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HomeMy WebLinkAbout44238-Z Zr Z--t - �og�FFol�oy Town of Southold 8/11/2020 P.O.Box 1179 o - 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41340 Date: 8/11/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1745 Aldrich Ln,Laurel SCTM#: 473889 Sec/Block/Lot: 125.-2-1.19 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/23/2019 pursuant to which Building Permit No. 44238 dated 9/30/2019 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: Construct an accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to Leiblein,Gary&Lorraine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44238 07/29/2020 PLUMBERS CERTIFICATION DATED 1% Au h i d Signature �g�FFO TOWN OF SOUTHOLD BUILDING DEPARTMENT y x 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#: 44238 Date: 9/30/2019 Permission is hereby granted to: Leiblein, Gary PO BOX 632 Laurel, NY 11948 To: demolish existing swimming pool and construct a new accessory in-ground swimming pool as applied for. Must maintain 25' side yard setbacks. At premises located at: 1745 Aldrich Ln, Laurel SCTM # 473889 Sec/Block/Lot# 125.-2-1-.19 Pursuant to application dated , 9/23/2019 and approved by the Building Inspector. To expire on 3/31/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Bui t nspector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines,streets, and unusual natural or topographic features. 2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial`building, industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building.and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00, Additions to dwelling$50.00,Alterations to dwelling $50.00, Swimming pool $50.00,Accessory building$50.00, Additions to accessory building$50.00, Businesses$50.00. 2- Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential $15.00, Commercial$15.00 Date. gjal 1 q New Construction: Old or Pre-existing Building: (check one) Location of Property: 1 q 4S_ ALM,►Ck b4 &�,eL House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section 12s �. ( Block a Lot 4 Subdivision CV%"o croo Filed Map. 1 Lot: Permit No. `4 l ��D Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ �� Applicant Signature pE SOVry®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 • �� sean.devline_town.southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To Gary Leiblein Address: 1745 Aldrich Ln city.Laurel st: NY zip. 11948 Building Permit* 44238 Section: 125 Block- 2 Lot: 1.19 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Laurel Lighting License No: 4718ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey 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 2 Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceding Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 4'LED Exit Fixtures Pump 2 Other Equipment. Pump on 220GFCI Breaker, Booster Pump on 220GFCI Breaker, Salt Generator Notes* Pool Inspector Signature: Date: July 29, 2020 S.Devlin-Cert Electrical Compliance Form.xls # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] SULATIOWCAULKING [ ] FRAMING/STRAPPING [ FINAL [ ] FIREPLACE-& CHIMNEY _ [ -] 'FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [_ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O RE KS: ( yxt; cc, DATE INSPECTORX61� souryo� 1 I rlLl S A L, et cq # * TOWN OF SOUTHOLD ILDING DEPT. `ycou765-1802 (L-t ib I INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ]- FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL)12OO [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE Sq/ u INSPECTOR 27� J FIELD INSPECTICiN REPORT -DATE COMMENTS b FOUNDATION (IST) -------------------------------- FOUNDATION ------------------------------FOUNDATION (2ND) el�i z o 'J ROUGH FRAMING& PLUMBING y r INSULATION PER N.Y. y STATE ENERGY CODE I ol< -1-Zq-ZD FINAL ADDITIONAL COMMENTS (b 06 ®" c,- I� p 00 Z Orn w b � N x TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPfARTMENT• 'Do you' yo - u have,o;need the following,before applying? TOWN HALL Board of Health '"SOUTHOLD,NY 11971 3 sets of Building Plans 7654802' PERMIT NSurvey O: �-/ Check Septic Form N.Y.S.D.E.C. Trustees. Examined ,20 Contact: Approved ,20 Mail to:. �zg ���_ Disapproved a/c — Phone: L. BuiWmWf6pector �• � -- Sr 3 2019, � ': APPLICATION FOR=BUILDING PERMIT Date 201Q INSTRUCTIONS a.This application MUST be completely filled in by typewriter onin 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,ofthe Town-of+Southold;^Suffolk?County,New1York,and