Loading...
HomeMy WebLinkAbout40123-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT y. Me TOWN CLERK'S OFFICE o . 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#: 40123 Date: 9/28/2015 Permission is hereby granted to: R17 Corp 578 Seaman Ave Baldwin, NY 11510 To: make interior demolitions to an existing single family dwelling. A building permit will be required prior to commencing any other work. At premises located at: 1285 Marratooka Ln SCTM #473889 Sec/Block/Lot# 115.-4-33.3 Pursuant to application dated 1/1/1900 and approved by the Building Inspector. To expire on 3/29/2017. Fees: DEMOLITION $100.00 Total: $100.00 7tz Building Inspector TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 r Survey SoutholdTown.NorthFork.net PERMIT NO. ©I Check Septic Fonn N.Y.S.D.E C Trustees C.0 Application Flood Permit Examined A 20 Single&Separate Storm-Water Assessment Form I, Contact: �'}} r Approved 20 Mail to:—Y Disapproved a/c t � �� &Ime si�/CGLY« Phone: Expiration 20 v� �L ? Building Inspector APPLICATION FOR BUILDING PERMIT f Date 4 ,20 I Cj 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. 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 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 sr e in described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and egula ons,and to admit authorized inspectors on premises and in building for necessary inspections. of apph ant or name,if a corporation) ID C( ei(/myx ,V %l^ euT (Mailing address of applicant) LL State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises Ar1f0 (D %�vB ewa (As on the tax roll or latest deed) If applicant is a corporation signature of duly authorized officer �GL(1PiG�G',4�1i26� (Name and title of corp r to officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. • _ p 1. Lti$oof land on whic pro osed work will be doneG ��(%l��-til �y House'�1umb�a�' Street 1�,� � Hamlet s ,Coimty,Tax.lVlapNo. 1000 Section Block Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and iWeij.ded up and occupancy of proposed construction: a. Existing use and occupancy �R esL b. Intended use and occupancy 3. Nature of woreck which applicable) New Building Addition Alteration Repair Q�,, Removal Demolition Other Work LID /t (Description) 4. Estimated Cost OP5000• Q0 Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units 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 Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zesning law,ordinance or regulation?YES_NO 13.Will lot be re-graded?YES NO I AA Will xces fill be removed from premises?YES NO Ell-14.Names of Owner of premises Address Phone No. (f 6 4-7 Z(46 Name of Architect Address Phone No Name of Contractor CL( pw Address I LVq Phone No. 6)$25 BB5'V Rehr/(�3mwcvk) A/1 c. R C3GkiLQ.w a'B A—ve— vice v<-(-I 2j, 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 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. 18.Are there any covenants and restrictions with respect to this property?*YES NO *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF K joaP46L J wqq_a being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (Contractor,Age t,Corporate Officer,etc.) of said owner or owners,and u iorized 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. TRACEY L. DWYER Sworn tqq.�before me this NOTARY PUBLIC,STATE OF NEW YORK )4tn day of ( 2015 NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY Uj Notary Public Signature of Applicant IRES JUNE 30,2-0)g ACIORIDO CERTIFICATE OF LIABILITY INSURANCE 4/14/2015) 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(les)must 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 Lorena Amoroso NAME: Dinegar-Schneider-Reaccuglia, Inc PHONE IC_ (718)423-1300 FACNot,(718)423-3175 2577 Francis Lewis Blvd E-MAI ADDLRESS: genc lorena@dsra corn rn INSURERS AFFORDING COVERAGE NAIC# Flushing NY 11358 INSURERA:Tudor INSURED INSURER B: M.marin Restoration Inc INSURERC: 1089 Rockaway Avenue INSURER D: INSURER E: Valley Stream NY 11581 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1541415505 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 ADDLTYPE OF INSURANCE JNSR SUER POLICY NUMBER MM/DY D/YYYY MMIDDCY EFF � LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE F_x]OCCUR LIPP8252589 /24/2015 /24/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acad.nt $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ P HIRED AUTOS AUTOS er accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE —] N/A NIA E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF SOUTHOLD BUILDING DEPARTMENT 54375 RTE 25 AUTHORIZED REPRESENTATIVE SOUTHOLD, NY 11971 Andrew Reaccuglia/LOR --- + = ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 t9ninnsi m The Ar(iPn nomc and Innn arc rcnic4crcrl mnrlrc of A(`()Rr1 New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,2ND FLR,MELVILLE,NEW YORK 11747-3166 Phone (631)756-4000 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^A A^^ 113380021 M MARIN RESTORATION, INC 1089 ROCKAWAY AVENUE VALLEY STREAM NY 11581 POLICYHOLDER CERTIFICATE HOLDER M. MARIN RESTORATION, INC TOWN OF SOUTHOLD 1089 ROCKAWAY AVENUE BUILDING DEPARTMENT VALLEY STREAM NY 11581 54375 RTE 25 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE H1274 343-1 769716 04/08/2015 TO 04/08/2016 5/7/2015 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO 1274 343-1 UNTIL 04/08/2016, 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 SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 04/08/2016 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 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 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 J, DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cerUcertval.asp or by calling(888)875-5790 VALIDATION NUMBER,416744574 U-26.3 STATE OF NEW YORK ANIO KERS'COMPENSATION BOATED CERTIFICATE OF INSU ArNCE COVERAGE LJNDER THE NYS DISABILITY BENEFITS LAW PART I. