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HomeMy WebLinkAbout48859-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT IGS 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#: 48859 Date: 2/6/2023 Permission is hereby granted to: Kovan, Aaron 1980 Stars Rd East Marion NY 11939 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1980 Stars Rd, East Marion SCTM #473889 Sec/Block/Lot# 22.4-19 Pursuant to application dated 1/20/2023 and approved by the Building Inspector. To expire on 8/7/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buildin 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 IlLtp a vw e i,lqdLowisi .I Date Received APPLICATION BUILDING 'I IT For Office Use Only PERMIT NO. Building Inspector: �, DAN 2 0 2023 UI' IN Opp ED Applications and forms must be filled out in their entirety. Incomplete TOWNOF8013THOLD applications will not be accepted. Where the Applicant is not the owner,an a I p pP p p Owner's Authorization form(Page 2)shall be completed. Date: 01 OWNER(S)OF PROPERTY: Name: Payton Kovan SCTM#1000- 2-7--4-19 Project Address: 1 g( G+Qrs Rd. Eas+ Mari, N 111301 Phone#: -720-5S()--72.1,4Email: Oiav'on 11k0v0.ri °' 9M06 Com Mailing Address: M4 Ne.1.M Si 11X3I CONTACT PERSON: Q q Name: Q fr (Binder Tools, Inc) Mailing Address: r BOX 191600She1.1-P.r 1 s land, NV 11964- Phone#: 1` 64- Phone#: X031 7A9 21)O (o) GSI l461370 (-)1Email: katy@ binder pooIS.Com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: (?index pools Inc Mailing Address: P� Bo x I (o d, S V1 1+gV- I Sa;1J NV 119(04 Phone#: &617461 2110 Email: .0 bim, Ot Is.cam DESCRIPTION OF PROPOSED CONSTRUCTION [%New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other J ' t pot 1,0 OVADCAVeX $ 113,56:0 00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises?XYes El No 1 PROPERTY INFORMATION Existinguse ofproperty: Intended use of property: res i devi-hal re$IC.�eh�0.l Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to O this property? ❑Yes 5dNo IF YES, PROVIDE A COPY. R4 Check Box After)ea u,ffitli . 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 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 rit name YJAuthorized Agent ❑Owner Signature of Applica Date: Ql/1?'/20.2-3 STATE OF NEW YORK) SS: COUNTY OF ,A 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 i day of ✓�1A�t) 2021-3 Notary Public o 1)1101)1111"I Y OWNERIIII( II II T N (Where the applicant is not the owner) ,, Aaron Kovan residing at 1980 Stars Rd EQs+ Maribh, NV , 0`130I do hereby authorize Binder Pools (Darrin Binder) to apply on my behalf to the Town of Southold Building Department for approval as described herein. ,Aa&&N, 1 /10/2023 Owner's Signature Date Aaron Kovan Print Owner's Name 2 Client#: 23825 BINDERPO DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSU DICE 10/04/2022 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 pollcy(1es)must have ADDITIONAL INSURED provisions orbe efrdO rsed'... 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER Kimberly L Schuerlem Amaden Gay Agencies,Inc. PHONE�631 324 0041 No 6313240671 tAr ,_wa,F1: _.I ..._ 11 Gay Road E MAIL kschuerlelrt IamadengITay.com P.O. Box 5004 _ ___..... _ ....w_. INSURER(S)AFFORDING COVERAGE NAIC# East Hampton, NY 11937 INSURER A:Valley Forge INSURED INSURER B:Continental Insurance Company Binder Pools Inc e _ INSURER C: American Fire and Casualty Ins.Co. 24 24066 PO Box 1960 .._. ._ INSURER oOhio Security Insurance Company 082 Shelter Island, NY 11964 .. mm m INSURER E: _.- . ... ----.. 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. ....