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HomeMy WebLinkAbout49599-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT m� 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#: 49599 Date: 8/18/202m3m�� Permission is hereby granted to: Buonocore, George 18 Waterview Ave Massapequa,ITNY 11758 _..._ITITITmmmm To: Construct an accessory inground swimming pool to an existing single family dwelling as applied for. Pool and pool equipment must maintain a minimum setback of 5'. At premises located at: 165 Gin Ln Southold # 473889 SCTMrr nwww............. .. . .................._..... _.. ... _.................. _. Sec/Block/Lot# 88.-4-2 Pursuant to application dated 7/11/2023 and approved by the Building Inspector. To expire on _2/,16/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 j ....... Building Inspector b u %/o///✓"r'. r//%�, //�/iii//" P R CoQ r,,, / a/ r,✓, �.�;r �, „ /� Existing use of property: - .L Intended use of property: ,. Zone or use district in which premises is situated Are there any covenants apd restrictions with respect to this property? ❑Yes LiJ'IVo IF YES, PROVIDE A COPY. r , i �u ° „ i, ,✓.,/e, ' e 1607► u�rd n Yana h anth r II (e rn/ rdnana�, �� aF' pfd fir` r /'°i//�,,,, „J//, / ra n d r anra a s d rigid , X ' f s o Fr fl a (, 1 fa(wa r rxat e '0 10 c d „ r , aci�4' enar r a a P ry a a l s a dl s r�nasder an hur t � r �o�4S of xhe t'11, Applicati n SuIbmitted By V(pIri : ' ' Authorized Agent ❑Owner Signature f Appiiant. ' � Oates �67 � STATE OF NEW YORK) COUNTY OF 2M'1CA 1 D ImacoMeiji W being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the _cAr (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 2 day of U 20 Notary Public CHEYFNNIE A'KEELAPJ Notary Public-State�:f:,IE York Qualif°�` county ROP RT'� OWNIER AUTHORIZATION 023 yCommission 5A zc (Where the applicant is not the owner) I _ > c> n ' Ce residing at IS14� yl do hereby authorize d apply on e ,aI 'fit a o of Southold Building Department artment forapproval as described erein. Owner”s Signat Date . � AF ff 6 Print taw er's Name 2 "'W Workers' CERTIFICATE OF TATIF Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Remegio Barrera 631-575-9431 DBA/TA BM Construction 18 Syracuse Avenue 1c. NYS Unemployment Insurance Employer Registration Number of Insured Medford, NY 11763 N/A 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 464-19-4064 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability & Fire Insurance Company GEORGE BUONOCORE 3b.Policy Number of Entity Listed in Box"1 a" 165 GIN LANE N9WC775918 Southold, NY 11971 3c.Policy effective period 12/08/2022 to 12/08/2023 3d.The Proprietor,Partners or Executive Officers are included.(Only check box If all partners/officers included) R 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: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 6, 06/29/2023 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are N T authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov ZS Workers'AK CERTIFICATE OF A' k Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured Remegio Barrera 631-575-9431 DBA/TA BM Construction ' 18 Syracuse Avenue 1c.NYS Unemployment Insurance Employer Registration Number of Insured Medford, NY 11763 N/A 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-tip Policy) Number 464-19-4064 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) National Liability & Fire Insurance Company TOWN OF SOUTHOLD 3b.Policy Number of Entity Listed in Box"1 a" 54375 MAIN RD N9WC775918 Southold, NY 11971 3c.Policy effective period 12/08/2022 to 12/08/2023 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box If all partners/officers Included) X❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'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 canceliation 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: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 06/29/2023 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 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 Y� workers' CERTIFICATE OF INSURANCE COVERAGE STATE Campensatian Coald 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) 1b.Business Telephone Number of Insured REMIGIO BARRERA DBA BM CONSTRUCTION 631-575-9431 18 SYRACUSE AVE MEDFORD, NY 11763 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,Le.,Wrap-Up Pollcyj 464194064 2,Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Caller (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company GEORGE BUONOCORE 165 GIN LANE 3b.Policy Number of Entity Listed In Box"1a" SOUTHOLD NY 11971 DBL628156 3c.Policy effective period 12/04/2022 to 12/03/2024 4, Policy provides the following benefits: © A.Both disability and paid family leave benefits. 