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HomeMy WebLinkAbout51521-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#: S1521 Date: 01/07/2025 Permission is hereby granted to: Eric Rosenblum 899 Lincoln PI Brooklyn, NY 11213 To: construct accessory in-ground swimming pool as applied for. Premises Located at: 1870 Stars Rd, East Marion, NY 119390128 SCTM#22.4-18 Pursuant to application dated 11/08/2024 and approved by the Building Inspector. To expire on 01/07/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total S400.00 _�.._ � �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 hit /wyNy v. outholdtownn Date Received APPLICATION FOR BUILDING PERMIT o w For Office Use Only i . L5�L PERMIT NO. Building Inspector._www_-,-k I'll, I NOV 8 20'24 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: / O 3 o d4 OWNER(S)OF PROPERTY: Name: 6�1xm SCTM#1000- Project Address: O s} ,"� c )9 �C Phone#: �y�Tj ����' Email: r AC�YaC�� - yak A w w G.Ortn Mailing Address: e CONTACT PERSON: Name: Mailing Address: w wW. Phone#: ��( ®" — 1 OLlEmail: .. AAA m)m DESIGN PROFESSIONAL INFORMATION: Name: Y o t` Mailing Address: P,o ) (P l o w Phone#: O-a 1 � �b s"® �-l15 q Email: We N,, t*A�9 (� 004k OWL , N CONTRACTOR INFORMATION: Name: A uI' �.o�5iw1 �� ��.���NS�t- t-14 `{3`f?a Mailing Address: ,P® 9 ��� �at(o ( ; I ;Z-,_eA Phone#: Email DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other S "' a $ `9 9 10 ): 6" Will the lot be re-graded? ❑Yes LKo Will excess fill be removed from premises? * Yes ONO 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covena t and restrictions with respect to this property? DYes .:i'No IF YES, PROVIDE A COPY. r tCheck Box After Rey::!'u n'lg: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by alpter 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 taws,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): OAuthorized Agent Owner Signature of Applicant: Date: STATE OF NEW YORK) I r`— SS: COUNTY OF �M being duly sworn, deposes and says that(s)he is the applicant (Name of i '. ividual signing cont_ M1ct) 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 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 f° 7 �rewith. Sworn before me this QN,d ay of IJ o u�be 20 „ Notary Public t�r r & Shahchia N Payne t Notary Public-State of New York Na wR . ..R GINNER i� I( IZ ..I�ION . N a No.01PA0003051 � .. ..M,. .... .,,,_....a,. . ......... Qualified in Kings County My CommissionExoiresMarch20,2027 (Where the applicant is not the owner) I, residing at ...._ d o __._ hereby authorize ::i o _t to apply on my behalf to th ow of Southold Building Department for approval as described herein. �....... Oven is i nature..�,.�ww.�.................._. . . Date ...�_� "J � JA/N Print Owner's Name 2 Note ALL SUBSUPIACE STRUCTURES UNAUTHORIZED ALTERATION OR ADDITION WATER, SUPPLY. SANBTAR'f SYSTEMS, TO THIS SURVEY IS A VIOLATION OF to JMu rtm JI.1 _ SECTION 7209 OF THE NEW YORK STATE I R dl3/A SHOWN DRYWEV_t.S AND BSER UTILITIES EDUCATION LAW. RNW In nm1e A10O ARE FROM MED OBSERVATIONS O OR DATA U`BPAIfJED FROM OTHERS. COPIES OF THIS SURVEY k*PINKED NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR SI THE EMSTEN-E DF RIGHTS OF WAY EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY kR ANY, NOTE S HOWNJ AYF FN RECORD rGUARANTEED GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Premises krr7wn os TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND 7870 Story Rcor' East Morton TO THE ASSIGNEES OF THE LENDING INSTI— TUTION GUARANTEES ARE NOT TRANSFERABLE Area = 20,224 sq.ft. 0.46 acres 7 LOT 14 .13' N 9, a' 4 4 z y Story Rams a m K ..,...... .. 4 L 'FI S �� . . 1 70r + ea x �f yt qn{ � " 0 oaereav gar �,��.. H "^� N ...� ,,.�+^'"'., ¢M✓u AA'a a.. erou'ud a" S d e` % .M'" J 193.09' w... LOT V Q v t_r mac . i S \j Certified to: Eric Rosenblum Rachael Rosenblum '"�'�'� S u rvey of Lot 13 Advocole's Abslrocl unp o!sounduest WDods, se(6011 I" Weslcor Title FILED June 9, 1969 FILE NO,5315 s�!uate of East Marion LANIJ SUHVE3'JNG Town of Southold r �� ..,�dknrc�wwlfdl.ak4aaau^rA ao a.o-den ,� Y Suffolk County, New York TITLE MOR'OA(;E SURVEYS TDPOCRAPHIC SURVEY'S Tax Map #1000-22-4-18 z j� LAND PLANNER$ Scale 1�1- 30' March 16, 2018 SITE PLANS GRAPHIC SCALE JOHN MINTO. L.S. PHONE: t63i) 724-4932 LICENSED PROF-ESSl-ONAL LAND SURVEYOR C 13 30 bm'4 NEW YOAK STATE LIC.NO 19 6 FA:,: (531) 724--54E5-r 93 SA11THTOW1V BOULEVARD SMf1'HTOWN, N.7'. Ili&% ...... ,,,, .,,. ......._..,...., ........... ........