HomeMy WebLinkAbout47539-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 #: 47539 Date: 3/11/2022
Permission is hereby granted to:
Carbia-Andriotis, Christine
....................... .....�......................._................._____ww____ww____......______________.-..__........_....._ _.a.............___...__._............................_..........
34 Homewood Dr
Manhasset, NY 11030..................................................... .. _ .. ... .... . ...____. �_.. ........wwww_
To: Construct in-ground gunite swimming pool at existing single family dwelling as applied
for and with DEC & Trustees #10008 approvals.
At premises located at:
500 Goose Creek Ln, Southold
SCTM #473889
Sec/Block/Lot# 79.-1-4
Pursuant to application dated _3/2/2022_ and approved by the Building Inspector.
To expire on ___9/10/2023.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO- SWIMMING POOL $50.00
Total: $300.00
�.... ............ _______ _.,,,,_
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
�b ` P ) )
�
Telephone 631 765-1802 Fax 631 765-9502���I
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only Prw
PERMIT NO. Building Ins ector� V ;R
Applications and forms must be filled out in their entirety.Incomplete 113ULUNG DEF1'I':
applications will not be accepted. Where the Applicant is not the owner,an T( 'I N iF` 0LD
Owner's Authorization form(Page 2)shall be completed.
Date:03/10/2022
._ ..�...ww....�.._.M-
OWNER(...... m-,
S) F PROPERTY:
Name:Christine Carbia-Androitis SCTM#1000-
Project Addressoose Creek Lane Southold, NY 11971
Phone#:914-557-9900 Email:christine.carbia.androitis@gmai I-com
Mailing Address:Same
CONTACT PERSON:
Name:Jennifer Del Vaglio
Mailing Address:PO Box 369 Peconic NY 11958
Phone#:631-734-7600 Email:office@eastendpoolking.com
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:Eastern End Pools, DBA East End Pool King
Mailing Address:PO Box 369 Peconic NY 11958
Phone#:631-734-7600 Email:Office@eastendpoolking.com
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
E Other 16"x32"gunite in-ground swimming pool $120,000
Will the lot be re-graded? Wes El No Will excess fill be removed from premises? BYes 0 N
1
PROPERTY INFORMATION
Existing use property: Single Family w.....__e..l.lin� Intended
Intended�NWus�e o�
.�._p_.r_o.._e_.rt
.y�: Single Family .Dwelling
..
Zone othis ❑ *Nor use district in which premises Is situated, Are there any covenants and restrictions with re............... � .w._
specC to
esidentNal
. ....._._..,. ..._._�._.w......__._. ._�__..__-._.�..�_..._.�..�.�...�,��.��. is property? Yes No IF YES, PROVIDE A COPY.
...
El Check
Box
After
Reading:
The
contractortrofessin lisrespnssible for all drainage and storm
_w.,a te r Issues
_a_s..provided h
yCof the Town e APPLICATIONS HEREBY
to BuildingDepartmentfor
.....m ....m_
f r 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,Ordlnances 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):Jennifer D e l Vag l i o
Authorized Agent ClOwner
Signature of Applicant. Date: 4/1/2021
CONNIE D. BUNCH
STATE OF NEW YORK) Notary Public,State of New York
No.01U6185050
SS: Qualified in Suffolk County
COUNTY OF Suffolk ) Commission Expires Aprd 14,2. C
Jennifer Ciel V'aglio
being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the Agent
,,said owner or owners, and is dui authantract�,
Y authorized t perform or have performed
( Agent, Corporate orate Of er etc.) �.�.�....._......._.._..�.,-_.„..M..... .��.
p
p armed the said work and o 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 o �. ,1,�� � .... ,.,,.�� �. ,�.✓�. '' mm
Notary Public
...� HCl"� .._....�.�
(Where the applicant is not the owner)
residing at ., ,. t.. '
w�
. do
hereby authorize , (� � � l � .__.. �" �� apply on
my behalf to the Town of Southold Building Department for approval as described herein,
Clwner`s Signature
Date
Print Owner's Name
7)I -1
N SURVEY OF PROPERTY
AT SOUTHOLD
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NY
1000-79-01-04
SCALE: 1 =30
OCTOBER 3, 2019
DECEMBER 9, 2019 (REVISED CER'11FICATION)
0 � JUNE 30, 2021 (PROP. POOL, ELEVATIONS)
00 RAMP
L r
� c EXISTING LOT COVERAGE
1A " LOT SIZE 18,688 oq.fL
"DouNE ° HECK k PORCH1w2 Sq70.
11 k' SHED - 101 SOFT.
�yw� ". n.✓"" ° 1,989 q.ft.
