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HomeMy WebLinkAbout40532-Z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Ilealih SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 �3 r] Survey.. ...........................� SoutholdTown.NorthFork.net PERMIT NO. o` Check Septic Form N.Y,S,D.E.C. I.rwNees C O Application Flood Permit Examined :"li Single&Separate ._: .. Storm-Water Assessment Form r..n. 7VAR Contact: ' ipbp rovcd, — & 20-_.�.._ Mail to: ... Disapproved a/c PR I TJ---e rw LV Phone:631- yTS - 1002. ptspector APPLICATION FOR BUILDING PERMIT I)ute 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 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. „,.... .. ... 6S 011 uuuc of al Ii ant or name,if a corporation) Mallin rirfdra1�a plrcant) State whether applicant is owner, lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises..,,P Cml C.... Lralo�/h (-As on the tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer 1-11,111,11111,_ ......._ ......... (Name and title of corporate officer) Builders License No, Plumbers License No. Electricians License No. Other Trade's License No,, I Location of land on which I'rccsl osedaotlk will be done: House Number Street Hamlet County Tax Map No. 1000 Section 35 Block Lot o2 Subdivision Filed Map No. 2. State existing use and occupancy ofpremises and intended use and occupancy ufproposed construction: o. Existing use and occupancy ^ \E4~~ b Intended use and occupancy ` � 3. Nature ofwork(check which opy|icuh|x):New Buildhq.t Additiono i Repair—-,'', 4. Estimated Fee (To be paid on filing this application) 5. )rdwelling,number nfdwelling units umternfdwelling units oneach Omx If garage, number ofcars 6. [fbusiness,commercial mmixed occupancy,specify nature and extent ufeach type ufuse. 7. Dimensions ofexisting structures,ifany: FmnL ____Rnu Height Number ofStorie ' DimenoionaofuamontructuvewdhnUamtionaoraddiUono: Fm,t *nor_________ Depth—- ­­­—NumbernfStories 8. Dimensions o[entire new construction:Front Rear Depth Height 'Number ofStories 9. Size oflot: Front Rear Depth 18.Date or Purchase ame of Former Owner 11.Zone or use district in which premises are situated )2.Does proposed construction violate any zoning law,ordinance orregulation?YES NO___ 13.Will lot bnro'gradod?YES NO __VVi\}excess fill hcremoved from premises?YE@___ND___ 14.Names ofO [ iAddress.&q5 Phone No. C37 Name of Architect --Plione No Name of[oiaoo re,"15t I p i mu |5u. [xthis property within |OOfeet ofatidal wetland nrufreshwater wetland?*YES__ NO____ * 1FYES,80UTH0L0TOVYNTRUSTEES d�D.B.C. PBR&4(7S��AYBDRBVO|KBD. h.Is this property within 30Bfeet of atidal wetland?* YES -----__N0___. * lPYkS.D.E.C.pBRk4lTQ&8/\YREKCOO|RBD. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. l7. )[elevation uoany point onproperty isat |Ofeet orbelow,must provide topographical data nnsurvey, 18.Aotheroumyoo,enuotuuudrostriodouowithrcupocttothixproperty?*Y20____N0____ * lFYES.pKOVlD8AC09Y. STATE OPNEW YORK) , C0OMTYUR-�-61'��/e) _ being duly owom`deposes and says that(o)heiothe applicant (Name of in(h lwd signing contract)above named, (S)xCiutile (Contractor,Agent,Corporate Officer,etc.) "fsaid owner mowners,and i,duly authorized mperforin whave performed the said work and mmake and file this npp!{catiow that all statements contained in this application are true to the best oflus knowledge and belief,and that the work will h* performed inthe manner set forth inthe application filed therewith. �ouwm It Cal i OWNS tot 31 rn OWN 0 m 9 _ i Mp U I O f , U u� I .mud P �I Oil r om > O„ � c CD CA < (CD CD tv 82 zr ■s H 0 coo0 a. C.D rA CD ��". � C D CD OQ < " ` O C. ® C M a (JQCD y .. N ® A Co Q.�q'.. W O A M d 4�6 �- tIQ '�'• < ® O -3 m O N gA� YI p ® m m �wmwramw uuu LIABILITY INSURANCE OP ID: KL DAYY) CERTIFICATE, OF TE(MMIDD/YY 12/11/2015 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 endorsements). PRODUCER NAME" Hometown Insurance of Ll,Inc NAMEFAX Weber A ency }; 631-567-1011 Ic Na) 631-589207 6 Orville rive,Suite 400 _ Bohemia,NY)1716AODREB"S.., M,b Diane Setter PROB70CER C p$T R ID O,A�NDER-1 INSURER(S)AFFORDING COVERAGE NAIC tl INSURED �u�ojk�i're;Ync:�i�A.." � pJSIIRERA:Arch Insurance Co. Anderson Fire Equipment Inc. e..w, ..