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HomeMy WebLinkAbout51685-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#: 51685 Date: 02/25/2025 Permission is hereby granted to: Randy A Statham 5805 Main Bayview Rd Southold, NY 11971 To: construct accessory in-ground swimming pool as applied for per Trustees Non-Jurisdiction letter and DEC No Permit Necessary letter with flood permit. Protection from vehicle impact shall be provided for the pool equipment. Premises Located at: 5805 Main Bayview Rd, Southold, NY 11971 SCTM#78.-7-5.5 Pursuant to application dated 01/14/2025 and approved by the Building Inspector. To expire on 02/25/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Flood Permit $150.00 Total S550.00 Building Inspector ar7a� 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 htt s://www,southoldtowtinv.mov Date Received APPLICATION FOR BUILDING PERMIT For Office Use OnlyFIQ {1� 4, I PERMIT NO. Building Inspectors Applications and forms must be filled out in their entirety. Incomplete J A N 1 4 %rpi:- applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: I/ 4 ZO � � OWNER(S)OF PROPERTY: Name: SCTM # 1000-ir 7 Project Address: ~~ vI U �" Phone#: .S9 7 ' 6 Email. " c. Mailing Address: CONTACT PERSON: Name: -� i Mailing Address: s, Phone#: _ 7 _ Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: l �' Jr ADL Mailing Address: 'eoKA Phone#: 63 1 - ? Z Emai DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: C Other -5'wl $ 3� iD O(> Will the lot be re-graded? ❑Yes I2J0 Will excess fill be removed from premises? ❑Yes 96ko 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? Yes [Ao IF YES, PROVIDE A COPY. x 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,building code, housing code and regulations and to admit authorized Inspectors on premises and in bullding(s)For necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 21OA5 of the New York State Penal Law. Application Submitted By(print name): DAuthorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF JG. V rj T J" being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, ( � ._ S)he is the � I� C.� � . . ........ �.._�..�..... �. (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. yrylrrtrrfrrr � Sworn before me thisOP i —day of �, _ 20y ,,' i (, Notary Public m ? �. Where the applicant ...�� m. ( is not the owner) f4rr"rrrrrrrsrrtt�s*���� �t(� F a tiAj 4 ♦tJ residing at °x ti a vi o �v Y �/U ` lea a sue., to apply on do hereby authorize _, ___w . __,,,, ,� my behalf to the Town of Southold BuilclirI4 Department for approval as described herein. ... Owner's Signature mnW Date �jPrint Owner's Name 2 Glenn Goldsmith,President � �� Town Hall Annex ski,Vice President 54375 Route 25 A. Nicholas Kru p �� P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 Coo BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 11, 2024 Robert Herrmann En-Consultants 1319 North Sea Road Southampton, NY 11968 RE: ANDREW M. PETTERSEN & RANDI A. STATHAM 5805 MAIN BAYVIEW ROAD, SOUTHOLD SCTM# 1000-78-7-5.5 Dear Mr. Herrmann: The Southold Town Board of Trustees reviewed the site plan prepared by Nathan Taft Corwin III, Land Surveyor, last dated November 4, 2024 and determined that the proposed construction of an 18' x 25' pool and pool fence is out of the 100 foot Wetland jurisdictional area under Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal and/or freshwater wetlands jurisdictional boundary, or within 100' landward from the edge of vegetated wetlands, without further authorization from the Southold Town Board of Trustees pursuant to Chapter 275 and/or Chapter 111 of the Town Code. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary fence, barrier, or hay bale berm. This determination is not a determination from any other agency. Sincerel , y Glenn Goldsmith, President l NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY,a Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-03651 F:(631)444-0360 www,decny.gov NO PERMIT NECESSARY-TIDAL WETLANDS ACT October 7, 2024 Andrew Pettersen Randy Statham 515 East 89th St, Apt 4B New York, NY 10128 RE: Application # 1-4738-03072/00003 Facility: Pettersen/Statham Property SCTM# 1000-78-7-5.5 Dear Applicant: The Department of Environmental Conservation (DEC) has completed a review of your proposal to install a swimming pool and fence. All proposed work is located greater than 75 feet from the Tidal Wetlands Boundary, and results in less than 20 percent lot coverage, as per the plans prepared by Nathan Taft Corwin III, last revised 4/16/2024. Based on the information you