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HomeMy WebLinkAbout35615-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEP~RTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-34689 ~te: 11/19/10 THIS U~4(TIFIEM that the building ALTERATIONS Location of Property: 40 THE SHORT LA EAST MARION (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 30 Block 2 I~t 12 subdivision Filed Map NO. -- Lot NO. -- conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 19, 2010 purs,,mnt to which Building Pexetit No. 35615-Z dated JVJNE 4, 2010 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 KITCHEN AND BATH ALTERATION IN AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to JOHN S & MARIA V DOOLEY ( OWNER ) of the aforesaid building. SUFFOLK CO~]TY DI~PARTM~r OF HEALTH APPROVAL ~.Rt-I-KICAL ~a~KTIFICATH NO. PLU[~ERS C~K'rIFICATION DA'r~u N/A 35612 08/13/10 10/17/10 JOHN ERICKSON '~A/r~zd/Si~gture Rev. 1/81 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUII~ING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 35615 Z Date JUNE 4, 2010 Permission is hereby granted to: JOHN DOOLEY PO BOX 161 EAST MARION,NY 11939 for : ALTERATION OF A KITCHEN & BATH IN AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR at premises located at 40 THE SHORT LA EAST MARION County Tax Map No. 473889 Section 030 Block 0002 Lot No. 012 pursuant to application dated MAY 19, 2010 and approved by the Building Inspector to expire on DECEMBER 4, 2011. Fee $ 200.00 ORIGINAL Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANC~ ~/ ~iOVi~,:~ This application must be filled in by typewriter or ink and submitted to the Building Depa~tme~ · J _. BLDG. A. For new building or new use: I~ TDwN.,OF $OgTHOLD 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 PI.arming 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 Certifieate 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 $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $I00.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, C~al $15.00 ~N'NJDat'6. IJJqJ,o New Construction: Old or Pre-existing.Build~ng: Location of Prope~· , House No. Street Owner or Owners of Pro~ ~1 Suffolk County Tax Map No i000, Section ,.~ Date of Permit. Filed Map. Applicant: ision Underwriters Approval: Health Dept. Approval: (checkone) Hamlet Lot Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ Final Certificate: (check one) 'l'omt 1 fall Annex 3137,5 Main Road P.(). Box 1179 S(mlhold, NY 11971-09,59 IH ~ILI)IN(; I)EPARTMENT TOWN OF $OUTHOLD Telephone (631) 76,;-1802 l"ax (631) ro.qer, richert~town.southold.n¥.us CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: J & M Dooley Address: 2165 The Long Way City: East Marion St: NY Zip: 11939 Building Permit #: ~) (y, t"~- Section: 30 Block: 2Lot: 12 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Janon Gen Cont License No: 31505 SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY ServiceServicelph ~ Heat3 ph Hot Water ~ Duplec Recpt ~ Ceiling Fixtures ,,]~ HID Fixtures ~GFCl Recpt Wall Fixtures Smoke Detectors Main Panel NC Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel NC Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances D~,er Recpt Emergency Fixture Time Clocks Disconnect Switches Twist Lock Exit Fixtures L.