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HomeMy WebLinkAbout42067-Z SUiFOI-tco Town of Southold 5/15/2019 0 P.O.Box 1179 o, g 53095 Main Rd Southold,New York 11971 1 � CERTIFICATE OF OCCUPANCY No: 40386 Date: 5/15/2019 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 550 Bailie Beach Rd,Mattituck SCTM#: 473889 Sec/Block/Lot: 99.-3-4.13 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/11/2017 pursuant to which Building Permit No. 42067 dated 10/19/2017 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: ACCESSORY IN-GROUND SWIMMING POOL,FENCED TO CODE,AS APPLIED FOR The certificate is issued to Gladitsch,William&Catherine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 42067 12-14-2017 PLUMBERS CERTIFICATION DATED o ' e Signature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY yayol � �ao�ys 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#: 42067 Date: 10/19/2017 Permission is hereby granted to: Gladitsch, William 3664 Collector Ln Bethpage, NY 11714 To: construct an in-ground swimming pool as applied for. At premises located at: 550 Bailie Beach Rd SCTM # 473889 Sec/Block/Lot#99.-3-4.13 Pursuant to application dated 10/11/2017 and approved by the Building Inspector. To expire on 4/20/2019. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Building I spector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial building,industrial building,multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. v B. For existing buildings(prior to April 9, 1957) non-conforming uses, or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date. New Construction: Old or Pre-existing Building: ` (check one) Location of Property: &QCA—, Z� M ��LIGI� House No. Street Hamlet Owner or Owners of Property: cam i 4 SCIS Suffolk County Tax Map No 1000, Section C�C� Block Lot Li .ol 3 Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ licant Signature pF SO Town Hall Annex Telephone(631)765-1802 54375 Main Road CAR Fax(631)765-9502 P.O.Box 1179 ® �Q roger.richert(a)_town.Southold.ny.us Southold,NY 11971-0959 c®UNT`I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: GladiitSch Address: 550 Bailie Beach Road city,Mattituck st: New York zip: 11952 Budding Permit# 42067 Section: 99 Block- 3 Lot: 4.13 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: All Wright Electric License No: 43457-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include; Bonding, Heat Pump, Salt Generator, 100A Control Panel, 3- GFCI Circuit Breakers, 3- LED Pool Lights, Cover Motor. Notes: Inspector Signature: Date: December 14, 2017 0-Cert Electrical Compliance Form.xls OF SO�TyOIo o • �o �yc0UN1'1,a TOWN OF SOUTHOLD BUILDING DEPT. 765-16®2 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLRG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ` j ELECTRICAL (FINAL) REMARKS: zf �A< DATE �`'� INSPECTOR �vo OF SOUTyO� # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ yASULATAON [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE &.CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REINA : .11�prj nA' t� DATE Iql INSPECTOR r FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) -------------------------------------- FOUNDATION -----------------------------------FOUNDATION (2ND) t� 0 � m t ROUGH FRAMING& y PLUMBING r P:. t� INSULATION PER N.Y: STATE ENERGY CODE pt- O ti AISve- L4 J t FINAL ADDITIONAL COMMENTS ® 0 141 C z wm ;o d °z d TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST DUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631)765-1802 Planning Board approval FAX:(631)765-9502 Survey Southold townny.gov PERMIT NO. Check Septic Form N.Y.S,D.E.C. Trustees C.O.Application Flood Permit Examined N 20_ Single&Separate Truss Identification Form CStorm-Water Assessment Form Contact: T ^� Approved G 0 +trMail to:`���%� l e� ry Disapproved a/c � M�`A`�i( �C 1�t�:J� "'Met; pvc-Im r Phone: 1=_la�'C�ID�I�j Y-\b O 4(LA Expiration 20 Building Inspector APPLICATION FOR BUILDING PERMIT V D Date 10t— - 20 INSTRUCTIONS a CT 1 10-1, application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or BJ ®ays. c. overed by this application may not be commenced before issuance of Building Permit. TOOF.