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HomeMy WebLinkAbout43394-Z sufFUl�-C Town of Southold 4/17/2021 0 P.O.Box 1179 o • 53095 Main Rd yfj�l �ao�. Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41973 Date: 4/17/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1125 Windward Rd., Orient SCTM#: 473889 Sec/Block/Lot: 14.-2-30.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/9/2019 pursuant to which Building Permit No. 43394 dated 1/16/2019 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 O'Hagan,James of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43394 11/8/2020 PLUMBERS CERTIFICATION DATED A ize ignature I TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o . 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#: 43394 Date: 1/16/2019 Permission is hereby granted to: O'Hagan, James 1125 Windward Rd Orient, NY 11957 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1125 Windward Rd., Orient SCTM # 473889 Sec/Block/Lot# 14.-2-30.1 Pursuant to application dated 1/9/2019 and approved by the Building Inspector. To expire on 7/17/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Building spector 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 gg Date. f q—l q New Construction: `` Old or Pre-existing Building: (check one) I Location of Property: H loll n0i4k1J R ©91en.�" House No. Street Hamlet Owner or Owners of Property: ,f 1�S ®` I Mqh,,J Suffolk County Tax Map No 1000, Section 6' Block Lot ( Subdivision 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: $ 50 D Ap icant Signature pE SO�j�®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road jr Fax(631)765-9502 P.O.Box 1179 c ® sean.deviinallown.southold.ny.us Southold,NY 11971-0959 .� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To James O'Hagan Address: 1125 Windward Rd city,Orient st: NY zip: 11957 Building Permit* 43394 section: 14 Block: 2 Lot 30.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: All Service Electric License No: 56980ME SITE DETAILS Residential X Indoor X Basement X Service Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceding Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures 1 Smoke Detectors Main Panel A/C Condenser Single Recpt 2 Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer LIC Lights Dryer Recpt Emergency Fixtures Time Clocks X Disconnect Switches 4'LED Exit Fixtures 11 Pump 2 Other Equipment, Pump on 230GFCI Breaker, Vacuum on 115GF1 w/ Switch, Salt Generator Notes. " AS BUILT, NO VISUAL DEFECTS " Pool P Inspector Signature: ,.- Date: November 8, 2020 S Devlin-Cert Electrical Compliance Form.xls pFSO(/Tyo� Lq 3 / /2-S7 # TOWN OF SOUTHOLD BUILDING-DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ,ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE-&CHIMNEY [ ] . FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION f ] FIRE RESISTANT PENETRATION, [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O �D '- REMARKS:c i 6�0 1 91 0 7 ' ao k\,V) .75100tgR1 08 C or Av6 DATE 2U INSPECTOR -1 o�aOF SOUTyO — h � # f TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECTION [ ] FOUNDATION 1ST [ r ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL'ATIOW HULKING [ ] FRAMING /STRAPPING [ FINAL [ ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS.-fit ) - - v Ak 0 goadv"c' 1 DATE INSPECTOR - * # TOWN OF SOUTHOLD BUILDING DEPT. - ��`y�ourm 765-1802 INSPECTION ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING/STRAPPING [ FINAL A,& ge'. ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: (!w C�AY&\61� v.1 4- 9K�� Ir fie"" r DATEril wkw'Yd INSPECTOR, `FIELD INSPECTION REPORT DATE COMMENTS b FOUNDATION (1ST) .