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HomeMy WebLinkAbout43496-Z Fac,f Town of Southold 9/17/2019 P.O.Box 1179 53095 Main Rd P44 pti Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40698 Date: 9/17/2019 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 500 Four Winds Ct, Southold SCTM#: 473889 Sec/Block/Lot: 88.-6-13.38 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/13/2619 pursuant to which Building Permit No. 43496 dated 2/26/2019 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issue&"is: IN-GROUND SWIMMING POOL,FENCED TO CODE, AS APPLIED FOR The certificate is issued to Zatcoff,Adam&Shira of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43496 07-24-2019 PLUMBERS CERTIFICATION DATED Signature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE v • 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#: 43496 Date: 2/20/2019 Permission is hereby granted to: Zatcoff, Adam 34 Joyce Ln Woodbury, NY 11797 To: construct accessory in-ground swimming pool as applied for. At premises located at: 500 Four Winds Ct, Southold SCTM # 473889 Sec/Block/Lot# 88.-6-13.38 Pursuant to application dated 2/13/2019 and approved by the Building Inspector. To expire on 8/21/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Building Inspector 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. 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. - o2— L)-15 New Construction: ✓ Old or Pre-existing Building: (check one) Location of Property: _ 500 RA �C1•J QL Q House No. Street Hamlet Owner or Owners of Property: &WA-r b 1 Suffolk County Tax Map No 1000, Section Block Lot 13,38 Subdivision Filed Map. Lot: Permit 140. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: -Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ s<� Applica it Sig ature f � Town Hall Annex /sem® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 • y®� sear.devlinatown.southold.ny.us ��C®UIQ 1 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To Adam Zatcoff Address: 500 Four Winds Ct city Southold st: NY zip: 11971 Building Permit* . 43496 Section- 88 Block: 6 Lot: 13.38 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Emerald Electric Inc. License No: 4868-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1 st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X 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 2 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 2 Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: Salt generator, Switch for heater, Heater, Pump main, Pump booster, Bonding, 220 GFCI breakers for pumps-2, 115 GFCI breaker for heater/ lights Notes, Inspector Signature: Date: July 24, 2019 S.Devlin-Cert Electrical Compliance Form.xls oFso�lL4 1� Ll 9 (o (rods) # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] 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: DATE 41 INSPECTOR ( 07�D SO(/ly0 # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION , [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ rSULATON FRAMING /STRAPPING [ NAL of [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: nrl �Vlkt W4 LAO) ir-damL-, mL&A- -�06 DATE INSPECTOR OF SOUTyO * # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION , [ ] FOUNDATION 1ST [ ] ROUGH PLSG. [ ] FOUNDATION 2ND [ ] *SULAT"N [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFE INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DAT INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) ' H i ---------------------------------- 'FOUNDATION (2ND) " � O ROUGH FRAMING& PLUMBING H INSULATION PER N.Y-. y STATE ENERGY CODE �0 { AJC • vl idi FINAL ADDITIOIJAL COMMENTS z z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CICKLIST BUILDING DE9PsARTIVIEN�" 4; Do you Have or need the following,:before applying? TOWN.HALL,, Board of Health