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HomeMy WebLinkAbout51693-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#: 51693 Date: 02/27/2025 Permission is hereby granted to: Elizabeth P Weiss 1330 Skunk Ln Cutchogue, NY 11935 To: construct accessory in-ground swimming pool as applied for. Pool and pool equipment must be located a minimum of 25 feet from the side yard lot lines. Premises Located at: 1330 Skunk Ln, Cutchogue, NY 11935 SCTM# 97.-3-11.4 Pursuant to application dated 11/07/2024 and approved by the Building Inspector. To expire on 02/27/2027. 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 �w Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 httt)s://�www.sotit.lioldtowilny.gov Date Received APPLICA1'ION For Office Use Only ECE � w t PERMIT NO. Building Insp cctor ',, Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,ana� � �i Owner's Authorization form(Page 2)shall be completed. Date: OWNERS)OF PROPERTY: Name: Elizabeth Weiss SCTM#1000-97-03-11.4 Project Address: 1330 Skunk Lane Cutchogue, NY 11935 Phone#: 631-744-5533 Email:epweiss@optonlin.net Mailing Address: CONTACT PERSON: Name: Long Island Pool Care Corp Mailing Address: 50,000 Main Rd Southold, NY 11971 Phone#: 631-765-8285 Email: li.poolcare@gmail.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Long Island Pool Care Corp Mailing Address: 50,000 Main Rd, Southold, NY 11971 Phone#: 631-765-8285 Email: li.poolcare@gmail.com DESCRIPTION OF PROPOSED CONSTRUCTION []New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther inground pool 57,500.00 Will the lot be re-graded? ®Yes El No 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 si Mated:: Are there an covenants and restrictions with respect to �,..� y p this property? ❑Yes NUD IF YES, PROVIDE A COPY. "heck 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,building code, housing code and regulations and to admit authorised 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): Q Authorized Agent ❑Owner Signature of Applicant: " Date: ONNIE D.BUNCH Notary Public,State of New York STATE OF NEW YORK) No.01 BU6185050 Civallfled In Suffotk County M SS: Commission Expires April k,Z �- s COUNTY OF ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)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 file therewith. Sworn before me this 1. day of .. .-tw, 20 � 'i Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) ,Iol 1 _ residing at , (,.,on TS\o.t.d QUc� l Care �U do hereby authorize 5 r1p to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date - Ss Print Owners Name 2 �10�1 Scott A. Russell ' 5�F 0>>[�I\\l[WAT1E]K SUPERVISOR 0 �w AWANAG]EMLENT SOUTHOLD TOWN HALL-P.O.Box 1179 16 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of So u th o l d CHAPTER 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, A Contractor,Agent, ontractor, Other NAME: ...: ..... 5 Date: �c .... .�.. � It -� Contact Information. �L.l mQvc?�_Ccs-�'e ..___ C.rz�k .�---....-�.- IIL',..,Mad F.t VelePhnne INmllbcl) Property Address / Location of Construction Site .� �. �._�. .. S.C.T.M. 1T)0,00 ..... .._ .aw_ ...... _..� Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT - Area of Disturbance is less than I Acre. No S.P.D.E.S. Permit is Required Project does Not Discharge to Waters of the State, No S.P.D.E S. Permit is I...- Area of Disturbance is Greater than I. Acre & Storrn-vvater 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 Building Permit 0 'area of Disturbance is Greater than t Acre & Storm-,t arer Runoff Flows Through Southold _ .� �.� ........�.....-.,P.� Towns MS4 Systems to Waters of the State of Nevv York THE APPLICANT MUST OBTAIN a S.P.D.E S. Permit through the Southold Town Enaneenn De artment Prior to issuance of a Building Perat � I J' � Zay Rey ie v ed By Date: _. `O workers' Yottrc CERTIFICATE OF INSURANCE COVERAGE sxATE 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 LONG ISLAND POOL CARliiii:CORP 631-765-8285 50000 MAIN ROAD SOUTHOLD, NY 11971 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) 275174033 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 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"Ila" Southold,NY,1197 1 DBL357404 3c.Policy effective period 04/19/2024 to 04/18/2025 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: R] 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. g Date Signed 5/16/2024 By 040� (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 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 