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HomeMy WebLinkAbout43672-Z r,UFFO l Town of Southold 8/3/2020 C, P.O.Box 1179 S a s 53095 Main Rd o� O`er r Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41308 Date: 8/3/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 260 Reeve Rd, Mattituck , SCTM#: 473889 Sec/Block/Lot: 100.-3-15.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/1/2019 pursuant to which Building Permit No. 43672 dated 4/25/2019 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 Modem Age Home Builders LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43672 7/27/2020 PLUMBERS CERTIFICATION DATED A e Si ature suFEQ�K TOWN OF SOUTHOLD a�v cOGy BUILDING DEPARTMENT cz TOWN CLERK'S OFFICE or • 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#: 43672 Date: '4/25/2019 Permission is hereby granted to: Drum, Mary 2615EMill Rd Mattituck, NY 11952 To: construct accessory-in-ground swimming pool as applied for. At premises located at: 260 Reeve Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 100.-3-15.1 Pursuant to application dated 4/1/2019 and approved by the Building Inspector. To expire on 10/24/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Bui ng r 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 I%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. 1 New Construction: Old or Pre-existing Building: (check one) Location of Property: &Q !`�-G�S� kcl. MAJ�?jl it.CJ- House No. Street Hamlet Owner or Owners of Property: Mae, J6r(t r-,--Ty-uA Suffolk County Tax Map No 1000, Section /60 Block Lot �S Subdivision Filed Map. ( Lot: 1 Permit No. Date of Permit. Applicant:y�Q� Health Dept. Ap roval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted. $ 0 Applican 0 gnature �wi rnrnirl�-�oeo)J Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) �(( A • residing at �j (Print property owner's name) (Mailing Address) � i Ado hereby authorize (Agent) to apply on my behalf to the Southold Building Department. ).28 /(0, ignature ( ate) (Print Owner's Name) ®�®F sovr�®� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 117 Southold,NY 11971-0959 sean.deviin(-)town.southold.ny.us �` ® �® ®l�C®UNTI BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Modern Age Home Builders LLC Address: 260 Reeve Rd city:Mattituck st: NY zip: 11952 Building Permit#: 43672 Section: 100 Block: 3 Lot: 15.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: PUCCio Electric License No: 4806ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 1 Recessed Fixtures CO2 Detectors Sub Panel 1 A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer 1 UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 4'LED Exit Fixtures Pump 1 Other Equipment: Pump on 220GFCI Breaker, Heater, Pool Lights on Pentair LV Tranny Notes* " AS BUILT " " NO VISUAL DEFECTS " Pool- Did Not See Bonding Inspector Signature: Date: July 27, 2020 S.Devhn-Cert Electrical Compliance Form.xls r^ �aUP SOrlo GTyo # # TOWN OF SOUTHOLD BUILDING DEPT: �O • �O �Yco 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] `ROUGH PLBG. [ ] FOUNDATION 2ND [' ] INSULA-PON/CAULKING [ ] FRAMING /STRAPPING [`FINAL P4 [ ] FIREPLACE & CHIMNEY [ ] "FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 4 'li(tjvt,c GJ �P� - `�/ S V✓� ,rig--- �q/r►�, �LyD� - - h DATE c4 �'° INSPECTOR �aoF souryo <� # # TOWN OF-SOUTHOLD BUILDING, DEPT. `ycourm '' 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] -FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) Pao [ ] CODE VIOLATION ] PRE C/O REMARKS: DATE 2,7 Sol , INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) ...................................... 