HomeMy WebLinkAbout44863-Z �4�gUEF�t,�C� Town of Southold 11/20/2020
0
P.O.Box 1179
a' x 53095 Main Rd
Southold,New York 11971
4416
CERTIFICATE OF OCCUPANCY
No: 41619 Date: 11/20/2020
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 25335 Route 25, Orient
SCTM#: 473889 Sec/Block/Lot: 18.-3-13
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
5/14/2020 pursuant to which Building Permit No. 44863 dated 6/12/2020
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 fenced to code as applied for.
The certificate is issued to Sellis,Zane
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 44863 9/30/2020
PLUMBERS CERTIFICATION DATED
Aho ' gnature
SUF QF TOWN OF SOUTHOLD
,moo`° cOa BUILDING DEPARTMENT
C* TOWN CLERK'S OFFICE
"� • SOUTHOLD, NY
} fx 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 #: 44863 Date: 6/12/2020
Permission is hereby granted to:
Sellis, Zane
10 Fern Dr
Jericho, NY 11753
To: construct an in-ground swimming pool as applied for.
At premises located at:
25335 Route 25, Orient
SCTM # 473889
Sec/Block/Lot# 18.-3-13
Pursuant to application dated 5/14/2020 and approved by the Building Inspector.
To expire on 12/12/2021.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO- SWIMMING POOL $50.00
1: $300.00
uild' g nspector
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.
New Construction: Old or Pre-existing Building: (check one)
Location of Property: MW O 120c d (9 f l PI4 y1 119 7
House No. Street Hamlet
Owner or Owners of Property: �� 5; //,(
Suffolk County Tax Map No 1000, Section b Block ? Lot
Subdivision I I Filed Map. Lot:
Permit No. Date of Permit. Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted: $ �
Applica ign re
CONSENT TO INSPECTION
Z11oI �• , the undersigned, do(es) hereby state:
Owner(s)Name(s)
That the undersigned (is) (are) the owner(s) of the premises in the Town of
Southold, located at.?S 3?75' /e f ajA) ,'d, t/Vi,o4/ ^J- -/
which is shown and designated on the Suffolk County Tax Map as District 1000,
Section ,Block_3 , Lot _.
That the undersigned (has) (have) filed, or cause to be filed, an application in the
Southold Town Building Inspector's Office for the following:
That the undersigned do(es)hereby give consent to the Building Inspectors of the
Town of Southold to enter upon the above described property, including any and all
buildings located thereon, to conduct such inspections as they may deem necessary with
respect to the aforesaid application, including inspections to determine that said premises
comply with all of the laws, ordinances, rules and regulations of the Town of Southold.
The undersigned, in consenting to such inspections, do(es) so with the knowledge
and understanding that any information obtained in the conduct of such inspections may
be used in subsequent prosecutions for violations of the laws, ordinances, rules or
regulations of the Town of Southold.
Dated: 37/ 20
ignatur �
P /// �.
(Print Name)
(Signature)
(Print Name)
VIM
Town Hall Annex ® Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 sea n.devIinCaD-town.southoId.ny.us
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICAL COMPLIANCE
SITE LOCATION
Issued To Zane Sellis
Address: 25335 Route 25 city,Orient St. NY zip: 11957
Budding Permit#: 44863 Section. 18 Block: 3 Lot: 13
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Kelrob Electric License No: 37725ME
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service
Commerical Outdoor X 1 st Floor Pool X
New X Renovation 2nd Floor Hot Tub
Addition Survey X Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan
Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures 4 Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors
Sub Panel X A/C Blower Range Recpt Ceding Fan Combo Smoke/CO
Transformer 2 UC Lights Dryer Recpt Emergency Fixtures Time Clocks
Disconnect Switches 4'LED Exit Fixtures Pump 2
Other Equipment. Jandy Panel, Pump on 220GFCI Breaker, Heater
Notes* " AS BUILT, NO VISUAL DEFECTS " Did Not See Bonding - Pool
Inspector Signature: S Q--�� Date: September 30, 2020
S.Devlin-Cert Electrical Compliance Form.xls
i
ot so
# -TOWN OF SOUTHOLD BUILDING DEPT.
�`ycouxn '' 765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I ULA
T OWCAULKING
[ ] FRAMING /STRAPPING [ FINAL 7
[ ] FIREPLACE &-CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS: e, l4a& Ay. �
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DATE 44 INSPECTOR
* a tic[ -po-ko
q4xf s 0 LA LA S 6S �M
# # TOWN OF SOUTHOLD BUILDING DEPT.
`ycourm ' 765-1802
INSPECTION ,
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ . ] FOUNDATION 2ND [ ] INSULATIOWCAULKING
[ ] FRAMING /STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ 'ELECTRICAL (FINAL)
[ ] CODE VIOLATION ] PRE C/O
REMARKS:
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A A V ."�T 4 eneJ
46aacl
-
DATE 0 INSPECTOR e�
l��07 �aOF SOUTyO - --- - -- ---
# # TOWN OF-SOUTHOLD BUILDING DEPT.
°`ycourm N�' 765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH.PLBG.
