HomeMy WebLinkAbout42044-Z $UFFot�rJ
Town of Southold 10/9/2019
3 ' P.O.Box 1179
0
53095 Main Rd
ooh � Southold,New York 11971
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CERTIFICATE OF OCCUPANCY
No: 40759 Date: 10/9/2019
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 2545 Plum Island Ln., Orient Orient
SCTM#: 473889 Sec/Block/Lot: 15.-5-24.2
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/4/2017 pursuant to which Building Permit No. 42044 dated 10/11/2017
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 Veith, Stephen&Linda
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 42044 12-13-2017
PLUMBERS CERTIFICATION DATED
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A o ' ignature
�saFFn��c TOWN OF SOUTHOLD
BUILDING DEPARTMENT
y TOWN CLERK'S OFFICE
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#: 42044 Date: 10/11/2017
Permission is hereby granted to:
Veith, Stephen
8 Falcon PI
Huntington, NY 11743
To: construct an in ground swimming pool as applied for
At premises located at:
2545 Plum Island Ln., Orient
SCTM # 473889
Sec/Block/Lot# 15.-5-24.2
Pursuant to application dated 10/4/2017 and approved by the Building Inspector.
To expire on 4/12/2019.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
—Buil 21nspector
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Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
1 TOWN HALL
j 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:
I. 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. Lf " oR®I—7
New Construction: Old or Pre-existing Building: (check one)
Location of Property: a. rJ S unAq LLsl OL nc by Or 1 f
House No. Street Hamlet
Owner or Owners of Property: a1P e 1
+h
/i��Suffolk County Tax Map No 1000, Section � �j Block � Lot o�
l�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: $
Applicant Signature
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Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
i TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANC
This applica ion must be filled in by typewriter or ink and submitted to the Building Depart ent with the following:
I
A. For nem building or new use:
1. Final survey of property with accurate location of all buildings,property lines,strec ts,and unusual natural or
topographic features.
2. Fin Approval from Health Dept. of water supply and sewerage-disposal (S-9 for ).
3. App oval of electrical installation from Board of Fire Underwriters.
4. Swo m statement from plumber certifying that the solder used in system contains lel s than 2/10 of 1% lead.
5. Con mercial building,industrial building,multiple residences and similar buildings,and installations, a certificate
of C de 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 all ld "pre-existing"land uses:
1. Acci irate survey of property showing all property lines,streets,building and unusu I natural or topographic
features.
2. A pi operly 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 appli ant.
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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. Terri porary Certificate of Occupancy-Residential $15.00, Commercial $15.00 j
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Date. a 01-7
New Construction: Old or Pre-existing Building:
(check one)
Location of :1roperty: VlUmb lclalncl Lul r ien
House No. Street Hamlet
I '
Owner or Owners of Property: VC l
/r Suffolk Cou ity Tax Map No 1000, Section— 15 Block S Lot 9 • o�
l�Subdivision Filed Map. Lot:
i
Permit No. Date of Permit. Applicant:
Health Dept Approval: Underwriters Approval:
Planning Bo rd Approval:
Request for: Temporary Certificate Final Certificate: (cl eck one)
Fee Submitt d:$
Applican Signature
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Town Hall Annex Telephone(631)765-1802
54375 Main Road y Fax(631)765-9502
P.O.Box 1179 • �� roper.richert(aD-town.southoId.ny.us
Southold,NY 11971-0959 Q
coupffn
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Stephen Veith
Address: 2545 Plumb Island Lane city,Orient st: New York zip: 11957
Building Permit#: 42044 Section: 15 Block: 5 Lot- 24.2
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
contractor: DBA: Bethel Electric License No: 40557-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 FixtureSIA Time Clocks 1
Disconnect Switches Twist Lock Exit Fixtures TVSS
Other Equipment: Inground Swimming Pool to Include: Bonding, Control Panel, Salt Generator,
1- GFCI Circuit Breaker, Pool Light.
Notes:
C _^
Inspector Signature: _ Date: December 13, 2017
0-Cert Electrical Compliance Form.xls
SOUI�olo
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL)
REMARKS:
DATE / /2 INSPECTOR�1
l
Ol "OF SO(/T�°
h� l0
# TOWN'OF SOUTHOLD BUILDING DEPT. ,
765-1802
.INSPECTION =
[ ] FOUNDATION 1ST [ ]. ROUGH PLBG.