1989/16868 a 0.118 or 11.8Y
+A PROPOSED LOT COVERAGE
EXISTING LOT COVERAGE-1,969 SQ.FT.
E 68 SQ
2581/18688-60.0.155 or or 15.51L
RarPTx G'Mp...
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HOUSE
w s 9L a„ �� ,a ,ti y_».came
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RICHARDD RUBUBINSTEIN
ALICE RUBINSTEIN
HOUSE dela
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ANTONETTE GUI00 o r 'R a
THOMAS GUIDO FRATI wa amnPOtA �
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CERTIFIED TO: GO
STEWART TITLE INSURANCE COMPANY
STANDISH TITLE AGENCY, INC.
BETHPAGE FEDERAL CREDIT UNION, ISAOA, ATIMA
CHRISTINE CARBIA ANDRIOTIS
KEY
Q =REBAR
0 — HELL
A =STAKE
9 = TEST HOLE
=PIPE
81 =MONUMENT
— WETLAND FLAG
— UTILITY POLE
ELEVA71ONS AND CONTOUR LINES ARE REFERENCED TO NAVD '88
ANY AL7ERA77ON OR ADDITQV TO THIS SURVEY IS A WOLATON OF N,YS, LIC No. 44618
WC77ON 7209 OF THE NEW YORK STATE EOUCAVON L4W.ELHOEPr PECONIC SURWMORS, P4
AS PER SECTQN 7209—SUMWSION 2. ALL CERTFHCANONS HEREON AREA= 16,668 SQ, FT. 765-1797
ARE VAUD FOR THIS MAP AND COPIES THEREOF ONLY PF SAID MAP (631) OX 90920 FAX (631)
OR COPIES BEAR THE IMPRESSED SEAL OF WE SURv1: WwIOSE TO TIE LINE P.O. Box so9 ... ..---------
SIGNATURE APPEARS HEREON. 1230 TRAVELER 'STFw-E-cT
SOUTHOLD, N.Y. 11971 19-057
YM MI
OAK, gkN
r
� BOARD OF SOUTHOLD TOWN TRUSTEES
r, SOUTHOLD, NEW YORK
PERMIT NO. 10008 DATE: OCTOBEk20*2021
r
ISSUED l I1° ' t`IIt. I t'17 i<; ARBi .-A N R]lo"I'll ..i'
PROPERTY ADDRESS. 500 CHOOSE CREEK LANE SOUTHOLD
SCTM# 1000-79-1-4
AUTHORIZATION
Pursuant to the provisions of Chapter 275 of the Town Code of the'Town of Southold and in
. accordance with the Resolution of the Board of Trustees adopted at the meeting held onQtgber0,,,ZO'711, and
in consideration of application .QQ fee in the sum of" _ 1. h.ristin C arbia- riotis and subject tache
. .paid b y 0.��
rr Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits
the followVirig:: -
y
Wetland Permit to construct a 16'x32' gunite swimming pool with a proposed approximately
980sq'.>et. at grade pool patio; install a drywell for pool backwash;and to install 4'. highzpool
enclosureTencing gates;ates; an`d as depicted on the survey,prepared by PecouicSurveyors, M
, P.C.,last dated October 4,2021and stamped approved on'October 20,2021.
nIN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be afftxed, and these a
presents to be subscribed by a majority of the said Board as of the 20th day of October,2021.
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Yo ?11( sl 141 E.11 FOENT' OF',
INvision of EnOonmentall Permits,Pecj�on 1
SUNY 4 Stony Brook,50 Orde Road,SAony Eirook.NY 11790
P,(631)444-0365 11 F (631)444,0360
vvww d ec ny gov
March 3, 2022
Christine Carbia Andriotis
34 Homewood Drive
Manhasset, NY 11030
Re: Permit No. 1-4738-01091/00005
Dear Permittee:
In conformance with the requirements of the State Uniform Procedures Act (Article 70,
ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit.
Please carefully read all permit conditions and special permit conditions contained in the permit
to ensure compliance during the term of the permit. If you are unable to comply with any
conditions, please contact us at the above address.
Also enclosed is a permit sign which is to be conspicuously posted at the project site and
protected from the weather, and a Notice of Commencement/Completion of Construction.
Please note, the permit sign and Notice of Commencement/Completion of Construction form are
sent to either the permittee or the facility application contact, not both.
Sincerely,
Eugene R. Zamojcin
Environmental Analyst 11
Enclosure
cul v'ervadon
f
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Faeiiity DEC ID 14738=0101
t
G
P.
