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HomeMy WebLinkAbout51580-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#: 51580 Date: 01/22/2025 Permission is hereby granted to: Eric W Foran 322 W 72nd St Apt 12B New York, NY 10023 To: construct alterations to existing single-family dwelling as applied for. Premises Located at: 1150 Laurel Ave, Southold, NY 11971 SCTM# 56.4-2.28 Pursuant to application dated 11/18/2024 and approved by the Building Inspector.. To expire on 01/22/2027. Contractors: Required Inspections: Fees: Single Family Dwelling- Alteration $376.00 CO-RESIDENTIAL $100.00 Total S476.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT �� re Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502],Itt 5.//WWA r. otl.tltoldtownn Zo Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only I � r PERMIT NO. 5 Building Inspector:, u 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. Date: OWNER(S)OF PROPERTY: Name: U f( C =CTM #1000- Project Address: 1 - 5 UI r LELSufis w� 1 h Phone#: L�- _ �� L _ �/ Email: ` G 02 Mailing Address: -°7 !'" CONTACT PERSON: p " Name: Mailing Address: Z(j P-A� J, Volap Phone#: "l �( �'�2 Email I,M 1 /( ,l GA-^ EM t DESIGN PROFESSIONAL INFORMATION: Name: J M S D Mailing Address: Phone#: j Email: C-S DLe(-k )S k CM C CONTRACTOR INFORMATION: Name: Mailing Address: -- C PL,C)A9 UC Ce t alv Phone#: G.j 1 C� 1�1q �� Email: 1 i�V i(�, �. 11 (A G ; DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition XAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other Will the lot be re-graded? ❑Yes IAO Will excess fill be removed from premises? ❑Yes5,No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or•use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES,PROVIDE A COPY. ❑Check Box After Read i : The owner/contractor/design professional Is responsible for all drainage and storm water Issues as provided by Chapter 236 of the Town Code. APPLICATION-ISHEREBY MADE tothe Bullding Department forthe,issuance of a-Building permit pursuant to the Building Zone Ordinance of theTown of Southold,Suffolk,County,luew.York and ether applicable Laws,Ordinances or Regulatlons,;for the construction of buildings, additions,.alta'atlons•or forremoval or demolition as herein described.The applicant 9grees to-comply with'all app6eabte laws,ordinances,building code, housft code and reguiationsand•to admit-authorized inspectans on,preJinlses,and tmbuildtng(s)for necessary inspections.False statements made hereimare punishable as a ClassA misdemeanor pursuant to Section 210.45 of the New York Stara-penaltaw. Application Submitted By(print name): `,Q, WW&, *J INAuthorized Agent ❑Owner Signature of Applicant: Date: �� CONNIE D.BUNCH Notary Public,State of New York STATE OF NEW YORK) No. 01BU6185050 Qualified In Suffolk County COUNTY OF SS: Commission Expires April 14, 2t } Y 1 L being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Cdn A GIM (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 Y 20� n��D J61 . Notary Public PROPERTY OWNER I (Where the applicant is not the owner) 1, 16 a t reslding at l\5 y N V `"11 i do hereby authorize LA ui/l olj to apply on my beh0f to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 NEW Workers' CERTIFICATE OF YORK STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Pro Spec Construct LLC (631)796-9923 320 Railroad Ave Center Moriches, NY 11934 c.NYS Unemployment Insurance Employer Registration Number of Insured 1d.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 84-1739873 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability&Fire Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box 1 a" 53095 Route 25 PRWC452265 PO Box 1179 Southold,NY 11971 3c.Policy effective period 11123/ 024 to 11/2412025 3d.The Proprietor,Partners or Executive Officers are []included.(Only check box if all partners/officers included) J] 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 _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 'lib 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 argent,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 reamed Insured has the coverage as depicted on this form. Approved by: Anthony Pomi)la (Print name of authorized representative or licensed agent of insurance carrier) Approved by: p _k (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-676-7020 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-106.2. Insurance brokers are NOT authorized to issue it. C-106.2(9-17) www.wcb.ny.gov PROSPEC-01 V =DATED/YYYY) CERTIFICATE OF LIABILITY INSURANCE 024 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 endorsemen s. PRODUCER ° CT this certificate does not confer ri hts to the certificate holder in lieu o suc I mm LPL Risk Management ���� Exc m 631 676-7020 Ntr,(631 676-7030 140.2 Remington Blvd. Ronkonkoma,NY 11779 ,lnfcr@lplrl k,00rn INSURER S�FFORNNG COVERAGE NBIC'Nf INSURERA:Utloa First Insurance o)i'npan INSURED INSURERB Mleerc'hants Mutual Ins.CoMpany Pro Spec Construct LLC INSURER C a NorGxuard Insurance CO 42390 320 Railroad Ave INSURER D Center Moriches,NY 11934 INSURER E INSURER F: COVETHIS I DG S B TO CERTIFY THAT THE POLICIES E OF INSURANCE S LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE , REVISIO7+4 NUMI9ER» 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 AI7DL 13USR POLICY EFF POLICY EXP LIMITS 1,000,,,000 TYPE OF INSURANCE POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY EACI°4 OCCWRRENCE $� ... CLAIMS-MADE OCCUR ART3000896271 4/6/2024 4/6/2026 DAMAGE TO RENTED or 60,000 I MED I XP Ar rrr can � 6,000 PERSONAL S ANJURY $ 1,i0 DV010,000 2,000,000 GEN"L AGGRE'GATE LIMIT APPLIES PER: GENERAL AGGREC9ti I E X POLICY ❑ LOC PRODUCTS.COMP'IOP AGG $ 2,000„000 CrT9 6ER': COMBINED SINGLE LIMIT 10010,000 B AUTOMOBILE LIABILITY ANY AUTO CAP1083466 1/6/2024 1/6/2026 BOD. INJURY Per O=n OWNED X SCHEDULED BODILY gNUftY'Peraccidenl' AUTOS ONLY AgU�qTO{�Sgg ������� O X H6HTIRS ONLY X NRTNOS fJt Y PN�e0sP 4 TY DAMAGE $ f? UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ ER C WORKERS COMPENSATION OTH- $� P AND EMPLOYERS`LIABILITY Y/N PRWC462266 11/23/2023 11/23/2024 100 000 ANY PROPR1ETOPJPARTNERIEXL-c;Qi E EA EACH ACCIDENT $ ' GPkCERIMMEMffi W EXCLUDED'? � N/A 100,000 anda o n N E.L DISEASE-EA EItiAPLCDVEE If as,Jezeribe under E.L DISEASE.-I?t LILY LIs{NT $ 600,000 DESCRIPTION OF OPERATIONS I M21-6 _w ... " DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) As pertains to the insured's operations. �w CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold L77777777=- 63096 Route 26 PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 26(2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD s �N�+�I► Workers' CERTIFICATE OF INSURANCE COVERAGE s ATE 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 carrie la. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured PRO SPEC CONSTRUCT LLC 631-796-9923 320 RAILROAD AVE CENTER MORICHES, NY 11934 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 841739873 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company 3b. Policy Number of Entity Listed in Box 1 a" DBL702603 3c.Policy effective period 10/05/2024 to 10/04/2025 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 10/24/2024 By /42=4�� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston Welsh Chief Executive Officer 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 413,4C or 56 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 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. D13-120.1 (12-21) 11111111IIIIIIIIIIpIIIII�IIIIIIIIINIIIIIIIIIIIINI1111