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HomeMy WebLinkAbout51633-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#: 51633 Date: 02/12/2025 Permission is hereby granted to: ARAD Irry Trust 46 Stauderman Ave Lynbrook, NY 11563 To: Construct in ground gunite pool at existing single family dwelling as applied for. Premises Located at: 1425 Orchard St, Orient, NY 11957 SCTM# 25.-2-22.1 Pursuant to application dated 12/16/2024 and approved by the Building Inspector. To expire on 02/12/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total $400.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT 1 . Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 4.* ." Telephone (631) 765-1802 Fax (631) 765-9502 htas: ww. ou ) oldtrw�an . o Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building lnspecton 0 EC 2024, " 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: OWNER(S)OF PROPERTY: Name: + l P SCTM# 1000- r Project Address: ( y S 5 Phone#: Email: Mailing Address: CONTACT PERSON: Name: '�bAN r' 1 J4 Mailing Address: -kl t 6 ra 14) A„ A& ("i `lie,' 'i -k& � S Phone#: (c3 I aCb14 --1 ®q QL Email: rIni QEIZ3 0, e DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: r k Phone#: Email: CONTRACTOR INFORMATION: Name:: A.i 14 '°�n l Mailing Address: Phone#: &9-(_ Email: Alu Yi C.O Fl JA , cj ►oo : Go M DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: R30ther dr�AwZjq, ��i Cr« � ,=t No CA)ftm smi- $ J��l lot be re-graded? ❑Yes lj�No Will excess fill be removed from premises? ❑Yes [KNo ®0 P m y cirr 1 r 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? i_]Yes []No IF YES, PROVIDE A COPY. ❑ Check Box After Re trod pr­ofmianal is responsWe for ag drainap and storm water inues as provided inr fopsar L"of the Toren Code. A®PlJEf UM 14 HEREBY MMI to On&Mdht{t eWUner►t for"Wusme,of M Sufti ft Pwmk pwswnt to rm& MMg Zme ordtaenw of On Town of SseRho ,,Covatki,NNW York.ad other applilimfile taws,orb or RW _ br for Ow conanH21om of b . titrtt The appNaant adreas Eo c=pfir%ft bill Wilding am* end reVABW=and to IIt saethastnd lns�ors premisaa and in huftn&j for r r .Pates !eta l gq in of tm ow,Ymi stow rww is. Application Submitted By( hint name,): ❑Authorized Agent �nef S�igna re of Applicant. Date. STATE OF NEW YORK) SS: COUNTY OF UaW %/oak ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the s (Contractor, Agent,Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the skid 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 Aim—day of ,Notary Public EVAN,STEYN-MEL NOTARY PUBLIC,STATE OF NEW YOR PROPERTY 0WNk LZ q2)' Registration No.01 ST0023148 (Where the applicant is not the owner) Qualified in KINGS County Commission Expires April 3rd 202 r _ residing at _— _do hereby authorize , to apply on my alf to the Town of Southold Building Department for approval as described herein. _ Y r s Signature Z Gate bA �cAb In 1Lf- Print Owner's Na e 2 FQ Albert J. Kru ski, Jr. 5 �'7C'�0�][�l��l[�wA��C'lE][� SUPERVISOR 1VA4A,NA,G IEIMIIEN F SOUTHOLD TOWN HALL-P.O.Box 1179 u 6 h o G r,] 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of s C TER 236 - STORMWATER MANAGEMENT REFERRAL FORM ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) - - — — - - — — — -- - - — — - — - - - — - - - - - — - — — — — - — - - APPLICANT: (Property Owner, Design Professional, Agent, Contractor, Other) Date: NAME: I d A-ina� Contact Information: L31 L) -� (G-Mail&Telephone Number) u s '4 Property Address / Location of Construction Site: S.C.T.M. #: 1000 District Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT - — — - - — - — --- - - - - - - — - - - - — - - ❑ - Area of Disturbance is less than 1 Acre. No S.RD.E.S. Permit is Re wired I ❑ - Project does Not Discharge to Waters of the State. No S.P.D.E.S. Permit is Re uired 1 ❑ - Area of Disturbance is Greater than 1 Acre & Storm-water Runoff Discharges Directly to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit DIRECTLY From N.Y.S. D.E.C. Prior to Issuance of a Buildi22 Permit. ❑ - Area of Disturbance is Greater than 1 Acre & Storm-water Runoff Flows Through Southold Town's MS4 Systems to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit through the Southold Town En ineerin De artment Prior to Issuance of a Building Permit. Reviewed By: Date: FORM # SMCP-TOS December 2024 Suffolk County Dept of IG" Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name MYKHAYLO ABRAMCHUK Business Name This certirjes that the AQUA COASTAL INC bearer is duty ticensed License Number H-43470 by the County of seffol Issued: 09/19/2007 Expires: 09/01/2025 OMMissioner Y Workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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) 1 b.