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Home My WebLink About50094-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 #: 50094 Date: 12/6/2023 Permission is hereby granted to Kruk EN Irry Trust 720 Horseshoe Dr Cutcho ue, NY 11935 To; construct accessory in-ground swimming pool as applied for. Pool equipment must be located a minimum of 15' from lot lines. At premises located at: 720 Horseshoe Dr, Cutcho ue SCTM # 473889 Sec/Block/Lot# 95.-4-18.19 Pursuant to application dated 11/14/2023 and approved by the Building Inspector. To expire on 6/6/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 -A-- , 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 latts:./lwww.southoi(ltowmi . xov. Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ° PERMIT NO. Building Inspecton E P i., Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an "m Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name:Conner Murphy & Samuel Rickabaugh SCTM#1000-095-04-018.019 Project Address:720 Horseshoe Drive, Cutchogue, NY 11935 Phone#:516 232 7124 Email:cw nurphy03@gmail.com Mailing Address:720 Horseshoe Drive, Cutchogue, NY 11935 CONTACT PERSON: Name:Gerard Gawlowski Mailing Address:164 McKinley Drive, Mastic Beach, NY 11951 Phone#:516 810 6306 Email:arcdesl@aol.com DESIGN PROFESSIONAL INFORMATION: Namelarry A. Rubinson, PE Mailing Address:380 Town Line Road, Suite 150, Hauppauge, NY 11788 Phone#:631 969 8535 indwengl@aol.com CONTRACTOR INFORMATION: Name:Gerard Gawlowski Mailing Address:164 McKinley Drive, Mastic Beach, NY 11951 Phone#:516 810 6306 1 Email:arcdes1 @aol.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther inground Gunite Swimming Pool $, 5,000.00 Will the lot be re-graded? ❑Yes iiiii'No Will excess fill be removed from premises? ❑Yes ®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 AC this property? ❑Yes �No IF YES, PROVIDE A COPY. IN Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 ofthe 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 taws,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(print name) Date: Gawlowski BAuthorized Agent ❑Owner Signature of Applicant: � � Date: 10/19/2023 STATE OF NEW YORK) SS: COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (N me of iri=tractor signing cosi' ract)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 day of f I 20 23 AeV¢�m.A.ArnwrArw 14otta ' Sia:(;o Nrm-1'�ua'fa �4DffV1 f11%5}i C)Yk V:su�iz es.➢vane z i„'r::��t� �.�„�..,....,,, PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) Conner Murphy&Samuel Rickabaugh residing at 720 Horsehoe Drive, Cutchogue, NY 11935 I, do hereby authorize Gerard Gawlowski to apply on my behalf to the T n f Soli Id Building Department for approval as described herein.. 10/19/2023 Owner's SiiKature Date Conner Murphy/Samuel Rickabaugh Print Owner's Name 2 Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I U � -� residing at (Print property owner's name) (Mailing Address) co rc Ito do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. (Owner's Signature) (Date) G OA�,A/ER— ML1P- r JA11 es,6L P/CA4A- 4F6 (Print Owner's Name) 6BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 � Telephone (631) 765-1802 - FAX (631) 765-9502 .,. ro err southoldtownn ov seand southoldtownn . Dov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: la Company Name: i�F 0 5-rl Name: J f r,?MA 47, IZA 75e; " License No.: email: THOMASP-A- S"C @, 6A14 A--00 Address:—,Pa Phone No.: 0/ JOB SITE INFORMATION (All Information Required) s Name: Address: " , ' � ' , � 0 1J ' : 41�5- Cross Street: , tl" Phone No.: / 2-;2- 712,0- Bldg.Permit /2,Bldg.Permit#: O q email: Tax Map District: 1000 Section: i:;19� Block: a, Lot:0/9" BRIEF DESCRIPTION OF WORK (Please Print Clearly) Ae� Circle All That Apply: Is job ready for inspection?: YES Rough In Final Do you need a Temp Certificate?: YE NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect- Flood Reconnect- Service Reconnected - Underground - Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION II Request for Inspection Form.xls 0 DATE(MM/DDNYYY) #%� E Rte' CERTIFICATE OF LIABILITY INSURANCE 10/20/2023 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(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 endorsement(s). CONtACT'......PRODUCER NAME;, William Brazier Brazier Insurance A/C N' Ead; (631)281-1700 (AIC,No 1490 Montauk Highway ADDRESS: thebrazieragency@gmail.Cont INSURER(S)AFFORDING COVERAGE NAIC# Mastic NY 11950 INSURER A: ATLANTIC CAS