~ TVSS Other Equipment: 1 oven, 1 cook top, 1 exhaust fan Notes: Inspector Signature: Date: Aug 13 2010 81-Gert Electrical Compliance Form Town Hall Annex S437S M~in Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631 ) '165.1802 Fnx (63 I) 7~$-~502 BUILDING DBPARTMENT TOWN OF 8OUTHOLn CERTIFICATION Oate:17- Building Permit No. 3 ~ ~ I '~" (Please print) Plumber:7~r0 [4r~ ~'1'~? (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. Sworn to before me this /~ dayof ~&7'~, , 20/0 ~ot~'~" ,(~,~& ~ County (Plumbers Signature) TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL []FIREPLACE&CHIMNEY [ ] FIRE SAFETY INSPECTION ~]] FIRE RE,ISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE INSPECTOR INSPECTIO N [ ] FOUNDATION 1ST [~-]-R'OUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING / STRAPPING [ ]FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT C0~UCTK)fl [.]FIRE REACTANT PENETRATION DATE INSPECTOR_~~-~? TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTI? ON [ ] FOUNDATION 1ST [/,,~"R~H PLBG. [ ] FOUNDATION 2ND [,~]~INSULATION [ ]FRAMING / STRAPPING [ ] FINAL [ ]FIREPLACE & CHIMNEY [ ] FIRE~A~'ETY INSPECTION [ ]FIRE RESISTANT CONS[RUCTION [~,,,.3~IRE RESISTANT PENETRATION REMARKS: ~/~~~- INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]FIRE RESISTANT CONSTRUCTION [ ]ELECTRICAL (ROUGH) REMARKS: [ ] ROUGH PLBG. [ ]INSULATION [ ]FINAL [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT I:ENETRATION ~;LECTRICAL (FINAL) DATE ~/~/~ INSPECTOR~-------~=~~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROU~/~G. [ ] FOUNDATION 2ND [ ]~JI. ATION [ ] FRAMING/STRAPPING [~/]~FINAL DATE ~ INSPECTOR TOWN OF SOUTHOLD BUILD,~NG DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown. NorthFork.net Examined ~ ,20 fid Approved ~ ~ ~t_ ,20 /tO Expiration /O'~-~- ~ ,20 {I MAY 19 2o10 BLDG. DEPT. a. Thl§V~b~q f, fliltil~IIMUST be PERMIT NO. BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying'? Board of Health 4 sets of Building Plans Planning Board approval Survey Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Form Contact: Mail to: Phone: Building Inspector APPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS 20/o :ompletely 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. f. Every building permit shall expire if the work authorized has not commenced within 12 months after 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. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance ora 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. ,, (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises ~ ~/,,~ S~ ~ /4//4/' ,'q '~ ~'o //o~ (As on the tax roll or latest dee'fiN If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License 1. Location of land on which proposed work will be done: RI 6 S- 'r e go.i,_), 0 House Number Street -" Hamlet County Tax Ma,~,No. 1000 Section ..30 Block c~ Lot /2...--- Subdivision (/e b 6 ]C° {~x~"~¢d ~9,~,,! 5, Filed Map No. ~,,.~t ~. ~ Lot / / 4. Estimated Cost ,~t,~ ~ 5. If dwelling, number of dwelling units If garage, number of cars State existing use and occupancy of premises and intended use and occ~,~ ancy of proposed construction:' a. Existing use and occupancy ~/~"~/-r' O,~,a {~ ~..,, / b. Intended use and occupancy ~, ,/-' ;/-t° O,,~ /-~r'/ Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work~ (Description) Fee (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Rear Depth Height. Number of Stories 9. Size of lot: Front 10. Date of Purchase Dimensions of entire new construction: Front Height Number of Stories Rear .Depth Rear .Depth /'~ '? Name of Former Owner 1 1. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO J 13. Will lot be re-graded? YES __ NO M/Will excess fill be removed from premises? YES__ NO J 14. Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor ffl~l,:'~ T"~O/,,r',,'~r? Address I-/d.~,.Jy~J- ~ctPhoneNo. ~31' 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES __ NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland7 * 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. 18. Are there any covenants and restrictions with respect to this property? * YES__ NO ~ · IF YES, PROVIDE A COPY. STATE OF NEW YORK) COUNTY OF _'~ ~/')y / C ~',8't°/ ~/fil:9/' .,~'//,~ ~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (Contractor, Agent, Co¢orate Officer, etc.) of said owner or owners, and is duly authorized to perfo~ or have performed the said work and to make and file this application; that all statements contained in this application are tree to the best of his ~owledge and ~0~ ~t the work will be perfo~ed in the manner set forth in the application filed therewith. No~ Public, State of New mr= No. 01BU6185050 Sworn tq before me this /C4.~ day of ~k,~6v~ 20 IO Notary Public Qualified in Suffolk Count,j Commission Expires April 14 ~""'Signature of Applicant . Town of $outhold Eros;on, Sedimentation & Storm-Water Run-off A_~SESSMENT FORr.'. Item Numbec 1 2 3 '4 5 6 · .... ~ a" ' u'~'u~ ~zeme~ oY site cleadng and/or caostmc~on actMites as well es all $1ta Improvements and the permanent creation of Impe~fous surfocas.) Does the ,Site Plan and/or Su~ey Show AJI Pmpnaed Drainage Structures Indfoatlng Size & LesaOon? ~ r~ This Item shall Include al Proposed Grade Changes and Slopes Co~lrelllng 8ur~ca WatefFIowl Will this Project Require any Land Filling, Grading or Excava~,l where 6'rare is a change to the Natural r~. Existing Grade InvoMng more than 200 Cubic Yards o( Material withio any Parcel? Wifl this/~opllcetfon Require Land Disturbing Ac6~tes Enoompessing an Area In Excess of Five Th0esand (5,000) ,~quare Feet of Ground Surface? Is them a Natural Water C~ume Running through the Sita? . Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach? ~.' Will the?e be Site preparation on Existing G~ade Slopes which Exceed Fifteen (15) feet of Vertical Rise to One Hundred (100') of Horizontal Distance? 7 Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off into ancFor in the direction of a Town right-of-way? 8 Will this Project Require the Placement of Material, Removal of Vegetation and/or the Construction of any Item Within the Town Right-of-Way or Road Shoulder Ama? (This Item Will NOT Include the Instaltattun of Driveway Aprons.) 9 Will this Pr°jec~ Require Site Preparation within the Oas Hundred (100) yeor Floodplain of any Watercoume? [~ NOTE: If Any Answer to Questions One through Nine Is Answered with a Check Mark In the Box, a Storm-Water, Grading, Drainage & Erosion Control Plan Is Required and Must be submitted for Review Pdor to Issuanee of Any Building Permifl EXEMPTION: Yes No Do.e. s this project meet Ute minimum standards for classification as an Agdcu#oral Project? Note: If You Answered Yes to this Question, a Storm-Wofor, Grading, Drainage & Ereelee Control Plan is NOT Requlredl b~ATE