HomeMy WebLinkAbout47472-Z r 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 #: 47472 Date: 2/22/2022
Permission is hereby granted to:
Sparacio, Sheri
330 Old Field Ct
.......... ......_.�__ ....ww_.._ ----- .....
Mattituck, NY 11952 ___________
To: Install in ground vinyl swimming pool at existing single family dwelling as applied for.
Minimum 15' setback from side and rear property lines required for pool and equipment.
At premises located at:.
330 Old Field Ct., Mattituck
SCTM # 473889
Sec/Block/Lot# 120.-3-8.26
Pursuant to application dated 1/27/2022 and approved by the Building Inspector.
To expire on 8/24/2023.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO- SWIMMING POOL $50.00
Total: $300.00
1111"N
Building Inspector
r TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. d. Box 1179 Southold,NY 11971-0959
�rAr Telephone (631) 765-1802 Fax (631) 765-9502 1 ¢1l
n A,,
Date Received
APPLICATION FOR BUILDING PERMIT
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For Office Use only
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
Owner's Authorization form(Page 2)shall be completed,
Date: - q-22
OWNER(S)OF PROPERTY: 2
Name: S,h-e--pZ `Jj !'�2� { l 5CTM # 1000-
Project Address: '330 OW R-eL-p - eN
Phone#: q(p�3 2, Email:
Mailing Address:
CONTACT PERSON:
Name: F - ` . .
Mailing Address: 4'2qpk-- 2w l0YC7�i�
Phone#: Email: O FVI C e 60,4e SIS,C'cm
DESIGN PROFESSIONAL INFORMATION:
Name..
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name: p Pas
Mailing Address: 2Qi P--I- 2-5-4 14� Ga� 1110Y I -AW
Phone#: �,�.� _-� � — _ Email: � i('2�0 °�i7.}1S �C�t►'I
DESCRIPTION OF PROPOSED CONSTRUCTION
El New Structure ❑Addition _Alteration ❑Repair ❑Demolition Estimated Cost of Project:
E10ther _nn I V --
Will the lot be re-graded? ®-Yes El No JODL �1_ Will excess fill be removed from premises? Ayes ❑No
1
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,
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Existing use of property: _gee,�@,Wca Intended use of pro ert
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑YesXNo IF YES, PROVIDE A COPY.
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Application Submitted By(print na e; C 1 ❑Authorized Agent Nwner
Signature of Applicant: Date:
STATE OF NEW YORK)
j SS:
COUNTY OF 6\JqS:&�z
Dl� 6PA-6-04 being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the ONPI-ef—
(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
Sworn before me this
day of ,
� �1JPt ........___.�.. 202 _ �
a_ 4&
MARGARE F A. KIDNEY
otary Public-State of New York
No. 01 K160211 11 AUTHORIZATION
Qualified.in Suffolk County PROPERTY OWNER
y Commission Expires March 8„2023 (Where the applicant is not the owner)
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
CERTIFICATE OF LIABILITY INSURANCE DATE(MMUDDIYYYY)
12/2=021
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 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 certificate does not confer ri hts to the certificate holder in lieu of such endorsements).
CONTACT
PRODUCER P ..............
Liberty Risk Management, Inc. 631 569.51633 rtll OAK
6
2333 Route 112 a..WW...(. �. fI�
X636
matttl IItN�rtywlala� ._.
Medford, NY 11763 �NsuRER s AFFkaRINI±c cravw w►c �,_,,,, c wM
_. _.. .... s._._._._..
INSURED _ ..
Arthur J.Edwards Mason Contracting Company Inc. INSURE rtwe,: ..........
DBA Arthur J. Edwards Pool&Spa Centre
929 Route 25A INSURER D
Miller Place, NY 11764 _INSURER E ......
INSURER F
COVERAGES CERTIFICATE NUMBER: 00005-1323810 REVISION NUMBER: 23
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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS S . .... Gkkfi TrQ4.ICY EXP _..w..w.w.
TYPE OF INSURANCE POLICY NUMBER LIMITS
A .....w_w..0.......n_-
-M--ERCIALOENERALLIABILITY
NPC-1004300-01 01/01/2022 01/01/20236( $
$ 1000000
___ _ ,300 OOLAIMS-MADE NXIOCCUR C----ww.. _ww__wwwwwwwwwwwwwwwwwwwwwwwwwwwwwww_ 0
000O
``.. PERSONAL&ADV INJURY $ 1 000 000
JEa..-^µ{.LIE LOCwwww w__. PAGGREGATE µXS 2000�O00
GEN`L AGGREGATE LIMIT APPLIES PER: GENERAL
POLICY RODUCTS-COMP/OP AGG S 2 OOO OOO
OTHER. $
AUTOMOBILE LIABILITY w�( �� .S).... ... a��..�..
