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HomeMy WebLinkAbout48321-Z om6 ' TOWN OF SOUTHOLD " BUILDING DEPARTMENT s� TOWN CLERK'S OFFICE SOUTHOLD, NY al �'' 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 #: 48321 Date: 9/22/2022 Permission is hereby granted to: Andrews, Jonathan 1365 Donna Dr Mattituck, NY 11952 To: legalize "as built" repairs and pool fence replacement to existing accessory in-ground swimming pool as applied for. Additional certification may be required. At premises located at: 1365 Donna Dr., Mattituck SCTM # 473889 Sec/Block/Lot# 115.-16-13 Pursuant to application dated ,8/12/2022 and approved by the Building Inspector. To expire on 3/23/2024. Fees: AS BUILT- SWIMMING POOL $500.00 CO- SWIMMING POOL $50.00 Total: $550.00 Building Inspector �" r VTOWN OF SOUTHOLD-BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 u' Telephone (631) 765-1802 Fax (631) 765-9502 https-://www.sotitholdtowiu'ly. o Date Received APPLICATION F BUILDING IT 1 For Office Use Only U. IT N0. � Building Inspector: u� G PERM g p Applications and forms must be filled out in their entirety.Incomplete BUH 1,11ING applications will not be accepted .,Where the Applicant is not the owner,an MVVT1 OF',0r M� Owner's Authorization form(Page 2)shall be completed. Date: N ,1 t9FPR a �Tr� blame: �4V` "' �✓to SCTM#1000 / /S ° �/4.o0 — c� 3 0 Project Address: . Phone#: _®Q Email:A4,gt v ; x.4,44 Mailing Address: CONTACT PERSON: Name: Mailing Address: 6OX Phone#: �— - Email: L61 j0(4r s"6- 6A- 'Pon_ j Q1 DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: pl Mailing Address: �� ,� Phone#: / Email: DESCRIPTION OF PROPOSEDCONSTRUCTION ❑New Structure ddition ❑Alteration Repair ❑Demolition Estimated Cost of Proect: ❑Other $ Will the lot be re-graded? Dyes No Will excess fill be removed from premises? ❑Yes No 1 fr :a.1 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) 765-95021itt s://www.soLitholdtowtiiiy.gov BUILDING PERMIT APPLICATION INSTRUCTIONS&CHECKLIST • Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. • The work covered by this application, including land clearing/site work, may not be commenced before issuance of a building permit. • No building shall be occupied or used in whole or in part for any purpose whatsoever until the Building Inspector issues a Certificate of Occupancy. • Every building permit shall expire if the work authorized has not commenced within twelve (12) months after the date of issuance or has not been completed within eighteen (18) months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing,the extension of the permit for an additional 6 months. Thereafter, a new permit shall be required. ALL APPLICATIONS MUST BE SUBMITTED WITH THE FOLLOWING MATERIALS: ❑ Building Permit Application: Complete, signed and notarized. ❑A survey/site plan, drawn to scale at original size, showing the location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas and waterways. ❑Four (4) sets of plans bearing the signature and original seal of a NYS licensed professional engineer or architect illustrating compliance with the Building Codes of New York State. ❑Contractor's proof of insurance and Suffolk County license: • Certificate of Workers' Compensation Insurance (C105.2 or U26.3) AND a Certificate of Disability Benefits Compensation Insurance (DB120.1) • Certificate of Liability Insurance **Note: Ifmirnall Fees wiillll Ihe caicu.allated by the Building Department using tlhne fee schedule„ If=ees wiii Ihe collected after the peirimit is written" ADDITIONAL DOCUMENTATION MAY BE REQUIRED AS IDENTIFIED BELOW: ❑Suffolk County Department of Health Services Approval (original copy) ❑Approval of the Zoning Board of Appeals, Planning Board, and/or Historic Preservation Commission (if applicable) ❑Electrical Permit Application (FILED SEPERATELY): Electrician must have an active license with Suffolk County El Flood Plain Develo ment Permit A1212lication (if applicable) ❑Southold Town Trustees Permits may be required: If any work will be done within 100' of a tidal or fresh water wetland. ❑NYS D.E.C. Permits may be required: If any work will be done within 300' of a tidal wetland or 100' of a fresh water wetland ❑1 copy of ComCheck/ ResCheck (if applicable) ❑1 copy of Manual J, Manual D and Manual S (if applicable) ❑Utiliization of truss re-en ineered wood timber construction form (if applicable) ❑Single and separate title.search (if applicable) ❑Curb cut permit (NYS or Suffolk County form 239F) (if applicable) ❑Original signed Owners Authorization: if applicant is other than owner, 3 NAM rk ns c r "Pr cr aFP 'S ism E, ins f e �� a O� ti r 98-kl� -A "Ot"aaoao s � , r ¢ ° J al Q 47 e L-F r „� �_ ' � 1 m jt r. �'d Ddb 00�• la r n F, �T �I oa-all V saob,OYOG�y lr o 4 51.:: 7Y I I LIABILITYCATE I DATE(MM/DD/YYYY) CERT• 2/24/2022 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. )PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. �r 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 endolrsemert'k(s,), PRODUCER 631-736-7500 e ,arc,Na, CONTAC.T:• NAMIE Angela Santangelo , UNFCU Financial Services LLC d/b/a Industrial Coverage P1,daNt; ' FAX ..631-736-7619 62 S Ocean Ave Ste 1 IARa.Nts. a1 z ). 1 MAIL Patchogue NY 11772 ADDRESS certs@ondus(R°ialcoverage.com INSURER(S)AFFORDING COVERAGE ' NAIC# R INSURE .,. .,. .,,._ w.- „e.A.t.Ohio SecUnl;„Ins Co 24082 INSURED JPGELEc 01 INSURER B m Safeco Insurance Company of America 24740 JPG Maintenance&Construction Corp. PO BOX 386 INSURER C.,,._ INSURER _ Ronkonkoma NY 11779 D: .. INSURER kNSURER P F: COVERAGES CERTIFICATE NUMBER:86136912 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. LTR I . ..... .. L..., Y}f IhMh!1,M(.3CMf"h"YYY ..