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Home My WebLink About50686-Z 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#: 50686 Date: 5/15/2024 Permission is hereby granted to: Karrass G Trust 1615 Stanford St Santa Monica, CA 90404 To: construct accessory in-ground swimming pool as applied for. At premises located at: 500 Youngs Rd, Orient SCTM # 473889 Sec/Block/Lot# 18.-2-18 Pursuant to application dated 4/4/2024 and approved by the Building Inspector, To expire on 11/14/2025. Fees: SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector arc 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.�s://www.souLholdtowiitt ►Ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only V PERMIT NO. Building Inspector: Applications and forms must be filled out in their entirety. Incomplete i 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: .� ,R��0.55 SCTM#1000- OI 02 oW Project Address: 500 yo v n L1 5 V,-1D ®r l � Phone#: Email: Mailing Address- CONTACT PERSON: Name: Long Island Pool Care Corp Mailing Address: 50,000 Main Rd Southold, NY 11971 Phone#: 631-765-8285 Email: Ii.poolcare@gmail.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Long Island Pool Care Corp Mailing Address: 50,000 Main Rd, Southold, NY 11971 Phone#: 631-765-8285 Email: li.poolcare@gmail.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: lil0ther inground pool $ 2=Q r) Will the lot be re-graded? ' Yes ❑No Will excess fill be removed from premises? RYes ❑No 1 PROPERTY INFORMATION Intended use of property: RESIDENTIAL use of propert DENTAL �� F�'Existing RE Zone or use district in which premises is situated Are there any covenants and restrictions with respect to this property? Yes iONo IF YES,PROVIDE A COPY. RESID ENTIAL E N TIA L t 6, r Aber Rear^i'il w° The owner/contractor/design profession responsible for all drainage and storm water issues as provided by 8 i i' g Department for the Issuance of a Building Permit pursuant to the Building Zone Chapter 236 of the Town code, APPUCATION IS HEREBY MADE to the Building Depa ordinances or Regulations,for the construction of buildings, Ordinance of the Town of Southold,Suffolk,County,New York and other applicable taw to comply with all applicable laws,ordinances,building code, additions,alterations or for removal or demolition as herein described.The apand In agrees herein are punishable as a Class A misdemeanor pursuant to Sectionp p 23Uo s of the New fork State Penalwv inspections,False statements made h � housing code and regulations and to admit authorised inspectors on premises and in buildingis)for necessary Inspe Application Submitted By(print name): �--�Sa�� BAuthorizedAgent OOwner Signature of Applicant: Date: - L4 _2`J STATE OF NEW YORK) S COUNTY OF �� 0 I V y being duly sworn, deposes and says that (s)he is the applicant Name of individual signing contract)above named ( g g v , (S)he is the �..m. ..��. .. .__..._ � _ontr�� or,Agent,f� ps�rate .n .�-_.» .._...� ... ...�.. it, g Officer, etc.) of said owner or owners, and is duly authorized t )r 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.applicdtion file therewith Sworn before me this �day of 20 2- _....._._ ... .t tary Public TRACEY L. DWYER PRCI) ERT"t OWNERLJTH � 1 j0P,l NOTARY PUBLIC,STATE OF NEW YiC7FlK _ ... ®, _ ....,.. NO.01 DW6306900 (,Where the applicant is not the owner) QUALIFIED IN 3UFFOLK COUNTY COMMISSION EXPIRES JUU NE�30,2 P9� �S / � V►— residing at 1"SC V +�1 G - y"J Long Island Pool Care ....do hereby authorize Corp. to apply on my ehalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name �b LONGISL-10 GANCONA DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 4/4i2024 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 endorsements. PRODUCER CONTACT 711 Union ue NY 11931 �OM itnlzd3 nSa2ft ure com "O 631)72.. 