-] .FOUNDATION 2ND [ JNSULAT ON/CAFloN
[ ] FRAMING /STRAPPING [ .] FINAL FIREPLACE & CHIMNEY [ ]` FIRE SAFETY IN
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION =
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
_ _ 0 n
� s OWA
DATE INSPECTOR
ho�aOF SOUTyo�
* # TOWN OF SOUTHOLD BUILDING DEPT.
`ycourm N�` 765-1802
INSPECTION '
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] SULAT N
[ ] FRAMING /STRAPPING [ FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMAR S:
siv
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ba%.w
Wc--
DATE
S 3 INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS
FOUNDATION (1ST)
H
------------------------------------
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FOUNDATION(2ND)
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ROUGH FRAMING&
PLUMBING LAH
b
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INSULATION PER N.Y:
STATE ENERGY CODE
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FINAL
ADDITIONAL COMMENTS
Stfo Po I�
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TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL VBoard of Health
SOUTHOLD,NY 11971 4 sets of Building Plans
TEL: (631) 765-1802 anning Board approval
FAX: (631) 765-9502 Jurvey
SoutholdTowfi.NorthFork.net PERMIT NO. Check
� 't� Check
Septic Form
D.E.C.
D Trustees
Flood Permit
Examined D
Trustees,20 OCT e 4 2017 Starm-Water Assessment Form
Contact:
7- A
Approved ,20 BUMDING DEPT.
Disapproved a/c TOWN OF SOUTHOLD
Phone: 6 31 g
Expiration 7 12P el
ing In pector
APPLICATION FOR BUILDING PERMIT
Date 1 d/2 , 20_1_7
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 comple`tdd within rS-ruonth§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 or name,if a corporation)
J6
(Mailing address of applicant)
State whether a plicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber r builder
Name of owner of premises 1��, f—f
(As on the tax roll or latest deed)
I applicant is a corporation, signature of duly authorized officer
(Name and title 6T corporate officer)
22-
Builders
2Builders License No. 7 y/J
Plumbers License No.
Electricians License No. /-/0 Al
Other.Trade's License No.
1. Location of land on which prop°bs'ed``woir �will;be done:
House Number Hamlet
County Tax Map No. 1000 :.Section �� Block QSd Lot
Subdivision®r'I e c+ M, Filed Map No. Lot /,S3
- x
2. State existing use and occupancy of premises and intended us and occupancy of proposed construction:
a. Existing use and occupancy /
J.
b. Intended use and occupancy6) 4J ,14ewocnjf
3. Nature of work (check which applicable):,,Xew_B,u*ldingF w ddition Al ration
:,: r c t_. ; >>, �Of
Repair RemovalDFmolition ( hbr Work i 1,je)
, : 1 . = a °. ; J
(Desc ption)'
4. Estimated Cost 3 20— Fee, ; �U
-
;j to (To be paid on filing this application)plication)
5. If dwelling, number of dwelling units Number of dwelling units on each floor
If garage, number of cars
PI'�?d b.i
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front 39 Rear -710® y Depth Z2, ,e
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 v
9. Size of lot: Front 2- 11 Rear , ' LDepth
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_Zl
13. Will lot be re-graded? YES NO_ZWill excess fill be removed from premises? ES/NO
14. Names of Owner of premises `rt✓ Address .�y6t/. k� 8,qev�fhone No. .3 3®959
Name of Architect Address Phone N
Name of Contractor % Tol Address 6/-X 1,9«e Vil®c G Phone NZ6'f (off'(-39.00
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland. YES NO V/
* IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BE QUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES NO pp//
* 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 urvey.
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 )
being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)He is the (0
(Contractor, gent, 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 f 1 no led e and belief; and that the work will be
performed in the manner set forth in the application file thev�th� N®WYEF?
ry
Public,State of NewYork
No.01OW6282704
Sworn to before me this Qualified in Suffolk County
ZnSo ay o C,3. 20� Commission Expires May 28
Q
NotaPublic Signature of App scan
VIWATI
EIK
STORh
Scott A. Musser (SUPERVISOR �v�[A\1�A\(G�)E�W ENT
SOUTHOLD TOWN HALL-P.0-Box1179 Town of Southold53095 Main Road-SOUTHOLD,NEW YORK 11971
CATER 236 - STOR a ATE-A'lt-�NAGEMENWORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES -rFIIS PROJECT INVOLVE ANY OF THE FOLLOWING:
(CHECK ALL THAT APPLY)
' Yes No -
® A. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
Bite preparation within. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area_
® C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
S 100 feet of wetlands, beach, bluff or coastal ;
erosion hazard area.
