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Home My WebLink About47671-Z rr�a 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 #: 47671 Date: 4/12/2022 Permission is hereby granted to: Suffolk County ._._... .. ._.__.____....._........_............_......_.._......................_.._.._... .._.._.._...............................w....wwwwwwwwwww.w_w.wwwwwwwww.�...ww 330 Center Dr ..................... Riverhead, NY 11901_________________________________________________ww... w To: construct accessory in-ground swimming pool as applied for. At premises located at: 155 Broadwaters Rd, Cuitcho ue SCTM...473889.. .._...._............ x�...___.........__....... Sec/Block/Lot# 104.-12-8.1 Pursuant to application dated 3/14/2022 and approved by the Building Inspector. To expire on 10/12/2023. Fees: ------------- SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 wilding Inspector "Fc� t TOWN OF SOUTHOLD -BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971 0959 Telephone 631 765-1802 Fax 631 765-95021 tt Hww <u1h ldtowuy-m Date Received APPLICATIONI IIT For Office Use Only E C PERMIT N0. .... w wwwwBuilding Inspector: it _" RMAI-? 0 ry DD Applications and forms must be filled out in their'entirety.Incomplete: applications will not be accepted. Where the Applicant is not the owner,an BUILDING S DEPT. PP_ p PP TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: SCTM # 1000- Name: �) t mrAl Project Address: Phone#: ( Email:t�� 6 Mailing Address: CONTACTPERSON: Name: 6d-�Y�na ar 0�ul("I Mailing Address: Phone#( Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address:. Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: p Phone� p Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition 0-Alteration DRepair ❑Demolition Estimated C st of Project: 990ther 1M on $, Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises?>'es ❑No 1 PROPERTY INFORMATION Existinguse of property: Intended use of ro ert :, p p Y 1- p p Y aOX4D .i— R' Zone or use district in which premises is situated: Are there any coven nts and restrictions with respect to l —qo this property? ❑Ye o IF YES, PROVIDE A COPY. �,/ChBox After Reading:I The owner/contractor/design professional is responsible;for all drainage and storm water issues as provided by eck pir 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 hereindescribed.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 buildings)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): �nck m( rcu(I CJ tktorized Agent ❑Owner Signature of Applicant: �&W&& Date: /w STATE OF NEW YORK) SS: COUNTYOF `. ►� ) 1 being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the In eja� I�Eontractor,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 Ma ✓G. —, 20 2Z n�w-jvfvl /I A, I/ Notary Public MICHELE A MEDUSKI Notary Public,State of New York F1 11:.:x' ,,,ry OWNER AUTHORIZATION Reg. No.01ME6393343 (Where the applicant is not the owner) Qualified in Suffolk County Commission Expires June 17,2023 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 Buildin a Department Application AUTHORIZATION (Where the Applicant is not the Owner) ______ v_r...rr. residing at M mmmmmWmYmmmBroadwaters Rd, Cutchogue, NY 11935 Rahul Sharma & Veena Isaac 155 (Print property owner's name) (Mailing Address) ............................................................ do hereby authorize mm.._......... Katrina Mercurio _w. ......w ..._ (Agent) _................................................................................................................ww. ww.wwww__wwwwwww_.................__ to apply on my behalf to the Southold Building Department. March 4, 2022 ............................................. _.__._................. mm._.........._._....._...... (Owner's Signature) (Date) Rahul Sharma ..... rvw(Print Owner's Name) ....................................................... A�o CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDIYYYY) 03/0112022 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(ies)must 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 �CNAOdN�TA.C....T PHONE .. ..�AXBrookhaven Agency,Inc. JA _...... 31 941-4405 EMAIL 100 Oakland Ave,Ste 1 ADDRESS—_certificates@brookhavena,gency.cam Port Jefferson,NY 11777 ......�..................IN��RIR.(;�]AEF .R!�!N��nv�l?!+G,!�,....... .. .. �............ .................. . .......... .. _................. 16 .4/R4A. Philadelphia Indemnity Insurance Co...._....... ......... INSURED INSI!RR.p Merchants Mutual Insurance Co. Patrick's Pools,Inc .il _/RgR,.Q,WescowInsurance Co.�,,,,,,, PO Box 3024 East Quogue NY 11942 (116URf INSURER COVERAGES CERTIFICATE 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,. .INSR TYPE OF INSURANCE .... .iADDL.'�S�UBR... ......... .................... ...............,,,,. POLICY EFF POLICY EXP.... _...e. e ........._.. .. ......... ......._,.,......., LTR U LIMITS mm x COMMERCIAL GENERAL LIABILITY EA,GH QGGURRENCE, $1 OOO O00_ww_........ ...,.,,..3 k ....., A „�CLAIMS-MADE ]OCCUR DAMAGE TO RENTED 10 3EMdSESdEa��ucracace)_ � Oz000 _. __ x Contractual Liabili X X PHPK2385555 02/28/2022 02/28/2023 MEP EXP AAny one„person)...............! 5 000111i1i1i1i1i1OO„_,,,,_Oe .� PERSONA n ADYlNsiRY „�a000 000 ..............____......... r,41A.(xCR&" i!,T'E LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 -�waaaaa„ prll k y rE PRO- LOC JECT 200OUO... T .,, , $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $5(�(�� _(Ea.acci2dma ......... _ .