�,. -- ----.. -_.._.... m,. . ...- 9 O'Neil Avenue INSURERS Bay Shore, NY 11706 INS!a q INSURER D INSURER E: 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. I� TYPE OF INSURANCE, ,,, O ual POLICY NUMBER R #I F P Li YY.. .. ........... ... ,,,,, fflyYL LIMIti,TS GENERAL LIAMWI'TY EACH OCCURRENCE $ 1,000,00 0AMACLAIMS-MAGE X /ABILITY MFPK07327903 04/24/2015 0412412016 (Anyone person} $ 105,0 OCCUR MIED EXP (r oma xiurgorw e) $ 0 e00 . COMMERCIAL GENERAL L X ADDITIONAL INSD PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000;00 n ,F _ ®., GENIL AGEIREGATE LIMIT A@"I'UrI s PER: PRODUCTS-COMP/OP AGG $ 2,000100 ------ X ICY x R'OLLOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) . ...... - ............. ANY AUTO Per p BODILY INJURY(Per $ ALL OWNED AUTOS .._._ BODILY INJURY(Per accident) $ SCHEDULED AUTOS .. .. PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MADE AGGREGATE $ ®... ... ---- ..... DEDUCTIBLE $ RETENTION $ $IH- WORKERS COMPENSATION TORY_/IMIT�I FR, ,,,,,,,,,,,,,,,, ,, AND EMPLOYERS'LIABILITY - IN ANY PROPRIETOR/PARTNER/EXECUTIVE YN/A E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? --- (Mandatory In NH) E L DISEASE-EA EMPLOYE; $ it lea desctllYsGaunder m,�, RESGRIFT1l.7N OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more apace Is required) Proof of Insurance CER"T"IFICATE HOLDER CANCELLATION TOWN014 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Town Route h ACCORDANCE WITH THE POLICY PROVISIONS. P.O. BOX 1169 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and logo are registered arks of ACORD New York State Insurance Fund VIII Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 Phone:(631)756-4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 113268460 SUFFOLK FIRE INC T/A ANDERSON FIRE EQUIPMENT CO 9 ONEIL AVE BAY SHORE NY 11706 POLICYHOLDER CERTIFICATE HOLDER SUFFOLK FIRE INC T/A TOWN OF SOUTHOLD ANDERSON FIRE EQUIPMENT CO 54375 ROUTE 25 9 ONEIL AVE PO BOX 1169 BAY SHORE NY 11706 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 1723 238-2 150283 10/29/2015 TO 10/29/2016 12/11/2015 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 723 238-2 UNTIL 10/29/2016, 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. IF SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 10/29/2016 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 POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PATRICK TURRO(PRESIDENT)OF A ONE PERSON CORPORATION 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 U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling(888)875-5790 VALIDATION NUMBER:997589177 U-26.3 STATE OF NEW,Y WORKERS'COMPENSATION CERTIFICATE F INSURANCE COVERAGE UNDER THE NYS DISABILITYFITS LAW pa w C rm p 1 �I e t IOlsir l Ily r ll rot or Ll �rt t..... A rt ... In. Legal Nwae amid Address of Insured(Use street address only) lb, $ttisi less Teleplioiie Ntutiberofhisured SUFFOLK FIRE INC ( 1)665-6862 dba ANDERSON FIRE EQUIPMENT I c.NYS Uneniploynient Inst ®lice Eniployer Registration ILL AVE Numaber of Insured BAY SHORE, NY 11706 !d.Federal Ernployer Identification Nuiriber of Insured or Social Smifify Nuinbei- 113-26-8460 2. Nanie mid Address of time Entity Requeaing Proof of 3a.Namite of hvsurance Carrier Coverage(Entity Behig Listed as the Certificate older) NEW YORK STATE INSURANCE TOWN OF SOUTHOLD 3b.Policy Nuniber of etntitw°fisled in box°°1 it": 54375 ROUTE 25 PO X 1169 DBL 5853 65- 1 11 1 3c. Policy effective period: SOUTHOLD, NY10/02/2015 to 10/02/2016 _..�.. .....................—---------_------------------ ........w...... . ...�...w. a. gg All of 1 e eiriployees etniplo} s eligible hander the New York Disability etre is Law only the tonowing class or classes of the eta iloyees eniloy sa U11(ker Penally of peij Lay,I certify that I not an arithorized represartative or licensed gent of the incur ace carrier referenced abow and that the imined insured has NYS Disability Beriefils instumace coverage its described above. 