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HomeMy WebLinkAbout42508-Z ��o�guFFOt�co Town of Southold 5/24/2019 3 P.O.Box 1179 53095 Main Rd `^y ® O`"� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40413 Date: 5/24/2019 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1780 Rocky Point Rd, East Marion SCTM#: 473889 Sec/Block/Lot: 31.-2-12 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/20/2018 pursuant to which Building Permit No. 42508 dated 3/30/2018 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 Dimitriades,Dimitrios&Constance of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 42508 07-27/2018 PLUMBERS CERTIFICATION DATED u t o V' ed Signature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ay • oAlc� 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#: 42508 Date: 3/30/2018 Permission is hereby granted to: Dimitriades, Dimitrios 126 Monahan Ave Staten Island, NY 10314 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1780 Rocky Point Rd, East Marion SCTM # 473889 Sec/Block/Lot# 31.-2-12 Pursuant to application dated 3/20/2018 and approved by the Building Inspector. To expire on 9/29/2019. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 B i pector 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 2110 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'Ian requirements. 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. FCes 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: House No. ` Street {� Hamlet Owner or Owners of Property: �lilll l�s 1 C 03f%voi1 CQ_ IJim I+Y\aejes Suffolk County Tax Map No 1000, Section 3� Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Tem ary Certificate Final Certificate: (check one) Fee Submitted: $ �. plicant Signature *pf SOUIy®lo Town Hall Annex Telephone(631)765-1802 54375 Main RoadN Fax(631)765-9502 P.O.Box 1179 i5i-I, �Q roger.richert(D-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Dlmltrlades Address: 1780 Rocky Point Road city,East Marion st: New York zip: 11939 Building Permit t 42508 Section. 31 Block: 2 Lot. 12 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor. DBA: East County Electric License No: 1005-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 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 Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks 2 Disconnect Switches Twist Lock Exit Fixtures 9 TVSS Other Equipment: Inground Swimming Pool to Include: Bonding, Control Panel, 4- GFCI Circuit Breakers, Salt Generator, 1- Pool Pump, 1- Polaris Pump, Gas Pool Heater, 1- Pool Light, Notes: Pool Cover Motor. Inspector Signature: Date: July 27, 2018 0-Cert Electrical Compliance Form.xls OF SOUTyolo # TOWN OF SOUTHOLD BUILDING DEPT. `ycou765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: �� i� DATE INSPECTOR v ho�*OF SOUlyolo # TOWN OF SOUTHOLD BUILDING DEPT. i'oum,�`' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ 1INtULAT N [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ]- CAULKING, REMARKS: 0 C, A tr� �J DATE 'L3 INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) 0 H ------------------------------------ FOUNDATION (2ND) t z 01 � o � r ROUGH FRAMING& y PLUMBING P INSULATION PER N.Y. �7 STATE ENERGY CODE Em FINAL Zj— ADDITIONAL'COMMENTS rn t� NO 0 z d *ted H r TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Doyou have or need'the following,before applying? TOWN.,HALL _ Board of Health_ ,,SOUTHOLD,NY 11971 3 sets of Building Plans ,JEL: 7654802 j� Survey : CEJ PERMIT NO: Check Septic Form N.Y.S.D.E.C: Trustees Examined ,20� Contact: Approved 1.3 p ,20 Mail to: Disapproved a/c Phone: Bu ing Spector MAR 2 0 201$ CATION FOR`BUILDING:PERMIT° Date 20 j INSTRUCTIONS TNid OF SOUTHOLD a.This app kation MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 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 onpublic streets or areas, and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. -d:Upon approval 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'a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ofdinance'of.the Town of Southold; Suffolk4County;-N6*,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,aJ regulations,=arid to admit authorized'inspectors on premises,andtin building for necessary inspections. _ i (Signator ,of applic o name,if a corporation) 424 �f A il� /I 7o (Mailing address of applicant) State whether applicant is owner, lessee, agent,�architect, engineer, general;contractor, electrician,plumber,or builder - I:JNi`1 LcC� I Name of owner of premises N) M I�i C �tiy4aAlee J/91(-tn a' des (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. � }� Plumbers License No. Electricians License No. -,;�Wt7- MC, Other Trade's License No. 1. Location of land on which proposed work will be done: House Number Street Hamlett., 4 .%- +, ,•, _ iit County Tax Map No. 1000 Section 3 Block ®`2 Lot Q Subdivision Filed Map No. Lot (Name) 2'. State existing use and occupancy of premisesprid intended use and occupancy of proposed construction: a. Existing use and occupancy II b. Intended use and occupancy �51 Zd�t !j 1/yt�'!/ (t? A)c 3'. Nature of work(check which applicable):New Building Addition Alteration Repair Removal, Demolition Other Work It1in�L caw. ZL (Description) 4. Estimated Cost ' , Q�l�' 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 y 6. If business, commercial or mixed occupancy, specify nature and,extent of each type of use. 7. Dimensions of existing structures,if any: Front_. 4--7'- ,Rear ���d, =• Depths Height Number of Stories ! j Dimensions of same structure witltalterations or additions: Front Rear r Depth Height Number of Stories 8. Dimensions of entire new construction: Front g I Rear 32 ''� '' "°'JDepth' Height, Number of Stories 9. Size of lot: Front, oda Rear 100 Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises,aze situated' 12. Does proposed construction violate any zoning law, ordinance or regulation: NO 13. Will lot be re-graded CA_44jOnL�. Will excess fill be removed-from,pre mises: YE 'NO ' '. -Pao Po ia{�QA QJ� 14. Names of Owner of premises rA-i+'6 , 4,1 n,\4nt��d'dress. &Va 10aN -Phone.No. 917- R-37- 690 Name of 9d`-h. ,AU 6 Re,11 Pr Address's&ae-=-L,J 6i 1' i4.,,J -Phone°No 01-7zz f 5=740 Name of Contractor-`�i�Cor^ms Pas Address Q2q A-2-m Phone No.