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HomeMy WebLinkAbout50533-Z r TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE , SOUTHOLD, NY i"91 No. 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 #: 50533 Date: 4/10/2024 Permission is hereby granted to: Gill, Michael PO BOX 507 Cutcho ue, NY 11935 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1875 Jackson St, New Suffolk SCTM #473889 Sec/Block/Lot# 117.-9-14 Pursuant to application dated 2/14/2024 and approved by the Building Inspector. To expire on 10/10/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector „tood 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 htt -,/ i„ P ( ) ( ) www, outicalltn_y'� L Date Received APPLICATION FOR BUILDING PERMIT S�3 For Office Use Only J0 PERMIT NO. Building Inspector: ry / r ��/////r%/Jr//dl//////�j //� ��G/�/il�//� //�r�r/✓iii r r/i /G r�'��%r°�/ ri / /r Date., j -�4- --�LLI r Project Address: f-%') S+ J P 11 hone#: _ Email: Mailing Address: y , Npo Q-%�"� ,,, ..., r ,.. l ..r.. rrr, r ,,.,.r. .///�r ./. ✓/./ rl r/ ,.,v,n 11 rm�„rrir' r ,,..,, r ✓r,t���r G, //�,iri.,�///�,r ,�wi//�:.c �,/.,,ri r%/r, rii,//lac/,�/rr���i„ � /./i r:v�%/G/// a/,rG/r „//�/;ir:,,0///�i;i��rlh/c%//�%�r�i�ir rr`//JJ�%�IttrN%,��. Name: Mailing Address: Phone# Email N 1 � 1 r.r/ � o/ � r : /C,~yfl:✓/,,,.,�r,;,rl r,r r/ r r//,r r„9,���; 'A� ����,J�!!f///;r„�1a,r//CLr/,�////�///�%//r„�/G,c,/ram,,,,,/�"ro,/;F/,,,, ,, ,i,�r%.,,/%r;,'�,°O�/I/,/ii !%/ir,%rlir//!�1!%r%�%/%,%�%�i%/ w m _ Mailing Address: �j , b Sail Phone#: tit ?1,S S 4 Email: o r r J �/ r�� /j��%%��%ir ri'rr/r,rar/Ir, ,,r/ rl riroir d9/rr irs. /!L/Name: Mailing Address: �3 a cfmAO.C'�. l C 1St_, 1 Phon 11 e#: , 1 Email” 'd�,�y��r��.w,� � AzkA � r � �/ �rf li i, r/1 / El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other 1 $ ' 7 60 : 6 Will the lot be re-graded? aes ❑No Will excess fill be removed from premises? eyes ❑No 1 G ;; ';pP� Ty IN�Q� ��©� 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 ❑No IF YES, PROVIDE A COPY. tE r Readirtg Th+ owr'ar�sorgractor/desEgn'prctfessianal�S respa aEbfe for ali drainage and%dam f wa#fir rs uE s as prgvided by „ ' r i er,��vhfe� q�pfJCA'n�}1V i�Nki;E�Y MAFJE"m the gu7ldfr��Depprtment for the issuance;©f a"Bniltllrtg Permifpurst�nt tea the Buiftifngjf�rne%== the / rs uff©tk, klrrty, , and atker "icable 44WA"6rtlinartic¢s or Regu�at�g s,fo} a ,1., drd ii he lrt�ifrea 1i ' iP4. ,/// ,: r'�i�,""ft �S ",W,-,, po ce)/ Ytl4lS Y�a�4„004 with���'skllliiCd�lB it#Wby,`4rSi�rM+$rlSSFI�, housfn e r}tl rar�z/antl tigrad tt krhurFied inspec#or cry premises arrd=iri Wfitli syfar necessary Insp�Cion$.A akse statement rrrarle he►ein�r�' prtkaa 'a4,9i�i�11 ¢$r7?r,p41f7(YlifltOGti4rfxy4.4t46he�i6iN !{1rk$t8$lJf3llllf "' r Application Submitted By(print name): � � ,� z� Authorized Agent ❑Owner„ Signature of Applicant: Cares. a ` ... late., a , - STATE OF NEW YORK) SS: COUNTY OF z" being duly sworn, deposes and says that(s)he is the applicant (Name of individual signin contra¢ above named, (S)he is the Art e-mi- 1.3 (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 ��20 2� Notary IPu i l blit ate of New Yofk No.0J 353ib,Suffolk County PROPERTY OWNER AUTHORIZATION Cftmisdo""ExpiresIV=21,2026" (Where the applicant is not the owner) 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 e Building DeDartMent ApRlication ALUTHORIZATION (Where the Applicant is not the Owner) S UQ- residing at, (Print property owner's name) (Mailing Address) o hereby authorize < (Agent) to apply on my behalf to the Southold Building Department. �ry Signature) (Date) (Print Owner's N40, w Suffolk County Dept.of p9�� �rla1 ! Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE y Name MYKHAYLO ABRAMCHUK Business Name AQUA COASTAL INC This certfies that the ,earer is duly licensed License Number H-43470 y the County of Suffolk Issued: 09/19/2007 �map, Expires: 09/01/2025 Commissioner I CERTIFICATE OF INSURANCE COVERAGE A r 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured AQUA COASTAL INC (631)697-1289 PO BOX 226 ISLIP TERRACE,NY 11752 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specificaw limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 202506176 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 RTE 25 3b.Policy Number of Entity Listed in Box"la" P.O.BOX 1179 DBL 5408 58-9 SOUTHOLD,NY 11971 3c.Policy effective period 04/01/2023 to 04/01/2024 4.Policy provides the following benefits: N A.Both disability and paid family leave benefits E] 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 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 described above. Date Signed 218/2024 By A4 ~;CA— (Signature of insurance carrier's authorized representative or NYS Ucansetl 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 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 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. D13-120.1 (10-17) Certificate Number 774576 SIF New YorklState Insurance Fund PO Box 66699 Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 202506176 PROACTIVE BROKERAGE INC 926 SUNRISE HIGHWAY916 WEST BABYLON NY 11704 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER AQUA COASTAL INC TOWN OF SOUTHOLD 38 CARLETON AVENUE 54375 RTE 25 EAST ISLIP NY 11730 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11415 789-5 212497 04/01/2023 TO 04/01/2024 2/7/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1415 789-5, 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/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MYKHAYLO ABRAMCHUK(PRES) OF ONE PERSON CORP AQUA COASTAL INC 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 DIRECTOR,INSURANCE FUND UNDERWRITING I:CK I INUA I C Ur LIACMILI I Y IMOUKANUr- 217/20 24 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(s). PRODUCER CONTACTNpAflg,_ Adapt Rostkowsk'( PROACTIVE BROKERAGE INC PHONE , y w3t482-18604, ... 8 � r�5 926 Sunrise Highway E-MAIL_AQp Infa proactivebro.com West Babylon,NY 11704 DING COVERAGE __�ITITmITITmm mmmmmmmm,,,NAtC# �' .....W _ _.-.....a.................. ... ........ ... �._..., w ...,�,�,,,,,,,,m.m INSURERA.:w IAtlantlC CiaSUait1/...,m.... .,_. ..._�.��_�......42846.�_........ INSURED INSURER B Aqua Coastal Inc. INSURERC: 38 CARLETON AVENUE INSURER D _..,,. __.. EAST ISLIP NY 11730 INSURERE: 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 S -----. POLICY NUMBER M.. MOLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY ..s EACH OCCURRENCE $ 1 000 000 . ❑ C7A�711u� 17 -._ _ CLAIMS-MADE /� OCCUR R Nll,mA ITm Ea cculrenc] $ 100,,000,,,,, MED EXP(Army on erson $ rJ,00 A _.......................m. Y L035013818-5 7/3W2023 7/30/2024 PERSONAL&ADV INJURY $ 1,00Q,000.. _................. GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z 000,OOOm POLICY JE� 7 LOC PRODUCTS COMP/OP AGG $ 1 w00Q QOQm _ .. OTHER: $ COMBINED SINGLE IJMfT' n.AUTAUTOMOBILE LIABILITY $ J.