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HomeMy WebLinkAbout51019-Z 4rt TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 'a 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#: 51019 Date: 8/1/2024 Permission is hereby granted to: deKerillis, Alain 3420_Rqq'ky Point Rd East Marion NY 11939 To: Install in-ground swimming pool at existing single family dwelling as applied for. Maintain mimimum 5 foot setback from property line to pool and equipment. At premises located at: 3420 Rocky Point Rd, East Marion SCTM # 473889 Sec/Block/Lot# 21.4-8 Pursuant to application dated 6/17/2024 and approved by the Building Inspector. To expire on 1/31/2026. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector s TOWN OF SOUTHOLD—BUILDING DEPARTMENT ° Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 �P Telephone(631) 765-1802 Fax(631) 765-9502 litt,) ://www. outholdtow rin o� Date Received. APPLICATION FOR BUILDING PERMIT For Office ice Use Only PERMIT NO. Building Inspector: ^" JN 7 2024 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Bun;DING DM. Owner's Authorization form(Page 2)shall be completed. OWN Date:June 10, 2023 OWNER(S)OF PROPERTY: Name:PALERMO FLOORING INC scTM#1600-021.00-04.00-008.000 Project Add ress:3420 ROCKY POINT ROAD EAST MARION Phone#:631-655-2920 Email:matt@palermoflorringinc.com MailingAddress:4128 SUNRISE HWY OAKDALE, NY 11768 CONTACT PERSON: Name:TONI BAKKER e-a,�( -�V Kul MailingAddress:P.O. BOX 521 CENTER MORICHES, NY 11934 Phone#:631-804-5551 Email:oni@kevinthepoolman.com DESIGN PROFESSIONAL INFORMATION: Name:SKEEZ INC DBA THE POOL MAN MailingAddress:P.O. BOX 521 CENTER MORICHES, NY 11934 Phone#:631-878-7796 Email:toni@kevinthepoolman.com CONTRACTOR INFORMATION: Name:SKEEZ INC DBA THE POOL MAN MailingAddress:P.O. BOX 521 CENTER MORICHES, NY 11934 Phone#:631-878-7796 Email:toni@kevinthepoolman.com DESCRIPTION OF PROPOSED CONSTRUCTION rer l ition^�;r structt�re L"y❑Addition ❑�Altera�tlon ❑Repai.f ❑Demo) Estimated Cost of Project: $49000.00 Will the lot be re graded? ❑Yes El No Will excess fill be removed from premises? igYes ❑No 1 PROPERTY INFORMATION Existing use of property:RESIDENTIAL Intendaanycovenants erty:RESIDENTIAL Zone or use district in which premises is situated: Are th and restrictions with respect to this pr ❑No IF YES, PROVIDE A COPY. ❑Check BoxAfterReading: The owner/contractor/design professional is responsible for all drainage and storm water Issues as provided by Chapter 236 of the Town Code. APPUCATION 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 pass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print nam :TO N I BAKKE R BAuthorized Agent ❑Owner Signature of Applicant: Date: 06/10/2024 STATE OF NEW YORK) SS: COUNTY OF U LI- ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)abpvp named, (S)he is the I(✓ (C ractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly auth zed 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 ,t 20SZS-4— , Not E2. Notary t'ubV1c..State at New York No,o iVA6307026 ty I� E �' OWNER AUTHORIZATIONQuaimed in Suffolk coon My CommiWon moils,Itrne 30.' 026 (Where the applicant is not the owner) MATT H EW B RU N O residing at 35 HOWARD DR CORAM, NY 11727 I, . do hereby authorize TON I BAKKER to apply on my behalf t wn Southold Building Department for approval as des ribed herein. w 21,2 Owner's Signature Date MATTHEW BRUNO Print Owner's Name 2 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 113328138 MORICHES BAY SWIMMING POOLS LLC DBA THE POOL MAN [REPS, PO BOX 521 SCAN TO VALIDATE CENTER MORICHES NY 11934 AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SKEEZ INC DBA THE POOL MAN TOWN OF SOUTHOLD PO BOX 521 TOWN HALL ANNEX CENTER MORICHES NY 11934 54375 MAIN ROAD SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12440169-7 900746 02/25/2024 TO 02/25/2025 6/17/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2440169-7, 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:/IWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 S7*2 NCE FUND 4 DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:658127604 U-26.3 a srSRK TE Compensation workers' CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW Pa R Name&..,.. -- Y � .