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HomeMy WebLinkAbout47378-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 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#: 47378 Date: 1/25/2022 Permission is hereby granted to: Caravanos, Jack 137 E 36th St Apt 10A New York, NY 10016 To: construct accessory in-ground swimming pool as applied for. At premises located at: 3700 Stars Rd., East Marion SCTM #473889 Sec/Block/Lot# 22.-2-16 Pursuant to application dated 1/10/2022 and approved by the Building Inspector. To expire on 7/27/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 �1 s dire_ hpector 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 hitI/ -w soutldtom�fn ov - Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only - _ ID) PERMIT NO. Building inspector: _ Applications and forms must be filled out in their entirety. Incomplete ' = applications will not be accepted. Where the Applicant is not the owner,an 1ILDING TOWN OF So THOLD Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Barrie: SCTM#1000-22-02-16' Email:jackcaravanos@gmail.com Project Address:3700 Stars Road, East Marion, NY 11939 Phone#: 646-275-2828 - - - - i Mailing Address: 3700 Stars Road,East Marion,NY 11939 1 O�TA�'PERSON• Name: Jack Caravanos I Mailiri Address: 3700 Stars Road, East Marion, New York, 11939 iEmail: jackcaravanos@ mail.com 1 Phone#: 646-275-2828 1 g , i III AN I Name: G t Ci'titt k Malin Addre s• PO Box 9, Cutcho ue NY 11935 P one Chituk@O torline.net #£ 631-734-7665 Email:I g p i Chituk Pools (Gene Chituk PO Box 9, Cutchogue, NY 11935 i Phone#: 631-734-7665 Email: gchituk@optonline.net CONSTRUCTIONDESCPJPZI8N OF PROPOSED 1 CNNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑0ther In-ground pool installation $ 32,000 Will the lot be re-graded? ❑Yes 91 No Will excess fill be removed from premises? ❑Yes (NNo , 1 PROPERTY INFORMATION Existing use of property: 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 ONO IF YES, PROVIDE A COPY. ❑ Check 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 an 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): i j< t�,� ( lq luo _S' ❑Authorized Agent 171 Owner Signature of Applicant: f - Date• _ } f 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 (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/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,T, yA-e, ' 204 4- Notary Public CAROLINE M MACARTHUR NOTARY PUBLIC-STATE OF NEW YORK PROPER—VWNER AU-11-1110RIZATION No.01 MA6384635 (Where the applicant is not the owner) Qualified In Suffolk County My Commission Expires 12-17-2022 i, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 K 'M mullz s 3 x U ° g OWN VJIM � 2� y € W dm p 9 U b l r _ < 37 = s sol O i ill *A 1-0 Vic To ej t fs x s i s \ KI s w _Workers' _ ATE Compensation CERTIFICATE OF INSURANCE COVERAGE {Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW !PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrieri 1 a.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured CHITUK POOLS LTD ( 631-484-4245 i PO BOX 9 CUTCHOGUE,NY 11935 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to i certain locations in New York State,i.e.,wrap-up Policy) 113306347 i 2.Name and Address of Entity Requesting Proof of CoverageI 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company r Town of Southold Building Department 3b.Policy Number of Entity Listed in Box"l a" P O Box 1179 DBL614067 Southold, NY 11971 3c.Policy effective period 05/01/2021 to 04/30/2023 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. i i B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: i 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 I insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. ' Date Signed 1/7/2022 By v U f /,,' Atv (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title I Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS i Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if sox 4B,4C or 5B have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees.11 i Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. II'I p DB-120.1 (12-21) 1111111 IIII�IIII�IIIIIIIIIIIIIIII(IIINIIIIIIIIIIII�IUI Additional instructions for Form 1313-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled 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 coverage indicated on this Certificate. (These notices may be 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. This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. This Certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (12-21) Reverse STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 9 O PBox P 0 Box 9 NY 11935 lc.NYS Unemployment Insurance Employer CutRegistration Number of Insured Work Location of Insured(Only required if coverage is specifically ld.Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 11-3306347 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold Building Dept P O Box 1179 3b.Policy Number of entity listed in box"la" Southold, NY 11971 WWC3563869 3c. Policy effective period 01/01/2022 to 01/01/2023 3d. The Proprietor,Partners or Executive Officers are included. (Only check boa!fall partners/officers included) X 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 INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this 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 ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for ane 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: Thomas A Dickerson (Pr=int e of aythortzed representative or licensed agent of insurance carrier) Approved by: 11712022 (signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-298-4700 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however, shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-07)Reverse > CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDD/YYYY) 01/07/2022 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 r Is an ADDITIONAL INSURER,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 end mer s). PRODUCER COttT'ACT Lauren Murphy Roy H Reeve Agency,Inc. Ptlut (631)298-0700 FAX (631)2 98-3850 PO Box 54 E-MAIL ADDS, Imurphy@royreeve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE I NAIC# Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B: Chltuk Pools Ltd. INSURER C: 1 PO BOX 9 € INSURER D: €_INSURER E: Cutchogue NY 11935 INSURER F COVERAGES CERTIFICATE NUMBER: CL2142814429 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 MAYBE 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 ADDL POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD 4yV0 POLICY NUMBER MMID D/YYYY)€-&Meg= LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR I DAMAGE IORENiED $ 1DO,DDO , PR€M!SES{Eao�urr€nc�l Contractual Liability MED EXP(Any one person) I$ 15,000 A € 6018146726 03/15/2021 03/15/2022 ,PERSONAL a ADV INJURY $ 1'000,000 GEN'LAGGREGATE LIMITAPPLIES PER: I GENERAL AGGREGATE $ 2.000,000 I POLICY C ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: 1 $ AUTOMOBILE LIABILITY I UUMbINtD 51NGLt LIMIT $ 'Ea accident) ANY AUTO I BODILY INJURY(Per person) OWNED SCHEDULED I AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ 1 HIRED NON-OWNED 1 € PROPERTY DAMAGEAUTOS ONLY AUTOS ONLY I v UMBRELLA LIAB OCCUR EACH OCCURRENCE $ F7EXCESS LIAB CLAIMS-MADE AGGREGATE _$ DED RETENTION$ ! WORKERS COMPENSATION PER 1 1 OTH- AND EMPLOYERS'LIABILITY Y/N _. STATUTE €ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE El - [ OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT S (Mandatory In NH) € - € E -DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached R more space Is required) Pool Permit: Jack Caravanos,3700 Stars Road,East Marion,NY 11939 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Building Department AUTHORIZED REPRESENTATIVE PO Box 1179 Southold NY 11971 ,! 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD � t � 1 JM ffiINWIM rT N �r) =.{�+ r T rm �r-1 1 " . M1 s .ri�• ----T--,..� � ._.•�... _ d ,• L �, -in• •--- - !' � • �� I d 1 ,, � A P ��5 �� S'. - ��. �� � I •yip ' +. y:'! • I E I &N-gilrol 77R AmEs-DEEmos P.E. 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