„..._, .......,,,.,.. ........._... ( IN FEET I mn h 30 ft.. Suffolk County Dept.of Labor,Licensing&Consumer Affairs /y HOME IMPROVEMENT LICENSE Name !� � t MYKHAYLO ABRAMCHUK Business Name AQUA COASTAL INC f his certifies that the earer is duly licensed License Number HA3470 y the County of Suffolk Issued: 09/19/2007 .,,.qe,r Cabrera. Expires: 09/01/2025 Commissioner NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 202506176 PROACTIVE BROKERAGE INC 926 SUNRISE HIGHWAY Imil WEST BABYLON NY 11704 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER AQUA COASTAL INC SOUTHOLD BUILDING DEPARTMENT P O BOX 226 54375 ROUTE 25 ISLIP TERRACE NY 11752 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11415 789-5 1 321561 04/01/2024 TO 04/01/2025 10/24/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1415 789-5, 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, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MYKHAYLO ABRAMCHUK(PRES) OF ONE PERSON CORP AQUA COASTAL INC 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. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY, NEW YORK STAT U NCE FUND 4 DIRECTOR,INSURANCE FUND UNDERWRITING I.CK I IrIl.A I t Ur LIAMILI I T II IZWKANUM 1012412024 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 e6W1rACT PROACTIVE BROKERAGE INC PHONE � (631 R-1860 ...R 86 �1 Rl�t $888596455 ... 926 Sunrise Highway 4"L ,.. lqf@progctivebro.com .1 .... Naa u.. West Babylon, NY 11704 INSURE S AFFORDING COVERAGE � .. ._...row _.. _ ._. ._.....a.__I,MsuRA, ...Atlantic Casual !......... ... ._ _..w..... 42846 INSURED -INSURER B: .. ... ............... ._. Aqua Coastal Inc. N§URfRc. w PO BOX 226 INSURER D: ISLIP TERRACE NY 11752 INsuRER E INSURER F 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. ...................... ........�, ......_._.._,..... r4i`ItrLIl,,. „�wm eewm m.�. ................. . INT TYPE OF INSURANCE POLICY NUMBER LIMITSPOLICY EFr= POLiCy EkP X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ I,aQQQ,OtIQ CLAIMS-MADE 1M R C d M/r dl FXIOCCUR ----AAR... A Y L035013818-7 7/30/2024 7/30/2025 PERSONAL .AD.VINJURY_...$, 1,000,000,,w ENPRO- POLICY ,A*. ECT E]LOC PRODUCTS COMP/OP AGG $ 1,000 OOO GGE 'L AGGREGATEAGGREGATE_ LIMIT APPLIES PER: GENE OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ........ AUTOS AUTOS ONLY AUTOS ONLY (Ptlf.IlISII )� HIRED NON-OWNED �LIPERTY DAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ HD E D RETENTION $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY YIN TATIITE„ R ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E L DISEASE EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached if more space Is required) The following are included as additional insured required by written contract subject to the terms and conditions of stated polices:Southold Building Department CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southold Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. N Workers' CERTIFICATE OF INSURANCE COVERAGE sr Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured AQUA COASTAL INC (631)697-1289 PO BOX 226 ISLIP TERRACE,NY 11752 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 202506176 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) SOUTHOLD BUILDING DEPARTMENT 54375 RTE25 3b,Policy Number of Entity Listed in Box"1a" SOUTHOLD,NY 11971 DBL 5408 58-9 3c.Policy effective period 04/01/2024 to 04/01/2025 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 perjury,I certify that I am an authorized representative 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 10/23/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT: If Box 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carner,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 mailed for completion to the Workers'Compensation Board, DB Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200 PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 has 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 with respect to all of his/her 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 (10-17) Certificate Number 811226 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"la"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Worker's 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 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. 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. 10113-120.1 (10-17)Reverse