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HomeMy WebLinkAbout51121-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE w� a SOUTHOLD, NY w uw 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 #: 51121 Date: 8/23/2024 Permission is hereby granted to: Gutherz, Sophia 235 W 76th St Apt 2C New York, NY 10023 To: construct accessory in-ground swimming pool with spa as applied for. Pool equipment shall be located in the rear yard with minimum 25' setbacks to lot lines. At premises located at: 4230 Grand Ave, Mattituck SCTM # 473889 Sec/Block/Lot# 107.-2-2.6 Pursuant to application dated 7/12/2024 and approved by the Building Inspector,. To expire on 2/22/2026. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector �I6.r�Y� `�G14�V4c ! '� i �"i - i.Vo'1C( tiIa'4- � �rr�w'w� t�� � I� tt �taBil °.Mvo� . TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 :24 Telephone (631) 765-1802 Fax (631) 765-9502 litt s://Nvm .soutlioldtonLLm2� 'w16Ja:i:M1f J� Date Received BUILDINGAPPLICATION FOR For Office Use Only �dL Y 1.\ D PERMIT NO, Building Inspector. JUL 1 2 2024 W-m—o" Z�:A Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUILDING DEPT. Owner's Authorization form(Page 2)shall be completed. TOWN =jF SOUTHOI Date: I � � OWNER(S)OF PROPERTY: Name: So SCTM #1000- Project Address: ) A� %tu I Phone#: Email: Mailing Address: -- CONTACT PERSON: Name: 1 Mailing Address: Phone#: ' Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: TTM71 CONTRACTOR INFORMATION: Name: AnL Mailing Address: �U r44 l i Phone#: 1_ Q� `--I Email: lei 1S f DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration []Repair ❑Demol�����+ Poo Estimated Cost of Project: VOther w ci i Y $ Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? es [:]No 1 PROPERTY INFORMATION Existing use of property: '�5{"~ 'e Intended use of property: I S4wmmlnq Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ilo IF YES, PROVIDE A COPY. Epte heck Sox After Reading: The owner/contracctoor/design professional Is responsible for all drainage antistorm w atewr issues as pr*vNded by r 256 of the Town Code.. APPUCA'TION 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 210.45 of the New York State Penal Law. Application Submitted By(print name): I(y)er��© Authorized Agent ❑Owner Signature of Applicant: d Date: _11 I a bL4 STATE OF NEW YORK) COUNTY OF 5 5 S; C*r w" being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the �- QoDntractor,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 � f . day of R ZD ., Notary Public VICTORIA A FERREMI Notary Public-State of New York PROP OWNER AU ZATION No,fr1Fi Suffolk c E y o is not the lowner) Qualified in Suffolk County My commission Expires Mar 14, 2026 (Where the applicant W NOW I, 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 Buildin&Degar nne t Allplication AUTHORIZATION (Where the Applicant is not the Owner) I 7 H t A Cqq C , residing at "7� � (Print property owner's name) (Mailing Address) do hereby authorize (Agent) 1f� o to apply on my behalf to the Southold Building Department. (Owner' Signature) Date (Print Owner's Name) y Workers' CERTIFICATE OF ORK ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name 5 Address of insured(use street address only) 1b.Business Telephone Number of Insured 631-996.4687 Patrick's Pools,Inc. PO Box 3024 1 c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of insured('Only required if covarap Is rally 1knited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations to Now'Yorlr State,Ia.,a'1Mrap-tip Po4y) Number 262929943 2.Name and Address of Entity Requesting Proof of Cove ge 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 3b.Policy Number of Entity Listed In Box"1a" Town Hall Annex WWC3714385 54375 Main Road Southold,NY 11971 3c.Policy effective period to nsri wnw; 3d.The Proprietor,Partners or Executive Officers are Included.(only check box if all partnerstollicers Included) QX all excluded or certain partners/officers excluded. This certifies that the Insurance carrier indicated above in box 03 Insures the business referenced above In box"1a"for workers' compensation under the New York State Workers'Compensation Law.