Loading...
HomeMy WebLinkAbout51881-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#: 51881 Date: 04/29/2025 Permission is hereby granted to: John Malley PO BOX 508 East Marion, NY 11939 To: replace door to existing single-family dwelling as applied for. Premises Located at: 1330 Gillette Dr, East Marion, NY 11939 SCTM# 38.-2-14 Pursuant to application dated 03/20/2025 and approved by the Building Inspector. To expire on 04/29/2027. Contractors: Required Inspections: Fees: Single Family Dwelling- Alteration $250.00 CO-RESIDENTIAL $100.00 Total S3SO.00 Building Inspector 6rL 4�Ip�GM1��° , TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 µ Telephone(631) 765-1802 Fax (631) 765-9502 htfosHwww.SOLIth old townn '. Gov' Date Received For Office Use Only C E PERMIT NO. U 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 Buil InR Department Owners Authorization form(Page 2)shall be completed. Town Of Sotl^iold Date: 1 z O 2 o zs OWNER(S)OF PROPERTY: Name: John Malley SCTM# 1000- � _ -Z —;-1 Z Project Address: 1330 Gillette Dr Phone#: 631-80O-4215 Email: jaCkid43199gmail.corn Mailing Address: PO Box 508 E Marion NY 11939 CONTACT PERSON: Name:John Malley Mailing Address: PO Box 508 E Marion NY 11939 Phone#:631-807-4215 Email: DESIGN PROFESSIONAL INFORMATION: Name: N/A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Renewal By Andersen LI Mailing Address: 2029 New Highway Farm NY 11735 Phone#: 631-843-1713 x 2255 Email: cvalente@rbalongisland.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition WAlteration ❑Repair ❑Demolition Estimated Cost of Project: Other I��P�-t�G� �K� oc $ 7309 Will the lot be re-graded? ❑Yes liNo Will excess fill be removed from premises? ❑Yes 10 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? Dyes No IF YES, PROVIDE A COPY. responsible for all drainage and storm water Issues as provided b W )fie@� CIS Af�° III Reading:. The owner/contractor/design professional is reap i g P Y 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):John Malley ❑Authorized Agent ROwner Signature of Applicant: 1 Date: I 2,0 1 .1,C)'Z y STATE OF NEW YORK) SS: COUNTY OF being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing c ntract)above named, (S)he is the Owner (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. Swor-rn before me this aO day of 20 Notary Public Richard D. offf+al"")Wll" Notary Public ,State of New York Ilz ..................lII L) I I I"°ION No.01WbI 2 �4106 .. .. IIII lll is not the �� � Cual�d In Suffolk ou Where the applicant owner) My Commission Expires June n20' I, residing at do herebyauthorize 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 o n � ^ 11 f f a rn `nJ pp v c� .-- 14 O� c� c �a ^I N O Es a A 0.0 - Ps s w 3 ¢ µ y 6 C� C7 o ° z u o O N Cal O O C V1 �s W � m�Zo� ti ca fee w WYw�c� Y` °OZom°j 'e g B �9$ E r, N, � u • Client#: 1721414 LONGICUS ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE 5/13/2024 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. RTANT:If the certificate holder is an ADDITIONAL INSURED, p........ y(i )must have ADDITIONAL INSURED provisions or be endorsed. NSURED,the olic ies 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER.... NA,iMEA... DJ Ha.rdisty USI Insurance Services LLC PHONE ' !C,,CN. €, � _ .__�1 N�1-610 537 4220 914 459 6200 333 Westchester Ave,Suite 102 EMAIL ADDss DJw Hamdisty a usi.com White Plains,NY 10604 �� ����'�� INSURER(S)AFFORDING COVERAGE NAIC# 914 459-6200 INSURER A:mSelective Insurance Company of. New York 13730 INSURED INSURER B r Long Island Custom Windows LLC INSURER C DBA Renewal by Andersen of Long Island __ "". ...... -------- INSURER D: 2029 New Highway INsuRER.. _ ..... ---...._ E Farmingdale, NY 11735 — ....., 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. . INSR TYPE OF INSURANCE ^^^^ADDLSUBR p POLICY N POLICY EFF POLICY EXP LIMITS LTR m ._ RANCE m UMBER w(MMIDD/YYYY� (MMIDD/YYYY), ,_ ... . CLAIMS-MADE X,� EACH OCCUR REINED s5r00000 A XMMERCIALGENERAL LIABILITY S200162113 5/01/2024 05/01/202 E Ill A RENTED OO OOO ... ,OCCUR ...... .