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Home My WebLink About49545-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 #: 49545 Date: 8/4/2023 Permission is hereby granted to: Henry, Paul 68555 C' R-48 _w ................w.w .. PO BOX 2111 GreenportNY 11944 _._ .... To: Construct an in-ground swimming pool to an existing single family dwelling as applied for. Pool and pool equipment require 25 foot setbacks. At premises located at: 68555CR48, Greenport SCTM # 473889 Sec/Block/Lot# 33.-5-13.1 Pursuant to application dated 6/27/2023 and approved by the Building Inspector. To expire on ......_.2/2/2025....1111 Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 ..... ...._.... _ ...... Total: $300.00 Building Inspector ale W � 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 lett !/WWti! OLltl"kCll�oidtowtiil ., Q Date Received APPLICATION FOR BUILDING pr,., f g a Vl i For Office Use Only w PERMIT NO. Building Inspector: Applications and forms must be filled out in their entirety.Incomplete r applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Dµate° .... .. a,,.. � ......µ ..,,, ._ M ._ �� ......,_ . _... ._.. .... OWNER(S)OF PROPERTY: Name, L SCTM # 1000- (� — _ q, 1 I f _ Project Address: i3 l r ._. y � -tC Phone#: Email: O'"lti i Mailing Address: LO � CONTACT PERSON: Name: _ t Mailing Address: IS, Dews V,) q r kC1 C Phone#: Email G�'1 .............��. �� a, .___. ._ „... �..tv DESIGNPROFESSIONALINFORMATION:,/, Name: Mailing Address: Phone#:_.�..__.._—___.._.._._......_.m.. ...�...W_...ww................__._...---------......_._._mEmail:,�....,�. CONTRACTOR INFORMATION: Name: CnC _... Mailing Address: 0 N � Phone#: ) , L)� - ILPU.5 Ema' . SCA G �1S, 61 ,S. DESCRIPTION OF PROPOSED CONSTRUCTION E New Structure ❑Addition ❑Alteration ❑Re air ❑Demolition ✓Z EstimatedCost roject: - t7ther l . , + C S� $ Will the lot be re-graded? ❑Yes)JVo Will excess fill be removed from premises?)Oes ONO 1 PitOPERTYINFORMATION Existing use of property: iz, Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Ll C) 'this property? I..IYes o IF YES, PROVIDE A COPY. -j�heck Box After Readirig� Ch4PWr236*fth0T0%"Codi, J*Pso*04, AW—Vto, '1040 forlibelf"W" pf... additioni,afterations or for housing code wo 0�0"tv *f0e;Are AS,40 Application Submitted By 1print name): J&tY�na )Kl�uthorizecl Agent Downer Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF MY11 0 61 6YC Lkl' being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, I (S)he is the &o 0,�qj— (6oijrractor,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 OOP 2rday of J 20Z-- L—) Ake" Notary Pub, 0"T W MlGh;�ti MEDUS10 S TE F NE R YO PROPER"ry OWNER AUTHORIZATION NOTARY PUBLIC,STATE OF NEW YOR .......................... �C NO. 01 ME6393343 (Where the applicant is not the owner) QUALIFIED IN SU;'FOLK COUNTY My COMMISSION EXi,i1RES JUNE 17�,202 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 Buildingr Department Application AUTHOR I]ZATION (Where the Applicant is not the Owner) ...... residing at 6,0 (Print property owner's name) (Mailing Address) do hereby authorize i�`L\—, ........... (Agent) to apply on my behalf to the Southold Building Department. ............. .. .................... (0 ner's Signature) (Date) ..,-PI .....[L,., , ...� -/-------------.----------------- (Print Owner's Name) Workers' CERTIFICATE OF ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board Ia.Legal Name&Address of Insured(use street address only) 1b.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 Quogue NY 11942 Insured Work Location of Insured(Only required Hcoverage is speciflcally limited to 1d.Federal Employer Identification Number of Insured or Social Security cortaln locations in Now York State,Le.,a Wrap-Up 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 3b.Policy Number of Entity Listed In Box"1 a" Town Hall Annex WWC3647363 54375 Main Road Southold,NY 11971 3c.Policy effective period to arll 912026 3d.The Proprietor,Partners or Executive Officers are ❑ Included.(only check box if all parfnerstotRcers included) Q 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 Now York State Workers'Compensation Law.(To use this form,Now York(NY)must bo listed under ftQMJA 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 atter 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 oertificate 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 now Certiflcate of Workers"Compensation Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New Yt rk State Workers'Compensation Law. Under penalty of perjury,I certify that 1 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 narne of authortwd repiesamadve or kensod agent of Insurance canter) Approved by: C Z 3 (Signature) (Dale) 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 C-105.2.insurance brokers are NQI authorized to Issue It. C-105.2(9-17) www.web.ny.gov EDA (MMlDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE023 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 of such endorsement(s). PRODUCER CONTACT Nicholas Zulkotske m PHONE Brookhaven Agency,Inc. Naf,E„ 31941 411 N11j 1. 