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HomeMy WebLinkAbout45471-Z �O��gUfFOt�cpG. Town of Southold 9/19/2021 y� P.O.Box 1179 o W _ 53095 Main Rd Oj �aQ ' Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42358 Date: 9/19/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 165 Ruth Rd.,Mattituck SCTM#: 473889 Sec/Block/Lot: 106.-7-23 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/6/2020 pursuant to which Building Permit No. 45471 dated 11/19/2020 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 Gabriel,Nicholas&Lillian of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45471 8/2A2021 PLUMBERS CERTIFICATION DATED 11 Aut ori Si afore s ' TOWN OF SOUTHOLD ��a�sUEFu�,r�oGy 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#: 45471 Date: 11/19/2020 Permission is hereby granted to: Gabriel, Nicholas 9 Wedgewood Ct Manhasset, NY 11030 To: construct accessory in-ground swimming pool as applied for. At premises located at: 165 Ruth Rd., Mattituck SCTM #473889 Sec/Block/Lot# 106.-7-23 Pursuant to application dated 11/6/2020 and approved by the Building Inspector. To expire on 5121/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Buildin nspector 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. I New Construction: Old or Pre-existing Building: (check one) Location of Property: Pj House No. Street Hamlet Owner or Owners of Property: I C[/1 a—s G�n,_e I Suffolk County Tax Map No 1000, Section jp Block Lotp?E Subdivision Filed Map. Lot: Permit No. �� /�� Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: y (check one) Fee Submitted: $ r J U Applicant ignature ®��OF SO!/r�„®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 @ sean.devlinCD-town.southold.ny.us COW, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Nicholas Gabriel Address: 165 Ruth Rd City:Mattituck St: NY zip: 11952 Building Permit#: 45471 Section- 106 Block. 7 Lot: 23 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Bethel Electrical Contracting License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceding Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 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 UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 4'LED Exit Fixtures 11 Pump 1 Other Equipment: Intermatic Pool Panel 4 Circuit, Pump 220GFI, Salt Generator, Heater, Light 1 Notes: Pool Inspector Signature: Q Date: August 20, 2021 S.Devlin-Cert Electrical Compliance Form / aOF SOI/Tyo� Ll�5HI # # TOWN 07 SOUTHOLD BUILDING DEPT. °`ycoutrn '' 765-1802 y '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: f,,�JvA-Goo, 4-6-774,t DATE INSPECTOR ljl�� of soblyo # # TOWN OF SOUTHOLD BUILDING DEPT. �`ycouxtr '' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] I ULATIOWCAULKING ] FRAMING /STRAPPING [ FINAL fp(, [ ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION- [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O MARK vAzoln f I(Alle T DATE' Q O INSPECTOR ---- # Ll TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION:21SID [ ] 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: _ s DATE INSPECTOR - / FIELD INSPECTION REPORT DATE COMMENTS fa b FOUNDATION(IST) y ------------------------------------ c ci FOUNDATION(2ND) z �-o ROUGH FRAMING& PLUMBING INSULATION PER N.Y. STATE ENERGY CODE fi FINAL - ADDIT ONAL COMMENTS fl� v z � � m o z � y C m It H St1fFQt,� TOWN OF SOUTHOLD—BUILDING DEPARTMENT h_ x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 haps://www.southoldtoygmy ov For Office Use Only Date Received PERMIT NO. Building Inspector: 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 �_ �. U �- Authorization form(Page 2)shall be completed. Noel ® 6 2-920 «r. 'APPLICATION FOR;BUILDING,PERMIT Date: OII!lNER(S),OF PROPERTY: -' �F e� Tax Map#:SCTM#100QE "r`ct Phy ical Address: It' Mailing Address: — � 'CONTACT'kR'SON: Name Mailing Address I — 11 Phone#: Email DESIGN,'PROFESSIONAL INFORMATION: .. " Name Mailing Address: Phone#: Email: �� . 034�g_ _ Vl l-.►�1�r. CONTRACTOR INFORMATION: Name: — Mailing Address: _ Phone#: _ pEmaiL � ��-.M� � DESCRIPTION OF-PROPOSED CONSTRUCTION - El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther rt' $ RD Will the lot be re-graded? s ❑No Will excess fill be removed from premises? ❑Yes o PROPERTY INFORMATION Existing use of propert Intended use of property: - _ (__ 4_ m�'yb _ .. . Date of Purchase: Name of Former Owner: 1 k Zone or use district in which premises is situated: Are there any covena is and restrictions with respect to this property?'❑Yes IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage Ch�ptand storm water issues as provided by Ch pter 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 219.45 of the New York State Penal Law. Application Submitted By(print name): ' �, ( �' Authorized Agent 0 er Signature of Applicant: STATE OF NEW YORK) SS: COUNTY OF ) • �[� being duly sworn,deposes and says that(s)he is the applicant (Name of individualsigning �contract)above named, (S)he is the A5\► � J Y : - (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 e o the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the Ication fil the i Sworn before me his /� day of 200 V Notally Publc\\\���I1811IIM��ii����/ ' `�``(L��•N 0 Tq q�����ii W . PROPERTY OWNER AUTHORIZATION _ NQUALIFIED11N-�: Where thea applicant is not the owner — SUFFOLK COUNTY pp ) — COMM.EXP, AUB LIG;. residing at) 6 RtK) Rd Ifijdo hereby authorizezz= J)! �'c KCL A (� to apply on my behalf to the Town of Southold Building Department for approval as described herein. M I L L )4 b-zogo 1//, Owner's Signature 6SARY ' . �. D e 0DA1623�657•t �j AMK C;00 T' 1 1.��( C SUFFOivIM P Print Owner's Name % �� 29 G•.�O��` '�.S'T'• �'U 13L� � ��� �OSUFFOCK`o _BUILDI`NG DEPARTMENT - Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 o _ - Southold, New York 11971-0959 y p� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aDsoutholdtownnV.gov — sea nd(cr southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail information Required) Date.- I LZ Company Name: 91E�T"5C.- n1 F--C-- 1 CA CO1NA-RAC'IN C.? LTD • , r;,._ Name: M t1VC—A17, V>J t_.0 License No.: email 0 PtbA li /\Q,, n Address: ? -- ° Lfneo1P. AV21e�i�. c��L, (`d� - �J 11 74- Phone No.: -15 JOB SITE INFORMATION (All Information Required) Name:i ��� �- �I�Li�N TZ, Address: lZk, P.00iA Cross Street: Phone No.:` BIdg.Permit #:. _- �!' _ -- em ail:- - Tax Map District: 1000 Section: I Ob Block: Lot: . BRIEF DESCRIPTION OF WORK (Please Print Clearly) -Gircle.All-That.Appl.y: Is job ready for inspection?: YES NO ,M Ro,u,gh In Final 4 Do you need a Temp Certificate?: YES NO_ issued On - - w•, Temp Information: _- -(AII 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 Add itionallnformation: ocnri�e �tr- AA ��`' e d c V-V4 _ . CC2S PAYMENT DUE WITH APPLICATION Request for Inspection Form As 6 RBS _ t�JK_L� PERMIT# A(dress: Switches Outlets GFI's 111 r Surface Sconces , H H's UC Lts Fans Fridge HW Exhaust :r Oven j Dryer Smokes DW Service Carbon Micro Generator- . - . _ .. ,. ,._ - ,.. -- •_ . Combo • Cooktop Transfer AC AH Mini Special: Comments.,, � )/T J �P 1 (1)UNAUTHOP_ZS ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW.(2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE JOT TO BE USED 10 ESTABLISH-PROPERTY LINES OR FOR ERECTION OF FENCES(3)COPIES OF THIS SURVEY NAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY.(4)CERTIFICATION INDICATED HEREON SHALL RUN ONLY TO THE POISON FOR WHOM THE SURVEY IS PREPARED AND ON HHS BEHALF TO THE TIRE COMPANY.GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON.AND TO THE ASSIGNEES OF THE LENDING INSTITUTION CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS (5)THE LOCATION OF WELLS(W).SEPTIC TANKS(ST)do CESSPOOLS(CP)SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND OR,DATA'OBTARHED FRO-OTHERS. I y 400 Ostrander Avenue,Riverhead,New York 11901 tel.631.727.2303 fax.651.72"1.0144 a I admin®youngenglneering.com I I I (Dwelling with I Howard W.Young,Land Survayor p Public Water) (Dwelling with Thomas G.Wolpert,Professional Engineer Public Water) (Dwelling with I Douglas E.Adams,Professional Engineer i Public Nater) (Dwelling with I I Public, Water) Robert G.Test,Architect - 1 MATER 51TE DATA S C�iVA�'f - .__ . . . — — —MAIN - �,_. _ 3 1 ��,P�• `s1 9 °l s�� . 801afg.i +57.75 �ED �� ® � — — — • — . — . _ AREA = 20,000 50. FT. ��� g 57.37 I +57,63 F'- %V'VMRTICAL DATUM = NAV.DATUM(11W) « GROSS FLOOR AREA =2,143 SQ.FT. HH b DI 57.07 •FD6E OF Pgyp„�T rwT� HE,ALTH DEPARTMENT USE s S '7')11'00"E7 104 O' j 57.43 I -+� ' �' N87°11'00"W 118.181 _ c +57.11 1 �"F—ST HOLE _ BY McDONALD GEoSGIENGE \ 1 L=34.541' N DATE: MAR 25,2016 I EL=55.5 0.0' 1 DARK DROWN � GONG. GFL03 10 LOAM I ' C9 (OL) 57.10 - L 3 ij 30.01 57.6 17.0'a _ BROWN SILTY l.o' L+� 6 (O Q _ 'De.6n 17,01 " Q 4) ® SURVEYORS CERTIFICATION SAND N O (y ED IT: I STORY FRAME N 6 n r HSE 6 GARAGE m 6 ' +� BEDROOM) 3.0 L V O t Z 6053 40.6'FFL®SILL IV O `rf ,N PALE DROWN 57.29 N 50.01 L ^u Y FINE SAND L Z j 56.65 L (5P) O i �- �� f COW—PATIO p - L 8.0' K U S —� O s 'ted s� 5 =' v Z ST +56.58 +56.34 ` �� A't�q BROM SILTY N _K C: IL E SAND EXISTING SANITARY SYSTEM TO BE lIl O O s ��' (5M) ADANDONED IN u' FE HOWARD W.YOUNG,N.YS.L.5.NO.4589s�< MT ACCORDANCE WITH O O O N Fi THE S.C.D.HS.STANDARDS O �', w Y•a I 28.0' �- 5516 d o° SURVEY FOR DROWN FINE , / 'i r ° Gj < 34.0' ° +55. � m NICHOLA5 GABRIEL 4 V � SUFFOLK COUNTY DEPARTMENT Off` HEALTV SERVICES &r=0R6r= &ABRIC-L b°" n°-• _ pEPM-1 AOR�PFRO�A��F Cis�R at Mattltvck, Town of Southold jyv "' • CONSTRUCTION FOR Suffolk County, New York �i e.;avtl •. _ I Sa3IxL-3TY'Sys"e ?mush 9 — i j'��3� +r��'11Z-. 3m i� SINGLE FAMILY RESIDENCE ONLY C3 t:ir= e ed sbi iI �r�v p D ,_ tCI3?I;s'?�'.�9I?b-mit f@/ / BUILDING-PERMIT 5M\/r=Y yym �t n"e<,. i �� Lia _ — ja SAY 0 9 �D96 ss.9 - N ®ATE - � ) a-- )� -003 County Tax Map Dlst<IQt 1000 seGe1°N 106 el°.k 07 Lot 23 •N 7011 100"►N 104.00' a �, FIELD SURVEY COMPLETED MAR 30,2016 APIaR®VrD MAP PREPARED MAR.31,2016 (Dwelling with I I Record of Revisions Public Water) Lot 2 I Lot I FOR MAXIMUM OF BEDROOMS RECORD of REvlsloxs DATE SUbdIvIsion - - "MOP Of Sunset Knolls I "Map of Sunset Kno dIvIsIon EXPIRES THREE YES'FR®P/9 ®/ATE �APPROA! LH I Suffolk County File No. 5023 1 Suffolk Gounty File Not. 5023 J I 0 (Vacant) (Vacant) o I ; m I I 40 0 20 40 60- o' I Scale: I'1 = 401 �4V2 .2016-0024 - •� 016_0029�p IOF 2 2>2 = MONUMENT SET ®= MONUh�NT FOUND Q= STAKE SET A= STAKE FOUND DI = DRAINAGE INLET ! l Suffolk.Cpun, pept 4f ` Labor,Ucensin4,&Con$Umergffairs HQME IMPROVEMENT LICENSE Name S RANDY T RODECKER • ?�flw" ThisceRAiesthatthe BUslne$s Name bearer isduly licensed FENCE KIN QOFROCKYpbINTINCDOA ! by the COu6ty of suffolk License Number:H-21412 RosalleDrago Issued; O6/Q1t1992 Commissigner Expires: 06/01/2022 r YORK Workers' STATE CoCERTIFICATE OF INSURANCE COVERAGE mpensation 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) 1 b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 471 ROUTE 25A ROCKY POINT,NY 11778 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Onlyrequired ifcoverage 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 1 ShelterPoint Life Insurance Company Town of Southold 3b Policy Number of Entity Listed in Box"1 a" 53095 Rte. 25 DBL37154 P.O. Box 1179 Southold, NY11971 3c.Policy effective period 02/01/2020 to 01/31/2021 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. F] 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 2/7/2020 By "d hf (Signature of insurance carner'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 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 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 policles and NYS licensed insurance agents of those insurance carriers are authorized to Issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111 IIIPiiiiiiiiiiiiiiiiiiiiiiii�iiiiiiiiiiiiiiiiillllll YO Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 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 Kings Pools&Patios 471 Route 25A 1c.NYS Unemployment Insurance Employer Registration Number of Rocky Point NY 11778 Insured Work Location of Insured(Only required if coverage is specifically limited to certain locations In New York State,I.e.,a Wrap-Up Policy) 1 d.Federal Employer Identification Number of Insured or Social Security Number 11-3092960 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 Co. 6.1 Town of Southold 53095 Rte 25 3b.Policy Number of Entity Listed in Box"1 a" P O.Box 1179 SW5WC00205-201 Southold,NY 11971 3c.Policy effective period 11/5/2020 to 11/05/2021 3d.The Proprietor,Partners or Executive Officers are XD Included.(Only check box if all partners/officers included) E] 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 valld for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon 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: Philip Colletta (Print name ,of�authorized representative or licensed agent of Insurance carrier) Approved by: a. - (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov '`����® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS28/2020 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 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 C CT NAME* Adam Stone AssuredPartners Northeast, LLC. PHONE (631)465-4000 FAX 100 Baylis Road E-MAIL AIC No: Suite 300 ADDRESS: adam.stone@assuredpartners.com Melville INSURERS AFFORDING COVERAGE NAIC# NY 11747 INSURED INSURERA:Philadel hia Indemnit Insurance Co. 18058 INSURER B:Everest IndemnitX Insurance Co. 10851 Fence King of Rocky Point, Inc. DBA: Swim Kings Pools 6 Patios INSURER C:Shelte oint Life Insurance 81434 471 Route 25A INSURER D: Rocky Point NY 11778 INSURER E COVERAGESINSURER F: CERTIFICATE NUMBER:20/21 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 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. TACLAIMS-MADE ADDL SUBR F INSURANCE POLICY NUMBER POLICY EFF POLICY EXP GENERAL LIABILITY MMIDD Y MMIDD YY LIMITS EACH OCCURRENCE $ 1,000,000 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence S 5,000 al L1ab111tV PHPK2175396 9/1/2020 1 9 2021 / / MED EXP(Any one person) $ 10,000 GEN'LAGGREGATE LIMITAPPLIES PER PERSONAL&ADV INJURY $ 1,000,000 POLICY PEC ❑LOC GENERALAGGREGATE $ 2,000,000 OTHER PRODUCTS-COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT A X ANYAUTO Ea accident) $ 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS, PHPK2175396 9/1/2020 9/1/2021 BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED AUTOS PROPERTY oaccident)AMAGE Per $ UMBRELLA LIAR $ OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE $ AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN sW5WC00205191 X STA UTE E OFFICERIMEMBER EXCLUDED? N IA 11/05/2019 11/05/2020 E L.EACH ACCIDENT $ 1 000 000 (Mandatory In NH) SW5WC00205-201 11/05/2020 11/05/2021 If yes,describe under E L DISEASE-EA EMPLOYEE $ 1 000 000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1 000 000 C NYS Disability DBL37154 2/1/2020 2/1/2021 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) The following are included as additional insured if required by written contract subject to the terms and conditions of stated policies: 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. PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE P Colletta/ASTONE f�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) I �� NOTES 40' N tt 1 NO SOIL 5URCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION ATTHE SHALLOW END,OR6 FEET OF EXCAVATION AT THE DEEP END O PPROVED AS NOTED 2 THI5 POOL MEETS THE REQUIREMENTS OFANSVAP5P/ICC-5'AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING 'v POOLS"AND 1496 BOCA CODE-SECTION 421 DIVING EQUIPMENT IS NOTALLOWED Cl- DATE: DATE: Bi 3 SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED IAW REQUIREMENTS OF _y SECTION R326 4 21 THROUGH 8326.4 2 6 OF THE NEW YORK STATE RESIDENTIAL CODE(2020)AND IN CONFORMITY WITH ALL SECTIONS CJ FEE: BY: OF THE SOUTHOLD TOWN CODE DWELLING WALL(S)MAY 5ERVEA5 PARTOFTHE POOL BARRIERAS PEP,SECTION R326 4 2 BAND N CONDITION(1)ARE MET OPERABLE WINDOWS IN THE WALL(5)USED AS A BARRIER SHALL HAVE SELF LATCHING DEVICE ACCESS GATE5 J NOTIF BUILDING DEPARTMENT ATH2 H20 A SHALL COMPLY WITH SECTION R326.52OFTHE NYS RE5IDENTIALCODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BESECURELY O { LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA O i 765-1 2 8 AM TO 4 PM FOR THE o- FOLL LNG INSPECTIONS: 4. DURING CONSTRVCTIONTHE CONTRACTOR SHALL ERECT ATEMPORARY BARRIERAROUND THE EXCAVATION IAW THE CODE OFTHE U � TOWN OF SOUTHOLD 5. POOL 1. FO NDATION - TWO REQUIRED MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER SOUNDING AZ Q z ;a iN � N FO POURED CONCRETE ' AUDIBLE ALARM UPON DETECTION THAT 15 AUDIBLE ATPOOLSIDEAND INSIDE THE DWELLING THEALARMMUSTBEIN5TAL-LED, 2. RO GH - FRAMING & PLUMBING MAINTAINED AND USED IN ACCORDANCE WITH THE MANVFACTI/RERS INSTRUCTIONS THE ALARM MUST MEETA5TM F2208 O "STANDARD SPECIFICATION FOR POOL ALARMS THE DEVICE MUST OPERATE INDEPEN PENT(NOT ATTACHED TO OR DEPENDENT ON)OF 0 3. INSI ILATIONPERSONS i� 0 4. FIN L - CONSTRLIf"TION MUST 6 POOL SUCTION FITT[NGS(EXCEPT FOP.SURFACE 5 KI MMERS)MU5T BE PROVI PEP WITH A COVER THAT CONFORMS TO ASMEIAN51 BE OMPLETE FC, C 0. PLAN A11219 SM ORA MINIMUM 18"x 23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM POOL CIRCULATION 5Y5TEM MU5TBE EQUIPPED WITH ATMOSPHERIC VACUUM RELIEF IN THE EVENT TI-IE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN SUCH ALL C NSTRUCTICN SHALL MEET THE NX5 VACUUMRELIEFSYSTEMSSHALLCONFORMWITHASMEA11219.17ORBEAGRAVITYSYSTEMAPPROVEDBYTHETOWNOFSOUTHOLD. POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE THE SUCTION FITTINGS SHALL BE REQUI EMENTS OF THE CODES OF NEW SEPARATED BY A MINIMUM OF3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A YORK TATE. NOT RESPONSIBLE FOR 20"ANYL COVERED STEPS VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMP5) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE INAN ACCE551BLE POSITION,MINIMUM 0F6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENT TO DESIGI OR CONSTRUCTION ERRORS. THE SKIMMER/SKIMMERS.A REQUIRED POOL ATMOS PH ER IC VACUUM RELIEF SYSTEM SHALL BE IN5TALLEDAS PER NY5 RESIDENTIAL CODE i N R326 6 3(2020)AND IN ACCORDANCE WITH TOWN CODE QJ M V 7 ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE680AND THE NYS COMPLY WITH ALL CODES OF RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND N 2'TO 4'5AND BOTTOM BE PROTECTED BY GROUND FAULT CURRENT INTERRUPTER(GFCI)CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR CS THOSE " NE YORK STATE TOWN CODES PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT5HALL MEETTHE SEPARATION REQUIREMENTS OF TABLE E4203 5 ALL Ln METAL ENCL05UPE5,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED C/ LNn DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED ASR QUIRED AND CONDITIONS OF SECTION A °J } 8 WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NY5 PLUMBING CODE 608 0 im jZ N.T.S 9 ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. -ts rOT-c v WATER LINE TOP OF WALL -� vvi U 3 -� BOARD 10 WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. 0 O S C4 S91�k49E6 T81A(QLTSTEES 4 4 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW AN51/AP5P/ICC-5 SECTION 6. CL I" 12 CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS ----- ^ 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAI NEI)ON THE SVB)ECTPROPERTY O OccupN CY O R 15 THE DESIGN 15 BASED ON A DRAINAGE SOI-WITH<10%SILT GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION IF GROUND co SECTI ON B WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED O USE I S 1 N LAW F U L N.T5 16 ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROVND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT POOL HEATERS SHALL BE TESTED IAW ANSI 22156 AND SHALL BE INSTALLED LAW MANUFACTURERS SPECIFICATIONS OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726, POOL HEATERS SHALL BE LOCATED OR r WITH® C E RT I F I�A GUARDED TO PROTECTAGAINSTACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS POOL HEATERS SHALL BE PROVIDED WITH T E_ 2'-2" TEMPERATURE AND PRESSURE-RELIEF VALVES FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM A BYPA55 LINE SHALL BE A V CHECK VALVE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER POOL HEATERS SHALL BE PROVIDED WITH THE �'" 00 COPING AND WALKWAY 10" 1 16 FOLLOWING ENERGY CONSERVATION MEASURES 00 OF OCC PANCY PUMP FROM SKIMMER (BYOTHERS) y WATERLINE GRADE 161 AT LEAST ONE TH ERMOSTATSHALL BE PROVIDED FOR EACH HEATING SYSTEM z y v a 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE 'M�' � TO DISPOSAV OPERATION OF THE HEATER WITHOUTAP)U5TING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE DRYWELL� VNDI5TVRBED EARTH PILOT LIGHT EAW j �-N 0 1-a a 16 3 HTED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM TH15 REQUIREMENT ARE OUTDOOR POOLS wy Q T-co co ai 3500 PSI POURED CONC a NDERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) IVLEVRErER VA3/8'REBAR 2)TYP a 164 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET .Y ti ti s O TO RUN THE MINIMUM TIME NECE55ARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE �J3 A' co ii. VINYL LINER ,d SANITARY CODE OF NEW YORK STATE i.^" = O c�e�5-M U cd rTl='�� 2'T04*SAN i W h o v"�y OFILTER 17. THIS DRAWING ISFORSTRVCTURALSHELLONLY ALLACCFSSORIESANDAPPURTENANCESAREDEFINEDBYOTHERS NYS 7t ® p Ololt-.pNSPJILE 7EQUIpEL/ 18 BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS DONOTALLOWTHEHEIGHTOFBACKFILLTOE<CEEDTHEHEIGHTOFTHE ~tea t'BB / v- 1 WATER IN THE POOL BY MORE THAN B", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" a _ CL ro RETURNS 19 PLACE CONCRETE ON SANDY TO LOAM 501L REMOVE ANY CLAY PEP051TANP REPLACE W/COMPACTED CLEAN BACKFILL N W y y\o CHECK VALVE VERTICAL 3/8'REBAR®3'OC 0'T� PLUMBING SCHEMATIC (NOTSHOWN) 20. THERE 15 NO MAIN DRAIN IN TH15 POOL STICTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY THI5 MEETS (NOhq�S U REQUIREMENTS OF THE NYS RESIDENTIAL CODE-SECTION R326 5 FOR ENTRAPMENT PROTECTION NTS WALL SECTION 21, THE POOL WAS DESIGNED IAW THE FOLLOWING: 4 N T5. 21.1. THE NEW YORK STATE RESIDENTIAL CODE-SECTION 8326(2020) _ M Lu 212 THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION 840310(2020) it . . �j - —� 21.3 THE NEW YORK STATE FUEL GAS CODE(2020) �� t{ V! 214. THE NEW YORK STATE SANITARY CODE, RETAIN ORM WATER RUNOFF R� ©3 't �:aF3� 3 ELY 21.5 AN51/AP5P/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS 'ENCLOSE POOL TO CODE 21.6 BOCACODE-SECTION 421 PURSUA T TO CHAPTER 236 j 21.7 CODE OF THE TOWN OF SOUTHOLD, ���F �88��� �Q OF THE WN CODE. ,PON COMPLETION o p s\o e FORE,„UVATEFI° 22 ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. ROFIE i