� ................................ .. 'FOUNDATION (2ND) Z O ROUGH FRAMING24 & PLUMBING INSULATION PER N.Y-. STATE ENERGY CODE AA I S a S �- FINAL ADDTTMONA.L COMMENTS o b- 1400.00 o ap o t z d b TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEP4ARTMENT Do you have,or need the following,liefore.applying? 'TOWN,1 ALL . Board of Health ',S - OUTHOLD,NY 11971 3 sets of Building Plans {:TEL: 765-1802. UY Survey PERMIT NO`. Check Septic Form N.Y.S.D.E.C. Trustees Examined la '20 .�, Contact: Approved 20 D Pt�h GSAJ Disapproved a/c b JAN __9 2019 Pho9.0�- (08 4 2 ,D �T,, � O , TO, ring Inspector APPLICATION,FOR BUILLDING;PERIIHT, ' Date � � � _ 20 I INSTRUCTIONS a.This application MUST"be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 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 pu pose wl at-so-ever until a Certificate of Occupancy is issued by the Building Inspector. 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,6idinances 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,an regulations,�Aff to admit authorized-inspectois on premises,an Jn building for necessary inspections. (Signature of applicant o e;Ta-corporation) OW (Mailing,address of,applicant), State whether applicant is owner,lessee, agent, architect, engineer, general contractor, electrician,plumber,or.builder- Name of owner of premises 0 1 17R 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 proposed work will be done: Z5 M14A4 0 (Ll2n 1' House Number Street Hamlet n, County Tax Map No. 1000 SectionBlock o2 Lot 6—VI Subdivision Filed Map No. Lot (Name) 4 .4 2. State existing use and occupancy of premises and intended use and occupancy of proposed-construction: a. Existing use and occupancy 6 gaQ_ b. Intended use and occupancy_ ? t02, +A—_- } I(nm i flg �( C. 3. Nature of work(check which applicable): New BuildingAddition Alteration Repair Removal- Demolition Other Work II18(-OJMo Vjnyc 1✓mA„✓ (Description) 4. Estimated Cost ��� '� - ` �'°� �(to;b "'d~pn filing this application) °� �d Jrw. dr a 5. If dwelling, number of dwelling units ber of dwelling ut its rQUch 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 '"93 '<" �, tear ,90 Depths Height Number of Stories N-7 ,� Dimensions of same structure v►iith'4alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front c96'1V Rear Depth 3'tZ 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: Nb 13. Will lot be,re-graded LL &,ek OM Will excess fill be removed from premises:R NO 6f�A _ 14. Names of Owner of premisesajg5 0'I�Rq� Address II?�hl'Mo► o Phone'No. Name of Architect Address Ph6n&'N6 Name of Contractor_ 3 Address 42-1 tt+',25-A Phone No. b31-316E &t Nt,I1,&- ,Q 2 I X71, 15. Is this-property within 100 feet of a tidal=Wetland? *YES NO ® IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE RtQUIRED 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. STATE OF NEW YORK) SS: COUNTY OF ) A&Vl)y� ED+J4rQS being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the 0'5�dC761 (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 44before me this ,^ - day of�f 20 1 q_ No P blic Signature o plicant Q MARGARE f A. KIDNEY Notary Public—State of New York No. 01 K160211 11 Qualified in Suffolk County My Commission Expires March 8,20A Scott A. Russell d°S11 S'7 O]KIM[WA\TIER.