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HomeMy WebLinkAbout51452-Z a , 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#: 51452 Date: 12/06/2024 Permission is hereby granted to: Scaglione KA Rev Trt 195 Railroad St Bayport, NY 11705 To: install window replacements to existing single-family dwelling as applied for. Premises Located at: 1155 Main St, Greenport, NY 11944 SCTM# 34.-1-9 Pursuant to application dated 10/15/2024 and approved by the Building Inspector. To expire on 12/06/2026. Contractors: Required Inspections: Fees: Single Family Dwelling- Alteration $250.00 CO-RESIDENTIAL $100.00 Total S350.00 Building Inspector ,40,, V 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 litt s,//www.soutl oldtowii.i v Date Received APPLICATION FOR BUILDING PERMIT r0 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 okra "d Owner's Authorization form(Page 2)shall be completed. Date: 9/30/24 OWNER(S)OF PROPERTY: n Name: Kim Stahl 0q.00c7 Project Address: 1155 Main St 10co,C)m 'OD 01 0 o-c" d 0 ".0Ov Phone#: 516-819-2730 Email: Kstahi15@aol.com Mailing Address: 195 Railroad St Bayport NY 11705 CONTACT PERSON: Name: Kim Stahl Mailing Address: 195 Railroad St Bayport NY 11705 Phone#:516-819-2730 Email: Kstahl15@aol.com DESIGN PROFESSIONAL INFORMATION: Name: N/ A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Renewal By Andersen Li / LiCC Mailing Address: 2029 New Highway Farmingdale NY 11735 Phone#: 631-843-1713 x 2255 Email: Cvalente @rba long island.corn DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition W Alteration IR Repair ❑Demolition Estimated Cast of Pr j ct: ❑Other $_.a-.® � Rai Will the lot be re-graded? ❑Yes @*No Will excess fill be removed from premises? ❑Yes WNo 1 N 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 this property? ❑Yes iiNo 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 210.45 of the New York State Penal Law. Application Submitted By(print name): Kim Stahl ❑Authorized Agent ®Owner Signature of Applicant: Date: STATE OF NEW YORK) S. COUNTY OF � � �C) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (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 October 20 24 Notary Public (Where the applicant is not the owneCNOTARY j1,T"o Y�a�aa 4 :idYl»Y'7 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 ma iauotsSIUELu(r,) NOW= =Pjr CNV ISI veaMl O JNO I 30 NHSdaCNV AH'Ih'MaNII2I SUMN snutaftsff �s� ossau� n uu gi BUIPS PUB SMOPUMSUMN i PP 0n IN3VaWWWI o nS o Juno J zip u `2IO OVUIROD ,LXMNaA0-d&'ql �]WOH r`se ssoutsnq lonpuoo oq pasuo3ii /,gwoq s! xzoA maNjo mS `3uojjnS j.o Alunoo atpjo suoi niaaa pm } sains 'stAq ajgnotiddvjo suoisTnoJd auk ol joafgns pue tgym aouupa000n u tpoj has sjuauxazmbaz ate paustum3 3uinnq VRG 3 I SMOGNaA NOZSRD CIKV ISI OAIOrl se ssouisnq Buiop SXD(IIXNHOf IaR Aiwoo of s< snU f asUa3z7 J013VJIu :) I UaUolaAoljulj,awoTj AJNIIOD VIOAAAS H-166£b 'ON soovoi/I :Q'3f1SSI alva 88LII XUOA AkkaM `HJ11VddnVH * AVtkMILI 'I MOWZK SMWalaA sjzbf'V iausnsuoD V .Suisuaal7 c joab7 fo juau j tvJaa djunoD :VlofnS Client#: 1721414 LONGICUS ACORD. CERTIFICATE OF LIABILITY INSURANCE 5/13 DATE(M/2024 M/DDNM/DD/YYYI� 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 A..DDITIO.NAL 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER N T DJ Hardisty USI Insurance Services LLC PH, NE 914 459-6200 610 537-4220 ANC No,E)d: NC N„, .s. 333 Westchester Ave,Suite 102 E-MAIL DJ.Hdist usi.com White Plains,NY 10604 ADDREa3S. ar y� INSURERS AFFORDING COVERAGE NAIC# 914 459-6200 Selective Insurance Company of New York 13730 INSURER A: P Y INSURED INSURER B Long Island Custom Windows LLC ___. ........................ ..._........._................ h_,,. INR""'C "'""� "....._..°°' """'""""""""DBA Renewal by Andersen of Long Island SURE� INSURER D _... ......... 2029 New Highway ................. .m __...... INSURER E Farmingdale, NY 11735 _........... 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 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. INSLTR TYPE OF INSURANCE.. ....... ADDL SUS POLICY EFF PO ............... ... M m........