Loading...
HomeMy WebLinkAbout51742-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE URI , 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#: 51742 Date: 03/14/2025 Permission is hereby granted to: Halsey MJ Revoc Trt 482 Waverly Ave Brooklyn, NY 11238 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 10feet. Premises Located at: 325 Bay Ave, East Marion, NY 11939 SCTM#31.40-11 Pursuant to application dated 02/07/2025 and approved by the Building Inspector. To expire on 03/14/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total $400.00 2Xb- Building Inspector 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 lit /�VWW.. itlioioL)IO OWII1���� -. Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only °� PERMIT NO. / I Building Inspectors 4 ' 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: mi (-a-" a\s QcIJ SCTM#1000- Project Address: 3aS Ave �, , d)V1 Phone#: Email: 1 Mailing Address: CONTACT PERSON: Name: Mailing Address: 5 rV Ki `�q4q Phone#: Email: FCxCrrti DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: �- Mailing Address: `� Phone#: � _ _ - email: �Ls tit 1 DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other L Will the lot be re-graded? ❑YesPo Will excess fill be removed from premises? NYes ❑No 1 PROPERTY INFORMATION s �y t� er t Existing use of property: moo` Intended use of property: �W Zone or use district in which premise is situated: Are there any covenants and restrictions with respect to this property? ❑Yes �o IF YES, PROVIDE A COPY. Ve k Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water Issues as provided by aptor 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 rdinanre of the Town of Southold,Suffolk,County,New York and other applicable taws,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 220AS of the New York State Penal taw. Application Submitted By(print name): �i.COI VIU Authorized Agent ❑Owner Signature of Applicant: mate: STATE OF NEW YORK) J COUNTY OF 5 U Ile:y l 1 (\ qt o^n q Ae ll"L J f` 0 being duly sworn,deposes and says that(s)he Is the applicant (Name of Individual signing contract)above named, (S)he is the Leen-j- (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 7 day of �e b/MCA/ r , 20 Z Notary Public s ANDREW BAAL Notary Public.State of New York PROP OWNER C� w�l;;,%t��95aitl6 (Where the applicant Is not the owner) y c° "x 0D E�poes�J0°29, 4r 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 1uildinp-Department Anplication AUTHORIZATION (Where the Applicant is not the owner) 1, (Y11 C R}k f� residing at (Print property owner's name) (Mailing Address) E(SST M H;,10 N - N`f do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. 2y 2 (Owner's Signature) te) fAi �4 kAAU -j (Print Owner's Name) Workers' CERTIFICATE OF Compensation and NYS WORKERS COMPENSATION INSURANCE COVERAGE Bo 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 631-996-4687 Patrick's Pools,Inc. PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured(Onty required If coverap Is speaftelly limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations In Now York *to.,a Up- Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesoo Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"la" Town Hall Annex WWC3714385 54375 Main Road Southold,NY 11971 3c.Policy effective period n1;m.3Q»d to nxvl xrongi 3d.The Proprietor,Partners or Executive Officers are Included.(Only check box if all partners/officers 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"1a"for workers' compensation under the New York State WorkeW Compensation Law.