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HomeMy WebLinkAbout43331-Z rte= �4�OgUFF�t�CaG , Town of Southold 6/24/2019 o - P.O.Box 1179 m 53095 Main Rd Oil Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40461 Date: 6/24/2019 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1200 Gin Ln., Southold SCTM#: 473889 Sec/Block/Lot: 88.-3-14 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/19/2018 pursuant to which Building Permit No. 43331 dated 12/19/2018 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: ACCESSORY IN-GROUND SWIMMING POOL, FENCED TO CODE, AS APPLIED FOR The certificate is issued to Terry,Brian&Patricia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 39379 12-22-2014 PLUMBERS CERTIFICATION DATED 0 -0(7 ed Signature �o�so Fo��co TOWN OF SOUTHOLD aye BUILDING DEPARTMENT TOWN CLERK'S OFFICE o SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 43331 Date: 12/19/2018 Permission is hereby granted to: Terry, Brian 68 Winifred Dr N Merrick, NY 11566 To: Construct an accessory inground swimming pool, fenced to code. Replaces BP# 39379 At premises located at: 1200 Gin Ln., Southold SCTM # 473889 Sec/Block/Lot# 88.-3-14 Pursuant to application dated 12/19/2018 and approved by the Building Inspector. To expire on 6/19/2020. Fees: PERMIT RENEWAL $125.00 — ot�i. $125.00 Building Inspector o�ga=21;��co TOWN OF SOUTHOLD �� ay BUILDING DEPARTMENT y TOWN CLERK'S OFFICE o • 4 SOUTHOLD, NY / BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 39379 Date: 11/21/2014 Permission is hereby granted to: Terry, Brian & Girandola, Kathleen 68 Winfred Dr North Merrick, NY 11566 To: construct an accessory inground swimming pool, fenced to code At premises located at: 1200 Gin Ln, Southold SCTM # 473889 Sec/Block/Lot# 88.-3-14 Pursuant to application dated 11/13/2014 and approved by the Building Inspector. To expire on 5/22/2016. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Building Inspector -5 W E ESI P�l NOV 17 2014 BLDG DEPT TOMN Or SOUTHOLD 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 I% 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 r Date. _W � 11 m b-a— 12)tll �z o)q l Y1 YG11�1'1D • New Construction: Old or Pre-existing Building: (check one) Location of Property: 0 a C I n Lan -e- S)ahn 0�(,k, 11 Q House No. Street Hamlet Owner or Owners of Property: YYI CLYX Suffolk County Tax Map No 1000, Section 0(i�16' , D Q Block-_ 23 r D D Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 0' W c , Applicant Signature 0 pF SOU��®l Town Hall Annex Telephone(631)765-1802 54375 Main Road c� Fax(631)765-9502 P.O.Box 1179 ® �� roger.riche rt0_)town.southold.ny.us Southold,NY 11971-0959 lycOUNV BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Brian Terry Address: 1200 Gin Lane City: Southold St: NY Zip: 11971 Building Permit#: g3331 -3937-9-Section. $$ Block: 3 Lot: 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Kel-Rob Electric License No: 37725-me SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 1 Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: in ground swimming pool to include, bonding,1-pool light, salt generator, pool hea 1-control panel, 1-GFCI circuit breaker Notes: Inspector Signature: yc: Date: Dec 22 2014 81-Cert Electrical Compliance Form.xls Of SOpI�,Olo LicOUNiY,� TOWN OF SOLITHOLD BUILDING DEPT. ' 765-1802 INSPECTION [ ] FOUNDATION IST - [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ]-ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE Z� INSPECTORX , . oFsouryO # TOWN OF SOUTHOLD BUILDING DEPT. u 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULAT N L!