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HomeMy WebLinkAbout44875-Z FOlk , Town of Southold 11/10/2020 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41590 Date: 11/10/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 5640 Westphalia Rd., Mattituck SCTM#: 473889 Sec/Block/Lot: 113.40-15.5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/28/2020 pursuant to which Building Permit No. 44875 dated 6/16/2020 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 Springer,Lisa of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44875 9/18/2020 PLUMBERS CERTIFICATION DATED YAuFre(Si ature TOWN OF SOUTHOLD BUILDING DEPARTMENT ca, - 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#: 44875 Date: 6/16/2020 Permission is hereby granted to: Springer, Lisa 5640 Westphalia Rd Mattituck, NY 11952 To: construct accessoryinround swimming-g g pool as applied for. At premises located at: 5640 Westphalia Rd., Mattituck SCTM # 473889 Sec/Block/Lot# 113.-10-15.5 Pursuant to application dated 5/28/2020 and approved by the Building Inspector. To expire on 12/16/2021. Fees: SWEVIlVIING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Bui g 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. 0 1 Date New Construction: Old or Pr�e-eistinTBuilding: (check onA., CU\ � Location of Property: House No. sfreet Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Block Lot 1��• Subdivision Filed Map. Lot: Permit No. "i `[ Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ licant Signature Buildiag.Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, residing PA (Print propertown 's name (Mailing Address) do hereby authorizZu�AVIA , 4 �,�Ls? (Agent) to apply on my behalf to the Southold Building Department. �nS t2— 2, 2,rr) (O Signature) (DAte) --SOv (Print Own 's Nam ®��OF SUr�®� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 CA sea n.devlinCC�(ED-town.towsthold.n us Southold,NY 11971-0959 y BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To, Lisa Springer Address. 5640 Westphalia Rd city:Mattituck st: NY zip: 11952 Building Permit# 44875 section: 1,13 Block 10 Lot 15.5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor, DBA: PSR Electric Corp License No: 4802ME 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 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 1 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 1 Disconnect Switches 4'LED Exit Fixtures Pump 1 Other Equipment- Intermatic Pool Panel, Salt Generator, Pump on 220GFI Breaker, Heater Notes Inspector Signature: � -�X� Date: September 18, 2020 S Devlin-Cert Electrical Compliance Form.xls L4(-1 SOF SOGJH V 7 s # # TOWN OF SOUTHOLD BUI DlWd sr cou765-1802 INSPECTION , [ ] 'FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ]" FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL.(ROUGH) I ELECTRICAL (FINAL)?&o_L__ [ ] CODE VIOLATION [ ] PRE C/O REMARKS: TIN DATE INSPECTOR ` 1 8 OF SOUryo * # TOWN OF SOUTHOLD BUILDING DEPT. a_ . �o co765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] I ULATI W154ULKING [ ] FRAMING /STRAPPING [ FINAL [ ]- FIREPLACE & CHIMNEY j ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) = [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARK �` • a eAl\ ( O W 1 DATE 0 Y! >Q ANSPECTO fir- ----,- -- - -- - - _ qqg o�ryo # # TOWN OF SOUTHOLD BUILDING DEPT. �`ycouam ' 765-1802 = INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATIOWCAULJKING [ ] FRAMING/STRAPPING [ FINAL Re, .