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HomeMy WebLinkAbout51696-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#: 51696 Date: 02/28/2025 Permission is hereby granted to: Head of Harbor LI LLC 2631 Merrick Rd Bellmore, NY 11710 To: Construct an inground swimming pool accessory to an existing single-family dwelling as applied for. Pool and pool equipment must maintain minimum side and rear yard setbacks of 25 feet. Premises Located at: 19620 Soundview Ave, Southold, NY 11971 SCTM#51.-3-12.3 Pursuant to application dated 01/21/2025 and approved by the Building Inspector. To expire on 02/28/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total $400.00 Building Inspector R'gym tt� r t � 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 tittps://www.soutlioldtownny.g-ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only kIL PERMIT NO. I Building Inspector: �A 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: 1 17 --10 OWNER(S)OF PROPERTY: Name:.JJeQC( �I,Q � Y " �� LL C SCTM# 1000- �" — r , -J Project Address: M 6 Zo soct ociV e'" Av-e, S Add N Phone#: — Z� — J� Email: �— fi N')� 4-0 L • �� Mailing Address: �� QjX ?j�� j N Y ( �S CONTACT PERSON: Name: 1)41 U EL Mailing Address: PC I ��� S , Phone#: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: sew C ( 10015 T hG Mailing Address: .11-1" c UN,+ y T S14, c, � N 1 1 7 (! 9 Phone#: Email:31 3 �a � Cr 411 Pi s w� �l, c�►� DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost o f Project: Other =n t VtiiJNc� 5 -,"r�+n-)n+" oa I�� 1 0D � Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? es ONO 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? Dyes ONO IF YES, PROVIDE A COPY. ❑ Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and stone 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 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): " LA- O ❑Authorized Agent MOwner Signature of Applicant: ^°� .� � Date: STATE OF NEW YO COUNTY OF m W 1Ndtt,V, being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the �l a (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 day of J{�N(�(�4 ,/ , 2p 2,L2 Notary Public JAOWICA,ACMESMABC AI Notary Public . 'Slate of New York No. fp1GJLOO19699 �'��� P NEB n� 1 11 V my Comm. Expires 1f11 028 (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 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? Dyes ❑No IF YES, PROVIDE A COPY. Check Box After 116ading: 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 building(s)for necessary Inspections,False statements made herein are punishable as a Class A misdemeanorpu rsuant to Section 210.45 of the New York State Penal Law. Arckae Application Submitted By(print name): or y ❑Authorized Agent L1dOwner i Signature of Applicant: , Date: l /1?12-)— STATE OF NEW YO COUNTY OF ^ 'V o ,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. i Sworn before me this day of � m ,20 � Notary Public Notary Public �l f Now York ft.0101.00I9E99, 1 -PROPERTY OWNER ALMHORIZATION Qualified In$ulfelk Couny Comm.Expires Jan, 10,2028 (Where the applicant is not the owner) �r� I V( UL60 residing at do hereby authorize to apply on f; my b ehalto the Town of boutholdtl ui ding Department for approval as described herein. F _ r ? s Own II I er's Signature Date Print Owner's Name i 2 i d-� 5JFFQ ID) Scott A. Russel SUPERVISOR AWA1�A�Gr�EI�� IE1�T SOUTHOLD TOWN HALL-P.oi69) 1179 0 Town of Southold 53095 Main Road-SOUT$OLL3,NEW YORK 11971 CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM ,i ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT f ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. APPLICANT: (Property t p y Owner, Design Professional, Agent, Cont cttr Other) NAME: C.h �,; � Date: Contact Information: IL-Mad& Ielephnne Numhe,l Pro- ert Address / Location of Construction Site: t o Sit.. S_C.T.M. #: 1000 District 1` Section Block to 4�1. � c�lrr W O�.MPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT ® - Area of Disturbance rs less than I Acre No S.P D E.S. Permit is Re uired l ` Project does Not Discharge to Waters of the State. No ,P,D.E,S. Permit v; Re aired 0 - Area of Disturbance is Greater than I Acre &Storm-water Runoff Discharges Directly to Waters of the State of New DEC Prior THE H s oncLICANT e c f a Bui diMUST OBTAIN a S.P.D.E.S. Permit DIRECTLY From N.Y.S. \rca of Disturbance is Greater than I Acre,& Storm-�\arPr Rminff Flows Thi'Uuah Southold Town's MS4 Systems to Waters of the State of Nei\ York, THE APPLICANT MUST OBTAIN a S P.D.E.S, Permit throe h the Southold Towtn Er trier°rn De ar tment Pryor to Issuance of a B u ild i 2g Permit, � Rey levved By: Date: F(1RNI CM! P- ' 3r CCCrV4� r� WaE.:x4 Tl# PW�AV1�`.�y�u a o NOV * ESN � pax vxor,,. L „,,,�..."d�•^^"'......�.:-"""'".�.�.�-.W---�Fdm„m ❑ 1� mb ffi Nq m Y o y N �-q Y..1 N LEGEND uGia.n r o xar 1@w ri wew C '� GhNSt#CWF�N rs+rw wee u a 0 a — 0 0 o � a i _ 5 > z n 0 LL z a � 5 0 z 0 i 6. ❑ 5 FOUNDATION AS-BUILT DESCRIBED PROPERTY SITUATE SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY.N.Y„ TAXMAPNO.:1000-051,00.03.00-012„003 w "" LOT AREA:80.03E 20 S,F..