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HomeMy WebLinkAbout47749-Z TOWN OF SOUTHOLD ra BUILDING DEPARTMENT � o 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#: 47749 Date: 4/27/2022 Permission is hereby granted to: Mamais,.Petros _ ... _ w _w_www__ _ _._..... 20 Pembrook Dr __. _ .. ............. �ww_. Mineola, NY 11501 To: construct accessory in-ground swimming pool as applied for. Swimming pool and pool equipment must be located a minimum of 5' from lot lines. At premises located at: 990 Central Dr Mattituckw_... SCTM # 473889 Sec/Block/Lot# 106.-2-16 wwwwww _w� __...w.............._... Pursuant to application dated 3/25/2022 and approved by the Building Inspector. To expire on 10/27/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 _w�_...._ �.._L M.._..- -----w...M. But ling Inspector 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 Jute w'wv�b c�ilth IQJU) 11LV Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ' /�f f' �I PERMIT NO. Building Inspector: MAR 2 Applications and forms must be filled out in their entirety. Incomplete °^^ applications will not be accepted. Where the Applicant is not the owner,an TOy'VIF O UTI N OF OU1 HOLO Owner's Authorization form(Page 2)shall be completed. Date:03/18/22- — OWNER(S) OF PROPERTY: �� Name:Peter Mamais SCTM# 1000-106-2-16 Project Address:990 Central Dr., Mattituck NY 11952 Phone#:(917) 939-2164 Email:pete@mamais.com Mailing Address:990 Central Dr., Mattituck NY 11952 CONTACT PERSON: Name:John Wysoczanski (Islandia Pools LTD.) Mailing Address:108 Fishel Ave., Riverhead NY 11901 Phone#:(631)727-6312 Email:john@islandiapools.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:John Wysoczanski (Islandia Pools LTD.) Mailing Address:108 Fishel Ave., Riverhead NY 11901 Phone#:(631 ) 727-6312 Email:john@isiandiapoois corn DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Cher Swimming Pool $76,295.00 Will the lot be re-graded? ©Yes El No Will excess fill be removed from premises? ❑Yes *No 1 PROPERTY INFORMATION EExistingof property: Intended use ofro e P P rtY: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes ®No IF YES, PROVIDE A COPY. ❑ Check Box After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town code. APPLICATION IS HEREBY MADE to the Building Department for the Issuance of a Building Permit pursuant to the Building Zon 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 cod housing code and regulations and to admite, authorized inspectors on premises and In building(s)for necessary inspectio punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York state Penal Law, ns,Felse statements made herein are Application Submitted By(print name):John Wysoczanski (Islandia Pools Ltd.) RAuthorized Agent ❑Owner Signature of Applicant: Date: 03/18/21 ' STATE OF NEW YORK) SS: COUNTY OF Suffolk I, John Wysoczanski (Islandia Pools Ltd) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the Contractor/ Agent (Contractor, Agent, Corporate Officer, etc, Of said owner or owners, and is duly authorized to perform or have performed the Id k and to a ke and this application;that all statements contained in this application are true to the best of I er nowled a and belielf;and that the work will be performed in the manner set forth in the application file there I( , Sworn before me this 1 8th day of March 2021 r, x ry ublic 0'1� PROPERTY OWNER AUTHORIZATION " ,f (Where the applicant is not the owner) Peter Mamais residing at 990 Central Dr., MattituWk NY 11952 John Wysoczanski (Islandia PoOIs do hereby authorize Ltd.) to apply on my behalf to thown of Southold Building Department for approval as described herein. �` ------- 03/18/21 Own r's