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HomeMy WebLinkAbout43698-Z U&F®l/(co� Town of Southold 8/25/2020 a P.O.Box 1179 . 53095 Main Rd f Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41383 Date: 8/25/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 460 Fred St,New Suffolk SCTM#: 473889 Sec/Block/Lot: 117.4-18.6 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore fled in this office dated 4/25/2019 pursuant to which Building Permit No. 43698 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 Auriemma,Linda&Paul of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43698 11/1/2019 PLUMBERS CERTIFICATION DATED th rize gnature 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#: 43698 Date: 5/1/2019 Permission is hereby granted to: Auriemma, Linda & Paul PO BOX 317 New Suffolk, NY 11956 To: construct accessory in-ground swimming pool as applied for. At premises located at: 460 Fred St, New Suffolk SCTM # 473889 Sec/Block/Lot# 117.4-18.6 Pursuant to application dated 4/25/2019 and approved by the Building Inspector. To expire on 10/30/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 (i Buil ctor / Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines,streets, and unusual natural or topographic features. 2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. - 4. Sworn statement from plumber certifying that the solder used in system contains less than 2110 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site 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 1 Date. )4-2s 1 New Construction: Old or Pre-existing Building: (check one) Location of Property: D� .dc) AA-{-Le.�-- �� �,ic House No. Street Hamlet Owner or Owners of Property: J_jj,\/t0r Ai,0194HA- Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. �llJ Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: - / Request for: Temporary Certificate Final Certificate: l/ (check one) Fee Submitted: $ f pplicant Signature rjv so Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 sean.devlinl-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Linda Auriemma Address: 460 Fred St city,New Suffolk sr NY zip: 11956 Budding Permit# 43698 Section Block Lot WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Leo's Electris License No: 2199-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor 1 st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceding Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 2 Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 Twist Lock Exit Fixtures 11 Combo SD/CO Other Equipment* Intermatic Pool Panel, Max-E-Therm Pool Heater, Salt Generator, Polaris Cleaner, Pump, Pool Cover, Pool Lights- 2, Switch w/ Lockbox for Pool Cover Notes, Pool Inspector Signature: Date: November 1, 2019 S Devlin-Cert Electrical Compliance Form As bo O �. ( F SOUIyo # # TOWN OF SOUTHOLD BUILDING DEPT. `ycout®ri, 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [" ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ' ] 'FIREPLACE &-CHIMNEY [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT tONSTRUCTION [: ] FIRE RESISTANT PENETRATION- [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) f [ ]' CODE VIOLATION [ ] PRE C/O REMARKS: V, tJhl, DATE INSPECTOR SOF SOUI TOWN OF SOUTHOLD BUILDING DEPT. `ycaurm,��' 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULAT ON [ ] FRAMING /STRAPPING [FINAL et--� [ ] FIREPLACE, & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REM RKS: r V G4 1, Vt.VCA V 66 DATE /0 INSPECTOR /V L41 SOF so # # TOWN OF SOUTHOLD BUILDING DEPT. `yco 765-1802 INSPECTION _ [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND, [ ] SULATIO CAULKING [ ] FRAMING/STRAPPING [ FINAL, , [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: o n , zo­� DATE INSPECTOR ' Macholz, Nancy<nancy@leoselectric.com> GTdfi�tin flJIM(;iaarn riLlit rr��iF3 460 fred st new suffolk 1 message Walsh, George<george@leoselectric.com> Thu, Jul 25, 2019 at 4:41 PM To: Nancy