HomeMy WebLinkAbout43699-Z SUFFGJtr Gy Town of Southold 9/17/2019
P.O.Box 1179
0
W 53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 40699 Date: 9/17/2019
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1455 Sound Dr., Greenport
SCTM#: 473889 Sec/Block/Lot: 33.-3-19.6
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
4/23/2019 pursuant to which Building Permit No. 43699 dated 5/1/2019
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 Lucas,Cedric&Ann
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 43699 07-12-2019
PLUMBERS CERTIFICATION DATED
ut o ' Signature
, SUFEo��co TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
o • 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#: 43699 Date: 5/1/2019
Permission is hereby granted to:
Georges , Jerry
880 5th Ave Apt 3H
New York, NY 10021
To: construct an in-ground swimming pool as applied for.
At premises located at:
1455 Sound Dr., Greenport
SCTM # 473889
Sec/Block/Lot# 33.-3-19.6
Pursuant to application dated 4/23/2019 and approved by the Building Inspector.
To expire on 10/30/2020.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
,aIMMING $50.00
: $300.00
ung
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$15.00
Date. t
New Construction: Old or Pre-existing Building: (check one)
Location of Property: Sou- c1
House No. Street Hamlet
Owner or Owners of Property: I„U('c�5
Suffolk County Tax Map No 1000, Section Block ® Lot
Subdivision Filed Map. Lot:
Permit No. Date of Permit. Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval: /
Request for: Temporary Certificate Final Certificate: ✓ (check one)
Fee Submitted:$ 50
5
Applican ign ure
Town Hall Annex ® Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179
Southold,NY 11971-0959 ® �� sean.devlin(a)-town.southold.ny.us
MUM
�
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICAL COMPLIANCE
SITE LOCATION
Issued To: Jerry Georges
Address: 1455 Sound Dr city,Greenport st: IVY zip. 11944
Budding Permit#: 43699 Section: 33 Block 3 Lot: 19.6
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA- L C Electric License No: 38043-ME
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service Only
Commerical Outdoor X 1 st Floor Pool X
New Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Gas 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 Fixtures Time Clocks 1
Disconnect Switches Twist Lock Exit Fixtures TVSS
Other Equipment- 2GF1 breakers for pump and lights, 1 breaker for GFI, bonding, salt generator, and
heater
Notes
Inspector Signature: Date: July 12 2019
S. Devlin-Cert Electrical Compliance Form.xls
SOUIyO 6
# TOWN OF SOUTHOLDB ILDING DEPT.
765-1802 '
1 NSPECTION-
[ ] 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 T10
DATE INSPECTOR -
J
o��OE SOUry�l
� o
coulm 0c�
TOWN OF SOUTHOLD BUILDING DEPT,
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] NSULA o
[ ] FRAMING / STRAPPING [ FINAL O
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMAR :
nri c�
DATE 0 INSPECTOR
2Ad 5W,
/V[� o��OFSOUI�,o
# TOWN OF SOUTHOLD BUILDING DEPT.
co765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2N13 [ ] SULATION
[ ] FRAMING /STRAPPING [ FINA 4- d-111
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
0 _ftfo, -4_ !xovv_ Oil l'm
DQ1
Ohl (iov VVJ4 91
DATE '� INSPECTOR
Jeffrey Sands Architect
September 11, 2019 LM
SEP 16 2019
Property/swimming pool location: �w
1455 Sound Drive
Greenport, NY
RE: Swimming pool rebar and drywell inspection
Attention Town of Southold Building Department:
Upon inspecting swimming pool rebar and drywell installation at the above mentioned property I
find both to have been installed to meet current building code requirements.
SincereI
C? P
7
OF N�
Jeffrey Sands Architect
6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916
email—ieffrey sands(M-hotmail.com
FIELD INSPECTION REPORT DATE COMMENTS
FOUNDATION (1ST)
.....................................
'FOUNDATION (2ND) " �
• o O
ROUGH FRAMING& � Q
PLUMBING H
' 0
INSULATION PER N.Y-.
H
STATE ENERGY CODE
1 ire si h- on
AL- CA
V /
WVA
] A
FINAL
OF
ADDITION4L COMMENTS t- ~
O
m �
G
' I
Scott A. Russell ��°Su ��� STO]RMWAT]EIK
SUPERVISOR - MAN AG]EMIEN T
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTHOLD,NEW YORK 11971 �l
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)
E]j�(A. 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.
❑ : Site preparation on slopes which exceed 10 feet vertical -rise to
100 feet of horizontal distance.
El D. Site preparation within 100 feet of wetlands, beach, bluff,or coastal
erosion hazard area.
❑Urk Site preparation within the one-hundred-year f loodplain as depicted
on FIRM Map of any watercourse.
❑ F. 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,A ent,Contractor;Other) S.C.T.M.., 1000 R-6
G Date ,1
,NAME S 2. C. Vt� / 0-5 t l \-f V I O'er
Section Block Lot
ILA
..o
�] ****
FOR BUILDING DEPARTMENT USE ONLY****
Contact information J� J 65�� Ciia6I ``)
tr.ireeorc nmn.,1
Reviewed By:
d _ _ _ _ —Dae_ —_ 3_
Property Address/Location of Construction Woi•k: _ _ _
Approved fol processing Building Permit.