other applicable Laws;"Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or dem ' 'on as herein described.The applicant agrees to comply withA applicable laws,ordinances;cbui�lding code,housing cc d regulations,-'and,to admit authorized"inspectors on premises,andtin building for necessary inspections. (SignWe of applicarddr name;if&corporation) , /I,, (Mailing,address of applicant), State whether applicant is owner,lessee, agent, architect, engineer,,general contractor, electrician,plumber.or.builder Name of owner of premises �� ��1�l l rN a (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. ,fib- 4T Plumbers License No. � Electricians License No. Me Other Trade's License No. 1. Location of land on which proposed work will be done: A 1741- & Lir e� a House Number Street Hamlet .r, ; ur '.N@Vl 10 9161a—oil 11A natoM County Tax Map No. 1000 Section 25 Block ►OI.�' Subdivision LR 6l to ftw Filed Map No. 7gti7Su�./r 411u i ,. ,��a�n9.cc(�yFu1 (Name) _u' �nJ,- 2. State existing use and occupancy of premises and intended use and occupancy of proposed"construction: a. Existing use and occupancy oewe b. Intended use and occupancy_ A-e5Nwr..ft Lw%mmIAfA 3. Nature of work(check which applicable): New-Building. Addition Alteration Repair Removal- Demolition Other Work_ lt�Jgn�„urs V►r�c Jwl/nn,rvc 4. Estimated Cost Lj, Ooo- Fee (Description) (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 nature and extent of each type of use. J I NP�4• 7. Dimensions of existing structures, if any: Front Rear = Depth l Height Number of Stories ” ; I Dimensions of same structure with"-61t6ratio ns or�additions: f=ront )8x 32- P�0'6!k-: Rear Depth Height' Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height - Number of Stories 9. Size of lot: Front _____Rear I"�O) Depth 5Bb 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: No 13. Will lot be re-graded f ODC Af,0A 00Will.excessfill be removed.from premises: YES NO I`7+S A,.oc►el, La 14. Names of Owner of premises Le-0o 1-e I n Address_ J Ajp , iw, 1i9.R Phone No. 31-7b�F770 Name of Architect Address - PhoneNo Name of Contractor F-WAcM c Address 42g et z:,A Phone No. --7 I pr" 15. Is thisproperty,within 100-feet of a tidalvetland? *YES NO s IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE Q 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 OFFf�Xk c JE6hJAGraS being duly sworn,deposes and says that(s)he is the applicant (Name of indivi ual signing contract)above named, (S)He is the LMA�e_ (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 f day of 20 !qi 4NO Public Signaturot Applicant o MARGARET A. KIDNEY Notary Public-State of New York No. 01 K1602111 I Qualified in Suffolk County My Commission Expires March 8.20_Z Scott A. Mussell f§UP))�� � - STO�]E�.I��1 WAT E K SUPERVISOR l��l[A\1�A\�G�]EI��1[]E1N'7C' SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 '� Town of Southold � CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE ANY OF THE F'OI LOWIING: Yes No (CHECK ALL THAT APPLY) ®[YA. Clearing, grubbing, grading or stripping of land which affects more �/ than 5,000 square feet of ground surface. ®[ E. Excavation or filling involving more than 200 cubic yards of material ®� within any parcel or any contiguous area. . Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ®�D. Site preparation within 100 feet of wetlands, beach, bluff or coastal ®[� erosion hazard area. E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ®E3"'1F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT. (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date. District NAME: -el Y- 2 7 Q Section Block Lot � c p **** FOR BUILDING DEPARTMENT USE ONLY n **** Contact Information. ��1��w —0 I ?Q (Telephone Numbed Reviewed By: _ _ Property Address/Location of Construction Work _ Date — — _ _ _ _ _ _ — _ _ _ _ Approved for processing Building Permit. W. Stormwater Management Control Plan Not Required, LA,W.e�- (9�`� Stormwater Management Control Plan is Required (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 Town Hall Annex ' Telephone(631)765-1802 54375 Main Road felUWl$O1)goP.O.Box 1179 rOger.rlChe8.nV .US -- ----—Southold;lVY 11971-0959--- -------- - - -'! - ----- - ' BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: q 1 q j1 Company Name: f aj � LjA-b_rj Name: �eN loense No.: Address: Q'7r] M,,(,,(, ko Lawc- W 1 I qq,6 Phone No.: 3 - c57-33b JOBSITE INFORMATION: (*Indicates required information) *Name~ CAR,/ Lel b t c n *Address: 174S vim, Lr\/ J_ PY 1q -?,. *Cross Street: -r , nic a wyj l,e_ Ro *Phone No.: 6,31- S- 8r7 Permit No.: Z-�; - Tax Map District: 1000 Section: . 