�� val of this application,the Building Inspector will issue a Building Permit to the applicant,Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. 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,or 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 for necessary inspections. (Siffimumw6f applicant or name,if a corparation)r t oke'r place G09. L CNN er P1gcc (Mailing address of applicant) 1 ,� b , St to whether applicant is owner,lessee,agent,architect,engi er,general contractor,electrician,plumber or builder � _1 State vt�--t%0 C tM-4Qdi2w Name of owner of premises w".\A e" (As on the tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) BuildersLicense No. Plumbers License No. Electricians License No. Other Trade's License No. /J 1. Location of land onQ>a which pr osed work will be done:Issa ( eack House Number Street p, Hamlet County Tax Map No. 1000 Section —` Block Lot '�\� a , Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b Intended use and occupancy �� ��� y1./V,�l 1 \Clci T—y� \ �S►o�t�` �,� 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work S.l)\1a l ti nG PM% (Description) 4 Estimated Cost Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units- Number of dwelling units on each floor If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth - Height Number of Stories 9. Size of lot-Front Rear Depth 10 Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO_ 13.Will lot be re-graded?YES—NO_Will excess fill be removed from premises?YES—NO_ 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO * IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.is this property within 300 feet of a tidal wetland?*YES NO *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16 Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?*YES NO * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF IV46a.,J a-Ltchac1 fti-AerlGy-- being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the W���G�'G�CLY �� \ l-�i► l Poo s' (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 knowledge and belief;and that the work will be performed in the manner set forth in the application filed therewith Sworn to before me this day of d C-A-z>bef'- 2011 Notary Public ature of Applicant NOTARY PUBLIC,STATE OF NEW YORK No.SoiLAW93001 QUALIFIED IN SUFFOLK COUNTY COMMISSION RES JUNE 23.2;'1 �0osuFFQ/rq STO�I[ IM[WA'7C']EIK Scott A. Russell SUPERVISOR W MANAGIE1\CENT SOUTHOLD TOWN HALL-P.O.Box 1179 O � 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town own of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE AN,Y OF THE FOLLOWING: Yes NO (CHECK ALL THAT APPLY) ❑�A..Clearin , grubbing, grading or stripping of land which affects more gg gg g PA g /than 5,000 square feet of ground surface. ❑ B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑� Site preparation on slopes which exceed 10 feet vertical rise to ❑100 feet of horizontal distance. Site preparation within 100 feet of wetlands, beach, bluff or coastal ,._.,/ erosion hazard area. E]L3" E. Site preparation within the one-hundred-year f loodplain as depicted ❑on FIRM Map of any watercourse. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tag Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT. (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. i`: 1000 Date. '' .