B. Site preparation within the one-hundred-year floodplain as depicted
-on-FIRM- -Ma-p--ofany water-course: - -
` ® F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater
proposal Management
Control Plan was received by the Town and the p p
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Number! Chapter
the Applicant 6 does notapplyelow yto your projth your ect.'
Signature, Contact Information, Date & County T p
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.
S.C.T.M. 1000 Date: P
APPLICANT: (Property owner,Design Professional,Agent Controcto Other) Dotrid
r-. a
NAME: Section Block Lot
=OR LiLi1LD1 G DEPART�'ti;NT t:SL: CI
Contact Informatio r �umnr
Reviewed By: A8
—
- - - - - - - — — — — — — — — — — Date: — - / 7
Property Address/ Location of Construct ion Work: — Approved for processing Building Permit.
�y P — — Stormwater Management Control Plan Not Required
ElStormwater Management Control Plan is Required.
(Forward to Engineering Department for Review.)
FORM 9 SMCP-TOS MAY 2014
so
Toxin Hall Annex O Telephone(631)765-1802
54375 Main Road
P.O.Box 1179 #12) Q ro er.dch ,. . , s
Southold,MC 11971-0959
DEC - 4 2017
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION TOWId®FSOLTIHOLD
QUESTED BY: ��®�-M aJ`� (1lrC�OC Date: 12g I�
ji-npany Name: 'j VV)Q- i. Jac r!C• CA,A,7md i' �n
ime:
-.ense No.: , I\1r--
Idress:
lone No.: 50 0 655�
)BSITE INFORMATION: (*Indicates required information)
arae: SFE11 GPq N FIT-
ddress: 75 i i -lda,/J Lode lQvr1-' N I I
ross Street: r Lm
hone No.: C�4 CZI J .6sf--
:rmit No..
tx-Map District: 1000 Section: 1�5z' T Block: 0 Lot: 2— . 2•
RIFF DESCRIPTION OF WORK (Please Print Clearly)
n
lease Circle All That Apply)
job ready for inspection: YES NO Rough In Final
o.you need a Temp Certificate: YES@:O:)
mp Information (11f,needed)
P,rvice Size: 1 Phase 3Phase 100 . 150 200 300 360 400 Other
aw Service: Re-connect Underground Number of Meters Change of Service Overhead
ditional Information: PAYME T DUE WITH APPLICATION
0pp,cc w i 01/\ d4�
'A atC�S- CAl [± 0vtlJA2r
82-Request for lnspecflob Form
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New York State Insurance wand
Workers'Compensation&Disability Benefits Specialists Since 1914
8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129
CERTIFICATE OF!WORKERS' COMPENSATION INSURANCE (R NEWE®)
j
A A i A A A 010648957
SPECHT-T CULAR POOLS INC �
3661 HORS BLOCK RD UNIT R
MEDFORD qY 11763
Scan to Validate
POLICYHOLDER CERTIFICATE HOLDER
SPECH -TACULAR POOLS INC TOWN OF SOUTHOLD
3661 H RSEBLOCK RD UNIT R BUILDING DEPT.
MEDFO RD NY 11763 MAIN STREET,TOWN HALL
SOUTHOLD NY 11971
POLIO NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
121 3666-9 770383 09/26/2017 TO 09/26/2018 9/20/2017
I
THIS IST CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2163665-9, COVERING THE ENTIRE OBLIGATION OF T IS POLICYHOLDER FOR
WORKER COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW'WITH RESPECT TO ALL
oPERATt S IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE DF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOY ES ONLY.
I IF YOU WI H TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VA (DATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:1/WWW.NYSIF.COMICERT/C RTVAL.ASP.THE NEW
YORK ST TE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NO, IFICATIONS.
THIS POLI�Y DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED ORPORATION.
DIETER SPECHT,FRES
OF SPECHT TACULAR POOLS INC
(ONE PERSON CORP)
THIS CE TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERA E UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ArVEND, EXTEND OR ALTER
THE CO RAGE AFFORDED BY THE POLICY.
