HomeMy WebLinkAbout46686-Z „ TOWN OF SOUTHOLD
„ ,gym BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
p SOUTHOLD NY
ryJ” xis,i,:
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#: 46686 Date: 8/12/2021
Permission is hereby granted to:
Konforti, BoYana
271 W 122 St Apt w1
".. .....
..................
... .......n _.. . —
__ _wwk ..-----......
New York, NY 10027
To: install hot tub as applied for.
At premises located at:
250 WendyDr, Laurel
SCTM # 473889
Sec/Block/Lot# 128.-5-2
Pursuant to application dated 6/2/2021 ..__ and approved by the Building Inspector.
To expire on 2/11/2023.
Fees:
SWIMMING POOLS -ABOVE-GROUND WITH REQUIRED FENCING $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
ng sector
- TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502
Date Received
APPLICATIONIIS D II PERMIT
For Office Use Only
PERMIT NO. Building lnsp rtor:, ,-
��.1i,4
Applications and forms must be filled out in their entirety. Incomplete
applications will not be accepted. Where the Applicant is not the owner,an fro,i°Ti
Owner's Authorization form(Page 2)shall be completed.
Date: t3/2-4)2 l
OWNER(S)OF PROPERTY:
Name: \C Irl b Nr.� SCTM #1000- —
Project Address: ZSp
Phone#: 01 F�— 3"'7 ( — —� � Email: P-sw tv 1-31 G� ctWtI_,.. (,'(>wl
Mailing Address: 4S �493rJ�E�
CONTACT PERSON: ^�
Name: S-� >,A�2'1 � ,r C C U S i}M._S /2 C-A-1aV&9-7I O N�
Mailing Address: /�5f i YOP9-1�j 12p /Vtv /e-,9-t6 l./-1
Phone#: 3 1 -76-7,33 `x"' Email: C/BTU ( ly;J-t(_ ' CCGit
DESIGN PROFESSIONAL INFORMATION:
Name: ILO1SC-12 1Q.C1k-kA
Mailing Address:
4-GO _ I'll /U0b> i L/C- LIC-77 1-16-n
Phone#: f T- C) Email:
CONTRACTOR INFORMATION:
Name: IMS C—�-�CJ(r1�T1 C�t�JS
Mailing Address:
N /Il
Phone#: 1 .—'Z'7( '` e,4, Email: C `S/ CliYllC_�Uj12.
DESCRIPTION OF PROPOSED CONSTRUCTION
p J C,0 ��~" $
EINewStructure ❑Addition ❑Alteration ❑Re air ❑Demolition Estimated Cost of Project:
UoClfhe � t�
Will the lot be re-graded? ❑Yes f Wt---- Vde Will excess fil be removed from premises? ❑Yes o
1
PROPERTY INFORMATION
Existing use of property: 2�S Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes El No IF YES, PROVIDE A COPY.
HJ I ec Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. 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,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(s)for necessary inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal law.
Application Submitted By(print name): uthorized Agent ❑Owner
Signature of Applicant: Date:
STATE OF NEW YORK)
SS:
COUNTY OF )
being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the ��w;, �, �
(Contractor,Age ,'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/her knowledge and belief; and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
—..day of w ZO
,
EVELYN J HOBSON
Notary IAV It ai`
Newyork
PROPER IIII E tJ 1 l
(Where the applicant is not the lowner)l ll MGM
residing at V P.
hereby authorize -FJa�-�— C� tJs to apply on
my behalf o the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
`�
Print Owner's Name
2
CERTIFICATE OF LIABILITY INSURANCE DATE`'"" /'27/2" o
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 poifDy(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 c"ficato does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER UUMACT
SPEC
204 RTE.112
INSURANCE&SERVICES ME ONEeans µPHE S'iE(I�t . .> Pq). _...
x
d,tELC
e........_......... .
PATCHOGUE,NY 11772 "..- SPECdALIZLDNN' URA,wICF COM
..m...w_....... . .....,-,_.....- ,.........��..._._._w.....-..
