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HomeMy WebLinkAbout40460-Z F �0�0 CO�ya Town of Southold 10/3/2020 P.O.Box 1179 C5 53095 Main Rd � �1 �'N' fig Southold,New York 11971 QJj��yj�17F CERTIFICATE OF OCCUPANCY No: 41497 Date: 10/3/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 9625 Route 25, East Marion SCTM#: 473889 Sec/Block/Lot: 31.-3-21 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/4/2016 pursuant to which Building Permit No. 40460 dated 2/11/2016 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 Dellaportas,Argyris of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 40460 3/22/2017 PLUMBERS CERTIFICATION DATED A o ' e(Y'S\g nature o�So�ol,��oTOWN OF SOUTHOLD BUILDING DEPARTMENT 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#: 40460 Date: 2/11/2016 Permission is hereby granted to: Porta LLC 21-55 Hazen St Flushing, NY 11370 To: Construct accessoryinround swimming-g g pool as applied for. At premises located at: 9625 Route 25, East Marion SCTM # 473889 Sec/Block/Lot# 31.-3-21 Pursuant to application dated 2/4/2016 and approved by the Building Inspector. To expire on 8/12/2017. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 B spector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1002 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$15.00 Date. 4!!/ New Construction: Old or Pre-e ' ting Building: (check one) , Location of Property: 0)'? House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000,Section 03/ Block - Lotf Subdivision Filed Map. Lot: Permit No. 0 Date of Permit. Applicant Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted:$ d Applicant 716rie so Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 ,c® �® roger.richert(a-)town.southoId.nV.us ��c®UWTI BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Porta LLC Address: 9625 Route 25 City: East Marion St: New York Zip: 11939 Building Permit#- 40460 Section: 31 Block- 3 Lot: 21 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: East County Electric License No: 1005-E 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 Surrey X Attic Garage INVENTORY Service 1 ph 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 Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 2 Disconnect Switches F2 Twist Lock Exit Fixtures �] TVSS Other Equipment: "AS BUILT" - "ELECTRICAL SURVEY' - "NO VISUAL DEFECTS" Notes: Inground Swimming Pool to Include; Bonding, 1- Control Panel, Pool Lights, Gas Pool Heater, 1- GFCI Circuit Breaker, 1- Dead Front GFCI, 4- Deck Lights. Inspector Signature: Date: March 22, 2017 0-Cert Electrical Compliance Form.xls Lk 0%o q souryo • �o TOWN -OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION , [ ] FOUNDATION 1ST [ ] ROUGH-PLEIG. [ ] FOUNDATION 2ND [ ] SULATION [ ] -FRAMING / STRAPPING FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) ARKS: I &0vioev S � we. • i f io `vrvl DATE 1 INSPECTOR OL y SOF SO(/r�, y ulo 0� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] 1 ULATIO [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PE ETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL INAL) REMARKS: (26 DATE INSPECTOR tis � f � : i o - s�'• ^ � •. r � s. i • � s . . If f O �. •.rte r u r TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 � Survey SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees ` C.O.Application Flood Permit Examined 20 Single&Separate Storm-Water Assessment Form Contact: Approved 20 Mail to: Disapproved a/c Phone: Expiration 20j_7 Buildin ns ct n I APPLICATION FOR BUILDING PERMIT FEB - 4 2016 Date 920 INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County,New York,and other applicable Laws, Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signatur of plicant or name,if a corporation) O (Mailing address of applicant) State whether applicant is owner, lessee,agent, architect,engineer general contracto lectrician,plumber or builder q_el7n�al rvz�&a2,lyr _' Name of owner of premises (As on the tax roll of latest deed) If ap1lie is a co at' , signature of dujy authorized officer (Nam title of corporate officer) Builders License No. 9q,§07- Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 9(oa5 w im koce) House Number Street Hamlet