HomeMy WebLinkAbout44278-Z �O�Osu t Town of Southold 10/5/2021
P.O.Box 1179
0
C*
_ 53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 42403 Date: 10/5/2021
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1125 Gardiners Ln, Southold
SCTM#: 473889 Sec/Block/Lot: 70.-8-46
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/3/2019 pursuant to which Building Permit No. 44278 dated 10/10/2019
was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
accessory in-ground swimming pool fenced to code as applied for.
The certificate is issued to Sommo,Donna&William
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 44278 1;/2020
PLUMBERS CERTIFICATION DATED
Aut or ze S gnature
Lam" TOWN OF SOUTHOLD
o�SUFEnt,r�o�, 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#: 44278 Date: 10/10/2019
Permission is hereby granted to:
Sommo, Donna &William
1125 Gardiners Ln
Southold, NY 11971
To: construct accessoryinround swimming-g g pool as applied for.
At premises located at:
1125 Gardiners Ln, Southold
SCTM # 473889
Sec/Block/Lot# 70.-8-46
Pursuant to application dated 10/3/2019 and approved by the Building Inspector.
To expire on 4/10/2021.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
Buil ng Inspector
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings,property lines,streets,and unusual natural or
topographic features.
2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I% lead.
5. Commercial building, industrial building,multiple residences and similar buildings and installations,a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and"pre-existing"land uses:
1. Accurate survey of property showing all property lines,streets,building and'unusual natural or topographic
features.
2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is
denied, the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
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 _I
Date.
New Construction: Old or Pre-existing Building: (check one)
Location of Property: I IZs GAAPhWs bi H43LIo
House No. Street Hamlet
Owner or Owners of Property: 11I lQ m Q_�OnVl &)MMLI)
Suffolk County Tax Map No 1000, Section 20 Block 2) Lot
Subdivision (J Filed Map. Lot:
Permit No. Date of Permit. Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: chec one
Fee"Submitted: $
Applicant Signature
i
U� �i
q Building�Department Application
AUTHORIZATION
(Where the Applicant is not the Owner)
I, ,l)tQM rnrn0 residing;at ItX GND)Kxs t
(Print property owner's name) (Mailing Address)
do hereby authorize EOWAIAS _
(Agent)
r to apply on my behalf to the
Southold Building Department.
I '�) Li
(Owner's Signature) (Date)
K S—).
(Print Owner's Name)
®��pF SOUr�®!
Town Hall Annex ® Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 G roger.riche rt(-town.south old.ny.us
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To Sommo
Address: 1125 Gardiners Ln City: Southold St: New York Zip: 11971
Building Permit#: 44278 Section 70 Block: 8 Lot 46
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Leo's Electric License No: 2199-ME
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service Only
Commerical Outdoor X 1st Floor Pool X
New Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt Ceding Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors
Main Panel AIC Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 2
Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 2
Disconnect Switches 1 Twist Lock Exit Fixtures 11 TVSS
Other Equipment. In ground swimming pool to include, bonding, control panel, salt generator,
2-GFCI circuit breakers, 1-ARC fault circuit breaker,2-time clocks, 1-sw3itch, 1-GFCI recpticle, 1-pool heater, 1-pool pump, 1"Polars"pump,
Notes: 1-pool light
Inspector Signature: Date: January 2 2020
81-Cert Electrical Compliance Form.xls
OE 50UTyOlo
# TOWN OF SOUTHOLD"BUILDING -DEPT:
cou765-1802
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
] -FOUNDATION 2ND = [ J- 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 1 7iU INSPECTOR
,f sobjyo
6
# TOWN OF SOUTHOLD BUILDING DEPT.
cou765-1802
-==A NSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND= [ ] SULATION/CAULKING
[ ] FRAMING /STRAPPING [ )FINAL eOUv
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION'
[ ] FIRE-RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
DATE 101412" -0 INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS
X
FOUNDATION (IST)
------------------------------------ °
FOUNDATION 2ND
o
ROUGH FRAMING&
PLUMBING y
®v
000
4
_ r
INSULATION PER N.Y. H
STATE ENERGY CODE
FINAL
ADDITIONAL COMMENTS
03
Z
m
b
O
Z
y�
d
TOWN OF SOUTHOLD BUILDING PERMIT APPLICAT.IO.N CHECKLIST
BUILDING DEPARTMENT, r Do you`>iave or need the following,before applying?
