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HomeMy WebLinkAbout45464-Z �o�OS�F �c Town of Southold 7/14/2022 P.O.Box 1179 � 53095 Main Rd Southold,New York 11971 � r CERTIFICATE OF OCCUPANCY No: 43247 Date: 7/14/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1745 Ole Jule Ln,Mattituck SCTM#: 473889 Sec/Block/Lot: 122.-5-2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/5/2020 pursuant to which Building Permit No. 45464 dated 11/18/2020 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 Levy,Dylan of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45464 7-13-2022 PLUMBERS CERTIFICATION DATED ut r Uiek Signature SnFFot,,r�. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE a . 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#: 45464 Date: 11/18/2020 Permission is hereby granted to: Papish, Eleanor 1745 Ole Jule Ln Mattituck, NY 11952 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1745 Ole Jule Ln, Mattituck SCTM # 473889 Sec/Block/Lot# 122.-5-2 Pursuant to application dated 11/5/2020 and approved by the Building Inspector. To expire on 5/20/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 B ' ector pF SOUryol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 ae sean.deviin(-town.southold.ny.us Southold,NY 11971-0959 QIyCQU�s�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Dylan Levy Address: 1745 Ole Jule Ln city,Mattituck st: NY zip: 11952 Building Permit#: 45464 section: 122 Block: 5 Lot: 2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Prime Electric License No: 52402ME 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 Ceiling 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 4'LED Exit Fixtures Pump 1 Other Equipment: Intermatic Pool Panel, (1) Light 120GFI, Pump 220GFI, Salt Generator, Heater 120GI Notes: Pool Inspector Signature: Date: July 13, 2022 S.Devlin-Cert Electrical Compliance Form oSUFFoc r�oy TOWN OF SOUTHOLD —BUILDING DEPARTMENT y z� Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://,,ww.sotitliotcltownny.gov For Office Use Only Date Receive PERMIT N0.� Building Inspector: J,/ �,/ D D Applications and forms must be filled out in their entirety. Incomplete applications NOV — 5 2020 will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Fri.4r'DEa Date: I '�Dti�l1 ��°�LD 1 1.11 PEI3MIl':.: :: :o >; OWNERs ; 0 E•PR PER TY;? Name: ' ' Tax Ma #: SCTM#1000- Ph ysic al 000-Physical Addr ss: '�L�—J . .... . . .-. �._..... .---. Phone#: _ Email: P a �� Mailing Address: "� . (� r - N• NTACT:P.ERSO .�• •::': CO .. Nan ie: Mailing Address: Address: Phone#: Email: DESIG 'RROFESSI NA INF Name: - - .. La a�ilr--,, Mailing Address: Phone#: Email: ..... .... ... ... .. .. .._... .... �. .. .......... .. ... ... ........_.,.�... .... .... .. .. .l._. %yam, ... �.. .. .V ?, 1i A T. FOR •!1 �COIVTR C_ OR=1N M J• ' 4 .{. Name: T— Mailing Address: Phone#: 1 C72 Email: '. • CO SCRIPT, DE ROPOSED RUCTI ONS ij r: ❑New Structure ❑Ad ition ❑Alteration ❑Repair ❑Demolition Esti a edje t0 Other $ `~� FM Will the lot be re-graded? Y s ONO Will excess fill be removed from premises? ❑Yes PRO•PERT'.Y..INFORMAT ON:; z.. i Existing use of proper 1 Intended use of property: .. .. .. . / _.... .. Date of Purchase: Name of Former Owner: 1 Zone or use district in which premises is situated: Are there any covenants a 9drestrictions with respect to this property? ❑Yes°Q o IF YES, PROVIDE A COPY. Vpte0heck BOX After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by r 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized Inspectors on premises and in building(s)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): ❑Authorized Agent