Macholz <nancy@leoselectric.com> Pool Bonding 5 attachments 20190725_163450.jpg 5380K �.t 20190725_163529.jpg 5517K 20190725_163615.jpg 3300K 20190725_163502.jpg 4804K 1 20190725_163436.jpg 5548K 1� . FIELD INSPECTIWORT DATE COMMENTS �► FOUNDATION (1ST) • �H ------------------------------------- 'FOUNDATION (2ND,) z ROUGH FRAMING& PLUMBING y � 1 • I ( n INSULATION PER N. Y-. STATE ENERGY CODE vitA a-c,wq! • s Sw -W . N✓ t tom, I . . FINAL AN& . I . ADDITIONAL COMMENTS to - l& L t j � m a 1 v • � h0y I - ,H TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DE,P=ARTMENT` ":' ;; ''` . - Do you have or,need the following,Before applying 7 TOWN HALL Board of Health `WUTHOLD,NY 11971 3 sets of Building Plans ,:.TEL: 765-4802 b Survey PERMIT NO. Check Septic Form N.Y.S.D.E.C. C� Trustees• Examined ✓ .20 Contact: Approved ,•20 4 Mail to: Disapproved a/c —br Phone: Dt 'F[-a D B din pector APR 2 5 2019 APPLICATION FORBUM-DINGPERNIIT TOWN OF SOUTHGAI D Date �C'����� .20 INSTRUCTIONS a.This application`MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans,accurate plot plan to scale.'Fee according to-schedule. b.Plot plan showing location'of lot and of buildings on premises,relationship to adjoining premises 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 a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone-Ordinance*of the Town of+Southol&,,SuffolklCouhty;New'York,and other applicable Laws;'0iclinances,or Regulations,for the construction of buildings,additions,or alterations or for removal or demolit' n as herein described.The applicant agrees to comply withAl'applicable,laws;ordinanceiibuil`ding code,housing code, regulations,,,and°to admit authorized"inspectors on premises,anddn building for necessary inspections. (Signa .applicant o name;if a=c.orporation) (Mailing,address of applicant), State whether applicant is owner,lessee, agent,architect, engineer, general contractor, electrician,plumber.or.builder Name of owner of premises 4,<)4 1416-e qg4 (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: ' tAA°° I -1:VQ4 f+"e--- House Number Street , ''Hamlet i V 1 ifj County Tax Map No. 1000 Section [ Block—4 Lott L'(0 Subdivision Filed Map No. Lot (Name) 2. State existing use and occupancy of premises.and intended use and occupancy of proposed-construction: a. Existing use and occupancy_ \.�-h� Qp�� d b. Intended use and occupancy_ ,�-�S� -✓ �y��rn �„/q �� 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal, Demolition Other Work i%ru,, z,,j,m rA,-i9 (Description) 4. Estimated Cost 1,�i 00J Fee (to be paid'on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify natur' and extent of each type of use. -J 7. Dimensions of existing structures,if any: Front .Rear �� ; ��'Y' `r' �a D Height Number of Stories Dimensions of same structure with-a'Iterations or�additions: f=ront Rear Depth Height Number of Stories-,,•.`.= ' .T., 8. Dimensions of entire new construction: Front_ Rears' Depth 8 Height Number of Stories 9. Size of lot: Front 3io0 Rear- Depth 20'7 10.,Date of Purchase Name of Forrner Owner 11. Zone or use district in which premises are situated; 12.'Does proposed construction violate any zoning law,ordinance or regulation: 13. Will lot be re-graded t''-xx Will excess.fill be removed from.premises(YES NO 14. Names of Owner of.premises)AM Ayet-enn Address4bo Fao 61#e'J&fff No.W(a-QG5--Zb7 Name of A�e�t`-R.