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HomeMy WebLinkAbout43217-Z Town of Southold 11/16/2020 P.O.Box 1179 0 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41608 Date: 11/16/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 215 Colony Rd, Greenport SCTM#: 473889 Sec/Block/Lot: 52.-5-60.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/2/2018 pursuant to which Building Permit No. 43217 dated 11/13/2018 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: accessorin-ground swimming pool and spa, fenced to code, as applied for. The certificate is issued to Lawi,Neil&Emily of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43217 6/11/2019 PLUMBERS CERTIFICATION DATED tho e i ature SUFFoc,r�, TOWN 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#: 43217 Date: 11/13/2018 Permission is hereby granted to: Yaxa, Dean 215 Colony Rd Southold, NY 11971 To: construct an in-ground swimming g pool as applied for. At premises located at: 215 Colony Rd, Greenport SCTM # 473889 Sec/Block/Lot# 52.-5-60.2 Pursuant to application dated 11/2/2018 and approved by the Building Inspector. To expire on 5/14/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 uilding 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. ZI New Construction: Old or Pre-existing Building:g (check one) Location of Property: C©� kh c 'M dila Uel House No. Street Ha let Owner or Owners of Property: L(D�J,C>e� a Suffolk County Tax Map No 1000,Section Block Lot ®� Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certi icate Final Certificate: (check o e Fee Submitted: $ 0 Applicant Signat e pF 50(/T�®! Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 e Southold,NY 11971-0959 ;4® ® a® roger.rich erte-town.south old.ny.us cou ,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Dean Yaxa Address: 215 Colony Rd City: Greenport St: New York Zip: 11944 Budding Permit#: 43217 Section: 52 Block: 5 Lot: 60.2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electrical License No: 38043-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt, 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 2 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches Twist Lock Exit Fixtures 11 TVSS El Other Equipment: In ground swimming pool and spa to include, bonding, 2-pumps, 1-spa blower, control panel, 1-GFCI recpticle,4-deck recpticles,4-GFCI circuit breakers,4-pool and spa lights Notes, Inspector Signature: Date: June 11 2019 81-Cert Electrical Compliance Form.xls OF SOUIyo� # # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECT-ION [ /FOUNDATIONlST /dAv-_____ [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE INSPECTOR �O�apF SOUlyo6 # TOWN OF SOUTHOLD BUILDING DEPT. °yco 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE INSPECTOR�' OF SOUIyo� # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. FOUNDATION 2ND INSULATION 7 [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) 194 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE G 1 INSPECTOR Z! �� l LI ,�,OF SOUTyO - * TOWN OF-SOUTHOLD BUILDING DEPT. courm��'' 765-1802 _, INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/C ULKING [ ] FRAMING /STRAPPING [v FINAL P [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION ( ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O �� JJ REMARKS: VV W � f On vy-t- -tvo;7 Don) 9 krVle4 DATE 1S INSPECTOR Sya v ��a{tt � �' W .� _� .. ,::. ,. �: - q•-- w_..,, �.�� � � '� a�� ._ � �,._ _ - ^�'� � '•z ` �\ \ .S 1� :� R R��\ �., / .