caner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF j oV being duly sworn, deposes and says that(s)he is the applicant (Name of individual s' Ing contract) above n4fned, (S)he is the .AI V d_dV V (Contractor, Agent, Corporate Officer,etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in t e pplication fi t eh... Sworn before me this LNFh, day of I � ;�\�c, o`PRY 1620 I 1 �0 Notar Public sPF�o�``� G •E iOWNER AUTHORIZATION the applicant is not the owner) I, residing at do hereby authorizeRto apply ori m behalf to the Town of Southold Building Department for approval as described herein.' " Y g p 0:"w­n e 4 Signature ; �2y _ •'•�d''; -Date a ter:u�i rint Owner's Name ��''�i,,����,;'~•••S;P\�o��\\` ul / o��Of SOUTyo 1A ' 9 t F7L-t s V /f i v ! # # TOWN OF SOUTHOLD BUILDING DEPT: 765-1802 1 NSPECTION - - [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING- [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [/ ']' PRE C/O REMARKS: &LA1 A,,* sn 'DATE INSPECTOR ho�aOF SOUTyo� 111 # TOWN OF SOUTHOLD BUILDING DEPT. 631-765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL IO ULKING [ ] FRAMING /STRAPPING [ FICA NAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: IPAq 4L 71 DATE l vv INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(IST) ---------------------------------- FOUNDATION(2ND) � O ROUGH FRAMING.& PLUMBING C-y 'I INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAf,COMMENTS via PIC -�-a� tido ) ' II � O S H z x tv U LL 5 BUILDING DEPARTMENT- Electrical lnspAffir - 1 2021 TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - P0,05i"1.177:9.' Southold, New York 11971-09',9`9 Telephone (631) 765-1802 - FAX (631) 765-9502 roqerr(cD_southoldtownnV.qov - seandRsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ' ELECTRICIAN INFORMATION (All information Required) Date- 0 2-- 2-22-2- Company Name: L )n L Name: License No.: email: Phone No� L]l request an email cop V of Certificate of Compliance Address.: JOB SITE INFORMATION (All Information Required) Name: Addra. ess 45 Cross Street: Phone No.: Bldg.Permit#: LA5H email: Dy'1M1C_T_ I Tax Map District- 1000 Section.- Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Ifs I=Ayx V4"1 @ ` .� Check All That Apply: Is job ready for inspection?: E2<ES 0�❑�NQQ E]Rough In E]Final Do you need a Temp Certificate?: F]YES 0 ❑ Issued On Temp Information: (All information required) Service Size F-11 Ph F-13 Ph Size: A # Meters Old Meter# FINew Service 11 Service Reconnect F] underground [--]Overhead 1# Underground Laterals El [:]2 [:]H Frame DPole Work done on Service? 0Y Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx j -r_;, V Ln rr BUILDING DEPARTMENT- Electrical�lnSPAM& ' 1 2021 TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PT''*Bok°'f7 '-r`P,' Southold, New York 11971 r�;e : ,fi►,<;,,:' Telephone (631) 765-1802 - FAX (631) 765-9502 . ' rogerrsoutholdtownny.gov — seand(a)southoldtownny.Qov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 02-- Z2--2 Company Name: L Name: i License No.: m �j2y�p2 email: Phone 01 request an email copy of Certificate of Compliance Address.: W0� f06-y _ 1 JOB SITE INFORMATION (All Information Required) Name: --k- N Address: 6112k9cL,n N"\ \10S2L Cross Street: �,W s IL . Phone No.: Bldg.Permit#: 45H U Pi . email: 1N.f_. Y M 12 Tax Map District:- 100.0 Section: Block: Lot: BRIEF DESCRI F WORK (Please Print Clearly) 0. �(1 - - Check All That Apply: Is job ready for inspection?: ®YES ❑�NQ ❑Rough In ❑Final Do you need a Temp Certificate?: ❑YES Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead # Underground Laterals 01- ❑2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx C ( e2 c lllnlvr - �— 0, c k L/V ) red CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT-THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY rh cts o 6C4- ,2b20 THIS INDENTURE,made the g day of October,2020 BETWEEN GLENN V.PAPISH and SUSAN E.MARTIN,as Cc-Executors of the Estate of Eleanor M.Popish,alkla Eleanor Mae Papish,pursuant to Letters Testamentary issued on October 19,2018,under File No.2018- 3344iA,with an address at 1745 Ole Jule Lane,Mattituck,New York 11952,party of the first part,and and DYLAN LEVY,residing at 386 Carpenter Avenue,Sea Cliff,New York 11579,party of the second part, WITNESSETH,that the party of the first part,by virtue of the power and authority given in and by said last will and testament,and in consideration of Six Hundred and Ninety Thousand($690,000.00)Dollars, paid by the party of the second part,does hereby grant and release unto the party of the second part,the heirs or successors and assigns of the party of the second part forever, ALL that certain plot, piece or parcel of land,with the buildings and improvements thereon erected,situate, lying and being in the See Schedule A Attached hereto Being and intended to be the same premises as conveyed to the Grantor herein by deed dated February 23, 1960 and recorded on March 1,1960 in the Suffolk County Clerk's office in Liber 4775,page 309. Said premises known as 1745 Ole Jule Lane,Mattituck,New York 11952 District 1000 Section 122.00 Block 05.00 Lot 002.000 TOGETHER with all right,title and interest,if any,of the party of the first part,in and to any streets and roads abutting the above described premises to the center lines thereof,TOGETHER with the appurtenances, and also all the estate which the said decedent had at the time of decedent's death in said premises,and also the estate therein,whlch the party of the first part has or has power to convey or dispose of,whether individually, or by virtue of said will or otherwise;TO HAVE AND TO HOLD the premises herein granted unto the party of the second part,the heirs or successors and assigns of the party of the second part forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever,except as aforesaid. AND the party of the first part,in compliance with Section 13 of the Lien Law,covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word'party`shall be construed as if it read"parties"whenever the sense of this indenture so requires. iN WITNESS WHEREOF,the party of the first part has duly executed this deed the day and year first above written. IN PRESENCE OF: ESTATE OF ELEANOR M.PAPISH a/k/a ELEANOR MAE PAPISH By Glenn V.Popish,Co-Ekecutbr ,,'By Susan E.Martin,Co-Executor Standard N.Y.S.T.U.Form 8005—Executor's Deed—Uniform Acknowledgment FIDELITYNATIONAL TITLE INSURANCE COMPANY AMERICANLAND TITLE ASSOCIATION OWNERS POLICY(6-17--2006) WITHNEW YORK COVERAGE ENDORSEMENT APPENDED (A.L.T.A.) SCHEDULE A Policy No 2730632-221160934 Title Number Effective Date Amount of Insurance FLT-45364 10/14/2020 $690,000.00 1. Name of Insured:DYLAN LEVY 2. The estate or interest in the land which is covered by this policy is: Fee Simple 3. Title to the estate or interest in the land is vested by: DYLAN LEVY who acquired title by deed from GLENN V.PAPISH AND SUSAN E. MARTIN AS CO- EXECUTORS OF THE LAST WILL AND TESTAMENT OF ELEANOR M. PAPISH A/S/A ELEANOR MAE WISH, deceased,pursuant to Surrogates'File No.2018-3344/A dated 10/14/2020 and intended to be recorded in the Office of the Clerk ofthe County of Suffolk- 4. uffolk4. The land referred to in this Policy is described herein on Schedule A Description of Premises. For Information:Premises Imown as: 1745 OLE JULE LANE,MAI=CY,NY 11952 District 1000 Section 122.00 Block 05.00 