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HomeMy WebLinkAbout47540-Z �t 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 #: 47540 Date: 3/14/2022 Permission is hereby granted to; Croteau, Paula 3150 Boisseau Ave Southold, NY 11971 To: construct accessoryinround swimming-g g pool as applied for. At premises located at: 3150 Boisseau Ave...,Southold _.. ........ .. . . ....... SCTM # 473889 m4 .w.__..................... . ._ w . Sec/Block/Lot# 55.-6-8 Pursuant to application dated 2/9/2022 ____, and approved by the Building Inspector. To expire on 9/13/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 ......................... Total: $300.00 Building Inspector TOWN OF SOUTHOLD — BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 (trl luwwr mjcra::l `goy Date Received APPLICA"nohl FOR BUILDIN(34 PERMIT For Office Use Only , �j f PERMIT NO. / Building inspector.-....,_... �W. Applications and forms must be filled out in their entirety. Incomplete 1r� ; applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: CRo-r;Ay SCTM # 1000- Project Address: Phone#: � Email ` C � �c��,-,cam,1, cures Mailing Address: :SI,6-() - ,` p, p Tl `b, �'! ��97/ CONTACT PERSON: Name: a& JE C►-�77c Mailing Address:.- � � q L�tY�'C t NUv� ,may i�g35 Phone#: X31 _ y_y�y$ Email: �c�r,',�wKa� coni' r►e, ne� DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: -- v -may r GU7c_14-e Phone#: �gl -y�y-yZ�/5' Email: �Cy�, s1�,o�cr �n��r"+e .✓?�, DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: M'Other ::?r'—/ Sc��.��/-r�.v "�t:t - $ 0, 000 caa Will the lot be re-graded? D, Yes L-1 No Will excess fill be removed from premises? Dyes fro 1 PROPERTY INFORMATION Existing use of property: i2c3,-)'>t7tt Intended use of property: �L/ Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yesl�No IF YES, PROVIDE A COPY. heck 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 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): &tZrA9UE cq-i- ,Authorized Agent El Owner Signature of Applicant: , Date: 21,5'-�z Z STATE OF NEW YORK) SS: COUNTYOF ) �- Z -�k being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the r—D,-ji2AG7&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 day of20 a y Public STEVEN L. HARNE,D VIII if' ..... � Notary PublicS of u �York(Whe e the applOPERTY icant is not thei owner) u. ff Lica ) uabflucl Muffolk County commission Expires March M. I, ( residing at CC "y 1f E ' _ do hereby authorize �7to apply on my bel f to the Town of Southold Building Department for approval as described herein. Owner's Signature Nate Print Owners Name 2 CERTIFICATE OF Worket's" NYS WORKERS'COMPENSATION INSURANCE COVERAGE YOWK, SIATE Com��)ensa,Aion Boar4 Insured Detail Ia.Legal Name and address of Insured(Use street address only) 1b.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 le.NYS Unemployment Insurance Employer Registration Number oflusured ld.Federal Employer Identification Number of Insured or Social Security Number Work I,ocation of Insured(Only required if overagc isspecyjicafly lifflifed to 113306347 cpyeain locadon in New Yor*.Sfaie,i.e.a Wrap-Qp 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 Town of Southold PO Box 1179 3b.Policy Number of entity fisted in box"Ia": Southold,NY 11971 WWC3563869 3c.Policy effective period: I/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"311 insures the business referenced above in box"Ia"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 cetifficate holder and the Workers'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 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 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 of authorized representative or licensed agent of insurance carrier) Approved By: (Signature) (Date) Title: SVP_mm .,Workexsf,�Piodt�fion Management ........... .............................. Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.1 farm.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 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 DATE(MM/DD/YYYY) AC"R" CERTIFICATE OF LIABILITY INSURANCE o2/os/2o22 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 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 NAME• Lauren Murphy _ . Roy H Reeve Agency,Inc. PHONE y (631)298-4700Xm"W mmm(631)298-3850 PO Box 54 AD KESS: Imu h ro reeve.com 13400 Main Road _ .,....,. .. ...w._.