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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.