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HomeMy WebLinkAbout44290-Z gU�F® �-taG Town of Southold 12/22/2020 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41714 Date: 12/22/2020 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1130 Strohson Rd., Cutchogue SCTM#: 473889 Sec/Block/Lot: 103.-10-6 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/8/2019 pursuant to which Building Permit No. 44290 dated 10/15/2019 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 Finnican,Michael&Leslie of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44290 11/26/2019 PLUMBERS CERTIFICATION DATED A tho9 Signature o�gl� TOWN OF SOUTHOLD ?el" - 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#: 44290 Date: 10/15/2019 Permission is hereby granted to: Finnican, Michael 1130 Strohson Rd Cutchogue, NY 11935 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1130 Strohson Rd., Cutchogue SCTM #473889 Sec/Block/Lot# 103.-10-6 Pursuant to application dated 10/8/2019 and approved by the Building Inspector. To expire on 4/15/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SW UVIING POOL $50.00 Total: $300.00 Bui din ector 4 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: I. 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, dditions to dwellin $50.00, Iterations 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.JLW)q___ New Construction: V Old or Pre-existing Building: (check one) Location of Property: House No. Street Hamlet Owner or Owners of Property: r Suffolk County Tax Map No 1000, Section Block f Lot Subdivision )) ,, Filed Map. Lot: Permit No. `T q Q Date of Permit. Applicant: Health-Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $_ U Applicant gnat ®�*of sovl�®� Town Hall Annex ~ ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 • �� roger.riche rt(a)town.south old.ny.us I�Coum,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To. Finrncan Address: 1130 Strohson Rd City Cutchogue St. New York Zip: 11935 Building Permit#. 44290 Section- 103 Block 10 Lot. 6 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA- Bethel Electric License No: 40557-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 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures 11 TVSS Other Equipment. In ground swimming pool to include, bonding, control panel, 1-time clock, 1-GFCI carcuit breaker,2-switches, 1-GFCI recpticle, 1-pool pump,salt generator, 1-pool light Notes: Inspector Signature: Date: November 26 2019 81-Cert Electrical Compliance Form.xls J — OF SOUTy�� # * TOWN OF SOUTHOLD BUILDING DEPT. rouffm 765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) �J ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: Vim' J 0 DATE �� �i �9 INSPECTORW t �O�aOF SOUIy�� # # TOWN OF SOUTHOLD,BUILDING DEPT. Nyco 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] ' FOUNDATION 2ND - [ ] SULATION/ AULKING [ ] FRAMING /STRAPPING [ FINAL [ ] 'FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] 'FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: l V- 1 DATE t ANSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(IST) H O � ------------------------------------ cn FOUNDATION (2ND) cn z 0 H ROUGH FRAMING& PLUMBING 9 I r INSULATION PER N.Y. H STATE ENERGY CODE rn FINAL ADDITIONAL COMMENTS Z), Z m z - c6 �o z d TOWN-;DF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST >'`� T Dli'_�1G DEPARTMENT T�j N HALL Do you have or need the following,before applying? SOUTHOLD,NY 11971 Board of Health TEL: (631)765-1802 4 sets of Building Plans FAX: (631)765-9502 Planning Board approval Southoldtownny.gov PERMIT NO. Survey Check Septic Form N.Y.S.D.E:C. r _ Trustees h C.O.Application Examined 20-4 0 �_ � Flood Permit o ���--��{{(--- Single&Separate 20 Truss Identification Form Storm-Water Assessment Form �ro rr f��"` 17P�,_ Contact: //,, Approved � '��� !