-. I.ICY EXP LIMITS ...^^^ ^^ ..m.— POLICY NUMBER LMMdDD MMIfSDN^rYY" , INSR _m_ ADD."0, w.... .............t 66_ . ,. ..m.�...-.-................ , A X COMMERCIAL GENERAL LIABILITY OCCURRENCE_ $1 OOOOOO .... S200162113 5/01/2024 05/01/202 F�cH CLAIMS-MADE X�.OCCUR PREM)SES,(„Ea)ac corrence $50O 000 MED EXP(Any one person) $15 000 ......_.. ....... PERSONAL 8 ADV INJURY $1,000 OOO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO PRODUCTS-COMP/OP AGG s3,000,000 ...I OTHER:❑JP LOC $ w_ ....... ......... . .................... ...... _._. AUTOMOBILE LIABILITY k COMBNNED SIGN�GLE.LIMIT A S200162113 5/01/20,24 05/01/202 raao rd rr2k... 1,0001000 X ANY AUTO DILY INJURY(Per person) $ � BO..................... ....._. BODILY INJURY(Per accident) $ OWNED SCHEDULED ......AUTOS ONLY AUTOS X..HIRED X NON-OWNED PPRO�PEcRT tDAMAGE $ AUTOS ONLY AUTOS ONLY __------._ $ A X UMBRELLA LIAB X OCCUR S200162113 5/01/2024 05101/2025 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS-MADE I,AGGREGATE $5 OOO OOO DED.._B X1 RETENTION$10000 �._._. ... . XWW-- -AND EMPLOYE-__... WORKERS COMPENSATION PER TH- ERS'LIABILITY Y/N _..... T.AT.U�.,........ �.. .,.._...._......_...-.... ANY PROPOFFICER/MEMBER EXCLUDED? N/A H ACCIDENT $RIETOR/PARTNER/EXECUTIVE(Mandatory in NH) ,E,LmmDISEASE-EA EMPLOYEE $ _._ -----_ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd PO BOX 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 LU& ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S44755512/M44564364 AEBZP vRK !workers' CERTIFICATE OF INSURANCE COVERAGE s'rArr Compensation 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 carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LONG ISLAND CUSTOM WINDOWS,LLC DBA RENEWAL BY ANDERSEN OF L DBA RENEWAL BY ANDERSEN OF LONG ISLAND 2029 NEW HIGHWAY 1c.Federal Employer Identification Number of Insured or Social Security FARMINGDALE,NY 11735 Number Work Location of Insured(Only required if coverage is speolfically+ 364619760 limited to certain locations In New York State,i.e., Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD BUILDING DEPT HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 54375 MAIN RD PO BOX 1179 3b.Policy Number of Entity Listed in Box 1a SOUTHOLD,NY 11971 LNY623001001 3c.Policy effective period 04-01-2024 to 03-31-2025 4.Policy provides the following benefits: Q A.Both disability and Pend Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5.Policy covers: 0 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 name insured has NYS Disability and/or Paid Family Leave benefits insurance coverage as described above. Date Si nedd 04-04-2024 By, F /eGCT (sigrrartur of Nrtuuransrt garter a autlrrwrtxed rspraseartativa rrr NYS Itcerraatl tnaurarlaa agarlt df drat lrrauuarttrx� rttaa) Tale honraNtrmber 212 553.8074 Name and Title» ELi2ABETHTELLtD-ASSISTANTDIRECTOR SfiATUTt�RYSER4l10ES 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 46,4C or 5B have been checked) State of New York Workers' Compensation Board LSigned nformation maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. By (Signature of Authorized NYS Workers'compensation Board Employee) er Name and Title Please Note:only Insuranca carriers ite NYS dislib itity end Laid Family Leave benefits irasrrance policies and NYS licensed irasuranoe agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 11111tilli �. it�:- _ 1111 YIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 364619760 US[INSURANCE SERVICES LLC ' 333 WESTCHESTER AVE SUITE 102 WHITE PLAINS NY 10604 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND CUSTOM WINDOWS LLC DBA TOWN OF SOUTHHOLD BUILDING RENEWAL BY ANDERSEN OF LONG ISLAND DEPT 54375 MAIN RD 2029 NEW HIGHWAY PO BOX 1179 FARMINGDALE NY 11735 SOUTHHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2403 991-9 671822 12/01/2023 TO 12/01/2024 4/9/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2403 991-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STT ' SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:739997371 U-26.3