SOUTHOLD,NY 11971 3 sets of Building Plans `TEL:-765-1802 rJ Survey PERMIT NO: J Check Septic Form N.Y.S.D.E.C. Examined 9X ad ,20Contact:Trustees _ - Approved d ,20 Mail to: Disapproved a/c S(/ 6 Phone: DBu ector -X FEB 1 3 2019 APPLICATION FORZUILDINGrPERM-JT 15UILD!iTC D��I%T r TOWN OF SOUTHOLD INSTRUCTIONS- Date- , 20 19 a.This application 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 orpublic 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- pur'po'se what-so-ever until a Certificate of Occupancy is is suped by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zon&Ordinance�of he-Town ofFSouthold •Suffolk;County;New'York,and other applicable Laws;bidiifances 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,•bufldmg code,housing,code, ,regulations,rand-to admit authorizdd7inspecf6rs on premises,apdf in building for necessary-inspections. (Signator of applic t r came;if a corporation) q)Oi kt- )-S-A 411& Pbu 11L,11170V (Mailing address of applicant),- - State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber;or,builder j. Name of owner of premises (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. 3b HT Plumbers LicenseNo. Electricians License No. 430y A-- 1-4�= Other Trade's License No. 1. Location of land on which proposed work will be done: 500 ",FAIR kAm" 0* House Number Street Hamlet t County Tax Map No. 1000 Section BlockLOt ,�8 Subdivision NS'geL wS Filed Map No. 7Zc Lot : )I� (Name) 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 ocouparicy QP�IW/VAt. Kw) r1i1NA)I- 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal- Demolition Other Work=„)J" Vlnv� '�1^prnV19AJ,I, 4. Estimated Cost 141000- Fee (Description) (to be paid on filing this application) 'S: ` 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 . i Rear Height Number-of Stories IQi,,� . .-, 4 Dimensions of same structure with`',alterations or-additions:Front Rear Depth Height Number of Stories . a � i 8. Dimensions of entire new construction: Front o Rear Depth T12- Height Number of Stories 9. Size of lot: Front I 10 Rear ' Depth 300 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: n N 13. Will lot be re-graded PQX Qf-eA d�,fZ� Will.excess,fill be removed from,premises YES, 'NO ]19-1k 14. Names of Owner.of.premises &whto -rwe-kiAd'dresssoc) �wwos ct- Phone'N6. 631- S � Name of Architect`Ji ONAS b fie%It C Adiiress/4 kec 4i /,AilPhone''No b3)420— 5746 Name of Contractor tz�A tos c.S Address q 1,91 Pk2�A Ptllzc_ Phone No. 631-NN 7lao�F 15. Is this4property within-1 00'-feet-of atidd1 wetland? *YES NO ® IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE FUIR.ED Q� 16. Provide survey,to scale,with accurate foundation plan and distances to property lines. 17. If elevation ut any point on property is at l 0`feef or below,must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF,�IRU-L- ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the &Jka'+L'��-. (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 thi day of 20�q�_ r of Public a e of licant MARGAREr A. KIDNE g Notary Public-State of New York No. 01 K160211 11 Qualified in Suffolk County My Commission Expires March 8,20J3 Scott A. Russell ®su '�� STO]RMWA\T]EIR. SUPERVISOR MA�NA\G]EM1EN1F SOUTHOLD TOWN HALL-P.O.Box 1179 ° w 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING. Yes No (CHECK ALL THAT APPLY) ®ffA. Clearing, grubbing,,grading or stripping of land which affects more than 5,000 square feet of ground surface. ®[3"/B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. 1:1 13/c Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. 0[3'/D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ d E. Site preparation within the one-hundred-year f loodplain as depicted ori FIRM Map of any watercourse. ®dF. 