� /, ` � F: 4�_ ���'�\i L ',_ 'i.. ��' � ._�� .y ad �_ ;� r' � _ � .. �. �. ,� �: � � � �, � �,. } .x, � \ F i t tv A V r � .. 47 7 w ov vv� � V-1 vvvv w vv ou iZ IWA gr � IIS reMM a'� Y .r a v z a y \ ` v v Al Aff � \ 40 � � Cv Ile 91, V �\ 7 • ��'}� ,.<�.nom'.'�=t:.., .. _ _ = e.. .d k Mme\. a � x� _Y a ..... ..... .._'.� .,._..�... ._....•ter-m.....« -30 a 4 u K 77�O p R. Y ._ y IL FIELD INSPECTION REPORT DATE CO •S ` FOUNDATION (1ST) � y ------------------------------------ 'FOUNDATION (2ND) LINO ROUGH FRAMING& C7 d PLUMBING 3 a INSULATION PER N.Y; y STATE ENERGY CODE Utt+pz 01M FINAL ADDITIONAL COMMENTS -l-co 1rip 4 I�� � z° d r� b H 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 f Survey Southoldtownny.gov PERMIT NO. ! Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined J 20 Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: ` a Approved 20 �i� Uingg Mail to: i�'CL Disapproved a/c �CV QN-,l Q fQ� Phone: 6-20 Expiration 20 D [ L 'OVL� f N O V — 2 2018 DLICATION FOR BUILDING PERMIT II Date 4A /'z�� , 20 BUILDING DEPT. INSTRUCTIONS TOWN OF SOUMOLID 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. N����_Vc, (Signature of applicant or name,if a corporation) Pees (Mailing address of applicant) State whether appli ant et qw er, l ee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises C�"-x (As on the tax roll or latest deed) If plic is co ora ' n, signature of d ly authorized officer (Name a titl of corporate officer) , t Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. `Locatio`of land on which propo d work rk wil e one: House Number Street Hamlet l�0 County Tax Map No. 1000 Section C_� Block Lot 60, a Subdivision Filed Map No. Lot 2. State existing use and occupancy of pre ises and intended use and occupancy of proposed construction: a. Existing use and occupancy b Rk 0_' j UV, G1-� - b. Intended use and occupancy Gj�4�l�`Qi v� ! SWIrA AA 00 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work c (Description) 4. Estimated Cost 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 'e-1 ! Depth Height Number, of€$tries., f_,- s 4 I 8. Dimensions of entire new construction:Front Rear Depth Height Number of St6ries 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 NOX/"� 13. Will lot be re-graded?YES NO ZWill excess fill be removed from premises?YES NO 14.Names of Owner of premises - ��( � Address 2«i�CA07 4' Phone No. 631 -+65' X05 b r Name of Architect Address IS a Phone No Name of Contractor �0'0 � cAddress 7 j l Phone No. M '�a°\ &5J5 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. PERMIT 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 ©1� c j\, being duly sworn,de]FOWINARYWAslhe is the applicant (Name of individ signing contract)above named (Votary Public,State of New York c ( No.01 BU61-85050 (S)He is the ` ^�C �1 _ Quakfied in,Suffolk County it 1 2 (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 t work will be performed in the manner set forth in the application filed therewith. Swor to before me this day of 2 'l 20 kkA6\ Notary Public Signatur of li a t Scott A. Russell ��°S� '��� ST 1R.MWA\' IER. SUPERVISOR MA\N A\1G 1EM1EN T SOUTHOLDTOWN HALL-P.O.Box 1179 o Town Of Southold 53095 Main Road-SOUTHOLD,NEW YORK 11971 r CHAPTER 236 - STORMWATER MANAGEMENT WORD SKEET (TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE ANY OF THE 1FOLLOW11 INN. Yes No (CHECK ALL THAT APPLY) ❑ A. Clearing, grubbing,grading,or Stripping of land which affects more ❑�Bthan 5,000 square feet of ground surface. . 