- FIREPLACE `FIREPLACE & CHIMNEY [ ] FIRE-SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION , [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE INSPECTOR cr s FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (IST) -------------------------------------- FOUNDATION (2ND) z � o ROUGH FRAMING& PLUMBING ry y S V) INSL:LATION PER N.Y. H STATE ENERGY CODE L u l- N AAAn �1 FINAL ADDITIONAL COMMENTS lo o X x r� x - - d H 1 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.NorthForLnet PERMIT NO. 7-5 Check Septic Form N.Y.S.D.E.C. Trustees 71% Flood Permit Exarmned 20—A V Storm-Water Assessment Form Contact: a ,1 Approved 20,OW rMl 'ir rl I V Disapproved a/c Phone: xpiration — 20 G 3' Bin ctor A M AY 2 8 2020 APPLICATION FOR BUILDING PERMIT DateMA-V 2 ;.-0 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. orke.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, —to lations,and to admit authorized inspectors on premises and in building for necessary inspections. .,,(Signature (Signature o a me,r a orporation� 1A AJ PC (Mail address of applicant) tate whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder to ti Name of owner of premises LAS41,1 —4 on the t x oll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) Builders License No. 2 I �I Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land ichro sed o k wil b M441+c�I House Number treet Hamlet County Tax Map No. 1000 Section 113 Block I v Lot t s. ry Subdivision d Map No. Lot VIOLP br 40- 10 IIC4)IYA Iq zq 7 � A4 2. State existing use and occupancy of premises and in nded us nd occup ncy of pro sp4 construction: a. Existing use and occupancy b. Intended use and occupancy x YD O� l,l) -� ,'� yy 3. Nature of work(check which applicable):New Building Addition W teratifn ° Repair Removal Demolition Other Work 190 to Description) 4. Estimated Cost 04 �� 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 Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new constriction: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 constriction violate any zoning law,ordinance or regulation?YES_NON/ 13.Will lot be re-graded?YES NO ,Will excess fill be removed from premises?YES_N� 14.Names of Owner of premise&— n �res, 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 N *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAYREQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NOXI— 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 NOX *IF YES,PROVIDE A COPY. / STATE OF NEW YORK) SS: COUNTY OFA being duly sworn,deposes and says that(s)he is the applicant (Name of individual sign g contr )above named (S)He is the (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is dal authorized to erfo erformed the said work and to make and file this application; Y P �� ll �tP PP that all statements contained in this application are s q�h4(g, owledge and belief,and that the work will be performed in the manner set forth in the applicati`o. c$t)ig� iF,QVIP Sw before t ,� O�Mtg2318 ti da {% •'tt QtE UN UpLIFCO tyr( �S�FFOLV 6 z- co 'Se No ary Public °t �ti � ; Signature of Applicant 11 Scott A. Russell �°SAF '� S]F 0)1RJ\M1WA�' 1E1K SUPERVISOR z IMIANA(GrIEMIEINT SOUTHOLD TOWN HALL-P.O.Box 1179 0 53095 Main Road-SOUTHOLD,NEW YORK 119710 Town of Southold 1 � r CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INV®L'1E ANY O F, THE T]F®ILWWING: Yes No ~ (CHECK ALL THAT APPLY) ❑ A. Clearing, grubbing, grading or stripping.of land which affects more than 5,000 square feet of ground surface. B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑ D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑ 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. —1 #: APPLICANT (P�ope(ty Owner,Design Professional,Agent,ConhS,C.T.M. 1000 ate acto�,Other) NAME e�ct(on Block Lot **** FOR BUILDING DEPARTMENT USE ONLY**** Contact Info(mation. r ` - Reviewed By:jdsa AkiDateP 696 Property - - - - - - - - Address /Lo atlo of Construction Work: — — — — — _ _ _ Z] Approved for processing Building Permit. Stormwater Management Control,Plan Not Required. — — — — — — — — — — — — — — — — — Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM * SMCP-TOS MAY 2014 �yF�Qt BUILDING DEPARTMENT-ElectricalInspector � � TOWN OF SOUTHOLD ® CO- Town Hall Annex- 54375 Main Road - P x 1179 D Southold, New York 11971-09 rrP 8 2020 Telephone (631) 765-1802 - FAX(631) 765-95t roper richert@ own.so tthold.ny.us B DiuPT. APPLICATION FOR ELECTRICAL INSPECTION ,g REQUESTED BY: f Date: 29 Company Name: / o Name: License No.: p ---email:- - c i� Address: Phone-No.: JOB SITE INFORMATION: (All Information Required) 0 Name: Address: Cross Street: Phone No.:M BIdg.Permit P. 7,Sr7 email: Tax Map District: 1000 Section: 3 Block: Lot: 15. 5' BRIE DESCRIPTION OF WORK(Please Print Cl e rly) � �Gv 1u Circle All That Apply: Is job ready for inspection?: YES t O Rough In Final Do you need a Temp Certificate?: YES/ NO Issued On Temp Information: (Ali information required) Service Size 1 Ph 3 Ph Size: A #Meters Old Meter# New Service-Fire Reconnect- Flood Reconnect-,Service Reconnected -Underground -Overhead 16#Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION \CP C� 82-Request for Inspection Formals S( BUILDING DEPARTMENT-Electrical Ins ector TOWN OF SOUTHOLD D : Town Hall Annex- 54375 Main Road- P x 1179 l Southold, New York 11971-09 ' Telephone (631) 765-1802 - FAX(631) 765-95 P S 2020 roper richettfttaWn-southoid.ML.us u1Pt G DPT. APPLICATION FOR ELECTRICAL INSPECTION Tai"'_'?C-, (-TTHQLID REQUESTED BY: / Date: f Company Name: / Name: License No.: c7 email: c J� ddress: o Phone No.: JOB SITE INFORMATION: (Ail Information Required) 0 Name: , Address: Gross Street: BIdg.Permit#: 7 S email; `tax M District: ' 1000 Section: 3 Block: I D Lot: l5. 5 BRIE DESCRIPTION OF WORK(Please Print Cl rly) ��, Circle All That Apply: Is job ready for inspection?: CYES t O Rough in Final Do you need a Temp Certificate*?: YES/ NO Issued On Temp Information: (Afi Information required) Service size 1 Ph 3 Ph Size: A #Meters Old Meter# New Service-Fire Reconnect-Flood Reconnect-Service Reconnected'-Underground-Overhead #Undergr©und Laterals 1 2 H Frsme Pole Work-done on Service? Y N Additional Informiation: PATENT DUE WITH APPLICATION — AP 6 o� \� 82-Request for Inspection Form As � � '/ I ' l � ! evil 2 � � � OJI1 i i I I I I I I Suffolk County Dept.of Labor,Licensing&Consumer Affairs ] '4 HOME IMPROVEMENT LICENSE Name RANDY T RODECKER i"' f•�.: Business Name This certifies that the I bearer is duly licensed FENCE KING OF ROCKY POINT INC DBA by the County of suffolk License Number: H-21412 Rosalie Drago Issued: 06/01/1992 j Commissioner Expires: 06/01/2022 I I i I I i i I I I YORKworkers' STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC DBA SWIM KING POOLS&PATIOS 471 ROUTE 25A ROCKY POINT,NY 11778 1c Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limded to or Social Security Number certain locations in New York State,i e,Wrap-Up Policy) 113008276 2 Name and Address of Entity_Requesting Proof of Coverage 3a Name of Insurance Carrier ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity Listed In Box"l a" 53095 Rte 25 DBL37154 P O Box 1179 Southold, NY11971 3c.Policy effective period 02/01/2020 to 01/31/2021 4 Policy provides the following benefits © A Both disability and paid family leave benefits B Disability benefits only F] C Paid family leave benefits only 5. Policy covers ® A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B Only the following class or classes of employer's employees. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above Date Signed 2/7/2020gy VW (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer 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 413,4C 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 513 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120 1 Insurance brokers are NOT authorized to issue this form. D13-120.1 (10-17) IIIIIIIIIII�IIIIIIIII�IIIIIIIIIIIII�I�IIIII 111 I IIDB-120.1 (10-17) III I III YY'Dq Workers' CERTIFICATE OF STE C€�rrtp�nsat€ort NYS WORKERS' COMPENSATION INSURANCE COVERAGE Berard 1a.Legal Name&Address of insured(use street address only) 1b.Business Telephone Number of Insured Fence King of Rocky Point,Inc. 631-744-8100 DBA Swim Kings Pools&Patios 471 Route 25A 1c.NYS Unemployment Insurance Employer Registration Number of Rocky Point,NY 11778 Insured Work Location of Insured(Only required if coverage Is specl/lcallylimited to 1d.Federal Employer identification Number of Insured or Social Security certain locations In New York State,l e.,a Wrap-Up Policy) Number 11-3008276 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest Indemnity Insurance Company Town of Southold 53095 Rt.25 3b Policy Number of Entity Listed In Box"ia" PO Box 1179 sw5wc00205181 Southold,NY 11971 3c.Policy effective period 11/05/2018 to 11/05/2019 3d,The Proprietor,Partners or Executive Officers are ❑X 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'1a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 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 after 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. 1 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: Kevin White It (Print name f aulho tied r r enlahve.or licensed agent of Insurance carrier) Approved by: 11-07-18 P(drlq UndeWrifft VICO PrOSldent (Date) Title: . Underwriting Assistant Telephone Number of authorized representative or licensed agent of insurance carrier: 714.371.9612 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) - V www.wcb.ny.aov - 2 SURVEY OF P-ROPERT LOTaSITUATED AT LOT SO MATTITUCK , LOT TOWN OF SOUTHOLD OT �8 J SUFFOLK COUNTY, NEW YORK _ T 77 L S.C. TAX No. 10'00- 1 13--10—'x-5_-.5 �� I • SCALE 1 "=S0' 1 I o OCTOBER 27, 1999 Z ' DECEMBER 11, 1999 REVISED MAP CA MARCH 27; 2001 ADDED TEST HOLE g3 FEBRUARY 6, 2OQZ, ADDED PROPOSED= 1NATER :I�CI�IE I cn I I LOT O I FEBRUARY 1 1 , 2002 REVISED PROPOSED` DOUSE; JULY 19, 2002 FOUNDATION I LOCATION I DECEMBER 20,- 2002 -FINAL SURVEY LOT AREA = 40.021 .48 sq. #t.. =I LOT 9-6 0.919 ac. . 70 70, PMP STEPS soa• I I ctnA,n,Ey o 2 STORY FRnos• ea< --- I NOTES: (� AME m ' HOUSE & GARAGE it _. m '� 1. L-0T NUMBERS SHOWN 80 THUS: LOT REFER TO • O I so.z'I A0' MAP OF TOLLEWU6D I _ FILE IN THE- OFFICE OF THE CLERK OF SUFFOLK COUNTY $ > F ovER 70 ON JANUARY 25, 1927 AS FILE-No. 175 ' ` - STEPS � N 2. ALL OFFSETS ARE' SHOWN TO FOUJNDATION. SEPTI ' r I �' n I TANK POOL • _ iv1.y�,., � r I I I 14`1, a ' ' �v/ - - - If i - - CERTIFIED TO: ,,R .� I �' I e .,�;1�2•g6 `� RYAN L. SPRINGER BY ti v' :• _- SUFFOLK FEDERAL CREDIT UNION BP 7HE b �• ° r ° i AQUE-BOGUE ABSTRACT Corp. 4f _ -N.Y.S.`id.,No-_4iib 1}36'arhm,x6'�NV101,oft mN -• - _ _ mCRT�JONSU-1t"t)F-1HE.NEW10RIt-5TAiE, - - �;'---:..'-•,=:z's _(y�:��,.• c LIOPIES'OF"THIS SURVEY 7AAp N0T8EARtNG �� ' l -g�_qI" ' 1HE.U)NB-SURVEYOfi'S--D3KEO SEl1L�tt_. - `.- _ EMBOSS83L I SWILL-NOL'6E 9 <_ u "•�; _ - - n - - :! TO 8E;A,VN.ID TRUE'G'DP1::_c. ;: ,iwa� ■VV _ . ` _ - - � _ - - - otaY:-ro-TFt�PERSON F>'R a�moY.1t3E SURv[x - : - •-• __'' - _ '..` <",,:•-�� •-:--�- - : - s PREPARm,_AND oN fUSB4IALE'i0-TETE - _ :mtE cxpm�Nr`- trA3 A�T�Cr ANS nd,a Surveys—Summshmi -Sita Plops;=;:Corishirofigri;Laryo+it_`; - LF1a1Nc Mi57Tit`1TIOPI1�57ED'lIDifON.