� `` Drstnct NAME tQ \a ��c �� sr,-VN C1.9 3 / + `l 4D13 /7j �p Section Block Lot ,,. - M40!"r—_ `_"g�°r //,w,'"1 1 p *�** FOR BUILDING DEPARTMENT USE ONLY**"" Contact Information \U '4a$ (O- IS 6-1." rReviewed By. Ne-0 6w\_ - - - - - - - - - - - - - - - - - - Property Date)o— Address / Location of Construction Work: — — — — — — — — — — — — — — — — — Approved for processing Building Permit. Stormwater Management Control Plan Not Required. ® Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 Town Half Annex Telephone(681)765.11802 54375 Main Road rlChert lffi la W. P.O.How 1179 to-ger. Wn so- 0 nv.uS Southold,NY 11971-0959 i BUII.DING DEPARTWINT I TOWN OF SOTT HOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY. Date: I ZQ Company Name: Name: License No.: Address: 12,9c> Phone No.: 6 3 )) 3 S 3'-5 c1 t 1 JOBSITE INFORMATION: {Indicates required information) *Name: , G1 Js G11 1 1 *Address: S O *'Cross Street: *Phone No.. 15 I.6 Permit No.: Tax Map C]istriat: 9000 Section: Block- Lot: *9R1EF DESCRIPTION OF WORK(Please Forint Clearly) (Please Circle All That Apply) +is job ready for inspecWn: �N O Rough In Final i *Do•you need a Temp Certificate: YES!"6—p) Temp Information(if•needed) *Service Size: 9 Phase Whose 900 950 '200 300 350 . 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional information: PAYME T DUE WWII APPLICATION {{ XD �d d W-Request for Inspection Form 19, Od Client#: 1095 SWIMP002 ACORD. CERTIFICATE OF LIABILITY INSURANCE F—DATE 6/29/2/DD/YYYI) 6/29/2017 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 NAME: Southampton Commercial PHONE 631 324-1440 A/C No Ext: A/C No Cook Maran&Associates E-MAIL 300 Hampton Road ADDRESS: Southampton,NY 11968 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Fire Ins.Co of Hartfo 20478 INSURED SwimTech Pool Services,Inc. INSURER B:Merchants Mutual Ins.Co. 23329 467 Miller Place Rd INSURER C: Miller Place,NY 11764 INSURER D: INSURER E 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 CONTRACTOR 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY 5099324804 2/01/2017 02/01/201 EArC�HOECCCURRENCE - $110001000 CLAIMS-MADE OCCUR PREMISES EaEo Tur erica $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000000 GEN'LAGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2,000000 POLICY F JECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER* $ B AUTOMOBILE LIABILITY CAPI060260 3/10/2016 03/10/2017 COMBINED SINGLE LIMIT Ea'cadent 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per acadent UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? El N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S815382/M741751 MSCHW 0 New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^"^^^^ 112855800 SWIM TECH POOL SERVICES, INC 467 MILLER PLACE ROAD MILLER PLACE NY 11764 ❑ Scan to Validate POLICYHOLDER CERTIFICATE HOLDER SWIM TECH POOL SERVICES, INC TOWN OF SOUTHOLD 467 MILLER PLACE ROAD P.O. BOX 1179 MILLER PLACE NY 11764 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12406522-9 595794 12/31/2016 TO 12/19/2017 6/29/2017 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2406 522-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK 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 WEBSITE AT HTTPS://WUWV.NYSIF COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 STATE INSURANCE FUND J, DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER.597069844 U-26 3 vORK Workers' CERTIFICATE OF INSURANCE COVERAGE STi4TE Compensation UNDER THE NYS DISABILITY BENEFITS LAW Board PART 1. To be completed by Disability 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 (631)928-2693 SWIM TECH POOL SERVICES INC 1c.NYS Unemployment Insurance Employer Registration Number of 467 MILLER PLACE ROAD Insured MILLER PLACE,NY 11764 7651869 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e,a Wrap-Up Policy) Number 112-85-5800 2 Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) 3b.Policy Number of Entity Listed in Box"1 a" TOWN OF SOUTHOLD DBL 5394 18-5 PO BOX 1179 SOUTHOLD,NY 11971 3c Policy effective period 02/01/2005 to 02/01/2018 4 Policy covers A All of the