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HomeMy WebLinkAbout33006-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33198 Date• 08/07/08 TNIS CERTIFIES that the building ADDITIONS Location of Property: 95 VISTA PL CUTCHOGUE (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 83 Block 1 Lot 21 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 17, 2007 pursuant to vPhich Building Permit No. 33006-Z dated MAY 7, 2007 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ONE STORY ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to FREDERICK LUBANSKI (OWNER) of the aforesaid building. SIIFFOL% CODNTY DEPARTM@7T OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 3045366 03/17/08 PLiAIDHRS CERTIFICATION DATED 06/03/08 J.ZEE PLUMBING ~~~~ti~~ ~~~~~ ~ Authorized Signature Rev. 1/81 ~~~~ ' Form No. 6 TOWN OF SOUTHOLD 7 ) ~ BUILDING DEPARTMENT ~ . TOWN HALL 765-1802 APPi,ICATION FOR CERTIFICATE OF OCCUPANCY L._- -_ - ~y ~6yy This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1 % lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy -New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 Date. $ ~'% ~~ O New Construction: Old or Pre-existing Building: (check one) Location of Property: q5 V{STA ~~--A C~ ~~ V ~~l}O('rU~ House No. Street Hamlet Owner or Owners of Property: ~R ~ D E R t C iC, Ct. C g R O L y ,.l LU /~ A~ S k Suffolk County Tax Map No 1000, Section O g 3 Block p O o / Lot Subdivision ;R //lC 1-{ /~/ILC.S Filed Map. y 90 ~ Lot: O a,I Permit No. ,3 3 0 0 ~ Z Date of Permit._ _5I!/~ Applicant: ~,pE~ 6/Z I G ~~ LV B A /`~$ ~ J Health Dept. Approval: Plarming Board Approval: Request for: Temporary Certificate o~ Fee Submitted: $ ~5 ~'lJ. Z 33i~~ Underwriters Approval: ~/ Dyf.~y ~ ,yJ~ /7-~~ /%t/fL ~~-%/~ Final Certificate: / (check one) Applicant Signature FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 33006 Z Date MAY 7, 2007 Permission is hereby granted to: FREDERICK LUBANSKI 95 VISTA PLACE CUTCHOGUE,NY 11935 for ONE STORY ADDITION & RAISED POOL SURROUND TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR at premises located at 95 VISTA PL CUTCHOGUE County Tax Map No_ 473889 Section 083 Block 0001 Lot No_ 021 pursuant to application dated APRIL 17, 2007 and approved by the Building Inspector to expire on NOVEMBER 7, 2 Fee $ 604.00 ~ AK?.uthori~ ignature ORIGINAL Rev. 5/8/02 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. northfork.net/Southold/ BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health ~~ I; 2~a1 .' PERMIT NO. 3 3t) n (7 ~ 4 sets of Building Plans Planning Boazd approval Survey Septic Form_ N.Y.S.D.E.C. Tmstees Examined _~, 20~ Approved ~' 7 ,20 O Disapproved a/c Phone: ' 3 y ~ 7G %/( Expiration ~// 7 , 20~ Contact: Mail to: f ~.P~ wing Inspector APPLICATION FOR BUILDING PERMIT Date ~/a i2 ~' H l S', 20a'r INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. £ Every building permit shall expire if the work authorized has not commenced within 12 months afrer the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafrer, a new permit shall be required. 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, or 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 for necessary inspections. (Signature of applicant or name, if a corporation) 95 VC s T P~.~ ~.~ C ~Tc H v GUS n/Er.~ ~0.2fG i/ J35' (Mailing a'ddres pf aos plicant) State whether applicant is owner, lessee, agent, azchitect, engineer, general contractor, electrician, plumber or builder Name of owner of premises FjQFD~R IGIC a" CARoLy,~/ Lvt3A~fS~C! (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No._ Plumbers License No. Electricians License N I5 a-~?5~ f~ Other Trade's License No. 1. Location of land on which proposed work will be done: 9 S 1/t sTi-~ ~~. FI e. ~ _._ C vT N o House Number Street County Tax Map No. 1000 Section 8.3 Block ~ Subdivision ~/Rc_N 1-1/L~~ Filed Map No. (Name) ,e.. Lot ~ J.., o ~ Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~QESi ~~~ %ifr/.. b. Intended use and occupancy ~e s ~ a ~-.