HomeMy WebLinkAbout42261-Z "HOLD BUILDING PERMIT APPLICATION CHECKLIST
`TMENT Do you have or need the following,before applying?
-Board of Health
/1 �4 sets of Building Plans
l Planning Board approval
/502 :Iirvey.
,ry.gov PERMIT NO. Check
-Septic Form
-N.Y.S.D.E.C.
-=I'r�.ustecs
0 Applicat oxt
V --- ood Permit
xamined ,20 --k'.lSingle&Separate
DD Ouss Identification Form
(Ann-Water Assessment Form
Contact: /�
Approved _.— 20 ii11 Mail to/I I utm a j LE—
Disapproved a/cTOWN OF SOS .m, LD C I 1 11901
Phone.
Expiration rj 20
.. ._.
B til Spector
APPLICATION FOR BUILDING PERMIT
Date — 201-
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. t
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r
Signature ol'applicant or name,if a corporation)
d i 16 lz
2-0& 0 J1 er, A i/Mijo by �.
(Mailing address of applicant)
State
whether applicant is pwner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
............. __.......
Name of owner of premises
...........
(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 No
Other Trade's License No.
1. Location of lq on which proposed work will be done:
...m .:..: __.._ ............—
House Number Street Hamlet
County Tax Map No. 1000 Section—_ Z,3. .....—Block--...0 0 .--.---Lot.
Subdivision ( = 1 �` _A :_.._Filed Map No. `50 Lot
2. State existing use-and occupancy of premises and intend d use and occupancy of proposed construction:
a. Existing use and occupancy nP .... ......_..._.............................
b. Intended use and occupancy
3. Nature of work(check which applicable): ? a NN3ali1da":na t" Addition Alteration
Repair Removal Demolitio Other Work
"--& 4 K (Description)
4. Estimated Cost 00, r� e )°r:"
..... ......... _....... __.
aid on filing this application)
5. If dwelling,number of dwelling units _ umber of dwelling ut3r each floor M
If garage, number of cars
6. If busni
ess mmercialorrmxed occupancy,spec
' ,specifynature and extent of each type of use. AIJA
' co
7. Dimension's of existing structures,if any:Front i"u=ar
height Number of Stories
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of e5tire new construction: front Rear Depth '2
Height 7.1-10" Number of Stories 2
1
9. Size of lot: Front d � Rear ) Depth
10.Date of Purchase Jr 7 Name of Former Ownerjii�L- FA TI'}
11.Zone or use district in which premises are situated Lio
12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO><
13.Will lot be re-graded?YES NO_KWill excess fill be removed from premises?YES NO
A9 J/Z7"Pl.
14.Names of Owner of premises AA) Addresses' bPhone No.(W J0
Name of Architect "e -t Address 1 Phone No 1)„ -
Name of C-ontractorQ dress ' wrceka s 'yll, Phone No. . 344-
(: LMOI NJ✓Mn9 IIga3
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 f NO—www
*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.or.property is at.10 feet or below,must provide topographical data on survey.
18.Are there any,cdvenun'ts'and restrictions-with respect to this property?*YES NO V '
*IF YES,PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF f tot _)
being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the_..._.... 1 ..... —.._m
..... _.
(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.
Swo t before memic � g
�1", N'n'ER '.", }
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Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
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$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- $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. q.. "
New Construction: �_Old or Pre-existing Building: (check one)
Location of Property:
House No. Street Hamlet
Owner or Owners of Property: . .......... a,'
. ... ..........
Suffolk County Tax Map No 1000, Section Block_06 Lot
...... ' . Filed Map. Ht Lot:
Subdivision 0k� '�,, „ .._ - ....
_.m._Date of Permit. Applicant:
Permit No. _. .... ...........
....... ....,�
Health Dept. Approval: PlAA Underwriters Approval;
Planning Board Approval:
Request for: Temporary Certificate Final Certificate:
(check one)
Fee Submitted: $ � '
A licant Su�u� m,. ........ .
PP g ua uure
� llfrl'•- � Jl � � � V �
Scott A. Russell 0 ][�I��l[\� A\I[']E][
SUPERVISOR
1\\11 A\1NA\G]E1\\Al1ENIF
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
1 "
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES THIS PROJECTNWOL.VE ANY OF THE FOLLOWING.
I
Yes NO (CHECK ALL THAT APPLY)
ak Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
00B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous[31C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
a E] D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
]' E. Site preparation within the one-hundred-year f loodplain as depicted
on FIRM Map of any watercourse.