'FOUNDATION (2ND) • O 'ROUGH FRAMING& PLUMBING H • 1 INSULATION PER N.Y; STATE ENERGY CODE w VACP &4 VAAAnr FINAL j AI)DIT ONA.L COMMENTS [to cl 7- e- o z m llzh 0 •H TOWN OF SOUTHbLD 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 Survey. ✓ Southoldtownny.gov PERMIT NO. �fj 1 Check Septic Form r N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined 4� ,20 Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: 'Approved 20� Mail to: ,Disapproved a/c C 6y-CXZM(O, Expiration 20 g9—D ` !a`a5VR Bui spector D APR - 1 2019 PLICATION FOR BUILDING PERMIT Date _,20 'aJDlir " ' INSTRUCTIONS TOWN OF SOUTHOLD 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. (Signaturef pplicant or name,if a corporation) / - �, C.aYa,n� (Mailing address of Tap1�, State whether a plicaptis owner,lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premiss j'?� 1 C V FDIC f 2YL-k(n � fC - (As on the tax 11 or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. + 0 D 2- Plumbers License No. Electricians License No. 4 9 U — E Other Trade's License No. 1. Location of land on w ' h proposed�kill>;e done: House Number Street 1� /` Hamlet �C County Tax Map No. 1000 Section 6 d Block Lot /S " ' u Subdivision ,,, Filed Map No. Lot j 2. State existing use-and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy 'Y(� b. Intended use and occupancyM 1 r—eS; C-e_ 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work — 4. 4. Estimated Cost Fee (D� t (To be paid on filing this application) 1, 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars j 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. �- 7. Dimensions of existing structures, if any: Front Rear Depth Height Number-of Stories Dimensions of same structure with alterations or additions. Front /� �— Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size-of lot: Front ��7 q Rear �J • J� l Depth I 10. Date of Purchase—SZ/L9/,93 Name of Former Owner D) M; �yi" SOovra!r �a��raf 11. Zone or use district in which,premises are situated 19 Q 12. Does proposed construction violate any zoning law, ordinance onregulation?YES NO___x 13. Will lot be re-graded? YES 16 NO Will excess fill'be removed from premises?YES NO� 14. Names of Owner of premises M;CW b(kw', Address Phone No. j Name of Architect A bCb Address_ � �' Phone No Name of Contractor— .�lCLM Address [ -. Phone No. bcco 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTUOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES,D.E.C.PERMITS MAY BE REQUIRED. i 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. i 18. Are there any covenants and restrictions with respect to this property? * YES NO * IF YES, PROVIDE A`COPY. I STATE OF NEW YORK)• SS: COOF lJt Ln1 J.—L.'e 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,Corate-O cerff� ,etc.�.t, �y Jamie �, Cwt o$New York of said owner or owners, and is duly authorized to pe rformlo}Liia�e'pbi� btm?d fhe a work and to ake and file this application;' �-�'�,1 % that all statements contained in this application are true to the bestldfhiA@CVwlec�gM`and belief- an that the work will be performed in the manner set forth in the application filed there�/ithipd in t�f#oik 0���ry$y — • I �R6.6r�. �'s G Commission Expires July Swo re met ' - • ay of 0 try u lic - *gn ofApplicant D 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 Survey Southoldtownny.gov PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined ,20 Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: Approved ,20 'Mail to: Disapproved a/c Phone: Expiration 120 Building Inspector •APPLICATION FOR BUILDING PERMIT Date , 20 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 Bui'l'ding 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) (Mailing.address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Naive 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. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: House Number Street Hamlet County Tax Map No. 1000 Section Block Lot 4jp"'V1, F'N4, BUILDING DEPARTMENT-Electrical Inspector ? ' TOWN OF SOUTHOLD z Town Hall Annex- 54375 Main Road - PO Box 1179. Southold, New York 11971-0959 Telephone 631 765-1802 - FAX T631 765-9502 rogerr@southoldtownnv.gov— seandOs* outholdtownny.00v APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: �- •L Name: N1;ry • License No.: email:Q • Address: y Phone No.: 15144— Q 1 JOS SITE INFORMATION (All Information Required) Name: Address: c Cross Street: Phone No.: Bldg.Permit##:-Lftft"ftA 43 0� email: Tax Map District: 1000 Section: '3 Block: Lot: BRIEF DESCRIPTION OF WO (Please Print ClearI ) Circle All That Apply: Is job ready for inspection?: NO Rough In <21 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 V\ �, oo, tot Request for Inspection FormAs /nQ�l I (�5W �t n'-a1 s� a-�.�, � . �r �"�` � Jennifer Leeds Land Use Expediting 134 Sequoia Drive Coram, New York 11727 631-879-2684 JenniferLeeds0255@gmail.com April 1, 2019 Connie Bunch Town of Southold Building Department Town Hall 54375 NYS Route 25 Southold, NY 11971 Re: 260 Reese Road, Mattituck SCTM# 1000-100-3-15.1 Dear Connie: Enclosed herein you will find a resubmission of an application for proposed in-ground swimming pool at the above mentioned location. The following is enclosed for your review: • Building Permit Application for a proposed in-ground swimming pool • Owner's Authorization • Application for Certificate of Occupancy • Proof of Workers Compensation, Disability and Liability Insurance • Storm Water Management Work Sheet with 2 copies of the plans • Survey of Property • 4 sets of Construction Plans If you require any additional information or have any questions regarding this application, please do not hesitate to call or email me. Yours very truly, Hnnifer s W w�fsrs CERTIFICATE OF INSURANCE COVERAGE sm, nsation 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 la.Legal Name$Address of Insured(use,street address only) 1b.Business Telephone Number of Insured BUKOWSKI HOMES INC. 6 8 HARLEY CT. 31-909-7115 HOLBROOK,NY 11741 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 205300333 2.Name and Address of Entity Requesting Proof of a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Town of Southold HARTFORD LIFE AND ACCIDENT 54375 Main Rd` 3b Policy Number of Entity Listed in Box"la" Southold, NY 11971 LNY815181 3c Policy effective period 01-01-2019 to 12-31-2019 4.Policy provides the following benefits: FVJ A.Both disability and paid family leave benefits. E]B.Disability benefits only. E]C.Paid family leave benefits only. 5.Poll overs: L✓�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,l 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. Date Signed 03-01-2019 Ze 45- (Signature 5-(Signature of insurance carriers authorized representative or NYS Licensed Insurance Agent of that insurance carrier) c Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services 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 513 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 B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and pa/d 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. ,I DB-120.1 (10-17) II�IIII��II,� ��II �I�III DB'f'1ZOr:-Ir`' . D 713. lH Additional lhstrtactions for Form DB-12"0.1 f 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"l 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 