__b31-7W-7 l FY- mt11f-_ Pau Xff, Il71oy 15. Is this tproperty within 100 feet of a tidal=wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES 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 10464 or below,must provide topographical'Hata on survey. STATE OF NEW YORK) SS: COUNTY OF ) E,A"6LroS 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 knowledge and belief; and that the work will be- performed in the manner set forth in the application filed therewith. Sworn tobeforeme this Q day of 201 Y Nof Public Signa e f Applicant MARGAREr A. KIDNEY Notary Public-State of New York No. 01 K16021 1 1 1 Qualified in Suffolk County My Commission Expires March 8,20� � l T � Scott A. Russell d°s"`FQ ST01KMWA%X1E][. SUPERVISOR AKAN\A(G IEl��l �T SOUTHOLD TOWN HALL-P.O.Box 1179 Z [lEl�'7C' 53095 Main Road-SOUTHOLD,NEW YORK 11971 . Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) i DOES T'IUS ]PROJECT nWOLVE ANY OF THE FOLLOWING: Yes No I (CHECK ALL THAT APPLY) ❑WA. Clearing, grubbing, grading or stripping of land which affects more 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. [:1 E,9 C. Site preparation on slopes which exceed 10 feet vertical rise to 1 100 feet of horizontal distance. ❑� D. Site preparation within 100 feet of wetlands, beach, bluff or coastal I erosion hazard area. ❑ E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. 0[,9 F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management 1 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 Tax 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. #: 1 000 Date- _6 District3 j I g j i`g NAME: 5 C;) ja (Pr'nd Section Block Lot Contact information O Q 7- (/ ****FOR BUILDING DEPARTMENT USE ONLY**** p,3�� �! 9� —fl'elephane Numbed — — — Reviewed By: ` Property Date: Address/Location of Construction Work: _ _ _ _ _ _ _ ��- TApproved for,processing Building Permit. Stormwater Management Control Plan Not Required. Stormwater Management Control Plan is Required, (Forward to Engineering Department for Review.) FORM # SIv1CP-TOS MAT20-14 114 BUILDING DEPARTMENT- Electrical Ins r0cj mff TOWN OF SOUTHOLD �% c Town Hall Annex- 54375 Main Road - P 1179 :o ' Southold, New York 11971-0959 JUL 16 2018 1p'1r Telephone (631) 765-1802 - FAX (631) 765-9502 � c roper.richertP-town.southold.ny.us T� O1NGDE". 1?SO OLD APPLICATION FOR ELECTRICAL INSPECTION -- - ---------- ------------------------ -- - - ----- -- -- - - EQUESTED BY: - - Date: 7--MO - ----- -- -- - - -- ---------------- - - ------ ompany Name: f9 U -- ame: R— cense No.: /©a'5-.eh�5 email: 1 r -6 la t C..G r12 Jdress: 013z b &i e VA ��• S6 U`on C) hone-No.: 6:),3 f 76)7 DB SITE INFORMATION: (All Information Required) qq ame: --3 V-1Vnn F-S `t iZt taG'4S ddress: opkAS 1 1V1 Flo&J N jr -Toss Street: hone No.: Idg.Permit#: _ a r)2�t email: ax Map District: 1000 Section: Block: Lot: RIFF DESCRIPTION OF WORK(Please Print Clearly) OfJ :ircle All That Apply: job ready for inspection?: G/ NO Rough In Final Io you need a Temp Certificate?: YES / NO Issued On emp Information: (All information required) ervice Size 1 Ph 3 Ph Size: A #Meters Old Meter# few Service- Fire Reconnect-Flood Reconnect-Service Reconnected - Underground- Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N ►dditional Information: PAYMENT DUE WITH APPLICATION SO Request for Inspection Form.xis ` ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: APPLICATION FOR OUTDOOR POOL PERMIT EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM [� CERTIFICATE OF WORKER'S COMPENSATION NM CERTIFICATE OF LIABILITY INSURANCE [� SUFFOLK COUNTY LICENSE SUFFOLK COUNTY ELECTRICIAN LICENSE [� 4 SETS OF PLANS - (3 STAMPED) [� 3 SURVEYS with FILTER LOCATION [ APPLICATION FOR ELECTRICAL INSPECTION [� APPLICATION FOR CERTIFICATE OF OCCUPANCY [ C.O. TAX BILL [ ] $400.00 CHECK FOR PERMIT FEE `ia�`» f- .i .. `;4:`.