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HomeMy WebLinkAbout50355-Z � rTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE � v 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 #: 50355 Date: 2/20/2024 Permission is hereby granted to: Mcdonald John 1235 Wunneweta Rd Cutcho ue, NY 11935 To: construct accessory in-ground swimming pool as applied for. Pool must be located a minimum of 20' from sanitary system. At premises located at: 1235 Wunneweta Rd Cutcho ue SCTM # 473889 Sec/Block/Lot# 104.-12-12.2 Pursuant to application dated 1/19/2024 and approved by the Building Inspector. To expire on 8/21/2025. Fees: SWIMMING POOLS -1N-GROUND WITH FENCE ENCLOSURE $300.00 CO - SWIMMING POOL $100.00 Total: $400.00 Building Insp or 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 littl)s://www.,soLitlioIdtowiviy.gov Date Received APPLICATION FOR BUILDING PERMIT ECEQISE For Office Use Only , Building Inspector. 4 JAN 1 � 024, PERMIT NO, 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. "off r. Z �i�"� Date: OWNER(S)OF PROPERTY: Name:. ' 1 SCTM# 1000- 101 — 12 Project Address: �23� (����," ,jyq0 N Phone#: (TJ 7 3b7--D, Email: Mailing Address: CONTACT PERSON: IJ Nam / Mailing Address: NqA Phone#: M .7Z-7 ��3 )2 Emai DESIGN PROFESSIONAL INFORMATION: Name:. Mailing Address: Phone#: Email:. CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email; DESCRIPTION OF PROPOSED CONSTRUCTION = 11100,7V/ L— . 5� ❑N�he�tructu�re ❑Addition ❑Alteration ❑Re p�r�❑Demolition Estimat �Co t of Project: Will the lot be re-graded? E:]Yesl6NO Wil xcess fill be removed from premises? [:]Yes �No 1 PROPERTY INFORMATION Existing use of property: intended use of property: 1 'r '' Zone or use district in which premises is situated: Are there any cov nants and restrictions with respect to this property? ❑Ye o IF YES, PROVIDE A COPY. 11 Check Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water Issues as provided by Chapter 236 of the Town Code, APi UCATION is HEREBY MADE to the Building Department for the Issuance of a'ulla'ing permit pursuant to the Building Zone Ordinance of the Town ofsouthold,Suffolk,county,blew York and other applicable taws,ordinances orReg�rlataorks,for the construction of buildings, additions,alterations or`for removaf or demolition as herein described,"a applicant agrees to comp wft�iii appilcabio laws,ordinances,building code, housingcode and regulations fatfons andto admit authorized Inspectors on Premises and In b I in lsl for.,.'necessary inspectionFalse statements ants made herein are punishable as a Class A misdemeanor pursuant to Section 21005 of the New York State penal law, Application Submitted By(print name): authorized Agent El Owner Signature of Applicant: Date: STATE OF NEW YORK) S • COUNTY OF s0 OLi� 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 wor and o make and file this application;that all statements contained in this application are true to the best of his/her howl dge and belief;and that the work will be performed in the manner set forth in the application file ther Sworn before me this dayof 'A 2 �4 otary Pub i "' try ip �b4sTMr PROPERTY OWNER AUTHORIZATION ni (Where the applicant is not the owner) (2 residing at/Z35 trl:4? IJf L&fH*do herebyauthorizes .., to to pP�n my behalf to the Town ofRiau hold Building Department for approval as described herein. Owner's Signature Date Pint Own I's Name 2 Buil din De ar trn+ nt A lication AUTHORIZATION (Where the Applicant is not the Owner) I, JC 3 residing at 1�. (Print opera owner's name) (Mailing Address) V do hereby authorize (Agent) .001 ,0to apply on my behalf to the Southold Building Department. ( 01/13/002.4 (Owner's Signature) (Date) (Print Owner's Name) DATE(MMIDD YYY) ►� CERTIFICATE OF LIABILITY INSURANCE 01/04/2024 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). PRODUCER i H mm) ciao swa ostTy FAX 1 631) 390 9790 Ed ewood Partners Insurance Center PHONE g 90 Marcus Drive 3rd Floor 631 390 9700 AIC Ne ,,,�.._.. E MAtL ADDR�I�; t�SSMCez»tsCMe 3"cbsa,kera.cogs .a..