~ ~-in, L ~ r Nature of work (check which applicable): New Building Addition / Alteration- Repair Removal Demolition Other Work 4. Estimated Cost ~ad ~ , CJ o O . o o Fee (Description) - (To be paid on filing this application) 5. If dwelling, number of dwelling units o7., Number of dwelling units on each floor ~. If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front '70' Rear CIO ~ Depth ~3 s ~ Height /a, ~ Number of Stories / Dimensions of same structure with alterations or additions: Front 90 ' Rear ~d ~ Depth ,So' Height /'y ~ Number of Stories / 8. Dimensions of entire new construction: Front o20 ~ Rear oZ0 ~ Depth .J n Height / f7' Number of Stories / 9. Size of lot: Front ~~~, _ 9 ~ Reaz ~ 9s ~ Depth % o~ O ~ 10. Date of Purchase o2// 9 3 `~ Name of Former Owner /t7fjR C~EC.LP, L E onl RR. t~ 11. Zone or use district in which premises aze situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 13. Will lot be re-graded? YES / NO Will excess fill be removed from premises? YES i/ NO FREOE F.ic.K d gs" v~sr~ P~~c~ 14. Names of OwnerofpremisesCAaoLy.~L.vliArJS~u AddressG'~fgo6.uE,~y~~9ds.' Phone No. 631 '73'I-194 Name of Architect tT M ~ S 7~EER. KoSk ~ P. £ . Address ~z°O ~E2 ~ ' i s Phone No ~3 t a 98 - ~ i / 6 Name of ContractoaSt,ln~SSe i0.1c~/S Cu¢~Address y(J~[lq~ Phone No. ~3y-'~1~'a- f lac. Ct,~(~vo~ 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetl ~ *YES NO '/ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO / * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNT/~Y OF .~/Gr//_ ) (ir? COL (/~/ LI~,C~.~?>y~K / being duly sworn, deposes and says that (s)he is the applicant (Name of incYividual signing contract) above named, (S)He is the (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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this~!! /,~ day ~et_GLY,c.~(_ 20~ -Notary Public Notary rude New Malt No.3~-$741154 QuaBfied in Nassau / S Cou ' Ganmission Expires 0 05 Signature o pplicant 336o6z TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ]FIREPLACE & CHIMNEY [ ]ROUGH PLBG. [ ]INSULATION FINAL ~P [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ] FlRE RESISTANT PENETRATION REMARKS: p DATE a ~ ~ ~ 8 INSPECTOR ~~ !~° ~ Z TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION REMARKS: ~t-'O''r i-¢.. Q DATE ~ ~/ ~ C ~ INSPECTOR ~ -~ - '~ 3300 ~ TOWN OF SOUTNOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [FOUNDATION 2ND ,[ ]\ FRAMING /STRAPPING [ ]FIREPLACE 8~ CHIMNEY [ ] RouGN F+LBG. [ ]INSULATION [ ]FINAL [ ]FIRE SAFETY INSPECTION [ ] FlRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION n~uwo~[c. 9 DATE ~~ ~ / - 0 ~ INSPECTOR `' i~ 33oa~ z TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION ,[FOUNDATION 1ST [ ]_ FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ] FIREPLACE A CHIMNEY [ ] FlRE RESISTANT CONSTRUCTION ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION REMORKSe DATE ~~ ~ ~~ INSPECTOR '~~ FIELD INSPECTION REPORT DATE COMMENTS ~~~~} ro ~ ~ FOUNDATION (IST) i0 ('Q' V ------------------------------------ (y" ~ i ~ FOUNDATION (2ND) ~~ ~y ~ z 0 S> U~ y ROUGH FRAMING & PLUMBING - `~ i~ --- --- ---- ----- 'x --_ -- f ~ INSUL TI - - ~" ~~ -" A ON PER N. Y. STATE ENERGY CODE n ?~ 1 ~J FINAL c~ r ' dv.- ~ ro. a m ~ _~ ~ ~ ADDITIONAL COMMENTS o-.2S-o'I /~ P Jt.