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HomeMy WebLinkAbout49362-Z m fFOLt TOWN OF SOUTHOLD a BUILDING DEPARTMENT 3� r TOWN CLERK'S OFFICE V` 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#: 49362 Date: 6/12/2023 Permission is hereby granted to: Nuzzi Christopher 60 Lilac Rd Westhampton Beach, NY 11978 To: construct accessory pool house as applied for per SCHD approval. At premises located at: 4832 Youngs Ave Southold SCTM #473889 Sec/Block/Lot# 55.-2-8.15 Pursuant to application dated 4/19/2023 and approved by the Building Inspector. To expire on 12/11/2024. Fees: ACCESSORY $234.40 CO-ACCESSORY BUILDING $50.00 Total: $284.40 Building Inspector zta „ 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 s:.//www.sout'la .l to,wi 8ov y Date Received APPLICATION FOR BUILDING PERMIT y� rc For Office Use Only "O P / �� „4 PERMIT NO Building Inspector- / APR 2023 -� 4 ty. pWN " Applications and forms must be filled out in their entire Incomplete applications will not be accepted. Where the Applicant is not the owner,an S00,jH O Owner's Authorization form(Page 2)shall be completed. Date: , i7/23 OWNER(S)OF PROPERTY: Name: 9yr}Cia- (�vZx� --7�� SCTM#1000- Project Address: '. S1 Phone#: 0).- -�)o Email: C 1lr^b° r Mailing Address: CONTACT PERSON: Name: Sftw P5 ,*,"e? Mailing Address: Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: G31 '3`� �'f3� Email: z ac, � • �w � CONTRACTOR INFORMATION: p Name: 0At'PO1- moo© c�►L�'�S ' t ►�� " • , Mailing Address: 1 i � 0-1(°'5 Phone#: ' 43a - a,80c Email: DESCRIPTION OF PROPOSED CONSTRUCTION New Structure r❑„jtAddition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: []Other- I ' —>--O 1OOD Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes ISAJO 1 PROPERTY INFORMATION ............... Existing use of property: (51Dep-l"l'A1, Intended use of property: k-05)r)63RAL Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? L✓JYes ONo IF YES, PROVIDE A COPY.. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION 15 HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By i ame): C"'5Me^ t317' ❑Authorized Agent Ro5wner Signature of Applicant: Date: Y//7/23 STATE OF NEW YORK) SS: COUNTY OF ) 4ht-1ST #►.)v2Z i being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the v OP C%— (Contractor, %—(Contractor,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 day of46� , 20 o �ary blit BRITTNEY JUBA PROPERTY OWNER AUTHORIZATION NOTARY PUBLIC-STATE OF NEW YORK (Where the applicant is not the owner) No.01JU6422904 Qualified in Suffolk County My Commission Expires 10-04-2025 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 Suffolk County Dept.of Labor,Licensing&Consumer Affairs %`kvrk 1yp m+'4, HOME IMPROVEMENT LICENSE !hr°' Name ROBERT HAYES r ' Business Name lToi opcR tl`c tl at tt�¢a Walpole Outdoors LLC o r is d,ty iic riwa r^� t e co,511 of sa�Idul License Number'.HI-6354 Rosalie Drago Issued: 06111!2020 Commissioner Expires: 0610112024 l FW Workers' CERTIFICATE OF YOM sTA Com NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured WALPOLE HOLDINGS,LLC WALPOLE OUTDOORS,LLC 508-921-4941 255 PATRIOT PLACE FOXBOROUGH,MA 02035 1c.NYS Unemployment Insurance Employer Registration Number of 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-Up Policy) Number 47-2556626 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) THE NORTH RIVER INSURANCE COMPANY Chris Nuzzi 4832 Youngs Ave 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 408-743973-9 3c.Policy effective period 10/15/22 to 10/15/23 3d.The Proprietor,Partners or Executive Officers are F] included.