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier Ia. Legal Ntune and Address of Instured([Tse street address only) ib,Bxrsirless Teleplioue Ntuuber of Insured M. MARIN RESTORATION INC. (516)825-8850 1089 ROCKAWAY AVENUE Ic.NYS Unemployment Insurance Employer Registration VALLEY STREAM, NY 11581 N-mnber of brsuivd. 1 d.Federnl Employer Identification I`himber of Imired Or Satcial Stem itv NumN% 113-38-0021 2. Name mid Address of the Entity Requesting Proof of 3a.Name of Insurance C alTier Coverage(Entity Beurg Listed as the Ceifificate Folder) NEW YORK STATE INSURANCE FUND Town of Southold 54375 Rte 25 3b.Policy riTtunber of entity listed ut bas"1a": Southold, NY 11971 DBL 5030 01 - 1 3c,Policy etTective period: 04/08/2015 to 04/08/2016 4.Policy covers: a.[@ All of the employer's employees eligible strider the New Yoik Disability Benefits Low b- El Only the follo%viug class of classes of'he eirtployer's eiuployees: Cinder penalty ofperjury,I certify that I ani an authorized representative or licensed agent of the insurance cannier referenced abo%v- and that the natued insured has NYS Disability Benefits insurance coverage as described above Date Signed 05/7/2015 By Joseph J Masi PgreYure of irruranm m rner's authonzed represertatrie of NYS itoereed imura rce Agara of that irmuranae m mer) Telephone\Tumber, (866)697-4332 Title Director of QisabiIity Benefits Insurance MWORT:'N—T. rfbox"ala"is chcAcd,aad tl3is form is sinned b4 vLe Licensed Uteuxanee Agan of that carrier,this cepificnte is CQb1PLETE. '.VWl it directly to the certificate bolder. lfbos"4b"is Cltecked,thus M&Iif nld is NOT COMPLETE for purposes of Section 210.SiM,8 of die Disability Beftefts Law. 1t must be retailed for completion to the Woffl ew Compensation Board,DB Plans Accepiance Unit,20 Pak Street.Alttiimy} Naw Yolk 12207. PART 2.To be completed by NYS Workers!Compensation Board)(Only If box'14V'of Part I has been checked) State Of New York Workers'Compensation Board According to mfonnatiou waitnained by the NYS Worken'Compensation Baird.the above-ranted wiplo}ger has coaVhed evith the NYS Disability Benefits Lew with fespeet to all of lriAker employees. Date Sijared By (Sitniatnre ofR'YS workers'Cotupoisation Board Employee) Telephone Number Title Please Note:Only insumuce caniers licensed to v-ite NYS disability benefits in-ntrnnce policies and NYS licensed insurance agents of those illsurtltce carriers are authorized to issue Foran DB-120.1. Insurance brokers are NOT authorized to issue this form. Certificate Number 321365 Additional Thstruct1o11s for Folm DB-120.1 By signing this form,the mi strance carrier identified in box"Y' on this form is certifying that it is insuring the business referenced in box"la"for disability benefits under the New York state Disability 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"T". This Certificate is valid fag'the earlier o ogre tear after this form is approved lit'the insurance carrier or its licensed agent,or thepolicy exI)ration date listed in via "3c". Please dote:Upon the cancellation of the disability benefits policy anclicated on this fomi,if the business continues to be named on a permit,hcense or contract issued by a certificate holder,the business must provide that certificate holder with a llew Certificate of NII S Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the NewYork State Disability Benefits Lary DISABILITY BENEFITS LABII §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 perinits, shall not issue such perinit Unless proof dilly subscribed by an insurance carrier is produced in a fortu satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article, Nothing herein. however. shall be construed as creating any liability oil 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, conunlsslon or office authorized or required by lave- to enter into any contract for or in connection with any work involving the employment of employees in employment as defined iii this article. aIld llotivithstandlna any general or Special statute requiring or authorizing ally such contract, shall not enter into any such contract Illness proof dilly subscribed by an insurance carrier Is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120 1(5-06)Reverse •..............................................se............................................. M. A14RINIWSTORATIONINC 1089 ROCKAWAY AVENUE VALLEY STREAM, NEW YORK 11581 (516) 825-8850 • Fax: (516)825.8852 Website: marifirestoration.com NYC'Department of Consumer Affairs H.I.C. LICENSE # 2001879-DCA September 28, 2015 RE: ITEMIZED ESTIMATED COST FOR DEMOLITION 1285 Marratooka Lane Mattituck, NY 11952 Contents removal and manipulation Removal of insulation Removal of sheetrock TOTAL AMOUNT: $5,000.00 1