have submitted, this Department has determined that the project is listed in the Tidal Wetlands Land Use Regulations (6NYCRR Part 661.5 (b) (#50)) as a use not requiring a permit. Therefore, no permit is required under the Tidal Wetlands Act (Article 25) of the Environmental Conservation Law. Please be advised that DEC has documented the summer occurrence of the Northern Long Eared Bat (NLEB) (Myotis septentrionalis), a species listed as "endangered" by both New York State and the US Fish & Wildlife Service, within 3 miles of the project location. We have determined that tree cutting at this location between March 1 and November 30 of any calendar year may result in the "take" of these endangered/threated species or their habitat within the meaning of Environmental Conservation Law (ECL) §11-535. The term "take" is defined in part as the direct killing or injury of individual members of a protected species, interference with critical breeding, foraging, migratory or other essential behaviors, or the adverse modification of the species' habitat. The "take" of a species listed as endangered or threatened is prohibited in the absence of a permit from this Department issued pursuant to ECL §11-535. In order to avoid an Endangered Species "take", no tree cutting activities should be conducted at the project site between the dates of March 1 and November 30 of any calendar y YNK Department of STATE Environmental Conservation Be advised, any additional work or modification to the project as described, may require DEC authorization. Please contact this office if any such activities are contemplated. Please note that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies or local municipalities. Sincerely, Mary MacKinnon Permit Administrator CC: En-Consultants, BMHP, File may. nun OF € -v 13R_ r n ow z c . j, ANT .,a a vm HIS y 1 _ i Nathan Taft Corwin III Land Surveyor_ CERTIFICATE OF Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE YORK A Compensation Board Insured Detail In.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of insured MaryMeg,inc. 631-566-2324 324 Doctors Pa(t Riverhead,NY 11901 le.NYS Unemployment Insurance Employer DBA:Bills Pools,Bills Pools Service,Jasons Pools,Jason and Bills Pool Registration Number of Insured Service Id.Federal Employer Identification Number of insured or Social Security Number 113168202 Nark Location oflnsured(Only mquim d cvwaragu isspecifrcall),lnniled to ce;rmirl lovallao in Nov Y011:Suite,l.r.ra tI"rap-Up Policy)' 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of insurance Carrier (Entity Being Listed as the Certificate Holder) Southern insurance Company TOWN OF SOUTHOLD BUILDING DEPARTMENT 54375 ItT 25 3b.Policy Number of entity listed in box"In": PO BOX 1179 OWC1010317 SOUTHOLD,NY 11971 3e—Policy effective period: 3/23/2024 to 3/23/2025 3d.The Proprietor,Partners or Executive Officers are: ®included(Only check box if all partners/otliccrs included) ❑all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under item 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"T'. 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 preuriums or within 30 days IF there are reasons other than nonpayment ofpretuiuins that cancel the policy or eliminate the insured fi'oin the coverage indicated on this Certificate.(These notices inay be sent by regular ruail.)Otherwise,this Certificate is valid for one year aji'er 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,ifthe 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. 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 the coverage as depicted on this form. Approved By: Matt Zender (Print name ofauthorized representative or licensed agent of inmurinco carrier) Approved By: 4/15/2024 (Signature) (Date) Tfi0c: Senior Vice President A ""•-"' � DATE(MM(DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE __J3l2412023 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 8Y THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,qND THE CERTIFICATE HOLDER. If SOBROGATION IScWAIVED sub ects an ADDITIONAL INS i p p y( y) p y q RED provisions or be endorsed. URED,the ol)c Ios must I^Pave ADDJTIONAL INSU J to the terms and cond'tions of the olic certain oliaes ma re woe arP endorsement. A statement on this certificate does not..confer r'i hts to the certlflcate holder In lieu of such endorsement�. .PRODUCER ""....."—.�.�'_".-•••••.... CGW4'�Cp4r 207 Hallock Rd Ste 1 I39 6100 _._. tcL (faFfF98 .,... _dam�A�v.,tr�tf.... _.) ..._�..�..�.� J IyRE ', NISUDR n�E_ yo B-rook NY- 11790 .. , XL_SN d REfl� GEA373 37tS t B; S _ _ m..