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HomeMy WebLinkAbout51475-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#: 51475 Date: 12/13/2024 Permission is hereby granted to; Richard N Kalich 605 Saltaire Way Mattituck, NY 11952 To: construct accessory in-ground swimming pool as applied for. Premises Located at: 605 Saltaire Way, Mattituck, NY 11952 SCTM# 100.4-19 Pursuant to application dated 10/21/2024 and approved by the Building Inspector. To expire on 12/13/2026. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 41 Total S400.00 Iding 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 lint)s:HwwN .soutioldtowtin, Y v Date Received APPLICATION FOR BUILDING PERMIT MII For Office Use Only � I IIyIyI I/ PERMIT NO, Building Inspector. Applications and forms must be filled out in their entirety. Incompletei �u ny r � t applications will not be accepted. Where the Applicant is not the owner,an roVV Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: SCTM # 1000- Project Address: Phone ' �, Email: Mailing Address: CONTA PERSOI'�. Name: OWN Mailing Address: 1;5A Phone#t Email. .,) DESIGN OFE0IONAL INFORMATION: Name: f s LaPwioo, Mailing Address: �kffi r)s— Phoin #031 Email: CONTRACTOR INFORMATION- Name : Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION pair ❑Demolition ' Estim crs��Pe ❑New Struct I� $ ;Other tion ❑Re ure ❑A dition ❑Alters Will the lot lbe re-graded? ❑Yes No Will cessfill be removed from premi�es I 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Ye o IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all d' Inae and storm water issues as provided by C tear 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 Orden ce 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 210.4S of the New York State Penal Law. Application Submitted By( i name : 1)4 utlori2ed Agent El Owner Signature of Applicant: Date: Ao121 1� STATE OF NEW YORK) SS: COUNTY OFP-4Q AJ A I k:ZkZ&�) being duly sworn, deposes and says that(s)he is the applicant (11ame of individ a 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 applicatio rel i q to the best of his,/her knowledge and belief; and that the work will be performed in the manner set fort,�I : k , 'I + Lin file therewith.. : 0.0111 152 1657"; � t Sworn before me this QUALIFIED 1� .. ;s Fol K COu1�1Ty day of ,2 ": tt-29. . vs + Not ry Public �Ip ti�, PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) 1, Ma fQ residing at do hereby authorizeA Ytap ply on z1111111I j my b�e�alf to the Town of Southold Building De, la1�m 944ftz"proval as described herein. .col A ZK :1o.01 M 162 3165 7 O 'er's ignature oUALIFIED M Date SUFFOI. COUNTY Comm. o . � G 11-26 Prin. Owner s Name �'�"��� . �'r'�'+Illl i I I14111ti"���� 2 N"W workers' CERTIFICATE OF INSURANCE COVERAGE Y' r 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 carriell 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A ROCKY POINT, NY 11778 1c.Federal Employer Identification Dumber of Insured or Social Security Number Work Location of Insured(Only required ifcoverage is specifically limited to 113008276 certain locations in New York State,i.e.,Wrap-Up Policy) 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 53095 Rt. 25 3b.Policy Number of Entity Listed in Box"l a" P.O. Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 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. B.Only the following class or classes of employers employees: Under penalty of pedury,I certify that II am an authorized representative or licensed agent of the Insurance carder referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/7/2023 By WAO, UI f (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White 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 5B 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 this form. DB-120.1 (12-21) 111111111 !°°11°1°1°°1°1°�11°��°°°1°°IIIIII 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 form 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. DB-120.1 (12-21)Reverse Workers' ��;�� CERTIFICATE OF STAr'F Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board ....... 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (631)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Insured Rocky Point,NY 11778 Work Location of Insured(Only required if coverage is specilically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11 3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest National Ins Co Town of Southold 3b.Policy Number of Entity Listed in Box"l a" 53095 Rt.25 SW5WC00205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 to 11/05/2024 3d.The Proprietor,Partners or Executive Officers are �X included.(Only check box if all partners/officers included) h ❑ all excluded or certain partners/officers excluded. WW� This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under yo-3A. 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 certificate holder and the Workers'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 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: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 certificate 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 York State Workers'Compensation Law. Uinder 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 the coverage as depleted on this form. Approved by: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 9�*— 11/03/2023 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)REVERSE ..Awwnom ACTMIMOR Au0W00% Mnow" �O�latllt 4 A r10M14DM Of 7w OF at mw Tm Sun Com of 40 HOB 1 aq qa o Vxrrrt rB`oom WA ot �IIAIAND� d MOWN fiW(ailr ZIM7 10 AR Po*m pm 1h"AR sum �� �� .1+WAMM w140 CM iB"4W 1010 r► � 'Of-��tAo 711i L10W0a. �} � ft%b%Are c0 Da^oxWmw C*"as4rc OWN, tA, 4 t s ,M " �1- � 14 " yea fie'" 1 SURVEY TOR THOMAS A. ER a DEBRA N. FLAD R LOT 22 49SALTAiRE ESTATES` , e MATTITUCK r TOWN OF SOUTHOLD SUFF. CO., N.Y. ' ' NOTE i YOUR ^4 L SUFFOLX C4UNlYTAX MAP w. T ,Wti N3,1987 a u/A�MMD 3 4 ODIHUEG MAP-nt.L"0 IN T'H OFFX R NO.4 ,