�•i�:.>�a �7.'`�:� 4�' 'Y.,• ,�:� tN +' ,Y^-, 1. ,;; r Ya„• " - ., _ `�is �,E;>=� ->+ iE €� 's .. ^�: _ '�' �,,• _=� ;� y�� ;=4.. (r�� M,�.� r _' . . n - 1 Suffolk County Department of Labor, Licensing & , . Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 WAN DATE ISSUED: 7/1/1978 No. 4436-H SUFFOLK COUNTY Home Im rovement Contractor License > _ R This is to certify that ARTHUR J EDWARDS p {;�� doing business as ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA WIN,having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOMEIMPROVEMENT CONTRACTOR,in the County of Suffolk. License Category -SUFFOLK COUNTY DEPT OF LABOR, GC }" ��- Additional Businesses LICENSING 8 CONSUMER AFFAIRS I Jx Pools&Spas/Certified HOMEIMPROVEMENT ' CONTRACTOR ARTHUR J EDWARDS MASON Pools/Spas ?� CONTRACTING CO INC DBA LICENSE " ARTHUR J EDWARDS ARTHUR EDWARDS POOL&SPA x" `- '' '�I• CENTRE This certifies that the susrrEss"""'F � `'^�" ARTHUR J EDWARDS MASON bearer is duly CONTRACTING CO INC DBA(1 SUPP) :"- Commissioner � licensed by the u u«�°e w neer County of Suffolk Duro 11°111 4436-H 07/01/1978 Ex""""°"D"r� 07/01/2018 i `£'',4,¢'�•Y; .-,r;��s"'a..f�.,`rvut.P.i�`.G�iS's,3"G:73xc:M,a7E+3.ra[z�"fiT:�.,�s".vnFT�+`.YZ,^" .,;.3:.."ins'�-='XrStc,r+P'.2ti �E��' 3i7fi�'.'•�.r„a'�'{'�r.s;�::y'f'�Y? i;••t."'c3��Pa��'�.*&F'n.:�3"�::'�•Fd'��"z*:�^�rt§'Ki:,'"us� .; R�iP?,'Chi+.L�'Y^�'���3.��°3a>",Ri%`F� s�' �'b s'h,� \��,_;tf �r.;,. 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Suffolk County Execative�g Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEWYORK 11788 DATE ISSUED: 5/1/80 No. 2740-NM SUFFOLK COUNTY Master Electrician License This is to certify that EDWARD S REIFF doing business as UNDERGROUND SPECLA�LTJES INC having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in .............. z accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York. 'PT OF LABOR. Additional Businesses SUFFOLK COUNTY M LICENSING CONSUMER AFFAIRS T MAUTER ELECTRICIAN EDWARD 6 REIFF at the GENRPADY, NC.DBA This cerflfles th bearer Is duly 0 licensed by tih County of Su k 1 W.I. A- 274D-ME ------- --- "w" ��Wq- ' ,4RT.HUA' F. THIS CERTIFICATE IS ISSUED'. AS-'AN S-'A;,IIflA*kk ®F<;IiV�O1tINAT10,6d,'.OYVLV"Aid®-CONFERS'id®�:RIGH'PS',UP®fE1 TI-0 '';'CERTIFIC IPS H06®ER:'�HIS 'v CERTIFICATE;DOES,INOT.'AFF,IRPPATIVELV'OR'PIED lTI1lELY PIRAEND,.',,EHYEY�D;:OR`ALTER;,TME<COlIEkACE-rAFFOR®ED BYr;TIiE P®LOCIES` ' BELOUlI.: TFIIS CER,TIF,ICATE OF" _8URAINCk4'DOES;NO,T,;C;OI�S71-TUTE<A";CO4NTR6ACT.`BE�EEV�T"e"S,SulNG`,1HSURER(S),`,`Ay_ bRIZED;,'' REPRESENTATIVE OR'PRODUCER;'AIdD}THE CERTiFIGATE,HOLDER: ' < y'j =., I1HIPORTANT: 'IP4ho-B:ti®rtlficate Bolder 1's�,ani'AD®ITIOV�AL�•fMSUR�d',�tFi�.poll'cy(I®sJ`_tQiusk'Iiave Ail7®1770id}lL°-I�SUO$EDyprovislolis,00:,ti®'®iidors®d.•;"„ WA9VE® subc .lthemoft ® orlollchsaIfSUSROGATION Ilm .requlre,'ar endors®merit.,i4 s4ate,mert on toil's cectlflcate`does n6t"confer rI hts tothe'certlftcate taolde[=lel�li_'eu•.of�such`®ndors®rratint s{,�':;'.M, .