Auto-Home-Business-cycle-etc. INS..... R 8 AFFORDING COVERAGE N )O$
ATLANTIC CASUALTY INSURANCE...
INsq�URE _
WIT__.__m_._._.�._...._._-................._�,. uRERA: RANG CO 42846
INSURED
AMS HOME IMPROVEMENT LLC INsaIREa;
1549 MAIN RD „4NSUwm c a_,
RIVERHEAD NY, 11901 I . =....._w,.......-.....__.__-..-...__ _ �_..__... ..._..._.._ _..
Ir uRER F rt
COVERAGES CE'RTIFICAT'E 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,
SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND CONDITIONS OF H
4i#SR PO�LiCY E
Jim. TYPE Of WSURANCECOMMERCIAL GENERAL LIABILIrY���^..... L08802fi104 M.M....�.w. FP
_._w ..._... C5& _..
POM.lCY N4I Gait LVMITS
A Y N 11/05/2020 11/05/2021 .EACHOCCURRENCE $ 1,000,010
CLAIMS-MADE ®OCCUR a `E'i11' x "
RRICL�tai..,...Wi w__.... 1001,000
__ _..._.�w.. .. _..
MED,.,ESP Ae nresavw ... ,1QC9
..wl.. ._.
GTEN`L'ACA RELATE LIMIT APPLIES PER: GENERAL AGC3RECYATE, $ 2000000
Po"CY yi RO,
1.__i JEC-r El Loc
OTHER: $
AUTOMOBILE LIABILITY
.-..
ANY AUTO
BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS 0 LYNLY AUTOS BODI
Y INJURY(Per acddenl) S
AUTOS ONLY AUTOS ONLY Elif DA
HIRED NON-OWNED
..IdI9
$
UMBRELLA LIA6 71-CUR EACH OCCL)R .GE $
EXCESS LIAeAIIAS MAGE AOOREGAI $
EO TENVON $ _ .
WORKERS CDMPENSATiON
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOWPARTNEWE%ECUTWE
OrE L EACH AA CiDENT _... $ w_ w
FBCEPJMC:MSER E%CLUN/A
OCi?"M
(Abandalorg In NI)) EAAPLOYE $
0' I dace dbe under E.L.08SEASC• A � .._..
D ti,MPT'ION OF ERATiONS I eBay n E.L OtSEAfiE•EOLICY LIMIT ,$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached 11 more apace Is required)
DRY WALL OR WALLBOARD INSTALLATION,PAINTING-INTERIOR BUILDINGS OR STRUCTURES AND REMODELING-INCLUDING ONLY THOSE
CLASSES SHOWN ON REQUIRED FORM AGL-REM
CERTIFICATE HOLDER IS ADDITIONAL INSURED AS PER WRITTEN CONTRACT OR AGREEMENT
CERTIFICATE HOLDER CANCELLATION
SOUTHOLD BUILDING DEPT SHOULD ANY OF BOVE DESCRIBED POLICIES BE CANCELLED BEFORE
54375 NY-25 THE EXPIRAT/ ATE THEREOF T`tCE WILL BE DELIVERED IN
ACCORCIANC TH ICY IONS.
SOUTHOLD NY 11971
AI,ITNORW%£D E: I� '
E � �
®19813-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
YORK Workers' Certificate of Attestation of Exemption
STATE 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 party.**
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 Business Applying For:
(Legal Entity Name and Address): Building Permit
Ams Home Improvements LLC P
1549 Main Rd From:southold town buildingdept 54375 main road PO box 1179 southold NY
Riverhead,NY 11901-6006 11971
PHONE:631-779-3727 FEIN:XXXXX1541 The location of where work will be performed is
250 Wendy drive,Laurel,NY 11901.
Estimated dates necessary to complete work associated with the building
permit are from July 1,2021 to August 6,2021.
The estimated dollar amount of project is $0-$10,000
Workers'Compensation Exemption Statement:
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: stuart daccus
Disabil&and Paid Famil w Leave Benefits LiNemotion 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: 1) 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,stuart daccus,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 true,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 govert uaent entity listed above.
SIGN 1,HERE Signature ��� /
Date /
Exemption Certificate Number Received
2021-034079 June 1, 2021
NYSE Workers'Compensation Board
CE-too 01/2018
m
CANADIAN HOT TUBS
1585 VICTORIA ST N.
MANIT LI N 519.745.1651
7'X5'OVAL WDEE,P TOLL FREE: 1-800-265-6355
REAR
SUCTION LIGHT
EXACT JET LOCATIONS COPING
DETERMINED AT INSTALLATION
• VINYL LINER �+ STAINLESS STEEL BAND
AC
S TS
� AYR FOIL TM
REFLECTNG INSULATION
1
6 JETS I
2X4 CLEAR BC WESTERN RED CEDAR �•
S TS
V
I
FRONT �L 1
CROSS SECTION DETAIL'A'
TOP PLAN
7'
DETAIL A
FAIR INTAI�
2X4 CONVEX CONCAVE
BEVELED EXTERIOR
11"
�AIR HOSE
STAINLESS WATER HOSE
STEEL 6ANDS
0
A.
u..•.. u ,„ u• r - iii - u - n n. _ A`l
FRONT ELEVATION REAR ELEVATION
t
r
N
UNAUTHORIZED ALTERATION OR ADDITION THE EXISTENCE OF RIGHTS OF WAY
TO THIS SURVEY IS A VIOLATION OF' ND/OR EASEMENTS OF RECORD 1F DRAWN NN CHECKED MM DATE NN21Sf 2019 DRAWING k JCB N0.19-1011
SECTION 7209 OF THE NEW YORK STATE ANY. NOT SHOWN ARE NOT
EDUCATION LAW. GUARANTEED
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAT.OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED Premises known as:
TO BE A VALID TRUE COPY
GUARANTEES INDICATED HEREON SHALL RUN # 250 Wendy Drive, Laurel 4
AL
ONLY TO THE PERSON FOR WHOM THE SURVEY f
NMID4
IS PREPARED. AND ON HIS BEHALF TO THETITLE 0 _ fA �`^\
LENDING INSTITUTION LISTED THEREON.OAND D Area- 20,112 s.f.
TO THE ASSIGNEES OF THE LENDING INSTI—
TUTION GUARANTEES ARE NOT TRANSFERABLE
u+
F°I�
VA t
Sl ¢
o N�
C`ve int 7a
e
\� 1g fum
0
``,, �a 50• 6 �� o .
dell curb ' •�'�r� s �6✓��
`lv Rc36.50' �,�00�' '��•'�� Poi°' z ��0
h
=z13.A6 Wt
W
bto
• fa`n`�mq� fMO� n\ �'• c �o' ?q�•
f m�\ g ��� 1a ° �0 FT FIxIt—
�r ?
`i�ZOPC"RT•f
O g/�s � a y�, h(p•
(p I�ecGssec�..
N,fN'ER'
19S 10 fp0.MEK�•l
�eJ�`a rA uS�-
� o
,tn-h re �y
�
Ili, 14G � —j r
1V
'e
Q ei .
Certified to:
RICHARD STEVEN MANN Surveyof Described Property
BOYANA BLANCHE KONFORTI t'pl
COMMUNITY ABSTRACT CORP situate at
FIDELITY NATIONAL TITLE INSURANCE COMPANY
WELLS FARGO BANK, N.A Laurel
Town of Southold
Michael W. Minto, L.S.P.C. Suffolk County, New York
LICENSED PROFESSIONAL LAND SURVEYOR
NEW YORK STATE LICENSE NUMBER 050871 District 1000 Section 128 Block 5 Lot 2
87 Woodidew Lane Scale 1"= 30' Surveyed August 28, 2019
Centereach, N.Y. 11`720 GRAPHIC SCALE
PHONE/FAX' (631) 580-1202
CELLULAR: (631) 766-9714 50 a is ao 00 Iso
w EMAIL: mikemintolspcOgmad.aom
( IN FEET)
1 inch = 30 ft.