Loading...
HomeMy WebLinkAbout51488-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#: 51488 Date: 12/17/2024 Permission is hereby granted to: Iris Zvi 375 Clearview Ave W Southold, NY 11971 To: Install replacement windows in-kind to an existing single-family dwelling as applied for. Premises Located at: 375 Clearview Ave W, Southold, NY 11971 SCTM#70.-8-6 Pursuant to application dated 10/24/2024 and approved by the Building Inspector. To expire on 12/17/2026. Contractors: Required Inspections: Fees: Single Family Dwelling- Alteration $250.00 CO-RESIDENTIAL $100.00 Total $350.00 C/) 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 http ://w�ww.southoldtowtirlv,.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only p 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. 1 L TM c-,ry Date: /D OWNER(S)OF PR PERTY: Name�—T- l` � I SCTM # 1000- Project Address: 3 7 C ea r V" A v- Phone#: (�' Email: �1 /' 1 1 Mailing Address: 37 5 CIS ,� I�J� Shy CONTACT PERSON: Name; Mailing Address: 3 r e -- Phone#: rj)fo �� � Email: lh� t ir'YY1kS6)v w,'r DESIGN PROFESSIONAL INFORMATION: Name: <:Ss(�Qd�' Mailing Address: C �� y�ba1 � OD 6tt Phone#: Email: CONTRACT <KINFORMA`fI" Name: go Mailing Address:Cal q i4e.P ea3 _ Jp A 36133 Phone#: 3 03 9"16 O6�� Email: DESCRIPTION OF PROPOSED CONSTRUCTION Other ucture ❑Addition ❑V erat'onr epair ❑Demolition Estimated Cost of Project: Re— co Will the lot be re-graded? Dyes No' Will excess fill be removed from premises El No I cam. e 1 PROPERTY INFORMATION Existing use of property- Intended use of property: AD rn t0f./ Zone or use district in which premises is situated„ Are there any covenants a restrictions with respect to 11 this property? ❑Yes o 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 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 misdemeanorpursuant rsuant to Section 230.45 of the P e New York State Penal Law. Application Submitted By(pri Inarn An+ rnq u,!-�->k ®'Authorized Agent ❑Owner Signature of Applicant: �. �.�..�-�"' Date: STATE OF NEW YORK) SS: COUNTY OF 2de-A vii �(^� }{ J II I� s k h 1 being duly sworn, deposes and says that(s)he is the applicant (Name of individual igning contract) above named (S)he is the (Contrcto �irm orporate Officer, etc.) of said owner or owners, and is duly authorized to Isor 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 t� o1. —day of 0CT0jI- , 20- ary Public TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK PROPERTY ' AUTHORIZATION NO.01 DW6306900 Ot.IALIFIED IN SUFFOLK COUNTY (Where the applicant is not the Owner) COMAAfSSION EXPIRES JUNE W, 4 i, ( residing at AveWe6A5� do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Sig a ure Date ---� - v r I Print Owner's Name 2 fib DATE(MMIDDIYYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 02/12/2024 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 NA MARSH USA,LLC. TWO ALLIANCE CENTER PHONE - 3560 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 CrDRE . - INSURER(SLAFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW:22-25 INSURER A:Old Republic Insurance Co 24147 INSURED INSURER B:Indemnify Ins CO Qf NOrMMI AmerlCa 43575 THE HOME DEPOT,INC. �"""'�"'" HOME DEPOT U.S.A.,INC. INSURER C 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-07 REVISION NUMBER., 2 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.' INSR A (}L'' POLICY EFF POLICY E:X�P ... LTR TYPE OF INSURANCE POLICY NUMBER D YY M DDNy LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY316648 03/01/2022 03/01/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE o u OCCUR PREMISES Eaoc�curnce „� $ 1,000,000 X SIR:$1,000,000 MED EXP(Any one erson) $ EXCLUDED PERSONAL&ADV INJURY _ $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 2,000,000X POLICY❑JECT ❑LOC - OTHER: $ A AUTOM0e1LELIABILITY MWTB316649 03/01/022 03/01/2025 CO�MBINdEeDISBNGLELIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS -- HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY UHENTI X OCCUR MWZX 316647 03/01/2022 03/01/2025 EACH OCCURRENCE _ $.... 