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 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. #: 1000 Date. Q' District NAME: �iI ?" �tJ J I Section Block Lot ,�,�/�� (j **** FOR BUILDING DEPARTMENT USE ONLY J **** Contact Information P`� "TKi 1 (Tdep6oiu Number) �J Reviewed By: — — — — — — — — — — — — — — — — — —/Approved — — — — Date_ �i Property Address/Location of Construction Work: _ _ _ for processingBuilding Permit. Stormater Management Control Plan Not Required. — — — — — — — — — — — — — — — — — ® Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM * SMCP-TOS MAY 2014 � FFpI�� BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 roger.richert(@-town.southold.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: - - Date: / 1p Company Name: 1v,g&-�aE � i^i✓C. Name: ^MAIXG 9r✓Z 2/r` License No.: - Q email: 3-1 Address: -0 D>< Rd �� 1,172- Phone No.: J7(P - 5-ZS JOB SITE INFORMATION: (All Information Required) Name: A6104 Address: Soo L&Lwlnvo s C:�-- vl� Cross Street: Phone No.: Bldg.Permit#: C�3C��(P email: Tax Map District:, 1000' Section: �' Block: Lot: BRIEF DESCRIPT N OF WORK (Please Print Cl rIY) i tj &V I, O0 l Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect- Flood Reconnect- Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Request for Inspection FormAs l ry 4 FOR SCDHS USE: NOTES. PARCEL AREA:45,861 SF or 1.05 Ac. } THE PROPOSED RESIDENCE IS TO CONTAIN 5 BEDROOMS. PROPOSED SANITARY TO CONSIST OF. 1500 GAL.SEPTIC TANK&(5)4'E.D.X V DIA.LEACHING POOLS }� GARAGE AREA=667 SQ.FT. ELEVATIONS ARE NAVD 1988 O^ 1 ST FLOOR AREA=1723 SQ.FT. THERE ARE NO SURFACE WATERSIWETLANDS WITHIN 300'OF PROPERTY AS DEPICTED /� 2ND FLOOR AREA=2174 SQ.FT. TESTHOLE #2 a LAND NOW OR FORMERLY OF JVOIq OFTHOMPSO OP PUBLIC WATERN (RESIDENCEe EN�O @q j" J �U C 8 /V 35 o2 40„ C Res IFN F�ppORMERC, \ ` UBC/CN x 9.6 91 ® wATeR _z x 9.7 \ 9�349�/ NF Ow OOR TEST HOLE INFORMATION: E�f�ENT �\ Res�OeAC�<<e FORME LAND NOW OR FORMERLY p� Q x F/C \ pOUN�\ E-pU�Cp RCy OF LOVERICH g x 10.4 10.0 �E S W RESIDENCE-PUBLIC WATER LO x101 x 113 \p� Tqk f 11 ® greR TESTHOLE #2 MAP OF ANGEL 102 x9'7 x10.2 c NSP SHORES MAP # 9729, 8/23/95 ® 10.8 11.1 x ,o Ts' E DRi �seo v CEAt x ¢� oar h Ay �� 50 DSS FE O. v_ C 0 4 Nc 05 �o o h � gE1BA W / 0' 0.7'N x 11.0 ZOp��Ury�O 3 0 4i FAR'q o r / / L xa p N Ts. / 13.4 , LAND NOW OR FORMERLY N 0 Ano Q•63 Ory 3e 13 2 / RESIDENCCEOF?PUITS L0 LU BLIC WATER ^ C x 1 0 1 x 6,0 "�Q�' �p ^i o / / � ^ LAND NOW OR FORMERLY LOAM ca 121 ? 2 S sx 13.6 10 F�N O OF CASTLENUOVO LU PROPOSED / OL x ?�' o , 13.4 . �o RESIDENCE-PUBLIC WATER � � / STORMWATER D - ST Ip EX / TC=13.33 Y PROPOSED 11.7 DRYWELL II�JJ �p Lp BC=13.07 4' DEEP s / �' DP o x B' DIA X 8' E.D. (2X) LP / � 8' DIA. PROPOSED LPR=50.0' TC=13.4 DRYWELL&OOL EQUIP. PROPOSED WATER SERVICE o PROP. EX x13.6 TC=13.20 BC=13.16 DD Ki (1500 GAL BC=1288 L=108.26 -5' EZ, PROPOSED SEPTIC TANK 11.7 11.7 121 129 U.G. UTILITIES CATCHBASIN WATER FE 13.5 1 .4 13.6 STAKE 13 .. RIM = VALVES (EXISTING 6"FOUR ®�®TER MAIN) p 0 5'N S 15°03378 FOUR V� I N®S C®tom RT SAND '52" W 265.82' TC=1 . AND BC=12.93 GRAVEL LAND NOW OR FORMERLY OF ROGAN TC=13 27 SP RESIDENCE-UNDER CONSTRUCTION PUBLIC WATER ® SITE PLAN -10' PROFILE NOT TO SCALE �+ SITUATED IN of:m P yo GROUND WATER ( ) SOUTHOLD rc INV=14.0 FINISHED FLOOR 16.5 INV=13.4 TOWN OF SOUTHOLD,COUNTY OF SUFFOLK,STATE OF NEW YORK FIN. GRADE 15.5 FIN. GRADE 15 0 �wO ®®Con nor ® Petito, L. L. G. 4' sdr SEPTIC LEACH. 