OF NEW YOP, K, / / co,s ............. ss .................................................................... mg y , poses aha s~ys ~ h~s~' ' t for Permi Owner and/or represen~ive of the Owner of Owner's, and is duly au~hori~l ~o perform or have performed ~he said work and ~0 make and file this application; flat all statements contained in this application are tree ~o the best ofhis knowledge and beJiel~ and that file work will be performed in the manner set forth in the applicalion filed herewflh. Sworn to before me this; (s~au~ ~ N~or~an~) Town Hall Annex 54375 Main Road P.O, Bo~ 1179 Soufl~old, NY 11971-095~ Telephone (631) 765-1802 roger, richertdt~w(~J~gu~l~o~, ny. us BUILDING DF~PARTMENT TOWN OF SOUTHOLD APPUCAT[ON FOR ELECTRICAL gNSPECTgON REQUESTED BY: Date: ~,~//¢'/a. Name: do e.,¢~,.- ~' ~./~~'~/'~"' ~ '. ~ ~ ~' Li~nse No.: ~ ~ ~ Address: ~ ~ ~ ~ ,~ ~,// Phone No.: ~( ~O~ - ~ ' ' JOBSlTE INFORMATION: (*lndi~tes required information) *Name: q~k~ ~ ~, ~ ~/~ ~ *Cross Street: ~,) ~ ~ *Phone No.: ~ ~/ ~ ~ ~ ~ ~ Pe~it No.: Tax Map Distd~: 1000 Section: ~O Block: ~ Lot: *BRIEF DESCRIPTION OF WORK (Please Pdnt Cleady) ~ ~ /c-/.~/ c~ ./~--~ .7~_c~,~..~ (Please Circle All That Apply) *Is.job ready for inspection: *Do you need a Temp Certificate: Temp Information (If needed}. *Service Size: I Phase 3Phase 100 *New Service: Re-connect Underground Additional InfOrmation: YES / NO Rough In YES / NO Final 150 200 300 350 400 Other Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form Town llall Amwx ,5 i375 Main Road P.O. Box 1179 Nouthokl, NY 11971-0939 Tclcl)honc (631) 765-1802 Fax (631 ) 76.i-9502 1½1 IlIA)lNG I)EI~ARTML'NT TOWN OF SOUTHOLD September 21,2010 John Dooley PO Box 161 East Marion, New York 11939 RE: 40 The Short Lane, East Marion TO WHOM IT MAY CONCERN: The following items are needed to complete your Certificate of Occupancy: Application of Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of $25.00. __ Final Health Department approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) __ Final Planning Board approval. __ Final Fire Inspection from Fire Marshal. __ Final Inspection from the Building Dept. __ Final Landmark Preservation approval. Building Permit: 35615-Z kitchen and bath alteration To~q~ llall Annex 54373 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telellhlme (631) 76,5-18(12 Fax (631) 76,5-9502 BUIL1)ING 1)EPARTMENT TOWN OF SOUTHOLD November 8, 2010 John Dooley PO Box 161 East Marion, NY 11939 Thank you for your $25.00 check and plumber's solder certificate, but we did not receive the Certificate of Occupancy application. I've enclosed another for you to complete. TO WHOM IT MAY CONCERN: --,~ Following Items Are Needed To Complete Your Certificate of Occupancy Application of Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of $25.00 Final Health Department approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) Trustees Certificate of Compliance. (Town Trustees #765-1892) Final Planning Board approval. Final Fire Inspection from Fire Marshal. Final inspection from the Building Dept. Final Landmark Preservation approval. Building Permit: 35615-Z kitchen and bath alteration STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKE~' COMPENSATION INSURANCE COVERAGE la. Legal Name and Addr~s ~ Inmted (Use ~ adar~s only) Jaa~ C, cmral Comrac6ag Co~. PO Box 439 Farmingvill~, NY 