12-5 dock: a Lot: I 19 *BRIEF DESCRIPTION OF WORK(Please Arint-Clearly) ►�P�C�i lax 32 InQ ruLi Vinyu (�h/lrn(MOV g PWc. (Please Circle All That Apply) *is job ready for inspection: YES NO Rough In Final *Do you'need a Temp,Certificate: YE / NO Ternp-information (If needed) *Service Size: 1 Phase 312hase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead dit[6-wgI-Infb-rm-atl0r: YMEN1`DUE-WITH APPLICA-TION c 82-Request for Inspection Forth PERMIT# Address: Outlets ` s Siirfate vonces mns Fr_idi •,' lP�S' ' -AN ! . - �rZF1--Q a.Lip. I/ Vl � 4youAWorker CERTIFICATE OF INSURANCE COVERAGE M Compensation DISABILITY AND PAID FAMILY LEAVE BENEFITS am 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 and Address of Insured(use street address only) 1 b. Business Telephone Number of Insured ARTHUR J EDWARDS MASON 631-744-4455 CONTRACTING COMPANY INC 929 ROUTE 25A 1 c. Federal Employer Identification Number of Insured or MILLER PLACE NY 11764 2700 Social Security Number 11-2377925 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the certificate Holder) The Guardian Life Insurance Company of America TOWN OF SOUTHOLD P.O.BOX 728 SOUTHOLD,NY 11971 3b. Policy Number of entity listed in box 1 a": 00984424-0000 3c. Policy effective period: 01/01/2019 to 01/01/2020 4. Policy provides the following benefits: ®A. Both disability and paid family leave benefits. ❑ B. Disability benefits only. ❑ C. Paid family leave benefits only. 5. Policy covers: ® A. All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B. Only the following class or classes or 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:o7/o3/2o19 By: FftryeJ d+r+OrLA."_ Raymond J.Marra (Signature insurance carrVes authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number: 1-888-278-4542 Title: Senior Vice President,Group and Worksite Markets IMPORTANT: If Boxes"4a"and Sa 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.Mall 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, DB Plans Acceptance Unit,PO Box 5200,Birmingham,NY 13902.5200. DB120.1 (1/18) PART 2. To be completed by 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 compiled with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed: By: (Signature of NYS Workers'Compensation Board Employee) Telephone Number: Title: Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. Additional Instructions for Form DB-120.1 By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business referenced in box 1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". The insurance carrier must notify the certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to non-payment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured form 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 the by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c,whichever is earlier. cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? 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 Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220.Subd.8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits 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. D6120.1 (1/18) New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y. 10007-1100 , CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112377925 � ❑ LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 53244 06/29/2019 TO 06/29/2020 06/21/2019 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: 506150454 I000R00000100007717667724 O011EII Form WC-CERT-NOPRINT Version 2(0229/2016)[WC Policy-24384919] U-26.3 40 1000000000000716724001[0001-0000243849191[01GII15159-06nCe�NoP.CERT 1][01-00001] 4`i' Suffolk County Department of Labor, Licensing & Consumer Affairs VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 0701/1978 No. H-4436 Suffolk County R- Home Improvement Contractor License This is to certify that ARTMTR J- RDWARM doing business as ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA(1 SUPP) 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 IMPROVEMENT CONTRACTOR, in the County of Suffolk. 