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Home My WebLink About096.09-04-10.000 07/2022�pRT1q H o TOWN OF CORTLANDVILLE 3577 Terrace Road, Cortland NY 13045 607-756-7490 BUILDING PERMIT APPLICATION /•I 07 Fee Paid: /� Permit No. Y�� Application Date: ►i�9�aa Tax Map No. 0' Oq_ -D 10 . O O Name of Property Owner: C/Vy AN15i LLG Phone#: p J �c Q Mailing Address& Email Address: '70 4: rrarr �.^,:`y°',F°�i� At lv6acn.K� �e��eSAsr•Ca+r Application is Hereby Made to (construct, add, modify, etc.) ->A u at (address) y f e2>�-�/'J�f. G�"�'•^�� rl3 u cl � Number of Family Units Basement?- First Floor Area (SF) $ `i Second Floor Area (SF) 44 Total Area above Second Floor (SF) /1/Size of Building /7 "r % d Size of Lot Setbacks: Front Rear Left Side Right Side Sewage Disposal F, y ('Z 5 Water Supply P `" , Type of Heat Date of Health Department Approval Builder's Name: � Arss `t C Estimated Cost: * 3: 0 04 Phone Number: `J'3 S o�J t7` o a OCC Class: Submit drawings showing the location of the building on the lot in relation to the property lines. A set of Building Plans detailing: the foundation, framing, grade and species of lumber, Energy Code Compliance, sheathing, interior walls, stairs, windows and other information that may be necessary to determine compliance with the N.Y.S. Building Codes. All Statements contained herein are true and the work will be performed in the manner set forth in this application in accordance with all codes of the State of New York and all laws, ordinances, codes and regulations of the Town of Cortlandville, New York. Certificate of Occupancy is required upon occupying the premises. The undersigned grant the Town Building Inspector permission to enter upon the premises at all fpsonable tim or the urpose of making necessary inspections. Inspections require 24- hour notice by lican 0 Per 't Approved V _ 111 0 t,, �m Signature of Applicant z �h Permit Disapproved �O��V Q1*��G�C ��' TOV� 4ignature of Inspector ^^ 1J 1 Date: it��/17i l� OO Signature of Cortlandville Town Clerk TOWN OF CORTLANDVILLE 607-756-7490 Building Permit # D22-07 Date Issued:11/15/2022 This notice, which must be prominently displayed on the property or premises to which it pertains, indicates that a BUILDING PERMIT Has been issued to: CNY-Cortland Estates Permitting: Demo and removal by owner sinale wide at 4 Penauin Drive At: 1054 Route 13 All work shall be executed in strict compliance with the permit application, approved plans, the NYS Uniform Fire Prevention and Building Code, and all other laws, rules and regulations, which apply. The building permit does not constitute authority to build in violation of any federal, state or local law or other rule or regulation. Soecial Notes (if anv) : Do not proceed beyond these points until countersigned below by the inspector. Footing before pouring concrete Framing before closina Plumbing before enclosing Insulation inspection Footing before backfill Electrical before enclosing_(BY OTHERS) HVAC before enclosina Final lnspection X Permission is hereby granted to proceed with the work as set forth in the specifications, plans, or statements now on file in this department. Any amendments made to the original plans or specifications must be submitted for approval. Permit Expires: 11/15/2023 Issuing 0 icer: Desiree Campbell/ Kevin McMahon TOWN OF CORTLANDVILLE HFW t0�� 607-756-7490 CERTIFICATE OF COMPLIANCE Having complied with the provisions of the Local Laws of the Town of Cortlandville and the NYS Fire Prevention and Building Codes as per application type: Demolition, The below named permit holder is hereby granted this Certificate of Compliance. Cortland MHPAssociates Inc 70 Stonefield Way Pittsford, NY 14534 96.09-04-10.000 Building Permit # D22-07 Type of Permit: Demolition Issued on: 11/15/2022 Completed on: 01/11/2023 Description of work: Demo and removal by owner single wide at 4 Penguin Drive By Order of _t NYS Code Enforcement Officers: Desiree Campbell & Kevin McMahon 4STNEW Workers' Certificate of Attestation of Exemption ATE Compensation from New York State Workers' Compensation and/or Board Disability and Paid Family Leave Benefits Insurance Coverage **This form cannot be used to waive the workers' compensation rights or obligations of any parry. ** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers' compensation and/or disability and paid family leave benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit, license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of (Legal Entity Name and Address): CNY \IHPS, LLC 90 Airpark Dr Ste 400 Rochester, NY 14624-5732 PHONE: 585-721-0602 FEIN: XXXXX5085 Workers' Compensation Exemption Statement: Business Applying For: Building Permit From: Town of Cortlandville The location of where work will be performed is 4 Penguin Dr, Cortland, NY 13045. Estimated dates necessary to complete work associated with the building permit are from December 1, 2022 to February 1, 2023. The estimated dollar amount of project is $0 - $10,000 The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS' COMPENSATION INSURANCE COVERAGE for the following reason: The business is a LLC, LLP, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or subcontractors. Partners / Members: Brian Cook, Jeff Cook Disabilitv and Paid Familv Leave Benefits Exemntion Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY AND PAID FAMILY LEAVE BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: I) owned by one individual; OR 2) is a partnership (including LLC, LLP, PLLP, RLLP, or LP) under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition, the business does not require disability and paid family leave benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. _(Independent contractors are not considered to be employees under the Disability and Paid Family Leave Benefits Law) I, Brian Cook, am the Member with the above -named legal entity. I affirm that due to my position with the above -named business I have the knowledge, information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are we, that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers' Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers' compensation insurance and/or disability and paid family leave benefits coverage is required, the above -named legal entity will immediately acquire appropriate New York State specific workers' compensation insurance and/or disability and paid family leave benefits coverage and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers' Compensation Board to the government entity listed above. SIGN Signature: �� Date: HERE �lEkem tioi Cep' cats Nilmtier,=`_ ~ ems"`- StY'�c�j<'x ' _ti V^ a�n�ri_n�eoec c:< Y, 4� ;r': t x;Novemlier 9 2022 _ 11 X 0 Ir V 1 nut a ^C W ul OLJ0.Llu CE-200 01/2018 All io yin „ranlP� e,m,,,• 46 s EA \0 o W � 3 f O o z 3 d v u „ a