11738~439 Work ~ of ~ (Only required ~ co~erage is ~pecifically tirnlted to certain Iocath~ns in New ~ State, i.e. a Wrap-Up policy) (631)806-7352 Number of Imur~l Id. Fe~kwal F, mployer I~ Numb~ of ]mural or Soc~l 8ecudO ~umber 53095 Rout~ 25 Souflmld. NY 11971 112209856 ~b. p~y N~ d m6ty I~d in box "la~: 46-822051-01-01 I~ 3A on the INFORMATIONAL PAGE e~ Ihe worke~' ~m,~maflom Imnu m~e ~ ~ ~ C~ ~ ~ ~ a~ ~ ~ ~* C~ ~ I~ m ~ ~ ~ ~ve ~ ~ ~fim~ ~M~ ~ ~ "2". T~ l~u~e ~r ~ll ~o ~ ~ ~ ce~ ~M~ ~ 10 ~ IF a ~ ~ c~ ~ ~ ~ ~pmm~ or ~ 30 ~$ IF I~re a~ r~ o~r ~ ~nt of pmm~ ~ ~el t~ ~ or e~ ~ ~4~ ~m ~ ~zmge ~ ~ tha ~. (~ ~ace~ ~ ~ sent by ~g~r ~iL) ~t, ~ C~ ~ ~ for ~ y~ ~ ~ f~ ~ ~ ~ ~ n~ i~ ~ ~ ~v~e ~ ~ic~ ~ ~ f~. A~ by: ~ by: ~~" ~19~10 Au~ ~ve C-105.2 MASTER ELECTRICIAN ROBERT D WEDDERBURN $1505-ME /2002 ~"=" ~ 0~01/20t0 t99 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE KEEVILY,SPERO-W HITELAW INC. 500 MAMARONECK AVENUE HARRISON NY 10528 POLICYHOLDER J EKSTROM & SON INC 200-14 EAST 2ND STREET HUNTINGTON STATION NY 11746 CERTIFICATE HOLDER TOWN OF SOUTHOLD 54375 ROUTE 25 SOUTHOLD NY 11971 POLICY NUMBER CERTIF CATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE G 1246 244-6 ~ 82743 05/01/2010 TO 05/01/2011 5/6/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1246244-6 UNTIL 05/01/2011, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 05/01/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 30 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLYANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U-26.3 NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:l/www.nysif, com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 167575860 ACORD. CERTIFICATE OF LIABILITY INSURANCE I l- os/o6/zolo ~oouc;~ (631)434-1000 FAX (631)434-7605 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Omni Risk Hanagement, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 308 Nest f4ain St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 100 Smithtown, NY 11787 INSURERS AFFORDING COVERAGE NAIC # ~su~ ~. EKSTRON & SON, TNC. ~NSURER~: Harlesyville Zns Co. 200-14 East 2nd Street INSURERS: The State Insurance Fund Huntington Station, NY 11746 ~NSURERC: First Rehabilitation Life /ns INSURER D: I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO "I~E INSURED NAMED ABOVE FOR ~'IE POLICY PERIOD INDICATED. NO~NI*~'ISTANDING ANY REQUIREMENT, TERM OR CONDmON OF ANY CON*I~RACT OR O~.tER DOCUMENT WITH RESPECT TO WHICH THIS CER~FICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. p.TRN~dR~T~I~EOf:INSURANCE P(~.JCYNUM~FJ~ ~)~T~iMIM/I~p~'~ ID~TI~i~MA:)p~fyyI UMI~ C~NE&U.U~mUT¥ MPATM4231 12/03/2009 12/03/2010 EACH OCCURRENCE $ 11000100( DAMAGE TO RENTED ~- COMMERCIAL GENERAL LIABILITY PREML~ES (Ea oc~ce) '-- -7 CLANEUADE [] OCCUR MEOEXP IAnyo~e~'so~) $ 51OO( A PERSONAL & ADV INJURY ~ Contractual Liab GENERAl. AGGREGATE $ 2,000,00~ PoL,cY jE , Loc Au~oa~u~u'r-,, BA7M4231 12/03/2009 12/01/2010 COm~.EDS~NOCEC~rr ANY AUTO (Ea accident) 1,000,00( ALL OWNED AUTOS BODLY INJURY ~- SCHEDULED AUTOS (Per PecE°~) $ A X HIRED AUTOS BODEY INJURY X- NON.OWNED AUTOS (Per ecc~d~mt) $ __ PROPERTY DAk~GE X~ OCCUR ~ CLAIMEMADE BE7H4231 12/03/2009 12/03/2010 AGGREGATE $ 1,000,0OC A om ---- RETENT~N $ 10, $ 0 OFFICER/MEMBEREXCLUDED? j ~ DERED DIRECT FROI, I SIF EL EACHACCIOENT ~PY~ate D~sab~lity DBL 99571 04/30/2006 Continuous until cancelled