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HomeMy WebLinkAbout50360-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE p' a 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 #: 50360 Date: 2/21/2024 Permission is hereby granted to: Stathakos, Nicoletta 1023 79th St Brooklyn, NY 11228 To: construct accessory in-ground swimming pool as applied for. At premises located at: 895 Jasmine Ln Southold SCTM # 473889 Sec/Block/Lot# 69.-3-24.1 Pursuant to application dated 1/22/2024 and approved by the Building Inspector, To expire on 8/22/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector e� •i y 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 https://www.southoldtownU.g!iv Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspection I 24 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: �- OWNER(S)OF PROPERTY: �„ Name: " , ill v' _s SCTM#1000-L. Project Address: 05 ��Ml 6�'Mj'cA 4"71 Phone#: J�, -7 - ��L� Email: Mailing Address: 02-3 f s:."IJ' /" q !" r I 2_,7 ), CONTACT PERSON: Name: A t%6 l l Mailing Address: 1 kf z� I U--ep,U--eIaCe- Phone#: i' �I Email: f�T )'qe& '(0 yr DESIGN PROFESSIONAL INFORMATION: Name: 1113 (t Mailing Address: !tL bi 11"M'-, ' 10T7 Phone#: 031- Email: CONTRACTOR INFORMATION: Name: .-Aldhjl- A�JAM� Las I r/ Mailing Address; q 9f- �A C II-& (ACC ! 7(/_�Y Phone#: q" 1�� Email: DESCRIPTION OF PROPOSED CONSTRUCTION ��� ❑Re air ❑Demolitio Estimate,� of Project: ❑New Structure ❑Addition ❑Alteration p cyst VOther am ( X3 Will the lot be re-graded? MY'es El No P130L, ATq Oci+/ Will excess fill be removed from premises? NYes 11 No 1 PROPERTY INFORMATION 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 X,o IF YES, PROVIDE A COPY. ❑ 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. 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. Application Submitted By(print name): � i4 K []Authorized Agent Xowner Signature of Applicant: �j� Date: f (J STATE OF NEW YORK) SS: COUNTY OF ) OU i cote++A 6-hF,4-tmcz)S being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the 0 k#j1e4Z- (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 202 otary Public MARGAREF A. KIDNEY lotary Public—State of New York No. 0I KI602► I I ..(Where the applicOPERTY aAUI nt s not It(th(e IliA°' i " N Qualified in Suffolk Countyowner) Y Commission Expires March 8,2027 I, 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 t 1 S ti,g �- e F u oagg lk Cour e art e t o Labor Licensing e fi o su er A fairs � 3 VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 07/01/1978 No. H-4436 ryUFFOf,K COL TY n All i Home I rovement Contractor License � This is to certify that ARTHUR J EDWARDS gry AN MJIMMIEdoing business as ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA 1 SUPP \\ having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR in the Coun of Suffolk. ty Mfs NOT VALID WITHOUT Restrictions Additional Businesses _ 4 V1, DEPARTMENTAL SEAL H1-GC ARTHUR J EDWARDS POOL&SPA CENTRE � � AND A CURRENT _ H26-Pools and Spas/Certified; _ i MMICONSUMER AFFAIRS H3-Pools/SpasIN ID CARD Suffolk County Dept.of � Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE \ Name ' — , ARTHUR J EDWARDS i - Business Name 11TWis ceffktiat the Rosalie D�-.ag� isdutyel ins ARTHUR JEDWA�RDSMASON 1 :)y'the County at suffolk CONTRACTING CO INC DBA(1 SUPP) � Commissioner License Number:H-4436 i Rosalie Draggy � - Issued: - 07/01/1978 CommissionerExpires: 07/01/2024 � � - DATE(MM/DD/YYM " "COR "' CERTIFICATE OF LIABILITY INSURANCE 1211812023 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). g l6d .N .. PRODUCER CONTACT NAME Matthew Ruperto LibertyRisk Management, Inc. PHf . aft_ (631)566-5633 xAIw,� ( 3x1) 9-56,36' 2333 Route 112 E-MAIL m�tkheua{ m em litrert risk org ..... .. ..... Medford, NY 11763 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A ,Greenwich InsulranlcP ,,,,,,,,,,,,,„ INSURED INSURER B Arthur J. Edwards Mason Contracting Company Inc. __..���. ................ DBA Arthur J. Edwards Pool 8r Spa Centre INSURER C: 929 Route 25A INSURER D Miller Place, NY 11764 INSURER E: .-. ••• .... INSURER F: -.. COVERAGES CERTIFICATE NUMBER: 00000005-1766199 REVISION NUMBER: 48 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 LTR TYPE OF INSURANCE L BR POLICY NUMBER MIMIoD EFF POL( EXP LIMITS A X COMMERCIAL GENERAL LIABILITY NPC-1004300-03 01/01/2024 01/01/2025 EACH OCCURRENCE $ 1 000000 ❑ MED gL,5(Any one person) $ uu..�... 000 MYR CLAIMS-MADE )( OCCUR ES Ea accurrenoe $ 30Q X000 PERSONAL 8 ADV INJURY $ 1OQ0,000 GEN,.---........ .. .-..�..... ......� T AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ QOQ0OQ m,...., POLICY FX]J 'C LOC PRODUCTS-COMP/OP AGG $ 2 0,00,000 OTHER: $... AUTOMOBILE LIABILITY OOMI31NE0 SIN-GLE LIMA $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ I AUTOS ONLY I �AUTOS _-.... _M........ERTY..� ...-,-- HIRED NON-OWNEDAUTOS ONLY rOec4(PAMAIaE $ AUTOS ONLY j I A $ UMBRELLA LIAB I I OCCUR EACH OCCURRENCE $ EXCESS LIAB ...L .. 1 CLAIMS-MADE'. AGGREGATE $ DED RETENTIONN$ __ $ $ PER OTH- WORKERS COMPENSATION STATUTE _., AND EMPLOYERS'LUIBILITY " Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE MJR ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/18/2023 at 02:07PM N' YS I F PO Box 66699,Albany,NY 12206 New York State Insurance Fund nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112377925 &I -Im LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 ■ SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J.EDWARDS POOL&SPA CENTRE TOWN OF SOUTHOLD ARTHUR J.EDWARDS P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 394600 06/29/2023 TO 06/29/2024 07/17/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, 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. 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/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 STATE INSURANCE FUND 4 DIRECTOR,iSURANC FUND UNDERWRITING VALIDATION NUMBER: 763749953 immiMII�m o®®�uIu Iwo I�u!I� 00000,00000011735153/ Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-24384919] U-26.3 41 [00000000000117351537][0001-000024304919][##G][16180-02][Cert_NoP-CERT_I][01-0W01] roRK Workers' CERTIFICATE OF INSURANCE COVERAGE A Coni , nsduon Btaaird 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 ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC DBA: ARTHUR J.EDWARDS POOL AND SPA CENTER 6317440174 929 ROUTE 25A MILLER PLACE,NY 11764 Work Location of Insured(Only required if coverage Is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations In New York State,Le.,Wrap-Up Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carver (Entity BeingListed as the Certificate Holder) Standard Security Life Insurance Company of New York TOWN OSOUTHOLD PO BOX 728 3b.Policy Number of Entity Listed in Box"l a" SOUTHOLD, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/3/2024 4. Policy provides°the following benefits: 0 A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑X 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 des above. Date Signed 6/5/2023 By (Signature of insurance carrkWsauthorlzkd reprts6ntailve or NYS Ucensed 6nsuran4e Agent of that insurance cagier) Telephone Number X212 3) 55-4141 Name and Title SUPERVISOR—DBUPOLICY SERVICES IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carriers 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 56 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,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 56 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) DB-120.1 (10-17)ii�llll 5vk1/EY op PPOPEPTY JOSHUA R. WICKS . - S . tot1 -Mapor SURVEYED BY:J.R.W. DRAWN BY:D.T.O. JOB NO.:JRW22-0472 Southold Villas P.O. BOX 593 Center Moriches, N.Y. 11934 5ed ion 2 Ic ehu ice .com Filed;Aumst 04, 1995 -Man No,A-15-4 sic, 'B31-4068106 � vo GRAPHIC SCALE 5111lM o 1(0, 2(40) 3 4697 50MW tOM OF 50UIPaO 5tfF0V COMP NSW YO& Suffolk Cam fax Map No,. 1000-069,00-05,00-024,001 PAt� 5W&MV 091 291202.2 SCFJ.� 1"=20' JASMINE LANE R=220.00 ' S 75043 '10" E 82.64 ' L=18.00 ' a= CURB � — --- VA REAR 11.1FND 205.00' CV n , 1 R/0 WOOD PORCH G o 3 2 STY. FR. RES. � a s' #895 ,7' ONLINE ` PVC FE. 7 1 F 01 IANI 1% 35.3 N 01 S CE L A N WDOD DECK OUTDOOR k' CONC. Uj 81" L o W T5 w ' N O = r. .. ko 0) _ FL CAR COt LOT 1e o 220 t 25' SCENIC EASEMENT FRA SHED 0.22 E ' MN UW FE. GEN. ONUNE GATE 7'E LOT AREA - LINE 17.661.10 S.F. MAP 4.8 p 0.41 ACRES) TAX LOT 10.8 N 75043 '10" W 120.00 ' R. GUARANTEED T0: NICOLETTA STATHAKOS CHICAGO TITLE INSURANCE COMPANY 06 ABSTRACTS. INCORPORATED LAND ABSOLUTE HOME 1[ORTGAGE CORPORATION, ISAOA mn RI T3 U LITHOWED ALTERATION OR TO THIS SLOVEY&UIP eW04 A TJCEt ED LAND SURVEYORa SES.IS A VIOLATION OF SECTION 72M,SL - a OfPIETY YORK SATE MILCATIMIN LM (3} ONLY BOUNDARY SAY mAPS wrrw THE SI VEYOR'S Eft SEAL ARE�! TRUE AND CORRECT COPIES OF Tt°I€SU � _13'7 RFFEAR i TH% W, .�'TH3T WAS PREPARED LR ACG WH THE CURRENT"WIND CODE OF PRACTICE FOR LAND YS O BY the N YO STATE✓E -ASSOCIATION OF ` LMD S, INC THE T IS T4 PERSONS FOR THE BOUNDARY SSURVEY MAP IE NI IS PREPARED,TO TTTrX COMPATo E[+NAL�'. D TO SM _ C LENDING INSTl1t�T N U €14 THIS; INOW SURVEY (4)THE�T04S HEREIN ARE TRANSFERABLE (S)TME LOCATION UNDEWROU W - OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND MEPP MUST ESTW7M IF ANY UNDERGROUND IMPROVEMEI OR ENCROACHMENTS UM OR ARE SKOWN,THE NPROVEMENTS OR c.=0ACH•ENTS ARE NOT COVERED BY NIS SUNY. {B}THE OFFSET(OR DIMENSIONS)SHOWN HEREON FROM TK S'TRUCTLMS TO THE PROPERTY LINES AITE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE P40T INTENDED TO GSE THE ERECTION OF FfINIESREtAA1 WALLS I PATIOS PLANT1 A� ADDITIONS TO SUILD]Ia AND OTHER TYPE CONSTRUCTION,(7) PROPERTY COMER a 1UOEIaTS WERE --- -- --— — --- —.—— -—­ ....,.,,o c, n .rc nC a " .w "AwU ARc UnT mMpAwrrm- i raehrm MD B F B Ahanlnum To Fifer From Mar 3 Pump To -To P.I.. okN" A Rosea woi F Plan Piping , Arrangement wo Sftivm #4� 42"_j Section B—B r ww P51 Corcreb ��of N 7/ y APs O�� H � dr 0" 1 Section A—A Typical Wall Section �� X43595 �OPcoo�nNP' SIZE A B C D E F G H AREA CAP , Ni' Ie-4-�4 Si eOS FEET FT FT FT FT FT FT FT FT SQ. FT GAL. `'` n Pmvbaw 14 X 28 14 28 13 8 4 3 3 8 350 12,000 r �at 1_�w'w&A �`7�j ��Shy(/►�� �/j e POOL&SPA CENTREAddrew 16 X 36 16 36. 12114 6 4 4 8 576 2116001 pERMACRETE WALL SYSTEM 18 X 36 18 36 12 14 6 4 5 8 648 24,300 X929 Route 25A Miller Place NY 11764CUT °° 20 X 48 20 48 14 14 6 4 5 10 800 33,000 , (631) 744-7185 FAX (631) 744-0174 (4) 371 -12B 24 X 44 24 44 18 14 8 4 8 10 798 35,000 Suffolk License #4436—HI 24 X 48 1 24 48 20 16 8 4 6 10 900 38,500 Nassau License #HI74450000