[ ] FOUNDATION 2ND [ ] I UL'ATION/CAULKING
[ ] FRAMING /STRAPPING [ FINAL 6a& Aa•
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
. ✓�� ' ' �
tiv
DATE ZD INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS ,
FOUNDATION(1ST)
--------------------------------------
FOUNDATION (2ND) l�
O
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ROUGH FRAMING& 4
PLUMBING `
a
INSULATION PER N.Y.
STATE ENERGY CODE
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FINAL
ADDITIONAL COMMENTS
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TOWN OF SOUTH LD
O 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)765-9502l l �L Survey
Southoldtownny.gov PERMIT NO. ` L v Check
Septic Form
MYSD.EC
Trustees
C O Application
Flood Pernut
Examined 20 Single&Separate
Truss Identification Form
�& Storm-Water Assessment Form
Contact:
Approved 20 Mail to.
Disapproved /c
Phone-
Expiration 20—
Building
20
f Building Inspector
1 a MAY 1 4 2020 APPLICATION FOR BUILDING PERMIT
Date 120
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 pemut
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 describe
applicant agrees to comply with all applicable laws,ordinances,building code,housing code, gu to o it
authorized inspectors on premises and in building for necessary inspections.
r v
(Signature f applicant or ric,if a co ration)
(Mailing address of-applicant)
State whether applicant is owner,lessee agent,architect,engineer,general contractor,electrician,plumber or builder
060
Name of owner of premises N JP'
(As on the tax roll or latest deed)
If applicant is a corporation,signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which propose orw'll be done.
House Number Street Hamlet
County Tax Map No. 1000 Section Block Lot
Subdivision Filed Map No. Lot
,J
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy
3 Nature of work(check which applicable):New Building Addition Alteratio
Repair Removal Demolition Other Work -L n !�l"D kj)d �!,i/:) 1 a)j n
4 Estimated Cost Fee (Description) aD
(To be paid on filmg 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 construction:Flout Rear Depth
Height Number of Stories
9. Size of lot:Front Rear Depth
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated
12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO
13.Will lot be re-graded?YES_NO Will excess fill be removed from premises?YES_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 )
being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the
(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 tp before me this
day of Mar 1 20SAE.BORGES
NOTARY PUBLIC,ST
—Rotary dublic Registration No.01B06347315 S gnae of Applic t
Qualified in Suffolk County
Commission Expires August 29,2020
PURSUANT TO CHAPTER 236
bf 0- OF THE TOWN COD
POOL NOTES:
TRACK FOR 1.POOL AND PROPERTY TO CONFORM TO 2017 NYS UNIFORM CODE,THE 2015 IRC,2
VINYL LINER nd'PRINTING,AS AMENDED BY THE 2017 NYS UNIFORM CODE SUPPLEMENT,2017
20' SUPPLEMENT TO THE NYS ENERGY CONSERVATION CONSTRUCTION CODE,TOWN OF
FILTER PUMP VINYL LINER SOUTHOLD.CODE AND 2014 NATIONAL ELECTRIC.CODE.
10' 10" 2.POOL SHALL'CONF,OAM TO ANSIf NSPI STANDARDS R326.3.1.
SUNDECK 3,500 PSI 3.SECTION1R326.7 POOL ALARM REQUIRED.
FOAM PADDING a CONCRETE 4.POOLSHALL COMPLY WITH BARRIER REQUIREMENTS SECTION R326.5.
a' 5.POOL SHALL COMPLY WITH INTERNATIONAL ENERGY CONSERVATION CODE
a. SECTION R463.10:
POOLS AND,PERMANENTSPATNERGY CONSUMPTION,(MANDATORY).
SECTION,•R403:16.1 HEATERS
§KIMMER I STEPS #3 REBAR a °' SECTION,R403.10.2 TIME SWITCHES
TOP, MIDDLE '° 42" SECTION•R4U3.10.3 COVERS
( �) I 30 & ',BOT. a 6.REBAWSHALLBE 3"MIN.CLEAR TO EARTH.