_ -.1 I`—t 1� °��'�"t �lJ LS 20 `�iF i A `,` Mai o. � Disapproved a/c o j � / `Phone• Expiration 20 / ' I il spctor APPLICATION FOR BUILDING PERMITL,- Date" - � - � , 20 �l INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. f (Signature o ne,if a coaton)., II � � (Mailing adldres of applicant) State whether applicant is owner,lessee, agent, architect,engineer,general contractor,electtalci Pler or builder Name of owner of premises (As on the tax roll.or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title o orporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of 1 d on hich proposed rk will b don 11 ,30 Ouse Num er Street amlet County Tax Map No. 1000 Section Block_ Lot Sub;iivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construc a. Existing use and occupancy tion: b. Intended use and occupancy 3. Nature of work(check which applicable): New Building Addition Iteration Repair Removal Demolition Other Work (—D 4. Estimated Cost to ( escription) Fee (To beon 5. If dwelling,number of dwelling units Number of dwelling unit naid ea each floorfiling this application) If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. I 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: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear_ 2 epi i -!-�7 ,LL 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 NOY—Will excess fill be removed from pre ses?YES NOK\\/ *__ 14.Names of Owner o premises ✓111 s `tel ` �9 � 3.q� �dc�r�ss Phone N Name of Architec Address �-I C -Phone N h Name of Contractor Address Lf 7 IRt:—Cow Phone N 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 E AEQUIRED. 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. _X STATE OF NEW YORK) SS: COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (NamlAind�ivival signing contract)abo 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`%Ij�the best of his knowledge and belief;and that the work will be performed in the manner set forth in the appl �n f �VW,,with. S. If, ;�jpiAftj- �,i Sworn to before me th' -f- da Of � : 'No.Ot MI623165T; -TTT y 90 ALIFIED IN ?SUFFOLK COUNTY cc • % aL�Not Public : �'•. •�` ��,y •.!'uB��c�y `per gnature of pplicant Scott A. Russell ° ']C'O] AIN�' r 61 s SUPERVISOR � � A.TIER `� OUTHOLDTOW1V HALL-P.0 Eft.1119 AMIANA\(GrIEAM[IEI T 59095 Main Road-50VMpLn,NW gol(K ii9n !p� Town O,f�"Qat�I+�ZG� CHAPTER 236 - STORATER MANAGEMENT WORK SISET TO BE COMPLETED.BY THE APPLICANT.) ------------------- -'DOW ,HIS I'IEtOJICT INVOLvl; ANY OF TM — —. FOLL©VMQ Yes No (CRECK ALL THAT APPLY) ❑ . Clearing, grubbing, grading or stripping of land which affects more than 5,000 square fent of ground surface, B. Excavation or filling involving•more. than 200 albic yards of•matt rial within any parcel or -any contiguous area. ❑ . Site preparation on slopes which exceed 1.0 feet vertical rise to. 100 feet of horizontal distance. [][ZD. 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. ❑ F. Installation of new or resurfaced impervious surfaces of' 1,000 ware feet or more unless � I prior approval of a Stormwater Management Control Plan wasreceived by the Tow 'nd the proposal includes in-kind replacement of impervious surfaces. Fand wered.NO to all of the questions above,STOP! Complete the Applicant section below.v th gQur'Nance, , contact Information,Date & County Tax Map Npmber! Chapter 236 does not.apply to your project wered TES to one-or more of the above, please submit Two copies-of a 5tormwater Management Control plan pleted Check List Form to tkeBuilding Department WISour Buil y ding Permit Application. APPLICAN (Prbpelty owner.Debi"Professlbnal,Agent,Contractor,other) Ef�slatf'-- W � 1,000 Date• NAME. Dls I16L(dp I ! Bloc t FOR BUILDING DEPARTMENT USE ONLY*"`**Cantect fnformatiom —�- - _ _ _ - - - - - - Reviewed.By: Pro e t Address/Location of Constrnttionork: ' dA _ _ _ _ _Date_ (� Ipproved for.processing Building Permit: I ormwater Management Control•Plan.Not Required ��IStormwa'ter Management Control'Plan is Required. I� `'—__ _____ __ ❑ (Forward to Engineering Department for Review.) FORM S12P-TOS MAY 2014 — I so 4? �all,A�e To Telephone(631)765-1802 543117 Mai,i Road xW(631?765- CJ0 P.O{Bok 1179 rogerd hert nog5bl n v.us Southold,NYt971116 ton ;;0 Anif BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION. QUESTED BY: MOMAOeP\ Date: )mpany Name: of( ctrl ime: A+k tA .i 0V tense No.: -7 ]dress- 8 tiAcoly-N �Nz, I rook i one No.: (0 )B,SITE INFORMATION: (Nndicates,r'equired information)- LQft- AKidVxie\ -Tinn"can 'd dr'68 8 Voms'-w! KC—)Q-d-Cu1CA)0C1Q-P, -U-\! 11q35- .ro§s Street:' ?)(Mm' 'in Plou hone No.: (o Ts .rmit No.: '4L4 ix-Map District: 1000 Section: JQ3 - Block: 10Lot: RIEF DESCRIPTION OF WORK (Please Print Clearly) lease Circle All That Apply) job ready for inspection: YES NO Rough In rl Dal o you need a Temp Certificate: Y E SONO mp Information (if needed) ervice Size: I Phase 3Phase 100 150 200 300 360 400 Other ew"Service: Re-connect Underground' Number of Meters Change of Service Overhead ditional Information: PAYMENT DUE WITH APPLICATION YVf - 0 ffICC LN ilk A/\- ISSzdja d A -UP- —7�o4k- �%t cc/h . ffi,/V)f,0VJJAQY- 04 CQ S-� ,82-Request for Inspeoflon Form r r a Certified, as' noted and limited below, only to: - MICHAEL FINNICAN &LESLIE FINNICAN - CHICAGO TITLE INSURANCE SERVICES LLC — SUBJECT PREMISES AREA= 28,800 SQ. Ff. (0 661 Ac.) IRON PIN — — _ THE PREIMSES HEREON BEING KNOWN AS LOT 6, BLOCK 10,--SECTION 103, DISTRIRICi FOUND — _ _ FENCE I 1000 AS SHOWN ON THE OFFICIAL TAX MAPS OF SUFFOLK COUNTY. REFERENCE IS BALD WIN PLACE POST / MADE TO USER 000012862, PAGE 732 RECORDED IN THE SUFFOLK COUNTY CLERKS OFFICE ON MAY z 2016. FENCE (50' MME) TOPOGRAPHIC INFORMATION HEREON WAS INTERPOLATED FROM AN ACTUAL FIELD uTTuiY - SURVEY BY THIS OFFICE ON SEPTEMBER 12, 2017. ALL ELEVATIONS ARE RELATIVE POLE WO 0S o TO NAVD-88 DATUM. UTILITY I THE PREMISES HEREON DOES NOT UE IN AN AREA OF SPECIAL FLOOD HAZARD wv OVERHEAD WIRES _ " POLE (PAVED ROAD) / I — — — — X84 5420 / Q (ZONE X) AS DEPICTED ON FLOOD INSURANCE RATE MAP NUMBER 36103CO164H, + E v I _ REVISED SEPTEMBER 25, 2009. WATER MON FOUND MENT16 4 — — 240.000 / I [DRY;:WELL] GRAVE — — I THE SURVEYOR'S SEAL, SIGNATURE AND ANY CERTIFICATION APPEARING HEREON �VEWAY I 3 SIGN — SIGNIFY THAT, TO THE BEST OF HIS KNOWLEDGE AND BELIEF, THIS SURVEY WAS + PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR LAND SURVEYS AS _ I W PVC PIPE 14.8 SET FORTH IN THE CODE OF PRACTICE ADOPTED BY THE NEW YORK STATE 0 ,t I I o•-� ASSOCIATION OF PROFESSIONAL LAND SURVEYORS, INC. O � ' ,I "_� DOME T o 40-OI o yf °° DOMES ; HYDRANT I I g`I 1+8 I W 3 0 L- /�oOL/loan GaL (FLANGE NUT 17.16) I I CERTIFICATIONS SHALL RUN ONLY TO THE PERSON FOR WHOM THIS SURVEY WAS C114A- d a9'0 SEPTIC o PREPARED, AND ON HIS BEHALF, TO THE TITLE COMPANY, LENDING INSTITUTION AND O [RaaFa �T se' TANK GOVERNMENTAL AGENCY LISTED HEREON; SAID CERTIFICATIONS ARE NOT INTENDED 617.81 � , ]�^��=4.tzs] - �--1 1oawM�,IuT r-.1 [DRY-WELL] TO RUN TO ADDITIONAL TITLE COMPANIES, LENDING INSTITUTIONS, SUBSEQUENT _i OWNERS OR FUTURE CONTRACT VENDEES. - ----+ ' i 17.6 METEER iC (STME�s+er] Ie 16.0 w� IZx2 - --- —I_ --+ 107'-0 �e°12� --� UNDERGROUND IMPROVEMENTS, STRUCTURES, UTILITIES OR ENCROACHMENTS, AND I ANY EASEMENTS RELATED THERETO, ARE NOT SHOWN HEREON UNLESS OTHERWISE -I 2 STORY FRAME I\� ' NOTED.ANY UNDERGROUND UTILITIES SHOWN HAVE BEEN LOCATED FROM FIELD [House N,113 CL \my I [FINISHED FLOOR \ 0 Q SURVEY INFORMATION AND EXISTING DRAWINGS AND IS NOT CERTIFIED TO ACCURACY t17 I CONCRETE PAVERS W 1 EL 20.5] I \ 5 OR COMPLETENESS. � X � PATIO�IrAttc] FENCE z' + PI - - -- E I �`-49'-2j. ., 1+ ;[ROOF DIMR{EA I>-� � UNAUTHORIZED ALTERATION OR ADDITION TO A SURVEY MAP BEARING A LICENSED �1 LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION 7209, SUB-DIVISION 2 OF THE 17.7+---�`� Lo o — GAS METER [DRY—WELL] � O NEW YORK STATE EDUCATION LAW. ` 1 / A.C.UNIT c::) r^ I o 19'1 a [DRY—WELL] ' C/) �/ 1 PROPANE [10 0 GAL]K f O — \J .