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HomeMy WebLinkAbout50354-Z a � at . TOWN OF SOUTHOLD BUILDING DEPARTMENT r' 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#: 50354 Date: 2/20/2024 Permission is hereby granted to: Artemis East LLC 11 Sherman Ave Bronxville NY 10708 To: construct accessory in-ground swimming pool with spa as applied for. Swimming pool and pool equipment must be located a minimum of 25 feet from lot lines. At premises located at: 2195 Aldrich Ln, Laurel SCTM #473889 Sec/Block/Lot# 125.-2-1.15 Pursuant to application dated 1/19/2024 and approved by the Building Inspector.. To expire on 8/21/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector Sqrsat� wrt„ 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) 765-95021ittOs'://WwwA-30L1t � (tltr-ML Date Received APPLICATION FOR BUILDING PERMIT E � � A r Office Use Only u J 56 �� I JAN V J ..,l 2 PERMIT N0. Building Inspector; di ., E tions and forms must be filled out in their entirety.Incompletetions will not be accepted. Where the Applicant is not the owner,an 's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: U�( SCTM# 1000- Project Address:Zlgs 11 k I LA� r'�i'a�-.- Phone#: J49> Email: Mailing Address: CONTACT PERSON: l L Nam ,. �A Mailing Address: ' Ema" ° , Phone#: � DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION Esti ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demol° n $ matte Projec her f * �U.�-v 1 � � .�.-....._.. .� Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? ❑Yes o 1 Intended use of property: Existing use of property: Zone or use district in which premises situated:is Are there any covenants and restrictions with respect to this property? ❑Yes No IF YES, PROVIDE A COPY. P hep 'Bp Afters; , adi ugi rrw r titre ter a BulM1dl sl ap + r itis aaauludlja S rrnl prurs at to the ieu llding n* ptpa of tha ��.�ar,, FCid iSw NaNI t Ntlsabla trwrrs,oral r4irMsor aa�utlons,dor ura co tswzon build , on of thti Town rata�l, arttd �Irst+,q or find othar pp icoabla laws,ordinance,bulidtng code, otoadaoltlons,aherstions or fern,' d+ral or d?srrl�alNtlon as therein dos!tribod,The appllcant azroas to csprrwpbw w�ltln all appl housin;code and regulations and to admtt autho ted lospec oris on prarnlras an In bulldlnliisi for nat�assrry Inspesttons,Falco statementsrrlade herein are puntshable as•pass A Mj$datrleanor pursuon#,to sactlo, tha New Vorl(state POW tAww. �puthorlzed Agent OOwner Application Submitted By Date: Signature of Applicant: STATE OF NEW YORK) SS: COUNTY OF v 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 e said work nd c make his/her kn w e ge and belief;file this application;that all statements contained In this application are true to the b estand that the work will be performed In the manner set forth in the application file therewith. Sworn before me this 1 2024 J �ry day of �_ ota P c J + VcLr0 m aG. Yk,- cr n�o� a3,l it iw l P r Ir t it l,Crraatf RO � OWNER AUTHORIZATION Oualfifled In t �lltn,lssion F'e Oac � PE (Where the applicant is not the owner) I, flix> s` i residing at orize do hereby auth t �apply or my behalf to the Town of Southold Building Department for approval as described herein. tie i s Signature Date Print Owner's Name Bniti'lrre artrnent A lleatlon AUTHORIZATION (Where die Applicant is not tI%C Owner) residing at ✓ I, Pl (Mailing Address) (Print property owner's name) L.j wL, do hereby authorize 0 V . (Agent) to apply on my behalf to the Southold Building Department. (Dte) (owner's Signature) (Print Owner's Name) DATE(MM/DD/YYYY) AC CERTIFICATE OF LIABILITY INSURANCE 01/04/2024 THI�RTIFICATE 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 r6ghts to the certificate holder in lieu of such endorsement(s). TCACT �w mm�rt PRODUCER �S1rC,, O -�' Edgewood Partners Insurance Center PH NvaE4) (M 90 9790 PHONE M e FAX _... u o 40 Marcus Drive 3rd Floor 631 390 970 y (631) 3.. a.a E-MAIL.. SMCext�s P., ?ro&e-rs c1 �A/c No ADDn. s _ Melville NY 11747 ..... ._ INSU..R.E�SA.FP_ CRDINC9J�tAG_, ..... �_... RA TECk4OLOY INSURANCE COMPANY I .. �..4.23N7A..6.Y�0...-1f_' ............. .__..... .._.... . .. .... _. 2772} ..... INSURED NANCE COMPANY � VNSUREFd B TRR�MULL ISUR � ._ -- Islandia Pools Ltd. I URERC HARTFORD FIRE & CASUALTY GROUP1­11- 00914 108 Fishel Avenue INUMD ...