TOWN HALL Board of Health
i",8OUTHOLD,NY 11971 3 sets of Building Plans
'.TEL: 765-1802 44�7?
Survey
PERMIT NO:
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Examined 2011 Contact:
Approved ,20-4
Mail to-_ Ar-i-R,�, wa/sl
Disapproved a/c a�
nw--�x)ob
Building pector
-' OCT _ 3 2019 APPLICATION FOR:BUILDINGPERMII'
x lf)� = ,7 I Date__ 12- 20]
INSTRUCTIONS
a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3
sets of plans,accurate plot plan to scale.Fee according to schedule.
b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or,public streets or
areas,and waterways.
c.The work covered by this application may not be„commenced before issuance of Building Permit.
d.Upon approval-of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit
shall be kept on the premises available for inspection throughout the work.
e.No building shall-be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupancy
is issued by the Building Inspector.
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;°Oriiinances or
Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The
applicant agrees to comply wirhA applicable laws,ordinances,;bui,ding code,housing code, egulati'ons,'-and to admit
authorized-inspectors on premises,an4in building for necessary inspections.
(Signature'd applicant o0amej if a corporation)
A2g P-t- 2sA 0 7�
(Mailing.address of applicant);
State whether applicant is owner,lessee, agent, architect, engineer, general contractor, electrician,plumber.or.builder
ODAtaeJ�t-
Name of owner of premises d k a M c kin q f m o
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate,officer)
Builders License No. `s
Plumbers LicenseNo.
Electricians License No.
a19Rw��
Other Trade's License No. ;
1. Location of land on which pro osed work will be done: ,( -
lZS CiMomers LtLI C�Uv�li�d
House Number StrdMt HamletV'J!,'i 'm
,4,dT vfcaj', io s1s12—3iidur4 VE10A
I i I I Soo*l 10 .'s
County Tax Map No. 1000 Section 70 Block S "Prnsa�;�I�' t2 ni b' J0
Subdivision 1
Filed Map No. __ os,e rl�,s��2�,rmiro,�a,,,�:. �.
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and*occupaticySi rn1Po
b. Intended use and occupancy es �JIYJMIAjq P�
3. Nature of work(check which applicable):New Building Addition Alteration
Repair Removal, Demolition Other Work_ i L,4(a fw, VIM,, I/"/At
(D6cription)
4. Estimated Cost �0\�- Fee
(to be paid on filing this,application)
5. If dwelling,number of dwelling units Number of dwelling units on each floor
If garage, number of cars
6. If business; commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front—L-3� .Rear Z5' Depth ' lio
Height Number of Stories
Dimensions of same structure With",dIterations orpadditions:Tront i Rear
Depth Height n Number of Stories
8. Dimensions of entire new construction: Front &3b &(Rear Depth
Height Number of Stories
9. Size of lot: Front j Rear 1 Depth (a5�
10. Date of Purchase Name of Former Owner
11. Zone or use district in which premises are situated;
12. Does proposed construction violate any zoning law,ordinance or regulation:
13. Will lot be re-graded )� nVW Will excess.fill be removed from premises• YES NO
X(7-5 04-'VtQrs La
14. Names of Owner of premises 6 Om MO . Address �a,`h,ao AY L iR�+ phorfe No. 631-7 -1Name of Architect Address 0
Name of Contractor ` ,g_ WA-I &LI Address 97-11 e1-2c-A Phone No. 631- 7W-7«'i-
M,l lug L as Ca A-e 11710.f
15. Is this�property,within-100 feet of a tidal=wetland? *YES NO�_
• IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED
16. Provide survey,to scale;with accurate foundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey.
STATE OF NEW YORK)
SS:
COUNTY OF
A,Qf&
x- j, being duly sworn,deposes and says that(s)he is the applicant
(Name of incrividual signing:contract)above named,
(S)He is the
(Contractor,Agent,Corporate Officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;
that all statements contained in this application are true to the best of his knowledge and belief,and that the work will be
performed in the manner set forth in the application filed therewith.