PERMIT
nder the Environmental Conse.r....v._.a.....t...�ion Law _'
.. .._.�......_
Permittee and Facility Information
Permit Issued To: Facility:
CHRISTINE GARBIA ANDRIOTIS CARBI.A ANDRIOTIS PROPI?RTY
34 HOMEWOOD DR 500 GOOSE CREEK L.N�1000-79-I-4
MANHASSET,NY 11030 SOT iTHOLD.,NY 11971
Facility Application Contact:
JEl' Nl ,ER DEL VA(Jrr1 I0
PO BOX. 369
PECONIC,NY 11958-0369
(631)734-7.660.
Facility. Location: in SOUT14OLD in SUFFOLK COUNTY 'V'illage: SOUTH.OLD
Facility Principal Reference Point: NYTME; 717.297 NYTM-N: 4547.4457
Latitude: 41°02'57.7" Longitude: 72924'52:Q"
Project Location: 500 GOOSE.CREEK.LN WATECO.URSE: GOOSE CREEK/PE
RIVER
Authorized Activity: Inst l;C An ire",ground pool Pith pool:kilter backwash dzywell,patio, and`fence
surround. l'nstall a.10 lbot wide splashpad adjacent landward ofthe:bulkhead, establish .10 foot wide
buffer, planted With native salt tolerant vegetation. All authorized activities shall be done in strict
conformance with the attached plans starriped."NYSDEC Approved" on 31312022. (QRZ)
Permit Authorizations
Tidal Wetlands - Under Article 25
Permit ID 14738-01091/00005
New Permit Effective Date: 3/3/2022 Expiration Date.;3/2/2027
NYSDEC Approval
Ry acceptance of this permit; the permittee:agrees that the permit is contingent upon strict
eomipliance with the ECL,sill applicable regulations, and all conditions included as part of this
permit.
Permit Administrator.: SUSAN A.CKERMAN,Regional Perrnit Administrator
Address: NYSDEC Region I Headquarters
SUNY @ Sto x BrookJ50 Circle Rd
Stony Brook, ,� " 1L13411
Authorized Signature: --
Date
Page I of
d
OWN
NEWYORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-01691
.
Distribution List
.. ......... ----------
E_
JETS NIF8R DELVAGLIO
Bureau of Matine Habitat Prote.ctio.n
tnvironrftental -Permits
Permit Components
........... ...........
NATURAL RESOURCE PERMIT CONDITIONS
GENERAL CONDITIONS,APPLY TO ALL AUTHORIZED PERMITS
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS.
NATURAL RESOURCE PERMIT CONDITIONS -Apply to the Following
............
Permits: TIDAL WETLANDS
1. Past:Perrnt Sign The permit signenclosed withthis permit shall be posted in Avinspi,
cuous
location on the worksite and adequately protected ftom the weather.
2. Noilice of 00mmencenlent At least 49 hours pr.ior to commencement of the project, the permittee
:and contractor-shall sign and return the top portion of the enclosed notification form certifying that:1.N'-y
are fully aware of and understand all terms and conditions of this permit Within 30 days of completion
of project,. j%ect, the bottom-portion of the'form must also be signed and returned, al Ong With photographs of
the completed work.
3. Concrete Leachate During construction,no wet or fresh concrete or Iea('hate.sh'dlI be allowed to
.escape into anywetlands or water.5 of New York State, nor shall washings:from ready-mixed concrete
trucks;.-mixers, orotherdevices be allowed to enter any wetland,or waters: Only watertight or
waterproof forms shall be used. Wet concrete shall not be poured to displace Water within the for=.
4. No Construction Debris in Wetland or Adjavelit Area An)p debris or excess material from
coristruction of this prqicct shall be completely removed from the adjacent area (upland') and removed to
an approved upland area.for disposal. No debris is permitted in wetlands and/or protected,buffet areas.
5. Materials Disposed at Upland Site Anyd6molitibn debris, excess construction materials, and/or
excess.excavated materials shall be immediately and completely disposed of in an authorized solid waste
p a
management facility.These,mateiials shall be suitably stabilized as not to TC-enteran ywaterb.6dy,
wetland or wetland adjacent area,
6. No Disturbance t Vegetated Tidal W tlands There shall be no disturbance to vegetated tidal
.0
wetlands or.protected buffer areas as a result of the permitted activities.
7. Storage of Equipment,Materials The storage of construction equipment:and materials shall;be
confined to the upland area larldward of the bulk-head.
Page 2 of 6
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID 1-4738-01091
8-. Seeding Disturbed Areas All areas of soil disturbance resulting from.the approved project shall be
stabilized with apptppriate vegetation(grasses, e1c.) immediately following project r
rqj� etcompletion o prior
to permit expiration,whichever comes first. If the pr6j pet site remains inactive for,more than 48 hours
urs
or planting:is impractical due to the season, then the area shall be stabilized with straw or bay mulch or
Jute;matting until weather conditions favor_germination.
