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HomeMy WebLinkAbout48359-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#: 4835922 Date: 10/3/2022 Permission is hereby granted to: M_oAgski, Lara 29 Sky ine Dr ....... _... ________ . 59 Warren NJ 070 _. . __. .. To: Construct an in ground swimming pool with spa to a single family dwelling as applied for. Must maintain a 15' accessory setback. At premises located at: 990 BridgewwwLn, Cutchogue SCTMm# 473889 Sec/Block/Lot# 97.-1-17 Pursuant to application dated 8124/4/2„022 and approved by the Building Inspector. „ _mmmmmmmmm� To expire on 4/3/2024mm m Fees: IN-GROUND SWIMMING POOL $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 Telephone (631) 765-1802 Fax (631) 765-9502 htt // ww.soutlioldtownti .&Yo Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only A j � PERMIT NO, Lt ✓5 I Building Inspector. _FJJ Applications and forms must be filled out in their entirety. Incomplete h'3UHwDR,io G 1EIP applications will not be accepted. Where the Applicant is not the owner,an q,.b, i' (V„;OL)FH Owner's Authorization form(Page 2)shall be completed. Dater ea OWNER(S)OF PROPERTY: Name: Ay .y,. SCTM # 1000- (.�'�-0) - 1-7 Project Address: qq Phone#: � -L I rEmatl: Mailing Address: C,gC) eDV,u CONTACT PERSON: Name: �CtYincx , Qono Mailing Address: y, 1 Phone#: � -953 - LOQ\ L K),nrMY) �Sl 4 Email; DESIGN PROFESSIONAL INFORMATION: T J1 Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: 4O ") U� 4 '"^�' � l(q °� Phone#: �° 03_ h Emaul: S", I DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other , l �' ``` $ 13P 1320 Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? es El No 1 PROPERTY INFORMATION Existing use of property: Duttimr, Intended use of property: 15 N y e %V13 U� Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes No IF YES, PROVIDE A COPY. VeCi' Box After IReadi rig. The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by N er 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 Bre(print name): 41iY;r1la l (&CUYI VAuthorized Agent ❑Owner Signature of Applicant: Date: �)STATE OF OF NEW YORK) SS: COUNTY OF M being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the Avin± ontractor, 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 / �" 20 Nota r DENNIS G STRITTMAT"rER Notary Public-State of New York N0.015T6137451 Qualified in Suffolk County PROFIERI"Y OWNERFORI r i ot im My Commission Expires May 12, 201 (Where the applicant is not the owner) 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 Buildine I rytment. I:ication AUTHORIZATION (Where the Applicant is not the Owner) Arthur Westphal... .......... residing at g C Wogue, NY11935 C. . A..._ �...�...... ��.. ...... __._. 990 Bridge Lane, utc (Print property owner's name) (Mailing Address) do hereby authorize PATRICK'S POOLS _._...._..�...........�_............................................._ (Agent) _. ..... to apply on my behalf to the Southold Building Department. 07/28/2022 (Owner's Signature) ..._.�... ..�.............................................__ (Date) Arthur Westphal �..........�......._..... ........... (Print Owner's Name) .........,� s�.lsTEA r workers'Compensation CERTIFICATE OF INSURANCE COVERAGE m. YORK ..�� - Board 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) 1b. Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE, NY 11942 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) 262929943 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 1 a" PO Box 1179 DBL318565 Southold, NY 11971 3c,Policy effective period 05/13/2022 to 05/12/2023 4„ Policy provides the following benefits: 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 employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law, B„Only the following class or classes of employer's employees: Under penalty of perjury, I certify 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 6/23/2022 By �Ur (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White 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 46,4C or 56 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) i iuiiiiii ii iiiiiiui i ii ii uiiuuii III I 1�1 DB-120. 