12/11/ 1 _ Joseph J. Masi Date Signed �. Pgratum of irsuranow ce rrier's authorized repaemrtattije of NYS User ed irsura ride ire of tt,at irsurarm ou Her) Telephone Iqunt to ( ) 733 Title insurance Director.,. r _i iii IMPORTANT: tf bac"4a"is checked.and this fentt is signed by the inturaitrce carries autherized repxvserrialive or NYS Licensed Insurance Agent of mltaat castiec this cerlificale is COMPLETE.. a it it 4iffeelly to like cerlificale holder. If box'4V is cluec° d.obis certificate is NOT COMPLETE for tae ses of Seaton 220.Subd.S of rlre Disability Eknefits Lar``. It must be®ruled for Completion to the W rkers Conapeltsation Boaffil.DB Plant Ateeplance Unit.20 a n to Al tty,New Y � 1220'. i " al test Contlp� ltatltt boat 1tt �i b r °X rtwt04 t �..,. ,,, ���.. .... ..... .___._.__ t.ri t # � York .�., Par, _ New Workers'Compensation Board According to inforinstimi.irmiutained try°the NYS Workers'Compensaliou Board,time a ve® erned enWloyer leas cQuiplied with ill N'YS Disability Benefits Law wiih respect to all of hi0ter ent l Deese Date Si tied ., , ® int tasnr cetl �" t`ptirka , rs'Compensation Board Etatlaloyee) Telephone Nuni r beTitle Please° ,-o�e: lily am>_stra �car� t ers licensed to write ..FY S� .......a�............... ......._ , , ......... �.•.w,o disability tte is artstt 4'Ice policies and 1P licensed nsed insurance a tarts of those.Isur nce carriers are atithori to isst ontt ®120.1, Insurance brokers erre NOT authorized to issue this fonw gy12 .1(5 ) Certificate Number 352514 Additiona I histructions foorill DB-1"10.1 Bv similug this form,the U'MIM11cf., C(Iffier Identified in box"Y' oil this form is cerrif%ing that it is Insuring the business referenced U'l box "la" for disability benefits tuider the Net`-York'tate, Disabilit-Y Benefits Law. The Listrance Camer or Its licenwd agent will send t11is Certificate of Insurance to the entity listed as the cevificate holder In box "22". This Certificate A valid for Lht�eyrfier "one Year after thisnvii is al.proved Av the insurance carrier m,its licensed agene, or thelmlicY m1dration date listed in box 'Ve". Please Note:Upon the cancellition of the disibilim,benefit;policy mckcated oil tiiis foan,if the ba[sel]ess C011M1116 to be imilled oma i p-lalut.I.CeMe Or contract nsued by i mlificite holder.the busims must pro%isle that cc-tificae holderxith a new Certificite of N1®S Disabillity Benefits Co"enve®; dier aumorized proof that Tile busilless is C0111I)IN1110"In-th the 11111161tory Co"'enge reclai-ements of the Netts York Stitt Disabili'7 Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board. commission or office authorized or requifed by law to issue any permit for or in connection with ally wnit involving the employffient of employees in emplovinent as defined in this article, and not withtandina, any, uneral or special statute requiring or authorizing the is-sue of such perinits, ,hall not issue such permit unless proof duly subscribed by all insurance carrier il; produced in a form satisfactoi3r to the chair, that the payluent of disability benefits for all employees has been secured as provided by this article. Nothing, herein. however. shall be construed as creating ally liability oil the part of such state or municipal department. board, commission or office to pay illy disability beilefits to ally such employee if so employed, (b) The head of a state or municipal department. board, cors miSNsion or office authorized or required by haw to enter into ariv contract for or ill connection with tally lNvork filvolviii2 the employffient of employees in employment as defined in this article. and nom itlistanding billy general oi- special statute requiring or authorizing any such contract. shall not enter into any such contract unless proof duly subscribed by ail insurance carrier is produced ill a form satisfactory to the chair. that the payment of disability beilefits for all employees has been secured m provided by this article. B-12`0.). (5-06)Reverse