County Tax Map No. 1000 Section 0,3/ Block „3 Lot �� Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy #a 1/5 C' b. Intended use and occupancy W I 3. Nature of work(check which applicable):New Building Addition Alteratipp Repair Removal Demolition Other Work (D cription) 4. Estimated Cost 2, G ` C:1.0 p 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 l 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, i : ,ront Rear Depth Height /I umber of Stories Dimensions of same structure with tions or additions: Front Rear Depth t Number of Stories 8. Dimensions of entire new cons ction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10. Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law, ordinance or regulation?YES NO 13.Will lot be re-graded?YES NO � ✓Will excess fill be removed from premises?YES 'ANO 14.Names of Owner of premises 1-")'P11a,0Dr,/�SAddress96.95' ZYC&a Phone No. Name of Architect Ad ess Phone No Name of Contracto t 1 moo. OTTV 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES N� * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C.PERMITS MAYBE QUIRED. b.Is this property within 300 feet of a tidal wetland? *YES NO * IF YES,D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property? * YES NO * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY QFy4r �c rr �(�/(✓ I ���`�0 being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the C 0' c� (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 ore me this f day of 20� Notary u ''AOR YO S'gnatu of Applicant NOTAQUALIFIED N SUFFOLK COUNTY No.01SH6083046 MY CON4MISSION EXPIRES NOV.12,20-LK Feb 091602:47p Jack Anthony Pools 631-878-7663 p.2 SW, Immin - _Jack T'l 1789A Past Jericho Turnpike 4 Huntington,NY 11743 4 (631)462-0046 4 Fax(631)462-0092 615 Hampton Rd 4 Southampton,NY 11968 4 (631) 283-8101 4 Fax(631)283-8515 619 Route 1124 Patchogue,NY 117724 (631)878-POOL ♦Fax(631)878-7663 Town of SoutholdFebruary 9, 2016 53095 Route 25FEB — 9 2016 PO Box 1179 e, ,m Southold,NY 11971 To'%%om This May Concern: - As requested Swimming Pools by Jack'Anthony will be installing a 4x4 drywell located at 9625 Main Road East Marion,NY. Any questions please contact me. fSinnc�e iy, Mice eriilo Pred Scott A. Russell �����°���`�� ST(0))[���][��� A\�C'�E)[Z SUPERVISOR C AM[A\N A�GIE1\\4[IE Nr][, z . SOUTHOLD TOWN HALL-P.O.Box 1179 b S 53095 Main Road-SOUTHOLD,NEWYORK 1197 � Town ofSouthold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET (TO BE COMPLETED BY THE APPLICANT) DOLES FIs PROJECT INVOLVE ANY OF THE FOLLOWING: ` Yr eS No (CHECK ALL THAT APPLY ❑Q A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. El Ej"B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑ED/C_ 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. ®ME. Site preparation within the one-hundred-year floodplain as depicted on-FIRM-Map--of-any watercourse: L i ® 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 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. C.T.M. �: 1000 Date APPLICANT- (Property Owner,Design Professional,Agent.Contractor,Other) S-C.T.M. NAME- Section Block Lot BLi11[_s,`NG D�PAP•.T4iff" TL-S), _..,; .._ Contact Information. Reviewed By: Date Property Addi ess / Locat lon of Const,UCt Ion Work — — — — — — — — — — — — — — — — — Approved for prom�ing Bwldmg Permit Stormwater Management Control Plan Not Required —�— — — Stormwaier Management Control Plaii i.,l.equired ---�---- (� (For +kard to Lngmeemia Department for Revie.,) 1-01-11M ° JMC-P - FOS til '\Y ?o I r Town Hall hex Telephone(631)765-1802 is 34375 Main Road (631)7��51� P.0.Box 1179 �a'RIn roger.richer( ;plfltn_so o .nV!2s Southold,NY 11971-0959 ® �® i BUJIDING DEPARTA ENT TOMW{0)F SOUMOLD APPLICATION FOIA ELECTRICAL INSPECTION ` REQUESTED BY: ©ate: V7 Company Name: , Mame: License No.: Address: Phone No.: i JOBSITE (NFOR TION: (*Indicates required information) - i *Name: �--rlq Address: *Cross Street: f *Phone No_: �f � Permit No.: �' � 00 ,. Tax-Map District: - 9000 Section.- 31 Mock: 3 Loft a *BRIEF DESCRIPTION OF WORK(Please Print Clearly) (Please Circle Ali That ply) *Is job ready for inspection: * , YES NO. Rough In Final-'Do-you need a Temp Certificate: YES t NO Temp Information(if needed) *Service Size: 9 Phase 3Phase 100 950 200 300 350 . 