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Home My WebLink About50850-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 #: 50850 Date: 6/21/2024 Permission is hereby granted to: Wirstrom M Liv Trust PO BOX 156 Mattituck, NY 11952 To: construct accessory hot tub as applied for. At premises located at: 4630 Nassau Point Rd, Cutchogue SCTM # 473889 Sec/Block/Lot# 111.-8-10 Pursuant to application dated 4/25/2024 and approved by the Building Inspector. To expire on 12/21/2025. Fees: SWIMMING POOLS -ABOVE-GROUND WITH REQUIRED FENCING $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 Spa,- Telephone (631) 765-1802 Fax (631) 765-95021itt,s:/l rww.sotitlioldtownny o Date Received - APPLICATION FOR BUILDING PERMIT ry x` "rvwR k dMww d' For Office Use Only „" A 2 5�' 2 PERMIT NO. S6 E5D Building Inspector, 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:04/24/2024 OWNER(S)OF PROPERTY: Name:Marc Wirstrom SCTM#1000-111-8-10 Project Address:4630 Nassau Point Rd, Cutchogue NY 11935 Phone#: Email:marc@wlrstrom.me Mailing Address:11 Hoyt Street, Apt 18, Brooklyn NY 11210 CONTACT PERSON: Name:Brad Hooks (Oza Sabbeth Architects) Mailing Address:PO Box 2007, Bridgehampton NY, 11932 Phone#:631-808-3036 Email:brad@ozasabbeth.com DESIGN PROFESSIONAL INFORMATION: Name:Brad Hooks (Oza Sabbeth Architects) Mailing Address:PO Box 2007, Bridgehampton NY, 11932 Phone#:631-808-3036 Email:brad @ozasabbeth.com CONTRACTOR INFORMATION: Name:Andrew Pennacchia Mailing Address:PO Box 2007, Bridgehampton NY, 11932 Phone#:631-899-4225 I Email:andrew@moderngreenhome.com DESCRIPTION OF PROPOSED CONSTRUCTION ®New Structure []Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other 20,000 Will the lot be re-graded? RYes El No Will excess fill be removed from premises? RYes ❑No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: S; C r Vl Zone or use district in which premises is situated: Are there any covenanttspnd restrictions with respect to this property? ❑Yes [VNo IF YES, PROVIDE A COPY. Rlhieck'Bost After Reading: The owner;/contractor/design professionall 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): BAuthorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS:COUNTY OF S 1--� —Ik G d 6 KJ 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 Z 4 day of r, I ,20 q tlblicert oestefano Notary Public.State of New York No,Of Ob6321 f44 ��®610 ouslllled In Sutfolk C,nuntyi „„9��. Oedrrrt4epslorr Expires Match 30a,2Q._ PROPERTY OWNS AUK" ° OIAO (Where the applicant is not the owner) Marc Wirstrom residing at 11 Hoyt Street, Apt 18 Brooklyn NY 11201 I, Brad Hooks (Oza Sabbeth Architects) do hereby authorize to apply on my eha o the tfSouthold Building Department for approval as described herein. February 14, 2024 Owner's Signature Date Marc Wirstrom Print Owner's Name 2 /7--d1\bN111 New York State Insurance Fund PO Box 66699 Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE jp i■ AAAAAA 261840723 BALDON GROUP INC 1 S OCEAN AVE SUITE 206 PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER MODERN GREEN HOME LLC TOWN OF SOUTHOLD PO BOX 2007 53095 ROUTE 25 BRIDGEHAMPTON NY 11932 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12234 366-9 711699 09/20/2023 TO 09/20/2024 4/23/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2234 366-9, 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, 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:/M/WW.