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HomeMy WebLinkAbout43597-Z Town of Southold 9/11/2020 P.O.Box 1179 a o ! S 53095 Main Rd Southold,New York 11971 r`=Q.zxcri%� CERTIFICATE OF OCCUPANCY No: 02627 Date: 9/11/2020 THIS CERTIFIES thalt the building IN GROUND POOL Location of Property: 375 Southern Blvd, East Marion I SCTM#: 473889 Sec/Block/Lot: 21.-3-27.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/26/2019 pursuant to which Building Permit No. 43597 dated 3/29/2019 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 Misthos,Paul&Thalia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43597 7/1/2019 PLUMBERS CERTIFICATION DATED a ut d ignature TOWN OF SOUTHOLD BUILDING DEPARTMENT moo � TOWN CLERK'S OFFICE • SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 43597 Date: 3/29/2019 Permission is hereby granted to: Misthos, Paul 169-48 24th Ave Whitestone, NY 11357 To: construct an in-ground swimming pool as applied for. i i At premises located at: 375 Southern Blvd, East Marion SCTM # 473889 Sec/Block/Lot# 21.-3-27.1 Pursuant to application dated 3/26/2019 and approved by the Building Inspector. To expire on 9/27/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 1: $300.00 Bui ding Inspector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 I I 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 Certificatejof Occupancy 4.25 4.- Updated Certificate of Occupancy- $50.00 ' 5. Temporary Certificate of Occupancy-Residential $15.00, Commercial$15.00 Date. New Construction: ,, Old or Pre-existing Building: (check one) Location of Property: 3�J� &JU-a-i 4WD E,NA4_A0r1 House No. n/ Street Hamlet Owner or Owners of Property: 7 i-LlA e PA J(- 14tS 3S Suffolk County Tax Map No 1000, Section Block 3 Lot o�1 Subdivision Filed Map. Lot: Permit No. ��� Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: - Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ �� Applicant Signature fjf so Town Hall Annex Telephone(631)765-1802 54375 Main Road! Fax(631)765-9502 P.O.Box 1179 ! roger.richert(Ct-town.south old.ny.us Southold,NY 11971-0959 MUM BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To. Paul Misthos Address: 375 Southern Blvd City: East Marion St: New York Zip: 11939 Building Permit#: 43597 Section: 21 Block- 3 Lot. 271 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Leo's Electric License No: 2199-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks 2 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment In ground swimming pool to include, bonding, 1-pool light, control panel, 1-pool pu 1-Polaris pump,3-GFCI circuit breakers,salt generator,pool heat pump Notes Inspector Signature: Date: July 12019 81-Cert Electrical Compliance Form As OF SOUIyOlo # TOWN OF SOUTHOLD BUILDING DEPT. courm,��' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: CG � DATE INSPECTOR<�` l of50UTyO 3�-� ,stn, mv& f # TOWN OF-SOUTHOLD BUILDING DEPT. °`ycourm765-1802 INSPECTION, [ ] FOUNDATION 1ST [ ] ROUGH PLBG. - ] FOUNDATION 2ND [ rFINAL7 ULN/C ULKING FRAMING /STRAPPING [ [ ] FIREPLACE & CHIMNEY- [ ] FIRE SAFETY-INSPECTION " [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 4 DATE b INSPECTOR jo Iv r , Ir JV k •I„rt �'r� ��^�� •�r �,. �'^' •..� „,�'.`� � ,s ly e 'f 04 . 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'■� !'a`..r �,j, ..- �. �.f" ..a Svc•, rs - _ �. ^� z ,.4 .. -8 y 7-4 �' F y' fir''�� Y-'•iG '� ��x�t��^!�, �:.�, ... 3.::.it 1`df j �+i- • v x 4 9- TOWN r _ 1 _ J Y y w •.�• •� Ism � :, 7 � - y.. r ��time -�� � ..� :..+ �• i �'�'. '., �w e Ei ik .. �, ,yam f„� � �!� '•',` - p � � +*' � � � �0 :,, Yet' .�•�It ..i.N'fi + �' v•..}f }.`. �� ,� u. ' vwi ' A FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) 'FOUNDATION (2ND) Vy 'ren ROUGH FRAMING& PLUMBING y INSULATION PER N.Y. y STATE ENERGY CODE FINAL Matti . 