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HomeMy WebLinkAbout49112-Z TOWN OF SOUTHOLD °�raBUILDING DEPARTMENT I TOWN CLERK'S OFFICE �1.1 ;` al 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 #: 49112 Date: 4/11/2023 Permission is hereby granted to- King,Kng, Daren 1330 Factory Ave Matti _...... ........ ^_ _._..... ......�. ........... tuck, NY 11952 m mm _ .... ....._ To: Construct an in-ground swimming pool to an existing single family dwelling as applied for. Pool and pool equipment must maintain a minimum setback of 5 feet. At premises located at: 1515 Sigsbee mRd, Laurel SCTM # 473889 Sec/Block/Lot# 144.-2-10 Pursuant to application dated 3/10/2023 and approved by the Building Inspector, mm To expire on 10/10/2024 „ Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 _._..._------....... _.... _._ ._... ... A. Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 *0 Telephone (631) 765-1802 Fax (631) 765-9502 https,1/www. oulholdtow yn . -ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only MAR 1 PERMIT NO. Building Inspector: ' Applications and forms must be filled out in their entirety.. Incomplete a'OViPN OF 1-1,01��g C.4€S'uj applications wlll not be acepfed INhere'the Applicant is not the owner,an i. „ Y, Ouvnar'S'Au*6"' ion;fof�m,�0&2)shall be completed. Date: � C> OWNERS)OF PROPERTY: Name , SCTM#1000- r — El mgko Project Address: ' [„. _/ Phone#: Email: - I r?qpo .,- / t 0 Me. , . Mailing Address: 15 / \S-(g sbe�c kc( M /�'Uc d, C CONTACTPERSON: Name; . 0 f� Mailing Address: Phone#: �"� ,_ �" Email: � I f� C7 "" -.in Cj,)22 DESIGN,PROFESSIONAL INFORMATION: . Name: Poo � "'' I sbeazl i'ii ." Mailing Address: ) Rhone#: Email: CONTRACTOR IMAT NFORION;' Name: " Mailing Address: a Phone#: ....,, Email: DESCRIPTION OF PR0� "06 ED CONSTRUCTION ,'New Structure ❑Addition ❑Alteration ❑ pRe air ❑Demolition Estimated Cost of Project: Other �� $ Will the lot be re-graded? es [:]No Will excess fill be removed from premises? Yes ❑No 1 �� PROPERTY INFORMATION" Existing use of property: ,� Intended use of property: 1t�.t'. ` Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes l�N° IF YES, PROVIDE A COPY, g ec BOX After Reading, 1Me owners writ for design orol ssional is resp �hI for all draoa ,e nod stoor1 w ter Issued 064144 by �pter of the Town drde, APPL(� I NIS HF 8�Y pe to the soil ing100poxtIrRen f issuance of a 1 mildingPermit pursvant koffha l�pQg1n, Zone Ordinance It rat ons or f s removal u' delmol6 nfy,New York and In described. applicable Laws,Ordinances or itegulatrons,,for the constructlon of buildings, d.Thea ' licant a reel to com ° " pp g ply Mrltti all e�ipifcable laws,ordinances,building code, housing code and regulations and to admit authorised inspectors on premises and In building(s)for necessary lnspcctions.false stater*' > 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)t � "i;t > w,ni j ❑Authorized Agent '❑towner ,.w" � . �� Signature of Applicant: Date"' � / c tt- STATE OF NEW YORK) SS: COUNTY OF 5 , I being duly sworn, deposes and says that (s)he is the applicant (Name of)individual signing c ntract) above named, . f.. (S)he is the Y _ ....� it b ' s (Contractor, Age nt;'Ct porate Officer, etc.) of said owner or owners, and is duly authorized to perforrl"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 19 day of � ��✓' ��"���^ .... mm, zo ,,., M„M No Public, le of New Nlr , 'b I i xrri0i&rusgl NOTARY ` �' W YOSIi No.01OR6280392 PWuc ual liod in siffoll.cowty PROPERTY OWNIER AUTHORS T14� r� M;p��,w�'' CMIMiSlonhpi 05/13l200�1 (Where the applicant is not the owner) residing at C A, d, �. do hereby authorize I �� {-J'��'..?�`�_ "� 1 to apply on my behalf to the Town of Southold Building Department for approval as described herein.. caner"s Signature Date Print Owner's Name 2 unty Dept of o isomer Affairs HOME MWROVDOENT LICENSE MICHAEL A OEWNKA Elusmess Name This cortities that the bearer is duly licensed POOL TIME IN THE HA PTO 3 INC by the County of suffoik License Num,bar-.H-25569 Rosalie Drago Issued: 08128/1997 Commissioner 08101/2023 k- Nt .Q - 1p- i _w-wom- m-r�A7_ - - Sd - - - - - - - - ------------ o- /-2-9/- Al- HT 57 - �_ - _�_ � - -- - g est - - _ _ - � �i � - - � zr � � ld-t� nei zi fi -- — - — - _� rr� _: � � � Il � rrar lucirbias _ -_� z _ - -- — - HU F �s -_ * r: �+r =r.��.�r+ra3n.ra " ',..'°•ir,+£tss-.., °cx. '`�a.€�£.s�.� sz��.> .�.�€,� esu+=e'+'- s€,rat:.�#�}' - ��rs:<s»t�� ' €'�t:ewrs�.ii%� ` ksrt ,s_a .r.