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HomeMy WebLinkAbout51507-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 40 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#: 51507 Date: 12/27/2024 Permission is hereby granted to: Victoria Emily G Trust 29925 Main Rd Cutchogue, NY 11935 To: Legalize "as built"second story bathroom alterations and door replacements as applied for.. Additional certification may be required. Premises Located at: 29925 Route 25, Cutchogue, NY 11935 SCTM# 102.-2-15 Pursuant to application dated 09/30/2024 and approved by the Building Inspector. To expire on 12/27/2026. Contractors: Required Inspections: Fees: As Built Addition/Alteration $564.00 CO Single Family Dwelling-Addition /Alteration $100.00 Total $664.00 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 hlWs://www.soutlioldto;manj.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only 6, M PERMIT NO. 5 ,50 1 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,an1� ,, Owner's Authorization form(Page 2)shall be completed. � " ' t° • Date: September 27, 2024 OWNER(S)OF PROPERTY: Name: Emily Victoria ISCTM::#:1000-473889-102.-2-15 Project Address: 29925 Main Road Cutchogue, NY 11935 Phone#: 631-734-7643 Email: N/A Mailing Address: 29925 Main Road Cutchogue, NY 11935 CONTACT PERSON: Name: Emily Victoria Mailing Address: 29925 Main Road. Cutchogue, NY 11935 Phone#: 631-734-7643 Email: N/A DESIGN PROFESSIONAL INFORMATION: Name: N/A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Leeco Carpentry LLC Mailing Address: 205 Horton Ave Riverhead, NY 11901 Phone#: 631-278-1740 Email: brigidocarpenter@gmail.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other Remodel of second floor bathroom 30,000.00 Will the lot be re-graded? ❑Yes 19No Will excess fill be removed from premises? ❑Yes ®No 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 @No 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. Emily �cto t«ia Application Submitted By(prin me). ❑Authorized Agent @Owner Signature of Applicant: b'� Date: , Z r �_0� STATE OF NEWYOR�K) COUNTY OF w f$ Emily Victoria 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 ` 94 dayof � , �° � 20�17' Notary Public JOHN A. MAKI Notary Public-State of New York No.01MA6164838 PROPERTY OWNER AUTHORIZATION Qualified in Suffolk County (Where the applicant is not the owner) My Commission Exp,04/30/202.7 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 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE "A A A A 364860041 RIVERHEAD LIGHTHOUSE INC GN 221 WEST MAIN ST RIVERHEAD NY 11901 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LEECO CARPENTRY, LLC TOWN OF SOUTHOLD BUILDING DEPT 205 HORTON AVE TOWN HALL ANNEX RIVERHEAD NY 11901 54375 MAIN ROAD(PO BOX 1179) SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12556176-2 259920 09/23/2024 TO 09/23/2025 9/26/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2556176-2, 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 POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. FDr� SE J241 hm m, m NEW YORK ST T CI F FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:529556099 11 Workers' CERTIFICATE OF INSURANCE COVERAGE Z_1150_ iCompensation Ioar+d DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured LEECO CARPENTRY,LLC (631)278-1740 205 HORTON AVE RIVERHEAD,NY 11901 1 c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage/s specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 364860041 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) TOWN OF SOUTHOLD BUILDING DEPT TOWN HALL ANNEX 54375 MAIN ROAD 3b.Policy Number of Entity Listed in Box 1 a" PO BOX 1179 DBL 7555 81 -7 SOUTHOLD,NY 11971 3c.Policy effective period 09/24/2024 to 09/24/2025 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. Date Signed 9/26/2024 By '& eA— (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 866)697-4332 Name and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT:. If Box 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 mailed for completion to the Workers'Compensation Board, DB Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200 PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 5B of Part 1 has 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 with respect to all of his/her 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 issue this form. DB-120.1 (10-17) Certificate Number 808069 0 DATE(MMIDDIYYYY) C<>R '" CERTIFICATE OF LIABILITY INSURANCE 9/26/2024 THIS S�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(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 endorsements C NTA'T PRODUCER NAMI : Ht Nr 631 359-9609.....� AXc m,631-369-967 Riverhead Lighthouse, Inc. EMAIL 221 West Main Street �.R Riverhead NY, 11901 rNstleeras A ORDING COVERAGE _ Na�ctl _. It§URE A: UTI A FIRST INSURANd COMPANY ........ INSURED NNS CURER B Leeco Carpentry LLC. INuRER tom ..._ . ...... _... 205 Horton Ave INSURER D: . _ - Riverhead, 11901 "NSIJr:R E' 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 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. t7uffi$ POLICY EFF POLICY EXP ILA R LIMITS TYPE OF INSURANCE POLICYNUMBER' WN OOC'fYYY MMI'DD OCCURRENCE $ _1000��0 COMMERCIAL GENERAL H , 'RM_U CLAIMS-MADE �✓ OCCUR PRE 500,00 000 XX ART3000037180 03/07/24 03/07/25 VIED I XP GAy one lawzron $ _ 5 A PERSONAL$ADV'INJUR'Y $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 PRO- ❑ PRODUCTS-OOMPIOP AGG $ INC POLICY JECT ❑ LOC $ O'fHER;, GhtDINE'D SINGLE LIMIT $ AUT OMOBILELIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PR r aE ideflt AGE $ AUTOS ONLY AUTOS ONLY Per ec��det ••- $� UMBRELLALIAB ]:::]OCCUR EACH OCCURRENCE $ EXCESS LIAB C&AIMgS.MADE AGGREGATE $ _. OE2 RETENTION $ WORKERS COMPENSATION &SCR OTH �TATIJTE ER._ .,.-. AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOPJPARTNLPJL)E:CM'IVE ❑ NIA E.L.EACH ACCIDENT 3 O F F ICERIMEMS ER EXCLUDED? (Mandatory In NH) E.L.DISEASE EMPLOYEE. S IIy ,describe order El.DISEASE•POLICY LIMIT $ OESCRIPTION OF OPERATIONS beGov DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CARPENTRY As additional insured : Town of Southold Building Department Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971 CERTIFICATE HOLDER CANCELLATION Town of Southold Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall Annex ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road P.O. Box 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971-0959 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD BUILDING DEPARTMENT-Electrical Inspector tfft TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631)765-9502 ro err southoldtownr . ov seand sou holdtownn o^ APPLICATION FOR ELECTRICAL INSPECTION . ELECTRICIAN INFORMATION (Ail Information Required) Date:Ir Company Name: 77 Name: License No.: ,r . ail: Phone No: request an elraail copy of Certificate Compliance Address.: JOB SITE INFORMATION (All Information Required) Name: ' Address: Cross Street: Phone No.: email: Bldg.Permit#: S 15 Block: a Lot: 15 Tax Ma District: 1000 Section: 0� RIEF DESCRIPTION OF WORK Please Print Clearly) Check All That Apply: NYES []NO '°Rough In []Final Is job ready for inspection?:: Do you need a Temp Certificate?: YES PNO Issued On Temp information: (Ail information required) Old Meter# Service Size 01 Ph 03 Ph Size: #Meters New Service ❑ Service Reconnect Underground Overhead Underground Laterals 1 H Frame Pole Work done on Service? N Additional Information PA1flIAEI T DLIE WITH APPLICATION Electrical Inspection Form 2020.xisx