400 Other } *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82=Request for Inspection Form a—� \00 pE SOV � o Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G • Q Southold,NY 11971-0959 'Q a July 24, 2017 BUILDING DEPARTMENT TOWN OF SOUTHOLD Porta LLC 21-55 Hazen St Flushing NY 11370 Re: 9625 Rt 25, East Marion TO WHOM IT MAY CONCERN: The Following Items(if Checked)Are Needed To Complete Your Certificate of Occupancy: NOTE: C of O for pool will not be issued until the complaint regarding the accessory bVilding has been addressed per Building Inspector. He said he spoke to you about it and Pats working on it. We have not received any paperwork in our office as of this date. to Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of$50.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 411/84) Trustees Certificate of Compliance. (Town Trustees#765-1892) Final Planning Board Approval. (Planning#765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept. Final Storm Water Runoff Approval from Town Engineer BUILDING PERMIT — 40460 —Swimming Pool ® Client#:36213 SWIMP001 ACORD,.CORD,. CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) 1 211 712 01 5 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 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 NAME CONTACT Cynthia A.Boumnaia Southampton Commercial (AIC,No, •631 324-1440 ac No): 631-287-2207 Cook Maran&Associates ESSD , certificates@cookmaran.com 300 Hampton Road Southampton,NY 11968 INSURER(S)AFFORDING COVERAGE MAIC# INSURER A:Valley Forge Insurance Company 20508 INSURED INSURER B:Rochdale Insurance Co. 12491 Swimming Pools By Jack Anthony,Inc INSURERC:Continental Insurance Company 35289 619 Route 112 Patchogue,NY 11772 INSURER DINSURERS: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICYNUMBER MM/DD MMIDD A GENERALLIABILITY X X 5084912171 2105/2015 02105/201C EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $300,000 CLAIMS-MADEFI -VI OCCUR MED EXP(Any one person) $15,000 X Contractual Llab. PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X j-T X LOC $ C AUTOMOBILE LIABILITY 5090892726 2/05/2015 02/05/201 ECOMBIa.NED sn)SINGLE LIMIT $1,O00,000 X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per a=dent) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Peraccrdent $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS PAIS CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY I ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ If yes,descnbe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Rerrorks Schedule,if more space is required) Certificate holder is listed as an additional insured with respect to the General Liability coverages. CERTIFICATE HOLDER CANCELLATION Town of Southold Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall Annex Building ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S879725/M879602 EH2 Certificate of NYS Workers' Compensation Insurance Coverage Page 41 of 87 Workers' Compensation Lady Section 57.Restriction on issue of permits and the entering contracts unless compensation is secured. ' 1.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 a hazardous employment defined by this chapter,and notwithstanding 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 compensation for all employees has been secured as provided by this chapter.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 compensation to any such employee if so employed. 2.The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-07)Reverse https:Hao.amtrustgroup.com/anawc/PolicyNYCertificateOfWclns.aspx?lndexld=1&Insta... 