Loading...
HomeMy WebLinkAbout49032-Z TOWN OF SOUTHOLD ' BUILDING DEPARTMENT 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#: 49032 Date: 3/15/2023 Permission is hereby granted to: Douglass, James 735 Ma'ors Pond Path Orient, NY 11957 To: construct accessory in-ground swimming pool as applied for.. At premises located at: 735 Majors Pond Path, Orient SCTM # 473889 Sec/Block/Lot# 26.-2-39.14 Pursuant to application dated 2/6/2023 and approved by the Building Inspector. To expire on 9/13/2024. 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 m^° Telephone (631) 765-1802 Fax (631) 765-9502 littp ://",w v t tliol(I oNvi�[�., Date Received APPLICATION FOR BUILDUINGPERMIT For Office Use Only lU IC II QUI PERMIT NO. Building Inspector: FFR 0 6 2023 ID Applications and forms must bulled out I�their entirety Incompletd BUOLIANU DEPS: Z I applications,will not be acts t d/mere the A�plkant�s pother,a TO�Ph�9OFSO1I OL D pp P/ i,f %G �7l//i/i Owner's,AuthorizAP!o�farm�� o'Z)Sh�1)�21C�R1F11d</ /%G %ii/ r jra%f/ / Date: OWNERS)OF PROPERTY ,// ;r',�/' % '� 1��/;rr / <, , i /, /J,/i/viii%�%%/ i % ���/,�� Les / Name: i Les SCTM # 1000- — �— 'Sq Project Address mm Phone#: 4 a -91461/1-7- . - IO Email: til4o1 Mailing Address: CC►NTACT P]EtISO1V. Name: L-) ,. ' 0 Mailing Address: `) S 000—K . Phone#: O _ Emai111tl• 11IfA Q /, //, / Is DESIGN PROFESStONAL �,O/R �/ / Name: Mailing Address: Phone#: Email: �,fi /idy 3f / it i77,77,r, 777'7177�7777 CONTRACTOR fNFORMA"TlON Name: Mailing Address: , Phone#: Email• �I DESGRIPTI,ON QI:PRQ/!C S I�% j�T ) ?�Ir ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of "roject: Other 5�zm t , $ Will the lot be re-graded? ❑YesIN0 Will excess fill be removed from premises? Ayes ❑No 1 Cv.rnsL °t � a� ak Existing use of property, Intended use of property: 11%nq wlauvLwfro" Zone or use district in which premises is ' uated: Are there any covenants nd restrictions with respect toy 1\^ this property? ❑Yes' &Uo IF YES, PROVIDE A COPY. r Chf,.,!ck Box Aft6r, R p id � ,/� eo�er �,y �f ip� ° f7sr � �y;{' 'ar 11,�1raina a rfdstb a} rissuesas; rovidedb . ,,,, P, Chapter 236 of the Town Code, APPUCAT14N tS Hf:IEB�IiIVf/i�E tp �i�6(jiprt�r��n�farMfe is��farfce/ /�ywfldln�Permit pu uant to the Building Zone Ordinance of the T)own of So4tt in / it additions,alterations or;for rem' alarr lr,r,, d"' housing code and re a ations and to adh x /� ��a sr rt n I f F � r, er�tf m d Ce► -:are ,i /r rl�.✓7l J �U//Oi//ir6/i/ /. / �i %/i./ li ��� /iii !,,D 1 i ,✓r / ///il i//iia r /�„l�T ,, ..: punishable as a Gass A;mrsdemeanar purruars S%1jn � /ffe YarI�S tc�;,�riat /// // Application Submitted By(print name): *uthorized Agent ❑Owner c pp Signature of Applicant: Date: aj(,p/13 g STATE OF NEW YORK) SS: COUNTY OF being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the 7 (ContActor, 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 ml day of - 20 a3 Notary Public MICHELE A MEDUSKI PROPERT .. OWNER . l„W)""�. O�RI "I..III Notary Public,State of New York M.. M.M. _ _............. .- Reg, No,01ME6393343 (Where the applicant is not the owner) Qualrfied in Suffolk County Commission Expires June 17,2023 N, 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 X_.'... ussell � c �T SUPE � � I��][A1�A�G�]EI��1[]E1� m:� « a �, HALL-P.O.Box 1179 [TT�•COLD,NE'WYORK 11971 °�, - Town of Southold - i " x = �~ CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM (APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) APPLICANT: (Property Owner, Design Professiona1,C41g,en Contractor, Other) NAME: p �"4 Date: C;N aL- L mr .. Contact Information: IE-Mad&Telephone Number! 