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. ❑ Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ E, Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse. ,/,.,,on of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP!, Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT Aopei ty 0,%nei,Design Professional,Agent,Conti actor,Other) S. .T.iVI. : 1��0 Date District Section Block Lot FOR BUILDING DEPARTMENT USE ONLY**** Contact information 6 Z/1` — O� Reviewed By: - - — — — — — — — — — — — — — — IV Date: Property Address/Location of Construction Work: — — — — — — — — — — — — — — — # Approved fol processing Building Permit. `�/ Stormwater Management Control Plan Not Required. ElStormwater Management Control Plan Is Required (Forwai d to Engineering Department fon'Revie�\,.) FORM # SMCP-TOS MAY 2014 fFaLKC �.� a � DING DEPARTMENT- Electrical Inspector( TOWN OF SOUTHOLD APR - 9 201 °W all Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 _ F _ ,Telephone (631) 765-1802 - FAX (631) 765-9502 z zT� -liq!.,2'i r�� �- roger richert(cDtown.southold.nV.us TOW1N OF S00� APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date:Lt �q Company Name: �Ac'�iJ6 Name: ' License No.: 3gp�3 email: lc_ell��'�j 1 Address: Phone No.: JOB SITE INFORIVC_ATION: (All Information Required) Name: Address: 6 Cross Street: �2T Phone No.: Bldg.Permit#: 3g 1 ? _ email: Tax Map District: 1000 Section: �a'-- Block: � Lot: 6C5�za BRIEF DESCRIPTION OF WORK(Please Print Clearly) S?p Circle All That Apply`. Final Is job ready for inspection?: OLES 1 NO Rough In Do you need a Temp Certificate?: YES ( NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: = '# 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: PAYMENT DUE WITH APPLICATION C 82-Request for Inspection Form As moo�/--- - .1 N G.•1 ,a o PROPOSED COVERED ENTRY (7`lrJ'•�6�"'TCP __ _—_ - (A°60 SOFT-) w? PROPOSED 2 STORY LIVING AREA 1 3 J (A°2816 6MFT GO�O PROPOSED SUN ROOM (A°215 SQFT) \ PROPOSED OPEN DECKS !A°215 SQF7J e\ \ ,\ \N \ 6t1 EXIST. BT T. -----5.66'30'00"W. --------- 200 0' `y'V1°�O \ 1 0, \ 1 Ie THIS 15 AN ARCHITECTS PLOT PLAN 4 \ 15 SUBJECT TO VERIFICATION BY A �m LICENSED SURVEYOR I INFORMATION OBTAINED FROM SURVEY \ PREPARED BY: \ I JOHN C.EHLERS LAND SURVEYORS \ } 6 EAST MAIN STREET RIVERHEAD,NY.IISOI 1 DATED:8/08/2005 \ IN \ 1 lP I - \ N PARTIAL SCHEMATIC PLOT PLAN \ 1� NgO-22=��u11�•-�- — i SCALE:P=501_011 \ I YAXA RESIDENCE 6\ I 215 COLONY RD. \ I' SOTHOLD,NY. 11,311 LOUISE A AGNES A I A ARCHITECT 1 162 Laurel Avenue NORTHPORT,NEW YORK 11768 _ (631)754-2950 1 w,, •) F= (631)261-9485 I 9I(C 4� 151'yaC� �`NEI.�V i PARTIAL SURVEY OF PROPERTY w SITUATE-AR5HAMOrYAQUE 5 TOM 5 I(nWL.D 5EE DETAIL SUFFOLK COUNTY, NY FOR LOCATIONS SuRVEYED PROPOSED H5E.0 2005 1zm o HEALTH DEPT.11-142001 h SUFFOLK COUNTY TAX flanxaa+ 's1 '-_i ScPTIf, iJETAIL ® i •`.ASO ,� ,1.{ JUL 1 I �O - Ie..e.,tp paaa Piu 1 a lrtf �• 14 tl� y} `••' '8'0 �'� wx wt _' �����BIIILDIiYG AE['T une � 1 'a uii c«1 ._.� 'm:•-ae- q � Test HOt® a-• � McDOn Id NOTES, MONUM1ETiT FOLNG0�,Qt �q1. - ,3' •, � o f 4 i `ISS Q1 i ENTIRE PROPERTY NOT SJRVEYEV,ANY ENGRDAGNFI pNT5 NOT SHOM HORK DOw ERE PJ THL PU�RP 5E OF MAIN IH6!f✓+LTHW APPROVAL FOR SEPTIC AND hE�A.'AND SU691:GUENT.TOM G.O. 14 }f ^)� �a a j a UNSUITABLE 50ILS TO BE REMOVED AND'RFPiAG W _ , n7 1 + SAND AS PER SL.DN5.REW-ATIONS ca't " - TOPO REFERENCES COUNTY TOPO HAP - r AREA n`S8i.949 5F or L`3SO ACRES i lays sS,ewSTlra9 HOUr aga 2366 F.TOTAL X J1 It01)SE 3,141 5F.TOTAL X J7 RAIf9'Al l=09b GP✓4223 10'X 9' LL Nt PROPOSED 4 B'DIAH X 4'DEEP U"'"' Ova' qO Gt_rAf, 'CEO' 6 6AS1 MAIN WRFlT N Y S.LIC.NO 511°07 RlYWAWIND NS 11901 OVERALL PROPERTY 1611-828$Pdn 4611-tQkil ItPf.