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HomeMy WebLinkAbout50981-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#: 50981 Date: 7/24/2024 Permission is hereby granted to: Schneider Jr, Michael 720 Stanley Rd Mattituck, NY 11952 To: legalize "as built" accessory in-ground swimming pool as applied for. Additional certification may be required. At premises located at: 720 Stanley Rd, Mattituck SCTM #473889 Sec/Block/Lot# 106.-7-31 Pursuant to application dated 6/3/2024 and approved by the Building Inspector. To expire on 1/23/2026. Fees: AS BUILT- SWIMMING POOL $600.00 CO- SWIMMING POOL $100.00 Total: $700.00 Building Inspector 40� fF#d& x TOWN OF SOUTHOLD—BUILDING DEPARTMENT `''° Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 r Telephone (631) 765-1802 Fax (631) 765-9502 Ott :/' vw�v. outltoiltnnn . tier Date Received APPLICATION FOR BUILDING PERMIT E EC El I For Office Use Only U -. 212 s PERMIT NO. Building Bn Rector; Applications and forms must be filled out in their entirety.Incomplete Building Oep'rtment applications will not be accepted. Where the Applicant Is not the owner,an Toi'vn of E^MIZA11 I '' Owner's Authorization form(Page 2)shall be completed. Date: h-31 ` OWNERS OF PR PERTY: Name: M 4ECISCTM #1000- �. Project Address: All W 11 k--A Phone#: 17 Email: Mailing Address: CONTACT PERSON: Name: �w Mailing Address: Phone#kj] Im K kb Y DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email CONTRACTOR INFORMATION: Name: Ly Mailing Address: Phone#: q Email: L) lkwj DESCRIPTION OF PROPOSED CONSTRUCTION Pw Structure ❑Addto ❑Alteration ❑Repair ❑Demolition Esti d �Project: Other $ Will the lot be re-graded? ElYeSIM, o Will excess fill be removed from premises? s ❑No 1 PROPERTY INFORMATION Existing use of property: Intended use of property:. Zone or use district in which premises is situated: Are there any cove ant and restrictions with respect to this property? ❑Yes o IF YES, PROVIDE A COPY. eck 8d x After Reading.*! The owner/cont'ractor/design professional is responsible for all ainage and storm water issues as provided by Chapter 23,6 of the Town Code,APPUCAwTION 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„. Application Submitted By ri name, , thor zed Agent ❑Owner i Signature of Applicant: STATE OF NEW YORK) SS: COUNTY OF being duly sworn, deposes and says that(s)he is the applicant (Name of individual sifning contract)above named, (S)he is the (Contractor,Agent,C rpprate 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 day of �rililir otary Public Z q PROPERTY OWNER AUTHORIZATION w (Where the applicant is not the owner) *. N, ` I, '' rep ► �.vlAk/Jding at do hereby authorizet4,� to apply on my be If to the n outhold Building Department for approval as described herei, . Owner's Signature/ Date Print Owner's Name 2 STAEw workers' CERTIFICATE OF INSURANCE COVERAGE TE 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 carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.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 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Onlyrequired if coverage is specificallylimited 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 it 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 (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 413,4C 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. .ww - 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) 11�11 lfi� �iaiii ii�i iiiiii� w�iii ii11 0 [ DATE(MM/DD/YYY1) 4CC>RV CERTIFICATE OF LIABILITY INSURANCE ,,,,. l 11/06/2023 ,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 endorsement(s). PRODUCER CONTACT Kym O'Gara NAME: AssuredPartners Northeast,LLC. PHONE (631)465-4000 A/FAX c No): 100 Baylis Road p�-MAIfsss, kym.ogara@assuredpartners.com Suite 300 INSURER(S)AFFORDING COVERAGE NAIC# Melville NY 11747 INSURERA: Philadelphia Indemnity Insurance Co. 18058 INSURED INSURER B: Everest National Insurance Cc 10120 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios INSURER c: ShelterPoint Life Insurance 81434N 471 Route 25A INSURER D: INSURER E: Rocky Point NY 11778 INSURER F: COVERAGE'S CERTIFICATE NUMBER: CL2382314181 REVISION NUMBER: THIS IS TO CERTIFYTHATTHE 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. INSR POLICY EFF POLICY FXP LTR TYPE OF INSURANCE IN SD WVp POLICY NUMBER MM/DD MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILI Y EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE [9 OCCUR PREMISES Ea occurrence $ 300,000 Contractual MED EXP(Any oneperson) $ 5,000 A X At incl Comp OpsIWOS/PNC PHPK2595157 09/01/2023 09/01/2024 PERSONAL&ADV INJURY $ 1,000,000 GENTAGGREGATE UmiTAPPLIE'S PER:: GENERAL AGGREGATE $ 2,000,000 POLICY [g yE 0.LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY CO1,1 aecYINED SINGLE LIMIT $ 1,000,000 Ima dda,rrtt ANY AUTO BODILY INJURY(Per person) $ -- A OWNED SCHEDULED PHPK2595157 09/01/2023 09/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYO AGUE $ AUTOS ONLY AUTOS ONLY Per armwent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ER AND EMPLOYERS'LIABILITY ST TUTS. ERH- Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE � NIA SW5WC00205-221/222 11/05/2022 11/05/2024 EL.EACH ACCIDENT $ OFFICER/MEMBCERIMEMBER EXCLUDED? (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/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 NEW Workers' CERTIFICATE OF YORK STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (631)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1 c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Rocky Point,NY 11778 Insured 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 1a" 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 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: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 9 2— 11/03/2023 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 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 . . 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