__ ) .mmmmmmmmmmmmm_m...._ .. ....... INSURERS AFFORDING COVERAGE NAIC#m,m,,,,,,,,,,,,,,,,,,,,,,, Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B: _.......... Chltuk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E Cutchogue NY 11935 INSURER F r COVERAGES CERTIFICATE NUMBEW CL213414038 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. _...... _...... /NSR ------------------------ n_a_n A wsD' ___.._. �P.�L"iEv""frrLI Y EXP __W.. .,..,.....,�................_._..,.....,..,.........,.,.. .....,_,.,... ._,.,.m_... m..,.m..,. LI'l ,,.�....�..,.MIDD - ... LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD M COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ _..,._,.�CLAIMS-MADE Fx—]OCCUR PREMISES F��r„s„�rrAnca $ 100 000 Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2021 03/15/2022 -PERSONAL m&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO7 F—]LOCPRODUCTS COMPIOP AGG $ µ2,O00,000 .,.M.�...... ....TI*K ,.,.,._..m..,......'........_ .. .,..._ ... AUTOMOBILE LIABILITY .._.. 9"�"4.9Drfk7dNE!D t"5NOU,L)Md& $ ANYAUTO BODILY INJURY(Per person) $ L SCHEDULED BODILY INJURY(Per acxadent) LY AUTOS NON-OWNED P'ftR'IPt"C„tThr C'hpP;JA#.E--- wM,M,MLY AUTOS ONLY „wL"arw arca ialrarca __ ...................................M..............M S A LIAB ACUR EACH OCCURRENCE $ AB IMS-MADE AGGREGArF $ OC CI AND EMPLOYERS' . ....,._..... RETENTION$ 1 COMPENSATION I � SER pI OTH RS'LIABILITY Y/N STATLITF ml mmmmm.ER M mm_ m_ _w k... ANY PROPRIETOR/PARTNER/EXECUTIVE N/A'... E.L.EACH ACCIDENT mm $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPI.OVEE $ IFyes,describe under `.,"`.""`."""""'""'""""' '""`.. ""'. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) _.,......�..._....�...........~µ~µ~µWµ......................................................M.M.M.M.M. Re: Paula Croteau,3150 Boisseau Ave,Southold,NY 11971 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 d Southold NY 11971 t„•°” )01 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW Workers' STAIIIEYOR CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.�To~be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier ....... —.......... 1 a.Legal Name&Address of Insured(use street address only) —. ...a..,_........... 1 b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245 PO BOX 9 CU.UTCHOGmUE,NYU 935 1 c.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 Entity Requesting Proof of Coverager Carrier 3a.Name of Insurance.Ca. �-....................... (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"1 a" Southold NY 11971 L1067 3c.Policy effective period 05/01/2021 to 04/30/202.3 4. Policy provides the following benefits: A.Both disability and paid family leave benefits ... B.Disability benefits only. El C.Paid family leave benefits only. 5. Policy covers: ❑X 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.......perjury,1.certithat I am an authorized representative or l...�.......... r al of perjury, fy p rcen ' sed agent of the'nsurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. 1.q/16/2021 / '/ Date Signed BY ............... ...,.,..,.,.,. (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) e ep one um er 829-8100 Name and Title iCh r White, Executive ..... .. _ 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. p......._......d yCompensation pon Board(Only if Box 4Cor 5B of Part 1 has been .... ............M....w PART 2.To be completed b the NYS Workers Com ensati 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 _.ww__ww._......ww........... _ ..,...,....w,W,_. By _ aaa — ......................(S.ignature of Authorized NYS Workers'Compensation Boa..r.d..Employee) ..,.____w ..._......... Telephone Number .... Name and Title _aaaaaaaaaaaaa a.. ____..._._w..._..__,__..._............... --------- --___..w.-____ ..... ...� 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. DB-120.1 (10-17) 1�1 Ill iIll 11l DB 120.1 (10-17) It I �g gN FallSCA W F.- -a got IT 0 cri fo J, Q� A f AI -NI lo 13> 4�- w f, _71 x "I 4W rn i'V m -4 41 tn �1' i 2K, m fo 2p < 1 18 3 � 10 LP Im 0 olvplt- -4 iz* z p (m z ID U