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HomeMy WebLinkAbout51615-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#: 51615 Date: 02/06/2025 Permission is hereby granted to: KP Realty of Greenport Corp 1359 Hewlett Ln Hewlett Harbor, NY 11557 To: Construct an inground swimming pool and spa combination accessory to an existing single-family dwelling as applied for per Trustees and DEC approvals. Premises Located at: 2006 Gull Pond Ln, Greenport, NY 11944 SCTM#35.-3-12.11 Pursuant to application dated 12/19/2024 and approved by the Building Inspector. To expire on 02/06/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 W 5PA/N6+ Tub CO Swimming Pool $100.00 Total $400.00 Building Inspector 1 4 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� :/Bw�. outholdtownn .goNi Date Received APPLICATION FOR BUILDING PERMIT VC d For Office Use Only c � J- 10 2021-1- PERMIT NO. Building Inspector; Applications and forms must be filled out in their entirety.Incomplete 6 . applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Da OWNER(S)OF Name:KP REALITY OF GREENPORT CORP. =CTM 1000-35-3-12.11 Project Address:2006 GULL POND LANE, GREENPORT, NY 11944 Phone#:(917) 797-6253 Email:KARENADLER814@GMAIL.COM Mailing Address:1359 HEWLETT LANE, HEWLETT, NY 11557 CONTACT PERSON: Name:KAREN ADLER (PRESIDENT); PASQUALE VARDARO (VICE PRESIDENT) Mailing Address:1359 HEWLETT LANE, HEWLETT, NY 11557 Phone#:(917) 797-6253 Email:KARENADLER814@GMAIL.COM DESIGN PROFESSIONAL INFORMATION: Name:THOMAS PETER DOMANICO ARCHITECT Mailing Address:108 MERRICK ROAD, LYNBROOK, NY 11563 Phone#:(516) 887-7147 Email:THOMASDOMANICO@AOL.COM CONTRACTOR INFORMATION: Name:PLATINUM SITE DEVELOPMENT, INC Mailing Address:286 ROUTE 109, FARMINGDALE, NY 11735 Phone#:(516) 681-0090 Email:BRUPNARINE@PLATINUMSDGROUP.COM DESCRIPTION OF PROPOSED CONSTRUCTION El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition =EstimatedCost of Project: ❑� Other GUNITE POOL,PATIO,DRYWELL&FENCE '� +� SON Will the lot be re-graded? .. Yes El No Will excess fill be removed from premises? ❑Yes ONO MINOR REGRADING 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 R_80 this property? ❑Yes *No IF YES, PROVIDE A COPY. IN 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 Bullding,Zone Ordinance of the Town of Southold,SuffoL%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 Yak State Penal Law. Application Submitted By(print name):y(�,�� A-. []Authorized Agent NOwner Signature of Applic t:- ' Date: STATE OF NEW YORK) SS: COUNTY OF 011�..--_ 106.. e./I being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the /����'�^ fi (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 Tffl ERIC MAY NOTARY PUBLIC, State of New York n / No. 02MA5087205 day of 141L.14111 , 20 2.''t My CommibWbWfRPW9 Oct. 27 2025 PRQRERpL0WfqERALTHQRIZATIQN (Where the applicant is not the owner) I, residing at do hereby a ize to apply on my behalf to the Town of Southold Building Depar' ' ►t for a val as described herein. Owner's Signature Owner's Name Steven Affelt, AIA PO Box 762 Architecture Great River,NY 11739 Intelligent Design (631) 553-6333 Sustainable Building January 13,2022 TOWN OF SOUTHOLD Department of Buildings 54375 NY Route-25 Southold,NY 11971 Regarding: 2006 Gull Pond Ln Greenpoint,NY 11944 Section 35,Block 3,Lot 12.11 To Whom It May Concern, This letter is written to certify that the storm water drainage for the proposed swimming pool,spa,and auxiliary structure installation has been reviewed and designed to retain a storm of up to 2" of rain. The existing system shall be modified as specified in the site drainage plan and supplemented as depicted.It is my professional opinion and with a reasonable degree of scientific:certainty that the newly supplemented storm water drainage system will prevent from up to a 2" storm from running into the wetlands on and adjacent to the subject property. Respectfully, a D A%, co ".. 