� FINAL ASBUILT N 84'5420" W 15.5 [� PREPARED FOR 240.00 - - - + ICHAEL FIATNICTY M © I AND I LAWN FOR DOMESTIC WELL LESLIE FINNICAN I � (NOT FOR DOMESTIC USE) I ��� NEW r - O IRON PIN '� 3, IV, 0 PROPERTY S1TUA TE A T R FOUND I ��,� 1130 STROHSON ROAD • - e I 1 � 'r C7 � TOWN OF ,SOUTHOLD COUNTY O_F S_U_F_F_OLK CONTRACTORS LINE & .GRADE SOUTH L.L.C. 2s�a �, STATE OF NEW YORK 23 Nepperhon Avenue 1_AND SCALE.- 1" = 30' Elmsford, New York 10523 Phone. (914) 347-3141 Dote: SEPTEMBER 12, 2017 • _ officeQMneandgrade.net ' Copyright (c) 2017 CONTRACTORS' LINE & GRADE SOUTH AH rights reserved. 0:/37-2J201130 STROHSON ROAD/DWG/2320-SURI/EY.DWG I Labor, Licensing &Consumer Affail I � it HOME IMPROVEMENT LICENSE t ' Name + RANDY RODECKER Business Name i Z FENCE KING OF ROCKY POINT INC i This certifies that the bearer is duly licensed License Number H-21412 i by the County of Suffolk Issued: 06/01/1992 Commissioner Expires: 0610112020 1, Y a YORK Compensation Workers' ATCERTIFICATE OF INSURANCE COVERAGE T ! 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) lb 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 rfcoverage is specifically limited to or Social Security Number certain locations in New York State,Ie,Wrap-Up Policy) 113008276 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 53095 Rt.25 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective penod 02/01/2019 to 01/31/2020 4 Policy provides the following benefits: © A Both disability and paid family leave benefits. El B Disability benefits only E] 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 camer referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above 2/1/2019 l rrl f'r' I a't N Date Signed By (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 58 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 wnte NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-12a 1 Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111111, 1°°!�°°°°1°1°I111B1°�!°�°°1111111 AW CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/28/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Bethany Purificato AssuredPartners Northeast, LLC. PHONE . (631)465-4000 AC No. 100 Baylis Road E-MAIL bethanurificato@assured artners.com ADDRESS: 1'•P P Shite 300 INSURERS AFFORDING COVERAGE NAIC p Melville NY 11747 INSURERA:Philadel hia Indemnity Insurance Co. 18058 INSURED INSURER B:Everest Indemnit Insurance Co. 10851 Fence King of Rocky Point, Inc. INSURER C:Shelterpoint Life Insurance 81434 DBA: Swim Kings Pools b Patios INSURER D: 471 Route 25A INSURER E: Rocky Point NY 11778 INSURER F. COVERAGES CERTIFICATE NUMBER:19/20 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 MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD POLICY NUMBER MM/DD MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 5,000 X Contractual Liability PHPK2024813 9/1/2019 9/1/2020 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 JET LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY [K] OTHER Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident A X ANYAUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED SCHEDAUTOS PHPK2024813 PHPK2024813 9/1/2019 9/1/202o BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N/A B (Mandatory In NH) SW5W000205181 11/5/2018 11/5/2019 EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E L DISEASE-POLICY LIMIT $ 1,000,000 C NYS Disability DBL37154 9/1/2018 Continuous DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The following are included as additional insured if required by written contract subject to the terms and conditions of stated policies: Town of Southold CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 53095 Rt. 