___ ... ____ ...__ ._....... .. Riverhead NY 11901 ENSURER E. ....m ....... . ... _ .mm I INSURER F COVERAGES HP CERTIFICATE NUMBER:Cert ID 18855 (12) 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, AND CONDITIONS OF SUCH AIDMS. _ LTA TYPE POLICIES.LIMITS SHOWN p�OLtC�EsForol CY EACHOCCURRENCE VSR MAY HAVE BEEN MMFDD/YYYY MMPUOPY LIMITS SIGNS A P REDUCED BY P ADtl�0S"# _ C X 1 000,00 TYPE OF INSURANCEGENERAL LIABILITY POLGCY NUMBER w a) 300 n 000 - CLAIMS-MADE X OCCUR 12UUNOZ9731 04/25/2023 04/25/2024 PLtw7ISEfr accl0 COMMERCIAL MERCIAL GENERAL uy 4 Sd000 MED EXP(Any oneorsoeue, $ _..... 1-111-........... .m. ... PERSONAL&ADV INJURYGENERAL $ 1-000 000 GENT AGGREGATE LIMIT APPLIES P AGGREGATE $ 2 p 000 a 000 PRO- PER: PRCDUCT COMP/OP AGG 5 2 r 00 q 000 2POLICY JECT OC _. 0,THER, COMB 6 EDI�SINGLE LIMIT AUTOMOBILE LIABILITY a ar _ .... _. $ITS,.1m�mm000w000�. '.�...Y.... $ B ANY AUTO 12UENOZ9729 04/25/2023'04/25/2024 BODILY INJURY(Per(Per INJURY DAN E ) $ RY OWNED SCHEDULEDacadent AUTOS ONLY X., AUTOS HIRED NON-OWNED taertPic !:� $ AUTOS ONLY X AUTOS ONLY .. ... C X UMBRELLALIAB �� OCCUR 12HHUOZ9730 04/25/2023 04/25/2024 EACHOCCURRENCE 1,000,000 EGATEGIIAB MS-MADEESS AGGR RKERSCLPER OTFN ® TtFTEN'IIOh#$ 10,000 COMPENSATION TWC4239232 04/25/202,3 04/25/2024 X STAT�IE LR A AND EMPLOYERS'LIABILITY �- 1 000,0 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N EACH CGBOECYT $ 1,000,000 N/A E E OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ O,O (Mandatory in NH) —_ If .descobe uindof F.L.DISEASE POLICY LIMIT S 1,000,000 DESCRIPTION OF_OPERATIONS below $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 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 53095 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 (�-O" .1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD m "I' Workers' CERTIFICATE OF IRATECompensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured (use street address only) 1b,Business Telephone Number of Insured Islandia Pools Ltd, (631) 727-6312 1c.NYS Unemployment Insurance Employer Registration Number of 108 Fishel Avenue Insured Riverhead NY 11901 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 112915558 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) TECHNOLOGY INSURANCE COMPANY I Town of Southold 3b.Policy Number of Entity Listed in Box 1 a" TWC4239232 53095 Main Road Southold NY 11971 3c. Policy effective period 4 2 202 to ___AjLkALZ024 3d.The Proprietor,Partners or Executive Officers are 7 included.(Only check box if all partners/officers included) 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 premiurns 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 forma, 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 complyingwith 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: Commercial Support (Print name of authorized representative or licensed agent of insurance carrier) Approved by: COO... (Signature) (Date) Title: Telephone Number of authorized representative or licensed agent of insurance carrier: (631) 390y9700 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. www.wcb.ny.gov C-105.2 (9-17) x workers'r-110i Compensation CERTIFICATE OF INSURANCE COVERAGE sar Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW _ W ART Paid Family Leave benefits carrier or licensed insurance agent of that carder P 1.To be completed by NYS disability and 1b.Business Telephone Number of Insured 1 a.Legal Name&Address of Insured(use street address only) ISLANDIA POOLS LTD. 6317276312 108 FISHEL AVENUE RIVERHEAD, NY 11901 1c.Federal Employer Identification Number of Insured Work Location of Insured(only required it coverage is specifically limited to or Social Security Number certain locations in New York SWe,i.e..Wr,11P-UP POSicY) 11-2915558 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 53095 Main Rd 3b.Policy Number of Entity Listed in Box 1a Southold, NY 11971 69146-00 3c.Policy Effective Period 1/2/2025 1/1/2014 to 4. Policy provides the following benefits: 0 A.Both disability and Paid Family Leave benefits. �] B.Disability benefits only. E] 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: penalty p t rY y e coverage as desco d above. carrier referenced above and that the named Underof perjury,I certify that I am an authorized representative or