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HomeMy WebLinkAbout49879-Z z TOWN OF SOUTHOLD RUILDINO DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NV BUILDINO 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 #: 49879 Date: 10/12/2023 Permission is hereby granted to: Beta 11 LLC 230 E 85th St New York, NY 10028 To: construct accessory in-ground swimming pool as applied for. Swimming pool and pool equipment must be located at a minimum of 10' from rear yard lot line. At premises located at: 610 Wildberry Ln, Southold SCTM # 473889 Sec/Blocic/Lot # SI.-3-12.1 0 Pursuant to application dated 9/27/2023 and approved by the Building Inspector.. To expire on 4/12/2025. Fees: CO - SWIMMING POOL $50.00 SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE $300.00 Total: $350.00 B ding Inspector TOWN OF SOiTTHOLD — BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1 179 Southold, NY 1 1971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 l�ttp :E _ otlolltoan . o Date Received APPLICATION I PERMIT For Office Use Only �3 PERMIT N0. 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_ nulIT 1110111'J- C� Date: OWNERS) OF PROPERTY: Name: , L L C SCTM # 1000-s1 67?, 1 Project Address: Y Phone #: _ Email. S - I OL c eAc 0 1� Mailing Address: CONTACT PERSON: - Name: 00 �L Mailing Address Phone #: � C) k Email. ` f DESIGN PROFESSIONAL INFORMATION - Name Mailing Address: Phone #: Email. ------.-_- -------------- - CONTRACTOR INFORMATION: Name: P _ - Mailing Address: (D Phone #: Email- z5cm ka- a DESCRIPTION OF PROPOSED CONSTRUCTION =New Structure =Addition ©Alteration =Repair =Demolition Estimated Cost of Project: Other NfLkA JOLC_C i 1Cr2yz Sw rp $ Will the lot be re-graded? %yes =No Will excess fiil be removed from premises? =Yes NNo 1 PROPERTY IINFC311MATICM Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? =Yes r)4zo IF YES, PROVIDE A COPY_ Check BO A'-erea- _11 = The owner/contractor/design professional is responsible for all drainage and storm water issues as provlded by Chapter 236 of the Town Code. APPUCATION IS HEREBY MADE to the Building Department far the issuance of a Building Permit pursuant to tha.Bunding.zore Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construct1cm of buildings,„ additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable Yews;ordinances,bultdllrjil 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 repunishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Suhrnittied By (print name): V– 1 .uthorized Agent []Owner Signature of Applicant: - - � Date: Q )ate l a� CONNIE D. BUNCH STATE OF NEW YORK Notary Public, State of New York SS: Na. 01 BU6185050 COUNTY OF ) Qualified in Suffolk County Commission Expires April 14, 2-Q`f 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.) 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 J ay of 20 Notary Public - Y OWN ER - UTA _ (Where the applicant is not the owner) 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 Building "cpax-tment Au>rl eat c►rl AUTHORIZATION (Where the Applicant is not the Owner) w,we t a tt�q r t '��a-T(rs �rat.E At /G.7f (Print property owner's name) (Mailing Address) v '-foel% `t lOy a do hereby authorize IL `r;n ok �n (Agent) F'� -k c C of.O to apply on my behalf to the Southold Building Department_ Y' �3 (Owner's Signature) (Date) Tw=13�t3cl-.W c 4-C- gr (Print Owner's Name) Workers' CERTIFICATE OF INSURANCE COVERAGE 4-1 sr�1€ 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 PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST CILIOGUE, NY 11942 1c. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State, i.e-, Wrap-Up Policy) 262929943 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" PO Box 1179 DBL318565 Southold, NY 1 1971 3c_ Policy effective period 05/13/2023 to 05/12/2024 4_ Policy provides the following benefits: © A. Both disability and paid family leave benefits_ Q B. Disability benefits only. 0 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_ Q B_ Only the following class or classes of employer's employees: _ 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 NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/26/2023 By oiil// (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 513 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 Ooard According to information maintained by the NYS Workers' Compensation Board, the abov -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 OB-120.1. lnsurance brokers are NOT authorized to issue this form. DO-120.1 (12.21) III IIIPI!"iiu�niniiiuuniiiin�ii�nuiiiiii11111111 Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate) to the entity listed 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 cancelled 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 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 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 Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220_ Subd_ 8 (a) 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 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 disability benefits to any such employee if so employed. (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 as provided by this article- OB-120.1 (12-21) Reverse CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/24/2023 '17HIS 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 13ELOW. 