Sworn to before me this
-- day of Q b-(- 20A_
N tary Public Signature of Aoficant
MARGARE r A. KIDNEY
a Notary Public-State of New York
No. 01 K1602111 1
Qualified in Suffolk County
My commission-Expires March 8,20,A3
r
OHO
Town Hall Annex J Telephone(631)765-1802
54375 Main Road ,ax �gg QQ$
P.O.Box 1179 ro4er.richertl�IOWR's) UihO A.ny.us
Southold,NY 11971-0959 Q ��
BUILDING DEPARTMENT
TOWN OF SOLrMOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY: Leo Date: 1012,119
Company Name: S 8I& ox
Name: ArjWAq Le O
ve -
License No.:
Address: 14 1 M, t+-m RD 610%A7-1040 nl by
Phone No.: 3 1. 2 _ V
JOBSITE INFORMATION: (*Indicates required information)
*Name: Wwm 4 onna c 3 mmo
*Address: 125 A-nqN2rS L.ai � 0�0
*Cross Street:
*Phone No.:
Permit No.: a-
Tax Map District: 1000 Section: Block:. Lot:. 4k -
*BRIEF DESCRIPTION OF WORK(Please Print Clearly)
V nyc. hli�m�lg H'J�II
(Please Circle All That Apply)
*Is•job ready for inspection: YES / O Rough In Final
*Do you need a Temp Certificate: YES NO
Temp Information (If needed}
*Service Size: 1 Phase 313hase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION
XD
to 14
82-Request for Inspection Form U a ��
1
Scott A. Russell sUFFQ Ir ST01K1\\1[WA\TlE1K
SUPERVISOR
MA\1NA\GIEM]EN'7C'
SOUTHOLD TOWN HALL-P.O.Box 1179 16
53095 Main Road-SOUTHOLD,NEW YORK 119M ,. Town of'Southold
O W
CHAPTER 236 - ST09MWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES THIS PROJECT INVOLVE 'ANY OF THE FOLLOWING-
Yes No (CHECK ALL THAT APPLY)
®RA. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
®( B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
00 C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
®W D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
®[0 E. Site preparation within the one hundred-year floodplain as depicted
on FIRM Map of any watercourse.
❑[9 F. Installation of new or resurfaced impervious surfaces of 1,000 square
II__ feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Coriplete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project.
If you answered YES to one or more of the above, please submiit Two copies of-a Stormwater Management Control Plan
and a completed Check List Form to the Building Department*lff your Building Permit Application.
APPLICANT: (Property Owner,Design Profe onal,Agent,Contractor,Other) S.C.T.M. *: 1000 Date:
District /f�,, I or'�l
NAME: �41a 0, &MM �® 8 9
�u Section Block Lot
1095. **`* FOR BUILDING DEPARTMENT USE ONLY****
Contact Information
(relephonettumber)
Reviewed By.
— — — — — — — — — — — — — — — — f
Date- - - - -
Property - - - - - - - -
Address/Location of Construction Work: _ _ _
2 s �A tDNIerS Approved for processing Building Permit.
d_ �,,� Stormwater Management Control Plan Not Required.
�AJ�6 1 Nt I ig7l Stormwater Management Control Plan is Required
I El (Forward to Engineering Department for Review.)
FORM * SMCP-TOS MAY 2014
SUR\/EY OF LOT 24
MAP OF FA IAV I EW PARK, SEGTI ON I N
51 TUNE: 5OUTHOLD s E
TONN: 5OUTHOLD
5UFFOLK COUNTY, NY
s
SURVEYED 05-II-2006
SUFFOLK COUNTY TAX #
1000 - 70 - 8 - 46
8'TIDFffi9 TO:
Q
SOIMO O
DONNA SOMMO ry
COMMONVARALTH(LAND T=
IFISLYRANCE COWANY
12#111HO6305,00 SOT
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NOTES:
�'� tier r k State Ex:atl_n La..'