I
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I
1
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:587773677
P-26.3
i
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I
I
DATE{NiM1DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 09/19/2017
THIS CERTIFICATE IS ISSUED ASA 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 ERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTA E OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If he certificate holder Is an ADDITIONAL INSURED,the poilcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATIO IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an ndorsement. A statement on
this certificate d es not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Valerie Zaverdas
Libe Risk Management,Inc. `'/ONe (631)569-6633 `X"`Nei: 631 569-5636
664 Blue Point Road,Suite A aoD`L Valerie Libe risk.o
Holtsivllle, NY 11742 INSURER(S)AFFORDING COVE RAGE NAIC#
INSURER A: o Insurance
INSURED
RER B:
Spec t-tacular Pools,Inc. INBURERC:
Diete Specht
INSURER D:
3661 Horsebloc[c Road,Unit R
Me Ord,NY 11763 INSURER E:
j INSURER F
COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISI N NUMBER: 8
THIS IS TO CERTf THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AB, VE FOR THE POLICY PERIOD
INDICATED. NOT MTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1A ITH RESPECT TO VVHIGH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS St BJECT TO ALL THE TERMS,
EXCLUSIONS AN CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDLSUBR POLICY EFF POLICYEXP
LTR TYPE OF INSURANCE POLICYNUMBER MMlODfyyyln (MmioDmIrn LIMITS
A X COMMERCULGENERAL LIABILITY WPP119817403 09118/2017 0911812018 EACH OCCURRENCE _ S 1,000,000
DAMAGE 0CLAIM (MADE OCCUR M E EaEoccurrence) S 100,000
MED EXP'Any one person) S S 0QQ
PERSON 1 A ADV INJURY S 11000,000
GEN'L AGGREGAIE LIMIT APPLIES PER. GENERALIAGGREGATE $ 2,000,000
POLICY[q
JECT ❑LOC PRODUC -COMPIOPAGG I S 2,000,000
OTHER Is
AUTOMOBILE LIA 31LITY COMBINE SINGLE LIMIT $
Me s id t _
ANY AUTO BODILY IJURY(Per person) S
OWNEDL SCHEDULED
AUTOS ONAUTOS BODILY INJURY{Para xi(lant) S
HIRED NON-OWNED PROPER DAMAGE S
AUTOS ONLY AUTOS ONLY (Per acd nt
I � S
UMBRELLA IIIAS
I OCCUR EACH OCCURRENCE S
EXCESSLIA§ HCLANS-MADE AGGREGATE S
OED 1 16TENnoNs g
WORKERSOOMPENSATION I PER OTH-
AND EMPLOYERS LIABILITY YIN STA EERi
ANY PROPRIETO ARTNER7DCECUTSVE E.L.EACHIACCIDENT S
OFFICEWMEMBERIXCLUDED? NIA
(MyaensdatoryInNH) ELMS F-HSE-EAEIAPLOYE S
IDESCRIPde TION OF OPERATIONS below EL DISEASE-POLICY LIMIT S
A Property WPP1198174 03 0911812017 09/18/2018 BPP 20,000
DESCRIPTION OF OPER kTIONSI LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may to attached If more space Is required) ;
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CERTIFICATE HQLDER CANCELLATION
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
Main Street,Town Hall f
SoUt!hold, NY 11971 AUTHORIZED REPRESENTATIVE
VMz
(D1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(201610 3) The ACORD name and logo are registered marks of ACORD
i Printed by VMZ on September 19,2017 at 09:33AM
STATE OF NEW YORK
WORKER'S COMPENSATION BOARD
1,
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BEN FITS LAW
PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier i
{
1a.Legal Name a d Address of Insured(Use street address only) 1b.Business Telephone Number of I isured
631-696-3900
SPECHT-TA ULAR POOLS, INC tc_NYS Unemployment Insurance E nployer Registration
3661 HORSES I OCK ROAD UNIT R Number of Insured
MEDFORD, NY 11763 11d.Federal Employer Identification gumber of insured
or Social Security Number
010648957
2.Name and Ad ress of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier
I (Entity being listed as the Certificate Holder) The First Rehabilitation Life I surance
! TOWN OF S UTHOLD Company of America
3b.Policy Number of Entity listed i box"1a":
( i BUILDING D PARTMENT D152822
i 3c.Policy effective period:
i MAIN STRE T,TOWN HALL
SOUTHOLD, NY 11971 9/26/2017 t' 09/26/2018
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4.Policy covers:
a All of the employer's employees eligible under the New York Disability Benefits Law
b F7 Only the following class or classes of the employer's employees:
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Under penalty c f perjury,I certify that I am an authorized representative or licensed agent of the insurance car rier referenced
above and that the named insured has NYS Disability Benefits insurance coverage as described above.