'M✓I ii Pro.ert Address / Location of Construction Site: S.C.T.M. #: District000 I Section Block Lot l TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT Areaof Disturbance is less than I Acre. No S P.D.E.S. Permit is Rea h-ed h � Project does Not Discharge to Waters of the State. Cho SYES .D. . . P rma R aired 1 4A - Area of Disturbance is Greater than 1 Adre & Storm-water Runoff Discharges Directly i to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit L DIRECTLY From N Y.S. D.E.C. Prior to Issuance of a Buildin Permit. Area of Disturbance is Greater than 1 Acre& Storm-water Runoff Flows Through Southold ❑ Town's MS4 Systems to Waters of the State of New York. THE APPLICANT MUST OBTAIN a. S.P.D.E.S Permit through the Southohd"Town En ineering De artrn Prior taa Issuance of a Iuilrtin Permit, ;I Rpvie�ved By: Date: Pnrz nn # qM(.. r(Vrr)t,Pr ?n i 4 Buildine De artsment Application AUTHORIZATION (Where the Applicant is not the Owner) (�es�lF oc residing at (Print property owner's name) (Mailing Address) �..�.. .� . G..,,.�....,do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. ( ° graature) (Date) r _� ...w .... �cc 1_�... ..._. (Print Owner's Name) ,1►co CERTIFICATE OF LIABILITY INSURANCE °"TE'MM'°°„,YY' 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 o such endorsement(s,• PRODUCER CONTCT Nicholas Zulkofske Brookhaven Agency,Inc. PHONE 941-4113 Fix f 16 1)941-_4405 ML 100 Oakland Ave,Ste 1 )DRE s. cert'ificatesebrookhayena ency.com �IT Part Jefferson,NY 11777 IN I�ER�§AFFORDING COVERAoI INSURER • Philadelphia IndemnityInsurance Co. .. ".. ...,m.,....."" ...... �.."....m. INSURED IN§URER B• Merchants Mutual Insurance Co. Patrick's Pools,Inc IOgIERs- Wesco Insurance Co. PO Box 3024 _INSURER?; East Quogue NY 11942 IO§oma IN§YRER 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. ...� ..... 9NSR ADOL UBR'. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE i vign POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH QCCURRENCE_.. $1 000 000 DAMAGE To RENTED e � A �CLAIMS-MADE OCCUR I'W�iFPW1I�apS Ip�C�wrtarucra9 $100,000 x Contractual LIabij!ty X PHPK2385555 02/28/2022 02/28/2023 MEDFxP An ane erson $5,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GFNERAL,AGGREGATE $2,000,000 POLICY IRE LOC PRODUCTS-COMP/OP AGG $2,000,000 .IH.R $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $SOO,000 mm� B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED )( X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ ,..... AUTOS AUTOS " NON-OWNED PROPERTY DAMAGE .. HIRED AUTOS AUTOS fPa .�...."."...""""""" $"""""""...m."""""".__ UMBRELLA LIAB _," H OCCURRFNGE $ OCCUR EAG. -�.�._....�...._.........._.�....�.............."..".."..""" EXCESS LIAB CLAIMS-MADE AGGREGATE~_~~__wawa "" $................................. R T T $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY .""......".ST.AT.US.EYIN ,..,—R —„_._ ...,w.... ANY PROPRIETOR/PARTNER/EXECUTIVEE..L EACH ACCIDENT $100,.000 C OFFICER/MEMBER EXCLUDED? Y I N/A WWC3587728 05/13/2022 05/13/2023 .(Mandatory in NH) E,L,DISEASE.-EA EMPLOYEE..$100,000 If yes,describe under DUQ131PTIQU QF QCEB,8JIQU�UQ1gA EI.,DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold is included as additional insured per written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <N Z> I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD , i _ _ _ _ _ _ _ »,mr=^:v�-msrr_-ne:.-ss�^•re_ ._ _:.•.z-z___.-z-x••..-s-p�cz,_.: _ _ ` �/;/� • -- f '�-",' _�:-%,-•c-�.r•... jcp�•t,.- .1.,. .�. %.J - .. 1 ...;•=,`-d��$;~ f-�:;1;. rt,_ }. . ; -.+ . � � ._1 � ;.1.0 t ; , , , ; , , r , . - , , I i 77 k Ir01— + S . , i �o 611Y : i t er�Gl t3�r�CA, : ..� ebo I SPA (� o ' Les l,� lD , I , I I , , , , J i i , I , t ' i : i v ------ cY) l i : 74- , , • • , -!?-.)iucs`�o Y--\ 'of c s OCA , • i YI l _ I ' I_ ._. _ ._._. .. , - --'- - - - _-. --,--j- _ i - r r'� Y NJ '1..�:...tet Cl - - • !, it 1' _ _ , , ;. r ..... -. _ .. - ; -Gun I : , - - - _, - - tT _ : g 1 , i I { �: , ; i EREpq• • t , or LIS r