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HomeMy WebLinkAbout42262-Z 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 119714 sets of Building Plans_ TEL: (631)765-1802 FAX: (631)765-9502 Planning Board approval — -- Survey,,. _.... _. Southoldtownny.gov PERMIT NO. �. Check Septic Form N.Y.S.D.E.C. Trustees 20 C.O.Application Examined N Flood Permit Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: Apps°Quad 247 ...m.. � .L: Mail Disapproved a/c ` �! Phone:1 Expiration >20 � C ' g lI Spector t APPLICATION FOR BUILDING PERMIT )l UULDING DEFT TO OF SOUTHOLD INSTRUCTIONS late � � ... .,20 a.Tliis aplilicatiou ML,IST 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¢stay not be commenced before issuance of Building Permit. d.Llpon 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 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. Vn (Signature of applicant or name,if a corporation) 4 A) aili add � ...... l ress of applicant) State whether applicant is owner 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 cor p( ation,signature of duly authorized officer (Name and of cmpotate officer) Builders License No.�...10 Plumbers License No. ------- Electricians License No. Other Trade's License No. - Location of lad on which proposed work will be done: House Number Street Hamlet . County Tax Map No. 1000 Section Block Lot Subdivision R. / P Filed Map No. SQ mm Lot a. Existing use and cups anc and t ended use and occupancy of proposed construction: 2. State existing use and occupoccancy of pre � 09AXf b. Intended use and occupancy 3. Nature of work(check which applicable):New Budding Addition Alteration Repair Removal DemolitionOther Work /" (Description) MO 4. Estimated Cost Fee _.m.m. _.. To be aid on filing this application) l ca i ( p ......... g 1 p ITtion) 5. If dwelling,number of dwelling units Number of dwelling units on each floor-44-4— If w. 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 Rea Depth Height Number of Sofiesi 8. Dimensions of entire new construction;Front Rear Depth Height Number of Stories 9. Size of lot:Front' "` -q 15R-ear 1 . 'M' Depth � ,�t 10.Date of Purchase 15 Name of Former Owner , `PYe)+r 11.Zone or use district in which premises are situated t_N 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO ✓ 13.Will lot be re-graded?YES NO VWill excess fill be removed from premises?YES NO V---- 14. '14.Names of Owner of prennises 121 imi 6m<_Address Phone No. Name of Architect Address Phone No Name of Contractor al r"d?' LAddress Jp1 f� . Phone No (k2q) —731p 0MOW, 1)963 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES V 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 U'' *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) MEot5l Emn being duly sworn.,deposes and says that(s)he is the applicant (Name of individual 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 thi�p Z2 day of,/ r �1iI? 20`� Tara E Fere G 1 to Public,State of Notary Public Salida C-ntyNo.01FAs344MI Signature of Applicant CcrMMrVMissk) Ex Aires duly is,2dZ-°�, rrq � C Scott A. Russell SUPERVISOR AMIA\I�A\(Gl]EI��1[]E1��C' SOUTHOLDTOWNHALL-P.O.Box 1179 Town of Southold 53095 Main Road-SOUTHOLD,NEW YORK 11971 CH"TER 236 - STOR 4W TER MANAGEMENT WORDS; SHEET ( TO BE COMPLETED BY THE APPLICANT ) ... e. ... Aee.�� � ... . DOES THIS PROJECT INTV®LVE ANY OF THE F'OLLONVINGr. Yes No (CHECK ALL THAT APPLY) 110"'A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. ❑ B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. 00,C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. O� D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑O-E. Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse. El ElF. Installation of new or resurfaced impervious surfaces of 1,000 square jfeet 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. APPLICANT: (Property-O�ner,Design Prti.�tla7� � tR'�C4�t.Ot�h.emt) j� S.C.T.M. IOOO t11t Distract YM W '7 NAME, I 'rtW_ �, nim Lot W if .... ---- r ..i... �:_ pp I� p 1'01't pp pp pp11 pp IIff IIII pp 1I� pp,yu 1�I Iq����P1I�1'N ll J 111.. W d.Wll II. �am.vhura w f 0"�.'IIa �.0 i4.,,.a 11 l�,V4 i ,x Vll°.V .'M.�II'A ll IVYV Contact Information Reviewed By: r Property Address / Location of Construction Work: — ---- — — — Date: — — - — — — ElApproved for processing Building Permit. Stormwater Plan Not Required. Stormw�ater Management Conti of Plan Control Pla g n is Required. (Forward to Engineering Department for Review.) FORM SMCP-TOS MAY 2014 ;" 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 LOVELL SAFETY MGMT CO.,LLC 110 WILLIAM STkr=E 12TH FLR NEW YORK NY 10038 a1 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 0212412017 THIS 1S 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.IIW WV.NYSIF.COMICERTICERTVALASP. 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 CORPORATIQN._ 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 0411 5I muiII0o000000006601 1111 1fl Fa WC4=T-10PRWFVallon2(0712912016)(WCYdley407454461 U20 6 1 7�1616656W001-0OOG1D7�6MBSIIIGr1657a.616Cx1 NWIC9iT 1W mWWII CERTIFICATE OF LIABILITY INSURANCE ;; ��•� FTP, CERTIFICATE I ISSUED AS A MATTER OF INFORMATION'ONLY AND CONFERS NO FIGHT'S UPON THE CER°nFI'CATE HOLDER, THIS TIFICATE DOES NOT AFFIRMATIVELY'OR NEGATIVELY AMEND, "TEND OR ALTER'.THE COVERAGE AFFORDED BY THE POLICIES OW. THIS 'CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISI„ AtrfHORIZE0 RESENTATIVE 08 PRODUCER,AND THE CERTIFICATE HOLDER, RTANT° II"the ConiffcaN hoidor is an ADDITIONAL INSURED,the policy(ies)must be endorsed., If SUBROGATION IS TII'AIVEO,s t to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to!be certificate holder in liau ofsuch andoesDmentl'sl. PRODUCER NAME,, Timothy S Purdy tJWc No.a]) (631)821-2200 � (631)821-22--- A 5 031)821-2LG95 Route 25A sulle D2 �o �ssr _ leshe webber@farm famllyziam Shoreham,NY 11786 m INSURERM AFFCMDWG COVERAGE _ 'INSURERA:Farm Family sualiy Ins.Co. INSURED INSURER B• e r_ Owen COnstructlon Corp WSURERG: INSU ... ................-., 101 Edwards Avenue RER D: INSURER E Baiting Hollow NY 11933 Ir4swiREra F:. COVERAGES CERTIFICATE NUMBER. REVISION NUMBER 'THIS IS TO CERTIFY THAT THE POLICIE'S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE-D KWED AIsCroc FOR T-HE POI'dr„ Wil. .... INDICATED NOTVa�'.THSTANDINC ANY REQUIREMENT TEAM Ott'CONDPTIOi'N OF ANY CONT'RACr 08 OTHER D(�ICUMENT'VATH RESPECT TO g;.."H'i�,�•I I"N•IS CCTITIPwICAIE MAY 9.E ISSUED OR MAY PERTAIN, THE MSIJRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO At,l, 7 TtRPJS EXCLUSIONS AND CONDITIONS OFSUCH POLICIES.LTI�MI`rS SHOiNl1'N MAY HAVE BEEN REDUCED BY PAID CLAIMS LNn �oON.SLNaTr PDIJOYNu PDszcruF� POLICY EXP TYPE OFINSUIWJCE USER .�. NTArddaDJ'!"r"Y'S"t TNMPnnN'M^rY'Y A X COMMERCIAL GENERAL LIABILITY X X 3152X3179 04101117" 04101/18 EEC,, - E,,,E S ...7 O.vj a Ii s.. T tr.00R3 ceA�,S-Maur 1 X 1 D�c� PRE►r�5 — I — ►_q FSPWy P „S 5.000 pE:45UTLtLa:.CPJ9tIL".?s 5 1.x'0. ctrsl acc+�LcrrFUMnaPr-IrsrPR GAIL s 2. 00f X I POLICY; P-LT - • J' .I><c� I ac FRruc:s CDtir As® s 2, prHER S A AUTORIoaILE LIAB1uTr315205596_..__ I tiNOra„m X ;scltFnulED...�.._..®. A ...