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE R Mastrantonio/BFRABIQ ,L �� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) oaK Workors' CERTIFICATE OF TE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 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 Rocky Point NY 11778 1c.NYS Unemployment ment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage Is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,I 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 PO Box 1179 3b.PoliccYy205181 Number of Entity Listed In Box"ia" Southold,NY 11971 SWSWM 3c Policy effective period ` 11/0512018 to 11/05/2019 3d.The Proprietor,Partners or Executive Officers are X❑ included.(Only check box if all partnerslofffoers 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'I 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: Kevin White (Print name auth lied r r entative,or licensed agent of insurance carder) Approved by: 11-07-18 ( i nure) (Date) Underwr�tIng' V1ce Pr®s(dont Title: r 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) www web,ny.gov a APPROV D AS NOTED DATE: 5 B.P.# —V2 FEE: BY: RETAIN STORM WATER RUNOFF NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE PURSUANT TO CHAPTER 236 FOLLOWING INSPECTIONS: OF THE TOWN CODE. I. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCT N SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR ELECTRICAL DESIGN OR CONSTRUCTION ERRORS. INSPECTION REQUIRE® COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF 6941-fHqmqm--�, S PJIS11Ql BOARD A T E L Y . .� SOtlTIN01MT17VI EES ENCLOSE POOL-TO COD'- fd'f§.B _UPON COMPLETION BEFORE-"WATERY' OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY NOTES 1O, 1 NO SOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR FEET OF EXCAVATION AT THE DEEP END. O 20' 10' 2 THI5 POOL MEETS THE REQUIREMENTS OFANSI/N5PI-5 AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING Q POOLS°AND 1996 BOCA CODE-SECTION 421. DIVING EQUIPMENT 15 NOTALLOWED o d 3 SWIMMING POOL SHALL BE COMPLETELY AND CONTTNVOU51_Y SURROUNDED WITH A BARRIER CONSTRUCTED IAW REQUIREMENTS OF _}y v SECTION R326.5.3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD �JJ TOWN CODE ACCESS GATES SHALL COMPLY WITH SECTION 8326 5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY Co LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. O 8.�. 4._y. S iV H2O H2O a br 4 DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIERAROUND THE EXCAVATION LAW THE CODE OF THE O �t TOWN OF SOUTHOLD CL O ° 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING A CHILD ENTERING THE WATER AND SOUNDING- V v o AN AUDIBLE ALARM WH EN DETECTED THAT 15 AUDI BLE ATPOOL5IDEAN1)ATANOTHERLOCATION ONTHE PREMISES WHERE THEPOOL Z Qz IS LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS N PLAN THE ALARM MUST MEETA5TM F2208 "STANDARD SPECIFICATION FOR POOL ALARMS. THE DEVICE MUST OPERATE INDEPENDENT(NOT v ATTACHED TO OR DEPENDENTON)OF PERSONS :3 a NTS 6 POOL5LICTION FITTINGS(EXCEPT FOP,SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASMUANSI 72'VINYL COVERED CONCRETE END STEPS 0 A112.198M ORA MINIMUM 18"x 23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH l/l ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN.SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH A5ME A112.