0" t OF N ` Steven Affelt,AIA Great River,NY 11739 PO Box 762 Tele:(631)553-6333 steve.affelt@gmail.com BUILDING DEPARTMENT- Electrical Inspector q� ,u TOWN OF SOUTHOLD A Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 mm: smash southoldtownn ov — seand southoldtownn ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: GJS Electric LLC Electrician's Name: Gary Salice License No.: ME-4839 Elec. email:Gary@NFAV.com NFAV.com Elec. Phone No: 631-298-4545 ❑I request an email copy of Certificate of Compliance Elec. Address.: 6615 Main Rd, Mattituck NY 11952 JOB SITE INFORMATION (All Information Required) Name: KP REALITY OF GREENPORT CORP. Address: 2006 GULL POND LANE,GREENPORT, NY 11944 Cross Street: MAIN ROAD Phone No.: (917)797-6253 Bldg.Permit#: 51& 16 email: KARENADLER814@GMAIL.COM Tax Map District: 1000 Section:35 Block: 3 Lot: 12.11 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): ELECTRICAL WIRING TO POOL EQUIPMENT,GFCI OUTLETS FOR OUTDOOR KITCHEN,OUTDOOR FIREPLACE& TO THE AUXILIARY STRUCTURE Square Foota e: Is job ready for inspection?: FI YES 0 NO Rough In Final Do you need a Temp Certificate?: El YES [] NO Issued On Temp Information: (All information required) Service Size DI Ph E,3 Ph Size: A # Meters Old Meter# ❑New service[-]Fire Reconnect❑Flood Reconnect❑Service Reconnect[]Underground❑Overhead # Underground Laterals 1 2 H Frame n Pole Work done on Service? Y ON Additional Information: PAYMENT DUE WITH APPLICATION Steven Affelt, AIA PO Box 762 Architecture Great River,NY 11739 Intelligent Design (631) 553-6333 Sustainable Building January 13,2022 TOWN OF SOUTHOLD Department of Buildings 54375 NY Route-25 Southold,NY 11971 Regarding: 2006 Gull Pond Ln Greenpoint,NY 11944 Section 35,Block 3,Lot 12.11 To Whom It May Concern, This letter is written to certify that the storm water drainage for the proposed swimming pool,spa,and auxiliary structure installation has been reviewed and designed to retain a storm of up to 2"of rain. The existing system shall be modified as specified in the site drainage plan and supplemented as depicted. It is my professional opinion and with a reasonable degree of scientific certainty that the newly supplemented storm water drainage system will prevent from up to a 2" storm from running into the wetlands on and adjacent to the subject property. Respectfully, 183. Of NS'44 . Steven Affelt,AIA Great River,NY 11739 PO Box 762 Tele:(631)553-6333 steve.affelt@gmaIl.com Steven Affelt, AIA PO Box 762 Architecture Great River,NY 11739 Intelligent Design (631) 553-6333 Sustainable Building January 13,2022 TOWN OF SOUTHOLD Department of Buildings 54375 NY Route-25 Southold,NY 11971 Regarding: 2006 Gull Pond Ln Greenpoint,NY 11944 Section 35,Block 3,Lot 12.11 To Whom It May Concern, This letter is written to certify that the storm water drainage for the proposed swimming pool,spa,and auxiliary structure installation has been reviewed and designed to retain a storm of up to 2"of rain. The existing system shall be modified as specified in the site drainage plan and supplemented as depicted. It is my professional opinion and with a reasonable degree of scientific certainty that the newly supplemented storm water drainage system will prevent from up to a 2" storm from running into the wetlands on and adjacent to the subject property. Respectfully, 1E-D % . .4 760 Steven Affelt,AIA Great River,NY 11739 PO Box 762 Tele:(631)553-6333 steve.affelt@gmail.com �;' .w ii i�iN xY rr� u+�r r�e�ru,am��tixrxv,rn ei ry :,rr rN "✓�u�"�'W�u��;'r,J!�p " �. 7r»wm�a W�craYJ�➢mrm$wr . 