F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project.
If you answered YES to one or more of the above,please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
® ® �j S.C.T.M. *. 1000 Date:APPLICANT: (Property O�%ner.Design Professional.Agent.Contractor,Other) I ` District
NAME: fy) Al"&§5
Section Block Lot
(�)IIS 1 1J� �HNG � U A � �N,11 Ir.
..._ ... .. �^ p ..,If I If... ..
k V &� 711. �.)i�011.
,' Con,3c1ln1orrna,io,, ✓
r i NA�
Reviewed By: 1111-MA
Date:
Property lv Address / Location of Construction Work: --
t-
Approved for processing Building Permit.
............. Stormwater Management Control Plan Not Required.
- - - - - - - - - - - - - - -
5 v Stormwater Management Control Plan is Required.
(Forward to Engineering Department for Review)
.:.:.......................i l
FORM * SMCP TOS MAY 201,.
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hlev� York State Department of Environmental i
Division it 1 Permits, Region
Building 40- SUNY,Stony Brook, New York 11790-2356
Phone: (631) 4-0365 : (631) -0360
ebsi .dec.state.ny.us
Denise M.Sheehan
Commissioner
LETTER OF NDN JI1 S1)1CT1DN
TIDAL WEIIJANDS ACI'
November 6,2006
Tack Farnsworth
P.O. Box 397
M ttituck, NY 11952
`Re: Application#1-4738-03633/00001
Farnsworth Property, 1140 Park Avenue,Mattituck, Southold 11952
SCTM# 1000-123-08-01
Dear Mr. Farnsworth:
Based on the information you have submitted the Department of Environmental Conservation
has determined that the property landward of the pre-existing bulkhead and gazebo, as shown on
the historical survey prepared by Van Tuyl&Son dated June 2, 1970, is beyond Tidal Wetlands
Act(Article 25)jurisdiction. Therefore,in accordance with the current Tidal Wetlands Land
Use Regulations(6NYCRR Part 661)no permit is required.
Be advised, no construction,sedimentation, or disturbance of any kind may take place
seaward of the tidal wetlands jurisdictional boundary;as indicated above,without a permit.
It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or
other alteration or disturbance to the ground surface or vegetation within Article 25 jurisdiction
which may result from your project. Such precautions may include maintaining adequate work
-,area between the tidal wetland jurisdictional boundary and your project(i.e. a 15'to 20'wide
construction area) or erecting a temporary fence,barrier, or hale bay berm.
Please note that this letter does not relieve you of the responsibility of obtaining any necessary
permits or approvals from other agencies or local municipalities.
Sincerely,
Mark Carrara
Deputy Permit Administrator
cc: Environmental East, Inc.
BMHP
file
Electrical Disconnect
Owner of Property: Ryan& Jennifer Stork
Property Address: 1140 Park Ave.Matti tuck,'N Y 11942
Owner's Home Telephone 917-566-3273
Date of Disconnect:
Name of Electrician: —Ralph Passantino Jr.
Address of Electrician: T. 0, 6c:Q
1, PAU?A hereby certify that I have disconnected
the electric from the detached garage for purpose of demolition.
I understand that the Town of Southold Building Department will be relying on this
certification. My Suffolk County Electrical License number is 4836-ME
Electvi6an'sCgnature
Date:
New York State Insurance Fund
............. .
999 CHURCH STREET,NEW YORK,N,Y.90007-1100
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A A A A 113369687 '` '
LOVELL SAFETY MGMT CO.,LLC
110 WILLIAM STREET 12Th FLR
NEW YORK NY 10038
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Scan to Valldate
POLICYHOLDER ... CERTIFICATE HOLDER
OWEN CONSTRUCTION CORP TOWN OF SOUTHOLD
101 EDWARDS AVENUE TOWN HALL ANNEX
CALVERTON NY 11933 54375 MAIN ROAD
SOUTHOLD NY 11971
P G 1074 544-6 R CERTIFI132446
CATE 14UMBER POLICY PERIOD DATE
04/01!2017 TO 04/01/2018 02/2412017
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 1074 544-6, 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 YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:IAWM.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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF
THE INSURED.CORPORATION.
MICHAEL R.OWEN-PRESIDENT
OWEN CONSTRUCTION CORP.
ONE PERSON CORP.
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,6
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 572155636
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Southold, INY '11971
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198B-2013 ACORD CORPORATION. All rights reserved.