�a�cc�¢�nblm..._......_____ ...................... ..........__.._.... .., ANY AUTO BODILY INJURY(Per person) $ -_ OWNED SCHEDULED _...... ............. ........._.....................�m m AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED F_ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY IPA a UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OEA RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE w _ ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT ,$ OFFICERIMEMBER EXCLUDED? N/A '�"'"""""" (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/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The following are included as additional insured required by written contract subject to the terms and conditions of stated polices:TOWN OF SOUTHOLD 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 54375 RTE 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 1179 AUTHORIZED REPRESENTATIVE SOUTHOLD NY 11971 If I e::;;-/r�,�&i 5��A t A,A 1988-2015 Ad,6RD CORIPORMICIN. All rights reserved. SURVEY OF V 'r PROPERTY SI TUA TE TOWN OF SOU TH OLD a APR 1 2024 SUFFOLK COUNTY, NEW YORK S85 43 1 Q E TAX No. 1000-11700-0900-014000 I �` SCALE 1'-20' , 3LI.NE 18, zo2� Y Lz Tax Map Lot 13 NIO/F of s"ko o bo WHITECAP NORTH FORK '"Wla w•° AREA — 15;722 s . ft w LLC 0.384 ac. FF o rr Rs'S W e'K> F� ca F� Liz o p 0 t -I.,.r Ll��;.3 20.2' Ln ca�a l L k O'd, r FE 0/1 Tax Map Lot 12 N/O/F of THOMAS 1wCKENZIE + Tax Map Lot 1. :. C avz.rI ::� � D 20 � iB75 a Ln d N 0 16.41 r - � 'rya t�3 STEP EQpEOF tad�."""""".-�..�.„-»e.�.—,,.,..._..." .....^^,«»....w.�.. .�,.. ..,„...,...�.».. ,......, N85'14 219"W J,�.GEND: J�C � - H UTILITY WIRES KS 0 S TR E P T qL V"UTY POLE WATER METER AERIAL LAND SURVEYING, D.P.C. etc. k=lmd Alis comnww w Aw "1st F�WX 1 @Wl N6N 1 24 AW W.' 'ANC,' *" Come. Mojq wN low„w 11041 WIMAINVINMCN QM WIRMWUMALL EM M ELEC. METtR f-WAIL SNlli LbWA1p SIP C tfiii. M .. WVM,x WV*"*AkI,PCA4,I,iMkftVR 4V*,, : rrwn w r.wwr�wr Door r +d www r Goa.® OAS METER O'bSTNRCT61000 LOT:Oi 4.000 V1„,Ox,I75.010 SECTIOW:1 17„OO WAP/l NO,: N A arm* T.01 w nxM ww IILE ur ,w�dr w rr a+wN anWw .ra wvMu awe4 M. P OF; 1401 ON A F1LED �"'u"RJISEdPMI58OR MAP" . - +xrAwYwr wwm w�mw +ww rewM�Me�clmraw wr�,.«» ar.ww TITLE P!N04 N,+�Ik N, MAP FILED GATE: N/A COUNTY TAX MAP V 1000•-1 17 0900-014000 SITUATED AT,, TOWN) OF' SOvIIMOLI? slus lvisION MAP LOT&KOCFi 'S: NA �,,, N wtlgf�Au11G�ld liEk AO CN 0A1E ANE Ilk 2023 Ww Tax Map WHITECAP NORTH FORK. ...... F{C.}L)S 4. . � i LLC . . p .�- — 5IhtC OD CSC) f f NC E I �M PAVE R WALKWAY � C•f(AIIJL.IFJK f�NCI�� CI. S ' 0 GRAVEL. DRIVEWAY a... LJ LjiU.- w 7IONE CURB 46'-8' ACCESSORY E";`ORY AN Ab k _wwww 1i 7XI ill tR � Nil �` r p � s 7"3. 14'-0' "/ ,�'✓" r"', �, o UJ �,;�..�._.s.,....m... . m 4 a n IIO J � 1a �•� p ._ � gyp; rm ¢'ti, I� Tax Map Lot, 14. r, 8 " & 'STEP 8's l WAI KWAY I)C c:.: OF PAV!FIv I N i °42'�4539W 111 . 91__...... _ __ ..... ____ .... PROJECT: II TITLE:POOL DIMS//POSI7IIXJ �"`clu AR AM ISS L,s���r10 1870 JACKSON STREET �A� SK �jr'jBO HO OO,LANE SOU Tp{00..0 NY 9707R NEW SUFFOLK,NY DATE: oa/ay2ou PROJECT NUMBER: 23-09