thatthe business is complying with the mandatory coverage requirerients of the New York State Disability and Pa14 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(1017)Reverse K STATE OF NEW YORK WORKERS' COMPENSATION BOARD ~ CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) Ib.Business Telephone Number of Insured (631)767-4816 Bukowski Homes Inc. 8 Harley Court le.NYS Unemployment Insurance Employer Holbrook,NY 11741 Registration Number of Insured Work Location of Insured (Only required if coverage is 1d.Federal Employer Identification Number of Insured specifically limited to certain locations in New York State, i.e., a or Social Security Number Wrap-Up Policy) 205300333 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Travelers Indemnity Company 3b.Policy Number of entity listed in box"1 all Town of Southold UB-2J303967 54375 Main Rd Southold,NY 11971 3c. Policy effective period 3/14/18 to 3/14/19 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X 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 "la" 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 Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may 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. Please Note: Upon the 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 I 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: Joseph W.Pires (Print name of authorized representative or licensed agent of insurance carver) Approved by: 03/01/2019 (Signature) (Date) Title: President—PF Northeast Brokerage Inc. Telephone Number of authorized representative or licensed agent of insurance carrier: (845)223-8107 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. aco o►® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) / 1 03/01/2019 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 REPRESENTA11VE 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 WANED,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 16 lieu of such endorsement(s). PRODUCER CONNAMTACT Cole Lahey PF Northeast Brokerage Inc PHONE 1035 Route 82 E-MAIL' Exl: (845)223-8107 aC Nol: (845)227-8816 ADDRESS: clahey@pfnortheastcom Hopewell Junction NY 12533 Harleysville Worcester Ins.Co.ING COVERAGE 261 82 INSURERA: INSURED INSURER B: Travelers Casualty Ins.CO Of Amenca 19046 Eukowskl Homes Inc INSURER C: P.O.Box 291 INSURER D INSURER E Holbrook NY 11741 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1831409454 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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 INSR I AUUL UUR POLICYEFF POLICYEXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE y OCCUR DAMAGE TO RENTE9__ PREMISES Ea occurrence $ 100,000 X ContractuallLiability MED EXP(Any one person) $ 5,000 A SPP00000038499Z 03/15/2018 03/15/2019 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 4,000,000 C POLICY JET LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCF 33 LIAB HCLAIMS-MADE - - AGGREGATE $ - - DED RETENTION$ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY YIN X STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE100,000 OFFICERWEMBEREXCLUDED9 ❑ N/A UB-2,1303967 03/14/2018 03/14/2019 E.L EACH ACCIDENT $ (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Provided it is required by written contract,the following are named as additional Insured as respects general liability with regard to work being performed by the insured under form SP-7174 0710,to the extent provided therein:Town of Southold CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd AUTHORIZED REPRESENTATIVE Southold NY 11971 Ci ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD SURVEY OF PROPERTY ,p x �12 C NO LOT 1 MAP OF �� LOT 2-WOODED VACANT LAND SEAAIRE ESTATES N74037'2'0'-' 270.00 W FILED: FEB. 5, 1979-MAP#.6750 59 SITUATE OD` '_; 20.0'_ � 6'0INGPO uj �.