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HomeMy WebLinkAbout45664-Z te"aFcp , Town of Southold 8/14/2021 G P.O.Box 1179 0 o _ A 53095 Main Rd ,,� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42241 Date: 8/14/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 4635 N Bayview Rd, Southold SCTM#: 473889 Sec/Block/Lot: 79.-3-16 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/23/2020 pursuant to which Building Permit No. 45664 dated 1/11/2021 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 McGurk,Michael&Linda of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45664 7/22/2021 PLUMBERS CERTIFICATION DATED A ho iz d Signature �o�SnFFoc TOWN OF SOUTHOLD �y 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#: 45664 Date: 1/11/2021 Permission is hereby granted to: McGurk,,Michael 3646 Collector Ln Bethpage, NY 11714 To: construct an:in-ground swimming pool as applied for. At premises located at: 4635 N Bayview Rd, Southold i SCTM #473889 Sec/Block/Lot# 79.-3=16 Pursuant to application dated 12/23/2020 and approved by the Building Inspector. To expire on 7/13/2022. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, ,i aCk CI fY) C eIUVY- residing at L)(� ,� N U Y3 h (Print property owner's name) (Mailing Address) SUAA�AOW ly A IIA-11 do hereby authorize j h(�Q r1 CSI V Y1 LC)-( S (Agent) to apply on my behalf to the Southold Building Department. IV � (Owner's Signature) ( ate) d (Print Owner's Name) oF so�,��®� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Ar Fax(631)765-9502 P.O.Bdx 1179 ® �� sean.devlin(cD-town.Southold.ny.us Southold,NY 11971-0959 ®lyC®UNTV,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To Michael McGurk Address: 4635 N Bayview city.Southold st: NY zip: 11971 Building Permit# 45664 Section: 79 Block 3 Lot- 16 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043ME 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 Ceding Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 1 Recessed Fixtures CO2 Detectors Sub Panel X A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixture Time Clocks 1 Disconnect Switches 4'LED Exit Fixtures Pump 1 Other Equipment: Intermatic Pool Panel 8 Circuit - 7 Used, Pump 220GFI, Salt Generator, Salt Generator, Pool Cover 120GFI w/ Key Locked Key Pad, Heater, (3) Lights on Pool Tranny Notes Pool Inspector Signature: Date: July 22, 2021 S.Devlin-Cert Electrical Compliance Form SOP so (e> LI V 5,g /v B -0w wr� # # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm '' 765-1802 ANSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] -INSULATION/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: l�cti � C�2�lG NOT DATE INSPECTOR # # TOWN OF SOUTHOLD BUILDING DEPT. '`yromm: � 765-1802 INSPECTION [ ] `FOUNDATION 1ST [ ] ROUGH PLBG. J ] 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: Tooll- -01/ /VG SON7D3=AclK DATE S Z INSPECTOR v laf 50UTyo6 V lTJ C s N\1 ' y V C-74/ # # TOWN OF SOUTHOLD BUILDING°DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/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: 1� DATE (J INSPECTOR �� �d y° # } TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [" ] FOUNDATION 2ND [ ] SULION/CAULKING [ ] FRAMING /STRAPPING [ FINAL 17 ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] -ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: _ 1 o IV DATE . Av 0104 INSPECTOR o��OFSO(/lyO ��� C ��� V ��-- -- # # TOWN OF SOUTHOLD BUILD G_ DEP . cou�m ' 765-1802 INSPECTION - [ ] FOUNDATION 1ST- [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ . ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE-& CHIMNEY _ [ ] FIRE SAFETY INSPECTION, [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT-PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ �] PR C/O REMARKS: DATE INSPECTOR BOE 5001 --— �o� yO�o * # TOWN OF SOUTHOLD BUILDING DEPT. `louffv 765-1802 -INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [- ] SULATION/CAUL [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE GG INSPECTOR wG,; - ' COMMENTS FIELD INSPECTION REPORT DATE FOUNDATION(IST) y ;; ------------------------------------ .. FOUNDATION(2ND) u„ lr. / tE� ROUGH FRAMING& ` PLUMBING dFr, H INSULATION PER N.Y. - ,�;�,;, STATE ENERGY CODEo v J 4_ r ('09 fox,FINAL FK L r�n F ADDITIONAL COMMENTS r �o i. TOWN OF SOUTHOLD—BUILDING DEPARTMENT y x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 y o� Telephone (631) 765-1802 Fax (631) 765-9502 https://wwNv.southoldtownny.x,ov For Office Use Only i „ Date'Received PERMIT NO. Building Inrector- DEC J�CJ 23 2020 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Af?PLI`CATlON.FOR`>�UIL®tIVG PERNiITbi % Date: �f :OWNE!1 'OF�PROPERT1f• Name: _ ,n/1 C C� Tax Map#: SCTM #1000- Physical Address: L,(9bS I-QQY41r) GCk VI-C W Qd ,9l k &C)[a JV'-4 I 19711 Phone#: Email: Mailing Address: . --S0liLrK0 . --, 1,ci_�j� I .. _..... ._ CO"IVT g;PERSON: ,s " ry{F;r w, Name: (�Y1. I_Vy Vv�oY1S. Mailing Address: v 3...4.. ++aryl 12ron,„ Phone#:.(_.3..1 Email:� •_C_e _. llYlClY1Gf blll$. G� DESIGW ROFESSIONgL INFORMATION:-;> .sIVI Name: Mailing Address: Phone#: Email: T�'`� a >�.> �;e'�:";^ :i' rf-:; x"fix`�' kt�z, "�`��,3,:`r'. ^�^�a,c c.$.";'�-..�.s•Mr, ;c=. �CO�IVTRACTOR 1NFORNIAT'ION:• - cs . * �;�s�•+.5s. !�;`> s.C?o�. i`t,�''>,�`t'r'�-,e i='- _-�, ,$y., 'Y, wa...• Name:`- Mailing Address: Phone#: UN 3,2-4 Em a` 6 5mt1kJ bd)v UG 15 • con" d, „ 'DESCRIPTION OF PROFOSED`CONSTRUCT,ION, rt,« ti El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other II'Li'MAMI Iq ' � 3�I V-1r)vI S1NImvn�ncj tQ00 $___..5"°�__, 3�_� , c�® Will the lot be re-graded? Dyes ❑No Will excess fill be removed from premises? Dyes [:]No n - p'PROPEItTY.INFORIbIAl IONS ' Existing use of property: Intended use of property: _ _- ._ _. res 1c�e��n CL i. _. .._ __ M S icnal Date of Purchase: Name of Former Owner: 1 Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes No IF YES, PROVIDE ACOPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. 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,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(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): Authorized Agent ❑Owner asL)Y sl - .rvrn aL__vS___ .._ ._.-. .__. Signature of Applicant: o Date: STATE OF NEW YORK) SS: COUNTY OF SAJP21 L ) Jelcon SIry-yfV1,l)YLS being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the n-t (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/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this qday of_ n Oy`CMb-& , 20�� Notary Public -4 M. °•,, PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) � canry, ` . mss'%, VON� ,�,�cc�,;�ti�•�,, I, Lj no CA rY1 ChLA,VLL residing at (-I CF 36 KID QAC1JV)' �001 ��til�'t�U1Gl, N 11 q'1 t do hereby authorize ,Ic sbn S) ry-yryl-on S to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date I..c SIU M C CtiLA_ Print Owner's Name ��SVFEp�,�co BUILDING DEPARTMENT- Electrical Inspector �y0 Gym TOWN OF SOUTHOLD CM =` Town Hall Annex- 54375 Main Road - PO Box 1179 o Southold, New York 11971-0959 4A' O� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr _southoldtownny.gov - seand(cD-southoldtownny.Qov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: -2 a-q- Company Name: /£c ,—AIC4/ &--0' Name: G NB e,4'1C9-11'A1 License No.: M E 3 g o,-r '3 email: ppcFr« Phone No: _ y _off 1 request an email copy of Certificate of Compliance Cdr Address.: a� ��p ,,,. L,g.v� ,� ; yHr,,2�c„ S lU y /l p Y JOB SITE INFORMATION (All Information Required) Name: M. Address: 6 N_ Cross Street: Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Check All That Apply: Is job ready for inspection?: [23-YES ONO ❑Rough InFinal Do you need