•_......�.-. A X COMMERCIAL GENERAL LIABILITY � BKS59537919 TYPE OF INSURANC POL • 3!12/2022 ,' 3/12/2023 EACH OCCURRENCE $1 000 000 DmAdEl.i,CLAIMS-MADE OCCUR ) PREMISES ._ .. X -I ( ence) )$ _... _ s .em ,MED EXP(An7 one person) $15,000 k PERSONAL..&ADV INJURY $1,000,000 __. e ,... _._ , .. „.,. .... . ... . , ,_ ,., ,.....,,.._,_. JECT S PER: � .. AGGREGATE �s 2,000,000 PPP PRODUCT. ,.., ,�... .,.em ,._A..... I GENL AGGREGATE LIMIT APPLIES LOC S COMP/OP AGO I $2,000,000 X , PRO- �,.. ,w m, .. J +� AUTOMOBILE LIABILITY BAS5953 .����� ,......"".7919 3I12I2022 i 3/12/2023������IF "yr�u.a�1��CURY(Per person} �$ �0 4 XQ ANY AUTO BODILY IN , PVr ]t. Per accident) $ _ )AHIRED UTOS ONLY e, AUOTOS ONLDY 4 Rd,DB�LRT�'s'LYAMAf>k..,. .$ X 4 OUTOSDONLY X AUTOSULED BODILY INJURY(lt} jl g $ ........R 23 OCCURRENCE �$5,000.000 I CLAIMS-MADEJ EXCESS LIAR OCCUR ,. � AGGREGA mmv ,.., 11 EACH „ TE �$5 000,000 _ US059537919 3/12/2022 3/12/2023 I F2 X UMBRELLA LIAB X iRFUENTI�RN,,.._ _ 7 DED x m I G$ fl WORKERS COMPENSATION PER OTH- iANDEMPLOYERS'LIABILITY •EL EACHI„RTE ER STAT YIN '.ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ NIA ACCIDENT,,", ,$ OFFICFRIMEMBPREXCLUDED? t — (Mandatory in NH) LIMIT If yes,describe under E L DISEASE EAE _ DISEASE-POLICYL $ I DESCRIPTION un OPERATIONS belowL. L MIT B ........,_.�. ........ .........._ . ._....... ................. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) �............. .. ....... 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. 54375 Main Rd. Southold NY 11971 AUTHORIZED REPRESENTATIVE USA 01 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD o r 1,�,�,,° CERTIFICATE OF INSURANCE COVERAGE NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW ...............- ................ PART 1.To be completed by NYS 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) 1 b. Business Telephone Number of Insured J.P.G. MAINTENANCE&CONSTRUCTION CORP. DBA J.P.G. ELECTRIC 631-467-6744 847 11TH STREET RONKONKOMA, NY 11779 1c. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i e., Wrap-Up Policy) 134236219 2. Name and Address of Entity Requesting Proof of Coverage 3a, Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 54375 MAIN RD 3b, Policy Number of Entity Listed in Box"'I a" SOUTHOLD, NY 11971 DBL260059 3c.Policy effective period 09/01/2021 to 08/31/2023 .............. 14. Policy provides the following benefits, 0 A. Both disability and paid family leave benefits. n B.Disability benefits only. F1 C.Paid family leave benefits only. 5. Policy covers: [K A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] B.Only the following class or classes of employer's employees: ............................................................................... ................................. ......................................above ......................................................................eµµµµµ- Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the amed insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 8/11/2022rF By 2 V,�,00,&,,v_ (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and TitleRichardWhite Chief Executive Officer . ........------ ...........- ................. 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 emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. ------------ ...........—------— ............. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 413,4C or 513 have 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(Article 9 of the Workers'Compensation Law)with respect to all of their 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 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 (12-21) 1 III I 1�1 DB-120.1 (12-21) Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled 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 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 NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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 permit 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 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 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. DB-120.1 (12-21) Reverse 1 NEW Workers' ATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured (use street address only) 1b. Business Telephone Number of Insured JPG MAINTENANCE&CONSTRUCTION CORP DBA JPG 1c. NYS Unemployment Insurance Employer ELECTRIC Registration Number of Insured PO BOX 386 RONKONKOMA NY 11779-0386 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e. a Wrap-Up Policy) 13-4236219 2. Name nand Address of the nEntity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Hartford Underwriters Insurance Company Town of Southold 30104 54375 MAIN RD 3b. Policy Number of Entity Listed in Box"1a": SOUTHOLD NY 11971-4646 76 WEG P15724 3c. Policy effective period: 09/05/2022 .. to 09/05/2023 3d. The Proprietor, Partners or Executive Officers are r Included. (Only check box if all partners/officers included) X 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 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 Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: ,! !108/11/2022 ................_ ........ (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877)287-1312 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into 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 www.wcb.ny.gov Form WC 88 3121 F Printed in U.S.A. Page 2 of 2 z E / o � 2 9 ) 2§ / _ % 00A@ ® r- 00 LD �L) 3 . # ] / G @ g 7$ 0 } \ 2 2 0 \ / \ ? 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