�.aCc.n LegalAddress o T' om leted b NYS disability and Paid Famil Leave benefits carrier or licensed Y) p need ins P Y 1b.Business Tele hone Number of Insure Y ranee agent of that Carrie f Insured use street address only) d SKEEZ INC DBA THE POOL MAN 516-878-2719 PO BOX 521 CENTER MORICHES, NY 11934 IC.Federal Employer Identification Number of Insured Work Location of Insured(()nly togijired it covera a is specifically limited to or Social Security Number certain kwations in New York Slate,ree Wraps-Up policy)' 113328138 2.Name and Add - (Entity Being Listed as the C� tees of Entity Requesting Proof of Coverage 3a.Name of Insurance C ( tY 9 Certificate Holder) airier TOWN OF SOUTHOLD ShelterPoint Life Insurance Company TOWN HALL ANNEX 3b.Policy Number of Entity Listed in Box"la" 54375 MAIN ROAD DBL130505 SOUTHOLD, NY 11971 3c.Policy effective period 05/13/2024 to 05/12/2025 ._ . 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. LJ B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Q 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 perthtty ehperju c-ertwi"y—that Tam am an ut,_O ec representative or hcenseh ag�hr_f the insurance carher referenced above and th_at the named insured has NYS Disabilityand/or Paid FamilyLeave Benefits insurance coverage as described above. Date Signed 6/17/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516- 29..8100 Name and Title LeSton Welsh Chief EXOcLtit ve 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. y � n�.._ �.. w. . I ..Y .... _.... ._.. ..... PAR 2 � ,4 have been checked) T 2.To be completed b the NYS Workers'Compensation Board (Only if sox a6 c or sa 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 aPease Note:Only insurance carriers licensed to write NYS disabilit and aid family le � � ' ents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers arte NOT authorized to issue this form.censed insurance DB-120.1 (12-21) �II�I�II�II��I��I�IIIII�II��I�II��I���I��II IIIIIIIIDB-120.1 (12-21) IIIIIII 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 farm 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 SKEEZ-1 CERTIFICATE OF LIABILITY INSURANCE DATE,M7120 4 � „.. 06/1712024 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 irl hts to the certificate holder in lieu of such endorsemen S), PRODUCER 631-589-5100 CT Jasmine Arettines ... ..•. .A,fC Na FOLKS INSURANCE GROUP PHONE 631-589.5100 I 6 1-569'-3335 33 MAIN STREET WEST SAYVILLE,NY 11796 Brendan Keane _INSURER FFORP.ING NAIL� ww. INSURER A:Hartford Accident&Indemnl COVERAGE 22367 yy Ep I N"IJRER B: kl0U0Z Inc.dba:The Pool Man 176 Main St. INSURE ., .. _..... _.,;..._.._ ........ - - PO Box 621 INSURETI D Center Moriches,NY 11934 INSURER'E INSURER F: COVERAGES CERTIFIC TE NUMBER: RI�VISfON NUMBS 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. UI$R I�OLICY EFF POLICY E8 P LIMITS IINSR OOL. TYPE OF INSURANCE POLICY NUMBER 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACIt OC'CURr hI�E g CLAIMS-MADE OCCUR 12UENOZ9743 0612312024 0512312025 PML EX ease I� d _ 6000 DAMAGE TO RENTED 300,000 17XSONAE�a AQLV INJURY $ 1,000,000 PLR E• ._mm C, GREGATE 2,000,000 000 C L AGGREGATE LIMIT APPLIES PER: GENERAL AG $ r ° POLICY PRO- ❑ LOC PRODUCTS-COMPIOP AGG S JECT OTHER' COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY - ANY AUTO BODILY INJURY'I'ep arsrar; S OWNED SCHEDULED RODItY INJURY Rea"acc:idenl AUTOS ONLY AUTOS ��OPFTY-•- (��IT PP'e HIRED NON-OWNED Y ItDAMAGE AUTOS ONLY AUTOS ONLY *DED RELLA LIAB OCCUR EACII OCCURREN;CF -- • -- •••• - SSLIAB CLAIMS-MADE AD-RE,_GATE . RETENTION$ - $ PER OTH- WORKERS COMPENSATION AT F4._-. •••••. AND EMPLOYERS'LIABILITY "'--" � •• Y 0 N E L.EACH ACCIDENT S ANY PROPRI RI RIEXECUTIVE "' OFFICER/MEMBMB EXCLUDED? EXCLUDED? N I A (Mandatory in NH) E L DISEASE.EA EMPLOYEE $ IF yes,des:xibe under EL iDISEASE POLICY LIMIT SDESCRIPTION OF OPERATIONS belong y I DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER. CANCELLATION TOWNSOH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold Town Hall Annex 54375 Main Road AUTHORIZED REPRESENTATIVE -w Southold, NY 11971-0959 ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD Building:lie vaarttmtent Ali+ atlon AUTHORIZATION (Where the Applicant is not the Owner) Matthew Bruno _residing at 4128 Sunrise Hwy (Print property owner's name) (Mailing Address) Oakdale, ny 11768 do hereby authorize Toni Bakker (Agent) to apply on my behalf to the Southold Building Department. (Own�;r's Signature) ate...... _ ....._. ... _.._.. ..... _.. ......_... (�� , (Print Owner's ame) Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE r Name KEVIN B CHERWINSKI Business Name This certifies that the Tearer is duly licensed Skeez Inc DBA Dy the County of suffolk License Number: HI-68018 Rosalie Drago Issued: 01/10/2023 Commissioner Expires: O1/01/2025 a 5UPVfY or PPOPEPTY JOSHUA R. WICKS P . L . S . SD T ]�r]�l j T ]-� 71 SURVEYED BY:J R.W, DRAWN BY:J.R.W. JOB NO JRW24-0076 U 1 i/�1 LH� 1/��N B 0 UL�► VA �D M5rMACONI rOWNI Or'%Ou��O J P.O. BOX 593 ;UcFO;K COUNTI. NSW YOpK Center Moriches, N.Y. 11934 1 •.•.-� _ ...�� Jos ua is s gmai .com 4 #631-405-6108 5UFfOlk COUf7ty f3X Map NO,. r, GRAPHIC SCALE i ar c - 1,00-04,00-005,00,0 o i z 3 (z°) (4°) (6o) PAtE 5UFM-YEP: 0A/06,1 2024 aal) °p '-CALF: 1"=20' N 88049 '00" E 212. 59 TAX LOT 7 -- 6' STOCKADE FE. MON. S FND. LO WOOD O I � n " a CONC. STEPS AC PROP. u PLAT LIJL_j TANKS 21.6' �1 I 4a.7' 00 1' STY. . ' FR. a W OVERHEAD WIRES N FR. RES. " b ' " ( 6 H C ;t ENCL.R. °i CQ,�OH •-m -•- OH —OH OH OH OH —OH r WOOD LO #3420 „D" PORCH �1 O 0 CONC. 15.5' _j � 341 nLO 00 LOT AREA METAL co METAL 19,068.00 S.F. O in COVER R 0.44 ACRE(S) ASPHALT DRIVEWAY N N WOOD REr. WALL( `) U.. s' PVC a` CHAIN LINK Ft, �pF NEIN ._ _ M, 4' WIRE FE. _ ... � .�.. �. ' 6' STOCKADE FE. "J" N , TAX LOT 14.3 ° S 85050 '40" W 211.27' LAND CHECKED Y„ -... r , ! ,, .; ,..c ..,,��„ � n; r _,� LAW ! BOUNDARY SURVEY MAPS IV '.',= SURVEYOR'S c D F A P I"il.:: TRUE AND CORRECT COPIES U4.. a 'AA , • 1 UNAUTHORIZED ALTERATION OR ADD!iION TO THIS SURvEY MAP BEARING A LICENSED LAND SURVEYOR'S SEAS IS A +nJ!...f,II,I, OF m,...L-�IC,�+ 7209. SUB-D.VIS!Oh 2, 0- NSW YGRK SATE EDUCATION .A N, ,7_) ONLY ,.DUNU SJ,VEY Lw 'I rV.„. EMBO„SE SEAL RE r JE r C L... ,;ll RVEYOR� ORIGINAL WORK ' !n ) _ _ _ _ ,; _ r AS SO _ _ r H� I^ ...� '1 N r i.a;. NDA SUR JEY IS PREPARED. TO II L I.,...1... COMPANY, ILI:... �..V�R\v_M1 A_ a W SIGNIFY iF+,!\: THE �11A.!' WAS PREPARED IN ACCORDANCE WITH THE CUP.RENI EXISTING CODE OF PRACTICE FOR LPN•:.; SUR\ElS +�11, "_L? 9Y �-n.... N�44 YORK STATE A�SO�.AI!ON Or PROFESSIONAL LAND SURVEYORS, INC. T c CERTIFICATION � ! A, ,...L., ,.. PERSONS ,OR WHOM ,„ BOU P. M.4 � ^•� ' J' - � - ,.,,.-.. ,�:�- „�..... r,:. :-.�, - T - � � � - - T- P, ENCROACHMENTS AP,E 14.i CnV_r7 By ,,,. ,I "v �r::,, ;!v; ,) �:; H- BOUNDARY SURVEY MAF ?S THE CERTIFICATIONS HEREIN ARE IJGT TRANSFERABLE 5 THE LOCATION OF UNDERGROUND IlAPROVEMEN:S P„�„I�„ r I��+�.V,T,., ARE =�..il ALWAYS +^:.NOWN AND ,.II Il....i� MUST BE ES IMAI EU I� ANY UNDERGROUND IMPRO JEMENTo OR ENCROACHMENTS EXIST OR ARE :,kVl�a, THE IMPROVEMEN� 0 '` � � "` • � ) ,.. ...... _ ,... _ ,.... ...,, - ,��,,... " .... ., - tri . ',gip." a e J ....... _ .. .... ,,. .,. ,.. ... r „. , ....n+ _:-,.. ._ I _,. .... ,, .. .! ,,• rl _I r II,.d..A ,,. ,, _.... _, I ! 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