a Temp Certificate?: ❑YES ENO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground [—]Overhead # Underground Laterals ❑1 ❑2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex - 54375 Main Road - PO Box 1179 - Southold, New York 11971-0959 4,- p� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD_southoldtownny.gov - seand(cbsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: V C, e Name: License No.: email: Address: Phone No.: JOB SITE INFORMATION (All Information Required) Name: Address: V72-r-,, Cross Street: Phone No.: - Bldg.Permit#: (—� �, email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp-Certificate?: YES /"NO- Issued"On Temp Information: - (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals 1 - 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Request for Inspection Formals PERMIT# Address: Switches Outlets GFI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini Special: c Comments 2�, 0 � c?A; 0 �� a MRA 0 -PD-J bL�1� �j C C wtw Workers' �STOAITE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured MARYMEG INC DBA JASON AND BILLS POOLS 1c. NYS Unemployment Insurance Employer PO BOX 1331 Registration Number of Insured HAMPTON BAYS NY 11946 1d. Federal Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State,i.e.a Wrap-Up Policy) 11-3168202 2. Name and Address of the Entity Requesting Proof of 3a, Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Property and Casualty insurance Company of Town of Southold Hartford Building Department 34690 TOWN HALL 3b.Policy Number of Entity Listed in Box°1a": SOUTHOLD NY 11971 12 WE OJ2629 3c. Policy effective period: 03/23/2020 to 03/23/2021 3d.The Proprietor, Partners or Executive Officers are El Included.(Only check box if all partners/officers Included) 0 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"1a"for workers'compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this farm. Approved by: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: s� '(3,nun)'.�2C� n 04/01/2020 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877)853-2582 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) k---- 1 10/2612020 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 AME: BARSON ASSOCIATES INC 1)689-6100 ac No: (631),689-6084 207 Hallock Rd Ste 1 E DQE Stony Brook,NY 11790 INSURERS AFFORDING COVERAGE MAIC p INSURER A: XL Specialty Insurance 37885 INSURED INSURER B Marymeg,lnc dba Jason Pools INSURERC: PO Box 1331 INSURER D: Hampton Bays,NY 11945 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 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 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 SUSR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MWDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 11000,000 CLAIMS-MADE a OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 2,000,000 MED EXP(Any one person) $ 10,000 A NPC-1003117-00 312312020 312312021 PERSONAL&ADV INJURY S 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000.000 X POLICY❑JECT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Eo a.d.tSINGLE LIMIT $ 11000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED A AUTOS ONLY AUTOSSCHEDULED N BA-1003121-00 3/23/2020 3123/2021 aoolLY INJURY(Per accident) $ HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA UAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE 3/2312020 3123/2021 AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILIY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYE $ Ityes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltlonal Remarks Schedule,may be attached If more space Is roqulred) 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 BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. TOWN HALL AUTHORIZED REPRESENTATIVE SOUTHOLD,NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Y workers' CERTIFICATE OF INSURANCE COVERAGE TRK 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) 1b.Business Telephone Number of Insured MARYMEG INC DBA BILL'S POOL SERVICE 631-324-7844 DBA Jason's Pools P.O BOX 1331 HAMPTON BAYS,NY 11946 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) 113168202 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 Building Department 3b.Policy Number of Entity Listed in Box"1a" Town Hall Southold, NY 11971 DBL446593 3c.Policy effective penod 01/01/2020 to 12/31/2021 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. B.Disability benefits only. 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 and/or Paid Family Leave Benefits insurance coverage as described above . Date Signed 11/9/2020 By "lel (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 413,4C or 513 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. p n p 1313-120.1 (10-17) 11111111 IIII�II�II�III�I�III�III(�II�IIIII�I�II�II11111 Ws WE,,t 6F.trtOn Cvrd5cato'sontnis� rysur�C� n gactr mcM,,�C'.es for Land .tO:F:.Ca •r.-.rJ+.:�, Su ado led Y 5 tJew Y ap s'9n,r�at L)e mai n- ✓;z a,� i � Ctha bourda try rap K p-,,, $tate Assx atp� �ssM z,a�a Ta:A a• as wrr e,�.-,. ,� y s r g o`P;or } Ary surrey map �rEd,tp the 11Le COT^s �'-%'rX---- Ulm J( 5 The • y fat^e �r'�i !r:_Fte . ,{3 k ;r sx5 �jj C��CBtiCnS �E'7'-'^ �J•c^,C a•jbp ' �ereh 6 The foCahnn i +mproverronts or encraachmen s oremer s orer�raa tuij' nents z c au�an Kv i ! St C a a sRrHn,Ltia i P.o ve:�3�eic�y tames �''��``�'s;—ec :a-a s•P—,_.: a� f [ NORTH BA T YVI�,�ti ROAD N21c"22 ' 30 "E ! 122 . �p ' o � Z CZz ; 837. 76 ,77 v Co rn r � o W w r1 y T ' O —i • i. v m ^ ►.� ' u v e4v v v � ►yi PAVER WALK } �� r.. 42.2' PLANER L 60.4' Gn .c� g.9� 'ONE STORY N� N Fr vi V DWELLING 130. 42.2' O.L. N/S c� 47.3' mom . > a m r _ > z o C') i 3� .20'N 0.6'S 0.9's w -- �i 1.9 rx C CN Z O m O A0ilt m0 T T `' /°o/vr p.6'$ 1 00 6'H]GH PVC FENCE 1 7- S26-04 ' 1 O "W 122. 91 ' o m� rafr 1 rn - m ;� z,� vddscib's Pools Estimate PO Box 1331 Hampton Bays, NY 11946 Date Estimate No. 631-324-7844 Fax 631-329-5127 9/8/2020 3421 Linda Mcgurk 4635 North Bayview Rd Southold, NY 11971 Date Description Qty Rate Total Installation of a 19'x 38'Vinyl Swimming pool.All permits included. 27,250.00 27,250.00 Pool Includes Liner Color of choice(28 mil) Standard 42"Shallow end with an 6'deep end Corner cake steps 3 Skimmers&4 Returns 1 Dual main drain suction line 1 Autofill connected to an existing spigot 4 Pentair LED color globrite lights 4 300.00 1,200.00 1 Pentair Intellipro Variable Speed/Flow pump Hayward DE 4800 with 2"Multiport Mesh Winter Safety Cover Green (additional colors available for upcharge) with anchors 1/4"thick pool foam and all the walls and steps Grip texture on both the steps and bench 5'deepend bench Using existing drywell 1 -1,00000 -1,000.00 2 door alarms(installed by homeowner) 1 pool alarm Pool includes all plumbing 2"poly underground and 2" rigid above ground "*Final grade of affected area around pool is included in base price' Poured equipment slab Removal and disposal of 4 stumps(Exact price TBD) 4 75.00 300.00 Pentair IC40 IntelliChlor salt system with power supply. Includes initial salt 1 2,500.00 2,500.00 start up(Roughly 1000 lbs) Removal of roughly 140 cubic yards of fill (TBD) 140 22.00 3,080.00 19 full length stadium step, extended first or second step, and other treads 19 12500 2,375.00 are 14"(3 steps total) Installation of 2"x 12"thermal bluestone coping (Labor only) 128 20.00 2,560.00 2"x 12"thermal bluestone coping (576'or 7') 128 18.00 2,304.00 AquaCal SuperQuiet 119,000 BTU Heat Pump(Pentair heat pump would 1 5,510.50 5,510.50 cost$4700) 3 water deliveries to fill pool completely 3 550.00 1,650.00 Rough electrical estimate with gas heater(electric heat pump would 0 3,200.00 0.00 increase the cost of the electric for the job roughly$1500) 10%to apply for permits,40%to start,25%after coping, 20%after liner install,5%when complete Subtotal Tax(0.0%) Date: Signature: age 1 Total i - _ I Bonding Wire connected to all Z �� r hardware DATE-1 B P � WASTE FILTER HAIR& `l Py FEE: / PUMP SKIMMER T AI RETURN _ / NOTA=` BUILG:i�u //GG e 65-18'J2 8 i l T� J;.� FOR THE FOLLOWING INSPEC,TIONS: 1 WATER LINE 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2"RETURN TO INLET 2. ROUGH - FRAMING & PLUMBING 3. INSULATION MAI � N 4. FINAL - CONSTRUCTION MUST H TER MIN i BE COMPLETE FOR C.O. S T PIPING SCHEil RTIC � i I ALL CONSTRUCTION ION SI-I�'�LL Mr- THE PUMP REQUIREMENTS OF TI�E CODES OF NEW FILTER 1 ,ALL ELECTRICAL WORK SHALL COMPLY WITH T 1C)ML TE5TS blo2b1€IE&ONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. —�I2'2" HORIZONTAL 4/8" 2 POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE DETECTING A CHILD - ¢� REBAR 4 PLACES ENTERING THE WATER AND SOUNDING AN ALARM AUDIABLE AT POOLSIDE AND AT ANOTHER LIGHT LOCATION ON THE PREMISES WHERE THE POOL IS LOCATED.THE ALARM MUST BE INSTALLED, SUCTION ,f, „ 10 UNDISTURBED EARTH MAINTAINEDAND USED IN ACCORDANCE WITH MANUFACTIRER'S INSTRUCTIONS.THE ALARM 3 ¢t4 8. MUST MEET ASTM F2208'STANDARD SPECIFICATION FOR POOL ALARMS'.THE DEVICE MUST > OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSON. VINYL CONC.MIN.3500 PSI LINER . VERTICAL 1/2"REBAR / WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION = ;. 2= PLACED 4'0.C. 3. -= SYSTEM. WALL CROSS SECTION q ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED-ALL PIPING TO BE POLYETHELYNE. NTS 5 POOL SHALL BE GREATER THAN 10 MEASURED HORIZONTALLY FROM ALL OVERHEAD WIRING. 4' -6 14 14 � f � POOL DESIGN INCLUDING DRAINS WILL MEET ALL 2017 CODES. COMPLY WITH ALL CODES OF �s REQUIRE®ATE & TO��,! �nOis®� NEW)' Jasons Pools , - - - --_' - -=- - -- - -- � ®��,. �� SOUTHOLD.0' PLANNINGEO AFID P y- Gom lies With: - � d' * ae ov n icT r s E®PAYE� I SOUTHO �WN45 t h Bayview 2020 Code Section 3032.1—303A Swimming Pools,Spas and Hot Tubs � � �-<�'A;', ,�,, ENCLOSE POOL TO CODE r= °'�[`i - N. DEC Southold NY Section R326 of the Residential Code of New York '1 UPON-COMPLETION` 7 Section 3109 of the Building Code of New York VIM Section N1103.12(11403.12)Residential Pools and Permanent Residential Spas cS' g lv - - r, o, 0 Z POOL TYPE: 19 x 38 REV SCALE: NTS Section 3109.3.1.2-3109.7.4 Pools and Spas Gates,Barriers p Section G106 Entrapment Protection ROFESS JAMES DEERKOSKI, P.E. DATE: 11/19/202b Section G107 Alarms 260 DEER DRIVE Section E4201-E4312Electrical Connections for Pools MATTITUK, NEWYORK 11952 DRAWING NUMBER (f 1 OF 1 C&MS%=0N REQUIRE® _t NOTES: 1. DIVING BOARD TO CONFORM WITH ANSI/APSP/ICC-5 SEC 6 2. NO SOIL DISCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION 3. POOL MUST BE SURROUNDED BY A CONTINUOUS BARRIER CONSTRUCTED IAW REQ.OF SEC 326.4.2.1-R326.4.2.6 OF THE NYS RESIDENTIAL CODE(2020)AND ALL SECTIONS OF THE SOUTHOLD CODE 4. WALLS MAY SERVE AS PART OF THE POOL BARRIER AS PER SEC 326.4.2 8 AND ALL WINDOWS HAVE A SELF LATCHING DEVICE 5. ACESS GATES SHALL COMPLY WITH SEC R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY LOCKED WHEN POOL IS NOT IN USE OR SUPERVISED. ALLL GATES ARE TO OPEN AWAY FROM THE POOL AREA 6. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECT A TEMPORARY BARRIER AROUND THE EXCAVATION IAW CODE OF THE TOWN OF SOUTHOLD. 7. POOL MUST BE EQUIPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER AND SOUNDING AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE AT THE POOLSIDE AND INSIDE THE DWELLING.THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH TEH MAUFACTURERS INSTRUCTIONS.THE ALARM MUST MEET ASTM F2208"STANDARD SPECIFICATION FOR POOL ALARMS" THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSONS 8. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIIMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI Al 12.19.8M OR A MINIMUM 18"X23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM.POOL CIRCULATION SYSTEM MUST BE EQUIPTED WITH ATMOSPHERIC VACUUM RELEIF.SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME Al 12.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. POOL SALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE.THE SUCTION FJ `TINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS).VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENT TO THE SKIMMER/SKIMMERS.,A REQUIRED POOL ATMOSPHERIC VACUUM RELEIF SYSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE R326.6.3(2020)AND IN ACCORDANCE TO TOW CODE 9 ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC),PRINCIPALLY ARTICLE 680 AND THE NYS RESIDENTIAL CODE SECTION 4102 THROUGH 4106.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GOUND FAULT CURRENT INTERRUPER(GFCI).CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5 ALL METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. 10. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608 11. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 12. WALKS, IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM THE POOL EDGE. 13. A MEANS OF EGRESS FROM DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/NSPI-5 SECTION 6. 14_ CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. 15. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. 16 THE DESIGN IS BASED ON A DRAINAGE SOIL WITH<10%SILT.GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IF GROUND WATER EXISTS WITHIN 60"FROM GRADE, DEWATERING FACILITIES WILL BE REQUIRED. 17 ALL GAS AND OIL WATER HEATERS(IF INSTALLED)FOR THE IN-GROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT.POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726.POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS.POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES_A BYPASS LINE SHALL BE INSTALLED FROM THE INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HATER.POOL HEATERS SHALL BE PROVIDED WITH THE FOLLOWING ENERGY CONSERVATION MEASURES: 17.1 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE PILOT LIGHT. AT LEAST ONE THERMOSTAL MUST BE PROVIDED FOR EACH HEATING SYSTEM.HEATED SWIMMING POOLS SHALL BE EQUIPTED WITH A POOL COVER.(exempt FROM THIS ARE OUTDOOR POOLD)DERIVING 20%OF THE ENERGY FOR HEATING THE POOL FROM RENEWABLE SOURCES OVER AN OPERATING SEASON. 17.2 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS,AND CAN BE SET TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITORY CONDITION IAW APPLCIABLE SANITORY CODE OF NEW YORK STATE. 18 BACKFILL WILL BE DONE WITH CLEAN EARTH FREE OF ROOTS AND DEBRIS. BACKFILL HEIGHT AND WATER LEVEL TO BE WITHIN 8"OF EACH OTHER. PLACE CONCRETE ON SANDY LOAM SOIL. CLAY TO BE REMOVED AND _ REPLACED WITH SANDY LOAM. 19 THERE ARE MAIN DRAINS IN THIS POOL.THERE ARE TWO APPROVED SUCTION OUTLETS WITH A MINIMUM OF T OF SEPARATION. THE SUCTION OUTLETS ARE PIPED SO THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM-RELEIF-PROTECTED LINE TO THE PUMP MPLIES WITH ENTRAPMENT PROTECTION AS PER CODE 20 THE POOL WAS DESIGNED REFERENCES AS THE FOLLOWING: �b Jasons Pools 20.1 THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE(2020)SEC R326 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 4635 North Bayview 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) /� Southold, NY 20.4 THE NEW YORK STATE SANITORY CODE. r ;� y , - n i,`�� z -r 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. POOL NOTES SCALE: NTS� .-} .�y-- d 20.6 BOCA CODE SECTION 421. O v 5 JAMES DEERKOSKI, P.E. 20.7 CODE OF THE TOWN OF SOUTHOLD 260 DEER DRIVE DATE: 11/19/2020 MATTITUK, NEW YORK 11952 DRAWING NUMBER 2 OF 2