�, epi ti 3 � NYSIF Neter York State Insuuea nce F urid PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^" 261747003 WALTER ROSE AGENCY INC 8 STAGE ROAD MONROE NY 10950 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER POOL TIME IN THE HAMPTONS INC TOWN OF SOUTHOLD PO BOX 761 530950 ROUTE 25 HAMPTON BAYS NY 11946 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11296633-9 926110 05/05/2022 TO 05/05/2023 3/2/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1296 633-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MICHAEL A BERDINKA,OWNER VALERIE J BERDINKA,OWNER OF POOL TIME IN THE HAMPTONS INC (TWO PERSON CORP) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STT4 ,71*1 NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 600464972 U-26.3 YORK�k tft" pIW"of ORK u r�������� ��������.� CERTIFICATE OF INSURANCE COVERAGE 4-" Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed bym NYS disability and Paid Family Leave benefits carrier or licensed insurance magent of that carrie 1a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured - � POOL TIME IN THE HAMPTONS INC 631-369-3633 PO BOX 761 HAMPTON BAY, NY 11946 1 c. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Onlyrequired if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 261747003 2.Name and Address of Entity Requestin.....m_ .__� w�-.,��.. _. ....._.__ _._..._�...._ �� ........._�_ ....__W._..._W. g Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 530950 Route 25 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL291915 Southold, NY 11971 3c. Policy effective period 04/01/2022 to 03/31/2024 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 3/2/2023 By ,4qf �, (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-329-3100 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 a corn tete b the NYS Workers'Compensation Board Only if Box w _ .. � y p ( 4B,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 Note.Please agents of those insurance carriersly insurance ers are/authorzed to to te NYS disability issue Form DB 120.paid Insurance brokers are NOT authorizinsurance ecies and NYS d ed to issue thiicensed s insurance is form. D113-120.1 (12-21) 111111111 'i ii°Ili'i iiiiii°lilil i i i iii111111 POOLT-4 op IM CH CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 03102/2023 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(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). PRODUCER APC No East .....5- __<.r— °iA Walter Rose Agency,Inc 845-783-2555 �P� Walter Rose Agency FA� No LLJLL 845-496-3622 enc 8 Stage Road ( I rr 55 )84 Monroe,NY 10950 Lisa@walte Oseagency com INSUR,PM1AFF9R01ING Cl)1(ERAS;E ... _m. NAt¢ ......... I►t IBgRA„Oantlnental Casualty Co. _ 20443 PO BOX761 . _.._.. �... w — I oolpfime in the Hamptons Inc 76 .... atRR_0 .. .. .. .._ _....._� NS D INER-�.,. . ..� ,.._ Hampton Bays,NY 11946 pp INSURER F COVERAGE'S CERTIFVCA NUMBER:, REVISIQN 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 CONDITIONSNsuRANCE LTM ADDL SUBR ITS SHOWN MAYHAVEBEEN REPO ICDE.FPOLICYEXP —� � � 0 VI TR"@NOF SUCH P Y PAIDCLAIMS, A X COMMERCIAL GE._.A 1,OC) N�� OF I POLICY NUMBER LIMITS GENERAL L I I EACH OCCURRENCE .. 000 CLAIMS-MADE FX OCCUR 6025522772 02/21/2023 02/21/2024 DAMAGE TO RENTED 9 BE6]1 E (E.. �It m ) _ w. ..w... M EXP LAnN c r e person), $ 5,000 _PERS.m._. INJURY 1,000,0 , PERSONAL&ADV INJURY„ _ _ G AGGREGATE PRO­ M .PPL _.. 2,000,00000 EN"L E LIMffAPPLIES PER: GENERAL.AGGREGATE $—,---__-� P' p F]LOC PROpLICTS-COMPIO------ �$ O L NC,Y — _,__ 1,000,0„ OTHER: COMBNNED SINGLE LIMIT AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY(Par,person)_-_$.._ ... OWNED SCHEDULED HIRgD N WNE PROPERTY DAMAGE �$ . AUTOS ONLY AUTOS pp ( 4) AUTOS ONLY AVJ C CAE I UMBRELLA LIAB OCCUR EACH OCCURRENCE,,,,,,,, ..... . EXCESS LIAB CLAIMS-MADE AGGREGATE..,,,, .... E .... --..,�e...._�. ED RETENTION$ WORKERS COMPENSATION PER OTN YINAND EMPLOYERS'LEABILITY N/A �.,...L.EACH_TE ANY PROPRIETOR/PARTNER/EXECUTIVE GGIDENT „„ (MandatoryMIn NH EXCLUDED? ) _L DISEASE EA EMPLOYE.' $ __ If yes,describe under DESCRIPTION OF OPERATION. bei.w I LE1,DISEASL-_pOI_1CYLINL1T mm DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Swimming Pools-Installation, Service or Repair. CERTIFICATE HOLDER CANCELt.ATIO SOUTH02 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. 530950 Route 25 PO BOX 1179 AUTHORRED REPRESENTATIVE Southold,NY 11971 ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. 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