~'. ~ 7~c o r~ m io- ~ ~ ~ i ~ ~~ --- ~- h n k ro - ~ ° ° z C - ,~ . _ -~ x d b y BY THIS CERTIFICATE OF COM~IANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET -NEW YORK, NY t 0038 CERTIFIES THAT Upon the application of upon premises owned by R.J. CORAZZINI ELECTRIC 320 RICHMOND LANE PECONIC, NY 11958, Located at 95 VISTA PLACE CUTCHOGUE, NY 11935 Application Number: 3045366 Section: Block: Lot: FREDERICK W. LUBANSKI 95 VISTA PLACE CUTCHOGUE, NY 11935 CertNicate Number: 3045366 Building Permit: BDC: ns11 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Basement, First Floor, Outside, Attic, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 17th Day of March, 2008. Name 42Y 13~ $tiSin¢ Citcuit TYl~ Ahrm and Emergency Equipment Sensor 1 0 Carbon Monoxide Sensor 3 0 Smoke Generator Portable Cowection 1 0 60a Appliance and Accasorks Air Conditioner 1 0 36.000 BTU Air Conditioner 1 0 30.000 BTU Paaets 1 60 11 Wiring and Devices Outlet 21 0 Fixture Fixture 3 0 Flotuescent Fixturo 18 0 Incandescent Outlet 37 0 General Purpose Receptacle 34 0 General Purpose _. ~ _ Switch 25 0 General Purpose _`~ -- ' , Paddle Fan 3 0 - _ sea/ Disconnect 2 0 60a Air Conditioner' Contlnuod on Nast Page 1 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the1ugation indjcated BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET -NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by R.J. CORAZZINI ELECTRIC 320 RICHMOND LANE PECONIC, NY 11958, Located at 95 VISTA PLACE CUTCHOGUE, NY 11935 Application Number: 3045366 Section: Block: Lot: FREDERICK W. LUBANSKI 95 VISTA PLACE CUTCHOGUE, NY 11935 Certificate Number: 3045366 Building Permit: BDC: ns11 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Basement, First Floor, Outside, Attic, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the lath Day of March, 2008. Name 4T_'1' B9[4 Reline Circuit 1Y~ Receptacle 6 0 GFCI Service 1 Phase 3 W Service Rating 150 Amperes Service Disconnect: 1 150 cb Meters: 1 seal 2 of 2 _ - This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indieatect. Town HaO, 53095 Mutn Road P. O. Box 1179 Southold, New Yak 11971 O si ,~ ~' ~l ~ ~' Fax (516) 765-1823 Telephone (518)785.1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N DATE s %'/ ~~0~ Buildingr~Permit No. .~ 3 4 ~ Owner: r rl q~ -^ ~ L It (,gyp ~A.v S ~.'. (please print) Plumberb ~,~ Ztc~S ~'tH• (please print) I certify that the solder used in the water supply systala contains lees than 2/10 of 13 lead. o~ . ~~ lutabere gnature Sworn to before me this r/ 3'~`~ day of ~~.1lJQ--- , -}~ ~~a Notary Public, ~Lr7-i'B-~.~ County JAMES J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631) 298-7116 Date: November 7, 2007 To: Town of Southold Re: Insulation Inspection Lubanski 95 Vista Place Cutchogue, NY 11935 Permit# 33006 To Whom It May Concern: An Insulation Inspection was preformed at the above mentioned property; all insulation was installed as per Plan and meets all State and local Building Codes. Any questions please feel free to call. `~\ Sincerely ,, ~ ~ \~ ~ James,~.~e~rkoski P.E. ~~ JAMES J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631)298-7116 Date: October 24, 2007 To: Town of Southold Building Dept. Re: Framing/ Plumbing/ Strapping Inspections Lubanski 95 Vista Place Cutchogue, NY 11935 Permit# 33006 To Whom It May Concern: A Framing, Strapping, Rough Plumbing inspection was preformed on the above property, and it is deemed that all this work was done as per plan and meet all state and local building codes. A pressure test was also performed on the lntire,plumbing system, and vent stack filled. Any other questions please feel free to c~11G ~ _ ~~~ ~ --- U ~~~ ~_ ~~ ~ 2s '~ _ L/ v ,; - -~ ~,~~ ~l ,JAMES J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631) 298-7116 Date: March 14, 2007 To: Town of Southold Re: Septic Survey Lubanski 95 Vista Place Cutchogue, NY 11935 To Whom It May Concern: This letter certifies that a septic survey was performed on the above mentioned property, and the existing system is in good working condition, and is more than sufficient to carry the new demands put upon it by the proposed addition. Any questions please feel free to call. P.E. ~3gd(p