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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 y RIX Workers' CERTIFICATE OF INSURANCE COVERAGE ___.,zATr 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 PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE, NY 11942 1c.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"l 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. C.Paid family leave benefits only. 5. Policy covers: M A,All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. F1 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 6/23/2022 B 9 Y (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 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 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 (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. D13-120.1 (12-21) 1111111111111111111111111111111°1111°1°°°111°111111 K NEW Workers' CERTIFICATE OF TAt`E Board Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996-4687 Patrick's Pools,Inc PO Box 3024 1 c.NYS Unemployment Insurance Employer Registration Number of East Ouogue NY 11942 Insured Work Location of Insured(Only required if 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-lip 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"1 a' 54375 Mein Rd. WWC3587728 Southold,NY 11971 3c.Policy effective period 0511312022 to ns11 anus 3d.The Proprietor,Partners or Executive Officers are 0 included.(Only check box if all partnersloficers 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 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 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,l 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 carrier) Approved by: S/11 7, 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 C405.2.Insurance brokers are NQI authorized to issue IL C-105.2(947) www.wcb.ny.gov , 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