- SUPERVISOR IMIA,NA\G IE1\A[IE N r SOUTHOLD TOWN,HALL-P.O.Box 1179 �f 53095 Main Road-SOUTHOLD,NEW YORK 11971 '� Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT) DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING: Yes No (CBECK ALL THAT APPLY) ❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. B. Excavation or filling involving more than 200 cubic yards of material i within any parcel or any contiguous area. ❑[ C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑[]� D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑Q E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. E][2[ F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date: D gistrict NAME: 5 O( � ren Section Block Lot a/" 0 (Slgnamrd W0972, FOR BUILDING DEPARTMENT USE ONLY Contact Information **** (Telephone Numher) Reviewed By: Aan_4tA Date: — — g Property Address/Location of Construction Work: dApprowved — — — — — — — -- — — — — i,a 5 r, '�NpuD for processingBuilding Permit. �/vStormater Management Control Plan Not Required. Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 o��pf-SOpr'y0 Town Hall Annex Telephone(631)765-1802 54375 Main Road H` (631)765- 5 P.O.Box 1176 G Q roger.richertCa town.southoltl.nv.us Southold,NY 11971-0959 �� BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name: ec, tG Name: _ • License No.: 43 0q — M r Address: ` (1rG11 ��� L 0 5 — Phone No.: S/6- 99 rJ3 JOBSITE INFORMATION:, (*Indicates required information) *Name: -'IQn1e5 0` l -A4W *Address: II jtjjA V,1Aio Ao Cele i- *Cross Street: I n RD *Phone No.: Permit No.: Tax Map District: 1000 Section: I4 Block:. Lot: 30. 1 *BRIEF DESCRIPTION OF WORK(Please Print Clearly) I(1,j(0jM3 �In•lt, �Jh/�niMidi (Please Circle All That Apply) *is.job ready for inspection: YES / NO Rough In Final *Do you need a Temp Certificate: YE / Temp Information (If needed} *Service Size: 1 Phase 3Phase 400 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICA N 82-Request for Inspection Form BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD E Town Hall Annex- 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 , Telephone (631) 765-1802 - FAX (031) 765-9502 roaerr@southoldtownny.gov:; seand@southoldtownny.Aov N FOR ELECTRICAL. INSPECTION: --• ��PiLIC'�1TI,0 t ELECTRICIAN-INFORMATION (All information Required) Date' Company Name:,.- - - G - - - -- Name: - G i - - _ - 'i License-No.: email:- ': F ct.S 4 Address: .. fi v_nf - : - _ _ __- - -- Phone No.: Y16 gd D JOB SITE INFORMATION (All Information Required) Name: Address: - � w9 -'%Zoe Cross Street: 0i21� It ,S _ 3i _ 4�_ Phone No: Bldg.Permit#: - 3 email: `f0,/ .0 h 40 - - - - - Tax MapDistrict: 1000 - _SecticiM _ Block: : -^Z —3 cp Lot::_e j BRIEF DESCRIPTION OF WORK (Please Print Clearly) 3015�'�`�S s'�lt-dl� �b2 /�/—C�+to�Ir_�__�goL j�c•`�� , , ---- - _ -- -_-_ ------------ -----fcL -- - Circle Ail That Apply: Is job ready for inspection?: (�Y�ESNO Rough In Final Do you need a Temp Certificate?: YES ONO 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** yJ 6� �oP c, ` 2 .PAYMENT.DUE WITH APPLICATION Request for Inspection Form7 .xls V v A) D 5oaf Fp1ot49, . BUILDING DEPARTMENT-Elera I eCIRT 1 5 2020 'Q Gy ctTOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO �JRG DWr- '� Southold, New York 11871-095 C��;���OLI3 s0~ �ao� Telephone (631) 765-1802- FAX (631) 02 rogerrOsoutholdtownny.00y- seand@southoldtownny.dov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 10/1.2/2020 Company (Name: All Service Electric Inc. Name: Donna M. Gathard 'License No.: ME-56980 email: jocgathard@allserviceelectric.us Address: 57 Aberdeen Road Smithtownt NY 11787 Phone No.: 631-265-6800 JOB SITE INFORMATION (Ali Information Required) Name: James _0'Hagan Address: 1125 Windward Road, Orient, NY 11957 Cross Street: Phone No.: Bldg.Permit#: 41q 4 Small: Ja es,0ha,jzan@aol,c^m Tax Map District: 1000 Section: Block;. Lot: i3RIEF DESCRIPTIO OR ase Print Clearly) Wiring for pool OA 220V Vacuu 520A 120VGFCI Photos Circle All That Apply: Is job ready for inspection qES NO Rough In final Do you need a Temp Certificate?: YES I& Issued On Temp Infonnation: (All Information required) ServiceSize 1 h 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 Request for inspection FormAs �l PERMIT# Address: Switches Outlets- GFI's \ Surface Sconces 'W H's UC Lis, ,Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC - AH - - Mini J Special: ( t c� Comments. � -41 a Cdr%�'�' l' � New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112377925 OD®R LEVITT-FUIRSTASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FLTARRYTOWN NY 10591 ` SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 765253 06/29/2018 TO 06/29/2019 06/12/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 � a DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 195404147 11111101oO 000 00 05 68�771111A1 Form WC-CERT-NOPRINT Version 2(02/292016)[WC Policy-243949191 U-26.3 74 [00000000000059684277J[0001-0000243849191[W]114901-06]Cer_NoP-CERT 11[01.00001] SUFFOLK COUNTY DEPT OF LABOR, } UCENSING&CONSUMER AFFAIRS - _ %'��• MASTER } ELECTRICIAN P7AW Y` " CALOGERO G BRUTTO This certifies that the aum's ' bearer IS dul=l STANDARD ELECTRIC CORPORATION licensed by the County of Suffolk ` ' °°` m °Co ° 43098-ME 07!99/280 � � 7 ceHe,auosa,or exPwsnav°s� 07/09/2899 A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 01/08/2019 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Brendan J Smith Liberty Risk Management,Inc. PHONE , (631)569-5633 a Ne•(631)569-5636 664 Blue Point Road,Suite A E oRRESS* brendan@libertyrisk.org Holtsville, NY 11742 INSURERS AFFORDING COVERAGE NAIC M INSURER A: Hartford Insurance Company INSURED INSURER B: Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J.Edwards Pool&Spa Centre INSURERC: 929 Route 25A INSURER D: Miller Place,NY 11764 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP TR POLICY NUMBER MMIDDNYYY) (MMIDDNYYYI LIMITS AIX COMMERCIAL GENERAL LIABILITY 16 UUN OZ8691 01/01/2019 01/01/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS MADE IF7VOCCUR PREM SES Ea occurrence) $ 300,000 MED EXP Any one person $ 10000 PERSONAL&ADV INJURY $ 4 000 000 GEN'LAGGREGATE LIMIT APPLIESPER GENERAL AGGREGATE $ 2,000,000 X POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acddant) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Peracudenl $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (per., Par ecadent $ UMBRELLA LJAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'IJABILI Y Y/N STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached N more space Is required) 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 Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE BJS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by BJS on January 08,2019 at 12 50PM Y Workers' CERTIFICATE OF INSURANCE COVERAGE sr�ae Compensatlon 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 Arthur J Edwards Mason Contracting Company Inc. 631-744-4455 929 Route 25A Miller Place,NY 11764 Work Location of Insured(Only required ifcoverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Pohcy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America TOWN OF SOUTHOLD P.O.BOX 728 3b.Policy Number of Entity Listed in Box"1a" SOUTHOLD,NY 11971 00984424-0000 3c.Policy effective period 07/01/2018 to 07/01/2019 4. Policy provides the following benefits: Q✓ A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: 0✓ A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits Insurance coverage as described above. Date Signed 06/22/2018 By S Gi,o t ---Y• S� w (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 1-888-278-4542 Name and Title Stuart J.Shaw,FSA,MAAA - vice President,Group Insurance IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carriers authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 46,4C 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 56 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) 1ii2i0�ii11i0illi1 lN���ll�l�l I PLUMBER CERTIFICATl��',',I w ,. IV LEAD CONTENT BEFC.';._ , A CERTIFICATE OF OCC!l.r�;,'; y SOLDER USED lir co SUPPL Y SYST EXCEED 2/9 0 O 9 APPR VEDAS NOTE® W I DATE:5 b.P.# 053 PLUMBING � N I N -EE: D e BY: :ALL PLUMBING WASTE o 0 M 1 M ' ';OT1FY BUILDING DEPARr,-,N7T AT °"&-WATER LINES NEED : c MI ,)765-1802 8 AM TO 4°M THE - Wd BEFORE COVERING ;; o 0 FOLLOWING INSPECTIONS: vs i z j ( 1. FOUNDATION - 7�S'CI REQU'REDM 66��c 6Z•9 S { FOR POURED CC}'dCRET� I /3dId ' 2. ROUGH - FRAMING & PLUMBING ,9 L'9 2Z0'0£ aNn0A 3. INSULATION 31014NM _ 03130 O Z 4. FINAL - CONSTRUCTION MUST 3dld rg X0e O I BE COMPLETE GC j 0,0 aNnou I I A'lYo i 7�p ALL CONSTRUCTION SHALL MEET T! T°"` � � �� �1= I M 4:98 \ Ii I d. REQUIREMENTS OF THE CGDES OF NEW — YORK STATE. NOT RESPONSIBLE FOR o^ DESIGN OR CONSTRUCTION ERRORS 00. ! COMPLY WITH 6i1f�L� 9ES ®6 NEW •�' ��� Qui f 6 (`oJ Vv l` { W YORK STATS � �® C®®�� — ,cme��_ -� d��,�,�2� �`' 6� s�,. ° ��,e� Z ,� ra ;byazd1 aN� I E° w O AS REQUIRED ®I� IONS ®� �ovssa 1 � i \ ® O LL07 O 4 '�� '1bd�- gr, `9� �y�010 1 A�2 { ts � oo ti L d , , MOMS SKAWd 1 9 Q v x ��O�o g �f ° d� a3Nnao z "snoua3d Z M N 0 a�0 cL5 I �a a (D • 0 0 0 z JSE S- LAWFUL - MTHWT CERT CATS 3dld 3dld aNnoi aNnOd ,.o }, (�OF OCCUPANCY � �p�N�({�M 30N3d 1iNfl NroHO 3oN3d 3 cc®Y c 6 Z�9 a (v� I( tlI V M.1'0 'N,£'0 c 6 Z• L� 30N � Z I RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. (kD 107 I v 1 I I II �Y APPR VED AS NOTED DATE:4m u B.P. FEE: 2!�FDb BY: RETAIN STORM WATER RUNOFF NOTIFY BUILDING DEPARTMENT AT PURSUANT TO CHAPTER 236 765-1802 8 AM TO 4 PM FOR THE OF THE TOWN CODE. FOLLOWING INSPECTIONS: r 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR CO. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW ELECTRICAL YORK STATE. NOT RESPONSIBLE FOR INSPECTION REOUIRED DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES e9��da ° U)', ELY®' AS REQUIRED ANDICONDITIONS OF ENCLOSE POOL TO CODE UPON COMPLETION BEFORE"WATER°', "� IC.60ARD —� 0 - TEES OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY r I I I B I I i l l l l l 11 .1 I I I MIl�MiaNOMO01hc-4lno)0 mminM,*in M�c-4tnNC14ItK) q* NMMCV UC)00W WLL.LL-(9ZZ I I I I I I I I I I I 1 1 1 1 1 1 1 1 1 43'9' -'_18'5• F 25'3' K A S J' s Zo M 3'-11• 12-7 C 12' T40'DEEP 7.-11 D 22'-5' T G R6'-10° 7'-71/2' L Hd B ' E j AREA= 6976q.ft. JOB NAME. 4 PERIMETERS 112 _ YDS CONC 12 �Ai"� / y r �� v SCALE- NOT TO SCALE REBM 17 F'v '"r `4' F9ENAME- LA-4444 FORM TIESw 174 % G L;$t<SPA{:V_° ORAYM Br: &4j P, J J L A same.. Fshme 4 B E B /Ahrrr,em To FYIr Fnrm Te�Fftw h Pomp To Fauna r (Ory Rao 00bo M"Tfol F Plan A Piping Arrangement Wd 5aNae wwo H Pow 42' Section B—B r PSL C...w H 10" ' Se �y�ij A-n Tvpical Wall Section SIZE AB CD EF G H AREA CAP. FEET FT. FT. FT. FT. FT. FT. FT. FT. SQ.FT. GAL. pwvh. 16x32' 16' 32' B' 14' 6' 4' 4' 8' 512 19,000 � '�, _ 16'136' 16' 36' 12' 14' 6' 4' 4' B' 576 21,600 POOL&SPA CE TM 1e'z36' 1e' ss' 12' 14' 6' 4' 5' B' s46 �1,30o PERMACRETE WALL SYSTEM 929 Route 25A Miller Place NY 11764 lute 20'x40' 20' 40' 16' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (631) 744-0174 i 24'x44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk License #4436—HI 24'x48' 24' 46 20' 16' B' 4' 6' 10' 900 30,000 Nassau License #HI74450000 I