Lot 002.000 r n orizackSi,Bn ara SCHEDULE A A J-TA2006OWNERSPOLICY FIDELUYNATIONAL TITLE INSURANCE COMPANY SCHEDULE A DESCRIPTION OF PREMSES Title No. FLT-45364 Policy No. 2730632-221160934 ALL that certain plot,piece or parcel of land,situate,lying and being at Mattituck,Town of Southold, County of Suffolk,and State of New York,bounded and described as follows: BEGINNING at a point on the Easterly side of Olejule Lane distant 227.64 feet Northerly from the comer formed by the intersection of the Northerly side of Kraus Road with the Easterly side of Olejuuld Lane; RUNNING THENCE along the Easterly side of Olejule Lane North 14 degrees 03 minutes 20 seconds West,160 feet to land of Janeczko; THENCE along said land of Janeczko South 87 degrees 24 minutes 50 seconds East 267.24 feet to land of Schiller; TBENCE along said land of Schiller South 02 degrees 35 minutes 10 seconds West,153.30 feet; THENCE North 87 degrees 24 minutes 50 seconds West 221.42 feet to the Easterly-side of Olejule Lane to the point or place of BEGINNING. , FOR INFORMATION ONLY.Said premises being more commonly known and designated by the street address 1745 Olejule Lane,Mattituck,New York 11952;tax map designation District 1000 Section 122.00 Block 05.00 Lot 002.00. SCHEDULE A AS,.T.A 2006 OWNERS POLICY r S,C.T.M. NO, DISTRICT: 1000 SECTION: 422 BLOCK 5 LOTS):2 MLAO .43 FENCE Mla :: % LAND H/r OF ROBOUA Y KALOVS Ln cb �,�.�( ra. r Iia R' ac FF 60' :m �o 87°24 50 ....... ... . 27.42. ..... ........A N: ' i ✓s�!Sra ME !N1(G!l St LOCA nays.Sh AND as DAM AREA:37y53" I: tir t7G: FF :, . tcCVancw n� ttrart - 4M7A1hY r fi_+iDLvl ±1►:7 5`=7 5 7LS: ,:HC�r17*f V•:#�F C}rJy Jt :? ."Tt�91C i71!? • : , Nar: C.s tt !'a s s�Ac s}rAEi;N'�r.:£a�;KKtJr hY�'�o.BE:�t:Y�Eun.7Rf�•c p. �i KRAUS' ROAD ��'�; r;F�. -;�: ►�� ���:��: ����:��- ��'.:� :etA4=& tts .'it►v :llt? 't -�Q:Jtszh7txs: J[s7C::t HRF"#IiFht ?_"si�3d[f J i�NF.7t f tYUh :M.. 4°rugL-1}V:�K[Nr:.O?F��d�.;:i:xXfl�+lrli S7Ri7:TtOf�S= f?*.: StIRFL7E^SI+ 1{k .: Et�C £4l. T::fr's� YL-1J1 :f'FI ^:E1fS!F&1 SUR�r OF;btSdkmllb---OROP"MTY ` `CER nnm TO: . JAP OF Vi \� _ x SfNA7FD AT. $uftolk:C.ou.�ty R.ept�,of ' j. Labor;Eicensin &Goiisiimer gffairs ; ' MQtv1EIMPROV EMQNFL"!CENSE Name r .'RANDh.T.:RQDCKER This ceit f`estfiatahe. Buslne s'�JaTA. i.. beareris'i 0y 'I 6sed "FENCE'kING OF 1�fJCKy.PQ1NT INC DBA by the•Coun(y:of suffolk Lic�nseN-Um qrr t&2,f4'2 Rosalie Drago Issued.; Q6/Q7t]992 I. Commissioner Expires: 06/0112022 I. i I i i i . i . I • YORK Workers srnre Compensation ' CERTIFICATE OF INSURANCE COVERAGE . Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance'Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS$PATIOS 471 ROUTE 25A ROCKY POINT,NY 11778 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage Is specilicallyllmlted to or Social Security Number certain locations In New York State,La.,Wrap-up Policy) , 113008276 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of-Insurance Carrier 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. 0 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. El 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'an tthat the named insured has NYS Disability and/or Paid Family Leave Benefits Insurance coverage as described above. Date Signed " 2/7/2020 By Will (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Name and Tide 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 56 is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits Insurance policies and NYS licensed Insurance agents of those insurance carriers are authorized to issue Form DB-120.9.