7•LOCATIONbF PROPOSED SWIMMING POOLAND POOL EQUIPMENT BY OTHERS
RETURN I I 'PROPOSED VINYL- ° AND SHALLCOMPLY WITH ALL LOCAL ZONING REQUIREMENTS. =,
I8.ALL DRAIN COVERSTO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME BAKER
(TYP•) 3 .SWIMMING POOL 20 a.d
(MIN.) 1,200 S.F. (VG B)'P.00LA'ND'SPASAFETYACT.
9.SLOPE;PATIO;SURFACE 1/4"PER FOOT AWAY FROM POOL.
I 2,MAIN DRAINS WITH I 10.BACKFILLIVIATERIALTO BE FREE DRAINING GRANULAR MATERIAL(NO CLAY OR
STRAINER,(VGB;SAFETY I ° LARGE,ROCKS).'
ACT APPROVED DRAINS) ,I ° 11.SUCTION OUTLETS SHALL BE DESIGNED AND INSTALLED IN ACCORDANCE WITH
ANSI/APSP-7:
12:POOL WALLS ARE NOT,DESIGNED FOR SURCHARGE LOADS EXERTED BY WHEEL'
' I A , I I LOADS W,ITMIN TENJ1,O)FEET;OF POOL WALL FROM CONSTRUCTION EQUIPMENT OR
TYPICAL WALL DETAIL ANY OTHER'LOADING,CON DITIONJMPOSED ON THE POOL'STRUCTURE BY EXISTING OR
+, , ' PROPOSED ADJACENT STRUCTURES.'
gyp• SCALE: 3/4 = 1 —,0 13.N 'DIVING EQUIPMENT PERMITTED.
14.CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR 70 INSTALLATION OF
`POOL:;
NOTE: ., O®� PLA 1�w�CLs SHALL BEAR ON.UNDISTURBED sOIL 15:THISOLAN IS-FOR CONSTRUCTION ON PROPERTY AT 25335 MAIN,ROAD,ORIENT,
A NON-DIVING POOL. 2.ALL CONCRETE SHALL BE PLACED ASA MONOLITHIC POUR. N•Y,'11957 ONLY.—
TRIS—IS ,
NOT'TO SCALE' 1'6.REINFORCING'STEEL,SHALL BE INTERMEDIATE GRADE BILLET STEEL WITH A,
MINIMUM LAP`OF•30'6'AR DIAMETERS.`
3'-4" 17,HM EN,tECHNIQUES OR�PROCEDURES BY,THE C
GiNEERING,'P.C.SHALL NOT;BE,RESPONSIBLE FOR CONSTRUCTION MEANS,
��p � NOTIED METHODS;
o� co BUILDING DEPARTMENT- Electrica rtWA69�OV F01� i
TOWN OF SOUTHOLD
o_ Town Hall Annex - 54375 Main Road T Bo5E' l 7P4 2020
Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 76
roger.richert@town.southold.hy.us�
APPLICATION FOR ELECTRICAL INSPECTION,
REQUESTED BY: Dater o
Company Name:
Name: - - -
License No.: � � �` - email:
P►tldress:
Phone No." - - --- _ - - -- -- --- - - --
JOB SITE INFORMATION: (All Information Required)
Name:
Address: -
Cross Street:
Phone No.: —� - -- • Z - - - --- --
Bldg.Permit#: ���� _ -- - email:
Tax Map District: 1000 Section: Block: _ Lot: I'
BRIEF DESCRIPTION OF WORK(Please Print Clearly) irr�
Circle All That Apply:
Is job ready for inspection?: YE Rough In Q Final
Do you need a Temp Certificate?: YES ACNDO 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: -
PAYMENT-'DUE WITH APPLICATION
82-Request for Inspedon FormAs ��
BUILDING DEPARTMENT-Electrica OVE
TOWN OF SOUTHOLD
Town Hall Annex - 54375 Main Road Bo5E�l�?4 2020
Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 76JU g�
NG DEPT.
roger:rrchert(ctown.soufhold:r�y, ,,., --.
