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HomeMy WebLinkAbout49209-Z ydat r TOWN OF SOUTHOLD BUILDING DEPARTMENT q TOWN CLERK'S OFFICE r 4 SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS ANIS SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 49209 Date: 5/4/2023 Permission is hereby granted to: Giblin, Frances 70 Washington St Apt#9E Brooklyn, NY 11201 To: construct accessory in-ground swimming pool as applied for. At premises located at: 2575 Skunk Ln, Cutcho ue SCTM # 473889 Sec/Block/Lot# 97.4-13 Pursuant to application dated 4/6/2023 and approved by the Building Inspector. To expire on 11/2/2024 Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buil' %ng Inspector TOWN OF SOUTHOLD-BUILDING DEPARTMENT :A Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 htt ://www. oulholdtownn . ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT N0. Building Inspector: I � �.�° APR 0 Applications and forms must be filled out in th"eirentirety.Incomplete '' applications will not be accepted. Where the ApPlicant isnot the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 31..,22 OWNER(S)OF PROPERTY: Name: SCTM# 1000- 97- 61 Project Address: �y //9 Phone#: p 1/ Email: wry Mailing Address: 5�75� jl;un�/ / �c1 �,vs�o aJ� //g 3,5- CONTACT 5CONTACT PERSON: Name: ZjZ-;'LJZ--5- Mailing Address: :; J .may Phone#: Email: Cn3 ��y�-yZ ys DESIGN PROFESSIONALINFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION:' 1 Name: Ch, �-Ulf 17WS LVA, Mailing Address:-7 o..-j?,,,x 9 i c y AV 1)9-?j5 Phone#: 3� ' 73y-,;76 LAS- Email: Com. c—k,4-vl� DESCRIPTION OF PROPOSED CONSTRUCTION El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other ` r $ G' 1 Will the lot be re-graded? NYes ❑No Will excess fill be removed from premises? Mes F-1 No 1 01 c,�A ,1 . PROPERTY INFORMATION P Pe e 57' �. Intended use ofPperty: . EExistingpro Zone or use district in which premises is situated: �Are t ereanycove covenants restrictions with respect to property? IF YES,PROVIDE A COPY, a ,AftLT in The owner/contractor/design professional is responsible for all drainage and storms Water issues as provided by P Chapter 236 of the Town Code.APPUCA'nON 1S HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the SuAdft y Zone thin of the T of !sold,Suffolk,county,New York and odier applicable Laws,Ordinanow or Regulations,for the construction of butldrLgsl addltlons,alterations or for removal or demolition as herein described.The appli nta r to comply with all applimble Jaws,ordirrances,building des housing code and regulations and to admix authorized inspedors on premises and in ding(s)for necersarV inspections.False nts made herein are punish-able as a class A misdemeanor pursuant to Sermon 22CL45 ofthe New York State Penal Law. I I w Application Su l e By(Print name): L�vr7 ' GJ/�CAuthorized Agent ElOwner Signature of Applicant./ mate: STATE OF NEW YORK) r ( COUNTY OF v� • ) is a"i�e z,,ppkaw :�eing di led`sworn, d pa0Fc_,s ar.9 �y �§a e c 'Nairne of indivliduai signing contract!above I arae , (S)he is the ._. ._._. .�.�_.. �. _m..__. (awon:trart-ora /agent,Corporate uM&fTicer, etc. o gsaiid ownei..or owners and is lal,a y authorized to}�e orrn r:;r have pe nrm o the said wo!k and t.�:v ake ran13 ffie t au^, d�d�r»0�lBq� �� a$'tion are trll.te io'the best Nib l6 her�;rNE;iPAl4BNedg e and 1,).elit'.f 'i�l��d application that a H statements con a&id a'p(11 11 n 2 a�),Ci "l,j ie l egd Sworn before me this .'9 7 dav of C ria lWllblic� PROPEDITY OWNER W(Where the applicant is not the owner) _m r ))W11I, S G e residing at .� NNY do hereby authorize �►� �.... �to appGy ori 0t, ti krll �i �4 kR.jthoV_ l'!�'rt ffdnJa 6-paYtb8 ent fr:n app?RBvae re1n. R 3/.?