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HomeMy WebLinkAbout44642-Z W ip Town of Southold 9/27/2020 (A 3 P.O.Box 1179 C3 _ c 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41476 Date: 9/27/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 3320 Bay Shore Rd, Greenport SCTM#: 473889 Sec/Block/Lot: 53.-6-38.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/17/2020 pursuant to which Building Permit No. 44642 dated 1/30/2020 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 with fence to code as applied for. The certificate is issued to WH Crumb LLC&Ano. of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44642 9/18/2020 PLUMBERS CERTIFICATION DATED 0 oriz S 0 ignature Vzk o TOWN OF SOUTHOLD FBIj�o Su BUILDING DEPARTMENT TOWN CLERK'S OFFICE 'vy SOUTHOLD, NY o � 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#: 44642 Date: 1/30/2020 Permission is hereby granted to: WH Crumb LLC 1365 Watersedge Southold, NY 11971 To: construct an in-ground swimming pool as applied for. At premises located at: 3320 Bay Shore Rd, Greenport SCTM #473889 Sec/Block/Lot# 53.-6-38.2 Pursuant to application dated 1/17/2020 and approved by the Building Inspector. To expire on 7/31/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 otal: $300.00 a B ilding Inspector 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. ///3 L0 New Construction: Old or Pre-existing Building: (check one) Location of Property: 33 0 '04YSkn F Ga.Wo&-T House No. Street Hamlet Owner or Owners of Property: ofyl, A44— Suffolk County Tax Map No 1000, Section Block to Lot _;,9'2 Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: heck one Fee Submitted: $ � Applicant Signature Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I V 1 a residing at J-3,5, oes-i- (Print property owner's ape) (Mailing Address) /U1 ly TJ �o hereby authorize alit 4, (Agent) FO-0 I�La���� to apply on my behalf to the Southold Building Department. ( wner's Signature) 0 (D te) (Print Owner's Na e) 1 c,Yv,evL ort-, k) y � �� �� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 sean.devlinCcD-town.southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To* WH Crumb LLC Address: 3320 Bay Shore Rd city,Greenport st: NY zip: 11944 Building Permit# 44642 Section: 53 Block- 6 Lot. 38.2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: VA Electric License No: 35591 ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures 2 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency FixturesTime Clocks 2 Disconnect Switches 4'LED Exit Fixtures Pump F2 Other Equipment: Heater, Pump on 220GFI Breaker, Booster on 220GFI, Intermatic Tranny, Salt Generator Notes* AS BUILT, NO VISUAL DEFECTS " Did Not See Bonding - Pool Inspector Signature: C Date: September 18, 2020 S Devlin-Cert Electrical Compliance Form.xls O�aOF SOUIH� /zo # TOWN OF SOUTHOLD BUILDINGDEPT. ��y�OUMV,N 765-1602 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O ` f REMARKS: DATE INSPECTOR �a0f SOUIy # # TOWN OF SOUTHOLD BUILDING DEPT. °`��ou►m ' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULAT ON/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O nA N-11 I RKS- L .07 �V�) 7W DATE OI&IVwleb INSPECTOR (�(,(� �o�aOF SOUIyOIo TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION , [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING - [ FINAL Ae-., [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: to v-v .00, DATE 'Yt7 INSPECTORA -- V wa �. v r _ Y ,!w-a . 'ate. ..` /e� .. # �. g�►"• 41 ice i io i �y T' Li 17 • s ` >A l ,a 7. 4 ti a . -1 Fes` Pe , t ' f ^ } r ,rr L�M•4 f �. •� �, G • i r ieq �' ` _ t r. la' a as .. ''P � r `� � •• � 1' ii r• r � 44k FSS r y - "' 4k'ii' r a , �y t '1_ If r y' w y ✓`" _ ,at -�-w � •. ' ,fT•I' y� n!"4� � AN 05 r -v i j 1 E •��» sly., _ Wrd„- w / F - r .a 4.5 �7 + .