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HomeMy WebLinkAbout51722-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#: 51722 Date: 03/11/2025 Permission is hereby granted to: Group For East End Inc PO BOX 1792 Southold, NY 11971 To: Construct repairs and alterationsto an existingoffice building as applied forto include removalof rear 2nd story deck, demolish and rebuild front porch "in kind" and siding and roof repairs. Premises Located at: 54895 Route 25, Southold, NY 11971 SCTM#62.-1-4 Pursuant to application dated 01/31/2025 and approved by the Building Inspector. To expire on 03/11/2027. Contractors: Required Inspections: Fees: Commercial- Repairs $433.50 DEMOLITION $112.00 CO Commercial $100.00 Total $645.50 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 +ww.soot igJdt( pnrtyM.o Date Received APPLICATION FOR BUILDING PERMIT ���d' r For Office Use Only 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. Date: OWNER(S)OF PROPERTY: ,yv Name: P F�� tires CX'sr ,rNp / �• SCTM# 1000-6Z—O/�O Project Address:S it 4 �S— � a� A/ Phone#: 74 S 5- EmaiiaN�a , w /:" + E"N✓/�t G�y`l�iV�p Mailing Address: e6 go / 9Z J4,0—(rto111 CONTACT PERSON: Name: t7fiQ .6e-c..oe,4 Mailing Address: U Apy �79Z SvTNe[.p V //?V Phone#:(31 -- n'b— sno Email �� ��A �v�Gi1/�//,rc►ewlt+Pe DESIGN PROFESSIONAL INFORMATION: Name: ,t /f•Q1� )Lfi91124rA"� Mailing Address: 9 7 4 /V.4/A/ST,�G��� S% j'/gl-�K /� Av Phone#:63/� �� re 5- Ema)q' �GA� t�fb EI'(/�?dll t -C1 CONTRACTOR INFORMATION: Name: �,SL�/0 �i�`1 Mailing Address: KQOZZo K7. A- ib ll 71 Phone#:431 —74-1—,SIJS5- EmaillQilL�{{��l°lCfrtBoSw�•�t.r DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ARepair []Demolition Estimated Cost of Project: ❑Other J� pdb • Ole Will the lot be re-graded? ❑Yes PrNo Will excess fill be removed from premises? ❑Yes E!!!oj 1 PROPERTY INFORMATION --------------------------- Intended use ofproperty: Exlsting use o property: 61 Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑YesKNo 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 210.45 of the New York State Penal Law, Application Submitted By(print name): X/CA*Xas��'�'� $'Authorized Agent ❑Owner _.. , Signature of Applicant: � ,� � Date: 70 � •, STATE OF NEW YORK) COUNTY OF �) being duly sworn, deposes and says that(0)he is the applicant (Name of individual signing contract) above named, (1k)he is the L �4� (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 ���' _ 20 --- � � Notary Public JOHN A. MAKI Notary Public-State of New York No.01 MA6164838 PROPERTY OWNER AUTHORIZATION Qualified in Suffolk County (Where the applicant is not the owner) My Commission Exp:04/30/202., r 2 residing at A � �� � ��,� L do hereby authorize �o r ¢ r� to apply on my behalf two the Town of Southold Building Department for approval as described herein. �`�/'�C �+� ode'. .. • �4Z.S Owner's Signature . � �: i Date •;���'''r 9 � cam„,✓'':,.�'�p ,,.,,,^`� Print Owner's Name 2 BOSWCON-01 DATE.,.�DDf 1/31/202IY CERTIFICATE OF LIABILITY INSURANCE 6 31125 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 rl hts to the certificate holder in lieu of such endorsement s. PRODUCER CT NIch") I Breen First Casualty Insurance Agency Inc. HOsNa E i300 352 3416 232 _ I,F c o w 10 692-9752 190A Turner St. Q. _N _..w_ I.. _ ... ............. Southern Pines,NC 28387 nbreelN�CN1CkItIM /NktRE A4FFC18IGti C .-_.__.._.w ..,�..............m,wd#Afc ._.w..... _..._�........_.,,,.._...........................�.__..ww ���� ����_,���.._,.. .Cep 35375 ........_.......� _.__......,.,,...._..w ........_.. IN$ R, M,. EV611StOT1�N3ffi6 C .w_ w_w... _m....w _...w..__. ,,,_ INSURED 1. .. .: _..�.�...�.�... ,..,,-... .. .�................. w....... .....,ww._..............ww �..._........_ ...�........._�.. Bosworth Construction Corp INSUAFR99. .......�.�_�....�............. -.-w.........M......-.._..,w _.......... ......_. .. 48220 Route 25 rN R D U,,,,,.,.,,,..,w�w_..............�_..�w __...,,...w. _............ ,....,_.............._.,........._._ _........_....._.,.... w...,. Southold,NY 11971 INSURER 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, .... o _D CLAIMS. INSERXCLUS... AND CONDITIONS NCE OF SUCH PADCLLCSICESaLIMITS SHPouCY NUMBER MAY BEEN REDUCED YYFBFY PAPOLI Y EXP _.m- LIMI._,.,.......,ww.M�.�,......�..w.. .......w �.�...�.�.�.�.�... JJJL TYPE OF LIMITS A )( COMMERCIAL GENERAL LIABILITY EA HAg4 L P/ l_ .-, _ 11000,000 ..... CLAIMS-MADE µ OCCUR 3AA758931 2/28/2024 2/28/2025 DpAMAOE To RENTED 100,000 6,000 ..