�' [ ] FRAMING /STRAPPING ] FINAL [ ] FIREPLACE &.CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING w REMARKS: �N✓aetePP �e4fovrv(� lft uvwIN II 5cil �h �80 " 16A r CWKA Ys" f J DATE / C INSPECTOR i •��� I50 �F Ulyolo # # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULAT N [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: S DATEINSPECTOR V. CONMENTS 1 STATE ENERGY CODE 11 WE 2 JP '"'''-MAW,,WW, 4 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 1 Planning Board approval FAX: (631) 765-9502 Survey South oldTown.NorthFor'met PERMIT NO. J' j 7 9 Check Septic Form My'S.D.E.C. Trustees C.O.Application Flood Permit Examined / ,20 Single&Separate Storm-Water Assessment Form Contact: WA"1. 3�,L`t101 Approved !l ,I 20Mail to: 1,ecy -90,0 is Disapproved a/c pp go)( 517, miilfr &Lce 11'7uq -1 Phone: (031 _ Z$ — Z Expiration )- ,20 f f, ay emctii -lo 300& Slt:ovtn-YeGnpvolS,Cosrl �°}� uilding Inspector PPLICATION FOR BUILDING PERMIT Nov 12 2014 -9 Date Nuye.yVlbtr 1o, 20 I'L BLDG DEPT INSTRUCTIONS TOV411,1 OF SOITIOLD --a. This application 1VZtT e 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. s u&V� T--ech Paa I S (Signature of applicant or name,if a corporation) UPON GQ1�� C1C � �L CTUn L (Mailing address of applicant) Bp C r.- ' p EFOPIE WATEf�" C"F VS State whether applicant is owner, lessee,.agent,arcliitect;'engmeer, general contra r, �l c rfctan, plum er or builder 1 S- ! ?f7UlS -'`�' ,�. ';', le �ad :�;;"n' i„} _ .a..l1,•I , ;ref+') :t"! FEE 152 ,BY Name of owner of premises e)ri an � • -T7_-v%rQ NOTIFY BUILDING DEPARTMENT AT (As dn the tax roll or lategl5dd66� 8 AM TO 4 PM FOKTTti If applicant is a corporation, signature.of dulyi authorized,o�fficen FOLLOWING INSPECTIONS ��t ,`1 , kph"t 1 FOUNDATION-TWO REQUIRED To�`. _ FOR POURED CONCRETE (Name and title of corporate of fiver),; 3 > ii l �x; - s 1 2 ROUGH-FRAMING,PLUMBING, Builders License No. – J4±J STRAPPING, ELECTRICAL&CAULKING Plumbers License No. 4° F i ; i, `'. I E _,a , ' -' 3. INSULATION Electricians License No. „�,�, , zt o. , 4 FINAL-CONSTRUCTION &ELECTRICAL Other Trade's License No. s"6� ter" "' -' 3 ''°" ' MUST BE COMPLETE FOR C 0 ALL 1.OnIcTPi 011 MFET THE 1. Location of land on which proposed work will be done: '. i;� S;"—TE rdOT r�E'�Fv +S 12.00 ( L o l �] I an- STRUCTION ERRORS House Number Street Hamlet County Tax Map No. 1000 Section J a 00 Block 0100 Lot 014 , 00 f' 4 Lot Subdivision Filed Map No. " 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy kAOM-e— b. eb. Intended use and occupancy UYASRhna c Gly 0-� U)(�(�u(',,L pL o 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost Fee (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 structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth lb"M Height Number of Stories 9. Size of lot: Front tear 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 13. Will lot be re-graded? YES NO Will excess fill be removed from premises?YES NO 14. Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 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 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. e - 18. Are there any covenants and restrictions with respect to this property? * YES NO - * IF YES, PROVIDE A COPY. DENISE MARIE OLSEN STATE OF NEW YORK) NOTARY PUBLIC-STATE OF NEW YORK No. 01 OL6282529 SS: Qualified in Suffolk County COUNTY OF Sjfrb IK f} ` My Commission Expires May 28, 2011 a n o being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)He is the <<,���(a ���_r (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 this day of0 ` �(�(_ 201 Notary Public Signature of Applicant or 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 Survey SoutholdTown.NorthFbr'k.net PERMIT NO. '/ 37 ' Check Septic Form Trustees D.E.C. Trustees C.O.Application Flood Permit Examined / ,20_ Single&Separate Storm-Water Assessment Form Contact: (aA4y\: J'„ OL, Approved /l �-/ ,20 Mail to: Std)tirn TeCA '9(j\,)15 Disapproved a/c PO gN 5l1 miller etace 0 11-Iuq Phone: (031 _ 9 18 - 2-(o a� Expiration S� ,20 Ifo ar.eMDJ 1 iD 3UA10Le GtA)1,m l-e0n-p001S,(01 � C, �, � E uilding Inspector D - i� PPLICATI,ON FOR BUILDING PERMIT Ili NOV 12 2014 , -M Date �(�� h�l' �} , 20 1t-_ R;;,G DEPT INSTRUCTIONS T0741, 11F�0!;T)!9l p - a.