0 o — 1 hhh License Category M Additional Businesses Ch H26-POOLS&SPAS/CERTIFIED M M CL ARTHUR EDWARDS POOL& H3-POOLS/SPAS 77 SPA CENTRE HI-GC 0 ID 0 CD / toCD M 0 W X-' 4 35 Z r 0 M0 Commissioner-r <0 00 4 CD 0 SO,M 2 2 0 X is z CD ODBE if-5 CA) (D 0 M M 0 z En M 1 ® DATE(MM/DDIYYYY) A`�® CERTIFICATE OF LIABILITY INSURANCE 0110812019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER NAMEA r Brendan J Smith NAME: Liberty Risk Management,Inc. PHONE • (631)569-5633 ac No•(631)569-5636 664 Blue Point Road,Suite A EMAIL brendan@libertyrisk.org Holtsville, NY 11742 INSURERS AFFORDING COVERAGE NAIC# INSURERA: Hartford Insurance Company INSURED INSURER B: Arthur J.Edwards Mason Contracting Company Inc. INSURERC: DBA Arthur J.Edwards Pool&Spa Centre INSURER D 929 Route 25A INSURERS: Miller Place, NY 11764 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. ILS TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDYEFF/YYYV MMIIDDffYYYY OLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY 16 UUN OZ8691 01/01/2019 01/01/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE AGE TO LAIMRENTED ®OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER* GENERAL AGGREGATE $ 2,000,000 X POLICY 0 PRO- [—]LOC PRODUCTS-COMP/OP AGG $ 2.000,000 JECT OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ DEC) I I RETENTIONS $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY YIN ER STATUTE I ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N/A E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED9 (Mandatory In NH) E L DISEASE-FA EMPLOYE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more apace 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 (BJSLJ ©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 C PLS'WITH ACL co NEW RK STATE �QaDWIN C AS REO EAfE39TIONS SOI D TaWVi ZBA >r11OLD TOMIPAMI F fiEE: � ' SY. b4 �� n ,. 1 ZO 65-im a TO M FOR THE N. DEC OWNG �, I FOUitln�aTtOldMED T1COR TRLE, GUARAt COMPANY 861 m� ar FR SUFFOLK COUNTY NATI AL BANK `�85 SURVEY OF VALL1AM T. BAIRD tiff SUSAN C. BAIRD, >t � LOT 6 . ,�aT b d HEAP OF FQVLyoT Q ��MAT. 0- LAND OF RICHARD J. CRON , yam FILE No. 7975 FILED SEPTEMBER 30. 1985 tJCT TSE ALL NSTRuC � > .:. �o i_ Ra;� �, CZ SITUATED AT EMERtTS OF TDfE MEET THE REQU ,� IE = d ; 3 LAUREL OR STATE. NOT RESPO FOR C0E OF TOWN OF SOUTHOLD t OR UCT ERRORS. NEW YORK SUFFOLK COUNTY; m:� ='`� S.C. TAX No. 1000-125-02-1..19 .? a�r�) � �,,. Moro L" ,� etc," —> SCALE 1-_40•GQ. OCTOBER 19, 1993 C ��� �����N �w - a'g � t �s � ;` �'` •0 NOVEMBER 10. 1994 (UPDATE-SURVEY)- "` r %aV_ A- F OD ®., PREVENTfON 20 P� 1 %w.� .� — s P.3 THOLE COME. N 10 a.� ` L0�61 t AREA = 102 590.90 sq. it. 2.355 °c. r A. 6 5 a ' wTL P,r ,c p�FN�gi'1 OF i a: vp '—DWN tilt • .t ;'' \ 66 N.Y.S. L;,— No. 498 to• � � �''' � �/ ) 1 1 G, ti Z IZIO Pte, J®seph A. Ingegn® I e i SAS W=06 7��w ww%a°` Land Surveyor PRrar{11� �EY�X D7lM 1H r-14 mwe&C!9 $ . tlV 19Dq av-= I rnxu�s�rr..s wa+r_ a w4v tie vso aeaare+s soxx sn OR meoam ax x ml.Nor ac Cr4amc D C7 l:s l.Al.i MC RPR1(•7 N R9 — C•xw6uc£.m LeyrX i '!E✓w'tc-t LY) .Td et r CACP MAX C�'Y. T1da S°7ela-'S�66.fcbry — sr.P"w •• DU�Nc,�a83 lmotuS NOlW 4451►.M dYY.TS 1!�'ESitw?I M7 tw.Dt.1fE str7ct PNON£ (�t6)72:-2090 Fax (510722-ST93 I _ - Tj'r 5 AMD a KM aflMf 70>� - Mta!O G i1S a iCCCR.' L(w Wa wsrri.7��-naoi�i.HOS O'TRXS L=70 AT eG1E.lJG AL1DRf55 NIX, Y-:.:SrNa'.i.RL h04 m G^. To-M RYA O 1!C tDtm�C6T- n'r4k t�Na[:RN.Cfilt etE m L qw sqjam Y 10.71 PA 8= 1931 A,FaOoI Riwfi.rnQ. NR Tai 119!`1 ' OCCUPANCY ENCLOSE POOL TO CODE USE- 10" UNLAMRX UPON COMPLETION BEFORE V ATE19" WITHOUT ag���'yyjq��{/��lq`_ @��gp$[$p��q?T7}:p�.��gjNn PROVED AS NOTED DATE:r� - B.P.# Kan FEE:oc B`r NOTIFY BUILDING rEPARTMENT AT RETAIN STORM WATER RUNOFF 765-1802 8 AM TC - PM FOR THE PURSUANT TO CHAPTER 236 FOLLOWING INSPECTIONS: OF THE TOWN CODE. 1. FOUNDATION - '"P10 REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3 INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEVA' YORK STATE. NOT RESPONSIBLE FOR ELECTRICAL DESIGN OR CONSTRUCTION ERRORS. INSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF --nIaLiitfBtB�B�V�I-Z�-�=-� ENCLOSE POOL TO C068 �'F t PQ1V COMPLETION OCCUPANCY OR #k Mqj n+a, f USE IS UNLAWFUL CERTIFICA7 251S' d� yitrd- WITHOUT OF OCCUPANCY se-loke-I- A Fabuno NIT.RFW �® T® ft cow Plan ' Piping . Arrangement 42w �-,OE OF NF �jj i b �0� _ Section A—A Typical Wall Section �Fss►oNPA-��G. SIZE A B C D E F G H AREA CAP FEET FT FT FT FT FT FT FT FT SQ.FT GAL. 14 X 28 '14 28 8 10 7 3 3 8 392 12,000 16 X 32 16 32 8 14 6 4 4 8 512 19,5001 POOL SPA CKNM ��� ����� � SYSTEM -- - �� 18 X 32 18 32 8 14 6 4 5 8 576 21,600 ,.929 Route 25A Viler Place NY 11764 20 X 40 20 40 14 14 6 4 5 10 800 33,000 (631) 744-7165 M (631) 744-0174 24 X 44 24 44 18 14 8 4 8 10 798 35,000 Suffolk incense # 6—M 24 X 48 24 48 20 16 8 4 6 10 900 38,500 , Nassau Uceffise # 0000