�rtn� Qe,li �� Address 8¢ae`/�JrPhone'IVo (0 3 -7 2�—5�� Name of Contractorl `t�,•.L �o�aros cs Address � , /Gtz(`1�y�.f,11 Q phone No. -�18r' 15. Is thistproperty within-100-feet of a tidalvetland? *YES NO IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE RE UIRED 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. STATE OF NEW YORK) SS: COUNTY OF �1 being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the - (Contractor,Agent, Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will,be performed in the manner set forth in the application filed therewith. Sworn to before me this 2—o�'"' day of 20Iq NkaryPublic Signature of Applit a MARGAREF A. KIDNEY Notary Public-State of New York No. 01 K 16021 l 1 1 Qualified in Suffolk County My Commission Expires March 8,20a3 } Scott A. Russell d°su '� STOWMMIWAXIEIK SUPERInSOR IOWA NA,GrIEMTENT SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 119710 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) ®[2r 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. ®[✓� C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑dD. Sitere aration within 100 feet of wetlands beach bluff or coastal P P , erosion hazard area. ❑E�E. Site preparation within the one-hundred-year f asdepicted lain de icted P P 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 re-ceived 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 witlyour Building Permit Application. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date: P7 DlstNct NAME: )-INON 1 / L l Section Block Lot a � FOR BUILDING DEPARTMENT USE ONLY Contact Information ��s-So�� **** **** rrelept=Number) ' Reviewed By: Property Address/Location of Construction Work: _ _ _ _ _ _ _ — Date_ �,eo K1,.-I� eef Approved for processing Building Permit. � ❑ Stormwater Management Control Plan Not Required. ElStormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM * SMCP-TOS MAY 2014 _ OF SO�j�,o Town Hall Annex 54375 Main Road W � Telephone(631)79ii5pp-1802 P.O.sox 1179 . O roger.richertCOW tt0wn Southol5.ny.us Southold,NY 11971-0959 VVvv � BUILDING DEPARTMENT TOWN OF SOUTHOLD- APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY:' Date: Company Name: L,e I S i✓(ect-Gle Name: Je O v. License No.: Address: 1 • J4 Mtf-m 40 by Phone No.. JOBSITE INFORMATION: (*Indicates required information) *Name: L%4'OA AURke o mA• , *Address: *oo F_YeD Site t *Cross Street: eqnw, " *Phone No.: Permit No.: Tax Map District: 1000 Section: ..117 Block: Lot: *BRIEF DESCRIPTION OF WORK/ (Please Print Clearly) Ax l G dJW0 U�1►uV 6h/►mrn INq (Please Circle All That Apply) 'FIs•job ready for inspection: YES / NO Rough In Final *Do you need a Temp Certificate: YE_ / NO Temp Information (If needed} • *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service -Overhead Additional Information: PAYMENT DUE WITH APPLICATION bo 82-Request for Inspection Form o VF I 0j4r'-. BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 ogenxibh 'L er" ftown.s6dfhol'd','.'hy—.'dt ta- APPI-i-bATiONFOR ELECTRICAL INSPECTION REQUESTED BY: Date,, _3 Company Name: Name: License No.: �5 Ci,Jont-:;- email:. I-g-o-::i cS cc�--C Address: I q A-,b rA k— -aa-a 76- J. NI-WN A U- J t S(.0�L Phone No..," L31- -'6B' SITE INFORMATION: (All information Required) Name: Q( Tr Address: LI&O r(nj Cross Street: Phone No.: Lf 41­7 'Bidg.Permit#: em mcgg 11f6x Map District: _ 1000 section: III Block:-,,u BRIEF DE RIP.TION OF WORK(Please Print Clearly) -----------7- Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES NO Issued On-, Temp In'formationi (All information required) 1 Ph 3 Ph Size: #Meters.,­ Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected -Underground -Overhead J#-Undeeground Laterals 1 2 H Frame Pole Work done on-Servic92-,,, Y R:\V6= Addition'61 Information* I D UE;:� U -A ;PAYMENT'DUE WITH APPLICATION 82-Request for Inspection FormAs `0(D ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: Nb APPLICATION FOR OUTDOOR POOL PERMIT 1p EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM [ CERTIFICATE OF WORKER'S COMPENSATION [� CERTIFICATE OF LIABILITY INSURANCE [)dD SUFFOLK COUNTY LICENSE -{�-- SUFFOLK COUNTY PLUMBER LICENSE [ ] SUFFOLK COUNTY ELECTRICIAN LICENSE NO 4 SETS OF PLANS - (3 STAMPED) [� 3 SURVEYS with FILTER LOCATION APPLICATION FOR ELECTRICAL INSPECTION APPLICATION FOR CERTIFICATE OF OCCUPANCY [ C.O. [ ] TAX BILL $400.00 CHECK FOR PERMIT FEE SITUATE �EoRGE's NEW SUFFOLK READ TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000- 117-04-18.6 SCALE 1 "=40' SEPTEMBER 7, 2012 FEBRUARY 4, 2014 UPDATE SURVEY AUGUST 29, 2016 FOUNDATION LOCATION FEBRUARY 9 2018 UPDATE SURVEY APRIL 3, 2016 STAKE PROPERTY LINES AREA = 64,873 sq. ft. ez'% 1.489 ac. CH41/y K�NCep`t^SC o CO 8 7 5 Ayz+S I moa, FR4M£S Nc MON ENCf D•830•� f Cf .