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HomeMy WebLinkAbout50779-Z " TOWN OF SOUTHOLD BUILDING DEPARTMENT 1 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#: 50779 Date: 6/4/2024 Permission is hereby granted to: Malloy, Peter 1670 King St PO BOX 476 Orient, NY 11957 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1670 King St, Orient SCTM # 473889 Sec/Block/Lot# 26.-2-42.3 Pursuant to application dated 4/24/2024 and approved by the Building Inspector.. To expire on 12/4/2025. 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 Telephone (631) 765-1802 Fax (631) 765-9502bttps:/fw ww titbol to ° n Date Received PERMITAPPLICATION FOR BUILDING 21 �, y For Office Use Only 4 PERMIT NO. 7J� Building Inspector: PR 2 4 202 Applications and forms must be filled out in their entirety. Incomplete �i' ai;;! ,°� .� t r applications will not be accepted. Where the Applicant Is not the owner,an NM.°lw Owner's Authorization form(Page 2)shall be completed. Date: Ll I D1 OWNER(S)OF PROPERTY: Name: A SCTM#1000- Project Address: —10 Sf Phone#: Email: a� v Marlin Address: - (( g C CONTACT PERSON: Name: l Mailing Address: s Aks 12bo way,cy V t`le. N\4 I 1 Q y C( Phone#: V� S� O Email: &�b nn DQhLVS QOI:�S C DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:k&6cL U�S-L )L Maili Address: E 0 Phone#: �'� _ _ Email. DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Si' \J\M %119 Estimated Cost of Project: then Kk U('e '-4 $ 1 Will the lot be re-graded? Xyes El No Will excess fill be removed from premises? ❑Yes XNo 1 PROPERTY INFORMATION g property: vvcfL. Existing use of �� � Intended use of property " bi l k Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to _12)6 this property? ❑Yes ONO 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 210AS of the New York State Penal Law. o Application Submitted By(p int name): � .,P)na �e �C U�(1 C7 uthorized Agent ❑Owner r Signature of Applicant: ) [4/)-6�"& Cate: �� -4 P)-H CONNIE D.BUNCH STATE OF NEW YORK) Notary Public,State of New York SS: No.01 BU6186050 Qualified In Suffolk County COUNTY OF ) Commission Expires April 14,2cQ9 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 hay of april ,20 Q Y Notary Public PROPERTY OWNER'��_UTHQRIZATION (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 Building De aartment Application AUTHORIZATION (Where the Applicant is not the Owner) f r z MA-Li.ci y IC ,residing at k1�G sl icFYur N �� +'� (Print property owner's name) (Mailing Address) I PO r715)�N'T do hereby authorize k 4'7'F- I✓y, A -CUR /C (Agent) to apply on my behalf to the Southold Building Department. (Ow ature) 'Date) Mft PE IZ <<t� efe r rca toy (Print Owner's N e) I CERTIFICATE OF LIABILITY INSURANCE [)ATE(MM/°°'�,""' A 0212112024 T 11 HI 11 S 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 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 ONrOT Nicholas Zulkolske Brookhaven Agency,Inc. PHONEWC N. 631 941.4113 jAM FAX , 631 941-4405 100 Oakland Ave,Ste 1 t4AIL certlllCates brookh,arrenaa enc .com Port Jefferson,NY 11777 INSURER(fI)AFFQRDIN9j C VERAGE INIIJRERA: Philadelphia Indemni Insurance Company_ INSURED • Merchants Mutual Insurance Com an Patrick's Pools,Inc. Wesco Insurance Company PO Box 3024 INgURgIR D East Quogue NY 11942 R 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 CONTRACTOR 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. IN9R ADOLSUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE M E X COMMERCIAL GENERAL LIABILITY EACH OCC E S1.000.000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED 100 000 X Contractual Liability PHPK2658571 0212812024 02128/2025 ME D ExPA�y ona oarsonl 5 000 PERS NAim$ADV INJURY $1,000,000 EN`LAGGREG T LIMIT APPLIES PER: GENERAL AG R ATE 2000,000 MPRO- POLICY 7 LOC RODUCTS-O MPIOP AGG 2,900L000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $500,000 B X ''ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X X CAP9267113 07/12/2023 07/1212024 BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS IX AUTOS ear I) UMBRELLA LIAB OCCUR EACH OCCURRENCE , EXCESS LIAB LAWS-MADE AGPRRGATE SS WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY ER ANY PROPRIETORIPARTNER/EXECUTIVE I E.L EA CIDENT 1100,000 C OFFICER/MEMBER EXCLUDED? Y N/A WWC3647363 05/13/2023 05/13/2024 '" (Mandatory In NH) E,L,01 EA E-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION QE.OHM1JONS below E„L,.DISEASE-POLICY LIMIT 600,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as additional insured per written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <NSZ> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD YOR workers'STATE 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 Carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE, NY 11942 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) 262929943 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 Ilia" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2023 to 05/12/2024 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. Ej 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. �"/26l2023 Date Signed BY U40 4t (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 515-829`-5100 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 6200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if sox 413,4C or 5113 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 DS-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 11111111 °°11°11°°°1°1°I11°�°°°°"°IIII1I K Workers' CERTIFICATE OF A + o IF+ nsation NYS WORKERS' COMPENSATION INSURANCE COVERAGE i3olllrtd •" 1 a.Legal Name&Address of Insured(use street addresfi only) 1 b.Business Telephone Number of Insured 631-996-4667 Patrick's Pools,Inc. PO Box 3024 1 c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured("Only required ff coverage Is specikcaffy limited to 111d.Federal Employer Identification Number of Insured or Social Security certain locatlons in Now York State,!a.,a wrepr-up Poffc� Number 262929943 2.Name and Address of Entity Requesting Proof of Cove� m age 3s.Nae of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 3b.Policy Number of Entity Listed In Box"1a" Town Hall Annex WWC3647363 54375 Main Road Southold,NY 11971 3c.Policy effective period o,111419n9a to nxllaMnm 3d.The Proprietor,Partners or Executive Officers are Included.(Only check box if all partneralof eers Included) []X all excluded or certain parinerslofficers excluded. This certifies that the Insurance carrier indicated above In box"3"Insures the business referenced above In box"I a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Rom 3A on the INFORMATION PACE 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 120. 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 10 there are reasons other than nonpayment of premiums that cancell the policy or eliminate the Insured'from the coverage Indicated ort 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upson 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 now Certificate of Workers''Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New Yorrk 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: Nicholas Zulkofske (Print name of auuthoKud mpaesentst ve or Ocefted agent of Insurance oarMsr) Approved by: 1 (69gnatu ) (Date) "4v AV Title: Authorized Agent q Telephone Number of authorized representative or ti�ensed agent of insurance carrier. 631-941-4113 Please Note:Only Insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NQI authorized to Issue it. C-105.2(9-17) www.wcb.ny.gov �i I NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY @ Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-03651 F:(631)444-0360 www:dec.ny.gov LITTER OE NO JURISDICTIO April 30, 2018 Peter Malloy Mary Perica PO Box 476 Orient, NY 11957 Re: Application #1-4738-01108/00009 Malloy-Perica Property: 1670 King Street SCTM# 1000-26-2-42.3 Dear Applicants: Based on the information you submitted, the Department of Environmental Conservation (DEC) has determined that the proposed additions to the existing single family dwelling are more than 100 feet from DEC regulated freshwater wetlands. Therefore, no permit is required pursuant to the Freshwater Wetlands Act(Article 24) and its implementing regulations (6NYCRR Part 663). Be advised, all construction, clearing, and/or ground disturbance must remain more than 100 feet from the freshwater wetland boundary. In addition, any changes, modifications or additional work to the project as described, may require DEC authorization. Please contact this office if such activities are contemplated. Please note that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies or local municipalities. Sincerely, 10040 Mark Carrara Deputy Regional Permit Administrator cc: Samuels & Steelman Architects BOH File tV�'yR D� rtwaa�t t N a " Ty l !iranrwntti Conwrvation 'rrs 00 z '* 0 Z rb '6y in �n 4 ,. oU... ^ , "" 0000 tn cr- o 'ca � / M , + �k .� .. 3�N33 833 ,8 1 l d,� x Y z l U m m so 0 no uj 1;N a Gy 110 �OZ.Ogl L" «00,ipo0ON IN Ott 0� p0' .�,., To ` � t D oa \G 6- CUIT ,s Wa1e 1,, i ,,6.5 IF VY CA • �. t..>��•'�f�'.�`�1 C.G�-1 �,j`L` �° L i at.� 4 _ ,. _ �'�'�rf'�'`= u ;