4n rII��M1�Ux1+�i ns ... ,. .. ..n. ... .a.., w�w .,�.. . fU r BOARD OF SOUTHOLD TOWN TRUSTEES ` I SOUTHOLD, NEW YORK PERMIT NO. 10685 DATE: tCTO1� ER� 16 2024 ISSUED TO: P REALTY OF GRIFENPORT CORP. PROPERTY ADDRESS: 200 GULL POND 'I�A.NI�!� f��Rl��'F�NI�O1' T � w SCTM# 1000-35-3-12.11 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 1" we—caber I3 2f124, 2�(l fl�l paid by 1W;.P l �AI...I y C) 08: E,hLL 91�" ;, and in consideration of application fee in the sum of 1,_. G and subject to the Terms and Conditions as stated in the Resolution,the Southold Town Board of Trustees authorizes and permits the following: 1 WetlandPermit for removing 1,108sq.ft. of existing grade-level masonry patio and B 179sq.ft. area of landscape retaining walls; construct 736 sf of"upper" masonry patio, ' 18.5' x 46' swimming pool with 50 sf hot tub, 410 sf of"lower" grade-level masonry pool patio, and associated steps and planters; construct 18' x 23.5" roofed-over open accessory structure, consisting of unenclosed, covered patio (to remain unenclosed), stone wall for outdoor fireplace, outdoor kitchen, and 16.33' x 21.84' subfloor/basement for pool equipment/storage; remove 34 if of existing stone retaining wall and construct +31.5 if of new +2.7-ft high stone retaining wall; and to establish and perpetually A wetlands B maintain a 50-foot wide non-disturbance/non-fertilization buffer adjacent to wet an e boundary, replacing approximately 3,850 sf of existing lawn with native plantings and allowing for 4-foot wide cleared access path; all as depicted on the site plan prepared by Thomas Peter Domanico Architect, received on October 16,2024, and stamped r approved on October 16, 2024. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of the day and year written above. 4 [ 7 2. � t . �`�f .•�" •,..••-•.""":' �: ✓„/Nd,w„ ✓fw'n��u+mNn*ufIWIXB,v Lrc�;,�o,�xC & aia .&�Wr o-unm, ,,,, tu�md/aw er r� M� rWXl�, mrrYd�,r4 adui. `:,. ws; "� l �'tl4,Jl Wr�ne r Ffiw,�'r_.,3:r?„„"i r e.q,�J,1, „,,wa YdNh�W+�'Ib„vii«W�r,x�.Nrva✓„� i � , ,�, � '¢^ " , e � ""r� a" ;'�"i rWa r„m� �a �T�� „,.'",yid! �"�"�war y�"�.,,"'*�,'* �`."; ';� z�^m �° y�e; ;� " 5� .�5 ""�� :,� �„! „�;', ,tt„�! r;�'Wp ��a " nor r+, 1w:^,. � '��•. `, ry , ..,,�... �, �,�.p 'Y'r TERMS AND CONDITIONS The nittee R[`ALTY OF E York as the consideration for issuance of the Penn 116It does understand and prescribe to the following: l. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages,of suits arising directly or indirectly as a result of any operation perforrtaed pursuant to this permit,and the said Perrnittee will, at his or her own expense,defend any and all such suits initiated by third parties, and the said Permittee assumes ball liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold. 2. That this Permit is valid for a period of 36 months, which is considered to be the estimated time required to complete the work involved,but should circumstances warrant, request for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved,to provide evidence to anyone concerned that authorization was originally obtained. 4. That the work involved will be,subject to the inspection arid approval of the Board or its agents,and non-compliance with the provisions of the originating application may be cause for revocation ofth is Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. T That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opin ion of the Board of Trustees,the work shall cause unreasonable obstruction to free navigation, the said pertnittee'will be required, upon due notice, to remove or alter this work project herein stated without:expenses to the Town of Southold. 8, The Perrnrttee Is req uired to provide evidence that a copy of this Trustee permit has been recorded with the Suffolk County Clerk's Office as a notice covenant and (feed restriction to the deed of the subject parcel: Such evidence shall be provided within ninety(90) calendar days of issuance of this permit. 