___- . _ ......._._. IINSR TYPE OF INSURA LIABILITY Amm POLICY NUMBER MMID tNy111177 LIMITS w m A X 11+X.I 508491 . ....._._..... t DOL sUsR POLI Y EFF POL CY EXP o. .... COMMERCIAL GENERAL 1313 0912512022 0912512023 EACH OCCURRENCE $1 000'000 _ . R OCCUR AMNED __L__CLAIMS-MADE Ec X PD Ded:1,000 MED EXP(Any one person) $15-0-00 PERSONAL&ADV INJURY $11000,000 GEN'L AGGREGATE LIMfr APPLIES PER: GENERAL AGGREGATE s2,000,000 X POLICY 'PRO- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER, D AUTOMOBILE LIABILITY X BAS60950488 0512912022 11512912202 ( �aM9cI"�O+l INGLE LIMIT 0,000 ANY AUTO YBODILY INJURY(Per person) $.._ m mm OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ONLY XAUTOS ONLY PROPERTY DAMAGE $ HIRED NON-OWNED X AUTOS ONLY X P a dent X Drive Oth Car $ B X UMBRELLA LIABX OCCUR X X 5086496894 9/2512022 09/251202 EACH OCCURRENCE $1.0000100 _ EXCESS LU►B � CLAIMS-MAOI AGGREGATE 61,000,000 WORKER Y MPENSATIOINN$10000 AND EMPLOYERS'[ --. ._ _._.. .- _.. ...... .. 0.E§ _ 1 RT $ _ CJED ..�- C ERs XWA60950488 10/01/2022 10/011202 LIABILITY ANY PROPRIETORIPARTNEREXECUTIVE YIN N/A E L AGM ACCIDENT $1000,000 -.. OFFICER/MEMSER EXCLUDED? �� ._ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S1,000 000' IFEs describe under DESCRIPTION OF OPEFIATIONS Iaslow E.L.DISEASE.POLICY LIMIT $1,000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is an additional insured as required by written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S75037/M75032 KLH STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured 631-749-2110 Binder Pools,Inc. 1 c.NYS Unemployment Insurance Employer Registration PO Box 1960 Number of Insured Shelter Island,NY 11964 1 d.Federal Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State, i.e.a Wrap-Up Policy) 11-3368250 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Liberty Mutual Insurance Town of Southold 3b.Policy Number of entity listed in box"la": 54375 Main Road XWA60950488 PO Box 1179 3c. Policy effective period: Southold,NY 11971 10/01/2022-10/01/2023 3d. The Proprietor,Partners or Executive Officers are: included. (Only check box if all partners/officers included) (X)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 "la" 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"T'. The Insurance Carrier will also noti the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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 maybe sent by regular mail.) Otherwise,this Certitcate 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"3c'; whichever is earlier. Please Note:Upon the 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: _James Amaden (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _ 10/4/2022 (Signature) (Date) Title: AGENCY PRINCIPAL Telephone Number of authorized representative or licensed agent of insurance carrier: 631-324-0041 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) vw ,vcl/state.tt .tts YORK Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation 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 carries 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured BINDER POOLS INC 631-749-2110 PO BOX 1960 SHELTER ISLAND, NY 11964 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) 113368250 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 PO 130x 1179 3b.Policy Number of Entity Listed in Box 1 a" DBL397420 Southold, NY 11971 3c.Policy effective period 01/01/2023 to 12/31/2023 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 1/11/2023 gy WA , 4f g (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100Name 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 48,4C or 513 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) II�IIPiiiii�1a2i0iii1iiii(i12ini2ii1)ii�l Suffolk,County Dept.of labor,Li nsiirn Cornsu r Affairs t HOME IMPROVEMENT LICENSE Name DARRIN C BINDER Businass Name this certifies that the yearsr is duty licensed BINDER POOLS INC ay the County of suffolk License Number:H-3717' Rosalie Drago issued; 04,912/2005 Commissioner Expires: 0490192023 This license is the property of Suffolk County * `! Uepartmecnt of Labor,Licensing&Consumer Affairs. ,:.� �" ��ws�sa�a��t•.;�s l��ii�ns�*�r�,s�ey c�:s�;s�ter i,5 t�l`�,nh{. ... u Additional Business Name License Category H3-Poris,,,Spas,H2 Pawls ar-j pas/CeiffFied Olz LAND N OVV OWN OF 5UT o48, 0t d low � ,et \toy 1 ri v Sb Lt's '21N�` � 'mar Aa .12W w SRS 9 a o f r� D° - . 1 .O 8