� � MI�IIeiNiM+ng��� I�IRIl1 �w + h .. c w + � M d OSJ. 5 p , c > =f Al. u r — i } 3 •1 0 e- • n a_ y u .. As - - t t �t • i, 1. R FIELD INSPECTIOi REPORT -DATE COMMENTS FOUNDATION (IST) ------------------------------------ FOUNDATION ---------------------------------FOUNDATION (2ND) z WIN ' o H ROUGH FRAMING& PLUMBING A • r INSULATION PER N.Y. H STATE ENERGY CODE ji� s FINAL ADDITIONAL COMMENTS Muh (46 L aj Z m ro � z H x d TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST - 'BUILDING DEPARTMENT Do you have or need the following,before applying9 TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 "� Survey Southoldtownny.gov PERMIT NO. L Check Septic Form N.Y.S D E C Trustees C 0 Application Flood Permit Examined 20 Single&Separate Truss Identification Form f}� Contact:Storm-Water Assessment Form' Approved 20 Mail to Disapproved a/c Phone:P1 U Expiration 20 (:agector APPLICATION FOR BUILDING PERMIT JAN 1 7 2020 Date �//3 ,20-AP INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 `s_efs of plans,accurate plot plan'fo 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. (Signature of applicant or name,if a corporation) /82, ,dJ�/� (Mailing address of applicant) State whether applicant J#owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder 2'4&r 4COO)& GMX. Name of owner of premises 8"42 (As on the tax roll or latest deed) If app' ant i a corat' ,signature of duly authorized officer (Name and title o cororate offsFer) Builders License No. 58.5'�—H .SOA" 4. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on whichmroposed work will be done: 33 .0 , t4.ytsl�lvatr Czb G���C<1��7- House Number Street Hamlet County Tax Map No. 1000 Section -53 Block 4 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 /X441/t y ,fjwfawi; b. Intended use and occupancy lAwAf P"U bYG S4 1d'*Ay6 A06- 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work SQv~10jey j;r�»L ylgyl (Description) 4. Estimated Cost yV/0wo Fee (To be paid on filing this applic tion) 5. If dwelling,number of dwelling units Number of dwelling units on each floor 'V If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. a%4 7. Dimensions of existi g structures,if any:Front ^'/ Rear �✓� Depth Height .v Number of Stories A l Dimensions of saZ structure with alterationsr additions: Front /* Rear ^'/Q Depth Z Height .�-�/�- Number of Stories 8. Dimensions of entire new ~/A--onstruction:Front ~� R ar � Depth .v Height tiA Number of Stories .�-fi 9. Size of lot:Front /25- Rear 12.5' IF Depth /ZS/ 10.Date of Purchase Name of Former Owner SL*v 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO_ie-"* 13.Will lot be re-graded?YES NO Will excess fill be removed from premises?YES NO_ 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 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 OF `./� �4/e( / 144A being duly sworn,deposes and says that(s)he is the applicant (Name of individual signingcontract)above named, (S)He is the G-igA'4/)_GG/h (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�-- ERIN E DELIVER day of /C1/a 20 Notary Public-State of New York No.01 DE6334906 Qualified in Suffolk County \ tary Public Signa App icant Y ��Exp. 12/28/2023 %•1 OS�fFOL,+- BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 o - Southold, New York 11971-0959 4,, pr Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(a-)southoldtownny.gov - sea nd(cD_southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: V14 g I@L1r:'C Name: License No.: ` �'�' S- f, mail: Address: ��� m,-r � ecs' Al G Phone No.: d 2 2— 9,.7 0 JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) 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 Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect- Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: 4 PAYMENT DUE WITH APPLICATION equest for Inspection Form As PERMIT# Address: Switches Outlets GFI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini Special: Comments jM 4�? d G 6? I-ell— fo �I r p "' - , � )-<? P-P-) 1 C A,oJ) a ti S ail S.C.T.M. NO. DISTRICT: 1000 SECTION: 53 BLOCK: 6 LOT(S):38.2 P/0 LOT 134 N 66°09'00"E 125.00' I 3 BEDROOM SYSTEM io 1250 GAL S.T. L o — — P/0 LOT 134 (5)8'0x2'DEEP LP LP LP 215'.