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 recluire an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTM-VAF-CT Nicholas Zulkofske Brookhaven Agency, Inc. PHONE 631 941-4113 FAx 631 941-4405 100 Oakland Ave, Ste 1 E-MAIL Certificate-F--Lhavena enc .Com Port Jefferson, NY 11777 SURER S AFFORDING-COVERAGE 1 MAIC# IN R A: Philadelphia Indemnity Insurance Company INSURED INRIIRFR ra Merchants Mutual Insurance Comnanv ® _ j Patrick's Pools, Inc. INSURER C Wesco Insurance Company PO Box 3024 INSURER D, East Quogue NY 11942 INSURER E: IN RER 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSR ADDL UBR Pi3LIay EFF = POL9CY EX.P Tg TYPE OF INSURANCE POLICY NUM,>BFR LIMITS - X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $1,000,OOU � ,,,. I DAMAGE TO RENTED A CLAIMS-MADE I�` - OCCUR _ _ .®' - $100-000 X Contractual Liability PHPK2517025 _02/28/2023 02/28/2024 MED EXP(Any onea om $5,000 rs PER.SOtIIAL&ADV -NJ 1,11 $1,000,000 GEN`L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000,000 POLICY X 0 Loc P�xpnuc7S-COK4PIr�P AGO _ $2.000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $500,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWAUTOS NED E AUTOSULED X X CAP926711 3 07/12/2022 107/12/2023 BODILY INJURY(Per accieenSCHEDt)- $ j I NON-OWNED PROPERTY DAMAGE X HIRED AUTOS AUTOS I / r o. f $ $ UMBRELLA LIAB I ' OCCUR I EACH OCCURFPZ-FNCE $ - EXCESS LIAB CLAIMS-MADE AGG_RE_G_ATE_ $ DED R TENTION I $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY ----- ANY PROPRIETOR/P ARTN ER/EXEC UTIVE Y t N € E.L.EACH ACCIOE NT $-100,000 C OFFICER/MEMBER EXCLUDFD? Y N/A I WWC3647363 05/13/2023 05/13/2024 (Mandatory in NH) € E_L DISEASE-EA EMPLOYEE $'100.000 IF yes,d.— he untlar DESCRIPTI N F PERATION below I E..L_DISEASE-POLICY LIMIT s 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Ramarka Schedule,may be attached if more space. required) Town of Southold is included as additional insured per written contract. CORTIFICATE HOLDER CANCELLATIQN 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 ©1988-2014^CORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Workers' CERTIFICATE OF Boa Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name S Address of Insured(use street address only) 1b.Business Telephone Number of Insured 631-996-4687 Patrick's Pools, Inc. PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Lor.atiDn of Ineured{Qnty rsquTrscf ff'cowerag,&is //m Ned to 1d. Federal Employer Identification Number of Insured or Social Security a s 1r3 Now Ydrk Slato,i.e.,a wren-s-#_/ II r) Number 262929943 2. Name and Address of Entity Requesting Proof of Coverage 3s.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"l a" Town Hall Annex WWC3647363 54375 Main Road Southold, NY 11971 3c.Policy effective period nffl to n-X;rJ aMf»a 3d.The Proprietor, Partners or Executive Officers are Q included.(only check box If all pa.b re/officers Included) 0 all excluded or certain parbhers/ofttcers excluded. This certifies that the Insurance carrier Indicated above In box"3"insures the business referenced above in box"1a"for workers' € mpensation under the New York tata WorkarW Compensation Lavtr_ (To use thls form, New York(NY) must be hated under itarrr 3A on ihe IINFCRNIATION PAi3E of the+f3rotkars'ccarnpensation Insurance policy)- The Insurance Carrier or its licansed agent will send this Cortificatoof:Insurance to the entity listed ahove,as Lite cert1ficate holder in box -- The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonparyment of promiums or within 30 days IF there are reasons other than nonpayment of lammiums that cancel the policy or eliminate tho Insured from the cxwaraage Indicated ori this Certificate. (Those notices may be sent by regular mall.)Cniharwvilser 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 ei rller. This rtifii;ate is rued as a matter of information o iy and €onfers no rights upon the certificate holder.This certificate does not amend, extend or alter tiro cxxkverage afforded by the policy listed, nor does it confer any rights ckr responsibilities beyond thoza contained In the faferanced policy. This certificate may be used as evidence of a Worke�rs'Compensation contract of insurance only while the underlying policy is in effect. Pteaser Note: Upon "neottaition,of ttte workarte rprnpensaticm poilcy Indicated on this form, if the busfnerss#--Onunues to be named on a permit, license or contract issued by a cartiiflcate holder,the bustness must provide that rtific.*te holder with a now Certificate of Wor-kera'C ornpansation Coverage or other authorized proof that the bustiness Is complying with the mandatory csverage requirements of the Now York State Workeirs'Compensation Low. Under penalty of perjury, 1 certtfy°that I am an authorized representative or licensed agent of the Insurance carrier referenced above and that the named Insured has that coversge as depictad art ithla form. Approved by: Nicholas Zulkofske (Print name of authartmd rop ntatfere or Iloensed agent€f Insurance€er+ster) Approved by: 3 (stnatura) (Date) Title: Authorized Agent Telephone Number of authorized representative or Ki ensed 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 NOT authorized to Issue It. C-105.2 (9-17) www.wcb.ny.gov Workers' Compensation Law Sectlon 57. Restriction on issue a permits land the entering into 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 auth4ortzed or required by law to enter Into any contract for or in connection with any work Involving the employment of employees In a ha r5dous employment defined by this chapter, not6vithstanding any general or special statute requiring or authoiriming 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 cfiapter_ i C-105.2 (9-17) REVERSE r"w•w.* .wr.r. wwe a.wtw.r, ra��"�"a. w"'°""�+w d� ..wr+«w+wrw+�w r�.u�w � ...m.�.w,� «wr.r .. ++wwreww,�. r"ww.m�.w w�w.«ww�w w.�w �r.�a r. rr.cron...r+a+u,rrwwiw Vis. o HEALTH DEPARTMENT USE.. . . ... �... L*401 "��I 631127 I" �" a N .�- .. 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