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HomeMy WebLinkAbout52366-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT 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#: 52366 Date: 10/16/2025 Permission is hereby granted to: Kristopher Ocker 245 Raccoon Rd Mattituck, NY 11952 To: construct an accessory in-ground swimming pool as applied for. Premises Located at: 245 Raccoon Rd, Mattituck, NY 11952 SCTM# 106.-10-11 Pursuant to application dated 09/08/2025 and approved by the Building Inspector. To expire on 10/16/2027. Contractors: Required Inspections: Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO Swimming Pool $100.00 Total 400.00 ing 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 htt s://www. o tho)dtow i . o Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only D E C E PERMIT NO. Building Inspector. T 025 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Building Department Owner's Authorization form(Page 2)shall be completed. Town of Southold Date: OWNER(S)OF PROPERTY: Name. ` SCTM# 1000- 0 Project Address: 2 C - Phone#: . _ �� �.QD Email: Mailing Address: CONTACT PERSON: Name: Mailing Address: Phone#: f _ coo Email: � , q DESIGN PROFESSIONAL INFORMATION: Name: ��6 S c", Ea�El LabW-2:&Q Mailing Address: Phone#: "" Email, CONTRACTOR INFORMATION: Name: Mailing Address: 1 —fft� Phone#: � 1 1 Lit—� Email, r. DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Add ition ❑Alteration ❑Repair ❑Demolition Est` Cher $ ill the lot be re-graded? ❑Yes No Will excess fill be removed from premises? es L o 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated; Are there any covenakNo nd restrictions with respect to this property. ❑Yes YES, PROVIDE A COPY. oheck Box After Reading: The owner/contractor/design professional is responsible for all draina and storm water Issues as provided by C r 2316 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the Issuance a Building permit pursuant to the Building Zane 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): � r� 1 � ❑Authorized Agent ,Owner Signature of Applicant: Date: 134s- s STATE OF NEW YORK) SS: COUNTY OF LaL eo �` being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract)above named, (S)he is the tvfw (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,i ,th '6l"Plication file therewith,. w r,. ty0T,,. Sworn before me this 0 i r �cy�.# t * uFr v day of Z S c 1yr . rI I ." ".��� tart'Public Ile NEVI ' JPIP I I lV��N OWNERPROPERTY I "n III (Where the applicant is not the owner) I, r residing at do hereby authorize ( to apply on my behalf to The Town of Southold Building DepalrtypVtfor approval as described herein. Owner's Signaturerlrl Date� I �)'dA ILaIN SUF OIKCOON-n Lt�ct rY� Ocicer- Comm _ P; Print Owner's Name Urltao ' ORIK Workers' CERTIFICATE OF INSURANCE COVERAGE TAPE 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 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS &PATIOS 471 ROUTE 25A ROCKY POINT, NY 11778 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) 113008276 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 Rt. 25 3b. Policy Number of Entity Listed in Box"la" PO Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2024 to 01/31/2026 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 1/22/2025 By lAtZE&�(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 513 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 413,4C 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) I011lDm1ii2i0iu1iiiii� 2iiM2ii�ll IWork ' Y RFK ers CERTIFICATE OF rATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-744-8100 Fence King of Rocky Point, Inc.,DBA:Swim Kings Pools Randy T Rodecker Inc DBA:Swim Kings Pools 1 c.NYS Unemployment Insurance Employer Registration Number of Fence King of Rocky Point,Inc dba Swim King Pools&Patios Insured 471 Route 25A Rocky Point,NY 11778 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11-3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 3b.Policy Number of Entity Listed in Box 1 a" 53095 Rt.25 WWC3748015 Southold,NY 11971 3c.Policy effective period 11/05/2024 to 11/05/2025 3d.The Proprietor, Partners or Executive Officers are ❑X 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"T'insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law,(To use this form, New York(NY)must be listed under 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"2". 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 premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year,after 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, 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: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 9A- 10/25/2024 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 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 (9-17) www.wcb.ny.gov N W _ E hs S e `V 'a 0. 00, oliAo O � M \o 0 rq w , r e 1 rNIP p � Vol." ON CA + a +� O -70 _ �, 2d N \w O i �► � - , o ti \ ° � -7 IVA 1� of NE 6:dl 3M YNx,Q �i4nudW�n=".w,tl p we r Gwm N�x y,,,rh L ryTxwwl rra M M+he IN'W,rU xhri J d du BMt* YNM41 kh m �,wrxa hr"'M ar a M.f ..wam dMr ,e .M a bWrp NrM, YMxa:.I.,rn Xmn ,t ^q.'^f"urxMroantlna9 1l f. M,�thaT ewrm«'Y+arw 9iCnagr.Mr 'u ewm wr nqr<r m m q�xv �smW 1w ",h¢owa co,link duwms r�rnaPo W.. L uMw.We m Nw✓�a«M wN wayl a�p p. "m� �y W,9 XSWq ItreMY,tt ap Clyy A'k1 "w""Y ��$�,. .. 0 '�,M'+i;+i wl h wy WMN CnNkrex I MYMrA kgrpgy w5) rw 4NaN r�rrvwa m„� pw NxxxMintrNk,YllawrGaunu DETAIL I"=40' J01HN Ca E IRS L NDSURVEYOR 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 RWERHEAD,N.Y. 11901 369-8288 Fax 369-8287 REF:C:\UsersUohn\D,ropbox\l l\11-189.pro