SlA1~E Uf' NEW YUKK i WORKERS' COMPENSATION BOARD CERTIFICATE OF PARTICPATION IN WORKERS' COMPENSTA'1'ION GROUP SELF-INSURANCE la. Legal Name and Address of Business Participating in Group Id. Business Telephone Number referenced box "la". Self-Insurance (use street address only) ~ _,_ Sunrise Builders East Inc. 631-734-7182 8500 Cox Lane ~ -- P.O. Box 1097 Cutchogue, NY 11935 Ib. Effective date of Membership in the Group: le. NYS Unemployment Insurance Employer Registration Number Trust Member # 4-1-07/08 / EC10051586 of Business referenced in box"la" 45-39554-1 I c. The Proprietor, Partners or Executive Officers are'. ^ Included (Only check box if all partners/officers included) If Federal Employer Identification Number of Business referenced ® All excluded or certain partners/officers excluded. in box "la": 11-3$34707 2. Name and Address of the Entity Requesting ProofofCoverage 3. Name and Address of Group Self Insurer. (Entity Being Listed as Certificate Holder) Elite Contractors Trust NY / CRM Frederick Lubanski 386 Violet Avenue 95 Vista Place Poughkeepsie, NY 12601 Cutchogue NY 11935 This certifies that the business referenced above in box "la" is complying with [he mandatory coverage Requirements of the New York State Workers' Compensation Law as participating member of the Group Self- Insurer listed above in box " 3" and participation in such group self-insurance is still in force. The Group Self- Insurer's Administrator will send this Certificate of Participation to the entry listed above as the certificate holder in box"2". The Group Self insurer's Administrator will notify the above certificate holder within 10 days IF the membership of the participant listed in box "la" is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for maximum of one year from the date certified by the group self-insurer. lfthis certificate is no longer valid according to the above guidelines and the business referenced in box "!a" Continues to be named on a permit, license or contract issued by the certificate holder, the business must provide the certificate holder either with a new certafcate or other authorized proof the business is complying with the mandatory coverage requirements ojthe New York State Worker Compensation Law. Under Penalty of perjury, I certify that I am an authorized representative of the Group Self-Insurer referenced above and that the business referenced in box "la" has the coverage as depicte d on this form. Certified By: Thomas Dickerson (Print name ofauthorized representative of the Group Self-Insurer) Certified By: ~ ~~ 06/13/2007 I (Signatu~ ~ (Date) Title:_ _president Telephone Number: 631-298-4700 ~ui`i ~ 5 GSI-105.2 (2-02) ACORD CERTIFICATE OF LIABILITY INSURANCE I??TE (MM/DD/VYYY> rM. `_ { 06113/2007 PRODUCER Phane. (631)298-4700 Fax'. 631498-3650 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ROY H REEVE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE'CERTIFICATE PO BOX 54 HOLDER. THIS CERTIFICATE DOES NOT ~LMEND, EXT p pR:~ MATTITUCK NY 11952 ALTER THE COVERAGE AFFORDED BY THE POLICIE •'~iOW. ~~ INSURERS AFFORDING COVERAGE NAIC # ( _ ___ - _ - INSURED SUNRISE BUILDERS EAST INC. INSURER A Preferred Mutual Insuran_ ce Company - -'~ ~ 15024 (INSURER B: PO BOX 1097 INSURER C CUTCHOGUE NY 11935 - - -- - -- - - - INSURER D: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANV 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 BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A LL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. IN$RI AOO C. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECirvE LTR IN$Rq POLICY EXPIRATIOx LIMITS DATE MMIDDM' DATE MMIDDIYY '. GENERAL LIABILITY II CPP0120501325 ~ 09129/06 09/29107 EACH OCCURRENCE I$ 1,000,000 X"COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ' PRE '$ 50 000 L _. _~ ! i CLAIMS MADE ~ OCCUR ~., . MIGEb_(Ea oc <nLe) _ MED EXP A ~ , t I L . ( ny one person) $ 5,000 A i PERSONAL BADV INJURY $ 1,000,000 I, II GENERAL AGGREGATE ;$ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMPIOP AGG. $ 2,000 000 ' POLICY I JECOT I LOCI __ __ _ _.. _..