�. .. ..,,. mom- m . Melville NY 11747 INSURER(S) AFFORDING COVERAGE NAIL# INs17RERA:TECRNOLOGY INSURANCE COMPANY I �... _ 42376 INSURED m—EFC 27120 INSUt B TRrJ� ELL INSURANCE COMPANY .,m__ ... Islandia Pools Ltd. � RE & CASUALTY GROUP 0,0914 INSURER C HARTFORD FIRE _.... _.. m .._.-_. _-....� 108 Fishel Avenue INSURER D: _..- .—— ... .......• Riverhead NY 11901 INSURERS. iNSURtMR F.' COVERAGES HP CERTIFICATE NUMBER:Cert ID 18855 t12i 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, " EDUCED BY PAID CLAIMS. ." IrIS HAVE BE .....OCCURRENCE LIMITS 1 0 . .I�� POLICY EFF POLICY EifP EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHO INSURANCE POLI TYPE OF INSU AD �I'-8R POLICY NU' R d1IMIDDIYYYY MMPD L 000":0....0 RAL LIABILITY EACH OC . CLAIMS-MADE _ can _$ 300",000 XOCCUR 12UUNOZ9731 09/25/2023 04/25/2024 PREMfl E Sao , ._ 5 000 C X COMMERCIALGENE�� NpNpNN MED EXP LAny one arsoaa $„mm 4_ PERSONAL&ADV INJURY $ _ .1 r 000 000 mm W.... _ — .,. ..� GENERAL AGGREGATE $ 2,000 000 GEN'L AGGREGAT POLICY E LIMIT APPLIES PER: $ X] PRO- ❑ LOC JECT PRODUCTS�OON+IPIOPAGG mmS 2, OTHER COMBINED SIN d�EL%MIT AUTOMOBILE LIABILITY as a :d n $ 1000,000__ 000'000 Y n) 13 OWNS ONLY X_ SCHEDULED BODILY INJURY(Per accident) ANY AUTO 12UENOZ9729 09/25/2023 04/25/2029 person) BODILY INJURY(Per erso AUTOS HIRED NON-OWNED PROPERTY DAMAG $ AUTOS ONLY X AUTOS ONLY Para lO nl C X UMBRELLALIAB X OCCUR 12HHUOZ9730 04/25/202304/25/20'24 EACH OCCURRENCE $ 11000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000"000 DEO ........... RETENTI 1 ..00 TION$ 10 000 $ WORKERS COMPENSATION TWC4239232 04/25/2023 04/25/2024 STATUTE CR yW 00 _X PER A AND EMPLOYERS'LIABILITY YINC ANYPROPRIETORIPARTNERdEXECUTtVE NIA E.L.ELEACH A CIDENT OTH $ 1„r 00 0 OFF ICERIMEMDER EXCLUDED? E.L.OtsFASE-EA EW4PI.OYEE $ 1 000000 (Mandatory In NH) m— _-_s. - Yfyyrr$,desc6beunder E.L.DISEASE-POLICY LIMIT $ 1"000,000 DESCMPTION OF OPERATIONS b tom u $ kS 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 AUTHHORIRI,Z,DEDDRREPRESENTATIVE Southold NY 11971 GKIV"eW ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ��W Workers' CERTIFICATE OF INSURANCE COVERAGE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW rRIVERHEAD, 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier gal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured NDIA POOLS LTD. 6317276312 FISHEL AVENUE NY 119011c.Federal Employer Identification Number of Insured Location of Insured(only required if coverage is specifically limited to or Social Security Number lccatons in New York State,i.e.,Wrap-t tp IociFcy) 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: Q A. Both disability and Paid Family Leave benefits. 0 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. 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 descr° d above. Date Signed 1/4/2024 By net's ai th rl d reprise (Signature of insurance carntatdv or NYS licensed insurance agent of that insurance carrier;) Telephone 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 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 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(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) DB-120.1 ur Additional Instructions for Form D13-120.1 By signing this farm, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave I enefits 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. DB-120.1 (12-21) Reverse 5NE Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.