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"l a" 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 employer's 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 ofthat 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 carrier,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 NYSIF New York State insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 202506176 PROACTIVE BROKERAGE INC 926 SUNRISE HIGHWAY 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 11415-1 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:NWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND 18 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 SU NCE FUND DIRECTOR,INSUI ANCE FUND UNDERWRITING VALIDATION NUMBER:645260485 U-26.3 ACC CERTIFICATE OF LIABILITY INSURANCE °ATE`MW°°"YYY' 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 CONTACT FAX PROACTIVE BROKERAGE INC -MA"L 631 482-1860 ( 8 8596455 926 Sunrise Highway Appg sa Info goactivebroxorn West Babylon, NY 11704 INSURE )AFFORDING COVERAGE NAIL# INSURER A: Atlantic Casualty.... _ITIT 42846 INSURED INSURER B Aqua Coastal Inc. INSURERC: 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. __...... IN SR I ADUL SUOR PQLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 CLAIMS-MADE ❑X OCCUR PRI MI ES Ea rran $ 1 p0 Im MED EXP(Any one arson) $ _......... 5 Q00 A Y L035013818-7 7/30/2024 7/30/2025 PERSONAL 8 ADV INJURY $ 1 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ _2 OOP O� 00 X POLICY ry LOC PRODUCTS-COMP/OP AGG $ 1000,000 OTHER: AUTOMOBILE LIABILITY CEOMBINdEEDtSIWLE LIMIT IT $ .. ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PAOPI RTY 4AMAGE AUTOS ONLY AUTOS ONLY Pal dae $ $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION TR TE ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y" E.L.EACH ACC AND EMPLOYERS'LIABILI (DENT $ .._..... OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yyas,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 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:Southoid 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. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD N/O/F N ORIENT CENTRAL CEMETERY ASSOC. NO WELLS OR CESSPOOLS 121.21' fTpi,VlP O.aw 1a'E s CNE w� PIPE FNa F? ,e a' SURVEY OF PROPERTY iI Naz4s 2-3'W � EL xad . AT ORIENT N170240 TOWN OF SOUTHOLD 47.00'� DEED / F ,za aa`.. SUFFOLK COUNTY, N.Y. N 1 T20'50'W � 1000-25-02-22.1 AMAL "'. �- ae•s4r `�,, SCALE.• 1'=30 NnVEw4BER sR 201e XA . 0 EL�a a. � o o 2'STONE a 6°� FR.HOUSE +ear.W a4SNErrc o m M M POOL PAVIA $ N N Pvl O N/O/F THEODORE ROCK N/O/F uy . DWELLING "^"'- - -aa,2'. ORIENT CENTRAL CEMETERY ASSOC. NO WELLS OR CESSPOOLS .11%ONE, FL 20.3' C m Prs^q:P4Nh„ a �. CATE pq , FL 9a.6° PIPE FNO. NQ FNOTN C2 5M'#75 0.6w , POOL iMPT,�^ 7 r$ POOL FL. FR.W1 M.�C7." � n p TEST HOLE DATA ~---�3..�°�^•-°-w-,. cE0 IETI McDOWALD SC CE 1012512018 EL. 20.9- DARK BROWN LOAM OL ,�__ 1• aE w/srer BROWN SILT ML BROWN SILTY SAND 107H GRAVEL SM x _ c r 'rtixa'ENa WnF49.Iw tllil�a7.YF' PEN.'wa BROWN FINE TO COARSE SAND WITH GRAVEL SW as M s w..a° zmp tw t rA 0 s aw�ak/Jsraw6"sroor - M d� �� P PALE BROWN ANE TO MMUM SAND SP m It aD a004C,COVER 17' Wrl NOTE. NO WATER ENCOUNTERED ELEVA7/0NS REFERENCED TO NAVD 88 00 $� y IN, SIDEMAUI 5 EL 2a2 aa'N KEY QQ =REBAR . ® = WELL a a 20.4' . A =STAKE e . 9 = 7EST HOLE 00 +! = PIPE =MONUMENT as r 13 7 14 E FN = W£7LAND FLAG of, 0.�� 2jo ) = U77LITY POLE 'Cr=HYDRANT CL F.I.20.8' ,._ ANY ALM?A71ON OR AM7701V 70 7HIS SURVEY IS A WOL47TON OF VACANT N.Y.5. LIC. Na 49616 SEC77ON 7209OF 7HE NEW YORK STATE EDUCA77ON LAW. EXCEPT AS PFCONIC"SURVEYORS, P.C. PER SEC7ION 7209,SUI71MWSION 2 ALL CER71F7C471ONS HEREON ARE VALID FOR THIS MAP AND COPES THEREOF ONLY IF SAID MAP C AREA= 44,103 SQ FT. A3'I X 90920 FAX 631 7ss—ns7 P,O: BOX 909 OR COXWE BEAR 777E SEAL of THE SURVEYOR WHOSE OR 1.0125 ACRES 1230 7RAVELER STREET s��rA7TI�E APPEAJtS HEREON. sou77dotD, N.Y 11971 18-174