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HomeMy WebLinkAbout50978-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT 71 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#: 50978 Date: 7/24/2024 Permission is hereby granted to. Israel, Isaac 889 Harrison Ave FI 2 Riverhead, NY 11901 To: construct swimming pool addition to existing single-family dwelling as applied for. Pool equipment must have a minimum setback of 15' from the side yard lot line. At premises located at: 75920 Route 25, Green port SCTM # 473889 Sec/Block/Lot# 48.-1-13 Pursuant to application dated 3/15/2024 and approved by the Building Inspector.. To expire on 1/23/2026. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $522.00 SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO -ADDITION TO DWELLING $100.00 Total: $922.00 Building Inspector i N TOWN OF SOUTHOLD—BUILDING DEPARTMENT I Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax (631) 765-9502 hip,s;l/www, OtitholdtormULov Date Received APPLICATION FOR BUILDING PERMIT [ G li Fir Office Use Only K PERMIT NO. Building Inspector � � �b�A Date:8-25-23 Project Address 621 Front Street ,�- . Phone# G631 9Q2 ,5294 Email Herbe .. �., G.-- "1 "11-1,0 i , _q_grp,.i301""M"1 Mailing Address:8 Harrison AVM, �1�� tloor, jiverhead BABY 11901 Name Jackie Glass Mailing Address BOX 21 amptgn N 1 Phone# 51 f77 93927 Email Jacltilegll Name Mailing Address:. Phone#: Email: SO" ", tl S L,, p Y ,. q 1�7 uwp�A "r � e((flE mri a wCa , o ryw��ppuAh o Name G Ill PQI Mailing AddressP.O 48 �cuharnptarl 11 Phon 11 e# '6312�1 Email G`UJ.1 O .u". ,� 0"We"? �1 yr �rN:* 7� w ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other Swimming pool 40000 Will the lot be re-graded? WYes El No Will excess fill be removed from premises? ❑Yes ONO 1 ,a d npa� d+ ' �' "+i''i� �„a`,.^r r*`,a;� ':.,Myai'•ti % a .o.:. M ap ;.u" k°,+�,1-'d .d' �. �'.. ..rF9, frM". �d '.,,a h�4 a,,.�-."".y'( N-,...�)M .T"7 ^)„� o P •,:! �✓1 io r m.,'.b y'M/ ;"fin;j M%7�+"y" ,,Mw: Ay ,r rN�". . � .a `� pe`y'a"4;'J,. 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. , s Application Submitted By(pr name): 8 Authorized Agent ❑Owner Signature of Applicant: Date:___ � , .............. ®,� STATE OF NEW YORK) COUNTY OF ) / e-1-/1 &�[,�` (' w, being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is they c� (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 F wledge and belief;and that the work will be performed in the manner set forth in the application file therewith. BARBARA H. TANDY Sworn before me this Notary Public, State Of Mew York No, 01 TA6086001 �, Qualified In Suffolk Ooun �,� �a,7 day of V�rcl ► 20 Cor° mission Expires Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) residing at do hereby authorize (f- C21 65f to apply on my behalf tot Southold Department for approval as described herein. b—it —20Z- Owner's Signa a Date ,(be,,4 t S Print Owner's Name 2 NEW Workers' CERTIFICATE OF Board Tali Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Guillo Pool Service Inc. 31283-7318 1533 County Road 39 Southampton, NY 11969 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 113352108 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Hartford Underwriters Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"1a" 12WEQD9BAD P.O. Box 1179 3c.Policy effective period Southold, NY 11971 01/01/2024 to 01/01/2025 3d.The Proprietor,Partners or Executive Officers are ❑ Included,(Only check box It MI partnersrollicers included) _wwW ❑ 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 3A 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 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: 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: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier) ...^ .. - eA., Approved by:, 3/13/24 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-390-9700 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 u Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE 4IARK Workers' v1 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured GUILLO POOL SERVICE INC 1533 COUNTY ROAD 39 SOUTHAMPTON, NY 11968 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 113352108 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"1 a., P.O. Box 1179 DBL312474 Southold, NY 11971 3c.Policy effective period 01/01/2024 to 12/31/2024 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: m 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 3/13/2024 By Val/ 4f (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-§I_OQ 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 Box 4B,4C or 5B 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) 1�1 J I 11111°°1°1°1°°1°1111111111°°°111°IIIIII Client#:275 GUILPOO DATE(MM/DD/YYM ACORDTM CERTIFICATE OF LIABILITY INSURANCE 3/13/2024 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(les)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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER N Commercial Support Edgewood Partners Ins.Center PHONE 631-390-9700C,NQ 631-390-9790 40 Marcus Drive E-MAIL bra RE NEcert�cates epicbrokers-com 3rd Floor INSURERS AFFORDING COVERAGE NAIC# Melville, NY 11747 INSURER A:Hartford Fire Insurance Company 19682 INSURED INSURER B:Hartford Underwriters Insurance Company ...30104 Guillo Pool Service Inc. INSURER c:Trumbull Insurance Company 27120 1533 County Road 39 INSURER D: Southampton, NY 11969 INSURER E 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 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, LTR INS r �.r._..__� __.__.._.a.. _._.�,...._.._.... TYPE OF INSURANCE SUEI'R POLICY'E f, P' CWX'P, LIMITS 1NSR SD iB IM I POLICY NUMBER MM/DD M�D A IC'' Y 12UUNOZ9073 D2/01/2024 02/01/202 EACH OCCURRENCE $1 000000 COMMERCIAL GENERAL LIABILITY CLAIMS-MADE EX OCCUR q5 a nce $300,000 MED EXP An ane person) $10 000 PERSONAL&ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2000000 PRO- PRODUCTS COMPIOP AGG s2 000 OOO POLICY I�I PRO- JECT LOC OTHER: $ _«wawa ___.... C AUTOMOBILE LIABILITY 12UENOZ9969 2/01/2024 02/01/202 Eaaei SINGLE LIMIT 0 1,000000 . _. ...®.w..__ X ANY AUTO BODILY INJURY(Per person) $ wwww� - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOSmm NON-OWNED DAMAGE $ X''AUTOS ONLY X AUTOS ONLY PPerr a 0 UMBRELLA LIABHCLAIMS-MADE OCCUR EACH OCCURRENCE $ EXCESS LIAR AGGREGATE $ DED RETENTION B WORKERS COMPENSATION 12WEQD9BAD 1/01/2024 01/01/202 X PER OTH- D EMPLOYERS'LIABILITY �YPFI'OPRIE"S"OR)PA N EXEOUER TIVE YdN E.L.EACH ACCIDENT $1 OOO OOO O PICERIEMSER ECUO �' N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $1 000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate holder is included as additional insured for general liability coverage as required by written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold 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. P.O.Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6410967/M6105862 NVE02