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HomeMy WebLinkAbout48847-Z m TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY 00p 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#: 48847 Date: 2/2/2023 Permission is hereby granted to: McDonald,Kenneth ------ ...................._... .. 280 Shipyard Ln.. _.. .. ....... East Marione ,NY 11939 To: Construct an inground swimming pool to an existing single family dwelling as applied for. Pool and pool equipment must maintain a minimum setback of 10 feet. At premises located at: 280 Shioyard Ln, East....Marion SCTM # 473889 Sec/Block/Lot# 35.-8-5.6 Pursuant to application dated 1/13/2023... and approved by the Building Inspector. To expire on 8/3/2024.___ Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 ......... Total: $300.00 m ................... Building Inspector yA TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 '67 Telephone (631) 765-1802 Fax (631) 765-9502 littps://www.sotithol(itowiin d Date Received BUILDINGAPPLICATION FOR For Office Use Only I lilt I II ,vl PERMIT NO. 1 I Building inspector. JAN 12 , LD ONii PT Applications and forms must be filled out in their entirety. Incompleteo'r-q6u nt. applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: ar�e_ JLCTM# 1000- 3$ Project Address: DL �`,� � P,0 , 0-Y, N y Phone#: C' y-) ���y' Email: Mailing Address: CONTACT PERSON: (� M Name: .R� Mailing Address: 5-0 1000 .� �" ti � IAJ I t 9 -71 Phone#: (P-i CoS FS -�)-FS Email: �--I nj DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Lb;.\ , �b �C-'- r\ C� C t3� Mailing Address: '5-U i �-kQ�Y---, -sU \ 9 11 Phone#: U`�!:)\ —1 u< - % -�)-E'S Email: L ( . �o ��r2 M ' DESCRIPTION OF PROPOSED CONSTRUCTION p Project: ❑New Structure ❑Addition ❑A ❑Re air ❑Demolition Cost of fetation Estimated 90ther Will the lot be re-graded? des El No Will excess fill be removed from premises? I;fes ❑No 1 PROPERTY INFORMATION Existing use of property: 29tyZyt �J1 Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes TNo IF YES,PROVIDE A COPY. beck Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by Chapter 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 demolltion 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 bullding(s)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.65 of the New York State Penal Law. Application Submitted By(print name): J G Authorized Agent ❑Owner Signature of Applicant: _ Date: CONNIE D.BUNCH Notary Public,State of New York STATE OF NEW YORK) No.01 BU6185050 SS: Qualified in Suffolk County COUNTY OF ) Commission Expires April 14, 2()4(� 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 (I 20j2 / 1 Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) ane TCL nP W i residing at� � �1 L � -h am ...�.��Y1 da hereby authorize t aPPI on my b, alf to the Town of Southold Building Department for approval as described herein. Z 14 F Owner's Signature �Da al ) 1&1 441 __ .... . Print Owner's Name 2 r YORK Workers'Coensation CERTIFICATE OF INSURANCE COVERAGE sr�a"tr mp 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 carrie 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured LONG ISLAND POOL CARE CORP 631-765-8285 50000 MAIN ROAD SOUTHOLD,NY 11971 1c.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) 275174033 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"1a" PO Box 1179 DBL357404 Southold NY 11971 3c.Policy effective period 04/19/2022 to 04/18/2023 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: Q 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: 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 9/19/2022 By �Jdd 4f (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 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 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 www_ ww_ (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) 111111111111111111111111111111111111111111111111111111111 .•- LONGISL-10 GA CO CERTIFICATE OF LIABILITY INSURANCE DATE(MMI022 DDfYYW) 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 have ADDITIONAL INSURED provisions or 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). CONTACT PRODUCER pp NeefUS Stype Agency PHOEMAIL Inf,.n-.sa!-.n-s.--u22-3 a aOm............. .......m�A No)(631)722-3591 711 Union Ave. (AIC No Ext 631 722 Aquebogue,NY 11931 IESS. _ INSURER(,$)AFFORDING COVERAGE , NAIC# '.. ,Mr1suRERA Philadelphia Indemnity lns Co 18058 INSURED INSURER 8: Long Island Pool Care Corp JNA c: 50000 Main Rd INSURER 0: Southold,NY 11971 INSURER E --- INSURER F: SDffRAGES EIMTIF ATE 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. ........ J ..... INSR ...............__. ��������������_-�F I ADDL SUBR. POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PHPK2402694 4/3012022 4/3012023 ^DAM t TO RENTED $. 5,000 DAMAGE TO RENTED . ----....--- ........., , ,000 MED EJCP(Any onP ersan 100 .. ...... PERSONALXADV„INIURY, $ 1,000,000 ......... ...G-EN'L AGGREGATE LIMIT APPLIES PER ......... GENERAL AGGREGATE $.,,,..., ------_2,000,000 —LOOT..-. ICY I X jECT F LOC �,„PRODUC7,S C,OMP,(OP AGG„ ,$ -------2 000 000. ER ........ AUTOMOBILE LIABILITY ,COMBINED SINGLE LIMIT $ ,.......-.-. ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS _BODILY INJURY(Per acadenl),$ , ,e_ „ , HIRED NON-OWNED P40PERSY AMAGE....... -.--.... .m...... AUTOS ONLY ..m....., AUTOS ONLY $ A_ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER 111OTH PSIlTE .. R .... ..... ..... - ANDEMPLOYERS'LIABILITY YIN — ST ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACGI(aENT $_ „ OFFICER/MEMBER EXCLUDED' l N/A (Mandatory in NH) E L DISEASE EA EMPLOYE $.... II yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-P041GY.LIMIT J I— _............... ..._............ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD LONGISL-10 GANCON '4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE (MMID IY ............ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME;. . Neefus Stype Agency PHONE 3500 I n c,No: 631 722-3591 711 Union Ave. (A/c No Ext) (631)722 Aquebogue,NY 11931 q°AaILss Inl o salnsure.com INSURM§),AFFORDING COVERAGE ---NAIC# INSURER Wesco Insurance Co 25011 INSURED INSURER B_; Long Island Pool Care Corp )NsuRa c; 50000 Main Rd INSURERD- Southold,NY 11971 - ._... IN$URERE. ------ ...,,...... 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 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 TYPE OF INSURANCE INSO WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR M. .GfYYYY. „ LII,....,,.,,.,/YYY:l.,.. COMMERCIAL GENERAL LIABILITY EACH _ PREM) _eSOCCURRENCE $, CLAIMS-MADE OCCUR O RENTED ........... .. DAIw9AGFT.(EdPAG47rr no] $. MED EXP An person)-..4, x one P -con i ..'..SIT...... ......... _....__. PERSONAL 8.ADV INJURY ._...... ............ ............................... _ _ ,...§.. ,,...,........., ENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRO- ............. G�.tPOLI(cy,�.......,.� F LOC PRODUCTS COMP{O,PAGG $ JECT T!,ER'�� $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY IN,AURY(PeF,person) .... .,,y........... .......�._.. OWNED SCHEDULED AUTOS ONLY AUTOS ._BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY ........., AUTOS ONLY ,rGP.eracrMd2�,nl) $,.... _ $ ... UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ _.... ----- .......... DED......._... . RETENTION.$ .................... ... ...... ...,,,.... . . . m A WORKERS COMPENSATION PER OTH- AND EMPLOYERS unealrYWC3580335 4/19/2022 4/19/2023 TATUTE Y 4 N W 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? p �. N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E L DISEASE P OUCY LIMIT $ DESCRIPTION OF OPERATIONS/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 Town of Southold Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 p ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall Annex PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD