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HomeMy WebLinkAbout50504-Z tF81 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 #: 50504 Date: 4/2/2024 Permission is hereby granted to: Moraitis, Simone ....................................� ... _---..........................................................................mm. - ....__.................... —a...... ���..........�...............................................����..m........ 6 Blenheim Dr.ee„�.�_ Manhasset, NY-1 1030 To: Construct an in-ground swimming pool to an existing single-family dwelling as applied for. Pool and pool equipment must maintain minimum side and rear setbacks of 15 feet. At premises located at: 2045 Willow Dr, East Marion SCTM # 473889... ....... — _ .._... ... Sec/Block/Lot# 22.-5-2 Pursuant to application dated 2/20/2024 and approved by the Building Inspector. To expire on 10/2/2025. _a Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 ...... .......................................................................... Total: $400.00 ...................................................... .....------.-.------ .�� .............._ Building Inspector °";; TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O.Box 1179 Southold,NY 11971 0959 ,A � Telephone (631) 7654802 Fax(631) 765-9502 l��tp Date Received APPLICATIONFOR, U .DNG PERIVIIII ( ° For Office Use Only PERMIT NO. �" D i— BuildingIns ector:—J-4b, FER Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an ; Owner's Authorization form(Page 2)shall be completed_ y _ �_ �-� Date: n OWNER(S)OF PROPERTY: Name: y ern,O1iu.i k kegs LLB SCTM#1000- Project Address: S ; lam-bf�, �O�g� �w l Phone#: Email: h Orvi 2 b(,l i(c(r o Mailing Address:. b$b Y S ` 1 1Le3 CONTACT PERSON: Name j (� - c i SeJV,�ce Mailing Address: 2d . 10 1 1 i't- S I'J)aJ 17L2Cn Phone#: 631-5C9 I Email: DESIGN PROFESSIONAL INFORMATION: Name: , f� Mailing Address: P, � I I t/1 Df4 Iv Phone#:_S 14 — 110 _53q�— Email: (`I�1 Rt�- CONTRACTOR INFORMATION: Name: Mailing Address: MY 10VI Phone#: --1 Email: DESCRIPTION OF PROPOSED CONSTRUCTION PSNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other C ti ' 1,�- `� �0 Will the lot be re-graded es , No Will excess fill be removed from premisesT Nes 1 PROPERTY INFORMATION Existing use of property: v� -I Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to 0 , L this property? []YesgNo IF YES, PROVIDE A COPY. heck Box After' ,eWll ng' 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 210AS of the New York State Penal Law. Application Submitted By(print name): Tenn i '- Lee-A-'� uthorized Agent ❑Owner Signature of Applicant: Date: `( STATE OF NEW YORK) SS: COUNTY OF �.) ,J-�n`n I�e ✓ '�-e d S 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 rLl\i3,.4 o day of 20 tary Public rXP, ��.f0 �"` (Where the applicant IS not the owner) STATE CF I, W r residing at eoo " Kfd�D rd- &N l l-7b3 do hereby authorize a r -P d- to apply on my behalf the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 3 u i ry I 2. e CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/02/ v24 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(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 rights to the certificate holder in lieu of such endorsement . CONTACT PRODUCER NAME Matthew Dale ' Farm FamilyInsuranceNtI, 631-744 3350C, 631-744-3383 -7 3 E-MA dale L matt. farm-famil Cpm 85 Echo Ave-Suite 2 �.,,. � y:.�..�...... INSUMhSjAFFORDING COVERAGE NAIL _Miller Place NY 11764 INSURERA: Farm Family Casualty Ins Co 13803 — ...... . INSURED INSURER B: United Farm Family Casualty Ins Co 29963 Bukowski Homes Inc INSUI ER c PO Box 291 INSURED_ INSURER E: �- HoIIIrGOk NY 11741 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. �w-...._.. _ ---.... _........ m.,.,,... � ._. INSR TYPE OF INSURANCE AO U POLICY NUMBER MM D�DfYYY`Y MM/LID/YYYY LIMITS UTR A X COMMERCIAL GENERAL LIABILITY 310319172 03/15/2024 03/15/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PRE.P41§ S, 111rrrenc 100,000at.. $ MED EXP(Any one person) $ 5,000 ...._. - .......,_. _ ._..-. ... ..,_...._. Contractual Liability PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 .. ....wwwwwwww ' ✓ PRO- POLICY E JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHEW B AUTOMOBILE LIABILITY 3101C8463 01/20/2024 01/20/2025 COMBINED SINGLELIMIT $ 500,000 (en accJdehll H',.ANY AUTO BODILY INJURY(Per S person) $ AUTO ONLY ^. SCHEDULED BODILY INJURY(Per accident) $ ^�.rr HIRED �/ NON-OWNED 4"}PF,R"CY DAMAGE $ - .... /.".. AUTOS ONLY /-,,,�, AUTOS ONLY Plgr---ac6denly UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ B WORKERS COMPENSATION 3104W7007 03/14/2024 03/14/2025 PER OTH- BILITY OFAM ER FCER RIE EREXCTNERIE YIN N/A W EASEE ID EMPLOYEE.-..-.�....�-. 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 (Mandatory in NH) E.L.DIS $ 000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,.000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Tile / Carpentry Town of Southold is listed as additionally insured on policy 31031_9172. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YOB Workers' CERTIFICATE OF TAT Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name&Address of Insured (use street address 1b Business Telephone Number of Insured only) 631-569-4513 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, 1c. NYS Unemployment Insurance Employer Registration i.e., a Wrap-Up Policy) Number of Insured Bukowski Homes Inc PO Box 291 1d. Federal Employer Identification Number of Insured or Holbrook NY 11741 Social Security Number: 20-5300333 2. Name and Address of Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage United Farm Family Casualty Insurance Co. (Entity Being Listed as the Certificate Holder) 3b. Policy Number of Entity Listed in Box"1a" Town of Southold 3104W7007 53095 Route 25 3c. Policy effective period PO Box 1179 03/14/2024 to 03/14/2025 Southold NY 11971 3d. The Proprietor, Partners or Executive Officers are o included. (only check box if all partners/officers included) o 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"la"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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? [x YES []NO 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 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: Matthew Dale (Print name of authorized representative or licensed agent of insurance carrier) Approved by: Aril 2 2024 (Signature) (Date) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-744-3350 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(9-15) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 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. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-105.2(9-15)REVERSE YORK Workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured BUKOWSKI HOMES INC 631-569-4513 PO BOX 291 HOLBROOK,NY 11741 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Onlyrequired if coverage is specificallylimited to certain locations in New York State,i.e.,Wrap-Up Policy) 205300333 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 3b.Policy Number of Entity Listed in Box"l a" 53095 Route 25 DBL686987 PO Box 1179 3c.Policy effective period Southold NY 11971 1 03/14/2024 to 03/13/2025 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. 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 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 4/2/2024 By �Jda 4� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat 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 4B,4C or 5B have 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) 11111111111°°!� 11°1°°°°° �°� )°I1I1I