Signature Peter mamais Date Print Owner's Name DKK, BUILDING DEPARTMENT- Electrical Inspector <✓ TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 �w� Southold, New York 11971-0959� Telephone 631 765-1802 - FAX 631 765-9502 ro err a southoldtownn . ov - seaInd 2southoldtownny,gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: ? Company Name: L Name: License No.: 3- rnail: Z 4r .OK`- Phone No: � i9 ,r 7 bequest an email copy of ertificate of Compliance Address.: ,j L Ra,,,J 0662224�� "�� L!l 0* JOB SITE INFORMATION (All Information Required) Name: h-)41 S Address: 6f1_rriv4L Cross Street.- Phone treet:Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: 107 BRIEF DESCRIPTION OF WORK Please Print Clearly) L- 507v1.4L lzzo�) Check All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES NO Issued On Temp Information: (AII information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service Service Reconnect Underground Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx Building Department Al2plication AUTHORIZATION (Where the Applicant is not the Owner) I, rriq ff f�-5 residing at qqM CPnTRA - (Print property owner's name) (Mailing Address) rroTT) do hereby authorize T L�111"Ir (Agent) 6-16)Ar\Z,iA L4 to apply behalf p� y on m yea to the Southold Building Department. (Owner's Sij ature) J*te) (Print Owner's Name) MAR '2 ) 1 eco� A- A. Russell ST�O Rj\\I W A\�C'�E�E� vTsoR MANAGEMENT SUPER SOU OLD TOWN HALL-P_O_Box 1179 53095 Main Road-SOLITHOLD,NEW YTown 11971 1 own of Southold ER MANAGEMENT WORK SHEET CHAPTER 236 - STOR "I ( TO BE COMPLETED BY THE APPLICANT) nomas Pt+oc '' vol. . OF ...... . THE FOLLOWING: (CHECK All.THAT APPLY) I Yes No A. Clearing, grubbing, grading or stripping of land which affectsmore 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. El C1,C_ Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. [:ID_ Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. EIEJ E. Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse_ 4F. Installation of new or resurfaced impervious surfaces of 1,000 square 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_ . Y »moi you answeredp .. all .I.�of the questions above STOP' Complete the Applicant section below with y ur Name, _� �, g _ atiol�i,--;bate- --County-� Map..l11u7Ciib�..---.�:lla teed u(It•" �aj;ectM .._�.. ....�._...,.. . If you answered YES to one or more of the above,please submit Two copies of a Storm-water Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application_ . . S.C_T_M_ �: ]000 te APPLICANT (Property Owner,Design Professional,Agent,Contractor.Other) District-- 1) .,� � qq 2 NAME 1' _. t T. -F� Block .LO.t.. o , ..� � m F-Vi1BUILDING JEi llaa �:;Y Coniact War atr+o ReviewedBy: �..ww_..n,.wwww_....�.___.�w.......�...._ Date: Ce L topera re s Location` ._of�C�onsh uClion.. work......: M _...... Approved pproved_r cng_B_uildigPermit. e mi teNaogesiControl Plan Not t._R,eq_u_..i red- Stormwater N)wa us.. .. . nagennent Control Plan Required- LJ (Forward to Engineering Department for Review-) ,PPLICANT: S,C,T,M. 1000 CIUPTEk 2x36 'rnporry Owner,Design Protessional,Agov,Contuetot,O k „ ID Stormwater Management Control Plan CTEECK LIST section 481OCk Lot � S M C P -Plan Requirements: Provide ONE coply of the Building P irmit Application. Date: The applicant must provide a Complete Explanation and/or 1?ea n for not providing I ' �3i all Information that has been Required by the following Checklistl .. ,v s� A Site Plan drawn to scale Not Less that 60' to the inch MUST if You answered No or NA to any Item, please Provide J `tif!cation Here! YE N0 show all of the followi£ NAg items: If you need additional room for explanatl' ns, Please