ACOIRD 25 1200; 04) rhe ACOI211:D name and logo are registered mail of ACOIRID
New York State Insurance Fund
199 CHURCH STREET,NEW YORK,N.Y.10007-1100
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A A A A 113369687 IE
LOVELL SAFETY MGMT CO.,LLC
110 WILLIAM STREET 12Th FLR
NEW YORK NY 10038
I
Scan to Validate
POLICYHOLDER CERTIFICATE HOLDER
OWEN CONSTRUCTION CORP TOWN OF SOUTHOLD
101 EDWARDS AVENUE TOWN HALL ANNEX
CALVERTON NY 11933 54375 MAIN ROAD
SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
G 1074544-6 132446 04/01/2017 TO 04/01/2018 02/24/2017
I_._.. .
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 1074 544-6, 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 YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:IMIWW.NYSIF.COWCERT/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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF
THE INSURED CORPORATION.
MICHAEL R.OWEN-PRESIDENT
OWEN CONSTRUCTION CORP.
ONE PERSON CORP.
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
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 572155636
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1Workers' CERTIFICATE OF INSURANCE COVERAGE
� i
Bo r
PART 1. To be completed by Disability Benefits Carrier or Licensed In �
surance Agent of that Carrier
I0C10ALVERTON,
.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
(631)369-7310
WEN CONSTRUCTION CORP 1c.NYS Unemployment Insurance Employer Registration Number of
1 EDWARDS AVE Insured
NY 11933
7164251
Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
113-36-9687
r_
2.Name and........................... ....... �...,
Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF)
3b.Policy Number of Entity Listed in Box"1 a"
TOWN OF SOUTHOLD DBL 3202 90-1
54375 MAIN RD
SOUTHOLD,NY 11971 3c.Policy effective period
05/15/1999 to 07/01/2018
4.Policy covers:
A.All of the employer's employees eligible under the New York Disability 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 Benefits insurance coverage as described above.
Date Signed 11/6/2017 Byg � Joseph J.Masi
(SignaP.me ofinsurance carrier's authorized representative,orNYS Licensed insurance
Agent
t ofthad:insurance carrier)
Telephone Number (866)697-4332 Title Director of NYSIF Disability Benefits Insurance
IMPORTANT: If Box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed
for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305
..PART 2.To be.... ��.�..w._ _ �.�. .... ..................��.... �..�
completed by the NYS Workers'Compensation Board(Only if Box"4b"of Part 1 has 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 Benefits Law with respect to all of his/her employees.
Date Signed By
.,,,... ... Sign "Wozkerd Cornpe-� �.,...,
..
Signature atnre oflYY�ro nsaCian Board T?rmpPoyea;}
Telephone Number Title
111--m........ .........
Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies 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 (9-15) Certificate Number 459700
DATE(MM1DDrYYrY)
CERTIFICATE OF LIABILITY INSURANCE 11/0612(117
tot.....
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 poll i os)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).
.. ........
PRODUCIF11
drt PA B_Timothy S Purdy
(631)821-2200 (631)821-2296
,15 Roll 25A suke D2
les1ie.webber@farrn-I`arniIy corn
I Slioreharn,NY 11786 INSURER(S)AF-Il rsAyYL!i5q!........................... NAIC 4
&NSILMEK A 11-12rff� Faiiinfly Casupjfty_��I) ,
-------------
INSUM.R l
oWel-a("C;1friStrLC,
C
101 Edwards,Avianue INSkMr.R 1)
ww
Baiting t IT)IJOW NY 11933
WSURFR,
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
I HIS IS 10 CEI TI [HAF RIE POLIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO TI IE INSURED NAMED ABOVE FOR THE POLICY Fp-- 65--
INDICATED NOTINI-11-15TANDil Al REQUIREMENT TERM OR CONDITION OF ANY CONTRAl OR OTHER DOCUMENT WITH RESPECT TO W-IICH THIS
C.EIRTIl MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE Al BY THE POLICIES DESCRIBED HEREIN IS SUBJECT '10 ALI THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES l sHowN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR1 TYPE OF INSURANCE Al SUOR
-I`�PA bicy l 'T.Ro.il l
L M LCY NUIVIGIER V)
A X MIRAIWHUI.All,GFHERAI, ]AP11-11T X X 3152X3179 04/01/17 04/01118 1,000,000
bAl'w(A-
C—APAS NA al X �0-',UR PIR'11.111,151 100,000
KU U EXP If'ry n7v plivs¢'q N 5,000
Pll-.zISONM,&AIN 014MRI. 2 1,000,000
a u.1011 V 11 11 11 H GI:M RAI, 2,000,000
PMMIIIIC¢s Ca hilw10 ll AG", S 2,000,U00
..........
