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HomeMy WebLinkAbout49021-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT ?w 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 #: 49021 Date: 3/13/2023 Permission is hereby granted to: DiFrancesco Family Trust 400 Ships Dr Southold, NY 11971 To: construct accessory in-ground swimming pool as applied for. At premises located at: 400 Ships Dr, Southold SCTM # 473889 Sec/Block/Lot# 79.-3-29 Pursuant to application dated 3/3/2023 and approved by the Building Inspector. To expire on 9/11/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 -4 Z� Building Inspector ppm 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 Date Received BUILDINGAPPLICATION FOR For Office Use Only k_�a d- L11 __, �r V I � Ply PERMIT NO. Building Inspector: MAR 0 3 2021, Applications and forms must be filled out in their entirety. Incomplete t pp �3U,11r011,46,DEPT applications will not be accepted. Where the Applicant is not the owner,an TOft)OI='SoO fn 1OLD Owner's Authorization form(Page 2)shall be completed. Date: S�� A I OWNER(S)OF PROPERTY: Name: SCTM # 1000- 72 _ 3 ---47 Project Address: Uv '41 , /1 Phone#: _7loS' 's,76I Email: l .�i�'rcu,cvSu�u7mc�L'. rYJ Mailing Address: M � CONTACT PERSON: Name: E�IJE C-14-176*1 Mailing Address: �x � � �� , / //935 Phone#: Email: K�c3� 0✓1 1`�rt . DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: C.'k7Ukv, Mailing Address: .� C> o , A-Y //9- s Phone#: X31_�f�[r yZ5�5' Email: oc-h',4L41�Q[qp�on1'jrLL_Q n2�? DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: IROther $. �—?OQ U&Y-) Eillhe lot be re-graded? WYes ❑No Will excess fill be removed from premises? Wes ❑No 1 PROPERTY INFORMATION Existing use of property: � Intended us of prop rty: --4jLrq, 2e5A&nd-e- Zone or use district in which premises'is situated: Are there any covenants and restrictions with respect to this property? OYesXt--'No IF YES, PROVIDE A COPY. heck 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 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(print name): � ���� 1�4-K ®Authorized Agent ©Owner Signature of Applicant: Date: �2/ -5-1a- STATE OF NEW YORK) SS: COUNTY OF 401 1C f&tSG /% 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 )5� I uC,-rSj 20c2( ry ublic . � w PER AUTO RI „I,,,,I (Where the applicant is not the owner) r, residing at ry-% C i r �w� do hereby authorize ? 1' 11-711 - to apply on y behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 DATE(MMIDD/YYYY) ACC>RV CERTIFICATE OF LIABILITY INSURANCE 02/15/2023 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 holderIs 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). CONTACT Lauren Murphy PRODUCER NAME:. Roy H Reeve Agency,Inc. PHONE (631)298-4700 c No; (631)298-3850 PO Box 54 p1DRILE3s: Imurphy@royreeve.com 13400 Main Road INSURERISIAFFORDINGCOVEIRAGE NAIL Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B: Chituk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 11935 INSURER F: COVERAGES CERTIFICATE NUMBER: CL228417514 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 MAYBE 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. POCY EFF POLICY EXP LIMITS 1 TRR AUDLLI TYPE OF INSURANCE $D POLICY NUMBER MMIDD MODWYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENT 100,000 CLAIMS-MADE �OCCUR PREMISES Eaoccunrence $ Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2022 03/15/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN`LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ROTHrPOLICY PR'O F—]LOCPRODUCTS-COMP/OPAGG $ 2,000,000 k JEC"f $ AUTOMOBILE LIABILITY COMB9NEI1 SINGLE LIPAIT $ Ea rldenr ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) '$ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Pw ac'cid l UMBRELLA LIAS =ILAIMS-IA.E EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER Or H_ AND EMPLOYERS'LIABILITY YIN STATUT ER ANY PROPRIETOR/PARTNER/EXECUTIVE [:] NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E..L,DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Barbara Difrancesco,400 Ships Drive,Southold,NY 11971 CERTIFICATE,HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 11 t �1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DAT DIYYYI� 022/15!2/15/2023 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 Lauren Murphy NAME: Roy H Reeve Agency,Inc. PHONE (631)298-4700 �x N _ (631)298-3850 PO Box 54 EMAIL Imurphy@royreeve.com ADDRESS;, 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B: '. Chltuk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 11935 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2321518551 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. INS. AUDL 507M TYPE OF INSURANCE POLICY NUMBER MM/DD EFF MW0DI POLICY PY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE O RENT 100,000 CLAIMS-MADE Fx�OCCUR PREMISE S.Faoccurrence) $ - 15000 Contractual Liability MED EXP(Any one person) $ , A 6018146726 03/15/2023 03/15/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN`LAGGRELATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY �JET F LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHEf $ AUTOMOBILE LIABILITY µCO MBJNEDSiKGLE L.IMrr $ Ea acdderill ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) s AUTOS ONLY AUTOS '.,. HIRED NON-OWNED PR,OPERTy DAMAC.wE. $ AUTOS ONLY AUTOS ONLY Per adddrii UMBRELLA LIAB OCCUR EACH OCCURRENCE s I_ H E%CESS LIAB '..CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y.I N STATUT ER ANY PROPRIETORIPARTNER/EXECUTIVE I NIA E.L.EACH ACCIDENT '.,$ OFFICER/MEMBEREXCLUDED? (Mandatory In NH) E.L DISEASE-EA EMPLOYEE 1 $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Barbara Difrancescw,400 Ships Drive,Southold,NY 11971 CERTIFICATE HOLDER CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 a t ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD p CERTIFICATE OF K Workers' NYS WORKERS' COMPENSATION INSURANCE COVERAGE YOR STATE Cornpensation Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 lc.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 113306347 certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold PO Box 1179 3b.Policy Number of entity listed in box"Ia Southold,NY 11971 WWC3623614 3c.Policy effective period: 1/1/2023 to 1/1/2024 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) 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 112". The insurance carrier iruist norm,the above certificate Bolder and the Workers'Compensation Board within 10 days W a polity is canceled due to tionpayinettt r prentiums or within 30 days lF there are reasons other 11#4111 nouptiyment of preinitiiiis that cancel the polh�y or eliminate the insured from the coverage indicated on this Certificate,(These noticecs inay be seat by regular mail)Otherwise,this "ertificate is valid for one year after this form is approved by the insurance carver or its licensed agent,or until the policy expiration date listed in box 73c",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: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 1/11/2023 (Signature) (Date) Title: Senior Vice President Telephone Number of authorized representative or licensed agent of insurance carrier:877-528-7878 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 iL C-105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering contracts unless compensation is secured. 1.The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however,shall be construed as creating any liability on the part of such state or municipal department,board,commission or office to pay any compensation to any such employee if so employed. 2.The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)REVERSE rr, Workers' CERTIFICATE OF INSURANCE COVERAGE s-rArE 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 carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245 PO BOX 9 CUTCHOGUE,NY 11935 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) 113306347 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 BOX 1179 3b. Policy Number of Entity Listed in Box 1 a" Southold, NY 11971 DBL614067 3c.Policy effective period 05/01/2022 to 04/30/2023 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 perjui ,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 PaidFamily Leave Benefits insurance coverage as described above. 8/4/202.2 ue ... Date Signed By g (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number f"1 - 2 . 100 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 4B,4C or 5B 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. p DIB-1120.1 (12-21) 11111111 11111 Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise, this Certificate is valid for one year atter 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. 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 NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (12-21)Reverse v 10�T O j~ wE� S' I dc _a W (� �ti rl o 4S j zi- µ � 0 w .«"a " OP o rte] Co�� Q t '-7 /2 2100 4--