(Only check box if all partners/officers included) 0 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, 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: KIMBERLY RYAN (Print name of authorized representative or licensed agent of insurance carrier) ,9 mber(-Ryan Approved by: Orfinc m 04/18/2023 (Signature) (Date) Title: EXECUTIVE UNDERWRITER Telephone Number of authorized representative or licensed agent of insurance carrier: 972-380-3187 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Doc ID: 20230418082242992 Sertifi Electronic Signature A� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/18/2023 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 CONTACT Claire Purser Marsh&McLennan Agency LLC PHONE 401 872.770 Fax 8144 Walnut Hill Lane, 16th Floor �A!c. Q)µ........... .nL1V�Me.F�4) � Dallas TX 75231 -APORI,sal,,,,,,purser, ,mnarshmma com .. RDINGCOVERAG ,..... NAIC# ..INSURER S,�„AFFO _,-�,,,-,.- - ._...-_- ......, INSURER North River Insurance Com alb mm .... 21105 .......... _.. _.....__..._ ..... _ ... �. INSURED WALPOHOLDI INSURER B United States Fire Insurance Com any_m 21113 Walpole Outdoors, LLC � a � 255 Patriot Place INSURER C g 1. I!D: _.-..,,.... .._....,e,,........ ................................ .,....—.... Foxborou h MA 02035 !s„� .� .�.�.�.................... �.._...........---- INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:107652606 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. INSR TYPE OF INSURANCE a I0R POLICY NUMBER PXDdYYYYDDdYYYY LIMITS 0-6Y-EFF CY EXP LTRVMh A X COMMERCIAL MS-MADEOCCUR ERAL��IABILITY 5432316336 10/15/2022 10/15/2023 COCCURRENCEnrr .t 30$1,000,000 m mmmTymmm^ CLA ,...MED FRCP ,/wn onempaerOGrn�.$15.000 ..._._ ............... ...._--.. ..^. PERSONAL&ADV INJURY $1 0000,00 ........ . ..,�.. ................_ ... _...... .... 200-0 00... t'EN"�AGGREGATE LIMIT APPLIES PER: .... 0 GENE'RALAGGREGATE $ ,.. .. ....,�... POLICY� X qPRO- .. 52,01: 000 .......�......LOC _POU COMP/OPAGG22_ ...� . . � OTHER B AUTOMOBILE LIABILITY 1337530725 10/15/2022 10/15/2023 COMMIN ED SINGLE LIMIT $1,000,000 X ANYAUTO BODILY INJURY Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ ,......__-- W-�. AUTOS ONLY ____, AUTOSNrROPERTY 4bAq�lF4GE^ __--'- HIRED NON-OWNED $ w AUTOS ONLY AUTOS ONLY PI'�t91.I •• A X UMBRELLA LIAB X OCCUR 5821198704 10/15/2022 10/15/2023 EACH,OCCURRENCEmm pm�,$10,000,000m TE $10,000,000 EXCESS LIAB CLAIMS-MADE A D EMPLOYERS'LIABILRKERS ITY ON'$ M $ DED RETENT COMPENSATION 4087439739 10/15/2022 10/15/2023 _.. OTN TY Y/N -- STAt"UT 00 ANYPROPRVETORIPAR"TN'EMEXECUI'IVE N N/A ACCIDENT $,. OOOd0 0 O Fi'CERIMEMBFREatCLUOED E L E ASH Iw (Mandatory in Not) � E.L.DISEASE F1�EhtPLCaYE S 1 000 000 ...-----..._� ........m______._....,.;�..,� .......�,_ 11 e ,describe under E.L.DISEASE-POLIC Y LIMIT $1 000,000 D SCRIPTI0N OF OPIERATtONS betrccrw DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional Insured harm#FM101.0.1848 edition 05/11 applies to the General Liability policy. Waiverof subr0atlon form#FM101.0.1206 edition 01/11 applies to the General Liability policy. Primary&Non-8ontributory form#FM101.0.1848 edition 05/11 applies to the General Liability policy. Additional Insured form#FM114.0.1378 edition 11/11 applies to the Automobile Liability policy. Waiver of subrogation form#FM114.0.1378 edition 11/11 applies to the Automobile Liability policy. Waiver of subrogation form#WC000313 edition 04/84 applies to the Workers Compensation policy. See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Chris Nuzzi 4832 Youngs Ave 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 THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE AGENCY CUSTOMER ID: WALPOHOLDI ..........._,.... LOC#: _ Ate"O ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED Marsh&McLennan Agency LLC Walpole Outdoors,LLC _... .__.... _ 255 Patriot Place POLICY NUMBER Foxborough MA 02035 ._ .... CARRIER NAIC CODE EFFECTIVE DATE: _ . ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM TITLE: FORM NUMBER: 25 CERTIFICATE OF LIABILITY INSURANCE . ITITITIT•_ ........