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HomeMy WebLinkAbout44821-Z xr S�FFOI�-CIoG, Town of Southold 7/25/2021 P.O.Box 1179 o - �' 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42185 Date: 7/25/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 550 Kraus Rd,Mattituck SCTM#: 473889 Sec/Block/Lot: 122.4-38 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/12/2020 pursuant to which Building Permit No. 44821 dated 5/29/2020 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: accessoryground swimming pool fenced to code as applied for. The certificate is issued to Gerard LI LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44821 9/18/2020 PLUMBERS CERTIFICATION DATED J th riz d S gnature s oFe TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S' :OFFICE o • SOUTHOLD; NY r 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 #: 44821 Date: 5/29/2020 Permission is hereby granted to: Gerard LI LLC 80-36 208th Ave Hollis Hills, NY 11427 To: construct an inground swimming pool. At premises located at: 550 Kraus Rd, Mattituck SCTM #473889 Sec/Block/Lot# 122.-4-38 Pursuant to application dated 3/12/2020 and approved by the Building Inspector. To expire on 11/28/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Build'y g Ins ector CONSENT TO INSPECTION Go A , the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersigned(is) (are)the owner(-) of the premises in the Town of Southold, located at '5-570 IC r q u,;e- � � „/life L` 4 /4, which is shown and designated on the Suffolk County Tax Map as District 1000, Section t-11 , Blockcam, Lot That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspecto '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: J �3 / Z 0 C' -C,U etc. (Print Name) (Signature) (Print Name) F SO(!T�®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 � sean.devliniQ-town.southold.ny.us C®UNTd,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Gerard LI LLC Address: 550 Kraus Rd city,Mattituck st: NY zip: 11952 Building Permit#: 44821 Section: 122 Block 4 Lot 38 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electrical Contr. License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures 1 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceding Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures 11 Pump 1 Other Equipment Pump on 220GFI Breaker, Salt Generator, Pool Heater on 250 Breaker, Pool Cover w/ Keypad Notes: Pool Inspector Signature: .�G� Date: September 18, 2020 S Devlin-Cert Electrical Compliance Form.xls qf so yob Li Lf v2--,l TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT"CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUG [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION ® � [ ] PRE C/O REMARKS: /AO r011- 94 Atq oly� DATE Z U INSPECTOR �"'� OE SOUTyp� L4 Li S.SA y row jr * # TOWN OF SOUTHOLD BUILDING DEPT. `yitiurm '� 765.1802 INSPECTION - x [ ] FOUNDATION 1ST [ ] 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: cm DATE INSPECTOR ��- %F SOOI,yo� # f TOWN OF SOUTHOLD BUILDING-DEPT. ��`y�ou►m ''� 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND f ] LNSULATIOWCAULKING , [ ] FRAMING/STRAPPING FINAL wt---- [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: V CJI/ DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. = 765-1802 INSPECTION [ ] ,FOUNDATION 1 ST [ ] ROUGH PLBG. FOUNDATION 2ND, [" ] SULA O CA n G [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ -]- FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH)- f ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 6),1& 1" OK _j L DATE IVA INSPECTOR *"A � t _1 - ,, ' Y � a. � � , is 4`�� ��� � -�' i '� k` � •\ r( df'=' ,�, rf� �, 41 !�a ,� ,1: ! „. �{ � ' A t /` ••�� Tt: � 'i (/ ' \ ,.� 1 \, Nil �4{ rl�� Y :• t�� ` �U,, 1•,',' r� •.� �` .1 �r1` ,yr'\.., .�/v� •��� ` �� •'.aG �y� �� i .. .. �', • ,. - t /j�f' +,'(.Ir, y i? ;+.,. 1,,'7'" i .��cl. `\�e� �' / �ii I, � ��" �,' •� 1, �`,. �ti. •\. '� v '.�..iy _�"� �. {', i, fa• :. a ��� � '1 y i r,�' r� ��r �,;e ,{. ti ��) r �� It- i �1'i. \ �q♦r_ i . �; ;V" ��;.: r � ,\ �S\1 � �•I�. �. P �� - ` ' V`�rl 1���. 'I � _�\� �}, �\ � ' S1r r� t .a. � 1 1a.:♦ 5j►- �: h . \- No Tl - y � 1.- ;� •� �� -r � ,�"jv� -� �' ` '�`� !off//'� �% •;PPP' '� �� {�i�; �A� � -i= • k� i r` ;.. '�• r+ '�• .!�`.�. ,y• k F � �"fir �*i., �, ti .w yam. a . r 6 ��rr` h�, ^`+, -. . ,ter' �p t { '��' 1�' •Y�y+ wit 4 �r h`` �� '�" ° ��#` �+':►: =� �+a� .. ♦. `mac � - _ ,� '.s',.-s•�ar. u a � r"ray , Z✓. r j k �,. �--� VS-' 2 / ----------------- k q �r. €lol d tr r �rc4 3 �w ti '� ` D o JUL 1 9 2021 BUiT.DTNG DEPT. S RR 4 Q ;oi HmD k . ;t F r a € �- ��._�.i�� (, ��- r ter`•.. - _' -!� �'~ �-�"- _-�/ ," '".. - ^'s ��" ��- I moi- '� � `'• Imo'i/ �-��- 141 Y - _ f T • 1 ~ ^sem "1 - „w``•.. . FIELD INSPECTION REPORT DATE COMMENTS b oil� FOUNDATION(1ST) -------------------------------- FOUNDATION(2ND) z ROUGH FRAMING& y � PLUMBING INSULATION PER N.Y. `H STATE ENERGY CODE w► nL .� ✓l�i✓. FINAL ' 017 A-0 ADDITIONAL COMMENTS 6 I d \ � o -1-aka-0 �(t1 i ob O l�.ow4 GTl2I z 9-� �' a - b �-y O z xx . ! y d t�7 �d H �l TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST ' BUILDI`XG DEPARTMENT Do you have or need the following,before applying? TOWN.MALL Board of Health SOUTHOLD, NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board"approval FAX: (631) 765-9502 Survey Southoldtownny.gov PERMIT NO. �'' Check Septic Form N.Y.S.D.E.C. Trustees j C.O.Application Flood Permit Examined 20 Single&Separate Truss Identification Form Storm-Water Assessment Form Z� Z� Contact: a Approved ,20 Mail to: J Disapproved a/c �� Qiv► ;c, Phone: G, I -5 5-T` 1.6 Expiration ,20 _IN Building Inspector 1APPLICATION FOR BUILDING PERMIT R - �� MAR 1 2 202® Date 20 INSTRUCTIONS a.phi's,applicatiol 1VIIIST ST-bb completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,-a' ate 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. (Signature of applicant or name,if a corporation) Vcf (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder 0 k-��lever Name of,owner of premises N,-�r; c, L1 1/24 u (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corj2orate officer) Builders License No. 0Ukiri4c1�ctclls , Plumbers License No. Electricians License No. 4 055-7 7A4 9' BPW oak G Other Trade's License No. 1. Location of land on which proposed work will be done: i 14--; � House Number Street Hamlet County Tax Map No. 1000 Section 2.2 Block Lot 3 Sut,division Filed Map No. Lot J 2. State existing use,.and occupancy of premise and intended use and occupancy of proposed construction: a: Existing use and occupancy Pte: c.ti •�„ ) b. Intended use and occupancy �e6 i 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work Pc,.c I ( � ' (Description) 4. Estimated Cost �V�I Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front C Rear Q Depth Height Number of Stories //"" Dimensions of same structure with alterations or additions: Front Z�' lX4dRear Z106r2c- Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories ' 9. Size of lot: Front Rear Depth ISS Z' I Name of Former Owner y g w v�z ���-+h e 10. Date of Purchase 15 l � 11. Zone or use district in which premises are situated - `'! �✓' 12. Does proposed construction violate any zoning law, ordinance or regulation?YES NO i 13. Will lot be re-graded? YES NO ill excess fill be removed from premises?YES NO I 'tAct 14-14,1L 14.Names of Owner of premisesQg-\„•c k-- G .c a,,Addre§ss SQA 1L~ 'Ui Phone No.�41 -t-1 I V (7 7 G Name of Architect -3cN.,-e-s 'Oe-v14-i k- Addres�a Aeov N� ionWe No �-1 4 -1'i �s Name of Contractor')1„4,r.fit. cr:�1 Address A l 1c, VtA-4 H-•:JPhone No. !S 4s 5 -1616 h►en"--% ***< 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 IZE 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 Y 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 ) ➢��,,, ��.a'�KO"�' being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the cc,V-t -1-rcj C-'�/ (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 to before me this f Y of—� da NOTARY PUBLIC,STATE OFYORI4 01-P16090455 otary Pu lic QUALIFIED IN SUFFOLK COUNTY ' Signature of Applicant PAY COMMISSION EXPIRES APRIL 14,20P Rb BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex - 54375 Main-Road - PO Box f179 ; _ N Southold, New`Y"-R1 11971-0959 " y �� Telephone (631) 765-122 - FAX (631) 765-9502 -- - ---------------- -- -- - roger"cosoufi o ownny.gov span. sou boiatownny:q� APPLICATION FOR ELECTRICAL_;.INSPECTION = ELECTRICIAN INFORMATION All fnformation Required) Date: --7L Company Name: Name: .. • J LAN License No. - -(� �- - :email 9 �. a A0.1 Address: baa "'` t . '= Phone' No. -- ��, r. _ _ %•sr JOB SITE I(t1FP ATION (All Infdrmatiofi Required) Name: c LtC � ..; Addres� � Cross Street: `3.At4 _. ,B1dg: TX '{apfstr�f 1!?x}13cfyId'[ ;r. , _ Brtbcf�, _ t:_ • 4i tT�'F - � � .-. Cil{i - - ;,��', i ZI,EF 6'ESCRIPTION-OF WORK (P'fease.Print Charly) AA ....-._,.-_...Ct_c7e Af["That A- - I -: -�- --.._ •-_. -_.,_..�._., . �.�. ...__.�_.4-_ _.__._. _ Is_tobeady Rough for inspection?: YES NO Rh In _.__.. _r.._..�. . __. _...._�_..� .,... . _ _- --- Final Do you-need a Ternp Certificate?: YDS NO Issued On Temp Information: (All information required) - - -----.-Service Size 1-Ph.-'_a,Ph•• --Size: - -- --.. _ A. # Meters--_-.,-. __ _Old Meter.#. .New Service - Fire Reconnect- Flood Reconnect Service Reconnected -Underground -Overheads ame Pole Work done on Service? Y N 1# Underground laterals ;1-. 2. H Fr.. _ . _._ . . . .-- -,- . .; - • .- -- - _ . . . . _ - Addifi6hal lrtformiation: ,•... I• .... _ ;_ s� �0�11 over �;(e. w_ AA JA e s . ren it,�kMT I HPLIOATAO -------MENI,-D L"_ r Lrv.�r rvN - _ boa Request for Inspection Form-As r � �f 2so ��� � J--GY-GC q-- �/f cci / �CIJ�l x`•11,`,N�r SYMBOL LEGENLI III MONUMENT FND, FIRE HYDRANT (M GAS METER FE. 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FENCE ® I.P. /I B. FND ® MANHOLE ® WATER METER MAS. MASONRY I.P. /I.B. SET ® "A"-INLET M GAS VALVE PLAT. PLATFORM *,mss SPOT ELEVATIONS I N "B"-INLET x WATER VALVE W.W. WINDOW WELL �--�� TRAFFIC SIGNAL POLE El "E"-INLET 10 TEST HOLE B/W BAY WINDOW CO..) UTILITY POLE ® YARD INLET TREE C/E CELLAR ENTRANCE >— GUY WIRE ® YARD INLET ® SHRUB 0/H OVERHANG UTILITY POLE WAIGHT ® CABLE TV BOX • BOLLARD R/O ROOF OVER LIGHT POLE A/C UNIT & WETLAND FLAG L.S.A. LANDSCAPED AREA -v- SIGN ® ELECTRIC METER CANT. CANTILEVER D.C. DEPRESSED CURB KRAUS ROAD (50' WIDE) __—_— ,----- —__EDGE OF PAVEMENT .. s i _ S80°37 20"E 132.88' ATO 6 zoll } FEN4 CHAIN LINK FEN. 14.31129.7Y b RMAGE, 77.8 {�STORM TAX LOT 37 FRAME RYDENCE 4, BRICK 4.21 4 \ a . �s' 9 g, W F S Tv ei to �y o Ari WOOD ri,• 31.2' :� 2N ry DECK (� N 27.3' is F/S� PROP. PROP.STEPS \ � 28' STONE TERRACE PROP. E� v 2 19.4' a PROP M p18.4' (4o xi6 9 casaNa W TAX LOT 38 r Ila V1 14.4' ID IR FEN �i121.71' FEN — 10.514- LO — LINK CHAIN FEN 0.3' 1V80e3s'10" 6'STOCKADE FEN, GATE � 201.16 CO 9*a (25' RIGHT OF WAY LAND OF ZEBROSK) h I^ -- -- -- -- FES I .z 08.4 CVD I � 1 I I TAX LOT 41 I TAX LOT 39 I � l I Z 1 a S74005'2011ir :lam cel � 48.92' 11.6' N, 4' CHLFEN. -► Cq FEN CQ O . �� OO/ -"AXLOT 46 O w l � Q c0 DAR ,4 dj �. � LOT AREA ?! M 27,155.99 S.F. c� c� t� 0.62 AC. N74e05',�0" � #,l TAX LOT 4Z 1�t 4 50.00 0 14167-4;,,00„ GRAPHIC SCALE R5.00 GUARANTEED TO: 40 0 20 40 COMPOSITE DECK FIRST AMERICAN TITLE INSURANCE COMPANY LANGDON TITLE AGENCY LLC. :911'r nrr GERARD LI ,LLC. ( IN FEET ) I inch = 40 ft. 1 1 103/03/202.0PROPOSED ADDED MC MJS REV I DATE I DESCRIPTION BY CHK OF NEWY �� J. SC. 'f SURVEY OF PROPERTY SCALICE l a n surveyingMAITATE m ' s I a n d survey . c om P: 631 -957-2400 TOWN OF SOUTHOLD ITUCK l � DR.:MC =CREW..JM SCALE: 1" = 40' 1000-1OLOOT X M P03O . 00 SUFFOLK COUNTY, NEW YORK LAND S DATE SURVEYED:07/30/2019 JOB No.S19-1692 AND 045.000 (I)UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY MAP BEARING A LICENSED LAND SUR�¢YOR'S SEAL IS A VIOLATION OF SECTION 7200,SUB-DIVISION 2.OF NEW YORK STATE EDUCATION UW (2)ONLY BOUNDARY SURVEY WAS WRH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND CORRECT COPIES OF THE SURVEYOR'S ORIGINAL WORK AND OPINION (J)CERTIFICATIONS ON THIS BOUNDARY SURVEY MMP SIGNIFY THAT THE MAP WAS PREPARED IN ACCORDANCE WITH THE CURRENT CQSTINO CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL LINO SURVEYORS,INC.THE CERTIFICATION IS LIMITED TO PERSONS FOR WHOM THE BOUNDARY SURVEY MAP IS PREPARED,TO THC TRIE COMPANY'TD THE GOVERNMENTAL AGENCY,AND TO THE LENDING INSTITUTION USTED ON THIS BOUNDARY SURVEY MAP (4)THE CERT=TIONS HEREIN ARC NOT TRANSFERABLE(5)THE LOCATION OF UNDERGROUND WPROVEMENIS OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND OREN MUST BE ESTIMATED.IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS DUST OR ARE SHOWN,THE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THIS SURVEY.(B)THE OFFSR o DM4NSK1N5)SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES.RETARRNG WALLS,POOLS,PATIOS PLANTING AREAS,ADDITIONS 70_RESIDENCES,AND ANY OTHER TYPE OF CONSTRUCTION (7)PROPERTY CORNER MONUMENTS WERE NOT SET AS PMT OF THIS SURVEY.(B)THIS SURVEY WA--WORMED WTIN A SPECTRA FOCL!S 30 ROBOTIC 70TAL STATION. (0)THE E%LTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD IF AMY.NOT• ARE NOT GUARANTEED i r—�yolm workers' CERTIFICATE OF INSURANCE COVERAGE raTZ 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 1a. Legal Name&Address of Insured(use street address only) ib.Business Telephone Number of Insured DUNRITE MANUFACTURING CORP_ 3510 VETERANS MEML HGHWY BOHEMIA, NY 11716 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.e.,Wrap-Up Policy) 112245133 2.Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ! Shelterpolnt Life Insurance Company Town of Southold 530950 Route 25 3b.Policy Number of Entity Listed in Box"la" PO Box 1179 DBL593730 Southold,NY 11971 3c.Policy effective period 01/01/2020 to 12/31/2020 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. 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 carrier referenced above and that the named Insured has NYS Disability andlor`Paid Family Leave Benefits insurance coverage as described above. Date signed 315!2020 By � 1(Y (S gnature 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 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 Lawwnth 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 carvers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) BIIIII�IIIIIIIIIIIIIIIIIIIIIIII(IIIIIIIIII�)II�IIO <11TEWATE Workers' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE Compensation COVERAGE Board la.Legal Name&Address of Insured(Use street address only) 1 b. Business Telephone Number of Insured 516-543-1616 Dunrite Manufacturing Corp 3510 Veterans Memorial Highway 1c.NYS Unemployment Insurance Employer Bohemia,NY 11716 1 , Registration Numberof Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e.,a 1d. Federal Employer Identification Number of Insured Wrap-Up Policy) or Social Security Number 112245133 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate-Holder) AmTrust Insurance Company of Kansas Inc Town of Southold 3b. Policy Number of entity listed in'box"1 a" 530950 Route 25 KWC1143762 PO Box 1179 Southold,NY 11971 3c. Policy effective period 10/20/2019 to 10/20/2020 3d. The'Proprietor,Partners or Executive Officers are ❑included.(Only check box if all partners/officers included) x❑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 "la" 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 will also notify the above certificate holder 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 the 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 carrierreferenced above and that the named insured has the,coverage as depicted on this form. Approved by: Kevin McDonough (Print name of authorized representative or licensed agent of insurance carrier) Approved by: d'-' 3/5/2020 (Signature) (Date) Title: President of Walter Rose Agency, Inc Telephone Number of authorized representative or licensed agent of insurance carrier: 845-783-2555 _ 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.wcb_state ny.us DUNRIA ID: CH 'q o, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDJYYYY) 03105/2020 THIS CERTIFICATE I'S 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(les)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 endorsemdrit(s). PRODUCER 845-783-2555 cT Walter Rose Agency Walter Rose Agency,Inc PHONE 84'5-783-2555 FAX 845-783-2423 8 Stage Road WC,No,Ext): (Arc,No): Monroe,NY 10950 ADDDRESS Isa wa erroseagency.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:Central Mutual 20230 INSURED INSURER B Dunrite Manufacturing Corp rte pools INSURER C: N0 Qt Memorial Highway Bohemia,NY 11716 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 WrrH 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 SUBSPOLICY EFF POLICY EXP TR Sp WVQ POLICY NUMBER IDDIYY M IDDIYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F_X]OCCUR CLP 9791864 04/01!2019 04/01/2020 DAMAGETORTTED $ 300,000 MED EXP(Any one erson 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY❑X SECT FILOC PRODUCTS-COMPIOP AGG. 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED egad DtSINGLE LIMIT $ ANY AUTO BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS E BODILY INJURY Per accident $ AUTO ONLY AUTOS ONLY PPe�accRdent AMAGE $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ANDEMPLCOMPENSATION YERSELIA IB L�TY Y 1 N PTR OTH- ANY PROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N!A (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I I EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Swimming Pools-Installation,Servicing Or Repair-Below Ground CERTIFICATE HOLDER CANCELLATION SOUTH02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 530950 Route 25 PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PoMsu vnthstep A B C D E F G H K L M N Gat Go.1,v4, d WITH I E H PALL CODES ®� 14,(30 14x34 14 30 3'•4" 61•6" 6 14 6 4 4- 6 4'-0" T-4^ 12900 YORK 16X28- . 16x32 - 16' 28 3'-4" 6'•6" 6 •12 6 4 -4 8 4'-0" 7`-4", 93200 �� Yl.1Re� STATE & `SOWN CODES _- -. 16x10 16#4 16 20" ,3'4" 6'-6" 4 E. 4 4 4 8 4`-0" r-e 9500 �� ��ODI��® A ®�� OF 16x30 - 16x34 16 30 3'-4" 6'•6" 8 12 6 - 4 4 8 4'-0" T-e• 14000 ! 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UPON COMPLI t0hr- _ Poolcousd�col� aiasg�s6lehoe�aeoetraeesxessp®sib' �� 4�; t :rte _ 8326.6 mmentll+oteC11011 astaltesl _._�.BEFORI �xWAT[ G ` _. . E ®®�� aur New York����� 8326"7 Sw g Pool and Spa Alarms must be installed a ii f �� 2015 c POOL TYPE:REC` ANGLI ���° SCALE' Sec R403.10.2 Time switches or odw contrd methods that can assn JAMES DEERKOSKI,P.E. - autowaticaDly tush off anon accmftg toa paeset sc$edule shall be A�Or F 10 �� DATE: WFICALP EL$7OFFNER instaliedforheatersand Pump motors. Modem and pump motors that i,-S 30BEER DRIVE have buile in titate StM03 sk It be iu complauce with Sec R 403.10.2 j �. f N A7TITUK,NEW YORK 11952 DRAWING NUMBER - 1 OF 9. - , i