HomeMy WebLinkAbout51462-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#: 51462 Date: 12/10/2024
Permission is hereby granted to:
Brian Pushic
29535 Main Rd
Orient, NY 11957
To:
Construct an inground swimming pool accessory to an existing single-family dwelling as applied for.
Pool and pool equipment must maintain rear and side yard setbacks of 15 feet.
Premises Located at:
29535 Route 25, Orient, NY 11957
SCTM# 14.4-1.1
Pursuant to application dated 10/01/2024 and approved by the Building Inspector.
To expire on 12/10/2026.
Contractors:
Required Inspections:
Fees:
SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00
CO Swimming Pool $100.00
Flood Permit $150.00
Total $550.00
It
---_ . �
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Southold,Town 54375 NY 11971-0959
Telephone l(63 765 1802MFax(63 )7650 9502 h�9 wwwoutholdt¢�Wnn . g
Date Received
APPLICATION FOR BUILDING PERMIT
For Office use only
j�
PERMIT NO. I Building l�vspecti:aa,�
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant Is not the owner,an ry
Owners Authorization form(Page 2)shall be completed.
b r 1 a
Date:09/20/2024
OWNER(S)OF PROPERTY:
Name:Brian Pushlc SCTM#1000-14.-1-1.1
Project Address:29535 Main Road, Orient
Phone#:330-518-0575 Email:BrianPushic@gmail.com
Mailing Address:29535 Main Road, Orient NY 11957
CONTACT PERSON:
Name:Jennifer Del Vaglio and/or East End Pool King
Mailing Address: PO box 369 peconic, ny 11958
P
hone#:631-734-7600 Email:jennifer@eastendpoolking.com
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address.
Phone#: Emait_.. ..�.m—_. w .e. .-..e,�._.0 M._ ..... _.
CONTRACTOR INFORMATION:
Name:Jennifer DelVaglio/East End Pool King
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Mailing Address:PO Boc 369 Peconic NY 11958
.............._.....
Phone#:631-734-7600 Email:cj@eastendpoolking.com
DESCRIPTION OF PROPOSED CONSTRUCTION
New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other 18x38 rectangular%iny pool with spa $99,666
Will the lot be re-graded? RYes El No Will excess fill be removed from premises? ❑Yes RNo
__..._ .. ....._...._ _...._........
1
PROPERTY INFORMATION
Existing use of property:Residential Intended use of property:Residential
_.... ...__. ...� .
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
R80 this property? Dyes❑No IF YES,PROVIDE A COPY.
91
Chapter 2 the Town Code.A
Check
Sox After
I The ewner/contractor;/des4M prole el is responsible for all drain and storm water issues as proAded b ye
PRICATION IS HEREBY MADE to the Burg Department for the Issuance of a Building Parmit pursuant to the Building Zone
ordinanw 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 bullding(s)for necessary inspection False statements made hereln are
punishable as a Class A misdemeanor pursuant to Section 210.4E of the New Yak State Penal law.
Application Submitted P rya anon McHugh Autflorized ent ❑Owner
Signature of Applicant: - CONNIE"61\16 I � -3
Notary Public,State of New York
No.01BU6185050
STATE OF NEW YORK) Qualified in Suffolk County
SS: Commission Expires April 14,2�
COUNTY OF
)
Jennifer Del Vaglio
being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the Contractor and Agent
(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
L , � M
day of O 20 0l \ __
Notary Public
PROPERTY OWNER, 'f 11
(Where the applicant is not the owner)
Brian PUshlc residing at 29535 Main Road, Orient
Jennifer Del Vaglio/East End Pool King
do hereby authorize � to apply on
my kohalf to the Town of Southold Building Department for approval as described herein.
w
. m. 9/20/2024
nafue Date
Brian Pushic
Print Owner's Name
2
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J�` �TF O�][�MWA\TIER
Scott A. Russell � � � � �.