employer's employees eligible under the New York Disability 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 Benefits insurance coverage as described above. Date Signed 6/29/2017 By f �.5'_ Joseph J.Masi (Signature of insurance carvers authorized representative or NYS Licensed Insurance Agent of that insurance carver) Telephone Number (866)697-4332 Title Director of NYSIF Disability Benefits Insurance IMPORTANT If Box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd 8 of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 PART 2.To be completed by the NYS Workers'Compensation Board (Only if Box"4b"of Part 1 has 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 Benefits Law with respect to all of his/her employees. Date Signed By Signature of NYS Workers'Compensation Board Employee) Telephone Number Title Please Note: Only insurance carvers licensed to write NYS disability 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 (9-15) Certificate Number 439159 Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in box"T'on this form is certifying that it is insuring the business referenced in box"1 a"for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? EJYES ®NO 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 Disability Benefits contract of insurance only while the underlying policy is in effect Please Note: Upon the cancellation of the disability benefits 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 NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed. (b)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 employment as defined in this article and 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 the payment of disability benefits for all employees has been secured as provided by this article DB-120.1 (9-15)Reverse APPROVED AS) NOTED DXI-E:xo.n—.I B.P.P.��f 06�� FEE — BY NOTIFY BUILDING DEPARTMENT AT 765-1802 3 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION ,SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. NEW YOI.e1 S I P & TOWN LOGES V S RLJ .�"7 tJ l.: U 5! E--1 SQ fIl.VL. Jm PN'r[.0 iitJI.I; 111!" i ;J!'..'S OCCUPANCY O USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE, "IMMEDIATELY" ENCLOSE POOL TO;CODE UPON COMPLETION BEFORE VATER" EL. CT CAL GENFRAI..NOTES 1.Install pool in accordance with approved site plan,local zoning and construction codes,2015 International Code with the NYS 2016 Uniform Code Supplement,2015 IECC and 2016 Supplement to the NYS Energy Conservation Construction Code. 2.Locate patio,pool,pool equipment and fencing as specified on approved plot plan. �] Install all products in strict conformance with manufacturer's instructions All warningPOOL DECK QP�� Z ¢N Z labels to be permanently affixed. 40-O° %"x1" BOLT WITH NUT 0 CL& 2 WASHERS � v- z 3.Install pool in free draining sub rade- Backfill with clean select ranular fill a ' = 0 P g g g \ (7 PER JOINT RED'D) x 4� l o Z MIN 6" THICK - /\\/ Z N n < 4.Water treatment plant to conform to the following minimum specification Pump to CONCRETE COLLAR / o w °O o < /\/\ WALL - STEEL 14 GA w a m rn P gP REO'D AT BASE OF >• //\\//\\/ 0 o turn 1 volume in 18 hours. Filter to ass no more than5 m/sf 1 skimmer. W/2oz (G235)\ � i WALL PANELS �� - �\\�\ GALVANIZING � 0 5.Provide potable water supply in pool area '-' v x pool interrupt \ DRE RODS THROUGH Ya"x2 " BOLT Z a o 6. ollccircuits sufficient ita HOLES 10W/NUT plantAelectric inarea to bePrroteced b ground fault in erruP Install treatment -T— TO UNDISTURBED electric in accordance with the N E.0&local requirements There shall be no o verheadI EARTH REINF m electric lines within 10'of the pool I I 2" SAND OR VERM //\// \//\/ ROD 7.Slope deck 4'per foot away from pool All concrete to be 3,500 psi,5-7%air I I I CONC entrained unless otherwise noted. I I UNDISTURBED EARTH SUPPORT 8.Install a temporary 4'hi h construction barrier about the pool during its installation II BRACE TIE SUPPORT MAY BE P ry g P g — - T I - - - - BACKFILL SHALL BE FREE-DRAINING CLEAR SUPPORT BOLTED TO THE ANGLE Maintain such barrier until a permanent barrier is in place o IN ANY OF THE J C14 GRANULAR MATERIAL SUCH AS SAND, TRACE O CLAY OR TRACE SILT PRE-PUNCHED HOLES 9.Install erosion controls prior to the start of construction as required and specified I � ` I hereon Maintain such controls during construction I I I TYPICAL LINER INSTALLATION DETAIL TYPICAL WALL BRACE ASSEMBLY O �r ,' 0 10.The permanent barrier about the pool area shall comply with local ordinance,the d Residential Code of NYS Part X,Appendix G-Swimming Pools,Spas and Hot Tubs I I I %"x1" BOLT W/NUT& CONCRETE DECK REO'D- Z Section 105 3 and conform to the following minimum specifications /L — — — 2 WASHERS CORNER BRACKET a.The top of the barrier shall be at least 48 inches(1219 mm)above grade measured I (TYP 14 EA CORNER) U m ^ z on the side of the barrier which faces awayfrom the swimming pool The maximum / I — #12-14x1" SELF DRILLING —RIM-LOCK COPING ¢ o 0 g P FASTENER(18"OC) EXTRUDED ALUMINUM H M: vertical clearance between grade and the bottom of the barrier shall be 2 inches(51 / —� O U) Z O mm)measured on the side of the barrier which faces away from the swimming pool. PLASTIC CORNER VINYL LINER (HUNG) Z �� Q z Where the top of the pool structure is above grade,such as an aboveground pool,the INSERT _tA W } barrier may be at ground level,such as the pool structure,or mounted on top of the RADIUS CORNER C3. X °e 6 O` 9 pool structure Where the barrier is mounted on top of the pool structure,the POOL PLAN COPING ~—POOL WALL PAN J q L, r maximum vertical clearance between the top of the pool structure and the bottom of TYPICAL CORNER DETAIL RIM-LOCK COPING DETAIL , F_ the barrier shall be 4 inches Cf- b Openings in the barrier shall not allow passage of a 4-inch-diameter(102 mm) y* = o I•, w sphere c.Solid barriers which do not have openings,such as a masonry or stone wall,shall 2 WALL DETAILS n a�1 not contain indentations or protrusions except for normal construction tolerances and DIVING PROHIBITED �- o tooled Maximmasonrum mesh s DIVE PROFILE NOT CONFIGURED FOR THIS POOL \\� 07 7 rjy d Maximum mesh size for chain link fences shall be a 2 25-inch(57 mm)square �-1 \ N S O�P a unless the fence is provided with slats fastened at the top or the bottom which reduce SCALE: NONE f P O FE S \ < the openings to not more than 175 inches(44 mm) �- e. Gates in the barrier shall be self closing,self latching and be secured with a key or = 0 0 ~ate 0 combination lock or other approved child proof mechanism Pedestrian gates shall zroz o< I a z Y 0 open away from the pool. Where the self latching mechanism is less than 54 inches HEIGHT OF WATER 0<N" c0i z o 3 z m a above the bottom of the gate the latching mechanism shall be on the pool side of the o n o o Z>z 5 Z U o 0 • zv�ir2 y�ww-w wZZ, barrier and the gate and barrier shall have no opening greater than z'within 18"of the - 0 z a 0 F a z F z t 'v PUMP WITH TIMER ��0s <NO0 0M< latch and its release mechanism I SWI TCH. 0 0 0 1 m V n 0 o o N o f.The permanent barrier shall be erected and functional no later than 90 days after the z ' FILTER a o Z 5 z woo 3 a < completion of the pool o 0 v a o z o o s > 41 -CHLORINE GENERATOR o X _0 oo<N =az Where the design uses a wall of the dwelling as a part of the permanent pool OD � z 4 w w o< o barrier installer shall provide one of the following access control measures I SKIMMER xo o o z ¢m w Z o 0 Y o ^ WASTE RETURN JET <o<c�3 >oow0 L- 00 a.The pool shall be equipped with a powered safety cover in compliance with ASTM <0<0 5 a U o.w o F1346,or b.All doors with direct access to the pool through that wall shall be equipped with an 4-0" 6-O" 14'-0 16-10" alarm which produces an audible warning when the