+— m z S.T. LP LP N33' LP 21' 0 j uWi — — 28' o I < CStri Ca m — — — _ OVERHEAD WIRES L ASPHALT DRIVEWAY Z C<L OTGARAGE;'::•^. p ' ': ;;•5.3': BELL. BLK. CURB J g LOT 1 �"" a;:: : :''•i :: 840 4 DE LP 2 STY FRM..n zag DWELLING* fn a' WOOD `FFL 17.7::.: O I STOOP ::::•..:#3320;:: •. 8 z 8.1'x3' 1 LOT 1 6 :•'•.'23.5';':':�:��•� .. _Wr _.. '......r �{ WATER SERVICE W V. ►AK' ryA �• 35.0' DRY WELL j i 8'0x4'DEEP N I i S 66009'00"W 125.00' LOT 137 0 Ca 0 ISLAND VIEW LANE DRAINAGE CALCULATIONS: A) DWELLING W/COVERED PORCH=1,658 SQ.FT. 1,658 x 0.166=275cf REQUIRED B) DRIVEWAY=670 SQ.FT. 670 x 0.166= 111 cf REQUIRED 334cf TOTAL (1) 8'DIA x 4' DEEP DRYWELL (1) 8'DIA x 5' DEEP DRYWELL= 398cf PROVIDED UPDATE SURVEY 11-05-19 REVISED SEPTIC TYPO 10-14-19 FINAL SURVEY 09-20-19 THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL FOUNDATION LOC. 04-16-19 LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS AREA: 15,625.00 SQ.FT. or 0.36 ACRES ELEVA71ON DATUM: UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING 7HE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO 7HE PERSON FOR WHOM 7HE SURVEY IS PREPARED AND ON HIS BEHALF TO 7HE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TU77ON LISTED HEREON, AND TO 7HE ASSIGNEES OF 7HE LENDING INS7777J77ON, GUARANTEES ARE NOT TRANSFERABLE. 77-IE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO 7HE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT 7HE PROPERTY LINES OR TO GUIDE 7HE ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE S7RUEFURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON 7HE PREMISES AT 7HE 77ME OF SURVEY SURVEY OF: P/0 LOT 134, LOT 135 & 136 INCL. CERTIFIED TO: PAUL K. BARRY; MAP OF: AMENDED MAP A of PECONIC BAY ESTATES BETH KAUFMAN BARRY, NEW YORK TITLE ABSTRACT SERVICES INC.; FILED: #1124 OLD REPUBLIC TITLE INSURANCE COMPANY; SITUATED AT:ARSHAMOMAQUE " TOWN OF:SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design P.O. Boz 153 Aquebogue, New York 11931 PHONE (831)298-1588 FAX (631) 298-1588 FILE # 18-124 SCALE: I "=30' DATE:SEPT. 15, 2018 4 N.YS. L1SC. NO. 050882 maintaining the records of Robert J. Hennessy & Kenneth M. Aoychuk YR Workers' CERTIFICATE OF STATE, Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Pooltastic Pool Works Inc 631728-3983- PO Box 112 631728-3983 Hampton Bays, NY 11946 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 112953125 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Twin City Fire Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box 1 a" 53095 Main Road 12WEOJ2695 Southold, NY 11971 3c.Policy effective period 11/19/2019 to 11/19/2020 3d.The Proprietor,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 Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is 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 expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a 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. 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: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier), Approved by: 1/9/20 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-390-9700 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov Client#:8041 POOLPOO ACORD,. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY) 1/0912020 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME T Cook Maran Cook Maran&Associates a/CO°Nr o Ell):631324-1440 a/c No 461 Pantigo Rd nooRlEss: Certificates@cookmaran.com East Hampton,NY 11937-2647 631 324-1440 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Twin City Fire Insurance Company 29459 INSURED Pooltastic Pool Works Inc -INSURERS:Merchants Preferred Insurance Co. 12901 P O Box 112 INSURER C Hampton Bays,NY 11946 INSURER D 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 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. LTR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP INSR WVD POLICY NUMBER MWDD MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY 12UENQY2614 9/06/2019 09/06/2020 EACH OCCURRENCE $1,000,000 DgMARET RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence $300000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $110001000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 ECT LOC PRODUCTS $2,000,000 POLICY® OTHER $ B AUTOMOBILE LIABILITY CAP9117665 9/06/2019 09/06/202 Ee acccl'EDdenSINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY t DAMAGE X AUTOS ONLY X AUTOS ONLY PROP. $ $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 12WEOJ2695 1119/2019 11119/2020 X IPER STATUTE IOH- ERT EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E L EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S2314871/M2237209 CCUMM yo K workers' lf- STXfE Compensation CERTIFICATE OF INSURANCE COVERAGE Board under the NYS 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Pooltastic Pool Works Inc PO Box 112 Hampton Bays, NY 11946 Work Location of Insured(only required if coverage Isspecifrcallylimited to 1c.Federal Employer Identification Number of Insured or certain locations in New York State,le.,Wrap-Up Policy) Social Security Number 11-2953125 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold Guardian Life Insurance Co of America 53095 Main Road 3b.Policy Number of Entity Listed in Box"1 if Southold, NY 11971 985612-0000 3c.Policy effective period 08/02/1994 to 08/01/2020 4. Policy provides the following benefits: x❑ A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: X1 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,t certify that 1 am an authorized representative or license t of the' surance carrier referenced above and that the named Insured has NYS Disability and/or Paid Family Leave Benefits insurance covers e s describe bove. Date Signed January 09, 2020 By 7/c� (Signature of insurance carrie s authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number (212) 964-2150 Name and Title Dan Saltzman — President IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 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 compiled 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 Form DB-120.1. Insurance brokers are NOT authorized to issue this form. 1313-120.1 (9-17) III�IIIfI111111111�I1�II�IiDI�I�IIIIIIIIIIIiIIIIIII DB-120.1 09-17 S.C.T.M. I DISTRICT: 1000 SECTION: 53 BLOCK: 6 LOT(S):38.2 P/0 LOT 134 N 66009'00"E 125.00' I 3 BEDROOM SYSTEM 00 1250 GAL S.T. a 2 — — P/0 LOT 134 (5)8'Ox2'DEEP LP LP LP 215'f —! m S.T. LP LP c 0 33' ILP 21' op 0 Ld o — — $ 28 - - - rn OVERHEAD WIRES L M a' 9.5' ::'28.8';:;:;:;:•.;. W I ASPHALT DRIVEWALLY ;:GF 9:¢;::• i p :::::::::::::::::•5.3': BELG. BUG CURB D_ LOT 1 ` `; ;i:;i:;:;:;:E' 7.0 QRY WELL 1 ::•::'.:::'•:: 3 80x4'DEEPI, STY FRM.:,"m, ` z I DWELLING'.i ;: R 332 WOOD FR 11.7 :..; IS- STOOP STOOP �.• o �I LOT If 3.5': W ........_ + .