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10.17) 111111111iiiiiiiiiiiiiiiiiiiiiii�iii�iiiiiiiiiiiiillllll YORK Workers' CERTIFICATE OF sTATE -Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board . 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 1 c.NYS Unemployment Insurance Employer Registration Number of Rocky Point NY 11778 Insured Work Location of Insured(Only required If coverage fs specifically limited to certain locations in New York State,Le.,a Wrap-Up Policy) 1d.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. Town of Southold 53095 Rte 25 3b.Policy Number of Entity Listed in Box"1 all 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 QX included.(Only check box if all partners/offlcers Included) [] all excluded or certain partners/officers excluded. This certifies that the .insurance carrier indicated above in box"3"insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation'Law.(To use this form,New York(NY)must be listed under Iter►i 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_W—Qjk.eTs'Compensation-Boaed_within-I` -IF-a policy is eariceled- -- due noonpayment 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 coverage1ndicated on this Certificate.(These notices.may be sent by regular mail)Otherwise,this Certificate is valid for one yeat after•this form is.approved,by the insurance carrier or its licensed agent;or until the policy expiration.dke 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 ofauthorized 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 ACC>RV® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 8/28/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 adADDITIONAL INSURED,the policy(les)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 Ileu of such endorsement(s). PRODUCER UUNIAUT Adam Stone NAME: AssuredPartners Northeast, LLC. PHONE (631)465-4000 Fax AAIC.No AIC No 100 Baylis Road ADDRESS:,adam.stone@assuredpartners.com Suite 300 INSURERS AFFORDING COVERAGE NAIC$ INSURED Melville NY 11747 INSURER A:Philadelphia Indemnity Insurance Co. 18058 INSURER B:Everest indemnitZ Insurance Co. 10851 Fence King of Rocky Point,- Inc. INSURERc:Shelte ' Dint Life Insurance 81434 DHA: Swim Kings POO1S 6 Patios INSURER D: .471 Route 25A IN5URERE: Rocky Point NY 11778' INSURER F:COVERAGES 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 MAYBE 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 LTR TYPE OF INSURANCE ADDL SUER - POLICY EFF POLICY EXP " imsr) wynPOLICYNUMBER fMM1DDronly) (MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY. EACH OCCURRENCE $ 1,b00,000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 5;000 X Contractual Liability PHPK2175396 9/1/2020 9/1/2021 MED EXPAn one arson $ 10,000 PERSONAL 8 ADV.INJURY $ 1,006,000 GEN'LAGGREGATELIMITAPPLIESPER GENERAL AGGREGATE $ 2,000,000 POLICY JET F"]LOC PRODUCTS-COMP/OPAGG $ 2.,0 0.0,000 OTHER: AUTOMOBILE LIABILITY $ _."--.-- _COMBdEOSINGLELIMIT..____.$_. - en" ----.�-]:;000000" X ANYAUTO ------ A ALL OWNED SCHEDULED AUTOS PHPK2175396 BODILY INJURY(Per person)' $ AUTOS AUTOS 9/1/2020 9/1/2021 BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED AUTOS PROPERTY DAMAGEJPer $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ HEXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ - WORKERS COMPENSATION X PER OTH- ANDEMPLOYERS'LIABILITY YIN A LITEE E ANY PROPRIETOR/PARTNERIEXECUTIVE SW5WC00205191 11/05/2019 OFFICERIMEMBE2 EXCLUDED? NIA 11/05/2020 E.LEACH ACCIDENT $ '-1,000,000 (Mandatory In NH) SRSWC00205-201 11/05/2020 11/05/2021 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000,000 C NYS Disability DBL37154 2/1/2020 2/1/2021 Statutory DESCRIPTION OF OPERATIONS I 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) i NOTES 1. NO SOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR 6 FEET OF EXCAVATION ATTHE DEEP END. l/l 2. TH15 POOL MEETS THE REQUIREMENTS OF AN51/APSP/ICC-5"AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING O POOL5'AND 1996 BOCA CODE-SECTION 421.DIVING EQUIPMENT IS NOTALLOWED. APR tlEi A� �ROTED 36' 10' 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY5URROUNDED WITH A BARRIER CONSTRUCTED LAW REQUIREMENT5 OF SECTION R326.4.2.1 THROUGH 8326.4.2.6 OF THE NEW YORK STATE RE51DENTIALCODE(2020)AND IN CONFORMITY WITH ALL SECTIONS Ll OF THE SOUTHOLD TOWN CODE.DWELLING WALL(5)MAY SERVE AS PART OF THE POOL BARRIER AS PER SECTION 8326.4.2.8 AND DAT B.P.# CONDITION(1)ARE MET.OPERABLE WINDOWS IN THE WALL(5)USED AS A BARRIER SHALL HAVE SELF LATCHING DEVICE.ACCESS GATES /�() SHALL COMPLY WITH SECTION 8326.5.2 OF THE NYS RES IDENTAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY V) CO FEE v L V: LOCKED WHEN POOL IS NOT IN USE OR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. O �' 4. PURI NG CONSTRUCTIONTHECONTRACTOR SHALL ERECT ATEM PORARYBARRIER AROUND THEEXCAVATION JAW THECODE OFTHE NOT Y BUILDING DEPARTMENT AT TOWN OFSOUTHOLD. Q p 765 802 8A TO 4P FOR THE AY-6' >_ H20 H20 5. POO L MUST BE EQUI PPED WIiH AN APPROVED POOL ALARM CAPABLE OF PETECTI NG ENTRY I NTO TH E WATER AND SOUNPI NG AN v FOL WING INSPECTIOiNIS: AUDIBLEALAPM UPON DETECTION THAT 15 AUDIBLE AT POOLSIDE AND INSIDETHE DWELLING. THEALARMMUSTBEINSTALLED, z QZ 1. F UNDAT!ON TWO REQUIRED MAI NTAINEE)AND USED INACCORDANCE WITH THEMAN UFACTURERS INSTRUCTIONS. THE ALARM MUST MEET A5TMF2208 Ln STANDARD SPECIFICATION FOR POOL ALARMS. THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACH EDTOORDEPENPENTON)OF F R POURED CCII',"PE T E d PERSONS. C � 2. R UGH - FRAMNG =LUMBING o 6. POOL5UCTION FITTINGS(EXCEPT FOP,SURFACE SKIMMERS)MUSTBE PkOVIPEPWITHA COVER THAT CONFORMS TO A5ME/AN51 3. I� ULATfON A112.19.8M ORA MINIMUM 18"x 23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MV5TBE EQUIPPED WITH B ATMOSPHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN.SUCH 4. FI AL - CONSTRUCTION MUST PLAN! VACUUM RELIEFSYSTEM55HALLCONFORMWITH ASMEA112.19.1708BEA GRAVITY SYSTEM APPROVEDBYTHETOWN OFSOUTHOLD. POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE. THE SUCTION FITTINGS SHALL BE B COMPLETE FOR C.O. N.T.S. SEPARATED BY MINIMUM OF3'AND MUST BE PI PEP SUCH TIIAT WATER 15 PRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE ALL ONSTRUCTI OI'I SHALL MEET THE POSITION,MINIMUM OF6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO REQ IREMENTS OF THE CODES OF NEW THE 5KIMMER/SKIMMERS.AREQUIREP POOL ATM05PHEPIC VACUUM RELI EFSYSTEM SHALL BEIN5TALLEDASPEP,NYS RE5IDENTTALCODE 16'VINYL COVERED STEPS 8326.6.3(2020)AND IN ACCORDANCE WITH TOWN CODE. YOR STATE. NOT RESPONSIBLE FOR DESI NOR CONSTRUCTION ERRORS. � '' 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQVIREMENTS OF NEPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE NYS RE5IDENTIAL CODE SECTIONS 4201 THROUGH 4206.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND M BE PROTECTED BY A GROUND FAULT CURRENT INTERRUPTER(GFC0 CURRENTCARRYING ELECTRICAL CONDUCTORS EXCEPT FOR TH OSE Ql PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENTSHALL MEETTHE SEPARATION REQUIREMENTS OF TABLE E4203.5.ALL U 4 METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED r: * 2'TO4'5AND BOTTOM DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. � N OMPLY WITH ALL CODES OF 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITHABACKFLOWPROTECTIONDEVICEIAWNY5PLUMBINGCODE608. roQ02 CV v Ln N W YORK STATE & TOWN CODES SECTION A 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERW15E STATED. 