APPLICATION-FOR ELECTRICAL INSPECTION
REQUESTED BY: , J Date:,
Company Name: _
Name: -
License No.: email:
address:
Phone No.:
JOB SITE INFORMATION: (All Information Required)
cs
Name:
Address: - -- - -- - ---- ---- -- - _. -
Cross Street:
Phone No.: - -
Bldg.Permit email:
-- - -- - -- - -
'Tax Map District: 1000 Section: Block;
BRIEF DESCRIPTION OF WORK(Please Print Clearly)
Circle All That Apply:
Is job ready for inspection?: QYE Rough In Final
Do you need a Temp Certificate?: YES NO Issued On,
'hemp Information: (All information required)
Servide-Size 1 Ph 3 Ph Size: _ .A # Meters Old Meter#
New Service- Fire Reconnect- Flood Reconnect-Service Reconnected - Underground - Overhead
#:Undetgrtsund Laterals 1 2 H Frame Pole Work done-on Service?__ Y N,__-
Additional Information: -
- --- ---- - -- - - ----
-----PMMENT_--DUE WITH APPLICATION - -- =_ - - - -- ------
�V
82 Request for Inspection Form ads �
�M
PERMIT# Address:
Switches
Outlets"`
GFI's '
Surface
Sconces
• I-I's
UC Lts
Fans Fridge HW
Exhaust Oven Dryer
Smokes DW Service
Carbon Micro Generator
Combo Cooktop Transfer
AC AH Mini
Special:
9 �
tar
Comments. 4 0,
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Pry(),0 it Tavi
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Of Southold Building Dept.
I would like to apply for a permit to install a pool. I am new at this and may need some guidance.
Here within this package is what I thought you may need. Please call me with any questions
House address for pool 25335 Main Rd Orient NY 11957
My Mailing address 10 Fern Drive West Jericho NY 11753
My contact information Zane Sellis 516 457-0377
electrician License number Kelrob Electric#37725-ME
Plumber Island Piping Solutions #58910-MP
Everything else should be in the package
Thank you
Zane Sellis
516 457-0377
i%psp
UNIVERSITY
This certificate is presented t
Thomas Svatek
f®r successfully completing
the recertification requirements for
i
CBP Certified Building Professional@
A
p . e
January 26, 2018 -
December 31, 2020
President & CEO
Expiration Date The Association of Pool & Spa Professionals
YRI Workers' CERTIFICATE OF INSURANCE COVERAGE
sTAre Compensation
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
1 a Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
SUNDANCE SWIMMING POOLS INC 631-862-1900
9 FARM ROAD
SAINT JAMES, NY 11780 1c Federal Employer Identification Number of Insured
Work Location Of Insured(Only required if coverage is specifically limited to or Social Security Number
certain locations in New York State,i.a,Wrap-Up Poficy) 112730466
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company
Town of Southold
54375 Route 25 3b Policy Number of Entity Listed in Box"1 a"
P.O. Box 1179 DBL55405
Southold, NY 11971 3c.Policy effective period
01/01/2020 to 12/31/2020
4 Policy provides the following benefits-
[A
enefits•[A A.Both disability and paid family leave benefits.
F] B.Disability benefits only.
n 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.
E] 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 3/8/2020 By wia 4f
(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 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 5131 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.
DB-120.1 (10-17) I�III��I��I��I��I����I�III��I��I���������I�
l II II I DB-120.1 (10-17) 1111111
NYS1F
New York state Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
� 0
^A^^^^ 112730466
SUNDANCE SWIMMING POOLS INC
9 FARM ROAD } ,
ST JAMES NY 11780
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
SUNDANCE SWIMMING POOLS INC TOWN OF SOUTHOLD
9 FARM ROAD 54375 ROUTE 25
ST JAMES NY 11780 P.O.BOX 1179
SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
11289 273-3 936415 02101/2020 TO 02/01/2021 3/8/2020
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER ' POLICY NO. 1289273-3, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS
OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/lWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
THOMAS SVATEK PRESIDENT
ALYSON SVATEK VICE PRESIDENT OF
SUNDANCE SWIMMING POOLS INC
(A TWO PERSON CORP)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSY,RANCE FUND UNDERWRITING
VALIDATION NUMBER.620551672
U-26.3
Suffolk County Dept of
Labor,Licensing&Consumer Affairs
HOME IMPROVEMENT LICENSE
Name
TOM J.SVATEK
r Business Name
SUNDANCE SWIMMING POOLS INC
This certifies that the
bearer is duly licensed License Number H-10921
by the County of Suffolk Issued: 05/01/1985
�
Commissioner Expires: 0510112021
1
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1
i '
HM ENGINEERING P.C.