__a._ ... ........... B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2021 07/12/2022 ILY INJURY(mmm� w_......, _,_.,,..... AUTOS AUTOS BODPer acadent) $ X_ HIRED AUTOS X NON-OWNED PROP DAfa+NA xF $ AUTOS (h al.aru UMBRELLA LIAB OCCUR ........w .a..w.............. M AcGRI°rATr ._,..._...,EXCESS LIAB .................. GLAI...5[N1,A�E....... .. .._._.... .., ,......m .. ...,_..._n...,.......,,...,,,,, _.,.,.......,...._.. 110 WORKERS COMPENSATION i .SPER 0TH AND EMPLOYERS'LIABILITY YIN LX..... T.ATU.T.E._ ......... „.rva. ww........ ...........wwa............... ANY PROP RIETOR/PARTNER/EXECUTIVEE L EACH ACCIDENT $1 OO OOO C OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) WWC3528513 05/13/2021 05/13/2022 ..E I.DISEASE FA FMP QyF�F „�100s000 If yes,describe under DESCRIPTION AT E,L,DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold is included as additional insured per written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE CNSZ> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD YORK C Workers' CERTIFICATE OF INSURANCE COVERAGE c Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disabi ity and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured �� PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required it co•erage is specifically limited to certain locations in Now York State,i.e.,Wrap-U, Policy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box 1 a" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: A.Both disability and paid family le ave benefits. 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. rj B.Only the following class or class as of employer's employees: Under penalty parltiry. cert° that am an autho za represents ve or icensat agent o t a nsuranca r re erancad a ovE an thrdt tlwa namod insured has NYS Disability and/or Paid Fai illy Leave Benefits insurance coverage as described above. �/Wa. Date Signed 3/1/2021 By �, (vi-tore of insurance carrier's authorized representative or NYS licensed Insurance Agent of that insurance carrier) Telephone Number 516-M-81 00, — Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A;ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.►gent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B i s checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Accept ince Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the P IY5 Workers'Compensation Board(only if Box 4C or 58 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained b 1 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 Name and Title Please Note:Only insurance carriers licen led to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt prized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issue this form. DB.120.1 (10-17) 11111DS-120 111a1111111 l i Workers' CERTIFICATE OF SIAYE i Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE ............ �C"Bus'iness Telephone Number of Insured 631-996-4687 Flatricks Pools Inc I' I@ Legal Name&Addross of Insured(use street address only 110 Box 5024 1 c,NYS Unemployment insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured(Onty requited it coverage is specifica0y limited to I d,Federal Employer Identification Number of Insured or Social Security cortain locations in Nets York State,r e,a Wrap-Up Policy) Number 262929943 2 Narne and Address of Entity ReClUesting Proof of Coverage 3a,Narne of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 54375 Main Road 1 3b.Policy Number of Entity Listed in Box 1 a" Southold NY 11971 VVWC3528513 3c Policy effective period 05113/2021 to 05/13/2022 3d The Proprietor,Partners or Executive Officers are included (Only chock box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"1a"for workers' II compensation under the New York State Workers'Compensation Law, (To use this form,New York(NY)must be listed under IAQM-)A 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 inurance carrier must notify the above certificate holder and the Workers'Compensation Board within 110 days IF a policy Is canceled due to nonpayment of prernfurns of,wiliiin 30 days if'there are reasons other than nonpayment of prerniums that cancel the policy of efirnawate the insured fror-rr the coverage indicated on this Certificate,(These notices nnay be sent by regular mar,)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"21c",whichever is earlier. This certificate Is issueri as a matter of information onty and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,sror does it confer any rights,or responsibdifies 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 ort 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: Nicholas Zulkofske (Print name of taut 00d represenlative or licensed agent of insurance carrier) Approved by/)). (Date) Title:Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-941-4113 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 (9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering Into contracts unless compensation Is secured. 1 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 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(9-17) REVERSE M STREET ADDRESS,155 BROADWATERS ROAD HEALTH DEPT, REF, NO, R10-98-0037 N SURVEY OF PROPERTY AT NASSAU POINT TOWN OF SO UTHOLD SUFFOLK COUNTY, NY 1000-104-12-8.1 SCALE: 1"=40' DEC. 19, 2001 Odie"'. 26, 200t (prop, h .) JA`, 14, 200 ( (k. fnd.) APRIL 14, 200,3 (conc. fndtn.) MARCH 17, 2004 (finol) O �;3�,14:"" � r � 40,r *4, s 1p ... ' MV ti . acv .491 ly ft ELLS FOR POOLS TABLE WAT ET FROM ALL m•.,., AREA=35,772 SF, TO TIE LINE urn forniliar with the STANDARDS FOR APt)ROVAL AIV() CONSI t"6?tdCTIOV OF SURSUR ACTT S67 Alit,. LOT (H Flt'.'FLP 'rl) 'A EB `D MAP A, OF A ,AQ) DISPOSAL OSAL SYS rEMS f Dl, SINGE F'-AMIL Y Rt.".5'IDM "ES POINT'FILED IN .P-,SIXFOLD COUNTY CLFRK 11"j7rr Ct` •..,,,.e ...,^rr ...a.:..m.. . w,. , .. .. AT,MAP Khrw tr41