10,000,000 X CLAIMS-MADE AGGREGATE $ 10,000,000 QON$ $ B WORKERS COMPENSATION SCFC50670533(WI) /01I2025 X PER GTH- STATUTE ER AND EMPLOYERS'LIABILITY 5,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A S,000OOO (Mandatory in NH) E.L DISEASE-EA EMPLOYEE' $ If yes,describe under Continued on Additional Page 5,000,000 DESCRIPTION OF OPERATIONS below _7E.L.DISEASE-POLICY LIMIT $ T1 , _ ... - DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC Ra' ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,LLC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE '.EFFECTIVEDATE: ADDITIONAL REMARK THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabilit Insurance Workers Compensation Continued: Carver:Safety National Casualty Corporation Policy Number:LDS4068089(AL,AR,AZ,FL,ID,IA,IL,KS,KY,LA,MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA,WV,WY) Effective Date:03/01/2024 Expiration Date:03/01/2025 (EL)Limit:$5,000,000 Carrier.Safety National Casualty Corporation Policy Number:SP4068090(QSI)(CA,OR,WA) Effective Date:03/01/2024 Expiration Date:03/01/2025 (EL)Limit:$5,000,000 SIR:$5,000,000 Carrier.ACE American Insurance Company Policy Number:WCUC50670375(QSI) (GA,MI,NV,OH,UT) Effective Date:03/01/2024 Expiration Date:03/01/2025 (EL)Limit:$5,000,000 SIR:$5,000,000 SIR(GA):$750,000 (EL)(GA):$4,250,000 SIR(NV):$1,000,000 (EL)(NV):$4,000,000 Carrier:Indemnity Insurance Company of North America Policy Number:WLRC50670284 (AK,CO,CT,DC,DE,HI,IN,MA,MD,ME,MN,MT,NH,NJ,NY,PA,RI,VT) Effective Date:03/01/2024 Expiration Date:03/01/2025 (EL)Limit:$5,000,000 TX Employers XS Indemnity: Carder:Zurich American Insurance Company Policy Number:NSL1138319-01(TX) Effective Date:03/01/2024 Expiration Date:03/01/2025 (EL)Limit:$6,000,000 SIR:$5,000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,LLC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING G20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabilit Insurance —HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot U.S.A.Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC H.D.W.Holding Company,Inc. Askuity,Inc. Home Depot Management Company,LLC Home Depot Solutions,LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YNcr Workers' CERTIFICATE OF 'STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 770-433-8211 Home Depot USA, Inc. 2455 Paces Ferry Rd., C-20 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Atlanta, GA 30339 76011130 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 58-1853319 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Company of North America Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 WLR C50670284 3c.Policy effective period 03/01/2024 03/01/2025 to 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"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 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: Eric Ton n (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 3/1/24 (Signatue) (Date) Title: Vi e President Telephone Number of authorized representative or licensed agent of insurance carrier: 678-795-4338 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 YORK workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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 la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HOME DEPOT U.S.A.,INC. 678-384-2193 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically Number limited to certain locations in New York State,i.e., Wrap-Up Policy) 581853319 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD 53095 ROUTE 25 PO BOX 1179 3b. Policy Number of Entity Listed in Box 1a SOUTHOLD,NY 11971 LNY713657008 3c.Policy effective period 01-01-2024 to 12-31-2024 4.Policy provides the following benefits: ❑x A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5.Policy covers: ❑X 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 Signed 11-20-2023 B (signature of insurance carrier's authorized representative or NYS licensed insurance agent of that insurance carrier) Telephone Number 212 553-8074 Name and Title: ELIZABETH TELLO-ASSISTANT DIRECTOR STATUTORY'SERVICES 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 513 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 baneffts Insurance policies and NYS ficensed insurance 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) DB-1-20.1 (12-21) HOME IMPROVEMENT LICENSE Name IL RICHARD TOUSEY This certffles that the Business-Name "earer is duly licensed HOME DEPOT USA INC(14 SUPPS) 'y the County of suffolk License Number:H-53429 Rosalie Drago Issued: 05/15/2014 Commissioner Expires: 11101/2024 This license is the property of Suffolk County Department of Labor,Licensing&Consumer Affairs. Possession of this license does not guarantee its validity. Additional Business Name License Categbry H1-GC