�Tfiis 6—p`hcation e 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. (Signature of applicant or name, if a corporation) e3 -WEDIRTELY'S l=N1cl. 5� P®ol T© ,not: . :° U I i t I� � U[+�`"ON(° CO_K11�((-���.�r'!`1-O]N �~' a^ (Mailing address of applicant) $1=i OPF- YYAICER" k..#b t, ,nss s�.�,. }' i v-` 't L 4 .^`^.31fi "fc�.�! ^-Cl4N �At<i � ..,LF:� State whether applicant is owner, lessee,.agentarpittec p ei Mme � general contrad r ri'c an, p um er or builder l FEE 2 BY :�-,:'. a � .,,.: iF•r ____-�_�-_....� Name of owner of premises _eyI an `1—eV jrQ NOTIFY BUILDING DEPARTMENT Al- (As E the tax roll or latef�dd&[? 8 ANI TO 4 PIVI FORME If applicant is a corporation, signature^of.duly,authorized:,offi'caen FOLLOWING INSPECTIONS- `_ L: e`tx�. .s ,1 t °3 g 1. FOUNDATION -TWO REQUIRED (Name and title of corporate officer)-' FOR POURED CONCRETE 2 ROUGH-FRAMING,PLUMBING, Builders License No. - k4 T' r ° STRAPPING, ELECTRICAL&CAULKING -Plumbers License No. t;t,s .' , .,. � a 10 I .. g INSULATION Electricians License No. &. ,.ti; ;-M„p� : „;b .;.,r 4. FINAL-CONSTRUCTION &ELECTRICAL Other Trade's License No. '�Y'' b> ` M+1ST BE COMPETE FOR C 0 Ai ,.1A� t-�-,I r••� �; .:'1I fi'l S—,-T THE F 4 L: _ 1. Location of land on which proposed work will be done: 12v0 L U G l iv 1 q,'` E l s;r,i r,.� TRUCTION Llt'OK House Number Street Hamlet County Tax Map No. f000 Section oOpq . 00 Block ®3, 00 Lot 014 , 00 "i Subdivision Filed Map No. ' Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy ��S-�[ � • Qr-�,Inaliynim d., goo 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost Fee (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-structures, if any: Front Rear Depth Height .-Number of Stories Dimensionstlof,samewstructure with alterations or,additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear' q ,pth eTr aha Height Number of Stories 9. Size of lot: Front Rear f Y 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 13. Will lot'be re-graded? YES NO Will excess fill be removed from premises?'YES NO 14. Names of Owner of premises Address Phone No. Name,of Architect Address Phone No Name'of Contractor Address Phone No. 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 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 topographicaf"data on survey. i3C d 18. Are there any covenants and restrictions with respect to this property? * YES NO v * IF YES, PROVIDE A COPY. DENISE MARIE OLSEN STATE OF NEW YORK) NOTARY PUBLIC-STATE OF NEW YORK SS: No.O)OL6282529 COUNTY OF =Qudidied in Suffolk County IK My Commission Bxplres May„28, 2017 V 11��1 Ql - lJ�t CILLO being duly:sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, ; (S)He is then( C �C e (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; l 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 this day of O bP_( 20 AN-1 `� Notary Public Signature ofAppli§ant Scott A. Russell ,��°SuFFQI STO]k I'OMIWA' IEIK SUPERVISOR AVIAN AG►]EM[]ENT ,Y SOUTHOLD TOWN HALL-P.O.Box 1179 � 53095 Mein Road-SOUTHOLD,NEWYORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) --- --- - -- - - -- - ----- -- --- DO ES THIS I'II,OJ EC r JINIVt LVE ANY OF THE FO-LI.OWING: Ye No 7CHECK ALL THAT APPLY El JA A. Clearing, gr=ubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. 