED? (Mandatory in NfI) E.L.DISEASE-EA EMPLOYEE $ If yea,doex6be wider DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD a Q THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 September 24, 2024 Town of Southold 54375 MAIN RD SOUTHOLD NY 11971-4646 Account Information: Contact Us Policy Holder Details : Daylight Properties LLC Need Help? Chat online or call us at (866)467-8730. We're here Monday-Friday. Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team a j�;No Workers' RK Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured DAYLIGHT PROPERTIES LLC (631)559-3142 73 HALF MILE RD MIDDLE ISLAND NY 11953 1c. NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1d. Federal Employer Identification Number of Insured or limited to certain locations in New York State,i.e. a Wrap-Up Policy) Social Security Number 87-2614972 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Accident and Indemnity Company Town of Southold 22357 54375 MAIN RD 3b. Policy Number of Entity Listed in Box"1a": SOUTHOLD NY 11971-4646 45 WEG BD7V5H 3c. Policy effective period: 02121/2024 to 02121/2025 3d.The Proprietor, Partners or Executive Officers are K 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 1 a" 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 Worker's 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: Sara Seier (print name of authorized representative or licensed agent of insurance carrier) '57a44_ `5�A 09/24/2024 Approved by: (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866)467-8730 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) Form WC 88 3121 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17) REVERSE www.wcb.ny.gov Form WC 88 31 21 F Printed in U.S.A. Page 2 of 2 (1) L. Lij U) z ui C) 0 <a E z 00 CD 0 Lu < Z E L) <2i M CL 06 W (h 01 > Z a 0 r- C. CD Cf) T) E CO 0 CL >1 :D ui 0 do(/) LIJ I.X 0 .3 ........................ c 0 jlrjvf C) 0 E 0 ��ggsz 5 pa/ to . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . ..........--/' 0.11#'..1 IFF ,