3591 Neefus St e Agency x � ( S w)_ 5 , .. m INSURER@)AFFORDING COVERAGE NAIC# INSURER A:PhiladeI hip a Indemnity Ins Co „_...... 1.8058 ......". ".,.._..m,.." .. ..._____...._, .."�,...___ INSURED INSURER B.WesCO Insurance CO 25011 Long Island Pool Care Corp WSURERC _ 50000 Main Rd INSURER D__ ... Southold,NY 11971 m "..................."._ ..... JN[WRER E INSURER F: COVERAGES CERTIFICATE.NUMBER EVISION 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. "ih—sk TYPE A X COMMERCIAL OGENERAL"CE LIABILITY POLICY NUMBER LIMITS 1,000,000 ADDL SUB,R (POLICY EFF POLICY EXP I X TY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PHPK2540741 4/30/2023 4/30/2024 DAMAGE TO RENTED $ 100,000 PPLN9SIL3 ............ .... .5 5,000 ,. .... 1,000,000 ".PERSQN:AL Y ADV INJURY. �,,,,,,,,,,, _GEN L AGGREGATE LIMIT APPLIES PER: 2,000,000 R: GENERAL AGGREGATE � .,W.... POLICY ,.JECT LOG '..PRODUGTSmm COMP/OP AGG..$_"""....... 2'��'��„ OTHER: $ COMBINED SIl"iGLE L'dMIT AUTOMOBILE LIABILITY ."LE�'_IROI'91tlf�P,IL. ............�,,,�....... ...�_—....... ANY AUTO ."gQDILX,.I„NJURY Per eson)......................." """_.................,,,,,,...... "..... OWNED _NJURY Per accident ......... _._............. AUTOS ONLY SCHEDULED AUTOS @ODILY I,,, ,,,,,_,,,„,,,,,�m,,,m,,,,,,,,,� _ {�yII� ((yy AUTOS ONLY ALITO�OI049 PROPERTY DAMAGE "Paragc�dentL, UMBRELLA LIAB OCCUR EACH OCCURRENCE $ .,EXCESS,LIAB CLAIMS—MADE ,AGGREGATEr._.".""_""".._.."""""....,,,,,,_, ..............."....�,,, DIED RETENTION$ _ B WORKERS COMPENSATION PER �OTH- Q.AUTE ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WWC3706134 4/19/2024 4/19/2025 mmm _.. _.... 500,000 AND EMPLOYERS'LIABILITY OFFICER/MEMBER EXCLUDED? N/A .L.EACH ACCIDENT $ (Mandatory in NH) E,1,DISEASE„EA EMPLOYEE $ 500,000 If yes,describe under 500,000 .DES RIPTION FQPERATL..NSbelow E,L,pjag8agL-PQLICYLIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIF ATE HOLDER CANCELLATIO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd PO Box 1179 Southold,NY 11971 AUTHORIZE D REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Nrr Workers' w. sORK Compensation CERTIFICATE OF INSURANCE COVERAGE 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 LONG ISLAND POOL CARE CORP 631-765-8285 50000 MAIN ROAD SOUTHOLD, NY 11971 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 275174033 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 54375 Main Rd 3b.Policy Number of Entity Listed in Box"la" PO Box 1179 DBL357404 Southold NY 11971 3c.Policy effective period 04/19/2023 to 04/18/2024 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: 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 ant 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 9/28/2023 By 0, 4f (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 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 sox 4B,4C or 513 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) 1111111,m111iiii imi1iiimii 1111I )ii III JOSHUA R. WICKS P.L.S SURVEYED BY J,R.W DRAWN BY D-10, JOB NO.JRWx3-oz38 s P.O. BOX 593 B Center Moriches, N.Y. 11934 JoshuaRWicks®gmail.com _ #831-405-8108 - --'£ GIRAPHIC SCALE S 77°36'00" E 200.00' 5U)�JVfy J PpUPf,�TY 4'1 E q CO ' O ' asa1nuT DME tar -. a�' .sTRUCrrjRE 03 o � s p"'� v = �O O I ~ F p M FAR, RES Q I #500 1 O F, PAL FE, s a' N 77°36'00" WCO 200.00' - LOT AREA - 0, ACRE( CE 00 0. ( 46 ACR A E MAIN ROAD CUA TO: sl ABSTRACTS. INCORPORATE® -r CARP KARRASS TRUST, ISAOA FIRST AMERICAN TITLE INSURANCE COMPANY ! - -