9. No Unauthorized Pill No fill or backfill is authorized by this permit without further written
approval frob the department(permit;(perm ,modification, amendment).
10. Lnng4eirw Plant Survival The area 10 feet landwatd of the 10 foot wide sPlashpad shall be.
planted with native salt tolerant vegetation and the permittee shall ensure.a minimum i imum.of 85%survival of
plantings by the.end of five growing seasons.asons. If this goal is not mer;the Permit holder shall re-evaluate
the restoration project in order to:determine how to meet the.mitigationgoaland submit plans to be
,approved by the office of
Marine Habitat Protection
NYSDEC'Region I I-leadquiarters
SUNY @ Stony Bro6k,150 Circle Rd
Stony Brook,NY 11790-3409
11. Area of Disturbance f6r Stritefiites Disturbance to the natural vegetation or topography greater
than 25 feet seaward of the approved structure is prohibited.
12. InstaIJ6 Maintain Erosion osion Controls Necessary erosion control measures.i.e., straw bates, silt
:etc.,are to be placed on the do,.smslope edge.of any disturbed area. This sediment barfierigto
be put in,place-before any disturbance of the ground occurs and. is to be maintained in good and
functional condition until thick vegetative cover is established.
13. No l) veils in or near Wetland Dry wells for pool filter backwash shall be located aminimum
of 32 linear feet latidward of the tidal wetland boundary.
14. No P661 Diseharges to Wetland There shall be no draining.of swimming pool Water directly or
indirectly into wetlands or protected buffer areas.
v;; Tidal Wedand Covenant The permittee shall incorporate the attached Covenant(or similar
t)epartment-approved language)to the deed for the property where the project will be conducted and Pile
it with the Clerk of SUFFOLK County within 30 days of the effective date of,this permit. This deed
covenant shall run with the land into perpetuity. A copy of the covenanted deed or other acceptable
proof of record, along with the number assigned to this permit, shall be submitted within 90-days of the
effective date of this permit-to
Marine Habitat Protection.
NYSDEC.Region I Headquarters
SUNY' Stony RrookJ50 Circle Rd
Stony Brook,NYI 1790 -3409
Attn. Compliance
Page 3 of 6
ti
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ti
Facility OIL,C ID.1-473$-.01091
16. Contain Exposedkp
Sto.ip fled Soils All disturbed areas where soil will be temporarily exposed or
stockpiled for longer than 48 hours shall be contained by a continuous line of staked haybales silt
curtains (or other NYSDEC approved devices)placed on the seaward,side between the fill and the
wetland or protected buffer area. Tarps are authorized to supplement these approved;methods,
17. Maintain Erosion Controls All erosion control.devices shall bernaintairied in good and functional
condition Lmtil the broipA has been completed and the area has been stabilized
is. State Not Liablefoe Damage The State of New York shall in no case be liable fbr any damage of
injury to the structure or work herein authorized which may be caused by or result from future operatioris
undertaken by the State for the conservation or improvernerit of navigation, or for other purposes, and no
claim or right to comoensation shall accrue from any such damage.
ig. State May Order Removal or Alteration of Work If future operations by the State of New York
require an alteration in the position of the structure or work herein authorized, or if,in the opinion of the:
Department of Environmental Conservation it shall cause unreasonable obstruction to.the free navigation
of said Waters or flood flows of ondainget the health, safety or welfare of the people of.the State, or cause
logs.or destruction of the natural resources of the State,the owner niay be ordered by the Department to
remove or alter the structural work., obstructions,,or hazards caused thereby without expense to the State
and if, upon the expiration or revocation of this permit,the structure,fill, excavation, or other
modification.of the watercourse hereby authorized shall not be completed, the owners, shall,without
expense to.the State, and to such extent and in such time and manner as the.Departmento'l
Environmental Conservation may req'uire,remove all or any portion of the uncompleted structure or;fill
and restore toits.former condition the�navigable and flood capacity of the watercourse. No claim shall
be made against the State of New Yorkon account of any such removal:or alteration.
2o. State May Require Site Restoration If upon theexpiration or revocation of this periftit,the
project hereby authorized has not been completed., the applicant shall, without expense to the State, and
to such exteni and in such time and manner as the Department of Environmental Conservation may
lawfially require, remove all or any portion of the:uncompleted structure or fill and restore the site to its
former condition. No claim shall be made against the State,of New York on account of any such
removal or alteration.