4 ' t ADDITIONAr,COMMENTS ` d C �ay Jl e i G p 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 3 sets of Building Plans NTEL:-765-1802 PERMIT NO: Survey • Check Septic Form N.Y.S.D.E.C. ' • - Examined ,20 Contact:Trustees Approved Z`� ,20 Mail to: G Disapproved a/c Phone: Building Inspector L MAA 2 6 2019 PLICATION,FOR:BUIL•DING,PER HT— Date ���Z- 20 q INSTRUCTIONS TOWN OF SOUTH010 - a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plats,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+Southold;�Suffolk;County;New=York,and other applicable Laws,�Oidinances or Regulations, for the construction of buildings,additions,or alterations or for removal or demolitio s herein described.The applicant agrees to complyith,all applicable laws,ordinances,;building code,housing code,an re ations,,-and to admit authorized'inspectors on premises,anddn building for necessary inspections. (Signature o plicant or y ,if a corporation) qzq jzj-z�A ,i! - P&W� 0 if 7&X (Mailing address of applicant), State whether applicant is owner, lessee, agent, architect, engineer,general,contractor, electrician,plumber.or.builder r Name of owner of premises PfiVL c A-uA (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. 1443b- HT Plumbers License No. Electricians License No. 1430%- HE Other Trade's License No. 1. Location of land on which pro osed work will be done: House Number Street Hamlet, County Tax Map No. 1000 Section o`1� Block Lot o2 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 N-2 -�rrh���� �-.25�gQ„i� b. Intended use and occupancyjC�L 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work 6j,m,,,j,4o, (�L 23-fY.p (Description)H tkox 1 b C_ IJr� 4. Estimated Cost �7 030- 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 nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front A ' Rear. 31 Depth 2b Height Number of Stories Dimensions of same structure witi!-Wterations or additions: Front Rear Depth Height Number of Stories S. Dimensions of entire new ce l: Front 73x� vil4 x J(p_L --D'e'pth `a'3'lz,�8 6,eP Height - Number of Stories 9. Size of lot: Front 1 Rear. /25-5- Depth a' 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situate(I 12. Does proposed construction violate any zoning law, ordinance or regulation: 13. Will lot be,re.,graded Q3X ON'-� Will excess fill be removed from,premises: �NO 14. Names of Owner of premises .PPAJL N16M:S Address 3K' &rt,,r-J. &-yrs Phone'No. 9t_7-f_'78- (0!S-2S Name of teetP►41de&- `ihz,Ac ,b keihN Address 4 &2eL_ 1.,j 4+-V&Xhbn&No U3--72Y-'5-140 - Name of Contractor AmhL LWA� ras Pa3,,s Address q2ot et 2_,�A- Phone No. 3)- 71NY 71&�- Mille- Kacd A-! 1176Y 15. Is this:property within-100 feet of a tidal-wetland? *YES NO o IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10'feet or below,must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF&Ff WI ) EDI&QS being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, ,�`,� (S)He is the "4L-X- (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 om-nro day of 20jq_ N tarry Public Si ature of Ap i t 9 MARGARE f A. KIDNEY Q Notary Public-State of New York No. 0l K16021 1 I 1 Qualified in Suffolk County My Comrrussicn Expires March 8,20, 3 it ',� BUILDING DEPARTMENT-Eldctrical ����,{ F,77 E�l TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - Box o . IV92 1 2019 Southold, New York 11971-095 Telephone (631) 765-1802 - FAX (631) 765-9502 Mgerxi6hert e- an APPLICATION-POR.ELECTRICAL INSPECTION REQUESTED BY: Date." Company Name: C Name: O�C Co!n r License No.: email:, f rn Li Address: jLl I ZCPN-1 11C,(0 Phone No.,�- JOB SITE INFORMATION: (All Information Required) Name: Q k;a Address: Cross Street: Phone No.; V Bldg.Per 9:3 6A-7 email: Tax Map. District: 1000 Section: Block: -Lot:. _, BRIEF DESCRIPTION OF WORK(Please Print Clearly) C\"A ca, Circle All That Apply: Is job ready for inspection?: YE / NO Rough In Final } Do you need a Temp Certificate?: YES /(1Sg> Issued On Temp Informatio'n: (All information reqUired) SenA66ISize I Ph 3 Ph Size:,Z. A #Meters Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected -Underground -Overhead k1ppoergroprid Laterals 1 2 H Frame Pole Work done,on Serv(ce?