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 sox 4B,4C or 513 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) II 11I11111111111111111111111111111111111111111111111 DB 120.1 (12-21) STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Long Island Pool Care Corp (914) 365-9514 50000 Main Road lc.NYS Unemployment Insurance Employer Registration Number of Insured Southold,NY 11971 Work Location of Insured(Only required if coverage is specifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 27-5174033 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Amtrust North America Town of Southold 3b.Policy Number of entity listed in box"la" 54375 Main Rd WWC3706134 3c. Policy effective period PO Box 1179 4/19/2024 to 4/19/2025 Southold,NY 11971 3d. The Proprietor,Partners or Executive Officers are included. (only check box if all partners/officers included) E]all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y' 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 will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or w ilhin 30 da)a.s IF there are reasons,other fluff n nonpgvrn&rtt q pvt7iniums Mat cancel the policy or eliminate the insuredµ,ironi the coverage indic'aated on this C.c rlq ficate. (These notices navy be sent bv regular mail.) Otherwise,this Cert4leate is valid for rune yearafler 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. Please Note: Upon the cancellation of the workers' compensation 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 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: ._.._�� ... .. Peter Sabat--NSA Insurance Agency... . ......._.... m ......._. (Print name of authorized representative or licensed agent of insurance carrier) Approved by: C d� 5/16/24 ........ (Signature) (Date) Title: Sr. Partner 500 Telephone Number of authorized representative or licensed agent of insurance carrier: 631 722-3-3 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter,and notwithstanding 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 compensation for all employees has been secured as provided by this chapter.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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter,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 compensation for all employees has been secured as provided by this chapter. C-105.2(9-07)Reverse LONGISL-10 �6112C CH A� CERTIFICATE OF LIABILITY INSURANCE [f5 /YYYY) �. r, --- 24 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.. t pe Agency CT ..PRODUCER Ave. Upr� Neefus S 711 Union 9 y P HONE A/C Ib Ext 631 722 3500 F1 7 3591 Aquebogue,NY 11931Iss info nsalnsure com �.r INJSUfdE Atl`FdAFCDINGCo��,E�AS36 — �IAtlCN INSURER World Insurance C.Om � ....,... 1g ;96U RB: INSURED INSURER ....,,,,� .,. . �.�.� --------.... Long Island Pool Care Corp JRsyRAR,p, ..... _ _.. _ 50000 Main Rd INS_11 ,UFRERD -- Southold,NY 11971 INSURER,.. 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, SHOWN MAY HAVE EDUCED BY PAID CLAIMS A X COMMERCIAL GENERAL LIABILITY _ .µ mmmm_._..�, - m. w w EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS -LTR --- INS FAO Pwvn POL. LIMITS 1k000 00.0... TYPE OF INSURANCE SUBR ICY NUMBER POLICY EFF POLICY EXP EACH OCC tJRRENCE CLAIMS-MADE I X� OCCUR NF"P801557 4/30/2024 4/30/2025 DAMAO�TO RI;wrED 100,000 I'B�Ir195ES,J.��Q��urt.�t1�"fi}_ w_...... _..... ...� 5,000 ......... ...... .._ Cd X 14 wy¢w a psmq) _ ... 1 mt100„I 00 ERSONAL,,F1 ADV tlNJURY .... t, __d".,wE.NERAL,mAit"aOIRC&3J'�"�E 2°000 .....EN"rWaaREaM1;ELIMITAPPLIESPER C �,000 0��P O TTOmpA0s...X OLwCYr QTHEI AUTOMOBILE LIABILITY 'COMiBIhdE.GY BINDLE LIMIT ANY AUTO _59DIt Y"IqA.YRK,C r PArfirY+e] ,..., ........... __........... OWNED SCHEDULED m AUTOS ONLY """"". AUTOS yW DILY Itl+IJURY�PerfuCCGderrvil $,,,, .,..,. HIRED S ONLY AU''rN'f,75 S" 2 _.QF?e"rO"aP"cEcdantA'IvRACC. ..... .�. UMBRELLA LIAB OCCUR ,EAR.�"61„{'34..PU'R"F&E.NCE,....... "..�.., EXCESS LIAB CLAIMS-MADE AG'CwRCf„rAp'h, ..". >r;,,,,„., ____- •..............,. ....___.^DED -...... RETENTION$..e� .............. S WORKERS COMPENSATION TA"CU7F' AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ""� E L IdACNCC4C7BN'0' SLL. ....,.,N/A -- OFFICER/MEMBER EXCLUDED? (Mandatory in NH) .. 'L,DflSE.7,,.,E, JkRu1P1�t,WEE..•».. .., A ,,,, if yam,describe under DESCRIPTION OF OPERATIONS below E L O1SE.A9,q•_POLICY L1MIT S, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ` 1 JI io�(anms puel s .. ouBaBul -V 4daso� F =r g t°.