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HomeMy WebLinkAbout47662-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#: 47662 Date: 4/11/2022 Permission is hereby granted to: Tuthill K & K Trust ...................................____._._._._._._._.______NNN�.�..... _..�....... ._..._..wwwww_.............wwwwwwwwwwwww �___ PO BOX 247 Whitefield, NH 03598 _ ----------------------------------------- .-_-_-_. _—._._.....­-­-- To: construct accessory in-ground swimming pool as applied for. At premises located at: 67.5...Cedar....DrI....Mattituck........ _.._...m__ ..............................._._�. _ _www__ SCTM #473889 Sec/Block/Lot# 106.-11-7 Pursuant to application dated 3/11/2022_ and approved by the Building Inspector. To expire on 10/11/2023.w_ Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: _�...� $300.00 ------------- Bt i knagector 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 Ligps.//N its to a ltt c v t yjqY Date Received �III'PL BUILDING IT For Office Use Only C E PERMIT NO. Building Inspects ra. _._... _ MAR 0 92022 Applications and forms must be filled out in their entirety. Incomplete ; i�N~�NN.DNN�NG DEPT (, VVN OF,,3 UTH1&D applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: �a2iS TV'T1I �—L SCTM#1000- 7 Project Address: Phone#: Email: ,Pe4L'J Mailing Address: CONTACT PERSON: Name: 4,F,1 j1 /_�/ r7iJ1� Mailing Address:-7 <<, .D,r 9, �-C4+,X,L-�, i�yy� X1935 Phone#: Co 31 - �/-`rZ�� Email: rte�- DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: �aCax cis �7�tw, AJY//y3S Phone#: (� 31 - 7gzl -26 laS cl-P+C'n I i ru. n e-+ DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: 00ther =7-/4 $ �5'9'4)00,c2� Will the lot be re-graded? ZYes 0N Will excess fill be removed from premises? IyYes ❑No 1 PROPERTY INFORMATION Existing use of property: 5;vZy . 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)Rj'No 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 286 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): 131Authorized Agent ❑Owner Signature of Applicant. Date: STATE OF NEW YORK) SS: COUNTY OF Z: 11k ) EJC?t7uC 614/7uk being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the Z (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 a� day of lgcLrc1-, , 20 I:v ......-,7V1j1A o a Public STEVEN L. HARNED PROPERTY NE f HORi I Notary Public State of New York No.OI A607 t 848 (Where the applicant is not theowner) Qualified inSuffolkounty. Commission ion Expires March 3, , 2„ residing at do hereby authorize to apply on my beh f 0 the Town of Southold Building Department for approval as described herein. Zo 2 Z Owner's Signature Date Print Owner's Name 2 �;," l DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/04/2022 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lauren Murphy Roy H Reeve Agency,Inc. Nlv Ext, (631)298-4700Al A'C.No (t 3'1)298-3850 PO Box 54 E-MAIL Imurphy@royreeve.com ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Malliluck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER 13: Chituk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 11935 INSURER F:' COVERAGES CERTIFICATE NUMBER: CL213414038 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 rA TYPE OF INSURANCE ( M POLICY NUMBER M9DIYYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -UA=F TO RENWim100,000 CLAIMS-MADE ®OCCUR PRFMfS,�5{EaonmarrContractual Liability MED EXP(Anv one person) $ 15,000 6018146726 03/15/2021 03/15/2022 PERSONAL&ADV INJURY $1,000,000 GEM.,AC#P;I'kEGAtlF 1..YMIT APWLtlES 8^"E,R'.: GENERALAGGREGAI-E $ 2,000,000 "PRO- 2,000,000 POLICY IRO- 1:1 LOC PRODUCTS-COMPlOPAGG $ I—H OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE IJMIT $ Eau nradl7n'ut ANYAUTO BODILY INJURY(Per person) $ OWNED tCLAIMS-MADE BODILY INJURY(Per accident) $ - _. ...... 'AUTOS ONLY HIRED I'' OP R Y UAW—M-7— $ AUTOS ONLY Per x�T^I;NabOetl $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $-...,..... DED-1 I RETENTION S WORKERS COMPENSATION I PEP, OIH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑'NIA EL.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Re: Chris Tuthill,675 Cedar Drive,Mattituck,NY 11952 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. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ,'t ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF INSURANCE COVERAGE sTA•rr Compensation "k- i Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW ...PART 1.