-,, Y N,__ ;.Additional lnfoemOtiom - :PAYMENT'DQE WITH APPLICATION. 06 82-Request for Inspection FormAs I Scott A. lxussell d° '�� STORA�1CWA\' IER SUPERVISOR AMIA.,NA.G lEMTENT 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 ) DOLES TMS )PROJECT INVOLVE ANY OF TM )FOLdLOWINQ I (CHECK ALL THAT APPLY) Yes No ❑[2*A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. ❑[fB. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑[ rC. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. d D. Site preparation within 100 feet of wetlands, beach, bluff or coastal [:]derosion hazard area. E. Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse. ❑[YF. 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 wiffyour Building Permit Application. APPLICANT. (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date: District ^� �J NAME: C 3 m — Section Block Lot `g f **** FOR BUILDING DEPART ENT USE ONLY**** Contact Information: rrelephm Numbed Reviewed By: Property Address/! /Approwed_ — _ _ Date_ 1 i Location of Construction Work: — — _ _ _ _ _ _ _ t� �1, for processing Building Permit. p �p� Stormater Management Control Plan Not Required. L � k4r �'` I1� Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 I r SUFFOLK COUNTY DEPT OF LABOR. LCENSING 3 CONSUMM AFFAIRS j7ALOGER ASTER LECTRICIAN G BRUTTO This certifies tt�t thebearer Is duty LECTRIC CORPORATION licensed by the County of Suffolk - 07/1C-fftb- 7/01/2019 i I i I ' i I i L �. _ _ '�f...,✓! •Z� /� a.-.lw �1+�n. ._.. r t �'"7A`�i�` ��, � y�,,, .�„�;. i ✓ "�... a,_ �•r�kS����.�.r�'-�i \�' p 035P.,91 �.A�':t'-:�.:!'St.�'c,. .' .:. �1 � w '. ..�, ...:� �•C.�. ` ����• ���a����,�y�,z„7�\ ;.� '. ' `''`:.:���/x.Nk .. ,� fli r Jl \ <'' 1 1 7 L b , I e o 1 _. � • -• � �- • � • Imo{�,4. • • • o e e o..-... T_ �' ,wEs;9�.Y7+,rt+ssx .. �1�1•�__�''='i • 1 - 1 ' �. �•' \4E •+,..S,y 'M'.?'.,� •.ny ;..'^EFf9R1fa."•'.,`•.' .."1 -,e•,,ti'r�t'�++fjz+w'd`' �_~ / t I ' ' t II i ® DATE(MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 01/08/2019 THIS CERTIFICATE IS ISSUED AS Ai 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 PRODUCERIiAND THE CERTIFICATE HOLDER. , I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. i 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 j Liberty Risk Management,'Inc. PHON; (631)569-5633 ac Ne:(631)569-5636 664 Blue Point Road,Suite A E-MAIL brendan libe risk.or i Holts Ville, NY 11742 INSURERS AFFORDING COVERAGE NAIC A INSURERA:' Hartford Insurance CompanyE INSURED 1 INSURERS Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur,J.Edwards Pool 8r Spa Centre INSURER C: 929 Route 25A INSURER D: Miller Place,NY 11764 INSURER E: INSURER F: i 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. ILTR NSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMD EXP LIMITS A X COMMERCIAL GENERALLIABILITY 16 UUN OZ8691 01/01/2019 01/01/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS MADE !X OCCUR DAMAGE PREM SE5 Ea oeeuTO E enee a 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 JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYi HIRED NON-OWNED PROPERTY DAMAGE $ AAUTOS UTOS Par acudant $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR �_ CLAIMS•MADE • _ _ AGGREGATE $ _ - DED RETENTION $ WORKERS COMPENSATION STATERUTE t AND EMPLOYERS'LUIBILITY Y/N ANY PROPRIETOR/PARTNEWEXECUTIVE ❑ NIA E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYE $ If yes,desenbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/(LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached H more space Is required) ' f CERTIFICATE HOLDER( CANCELLATION 4 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall I ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE r i (Bis)j ©1988-2016 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 ' I I � ! 