MONUMENT FOUND 66 F
�^ ,d �.• rea,ttn x=r,�.,a_r era la+�xr
>taapetl>eal>Tml to a rsoeretl ee to aue v:e
o PIPE FOUND ALJGE AND No �3W c��r t
/^I r ;r, w� �, eruratlan>ne¢ataar recn sr tnm tro>
Y aye...»FreFxe�n _r�xvec.!"e e
DARTA � •_,., wtnc Cleaa_r PrxLce ra Lxa> . >> cptetl
R7 Fp �� n t kState—»a_at.n Frola,,mal
O BOLT FOUND 1 ASSET RMER
M LY �-�% s02 / ea tno Fer__n rar rn,tm><r,i FreFxe�
aNA6E OF - `r�0 V`�• Ana an nes rd.- ea me Ltla T'Atx ga.ernnen-
eal agen_y as lens 3 rsea.nan I�>tatl narecn a�
FEMA FLOOD ZONE AE (8) AFFECTS MENT rp'tj
THE PROPERTY
a JOIN C. EHLERS LAND SURVEYOR
AREA = 21,504 SF OR 0.4q ACRES e
6 EAST MAIN STREET N.Y.S.LIC.NO.50202
GRAPHIG 5GALE I"= 30' RIVERHEAD,N.Y. 11901
369-8288 Fax 369-8287 REF.—\\Compagserver\pros\Ol\01-314.pro
New York State Insurance Fund
199 CHURCH STREET,NEW YORK,N.Y. 10007-1100
, CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
A A A A A A 112377925
LEVITT-FUIRST ASSOCIATES LTD
520 WHITE PLAINS ROAD,2ND FL
TARRYTOWN NY 10591
Ism
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD
CONTRACTING COMPANY INC P.O.BOX 728
929 RTE 25A SOUTHOLD NY 11971
MILLER PLACE NY 11764
POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE
G 2438 491-9 53244 06/29/2019 TO 06/29/2020 06/21/2019
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS'
COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE
STATE OF NEW YORK,EXCEPT AS INDICATED BELOW.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF
CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/
CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH
NOTIFICATIONS.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER: 506150454 pin
IIIIBI11IIII,0 IQIIIAS00 0leiI0el!Ifsted®u10�11jSIIlI
00000000000071672400
Form WC-CERT-NOPRINP Version 2(02/2912016)[WC Policy-24384919] U-26.3
40 100000000000071672400][0001-000024384919]10*G][75159-06JCerLNoP-CERT 1][01-00001]
4"VIEWorker '
��� � CERTIFICATE OF INSURANCE COVERAGE
co DISABILITY AND PAID FAMILY LEAVE BENEFITS
)AWMc
LAW
PART 1. To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent
of that Carrier
1 a. Legal Name and Address of Insured(use street address only) 1 b. Business Telephone Number of Insured
ARTHUR J EDWARDS MASON 631-744-4455
CONTRACTING COMPANY INC
929 ROUTE 25A 1 c. Federal Employer Identification Number of Insured or
MILLER PLACE NY 11764 2700 Social Security Number
11-2377925
Work Location of Insured(Only required if coverage is specifically
limited to certain locations in New York State,i.e.,a Wrap-Up Policy)
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage (Entity Being Listed as the certificate Holder) The Guardian Life Insurance Company of America
TOWN OF SOUTHOLD
P.O.BOX 728
P.O.B O 72 NY 11971 3b. Policy Number of entity listed in box"1 a":
SOUT00984424-0000
3c. Policy effective period:
01/01/2019 to 01/01/2020
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 or 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:o7/o3/2o19 By: Fftyyor%� lVvkx.4L_ Raymond J.Marra
(Signature insurance carrUes authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number: 1-888-278-4542 Title: Senior Vice President,Group and Worksite Markets
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,
DB Plans Acceptance Unit,PO Box 5200,Birmingham,NY 13902-5200.