�" _.. - -. _ 15954 _ rNsIaRER Marymeg,lnc dba Jason Pools N� RER o .,-._.__._._. ... ,.. ._... ... . ......� PO Box 1331 ,SLP..",__u" Hampton Bays, NY 11945 -� LNgk_( —r NY 1— INSURER P"... . COVERAGES minµ CERTIFICATE NUMBER: ED BELOW HAVE BEEN ISSUED TO THE INSURED REVISION NUMBER:. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI " INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIAMED DTH RESPECT TO WHICH VE FOR THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN„ THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, iaa EXCLUSIONS CONDITIONS OF _. OLI IES.`I REDUCED BY PAID CLAIMS. _..�.. .. �. mod ._ _ _r HnTld� SIONS�PD FO SDIT�INCE OF SUCH POLICIES.LIMITS SHOWN�MAoY��H�VE BEEN RE�L DAY MMD[a E�� LIMITS XCOMMERCIAL GENERAL LIABILITY N ICY OFF" PDP.Yr'FV�r , I w. EAAC8OCCURRLNCE S e -1x 00 0 _- i CLAIMS-MADE Ir 'OCCUR r)Y'fAAT ��ri N P SL AY E x-tE¢o mr rn n�D 5 .16: yI)00 .�_N6. � F,+FED EYE� �wre+a 9aarsCms s ICI CI�fJ A "K X NPC-1003117-03 3/2312023 312312024 a INSONAr4ADV INJUR 5 11,Q00 111 GENL AOGREGATE LIMIT APPLIES PER: CEEnmERAL,AC'CR'ECATE '�, 2,t)�f�f)�i�.. . X POLICY F p'RG- ...._.,n,_..._. _. . JEST -- LOG PRDUCg rs COMP9DPAGG s 2000 t30,� 7HI R s AUTOMOBILE LIABILITY V I d,DMgttll„l�E�CY SlNC3P.E L'I'll S Y i�,TM.1 dim) ,00dJ,i1t1t.,- ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acHdenl) 5 A AUTOS ONLY AUTOS NBA-1003121-03 312312023 3123/2024 HIRED ..... NON-OWNED fyPt23PENd'C"F UAFAACE• 5 .. ..... AUTOS ONLY AUTOS ONLY y qqq g UMBRELLA LIAR j,. I ° I EACH OCCURRF„Rcc S OCCUR y -... ,... {........,._ CLAM W� EXCESS LIAB IS 4,y,FTPh C9F II . � ACrGR'"- ...._ VJ KE',R'OR a COMPENSATION A T- ✓'„.,. CttRPA AND EMPLOYERS'LIABILITY Y 1 N ANY PROPRIETOW?4,RTI4FRc ECUTrvE er,cH ACCIDENT s 1„000.00D B C,n R M2MSER EXCLUDED? El N 1 '• OWC 1009126 3/2312023 3l2312024 E.L WSEASE•EA VAPLOYE°'.5 "I 000 000 IMandnlory In NH) _-..,,...._..,w-.......-.r_.,. ... if 1�.dersve be Urrdef E,L,DISF,,hSF•POL CY 1IMJIT S 1 000 000 '.... IryI QJ S'CP?pPt3OM°I C7P OPERA'11 „.,..0NS,be0oa DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Addlllonal Remarks schedule,may 6e adechad If more sparse Is required) Certificate Holder is additional insured CANCELLATION CERTIFICATE HOLDER SHOULD ANY QP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE. ExPIRATBON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLMY PROVISIONS. VILLAGE OF SOUTHOLD BUILDING DEPARTMENT AUTHORIZED REPRESENTATIVE PO BOX 1179 � SOUTHOLD,NY 11971 p ©1988-2015 ACORD CORPORATION° All rights reserved„ ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD E"��" I i .. I �.I ! `„ �"'� T rare Imo •. r .� ! I N �P _��E worker oR s' CERTIFICATE OF INSURANCE COVERAGE scar 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 carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured MARYMEG INC DBA JASON'S POOLS 631-324-7844 P.O BOX 1331 HAMPTON BAYS, NY 11946 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e„Wrap-Up Policy) 113168202 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 Building Department 3b. Policy Number of Entity Listed in Box"1 a" Town Hall DBL446593 Southold, NY 11971 3c.Policy effective period 01/01/2025 to 12/31/2025 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 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 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 1/13/2025 By (Signature of insurance carrier's authorized 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 carriers 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 Box 4B,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°°°1°1°1°1°°1°111°11°°�u°°IIIIIII EXISTING L ' COVERAGE TOWN DEFINED 70POSED LOT COVERAGE LAND AREA ( i,370 sq. ft.) OVER BUILDABLE )uAND AREA (51,370 sq. ft.) AREA % LOT COVERAGE DESCRIPTION AREA % LOT COVERAGE 2,068 sq. ft. 4.03% HOUSE 2,068 sq. ft. 4.03% 33 sq. ft. 0.06% ROOF OVER WOOD DECK 33 sq. ft. 0.06% t0- O 42 sq. ft. 0.08% FRONT DECK 42 sq. ft. 0.08% S 590 sq. ft. 1.15% REAR (2) WOOD DECKS 590 sq. ft. 1.15% 2,733 sq. ft. 5.32% PROPOSED POOL 450 sq. ft. 0.88% TOTAL 3,183 sq. ft. 6.20% FLNG S (A AL 46 £ N 4.2VLNG Of lb ._ AL ; . t r e FLAG E5 �Y 4 FLAG 6 2-6 - ' si < \ t_ x2 x3a FLAG E7 5` wo FLAG EB � t rr 3 e 1 6 FLAG E9 6�4- OO \ 1 FLAG El # ilk FLAG El .. I $ x 3 7— —� 13.9 FLAG El FLAG El \ 10 1I1, � � - A f FLAG El \ 4rS F' G AYA 1 Y1ti $114• s . a 33 GG 1tD x3.4 FLAG E15 AL TEST p.• '' + \ xAA / x 3 FLAG El • '. X W 100 J&cr FLAG El 7 . ,. 0 to Ck co 100 s CTt \ nAG E18 x \ \ n <F \ a q \� i 3.5 - - \ .,, FLAG Ego AL ti . a5 \ A o, k -61 a _ a♦ __ ��OC�t � �h ' \\ _