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HomeMy WebLinkAbout51057-Z p: 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#: 51057 Date: 8/12/2024 Permission is hereby granted to: Calderale, Frank 2190 Henrvs Ln Peconic, NY 11958 To; Construct an inground swimming pool accessory to a single-family dwelling as applied for. Pool and pool equipment must maintain a minimum side and rear yard setback of 15 feet. Pool must be a minimum of 20 feet from septic. At premises located at: 2190 Henrys Ln, Peconic SCTM #473889 Sec/Block/Lot# 74.-1-44.10 Pursuant to application dated 6124/2 ......._ mm024 and approved by the Building Inspector. To expire p _.....on 2111/.... Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $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 Telephone (631) 765-1802 Fax (631) 765-9502 h :llwww. outholdtownn . Dv Date Received APPLICATION FOR BUILDING PERMIT % a S For Office Use Only V C� 510 5 '1 Building Inspector, PERMIT NO t ✓ r r Jsdr r✓�r r r ,/ r/' r%1r, r r rrr r rr r, '' ' y�{"%oA l IC�IyY.k* � � r r r /r r/r r/���r: �l/r/,! ✓lli"/Y'r� 1f �,�fd�/ r r / / +�,ryy�� � l r 1 r Y �il r fy Gn N� V� i f ➢ ✓nr T ��� ,r �, "w pia m r1�,7 ��,"� lIrrl%l/r 4�� r�,�J1 r phi ��✓`rrla�r�,�>�'J� ��r�//j� � r�rm �%�r�/�i rrr%���/r �w r� r� rr'�r � ✓J��(/�`�r r� /%�;�rrr�i ri% ��?r�r%,�,r ti r y„ r Date rio ,, ,,,�r i„ / r r r + r/ r t / �r ,d r, f�i %/�rf ,.�ln'„� r� ri �� J "// rr Gr rr r / r lrfG/�'i� r i rr/rr //Jr/l r JJ/ +r � i � � r r rr�� r, r, ter,lr'„��rl(.i�/,//✓. ! "✓!„��r,� !; scTM# i000- `]`k - _ �,� � 10 � N I i q Project Address. Z1 C�O S Ln �(�fl L 2 Email* Phone#: &J l` Z��o- �9�0 Mailing Address 7 r ti /r rf r r r /ar i/ rr � ri/ yrr ,Ur/Gir rf�r r � J rr rr// Name: J Mailing Address: q2(� Email: S POO , (►� Phone#: �p?j)- — 7 d��It! 777777777777 rr rrr z„ e rl,, ...Name: � �t,�.S � Qe l�! �C Mailing Address I �U ,Z�� Phone# �Zq 5 r 0 PA Email c r Yr r r !r r nr r"� r r r P r6r P; ,�r�"rr„3i" r r,r m„ ,irrr!r'../r r/r Yi/�;r ` e/.:.J'l r �f rn r,G f! yrI%d d� / rrif! / r ;�J r yrY lr a rf 9 r / �i;rrr ��rrl>'r//�� /gAY rir �i%;�,�f�I i rr i .,r /1✓,%/f^rrr/,%%/YI �r,„ r ,' f,ra i M?%fl�lu,,,,,^ ,�rl/,i ,,,f„v„ i,✓„//,/J/,,, r✓ ✓, , Name ,�, EI)WA-1 s 's. Mailing Address: Q:�q kt- �/4 I�z Ol4u AY 117W Email: &FFICe64DAe-ia GS,e3r77 Phone# r r 9J J r/ %U l rr � V Frl/✓Ik o y ea of Estimated Cost of Project: ❑ ❑ ❑ atin ❑Re New Structure Addition Alte p Ir ❑Demolition �pther I � 1 ti 1 Jt''►o $ Will the lot be re-graded? ❑Yes�No � �'Q Only Will excess fill be removed from premises? Zes ONO 1 PROPERTY INFORMATION ' Existing use of property: Intended use of property: n , Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? OYes No IF YES, PROVIDE A COPY„ Check Box Afte'e Reading: The owner/contractor/design professional is responsiblefor all drainage and stoFin water issues,as-provided by P Chapter 236 of the Town Code. APPLICATIQN;iS HEREBY MADE to the Building Department for the issuance ofa Building Permit pursuant to the Building Zone Ordinance of ihe,Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alteratibns or,1'o►removal or demolition as herein described.The applicant agrees to-comply with aUappliwble laws,ordinances,building'code, housing code antl`r'egulations and to admit authorized mspedors on premises and in buildings)"for necessary'inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to section f10.45 of,the New York"State�Perial Law. Application Submitted By(print name): �cf1\� C �el�r6-e. ❑Authorized Agent Owner Signature of Applicant: Date: 6-(Z-2-V STATE OF NEW YORK) SS: COUNTY OF J/tfRiXA,- ) I< ekhk 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 day of —Vu 20z!�L— MARGARE ✓- A. KIDNEY Notary Public Notary Public- State of New York No. 01 K16021 1 1 1 Qualified in Suffolk County PROPERTY OWNER AUTHORIZATION My Commission Expires March 8,202Z' (Where the applicant is not the owner) 1, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 NYSIF PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysitcom CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112377925 w " LEVITT-FUIRST ASSOCIATES LTD r , 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J.EDWARDS POOL&SPA CENTRE TOWN OF SOUTHOLD ARTHUR J.EDWARDS P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 394600 06/29/2023 TO 06/29/2024 07/17/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.