Loading...
HomeMy WebLinkAbout51304-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#: 51304 Date: 10/22/2024 Permission is hereby granted to: Kirkland DA Revoc Trt 2275 Deep Hole Dr Mattituck, NY 11952 To: Construct an inground swimming pool accessory to an existing single-family dwelling as applied for. Pool and pool equipment must maintain a minimum side and rearyard setback of 5 feet. Premises Located at: 2275 Deep Hole Dr, Mattituck, NY 11952 SCTM# 115.-14-14 Pursuant to application dated 09/03/2024 and approved by the Building Inspector„ To expire on 10/22/2026. Contractors: Required Inspections: FOOTING/REBAR, ELECTRICAL- ROUGH, ELECTRICAL- FINAL, DRAINAGE, FINAL, Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total $400.00 ........... ju 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 litt s:HwNvNv, o tholdtownriL o o- Date Received APPLICATION FOR BUILDING PERMIT I 9 .11 avol i For Office Use Only PERMIT NO. Building Inspector;—JA�& �U � �� ' Applications and forms must be filled out in their entirety. Incomplete T011DIt applications will not be accepted. Where the Applicant is not the owner,an SO UT1101 Owner's Authorization form(Page 2)shall be completed. " Date: q OWNER(S)OF PROPERTY: Name: SCTM #1000- Project Address: Q2 IC`a r\,Jc Phone#: y� Email: Mailing Address: CONTACT PERSON: Name: KQLwCA Mailing Address: 5ql ke- Phone# _ "1 -' � Email: S t\ , DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: S Mailing Address: a S O U Phone#: . Email: Wncf DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other" '�C $ Will the lot be re-graded? I9Yes El No Will excess fill be removed from premises? ❑Yes ly0 1 PROPERTY INFORMATION Existing use of property: I �'� � '" r>Le Intended use of property: i Qqr, (,Z� 7 Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to K_ 40 this property? ❑YesOo IF YES, PROVIDE A COPY. heck Box After Reding: The owner/contractor/design professional Is responsible for all drainage and storm water Issues as provided by Chapter 236 of the Town Code. APPLICATION 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 Lbrint name): 6t�n a Authorized Agent ❑Owner Signature of Applicant: Date: q)31 3kq STATE OF NEW YORK) SS: COUNTY OF ) vg�k,irl)Lc& 'AR, being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the 4 �Itontractor,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 , 20 Notary Public VICTORIA A FERREMI E Public^'State of New York110 moN OIFE6430360OPERTY OWNER alified in Suffolk County Wherthe a I ant Is notthe u n C " IIImission Expires Mar 14, 2026 •� ��. ( pp owner) 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 Building a artmgent Aj2gliegtion AUTHORIZATION (Where the Applicant is not the Owner) I, q ._._.residing at 0j Ur (Print property owner's name) (Mailing A. ess) do hereby authorizeKa4ri'm-Me-maric, (Agent) to apply on my behalf to the Southold Building Department. Q-0 0(0 ner's Signa ire (Date) (Print Owner's Name) DATE(MMIDDIYYYY) �coirn CERTIFICATE OF LIABILITY INSURANCE 108/23/2024 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(ies)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 endorsement(s). PRODUCER ° . T Nicholas Zuikolske Brookhaven Agency,Inc. PHic No ONE 63I 941-4113 F 6311 941 4405 100 Oakland Ave,Ste 1 tl certificates brookhavena enc .com Port Jefferson,NY 11777 I INGCOVERAGE Philadelphia IndemnitV Insurance Company INSURED Merchants Mutual Insurance Company. Patrick's Pools,Inc. INSURERC.Wesco Insurance Company PO Box 3024 INSURER 0: East Quogue NY 11942 INSLI858 I. 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 AOOL SU POLiCY EFF P ICY EXP LTRTYPE OF INSURANCE I LIMITS X" COMMERCIAL GENERAL LIASILJTY EACH,OG U E C $1 000,000 �� OAMAGETO RENTED A CLAIMS-MADE XX OCCUR 100 O X Contractual LiabilityPHPK2658571 02/28/2024 02/28/2025 EXP one S5,000 P m II v INJURY 1 000 000 GEN'LAGGREGAT LIMIT APPLIES PER: NE G R TE 2,000,000 PC?LiCY X�JEC LOC P T MPI P A $2,000,000 $ AUTOMOBILE LIABILITY COMBiP9ED SiNGB E LIMiT $500 000 7 B X ANY AUTO BODILY INJURY(Per person) $ AALL UTOS OWNED r7 SCHEDULED X X CAP9267113 07/1212024 07/12/2025 BODILY INJURY(Per accldeM) $ UTOS + HIRED AUTOS )( NON-OWNED PROPERTY DAMAGE AUTOS $ UMBRELLA LIAR OCCUR EA H CCURRENCE EXCESS LIAS C IIw1 E A GRE TE DED $ WORKERS