--------- ......... .... MED EXP(Any one person) $15,000mIT_ ADV INJURY $1,000,000 -..�....,,� ................ .... PERSONAL&.......... w.,..................... GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 n . . ... POLICY -_-X„ PRO- POLICY LOC PRODUCTS-COMF/ AGG m m$m3m 000,000 OTHER: $ A S200162113 5/01/2024 05/01 ,. AUTOMOBILE LIABILITY /2O2 f"OMBpNLO'�INGL�"LIMi'i �1 OOO,OOO X'.,ANY AUTO ' BODILY INJURY(Per person) $ .w. .. .......................... ----.....-- OWNED SCHEDULED BO DILY INJURY(Per accident) $ I AUTOS ONLY AUTOS ••••--•• .,,m X AUTOS ONLY X NON-OWNED AUUTOS ONLYY i f AGE $ $ EXCESS LIAR ,CH OCCURRENCE $S,OOO,OOO_ '..LA LIAR X CLAIMS-MADE S200162113 5/01/2024 05/01/202 En AGGREGATE $5,000'000 I,DED, X;l RETENTION$'.10000 ANDEMPLOY'E 4PER I` � WORKERS COMPENSATION T OTH ! IRS"LiAt'1iLITY T ,,,,,_ FR ....... ANY PftOPRIC-,,�C�'�C.DRIPAR'I`NERIE'Y.ECUTIVE Y I N IlT,F E..L EACH ACCIDENT $ OFPICERft'EMSER EXCLUDED? NIA ......... IMaodatory in NH) A EMPLOYEE $EL DISEASE-EA M� �� _mmmmmmmmmmmmmm,mmm, 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) CERTIFICATE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd PO Box 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971 Uta 7 •JcArlat ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S44755512/M44564364 AEBZP ' K Workers' OF INSURANCE COVERAGE a STATE COMpenSati�on 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 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LONG ISLAND CUSTOM WINDOWS,LLC DBA RENEWAL BY ANDERSEN OF L DBA RENEWAL BY ANDERSEN OF LONG ISLAND 2029 NEW 1c.Federal Employer Identification Number of Insured or Social Security HIGHWAY Number FARMINGDALE,NY 11735 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD BUILDING DEPT 54375 MAIN RD PO BOX 1179 3b. Policy Number of Entity Listed in Box 1a SOUTHOLD,NY 11971 LNY623001001 3c.Policy effective period 04-01-2024 to 03-31-2025 4.Policy provides the following benefits: Q A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5.Policy covers: X❑ 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. F re&�;,- Date Signed 04-04-2024 B ISfguature of insurance carrier's authorized representative or NYS licensed insurance argent of that insurance carrier) Telephone Dumber (2121 553-8074 Name and Title: ELI7ABET'H TELLO—ASSISTANT DIRECTOR STATUTORY SERVICES 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 sox 413,4C or 5B 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 S 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 disabildy and Paid Fancily Leave benefits insurance policim 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) � �� I �� II �Illl��lI�MI� I�� I� D I :.Z 2,.1. ) NYSIFPO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 364619760 err USI INSURANCE SERVICES LLC 333 WESTCHESTER AVE SUITE 102 WHITE PLAINS NY 10604 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND CUSTOM WINDOWS LLC DBA TOWN OF SOUTHHOLD BUILDING RENEWAL BY ANDERSEN OF LONG ISLAND DEPT 54375 MAIN RD 2029 NEW HIGHWAY PO BOX 1179 FARMINGDALE NY 11735 SOUTHHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE FH 2403 991-9 344697 12/01/2024 TO 12/01/2025��12/03/2024 .......... THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2403 991-9, 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://VI WW.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. NEW YORK STATE INSURANCE FUND 4 DIRECTOR,N(SURANCE FUND UNDERWRITING VALIDATION NUMBER: 288628763 IIII IIII1111111110nmimii all niimmniimiiunmm�iiiin Hill nnimnl Ilp I� Il II0000000000134959031 II Form WC-CERT-NOPRINT Version 3(09/29/2019)[WC Policy-24039919] U-26.,3 86 [00000000000134959031][0001-000024039919][##H][16527-05][Cerl_NoP-CERT 11[01- 01]