12/17/2015 Certificate of NYS Workers'Compensation Insurance Coverage Page 40 of 87 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF NYS WORIKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name and address ofinsured(Use street address only) lb.Business Telephone Number of Insured Swimming Pools by Jack Anthony,Inc. 631-878-7665 619 Route 112 Patchogue,NY 11772 lc NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Indentitication Number of Insured Work Location of Insured(Only required rf coverage is specifically limited to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold Building Department;Town Hall Annex Building 3b.Policy Number of entity listed in box"la": PO Box 1179;53095 Route 25 W WC3178802 Southold,NY 11971 3c.Policy effective period: 12!1/2015 to 12/1/2016 3d.The Proprietors Partners or Executive Officers are: ,! included(Only check box if all partners/officers included) 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"1 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 Certification of Insurance to the entity listed above as the certificate holder in box"2 The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment ofpremiums 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 forst is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c"whichever is earlier. Please Note:Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or ficensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By. Henry C.Sibley (Prmtname of authorized representatwe or licensed agent ot insurance carireri Approved By: 12/17/2015 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or hcensed agent of insurance carrier CamerPhone Please Note:Only insurance carriers and herr bcensed agents are audionzed to issue the C-10.£2 form.Insurance brokers are NOT authorized to issue it. C-105.2(9-07) https:Hao.amtrustgroup.com/anawc/PolicyNYCerfficateOfWclns.aspx?lndexld=l&Insta... 12/17/2015 Feb 09 16 02:47p Jack Anthony Pools 631-878-7663 p.3 SUFFOLK COUNTY DEPT OF LABOR LICENSING&CONSUMER AFFAIRS HOME IMPROVEMENT L T CONTRACTOR NFM6 MICHAEL R INZERILLO This certiFies that the ®"""E-"""e bemw is duly SVAMMING POOLS BY JACK ANTHCNY INC licensed oy the County of Suffolk ��il 24507-H .Y.wirfw.r •emo c.n.+..i.., I dmwnon Dire 03101/2017 f sp ` l . r or1Jr 1� 4w ..' Z cTg m } . Q 0' it 73 it AA Sifl- jl:• ra df�lrr- ers LV At 7't �•Yy'��,' •1 + e,BS.Q N fr0'L6Z r 7N_CQfO.L,.�; rpt j y�r�' tF� .. { �S•�Y._�(1 `� �.. �.•,' �1.:_ft?'°JC7jJ�1 � !.' , '; -, :.sry .��;�re�if7'T�u F�VLI(:Y 6akRTM Z0 3n17d SNI990E) 0 WdITUM thTZP86ZSTS TT ;T 866T jZ TIS AIRM VED AS NOTED RETAIN STORM WATER RUNOFF DATE:-2 8.P.it PURSUANT TO CHAPTER 236 OF THE TOWN CODE. FEE: 1 BY: NOTIFY BUILDING DEP4tAtRrTl AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING- & PLUMBING 311MAEUMTELY 3. INSULATION t-NCLOSElPOOL.TO CODE , 4. FINAL - CONSTRUCTION MUST 'UPCX4 COMPLETION BE COMPLETE FOR C.O. BEFORE"WATERr . !; ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SOU 1:O MAN ZOA - 880ftl)fftft"G BOAR 80bTM tDT0WWrRGMES OCCUPANCY OR USE IS UNLAWFUL 'WITHOUT CERTIFICATE OF OCCUPANCY DETAIL A ' _ WALL BRACE ASSEMBLY DETAIL I / �`-2' 2`L- � 1GAlGMIIZED ANGLE i GA. .� I I I 14 GA. GALVANIZED— STEEL ALVANIZED—STEEL WALL PANEL L I I 6- CONCBE 42 FOOTER UNDISTURBED EARTH I WALL BRACE ASSEMBLY I � I ' - - - - -\ 2' BOTTOM MATERIAL +- 7 1/2 x 4 '1/2 x 1 BEARING PLATE 3/8' REBAR 1 1/2" x 24' x 14 GA. GALVANIZED ANGLE NOTE:BACKFILL TO BE SAND, GRAVEL, OR OTHER NON EXPANSIVE MATERIAL B I D ETAI L A A / 1 K - - - - - - - - - - - - - - - G - - - - - - - - - -- - -�- F N c D P o . . . W ��' H -J— F- 0 Donald C. Meserlian, P.E. 264 Park Ave. ='_ —NOTE— N. Caldwell, NJ 07048 F'', GY f y ILL THESE DIG DIMENSIONS COMPLY WTTH THE NATIONAL SPA AND POOL INSTITUTE SUGGESTED MINIMUM (201) 228-225 ?J' 'I'o �f 1�' ' '``' STANDARDS FOR RESIDENTIAL POOLS. WARNING - DO.NOT DIVE IN THE SHALLOW END. IF DIVING WARDS C7:�7�, ��L OR SLIDES ARE TO BE USED WITH THESE POOLS PLEASE CONSULT THE MANUFACTURE'S INSTRUCTIONS BOARDS OR SLIDES ON THESES POOLS.I FOAND 111E NATIONAL SPA AND POOL R NFORMAT10N CONSERNING NSPI TO'S MINIMUM STANDARDS DIVING INSTALUNG STANDAROS, WRITE: " NO DIVING BOARD ALLOWED 2///�� v.ti'� ` HATIONN. SPA AND POOL INSTITUTE. 2111 EISENHOWER AVENUE. ALEXANDRL" VA 22314 X703) ass-ooa3 POOL SIZE A B C D E F G H J K L CARDINAL SYSTEMS 12 x 24 * 12 24 8 7 6 6 2 6 6 2 6 7 3 6 26 10 -389 S. RT. 81 14' x 26'*1 14 26 10 17-6-1 6 2'61 6 2-61 9 13'6 29 6 3 8 (717) 3a5-4733SCNITYLKILL RAVEN, PA. (717) 385-1318 FAX. 16 x 32 16 32 8 14 6 4 8 14t' 8' 3 6 359 1 4" DATE 2-18-97 7rLF' 6" R. CORNERS 16 x 36 16 36 12 14 6 4 8 3 6 39 4 3 418 x 36 18 36 12 14 6 4 8 3 6 40' 3 sc NONE RECTANGLE �0 40 20 40 �T 14 0 s 4 12 13'6" 44 8 5 s 1 DRAWN: D.D. �'� NAUE RECT6RC