DB120.1 (1/18)
PART 2. To be completed by 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 NYS Workers'Compensation Board Employee)
Telephone Number: 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.
Additional Instructions for Form DB-120.1
By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business
referenced in box"l a"for disability and/or paid family leave benefits under the New York State Disability and Paid
Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the
entity listed as the certificate holder in box"2".
The insurance carrier must notify the certificate holder and the Workers' Compensation Board within 10 days IF a
policy is cancelled due to non-payment of premiums or within 30 days IF there are reasons other than nonpayment of
premiums that cancel the policy or eliminate the insured form 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 the by the
insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c,whichever is earlier.
cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate
prior to the end of the policy effective period?
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 Disability and/or Family Leave Benefits contract of insurance only while the
underlying policy is in effect.
Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits
Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of
the New York State Disability and Paid Family Leave Benefits Law.
DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW
§220.Subd.8
(a) The head of a state or municipal department, board, commission or office authorized or required by law to issue
any permit for or in connection with any work involving the employment of employees in employment as defined in
this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits,
shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory
to the chair,that the payment of disability benefits for all employees has been secured as provided by this article.
Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal
department, board,commission or office to pay any disability benefits to any such employee if so employed.
DB120.1 (1/18)
/ , ® DATE(MMIDDIYYYY)
A'►`R v CERTIFICATE OF LIABILITY INSURANCE
01/08/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must 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 NAC
T ME: Brendan J Smith
Liberty Risk Management,Inc. PHONE (631)569.5633
FAX No:(631)569-5636
664 Blue Point Road,Suite A ADDDRESS: brendan@libertyrisk.org
Holtsville, NY 11742 INSURERS AFFORDING COVERAGE NAIC N
INSURER A: Hartford Insurance Company
INSURED INSURER B:
Arthur J.Edwards Mason Contracting Company Inc.
INSURERC:
DBA Arthur J.Edwards Pool&Spa Centre
INSURERD:
929 Route 25A
Miller Place, NY 11764 IN :
INSURER F
COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2
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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCEim imPOLICY NUMBER IDD MIDD
A X COMMERCIALGENERAL LIABILITY 16 UUN OZ8691 01/01/2019 01/01/2020 tDAT
CURRENCE $ 1000.000
ED
CLAIMS-MADE �OCCUR Ea occurrrence $ 300,000
(Arty one erson) $ 10 000
L 8 ADV INJURY $ i'000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000.000
X POLICY 0 PRO- 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER
AUTOMOBILE LIABILITY CEa aOMBcddenlINED SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per aedda t
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIA13 CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKER8COMPENSATION STATUTE ER
YINATH-
ND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTtVE 7 NIA E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E L DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below I E L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 181,Addltlonst Remarks Schedule,maybe attached It more apace 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
Town Hall ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Box 728
Southold,NY 11971 AUTHORIZED REPRESENTATIVE
BJS
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Printed by BJS on January 08,2019 at 12:50PM
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VETERANS MEMORIAL HIGHWAY * HAUPPAUGE NEW YORK 11788
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DATE ISSUED: 0701/1978 No. H-4436
Suffolk Count
Home Improvement Contract r License
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APPROVED AS NOTED RETAIN STORM WATER RUNOFF
DATE: lJ D B.P.# PURSUANT TO CHAPTER 236
FEE: 0,66 BY:_ OF THE TOWN CODE,
NOTIFY BUILDING DEPARTMENT AT "
765-1802 8 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWC REQUIRED
FOR POURED CONCRETE
2. ROUGH -.,FRAMIN-1- � PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE: �-DF C.O.
ALL CONSTRUCTL 4 SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW ELECTRICAL
YORK STATE. NOT RESPONSIBLE FOR INSPECTION REQUIRED
DESIGN OR CONSTRUCTION ERRORS.
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
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PAN
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OF OCCUPANCY
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18 X 36. A18 36 12 14 65 8 648 24,300 :929 Route 25A Miller Place NY 11764 •
20 X 48 20 48 14 14 6 4 5 10 800 33,000 (631) 744-7185 FAX (631) 744-0174
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