(To use this form,New York(NY)must be listed under item 39 on the INFORMATION FADE of the w rs'compensation Insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above,as the cedliftate holder In box"2". The Insurance carter must notify the above certificatlaholder and the Workers'Compensation Board wWjn 10 days IF a policy is canceled due to nonpayment of premium or within 30 days IF Otere are reasons other than nonpayment of premiums that cancei the poky or eliminate the Insured the coverage indices on'this Ce ts.(Thm nodm may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form Is approved y ft Insurance carter or its[Wartsed agent,or until the 1polloy expiration date listed In box"3c",whichever is ter. This certificate is Issued as a matter of information only and confers no lights upon the certificate holder.This certificate does not amend, extend or after the coverage afforded by the policy listed,nor does it confer any rights or respon ib 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 canceltation of the workers'compensetion policy Indicated on this fonn,It the business continuesto be named on a permit,license or contract by a certificate,homer,the butsirms,must provide that cortfificate holder with a new Certificate of W rs'Compensation Coverage or other Authorized proof that the business is complyring with the mandatory coverage requirements of the Now York State Workers'Compensation Law. Under penalty of perjury,I certify that 1 am an authorized representative or licensed agent of the insurance caller referenced above and that the named Insured has the cove as depicted on this form. Approved by: Nicholas Zulkofske 0 t t name of representative or agent carrier) Approved by: _ 2''j ?'q (iig- ) Title: Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier. 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C405.2.Insurance brokers are�QI authorized to issue It. C405.2(947) www.web.ny.gov Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L i 08/23/2024 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 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 Nicholas Zulko ske Brookhaven Agency,Inc. PHONE 531 941-4113 Fes- 53 941 05 100 Oakland Ave,Ste 1 cef tcates brookha: vena enc .com Port Jefferson,NY 11777 R F 0n1fdr COVERAGE INSURER A: Philadelphia Indemni Insurance Company } INSURED INSURER B Merchants Mutual Insurance Company Patrick's Pools,Inc. c:Wesco Insurance Com an PO Box 3024 INSURER East Quogue NY 11942 INSURERF: 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. INSRI T TYPE OF INS(1RANC€ LADDL SUB P M POLICY POLICY - LIMITS )( ,COMMERCIAL GENERAL LIABILITY € ACH 0 CURRENCE °$1,000,000 A �CLAIMS-MADE .�OCCUR DAMAGE TO KENTES{ rR�r��s:s r s, t $100 000 LX Contractual Liability E PHPK2658571 02/28/2024 02/28/2025'MED ExP(Anv one person )$5,000 ! ( f PERSONAL&-ADV INJURY i$1.000,000 I GE#d L AGGRE TE LIMIT APPLIES PER: i GENERAL AGGREGATE I 2.000,000 POLICYJLX JECOT ❑ LOC I PRODUCTS-COMPIOP AG $2.000.000 I R II $ AUTOMOBILE LIABILITY [ 3 iEtS iNG' LIMIT $500,000 —� B °X ;ANY AUTO ! BODILY INJURY(Per person) $ ALL OWNED r SCHEDULED X X CAP9267113 07/12/2024 I 07/12/2025 I BODILY INJURY(Per accident) $ AUTOS AUTOS k PROPERTY,DOGE X I HIREDAUTOS 1 1 NON-OWNED 1 $ AUTOS = i -.$ i UMBRELLA LIAB �� OCCUR _ EACH OCCURRENCE [ EXCESS LIAB CLAIMS-MADE =AGGREGATE ? $ R T NTI i $ j WORKERS COMPENSATION X ?PERT1 OTH ;AND EMPLOYERS'LIABILITYY1 i - =STA_IJTF =ER ZANY PROPRIETORIPARTNER/EXECUTIVE ; ) 'E L EACH ACCIDENT s$100,000 C iOFFICER/MEMBEREXCLUDED7 Y NIA: WWC3714385 105/131202410511312025 ;(Mandatory In NH) i E.L.D! EASE- EMP OYES $100,000 Wyss yes,describe under IP I F P TI b I yv E L DISEASE-POLICY LIMIT $500.000 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as additional insured per written contract CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS, Southold,NY 11971 AUTHORIZED REPRESENTATIVE <NS I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD vox Workers'-- sT4Tc;Compensation CERTIFICATE OF INSURANCE COVERAGE ;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 carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c. Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number 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 (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"l a" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2024 to 05/12/2025 14. 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: 2] A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] B.Only the following class or classes of employer's employees: i Under penalty of perjury, I certify that I am an authorized representative or licensed agent cif 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 6/20/2024 By 14=4� (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) `Telephone Number 516-829-8100 Name and Title LeSton WeISh,Chief Executive Officer 1 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 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'Compensatlon 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 DS-120.1. Insurance brokers are NOT authorized to Issue this form. DB-120.1 (12-21) 1111111111°°1°1°1°°1°1°111°°°°°°1°IIIIIII OAF/ cc--, APPROVED AS NOTED 5l14 a DAB ` �'� B.P.B COMPLY WITH ALL CODES OF FED D BY. _ NEW YOP STATE TOWN CODES NOTIFY BUILDING DEPARTMENT AT AS ICE IRED AND CONDITIONS O 631-765-1802 8AM TO 4PM FOR THE M I SIX T FOLLOWING INSPECTIONS: VJMTOWN RAING BOAM FOUNDATION-TWO REQUIRED SOUMTONTRUSTES FOR POURED CONCRETE - ROUGH-FRAMING&PLUMBING - INSULATION - FINAL-CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEff THE REQUIREMENTS OF THE CODES OF NEW RETAIN STORM WATER RUNOFF YORK STATI- NOT RESPONSIBLE FOR PURSUANT TO CHAPTER 236 DESIGN OR C NSTRUCUM ERRORS OF THE TOWN CODE ELECTRICAL INSPECTION E UI E "IMMEDIATELY" ENCLOSE POOL TO CODE ION COMPLETtON BEFORE ATER" New York State Law You Must Call 811 Before You Dig la'N d . r a- \ueS i TL- dtsY 4�aOIL, ana, ``O (-, r' t r iCAI l4ms" 02-r V* S.C.LM. NO. DISTRICT: 1000 SECTION:31 BLOCK: 10 LOT(S):f1 SANIIARY N POW I A' 1 E'10 �4 I/A SEPIX tas' 24V !!AA' at` `-�s 5W S.S' LP•a �• +as OF { LAND NfF OF ARGERIE TSIKLIDIS Lp LAND N/F OF Q ;r KOSIAS ROUSTAS sp V0 ORM PAN! Q SF to h^� / 13 Y- s # + LAND N/F OF NICHOLAS JONNSON 11 w t C rs fi `Z \ FINAL SURVEY 07-01-24 REVISED 05-15-23 FLOOD ZONE X THE WATER SUPPLY, WELLS. DRYY&US AND CESSPOOL LOCA77ONS OWV ARE FROMOB FEMA MAP#36103CO064H EFFECTIVE 09/25/09 AND OR DATA OBTAINED FROM�ELD SOTHERSERVARONS AREA:20,264.30 SQ.FT. or 0.47 ACRES ETEVA770M DATUM: UNAUTHORIZED ALTERARIXV OR AM7701V TO THIS SURVEY IS A VIOLARON OF SEC77ON 7209 OF THE NEW PORK STATE DUCA77ON LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR BHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 177LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TV77ON LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INS7ITUT70N, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SFiOlW HEREON FROM THE PROPERTY LINES TD THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO M01VUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES; ADD17701VAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS ANDIOR SUBSURFACE S7RU=R£S RECORDED OR UNRECGRDD ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY oF:DESCRIBED PROPERTY �F N«`' CERTIFIED TO:MICAH JOHN HALSEY; ✓`' J�MAP OF: SIMONE BETH LEVIEN; "', .. MICAH JOHN HALSEY, TRUSTEE, FILED: SIMONE BETH LEVIEN, TRUSTEE; SITUATED AT-EAST MARION F FIDELITY NATIONAL TITLE INSURANCE COMPANY; rowla oF:SOUTHOLD KENNETH M jOYCHLTK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design N `, P.O. Box 153 Aquebogue, New York 11931 PHONE(631)2M-15BB FAX(631) M-15M FILE/221-162 SCALE:1 a=30- DATE: SEPT. 09, 2021 N.Y.S LTSC• NO. 050882 m J t mIbM the,soma.of R b t.i.B-.-V&K---tn Y.Ooy-nuk