_.. _.... . — — The.General Liability policy includes a blanket additional insured endorsement to the certificate holder only when there is a written contract between the named insured and the certificate holder that requires such status. The General Liability policy contains a blanket waiver of subrogation endorsement that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. The General Liability policy contains a Primary and Non-Contributory endorsement that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. The Automobile Liability policy contains language that provides additional insured status to the certificate holder only when there is a written contract between the named insured and the certificate holder that requires such status. The Automobile liability policy includes waiver of subrogation wording that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. The Workers Compensation policy includes a waiver of subrogation endorsement that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. Excess Liability is follow form pursuant to form#FM101.0.302 and 08/18 edition date ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YORK Workers'STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW rPA completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier &Address of Insured(use street address only) 1 b.Business Telephone Number of Insured TDOORS,LLC 781-349-4911 PLACE H, MA 02035 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) 472556626 2. Name and Address of Entity Requesting Proof of Coverage i 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Chris Nuzzi 4832 Youngs Ave 3b.Policy Number of Entity Listed in Box 1 a" Southold, NY 11971 DBL572986 3c.Policy effective period 01/01/2023 to 12/31/2023 4. Policy provides the following benefits: R 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 pedury,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 4/18/2023 By Aja 4t (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 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 (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. DB-120.1 (12-21) 1�1 II1°°1°1°1°1°°1°���I11111°°1°1°°III III SUR VEY OF PROPERTY AT SOUTHOLD 3r Y rw DID I TO OF SOU LD SUFE N Y OLK COUNT , 1000-55-02-8. 15 N OUT DETAIL -ter_.. ., , 1 , I � NOVUBE fB, 2020 y — �� DECEMBER 3, 2020 (�R T1FCA ON ADDED) XD SEP77C SYSTEM __ MAx.eEDRooM HousEf s ;1 _ F, -, Y THE DECEMBER 14, 2020 (REVISIONS) DIA.x 8 FT. HIGH PRECAST CONCRETE LEACHING RINGS'! r ti F .s g MAY 2, 2021 (PROPOSED/ SITE PLAN) 9LL MATERIAL COURSE SAND AND GRAVEL (3 COLLAR) SUFFOLK ��1U['`iT°s` DEPT. �,i� , �._,T€-. ,.sie�strl�;'E..s 7IA. 2,500 GALLON CYLINDRICAL PRECAST SEPTIC TANK. CALL ���"�� "� ��� ����I-'� "' ��T����a�•E r � MAY 14, 2021 T6t�Sl�S) JUNE 28 2021 (REVISIONS) TO SCHEOLN.- — _ 55.5 25' RIGHT OF WAY TO INCORPORATE WATER LINE AND OTHER UTILITY EASEMENTS ' 1t ' O L-39.27' E 125. 4 /""%--R=25.00 i EL. 41.0' L=39.27 L.EL 41.6' ig7T34 +,..+"" , ELECT, ``gv 5' MIN. METER '�T ' SNUMBERION TESTHOLE � (typo TRANS ELEVATION= 40.5' E4�0= 8 min ( FORMER LP N } ' LP II -� RAIN RUNOFF CONTAINMENT: 9' min 0. �in "" 1 � ' PROPOSED HOUSE, PORCHES, DECK l.E, .0 0 i l-,3a o & ACCESSORY BUILDING = 4,836 Sq.Ft. 0 4,836 x 0.17 x 1 = 822 Cu.Ft. c/° 1-i 822/42.2 =19.5 VF (8'DIA.) _ 0 ` PROVIDE [5] D 8'0 x 4' DEEP (or equivelant) 1 W 0 ICO QP Connected by Gutters & Leaders OP ti OUSEx On 71 err ovo ; � .. 01 N 10 . p LOT 4 D Wpity GE P ��P' TE¢R VACANT M-V M CLASS24M PiPE OR ED UT $OM CLEAN 0 _ `y n C> PpOL Q X PFtpQ` 1 AOS REBAR L3 p I — o $ 1 0 0 \ LOT 16 io •� 1n YELL 150'+ 013. REAR s-" U.4 � D E PECONIC LAND TRUST INCORPORATED VACANT N.Y.S LIC. NO. 4! VE VAS, P.C. 502 P '631) 765—1 J SO. FT. P O-,B _V0 1230 TRA MILER STREET1 on ,n ol,