INS CO 42846 INSURED - INSURER B: Gerard Gawlowski DBA Architectural Design INSURER C., Restoration&Building By Gerard INSURER D: 61 TONOPAN ST INSURER E: MASTIC NY 11950-4619 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDR= JMMTDNYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR X PREMISES W. 100,000 FX MED EXP((Ea oexureenda) $ Any one person) $ 5,000 A Y L068028226-1 06/27/2023 06/27/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ❑PRO- ❑ PRODUCTS-COMP/OP AGG $ 2,000,000 )CIPOLICYJECT LOC $ OTHER: AUTOMOBILE LIABILITY $ a�ral. ANY AUTO BODILY INJURY(Per person) $ OWNED 'SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED Peradcndant $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB RCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION STATUTE ER D EMPLOYERS'LIABILITY Y/N NY'PROD°RIETORIPARTNERCEXECUTIVE❑FNI E.L.EACH ACCIDENT $ PFICERIMEMBER EXCLUDED? Mandau wy In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Remodeling/Swimming pools-repairs,installations,servicing Certificate holder is also listed as additional insured as per written contract 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 Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road 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 It p__**N-1 I I IN NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A^^^^^ 098663211 GERARD GAWLOWSKI DBA ARCHITECTURAL DESIGN RESTORATION&BLDG BY GERARD 61 TONOPAN STREET MASTIC NY 11950 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER GERARD GAWLOWSKI DBA ARCHITECTURAL TOWN OF SOUTHOLD-BUILDING DEPT DESIGN RESTORATION&BLDG BY GERARD 54375 MAIN ROAD, PO BOX 1179 61 TONOPAN STREET SOUTHOLD NY 11971 MASTIC NY 11950 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12120867-3 1 805276 11/29/2022 TO 11/29/2023 10/20/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2120 867-3, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SU NCE FUND 4 */ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:453039555 U-26.3 4-0 workers• CERTIFICATE OF INSURANCE COVERAGE A Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by 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 GERARD GAWLOWSKI (631)281-2334 DBA ARCHITECTURAL DESIGN&BUILDING 61 TONOPAN ST. MASTIC,NY 11950, 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 098663211 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) TOWN OF SOUTHOLD 54375 MAIN ROAD 3b.Policy Number of Entity Listed in Box"1 a" PO BOX 1179 DBL 6545 28-0 SOUTHOLD,NY 11971 3c.Policy effective period 10/03/2023 to 10/03/2024 4.Policy provides the following benefits: ® A.Both disability and paid family leave benefits ❑ B.Disability benefits only F] 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 F] B.Only the following class or classes of employers 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 10/20/2023 By " (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT: If Box 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 413,4C 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 mailed for completion to the Workers'Compensation Board, DB Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200 PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 has 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 with respect to all of his/her 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 (10-17) Certificate Number 760654 \ � Iff I 1'4,5145 7 RYE 125-00 a� gUpiTF, -vi/jMM i At t4 iff p co FIE' ,�Yddta4i,J�YIn/� �r7 '� 16 - LAJ TE J-81 = rSDWORY ELUNG FRAME N0.720 F � SLATE GRA VCL Qj DRIVEWAY h^ � v ^ h 113 , ►i ii � $ v L 6.x°4 43ORIVE .1 00 SESH LEQ�VD: ®AIR CON&MVER FRIL FRAYS EHL'. ENCLOSED INS YAsoAwr CHMW. CANMAMMFENCE come. CONCRETE O.H. O — CAR FRX MW 240 R/D ROOF OVER . A.C. AIR COMMNER A 7 C/W CONCRETE WNX CE CELLAR Emmr O.H. UAL OyfRHEAO U7/mis fry, smRr W.W *NOOW M L O.r. 0/1 TANK Y/W YASOHRy WALK FENCE GRAPHIC SCALE FE FRE ESCAPE CTL i murr POLE 1 /NCH = 40 FEET MAP OF LOT 19 AS SHOWN ON "MAP OF OREGON VIEW ESTATES" SITUATED AT CUTCHOGUE, TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK MAP NO.6241 FILED 4/4/1975 TAX MAP DESIGNATION 1000-095-04-018.019 REFERENCE NO. 22302 DA T£ 6/9/2023 CHRISTOPHER HENN, L.S SURVEY SOLUTIONS cl CERTIFIED TO. SAMUEL BENJAMIN RICKABAUGH LA S WFG NATIONAL TITLE INSURANCE COMPANY 100 STEVEN PLACE UNITED MORTGAGE CORP. HAUPPAUGE, NY 11788 AMERICAN DREAM ABSTRACT, INC. (631) 858-1675 TITLE NO.ADAW8165—S info Ptitlesurvey.comY.S. LIC. NO. 49857 (C)COPYRIGHT