9. That the said Board will be notified by the Permittee of the completion of the work authorized. 10, That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. 11, No right to trespass or, interfere with riparian rights. This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the Impairment of any rights,title, or interest in real or personal property held or vested in a person not a party to the permit. 17----I N\141 NYSIF PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 201369798 PLATINUM SITE DEVELOPMENT INC 286 ROUTE 109 �"� FARMINGDALE NY 11735 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER PLATINUM SITE DEVELOPMENT INC TOWN OF SOUTHOLD 286 ROUTE 109 TOWN HALL ANNEX 54375 FARMINGDALE NY 11735 MAIN ROAD P.0 BOX 1179 SOUTHOLD NY 11971-0959 POLICY PERIOD DATE =ZZ2416 MBER FCERTIFICATE NUMBER 07/01/2024 TO 07/01/2025 11/18/2024 39-6 875217 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2416 339-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OUTS OPERAIONS NEW YORK, TOT HE POLICYHOLDER'S REGULARCATED BELOW, AND, WITH NEW YORK STATE EMPLOYEES PECT TO OPERATIONS F NEW YORK, EXCEPT AS ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, CERTIFICATE,OR TO VALIDATE THIS VISIT YORK STATE INSURANCE FUNDIS NOTLIAB EVIN THE EVENTF FAIILURNTOI GIVE MSUCH TNO IFICATIIONS. NEW THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT ANTHONY LAURO OF PLATINUM SITE DEVELOPMENT INC ( 1 OF 1 ) THIS CERTICATERS O RIGHTS NCE COVERAGEIF UPON I THESUCERTIFICATE A HOLDER.INFORMATIONTTER OF THIS CERTIFICATE NDOES NOT NAAM ND, EXTEOND IORUALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT S4 7*1, NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:259700894 U-26.3 =DATE(MMIDD/Nrffy)CERT IFICATE OF LIABILITY INSURANCE 4 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 PRODUCER nnlfer Heiser -µ...... this certificate does not confer rI hts to the certificate holder In lieu of suchONTACT dorsem Je FAk PHONENicholas DeVlto Agency, Inc. I 631 509.63 /N �� l 61 271-2 Route 25A EMAIL ernlfe devltoaenc7 tomµ _ ...u..._ Mount Sinai, NY 11766NrasuRl ..s ArFccraNG COVtAGE W ° +uc IrIsuRER A r!I11" .�111+0��_NI]IIIa11'�IIiIgI3w !��!"._ W, INSUREDINSIJREbt.,16 ........ ......._... ..w........ .,.._.,_.......,.._._...._..,.,......._.....-..,.......,. .._....... .... ..,,....._...,�......, Platinum Site Development Inc. 286 Route 109 Farmingdale, NY 11735-1561 IN$tdR6t E .. INSURER F COVERAGES CERTIFICATE NUMBER: 00009298-0 REVISION NUMBER: 47 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT„TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT E TERMS, DESCRIBED HEREIN IS SUBJECT TO ALL TH EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWNYMAY HAVE BEEN REDUCED CCE AFFORDED BY THE I� F Y PAID CLAIMS. EXCLU CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,CER _.. r X, ......... T r)"ClL .LIMITS$., ..... t TYPE OF INSURANCE M Y Y M.RR_.� 0()0�00 COMMERCIAL GENERAL LIABILITY Y 1 5099526655 .URRFNCE " 0 ...MED EXPO)tI IMI"IV7 .........., .. ....a .. . aF�IrL $ 100 000.. 811612024 8116120 EACH ca 4�AI�at CLAIMS-MADE ❑X OCCUR i P("CI�11 � X .Ccrlractal.l.labw . .... r ( nn 5 0I10._. a _..m .....1Q�10;III ... fAGGREGATE ...,,,, ................ ...,... ... .... ... .EN%A GREGATE LIMIT APPLIES PER: ,..,IT ..AI„AG:xGI'IEGATE „2�000,00t1 OENrR POLICY ...... PRO- ` Itt DUt I (l1AkPJOf?AGG .$_. .. ww ,I I fI (I ... G LOC ... .......... JECT ..... ��.� $ O"I"HEM COMBINED SINGLE LIMIT $ A AUTOMOBILE LIABILITY 7039941115 8J13/2024 8H 3/2025 ..tea Al you aw,(i Y AUTO BODILY INJURY(Per person) $ AN ..,._. ODILY INJURY(Per ...- OWNED ._',...SCHEDULED r accident). .. L.