licensed agent of the insurance carr insured has NYS disability andlor Paid Family Leave benefits insuranc 9 1/4/2024 By insurance car r) Date Signed ��..g . Si nature of insurance carrier's,authori and representative or NYS licensed insurance agent ofthat insurance carnet) le hone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200, completion to the Workers' Compensation Board„ p y . . W PART 2,To be Com leted b the NYS Workers Compensation Board (Only if Box 4B,4C or 56 of Part i has been checksd) 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 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) 11111RDIIBI�1-11120.1 (12-21)°1111111 Additional Instructions for Form D13-120.1 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/ c nFamily d ` II send this Certificate of e benefits under the Insurance Coverage bility and � F �(Certificate)to Benefits Law, The insurance carrier or itsagent the entity listed as the certificate holder in Box 2. n 10 days The insurance carrier must notify the above ceftl1� trwithin 30 days ll l ruasnst'other than non Board lonlpayme of F a policy is cancelled due to nonpayment of premiu premiums that cancel the policy or eliminate the insured from coverage indicated on this Certifia notices may be sent by regular mail.)Otherwise, this Certificate is valid for one year after this form is approved by the urance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier. ate This certificate is issued as a matter of information only and ger listed,no rights upon does it confer any holder. . This responsibilities apes does not amend, extend or alter the coverage afforded by t policy beyond those contained in the referenced policy. Tand/or Paid Family Leave benefits contract of insurance only This Certificate may be used as evidence of a NYS disability while the underlying policy is in effect. ts indicated on this Please Note, Upon the cancellation of the,d on�a�tyermit�iicense orr Paid nccyi tread issuedave Eby c�erytificate bolder, he form, if the business continues to be named pInsurance Coverage for NYS business must provide that certificate holder with wed anow that thicate of s business is complying with the mandatoryy and or(Paid Family Leave Benefits or other au proof coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 mission or office (a) The head of a state or municipal depanvolvin rtmentbthe oard, corn permit for or in connection with any workg employment of employeestion employment zed or eas defined in thred by law to is article, and not withstanding any general or special statute requiring or authorising the issue of such.permits, shall not issue such ir, that the permit unless proof duly subscribed by January f gist, two an insurance pthousand and twenty-one, the payment er is produced in a form satisfactory to tof famhe ily leave benefits payment of disability benefits and after January for all employees has been secured as providedbyhis artdepartment, board, commission or office tolpay a�y disability benefits to any liability on the part of such state or municipal any such employee if so employed. mmission or or required by law to enter into (b)The head of a state or municipal work department, board the employment office employeesdin employment as defined n this any contract for or in connection with any w 9 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 o t of satisfactory ry to the chair,benefits that the payment of disability benefits and often January fiat,leo thousand eighteen, the pay Y for all employees has been secured asp Y D13-120.1 (12-21) Reverse j i �i j 1 6 UA s 4 z C) .4 joP� eS CD g 5a 0._ kli�(D l' 9. ,s � t` S' r a� j I SURVEY FOR JOHN GUNTHER OCT. 25 , 1966 LOT NO.2 , RICHARD J.CRON JUNE 6 ,19ee 0I JAN, 6 ,1988 AT LAUREL DATE SEPT 280987 MWN OF SOUTHOLD SCALE 1"=100' SUF'F'OLK COUNTY, NEW YORK N0. 87- 1465 KLWAUTMOaiito ALTERAPON 04 ADDITION M THIS GUARANTEED TO; _ $URVEY IS A Y a.ATI H OF SECTION 72on of THE JOHN GUNTH" NEW YORK STATE EDUCATION LAW OPIES OF THIS SURV E Y HOT KAMime ►HE LAND COMMON ttrRL E INSURANCE SURVEYOR'S INXED SEAL OR tl aOsSEO SEAL SMALL COMPA' NOT 1t CONSIDERED T4 ISE A VALID TRUE Cts X GGA lAKT ES INDICATEV HEREON SMALL R Q4L To PPp �' hl DEPARTMENT-DATA FOR APPRQWI to rrweTboloT THE PE)jvw rola wunu fur _, �.�� ,- -------- a