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HomeMy WebLinkAbout43407-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 11971 4 sets of Building Plans TEL: (631)765-1802 Planning Board approval FAX: (631)765-9502 xx �j Survey Southoldtownny.gov PERMIT NO. v I Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined 20 Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: Approved 20 Mail toafL� r lL�' Disapproved a/c 'l `IL 1`at tl 11°i� j Phone:-71 Jq Expiration 771 dd ., 7But Spector 4PLICATION FOR BUILDING PERMIT Date S— ,2'01 TOWS C�`'�m ti"i"��"�°° � 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 shal I 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. (Signature of applicant or name,if a corporation) l,�me,,7t ye�� ��t L C -7.4 c-t-,ot, U-- YUP t(q 5 a (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises t. r 1 Gz t o e rl r,C1 (As on he tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer tt (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. 52 to k 1� l � Other Trade's License No. 4 3 g2 IF– l,--1 1. Location of landyn which proposed worl!will be done: -�L 4'./�E h �r,, V –n,V� C 11 i-,K kx to k 0 � l a �'-L- House Number trees Hamlet County Tax Map No. 1000 Section 1 Block 3 Lot 2, 3 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy e s k,-t-1,a- b. Intended use and occupancy sy 1 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal. Demolition Other Work 6olair S h 751,, 4. Estimated Cost Fee (Description) (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,structuros,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front-- Rear Depth Height NOml:k et oStories 8. Dimensions of entire new construction:Front Rears 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 zoning law,ordinance or regulation?YES NO V/ 13.Will lot be re-graded?YES NO.tj Will excess fill bexemoved from premix 's?YES NO 14.Names of Owner of remises �.ria l o u "��f ���'4��au�� � � ""� �-( I��� p ddress Z 4 r Phone No. Name of Architect Address Phone No Name of Contractor F1Pyne1,4- &�L,�a .1„��Address o �, .oe-phone No. �� r'n'tt-t uc Ajt1614s� 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:PERNfITSMAY'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. i 7.If elevation at any poinf-oil-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 r/ *IF YES,PROVIDE A COPY. iTATE OF NEW YORK) SS: :OUN{T.�Y OF// IXM Q e l 1 Q tj- o h being duly sworn,deposes and says-tl%t(s)he is the applicant (Name of individual sig�,,n,contract) b/ove named, S)He is the ^{ e' (Contractor,Ag t,Corporate Officer,etc.) �f said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; aat all statements contained in this application are true to the best of his knowleilt'o M*Wand that the work will be �erformed in the manner set forth in the application filed therewith. Nr-'tIllY PUBLIC-STATS of NEW YORK No. 01 MA4676634 worn to before me this :twollfletl 1n Suffolk County. day of �`�20 19 'Y�omrnlsslon Expires March 30,201-- . Notary Public Signature of Applicant 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. J 1 New Construction: Old or Pre-existing Building: (check one) a 6 ou h al /I .e . Location of Property: w ITIT h-( C� tu C N t 1 I Z House No. Street Hamlet Owner or Owners of Property: � 1 Q r i Suffolk County Tax Map No 1000, Section `� Block Lot 7, . . Subdivision .. Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: ...Underwriters Approval: Planning Board Approval:.... Temporary for: Request q p ry Certificate Final Certificate: � _ (check one) Fee Submitted: $ Applicant Signature New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR, MELVILLE,NEW YORK 11747-3129 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^"^^^ 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD 7470 SOUND AVENUE 54375 MAIN ROAD MATTITUCK NY 11952 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449444-5 869870 07/13/2018 TO 07/13/2019 7/20/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449444-5, 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 YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS-IIIIVWW.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 THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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: 565913021 I1_�R CERTIFICATE OF LIABILITY INSURANCE DATE(MM7/2O 8 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 have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER ICONTACT PAS � .,�M..... FAX 23 REEN STREET,SUITE INSURANCE AGENCY IAICAIL N� 1 3 HUNTINGTON,NY 11743 ORESSJ INSURERS ROBERTS.FEDE INSURANCE )A NG COVERAGE NAIL III INSURER A INSURE _ .... �. �. T...._... 'INSURER s STATE INSURANCE FUND D Element Energy LLC INSURERC:AMORTFIA�ERYCK ELEMENT ENERGY SYSTEMS INSURER . INSURER � �.._ ._.. . 7470 SOUND AVENUE U _.. .. _. RER E MATTITUCK, NY 11952 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. R TYPE OF INSURANCE _ ....... _.... __...ww_w__w_.....- `. "...,. ..a_._.-_ O'LICY EI~'F'� POLICY EXP LIMITS INSR D L '3' POLICY NUMBER M:.. M IDDly COMMERCIALGENERALLIABILITY CL00274149 7/14/2018 7/14/2019 EACHOCCURRENCE $ 1,000,000 X $ 100 OOOPE9.2-MADE I-1 OCCUR neel A MED EXP(Any one person) $ 5000 PERSONAL&ADV INJURY $ 1000000 GGREGATE LIMIT APPLIES PER: GENERALAGG REGATE $ 2,000,000_ POLICY❑JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000' 071 IER;. $ AUTOMOBILE LIABILITY SJdn I IT COMBINED�f L $ ._.. _... ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PRC7PERTY DAMAT $ AUTOS ONLY AUTOS ONLY Per aoc dentl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PEI' 0TH AND EMPLOYERS'LIABILITY YIN #24494445 7/14/2018 7/14/2019 X STATUTE ER .._ ... ,,_. I ANY PROPRIETORIPARTNER/EXECUTIVE �¶ N/A E.L.EACH ACCIDENT $ B OFFIOEPJMEM13ER EXCLUDED? I� (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,descdbe under INY SCR PTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ State Disability statutory WDL10279340 7/14/2018 7/14/2019 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE R&be:rtS. Fede, Sr. ©1988-2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD