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HomeMy WebLinkAbout45624-Z �p�OStlFfl Town of Southold 9/2/2021 yU P.O.Box 1179 co 53095 Main Rd lro4; �a Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42322 Date: 9/2/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 810 Hiawathas Path, Southold SCTM#: 473889 Sec/Block/Lot: 78.-3-50.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/9/2020 pursuant to which Building Permit No. 45624 dated 12/29/2020 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: accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to Towey,Michael&Mary of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45624 8/17/2021 PLUMBERS CERTIFICATION DATED th riz ignature �o�SUFF01 TOWN OF SOUTHOLD ay BUILDING DEPARTMENT N z 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#: 45624 Date: 12/29/2020 Permission is hereby granted to: Towey, Michael 275 Crocus Ave Floral Park, NY 11001 To: construct an in-ground swimming pool as applied for. At premises located at: 810 Hiawathas Path, Southold SCTM #473889 Sec/Block/Lot# 78.-3-50.1 Pursuant to application dated 12/9/2020 and approved by the Building Inspector. To expire on 6/30/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 tal: $300.00 Building Insp Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building,multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing"land uses: 1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling $50.00, Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial $15.00 Date. f 10 2� New Construction: ✓ Old or Pre-existing Building: (check one) T � I Location of Property: l d G�.W0 ACLS I( aAlh t sl&u"La ' _N l House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section g Block 3 Lot 50 Subdivision Filed Map. Lot: Permit No. ?/� Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 3 O O A plicant Signature CONSENT TO INSPECTION rYl l IGiP_ T-u\m� ,the undersigned, do(es)hereby state: Owner(s)%me(s) That the undersigned(is) (are)the owner(s) of the premises in the Town of Southold, located at %1 n f:�I n in.n—A lgaS QCx-rh 1 S(U,'1 D d Nk�j 0-11 which is shown and designated on the Suffolk County Tax Map as District 1000, Section Block_3 Lot &,o That the undersigned(has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: rl s+c CLIgQ 'l O-P C1 IO ` X 3V Virivt 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: 11110 / 7-0 Signature (Print Name) (Signature) (Print Name) Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, LAVA [ FoWa!l residing at 81 DR L ALA)ATI&DkS (Print property owner's e) (Mailing Address) U do hereby authorize �So�aJ��j v��$�f Ca lS viS p W �1 Wvt or o (Agent) to apply on my behalf to the Southold Building Department. �D (Owner's Signature) (Date) lam [ 'i (Print Owner's Name 0f SO(/r�„®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 ® sean.devlin(cD-town.southold.ny.us Southold,NY 11971-0959 couff BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To- Michael Towey Address: 810 Hiawathas Path city:Southold st: NY zip: 11971 Building Permit* 45624 Section: 78 Block. 3 Lot: 50.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electrical Contr. 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 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer 1 UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: Intermatic Pool Panel 8 Circuit/ 3 Used, Pentair Salt Generator, Pump 220GFI, Heater, (2) Lights on Pentair Tranny Notes: Pool Inspector Signature: Date: August 17, 2021 S Devlin-Cert Electrical Compliance Form OF soblyO� Ll 5_6 f,2q # # TOWN OF SOUTHOLD BUILDING--DEPT. °`ycourm N�' 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: . DATE � ��I Z� INSPECTOR �- f1 I 1 � TOWN OF SOUTHOLD BUILDING DEPT. courm,��' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATIOWCAULKING� [ ] FRAMING /STRAPPING [ FINAL ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION' [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 0 1 6, c &kj C.", v O - S DATE INSPECTOR --�- ---per - -- -- - - -- - �"OF SO4 UIyo �t!' ! Cs yam/���"' •e���(�+--� � l # f TOWN OF SOUTHOLD BUILDING DEPT. �y'coam, 765-1802 - INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAUL-KING [ ] 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 _r DATE �' / 17 INSPECTOR � IZ c.. �i Ste'`-'�>�' - `, "' "`., "r� IN u Y r 7 SM f' t Sol Aly I � 1 t .� arty Y i ' s T d 4 ^ �r, G ' e ):Sol- Opp fi 1 F^i o.. .�.. ' �' 1 :�, t. a � ..� t ..�'l• - '\:v�.4? t t..•, rte. f /: .�• ,i7r' � ; rt t �� �)�fti�7 ,VCY��n Y...�, aTtt..SS��•+.1. �`,_-L���,� ,,C{t.ti-. ��. Is;`��i-fr ���>'"f'y � `',. �r:��..i.��.i� t\. '•, �}, _,��to ti• '• •>�* �'.�,� f���,`` + �. : c �i:",1,� :. r}� ;X �,i`r r �. - -fir, t.:i�•r?:��>'�` �ry. ,icy. L.' �f. L. ,C'2, ~< '1 Vc ♦� '' _, !..' -� 1 4,K w"� �� 'mar �- _ 71 00 �. 3 dol a , t • ;r-+moi- �< r . - -ice `^ • Z.� ��;, �-ah1+.�ti', R J 1 1 1 • • FOUNDATION(IST). • i • 1 ROUGH - PLUMBING INSULATION.PEA N.Y. py • ! � I • D b i3 • /3 9, ° --- _ I '� _ �ZMEM-NOj °sv���lko TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone 631 765-1802 Fax 631 765-9502 https://www.southoldtownny.gov 2For Office Use Only Date Received PERMIT NO. �i Building Inspec r: •-- �� I �'!' �/�j'•µ' I r ._ 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 DEC 9 2020 Authorization form(Page 2)shall be completed. ; 1VD6V '4PPLsDate:4 PR Name: Name: Tax Map#: SCTM # 1000-'1'? Physical Address: a wam CLIS <)1/1. L d ...� [ I Cq1 _ Phone#: 2-q JEmail: Mailing Address: MI " 1![•1�S µ S tai, l - - ,OA, I,.10i -1 CO IACTP,ERSON: t, Name: _.SI..ry_-)rYLI� �._.. I �( Mailing Address �_ - 171,�X I.J 3 I NGIi'�L I-l�l� _I _ �I_ _.I"! ..". .- ,__._ . Phone#: 3 2 y `� 4,z3,y Email © i'Ce. gSorYayrJ 10J.) � l.�I S QQIS. U y'�►_,. _ N �y, � . Name: Mailing Address: Phone#: Email: CONT;R "C TQR I IVFQ21VI4TION;% 41:x'.< „';�� ,W. ",f xt., �et,. =%i.�"n�:•`;i;"�,?°;. zr. Name: .JOISOn, I- Y-n Mailing Address 7-0im 13X U rte 'S_ ,N y . t,[_Q LAP- .. . . ...__ " . Phone#: ?)' ZL --I g� 1 Email: �iC�L',)GSOt?Citlo,ll SpUO)S LO(Y) °DESCftI PTION,OpFm��P-ROPOSED = � �r:a ,�« '.✓�-,A'x�. ''�` "?x:,�;rS - t.s'.�xr ,,,��.,�k,.S F:"�,..;",.`...,-, -zF� ,tc':`,�is.Ax_. a;r,�xi ksy; EJ New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other j l'1Ci ybVtlt11G1 Ile` X � V 1n' l SinJnryl tVIGI i ,00 $ 39, 000 Will the lot be re-graded? ❑Yes 1XNo Will excess fill be removed from premises? �PlYes []No � :PROPEEtTY>IIVFORIVIATI.ON; -�'�`�: ;�,� Existing use of property: Intended use of property: Date of Purchase: Name of Former Owner: 1 r Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to ""--- _ -- �,. - _ this property? ❑Yes XNo IF YES, PROVIDE A COPY. _.._. . 5Check 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): -J coon_S lmYl� u S �p{Authorized Agent ❑Owner Signature of Applicant: � — Date: STATE OF NEW YORK) SS: COUNTY OF ()a S i f'YN-fU 1'LS being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the 0,Q1� A- (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 I 0 day of n 20 1 1 1 °••.,, Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) YYl l Le Imp' residing at 1a t4JlA�-S z %ywD1d ( NA I I G11 do hereby authorize_S)Q-1Q0VX- S j r1--LVK-(6 VA—E to apply on my behalf to the Town of Southold Building Department for approval as described herein. if A taw,a P 0J2c� Owner's Signature Date MA1L�e I�V�iL Print Owner's Name .l BUILDING DEPARTMENT- Electrical Inspector 9 � TOWN OF SOUTHOLD r, Town Hall Annex - 54375 Main Road - PO Box 1179 Southold,-New York 11971-0959 , 631 Telephone Tele 2� _ � �� `,�ti h�, , '�7•-�" p ( ) 765-1802 - FAX (631) 765-9502 rogerrCcD_southoldtownny.gov, seanda-southoldtownny.gov APPLICATION FORELECTRICAL INSPECTION ELECTRICIAN'INFORMATION (All Information Required) Date. 01/27/2021 Company Name:,LC Electrical Contracting Inc Name: License No.: ME-38043 email: office@lcelectricalcontracting.com - Phone No: 1,31-_f?'y^o ff gs ZI requesf an email copy'of Certificate of-Compliance. Address.: 944� JOB SITE INFORMATION (AII Information Required) Name: , Address: Cross Street:. Phone'Nb.- - BIdg.Perm it.#: -45624 w email:_ office@Icelectricalcontracting,com Tax Map District: 1000 Section: = " Block:' Lot: BRIEF DESCRIPTION OF WORK(Please Print Clearly) Pool Pool, Poot ; Check All That Apply: Is job ready for inspection?: QYES NO Rough In 'QFinal Do you need a Temp Certificate?:- ❑YES ❑NOIssued On 01/27/2021 Temp Information: (All information required) ; Service Size EJ1 Rh 03 Ph = . Size: A #-Meters - :Old'Meter#." ❑New Service 0 Service Reconnect Underground Overhead #Underground Laterals 01 02.; 'QH Frame Opole- "Work done on,Service7 ' .QY -.•ON Additional-Information: ;+ PAYMENT DUE WITH APPLICATION CP &\CP Electrical Inspection Form 2020.xlsx ��/ PERMIT# Address: Switches Outlets G FI'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: Commentsdl ` " �✓� JI box 011,J14 ' S � � ���.. Jason's Pools Invoice PO Box 1331 Date Invoice# Hampton Bays, NY 11946 (631)324-7844/(631) 728-8664 11/4/2020 26842 Fax(631)329-5127 Bill to: Service to: Mike Towey 810 Hiawathas Path Southold,NY 11971 FDue Date 11/4/2020 Serviced Item/Description Qty Rate Amount Installation of a 16'x 38'Vinyl Swimming pool. 27,000.00 27,000.00 Pool Includes: Liner Color of choice(20 Mil) Standard 45"Shallow end with an 8'deep end Corner cake steps 3 Skimmers&4 Returns 1 Pentair Variable Speed Pump 2 Pentair 400 Watt Light 1 350 Sq. Ft. Sta-Rite Cartridge Filter Loop-Loc Green Mesh Winter Safety Cover(Additional colors available for upcharge) 5'Deep End bench 475 gallon drywell 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** Pentair IC20 IntelliChlor salt system with power supply. Includes initial salt 1 2,300.00 2,300.00 start up(750lbs) Removal of roughly 160 cubic yards of fill.All fill to remain on site 0 2400 0.00 Sta-Rite 400,000 BTU HD LP Heater 1 4,200.00 4,200.00 Installation of 2"x 12"natural stone coping 116 22.00 2,552.00 2"x 12"thermal bluestone coping ($15+tax) 116 16.30 1,890.80 Engineer stamp for obtaining pool permit 1 600.00 600.00 Trimming of tree's effecting the pool 1 750.00 750.00 discount 1 -292.80 -292.80T ***Due to the large machinery used during this process, access to pool area is needed.We do not re-install fences, gates etc..Due to the large machinery used during this process your landscape, grass and irrigation will get damaged.We will do our best to limit the damage caused but repair work(to be done by others)will be required after we are done.*** Payment: Deposit-$4000 Start of construction-$15,000 Subtotal 10%to apply for permits, 40%to start, 25% after coping, 20% after liner install ,5% Sales Tax(0.0%) When complete Total email: office@asonandbillspools.com website:www.jasonspools.com Payments/Credits Page 1 Balance Due Jason's F�bols Invoice PO Box 1331 Date Invoice# Hampton Bays, NY 11946 (631)324-7844/(631)728-8664 11/4/2020 26842 Fax(631)329-5127 Bill to: Service to: Mike Towey 810 Mawathas Path Southold,NY 11971 FDue Date 11/4/2020 Serviced Item/Description Qty Rate Amount After walls poured, coping installed system plumbed-$12,000 Pool is finished and cover installed-$8,000 Any past due balance is subject to a finance charge of 1.5%per month.(Annual rate: 18%) Subtotal $39,000.00 10% to apply for permits, 40%to start, 25% after coping, 20% after liner install ,5% Sales Tax(0.0%) $0.00 when complete Total $39,000.00 email: office@jasonandbillspools.com website: www jasonspools.com Payments/Credits $o.00 Page 2 Balance Due $39,000.00 NEW Workers' STAITE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. 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 0 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"3" insures the business referenced above in box 1 a"for workers'compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a 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 form. Approved by: Danielle Clausen (print nam/e�of authorized representative or licensed agent of insurance carrier) Approved by: aue�. (,.a�xrxa' 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 AC40RV® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 10/26/2020 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()es) 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 E• BARSON ASSOCIATES INC PHONE631 689-6100 A/C Nal: (631)689-6084 207 Hallock Rd Ste 1 E-MAIL PRESS: Stony Brook,NY 11790 INSURERS AFFORDING COVERAGE NAIC 0 INSURERA: XL Specialty Insurance 37885 INSURED : B INSURER Marymeg,lnc dba Jason Pools INSURER 8: PO Box 1331 INSURER D: Hampton Bays,NY 11945 INSURERS: 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. ILTR TYPE OF'INSURANCE ADDL SUER POLICY EFF POLICY EXP POLICY NUMBER MMIDDIYYYY MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH'OCCURRENCE S 1 000 000 CLAIMS-MADE X OCCUR PREMISEs EaI ATE enre $ 2,000,000 MED EXP(Any one parson) $ 10000 ' A NPC-1003117-00 3)2312020 3/2312021 PERSONAL 8AOVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑jEa 7 LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY EO aBINdEDISINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A OWNED AUTOS ONLY AUTOSULED NBA-1003121-00 3/23/2020 3/23/2021 BODILY INJURY(Per accldent) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UMBRELLA CLAIMS-MADE 3/23/2020 3123/2021 AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N IS ATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE = E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. TOWN HALL AUTHORIZED REPRESENTATIVE SOUTHOLD,NY 11971 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marcs of ACORD 1"'NIEW workers' CERTIFICATE OF INSURANCE COVERAGE TATE 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 la.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"'I a" Town Hall Southold, NY 11971 DBL446593 3c.Policy effective period 01/01/2020 to 12/31/2021 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. n B.Disability benefits only. rL�l 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 & Wi hf (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 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 p p DB-120.1 (10-17) 18kA W am W 1 m fa All I m=S JB m t7- ' TME EwGrEAIeT Or R?'Wm Or W" un.unnwzrD ALTERATION Die ADD=. AND/OR EASEMENTS Or RTCORD IF TO TAS SURIEY IS A VWIAYAN Or ANY,NOT SNDRN ARE Nor SECWN 7209 Or THE NOW YORK STATE OVARAMMED. =VCATID.N NW CORES of rues SVIAEY YAR NOT VOWDIa Area=26,797 sf. Premises known ox THE Ds�SfA6crows SkA"Nor Or WL 9DFLpEO 810 f5owa0fa's Path,Southdd TO BE A VAUD TRUE CD". GUNUNTus 90147=NeRWN SNui Ruro 1 ONLY TO TNT FROWN FOR WNDY THF SWv[Y TR15 PtEREPAR=.CO"PANYAND ON fN5 Na,A{f'TO THE ,DOV69NdTTTAL AOCNCY AND 1. the s Path CD4 9sTm��KREM AND F 1181N8 �pNl To THE A59CNR5 OF Ti E LENINNE Ran- RMDN-CIJARAN ART NW TRANSrERAVLC wv Nei 21'o0'E F '�• q O r O g O c ( r°�'° m ❑ o e ~ ,.Alga ar a 'r NES 9 124.05' + sei21'00nw 0 TD ,ael GR�� yDw91D ��'O�p yp�� t F•31� � 0 Certified to: tm GEORGE MUM Survey of Described Property (IRST AWA+CAN MU LYSM.CE COYPAiY situate at SALE MEN BRE GGEM(SRt78426)8 WaLS FARSouthold GO 4tH( 1 Town of Southold Michael W. Minto, L.S.P.C. Suffolk County, New York LICENSED PROFESSIaNAL LA,a°9URVEYDR District 1000 Section 78 Block 3 Lot 50.1 NEW YDRH STATE UCENSE NUMBER 050671 87 Woodvtew Lane Scale I"= 30' ,Surveyed October 19, 2017 Centereach, N.Y. 11720 GRAPHIC SCALE PHONE/PAX.'(67f)560-120: cELLUTAR, (671) 766-9714 EMAIL mnem.nlWVReOg loam (m EELT) ' I l6eD 30 rL ,1 3 1 coMPLY WI T H ALL CODES OF ��� � ��� � � NOTED NEW YORK STATE & TOWN CODES �� AS REQUIRED AND ONS OF D'ATEdZ .p.�'L4 -—SOUTHOLDTOWN A F�E.a /Y: _.- SOUTHOLD N PLANNING BOARD N:ITIFY UILDING "'DEPARTiEIJT AT Sp LD TOWN TRUSTEES 785-1802 "9-AM TO 4 PM FUR THE FOLLOWING'," SPECTIONS:', Y.S.DEC 1. FOUNDATION `- TWO-REQUIRED FOR POUREtft-OIJCRETE 2. ROUGH-= 'FRAMING.& PLU„4BING 3. INSULATIOKI'�� ': 4. FINAL - coN§tkUCTION-MUST MP BE COLETE FOR. C.O. �.�ct�atw mspwi><aw►OURM ALL CONSTRUCTI614”!;SHALL MEET THE REQUIRE"MENTSrOF THECODES OF NEW YORK STATE._"NOT RESPONSIBLE FOR DESIGN'bR"'CONSTRUCTION ERRORS. °e� '�®'/QTE_'L_Yif ENCLOSE POOL TO CODE UPON COMPLETION BEFORE"!NATER" Bonding Wire connected to all hardware ! WASTE FILTER HAIR& PUMP SKIMMER RETURN WATER LINE, 2"RETURN TO INLET I PIPING SCHEMATIC MAIN DRAIN 6' ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF 2015 IECC MIN 1 3'APAR �? 2'2" - 2 POOL MUST BE EQUIPPED WITH AN APPROVED POOLALARM CAPABLE DETECTING A CHILD PUMP HORIZONTAL 4/8" -` REBAR 4 PLACES ENTERING THE WATER AND SOUNDING AN ALARM AUDIABLE AT POOLSIDE AND AT ANOTHER FILTER LOCATION ON THE PREMISES WHERE THE POOL IS LOCATED.THE ALARM MUST BE INSTALLED, 10"=i' UNDISTURBED EARTH MAINTAINED AND USED IN ACCORDANCE WITH MANUFACTIRER'S INSTRUCTIONS.THE ALARM f_ 45" MUST MEET ASTM F2208'STANDARD SPECIFICATION FOR POOLALARMS'.THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSON. SUC ON SUC ON VINYL ",x. "; CONC.MIN.3500 PSI LINER �,_t VERTICAL 1/2"REBAR PLACED 4'0.C. 3 WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION SYSTEM. F 1-�/l "_ 1 E I I — WALL CROSS SECTION 4. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED.ALL PIPING TO BE POLYETHELYNE. LO NTS 5 POOL SHALL BE GREATER THAN 10 MEASURED HORIZONTALLY FROM ALL OVERHEAD WIRING. POOL DESIGN INCLUDING DRAINS WILL MEET ALL 2017 CODES. i 14' 12' —�-8' 4' — 0 NEW j'O� Jasons Pools A< �a � Complies With: `per�,� � 810 Hiawathas Path 2020 Code Section 303.2.1—303.4 Swimming Pools,Spas and Hot Tubs ` � � td �' = 'I, Southold, NY Section R326 of the Residential Code of New York TIM2�, _� Section 3109 of the Building Code of New York Section N1103-12(R403.12)Residential Pools and Permanent Residential Spas FQA a_ q� POOL TYPE: 16 X 38 REV SCALE: NTS Section 3109.3.1.2-3109.7.4 Pools and Spas Gates,Barriers ���� JAMES DEERKOSKI, P.E. Section 6106 Entrapment Protection 260 DEER DRIVE DATE: 11/17/202D Section G107 Alarms Section E4201—E4312 Electrical Connections for Pools MATTITUK, NEW YORK 11952 DRAWING NUMBER , 1 OF 1 11 I` I d i 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 A112.19 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 FITTINGS 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 6'0"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 COMPLIES WITH ENTRAPMENT PROTECTION AS PER CODE 20 THE POOL WAS DESIGNED REFERENCES AS THE FOLLOWING- Jasons Pools 20.1 THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE(2020)SEC R326 of NEW y 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 ry �9 DEFUia� 810 H iawathas Path 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) *��� p &�� Southold, NY 20.4 THE NEW YORK STATE SANITORY CODE to Z 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. �- c-'�= � � POOL NOTES SCALE: NTS N �_«a 206 BOCA CODE SECTION 421. 7 ' _ ,o �k. JAMES DEERKOSKI, P.E. DATE: 11/17/2020 20.7 CODE OF THE TOWN OF SOUTHOLD �OFE$ O P 260 DEER DRIVE MATTITUK, NEW YORK 11952 DRAWING NUMBER i 2 OF 2 i i