("1 l� ALIS r IStormwatei Management Control Plan Not Required.
M Stormwater Management Control Plan is Required.
(Forward to Engineering Department for Review.)
FORM # SMCP-TOS MAY 2014
EFaL�C BUILDING DEPARTMENT- Electrical Inspector
0�9 Q TOWN OF SOUTHOLD
~� r�
x Town Hall Annex - 54375 Main Road - Box 1179
Southold, New York 11971-0955 9
Telephone (631) 765-1802 - FAX (631) 765-9502
roger.richert@town.southold.ny.us
APPLICATION FOR ELECTRICAL INSPECTION
Date.
rEQUESTED BY:
ompanyName: /p
Name:
License No.:
3 X0`1.3 _ /076 email:
Address: �Z G✓d��PQl�' F,�S� /,?Z/0
Phone No.:
JOB SITE INFORMATION: (All information Required)
- - Name: - -
Address: l�f 5- .50Y
Cross Street:
Phone No.: email: •
Btdg.Permit#: 'V3 4 Bock: Lot:
Tax Map District: 1000 Section:
BRIEF DESCRIPTION OF WORK(Please Print Clearly) eco( IsO4/3
Circle Al[ That Apply= NO Rough In < Ina
Is job ready for inspection?:
Do you need a Temp Certate?� YES /� issued On
ific
(All information required)
Temp Information:
1 Ph 3 Ph Size: A # Meters Old Meter#
Service Size
New Service- Fire Reconnect- Flood Reconnect- Service Reconnected - Underground-Overhead
t Underground Laterals 1 2 H Frame Pole Work done on Service? Y
Additional Information:
PAYMENT DUE WITH APPI-KATION ���
82-Request for Inspection FocmAs
TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING 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 �j Survey
Southoldtownny.gov PERMIT NO. l/ Check
Septic Form
N.Y.S.D.E.C.
Trustees
C.O.Application
Flood Permit
Examined ,20n� Single&Separate
(17 / Truss Identification Form
D
Storm-Water Assessment Form
2 3 2019 Contact:
Approved ' 20
APR Mail to: PaArd-
Disapproved a/c C
't®
OF$® Phone:
Expiration 20
\ tlding Insp to
APPLICATION FOR BUILDING PERMIT
Date , ,20J
INSTRUCTIONS
a.This 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
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 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.
(Signature of applicant(orr n mel,if a corp io(11n)
(Mailing address of applicant)
StatA whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises
(As on the tax roll or latest deed);
If pp • a t is a c oration, sigr5Lure duly authorized officer
(N e d title of corporat officer)
Builders License No.
Plumbers License No.
Electricians License No. LA7-)
Other Trade's License No.
1. Location of land on which proposed work will be done:
I H S S 50i'-\ G cC,0,/I�a
House Number Street Hamlet
County Tax Map No. 1000 Section �j�j Blockl:,' Lot �C'( •�j
Subdivision Filed Map No. Lot
2. State existing use and occupancy of premises and in ended use and occupancy of proposed construction:
a. Existing use and occupancy � 5+&8 V1,
b. Intended use and occupancy--a— �0 - u 8 bu A I
3. Nature of work(check which applicable): New Building Addition Alt t, n 1
Repair Removal Demolition Other Work QC-CM --1fpp 1.
(Description)
4. Estimated Cost g d (D
.r�i ' (T�-be paid on filing this application)
If dwelling, number of dwelling units t,1 Number oft7 Jd e111A units s on each floor
If garage, number of cars
`C. If business, commercial or mixed occupancy, specify nature and`extent of each type of use.
Y,
Stories'—"'Dimensions of existing structures, if any: FroDt , -__ _ Rear Depth
Height Number of Ses'—"' `-10 416�' °j,
Dimensions of same structure with alterations or'additions: Front Rear
Depth Height Number of Stories
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
® La� � q a ,ID� ,FF,ao��
11. Zone or use district in which premises are situated LAD a "'� �D�xs�=35oa- ��1���euo=$oo 10 1=4W,
12. Does proposed construction violate any zoning law, ordinance or regulation?YES NO�
13. Will lot be re-graded?YES N0-X-`W`i11 excess fill be removed from premises?YES.0 NO
14.Names of Owner of premises n Address 0� Phone No.6'50--t9q-1?'3I 0
Name of Architect l f-�fit_ S Address6 RjWzvo .F Q Phone No 631- ` y
Name of Contractor ,6,e-Vs Pop�,,r _ Address S R .r., -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 BEREQUIRED.
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 rvey.
18. Are there any covenants and restrictions with respect to this property? * YES NO
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
CC;; SS:
COUNTY OF5"
�nc�� )&r)ywv being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing co tract)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 tgna#ke and file this application;
that all statements contained in this application are true to the best of his knowledge and belie • nd t at the work will be
performed in the manner set forth in the application filed therewith.