Prov a additional Paper. a, Location & Description of Property Boundarl is , Total Site Acreage, i C. Existing - Natural & Man Made Features wit ' 500 L.F. of the Site Boundary as required by §236-17(C d, Test Hole Data Indicating Soil Characteristics&Depth ti Ground Water, e. Lirnits of Gearing & Area of Proposed land Disturbance, f. Ex ist ing & Proposed Contours of the Site (Mint num z Intervals) i g, Location of ail, existing & proposed structure4 roads, driveways, sidewalks, drainage improvement &utilities, _ 1 h. Spot Gr=ades & Finish Floor Elevations for alllexisting & L4 1 i proposed structures, L Location of proposed Swimming Pool and discharge ring, kation of proposed Soil Stockpile Areaisi, , k. Location of proposed Construction Ei)trance/Staging A ea(s), I, Location of roposed concrete washout at M, Location of all proposed erosion&sediment control me ures. ?. Siormwater Management Control Plan must include Calcultlons showing l Ihat the slormwater Improvements are sized to capture,stole,and infiltrate I on-site the run-off from all impervious surfaces generated y a two(T)inch . rainl'all /storm event, i, Deiaiis 8 Sectional Drawings for Stormwater practices are red lred for approval I Items requiring details shall include but not be limited to: a, Erosion & Sediment Controls, II b. Construction Entrance & Site Access, c. Inlet Drainage Structures (e,g,catch basins,trend drains,etc,) l d, Leaching Structui'eS (e. . Infiltration basim,swat etc.) L 1 I �)it 1�:;`�C,I��il°,k:;rz,i�ia rai-,laAfi•rMWT USE NLY i�,�x, . .. ,.,....�a..,.-.�..�_���..�..� a.. Additional Information is P. uired. Reviewed & Stormwater Management Control Plat i1r;jj of Complete, 'APhroved By; I . l Stormwater Management Cntrol Plan is Fomplete, Date: SMCP has been approved bthe �nginee ng Department. I -rnr t,rt e s nni 4 t HM ENGINEERING P.C. P.O.BOX 914 EAST NORTHPORT,IVY 11731 TEL:516-476-5392 EMAIL:HMARNIKA@OPTONLINE.NET March 18, 2022 u $ MAR 2 ., ' t Do Town of Southold BUILI INN DEPT Building Department TOWN OF SOOT OLD Town Hall Southold,N.Y. 11971 Dear Sir/Madam: This is to certify that the drainage facilities to be used exclusively for the construction of a swimming pool on the premises of: Mamais Residence 990 Central Drive Mattituck,N.Y. 11952 will not require draining because the pool is constructed with a vinyl liner. The pool water will be continuously recirculated through the filter and will be reused from year to year. The drainage from the filter backwash will be piped to a drywell located on the subject lot and will not iaiterre with the public water supply system, existing sanitary facilities, adjoining property owners, public highways or private roads. Sincerely, HM B gineering P.C. 1vcj arni�ka;, P.B. I l NEW Workers' CERTIFICATE OF INSURANCE COVERAGE sraTw* Com ation ens 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 Carriermm 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured ISLANDIA POOLS LTD. 108 FISHEL AVENUE 6317276312 RIVERHEAD, NY 11901 Work Location of Insured(Only required if coverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 11-2915558 2.Name and Address of EntityRequestingProof of Coverage _ 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold Standard Security Life Insurance Company of New York 53095 Main Road 3b.Policy Number of Entity Listed in Box"I a" Southold, NY 11971 69146-00 3c.Policy effective period 1/1/2014 to 3/20/2023 4. Policy provides the following benefits: ❑X A. Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑X 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 decabove. Date Signed 3/21/2022 By _ .... (Signature of insurance carrier's;authcta(¢d rt,paresent tine or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES 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 56 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number ._......._. _e_ 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-120.9. Insurance brokers are NOT authorized to issue this form. D13-120.1 (10-17) I I ii InI1iiu111111iiiiii1111111111111111111111111 DB-120.1 (10-17) Additional Instructions for Form D13-120.1 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 1 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 above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid 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, cornmission 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 and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has beer) secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the pail of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance Garner is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article, DB-120.1 (10-17)Reverse 2��F ) Ate" CERTIFICATE OF LIABILITY INSURANCE TE HOLDER. THIS THI�RTIFICATE IS ISSUED AS A MATTER ONINFORMATION ONLY AND CONFERS NO EGAT VELY AMEND, EXTEND D OR ALTERTIHE COVERAGE AFFORDEDGHTS UPON THE ABY E HOLDER THIS THE PS CERTIFICATE DOES NOT AFFIRMATIVELY OR BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. the olicy(fes)must have ADDITIONAL INSURED IMPORTANT: If the certificate holder DDITOLINSURDe policy,certainpolicesmaequie ane endorsement. A statement on If SUBROGATION ISWA WAIVED,subject to thesado of th this certificate does not confer rights to the certificate holder in lieu of suchendorsement666er4al support 63 PP PRODUCER �EAX PHONE I 4 7475,,,., 390 9700.. Fde;yr¢sad Partners Insurance Center CAI ,NS.EIIII 40 Marcus Drive 3rd Floor E4AiC rasrlrertso4A ePicksroker com,,,........ .. PI2I?FE „ _ NAIC Melville NY 11747 fblffiURERjSAEFORDtNGCOVESGE '�" AIIALTY rwRODP.. 00914 INSURER, ._.�. ......_.....w�w..-.�.....,�._........._ _,_.._._._ ,....�...�. _ .. w........ _..�..._...._ _.... � �_..w_ 42376 A INSURED &NS4dFk ,R.6, "Ce ;hnol0 InStl,ra .., Islandia Pools Ltd. INSUREY#,C 108 Fishel Avenue Riverhead NY 11901 INSURER F: REVISION NtIIIaIBERa COVERAGES CERTIFICATE NUMBER:Cert ID 316 ISSUED TO THE INSUR AMED ABOVE FOR THE ICY THIS IS TO ES OF NCE LISTED BELOW E BEEN FtLNT ICATED.CNOTTWITHSTANDING ANY IREQUIREMENT,TERM OR CONDITION V F ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOLWHICH THIS IS SUBJECT TO ALL THE TERMS, .. .. LI ..w,..... ... . N REDUCED �BY P PII ICY E MSD...HEREIN..... ..., .-....� _..,........, CLUSIONS AND CONDITIONS OF SUCH PAOLDIC4IUES LIMITS SHOWN MAY SHARVE BEE MNII OYYYY M0,6 7 PYYY NCE AFFORDED BY THE POLICIES DESCRIBED RTIFICATETMP oBINsIuRANce OR MAY PERTAIN THE INSURANCE � LIMITS POLICYNUM 000 EACH OCICURRCiNC E $ 1,000 n, A X COMMERCIAL GENERAL LIABILITY 11AIa�Aa3I ICS rII N CI I 3Q0„000 CO $ X OCCUR 12UUNOZ9731 04/25/202'1.09/25/2022 1�i�EM("�ESII=eCw�or<rrra��xrl.`1: .............w_ .�I CLAIMS-MADE E I 5 000 w. .. - RudED EXP AMMe paresarAr}_,µ _ CroENERALAt GRECaATE $ 2 000 w000 GEN'L AGGREGATE LIMIT APPLIES PER: '". PRO- ,..PRODUC.TS-COMP/OP FAtaCi,M✓$., ......2,„„d 000y ... POLICY EX JECT D LOC ..... ..�. ..w�..._-.,.._...... $.._ .. OTHER C%MBBNCIbsItIGLELdMI1 $ 1 000 1100 I .I;N.�IIII ............_.,d,.,_.,... Rte. AUTOMOBILE LIABILITY 04/25/2021104/25/2022 BODILY INJURY(Per person ANYAUTO 12UENOZ9729 ) $ A BODILY INJURY(Per accident) $ .....-.OWNED W_'.SCHEDULED M^'al0„YF"E&t.—....AG'E:� ,a AUTOS ONLY X AUTOS $ X X HIRED . .. NON-OWNED O-O oNED AUTOS ONLY 04/25/2021 04/2`5/20221 p� X UMBRELLALIAB..Nm.I X (OCCUR 12HHUOZ9730 EACHOrtCUItHI:hIC;E,w,,..... .,., .. . ...,.,.2 .0 'rODLI,...,. - AGGREGATE REC;ATE ..... EXCESS LIAB CLAIMS-MADE .......,....n_._.,....._..... ... . e.. .......w,. DED X RET"EWION$' 10 000 P TH. WORKERS COMPENSATION TWC3961844 '04/25/2022 X S9PAHtl H AND EMPLOYERS'LIABILITY YIN 04/25/2021 E.L.EACH ACCIDENT $ 1,000,000 ANYPROPRiE'TORJPART'NEPJE'XE(',UTUVE Y N/A 1,000,000 FFICaNs Irl BE DEDl E.L.D4SEA3E.PO,LNAPLOYEE5.... ... OfFICErI/MCMBCREXCLU EL DESEASE FJAE _.. pI as dem 8bo under ICYLIMI'T. $ 1,000,000 O RIPTK)N Or OPERATIONS belO w DESCRIPTION OF11 OPERATIONS/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 THE. EXPIRATION (DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold AUTHORIZED REPRESENTATIVE 53095 Main Road Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Page 1 of 1 J Workers' CERTIFICATE OF YORK sTATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (631) 727-6312 Islandia Pools Ltd, 1c.NYS Unemployment Insurance Employer Registration Number of 108 Fishel Avenue Insured Riverhead NY 11901 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 112915558 3a.Name of Insurance Carrier 2.Name and Address of Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Technology Insurance Co, Inc. Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" TWC3961844 53095 Main Road Southold NY 11971 3c.Policy effective period 3d.The Proprietor,Partners or Executive officers are ❑ 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 w"3"insures the business referenced above in brief a"for workers' con1pensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under jff««tt"t.. A. 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 premitrms that cancel the policy or eliminate the insured frorn the coverage indicated on this Certificate.(These notices may be sent by regular mail,)Otherwise,this Certificate is valid for one year softer 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 business his form, must provide business continues to be with a named on a permit,license or contract issued by a certificate holder, new Certificate of mandatory coverageorequirementtsrsation Coverage or of the New York Statether authorized proof that theWorkers'Compensation Law.buslness Is complying with tate 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. Commercial Support Approved by: � w._.. --------- (Print name of authorized representative or licensed agent of insurance carrier) Approved by: *" (Signature) (Date) Title: Leonard scioscia � _ q (866) 414-7475 Telephone Number of authorized representative or licensed agent of insurance carrier: 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. www.wcb.ny.gov C-105.2 (9-17) Pace 1 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. The head of a state or Municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE Page 2 of 2 & kt a 92��' I82o 00'00" E N FE 0.3'W. p z4� � 're 19'W � �}/ N N (% LOT 95 LOT 93 BRICK 6B0 "r....... CELLAR fl7 L. EN IRANCE W000 OECR' re$ o ae'" 7."x.f'F,°,'r" I , 1 STORY FRAME 'O F „G 9,4' vJ No 990 w- ey Q 34.8' G 171' 16.4' 't' ,. R=25.00' t, L=39.27' n m v 389.71" N 86'00'30" W 90.00" CENTRAL DRIVE (50'WIDE) 1HE EXISTENCE 7;"A" �'AY."d+f 1' OF WAYS AND/OR EASEMEN[$ OF RgE^CUR�O^. I�Fy�}ArpI�Y, NOT,SgHOVM A�y.REp�yNO7 CER iIC^IEyD LlAhaND SURVEYOR SCALE: 1 30' �(' 2073 " SURVEY OF., LOT 94 CERTIFIED TO: PETROS MAMAIS JPMORGAN CHASE BANK, NA(�';v' FILED MAP: CAPTAIN KIDD ESTATES EAGLE ABSTRACT CORP. FILED: JANUARY 19, 1949 MAP No )672 IOCATED AT: MATTITUCK, TOWN OF SOUTHOLD TITLE NO,: FTI-S-23442 SUFFOLK COUNTY, NEW YORK DATE: OCTOBER TAX DESIG: DISI 1000; SEC 1061 RLK C; LOT 16 El Y: Z 15 jl MAS 2tiu A 1 €= POOL NOTES: 1.POOLAND PROPERTY TO CONFORM TO 2020 