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HomeMy WebLinkAbout49272-Z rte. TOWN OF SOUTHOLD BUILDING DEPARTMENT e� TOWN CLERK'S OFFICE SOUTHOLD, NY y 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#: 49272 Date: 5/18/2023 Permission is hereby granted to: Nevin, Jennifer 100 Manhattan Ave Apt 405 Union City, NJ 07087 To: construct accessory in-ground swimming pool as applied for. At premises located at: 411 Sixth Ave, Greenport SCTM # 473889 Sec/Block/Lot# 42.-1-10 Pursuant to application dated 4/17/2023 and approved by the Building Inspector. To expire on 11/16/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Tidal: $300.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 ht!ps://www.southoldtownnv.izo Date Received APPLICATION FOR BUILDING PERMIT tf For Office Use Only L, Y It �1 PERMIT N0. L Building Inspector: Ile, APR 171r Applications and#orms muni be filled out in thei'r entirety.:lncomplete Owner's Authorization form(Page 2 shall be 6Mp ted not the owner,an A ti Date: / OWNER(S)OF PROPERTY: Name: ,I: SCTM # 1000- I/Z —/—/D 60L4A"1 y- .. Project Address: Phone#: � Email:9 vJvneS OYcOsrrmci �,C'�� Mailing Address: CONTACT PERSON: Name.: MailingAddress'?G --1z>C,X c� �u �,vs �' II9 3� Phone#: Email• ���c �on�`-n , rz�� 3 73y-- 7&�S DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION Name: Mailing Address:--p Phone#: �3�_73y-7���5 Email: nye. Y-, DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: other �" p rr �,000 Cao Will the lot be re-graded? Zes El No Will excess fill be removed from premises? Alles El No 1 1pPPERTY I I O kM TY I Existing xistin use o_f.__.r.oPe..rt.�Y: �.F� irTyUvcc ......... m..._. Intended use o._f prop � Zone or use district in which premises is situated.: Are there any covenants and restrictions with respect to this property? ❑Ye �XNo IF YES, PROVIDE A COPY. ck 80 h ' Aft0A eading: 1,6ipawnppsible Wall drainage and stearin waterissuas as provia'0d Ov eptar2A ofrfho wuun�.: lPPMCATi b7 i$HERMY A0 *.'ate Splldin VepaMnent for the4MOott Of a F100di p rnr It pursuaugrtttw,4 BuildingZone tPrr lnart�izf b t o wsi so t eld, Nk,C�t+rrty, �Ycar nrwd er appiieable ws, rwlisw Haas or a ui ion , r.t� anstxuc ar awl buaiidV'rr�„ udd�tiurws pl rdllo wr a emn�I r-rl msali jon wt herein described.The applicant agmes,1n comply urwl eNi bui1ldin code, housing iodU regulatloosandtoa4mit aullbs rbed Wspe0orson,prernisesand in bupldirt (s)for neressdry hispections.(False statement e40 horw�Are paunishable as a class A misdemea nor pursuant to Section 210.45 of the Never York State Penal Law. -c. k, 2(uthorized Agent El Owner Application Submitted By(pr��name): �n� ��"4 ' Signature of Applicant ' pate: STATE OF NEW YORK) SS; COUNTY OF _ w_) 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.) .._._ _ .... .�._ ._ .WW_._ ..� 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 vrr /day of_ �. � 20-- m ......__._.. . blit PROPERTY TY O EAUTHORIZATION, 1 NOtIfY�r�0SW L. ofENew Ya* CS (Where the applicant is not the owner) NOW irtSW'*C COMWSSI10111 DOM M rCh 3,:L(11 l residing at _.. eenport NY 11944 Grant Jones g__...__._.���_... .. _..._.�, 411 6t Ave, t....___ _ .A.. �. _a..__._...... hereby authorize Gene f hituk ��io i, � � ,/" to apply on my behalf to the Town of Southold Building Department for approval as described herein. r 04/17/23 Date _ ... .. Grant Jones Print Owner's Name..._..... 2 "+� DATE(MMIDD/YYYY) CWID" CERTIFICATE OF LIABILITY INSURANCE 04/18/2023 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 NAME Lauren Murphy P ONS I Roy H Reeve Agency,Inc. 6,31 2'98-4700 (631)29838'50 APG Naa Ekr; ( ) LA 350 Ne PO Box 54 EAO RE ,a: imurphy@royree:ve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 wsuRERA: Valley Forge Insurance Company 20508 INSURED '..INSURER B Chlluk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E Cutchogue NY 11935 INSURERP, COVERAGES CERTIFICATE NUMBER: 01:2321518551 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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. LNTR AUW65UBH POLICY EFF POLICY EXP R TYPE OF INSURANCE INSO WVD POLICY NUMBER MM/DD/YYYYI (MMIDD/YYYY. LIMITS XCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 13AWGE TO KEN I FV CLAIMS-MADE ©OCCUR 100,000 P'R[MIS-S T�rca�nulrmmrx� $ X Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2023 03/15/2024 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 0 JERO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY �'OMt&INED SINGLE LIMIT $ Eix aM�{Wtkwiv4 ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED ROPE R'r'Y I,nFAMACE; $ AUTOS ONLY AUTOS ONLY I7ksr ecc7elrynL UMBRELLA LIAB OCCUR EACH OCCURRENCE s EXCESS LIAB OLAIMS-MADE AGGREGATE $ TDED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE NIA L.EACH ACCIDENT $ ''.OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (AGORD 101,Additional Remarks Schedule,may be attached If more space Is required) Re: Grant Jones,411 6th Street,Greenport,NY 11944 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF J NEw Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE YOOK -,,--,,,,,,STATE Compensation Board Insured Detail la.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Chinik Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 le.