003 TANK POOL 27 Forest Avenue AtA O V� BASEMENT FLOOR 7.0 Land Surveying Locust Valley, NY 11560 ANO 'UNAUTHORIZED ED VIOLATIONR ADDITION TO A SECTION 7 09 OF THE NEW YOMAP REPA ED AND BY A LICKED �D INV=13.6 INV=13.2 3' MINIMUM CMI Engineering g g (516)676-3260 'COPIES FROM THE ORIGINAL OF THIS SURVEY MAP NOT MARKED WErH AN ORIGINAL OF THE LAND SURVEYOR'S INKED SEAL OR HIS EMBOSSED SEAL SHALL NOT BE CONSIDERED A VAUD TRUE COPY." "CERTIFICATION GROUNDWATER 5.0 MAP ANGEL SHORES,MAP No 9729,8/23/1995 DIST.1000 SEC. 88 BLY- 6 LOT 13.38 INDICATED HEREON SIGNIFY THAT THIS SURVEY WAS PREPARED IN ACCORDANCE WITH THE EXISTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL LAND REVISED: MAR.3,2018 SURVEYORS. SAID CERTIFICATIONS SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, DATE: DECEMBER 3,2017 ADD POOL,REVISE HOUSE SCALE: 1"=60' SHEET: 1 OF 1 - #:�bi� �,�:`�7' ���e=, ,�"�,r�"",y,�+• �` r,-� ' �_��'.°V"y",.��/� r � ^y�4�: ,a _,� r.. �a� �_��, - •°•,�:��"yl,�,� N �• a;•-t'�`�. .� w~ •7 �.si ,s.. F '� :�,tr.- �'""I r;l - - � - f - �.--- - - f�- �y.r..•- -- 6��� - __ _ "r r.'�a• - \ q- _ -- -- �'��—'�-'�'�.fG-',~ '�R'{.+;� 3 Suffolk County Department of Labor, -Licensing & -ki Consumer-Affairs -> VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 E a6` DATE ISSUED: 0701/1978 No. H-4436 Y Tart � 'P s; &� Suffolk County <, a Home Improvement Contractor License :'' fF This is to certify that ARTNTTR J- FDD RWR doing business as ARTHUR J_ EDWAR_DS'MASON CONTRACTING CO 1NC'1i8A`(1 SUPPL_ F;y VV { having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules - e and regulations of the County of Suffolk,Mate of New York is hereby licensed to conduct business as a HOME "$ IMPROVEMENT CONTRACTOR, in the County of Suffolk. ` License Category %'' NOT;VALID:WITHOUT Additional Businesses R; DEPARTMbiTAL SEAL- - H26-POOLS&SPAS%CERTIFIED `n ANp ACURRENT ARTHUR EDWARDS POOL& H3-POOLS/SPAS =gf CONS UIyIEk AF'I_;'AIR.S SPA CENTRE HI-GC _M V ID'CARD y _ Suffolk County Dept of j Labor-;Licensing&Consumer Affairs ° �Iti HOME IMPROVEMENT LICENSE Commissioner Name ` ARTHUR J.EDWARDS Business Name r ' ARTHUR'EDWARS,MASON _ v ,C = CONT.CO INC DBAg This certifies that the e, l5�r I is duly licensed License Number H-4436 ' Dy ine County of Suffolk 07/01'/1'978 w ;> Issued: Expires: 07101!2020 `' Gommisswner 1_l(p ,�� s,,�P.� �•�" �,gx� �. " ;� �" _' „- _ Y ` r,, �� r - _ _ `•y; "?� �"� :S' u- i��,Y� �- �� � y���-.t"Pr4riX°'s Fp� i�.�•�^ �__&"�+��`k' , New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE All A A A A 112377925 Q LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL 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 I CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 765253 06/29/2018 TO 06/29/2019 06/12/2018 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://WWW.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 —4„ lj DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 195404147 111110100000000000059nn10,MT�TI,N,10m�68427���71111jjI�1IJI Form WC-CERT-NOPRINT Version 2(02/29/2016)[WC Policy-24384919] U-26.3 74 [000000000000S9684277][0001-00002438491911##G][14901.06][Cert NoP-CERT_11[01-00001] ► 4 a Workers!STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Arthur J Edwards Mason Contracting Company Inc. 631-744-4455 929 Route 25A Miller Place,NY 11764 Work Location of Insured(only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (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 07/01/2018 to 07/01/2019 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. l Date Signed 06122/2018 By S� t; 7�• S h�L j (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) Telephone Number 1-888-278-4542 Name and Title Stuart J.Shaw,FSA,MAAA - Vice President,Group Insurance 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 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 4C or 513 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 and Paid Family Leave Benefits Law with respect to all of his/her 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. D13-1120.1 (10-17) 111111101111111110111 IIIIIIIIIIIIIIMIIIIIIII Additional Instructions for Form D13-120.1 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 and/or paid family leave benefits under the New York State Disability and Paid Family Leave 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. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave 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 and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE 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 and after January first,two thousand and twenty-one,the payment of family leave 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 and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17)Reverse 1 ® DATE(MMIDD/YYYY) ACoORo CERTIFICATE OF LIABILITY INSURANCE 01/08/2019 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(les)must have ADDITIONAL INSURED provisions or 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). CONTACT PRODUCER NAME: Brendan J Smith HONE Liberty Risk Management,Inc. (PAIC e (631)5695633 FAX (631)569-5636 664 Blue Point Road,Suite A ADDRRESS' brendan@libertyrisk.org Holtsville, NY 11742 INSURERS AFFORDING COVERAGE NAIC N INSURER A: Hartford Insurance Company— INSURED om anINSURED INSURER B: Arthur J.Edwards Mason Contracting Company Inc. INSURERC: DBA Arthur J.Edwards Pool&Spa Centre INSURER D 929 Route 25A Miller Place,NY 11764 INSURERS: INSURER F COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2 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. ILTSRR ADDL SUER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY 16 UUN OZ8691 01/01/2019 01/01/2020 EACH OCCURRENCE $ 11000.000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER* GENERAL AGGREGATE $ 2,000.000 JECTX POLICY F-1PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY Ea aacld.n SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acadent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acddent UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YI N/A E L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below IE L DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE BJS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by BJS on January 08,2019 at 12.50PM SUFFOLK COU NtY DEPT OF LABOR, p�. UCENSING&CONSUMER AFFAIRS MASTER ELECTRICIAN CALOGERO G BRUTTO This certifies that the �'�a""'� bearer is duly STANDARD ELECTRIC CORPORATION licensed by the County of Suffolk !�3098-ME 07/19/1007 o ��R euouun°v VAM 07/01/2019 i 2 - V APPROED AS NOTED/ 7 DATE: B.P.# 34'T� FEE: 5 1 BY: NOTIFY BUILDING DEPARTME T AT 765-1802 8 AM TO 4 PM FOR THE OCCUPANCY ®� FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED USE IS UNLA��F° `� FOR POURED CONCRETE WITHOUT CERT I r p 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST OF OCCUPANCY BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET TH REQUIREMENTS OF THE CODES OF NF', YORK STATE. NOT RESPONSIBLE F! DESIGN OR CONSTRUCTION ERRORS 'RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ���{ALD TQW�7RA T _ OARf ELECTRICAL SQIJTRR --rB ES INSPECTION REQUIRED 'qti @fir ENCLOSE POOL TO CODE UPON COMPLETION GORE'WATER"` A i% s 0 �Sldmmar� Mame ® (J B /A1umlrmm To F9Par From Fllter &PurnP To To PA&UM (Dry weH Oobwo Rom 1doH F Plan A Piping Arrangement won SwwM wo #+Robw 42" Section P—P ao 3=PAIL Cowaft H 4 10 LL. u o Section- A—A Typical Wall Section le SOH Seo SIZE AB C D E F G H AREA CAP. b o FEET FT. FT. FT. FT. FT. F T. FT. FT. SQ.Ffl. GAL. 16X32' 16' 32' 8' 14' 6' 4' 4' 8' 512 19,000 ���� 500 Fa)q 14 a�n S Ct 16'X36' 16' 36' 12' -14' 6' 4' 4' 8' 576 21,600 &S)�A C> E PERMACRETE WALL SYSTEM[ 18'X36' 18' 36' 12' 14' 6' 4' 5' 8' 643 24,300 929 Route 25A Miller Place ICY 11764cfiF \ 20'X40' 20' 40' 16' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (631) 744-0174 ��Jr 4q'7 I��I w 24'X44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk lAcense #4436—H1 2448' 24' 48' 20' 16' 8' 4' 6' 10' 900 30,000 Nassau JAcense #H174450000