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Home My WebLink About49831-Z �r TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY 49-ft ?? 1 w 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#: 49831 Date: 10/4/2023 Permission is hereby granted to: Gibbons, John 220 Water St A t 334 Brook/ n, NY 11201 To: Construct in ground swimming pool with spa at existing single family dwelling as applied for. At premises located at: 1380 Orchard St, Orient SCTM # 473889 Sec/Block/Lot# 25.4-11.1 Pursuant to application dated 6/27/2023 and approved by the Building Inspector, To expire on 4/4/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 1111y� 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 httos://www.sotitlioldtownny.gQAPPLICATION FOR BUILDING PERMITv w, For Office Use Only PERMIT NO. Building Inspector. _ Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: ZU23 OWNER(S)OF PROPERTY: Name:John Casey Gibbons& Marissa Gibbons scTM# )o-025-04-11.1 Project Address: 1380 Orchard Street, Orient NY Phone#:(60) 435-8225 Email:casey@f riendsfamily.co Mailing Address: 220 Water Street, Apt. 334, Brooklyn NY 11201 CONTACT PERSON: Name: Melissa Butler Mailing Address: 206 Lincoln Street, Riverhead NY 11901 Phone#: (631) 338-8449 Email: mbut1er75@mac.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: e Name: Mailing Address: '?S Phone#:C4130 `592--jI y10 Email DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: [n]Other Proposed in-ground pool POOL, Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? ❑Yes 9i No 1 PROPERTY INFORMATION Existing use of property: Residential Intended use of property: Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R-80 this property? ❑Yes iiNo IF YES, PROVIDE A COPY. Check( tax Aft.elir Read fing: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS 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. Melissa Butler Application Submitted By(print nam @Authorized Agent ❑Owner Signature of Applicant: � ^ Date: 6-1242-0z-:5 STATE OF NEW YORK) SS: COUNTY OF 5LINOUC, ) Melissa Butler being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract) above named, Agent (S)he is the (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 ! da of l/ ,20 Y Notary Public MA RIA" 'lMARD p UBUIC.,STATE OF NF-WYOR PROPERTY R -i'- (Zistrabon No.01'� I4 1 20 a�. ..- Where the applicant isnot the owner ualBFedfitr B�LkC�RY" g mis ion Expire$CdObOr 1%2V 220 Water Street, Apt. 334, I� John Casey Gibbons residing at Brooklyn NY 11201 Melissa Butler do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. 5/25/23 0 ner's Signature Date John Casey Gibbons Print Owner's Name 2 rum so g zx UR "R 'A IN, o'\Ng" 3" Q�K n ,Rs I'A e': p" ","Jffi a- Np IN gg a MEN\\ Wl� 01, -34"JO A M, "'P Allb \M ,k Al A A bm �i Al� N m W A R ik g�, OW, Wl�lot a t j&4 fil'+-lCF i-ij"All 14) i "pq �Q 3, TOWN OF SOUTHOLD BUILDING DEPARTMENT SOUTHOLD,N.Y. NOTICE OF DISAPPROVAL DATE: August 22, 2023 TO: Melissa Butler(Gibbons) 206 Lincoln Street Riverhead,NY 11901 Please take notice that your application dated June 27, 2023: For permit: to construct an, access��.pool (inclusive of fence cool equipment and heater), and to construct a deck addition to an existing sin 7Ie-fa�nil dwelling at: Location of property: 1380 Orchard. Street Orient NY County Tax Map No. 1000—Section 25 Block 4 Lot 11.1 Is returned herewith and disapproved on the following grounds: The construction is not )ermitted pursuant to Chapter 170 of the Southold Town Code and is subject to Historic Preservation Corprnission approval. Authorized Signature Note to Applicant: Any change or deviation to the above referenced application may require further review by the Southold Town Building Department. CC: file,Landmarks � � Workers' CERTIFICATE OF STATE Com NYS NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business TelephoneNumber Numb r ............ ... ___- _..._ www-.................. of Insured RICCIARDI &SONS POOLS&SPAS INC (631)592-4410 63 BEDELL STREET 1c. NYS Unemployment Insurance Employer Registration Number of LINDENHURST, NEW YORK 11757 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e., a Wrap-Up Policy) Number 20-2576659 2.Name and Address Wof Entity Requesting Proof of Coverage 3a.Name of Insurance .... Carrier (Entity Being Listed as the Certificate Holder) UNITED FARM FAMILY INSURANCE COMPANY TOWN OF SOUTHOLD 3b. Policy Number of Entity Listed in Box"l a" 54375 MAIN ROAD 3102W6369 SOUTHOLD, NEW YORK 11971 3c. Policy effective period 07/11Z2022 to07/1,1/023 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"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 lteLml 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: George R. Grossmann xo d' �tt�ori�e preser�tatflve car licensed agent of insurance carrier) Approved by: 05/31/2023 (Signature) (Date) Title: Agent, LUTCF Telephone Number of authorized representative or licensed agent of insurance carrier: (631)439-4650 ........... 