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"l a" 53095 Main Road TWC4239232 Southold NY 11971 3c. Policy effective period 04/2512023 to 4 25/2024 3d.The Proprietor,Partners or Executive Officers are ❑ 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 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 validfor 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 dogs 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. Commercial Support (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 001F (Signature) (Date) Title: p P g (631) 390-9700 Telephone Number of authorized representative or licensed agent of insurance carrier: 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 Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1Tha head of state or municipal depa�mant, boand, commission or office authorized or required by law to issue any ' enn��rm[inconne�imm \withany v*ork |nvo� employment employment - rythis �M��t��. �n� �ohw����en�[n� �n� ��n�r�l �r ����i/ | mt�tubemmquir|ng or authorizing the issue mfSuch permits, i shall not issue such permit unless proof duly subsohbed by an insurance carrier is producedn a form satisfactory to the chair, that compensation for all employees has been secured as provided by this ohepCer. Nothing hera|n, 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 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 mfemployees in a hazardous employment defined bythis chapter, notwithstanding any general orspecial statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed byaminsurance carrier is produced in aform satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105'2 /9-17\ REVERSE ~--- - -~ ~ HM ENGINEERING P.C. P.O.BOX 914 EAST NORTHPORT,NY 11731 TEL:516-476-5392 EMAIL:HMARNIKA@HMENGINEERINGPC.COM January 15, 2024 Town of Southold Building Department Town Hall Southold,N.Y. 11971 Dear Sir/Madam: This is to certify that the drainage facilities to be used exclusively for the construction of a swimming pool on the premises of. Spahidakis Residence 1235 Wunneweta Road Nassau Point,N.Y. 11935 will not require draining because the pool is constructed with a vinyl liner. The pool water will be continuously recirculated through the filter and will be reused from year to year. The drainage from the filter backwash will be piped to a drywell located on the subject lot and will not interfere with the public water supply system, existing sanitary facilities, adjoining property owners, public highways or private roads. Sincerely, HM B gineerin,g P.C. Iry arnika,P.E. SURVEY OF PART OF LOTS 203 & 204 ` AMENDED MAP A • ` "� '� NASSAU POINT SECTION No. 2 ,., . FILE No. 156 FILED AUGUST 16, 1922 SITUATE NASSAU POINT � TOWN OF SOU NEW YORK SUFFOLK COUNTY, NEW S.C. TAX No. 1000-104^-12-12.2 '`"�,, N SCALE 1"=20' F y.41 / w NOVEMBER 28. 2023 / # / AREA = 27,870 sq. ft_ �.. / (TO 70 IRREGULAR ROAD LINES) 0.592 Oc. a �,. •f a� // \ ,f,�. '"a�'eN� 4, ,� Via„Mtivw.;s'./ L01+ ,�.C� P f 0 Ld.1T # / ✓ \ "* w SARA NERdMANN SPAHIDAKIS GEORGE SPAHIDAKIS poll, CHASE WATER MILL ABSTRACT Corp. FIRST AMERICAN TITLE INSURANCE COMPANY * // F'J0, LOT 204 \ s .mow,.^' rA, i 0 » t . �w �W Lrs . tom Sd" w FUZE S. r I a { O / s�emN xxnrer nrwwc+www+wwe�waalw:. rn / O a / * w / 205 na vs wa..4a rorrlre colt w rawRala�.'1r�r 5w+u sw+ti,a ncrx Pc�wcu LOT 36 / sAxw xa xrrA rwcmrw.w+wcw w«.rw++,w xNww['r' 1J:RwIXAhe'i awsn�,r'vr�+w a.rz'rwc w+clnw,n«„ a �° �" 1HL wxrsxs»r ❑v Jaz+� wN'AY"8 a. a�N �iarr�Fr+aar4aaaa era e Nathan Taft Corwin ill. Land Sur a or N 5 F NEIV r m � PHONE 631)727--20 % Fax (631)�7^a7-1777 C 1 " L'e•. ( 5tM4 04FAY17PEZ +�"' lfi °".:w ,,•' OffXEZ*WrATEO'AT P.o.Boa 16 1*56 Kann tllk 4 Jarr p.'L New York 11447 '�,• "^„ ., Ake '"r1 ,y+w Joerwmrypw 11 Nww Yom, 11947 E—Yw"t NC—.6,30—L— ��✓fir