21. Conformance With Plans All activities authorized by this permit must be in strict conformance
with the-approved Plans submitted by the applicant of applicant's agent as part of the permit application.
Such approved plans were prepared by Jennif6r DelVaglio, last revised on 2/11/2012.
22. Precautions Against:Contamination of Waters All necessary precautions shall be taken to
preclude contamination of any wetland or waterway by suspended solids,sediments fficls; solvents.
lubricants,.epoxy coatings,paints, concrete, leach,qteorany other environmentally deleterious materials
associated with the project.
Page 4 of 6
I
pk
4
NEW'YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Facility DEC ID:1-4738-0.1491
,
GENERAL CClNDXTI�NS Apply to ALL Authorized Permits:
t. Facility Inspection byThe Department The permitted site or facility;including relevant records,.is
subject toirispection at.reasonable hours and intervals by an authorized representative ofthe Department
of Environmental Conservation (the Department)to determine whether the.permittee is:complying with
this.permit and the ECL. '.Such representative may order the work suspended pursuant to ECL 71- 03.01
and.SAPA.40:1
The permittee shall provide a,persorr to accompany the Departibent.'s representative,during an inspection
to the permit area when requested by the Department. }
A copy of this permit,including:af 1 referenced maps, drawings and special conditions,must be available
for inspection by the..Department at all times at the project site or facility. Failure to produce a copy of
the permit upon request by a Department representative is a violation of this permit.
2. Relationship of this Permit to Other Department.Orders and.Deteeminations Unless expressly
provided far by the:Departmerit, issuance of this penhit does not modify, supeisede:or rescind any order
or determination previously.issued b'y the.Department or any:of the terms, conditions or requiirepientS
contained in such Order or determination.
3. Applications For Perm' it Renewals,Modificatioas or Trans ers ne permittee must submit a
separate written application to.the Department for permit renewal,modification or transfer of this
permit. Such.application must include any forms or supplemental information the Department requires.
Any renewal,modification or transfer granted by the Departrrfi nt must be in writing. Subrimission of
applications for permit renewal, modification or transfer are:to be. subruitted..to:
Regional Permit Administrator
NYS.DEC Region I Headquarters
SUNY @ Stony BrookJ50 Circle Rd
Stony Brook,NY11790 -340.9
. Submission of Renct al Application The permittee must submit:a renewal application at feast 30
days l afore perµrnit expii°adon for the following permit Authorizations: Tidal Wetlands.
S. Permit Modifications,Suspensions and.Revocations by the Department .The Department
reserves the right to exercise all available authority to modify, suspend or revoke this permit. The
grounds for modification,suspension or revocation include:
a. materially false or inaccurate statements in the permit application or supporting papers;
b. failure by the permittee to comply with any terms or conditions of the permit;
c. exceeding the scope of the project as described in.the permit application;
d, newly discovered material information or a material change in environmental conditions,.relevant
technology'or applicable law or regulations since the issuance of the.existing perinit;
Page 5 of 6
I
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL C0.NSERVkTT0N
Facility DEC ID 1-47$9-61091
e. noncompliance with previously issued permit conditions, orders-of the commissioner,any
provisions of the Environmental Conservation Law—or regulations of the Department related to
-
the permitted activity.
6. 'Permit Transfer Permits are transferrable unless:specifically prohibited by statute,regulation or
another permit Ondition'. Applications.for permit transf&r shouldbe submitted prior to actual transfer of
ownership.
i
T
�O —�iC A�, 4�7-0
Item A: Permittee Accepts Legal Responsibility axid Agrees 10 Indemn
The permittee; excepting state or federal agencies, expressly agrees to indemnify and
h Id harmless the
0
Department of Environmental Conservation of the State of New York., its representatives,,employees,
and agents ("DEC") for all claims,.suits, actions, and damages, to the exte.pt attributable to the
permittee's acts or omissions.in connection with the periniftee's Undertaking of activities in connection
with or operation and maintenance of,the facility or facilities authorized by e thpermit whether in
- I
compliance orriotin compliance with the terms and conditions of the permit This indemnification does
not extend to any clairns,:suits, actions; or damages to the extent attributable to DEC's own negligent or
intentional acts or omissions, or.toany claims, Suits,Or actions naming the DEC and arising under
Article 78 of the New York Civil Practice Laws and R.416s.or any citizen suit or civil rights provision
under federal or state.laws.
Item B':*Perinittees Contractors to Co idly with Permit
The permittee is responsible for informing its independent contractors, employees-,agents and assigns of
their responsibility to coriiply With this'pernAt, including all special conditions while acting:as the
-peirnittee's agent with respect.to:the permitted activities, and such persons shall be.subject to the sArn&
sanctions for-violations of the Envirorimental. Conservation Law as those prescribed for the permittee.