$ .. AUTOS ONLY „w,X,„., AUTOS BROI LFi1 M CIAMIACar HIRED NON-OWNED $ X AUTOS ONLY AUTOS ONLY $ 811612024 8/16/2025 EACIIOC A X 1 UMBRELLA LIAB )( OCCUR 6079150616 __ $ 1 400 000 .. '�sMA .. ACiC"RECaATF ..$.... .... ... . ...... ........ ......_.........,EXCESS LIAB.............-..... .._ C I�`kIM UI.,....._.._....,,. E'LENT`ION' ,...,,.„,...... ___�---� PEIt .. O K WORKERS COMPEN SATION .,.. .R................w.... .... -._.......,,,,... AND EMPLOYERS'LIABILITY YIN E.L.P:ACI4 ACCIDENT $ ANY pRop in1 OpJPAR1 NL.RA-,XECUTIVE Fro N I A ,. . w r ANY PROF EA^GB&:feF,XCI.UDED"A _� EA.. �;kLICYLI�YEL $(Ma ._,... 11 told da ra under LIMIT $ 0, SCRIPTION OF OPERATtON Ww+ itional Remarks Schedule,may be attached if more space Is required) DESCRIPTION OF OPERATIONS f LOCATIONS dVEHICLE5 (ACORD 101„Add Town of Southold,Town Hall Annex 54373 Main Road,PO Box 1179,Southold, NY 11971 is included as additional Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WrrH THE POLICY PROVISIONS. Town Hall Annex 54373 Main Road PO Box 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971 ...., J-H ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by J-H on 11/18/2024 at 11:19AM .,.., my re j Workers' CERTIFICATE OF INSURANCE COVERAGE Yo I;._...._. s-rATE Compensation 1�— Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW .......11 _.._.ww.............._w__..o..........."et,............................................_._.........._ilit. ....._....._.Paid Family Leave benefits carrier or licensed.insurance agent of that carrier. PART 1.To be completed by NYS disability and Pard Fa y .. _.. __... _..._..._�.w.........._..,...w...._...........,�_..._.__w......_......... m�a: .,g ( 1 51 Business Telephone. of PLATINUM DEVELOPMENT Address ......................._._....__stree._w�....��._..._............__.m_._. Legal Name Insured use t address only) b.Busin Number of Insured PLA INC. 6-681 286 ROUTE 109 FARMINGDALE,NY 11735 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 201369798 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 .....__ww.._..- (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" Town Hall Annex 54375 Main Road DBL554365 PO Box 1179 Southold, NY 11971 3c.Policy effective period 04/18/2024 to 04/17/2026 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: ❑X A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employer's employees: Under penalty of perjury,I ert6fy that I am an'authorized representative or I�censed agent of the insurance carner r 0en�d above and tk�a4 the tiar¢1ed insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/18/2024 By of insurance carver' authorized au (Signature orized representative or NYS Licensed Insurance Agent of that insurance carrier Telephone Number 516-829-8100 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 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 Ycompletion to the Workers'Compensation Board, Board (Only if Box 4B,4C o Unit, PO Box 556 ha200, Be been-checked)inghamton, NY 1„8902-520Y0 Y Compensation ( v .,._..�..__ _.,w... ._..., _...T 2,To be completed by the NYS Workers............ .. ._..__.�......._.....� w ..�.w._. PAR..._..._...._.......... ......�....�.w_.....�..v, State of New York Workers' Compensations 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 L.aw(Article 9 of the Worker's"Compensation Law)with respect to all of their employees. Date Signed _ w w .. By iSignature 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 porcies and NYS to issue this rased insurancem agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized 1313-120.1 (12-21) 111111 Ill 111111111111111111111111111 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 NEWYORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY cn7 Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-03651 F:(631)444-0360 www.dec.ny.gov July 5"' 2022 Karen Adler Adler Property 2006 Gull Pond Lane Greenport, NY 11801 Re: NYSDEC# 1-4738-04088/00004 Adler Property: 2006 Gull Pond Lane,Greenport, NY 11944 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act(Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please carefully read all permit conditions and special permit conditions contained in the permit to ensure compliance during the term of the permit. if you are unable to comply with any conditions, please contact us at the above address.This permit must always be kept available on the premises of the facility. Also enclosed please find a permit sign which is to be conspicuously posted at the project site and protected from the weather. Sincerely, Torey K. Kouril Environmental Analyst Enclosures TKK/file cc: NYSDEC-BMHP KP Realty of Greenport rtAttr xottt Department of K rn rruw«rrw Eavlrrrrrmental Conservation NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION � Facility DEC ID 1-4738-04088 PERMIT ,Ion I1aw ;C vw..........,w...........�___.w.�M_...................._. ' tal Conservat' _�-NumkM,�,,,,k... Under the Environmental Permittee and Facility Information - - ..w....ww._ .__.... . Permit Issued To: Facility: KAREN ADLER ADLER PROPERTY 2006 GULL POND LN 2006 GULL POND LNG 1000-35-3-12.1 1 GREENPORT,NY 11944 GREENPORT,NY 11944 Facility ion: in SOUTHOJ-D reenport Facility Principal � � ipal Reference Point: N Y"1"4ryM1'�,. 722.328 1 Y N YI G I`M N 4554,316 Latitude: 41'°06"47.9" Longitude: 72 21 07.3" Project Location: 2006 Gull Pond Ltane,Greenport, NY 11944 Authorised Activity: Construct tea new 18 foot by 46 foot swinitning pool with a surrounding patio and associated accessory structures ine.lueling a 8 foot,by 8 1''taot pool spa, planters, and various steps. All work shall be done in strict conformance with the attached plans prepared by Platinum Site Development Inc., last revised 06/01/2-022, and stamped "'NYSDEC Approved" on 07/05/2022. l 1InvironIne lta1 Note: Lased on t1��. information you saabnaittecl flee New York State Department o1°. Ccanservat,ion has determined that the work shown on ttae above ac l'rer ccd approved plans, N: located ,tore than 100 fact:from DEC � gulatc d 1°`ieshwater wetlands. 'I"hefaefore, no Freshwater Wetlands permit is, required pursuant:to the Freshwater Wetlands Act(Article 24) and its' implementing regulations (6NYCRR fart 663) to carry out this PRcJect. PermIt Authorizations _.........-..,...�..... _.-.-.,_ww_-.w...�ww.._,�. R ...- �...^._._-_-.....__..___....... Tidal Wetlands-Under Article 25 Permit ID 1-4738-04088/00004 Expiration Date:7/4o°2_027 New Permit Effective Date: 7/5/2022 P _.-....w_�,..�....._,�.w. ,.w,__. ..._...�.-..._. NYSDEC Approval �.... ..._.._.. �...�........._.� By acceptance of this perrnit, the perinittee agrees that the permit is contingent upon strict compliance with the ECIL,all applicable regulations,and all conditions included as part of this permit. Permit Administrator:KEVIN A KISPERT, Deputy Permit Administrator Address: NYSDEC Region 1 Headquarters SUNY @ Stony BrookJ50 Circle Rd Stony Brook,NY 11790 -3409 Date Authorized Signature: ..._. _ w.._. ......., _.. __w_..._.� . _ _.... :Page 'I of 6 NEWYORK Department of STATE O OPPO#2TUN9T '. Conservation NOTICE i i i Iment of Environmental Conservation (DEC) has issued irsuant to the Environmental Conservation Law for work being I at this site. For further information regarding the nature and ork approved and any Departmental conditions on it, contact it Permit Administrator listed below. Please refer to the permit )wn when contacting the DEC. Regional Permit Administrator I Is S a z s a s NOTE: This notice is NOT a permit