door and its screen,if present,are opened The alarm shall sound continuously for a minimum of 30 seconds =_ immediately after the door is opened and be capable of being heard throughout the AFFIX TAG 2 0 SCH40 U house during normal household activities. The alarm shall automatically reset under all STATING "MAIN PVC, TYP O U N 4 It (00 conditions The alarm system shall be equipped with a manual means,such as touch L DRAIN" pa ti switch,to temporarily deactivate the alarm for a single opening. Such LATERAL SECTION THROUGH POOL Q W I } deactivation shall last for not more than 15 seconds The deactivation switch(es)shall be located at least 54 inches(1372 mm)above the threshold of the door,or 0- C) >- ,U-I U c Other means protection,such as self-closing doors with self-latching devices, POOL DETAILS 18X23 BOTTOM 3-0 �/J rn U ga- which are approved by the governing body,shall be acceptable so long as the degree of '� DRAIN, TYP. OF 2- F WW protection afforded is not less than the protection afforded by Items 4 a or 4 b described above. J 1�1-� = 12.Install all suction fittings in accordance with New York Residential Code O k SCALE: 1/8" 1'-0" <WATER TREATMENT a O Appendix G,"Swimming Pools,Spas and Hot Tubs",section G106,"Entrapment � � � O O Protection for Swimming Pool and Spa Suction Outlets" z = a 0 a A minimum of 2 suction outlets shall be provided for the main drain line and be _ �/� O w separated by a minimum distance of 3 feet Each suction outlet shall be equipped with A-1 SCALE: N ONE J n w U 0 a cover conforming to ANSI/ASME Al 12.19 8 or have a minimum projected J n dimension of 18"by 23" Dual suction outlet covers shall be Hayward WG series or in m J LU equal where the minimum projected dimension of the suction outlet is less than 18"by ® m J 23" o , b Pool cleaner fittings,if provided,shall be located in an accessible area and be U)z ,� located between 6 and 12 inches below the minimum operational water level or be an _ J attachment to a surface skimmer I_ c.No suction outlet shall be situated on any seating area or the backrest for such U seating area / Survey for. geo WILLIAM GLADITSCH & yea 500 �n CATHERINE GLADITSCH Re wu" Lot 13, "Honeysuckle Hills" At ,,�•rL ,�,� Mattituck Town of Southold Vot 13 Suffolk County, New York S.C.T.M.: 1000-099.00-03.00-004.013 k iD `�•� `� VOt SCALE:1"=30' NOTES: 1. AREA= 25,000 S.F. `'Iice y �� s'd"F 2. ■= MONUMENT FOUND, ♦ = STAKE FOUND, 0=SPIKE SEL D =STAKE SET. 3. SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK \\ s OF SUFFOLK COUNTY ON OCT.16,1981 AS FILE NO.7019. OCT. 25 2007 MAY 5,2004 Fm■m,mn i TKN MAR. 6, 2004 m,.Fom carswuCnm OCT. 25, 2002 Awmm ccRTF"w 6 SEPT. 10, 2002 nDDm CMn CATM N� - DATE: SEPT. 05, 2002 i - JOB NO.2002-441 V-3 1% % % 28 CERTIFIED T0- uvea P<e0 'P,' ``\ O CATH71 WILLIAM GLADITSCH CATHERINE GLADITSCH e5 • �` W COMMONWEALTH LAND TITLE INSURANCE COMPANY \'or rya` a ` N$ 1z5.00 00 DAVID H.FOX L.S.P.C. N.Y.S.LS./50234 Q PDX LAND SURVBYLNC $y$�O p• \' 64 SUNSET AVENUE JE� WESTHAMPTON BEACH, N.Y. 11978 (631)288-0022 Eamuanw'uv aeras a<,mss�.,,.�„ar ecuano muu,nor at caxsomm ro ae�v,,.,o rnaC carr F,m aw wm` ''i n+'%w,cn his an�urn °"`wva w ws az,u,s ro ra nna couo,u.r coevruanru,wanev wm uwarm werm,nw us>m waa...xm m r.a Fear m'wro�mnai.,�wmsniu�nws D an aesFa,mr av�me, 0w0: 2002-441 N680 8'30"E 125.00' 4' Nz 10'-11 •," IIIII ' m FEN 0.4 ' S WFI 0.5'E 16 20' C H/ 43' Lot 13 p i n 11' cin v � N N Z � 1 ' � 31 10' ' O } { I ., I 28' 8'-114" '. I 19'-216" ' I ' 6 5.8' ?c� 2.1' 2.2' 2.3' 2.3' P ? N 11.0' ---42.8 —_ —— 23.1' 0 0 la�a �1 PD n 2 STORY FRAME �.-.+ HOUSE & GARAGE V —20.1'— 13.3' ry in 10.8' N U 13.0' J ROOF OVER i 25.3' ti,i N PAVER WALK I o Q..• 5ti, . I m m ST I D X ' I z co 0 CP CAST IRON 0 O COVER c 0 0 O m O i I , I • I I I I S68°18'30"W 125.00' UTILITY POLE �- EDGE OF PAVEMENT BAILEY ROAD - ( REEVE AVENUE ) t•,