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. rrrr NEW YORK STATE INSURANCE FUND DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 763749953 r�lr�1 lr��m on®=Ili llr lw�l l 0000000000011'7351, 37' 11111 Form WC-CERT-NOMNT Version 3(08/29/2019)[WC Policy-24384919] U-26.3 41 [ODD000D0000117351537][0001-000024384919][##G][16180-02][CerLNoP{ERT_1][Ol-0D001] NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 112377925 LEVITT-FU I RST ASSOCIATES LTD = r 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J.EDWARDS POOL&SPA CENTRE TOWN OF SOUTHOLD ARTHUR J.EDWARDS TOWN HALL 929 RTE 25A P.O.BOX 1179 MILLER PLACE NY 11764 SOUTHOLD NY 11971-0959 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2438 491-9 881301 06/29/2024 TO 06/29/2025 6/10/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.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 SU N E FUND 4 �V DIRECTOKINSURANCE FUND UNDERWRITING VALIDATION NUMBER:718888089 U-26.3 NEW workers' CERTIFICATE OF INSURANCE COVERAGE siAM 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 1a.Legal Name 1£Address of Insured(use street address only) 1b.Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC DBA: ARTHUR J.EDWARDS POOL AND SPA CENTER 6317440174 929 ROUTE 25A MILLER PLACE,NY 11764 1c.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) 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier TOntity WN eOgLSed as the OUTHOLD to Holder) Standard Security Life Insurance Company of New York PO BOX 728 3b.Policy Number of Entity Listed in Box 1a SOUTHOLD, NY 11971 Z06874-000 3c.Policy Effective Period 7/1/2020 to 6/4/2025 4. Policy provides the following benefits: ❑)f A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5. Policy covers: ❑X 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 desor$�d above. Apt Date Signed 6/5/2024 By - (Signature of insurance carrier's authort d�Presenta&e*_.' r NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 NameandTitle SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4B,4C or 5B of Part i has 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(Arlicle 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) pllla! �- N ��NNi � 1,� ACCOREO CERTIFICATE OF LIABILITY INSURANCE DI;/18I�/Y " 12/18 3 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 endorsements. PRODUCER N atthew Ru erto�mm & Liberty Risk Management, Inc. PHDNE 631 569•a633 ,,) 1yw6s 2333 Route 112 E4WL rl ttheW IlID k pm...... Medford, NY 11763 _���......u�N IJRER s AFFORDING COVERAGE � NAIL t... ... �... ._ _.m... INSUI ERAS +fit e � . lane rw a e' ... Arthur INSURED INSURER :,,,,• _ ..._.......�.. ..••. .. ..— J. Edwards Mason Contracting Company Inc. DBA Art hur J.Edwards Pool 8r Spa Centre INSURER C '.'_' ••• ---- 929 Route 25A INSURER ram..... ..... Miller Place, NY 11764 INSURER E •••••.... INSI/RER r COVERAGES CERTIFICATE NUMBER.' 00000005-17'66199 REVISION NUMBER: 48 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.--... _...... ,,,w•_ ... -� ........ - FIOLICY PF gPOUC"W"EIaI S NNTSRR A DL SUaR LIMIT. TYPE OF INSURANCE POLICY NUMBER MMID A COMMERCIAL GENERAL LIABILITY NPC-1004300-03 01101/2024 01/01/2025 EACH OCCURRENCE' $ 1 000 000 Y� hi� 1 � CLAIMS-MADE NJ OCCUR PR I Ea orranca _$"__ ""'"" MED EXP QAny one Prrrsnn) 6 10,000 I..PERsOra .&ADv IF&JU RY s 1000 µ0 ._ GGREG�AH s _Q0 - . AGGREGATE LIMITAPPLIES PER: m•PROI' S $ „• G NL AGGRE -COMPIOP AGG $ 2 000 000 POt.ICY o JECT 0 LOC OTHER;'. OOMBIN-�wouL LImr AUTOMOBILE LIABILITY ....( $ .. ANY AUTO BODILY INJURY(Per person) $ 15AM(P L... ..A _�.,_...._ OWNED SCHEDULED L' N ( accident) AUTOS ONLY AUTOS t3PORODII�LEY FURY Per HIRED NON-OWNED $ AUTOS ONLY .-.--.. AUTOS ONLY UMBRELLA LIAB EACM OCCURRENCE S_„ ••,_,,,,,,_,_ OCCUR ••••• EXCESS LIAB CLAIMS•MAD .. REGATE 5 .. _...... AGG,......� �._ $ UED RETENTIONS PER OTH- TAND RKERS COMPENSATION 3E T' ......IT E;R.-. ••••--,_ EMPLOYERS'LIABILrrY Y/N PROPRIE"ICFUPANTINERJEXEC'UTN'V'E E L.EACH ACCIDENT .,''.,,,,-„• ,....ICE"EMSER EXCLUDED? N/Andatory dn NMIE L.D....:ASE FJ�EMPLOYE a,describeuindar E L.DISEASE-EPJCY LIMITCRIPTION OF OPERATIONS kialowv DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Addklonal Remarks Schedule,may be attached H more space Is required) Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIPICATF HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall P.O. BOX 728 AUTHORIZED REPRESENTATIVE Southold, NY 11971 Rin 1-11 MJR ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/18/2023 at 02:07PM