00 v Z AS REQUIRED AND CONDITIONS OF N.T.S. 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. Qj_ v -� o zs ��,„,,nl B nIA ISI WATER LINE TOP OF WALL 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/APSP/ICC-5 SECTION 6, v p Qj R �t1f:i}{��+at 4, B, 4, y co TO PLACE hIE POOL IAW TOWN OF 50VTHOLD CODE SETBACKS. d !- �C Pt;idi�fl�u BOARD ° 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. W� ^VV?i IVLU T ' 'iI TRUSTEES ^ 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH<10%SILT. GROUND WATER SHALL NOT EXI5T WITHIN THE EXCAVATION. IFGROUND O WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. Q CO `I'v 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONALAPPLIANCE ENERGY O ®C [ I Lip fy SECTION B CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED LAW ANSI 7-21.56 AND SHALL BE INSTALLED IAW U (!i`t (�/p MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATER5 SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR N.T.S. GUARDED TO PROTECT AGAIN5TACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH U I Il�ll r A n l�V(e l TEMPERATUREAND PRE55URE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM.A BYPASS LINE SHALL BE /L9i i INSTALLED FROM INLETTO OUTLETTO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE Il FOLLOWING ENERGY CONSERVATION MEASURES: ^• WITH® T CERTIFICATE F4 CD E COPING AND WALKWAY 1O" 16.1 AT LEAST ONE TH ERM05TAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. 00 CBY OTHERS) 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE CD PVMP FROM SKIMMER GRADE OPERATION OF TH E H EATER W ITHOUT AP)U5TI NG TH ETH ERMO5TAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE E ®F ®CC JPANCY WATERLINE A. PILOTLIGHT. To DI5PO5Av 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THI5 REQUIREMENTARE OUTDOOR POOLS ti w DRYWELL VND15TIJRBED EARTH DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) • 16.4 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET w B r Y / 3500 PSI POURED CONC. d TO RUN THE MINIMUM TIME NECE55ARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SAN ITARY CON DITION IAW APPLICABLE z DIVERTERJ O 5/B°REBAR.2)TYP. . a SANITARY CODE OF NEW YORK STATE. g ccc�iii777 000 T �i VALVE RETAIN ST vINYLLINER 17. THIS DRAWING I5 FOR STRUCTURAL SHELL ONLY.ALL ACCESSORIES ANDAPPURTENANCESAREPERNEI)BYOTHERS. z = prrQ M WATER RUNOF 2°T04°SAN r PURSUANT 0 CHAPTER 206 F�TER 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTSAND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHT OFTHE N o WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" OF THE TO N CODE. 19. PLACE CONCRETE ON SANDY TO LOAM 501L REMOVE ANY CLAY PEP051TANPREPLACE W/COMPACTED CLEANBACKFILL. w C [ TO RETURNS 'pF NEW Y 20. THERE 15 NO MAIN DRAIN IN THIS POOL,SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY.THI5 MEETS y CHECK VALVE VERTICAL 3/8"REBAR 0 5'O.C. REQUIREMENTS OF THE NY5 RE5IDENTIAL CODE-SECTION R326.5 FOR ENTRAPMENT PROTECTION. i PLUMBING SCHEMATIC (Nor SHOWN) 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: T HO/ygS ' �. N.T.S. WALL SECTION 21.1. THE NEW YORK STATE RESIDENTIAL CODE-SECTION R326(2020) ,fi <' T 21.2. THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2020) 11 (' c•, -r" N.T.S. 21.3. THE NEW YORK STATE FUEL GAS CODE(2020) �' W A F7.art 21.4. THE NEW YORK STATE SANITARY CODE. ! I c` EQ� CT�°ni��a�l. c �, y ��fv 21.5. ANSI/APSP/ICC-5STANDARD FOR RE5IDENTIALIN-GROUND SWIMMING POOLS. IP° itd �•� IDti�'Tj`�� P,EF ENCLOSE FOOL TO CODE- 21.6. BOPEOFTHECA OWNOFSCTION \ r �� ��✓✓n i . Sol g� E 21.7. CODE OF THE TOWNOFSOVTHOLD. � S� Q�aa1� �S 'UPON COMPLETION 22, ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. ;:BEFORE"WATER" �ROFESS\O