%. Eb WIRE STpC W 4£f&INCE KADf NCC DD,00.01 p. 0.8.. ee FNCf lbvC£0 L. PIpE In 8 O; SS1� rJ; YLU O+ U O y+ m m n�o o n 3 72.80. s, A' l,1c.� t;`� 30•, coo o o co NC Mp OE 03N Wj N fNkAD£INCE '18--37' i EDGE OFC 0 /yN / ®�-C�N .• j WIRE"ENCE, MON ��� .. .8 C MO f,Drt4C M ER fDGE•OF C� 4D oN c. N R/NG �;R A 50,3 N 72. mar r rn o m N •2 °, f oRya`!'k 8�R 12S'00' MCo°IN/c „•.' ,•a' �c s� WO 6BR OD f STAKE a.. .DRAIN s po GRATE N • SA 24.4' p� `3`3`• ' N N6' 3 � a5 20 N 4 24.3' N 31.7' o E CEtIAR w HpUSE R8t GARAGE, 126 — u C011C. SIAB N 32.3' /3 a>� OUTSIDE SHOWER DEC WOOD pC q WOOD STEPS I o xN I o QQ - I r SET WOOD STAKE o W I 3 w � I W I O O��o� 2 2 J < O O O o I EDGf OF CDo LfARIN 40' : O��S � 4 ❑ &es R 55 6' rani G O -r .Logic£ N 133'17' 0,, W ul SLAB 1.2's EDGE o WOOD, CONC. MON EDGE OFI WOODS METAL SHED ON 1.6'S 24' CONC. SLAB PREPARED STANDARDS FOR TIOTREANCE SURVWITH THE EYS AS ESTABLISHED �A14CAUM RjT.g SSCO m 208.3 ACT• CONCH BY THE L.I.A.L.S. AND APPROVED AND ADOPTED ZLlCO g NCO/� DEED MON. FOR SUCH USE BY THE NEW YORK STATE LAND TITLE ASSOCIATION. NAf�FE E ... ` ArESip Np O HOMARD a � f 1 >•�,CN S. Lic. No. 50467 ■ SE UNAUTHORIZED ALTERATION OR ADDITION NOTES: at h an oaf t�- Corwin®r w 1 n III THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM EDUCATION LAW. EXISTING ELEVATIONS ARE SHOWN THUS: Land Surveyor COPIES OF THIS SURVEY MAP NOT BEARING 2. DEED REFERENCES ARE TO DEED LIBER 11840 PAGE 186 THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. Successor To: Stanley J. Isaksen, Jr. L.S. CERTIFICATIONS INDICATED HEREON SHALL RUN CERTIFIED T0: Joseph A. Ingegno L,S. ONLY TO THE PERSON FOR WHOM THE SURVEY 'IS PREPARED, AND ON HIS BEHALF TO THE PAUL AURIEMMA Title Surveys — Subdivisions — Site Plans — Construction Layout LE DING LE �INSTITUTIIONEUSTIEDTHE EON,AL AND LINDA LINDA AURIEMMA To THE ASSIGNEES of THE LENDING INSTEWART TITLE INSURANCE COMPANY ZONE (631)727-2090 Fax (631)727-1727 TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. WELLS FARGO 9FFICES LOCATED AT MAILING ADDRESS THE EXISTENCE OF RIGHTS OF WAY 1586 Main Road P.O. Box 16 AND/OR EASEMENTS OF RECORD, IF -sport, New York 11947 Jamesport, New York 11947 ANY, NOT SHOWN ARE NOT GUARANTEED. YORECompensation Workers' STATE CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Arthur J Edwards Mason Contracting Company Inc. 631-744-4455 929 Route 25A Miller Place,NY 11764 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America TOWN OF SOUTHOLD P.O.BOX 728 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD,NY 11971 00984424-0000 3c.Policy effective period 07/01/2018 to 07/01/2019 4. Policy provides the following benefits: ✓Q A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: ❑✓ A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 06/22/2018 By S Glxl3�� S 4�at- (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 1-888-278-4542 Name and Title Stuart J.Shaw,FSA,MAAA - Vice President,Group Insurance IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carriers authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Foran DB-120.1. Insurance brokers are NOT authorized to issue this form. � n D13-120.1 (10-17) III iiiiiiiiaiiiiiii iilll�n� 1 New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112377925 Q � LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL ' TARRYTOWN NY 10591 } t SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 765253 06/29/2018 TO 06/29/2019 06/12/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK,EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED'AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 195404147 pp I III �uamiliminimmilniemmsnmIlRI� � 00000000000059684277 Focm WC-CERT-NOPRINT Vcrsion 2(0229/2016)[WC