-AND - s - - TO 113E}ISSGNtFS-OF`iRE'LEHD976,1NSR - - , nmox.cfxnricAnoNs•ARI 1ar_TRArRAm E -PHONE-(431)727-2090, Fax (63#�y�7 U727'- -•„ - - THE EXIS�ENCE_OE;RIO OF-WAYS 0'Ffl9EB L=7E0;AT - • i ANYf NCT SHS EWtOWlIA ARM-DF NQT�CtiAiiAN7EE0. 13B0 [iOAMRKE AVENUE, P.Or Boi:7931 RN *:t E ; Now York 11901. Rivefiebd;lsw.,NcLk24 1:1901-0965 r NOTES 10` ,D" 40' V 1 1 NO SOILSVRCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR FEET OF EXCAVATION ATTHE DEEP END O o BENCH 2 THIS POOL MEETS THE REQUIREMENTS OF AN51/AP5P/ICC-5 AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROVND 5WIMMING I'— POOLS"AND 1996 BOCA CODE-SECTION 421 DIVING EQUIPMENT 15 NOTALLOWED Q I 3 SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED IAW REQUIREMENTS OF APPROVED AS NOTED SECTION R326 4 21 THROUGH R326 4 2 6 OF THE NEW YORK STATE RESIDENTIAL CODE(2020)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD TOWN CODE,DWELLING WALL(S)MAY SERVE AS PART OF THE POOL BARRIER AS PER SECTION R326 4 2.6 AND L/l CO [:31:2 CONDITION(1)ARE MET OPERABLE WINDOWS IN THE WALUS)USED AS A BARRIER SHALL HAVE A SELF LATCHING DEVICE ACCESS GATES Hz0 A SHALL COMPLY WITH SECTION R326 5 2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY 0 DAT p # LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOLAREA Q Y FEE: BY: 4 DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROUND THE EXCAVATION IAW THE CODE OF THE TOWN OFSOUTHOLD. V 3 NOT BUILDING DEPARTMENT AT a - Z Q z 765- 02 8AM TO 4PM FOR THE 5 POOL MUST BEEQUIPPED WITH ANAPPROVED POOL ALARM CAPABLE OFDETECTING ENTRY INTO THE WATER AND SOUNDING AhV Ln+ AUDIBLE ALARM UPON DEFECTION THAT 15 AUDIBLE AT POOL5IDE AND INSIDE THE DWELLING,THE ALARM MUST BE INSTALLED, N FOL WING INSPECTIONS: MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS THE ALARM MUSTMEETA5TM F2208 < 3 B "STANDARD SPECIFICATION FOR POOL ALARMS THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF G 0 1. F ONDATION-- TWO REQUIRED PERSONS F( R POURED CONCRETE PLAN 6 POOLSUCTIONFITTINGSCEXCEPTFOP,SURFACESKIMMERS)MUSTBEPROVIDEDWITHACOVERMATCONFORM5TOASME/ANSI ''� R UGH - FRAMING & PLUMBING NTS A112198M ORA MINIMUM 18"x 23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH 2. 3. R( U H F 1B'VINYL COVERED CONCRETE 5TEP5 ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN SUCH VACUUM RELI EF SYSTEMS SHALL CONFORM WITH A5ME A1121917 OR BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD 4. Fli AL - CONSTRUCTION MUST POOL SHALL BE PROVIDED WITH A MINIMUM OF SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE THE SUCTION FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A BE COMPLETE FOR C.O. VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCE551BLE M ° POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO ALL I ONSTRUCTION SHALL MEET THE THESKIMMER/5KIMMER5 A REQUIRE[)POOL ATMOSPHERIC VACUUM RELIEF 5Y5TEM SHALL BE INSTALLED AS PEP,NYS RE51DENTIAL CODE 8326 6.3(2020)AND IN ACCORDANCE WITH TOWN CODE U REQ REMENTS OF THE CODES OF NEW z'To4°sANDBorroM E: YOR STATE. NOT RESPONSIBLE FOR 7 ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE NYS N RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND rt5 DESI( N OR CONSTRUCTION ERRORS. SECTION A BE PROTECTED BYAGROVNDFAULT CURRENT INTERRUPTER(GFCI)CURRENT CARRYINGELECTRICAL CON DVCTORSEXCEPT FOP,TH05E in PROVI DING POWER TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203 5 ALL iy o N METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR AD)ACENTTO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED OMPLY WITH ALL CODES OF NTS DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED Imm NE YORK STATE & TOWN CODES WATERLINE TOPOFWALL 8 WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITHABACKFLOWPROTECTIONDEVICEIAWNY5PLUMBINGCODE60B. 0 c: z AS EQUfRED AND CONDITIONS OF 4' 4' 9 ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 1Cy� a 51 10, WALKS IF PROVIDED SHA-L BE NONSLIP AND SLOPE AWAY FROM POOL EDGE v a 4 J n�I ITt I/`11 T�T(11Aj�I7 m o O 0 �'.