1:1 C6 B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑M C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑fZ 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. ❑5d 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. -_.-----__._ NI T. . C. #: APPLICANT tPropet 1y Oe•ner,Design Professional Agent Contractor.Otherrici ) S. 10Date Du00 00 ,g4jE '\ " 00IS O'N.66 alb r• iLAol�(� u 1 r, Section Block Lot (yFecS FOR BUILDING DEPARTMENT USE ONLY��*W Contact Information — — — — - -- — — — — — — — — — I Reviewed By: Date: Property Address/Location of Construction Work: Approved for processing Building Permit. 200 Gil i (\ L—CLY)ei , 1G11 Stormwater Management Control Plan Not Required. �dU-fir°l()IC� , - - - - - - - - - - - - - -- - - - r Stormwater Management Control Plan Is Required. (Forward to Engineering Department for Review) 3 FORM SMCP-TOS MAY 2014 SQ�jr�,o! Town Hall Annex 4 Telephone(631)765-1802 54375 Main Road -Rax(631)765-gg5 P.O.Box 2179 S y@ roger rich ert(CU_toWn.so5thOQ5.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: o r-1 a Date: l Company Name: Kc-l- ka-6 Name: B06 b ►Grp of) n License No.: J -1-1 D-f /V1 Address:, JIS .e1cons-r-4 f, w 410� Il-1q Phone No.: JOBSITE INFORMATION: ( `Indicates required information) - *Name: rt a r1 Jiff µ ,'Address: l a o o , Gin L4& -.S L) o 1 J tCross Street: Maio &rz e-F "Phone No.: 516 - 219 - q0 9 o r 3.� a - �► 2 � aermit No.: 3 rax-Map District: 1000 Section: $ . o O Block: 0 3,1)o Lot: G ► 9 ,'o wl `BRIEF DESCRIPTION OF WORK(Please Print Clearly) �6LAIinrninq Poo) Please Circle All That Apply) Is job ready for inspection: ES NO Rough In Final Do-you need a Temp Certificate: YES K& , Temp Information(if needed) Service Size: 1 Phase 3Phase 100 150 200 300 350 400' Other New Service: Reconnect Underground Number of Meters Change of Service Overhead ►dditional I ti PAYMENT DUE WITH APPLICATION' - OMA HUIr ,S2=Requ for Ir spec(lon Form - BLDG DEPT , TOWN OF SOUTHOLD I �� Date File # TOWN OF SOUTHOLD COMPLAINT REFERRAL FORM Location of Complaint: G(k) L�"L SCTM# Property Owner: 6v/� 7,2 / Phone Address: NATURE OF COMPLAINT: aI pzZ4-LC( 0 TTION TAKEN: Optional: Complainant: //'J By Phone Mail In Person Address Phone: Report Taken By: Date Date Referred to Code Enforcement: CODE ENFORCEMENT REPORT SITE INSPECTION REPORT/DATE: ACTION/DATE: f N i* 1 Y Y t Southold Town Building Department 4\ps��FOj, cOG P.O.Box 1179 Permit#: 39379 53095 Main Rd o . � Southold,New York 11971 Permit Date: 11/21/2014 4,� �ao�' (631) 765-1802 Expiration Date: 5/22/2016 Parcel ID: 88.-3-14 BUILDING PERMIT RENEWAL LETTER Dated: 11/16/2018 Applicant: Terry, Brian&Girandola,Kathleen Location: 1200 Gin Ln, Southold Work Description: IN GROUND POOL construct an accessory inground swimming pool, fenced to code A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Terry,Brian& Girandola, Kathleen Address: 68 Winfred Dr North Merrick,NY 11566 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold, New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. i 7_oby4', t V t D 3 VERHANG, HE =HEDGE, TC.=TOP CURB ELEVATION , L.G = LEGAL GRADE, G=GUTTER ELEVATION, Ari �iW=MEAN HIGtiIWATER,EL=ELEVATION, IRR.= IRREGULAR, TITLE No. LT 1762-9 r t 5 irr plastic wire ie around irr. wood pile I clear Q C3 C324 4'1 ; E") < _ ac ❑ ,,n I 124.2 _ o i i frame 1IE 1, J I CD shed _ 5.5' 7. 8 ' l'- z � ' O Z i a O I —� NO-, 1200 LL0 S STORY �- k A ME _N i (n RESIDENCE 4_19' � L 3 1 / C D U) -_ C d Cr I f C C, I } C V 0 Ld O .O .0 �J C J C1 2 4 3' CE) r- L N i 9 v- l i 2Ak q0 VERHANG, HE =HEDGE, T C-=TO P CURB ELEVATION , L-G =LEGAL GRADE, G=GUTTER ELEVATION, MIIW=MEAN HIGH WATER,EL=ELEVATION, IRR.