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Home My WebLink About51576-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#: 51576 Date: 01/21/2025 Permission is hereby granted to: Michael Nemeth 115 Ernest St Massapequa, NY 11758 To: Construct a pavilion accessory to an existing single-family dwelling as applied for. Structure must maintain minimum rear and side yard setbacks of 10 feet. Premises Located at: 2900 Stillwater Ave, Cutchogue, NY 11935 SCTM# 136.-2-15 Pursuant to application dated 11/20/2024 and approved by the Building Inspector. To expire on 01/21/2027. Contractors: Required Inspections: Fees: Accessory-New Structure $28S.00 CO Accessory Structure $100.00 Total $385.00 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 htt s://www southoldtgMM.n .Lynv. Date-Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building lnspecton-... O 2024 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an l t t3 "�07,virtrn rat Owner's Authorization form(Page 2)shall be completed. aGiptd' Date: 11/11/2024 OWNER(S)OF PROPERTY: Name: Michael Nemeth SCTM#1000-136.-2-15 Project Address:2900 Stillwater Avenue, Cutchogue, NY 11935 Phone#:631-734-7923 (Agent) IEmail:creativeenvdesign@yahoo.com Mailing Address:P.O. Box 160, Peconic, NY 11958 CONTACT PERSON: Name:David Cichanowicz / Creative Environmental Design Mailing Address: P.O. Box 160, Peconic, NY 11958 Phone#:631-734-7923 Email:creativeenvdesign@yahoo.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Creative Environmental Design Mailing Address:P.O. Box 160, Peconic, NY 11958 Phone#:631-734-7923 Email:creativeenvdesign@yahoo.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project; ❑• other Pavillion 16x20 see attached plans $30,000 Will the lot be re-graded? ❑Yes iiJ No Will excess fill be removed from premises? ❑Yes WNo 1 PROPERTY INFORMATION Existing use of property: Intended use of property: C 4 J1f � t �0. Zone or use district in which premises is situated: Are there any covenan�ttsff nd restrictions with respect to this property? ❑Yes L1dNo IF YES, PROVIDE A COPY. IV Check x After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Civapter 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. t e : ; ENditch rnUa�l�� bCSi N IIQAuthorized Agent ❑Owner Application Slubrrrltte n ) �` ,� Signature of Applicant: , Date: STATE OF NEW YORK) SS: COUNTY OF S u lij�aAV-, ) t1.7 t being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the o 113 (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 NCO exys e.C 20 ')YILA%l DN No Public iEl�ilaY LO�ilil INOTARY PI.BLI�C,STAtRegi tion No.0Quaiifiedn�ufWhere the appyant is not OPERTY OWNER )Z )ON Gr�rrrrrliWon Expires D0 ( the owner) I, residing atI00 2A'NkWmNerAve, t e- do hereby authorize to apply on C, f to the Town uthold Building Department for approval as described herein. �[3 202�wner's Signature Date c�C� �� S 1 V 12LIiL Print Owner's Name 2 w° Wall( rs, CERTIFICATE OF INSURANCE COVERAGE Yattta •• 5Ta7f: Cord nsation Board NYS DISABILITY AND PAID FAMILY LEAVAE-BENEFITS LAW PART 1.To be cam Aeted by NYS Disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address or insured(use street address only) 1b.Business Telephone Number of Insured INDIAN NECK COR DBA CREATIVE LAND-SCAPE DESIGN, 39160,ROUTE 25 PECONIC,NY 1105 re 1 c.Federal Employer Identification Number of Insured or Social Security Work Location of Ins ' ad(Only required if coverage is sppclticadly Number limited to certain facet/ sin New Vork State,i.e., Wrap-Op Policy) 112294493 2.Name and Address Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as he Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 3b.Policy Number of Entity Listed in Box•1a LNY323682 3c.Policy effective period 0110112024 to 12131/2024 4.Policy provides the f Ilowing benefits: ❑x A.Both disa Ility and Paid Family Leave benefits. ❑ B.Disability beneflts only. ❑ C.Paid Fam ly Leave benefits only. ,,, 5.Policy covers: ❑X A.All of the inployer"s employees eligdble under the NYS Disability and Paid Family Leave Benefits Law. B.Only the f Mowing