Date Signed 9/25/2017 By
(Signature of insurance carrier's authorized representative or YS Li ed 1 isurance Agent of that insurance carrier)
Telephone Number
516-829-8100 Title Sr. Vice President
IMPORTANT: f box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Li Fensed Insurance Agent
f that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. !i
f box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability Benefits Law.
t must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,20 Park Street,Albany,NY 12207. i
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PART 2 Toe completed by NYS Worker's Compensation Board (Only If box"4b" o Part 1 has been checked)
State of New York
Worker's Compensation Board
' by the NYS Worker's Compensation Board,the above-named employer has complied ith the NYS
According to information maintained I
Disability Benefits Law with respect to all of his/her employees.
Date Signed By
(Signature of NYS Worker's Compensation Board Employe
Telephone Number
Title
I 3
Please Note,Only insurance carriers licensed to write NYS Disability Benefits insurance policies and NYSILicensed Insurance Agents of
those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this farm.
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DB-1201 (5- 6)
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CERTIFIED TO: SURVEY OF PROPERTY
BANK OF AMERICA, N.A., ISAOA/ATIMA
FIDELITY NATIONAL TITLE INSURANCE SERVICES, LLC. AT ORIENT
LINDA VEITH
STEPHEN VEITH TOWN OF SO UTHOLD
SUFFOLK COUNTY, N. Y.
1000-15-05-24.2
SCALE.- 1' 30'
OCTOBER 22, 2014
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/v LOT 158
LOT 157
OF N';Z. J-,
AREA = 40,820 80. FT.
LOT NUMBERS REFER TO MAP OF ORIENT BY THEW* r;
SEA, SEC11ON THREEN FILED IN THE SUFFOLK
COUNTY CLERK'S OFFICE ON OCT. 16, 1974 AS ;
FILE NO. 6160.
ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION LIC. NO. 49618
OF SEC71ON 72O9OF THE NEW YORK STATE EDUCATION LAW. PECONIC , P.C.
EXCEPT AS PER SEC77ON 7209—SUBDIVISION 2. ALL CER7IFICA7IONS (631) 765-5020 FAX (631) 765-1797
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF P.0. BOX 909
SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 1230 TRA VELER STREET
WHOSE SIGNATURE APPEARS HEREON. .14-108
SOUTHOLD, N. Y. 11971
40'
NOTES
t NO SPOIL SURCHARGE PERMITTED WITHIN 4 FEETOF EXCAVATION ATTHE 5HALLOW END,OR6 FEET OF EXCAVATION AT THE DEEP END. Z
APPROVED AS NOTED 2 THIS POOL MEETS THE REQUIREMENTSOFANSI/N5PI-5 'AMERICAN NATIONAL STAN PARD FOP,RESIDENTIAL INGROUNDSWIMMING
POOLS'AND 1996 BOCACODE-5ECTION 421. DIVING EQUIPMENT 15 NOTALLOWED O
ATE: � B.P.# Hzo Hzo 5 5WIMMINGPOOLSHALLBECOMPLETELYANDCONTIN000SLYSURROUNDEDWITH ABARRIER CONSTRUCTED LAWREQUIREMENTS OF Q
SECTION R32653 OF THE INTERNATIONAL RESIDENTIAL COPE(2016)AND INCONFORMITY WITH ALL 5ECnON5 OFTHE SOUTHOLD IZ
EE. BY: `v q TOWN CODE. ACCE55 GATES SHALL COMPLY WITH SECTION 8326.5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECVRELY
LOCKED WHEN POOL IS NOT IN USE OR 5VPERVISED. ALL GATES ARE TO OPEN AWAY FROM TH E POOL AREA
OTIFY BUILDING DEPARTMENT AT g p
4. DURING CONSTRUCTION THE CONTRACTOR$HALL ERECTA TEMPORARY BARRIERAROUNP THE EXCAVATION LAW THE CODE OF THE Q �C
5-1802 8 AM TO .4 PM. FOR THE I TOWN OFSOUTHOLD.