= IRREGULAR, TITLE NO. Lf 1762-9 E z If( plastic wiry 1E around irr. wood pile 1' clear S ° u1c), - j P ; 2 1.7' C. Gi 2 4 1'1 i '~—� L' O.C. Lu� n �,� (v) ammum i 24 2 w 0 frame f ; t shed 1 � co 5 78 LA- 5 I � s , a O a- `Uo N 0- 12 CIO c o L� U- 1 STORY L- T 3 , F NAME , L E I REST CENCE 7 41 g' — o f L C O (� Q _ cr I O I W c i — , 3 ¢ �J jrT Q — z (,1 24 3' ' 'rIT i LCI a Cr CX) - „ U � U) N to U. C F-7 n:a 1 \A.7 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE la.Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured Swim Tech Pool Services,Inc. (631)928-2693 dba Swim Tech Pool Services,Inc. lc.NYS Unemployment Insurance Employer,Registration 467 Miller Place Rd Number of Insured Miller Place,NY 11764-3232 Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically 112855800 limited to certain locations in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Continental Indemnity Co. Town of Southold 3b.Policy Number of entity listed in box"la": Town Hall Annex Building 46-885823-01-01 54375 Route 25 Southold,NY 11971 3c.Policy effective period: Attn:Project Manager 02/28(14 to 02/28/15 3d.The Propietor,Partners or Executive Officers are: ® included.(Only check box if all partners/officers included) ❑all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3"insures the business referenced above in box "la"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATIONAL PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send the Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.)Otherwise,this Certificate is validfor one year after this form is approved by the insurance carrier or its licensed agent,or until thepolicy expiration date listed in box"3c';whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage-requirements of the New York State Workers' Compensation Law. 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 the coverage as depicted on this form. Approved by: Chris LaMantia (Print name of authorized representative or licenced agent of insurance carrier) Approved by: 11/06/2014 (Signature) (Date) Title: Authorized Representative Telephone Number of the authorized representative or licensed agent of insurance carrier: (877)234-4420 Please Note:Only insurance carriers and their licensed agents are authorize to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) t I i ' I Client#: 42822 SWIMP002 ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/05/2014 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 endorsement(s). PRODUCER CONTACT Southampton CommercialPHONE FAX Cook Maran&Associates A/c No Ext 631 324-1440 E-MAIL A/C,No): 300 Hampton Road ADDRESS: INSURER(S)AFFORDING COVERAGE 1 NAIC# Southampton,NY 11968 INSURER A:National Fire Ins.of Hartford 20478 INSURED Swimtech Pool Services,Inc. INSURER B:Merchants Mutual Ins.Co. 23329 467 Miller Place Rd INSURER C. Miller Place,NY 11764 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 CONTRACTOR 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 INSR ADDLSUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MWDD/YYYY MM DDNYY LIMITS A GENERAL LIABILITY 5099324804 - 2/01/2014 02/01/201E EACH OCCURRENCE S1,0 0,000 X COMMERCIAL GENERAL LIABILITY PREMISE To RENTED occurrence $100,000 CLAIMS-MADE E–x1 OCCUR MED EXP(Any one person) s 5 000 PERSONAL&ADV INJURY S1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2,000,000 X POLICY PRO- JECT LOC $ B AUTOMOBILE LIABILITY CAP1060260 3/10/2014 03/10/201 E°a6�deINGLE LIMIT n S $1,000,000 X ANY AUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident S S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S F—FDED RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY IIQBY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEY/N OFFICERIMEMBER EXCLUDED? ❑ N/A EL EACH ACCIDENT $ (Mandatory In NH) E L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - 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 Town Hall Annex Building ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 PO BOX 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S649180/M543221 RC5 pp.