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 ifcomragge is specifically(inlited to 1 1 3 306347 certain location in N",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"In"; Southold,NY 11971 WWC3623614 3c.Policy effective period: 1/1/2023 to I/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"Y insures the business referenced above in box'A 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"T'. 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 ofln-emiunis that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular nail.)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 fisted,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 lender (Print name of authorized repiesenronve or licensed agent of insurance ca I Her) Approved By: 1/11/2023 (Signature) (Date) 'hdc� Senior Vice President Telephone Number of authorized representative or licensed agent of insurance carrier:877-528-7878 Please Nate:Only insurance carriers and their licensed agents are authorized to issue the G705.2form.Insurance brokers are A'OT 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 '_1 w sRers' CERTIFICATE OF INSURANCE COVERAGE ����,,At compensation ensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed b NYS disability an y y d Paid Family Leave benefits carrier or licensed insurance agent of that Carrie 1a Legal Nam. _. e&Address of Insured(use street address only) 1b.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 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 3 _ . a.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"l a" Southold, NY 11971 DBL614067 3c.Policy effective period —......05/01/2022 to 04/30/2024..- 4. Policy provides the following benefits: ❑X A. Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑K 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 p6y of Flery„_icertify that I am—anauthorized represef ffie tatative or licensed agent insurance rtW trlcarrier referenced above and maYiat the rlsmed insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. g c Pi Date Signed By 4/4/2023 " il/r91 _.. ............. '� -.m.. �.......... .,.. (Signature or insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8160 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 413,4C or 513 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 _ �.-......................... ,�ww....,..._.... ... ........ - ........... (Signature ._......__ g of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disabilityand aid family leave benefits insurance .............� _. y �.. p y rice 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) 11111111 ° 111111IIIIII1°°°° ° 111111! ° Additional Instructions for Form D13-120^1 By signingform, incarrier form is certifying that it isinsuring the business referenced;mBox 1mfor disability | Leave benefits under the NYS Disability and PaidFamily Benefits Law. The insurance carrier m*its licensed agent will send this Certificate ofInsurance Coverage (Certificato)no the entity listed uothe certificate holder inBox 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy[acancelled due tonomp�aymnentoYpremiums orwithin 3Odays[Fthere are reasons other than nonpayment of premiums that cancel the^o ^ )i or eliminate the insured from omvemygphndicaled onthis Certificate.(These notices may be regular ua/ mail.)Otherwise, Certificate yearafter this form is approved bythe insurance carder or its licensed agent,or until the policy expiration date fisted in Box 3c, whichever is earlier. This Certificate is issued as a matter nfinformation 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 inthe 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 Farnilly Leave benefits policy indicated wnthis form, ifthe business continues tabwnamed mnapermit, license or contract issued by a certificate holder,the business mmomt' idwith anaxvCertificate mfInsurance Coverage for NYS disability and/ orPaid Family Leave Benefits orother authorized proof that the business iscomplying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220' Smbd' 8 (e) 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 haruin, hovvever, 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 ifsoemployed. (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 aaprovided bythis article. DB'12o.1 (1u'21)Reverse „�cnoxa LOT 39 , S 75”13'20"E 3'20"E asPwoLr 150.00' DRNEWa � I ��Gsco y°xv' ti cmcAlm azYwrw` 365»— — °— wow/mm O I 2 oI g I� �wT WOAD FRAME 5z- 1 NV w 30' I W 4,% I � 0 7 /fa r3� g o RESIDENCE ' F— 0 calm J 1. Is LmaLaw COOP-6 F 751"1 20 no" -r i 5 7.00 04 ff"m 'OZ LOT 41 �t SURVEY OF MAPLE STREET LOT 40 FM# 851 IN DATE FILED DEC 12. 1927 SUBDIVISION MAP PART OF SURVEYED: 12 DECEMBER 2007 GUARANTEED To: ESTATE OF THOMAS F. PRICE, SR. JENNIFER A. NEVIN SCALE 1-- 20' GRANT 0_ JONES SITUATE COMMONWEAITHO ANTITLE D E INS. CO. GREENPORT, TOWN OF SOUTHOLD AREA = 7"500 S.F. tifleOR WELLS FARCO BANK. NA. SUFFOLK COUNTY, N.Y. 0.172 ACRES OVAR,WTM M&CAF0 WR9 CW SMAL4 MN SURVEYED FOR: JENNIFER A. NOON � ', AWD,AW Y GRANT 0. JONES SURVEYED BY PANY. =KRWENTAt AGENCY„ STANLEY J. ISAKSEN, JR- LFW NC 116At9,RON, or LJSrED H4REW. AW P.O. BOX 294 M 7W ASSrs:VUS Or retf LEAUNG INS171V . ARowmrs ATE Nor MANSPrRA&S to N 1. 1256 637-73A4-5835 /17 VNAUtNCRZW AF.TEAAAOFV OR AWTIOR 7'0 Dus SLWOVYCS'A I+a.Amw Or SECA[M! 720 or TRE NEW YORK 5TA7E EDUCAADM LAW, roplFS 5 SURVEY AMP NOT KARAG L EN SE L RVEY OR Nor sE � TO SE'A wAd�lY TIE YS Lica No. 4 '273 07R i 646 COPY. _.-., ..,,......, �°.. ,,,.,...„P,.,."�.,.f•..- ,,.�, ... .. ..;. �"�w" '„'+�'.. _»,.. , .. . .,.