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 ►� workers' CERTIFICATE OF INSURANCE COVERAGE Y{yW ,,Vdt 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 carrier ......... ........ ........_. _._ 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured RICCIARDI&SONS POOLS&SPAS INC (631)592-4410 63 BEDELL STREET LINDENHURST, NY 11757 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) 202576659 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 3b. Policy Number of Entity Listed in Box"l a" 54375 MAIN ROAD DBL464807 SOUTHOLD, NEW YORK 11971 3c.Policy effective period 05/08/2023 to 05/07/2024 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: 0 A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] B.Only the following class or classes of employer's employees: __.. ...... .. .............,. ._ ..._....... . Under penalty of perjury, 1 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. _ a, Date Signed 5/31/2023 By _......., mmmof insurance carrier's authorized r (Signature mmepresentative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 5116-829-8100 Name and Title Richard White ChlefITExecutive 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 4B,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 ....._................_ ................. ......... ................... Si of A _m........ .__ ....,,.,,,. .......�. (Signature Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title w............. 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) I I Il!11111!11!111111!1111111!11!111!11!1!11111111 DATE(MM/DD/YYYY) C R" CERTIFICATE OF LIABILITY INSURANCE 05/30/2023 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 Barbara Dammers NAME: Roy H Reeve Agency,Inc. PHONE (631)2 98 4700X (631)298-3850 = No Ext); ... 'APC,Mo I: PO Box 54 ADDRESS bdammers@royreeve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Twin City Fire Ins Co Co 29459 ._..... INSURED INSURER 8: ...... ........ _..._ ..... Ricciardi&Sons Pools&Spas Inc. INSURER C 63 Bedell St.,ApL 1 INSURER D: INSURER E: Lindenhurst NY 11757 INSURER F COVERAGES CERTIFICATE NUMBER: CL235519083 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 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. ADDL'SIIBR „ P LI EFF POLI Y EX-0 .:... . LTR TYPE OF INSURANCE IN D.WVD POLICY NUMBER .MM/DO. MMIDD LIMITS * COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 770TAn,—110-REN I ED CLAIMS-MADE X OCCUR -PREMISES Earaccuatence $ 300,000 MED EXP(Any one person) $ 5,000 A Y Y 12UENOJ2200 05/18/2023 05/18/2024 PERSONAL&ADV INJURY $ 1,000,000 .... GEN'L:AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE is 2,000,000 POLICY . PRO- 0 LOC 2,000,000 JECT �I PRODUCTS-COMP/OP AGG $ Is %HEIR;: _ AUTOMOBILE LIABILITY COMffNEDSINGLE LIMIT $ _kE ra acoltte:nt 9 ... ... ANYAUTO BODILY INJURY(Per person) $ .. ... .............. OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED MOPE RTY DAMAR.E:. $ AUTOS ONLY AUTOS ONLY (Per acdd'enl UMBRELLA LIAB OCCUR EACH OCCURRENCE ... $ .�..:„.-. ... EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN „......••, STATUTE ER. ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E..LEACH ACCIDENT OFFICER/MEMBER EXCLUDED? El (Mandatory in NH) E L.DISEASE EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT $ ...:_..._ _ ...... ....... ....... .. �...... ... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is listed as additional insured as per the terms and conditions of form#HG0001(06/05)-Commercial General Liability Coverage Form,as required by written contract or agreement.Coverage under general liability is primary&non-contributory and a waiver of subrogation applies. 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. P O Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 i @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD l 7 6 5 4 3 ---- 2 �, b'-8" 3'-3" 4'-0" 4'-0a 4'_a' 4'-0" 14.-0" 4'-C+ 4'-Y" 2'-1" " �/ f I 4'-7" ' 1 F 1 MOM r - I 7 E E;e '� �f�l� •/—Q" , 1 i ' (1 ____. . _.,__._ .,`mac 1V lir {+J 1 O f 1 D 1, Ic go r = j Go i 1 t M e 1 I = cIc- 2'-3" a ._ iV A r-I00Ll B in LO PLo is N ^ W-r-- { 28'-C"' ,o f _ Leisure Paoks and Spas Manufacturing North America Irc. � Area: 616.7 Sq ff 2901 leisure[stand WaY•KnowMe.Tennessee 37914 Ultimate 40 Volume: 17,690 gal A rlaaC*At ca"taE LEISURE POOLS a.w;XE POW M, 1•:•++!H. +c..n..c y;rS k'£F�C�YSC�CIiM►llY.f'. JISA Perimeter: 110' 10" lin ft ' a 40'LONG X 15'S' WIDE a/06 rn�lc� I 87 6 I 5 4 ( 3 2 1