Item C;Permittee Responsible for Obtaining Other Required Permits
The:pbribittee is fesporisible for obtaining any other permits, appoval s, lands easements and rights-of
way that may be required to carry out the activities that are authorized by this permit.
Item D: No Right to Trespass sir:Interfere with Riparian Rights
This permit does not convey to the permittee any right to trespass upon the:lands,or interfere with the
riparian rights of others-in order to perl'orm the permitted work nor does it.authorize the iinvairment of
any rights.title, or interest in real or personal property held or vested in a-persbn not a party to the
permit.
Page 6of 6
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sisco.m.cl
Sensation D S BTIFICAT AN
1TY AND pAUlb INSURANCE GOVERgG
PART 1. To FAMILY E
be completed b . 'p" 'P—aid _ LEAVE gENEFtTS LAW
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Benefits Carrier or Licensed Insttrance A
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lNork Location of Insured
�0ftin/ot"utaisrrs in New Oti/t rr�t/d�aratdif oeaa�r a�,fe i�°sizeciiicallylimlted to
ycr'f at�ata,r r 1 Number federal Employer identification Number of insured or Social Sec
Wrrai5 d ire F zroiio l Fed
2. Name and Security
Address of Entit Reg208053619
(Entity Being Listed as the ertifictttgtftProof of Coverage
TOVb N OF`�OUTi-1'OtLD 3a.Name of insurance Carrier
P()SOX 1179 New York State Insurance Fund(NYSIF)
8OU'i"i-60LD,C^i""'ttl?71
fr.. 3b. Policy Number of Entity Listed In Box"la"
DBL 5708 00 .4
3c, Policy effective period
4.Policy provides the following benefit& 04123/2020
to 04/23/2022
®
A. BOth disability and paid family leave benefits
B.Disability benefits only
❑ C.Paid family leave benefits only
5. Policy covers:
❑® A.All of the ernployer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law
B.Only the following class M'Classes of empioyer's employees,
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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.
Date Signed 4/2/2021 B
y
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number ('t`fl`"�6)kaft7_�t2 Name and Title Melissa,tensen Director of IONsatailt Insurance unit
IMPORTANT: If Box 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,
DB Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200
PART 2.To be completed by the NYS Worker Compensation Boa
"'rd rd(Only if Box 4C or 56 of Part 1 has been checked)
State of New York ._m.........
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
.........w. (Signature of Authorized NYS work
o Compensation Board Employee).�..............�. ................�.
Telephone Number Name and Title
'lease Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents
)f those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form.
By signingditi on,31 Instructions this fdrr�n, the insurairce carrier Identified DS D � ►
referenced in boy dg-120.1
Leave Benefits La"laps for disabilityin burr "3"on
andfor paid family this form is certifying
the certificate , The Insurance farrier or its licensed a
y leave benefits under the e that it is, inurin
holder in box �R „, + York State Disability and business Family
agent will send this ertlfi"o�ate of Insurance to t'he entit
The insurance carrier must notify listed
a
Policy is cancelled due to non ay the above certificate holder and the Worker's t;c Y Iis�ted as
r ffi ttIs cancelled
cancel the p rnent of premiums or Within tJ days IF there are reasons
policy or eliminate the insured from coverage indicated o"` axons tion Board within 94 days ' a
sent by regular mail.) Otherwise, this Certificate is valid for one
licensed went,, or until the policy expiration date Ii year other than nonpayment of
n this ved b te. (These mine notices airy rbe
i
listed in Box'3c, wvhicheveriisfea earlier,
by the insurance cornier or its
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 polio li
Y sted, nor does it confer any rights or responsibilities
beyond those contained in the referenced policy,.
This certificate may be used as evidence of a Disability and/or Raid Family 1.
the underlying policy is in effect, y save Benefits contract of insurance only while
Please Note; upon the cancellation of the disability and/or paidmity leave benefits policy indicated on this form,
i the business continues to be named on a permit, license or contract issued b a
certificate holder, the business
must provide that certificate holder with a near Certificate of NY$ Disability and/or Paid FamilyLeav
:overage or other authorized proof that the business Is complying with the mandatory coverage requirements of
the New,York State Disability and paid Family leave Benefits Lave. e Benefits
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 perrnit
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 spacial statute requiring or authorizinq any such contrast, shall a°°poi enter into ai°uy such
contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chain 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.