�Avro 06/16!17 l 05116Ii8 tEa 7LrIDOGILYINJU�T1 rrLzvr y DGE AUTOS _.AUTD-9 r X III*D AU:as ,X'AUTOS NON LIVED tPNm Tr Da S rS MI A tWUR LiAB I Mints-T TAN 3152E2658 T04/01/1T µ04J01118 EACH AC C!CCU EhGC 5.Ob0.I1'OL) x _X ua,ta t.tTrNrbus I;I T En r+EGATE j .ww 5 116F WORREPLOYER EYSATIONILFT r�......,N7A 4 -„STATUTE... m, 04 .... AND l]aPLDYEFTS LIABILITY I ANY IIOPNILIORn'ARINERd U I,UTIVE I CL EX--i CCIDEN- 5 GAIE, ILMLMULR'NCI!1DEW ” IMamTalsnr9 r",NM EL W Erm ✓yE£5 uT�yew.yC.lWa9tpcl GNreNaf yyy[ .. OFSGRIP'TMN Of QPERAi IONS xl:nv 4 EL DISENSE-PIX-ICY L.AKT,5 SCRMTION Of nPERATTOTdS 1 LOCATIONS 1 VEHICLES(ACORD 101,Addifibmi Remarks Sdaedulc,may be aaached If mQe*pars Is n,"redJ Carpentry/Home Construction/ Remodeling Additional Insured is Certificate Holder CERTIFICATE HOLDERIT mm CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POL.ICtES BE CANCELLED BEFORE Town Hall Annex THE EXPIRATION DATE THEFUECIF, NOTICE WILL BE DEL1YERc-D IN 554375 Main Read ACCORDANCE WITH THE'POLICYPR,OVIS M . YV Southold, I I 11971 AUTPORRED REPRESENTATIVE ©1985-2013 ACORD CORPORATION. All d reserved ACORD 26(2013104) The ACORD name and logo are registered marks of ACORD <NEW YORK Workers' CERTIFICATE OF INSURANCE COVERAGE TAT I COMPensation Board UNDER THE NYS DISABILITY BENEFITS LAW r,-om— by ple—ted —Dis—a -1111— PART 1. billity Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.L al Name&Address of insured(use street address only) 1 b.Business Telephone Number of Insured (631)369-7310 OWEN CONSTRUCTION CORP 101 EDWARDS AVE 1c.NYS Unemployment Insurance Employer Registration Number of CALVERTON.NY 11933 Insured 7164251 VYbrk Location of insured(Only raqvired if coverage iS Wecfflcally limited to certath locations in Now Yod<Slate,l:e_,a Wrap-Up policy) 1 d.Federal Employer Identification Number of Insured or Social Security Number 113-36=9687 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Usted as the Certificate Holder) New York State Insurance Fund(NYSI,F) TOWN OF SOUTHOLD 3b.Policy Number of Entity Listed in Box"I a" 54375 MAIN RD DBL 3202 90-1 SOUTHOLD,NY 11971 3c.Policy effiactive period 05/1511999 to 07101/2018 4.Policy covers: N A.All of the employees employees eligible under the New York Disability Benefits Law E] B.Only the following class or classes of employees 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 1116/2017 By Joseph J.Masi �vanrNY�SU-,wudl���XCAS.tdthvi-,..d.) Telephone Number(866)697-4332 Tiffe,Director of NYSIF 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 fur completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 -PART'ZTo be'coMplleted by the NYS—Worke—rs'Compens—ation rt Board(Only if Box"4b"of Pa I has been checked) State of Now 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 i f N—Yw&,t ffEp I—uyrt,— Telephone Number TrUe Please Note. Only insurance carriers licensed to write NYS offsability 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 Nevi York State t of Environmental Conservation Division of Environmental Permits, Region One AIM Building 40-SUNY,Stony Brook,New York 11790-2356 "hone:(63:1)444--036 - FAX:(631)444-0366 �� d Website:W!.dec.state.ny.us Denise M.Sheehan CommTssloner ETTER OF NON P'SDICTION T A.0WE DS ACI' _ November 6,2006 :lack Farnsworth iP.C.Box 397 Mattituck,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 ldnd 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. -•l 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, J Mark Carrara Deputy Permit Administrator cc: Fnvironniental East,Inc. BMH? file 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. _ . New Construction: Old or Pre-existing Building: mmmmww____ _w (check one) Location of Property: j ..I 661. _-w __/ House No. Street Hamlet �. .. Owner or Owners of Property: ��� � �,� Suffolk County Tax Map No 1000 SectionBlock � 0 -- „_ _................. Lot �,. �.. .. Subdivision Filed Map.. Lot: Permit No. . Date of Permit. Applicant: Health Dept. Approval: ..... ......_ Underwriters Approval: Planning Board Approval: )a' Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ applicant.Signature