AUrOMOSII-r LIADIUVY 13152l 0611(311-1 06/ll 81.000,000
II ¢ Ilu.a;axu aro
0H
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A Y, UMW�FLLA LIAB X '3152E2658 04101117 04/01/18 i�,Cu o crr:,,LJRI'�Nil 5,000,000
EXCESS l 1011��JS AGDRI: I
CCAVENSAII K I-H i i1H
AND LhVi Mi IRS'UMIll,111R!'
�NywpdaWrDOdIM II y�n W1,6l l)lS1A,,L CA ?411N,)Y�f: S
Dil Nn"i C1 0K PA,K.-VA", L 3""I-ASL P011-l'CV 1'11110iN S
............ —-----I
DrSCRIP TION OF Ol IONS I LOCATIONS f VEHIGLES
Carpentry I Horne Construction/ Remodefing
Additional lnsured is Certificate Holder
...........................
CERTIFICATE HOLDER CANCELLA TION
Town of Southold
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Hall Annex THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
54375 Main Road ACCORDANCE WITH THE POLICY PROVISIONS.
Southold, NY 11971 AIJIFOR)ZIEDREPU"SENTATIVE—
7
(D 19BB-2013 ACORD CORPORATION. All rights reserved.
ACORD 25(2013/04) The ACORD name and logo are registered marks of ACORD
YORK
EWWorkers' CERTIFICATE OF INSURANCE COVERAGE
STATE Compensation
Board UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. Disability or Licensed Insurance Agent of that Carrier
e completed b
To b p y Ili Benefits
Disab' Carrier
1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
(631)369-7310
OWEN CONSTRUCTION CORP 1 c.NYS Unemployment Insurance Employer Registration Number of
101 EDWARDS AVE Insured
CALVERTON,NY 11933
7164251
Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
113-36-9687
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF)
3b.Policy Number of Entity Listed in Box"l a"
TOWN OF SOUTHOLD DBL 3202 90-1
54375 MAIN RD
SOUTHOLD,NY 11971 3c.Policy effective period
05/15/1999 to 07/01/2018
..........
4.Policy covers:
F A.All of the employer's employees eligible under the New York Disability 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 Benefits insurance coverage as described above.
Date Signed 11/6/2017 By '!5 ' _;;'� Joseph J.Masi
('i afore of... ... �.
S gn insurance carvers authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number (866)697-4332 Title Director of NYSIF Disability Benefits Insurance
IMPORTANT: If Box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed
for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305
PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box �
"4b"of Part 1 has 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 Benefits Law with respect to all of his/her employees.
Date Signed By
Siyna.ture of NYS Workers°Compensation Hoard Ernpkoyec)
Telephone Number Title
Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies 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 (9-15) Certificate Number 459700
Town Hall Annex �A`w Telephone(631)765-1802
54375 Main Road � Fax(631)765-9502
P.O. Box 1179
Southold, NY 11971-0959
BUILDING DEPARTMENT
NOTICE OFUTILMATION OF TRUSS TYPE CONSTRUCTION PRE-ENGINEERED
WOOD CONSTRUCTION AN�DIOR TIMBER CONSTRUCTION'
Date: i i P2 fil.7
Owner: A)
Location of Property:
Please take notice that the (check applicable line):
_� New commercial or residential structure cDvv o 6,VW0
Addition to existing commercial or residential structure
Rehabilitation to an existing commercial or residential structure
to be constructed or performed at the subject property reference above will utilize
(check applicable line):
................- Truss type construction (TT)
Pre-engineered wood construction (PW)
Timber construction (TC)
in the following location(s) (check applicable line):
Floor framing, including girders and beams (F)
Roof framing (R)
Floor and roof fa (F
Signature:
Name (person submitting t for ti.
Capacity(check applicable line):
Owner
Owner representative
TnissRegl5.docx Effective 1/1/2015
SITUATE AT:
MATTITUCK,NY
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SUFFOLK WUNTY,NEW YORK
P90F.STORA DRANA&E PIPE—so—so—3O— SGTM No..10001
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for more information.
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EL.13B'-IIB' DEPTH OF RANGE 4'TO b' encouraged to call as well when planning any
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can contact us directly at 1-800-272-4480 or by
EL IIB'-9B' o DEPTH OF RANGE V TO 6' calling 811,the national call before you dig EN61NEEf2=
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