(1,837 ACRES) q' DATE SURVEYED:MAY 16.2023 SET STAKES:FEBRUARY 28.2024 SET FOUND.STAKES:MAR..25.,2024 v FOUNDATON AS-BUILT:NOV,15.2024 „CG�"Mtirisy!¢M.kb5'AxptttlfiaWW'l1WNN yj', D�fid;�ygy G CERi10 E0 ONLY TO' �j�' EAO FF7HEHAHBON— ' NONGLLC.ISAOA/ATIMA 11C hA E1 ffN C X' eA v Fu Nm'AesYRA01' COMPANY�.. aLo 6EP❑BUC NATIO x ��«JS,p �— 7q En Feel m � SCALE:111—30 m o B 11 p 143.32 579°25'15W rWILEDBERRYUR°VEP1 ° tJ I waF d mraca Flo , raa� ANE PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) Ca' 1 A A A A A 030486684 SEA CRYSTAL POOLS INC 200 BLYDENBURGH ROAD STE#4 ISLANDIA NY 11749 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SEA CRYSTAL POOLS INC TOWN OF SOUTHOLD 200 BLYDENBURGH ROAD STE#4 53095 MAIN ROAD ISLANDIA NY 11749 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11336 880-8 297961 10/19/2024 TO 10/19/2025 10/14/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE 13 INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1336880-8, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YOLK WORKERS" COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WIESSITE AT HTTPS:IAVWW.NYSIF.COM/CII RT/CER"'I VAL-ASP. 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. NEW YORK STAT' SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:511668580 U-26.3 YORAWorkers' CERTIFICATE OF INSURANCE COVERAGE STAT 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 SEA CRYSTAL POOLS, INC. 631-757-9465 200 BLYDENBURGH ROAD SUITE#4 ISLANDIA,NY 11749 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required ifcoverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 030486684 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 53095 MAIN STREET 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD, NY 11971 DBL188483 3c.Policy effective period 10/17/2024 to 10/16/2025 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 R 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 1/21/2025 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 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 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 4113,4C or 5113 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) 111111 11°°°1°°1°1°°1°°°°1°°°°1°IIIIII DB 120.1 (12-21) DATE(MNUDDIYY C YI� " CERTIFICATE OF LIABILITY INSURANCE 019024 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 erNdorserj. 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 endorsemen s- PRODUCER Rebecca An ellnas Liberty Risk Management, Inc. 631 569633 F 631 569 5636 PN 2333 Route 112 rebe Ilbe ° Medford, NY 11763 INala AProNZDtrNG COVERAGE ' NAIc INstNRERA: Ha, A d...M. rdm...�'C.q INSURED INSURER e: Sea Crystal Pools Inc INSURER C: ..�. —_- 200 Blydenburgh Road INSURER -- Islandia, NY 11749 Nr WRER F Nr,tsuRM F; REWSION NUMBERO CO TTHISRIS OECERTIFY THAT THE POLICIES ES OP FICATE INSURANCEMLISTEED BELOOWR. 0001 HAVE BEEN ISSUED TO THE INSURED NAMBOVE FOR E POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT„TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. IL R Y 12UUNOM9318 9110 2024 P 01�1025 LIMITS mm� TYPE OF INSURANCE POLICY NUMBER A ^ COMME ICLAL CLAIMS-MADE�X LIABILITY ACCUR 9/10/2025 EARCH OCCUERSR NNE 1, 0 () ❑ MELEEXP one '$ 5 000 PERSONALBAOVINJURY $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2+0' 0.�000' POLICY JE O- LOC PRODUCTS'-COMPIOP AGG $ 2,_000 0,00 OTHER: N L t, $ AUTOMOB ILE LIABILITY ANY AUTO Ea BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS t'ROPER DANVIAG $ HIRED NON-OWNED em nt AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR... EACH OCCURRENCE; $ EXCESS LU%3 LJCLAIMS-MADE AGGREGATE $ $ DED RE"ENtTtON PER OTRH- WORKPAS COMPENSATION — AMP EMPLOYERS'LIABILITY ANYPROPRIETORNPARTN`NERJEXECUTIVE' Y E.L.EAOFCAGCCIJENT _ $ OFFICERMIIEMBER EXCLUDED? N/A E.L DISEASE-EA EMPLOY $ (Mapdatory In NR) IN s„dIbo under E.N_OLSE#kSE-POLICY LtAbNT $ O�cRNPTION OF OPI„RATIONS RtsloMr DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddManal Remarks Schedule,may be attached If more space Is required) Town of Southold is included as an Additional Insured,ATINIA,as required by written contract,subject to policy terns and conditions. 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. 53095 Main Street Southold, NY 11971 AUTHOR REPRESENTATIVE RIP, A ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by RPA on 09/09/2024 at 04:OOPM Suffolk County Dept of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name DAVID KOCIS Business Name SEA CRYSTAL POOLS INC This certifies that the bearer is duly licensed License Number HI-62791 by the County of suffolk issued: 09/09/2019 R054tiR,Dragv- Expires: 09/01/2025 Commissioner This license is the property of Suffolk County se Department of Labor,Licensing&Consumer Affairs. Possession of this license does not guarantee its validity. Additional Business Name License Category H26-Pools and Spas/Certified r'