ALLOWING INSPECTIONS:
5 POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTINGA CHILD ENTERING THE WATER AND SOUNDING Q J 3
FOUNDATION - TWO-REQUIRED AN AUDI BLE ALARM WHEN DETECTED THAT 15 AUDIBLE ATPOOLSIDEANDATANOTHERLOCATIONONTHEPREMISESWHERETHEPOOL O
FOR POURED-CONCRETE CONC WALLS THE ALAISLOCARM MUST MEETA5TMF22 8 'STANDARDED. THE ALARM MUST BE INSTALLED, I PECIFICATIONFOP,POOL ALARM5 THE DEVINTAIN ED AND USED IN ACCORDANCE WITH CEMUST O ERATERNDE ENDENT(NOT ERS INSTRUCTIONS. w(j
ROUGH - FRAMING--& 'PLUMBING ATTACHED TO OR DEPENDENT ON)OF PERSONS = c Z CZ
INSULATION, _ .' , .• RETAIN STORM WATER RUNOFF e 0 0 0
�+ c 6. POOL SUCTION FITTINGS(EXCEPT FOP,SURFACE SKIMMER5)MUST BE PROVIDED WITH A COVER THATCONFORM5 TO A5MFJANSi Lu
FINAL - CONSTRUCTION MUST PURSUANT TO CHAPTER 236 A112.198MORAMIN[MUM I8"x23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH d LLJ
BE COMPLETE-FOIA C.O: ATMOSPHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME M155ING OR BROKEN. SUCH N m
LL CONSTRUCTION -SHALL MEET THE OF THE TOWN CODE. VACUUM RELIEF SYSTEMS SHALL CONFORM WITH A5MEA11219.17ORBEA GRAVITY SYSTEM APPROVED BYTHE TOWN OFSOUTHOLD•
POOL SHALL BEPROVIPED WITH AMIN]MUM OF2SUCTION FITTINGS OFTHE ABOVE MENTION EDTYPE. THE SUCTION FITTINGS SHALL BE
PLAN SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A Ln
EQUIREMENT$, OF THE-CODES OF NEW VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEAN ING FITTINGS SHALL BE IN AN ACCE551BLE
RK STATE. NOT RESPONSIBLE FOR TO, MINIMUOF6 AND NO GREATER THAN 12-BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEANATI'ACHMENTTO
ESKNM
Z
ESIGN OR CONSTRUCTION ERRORS. 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA70(NEC)PRINCIPALLYARTICLE680 AND THE IRC SECTIONS
v
ECT
4201 THROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A V O
POURED CONCRETE GROUND FAULT CURRENT INTERRUPTER(GFCD CURRENT CARRY[NG ELECTRICAL CON DUCTORS EXCEPT FOR TH05E PROVIDING POWER
i WAUSANDAEPS TO POOL LIGHTING ANDPOOL EQUIPMENT SHALLMEET THE SEPARATION REQUIREMENTS OFTABLE E42035 ALL METAL ENCLOSURES, v y
�t )IMPLY tt'� r J� 1��1 FENCES OR RAILINGS NFARORAD)ACENTTOTHESWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE ToCONTACT -u c
R' CODES O� N WITHANELECTRICALCIRCUITSHALLBEEFFECTIVELYGROUNDED t v
N EVj YORK STATE E & TOWN
COf�c ° S. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NY5 PLUMBING CODE 608. ti �
/I�VG+C 7 VtfNIV lr p 0
"17 RI Ql91RE� , z,tod•SANDBOTOM a 9. ALL PIPING I5 DIAGRAMMATICVNLES50THERWI5ESTATED. S E
THOLD T_0V ZBA 10 WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPEAWAY FROM POOL EDGE
11, A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED TAW ANSI/N5PI-5 SECTION 6. 2 2 N
OARD 12. CONTRACTOR TO PLACE THE POOL LAW TOWN OFSOVTHOLD CODE SETBACKS.
` n ! v TRUSTEES SECTION A
-�^ - 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THESUBIECT PROPERTY,
ELECTRICAL
Dom
PASPEC— p�� 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH(10%SILT GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IFGROVND b
ON F-Ot RED WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED, Ln
N
16, ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROVND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY °\.
