HomeMy WebLinkAbout48576-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
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Name: SCTM# 1000- Ion . — 11 "
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Project Address: 1305 V6AAqe LkiJe J am )(-
Phone#; Email: n'1b� 1v1G�1 �0
Mailing Address: '3s--30 S 'Q fi4oelk71
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Mailing Address
Phone#: Email:
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Mailing Address:
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Phone#: 3) -744--71 IRC Y—I Email: Mc e- 0 Af
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❑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
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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]
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
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ORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/22/2021 at 01:26PM
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