-;Cump.ulsea.crllwea lO5W4 LS^H1)AMILICATIO,N 11-IJ-HI021nl, I5-1—ALM I° 800' i -vatrick S '001S ; P.O. Box 3024 j' East Quogue,NY 11942 Phone 631-903-7665 Fax 631-245-6513 www.12atrickspools.com Hi John, I hope you are well. We have the pool project tarped to keep the ground from freezing with these very low temperatures. I apologize for the inconvenience. I have printed out these pictures so that you can see our rebar work. Thank you Patrick '031599 6529 Custom Gunite&Vinyl Construction-Maintenance-Marble Dusting-Liner Replacements-, Complete Renovations Safety Covers-Leak Detection-Heater Installations-Child Proof Fencing-Saltwater Chlorine Generators Patios-Solar Attic Heaters-and more- ) YORK W°rkers' CERTIFICATE OF STATE olmpensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE B 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Palricks Pools Inc 631-9964687 PO Box-3024 East Quogue NY 11942 1 c.NYS Unemployment insurance Employer Registration Numoer of Insured i Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer,identification Number of Insured or Social Security certain locdtions in New York State,i,e.,a Wrap-Up�Pghcyl Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 54375 Main Road Southold NY 11971 3b,Policy Number of Entity Listed in Box"1 a" VVWC3349994 3c:Policy effective penod 05/1312018 to 05/13/2019 3d The Proprietor,Partners or Executive Officers are [I included.(Only check box If all partnerslotricers included) Q 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"Ia"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under em 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'. Will the carrier notify the certificate,holder'within 10 days of a policy being cancelled for non-payment of premium or within 30 Days if cancelled for any other reason Or if the insured is otherwise eliminated from the coverage Indicated on this certificate prior to the'end of the policy effective period? []YES ❑NO 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 isIJn 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 it e 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 ttie coverage as depicted on this form. Approved by: 'Nicholas Zulkofske (Print name o a ihorized representative or licensed agent of insurance carrier) Approved b . , -�, (Ni ure) (Date) Title:Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier 62'=941-4113 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(9-15) www.wcbmy.gov CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 06/17/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS f- CERTIFICATE DOES NOT AFFIRMATIVELY OR AEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i` BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 'i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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). �i PRODUCER CONTACT I Brookhaven Agency,Inc. ACIND 631 941-4113 FAX )(63'i�941-4405 128 Old Town Road,Suite C E-MAIL ❑ORF_ss. brookhaven,agencYwerizon.net i P.O.Box 860 INSURERS AFFORDING COVERAGE NAIC9 East Setauket NY 11733 INSURER A: Colony Insurance Company 39993 INSURED INSURER B:W@SCO Insurance Company j Patrick's Pools,Inc INSURER C: PO Box 3024 INSURER 0 i i East Quogue NY 11942 INSURER E: �+ I INSURER F• �V_-is COVERAGES CERTIFICATE,NUMBER. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING,ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH P.O ICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADL SUBR POLICY EFF POLICY EXP LTR .TYPE OF INSURANCE POLICY NUMBER 11DO/YYYY1 fMM1DDfYYYY1 I LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,600 DAMAGE TO RENTED +; A CLAIMS-MADE X OCCUR 41SFS rEn octt re S 100 000 X X GL4188846 02/28/18 02/28/19 MED EXP(Any oneperson) S 5,000 PERSONAL 8 ADV INJURY S'1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I S!,000,000 POLICY O JET T F LOC PRODUCTS-COMPIOP AGG S2,000,000 it OTHER' AUTOMOBILE LIABILITY COB�INwEeII SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) S~ i' AUTOWNED AUTOSULED BODILY INJURY(Per accident) S NON-OWNED PROPERTY DAMAGE S ( HIRED AUTOS AUTOS Per aee dent 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE SS {; EXCESS LIAR CLAIMS-MADE AGGREGATE I S, DEO I I RETENTION S �j WORKERS COMPENSATION PER I OTH- r AND EMPLOYERS'LIABILITY TA ITE I Ir-P — ANY PROPRIETOR/PARTNERIEXECUTIVE Y f N E L EACH ACCIDENT 5.100 000 i; B OFFICERIMEMBEREXCLUDED? NIA WWC3282511 06/13/2017 05/13/2019 (Mandatory in NH) E L DISEASE-EA EMPLOYEE S100,000 { If yes,describe under DESCRIPTION OF OPERATIONS balow E L DISEASE-POLICY LIMIT S600,000 1 ix j DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may bo attached if more space Is required) it i Town of Southold is Included-as additional insured i, ?€ CERTIFICATE HOLDER CANCELLATION f Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54376 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE q �� E ©1988-2014 ACORD CORPORATION. All rights reserved. I ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Gouss of�� v " . 1 aa9°`c �• <w k« �;€ '.r 3 a t � VVI�H ALL t®�� `� �� JosR�SIXT®I c�w1�1'�IQN t " SP Ill i tn� NFW 0 , g Nc fi 1t 1�/' I . t j� Q T �{ y� �F NE`N S ✓ 3 I 4 1 I pt - .r.. - - -• - - na .r._ •. ..s _ �v..- S� 1 i tai M1�� .'� s� !_•- re � `0� -� _p � '•" -_. - .-.-- - r - - - -. - - .._ - - - "r� ;_. � i �,, t SW"" `-lf 1 n\ �i:i ;4....e..L 1100..!! , FrAi' D t� .� 4 � .F��5 a �C� t ,_yS�_ �i"ft I� �' ;i i �.xu.aoa..>'.•e-.a,.-w..r.v..-,-a.,•....e.._>,.__-_.. ,_ ,a-..:�..ww.-,oa «w_r.v .w-c.�ca:_---�'- F.-1-s_- v.- .n_.v«... _..aa.-cn�>- V NOTED DATE: 11.13•« B.P. F E E.-j • i Iif 1' T 1 DEPARTMENT C Z_ R 7R # I JO IFY BUILDIPI= ,DEP MENT AT 765-1302 8 AM i0 Arl l #, r 4 r=,., FOR THE FOLLO4"JIi 1G INSPECTIONS: 'I. FOUNDATICN -'IT 11'JO REQUIRED t FOR POUPED •CONCRETEr L 3 >� 1 `, I� 2. ROUGH - FRAIr+JING_& PLUMPING - f °' 3. INSULATION I It �� g, ,'RUCTION MUST FINAL COtiST BE COMPLETE FOR C 0. �Nv�p V SMALL MEET THEALLCONSTRUCTi�I �❖ at , r: ; SER 236 REQUIREMENTS Q THE CODES OF NEW €; r � YORK STATE. NOT RESPONSIBLE FOR O\Nn _ DESIGN OR COPJSTNUCTION ERRORS. L- D n 4 ti ''. h � 8 r> �' i r�.✓ Ott. - :..� -o. .,✓ K Com' ;, 1 � �V�f� '' a�y{I✓' s. l.. 171 F___- F _ _'- _.__ - _ � -� a[r�,_w._ _ .. '.,..w+....-.....e.+.u..0 � .,�s..•�,.�`...'�.+ss r--�w,-,a .t�._E� �_ _ - ,—--. _ �n-:�. a-, _->_ ._ �-.- ..,-._�....,... �, { � ! __- - � - "tl"__�__"'�'^`'_-___�—"^..,•,-'"'"`nom �,�. -��`--„._��,��..~at' -_o�..�c..._�_a--,�..�a:. •-�__w.�_�a��....'.c...a_-�^�--->----�� ? �(,� e.. sQ ®IAS _.�--~Y u ,� Tb C+O�E, ...,--�'' _--'�.---_ ;i x poctbsnav►of�e EN C`OSE PMOL E�ION ,'r y ° 1 = Patrick Kenney,CaP k t UPON COMwATFER” c=— c � `. g.. a a j �v,'�t q P CEATSf1ERE9MtE2013�`�1 '\ a B�E `-•='^-',.,..-,'r' '� j J 4 ` 4t ...., .."w S'�`:�.! �j• EXPI 2019 `\ r j 1