class or classes of employer's employees; Under penalty of periu ,I certify that I am an authorized representative or licensed agent of the Insurance carrier referenced above and that the name insured has NYS Disabi ily and/or Paid Family Leave benefits insurance coverage as described above. Date Signed "i`24 024 fanalure of I:nzuvanco oarrfor'a aul.Nvorizod reprr,aaa2totVvo or d�YS Ilcoetiaed Insurance agent.of t4iot Insurance eardar) Tole hone Number 21 553-5074 Name and Titloa ELI'ZABETH TELLO—ASSISTANT DIRECTOR STATUTORY SERVICES IMPORTANT: If Box s 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licen ed 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 compl iron 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 413,4C or 5B have been checked) State of New'York Workers' Compensation Board According to informa ion maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and P 'tat Family Leave Benefits Law(Article 8 of the Workers'Compensation Law)with respect to all of their employees, Date Signed By (Signature of Aulhorizud NYS workoro'Componsatlon Board Employee) Telephone Number Name and Title Please Note:Only insuran'e carriers licensed to write NY+S disability and Paid Family leave benefits In policies and NYS licensed insurance agents of those Insurance carriers ar authorized to Issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) W" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/01/2024 THIS CERrfirICATE IS ISSUED AS A MATTER OF IN'OORMATION ONLY AND COkFERS 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, CONTACT PRODUCER NAME: Matt Daley Farm Family Insurance f�IaoNE 631-744-3350 FAA Nc,y 631-744-3383 85 Echo Ave-Suite 2 ADD IESS. matt.d ale farm-family.com Miller Place, NY 11764 INSURERS AFFORDING COVERAGE NAIL N INSURER A: Farm Family Casualty 13803 INSURED INSURER B A Indian Neck Corp. DBA Creative Environmental Design INSURED : PO Box 160 INSURER D: INSURER E: Peconic NY 11958 INSURER P 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. L, R POL CY'EFF OL CY P LIMITS T TYPE OF INSURANCE POLICY NUMBER MMIDDFYYYY M7YIIDDrtYYY A COMMERCIAL GENERAL LIABILITY 3152X2360 06/01/23 06/01/24 EACH OCCURRENCE $ 1„000,000 06/01/24 06/01/25 IE 100 CLAIMS-MADE OCCUR I,Ps = urrence $ ,000 x Select Business PKG MED EXP(Any oneperson)_ s 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO- ❑LOC PRODUCTS-COMPIOPAGO S 2w00011 +J0 JECT 071459: $ AUTOMOBILE LIABILITY COMBINED SINGLE'tIMIT $ IER a�ccNd�ertl" ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) ' AUTOS ONLY AUTOS HIRED NON-OWNED OPETY DAMAGE S AUTOS ONLY AUTOS NLY PPer R S UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN PER, ERH ANYPROPRIETORIPARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) MASONRY/LANDSCAPING CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD 54375 MAIN ROAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O. BOX 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTHOLD, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserve ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Now York State Insurance Pund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112294493 b AMWINS INSURANCE BROKERAGE LLC 200 ELWOOD DAVIS ROAD mw SUITE 200 LIVERPOOL NY 13088 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER INDIAN NECK CORP. TOWN OF SOUTHOLD T/A CREATIVE ENVIRONMENTAL DESIGN PO BOX 1179 PO BOX 160 SOUTHOLD NY 11971 PECONIC NY 11958 POLICY NUMBER CERTIFICATE NUMBER L POLICY PERIOD DATE Z1318 046-8 738667 05/01/2024 TO 05/01/2025 5/1/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1318 046-8, 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. 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 STATE SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:412189446 U-26.3 �• ,n° Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name DAVID J CICHANOWICZ Business Name INDIAN NECK CORP DBA This certifies that the bearer is duly licensed License Number H-29895 by the County of suffolk Issued: 12/13/2001 Jefto'ifwCabYefa, Expires: 12/01/2025 Commissioner v ,o