{� Client#:42822 SWIMP002 ACORD,.■®Tu CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) 11/05/2014 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(ies)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). PRODUCER CONTACT NAME: Southampton Commercial PHONE 631 324-1440 FAx Cook Maran&Associates LHC E t ac,No E-MAILL 300 Hampton Road ADDRESS: Southampton,NY 11968 INSURERS)AFFORDING COVERAGE NAIC p INSURER A:National Fire Ins.of Hartford 20478 INSURED Swimtech Pool Services,Inc. 33INSURER B:Merchants Mutual Ins.Co. 229 467 Miller Place Rd INSURER C: Miller Place, NY 11764 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 CONTRACTOR 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 INSR ADDLSUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MWDD/YYYY POLICY DDD/YEXP LIMITS A GENERAL LIABILITY 5099324804 2/01/2014 02/01/201 EACH OCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY DAMAGPREM E RENT occur ante $1007000 CLAIMS-MADE 51OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2 000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 X POLICY JEPRO CT M LOC $ B AUTOMOBILE LIABILITY CAP1060260 3/10/2014 03/10/201 CEa acct den_MINED SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC SORYTATU- OTH- AND EMPLOYERS'LIABILITY ANY PRER OPRIETOR/PARTNER/EXECUTIVE Y/N E L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ NIA Mandatory In N (f yes,describe under E L.DISEASE-EA EMPLOYEE $ I DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) 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 Town Hall Annex Building ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD 4tS649180/M543221 RC5 STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE Ia.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured Swim Tech Pool Services,Inc. (631)928-2693 dba Swim Tech Pool Services,Inc. lc.NYS Unemployment Insurance Employer Registration 467 Miller Place Rd Number of Insured Miller Place,NY 11764-3232 1d.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically 1128 unity limited to certain locations in New York State,i.e.a Wrap-Up Policy) 5800 2.Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Continental Indemnity Co. Town of Southold 3b.Policy Number of entity listed in box"Ia": Town Hall Annex Building 46-885823-01-01 54375 Route 25 Southold,NY 11971 3c.Policy effective period: Attn:Project Manager 02/28/14 to 02/28/15 3d.The Propietor,Partners or Executive Officers are: © included.(Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3"insures the business referenced above in box "Ia"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATIONAL PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send the Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c';whichever is earlier. Please Note: Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. 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 the coverage as depicted on this form. Approved by. Chris LaMantia (Print name of authorized representative or licenced agent of insurance carrier) Approved by: 11/06/2014 e- (Signature) (Date) Title. Authorized Representative Telephone Number of the authorized representative or licensed agent of insurance carrier: (877)234420 Please Note.Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) ?5 -- -------- A 0