.
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Peraccldent) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PRiPEFYrYD
AUTOS ONLY AUTOS ONLY $
$
UMBRELLA LIAB_U
OCCUR EACH OCCURRENCE $
....,,,,. ..___www..wwww.www.____.........__...wwwwwwwww_......................._.._.ww...._
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEO RETENT ON $
WORKERS COMPENSATION PE O
AND EMPLOYERS'LIABILITY Y/N 8TT4In5.........___ ..___ _......
AMY PR0PRkET0RPPAR1HEWF:;XF:C1a'11VE: EL EACH ACCIDENT $
OFFICE"EMSER EXCLUDED? NIA .—-----____________ .....
(Mai r1*M NH)' EL DISEASE-EA EMPLOYEE $
O SC aserift OF er
OPERATIONS OF OPERa T10NS below
II yos, IPTIE.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 701,Additional Remarks Schedule,may be stleched I mars specs larequired)
Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms,
conditions,and exclusions.
CERTIFICATE MOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town Hall ACCORDANCE WITH THE POLICY PROVISIONS.
P.O. Box 728
Southold, NY 11971 AUTHOR—ZED REPRESENTATIVE
I - _k� MJR
01988-2015 A ORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/22/2021 at 01:26PM
NYSIF
199 CHURCH STREET,NEW YORK,N.Y.10007-1100
New York State Insurance Fuad I nysif.00111
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A A A A 112377925 m r�
LEVITT-FUIRST ASSOCIATES LTD
520 WHITE PLAINS ROAD,2ND FL
TARRYTOWN NY 10591
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD
CONTRACTING COMPANY INC P.O. BOX 728
929 RTE 25A SOUTHOLD NY 11971
MILLER PLACE NY 11764
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD 7]7DATE
G 2438 491-9 633479 06/29/2021 TO 06/29/2022 06/16/2021
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS'
COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE
STATE OF NEW YORK,EXCEPT AS INDICATED BELOW.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF
CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/
CERTVAL.ASP. THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH
NOTIFICATIONS.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICY.
ommmmmon
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 391287892
111111101100 TOOMOTO 01140TO 10"00012093611)
Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-24384919] U-26.3
,NrwWorkers!YORK CERTIFICATE
E.-NITATIE fotnpensation
BoardDISABILITY AND PAID FAMILY -BENEFITS
PART .To be completed i ility and Paidit n is Carrier or Licensed Insurance Agent of that Carrier
1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC
929 ROUTE 25A 6317440174
MILLER PLACE,NY 11764
Work Location of Insured(only required If coverage Is specifically Ilmited to 1c.Federal Employer Identification Number of Insured
certain locations In New York State,i.e.,wrap-Up Policy) or Social Security Number
11-2377925
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Bern Lis as the Certificate Holder) Standard Security Life Insurance Company of New York
Town of Southold
PO Box 728 3b.Policy Number of Entity Listed in Box"la"
Southold, NY 11971 Z06874-000
3c.Policy effective period
7/1/2020 to 6/9/2022
4. Policy provides the following benefits:
Q A.Both disability and paid family leave benefits.
E] B.Disability benefits only.
❑ C.Paid family leave benefits only.
5. Policy covers:
0 A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law.
B.Only the following class or classes of employers employees:
Under penalty of pedury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named
insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as des d above.
Date Signed 6/10/2021 BY
(Signature of Insurance carrier's.'aho'i ,d represen tine or NYS Licensed Insurance Agent of that Insurance carrier)
Telephone Number 12 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES
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 413,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 210,Subd.8 of the NYS
Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation
Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200.
. c I r ® s i r (Only' o r f Part i has en check )
State of New
York
Workers' Compensation Board
According to information maintained by the NYS Workers'Compensation Board„the above-named employer has compiled with the
NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees.
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 benerds Insurance policles and NYS licensed Insurance
agents of those insurance carriers are authorized to Issue Form B-120.1. Insurance e T authorized to Issue this fbi7n.
DB-120.1 (10-17) II II
DB-120.1 (10-17)
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