• .p fO' 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW AN51/AP5P/ICC-5 SECTION 6 0- d F- Ln SG41lN49*44�GBOARD 12 CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS V I�Ru4STLLS 13 ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SVB)ECT PROPERTY O �� 1 VMP[tl FIUJ CJ SECTION B 15 THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH<10%SILT GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION, IFGROUND WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED ry NTS 16, ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROVND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT POOL HEATERS 5HALL BE TESTED IAW ANSI 7-2156 AND SHALL BE INSTALLED IAW MANVFACTVRERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED LAW UL726 POOL HEATERS SHALL BE LOCATED OR CHECK VAI VE GUARDED TO PROTECTAGAI N5T ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL H EATERS SHALL BE PROVI PEE)WITH U COPING AND WALKWAY TEMPERATURE AND PRESSURE-RELIEF VALVES FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM A BYPASS LINE SHALL BE h t� FROMSKIMMER (BY OTHER$) INSTALLED FROM INLET TO OUTLETTO ADJUST WATER FLOW THROUGH THE HEATER POOL HEATERS SHALL BE PROVIDED WITH THE 0. 00 PUMP E WATERLINE GRADE FOLLOWING ENERGY CONSERVATION MEASURES p TO YDISPOSAV 161 AT LEAST ONE THERM05TATSHALL BE PROVIDED FOR EACH HEATING SYSTEM `�„� N DRWELL _ 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE p�q, fy�q qpm, UNDISTURBED EARTH ® OPERATION OF THE HEATER WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE �+ 00 E �`��``�®�� BSOOPSIPOUREDCONC °• PILOT LIGHT W ;r` N INSPE ION REQUIRMER 16 3 HEATED SWIMMING POOLS SHALL BE EQUIDPED WITH A POOL COVER(EXEMPTED FROM THIS REQVIPEMENTARE OUTDOOR POOLS W a T 00 c O 3/B'REBAP 2),YP DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) Z VINYL LINER • 16 4 TIME CLOCKS SHALL BE INSTALLED 50 THE DUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE 5ET ►`+ Y ° TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE tEL .a z To4'SAND� / •° \ SANITARY CODE OF NEW YORK STATE = 0�m Q0 m FILTER Cc Lu co 17 THIS DRAWING 15 FOP,5TRVCTURALSHELL ONLY ALLACCESSORIES AND APPURTENANCES APE DEFINED BY OTHERS \ \ \ aR " E� TOREURN5 18 BACKFILL WITH CLEAN EARTH,FREE OFROOT5ANDDEBRIS DO NOT ALLOW Tl-IE HEIGHT OFBACKFILLTOEXCEED THE HEIGHT OFTHE 09LO� � WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" W d: A CHECK VALVE VERTICAL 3/8'(NOTHOWN)REBARP3'OC 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL U PLUMBING SCHEMATIC ml NE\'N OR N T5 20. THERE 15 NO MAIN DRAIN IN THI5 POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE 5KIMMER5ONLY.TH15 MEETS 0 - UPANCY ORWALL SECTION REQUIREMENT'S OF THE NYS PE51DENTIALCODE-SECTION R326.5 POP ENTRAPMENT PROTECTION _ 21 THE POOL WAS DESIGNED IAW THE FOLLOWING- US IS UNLAWFUL p,� NTS °`' `= ;' r'` 211. THE NEW YORK STATE RESIDENTIAL CODE-SECTION R326(2020) rJ- { r ` y� L'S PE � �Q/to ry 21.2 THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION 8403.10(2020)'OhWhIMEh I =� i 213 THE NEW YORK STATE FUEL GAS CODE(2020) L _0 WI ROUT CERTIFICATE ",-,E'N'-c�oSEPOOL-TO CODE� 214 THENEWYORK517ATESANITARYCODE 215 AN51/AP5P/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. c", PON CONIPL'ET4N 21.6 SOCA CODE-SECTION 421 Wy �BEFQRE_ 217. CODE OF THE TOWN OF SOUTHOLD OF OCCUPANCY _ ATI11j 22 ALL BACKWASH TO BE SELF-CONTAINED ON-51TE " -f c_\0