Sworn to before me this
day of A pri 2011
I �)/) RJO 4
k
NotVry Public 'TRACEY L. DWYER Si ature of Applicant
NOTARY PUBLIC,STATE OF NEW YORK
NO.01 DW6306900
QUALIFIED IN SUFFOLK COUNTY
COMMISSION EXPIRES JUNE 30,2?Q
SC,T.M NO, DISTRICT SECTION BLOCK, LOT(S)
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THE WATER SUPPLY. BELLS, ORYti2ZLS AND CESSPOOL
LOCA77ONS SHOWN ARE FROM FIELD OBSERVATIONS
AND OR DATA OBTAINED FROM OTHERS
AREA-24,107 73 SO FT- or 0 55 ACRES ELEVATION DATUM __._._-------— __ ______
1
UNAUTHORIZED ALTERATION OR ADDITION TO TH15 SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, COPIES OF THIS SURVEY
bf4P NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY GUARANTEES INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR h1gOM THE SURVEY IS PREPARED AND ON 1415 BEHALF TO THE TIRE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITU770N
LISTED HEREON. AND TO THE ASSIGNEES OF THE LENDING INS1IiUI1UN,-GUARAN7ETS ARE?iDi ixA,VSFiRA&E
THE OFFSETS OR DIMENSIONS SHOE#N HEREON FROW 714E PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC FURPOSE'AND USE THEREFORE THE),ARE
NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE 714E ERECRON OFFENCES, ADD1770NAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
ANDJOR SUBSURFACE SMUCTURE5 RECORDED OR UNRECLIRDEO ARE NOT GUARANTEED UNLESY PHYSI,-ALLY EVIDENT ON 714E PREM1SES AT THE TIME OF SURVEY
SURVEY OF LOT 6 CERTIFIED TO: CEORIC A.M. LUCAS,
MAP OF,ROCKCOVE ESTATES ANP! CHO LUCAS,
FLED JUNE 11, 2001 No 10637O'LD REPUBLIC TITLE iNSURANCE COMPANY,
FIRST REPUBLIC BANK,
SITUATED AT GREENPORT
7O54N OF. SOUTWflLD KENNETH hi WOYCHUK LAND SURVEYING, ,PLLC
SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design
P.O, Dor 153 Aquebogue, Nen York 11931
FILE 19-2 SCALE 1`=30 DATE! MARCH 7, 2019 PHONE (631)208-16a8, FAX (831) 298-1503.
NYS LISC NO 050882 maintalnfng the reeorda of Robert 1, flennemy k Kenneth Y.WoyehuL
I
Workers'
YORK CERTIFICATE OF
STATE Compensation
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Patncks Pools Inc 631-996-4687
PO Box 3024
East Quogue NY 11942 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Idenfification Number of Insured or Social Security
certain locations in New York State,Le.a Wrap-Up Policy) Number
262929943
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) Wesco Insurance Co
Town of Southold
54375 Main Road
Southold NY 11971 3b.Policy Number of Entity Listed in Box"1 a"
WWC3349994
3c.Policy effective period
05113/2018 to 05/1312019
3d.The Proprietor,Partners or Executive Officers are
E] included.(Only check box if all partnerstofricers Included)
QX all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box'1 a"for workers'
compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A
on the INFORMATION PAGE of the workers'compensation Insurance policy). The Insurance Camer or its licensed agent will send
this Certificate of Insurance to the entity listed above 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 ONO
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 maybe used as evidence of a Workers'Compensation contract of insurance only while the underlying policy isin effect.
Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be
named on a permit,license or contract Issued by a certificate holder,the business must provide that certificate holder with a
new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the
mandatory coverage requirements of the New York State Workers'Compensation Law.
Under penalty of perjury,I certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named Insured has the coverage as depicted on this form.
Approved by: Nicholas Zulkofske
(Print name ollaillhonzed representative or licensed agent of insurance tamer)
Approved b/2 1110 474
( g re) (Date)
Title:Authorized Agent
Telephone Number of authorized representative or licensed agent of Insurance carrier. 62'-941-4113
Please Note:Only Insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NO
authorized to issue it.
C-105.2(9.15) www.wcb.ny.gov
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APPROVED AS NOTED .
RETAIN STORKWATER RUNOFF
k; Ds! 0 V,
T
-. j PURSUANT�TO"CHAPTER'23G�
OF THE TOWN CODE.
NOTIFY BUILDING DcPARTiv1ENT AT
76� 1802 8'Al� TO 4�PM 'FOR THE
r FOLLOWING INSPECTIONS:..
FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE - ;, 1.-- ,�
` 2. ROUGH - FRAMING & PLUMBING /
3. INSULATION F; ; ;��"
' - -
=' ;! 4. FINAL , CONSTRUCTION MUST � � '•��
'•<`i'' !� - ” --- - BE COMPLETE FOR CO. -�-�—
}`" {@y ALL CONSTRUCTION SHALL MEET THE iu.,
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE' FOR
DESIGN OR CONSTRUCTION 'ERRORS. 9CCANC� `' f `s, G! Pt[ qtk 5r`(� n' "" '
USE 3
z
= UNLAWFUL
WI C CERTIFICATE
FCi'' U i IlY C ' I ' • !t1` iC ` _ t ` , ,t
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