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. N , POOL SHALL BE PROVIDED WITH AMINIMUM OF2SUCTION FITTINGS OFTHE ABOVE MENTIONED TYPE. THE SUCTION FITT]NG5SHALL BE m SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRE55VRE CLEANING=ITTINGS SHALL BE IN AN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENTTO 2.1n 4•- M THESKIMMER/5KIMMER5 7 ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRC SECTIONS QI _ 4201 THROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BYA V GROUND FAULT CURRENT INTERRUPTER(GFCI) CVRRENTCARRYINGELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER SECTION A TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUI REM ENTS OF TABLE E4203 5.ALL METAL ENCLOSURES, -S FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT N.T 5 WITH AN ELECTRICAL Cl RC V IT SHALL BE EFFECTIVELY GROUNDED. TOP OF WALLWATERLINE 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NYS PLUMBING CODE 608. .. c:m°` I- V0C >- 4, 4' ( 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. _ z N O C: O 4 ° ' 10 WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE, a C s a v 2 m v 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED LAW AN51/N5PI-5 5ECTIION 6 ti p vI i s v 12 CONTRACTOR TO PLACE THE POOL LAW TOWN OF SOUTHOLD CODE SETBACKS a ate_ eM V SECTION B 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE 5VB)ECTPROPERTY. N T5• 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH(10%SILT. GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION IF GROUND WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED o 16, ALLGASAND OIL HEATERS CIF INSTALLED)FOR THE INGROVND SWIMMING POOLSHALL BE NATIONAL APPLIANCE ENERGY ry CONSERVATION ACT(NAECA)COMPLIANT POOL HEATERS SHALL BE TESTED LAW ANSI 22156 AND SHALL BE INSTALLED LAW p� MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED LAW VL726. POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPA55 SYSTEM.A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE U N CHECKVALVE FOLLOWING ENERGY CONSERVATION MEASURES ^• F� 00 FROM5KIMMER 16.1 AT LEAST ONE THERMOSTAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. 00 PUMP 16 2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUT ADN5TING THE THERMOSTAT SETTING AND TO ALLOW RESTART!NG WITHOUT RELIGHTING THE v PILOT LIGHT Z z O 163 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THI5 REQUIREMENTARE OUTDOOR POOLS DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) w a)ti N a j TO DISPOSAV 16,4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAt�f BESET w q�'co 07 DRYWELL TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE g SANITARY CODE OFNEWYORKSTATE. nn •- COPINGAND WALKWAY 10• Y ti ti $ cO DIVERTER (BY OTHERS) 3' A w 0 a a VALVE O GRADE 17. TH15DRAWING 15FOP,STRUCTURALSHELLONLY.ALLACCE5SORIESANDAPPURTENANCESAREDEFINEDBYOTHERS. z = c-� cts WATERLINE W ;2 � Y M(O Ij 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHT OF THE Wn tWATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" N FILTER I/NDISTVRBED EARTHL-19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAN1)REPLACE W/COMPACTED CLEAN BACKFILL3500 PSI POURED COi/B•REBAR.2)TYP 20. THERE I5 NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY.THIS MEETS U VINYL LINER REQUIREMENTS OF THE IRC-SECTION 8326,6 FOR ENTRAPMENT PROTECTION. 02'To 4'&ANDD 21. THE POOL WAS DESIGNED LAW THE FOLLOWING. P TH(o) 211. THE INTERNATIONAL RESIDENTIAL CODE CIRC)-CHAPTER 42(2016) S "! 212 THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION 840310(2015) y /�: y 7o RETURNS 21.3. THE INTERNATIONAL FVEL GAS CODE(2015) 21.4 THE NEW YORK STATE CODE SUPPLEMENT-SECTION R326 (2017) CHECK VALVE 215, THE NEW YORK STATE SANITARY CODE r = VER71CALi/8'REBAR®3'OG 216. ANSI/N5PI-S STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. CI U .u"=y m u (NOTSHOWN) 21.7. BOCA CODE-SECTION 421. Cn + 21.8 CODE OF THE TOWN OF SOUTHOLD. Z �RY3 rar7 22. ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. �� �884"I PLUMBING SCHEMATIC WALLSECTION ,oho NTS �Essk