- _. , . ~' AUTOMOBILE LIABILITY I ' ' (COMBINED SINGLE LIMIT ~ ~, ANV AUTO I I I (Ea eccitlenq I $ ,ALL OWNED AUTOS II BODILY INJURY (Per person) $ I SCHEDULED AUTOS i - HIRED AUTOS ', RODILV INJURY I I NON-OWNED AUTOS _,I ((Per awidenp ___ $ . ~ -- - - -- _ --- - PROPERTY DAMAGE $ ' (Per accidenp ' ~, I GARAGE LIABILITY j AUTO ONLY-EA ACCIDENT ,$ ; i ANY AUTO I OTHER THAN EA ACC $ I I I _ AUTO ONLY: AGG '~$ E%CESS/UMBRELLA LIABILITY ' EACH OCCURRENCE $ OCCUR I _1 CLAIMS MADE -_ . '. AGGREGATE _ _ --. __ I$ $ DEDUCTIBLE ~ I $ ' ~ RETENTION $ $ WORKERS COMPENSATION AND ' WC STATU I OTHER TORY UMITS EMPLOYERS'LIABILITY l _ ' ANY PROPRIETORr-AflTNEfl/EXECUTIVf ~I I E L EACH ACCIDENT _. $ IOFFICER/MEMBER E%GLVOEDi E.L. DISEASE-EA EMPLOYEE ' $ ~,nyea, aeamue ~nem ~ -._-_ __. I IsPEaAL PflovISlONb below I E. L. DISEASE-POLICY LIMIT I$ OTHER: I I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONSADDED BY ENDORSEMENT/ SPECIAL PROVISIONS I:CK I IhIGA I C KULUtK CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE Frederick Lubanski , TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, 95 VISta PIBCe IT'S AGENTS OR REPRESENTATIVES. CUtchO Ue NY 11935 g Attentio AUTHORIZED REPRESENTATIVE h ~ n: T ek ACORD 25 (2001108) Certificate # 9916 ©ACORD CORPORATION 1988 IMPORTANT JIiIV i '~ If the certifcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. ,A statement on this certificate does not confer rights to the certificate holder in lieu of such endorse~ent(S): 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S (2001/08) Certificate #9916 REScheck Software Version 4.0.1 Compliance Certificate Report Date: 03/01ro7 Data filename: C:1Program Files\CheckU2EScheckUUbanski.rck Energy Code: Location: Constmdion Type: Heating Type: Glazing Area Percentage Heating Degree Days: Construction Site: New York State Energy Conservation Construction Code Suffolk County, New York Detached 7 or 2 Family Non-Electric 15% 5750 Owner/Agent: Lubanski Cutchogue, NY Designer/Contractor: James Deerkoski 631-298-7116 Ceiling 1: Flat Ceiling or Scissor Truss: 600 30.0 0.0 18 Skylight 1: Metal Frame with Thermal Break:DOUble Pane with 72 0.560 40 Low-E: Ceiling 2: Cathedral Ceiling (no attic): 400 30.0 0.0 14 Wall 1: Wood Frame, 16" o.c.: 1080 21.0 0.0 52 Window 1: Wood Frame:Double Pane with Low-E: 124 0.330 41 Door 1: Glass: 41 0.330 14 Floor 1: All-Wood Joist/1'russ:Over Unconditioned Space: 1000 38.0 0.0 26 The proposed building represented in this document is consistent with the building plans, specifications, and other calculations submitted with this permit application. The proposed systems have been designed to meet the New York State Energy Conservation Construction Code requirements. When a Registered Design Professional has ped and signed this page, they are attesting that to the best of his/her knowledge, belief, and professional judgment, such plans~lf cations are in compliance wkh this Code. _~ ~ r11~5 ~C~-l~5 ~~ V 3 4 07 Name -Title SignaW \\\ Da J Page 1 of 1 l~~Gn51c~ ~3- t- a \ 33u~ lP Erosion, Sedimentation ailll Storm-water Run-off Control Plan ASSESSMENT FORM Yes No A. Does this project meet the minimum standards for classification as an Agricultural Project. %' Note: If you answered. Yes to any of the above, aStorm-water,. Grading, Drainage 8 Erosion Control. Plan is not required. ------------------------------------------------------------------- ACTIONS. REQUIRING THE SUBMISSION OF ASTORM-WATER. GRADING, DRAINAGE & EROSION CONTROL. PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. Item Number:. (A Check Mark (J) for each question is required for complete application) Yes No 1. Will this project retain all Storm-Water Run-off generated on Site? (This. will include all run-off created by site clearing and/or coristmction activities aswell asap / ^ Site Improvements and the permanent creation of impervious. surfaces.) 