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HomeMy WebLinkAbout44281-Z goy�S�FF01c�Gytt Town of Southold 8/11/2021 �}a P.O.Box 1179 �o ® �� 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42229 Date: 8/11/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 815 Park Ave, Southold SCTM#: 473889 Sec/Block/Lot: 56.-1-2.4 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/3/2019 pursuant to which Building Permit No. 44281 dated 10/11/2019 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 McMahon,Eileen of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44281 1/3/2020 PLUMBERS CERTIFICATION DATED A ifthoiize i nature o�s�F of ��co TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 44281 Date: 10/11/2019 Permission is hereby granted to: McMahon, Eileen 57 Montague St Apt 7B Brooklyn, NY 11201 To: demolish an existing swimming pool and construct an accessory in-ground swimming pool as applied for. At premises located at: 815 Park Ave, Southold SCTM # 473889 Sec/Block/Lot# 56.-1-2.4 e Pursuant to application dated 10/3/2019 and approved by the Building Inspector. To expire on 4/11/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Bui di spector 6 r 9 a 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 I%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 I. Certificate of Occupancy-New dwelling$50.00, dditions to dwelling$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. ' 14 New Construction: i Old or Pre-existing Building: (check one) Location of Property: House No Street Hamlet Owner or Owners of Property: M6 Suffolk County Tax Map No 1000, Section Block _ © Lot �a Subdivision Filed Map. Lot: Permit No. �1_( Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate 5 Final Certificate: ✓ Fee Submitted: $ (chec one) Applicant Signature , - /hf-WICM On xWdmat rite/ p , 5 r I, oF sovr�®� Town Hall Annex ~ ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G Q roger.richert(a)_town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Eileen McMahon Address: 815 Park Ave City: Southold St: New York zip. 11971 Budding Permit#: 44281 Section 56 Block- 1 Lot: 2.4 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 Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 1 Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 Twist Lock Exit Fixtures 11 TVSS Other Equipment. In ground swimming pool to include, bonding, control panel, time clock, 2-switches 1-GFCI circuit breaker, 1-GFCI recpticle,pool light, 1-pool pump,salt generator,pool heater, 1-single recpticle Notes. Inspector Signature: S74�_4�zgDate: January 3 2020 81-Cert Electrical Compliance Form.xls SOUIyO� # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION. [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND . [ ] SULATIO CAULKING [ ] FRAMING/STRAPPING [ FINAL [ ] FIREPLACE'& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: (k) So, pbrw-,-, 6., DATE "-)leLO INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS o FOUNDATION (IST) ------------------------------------ Li V FOUNDATION (2ND) tai T z o H ROUGH FRAMING& PLUMBING r INSULATION PER N.Y. H STATE ENERGY CODE FINAL ADDITIONAL COMMENTS ® Z � rn Cb O x t - 1 TORN OSOUTHOLD BBUILDINGGDEPARTMENT BUILDING PERMIT APPLICATION CHECKLIST TOWN HALL Do you have or need the following,before applying? SOUTHOLD,NY 11971 Board of Health TEL: (631)765-1502 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. Trustees C.O.Application (J Flood Permit Examined ,20 Single a Separate Truss Identification Foran Storm-Water Assessment Foran Contact: \ Approved // ,,�� �,� A—PS,PP 20 ff Mail to�W�, t l l Disapproved a/c (L'� E Phone: Expiration 20 1 ctor 0 C T m 3 2019 APPLICATION FOIL BUILDING PERMIT �i S DateB 1 INSTRUCTIONS Y �20a 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,housin code,and regulations,and to admit f..._ authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) ru '}� g Na -sslo of lic t State whether applicant is owner, lessee, agent, arc 'tect engineer, general tractor, electrician,plumbe or builder Name of owner of premises As t eta roI or latest de ) If applicant is a corporation, signature of duly authorized officer (Name and title of c ate o r Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Loc ion of land on Thmichn proposed work ill a done: House Number Street Hamlet County Tax Map No. 1000 Section �CL Block Lot . i I Subdivision �U VIA Filed Map o. Lot Ni 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy 5l 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work ap 4. Estimated Cost_ ? Fee ' (Description) (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front �-�5'0 Rem—ZR � Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated ' 12. Does proposed construction violate any zoning law, ordinance or regulation?YES NO N 13. Will lot be re-graded? YES N0 Will excess fill be removed from remises? S NO 14.Names of Owner o xemis AA Z)A.0 R �ddress .B�avo6 �iif'one N� Name of Architec SLS 111 a- Address Z Rao y' GPhone N W 6- Name of ContractorJ ti • ddress �J- Phone No �l�1 -�1 a`L. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetl d? *YES NO *IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C.PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16. Provide survey,to scale,with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? *YES NO>, *IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) v�e�g duly sworn,deposes and says that(s)he is the applicant (Name of individual signing ontract)above named, (S)He is the (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this applica'QQAN�' �t' '(p/Pe best of his knowledge and belief;and that the work will be performed in the manner set forth in the-VQ'ic ipgQ :9dQ the with. Sworn tghefore me thi 1_ ,`w: o `y day Qf • �,� a /l '.s a Notary Public .4 �"0,`N`;�\�`� Signature of Applicant Scott A. Russell 9PO)[ IM[I ff A�C]E]E SUPERVISOR . S()UTH0LDT10WN HAL',-P,0,oft j�,19 IWA\l�,At(Gr]EA K]EN 7[' 59095 Win Road-SOVTHpLD:NS4V YOl(K 11071 � : `, Town., ofSouthold CHAPTER 236 - STORMWATER.MANAGEMENT WORK SHEET ( TO BE COMPLETED.BY THE APPLICANT ) I = DOES 'MS PROJECT INVOLVE ,NY OF TM FOLLC)Va — A 190 fCNECK ALL TEAT APPLY) �• A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feQt of ground .surface, ❑ . Excavation or filling involving'MOte. than 200 au'bic yards of material within any parcel or any contiguous area. ❑ac. Site preparation on slopes• which exceed ,1-•0 feet Vertical rise to. .100 feet of'horizontal distance. '.D. Site preparation within 100 feet of wetlands beat erosion hazard area. ht bluff or coastal ❑ E. Site preparation within the one-hundred-year floodplain-as depicted on FIRM Map sof any watercourse. ❑ F. Installation of new or resurfaced impervious surfaces of 1,000 square I feet or,more, unless prior approval of a Storm water Management `Control Plan was .received by the Town 'and the-proposal includes in-kind replacement of impervious surfaces. If you answered,h10 to all ofthe questions above; STOP! Complete the Applicant section b'elow:u a•your Name, Signatures.Contact information,Date &•County ThX-Rap'Numbet! '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 witG Your BRH&g Permit Application. rAPPLICA : (P n rt Owner,Des(gn ProfeWbnal,Agent,Contractor,other) S'CST•M. L�Q� DW! _ Istn O 1 NAME: Inl I l II 5�rtion .g(� Lot I , �� I FOR BUILDI DING DEPARTMENT USE ONLY "°�I� Contact Inr atlo _ I � RdephSn.Nnmbv: 1 `^ � 1 I 1 Reviewed By: Pf(?R Address/Location of Construction Work _ Date: d 3 Approved•for processing Building Permit. Stot•mwater Management Control-Plan-Not Required 1 ( — — — t — — — _ _ I ® Stormwa'ter Management Control Plan:is R�equjrLd ________ _____ (Forwatd to Engineering Department for Review.) FORM * SMCP-TOs MAY 2014^�� _ — - -- -- - -- ----� ' OF SO�ryo! � o Toxin Hall Annex Jjt [ Telephone(631)765-1802 54375 Main Roady (631)765-95 P.O.Box 1179 �; 0 roger.richert oown.soutrio16.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOU'THOLD APPLICATION FOR ELECTRICAL INSPECTION QUESTED BY: ���!-M� OeJ`� 9v 1(�trC14C Date: ?mpsmy Name: �Q rr � �'�C�11 �A '� ('i7i ►�' IL J Ime: -2LA i vv -ease No.: NA - ]dress: co Y-N ki e, 4 1r-o©k Ni ) 174-( ione i74- ione No.: -150 (5; -)BSITE INFORMATION: (*Indicates required information) !ame: F W "C'tArlhon ddress: Toss Street: ��, Ave hone No.: , W5, DA8 B5 :rmit No.: Ix-Map District: 1000 Section: Block:_ Lot: a� RIFF DESCRIPTION OF WORK (Please Print Clearly) lease Circle All That Apply) job ready for inspection: YES NO Rough InFinal o-you need a Temp Certificate: YESNO tip Information (if needed) ~�6-1 ervice Size: 1,Phase 3Phase 100 150 200 300 350 -400 Other ew Service: Re-connect, Underground Number of Meters Change of Service Overhead ditional Information: PAYME T DUE WITH APPLICATION r---- t�j C AA 1�gLeJju, ofo;jc —7�qdc @�CCAI u. OvU �-f' 82=Request for Enspectlon Form BUILDER'S NO. MAR 2 tia 1v N /Glop 3 -70 38"54 E r 14- % d o,0/"7 s� 0 N N a.. Yjm MIA •: SUr-FOLK CaWliiY_DEPARTMENT OF HEALTH SEFR*LV Ea 1� OAY_ SINME FAMILY DWELLING ONLY of CamUmbd Weft _69A ., ° 83 ('Q / '� �$• •drV.�.�.�v6. � K , 1 V JrL ,mss �� , ��C: 7b'��.��� b1K3a3 ft�� �el ° • g• 784. Sariti {r o . ,w..ATE1°t • teixP.E.,Chief 11 —7- ti N Offtc� ws, Rd�1B (dna M c�+t-.ti",- ,^r.",•t.tc:s�'ss '7ru'�-e••-"s,,�R•1_tg ' �2__, -.y x:.. =� ,- —-j._,-•- _-',_" - � ^01��^ — - - \V -+_• - •w— r _ _ _ -_ - ___ N THE',EXISTENCE OF RIGHTS OF WAY CERTIFIED TO: ANDIOR EASEMENTS OF RECORD IF ANY, NOT SHOWN ARE NOT GUARANTEED. ` ��(� � kl. � - �• F'/G7�Ll7'Y ,c...I�s.7"lO,v.�.[Y 7`ir�� �Q.��'C '�� O� /�I:3LIea.��•tC.JCE CC's. UNAUTHORIZED ALTERATION OR ADDITION BAAJK TO THIS SURVEY IS A VIOLA`tION OF SECTION*7209 OF THE NEW YORK STATE EDUCATION LAW. a COPIES OF THIS SURVEY MAP NOT BEARING �' No.049841THE LAND L OR EMBOSSED SEAL SOHA'LLINOTDB SE SS � LANo SJ�y TO BE A VALID TRUE COPY, THE WATER SUPPLY AND SEWA E. DISP AL SYSTEMS FOR THIS RESIDENCE WILL CONFORM GUARANTEES-INDICATED HEREON SHALL RUN TO THE STANDARDS OF THE SUFFOLK COUNTY ONLY TO THE PERSON FOR WHOM THE SURVEY Q DEPARTMENT OF HEALTH SERV/CES. IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI ° TUTION, GUARANTEES ARE NOT TRANSFERABLE. SIGNED SURVEY OF: LOT NO 14- KENNETH H. BECKMANr L.S. MAP OF: G.-<DA-JG oo�� C7-:5 �" :S sE'c. a-vE Surve in and Land Planning �F•�c.Eo : ate, 2.-r , ��8�. �-.��u�o. eo3-r) - Y b SITUATED IN: Expressway Drive South TOWN OF: _-sou'r"HOL.CD Suite 202 SUFFOLK COUNTY, NEW YORK. Ronkonkoma, N.Y. 11779 0(516) 588-0380 BATE:'! I-Z9.94-JOB NO. 54.144.reSCALE: I " - 40' FAX (516) ,588-6395 DIST. SEC. BL.K. LOT -'�Ife- &O.T.M. NO. logo 5<26 Z.¢ ;vb f'a"' .cJ. tom. /Z=� =9' 29 - 94 54 l4.4G A�® CERTIFICATE OF LIABILITY INSURANCE DATTE(MMIDDNYYY 9) 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER , CONTACT NAME Bethany Purificato AssuredPartners Northeast, LLC. PHONE . (631)465-4000 FAX A/C No 100 Baylis Road E-MAIL bethanurificato@assure ADDRESS. y.P dpartners.com Suite 300 INSURERS AFFORDING COVERAGE NAIC# Melville NY 11747 INSURER A:Ph3.ladel hia Indemnity Insurance Co. 18058 INSURED INSURER B:Everest Indemnity Insurance Co. 10851 Fence King of RoclePoint, Inc. INSURER C:Shelterpo3.nt Life Insurance 81434 DBA: Swim Kings Pools 6 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 POLIC-PNUMBER MM/DD/YYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR DAMAGETO .or 'T 5,000 IS Ea occurtence $ X Contractual Liability PHPK2024813 9/1/2019 9/1/2020 MED EXP(Any one person) $ 10,000 • PERSONAL 8 ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY [K]JPERCOT ❑LOC PRODUCTS $ 2r000r000 OTHER, Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident A X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED PHPK2024813 9/1/2019 9/1/2020 BODILY INJURYPer accident $ AUTOS AUTOS` INJURY(Per HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I IER ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? E]B NIA (Mandatory In NH) SWSWC00205181 11/5/2018 11/5/2019 EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1 000 0 C NYS Dlsabi.11ty DBL37154 9/1/2018 Continuous DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The following are included as additional insured i£ rear„red by written contract subject to the terms and conditions of stated polid6es: 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. I PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE, R Mastrantonio/BFRABI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) I -ter Yo& Workers' CERTIFICATE OF STATEmpensat€on 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 Kngs Pools&Patios 471 Route 25A Rocky Point,NY 11778 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Onlyrequired if coverage is specificallyllmlted to 1d.Federal Employer identification Number Insured or Socia{Security certain locations In Now York State,I e.,a Wrap-Up Policy) °� y 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 26 PO Box 1179 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 sw5wC00205181 3c Policy effective period 11/05/2018 to 11/05/2019 3d.The Proprietor,Partners or Executive Officers are XQ included.(Only check box if all partners/officers Included) all excluded or certain partners/officers excluded. This certifies that the Insurance carrier indicated above in box 7'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'7. 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 contract7of 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 1 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 (Pdnt name auth lied r r entative.or licensed agent of insurance carrier) V Approved by: 11-07-18 ('i n ure) (pate) Undclwrr1ting Vlce President Title: Undenvriting 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.wctDy.gov li" v"o X Workers' CERTIFICATE OF INSURANCE COVERAGE T/+re Cotnpensatfan 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) 1b.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 if coverage is specifically limited to or Social Security Number certain locations in New York State,i e,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 period 02/01/2019 to 01/31/2020 4. Policy provides the following benefits ® A Both disability and paid family leave benefits E] B Disability benefits only n C Paid family leave benefits only 5. Policy covers. © A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. 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 carver referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above fir' ;�'� •:� j r f Date Si ned 2/1/2019 By r' . .i!l eL. +r 9 , w (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 5B of Part i 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 carvers are authorized to issue Form DB-120 1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111°°��!n1°1°°1°1°111°�°�!�!�°°111111 NOTES 1 NO SOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR 6 FEET OF EXCAVATION ATTHE DEEP END. O 10" 24' 10" 2 TH15 POOL MEETS THE REQUIREMENTS OFAN51/NSPI-5 AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING I"_ POOLS-AND 1996 BOCA CODE-SECTION 421. DIVING EQUIPMENT 15NOTALLOWED. Q o �- 3 SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED LAW REQUIREMENT50F _y SECTION 8326.5 3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD [PPROD AS NOT D TOWNCODE. ACCE55 GATES SHALL COMPLY WITH SECTION R326 5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY mLOCKEDWHENPOOLISNOTINUSEORSUPERVISED. ALL GATES ARE TO OPEN AWAY FROM THIE POOL•AREA -- I,, g.-0. 3,_R.Zo H2O H2O N 4 DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROUND THE EXCAVATION LAW THE CODE OF THEDATE: B.P.# ELECTRICALTOWN OFSOUTHOLD0i� 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING A CHILD ENTERING THE WATERAND SOUNDING-FEE: BY: INSPECTION REQUIRED AN AUDIBLE ALARM WHEN DETECTED THAT 15 AUDIBLE ATPOOL51DEANDATANOTHERLOCATIONONTHEPREMISESWHERETHEPOOL _Z QZ IS LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS Ln NOTI BUILDING DEPARTM AT THE ALARM MUST MEETASTM F2208 "STANDARD SPECIFICATION FOR POOL ALARMS THE DEVICE MUST OPERATE INDEPENDENT(NOT N 765-18 8AM TO 4PM FOR THE PLAN ATTACHED TO OP,DEPENDENTON)OFPERSONS 4S 0 �d FOLLO ING INSPECTIONS: NT5. 6. POOL SUCTION FITTINGS(EXCEPT FOP SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI } QC 1. FO DATION - TWO REQUIRED 12'VINYLCOVEREDCONCRETEENI>STEPS A11219SMORA MINIMUM I8"x23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM POOL CIRCULATION SYSTEM MUST BEEQUIPPED WITH �? �� ATM05PHEPIIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME M155INGOR BROKEN SUCH FO POURED CONCRETE VACUUM RELIEF SYSTEMS SHALL CON FORM WITH ASMEA112.19.17 OR BEA GRAVITY SYSTEM APPROVED BYTHE TOWN OFSOUTHOLD. 2. RQ H - FRAMING & PLUMBING N POOL SHALL BE PROVIDED WITH AMINIMUM OF2SUCTION FITTINGS OFTHE ABOVE MENTIONED TYPE. THE5UCTIONFITTINGS5HALLBE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A 3. INS CATION VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING=ITTING5 SHALL BE IN AN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENT TO 4. FIN - CONSTRUCTION MUST y 2'lo4'5ANDBOTTOM THE SKIMMER/5KIMMERS _ Q, BE OMPLETE FOh C.O. 7 ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLYARTICLE 680 AND THE IRC SECTIONS ALL C NSTRUCT, d SHALL MEET THEa 4201 THROVGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY Q) ®� � '� � ���� GROUND FAULT CURRENT INTERRUPTER(GFC0 CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FORTH 05E PROVIDING POWER '13 REQUI EMENTS OF THE CODES OF NEW SECTION A . au, , TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E42035 ALL METAL ENCLOSURES, YORK TATE. NOT RESPONSIBLE FOR ENCLOSE POOL TO CODE FENCES OR RAILINGS NEAR OP AP)ACENTTO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT N.T5 "' WITH AN ELECTRICAL CIRCUITSHALL BEEFFECTIVELYGROUNDEP. DESIG OR CONSTRUCTION ERRORS. '���I'QN COMPLETION TOP OF WALL WATER LINE ; $E ,ORE', ATE8?.'?l 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608. .. Q Y' OMPLY WITH ALL CODES OF 3 3' ! 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED 0 Sru 5", } NE YORK STATE & TOWN CODES m 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOLEDGE Ove V Q AS EQUIRED AND CONDITIONS OF 11. AMEANSOFEGRESSFORDEEPANDSHALLOWENDSMUSTBEPROVIDEDIAWAN51/NSPI-SSECT110N 6. v 0 i w Q) 12 CONTRACTOR TO PLACE THE POOL LAW TOWN OF SOUTHOLD CODE SETBACKS � ' - po SECTION B 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY � 18tB-�6Wi�f�PfPd}I ARD N.T5 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH<10%SILT GP OLIN DWATER SHALL NOT EXIST WITH INTHE EXCAVATION. IFGROUND WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. o. ITHOCCUPANCY OR 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY Ln RETAIN STORM WATER RUNOFF CONSERVATION ACT CNAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED LAW ANSI 721.56 AND SHALL BE INSTALLED LAW � MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED LAW VL726. POOL HEATERS SHALL BE LOCATED OR USE IS UNLAWFUL GVARDEDTOPROTECTAGAIN5TACCIDENTALCONTACTOFHOTSURFACESBYPEPSONS POOL PURSUANT TO CHAPTER 236 TEMPERATURE AND PRE55URE-RELIEF VALVES FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPA55 SYSTEM. A 15YPA55 LINE 5HALL BE OFTNETOWN CODE. WITHOUT CERTIFICATE FOLLOWING ENERGY CONSERVATION ADJUST ATERFLOW THROUGH THE HFATER. POOL HEATERS SHALL BE PROVIDED WITH THE CHECK VALVE FOLLOWING ENERGY CONSERVATION MEASURES• FROM SKIMMER 161 AT LEAST ONE THERMOSTAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. 00 PUMP OF OCCUPANCY 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCE55 TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUTAP)U5TING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE K� PILOT LIGHT z p 163 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTARE OUTDOOR POOLS DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) L DISPOSAL 16 4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE 5ETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET W Q rl m co DRYWELL 2.-2" TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION LAWAPPLICABLE SANITARY CODE OF NEWYORK STATE, 21 co a COPING AND WALKWAY 1O, Y h h$ � DIVERTER 3 c c a vALVE O (BY OTHERS) GRADE 17. THIS DRAWING 15 FOP,STRUCTURAL SHELL ONLY ALLACCE55ORIE5 AND APPURTENANCES APE DEFINED BY OTHERS. ETr,ro CIS WATER LINE r., _ M co U s 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTSAND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHT OF THE W N Ess d 0 WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" N y �+ FILTER UNDISTURBED EARTH a O I�LL h Ir 3500 P51 POURED CONG • 19. PLACE CONCRETE ON SANDY TO LOAM 501L REMOVE ANY CLAY DEP051TAND REPLACE W/COMPACTED CLEAN BACKFILL W ►a a 3ie°REBAR 2)TYP a 20 THERE IS NO MAIN DRAIN IN TH15 POOL, SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY. THIS MEETS VINs.LINER REQUIREMENTS OF THE IRC-SECTION 8326.6 FOR ENTRAPMENT PROTECTION !/"' NEW Y (� 2'TO 4'SAN� a 21 THE POOL WAS DESIGNED LAW THE FOLLOWING: P�V .r HOiyJ O•Gf- 211, THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER42(2016) 21.2 THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION PA0310(2015) �•j d 9 roREfVRNS 213. THE INTERNATIONALFUEL GAS CODE(2015) )�0 21.4. THE NEW YORK STATE CODE SUPPLEMENT-SECTION 8326 (2017) c, CHECK VALVE 21 5 THE NEW YORK STATE SANITARY CODE. a- m VERTICWREBAR®3'OC 21.6 ANSI/NSPI-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. CNorSHOHowN> 21.7. BOCA CODE-SECTION 421 218. CODE OF THE TOWN OF SOUTHOLD WALL SECTION 22 ALL BACKWASH TO BE SELF-CONTAINED ON-SITE 0884 G0 � PLUMBING SCHEMATIC NI TSI O pROFESs\�C,P NTS