Cr
THIS C TI ICArIw IS ISS Ia CERTIFICATE ` "
CERTIICAr IIIwSIcaTAI= IIrATlvc Aarly �
A IVI"rr t 3IE GATI��IATNt M CHID, AI�I�C4�Id I2S PdCJ INSURANCE DATE/18/20 YYYW^P
BELOW THIS CS TII=ICAT O INS� ER
t��1C CCAS M�CIr Q pu�+ryy�.r
rypry+y��y�E�*`�+r ENjyp }y. Vp O�r�ypy�/p�yyWWRpW1yO��xryey��pp/�``44�^'��"y py o�{{ja�� Cyt D(spy NOT
g�AMEND,U "TSMC CCT AI.r `I�rppl��-dp/�,w�Cy COVERAGE
yC�ro� .F'y`t�p�;�iC }�. (��y�y p� 11118/2021
H PRESENTATIVE Vv�rrq,.PRO
+A rY'LJ THC',CG1"'CrI pM✓.MrIG�H' "p�^Ahy7d`�1yT'`I A""V�+r.'fW�aT C�".,td tl�.^'PW rI I�ur TC.PTVt,ifd THIS
CONSTITUTE V F rlry TIAL 1 4rRNMW THE I� g p17M7 INSURERKM4
� I ( I TATTY; If the CBrtIFlCate IIOIder IS an AI►CIrIt7'IsIA� IIWSIl�l I Ie t rH I�t)t ICII
It SIJI3I Ot ATION IS�IAI1� I� ` �,AUTHORIZED
this Der IIIIcaIB dGea nGt oGnfer rlghtxs ,tlfe certllloatB holder In Ileo of ch
end
r subject to the teraTts arrd oOndltlOnG Oi the �� )rnLrat have AbI�I1"IC)NA;I„IMtIIRp FlrOviP,slOna or ba endorsed„
PRODUCER �rrollC�a certain poIICIs may rertUlre an endorsement,Roy H Reeve Agency,Inc. endorsement s), A statement on
PO Box 54 NAME, BCarbW'a Cart"overs
PN'oNE x831 298M ?'410
13400 Main Road c Nda X850
ADDR,E�SS. (C'/n.OfdpdklCr S/rCTyCe9Va.COnl
Mattituck
INSURED NY 11952 INSURERS AFFORDING orpvEaAGF
INSURER A CNA 6nsurance Co paraVa NAfC#
Eastern End Pools LLC,DBA:East End Pool King INSURER B ConfrnerltLad IneUraroae d o.
P O Box 369 INSURER c Tran sporGttlon lrasadrarrerea Co
INSURER D; 20494
Peconic INSURER E
d d&d IS 70 NY 11958
:tr 111181r1INSURER F;
Ct�rII=ICAT IIIIIIVpC tt
C11fIAt
(Lb616 1CAiT IRI:Gt1VR88PC/tN4r _ FtII 'ItII IMIII7IrPICiI�:
` t:I�Ttf�"8"t1h4t'TYd�'Ft"J&14
r � &.,ta Dt�N1a AF4`r, F Ll a1I t"t BFLCW d....
w k, M DCT P`t("t�'E h&EIS k N' VV - CtP TFtE'POLICY PERIOD
J4,kYP At'h.Ct, NOt�Y"d'H,.r�AIN
fAF I1FEN 15Ut 9V 1RFD NAMFLI ABOVE
F MAY FE IrFI1 t1Ft�ryA PEH fAtRaG PtIFVh&.LIRANVt I AFFG1Ft1ELt FbY THF F fblL@4lFS GESCRILfFD 4 tFha"FdN t„„ LlB
TR, C;V.USIC I�re ANDY E C1NC4f1"PC')N! C)d a t1L,N t POL tC fFS.LIMk fi aI TOWN hflAW'FCAVF 9F'E'N RED4�dCF`D BBV PAtd':1 I LAMS. L1@� t l'P ti RESPECT TOAIA TO WHICH THIS
SUBJECT TO AIA THE TERMS,
TYPE OF INSURANCE
X COMMERCIAL GENERAL LIABILITY POLICY NUBt eER MMdD[ERY y Y MMIDDfYYY
LIMITS
CLAIMS-MADE 2OCCUR EAEhd CPC:{„I.9rdREPtCE;; 1 04 0n 000
Contractual Liability FdRLMIt1 "�°eV� r #00,00
A 0
Y Y 6080837145 MLO EXP.n Arn uanr, u r aorl , 15,tJCkO -----
GENt;SGI~aLGp��ciE p.WI APP 11/15/2021 11!15/2022
LPk'�'� FC�la�. PER�arNAt.stADv4N,Iura'° ;C R OOO,G00
POLICY PRO'
JT LOC GENERAL AGGREGATE Y2,000,0oo
IoTHEk 2222Il CT,S-COMPIOPAGO T, 2,001
AUTOMOBILE LIABILITY $
ANYAUTO �° M I :D SIN�,xLE",DMI S � 04 0 U00
u
OWNED SCHEDULED BODILY INJURY(Per Gerson) S
AUTOS ONLY AUTOS 6080837159
HIRED NON-OWNED 11/15/2021 11/15/2022 BODILY INJURY(Per accident)~ S
AUTOS ONLY AUTOS ONLY P % Elt1'Y;&A AG
Pp rrr ent :S
UMBRELLA LIAB S
OCCUR
EXCESS LIAB EACH OCCURRENCEE�.,.,...