1 YNOBK Workers; CERTIFICATE OF INSURANCE COVERAGE STA7E Compensation Board I DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW I 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 Masons Contracting Company Inc. 631-744-4455 929 Route 25A I Miller Place,NY 11764 Work Location of Insured(Only required ifcoverage is specifically limited to 1 c.Federal Employer Identification Number of Insured i certain locations in New York!State,i.e.,Wrap-Up Policy) or Social Security Number i 11-2377925 I 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 I TOWN OF SOUTHOLD P.O.BOX 728 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD,NY 11971 , 00984424-0000 i j 3c.Policy effective period 07/01/2018 to 07/01/2019 4. Policy provides the following benefits: FZ A.Both disability and paid family leave benefits. i ❑ B.Disability benefits only. E] 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: { i Under penalty of perjury,Ii 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 ii By �j G � S(rhaw ' j - (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) r � Telephone Number 1-888-278-4542 Name and Title Stuart J.Shaw,FSA,MAAA - Vice President,Group Insurance i I � 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 46,4C 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. I I ! Date Signed By j (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 Form DB-120.1. Insurance brokers are NOT authorized to issue this form. j DB-120.1 (10-17) IIIIIIIIDB-120.1 (10-17) I i a � i 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 112377925IN � LEVITT-FUIRSTASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE i POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A i SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2438491-9� 765253 06/29/2018 TO 06/29/2019 06/12/2018 I 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. ' I ,I NEW YORK STATE INSURANCE FUND j f I DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 195404147 i�m�li�a�ml�e>Immne�in�lofl � J 11111100000000000059684277¶I1fill Fovn WC-CERT-NOPRINT Velrston 2(02/2912016)[WC Policy-243849191 U-26.3 74 � [0000000000005966427Tp0007-000024384979][##GJ[14901.06)(CeR_NoP-CERT 1][07.00001) i 1 I i ' c NE7 Workers" CERTIFICATE OF srATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE isoard I t 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Standard Electric Corp 516-819-8684 6500 Jericho Tpke. 1 c.NYS Unemployment Insurance Employer Registration Number of Syosset NY 11791 Insured ! Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 208322723 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Hartford Fire Insurance Co i 3b.Policy Number of Entity Listed in Box"l a" own of Southold 12WECAC1771 Town Hall Annex 4375 Main Rd 3c.Policy effective period Southold,NY 11971 12/23/18 TO 12/23/19 3d.The Proprietor,Partners or Executive Officers are F] included.(only check box if all partners/otficeri included) El 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"l a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation,Insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder ang the Workers'Compensation Board within 10 days IF a policy is canceled 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 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 i ,expiration date listed in box"3c",whichever is earlier. k 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy,indicated on this form,if the business continues to be named on a permit,license or contract Issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. I 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: Borg& Borg Inc., David M Borg President (Print name of authorized representative or licensed agent of insurance carrier) 4.Z.....�.