(To use this forth„New York(NY)must be listed under RomA 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 cediffica holder and the Wlfor aW 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 mall.)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 boat 1130'",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 Notes 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 cer00cate 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 Yrark State Workers'Compensation Law. Under penalty of perjury,I certify that II am an autIhor^ized 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: Nicholas Zulkofske (r'rint rrdrne 4iLL adepre, true or cenned agent of Inauranoa cemor) Approved by: —1 2� 2� (Date) Title: Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier. 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form G105.2.Insurance brokers are bw authorized to Issue It. C405.2(947) www.wcb.ny.gov 6 °ATE(MM/°° CERTIFICATE OF LIABILITY INSURANCEkh� "'�"' A R/JRn FO4/17/2024 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 polic (les)must 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 endorsemen . PRODUCER NA ONTACT NiChOIaSI Zulkofske Brookhaven Agency,Inc. PHONE , 631 94t-4"I13 FAX • 53't 941-4405 100 Oakland Ave,Ste 1 AMAID certificates larookhaverla 'enc .com Port Jefferson,NY 11777 INSURER F RDING COVERAGE INSURERA: Philadelphia Indemn4 Insurance Com an INSURED • Merchants Mutual Insurance Com an Patrick's Pools,Inc. Wesco Insurance Com an PO Box 3024 East Quogue NY 11942 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 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 TYPE OF INSURANCE ADOLSUSR CQLICY NUM POLICY EFF POLICY EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 12 000 000 DAMAGE TO RENTED 10O OOO A CLAIMS-MADE X OCCUR �o X Contractual Liabil'i PHPK2658671 02/28/2024 02/28/2025 MED EXP An one arson • 5,000 PERS N_ &ADV INJURY 1 000 000 701HER� L AGGRE AT LIMIT APPLIES PER: ENERAL GREGATE 2 000 000 XX PRO- POLICY LOC PRODU TS- MP/OP AGG 2 000 000 AUTOMOBILE LIABILITY COMBINED SINGLE.LIMIT $50O 000 �ISW�rctl).. B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2023 07/12/2024 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X HIRED AUTOS X AUTOSWNED $ UMBRELLA LIAB OCCUR EA O RRENCE _---- EXCESS LIAB CLAIM -MADE AGGREGATE WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY SIATLITE ANY PROPRIETOR/PARTNER/EXECUTIVE�Y 1 N E.L.EA A CIDENT 10O 000 C OFFICER/MEMBER EXCLUDED? h JG N/A WWC3714385 05/13/2024 05/13/2025 (Mandatory in NH) E.L DISEA E-EA EMPLOYEE 100 000 If es,describe undRIPTION OFer E.L,DISEASE POLICY LIMIT 500 OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as additional insured per written contract CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex 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. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <NSZ> ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD j,YN0'WRKworkers'eCompensation 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 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Onlyrequired if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 262929943 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 1a" PO BOX 1179 DBL318565 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. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: m A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. rl B.Only the following class or classes of employers employees: Under Penalty of perjury,I certify that I am an authorized I irepresentative 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 6/20/2024 BY (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 515-8 9.5100 Name and Title Leston Welsh,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 sox 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(Artible 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. oB-120.1 (12-21) IPI�IINIIIAIIIIIInIIIIIInIIIIIIIN�III�111 r� jJ V, lip 1 , 4'a 7' R i a + I . R r e: a fi s sellr .a I. t7ltli w � 1 � erg€: ' z" •o i c .o- N r t T � 4 A F `1 P 1 MJCFIAEL MA/LCaAI�'ET 7'oWN OF So✓TtIO 4D ^• �r11 FFG�r�, eotl�(TY,N.Y. - �• Eta � s ak u 00 I smw 3- s 00 gu R J•. ro�'S,P c. ot. ' qN 1j.Y: Pc,:7r;7z ¢�o° �'/ts�' � Lo. 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