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HomeMy WebLinkAbout50977-Z TOWN OF SOUTHOLD a BUILDING DEPARTMENT TOWN CLERK'S OFFICE Yy SOUTHOLD, NY "am 6 Y T2p . 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 #: 50977 Date: 7/23/2024 Permission is hereby granted to: Na olitano, Thomas 343 Van Wan ner PI Williston Park, NY 11596 To: construct accessory in-ground swimming pool as applied for. Pool equipment shall be located in the rear yard with minimum 15' setbacks to lot lines. At premises located at: 1275 White Eagle Dr, Laurel SCTM #473889 Sec/Block/Lot# 127.-9-20 Pursuant to application dated 6/3/2024 and approved by the Building Inspector. To expire on 1/22/2026. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector 86 d f � F� , TOWN OF SOUTHOLD—BUILDING DEPARTMENT ,�pF 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.soutlioldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only 3 202 PERMIT NO. SN-,E/7 Building In ,laectnr., wJUN �.� Applications and forms must be filled out in their entirety. Incomplete Building Department applications will not be accepted. Where the Applicant is not the owner,an Town of Southold Owner's Authorization form(Page 2)shall be completed. Date:IS OWNER(S)OF PROPERTY: Name: . I #1000- Project Address: Phone#: � — if n ail; Mailing Address: , 27A CONTACT PERSON: Name: Mailing Address: Phone#: ?)LL L� Email: DESIGN PROFESSIONAL INFORMATION: Nam Mailing Address: Phone#: Email: ETA CONTRACTOR INFORMATION: Name: E3bn(hJ -r. Mailing Address: Phone#: (��J Email: DESCRIPTION OF PROPOSED CONSTRUCTION few Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Est' ted Colt of P oJect: ❑other Will the lot be re-graded? ❑Yes Will excess fill be removed from premises? ❑Yes N 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any cove is and restrictions with respect to this property? ❑Yes 2!� IF YES, PROVIDE A COPY. Ga heck o After eading: The owner/contractor/design professional is responsible for all dz 0age and storm water issues as provided by er 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 ante 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 (ip tit name)- hori ed Agent ❑Owner Signature of Applican Oa STATE OF NEW YORK) � �� ,-\JIrr��"`�� "w o COUNTY OF O. JA being duly sworn, deposes anus t a pllcant (Nam of indivi aI signing contract)above named, 0 �' "�"•' �� (S)he is the r r (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 r of , ---f� Otary PUbIIC . PLp�;,, OPERTY OWNERAUTHORIZATION" Nhere the applicant is not the owner) kjye14Pg at 276 VJHt5 r. do hereby authorize to apply on my behalf to the Town of Southold Building DepOwwof9f,approval as clescrnbed herein01 o, W Owner � �'s Sin ate cra: o" r4- �4'o ' ,,, q,�c6o,/* Print Owner's Name '. ••" ��' �'djr�rrarlrrltr�'�"��Z Y Workers' CERTIFICATE OF sTATr Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (631)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Insured Rocky Point,NY 11778 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11 3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest National Ins Co Town of Southold 3b.Policy Number of Entity Listed in Box"la" 53095 Rt. 25 SW5WC00205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 to 11/05/2024 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Only check box if all partners/officers included) ❑ 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 1 a"for workers' compensation under the New York State Workers'Compensation Law.('To use this form,New York(NY)must be listed under Item 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". 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 IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one,year after this farm 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: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: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) �� — 11/03/2023 Approved by: (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 031-465-4000 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 (9-17) www.wcb.ny.gov X RK workers' CERTIFICATE OF INSURANCE COVERAGE 4___—,2Arc Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW WWWW__ 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) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A ROCKY POINT, NY 11778 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) 113008276 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 53095 Rt. 25 3b.Policy Number of Entity Listed in Box"la" P.O. Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 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 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 11/7/2023 By wid hf (Signature of insurance carrier's authorized representative 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 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 413,4C 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, m111111oi 11111111 iii ii I Additional Instructions for Form D13-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on 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 NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed. (b)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 employment as defined in this article and 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 the payment of disability benefits and after January first,two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (12-21) Reverse � 'M DATE(MM/DD/YYYY) AC"RE), CERTIFICATE OF LIABILITY INSURANCE � 11/O6/2023 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 endorseme'nt(s). PRODUCER CONTACT Kym O'Gara NAME: AssuredPartners Northeast,LLC. PHONNE ex , (631)465-40O0 A azlt No 100 Baylis Road 94A1 . kym.ogara@as uredpartners.com ADDSuite 300 INSURER(S)AFFORDING COVERAGE NAIC# Melville NY 11747 INSURER A: Philadelphia Indemnity Insurance Co. 18058 INSURED INSURER B: Everest National Insurance CO 10120 • Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios INsuRER c: ShelterPolnt Life Insurance 81434N 471 Route 25A INSURER D: INSURER E: Rocky Point NY 11778 INSURER F: COVERAGES CERTIFICATE NUMBER. CL2382314181 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. NSR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD EFF MMIDDPOLIO/YYYY LIMBS LTRX COMMERCIAL GENERAL LIABILITY EACH OOCURRENCE $ 11000-000 CLAIMS-MADE �OCCUR PREMISE Ea❑cctpucgna o ,S 300,000 " Contractual MED ExP(Any one person) $ 5,000 A X Al incl Comp Ops/WOS/PNC PHPK2595157 09/01/2023 09/01/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIE'S PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO. LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SWGLE LIMIT $ 1,000,000 Ea—Wen6 ANYAUTO BODILY INJURY(Per person) $ '...... A OWNED SCHEDULED PHPK2595157 09/01/2023 09/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED PROPERTY'DMIAGE. $AUTOS ONLY AUTOS ONLY Pee ecrdden9 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ PER WORKERS COMPENSATION ,STATUTE ERH AND ANY OFFICER/RIETOR PER B NERID ECUTIVE E.L.EACH ACCIDENT $ 1,000,000 YIN B Y N/A SWSWC00205-221/222 11/05/2022 11/05/2024 (Mandatory in NH) E„L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ NY Disability C DBL37154 02/01/2023 02/01/2024 Statutory&Continuous DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The following are included as additional insured if required by written contract subject to the terms and conditions of stated policies:Town of Southold 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 Rt.25 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 MCI \ �A y �. A v - s.� �� - \,., \\ \ ` s \ \ _ �...�,.. ymow — vv 01 \ \ \ CIA- ARM a F _ 0 - \ = v .� F: 4, VA � MEMO -05 \\ \� � A \ PER EAWWO 'KNANC III _ >. \�ff A\O ��� � � � � � �