O C U ® B CY O TOP OF WALL WATER UNE CONSERVATION ACT(NAECA)COMPLIANT, POOL HEATERS SHALL BE TESTED LAW ANSI 221.56 AND SHALL BE INSTALLED LAW
MAN VFACTVRERS SPECIFICATIONS OIL FIRED POOL HEATERS SHALL BE TESTED LAW UL726. POOL HEATERS SHALL BE LOCATED OR
U S E I UNLAWFUL GUARDED TO PROTECT AGA]N5T LIEF VALVES CONTACT OF HOT SURFACES BY PERSONS, POOL HEATERS SHALL BE PROVIDED WITH
4' t2' 4' TEMPERATVREAND PRESSURE-RELIEF VALVES FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASSSYSTENI A BYPASS LINE SHALL t 1
a BE INSTALLED FROM INLET TO OVTLETTO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE V
o y FOLLOWING ENERGY CONSERVATION MEASURES, Q.
WITHOUT CERTIFICATE m
16.1 AT LFASTONE THERMOSTATSHALL BE PROVIDED FOR EACH HEATING SYSTEM (�
QcK vA® C U PAN@v"'y� 16.2 ALL POOL HEATERS SHALL BE EQVIPPED WITH ANON-OFF SWITCH MOUNTED FOR EASY ACCE55 TO ALLOW SHUTTING OFF THE
OPERATION OF THE HEATER WITHOUT AD)USTINGTHE THERMOSTATSETTING AND TOALLOW RESTARTING WI THOUTRELIGHTINGTHE I-+
PILOT LIGHT, a 0
FROM SKIMMER ! 165 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQVIREMENTARE OUTDOOR POOLS W >,-�m a
PUMP DERIVING20%OFTHEENERGY FOP,HEATINGFROM RENEWABLESOURCE5A5COMPUTEDOVERANOPERATING SEASON) w Q
16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIOD5AND CAN BE SET IZ c
TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN ACLFAN AND SANITARY CONDITION IAWAPPLICABLE Y
SECTION B SANITARY CODE OFNEWYORK5TATE 9 Amm a
Z m E
TO DISPOSAL/ 17 THIS DRAWING IS FOP,5TRVCTVRALSHELL ONLY ALL ACCES50RIE5AND APPURTENANCES ARE DEFINEDBYOTHERS.
N O_ X t!
DRYWELL COPINGAND WALKWAY i0" �i C N OL.o
(BY OTHERS) 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS, DO NOTALLOW THE HEIGHTOF BACKFILL TO EXCEED THE HEIGHTOF THE W 0 I•-LL a
GRADE WATER IN TH E POOL BY MORE THAN S", OR TH E WATER TO EXCEED BACKFILL BY MORE THAN S" lz cc
DIVERTER WATERLINE ,� ,
VALVE O a• ..i•.•:'' 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSIT AND COMPACT CLEAN BACKFILL V
UNDISTURBED EARTH ~ --
FILTER 3500P51POVREDCONC •O; 21 REQVEREM15 �TSOLFTHEIR(N PRAIN�SECTION8326. FORENTRAPMEN THIS POOL SUCTION FOP, ONTPROTECTION L WATER Cl TION 15 PROVIDED BY THESKIMMERSONLY THISMEET5 OF NEvV
3/8•REBAR 3)TYP �, 22, THE POOL WAS DESIGNED LAW THE FOLLOWING- '��P ��R TN��/� .�
VINYL LINER ,+
• 22.1, THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER 42(2016) y
2'T04'SAND\ �• �,�'• 2 1 1•t ' t�
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22.2. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-5ECf70N 848.10(_015)
22.3. THE INTERNATIONAL FUEL GAS CODE(2015) ?�
22.4 THE NEW YORK STATE CODE SUPPLEMENT-SECTION 8526 (2016) ! r = i I
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22.5. THE NEW YORK STATE SANITARY CODE U 6 I
226 AN5L/N5PI-5STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS ��,•>---
TO RETURNS 22.7. BOCA CODE-SECTION 421. — ��a-+"•�4 -`� O�
VERTICAL3/8"REBAROYOC 1 22,8. CODE OF THE TOWN OF SOUT'HOLD.
CHECK VALVE (NOT5HOWN) WALL SECTION 25, ALL BACKWASH TO BE SELF-CONTAINED ON-SITE '� 088475
PLUMBING SCHEMATIC NTS AROFEss10� ,
N.T.S.