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 THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY,. 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 SUR NDE FUND 4 DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:462965099 U-26.3 fftt. Workers' CERTIFICATE OF INSURANCE COVERAGE e rE 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 carrie 1a.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured MODERN GREEN HOME LLC 631-899-4225 ATTN: MISSY PO BOX 2007 BRIDGEHAMPTON, NY 11932 1 c.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) 261840723 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"I a" 53095 Route 25 DBL385050 PO Box 1179 3c.Policy effective period Southold, NY 11971 10/04/2023 to 10/03/2025 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: Z 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 4/23/2024 By (Signature of Insurance carrier's authorized re p resentatl ve or NYS Licensed Insurance Agent of that 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 4s,4C or SB 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. 0113-120.1 (12-21) 111111111iiiiiiuiiiiiuiiiiuiii�iiiiiiiiiiimiii1llll AC CERTIFICATE OF LIABILITY INSURANCE DATE4/23/2024 Y, 04/23/2024 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 NAB „OT Peggy Musarra Baldon Group,Inc. PHONE (631)289-8822 (631)289-8833 r AIC No: 1 South Ocean Avenue,Ste 206 ADDR ft pmusarra@baldongroup.com INSURERS AFFORDING COVERAGE NAIC# Patchogue NY 11772 INSURERA: Southwest Marine&General Ins.Co. 12294 INSURED INSURER S! Modern Green Home,LLC INSURER C: PO BOX 2007 INSURER D: INSURER E: Bridgehampton NY 11932 INSURERF: COVERAGES CERTIFICATE NUMBER: 23-24 GL/XS REVISION NUMBER, THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE POLICY NUMBER IMagm MWDDOM LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE � OCCUR PREM occurrence s 5,0,000 e on 5,000 M P An one person) S EO EX ( p A GL2023LHBOO238 08/06/2023 08/06/2024 PERSONAL&ADV INJURY S 1,000,000 GEWLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 PRO- {,� 2,000,000 POLICY JECT L] LOC PRODUCTS-COMP/OPAGG $ OTHER; OOMBINEOSINGLE LIMIT $ AUTOMOBILE LIABILITY S Ea rdr n ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS NON-OWNED PROPE TY DAMAGE HIRED O S AUTOS ONLY AUTOS ONLY dent' S UMBRELLA LIAB OCCUR EACH OCCURRENCE S 3,000,000 A X EXCESS LIAR El CLAIMS-MADE EX2023LHB00063 08/06/2023 08/06/2024 AGGREGATE $ 3,000,000 DIED RETENTION $ S WORKERS COMPENSATION I OTH- AND EMPLOYERS'LIABILITY y I N STAT TI ER OFFICER/MEMBER EXCLUDED? E.L,EACH ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE F NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL,DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route25 AUTHORIZED REPRESENTATIVE PO Box 1179 Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD S.C.T.M. NO. DISTRICT: 1000 SECTION: 111 BLOCK: 8 LOT(S): 10 DWELLING WELL \ W/WELL WATER 701 VACANT 70 100' E 265 50 . � Ww 72 LOT �� p6 PG2 ,�8036,5 0 ' + ��. .A 2.9"tN 16 la, W fi DWELLINGS W/PUBLIC WATER 150' 7 rspuw�Vr7ai� — MON. d 1i,& 72Y# — 2X u ,f1lGtlha iwa ;x W ar N T�Ng4S,pGV LOT 157 'W.M. e U.P. 7E r r 70 " 1 �z ,w STOOP g , sk + 1Gk•B IN VACANT „ + p MON. `rh LOT 156 150' 5 ` 7 2 U.P. Sj ry� as UP, R wx 4 w i 74 72 48.5Ar Lti�Nc, .N A � � / ***NOTE: THE FILED MAP IS MARKED THERON �� .. �0 0EE w . 