` ry IEMIENT
SUPERVISOR ��1CA�1�A��Gr
SOiTfHOLD TOWN HALL-r.O.Boa 1179
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530951VTain Road-SOLiTHOLD,NEW YORK 11971 �"'� �' "� �"` '�" � Town of Southold
CHAPTER 236 STORMWATER MANAGEMENT REFERRAL FORM
( APPLICANT INFORMATION
�ATfTI .� TO BE COMPLETED BY THE APPLICANT
ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. )
APPLICANT: (Property ert Ow
ner n rsfe ; ional, Agent, Contractor, Oth r) ..`
..,,
NAME: Y �� Date:
..�a °
Contact Inf'ornlation:
1:t'Idl CS I21t�111111F:JtIhlhCi�
Property rty Address / Location of Cons roction Site:
D1511'1Ct
Section Lot
TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT
- Area of Disturbance is less than I Acre. li'o S.P.D.E.S. f'' q r�� t ss 13et 1lx`ed i
- Project does Not Discharge to Waters of the State. No S.P.D E.5. Permit is Re uired !
- Area of Disturbance is Greater than I acre&Storm-water Runoff Discharcres Directly
to Waters of the State of New York. THE'APPLICANT MUST OBTAIN a S-P.D.E, . Perma
DIRECTLY Froze N.Y.S. DEC. Prior to 1 sl anc oI a Bt�llctitt P r�r� t.
Area of Disturbance is Greater than 1 Acre & Storm-watPr Runoff Flows Through Southold
Towns MS4 Systems to Waters of the State of Ne,N York, 1"14E APPLICANT l I ST OBTAIN
a SRD.E.S Permit through the Southold Trtrwn Erg meering Department
Prior to Issuance of a Building Perrttit.
Re .e-wed Bv: Date:
y
rnR rn .., om. ( P-'rr•,�
DATE(MM/DD/YYYY)
"► ' CERTIFICATE OF LIABILITY INSURANCE
11117/2023
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 Barbara Dammers
NAME:
Roy H Reeve Agency,Inc. aIGNNo E#: (631)298�700 N� :, (631)298-3850
PO Box 54 AWpt16dESSo bdammers@royreeve.com
13400 Main Road INSURERS)AFFORDING COVERAGE NAIL#
Mattituck NY 11952 INsuRERA: Transportation Insurance Co 20494
INSURED wsuRER B: Continental Insurance Co. 35289
Eastern End Pools LLC,DBA:East End Pool King INSURER C: Continental Casualty Company 20443
PO BOX 369 INSURER D:
INSURER E
Peconic NY 11958 INSURERF:
COVERAGES CERTIFICATE NUMBER: CL23111720048 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 CONTRACTOR 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.
LTR TYPE OF INSURANCE tNSD WV0 POLICY NUMBER IYYYY MMIDD (MMI DY LIMITS
X.COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
'.CLAIMS-MADE F;Zoq OCCUR PREMISES Ea occurrence $
100,000
Contractual Liability MED EXP(Any one person) $ 15,000
A Y Y 6080837145 11/15/2023 11/15/2024 PERSONAL&ADV INJURY $ 1,000,000
GEN'tAGGREGAfE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POkJOY JECT LOD PRODUCTS-COMP/OPAGG $. 2,000,000
--
OTH_ER: $
AUTOMOBILE LIABILITY COMBINED SINGLELI!Mr $ 1,000,000
Ba a-deni
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED 6080837159 11/15/2023 11/15/2024 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY JPav accident
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE AGGREGATE $
DED RETENTION$ $
OT
WORKERS COMPENSATION _ /\ PER ER
AND EMPLOYERS'LIABILITY YIN 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E,.L,EAOH ACCIDENT $
C oFF1cER/MEMBEREXCLUDEI I NIAI 6080837162 11/15/2023 11/15/2024
(Mandatory in NH) t1, DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required)
Certificate holder is included as additional insured under General Liability as per the terms and conditions of form#CNA75079XX-Blanket Additional
Insured with Products-Completed Operations Coverage Endorsement, Form CNA74705NY-Contractors GL Extension Endorsement,NY includes waiver
of subrogation&primary&non-contributory coverages as required by written contract or agreement. Additional insured under the business auto is included
under Form#CNA63359XX-Auto Contractors Extended Coverage Endorsement-Business Auto Plus.
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.
PO Box 1179
AUTHORIZED REPRESENTATIVE
Southold NY 11971
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD