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Home My WebLink About48576-Z { fir m TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE p 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 #: 48576Date: 12/8/2022 Permission is hereby granted to: Lymberopoulos, Hariklia 35-30 28th St Astoria, NY 11106 To: Construct an in-ground swimming pool to an existing single family dwelling as applied for. Pool and pool equipment must maintain minimum setbacks of 10 feet. At premises located at: 1305 Village Ln, Mattituck SCTM # 473889........................ ........... _................. .......... ...._.........m_.. Sec/Block/Lot# 107.-11-6 Pursuant to application dated 10/6/2022 - and approved by the Building Inspector.. To expire on 6/8/2024. 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 Telephone (631) 765-1802 Fax (631) 765-9502 h :// soutaojdtwnn • acv Date Received APPLICATION BUILDING PERMIT For Office Use Only . I r1\ B I DD PERMIT NO. !J(� Building Inspector., I � �/li,� F/,rii/ r�%/Ij%//l;;l, r%/�:�j%/%„i%��//G/�/��Ir/!r/✓////��//d/��/��/�///�%/��/,e%% ��rri r//�%/i /,F; r .. F. � - a ` OWN OF St3UTHO D / r Date: -2q,2-'2 ,/!� / yr i✓.. ,. / /..././ /...7-7,7777777-7--7— ./'f7 ril,� ,,,o..r. Name: SCTM# 1000- Ion . — 11 " I�AR�I«�a oda . IuBe�c �UL-oS Project Address: 1305 V6AAqe LkiJe J am )(- Phone#; Email: n'1b� 1v1G�1 �0 Mailing Address: '3s--30 S 'Q fi4oelk71 /r 7/ r / /�//%/rF:'..�/% „�i ✓r/i %r JF/ri'.;'p� /r/ // / , l/Y/� l r/yri�//%ir/ ///i/�Ft/ r, /J// 9f,', ,r Name: Mailing Address Phone#: Email: Y J /r Name: wa Mailing Address: Phone# b31 �Z`t � � Email r 9 / i y/r / I/i/ l//r ��%///� r f r/Y l /r r✓ , Name: Mailing Address: okt 2S-A Phone#: 3) -744--71 IRC Y—I Email: Mc e- 0 Af rr , , , Of � � �/ u717,77777 77- ,. N . ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project;. tben✓nv✓ O)L $ 25,23 - Will the lot be re-graded? 19Yes F-1 No Z3l_ k-' OnJV Will excess fill be removed from premises? Yes No 1 /?k\ NYSIFPO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112377925 LEVITT-FUIRST ASSOCIATES LTD ' 520 WHITE PLAINS ROAD,2ND FL r TARRYTOWN NY 10591 � v SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 971085 06/29/2022 TO 06/29/2023 06/02/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK,EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,4SURANCE FUND UNDERWRITING VALIDATION NUMBER: 370218050 11 1111000 000 000 0m01 01 2 w2 Foam WC CERT-NOPRINT Vcmion 3(08/29/2019)[WC Policy-24384919] U-26.3 59 [00000000000109927129][ 1-000024384919][#*G][15901-03][CWU"--CEU 1]101-00001] Workers! CompensationCERTIFICATE OF INSURANCE COVERAGE 'r 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 631-7444455 MILLER PLACE,NY 11764 Work Location of Insured(only required if coverage is specificalty limited to 1 c.Federal Employer Identification Number of Insured certain locations In New York State,i.e.,Wisp-UP Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold PO BOX 728 3b.Policy Number of Entity Listed in Box"I a" Southold, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/5/2023 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Polity covers: ❑X A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. n 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 desc d above. Date Signed 6f6/2022 By 4ut (Signature of insurance carrlees authoriz d represents lve or NYS Licensed Insurance Agent of that insurance carder) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES 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 413,4C 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. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or SB of Part 1 has 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 with respect to all of his/her employees. Date Signed BY (Signature of AuthorVzad 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 ff form. DB-120.1 (10-17) I DB-120-1 (10 201OII e CERTIFICATE OF LIABILI L SU 2�2 NCE D7 � . IATE 10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCERK,AND THE CERTIFICATE HOLDER. If SUBROGATION IS WANED,subject to the terms and conditions of the policy, have ADDITIONAL INSURED provismoment or at m nt on IMPORTANT: If the cellif Bate holder is an ADDITIONAL INSURED,the policylle )must certain policies may require an endorsement A statement on this certificate does not confer riahts to the certificate holder In lieu of such andoreement s. CONTACT PRODUCER M RLI elto Liberty Risk Management,Inc. PHONE631 3 FAx N 631 562»5lt3fw 2333 Route 112 Ao L mlrtthe INas alto Medford,NY 11763 UIBU AFFDRDINITCOIIERAIiE NAlos INS'UriER A: NI INSURED INaURI�It B' Arthur J.Edwards Mason Contracting Company Inc. INeURER DBA Arthur J.Edwards Pool&Spa Centre INSURER D; 929 Route 25A Miller Place,NY 11764 jNMOS rE INaURER r COVERAGES CERTIFICATE NUMBER: 000000054323010 REVISION NUMBER, 23 THIS IS TO CERTIFY THAT THE POLICIES OF INSURAINCI LISTED BELOW HAVE BEEN ISSUED TO THE(9NSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED'. NOTWNTHSTANDING 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, RTYPE ES,LIMITS SHOWN MAY RAVE,BEEN REDUCED BY PAID CLAIMS. POI.—y IJsm rA CLUSION DOFI INSURANCE F TIONS OF SUCH PDL/ POLICY (M NUMBER COMMERCIAL GENERAL LIABILITY NPC-1004300-01 11022 0110112023 ACHOCCURRENCE s 1.000000 CLAIMS-MADE FW1OCCUR MED EXP one n s 3000 s 10.000 PERSONALL,&AOV INJURY —$----I,-00-0,-000 GEN"L AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE s 2,000000 POLICY PRO- ❑LOC PRODUCTS.COMPVOPAM s 2 000 000 JECT $ OT KEq S N IN MTr $ AUTOMOBILE LIABILITY a e ANYAUTO BODILY INJURY(Per pemw) $ OWNED SCHEDULED BODILY INJURY(Per aceldeM) $ AUTOS ONLY AUTOS ROPERTY CiAMA0 S HIRED NON-OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAR OCCUR EACH OCO'RRRENCE S EXCESS LIAB CLAIMS E AGOREGATE s S_ TIED RETENTION a ERCT" RS gPENaATION STAT E AND EMPLOYERS'LIABILITY YIN EL EACH ACCIDENT' S ANY PROPRIETORMARTN CtM ❑ MIA A CERIM�MSNEHR)EXCLUDED? EL DISEASE•EA_EMPLOYEE S N "ESI RIPTION O 'ERA7IONS E L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddNk"=I Remarks Schedule,may be attached If mon specs Is required) Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall P.O.Box 728 ,AUTHORIZED REPRESENTATIVE Southold, NY 11971 M,JR tdog ORATION. All rights reserved. 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