C CERTIFICATE HOLDER CANCELLATION Town of Southold 54375 Rt 25 Southold, NY 11971 ACORD 25 (200910t) Robert Hastranton~o/CS © 1988-2009 ACORD CORPORATION. All Hghte reserved. The ACORD name and logo are registered marks of ACORD B.P. ~ BUILDING PERMIT EXAMINER CHECKLIST Applicant: Architect/Engineer: SCTM# 1000- Property Address: ~" [ (~ '-~- Building PermRs (Open/Expired): BP ~-Z/UOZ- ~ Info: BP~-Z / C/0 Z-~, Info: BP ~ -Z / C/0 Z- , ~fo: S~gle & Separate Search Required? Y o~Determination: ~Q. ~t Size: ~ . ACT. ~t Size: ~Q. Front ~ ACT. Front ~ ~QSide ~ ACT. Side *Date Submitted: :~- Iq ~' lO Date Reviewed: (- t{-_ · --~ Estimated Cost: ~770.~ oo0, Subd~ws~on: -~ ~-~b6) ~- ti Zone: ~ Conforming? City: ~-a~ ~~ Pre COs? BP -Z / C/O Z- , Info: BP -Z / C/O Z- , Info: _ REQ. Lot Cov. - REQ. Rear ACT: Lot Co .V7-'~ - PROP. Rear Project Description: ~t~j~ e Waterfront? Y or~? If yes, water body: ~ Panel# Flood Zone: ~'- Bulkhead/BluffDistance: ADDITIONAL APPROVALS REQUIRED Suffolk County Health: Y or~- If yes, *Bed//: *Date: / / . *Permit#~ - If no, certification required: Y or N Received: Y or N By: NYS DEC: PRg-DEC 9/1/75 Y or~ Date: Southold Trustees: Y or~ Date: /__ Southold ZBA: Y o~ Date: / /__ Southold Planning: Y o~- Date: Town Landmark C of A: Y o&TE: __ Town Septic: Y c~ / / Permit #: or NJ Letter- Notes: / Permit #: or NJ Letter - Notes: Permit #: - Notes: /Permit #: - Notes: // *NYS CODE Compliance (page 2): Y or N Fee Structure: Calculation.'. Foundation: SF 1. ( First Floor: ~,~0 ,~' SF Second Floor: SF ')ther: SF 2. ( oral: ~-o,5' SF SF)- ( SF)- ( .SF)= SF X $__=$ + Initial Fee: $ + Additional Fee ( ): $ .SF)= SF X $__=$ + Initial Fee: $ + Additional Fee ( ): $ oo TOTAL:$ ~0' oo NEW YORK STATE CODE COMPLIANCE CHECKLIST CLIMATIC/GEOGRAPHIC DESIGN CRITERIA: · Grollnll Snow Load: i~0 Wind Speed: I20MPH .. Seismic Design Category." B .... Weathering: Severe __ . ·Frost Depth: 36" __ Termite: M-H' Decay: S-IV[ _ .. Design Temp: I 1 ' Ice Shield Underlay: YES . Flood Hazai'ds: USE/OCCUPANCY CLASSIFICATION HEIGtlT/FIRE AREA: TYPE OF CoNsTRucTION: DESIGN CRITERIA: ENGINEERED/pREscRIPTiVE FULL FP,/AIvlING DESIGN ELEMENTS: Y/N HEADERS: Y,q'q WALL STUDs: Y/N CEILING JOISTS: Y/N FLOOR JOISTS: YfN LUB{BER SPECIES AND GRADE: Y/N GIILDERS: YfN ROOF RAi~ERS: Y/N WINDOW AND DOOR SCHEDULE: .M[ISSLE TEST REQUIREMENTS: Y/N EGRESS 5.7 S.F.: Y/N LIGHT 8%: Y/N '~rENT 4%: Y/N NAILING/CONSTRUCTION SCHEDULE: Y/N MEANS OF EGRESS: Y/N PLUMBING RiSER DIAGRAM: Y/N LOCATION OF FI1LE PROTECTION EQUIPMENT: Y/N TRUSS DESIGN: Y/N CERTIFICATION: Y/N ENERGY CALCS: Y/N TOTAL COMPLIENCE? Y/N (RETURN TO PAGE ONE) (voconl) TITLE NO 77-S-01749 ii NO 0~££UN65 YOUNG & YOUNG PLUMBER CSRTIFtCATION ©N LEAD CONTENT BEFORE ~ C: ER TIFICA TE~OF OCCUPANCY ~OLO~ ~ ~ WA TEe ~E~ :EEU 2/t0 OF 1% ~EA[~ PLUMBING ALL PLUaS~NG W~TE & WATER LINES NEED ~E COVERING 765-1802 8/~1 TO 4 PM FOR THE~-/ FOLLOWING INSPECTIONS: --- ~ I ~ fecUNDATION - TWO REQUIRI=u ~ "~ ~U.EO CONC.E~ ROUGH- F~NG' '~-~ -- REQUIREI4ENT$ ~_~y~ ~; Kathleen Fredrich, Sales & Design })hone: 631-957-6810, Ext. 119 / Fax: 631-9fi7-7~65 Approved r ~ _ ~ j~ ~r~<-- --- DOOR-NH D~R-NH [ 43" i,. ~f ~5~z~i .~.. ~."~ ~.¥' ~' [ ' 12~6~ST-R ' I [ 12~636ST-[ DEP3W SB30B Tras¼ CVTRMS Ii J ,, i · ;~ - ~" ~* ..... 4- 30" '/ 40 ' Note: Any rendering is an artistic Designed :2/23/2010 ~ .~ appearance of the room h is