�To._becom completed b,......isab.1.1.1.{mm,man..�w.�....._.�....... .._........._w.._._._.................-.._...._.._r Li....._....w�w�w_ -..�...._w_...........................___...,m,..,,,_,.ww._..__.._..._ D d Paid Family Leave Benefits Carrier o p y y ytensed Insurance Agent of that Carrier 1 a.Legal Name.......................w_s of Insured(use street�address�only).... ���� ������b.�6...siiness Telephone of 1...-�.�,e��-�� �� �����-�-- g 8 Address y) 1b us p Insured CHITUK POOLS LTD 631-484-4245 PO BOX 9 CUTCHOGUE,NY 11935 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 113306347 2.Name and Address of. .w Entity Requesting Proof of Coverage _ 3a.Name Insurance Carrier Wmmmmmmmmmm�--,., ww ._._._ (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold PO BOX 1179 3b.Policy Number of Entity Listed in Box"ll a" Southold NY 11971 DBL614067 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. E] B.Disability benefits only. E3C.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: Under penalty of perjury, I certify lfiat"1-am�-an�authonzed.re,presentatve or licensedg�"n—t J------- ..... --....".........................................����""���-��-������i� .__...a n a.. ent o the insurance carrier r�e�fern�;�t1 above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/16/2021 _ By .........................._..................._...... _ ..,.w_ _.... ....wwwwwwww_..ww.........., (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 51.6-829-8100 ............._ Name and Title Richard White,,Chi fxecutiv_e � i qww,_.._..__...................................._a....... 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 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. To be completed by the NYS Workers'Compensation Board (only if Box 1.M-._s_... .....h PART 2 _.. � +� YYY -�-,M,m_m...m... www_. .ww. x 4C or 56 of Part 1 has 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 with respect to all of his/her employees. Date Signed _. .... .... ....... ................... By (Signature of Authorized NYS Workers Compensation Board Employee) Telephone Number .,ww-w_....w-.._.._. Name and Title _..........._._. _. .,_Mw-wwww-ww........................ Please Note:Onl insurance tamers licensed to write NYS disabilityandaid....... insuranc es and N..,,,,n Only y p family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form D8-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) I I I I re DB-120.1 iiiiiiiiiiiii(iiiiiiiiiiiii)iillll '-—J CERTIFICATE OF 2 NEW YORK Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE STATE Compensation Board Insured Detail In.Legal Name and address of Insured(Use street address only) I b.Business Telephone Number of Insured Chink Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 le.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number Work Location oflnsured(Only required if coivrage is spec:ifically limited to 113306347 certain location in New York State,Le a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company To«m of Southold PO Box 1179 3b.Policy Number of entity listed in box"la": Southold,NY 11971 W WC3563869 3c.Policy effective period: 1/1/2022 to 1/1/2023 3d.The Proprietor,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"1 a"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 must notify the above certificate holder and the lVorkers'Compensation Board 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 Certi ficate.(These notices may be sent by regular ntaiL)Otherwise,this Certificate is valid,for one year after this form is approved by the insurance carrier or its licensed agent,or until the police 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon 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: Matt Zender (Print name ofautlaorized representative or licensed agent or insurance cariier) Approved By: 2/3/2022 (Signature) (Date) Title: SVP,Workers Comp Production Management Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Onlr insurance carriers and their licensed agents are authorized to issue the C-105.1 ftrin.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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 duty 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(9-17)REVERSE 0 Vol .00 41 t, �f oPt vc,,,N P '41 46 tt 4av Opal' in n r ilo�t� SANDY O�Nf- OF pD sA, 44, Aa �$7 FESSI PV MAPFUE0 IN rHE OFFICE e (:11?AVEL 'Roy OF suFFoLx co uN r Y ON