0 B.Disability benefits only, ❑ C.Paid family leave benefits only. '5. Policy covers: © A.All of the employers 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 ce fit that I am an authorized representative or licensed agent of the Insurance carrier ne-firenc-R a ove and tat a named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 6/29/2023 BY AW, 4f (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 5 ..62 -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 48,4C 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 beneflfs Insurance policies and NYS licensed insurance agents of those Insurance carriers are authorized to issue Form DB-920.1, Insurance brokers are NOT authorized to Issue this form. II DB-120.1 (12-21) . �III�A�II��IE�I��llll���lll�I���I�II I DB-120.1 (12-21)(12-21) ��IIII E& Workers' CERTIFICATE OF INSURANCE COVERAGE TA°rs ICdrmpensation �ioard. 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) 1b.Business Telephone Number of Insured REMIGIO BARRERA DBA BM CONSTRUCTION 631-575-9431 18 SYRACUSE AVE MEDFORD, NY 11763 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limlfed to 464194064 certain locations in Now York State,i.e.,Wrap-Up Policy) 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 54375 MAIN RD 3b.Policy Number of Entity Listed in Box"l a" SOUTHOLD NY 11971 DBL628156 3c.Policy effective period 12/04/2022 to 12/03/2024 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. F1 B.Only the following class or classes of employer's employees: Under pinally penallyof penury,I cartifythat I am an authorized representaive or licensed agent of the Insurance carrier referenced above and that the named insured ties NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. 6/29/2023 �"/Date Signed BY (Signature of Insurance carders aothorized representative or NYS Ucensed Insurance Agent of that losurance+carded Telephone Number 516-829-810 ____ 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 48,4C 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 sox 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 compiled with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Dare 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) III 1p!ni����iiiiii��ii�Iu�i�iiiu��i'IIIIIII 5uffo1(t County Dept.of Labor,Licensing$Consumer Affairs HOME hMPROVEMENT LICENSE Name REMIGIO BARRERA Business Name cehil that the ,rer is au ly licensed BMICONSTRUCTION to ourroty Of suffol u. s License Number H-53123 Rosalie Drago Issued: 03/27/2014 4"ru uivas"ioiim!yi,. 11"":'x jj�j' i S 3/1/�1924 * v § 2 � ' ^R2 \ ƒ�E \ {� ƒ (k E / ro ` ■ \7a } 2 \ \$\ 32 a §k , g $ J■i R� x ) o ei » $ ° i� > Mo � + DATE(MMIDD/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 7/6/2023 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 Ipallcy(les)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 endorrsement s CONTACT PRODUCER B 8g Risk Main Sreet Management Services, Inc 631 673-7CIDa 'No:631-351-1700 NAR.AE, Huntington NY 11743 AD s; insuranceIns.cam INSURER,5 AFFORDING COVERAGE NAIC/$ I INsuRERA;Utica First Insurance Com an 15326 INSURED BARRREM-01 INSURER B: Remigio Barrera Dba B M Construction INsuRE1 c: 18 Syracuse Avenue Medford NY 11763 INSURER D_- INSURER INSUREI'd,'F COVERAGES CERTIFICATE NUMBER:1494602555 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 0 S POI ICY EFF PO Cy EXP LIMITS 7 TYPE OF INSURANCE POLICY NUMBER iMWDDfYYYY A X COMMERCIAL GENERAL LIABILITY Y ART3000223170 4/26/2023 4/26/2024 EACH OCCURRENCE $500,000 CLAIMS-MADE OCCUR I?REIISES,CEaowreFeticarot $60,000 MED EXP' n one a/sin $ 000 PERSONAL&ADV INJURY $500„000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL,AGGREGATE $1 000,000 JECT❑ PRO- ❑ PRODUCTS-COl0,?/OP AGO 'S 1„000„000 X POLICY PRO- LOC $ OTHER; COMBAUTOMOBILE LIABILITY {, a 8Cc $INOI E LIM11 $ ldaO ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS ONLY AUTOS PROPERTY OHMAGE' HIRED NON-OWNED _Eqr Aceldonl $ AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RE PENTION S $ PER OTH- '. WORKERS COMPENSATION S" TLITE ER Mandato ETO AND EMPLOYERS'LIABILITY yJ'N ANYPROPRIETOFO'PARTNIwRfEXEOUTI'JE E.L.EACH ACCIDENT $ OFf:IC WMEMSCREXCLUDEDT N/A ( ,. ) E.L.DISEASE-EA EMPLOYEE 11yres,descnhe under E.L.DISEASE-POLICY LIMIT S DESCRIPTION OP OPERATIONS befiow DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Client:George Buonocore 165 Gin Lane Southold NY 11971. Town of Southold is included as Additional Insured under General Liability,with respects to the operations of the named insured as required by written contract. Subject to policy terms,conditions and exclusions. 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. Town of Southold 54375 Main Road RUTH RIZEDREPRESENTATIVE Southold NY 11971 � � ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD