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Home My WebLink About51479-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#: 51479 Date: 12/16/2024 Permission is hereby granted to: Rosmarin AP Revoc Trt 31 Annandale Dr Chappaqua, NY 10514 To: Construct an inground swimming pool accessory to an existing single-family dwelling as applied for perTrustees approval. Pool and pool equipment must maintain minimum side and rear yard setbacks of 10 feet. Premises Located at: 640 Lloyds Ln, Mattituck, NY 11952 SCTM#99.-3-4.1 Pursuant to application dated 10/21/2024 and approved by the Building Inspector. To expire on 12/16/2026. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total $400.00 Building Inspector 4, TOWN OF SOUTHOLD—BUILDING DEPARTMENT if Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 u Telephone(631) 765-1802 Fax(631)765-9502 https-://wwwsoutholdtgmppy.gov Date Received f APPLICATION IG For Office Use Only � ' 4 PERMrr NO. c l Building Inspector-, i, °N " "O Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:October 21 st, 2024 OWNER(S)OF PROPERTY: Name:Rev.Trust ofAbby P.Rosmadn, Abby Rosrnarin and David Ross Tr stew SCTM#1000-99-3-4.1 Project Address:640 Lloyds Lane, Mattituck, NY 11952 Phone#:631-734-7923 (Agent) lEmail:Creativeenvdesign@yahoo.com Mailing Address:P.O. Box 160 PeconiC, NY 11958 CONTACT PERSON: Name: David Clchanowlcz/Creative Environmental Dealgn MailingAddress:P.O. Box 160, Peconic, NY 11958 Phone#:631-734-7923 Email:creativeenvdesign@yahoo.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Creative Environmental Design Mailing Address P O. Box 160, Peconic, NY 11958 Phone#:631-734-7923 Email:creativeenvdesign@yahoo.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure [--]Addition ❑Alteration ❑Repair ❑Demolition Esti ted Cost of Project: ❑OtherPool $ Will the lot be re-graded? ❑Yes to No Will excess fill be removed from premises? ❑Yes,,No 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 this property? ❑Yes @@No IF YES, PROVIDE A COPY. it Check Box After Reading- 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,bullding code, housing code end 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. David CichanowlezlCreative Environmentai Design Application Submitted By(print name): Authorized Agent ❑Owner Signature of Applicant: Date: d f [ lag STATE OF NEW YORK) SS: COUNTY OF David Cichanowicz being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Ag ent (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 (Y� cf .20 FENNY LOUISE M FFETONE Notary PAWir NOTARY PUBLIC,STATE OF NEW YORK Registration No. 01 MA6402379 Qualified in Suffolk County 3ROPERTY OWNER ) ( ( fission Expires December 30t6,2027 (Where the applicant is not the owner) I, residing at Abby Rosmarin 640 LLoyds Lane, Mattituck, NY 11952 David Cichanowicz/Creative Environmental Design do hereby authorize to apply on my behalf tQ the Town of Southold Building Department for approval as described herein. /dzZ Owners Signature 6ate Abby Rosmari n Print Owner's Name 2 F t fi a', „b ,.... „� p N I 1' BOARD OF SOUTHOLD TOWN TRUSTEES , SOUTHOLD NEW YORK PERMIT NO.10645 DATE: SEPTEMBER I .20Z4 >, a k ISSUED TO: REVOCABLE TRUST'OF ABBY P. ROSMARIN DATED OCTOBER 19 tt.2020. coo ABBY P. ROSMARI� & DAVID M. ROSS AS TRUSTEES PROPERTY ADDItl+1 SS: 640 LLOYDS LANE MA"1 rITUCI SCTM# 1000-99-3-4.1 AUTHORIZATION Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on Member 18.2024. r and in consideration of application fee in the sum of$1,250.00 paid by REVOCABLE TRUST OF ABBY P. ' CTOBER 191"' 2020.c/o ABBY P.ROrrOSh4RIN 1 IE O . R1N&I)AV1D 1vt.ROSE TRUSTEES and subject to the Terms and Conditions as stated in the Resolution,the Southold Town Board of o Trustees authorizes and permits the following: w a J� Wetland Permit to remove existing pool and construct a new 16'x36' in-ground pool; b G y °wf ""y remove existing pool patio and construct a 1,570sq.ft, patio surround with steps; , connect drainage to drywell; install 4' high pool enclosure fencing with gates; existing black cherry tree to be removed and replaced with a 3" caliper oak tree; and remove 'U steps on east side of patio; with the condition that the drywell be moved to the easternr ; side of the property; and silt fence and hay bales installed prior to construction; all as depicted on the site plan prepared by Creative Environmental Design, received on 4w" ' September 20, 2024, and stamped approved on September 27,2024. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, fand these presents to be subscribed by a majority of the said Board as of the day and year written above. fl pry A _. 53 r° i .r ,, f a"f, Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name DAVID J CICHANOWICZ Business Name " INDIAN NECK CORP DBA This certifies that the bearer is duly licensed License Number H-29895 by the County of suffolk lsgsued: 12/13/2001 J94'L �CbYelra, Expires: 1 210112 02 5 Commissioner 5 Y N r work rs' ,s °r i onroi nsation CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE-BENEFITS LAW PART 1.To be corn leted by NYS Disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Add ss of insured(use street address only) 1b.Business Telephone Number of Insured INDIAN NECK CO DBA CREATIVE LAND-SCAPE DESIGN. 39160,ROUTE 25 PECONIC,NY 1195 1 c.Federal Employer Identification Number of Insured or Social Security Work Location of Ins red(Only required if coverage is,s,pecificallg Number limited to certain localio s in New York Stale,i.e., Wrap-Up Pollcy) 112294493 2.Name and Address f Fntity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as he Certificate Molder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 3b. Policy Number of Entity Listed in Box•1a LNY323682 3c.Policy effective period 01/01/2024 to 12131/2024 4.Policy provides the f Ilowtintd benefits: Q A.Both dice liity and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C,Paid Fam y Leave benefits only. 5.Policy covers: ❑X A.All of the mployer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the f ,lowing class or classes of employer's empioyeesa Under penalty of pergui ,I certify that I am an authorized representative or licensed agent of the Insurance carrier referenced above and that the named insured has NYS Disabi ity and/or Paid Family Leave benefits insurance coverage as described above. Date Signed 01-24- 024 (Siery,naYarortf or Ynsrarsaroak caurrl�r"�aaNkhorizod mapraaco�t4nbivoor NYS Ilarannod Insurnneo a,{9onk of 1Nsn1 Rn�+arancm cnrrqrrl Teie hone Number 21 55:1.3074 Name and Tttio. EL IZABC l't-I TELLO—ASSISTANT DiRECTOR STATUTORY SERVICES IMPORTANT: If Box s 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licen ed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 513 is checked„this certificate is NOT COMPLETE for purposes of Section 220,Subd<B of the NYS Disabt Ity and Paid Family Leave Benefits Law.It must be emailed to PAU@wcb.ny.gov or it can be mailed for comp] tion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200.Binghamton,NY 13902-5200. PART 2.To be comple ed by the NYS Workers' Compensation Board(Only If Box 4B,4C or 5B have been checked) State of New York Workers' Compensation Board According to informa ion maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and P Id Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees.. Date Signed By (slynalura of Aulhorizad NYS Workers'Componsallon Board Emplayoo) Telephone Number Name and Title Please Note.Only Insuran e Carrierstic' eiiself to wrr'te NYS disability acid Paid Family Leave benefits insurance pollclas and NYS licensed Insurance agents of those Insurance carriers or authorized to Issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) IIIIM11i11I1M1�1111611MI111I1Il� C�7"Rbr CERTIFICATE OF LIABILITY INSURANCE DATE 05/01/202YY, „ 05/01/2024 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 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( ). Y ACT Matt Daley Farm Famil Insurance P111 631-744-3350 N : 631-744-3383 PRODUCERCIOONN I - 85 Echo Ave-Suite 2 E-MAIL g§s: matt.daley@fare-n-family.com Miller Place, NY 11764 INSURERS AFFORDING COVERAGE maw.fi INSURERA: Farm Family Casualty 13803 INSURED INSURER B t Indian Neck Corp. DBA Creative Environmental Design INSURER C:' PO Box 160 INSURER o INSURER�•: Peconic NY 11958 INSURERF. 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. Off A 0 OL R'U—B-R polidy EFP cy 1W LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMf0DIY'YYY MMID'DIY'YYY' 1 DO0,00'0 A COMMERCIAL GENERAL LIABILITY 3152X2360 0610''1/23 06/01/24 EACI-IOCCURRENCE $ CLAIMS-MADE �OCCUR 06/01/24 06/01/25 mPREtiItlSES� occurrance 5 RENTED 100,000 x Select Business PKG 5„000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY ❑PRO-JECT ❑LOC PRODUCTS-COMPIOPAGG S 2,000,000 X S OTHER; _T AUTOMOBILE LIABILITY Eaa accl enflOBINED NGLE q lMfl $ ANY AUTO ( person) $ INJURY Per erson BODILY ...�..... �...N...,�... OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAM9GE S AUTOS ONLY AUTOS ONLY Pc�r a cldenl $ .. UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLcylpgS.p�AD"E AGGREGATE S DED RETENTIONS S OTH- WORKERS COMPENSATION SPERTATUTE AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) MASONRY/LANDSCAPING CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD 54375 MAIN ROAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BOX 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. P.O. BO OLD, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHAUTHORIZED REPRESENTATIVE 1988.2015 ACORD CORPORATION. All rights reserver ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD New York State Insurance rued PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112294493 %.* 1fc AMWINS INSURANCE BROKERAGE LLC200 ELWOOD DAVIS ROAD SUITE 200 LIVERPOOL NY 13088 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER INDIAN NECK CORP. TOWN OF SOUTHOLD T/A CREATIVE ENVIRONMENTAL DESIGN PO BOX 1179 PO BOX 160 SOUTHOLD NY 11971 PECONIC NY 11958 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z1318 046-8 738667 05/01/2024 TO 05/01/2025 5/1/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSUF;ED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1318 046-8, 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:/fWWW.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 STATrSUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:412189446 U-26.3