4tl3 100 Oakland Ave,Ste 1 E•MML cPrtits atesd>Irrookhaven enC crrTr dam._ _.. __....�.,w� ..._...... . :....y. ...� ._w.._� ...�....�._. .. . ......., PortJe 6agRD fferson, NY 11777 Pllilmadlia1 ndemniINlnsuraa Cpm alb ...... .... Jt# O�.A L.m _.wM..�.��..._t'.._. p....�" ....... �.._,AI a 11gg8kj3.tr.,W Insurance Corn auu ny INSURED nts k Patrick's Pools,Inc. I� q��Wescoautua nsaa�n�cye omZe... ..__... _ .!..___.. ....... ... PO Box 3024 M1J18 p _ ...w_..� _..w. East Quogue NY 11942 ?1t661p . ._. .. .._ _ _M. ......w_.. ........_......._. ._... INSURER 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. _....,_... _ _. ....,__w _ ...._.,.� __ IMS TMPD CONDITIONS OF SUCH POLICIES,LIMITS SHPOLOWN MAY R HAVE BEEN REDUCED BY PAID CLAIMS .,.,..v NSRXCLUSIONS„A,E OF INSURANCE DDLSUSR POLICY EFF POLICY EXP LIMITS LTR I X COMMERCIAL GENERAL..L. IABILITY ADtf rare€€arRRrra�.L... s 1000 000 p DAMAGE Tia RENTED 0 . A ._ €CLAIMS-MADE uX U OCCUR kEt dET.C¢&a¢CA66�j!90.000. _ 5 ODD X Contractual Llablli PHPK2517025 0212812023 02128/2024 M 9rXFmuy sangmwso „w,_,... ._ I .��tcaNa��_�aaDy_ns�laa oPv ..�1 X000,000 . Pu~AI iL X x; .. NERAAcr R PATI �, 2 000 ODO _... . a At,A�RFej�., � �A1�Ecr APPLIES u lir s PFR 2 00Oµ000 I�.u��I.`�. �.�)a�FA ,�AC C� r°,T •R i � '' l 0 ”-4t.',.,!4 lMkSS0.NEl(C&,aUNO4E L.M..T AUTOMOBILE LIABILITY .__5..00a 000 BXANY AUTO BODILY INJURY a Person) ALL OWNED SCHEDULED BODILY INJURY(Per accident),X 'AP9267113 o! 12 2022 D711212D23 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS ._..... ... .... ..._. . AUTOS ° tL.. ..r..._,,. ._... ._. O Ali'R BEACH OCCURRENCE.. .... ..} ..,. ...... UMBRELLA LIAR OCCUR 11 . EXCESS LIAR ...... ....r_...:95 MADE i I ARF,C,�AyfF 9�................ ...._ _ ..._ i WORKERS 1 AND EMPLOYERS'LIABILOITY Y�N'N f A� � i� i,�...U U k3 OTH . ZANY PP.OPRIETOR/PARTNER/EXECUTIVE E L EFlI,H A(,LIDENT $100,000 C rOFFICER/MEMSEREXCLUDED Y WWC3647363 0511312023 05/13/2024 y A FA $100 DDD DESCRIPTION )F OPERATIONS below . ...",�.u..SMPLOYEE ....... ...,. ;(Mandatory in NH) C D15F If OF O - 4 E L DISEASE POLICY LIMIT f S 500 DDD d DESCRIPTION OF OPERATIONS 1 LOCATIONS I 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 <BS> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Workers' CERTIFICATE OF INSURANCE COVERAGE �.__...- sTATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefitsµcarrier or licensed insurance agent of that carrier ' 1P, Legal Name &Address of Insured (use street address only) -�'1_p...B sines Telephone o Insured�w.__w..__ww_.._ y, pone Number of Insured LS INC 13 PO BOX 3024 EAST QUOGUE, NY 11942 1c 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) 262929943 2.Name and Address of Entity Requesting Proof of Coverage................- 3aName of Insurance Carrier .................. _.w_............... - (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd 31b 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 i ., 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- .. _._....�....... ,_-..............._. --.... —__—.w_ ...... Under penalty-of perjury, I certify that I am an authorized representative orlicensedagent 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 By °�........ � .._...................�..........._.,.,.23/2022 �� Isignatu...v.............. ................ ....... ..m......... M._.........�....� .....ww „ re of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-81t 9 Name and Title j�jChar{i 1/�/hlt 2f x ° ktl"tPe CifflCe.r------ - 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 ............... ww- _. _.........w_ _... PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 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 PSignature of Authorized NYS ark vVers'Compensation board Employee) Telephone Number Name and Title ......__..._._a...._.-w_, Please Note:Only insurance carriers licensed to write NYS disability and aid family leave benefits insurance policies and pl ty p y p sand 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) 1111 {i uiiiu11u11111111111111111ii11 COMPLY ITT ALL CODES OF NEW YORK TATS &TOWN CODES APPROVED AS NOTED AS REQUIREDCONDITIONS °11",. TOWN ZU DATES '=B.P. # T , NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE SOUTHOLD T OWN TRUSIM FOLLOWING INSPECTIONS: 1. FOUNDATION -TWO REQUIRED KYS.DEC FOR POURED CONCRETE 2. ROUGH-FRAMING,PLUMBING, STRAPPING, ELECTRICAL&CAULKING 3. INSULATION 4. FINAL-CONSTRUCTION&ELECTRICAL MUST BE COMPLETE FOR C.O. OCCUPANCY OR ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW USE IS UNLAWLFUL YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. WITHOUT CERTIFICATE OF OCCUPANCY ELECTRICAL INSPECTION REQUIRED All extetior lighting installed,replaced or RETAIN to Chapter 172 p�.�RSUANT OF THE TOYM CODE. ..... .......__ .... _...__..____ _....._.��.---_ _�._ 1. 0. �AP �^�p �•-� ..ym 3q z \ a LM-f cr -is s ot— J µyR e a f� d MP`P PR tRwtti c �t�ARA �vl1E r-7 ER C�J A-TE- Ca�Fr "POR k C-qua ►— i PC)Pt—i T�.V� X701..2. PREPAREn: �es�co i9B� .50' p i r�Y i f I r " V5 A f r +r t 8 ' i , l c� "ra .Y µ" P .. ..w, �,.., ,ms.µ,........ 5 ,M y „ .s