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HomeMy WebLinkAbout51587-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#: 51587 Date: 01/24/2025 Permission is hereby granted to: Basilice DM Rev Trt 3255 Bay Shore Rd Greenport, NY 11944 To: Constructa roofed overentrance areato an existing single-family dwelling as applied for per Trustees approval. Premises Located at: 3255 Bay Shore Rd, Greenport, NY 11944 SCTM#53.-6-8 Pursuant to application dated 11/25/2024 and approved by the Building Inspector. To expire on 01/24/2027. Contractors: Required Inspections: Fees• Single Family Dwelling- Addition &Alteration $316.50 CO Single Family Dwelling-Addition /Alteration $100.00 Total $416.50 Building Inspector r r r r / r r r /� <.Existing use of property: Single family dwelling Intended use of property:single faMily dwelling Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes MNo IF YES, PROVIDE A COPY. r� / l/ i / rr✓ / �%i l ////// i// /./ /:://r., /../r. ,/i,G/t..:rll, ,// c,/�./i,�if n,,, fir,.. I E r j i✓� rrr,,r„/lr r r/,/ rl, %�/i/; ,fir(, �.,:r�/� /F //„ r/�/�r ��l/%r rlt>�//i/ JJ% r/ � / //I// lr. /ir�/�i: J� 1 f f 0 /: r -.i i i � ;!r ✓ �/�ri rra /i,,, r�/r��� '/ r %,r/,r rf ��///,/� rr r / ��`.. Application Submitted By(print name): Heidtmann & Sons, Inc. BAuthorized Agent ❑Owner Signature of Applicant: Date: November 25, 2024 STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Glenn F. Heidtmann being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the Contractor (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 25 day of November 2024 Loretta Lamb Notary Public LORETTA LAMB Notary Public,State of New York #01 LA6179883 PROPERTY OWNER AUTHORIZATION Ouaiified in Suffolk county (Where the applicant is not the owner) Term Expires December 31,20 Z- Glenn F. Heidtmann residing at PO Box 932, Cutchogue, NY do hereby authorize Heidtmann & Sons, Inc. 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. GlennTown Hall Annex Goldsmith, President � U 54375 Route 25 A.Nicholas Krupski,Vice President ,, C � P.p_Box 1179 Eric Sepenoski L Southold, New York 11971 Liz Gillooly _ Telephone (631) 765-1892 Elizabeth Peeples PS Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10669A Date of Receipt of Application: October 24, 2024 .Applicant: Dahna Basilice Revocable Trust SCTM#: 1000-53-6-8 Project Location: 3256 Bayshore Road, Greenport Date of R olution/Issuance: November 13, 2024 Date of Expiration: November 13, 2027 Reviewed by: Board of Trustees Project Description: To construct a 133 sq.ft. roof over entrance area to dwelling; install a generator on a concrete pad on-grade plus small pad for propane tanks. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Nicholas J. Mazzaferro, P.E., received on October 24, 2024, and stamped approved on November 13, 2024. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees soar Town Hall Annex Glenn Goldsmith, President �� 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski 1 Southold, New York 11971 Liz Gillooly A Telephone(631) 765-1892 Elizabeth Peeples ' Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BE INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 111 day of construction '/z constructed XWhen project complete, call for compliance inspection; TRU EES SOUT 'HOLD ST No. � Issued To,,U��^�a I ("sT Date ►11-� Address. 3�55 Q�c�KS�nacL Qoab , Gceenpor►— THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION I, TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 \ \ a, Mall 120 A�y ` �1 OR \.`� 2V � ... �\v�\i V AAV A\\ \\ ` \ \ \. RNOW\ ` IN \ � ` \ \ \ \ \ \ \ MI o\ill ` \\. \ \ \ ` \ \ \ \IT� INS W, \�: \ ii� \ W z \ \ 41 o' �-71 4, `va 7, �............ IL It N� k , �,w \ \ A V� NE wo "IN \ \ \\\ \ \\ `V \ '411" aw - \ � ��� V A\ iN V v m\ l \ W \\ IN\V \\ DATE(MWDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/25/2024 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 CONTACT Christine Schuller NAME: AssureclPartners Northeast,LLC. PHONE (631)465-4000 A/C No: N EM 100 Baylis Road aDDRss: chris.schuller@assuredpartners.com Suite 300 INSURER(S)AFFORDING COVERAGE NAIC A Melville NY 11747 INSURER A: Mesa Underwriters Specialty Insurance Co. 36838 INSURED INSURER B: State Insurance Fund-NY Heidtmann&Sons,Inc. INSURER C: Standard Security Life Ins.Co. P.O.Box 932 INSURER D: Sutton Specialty Insurance Company 16848 INSURER E; Cutchogue NY 11935 INSURERF: COVERAGES CERTIFICATE NUMBER: "24-25" REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 MAYBE 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. IN SR TYPE OF INSURANCE POLICY NUMBER ly MIDD/YYF!Y POLICY Y LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 rJAMAGETi5A9N1rff_ 100.000 CLAIMS-MADE F OCCUR PREMISES Ea ocrArrence $ Contractual Liability MED EXP(Any one person) $ 5,000 A MPOO82001007556 02126/2024 02/26/2025 PERSONAL&ADV INJURY $ 1,000,000 GEWLAGGRECATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OCHER. $ AUTOMOBILE LIABILITY B N ) GR.L L M $ Ea arxdr6ecnt ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPER"fY DAMAGE $ AUTOS ONLY AUTOS ONLY Mor acc)der'nw UMBRELLA LIAB OCCUR EACHOCCURRENCE $ 3,000,000 D EXCESS LIAB CLAIMS-MADE ISCEX0300001703-00 OB/07/2024 02/26/2025 AGGREGATE $ 3,000,000 DIED RETENTION$ vv $ WORKERS COMPENSATION ^ PTATUTF FO."Rµ AND EMPLOYERS'LIABILITY Y/N 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA 1 2206 943-9 05/03/2024 05/03/2025 E.L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? i�. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ NYS Disability I 64522-00 01/01/2024 01/01/2025 Limits Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:3255 Bayshore Road,Greenport,NY. The following are included as additional insured if required by written contract subject to the terms and conditions of the stated policies:Town of Southold, P.O.Box 1179,Southold,NY 11971,Vincent Basilice,Dhana Basilice. General Liability&XS Liability coverage applies on a primary&non-contributory basis with a Waiver of Subrogation in favor of additional insured's 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 ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 a V ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AFRON-IN, NYS F New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE %11.ff ^A A A A A 263528632 HEIDTMANN&SONS INC PO BOX 932 CUTCHOGUE NY 11935 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER 3255 BAYSHORE ROAD HEIDTMANN&SONS INC TOWN OF SOUTHOLD PO BOX 932 54375 MAIN ROAD CUTCHOGUE NY 11935 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12206 943-9 1 481786 05/03/2024 TO 05/03/2025 11/25/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2206 943-9, 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:/IWWW.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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. GLENN F HEIDTMANN JR, PRES& JEFFREY W HEIDTMANN,VP OF HEIDTMANN&SONS INC (TWO PERSON CORP) 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 20 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY, NEW YORK ST T SUR NC:E FUND DIRECTORJNSURA,NCE FUND UNDERWRITING VALIDATION NUMBER:899351474 Y. Workers' CERTIFICATE OF INSURANCE COVERAGE 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) 1 b.Business Telephone Number of Insured HEIDTMANN AND SONS INC. 7675 COX LANE 6317347484 CUTCHOGUE, NY 11935 Work Location of Insured (Only required if coverage is specifically limited to 1c. Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 26-3528632 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 Standard Security Life Insurance Company of New York PO Box 1179 3b. Policy Number of Entity Listed in Box 1a Southold, NY 11971 64522-00 3c. Policy Effective Period 1/1/2014 to 11/24/2025 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: ❑)f 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 descr' d above. Date Signed 11/25/2024 By (Signature of insurance carrier's author' d r"epreserstte or NYS licensed insurance agent of that insurance carrier) Telephone Number 212 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 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(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. DB-120.1 (12-21) 11111111°°°1°1°1°� °°�u°11°!��1°IIIIIII Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed 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 cancelled 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 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 NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first,two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. 1313-120.1 (12-21)Reverse