3 CHERRYWOOD DRIVE
EAST NORTHPORT,NY 11731
TEL:516-476-5392
EMAIL:HMARNIKA@OPTONLINE.NET
March 6, 2020
Town of Southold
Building Department
Town Hall
Southold,N.Y. 11971
Dear Sir/Madam:
This is to certify that the drainage facilities to be used exclusively for the construction of a swimming pool
on the premises of
Sellis Residence
25335 Main Road
Orient,N.Y. 11957
will not require draining because the pool is constructed with a vinyl liner. The pool water will be
continuously recirculated through the filter and will be reused from year to year. The drainage from the
filter backwash is nominal and will not interfere with the public water supply, the existing sanitary
facilities or public highways.
Sincerely,
HM En ineering P.C.
v
zoje arnika P.E.
i
CAST IRON FRAME & COVER
IF UNDER PAVED AREA FINISHED GRADE
8' MIN. - 12' MAX. 24' x NOTES:
BRICK LEVELING COURSE ��MIN
CONCRETE COVER1. UNSUITABLE MATERIAL SHALL BE REMOVED UNDER LEACHING POOL UNTIL
PRECAST CONC. COLLAR 27' 6' MINIMUM PENETRATION INTO VIRGIN STRATA SAND AND GRAVEL AND
AS REQUIRED MAX BACKFILLED WITH SAND AND GRAVEL TO BOTTOM OF BASIN.
PRECAST 2. AS AN ALTERNATIVE TO THE DOME TOP, A FLAT SLAB CAN BE
REINF. CONC. SUBSTITUTED WITH APPROVAL OF THE ENGINEER.
DOME
4'0 PVC 3. LOCATION OF DRAINAGE POOL TO BE DETERMINED BY OTHERS.
MIN. SLPER FOOT ® ® ®®0 4. ALL DRAINAGE PIPES MUST BE PROVIDED WITH A MINIMUM 2'-0" COVER.
INVER ® ® ®0 i
NON-SHRINK 5. COLLAR IS NOT REQUIRED WHEN RATEABLE MATERIAL EXISTS FOR
GROUT ® FULL DEPTH.
3' MIN. SAND 6. THE MATERIAL USED FOR COLLARING SHALL BE COMPRISED OF SAND
_ AND GRAVEL AND GRAVEL CONTAINING LESS THAN FIFTEEN (15) PERCENT FINE SAND,
CL COLLAR (TYo Iii SILT AND CLAY. SILT AND CLAY FRACTIONS ARE NOT TO EXCEED (5)
a ALL AROUNDUND cu H PERCENT.
61
PRECAST REINF. o
CONC. LEACHING
.,
W RINGS w
y W
��
'v 8' DIAMETER
M o •�
�>
tiw v o DRYWELL; CALCULATION:
z� BACKWASH FROM POOL 70 GPM ® 5 MIN. = 350 GAL. (47 CF)
DRYWELL'i CAPACITY = 1,263 GAL. (168.8 CF)
Z 6' MIN, PENETRATION
a c INTO VIRGIN STRATA
GROUND WATER
OF SAND & GRAVEL
DRAINAGE POOL DETAIL
NOT TO SCALE
I
PREPARED FOR:
SELLIS RESIDENCE
25335 MAIN ROAD
ORIENT, N57
/ ',�l:
>>> HM ENGINEERING, P.C. DATE: 03106/2020
SCALE SCALE: NOT TO SCALE
THESE PLANS ARE AN INSTRUMENT OF SERVICE AND ARE THE PROPERTY OF HM ENGINEERING P.C..UNAUTHORIZED J ! SHEET: 1 OF 1
ALTERATIONS OR ADDITIONS TO THESE DOCUMENTS AREA VIOLATION OF SECTION 7209 OF THE NEW YORK STATE 3 CHERRYWOOD DRIVE FAST NORTHPORT,NY 11731
EDUCATION LAW.INFRINGEMENTS WILL BE PROSECUTED. i FTelt516)476-5392 Fax:(631)980-7671 www.hmarnika§optonline.net
VOID WITHOUT RAISED SEALAND BLUE SIGNATURE DRYWELL DETAIL
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PROPOSED
i SWIMMING
pp'
i POOL
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t ---t- e ;TtN�Nal3sel- r_ ` h t 3cJ i
t � 1 y' r. Y�,,Y1� v��"a'•�y� �s S�70 '�E�ENCE ��p � � us e� a0 COI
Off, o / I ` STOCKA FENCE $`• -�.� ��; /y'.Fiwt; ; '! -------------------`--I SELLIS RESIDENCE
tQO 263IF5 A1AHN ROAD
/ 231.28' 2` ORIENT,NY
ore N 28" '40"
1 711m,a 2020 =
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