74 "LOT DIMENSIONS ARE APPROXIMATELY ONLY" � ��" AND BECAUSE OF THIS LEGEND DIVISION — ° ✓ LINES ARE INDEFINITE AND UNCERTAIN. u �py " ` , .I� 1 � PROPERTY LINES SHOWN ON THIS MAP ARE REPRESENTED H "v ON SURVEY RECORDED IN LIBER 2006 PG. 426 AND IN COMBINATION WITH PRESENT DAY MEASUREMENTS AND FIELD OBSERVATIONS. EL 73.5 VACANT pOp `w 7 ," 1 DWELLINGS 150' N W/PUBLIC WATER 150' 155 7 Lu�A��77wIR1" � �',� �,,,"�'�5 .� BROWN LOT FIRE Pf7 ." r "1 SM LOAMY SAND 2 8' I / 7HE WATER SUPPLY�r^ n 7 OCA71ONS SHOWN ARE FROMFIELD�OBSERDVA77ONSOOL & GRAVEL 676AND OR DATA OBTAINED FROM OTHERS. PALE pw EDffAN"NONeN AREA 1 / NAVD88 SW BROWN w AREA: 37,806 S.F. or 0.87 ACRES ELEVATION DATUM. MEDIUM 2.5" ✓ W�NT �� SAND // UNAUTHORIZED ALTERATION OR ADD177ON TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCA77ON LAW. COPIES OF THIS SURVEY �p MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN 78 ONLY TO THE PERSON FOR WHOM 774E SURVEY 1S PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING 1NS777U7ION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, TEES GUARAN ARE NOT TRANSFERABLE. PALE �V """ � THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE MBROWN EDIUM �00� NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCE$ ADD17IONAL STRUCTURES OR AND 07HER IMPROVEMENTS EASEMENTS SAND AND/OR SUBSURFACE S7RU&7URES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY ON. CE & GRAVEL 07'N -'60 SURVEY OF: LOT 157 CERTIFIED TO:ADVANTAGE TITLE GROUP AGENCY, LLQ' 11 7 /M MAP OF:AMENDED MAP A" OF NASSAU POINT MARC WIRSTROM UI1NG TRUST DATED MARCH 5. 2021• / FlLED: AUG. 16, 1922 No.156 AMTRUST TITLE INSURANCE COMPANY AN AMTRUST �1 TINANCIAL COMPANY, JAN. 6, 2021 — 17 < REVISED 04-16-24 SITUATED AT. CUTCHOGUE K. WOYCHUK LS REVISED 02-15-24 TOWN OF: SOUTHOLD ]KENNETH W. IMDYCHUK LAND SURVEYING, PLLC REVISED 01-20-24 SUFFOLK COUNTY, NEW YORK REVISED 07-20-23 Professional Land Surveying and Design r P.O. Boa 159 Aquebogue, New York 11931 UPDATE 07-07-23 FILE #221-04 SCALE: 1"=30' DATE: JAN. 6, 2021 M Y.S, 09C. NO!, 050682 PHONE (691)296-1666 FAF (631) 296-1566 I DiLandro Andrews NOW Engineering 158 County Rd. 39, Suite 10 Southampton, N.Y.11968 Office: (631) 259-3959 Info@DiLandroAndrews.com Certificate No.: 0019523 Professional Seal I I #4 TRANSVERSE BARS @ 10" O.C. MAX. #4 BEND 09 BAR @ 10"O.C. — TYP. #4 BEND 06 BAR @ 10"O.C. :JTn TYP. #4 BEND 07 BAR @ 10"O.C. j�OF NERVY — TYP. � �P HENRY O #4 BEND 08 BAR @ 10"O.C. 0� 4 TYP. 2 m cc EL r s w I • Fp vL/,g 2 CONTINUE BOTTOM POOL AR�FESStBNP� — I REINFORCEMENT INTO SPA 10"THICK(MIN) GUNITE POOL d o a 4 da 0 2 102 SHELL AT BOTTOM 'd ed d as . a v d• a v .d',p a Id, L - - -J I 2 SPA SECTION S-102 SCALE: 3/4"= 1'-0" W 61" 06 82� Q 1 SPA J S-102 SCALE: 3/4"= 1'-01, I iv Q o � ~ U) I— CV i `9'9 0 0 - 13So 135 r - 0 1'-92" T �— BEND 06 BEND 07 BEND 08 BEND 09 z O � a. z D LLl Q Z) (/) (D � O Q = z W o cY) W C'M 0) O (fl Ir d- C ) r- a Revisions No. Date Description 1 02/02/2024 FOR PERMIT 2 --/--/-- ---- 3 --/--/-- ---- 4 --/-4-- ---- 5 --/--/-- ---- Designed By : AN Drawn By : AN Checked By : AA Date : 02/01/2024 Scale: AS NOTED S � l 02 Sheet#