} p LEACHING POOL Q I\ MATTITUGK I IL � EASEMENT LF'IMIN�STI1250G� d O❑EQUIP. z TOWN OF'SOUTHOLD W W W u.-I: U, ppU, �( SEPTIC TA K ��\ 0 SUFFOLK COUNTY, N.Y. fv >I W EGRESS ol3 °;I N H OWtND.WELL I� CHIM +n N ❑ TAX MAP NO.: 1000-10003-015.001 55.0' = so 0o WirRiD WELL °z a N N U >Dir W-W PROPOSED W a LOT AREA:40,274.63 S.F.(0.925 ACRES) W % W-�- SINGLE FAMILYm 3 F g o m m DD Y O V 2STORY 14 Z m a DATE SURVEYED:DEC.27,2018 ❑ 4BEDROOM d �g Ir U) REVISED:JAN.21,2019 g �$ 0 z FEFL-610 m a o E e 5o LOT 1•WOODED VACANT LA D a O❑ ELEVATIONS REFER TO NAVD88 B 733 WIND WEL " °z z NO WETLANDS WITHIN 300'OF PROPERTY a "' •' ••............ m $� 00 R40 ZONING z g uj °� GARAGE 590" ADW) Q U ............��� ••. Q I 62.0' 22.67 fl��- LY7PLItvtP j QW'I GUYOLWIRE - 'O BE i%c)V.ED > ` 5e �kisy�NGc` Nc TEST HOLE (NOT TO SCALE) I : . ,i r ��NB "••...,, wl MCDONALD GEOSCIENCE rY� ROPOS�D••• DRIVT., N EA 2018 DATE: 12-26 —®. ® ®®®® GRADE ELEV.58.50' BROWN LOAM(OL) 12011WS729 BROWN SILT(ML) U'a n 270.25 E DRAINA MENT 5' S7 r TOWN OF SOUTHOLD CL 0 CL TD* rn LOT COVERAGE MQN.FND. 10' PALE BROWN FINE RESIDENCE PUBLIC WATER RESIDENCE PUBLIC WATER N TO MED.SAND(SP) RESIDENCE=1960 S.F. M POOL=800 S.F. I N `o TOTAL=2760 S.F.(6.8%) 15' ROOF DRAINAGE CALCULATION: m 17' (1 960 S.F.) '(3"/HOUR)=490 CUBI FEET REQUIRED �p SCALE: 1 INCH =40 FEET PROVIDE MINIMUM(2)8'DIAM.X 5'DEE DRYWELLS OR .- m NO WATER ENCOUNTERED EQUIVALENT 0 20 40 80. o J LEGAL NOTES' 1 COPYRIGHT 2018 ANGELO J CECERE PROFESSIONAL LAND SURVEYING ALL RIGHTS RESERVED } w 2 UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY MAP BEARING A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION 7209,SUBDIVISION 2,OF NEW YORK STATE EDUCATION LAW 30NLY BOUNDARY SURVEY MAPS WITH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND CORRECT COPIES OF THE N SURVEYOR'S ORIGINAL WORK AND OPINION •MON.FND. O) 4,CERTIFICATIONS ON THIS BOUNDARY SURVEY MAP SIGNIFY THATTHE MAP WAS PREPARED IN ACCORDANCE WITH THE CURRENT EXISTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS,INC THE CERTIFICATION IS LIMfTEDTO PERSONS FOR WHOM THE BOUNDARY SURVEY MAP IS ���ROAD � PREPARED.TO THE TITLE COMPANY,TO THE GOVERNMENTAL AGENCY.AND TO THE LENDING INSTITUTION LISTED ON THIS 5BOUNDARY S ICATI MAP 5THE CERTIFICATIONS HEREIN ARE NOT TRANSFERABLE. 6 THE LOCATION OF UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND OFTEN MUST BE 1�R E ESTIMATED,IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS EXIST OR ARE SHOWN,THE IMPROVEMENTS OR ®IF E29V� o ENCROACHMENTS ARE NOT COVERED BY THIS SURVEY ® p 7 THE OFFSETS(OR DIMENSIONS)SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A SPECIFIC Rj PURPOSE AND USE AND THEREFORE ARE NOT INTENDEDTO GUIDE THE ERECTION OFFENCES,RETAINING WALLS,POOLS, `� m PATIOS PLANTING AREAS,ADDITIONS TO BUILDINGS,AND ANY OTHER TYPE OF CONSTRUCTION ° �(f� m 6 COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED OR EMBOSSED SEAL SHALL NOT BE CONSIDERED m TO BE A VALID COPY 9 PROPERTY CORNER MONUMENTS WERE NOT SETAS PART OF THIS SURVEY UNLESS OTHERWISE NOTED - Da N U Co- LAI`ID-SU-RYEYhNC-PLLC-- LAND SURVEYING &-PLANI`II�NC`�l � �• 77 S. COLEMAN,ROAD, CENTERE:ACH, NY,1 11720 PHONE:®631.846.9973 - `1 �- �'—- �— A ELO JOSEPH CECERE %@EMAIL:AJ C246NOPTONLINE.NET i PRGPESSIONAL LAND SURVEYOR SCHD USE ONLY j U i 1 POOL NOTES: 2" X 6" CCA 1. POOL AND PROPERTY TO CONFORM TO 2015 IRC&NYS 2016 UNIFORM CODE I TPRESSURE REATED WOOD SUPPLEMENT SECTION R326 AND CODE OF THE INCORPORATED VILLAGE OF t VINYL LINER0 (RAIN.) 2.POOL SHALL CONFORM TO ANSI/NSPI STANDARDS R326.3.1. FILTER SKIMMER (TYP.) QUANTITY �® 3.SECTION 8326.7 POOLALARM REQUIRED. PUMP S.F.AND LOCATION BY POOL FOAM PADDING 3,:00 PSI 4.POOL SHALL COMPLY WITH BARRIER REQUIREMENTS SECTION R326.5. ; i CONTRACTOR a CONCRETE 5.POOL SHALL COMPLY WITH INTERNATIONAL ENERGY CONSERVATION CODE t e SECTION R403.10: I T POOLS AND PERMANENT SPA ENERGY CONSUMPTION(MANDATORY). ` SECTION R403.10.1 HEATERS REBAR a. SECTION R403.10.2 TIME SWITCHES / a a SECTION R403.10.3 COVERS \ / / TOP, MIDDLE 42m 6.REBAR SHALL BE 2"MIN.CLEAR TO EARTH. BOT. :a I I c 7.CONSTRUCTION METHODS AND PRECAUTIONS ARE DICTATED BY GROUND AND ; ° SOIL CONDITIONS TO BE DETERMINED BY CONTRACTOR. RETURN 8.LOCATION OF PROPOSED SWIMMING POOL AND POOL EQUIPMENT BY OTHERS ' I SW IMING POOL Z a C AND SHALL COMPLY WITH ALL LOCAL ZONING REQUIREMENTS. i I I 9.ALL DRAIN COVERS TO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME BAKER I I (VGB)POOL AND SPA SAFETY ACT. , I e` 10.SLOPE PATIO SURFACE 1/4"PER FOOT AWAY FROM POOL — — -1111.BACKFILL MATERIALTO BE FREE DRAINING GRANULAR MATERIAL(NO CLAY OR LARGE ROCKS). / I 12.SUCTION OUTLETS SHALL BE DESIGNED AND INSTALLED IN ACCORDANCE WITH r ANSI/APSP-7. TYPI C/4L BALL ®EAI 13.NO SURCHARGE ALLOWED WITHIN_4'OF SHALLOW END AND 6'OF DEEP END. 14.NO DIVING EQUIPMENT PERMITTED. 0\ SCALE: 3/4" = V-0" 15.CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR TO INSTALLATION OF r POOL � { I STAIRS SHALL BE OF 16. THIS PLAN IS FOR CONSTRUCTION ON PROPERTY AT 66 DALE STREET ; A _ NOTES: SOUTHAMPTON,NY 11968 ONLY. NOT TO SCALE MON-SUP DESIGN i.WALLS SHALL BEAR,ON UNDISTURBED SOIL 17.REINFORCING STEEL SHALL BE INTERMEDIATE GRADE BILLET STEEL WITH A 2.ALL CONCRETE SHALL BE PLACED ASA MONOLITHIC POUR. MINIMUM LAP OF 30 BAR DIAMETERS. 18.HM ENGINEERING,P.C.SHALL NOT BE RESPONSIBLE FOR CONSTRUCTION MEANS, METHODS,TECHNIQUES OR PROCEDURES UTILIZED BY THE CONTRACTOR,NOR FOR THE SAFETY OF THE PUBLIC OR CONTRACTOR'S EMPLOYEES,OR FOR THE FAILURE OF OCCUPANCY PNCY OUR THE CONTRACTOR TO CARRY OUT THE WORK IN ACCORDANCE WITH THIS PLAN. , 3.5' CONCRETE WALL USE ISUNLAWFUL (SEE SECTIONWITHOUT 1 1/2- TO WASTE I ® 9 3 ® THIS SHEET) VYI 1T UT CEN ITIFICA��I OF OCCUPANCY HAIR 6c LINT STRAINER °� �J 9� V PUA�P 3` COMPACTED SAND �'IIMMEMA g ELY ©�'_ FILTER AUTO SKIMMER UNDISTURBED EARTH ENCLOSE POOL TO �TYP.) UPON_COMPL;ETI` ' ORAINIAGF INSPECTOONIS ARE REQUIRED APPROVED AS NOTED Contav TOS Engineering at 765-1560 before POOL I " Q_.. I� �O � Sa�IsIIDI, ®R Provide Engineer's Certification ' , II - ----RO BACK TO DA 2� B.P:# -t NOT TO SCALE that thin drainage has be installed t®C®sfllg. POOL FEE BY; COMPLY WITH ALL CODES QE NO FY BUILDING DEPARTME AT NEW YORK STATE & TOWN CODES ELECTRICAL 765:1 8fl2 8 A TO 4 P FOR THE AS REQUIRED AND CONDITIONS OF .INSPECTION REQUIRED SCHERAATIC PIPING ARRANGEMENT FO OWING INSPECTIONS:, SeblfftDNOT TO.SCALE } 1. FbUNDATION - TWO REQUIRED ; R POURED CONCRETE "VVV 1969 TOWN-RAU40ARD ! 2. RDUGH - FRAMING & PLUMBING 3. I SOLATION =XWN;RUSTEES 4. F NAL - CONSTRUCTION MUST -. -- - -- -- - I� - - ; DATE: ®4/941a®17� COMPLETE FOR H L 0 MRA EN � �I ERH^� , P.C. SCALE. As S50m , ALL; DUCTION SMALL MEET THE - ` �!� -� ! Int I>=u�� a�I� u-u 9 RE IIT2 {� SERVICE AND ARE THE PROPERTY OF HM ENGINEERING P.C..UNAUTHORIZED SHEET; 1 OF 2 ' `iEDOCUMENTS ARE A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE 3 CHERRYWOOD DRIVE EAST NORTHPORT,NY 11731 YO 1RE® TKftL BE PROSECUTED. Tel:(516)476-5392 Fax:(631)960-7671 www.hmamika@optonfine.net RESODENTIAL.CONCRETE a VOID m I HOUT RAISED SEAL AND BLUE SIGNATURE VINYL.LINER POOL.PLAN DEcjpN OR CONSTRUCTION ERRORS.