C:`LAIIMS 44A DE �.....,..,......m...,.......,...
,(
DED RETENTION $ AGGREGATE- .....�..._.
WORKERS COMPENSATION S �'
AND EMPLOYERS'LIABILITY ER O H- u
'AN'MPROPMEIrORIPAR"gNER&XECUTIVE YIN STATUTE EIR
GFFIC EHrPtEMBER EXCLUDED? � NIA 6080837162 11/15/202111/15/2022 E.L.EACHACCiDENT S 1,000,000
QMaandatory to NH) �--J 1,000,000 �—'
If%e describe under E.L.DISEASE-EA EMPLOYEE S
DE art IP"IkON OF rWPtPd4N Pa" m,duaaai., d
E.L.DISEASE-POLICY LIMIT $ 1,000,000
SCRIPttON OF OPERATIONS I LOCATIONS d VEH CLEZ (ACORD 10i,AdI RerroI S.hed.tm, nay be attached if mars space is rddrteetred)
tiflcate holder kr,incrILIdecd as additional insured Lander Ga�oner-al L iabibty as per the terms and alOnddf onws of fGrrn CNA'75079'XX-Fel anWetAdditdantal
;Wed wdh J ai ntnt, rri C a "aY rrntsar4eCL
ou Endorsement,
NYIncludes Walersubrogation (riMa 5 nor ;GetDduQory Cefe0eS ab N-Ui red by Itipntrctoraori4dr14iaroM imsUrermdertFe Erarrrns aan&z BwLaraa
tder Form#CNA633,53XX-Auto lrstlrrec.tass Extended Coverage Endorsement-Business Auto Pfaw,
:RTIPICAT
HOLDERCANCI IArltra
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE BE
IN
Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 1179
AUTHORIZED REPRESENTATIVE
r ,
Southold NY 11971
ernon r.nRPORATION. All rights reserved.
STATE OF NEW YORK
WORKERS'COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la.Legal Name&Address of Insured(Use street address only) lb.Business Eastern End Pools LLC
Telephone Number Of Insured
dba East End Pool King 00
P O Box 369
Peconic, NY 11958 1c.NYS Unemployment Insurance Employer
Registration Number of Insured
Work Locatfoll Of Insured(Only required if coverj.,ge&,viyecyleally 1d.Federal Employer Identification Number of Insured
"W'te(f u` certain locations in New
Policy) York Vtate, ie., a ff'rap-up or Social Security Number
208053619
2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Fisted as the Certificate Holder) Name
Town Of Southold Transportation Insurance Company
P 0 Box 1179 P
Southold, NY 11971 3b.Policy Number of entity fisted in box Ilie
Policy
WC680837162
Policy
Holder)
Policy effective period
11/15/20 to 11/15/21
3d. The Proprietor,Partners or Executive Officers are
❑ included. (Only check box if all partners/officers included)
all excluded or certain partners/officers excluded.
Alis certifies that the insurance carrier indicated above in box "Y' 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 3
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"T'.
The Insurance Carrier~ ill also notV
,y the abo w certiticate holder within 10 days IF a polity is canceled due to nonlaq In qfPreinitans or
POUCY or eliminate the insured/renn,the 101,age,
ancelthe co
Ivithin,30 dqb�v IF there are reasons other than 12MIPqvinent olprenihans that c v ent
91 Otherwise,Ilds Cert?f1cate is validfir eyear after thisfirill
xpiration date listed ill box"3c P1
is aj)proved by the in,01ralice carrier or its licenseel agent,or unfil the politly e. oll
t
PleasPlease Note: Upon the Cancellation of the workers' compensation Policy indicated on this form, if the business colltinues to be
on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with 41 flew
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 tills form.
Approved by: Thomas A Dickerson
orized representative or licensed agent of insurance carrier)
Approved by: 77-
12/30/2020
(Signature) (Date)
Title: Authorized Representative
Telephone Number of authorized representative or licensed agent of insurance carrier:
B31-2
lease 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