NYS UNIFORM FIRE PREVENTION PUMP ( TRACK FOR AND BUILDING CODE,TOWN OF SOUTHOLD CODE AND 2017 NATIONAL ELECTRIC FILTER it VINYL LINER CODE. RETURN SKIMMER 2.POOL SHALL CONFORM TO ANSI/APSP(ICC 5 STANDARDS R326.3.1. (TYP. Of 2) VINYL LINER - 3.SECTION R326.7 POOL ALARM REQUIR€D. (TYP.) r 4.POOL SHALL COMPLY WITH BARRIER REQUIREMENTS SECTION R326.4. r3.5" I FOAM PADDING 3,500 PSI 5.POOL SHALL COMPLY WITH 2020 ENERGY CONSERVATION CONSTRUCTION CODE OF NYS SECTION R403.10: - CONCRETE POOLS AND PERMANENT SPA ENERGY CONSUMPTION(MANDATORY). V-4" a - SECTION R403.10.1 HEATERS SECTION R403.10.2 TIME SWITCHES I �! PROPOSED VINYL I SECTION R403.10.3 COVERS I I SWIMMING POOL I #4 REBAR TOP 6.REBAR SHALL BE 3"MIN.CLEAR TO EARTH. I I I 648 S.F. I 1$, & BOTTOM a 42" 7,LOCATION OF AND HAIL COMPLYOPOSED SWIMMING WITH ALL LOCAL ZONIN6LAND REQU POOL EQUIPMENT BY OTHERS ( 3 I (MIN.)I I I B.ALL DRAIN COVERS TO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME DUAL MAIN DRAINS WITH BAKER(VGB)POOL AND SPA SAFETY ACT. I STRAINER (VGB SAFETY 9,SLOPE PATIO SURFACE 1J4"PER FOOT AWAY FROM POOL. ACT APPROVED DRAINS) 10.BACKFILL MATERIALTO HE FREE DRAINING GRANULAR MATERIAL(NO CLAY OR J— LARGE ROCKS). C 5--1 f I STEPS 11,SUCTION OUTLETS SHALL BE DESIGNED AND INSTALLED IN ACCORDANCE WITH AUTO—+—( ! I L ANSI(APSPJICC 7. COVER i < 12.E14TRAPMENT PROTECTION REQUIRED SECTION R326.5. VAULT I '�_4 13.CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR TO INSTALLATION OF L BENCH SWIM—OUT 12,5' POOL I 14,THIS PLAN IS FOR CONSTRUCTION ON PROPERTY AT 990 CENTRAL DRIVE TO CODE � i1t MATTITUCK,N.Y.11952 ONLY. 36' DP1CAL. fi>AU DAL 15.NO DIVING EQUIPMENT PERMITTED. SCALE: 3/4" = 1'-O" 16.REINFORCING STEEL SHALL BE INTERMEDIATE GRADE BILLET STEEL WITH A t MINIMUM LAP OF 30 BAR DIAMETERS. 17.POOL WALLS ARE NOT DESIGNED FOR SURCHARGE LOADS EXERTED BY WHEEL I!QQL PLAN NOTES: LOADS WITHIN SIX(6)FEET OF POOL WALL FROM CONSTRUCTION EQUIPMENT OR 1. ACLS SHALL BEAR ON UNDISTURBED SOIL. NOTE: NOT TO SCALE 2.ALL CONCRETE SHALL BE PLACED ASA MONOLITHIC POUANY OTHER LOADING CONDITION IMPOSED ON THE POOL STRUCTURE BY EXISTING R. Hf S ANON-DIVING POOL. OR PLAN, SED REUJACENT STRUCTURES.IF SITE CONDITIONS DIFFER M THIS IT IS RESPONSIBILITY OF CONTRACTOR TO CONTACT HIM ENGINEERING,P.C.BEFORE ANY CONSTRUCTION BEGINS. F 18.KM ENGINEERING,P.C.SHALL NOT BE RESPONSIBLE FOR CONSTRUCTION t MEANS,METHODS,TECHNIQUES OR PROCEDURES UTILIZED BY THE CONTRACTOR, NORFOR THE SAFETY OF THE PUBLIC OR CONTRACTOR'S EMPLOYEES,OR FOR THE 3'-4" CONCRETE WALL FAILURE OF THE CONTRACTOR TO CARRY OUT THE WORK IN ACCORDANCE WITH THIS PLAN. — B - - - - - - THIS SHEET) 1 1f2" TO WASTE UNDISTURBED PUMP HAIR Be LINT STRAINER ` EARTH (TYPJ 4` 6' 14 12' FILTER AUTO SKIMMER 3" COMPACTED �t SAND POOL rl PROg1LE .. _ - POOL p TO NOT TO SCALE ' 2 MAIN DRAINS GENERAL NOTE: VATH HYDROSTATIC ALLMANUFACTURED ITEMS AND CONSTRUCTION SHALL COMPLY WITH THE 2020 SUH-D„NGDEPT PREPARED FOR: 5LHW 'TIC PIPING ARRANGEMENT VALVE AND RESIDENTIAL CODE OF NYS,INCLUDING THE SPECIFICATIONS IN SECTION R326. Tv'=Ni OF SOUT HOLD MAMAIS RESIDENCE NOT TO SCALE COLLECTOR TUBE 990 CENTRAL DR VE IN GRAVEL BASE MA ITUCK,N.Y 119.52 ` DATE: 03AS12022 NOTE: -p 7j( - HM ENGINEERING, F.C. SCALE: AS SHOWN THESE PLANS ARE AN INSTRUMENT OF SERVICE AND ARE THE PROPERTYOFHM ENGINEERING P.C.. UrJ/��/gy�pp SHEET; tOF1 UNAUTHORIZED ALTERATIONS OR ADDITIONS TO THESE DOCUMENTS AREA VIOLATION OF SECTION 7209 OF THE L�t-^� P.O.BOX 974 EAST NORTHPORT,NY 11731 NEW YORK STATE EDUCATION LAW.INFRINGEMENTS WILL BE PROSECUTED. Tel:(516)476.5392 Fax:(631)980-7671 Email:hmafnika@)optonAne.net RESIDENTIAL CONCRETE v ID:Z'S.SEAL AND BLUE SIGNATURE VINYL LINER POCK_PLAN