�- %A.,ner's Signatufe Date z Print Owner's Name I b 2 i` AC 6 CERTIFICATE OF LIABILITY INSURANCE DATE(M `n 04/044/202/202YY3 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). CONTACT Lauren Murphy PRODUCER NAME:' Roy H ReeveAgency,Inc. PHONE (631)298-4700 arc No� (631)298-3850 PO Box 54 ADDRESSr Imurphy@royreeve.com 13400 Main Road INSURERS)AFFORDING COVERAGE NAICA Mattituck NY 11952 MSURERA: Valley Forge Insurance Company 20508 INSURED INSURER S; Chituk Pools Ltd. INSURER C: PO BOX 9 INSURER D! ?INSURER E Cutchogue NY 11935 INSURERF: 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. SUSKI `�9 POLICY EFF POLICY EXP ?LTR TYPE OF INSURANCE INS POLICY NUMBER.. MMdOOPYYrY MSI DD YYYY LIMITS AMA'. E s 1,000,000 X COMMERCUIL GENERAL LIABILITY EACH OCCURRENCE _.. h rD 100,000 CLAIMS-MADE ©OCCUR P'EWSES La.1lrxurrence X Contractual Liability Y MED EXP(Any vie s emn) S 15,000 A P6018146726 03/15/2023 03/15/2024 PERSONAL&ADV INJURY S 1,000,000 CsEI^t"'L..AGGREGATE LIIMtITAPPLUES PER'' jjq GFNERAL,AGGRrGATE S 2,000,000 PROS # ; .PRw:DLGOTS-coMP/oPAGG ; 2,000,000 .. POLICY JECT ��LOC f 'OTHER: COMBINED SINGLE LINIff $ AUTOMOBILE LIABILITY ca,accddanI ANY AUTO 1 V BODILY INJURY(Per person) I S H AUTOS ONLY � AUTOS OWNED SCHEDULED BODILY INJURY(Per accident) S{HIRED ^ NON-OWNED y �� PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY @4P Pgde g UMBRELLA LIAR OCCUR l C i.EACH OCDURRENC '. _._ 15 EXCESS LIAB CLAIMS-MADE P t AGGREGATE 'S DED RETENTION S S WORKERS compex$ATION CI PE'R rJTH• 9 AND EMPLOYERS'LIABIUTY �- Sr,ATI,N E. ER Y/N e I ANY PROPRIETOR/PARTNER/EXECUTIVE r-7; E L EACH AC'CMENT S NIA, A, OFFICER/MEMBER EXCLUDED? P i I (Mandatory In NH) E I_,DISEASE EAE�MPLOYEE IS If yes,describe under DES%CRIP'NO'N OF OPCRATIGNS below E L DISEASE POLICY LIMIT S' 6 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101,Addhlonal Remarks Schedule,maybe attached if more space Is required) 1,. Francis Giblin and Lori Levinson,2575 Skunk Lane,Cutchogue,NY 11935 4 � C 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 6 AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF NEMO' ' orker " NYS WORKERS' COMPENSATION INSURANCE COVERAGE w YORK . STATE Compensation Board Insured Detail la.Legal Name and address of Insured(Use street address only) Ib.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) s f 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 p PO Box 1179 �3b.Policy Number of entity listed in box"18": Southold,NY 11971 WWC3623614 A 3c.Policy effective period: 1/1/2023 to 1/1/2024 4 43d.The Proprietor,Partners or Executive Officers are: � included(Only check box if all partners/officers included) ' u 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 rrirrst rtrati(ip lite abrai"e cert tate holder and the l"l orhers"Comlaerr satirrrr Board ta�itlrin l tl tla�),s.11 rr pralrc x is canceled due to noupay rent orf preinhitns or within alt days lFtherae are reasons rather than ncrnlrayinent of prenduns drat cannel lite lroli l$or eliminate the tenured front the eoteral a indicated on this Certificate. (Tioeser notices map be sent by regular mail)i 1141 mise,this(ertlficate is i�alid for caneye r after°this /arin is approved lip^fire insurance carrier or itis licensed agent,or until the policy e pirativn date listed in bray"3e",whicheiser 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 it 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 �,..a�r.w . YORK workers' CERTIFICATE OF INSURANCE COVERAGE e srATE I'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 1a.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 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required ifcoverage 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 04/30/2024 4. Policy provides the following benefits: A. Both disability and paid family leave benefits. { ® B.Disability benefits only. EJ C.Paid family leave benefits only. 15. Policy covers: Q 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: i Under penalty of perjury, I Certify that l 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. i Date Signed 4/4/2023 By C`r (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. I If Box 46,4C 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. D13-120.1 (12-21) ;DB-120. 1 (12-21) 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 after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listen 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 pan: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 'C � ) y .� � £ ` L zPA , x 4z a -4,7 voll s Fk Vr MAP or LOW W..AAV MIN"VANK sovirr DESCRIBED PROPERTY SITUATCD A7' 3 SARWA A.,0WKZl AECONIC -5 e a WIV 0, SQU7HOLD and UFa N.. • �� �111,vellll 10 West main street riverheo , nein yOrk 11901 4_ 434Y LARMA:l9,.ST0 3O. FT (Q