1 (12-21) /1 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/10J'2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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 CONTACT Nicholas Zulkofske Brookhaven Agency,Inc. P "E ��631941-4113 1fi941-4405 100 Oakland Ave,Ste 1 E-MAIL certificates brookhaveD na enc corn .. .. Port Jefferson,NY 11777INgURER(SI AFFRDING„COVERAGE I`AIC INSURED � ... ..�. _ ..... ..--_..--........�--__......- A Philada elphia Indemni Insurance Co. INSURERd.Merchants Mutual Insurance Co. Patrick's Pools,Inc INSURER C.Wesco Insurance Co._.____ PO Box 3024 INSURER o, ...mm..__............... East Quogue NY 11942 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`' ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE im-qn iwn EQLICY UUMBERLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRE,NCE ,$1 99,,0 00 A `�I CLAIMS-MADE OCCURMEMAGSEETO RENTED $-PR1 QOXOOO x Contractual Liability X PHPK2385555 02/28/2022 02/28/2023 MEDEX.P An one erson $5,000 ,.......,_. ,.�a.....m........ ...m.............___......._...... PERSONAL&ADV INJURY $,.,,,,,,.�a000 OOO .I PtlI.,AGGREGATE J LIMIT T APPLIES PER: GENERAL AGGREGATE '. OOO�OOO POLICY 7t PRO LOC PRODUCTS-COMP/OP AGG $22000,000 rI-L,I IP` $ AUTOMOBILE LIABILITY COMBINEO..SINGLE LIMIT” $500000 B X ANY AUTO BODILY INJURY(Per person) $ .................. ....................... .........................................................-.......-........... ALL OWNED SCHEDULED X X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ AUTOS AUTOS XHIRED AUTOS XNON-OWNED PROPERTY DAMAGE $ . , .... .a�adetat)m� AUTOS m,,,,,,,, UMBRELLA LAB OCCUR EACH OCCURRENCE... _, ...__ www..w. � �................................................ ..m_�..,. m CLAIMS MADE AGGREGATE 4 -, DEC I 'I"®INT' N $ WORKERS COMPENSATION X I PERTUT, OTH- AND EMPLOYERS'LIABILITY T Y/ ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $100,000 .. C OAF ICERIM n NH)EXCLUDED? Y N/A wwC3587728 05/13/2022 05/13/2023 E.LDISEASE SEA EMPLOYEE $1 OO�OOO If yes,describe under __, ���....,.,_m ..... .,�.__. DE. .,RIPTI N F P.RATI N, below E L DISEASE-PpLICY 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 <NSZ> ©1988-2014 ACORD CORPORATION. All rights reserved,. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NEW Workers' YORK CERTIFICATE OF S,FATC Compensation Com NYS WORKERS COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996-4687 Patrick's Pools,Inc PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured(Only required ifcoverage Is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold,Town Hall Annex 3b.Policy Number of Entity Listed in Box'1a" 54375 Main Rd. WWC3587728 Southold,NY 11971 13c.Policy effective period 00312027 to 0511117023 3d.The Proprietor,Partners or Executive Officers are 0 included.(Only check box Hall parinerslofricers included) QX all excluded or certain partnerstofficers 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 hem on the INF'ORf4MA71ON 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"20. 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"1c",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: Nicholas Zulkofske (Print name of authorized representative or licensed agent of insurancef carrier) Approved by: Z Z (signature) (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 C405.2.Insurance brokers are lm authorized to Issue It. C-105.2(9-17) www.wcb.ny.gov &N'CSJAo•7 aOIA3010 Sb aNOl2o:l.s MI;WASIO Aar'�.1�11'9VOs VYxl;A3a�a$aYo 1.N9 WJ:N V1a0 blk'S74M:ON Wal NaL'a."EO Sa•IavIIJ OU!NVIOOLSnJ'AA'vdlaoJAsnx1 A UMI wf'mYA 6Mr ANYJWOJ aSNVansNla•IAI2ONY tl=. iatll. ara✓aA ^RaaraV e � %OA.Ca4aalaAtll,7 NXY idiaa Y3VkaS SMC LA0 ihAdtlp [I'IUII�"a'as'aC)w.Nn:9SaiY :a•a WnRis }I103 4 a.... -':ON fA,tmra A6+aaM1rLr6/6 �V& tl� I'AI.:'i:.. SNOIMA33 ...w fCa{* xwinMic't.'wna>bPm ' •INca IwauuYmlwlmuvusruA%NcIWm+atoTwa , " L cG�o-.AS.LS-Z4MU!S/23BIN1SSCAlJ i'A #E%l.. 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