�.. _ ................................. ... __...._----.._. ,P D4JRY_..�.�..�. .. ..........,,_..1,000,000 _.w ...ww............ __...,_.w...... Rsr __.......... ...... ,. 2M00 ,000 GEN'C.ACrGREGATE LIMIT APPLIES PER: ,EhIERALAGGREGATE __ _ _. 2„000,000 X�00OIL:l Y PE� LOC _PFlCk9S41 � ...CChOW"AQ3_ _.. _...... .... ..... .. E: AUTOMOBILE LIABILITY COMBINED SINGLEYLIMIT �m www.. ANY AUTO .,���'.P)�"�tN;�tlk��'d„ ?? �.���_,.. ............,wm..._...... _.n�.�.�.............., OWNED _.- SCHEDULED AUTOS ONLY AUTOS %�LhlLms",.,VG J 2Y L L� �?EI ..._,.. ....,.......... ... HIRED ���_� A1160�C1NC C�F? E�RYtAMAC+E _..-....-...-,w_ AUTOS ONLY MBRELLA IAB OCCUR EXCESS AB CLAIMS-MADE1 (tl ........?.... __._.. ,.__......... ............. ... DED RETENTION$ &q�COCHw-m^. ..... ,._.,,,......._... ..,,,, YIN R WORKERS COMPENSATION T AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E I OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) - n�:.PPEAE F.,A „AAk�L,t�YE�,. � ............. .... ...._..... If as,des cdt a under DESCRIP"P'[ON S PFRATIO S gavr glz ON EA -POLICY k.WT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) w_. wf�EEFBTIFI A'�E HCILCBER w_wwwwwww A�NCLI-ATI >N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold Buildin De artment THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 p ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd Southold,NY 11971 AUTHORIZED REPRESENTATIVE J"`vwlil ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Suffolk County Dept.of ` Labor,Licensing&Consumer Affairs y HOME IMPROVEMENT LICENSE Name RICHARD T BOSWORTH Business Name BOSWORTH CONSTUCTION CORP This certifies that the bearer is duly licensed License Number HI-62460 by the County of suffolk Issued: 06/27/2019 R soA,iz,•Drago- Expires: 06/01/2025 Commissioner a s - - Suffolk County Department of Labor, Licensing & Consumer Affairs -01 e VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 DATE ISSUED: 6/27/2019 No. HI-62460 e SUFFOLK COUNTY Home improvement Contractor License This is to certify that RICHARD T BOSWOR_TH M ' doing business as ` BOSWORTH CONSTUCTION CORP } having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules a and regulations of the County of Suffolk,State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR,in the County of Suffolk. Additional Businesses Restrictions 1 NOT VALID WI1HOUT D-%%AR'i'ivli NTAL SEAL AND A CURREN C C(iVy.1�;;E�i AFFAICS ID CARD 1 Frank Nardelli Commissioner e 4% N YS I F New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 833423095 BOSWORTH CONSTRUCTION CORP„ 48220 ROUTE 25 mt. SOUTHOLD NY 11971 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER BOSWORTH CONSTRUCTION CORP. TOWN OF SOUTHOLD 48220 ROUTE 25 54375 MAIN ROAD SOUTHOLD NY 11971 PO BOX 1179 SOUTHOLD NY 11971-0959 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12465 420-4 687671 02/20/2024 TO 02/20/2025 1/30/2025 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2465 420-4, 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 W'EBITE AT HTTPS:/MIWW.NYSIF.COM/CERT/CERTVAI_.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. PRESIDENT RICHARD BOSWORTH BOSWORTH CONSTRUCTION CORP (ONE 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. NEW YORK STAT SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:217548631 U-26.3 G o Workers' CERTIFICATE OF INSURANCE COVERAGE nr4"Wr Compensation Board 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 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured BOSWORTH CONSTRUCTION CORP (631)767-5085 48220 ROUTE 25 SOUTHOLD,NY 11971 1c.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) 833423095 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 54375 MAIN ROAD 3b.Policy Number of Entity Listed in Box"1 a" PO BOX 1179 DBL 722140-2 SOUTHOLD,NY 11971 3c.Policy effective period 02/23/2024 to 02/23/2026 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 1/30/2025 By 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 Authorbed 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 823185 Additional Instructions for Form D13-120.1 By signing this form,the insurance carrier identified in box"T'on this farm is certifying that it is insuring the business referenced in box"1a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Worker's 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 farm 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 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. 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. DB-120.1 (10-17)Reverse