—I _�{ WATER SERVICE 'w-V. 35.0' N r rN Ca Ca DRY WELL ki 8'Ox4'DEEP U I S 66009'00"W 125.00' LOT 137 w m C I ISLAND VIEW LANE DRAINAGE CALCULATIONS: A) DWELLING W/COVERED PORCH=1,658 SQ.FT. 1,658 x 0.166=275cf REQUIRED 8) DRIVEWAY=670 SQ.FT. 670 x 0.166= 111 cf REQUIRED 334cf TOTAL (1) 8'DIA x 4' DEEP DRYWELL (1) 8'DIA x 5' DEEP DRYWELL= 398cf PROVIDED UPDATE SURVEY 11-05-19 REVISED SEPTIC TYPO 10-14-19 FINAL SURVEY 09-20-19 THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL FOUNDATION LOC. 04-16-19 LOCA77ONS SHOWN ARE FROM FIELD OBSERVA77ONS AND OR DATA OBTAINED FROM OTHERS. AREA: 15,625.00 SQ.FT. or 0.36 ACRES ELEVA77ON DATUM: UNAUTHORIZED AL7ERA77ON OR ADD177ON TO THIS SURVEY IS A WOLA77ON OF SEC77ON 7209 OF 7HE NEW YORK STATE' EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TV77ON LISTED HEREON, AND TO 7HE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT 7RANSFERABLE. 7HE OFFSETS OR DIMENSIONS SHOWN HEREON FROM 774E PROPERTY LINES TO 7HE STRUCTURES ARE-FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT 774E PROPERTY LINES OR TO GUIDE 774E EREC77ON OF FENCES, ADDIT70NAL STRUCTURES OR AND 07HER IMPROVEMENTS. EASEMENTS AND/OR SUBSURFACE STRUMRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY OF: P/0 LOT 134, LOT 135 & 136 INCL. CERTIFIED TO: PAUL K. BARRY; MAP OF: AMENDED MAP A of PECONIC BAY ESTATES BETH KAUFMAN BARRY; NEW YORK TITLE ABSTRACT SERVICES INC.; FILED: #1124 - - OLD REPUBLIC TITLE INSURANCE COMPANY; SITUATED Ar:ARSHAMOMAQUE TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design P.O. Bos 153 Aquebogue, New York 11931 FILE SCALE: 1 "=3Q' DATE:SEPT. 15, 201$ PHONE (831)298-1588 FAX (631) 298-1588 # 18-124 N.Y S LISC. NO. 050882 maintaining the records of Robert J. Hennessy k Kenneth M. Woychuk NOTE: QUANTITY OF WALL PANELS [PANEL N LENGTH DIFFER FOR EACH POOL SIZE. CONCRETE do 2'-I"—� �5ELF-DRILLING REFER TO TABLE BELOW. (RECEPTOR COPING 5" �f FASTENER T T MIX O �A�. Q®[z_:D(� �COPING M. i �, -l� ! ALL WALLS * ,. I ,DATE! d, B.P• � -GA• GALVANIZED 1��; 3�8BOLTS i� D ,STEEL.080 EXTRUDED- �`±=%' CADMIUM G - ___ F3Y COPING. j �,. PLATED �lTli`. 'UILDINu IDE-PAR-11 4ENT AT I !� �'�1 705-1802 8 A?^ TO n Pert FOR THE \ 42 r I " ® �' �- . ®to FO LL OWN`t� iI:APECT!ONS: � � F--I�r I,� IIG ,�� U; g 1 ,� � �tl a`a ki i -1 1FOUN )JION - TVNO REQUIRED \ i GALVANIZED ,` 1 •t � "•� IRON -e I I FOR T URED CONCRETE [ C�'en' � �d 2. �OUC - rRr+�eilrli� PLUj�SIN!G. �. VINYL �1 - 3. IN\,Q Q TION +� LINING i UNDISTURBED Qin CON! T RUC I!ON MUST � •�' '�•� � `\ EARTH i BE CO1ttNLETE i=0 C.O. SUBSTRATE ' .1 12"x12'"14 GA ALL CONSTRUCTION SHALL NyE'ET THE � BOTTOM 1 f t2, 1�'�Y 14G BEARING PLATE ",.MATERIAL 2 B RGr I 1MENTS OF THE CC�D`FS OF NEIN . A ? ANGLE I YORK S SATENOT RESr0V !BLE FOS=, REBAR� I , �-�-s , C CC)7,0 0 'v G H-«t---- J — H­ S°G%17OZDTo ® s m\� SOUTho( WNF EXCAVATION NOTES: SO. lVp PANEL SIZEf I, EXCAVATION SHALL BE 2'LARGER THAN POOL O(DTEUDO �+ POOL 512E A g POPE DIMENSIONS K N ALL SIDES. L QTYS(0, 8,9, 2. BACKFILL SHOULD NOT EXCEED WATER HEIGHT fv��DFC WiyTAVSTE�B BOA ®' 12'r 24,-t 12' 24' 8­7E; 6' 2% 6 ' 7' 1-6 2,,-10 4 6 BY MORE THAN 12:' WAl ER LEVEL SHOULD 14'o,26'y 14' 26 10' -(i Ei 6 (i 2-6 9' /-6 29'-6.4' 2 4 4 NOT EXCEED HEIGHT OF TAMPED BACKFILL 6' 12' I6' �2 6' S-9 2 BY MORE THAN 12: F=ti -, r; y�.t, ..�� v�, � , , {, ; aur 1 4 8 4' 8 9-6 I 3. BACKFILL TO BE SAND GRAY ,rwar.'6:• aa; k' :{: .¢a, r., �..; 16,16 16 36 1L' 6' 4' 8' 4' 8' x=639'-4 4 8 OTHER NON-EXPANSIVE IS`-3Ei 18' 1G:r'0'J. $ 4'18'1 4'110 3=6 40'-3 12 3 u a{ ;t,.;¢, „nr €r tks 'r•v, ,u : war t„ }',. 0 20'- 40, 20a u 1 k, h u , ' 40 IL 4' 8' 4' 12' 44'-8 4 12a� i ,H is tlIUI1 . NO DIVING D ERMITED 1` b G BOAR P �j;"•� ,t,;f%t•1,Y ..},�^ ' 5r'avStR"1l`n � _ ®® — 1 .'��`�:r;01, i" �}�ja=p�',��{ „�a•r4�'��,�;�tfi�; ®® pp���{ l�NT `Yn, _ • "'`i ;�d.�,�� 1 mi r '��)°�L7'V F”, POOL '0 EtECMCAL INSPECTION UMEO s E`x, "1� s;� _ ENCLOSE _ y ,> 7 ,3: 0;�.. t MPLETION ^ : PON . .... ,L TER" ' t.; BEFORE-WA �. i� �✓.a) flu��hf{.��t`ri F4,',}a "H\^p1.t1,�lf'V?;, 4�i�t. �!- k"