COMPEN SATION X PER OTH- AND EMPLOYERS'LIABILITY YIN AT 100,000 ANY PROPRIETORIPARTNERIEXECUTIVE L.EACH GGIDEN C OFFICERIMEMBER EXCLUDED? NIA WWC3714385 05/13/2024 05/13/2025 (Mandatory in NH) r E.L.DISEASE-EA EMP OYEE $100 000 If es,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD NEWworkers'R CERTIFICATE OF INSURANCE COVERAGE ...._._\ T E Compensation ��-1 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 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) 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"I a" 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: © A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. 0 B.Only the following class or classes of employers employees: Under penalty of pei)ury,I cerC that I am an authorized representative or licensed agent of the insurance carder refeienoad 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 51 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 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 56 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 Oils form. DB-120.1 (12-21) GI�II � 1�2i0ui uiiiiwdi-N ill V Workers' CERTIFICATE OF Z4 rYOA% Compensation cation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Boaid 1a Legal Name&Address of insured(use street address only) lb.Business Telephone Number of Insured 631-896.4687 Patrick's Pools,Inc. PO Box 3024 1c.NYS Unemployment insurance Employer Registration Number of East Quogue NY 11942 Insured Work Locatlon of insured(O*mgefted ff coverage Is ire. W fbnw to 1d.Federal Employer Identification Number of insured or Social Security cerfaar focaffons for Now York State,to,a Up Poky)� Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 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'lam Town Hall Annex WWC3714385 54375 Main Road Southold,NY 11971 3c.Policy effective period 3d.The Proprietor,Partners or Executive Men;are �] Included.(Orly d"box Ir an pa*wsloificers Included) X� an excluded or certain pertnerslofticers excluded. This certifies that the insurance carrier indicated above In box ur Insures the business referenced above In box'16"for workers' compensation cinder the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Rom 39 on the INFORMATION PACE of the rs'compae satlon 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"20. The Insurance carrier must notify the above cettifica holder and the Workers'Compensation Board within 10 days IF a policy Is canceled due to nonpayment of premiums or within 30 days Il�them are reasons other than nonpayment of premiums that cancel the policy or eliminate the Insured from the coverage Indicated oil this Certificate.(These notices may be sent by regular rnalL)Otherwise,this Certificate is valid for one year after this form Is approved by the Insurance carrier or Its licensed agent,or until the pollcy expiration date listed In box OW,whichever is sidler. This certificate Is issued as a matter of information only and confers no rights upon the certificate hnder,.This certificate does not amend, extend or after the coverage afforded by the policy 1#6d,nor does it confer any rights or responsitatiities 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 Noted Upon cancetlation of the workers'compensation policy Indicated on this form,..If the business continues to be named on a permit license or contrad Issued by,a cortifiesto holder,the business,must provide that cerifficale holder with a new Certificate of W rW Compensation Coverage or other authorized proof that%a business is complying with the mandatory coverage requirements of the New YO state Workers'Compensation Law. Under penalty of Perjury,I oorft that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has the coverage as depleted on this form. Approved by: Nicholas Zulkofske (Print name of representave or ftensed agent of I mmnoe comer - Approved by: ( ) 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 C 105.2.Insurance brokers are�Z authorized to issue it. C-105.2(947) www.wcb.ny.gov i l JUN wvn�i OFFICE OF lo/ E 28 �g LOT TOWN OF SOUTHoi S�OCKw SfOCIfME FENCE ROW OF ARBORVITAE II IIQ 0 r�/ j //�3� ��, n'''� r r /Ff Iti / /0 21, r r t t li" Jl, CE 1/2 fST60y FRAME r AGE Gl�K e "AM " 14 4 /�r ++rx �r If M c„ j J uVVVVI 7 t, m ^rp1' // n " / r , �j,