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Home My WebLink About48693-Z sx- ttt "; TOWN OF SOUTHOLD .` � BUILDING DEPARTMENT TOWN CLERK'S OFFICE ,off{, 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#: 48693 Date: 1/5/2023 Permission is hereby granted to: O'Brien, Rebecca 355 Willis Creek Dr Mattituck NY 11952 To: Construct in-ground gunite swimming pool at existing single family dwelling as applied for. Must maintain 15 feet minimum to pool and equipment from side and rear property lines. At premises located at: 355 Willis Creek Dr Mattituck SCTM # 473889 Sec/Block/Lot# 115.-17-17.16 Pursuant to application dated 11/14/2022 and approved by the Building Inspector. To expire on 7/6/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector Nq 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 https://www.southoldtownu.m a Date Received „ IIS II „ PERMIT Y r For Office Use Only PERMIT NO, Building Inspector: 4 e m w.d.... Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an gFr ug.w .w m`'C k'yP ',..✓ ,y 0`"9 4 a.J r d.,., ,d Owner's Authorization form(Page 2)shall be.completed. Date: 0 I I y a'I��a— OWNER(S)OF,PROPERTY: Name: R , f-i n SCTM # 1000- 115-- 11 _ 11, Project Address: Phone#:3`i-7_ . pcooEmail: C . Mailing Address: CONTACT PERSON: Name:. � Mailing Address:5� \4 Phone#: ) _ 5 - () Email: MC,\ t DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:`7Q Mailing Address: s N ))61L4-q), Phone#: f_ _ rEmail:' GlM i DESCRIPTION OF PROPOSED CONSTRUCTION p +� ❑New Structure ❑Addition ❑Alteration ❑Re alr ❑Demolition Estimated Cost of Project: ther �� i'w. Swr-p rn $ Will the lot be re-graded? Dyes o Will excess fill be removed from premises? es ❑No 1 PROPERTY INFORMATION Existing use of property: ,'W® Intended use of propert :T�u�' � insVVIV1 Zone or use district in which premises is sl uated„ Are there any covenants and restrictions with respect to this property? ❑Yes Aqo IF YES, PROVIDE A COPY. Na Ghaptheck Box theAfteir Read Code. lung: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by APPLICATION Town 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( int name); 4{�G� 1�Y1� L �� Authorized Agent ❑Owner Signature of Applicant: ,4�- JUCL,�� Date: I � )L4 b STATE OF NEW YORK) C COUNTY OF J S ) y4ln An 'Me 60ri3O being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the (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 of ,( 20 'ZZ— NotEMyCornmission NNIS G STRITTMATTER Public-State of Ne:v York NO. 01ST60745'lified in Suffolk County �'�IROPE'RI N �',:I � T'HI 'ir Expires May 12, 20V16 (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 Building.,Department Ap2lication AUTHORIZATION (Where the Applicant is not the Owner) I, Rebecca O'Brien residing at 355 Willis Creek Drive,Mattituck NY (Print property owner's name) (Mailing Address) do hereby authorize Katrina Mercurio (Agent) of Patrick's Pools to apply on my behalf to the Southold Building Department. For the purposes of a pool permit. (Owner's Signature) (bate) (Print Owner's Name) YORK Workers' CERTIFICATE OF "TA1fE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 631-9964687 Patrick's Pools,Inc PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Ouogue NY 11942 Insured Work Location of Insured(Only required it coverage 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 3c.Policy effective period nwww to 0511 X2023 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partnersfoffioers included) QX 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 farm Is approved by the Insurance carrier or its licensed agent,or until the policy expiration date listed to box 11c",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 insurance carer) Approved by: .S/11 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 C-105.2.Insurance brokers are N!2I authorized to issue IL C-105.2(9-17) www.wcb.ny.gov i� DATE(MMIDDIYYYYY) �coRn CERTIFICATE OF LIABILITY INSURANCE 05/10/2022 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' N6I3C1 h..o..la..s....Zu..lk...o...f..s...k. e Brookhaven Agency, Inc, PioN.. {Aac N�I.EtI m)ITIT941-4113 FAX 631 941 4405 _ 100 Oallclaind Ave,Ste 1 EE-MAIL certificates„a7brookhavena enc .com .n..W.W...n _.._ ....... Port Jey»'ffersorl,NY 11777 INSVRgR„(§,IAFfQRpjN,C�_C,OVERAGE„��-, NAIC# . ......... ........ ......... _..__...................................._ ......... ............... ...... mmmm ..„ m 465 3'?RA; Philadelphia Indemnitor ___............�rrr INSURED IN RE B: Merchants Mutual Insurance Co mm. R Patrick's If�ools, Inc INTI RRp: Wesco Insurance Co. PO t3oX 302.4 INSRR D; ......-..�.-....m ..._._._.- _.. East Quogue NY 11942 INSURER INSURER F: 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 CONTRACTOR 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. _... . -- ... IN RR ADDL UBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY'N MBER JIX COMMERCIAL GENERAL LIABILITY EACH OCCI�IRR.ENCE $1,000.000 A CLAIMS-MADE X OCCUR DAMAGE 7 _ pAMACC'"fD RENTED � $100,000 ...... x Contractuall LiabM,!y w w X PHPK2386555 02/28/2022 02/28/2023 MED ExP(Anyone ersonlmm,mm„ 5,OQ0�___ ____ --........................... PERSONAL B AQVwNJ,URY $1,000,000 _-......r.�._ — GENI'L AGGR GATE LIMIT APPLIES PER I GENERAL AGGREGATE $2,000,000 _ POLICY PRO- II LOC PRODUCTS gQK1I !QP AGG, „$2,000,000 JECT 994 .... OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY ( a a,.ride�t $500,000 E3 +, ANY AUTO BODILY INJURY(Per person) $ ww_ .w.......__.. ALL OWNED SCHEDULED X X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ AUTOS AUTOS e...................................$_.�.. NON OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OC URRENCE $ EXCESS LIAB CLAIMS-MADE A.GGREGATF..,,,,,. $ ED R-TEN I $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE C3587728 05113/2022 05/13/2023 E AqH ___NT $100,000 OFFICER/MEMBER EXCLUDED? Y NIA ACCIDENT „m_m .._.__ (Mandatory in NH) E L DISEASE EA EMPLOYEE $100,000 If yes,describe under mm_ .�� - DESCRIPTION OF OPERATIONS beiow E L DISEASE-POLICY 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 Souatlhlolld,Town I-IaII Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Maiin IRd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE MNSZ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD . YORK workers' CERTIFICATE OF INSURANCE COVERAGE sTArr Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW ....... PA _ RT 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carriell 1a. 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 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) 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. F1 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. 6/23/2022 Id &; Date Signed By r (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-MAO 00 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 413,4C 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) 1111°°1°°°°°1°1°°1°11°11°111°1111111 ,O£=„1 3WOS OlHdVNO SY0SWHdF#UNUO W 53OW s3bUMW 3nVO"do NoNO3a33O a3itm=ZN 3W A3W9S SNL NO NNONS WN MW38 x SU Saw 0 Amm st3 m 300M sam"o 3t nmwt s WOW sw€Wwxmsra AdW 3n&am V 39 at aWOMW 39 WN 31685 TM mSSM On 09 OF 91 0 OF XWS AWA AUN 3M JV biz[N00035-40 AMV70M V.9 7W&WA3 N31218,0 -0 V003838 MILVIVOV'S1 `b"N 3SNH0 Nb`OMONd' '0N1 AON3.9V 37111 XNVNONb'7 ANVdNOO 3ONvdnSNf 37111 7VNOl1bN 0178f1d3d 070 1060L17 'ON 37111 -*Ol 031311830 9t# s/N3�Nl73W.00000'992 scs - M „01,91.88 S ""*y Norr 30�+ GSHr •NOtY Qj �0 3NW5 Z X May L�w �. 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