Policy-24384919] U-26.3 74 [000000p00000596842M[0001-000024384919][##GI[14901-08ICen NoP.CERT 1][01-00001] DATE(MMIDDIYYYY) ACC> CERTIFICATE OF LIABILITY INSURANCE 11%. � 1 01108/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Brendan J Smith Liberty Risk Management,Inc. PHONE (631)569-5633 1 ac Ne•(631)569-5636 664 Blue Point Road,Suite A ADDRESS: brendan@libertyrisk.org Holtsville,NY 11742 INSURERS AFFORDING COVERAGE NAIC i INSURERA: Hartford Insurance Company INSURED INSURER 9: ' Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J.Edwards Pool&Spa Centre INSURERC: 929 Route 26A INSURERD: Miller Place,NY 11764 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000.0 REVISION NUMBER: 2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MPOI D EFF PMIODY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY 16 U U N OZ8691 01/01/2019 01/01/2020 EACH OCCURRENCE $ 'I'0001000 DAMAGE TO RENTED CLAIMS-MADE �OCCUR PREMISES Ea occu encs $ SOO OOO MED EXP(Any one person) $ 10,006 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000.000 X POLICY 0 JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea awdent ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per a'ddent $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAS HCLAIMS-MADE _ _ AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE BJS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by BJS on January 08,2019 at 12.50PM } Suffolk County Department of Labor, -Licensing & Consumer Affairs a ` VETERANS MEMORIAL, HIGHWAY * HAUPPAUGE,NEW YORK 11788 r ' sty DATE ISSUED: 0701/1978 No. H-4436 - d''l'- L K Suffolk County Home Improvement Contractor License d This is to certify that ARTL-TIIR T_ EDWARDS doing business as ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA (1 SUPP) a: having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME F yY n§ IMPROVEMENT CONTRACTOR, in the,County of Suffolk. z} teY License Category { NOT,VALID YVITHUUT Additional Businesses 1• a "� DEPARTMENTAL-SEAL. H26-POOLS&SPAS/CERTIFIED 1} 1 AND A dbt&ENT ARTHUR EDWARDS POOL& H3-POOLS/SPAS CONSUMER AF'F'AIRS SPA CENTRE Hl-GC ID CARD _ Suffolk County Dept of i Labor,Licensing&Consumer Affairs ld -h i Commissioner p:h , HOME IMPROVEMENT LICENSE $" Name ARTHUR J.EDWARDS Business Name ,? ' 7iARTHUR EDWARS MASON P- M CONT.CO INC DBA `" This certifies that the s bearer is duty licensed License Number H-4436 by the County of Suffolk Issued: 07/01/1978 ' CommissionerExpires: 071011-2020 `•" Commi ,��°,�y,,� ..._,�. _ '..""+;'nen`h'- .a'` - .+;'=;,+:+`• -b .w^i. - � ws-r. �'«"`K _:nj-.. goaj APP. VED AS NOTED p� DATE: B.P.# 3 O FEE: BY: OCCUPANCY OR NOTIFY Bl1ti:DING DEI AR ENT AT 765-1802 8 A TO 4 PM FOR THE USE IS UNLAWFUL ,FOLLOWING INSPECTIONS: I. FOUNDATION - TWO REQUIRED WITHOUT CERTIFICATE FOR POREb 2. ROUGH'-- fl F_AMINGCRETE& PLUMBING OF OCCUPANCY 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEWaed til9`F 1 �mv YORK STATE. NOT RESPONSIBLE FOR ENCLOSE POOL TO CpDE. DESIGN OR CONSTRUCTION ERRORS. k RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 i?ON COMPLETIU4 - OF THE TOWN CODE. ��;-�-_�E�®R�:-CATER COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF uV S0�'�'�^rrneini of AAIAI__._Ils/` ELECTRICAL BOARD v "� •,�, r^' INSPECTION REQUIRED SOUT TEES h A 0 H 0F H AkWnin m To nr" From F45r&PwV To To itrberr fNwaOPW4 A - raoo.a ww<or F Plan Piping . Arrangement WON SecHan 42~ Section B—B r PSL Ca„d,e 10M Section A—A Typical Wall Section SIZE A B C D E F G H AREA CAP FEET FT FT FT FT FT FT FT FT SQ. FT GAL. pardbaft 15 X 30 15 30 10112 5 3 3 9 450 15,000 "� ` POOL&SPA CENTRB 16 X 36 16 36 12114 6 4 4 8 576 21,600 PERMACRETE WALL SYSTEM 18 X 36 18 36. 12114 6 4 5 8 648 24,300 929 Route 25A Miller Place NY 11764 c"YStu" 20 X 45 20 45121114 6 4 5 10 900 33,000 (631) 744-7185 FAX (631) 744-0174 24 X 44 2444 18 14 8 4 8 10 798 35,000 ; Suffolk License #4436—HI PbM 24 X 48 24 48 20 16 8 4 6 10 900 38,500 f Nassau License #HI74450000