2. Will this project require any land filling, grading or excavation where there is a change to the natural existing grade involving more than 200. cubic yazds of material within any pazcel? 3. Will this application require. land disturbing activities. encompassing an azea of five thousand (5,000). square feet of Bound surface or more? 4. Is there. a Natural Water course running through the site or is this project within One hundred (100) feet of wetlands or a beach? 5. Will there be site preparation on slopes which exceed fifteen (15) feet of vertical rise to One hundred (100) feet of horizontal distance? 6. Will driveways,. parking azeas or other impervious surfaces direct Storm-Water Run-off into and/or in the direction of a Town Right-of--Way? 7. Will this application require the placement of material, removal of vegetation and/or the construction of any item within the Town Right-of--Way or road shoulder area? (This item does not include the installation of driveway aprons.) 8. Will there be site preparation within the one hundred (100) year floodplain of any watercourse? ~ / Note: If any answer to questions one through. eight is answered. with. a check mark in the Box, aStorm-water, Grading, Drainage & Erosion Control Plan is required and must be submitted for review prior to issuance of any building permit. STATE OF NEW YORK, ~ COUNTY OF....~.,).i-.(~.1..aG, That l, ...L'.9k0~.~~/.....C-`!.~~~A.^(5..~.!.. (Name of individual signing Document) And that He/She is the .........~.C.V NE~Q,. to Owner and/or representative of the Owner or O and file this application; that all statements con work sill be performed in the manner set forth Sworn to before me this; ......... ~. ~.. - ................day of ... Notary Public: ....1J.~.. ~~:... . MEL~I~l~I~ NOTARY PUBLIC SI No. 01Db4i Oual(fied in Suf t'artsrdssiolt E~ires St ss .................. being duly sworn, deposes and says that he/she is the applicant for Permit, ................................................................................................................................... caner, Conhac[or, Agent, Corporate Officer, etc.) wner's, and is duly authorized to perform or have performed the said work and to make twined in this application are tore to the best of his knowledge and belier; and that the in the application filed herewith. ............ . OROSIO (StgnatureofA plicant) YMII U ~ - _ a. n. arm #.L_`C~_ o1L ~c T o ~- -. -~. •f it 1 ]ci L, i >'"~M: 22,440 ;,q. ft. o cry .. ' So, ui.c .., ~~ ~ p a I ~ w... Sp• ... -ha>.c 4( ,~ r,9. .e1.~~w~+' ~; ' ~. .a Z !~ I ~.. UI ~ tshcal w --- 3y' ;... ~ yy 9arvyf - 3 ~ .~ ' Si ~d~ j~a FS a ~I. ~ n ' - 4„`77 :i ~ . i - ' _. ~ _ _. ; r. '7'. ~; ml u ~ ~ ;, m ~., ~ - ; ~ Q. in '' ~ ' ~'% ,~~' ~ acaLe ~ ~`7'i i 1 YS r .. ~{ d,". FPiDZ.Ert ,. ~ Ti. rr k~~ 0 ~. v~' . t. f ~ 1 CpYlVH{M~ ~~"~~~~ C f6~ ! /.. r-~. L:L-s Ms~F' OF LaT h iE~#BGJ-! f3~(G.LS AT GLITGNOt5t,lE'~~ -~D11c co F;te nail. nh.~) c ' RDR•,A1Nv/-OYAL O1 GONiTRDGTION ONLY ''• ; ~~.~ h ,; '. ry ¢ 3 k~s, "" 1-4- SO- 16 v, nI s•s .: ItRPltc#ED: < '[0 DiR swvn Is w nu , "~ OllpOv S• ~ ~@'IIQV )M/ q fMF Xfw YJ C -A.! (YQCa,r'l'j UFAT1oN lAW, fJU C n s... L 1 1" ..vA? Sd= STAM Cx,anan-Im~cl ~ ~FGre n ~~ rt~n-i '{! SEAL CUmmoH wsalNi C,nr,,d T /er 1'. -. ~i ~~f,~e=. RODEIq CK MAN TUYL. P. C. ~. 1~4.__..~ •. ~ t UC. UNO fU RVfYORf~6R RT, N. Y. - THE WATER SUPPLY AND 9Ew4L-F. DIf POML fY6T6Mf POR THIS RE61~ DENCE Will. CONFORM TO THE STANOAf106 OP SUFFOLK GO. OFFT OF HEALTH. BERYICE3. (f 1 _~.. APPLICANT