� 1 2/5/2019 Approved by: (Signature) (Date) Title_Authorized Representative k l ' Telephone Number of authorized representative or licensed agent of insurance carrier: 631-673-7600 Please Note:Only Insurance carriers and'their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT i authorized to issue ILL C-105.2(9-17) . www.wcb.ny.gov t t STANDAR i CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) i 02105/2019 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 l` 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 Ito 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 631673-7600 C NTACT Borg 6 Borg Inc. PHONE 631-673-7600 FAX 631J51-1700 148 East Main Street ! (AIC,No,Ext): Huntington,NY 11743- (A1C,No): E DRQ .certificates@borgborg.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:Merchants Mutual Insurance Co. 23329 INSURED Standard Electric Corp INSURER B•Utica National Ins Co of Ohio 13998 Calogero G.Bndto 6500 Jericho Tpke. INSURER C:Hartford Fire Insurance Co 19682 Syosset,NY 11791 INSURER D:National Union Fire Insurance INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILTR NSR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ,OCCUR X BOP106359402/0112019 02/01/2020 PREMGETO aooaurrDence $ 500,000 LSES MED EXP(Any oneperson) 15,000 PERSONAL&ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY❑X PE� LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER B AUTOMOBILE LIABILITY O aBBIN D SINGLE LIMIT nt) $ 1,000,000 X ANY AUTO 4723493 02/111/2019 02101/2020 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS p BODILY INJURY Per accident $ X ALT OS ONLY X AUOS ONLY Pe�acG�t AMAGE $ UM13RELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR iCLA1MS-MADE AGGREGATE $ DED I I RETENTION$ C WORKERS COMPENSATION SER LITE ER H AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 12WECAC1771 12/2312018 12/23/2019 1,000,000 OFFICER/MEMBER EXCLUDED? N/A E.L EACH ACCIDENT $ (Mandatory In NH) 1,000,000 E.L DISEASE-EA EMPLOYE $ yes, under D 1,000,000 DESCRIPTIONIPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached H more apace Is required) Toxin of Southold Is additional Insured i I CERTIFICATE HOLDER CANCELLATION TOWSOUT 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. Town Hall Annex 54375 Main Rd AUTHORIZED REPRESENTATIVE Southold,NY 11971 ACORD 25(2016/03) j ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v[�tigc�lF6C'sF5i4Ra._.R••_.q::.+•••••v..n�n:7r�,•wa.rr.•�nn..cet.� P I ,IDB IVO. 99-26 REV 02/21/02 HMSE Loc TAX I.D. 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FIND • FOR MEET , C. � TRE BE COMpL`fc SHALL ALL CONSTRUCTION OUIREMENTS OF TRESPONS g�E FOR RE R ERRORS' YORK STATE.' NOT , DESIGN OR CONSTRUCTION � L ®'1� 0T Q coli ENCLOSE POON UPON COMPL' I 4 BEFORE'" AT raa 23 j .1 6 7 6 5 4 3 2 � 16' H _ AREA= 1,074 sq.ft H PERIMETER= 153 DS.CONC.= 17 REBAR= 23 FORM TIES= 219 i c N l, ' Na, 4F�C �-0 N nom' `Lc �0 I fV - 4r N N Ora m � F 16,N N I 44 F CU N A 43595 CU N E N j6 2 2 2I 2 I 2 2 2 1 2 2 E N 36' 407 DEEP N S' N D N N D N N N 8' DEEP c N N 20' 14' 6' 4' c N N N B N N 5r N 11/ 9 Z 2 I Z I 2 2 Z 1 2 1 2 j 2 1 Z 1 2 1 Z i2 2 2 2 Z � Arthur Edwards Pool A P224 A 6 7 6 5 4 3 2 1 A ® 5tlmmrra tt.Wnu H B /R-M— E F To Faw F— TO FYhr k iurq To Wmir) �—Ta Rnhmr N7•d apfiwQ ' A RoOod W,4F Plan Piping Arrangement Wd Sation OF NF ""'Lk. 14 Rebw SPOONS D.RFi��O 42" Section B—B z- mw R-sl 4 A . Section A—A Typical Wall Section 10 SIZE SIZE A B C D E F G H AREA CAP. IL FEET FT.FT.FT.FT.FT.FT.FT.FT.SQ.FT. GAL. rr�n..a LJ 12 X 20 12 20 8 9 0 3 3 6 240 8,000 /�L'� rd�. 3�s / 6wb 16 X 36 16 36 12 14 6 4 4 8 576 21,600 P()�L&SPA CENTRE 18 X 40 18 40 16 14 6 4 4 8 720 28,500 PERMACRETE WALL SYSTEM . �yy ,�,� PJ 929 Route 25A Miller Place NY 11764 `' 20 X 40 20 40 16 14 6 4 6 8 800 30,000 (631) 744-7185 FAX (631) 744-0174 ( I jqA 24 X 44 24 44 18 14 8 4 6 10 796 30,000 Suffolk License #4436—HI Pbw 24 X 48 24 48 20 16 8 4 6 10 900 31,0001 Nassau License #HI74450000