�.'r-•x �- -- PRODUCER' 631 111; �?ui`�agBttB%{®ISS®C18tt~S,'InC.', - r Bagatta.ASsoclates,Inc: ,PHONE y :''X31_=E64=91:11:` ;;,i ' C,�0 631=864=i1974,; 823tW'Jerlcho YurnpFke Ste 1.4 ( )•> Smithtown,NY1'1787 Bagatta Associates,Inc. d,.=, ; r _ , '- 11 "INSURER'' aFFORDING. COVERAGE NAIC 0: -NSURERa`�n8°InSUIBnCe'CAI11�aItJlw• _'?0443' INSuRED Arthur J Edwards Mason" ii�suiaEr I- 929 ~ _ Contracting,Company Inc. ,.,.:. . 929 Route 25A Miller Place,NY 11764 .>iMsuRERD': . INSURER E ' INSURER F COVERAGES CERTIFICATE NUMBER:._ 'REVISION NUMBER:, THIS IS-TO CERTIFY THAT THE POLICIES OF,IRISURANCE=LISTED•BELOW;HAVE BEE N,ISSUED-TO,THE 1NSURED'NAMED;ABOVE-,FOR THE:POL'ICY,PERIOD INDICATED. _NOTWITHSTANDING,ANY°REQUIREMENT,TERM"-OR'CONDITION:,OF`ANY'CONsTRACT:OR OTHER,"DOCUMENT WITH'RESPECT TO-WHICH;THIS, CERTIFICATE MAY BE ISSUED-011MAY PERTAIN;tTHE°INSURANCE"AFFORbED"-BY;THE+apOLI'CIES',DESCRIBED"HEREIN,IS SUBJECT TO ALL THETERMS; ' EXCLUSIONS AND'CON DITIONS OF SUCH,POLICIESi',LIMITS SHOWN MAY HAVE BEEN,REDUCED_BY PAID CLAIMS. INSR TYPE OF INSURANCE SUB POLICY,NUA9BER' "POLICY EFF; POL'ICY EXP-' " LIMITS A' X COMMERCIAL GENERAL'LIABILITY 7,000 000 M1, EACH OCCURRENCE $ CLAIMS-MADE ®OCCUR '6043396248' °09/O_7/201$ x01101/2 01 9:fDAMAGETO RENpgEMISESaOcTED - $ 10g0o000 r�,•,. •BD " n one erson " X BLANKET•ADDITIONA PERSONAL8ADVINJURY $ -1,000,000 'GEaL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE "`$ 2,000,000 POLICY PT 0 LOC PRODU S-CO OP AGG 2,000;000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANYAUTO BODItY INJURY Perperson) OWNED SCHEDULED " AUTOS ONLY AUTOS' p BRODILY.ITNJURY.Rer`accldent $ AUTOS ONLY AUTOS O fV PPe�accRdent,AMAGE $ UMBRELLALIAB OCCUR EACH,OCCURRENCE $ EXCESS LIAB CLAIMS-MADE " AGGREGATE $ DED 'RETENTION$. WORKERS COMPENSATION PER� OTH- AND EMPLOYERS'LIABILITY :. ' UTE E12 APROPRIETORfPARTNERIF�rECUTIVE YIN NY `=- •E L EACH'ACCIDENT- $ OFFICEi/MF�M2 EXCLUDED? N l A . l arida ory n ) EL DISEASE•EA EMPLOYEE,$ If Yes,describe under DESCRIPTION OF OPERATIONS below - = E'L-DISEASE=POLICY LIMIT - a DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Rarrlerks'Sched@e,may be attached IT more space Is re'Ir®d), rr 0000000 "SH®UL®"ANY;OF_1f1E Ali0VEe'DE6CRIBED'POLICIEB BE CANCELLED 1366RE: _ TIIE,:EXPIRA7I®N,.DAY`E':741EREOF;.N!®410E"UIIILL BE DELIFIER `"IN „ T®�Jn<off Southold. ACCORDANCEVITH'T,HEVOLICYPRBHISIONS. ` To1�tiHall- _';,• _ AU R.,b,"I30X 72x3 . ' ...EDREPRESEPTTATIVE' Southold;MY 11971 ,{.s `All rig A "RRPORATION: Fats reserved. ACOR®a5{2016103} " "„ ...n' <<; M. ':(0 9988-2015 CO DCO Th®CORD narti®°and`logo'ar®.registered inaiks of�1CORD:a VOA WOl �lr CERTIFICATE OF INSURANCE COVERAGE TA'M Saa rCompensationdUNDER THE NYS DISABILITY BENEFITS LAW B PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a. Legal Name and Address of Insured (use Street address 1 b. Business Telephone Number of Insured only) (631) 744-4455 Arthur J Edwards Mason Contracting Company Inc 1c. NYS Unemployment Insurance Employer Registration 929 Route 25A Number of Insured Miller Place, NY 11764-2700 24-10871 1d. Federal Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State,i.e.,a Wrap-up Policy) 11-2377925 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America Town of Southold P.O. Box 728 3b. Policy Number of entity listed in box 1 a": Southold, NY 11971 00984424-0000 3c. Policy effective period: 07/01/2017 to 07/01/2018 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 the 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. SLiX .t -:Y. S haw Date Signed:07/07/2017 By: Stuart J.Shaw, FSA, MAAA (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number: 1-888-278-4542 Title: Vice President,Group 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 NYS Workers' Compensation Board(Only if box"41b"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'Com pensabon Board Employee) Telephone Number: Title: insurance o �s/ofoersancclicensed rersatuthredofissueoft1 .1• snorstagehsinu e atiare FrmDB 20nurace and eare NOT authorized to issue this form. DB-120.1 (09/15) Additional Instructions for Form DB-120.1 By signing this form,the insurance carrier identified in box"3"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? ❑ YES ® 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 (09/15) Reverse 0 New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 141 D D ^^^^^^ 112377925 LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL 0No TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2438 491-9 328250 03/02/2018 TO 06/29/2018 3/8/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, 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:UWWW.NYSIF.COWCERT/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. I NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:767045530 U-26.3 ' ^u� UL/ 08/04%0L FRI 18,.38 AAZ B: '300 ORGANSTERN&��U,�' N 003 'OR Now- or Regm AO r' � 1' •! .,..•.,. duo lo, o�° �e Fw* - w foe rye, 6 6 1w cwt , it dip A too �/'F-.A�ili:�' �'.F6RV�'Y� ,/'ivi0�i�f�.1l�A.,'.�'.,Lrw„� • , �; ��'r►�.n1 � , k, 1A Ald LA "n Ad K _. or I AWAO w F. YYY • I z� F i i X a 4 S r B ♦ i APPR,O. ED AS NOTED FEE: 02_ O ibb BY: NOTIFY„ BUILDING DEPAR TAT RETAIN STORM WATER RUNOFF 7654802 SAM TO 4 PM FOR THE - PURSUANT TO CHAPTER 236 FOLLOWING INSPECTIONS: OF THE TOWN CODE. 1: FOUNDATION , TWO REQUIRED .FOR POURED CONCRETE 2-,ROUGH !-'FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. 71MRAED A'FEL Y" ALL CONSTRUCTION SHALL MEET THE ENCLOSE-POOL TO CODE REQUIREMENTS OF THE CODES OF NEW ' PdN,COMPLETION YORK STATE. NOT RESPONSIBLE FOR 'BEFORE"WATER"' DESIGN OR CONSTRUCTION ERRORS. V COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF '�R8t8'fi6�IGZB� Tl T7M BOARD 6t6i@f+PlTRI VMS- OCCUPANCY O USE IS UNLAWFUL WITHOUT CERTIFeC ` OF OCCUPANCY ELECTRICAL INSPECTION REQUIRED A r - I Rah�ma B ® F /H Neun�unf NI-I To Fir F. To aft `—To Rahn. ftMd00bo RaCaA VMPlan APiping Arrangement R.bw 42- ®� %EW Y® Section B—B 2. Pte, �'� ®. IRE c CO H 1 10p Section A—A Typical Wall Section �0 PROFESS`® SIZE A B C D E FG H AREA CAP FEET FT FT FT FT FT FT FT FT SQ.FT GAL. � ,_ , .`• n 18 X 32 18 32 8 114 6 4 1 5 8 576 21,600 PcI. cSPA CF.1E 16 X 36 16, 36 12114 6 4 4 8 576 21,600 PERMACRETE WALL SYSTEM , 18 X 36 18 36 12114 6 4 5 8 648 24,300 - etas. 29 Route 25A Miller Place NY 11764 20 X 44 20 44 20 14 6 4 5 10 880 36,300 (631) 744-71+35 FAX (631) 744-0174 2&5 I �� Q 24 X 44 24 44 18 14 8 4 8 10 798 35,000 Suffolk Ucense #4436—HI 24 X 48 24148 20 16 8 1 4 6 10 900 38,500 Nassau License #I-H74450000