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HomeMy WebLinkAbout45855-Z ��o�0g11EFOCK G� Town of Southold 7/9/2022 P.O.Box 1179 0 W m 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43235 Date: 7/9/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 225 Marion Ln.,East Marion SCTM#: 473889 Sec/Block/Lot: 31.-8-12.11 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/20/2018 pursuant to which Building Permit No. 45855 dated 2/26/2021 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 Mulvaney,Diane of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43079 11/29/2018 PLUMBERS CERTIFICATION DATED '49A-/'A- jd46-� th ri d ignature TOWN OF SOUTHOLD O�SI1FFQik�o . BUILDING DEPARTMENT z TOWN CLERK'S OFFICE ©� • SOUTHOLD, NY dal 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 #: 45855 Date: 2/26/2021 Permission is hereby granted to: Mulvaney, Diane 225 Marion Ln East Marion, NY 11939 To: Construct accessory in-ground swimming pool as applied for. Replaces BP#43079 At premises located at: 225 Marion Ln., East Marion SCTM #473889 Sec/Block/Lot# 31.-8-12.11 Pursuant to application dated 2/26/2021 and approved by the Building Inspector. To expire on 8/28/2022. Fees: PERMIT RENEWAL $150.00 Total: $150.00 Bui g In for TOWN OF SOUTHOLD 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#: 43079 Date: 10/1/2018 Permission is hereby granted to: Mulvaney, Diane 225 Marion Ln East Marion, NY 11939 To: construct accessory in-ground swimming pool as applied for. At premises located at: 225 Marion Ln, East Marion SCTM # 473889 Sec/Block/Lot# 31.-8-12.11 Pursuant to application dated 9/20/2018 and approved by the Building Inspector. To expire on 4/1/2020. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 it spector 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, dditions to dwelling$50:00 Iterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 . 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date., /b New Construction: Old or Pre-existing Building (check o Location of Proper rtY� House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section I Block Lot _ Subdivision Filed Map. Lot: Permit No. 0 Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate; (check one) Fee Submitted: $ AA'pp4licantignature pF SOpl�ol h O Town Hall Annex Telephone(631)765-1802 54375 Main Road N Fax(631)765-9502 P.O.Box 1179 G Q �. • yo Southold,NY 11971-0959 roger.richerta-town.southold.ny.us Q �yCOUNT`1,� BUELDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Mulvaney Fenn Address: 225 Marion Ln City: East Marion St: New York Zip: 11939 Building Permit* 43079 Section: 31 Block: 8 Lot: 12.11 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Bethel Electric License No: 40557-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1 st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors- Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: In ground swimming pool to include, bonding, control panel, 1-pool pump, 2-pool lights, heat pump,salt generator, 1-GFCI circuit breaker, 1-GFCI recpticle Notes: Inspector Signature: Date: November 29 2018 81-Cert Electrical Compliance Form.xls 50UjH � O * TOWN OF SOUTHOLD BUILDING DEPT. 76S-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [- ] SULATIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL l [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 1 Q l U�0 up✓ VIA �w IV DATE 3 INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(IST) ---------------------------------- 'FOUNDATION (2ND) No ROUGH FRAMING& PLUMBING H — INSULATION PER N.Y: y STATE ENERGY CODE -I- rliA CoOoor FINAL AD4IIONAL COMMENTS qaq 0 nzi lcn d b H TO OF SO�UTHOLD BT "k-DING DEPARTMENT BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following,before applying? AWN HALL g, SOUTHOLD,NY 11971 Board of Health TEL: (631)765-1802 4 sets of Building Plans__ FAX: (631)765-9502 Planning Board approval Southoldtownny.gov PERMIT NO. Survey Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application ExaminedFlood Permit I '20A Single&Separate Truss Identification Form n Storm-Water Assessment Form Contact: Approved (/ 20 000 Mail t Disapproved a/c Phone: Expiration 20 D M � V ector (, -� 4�O I C�� i PI-1E ►� SEP 2 0 2018 APPLICATION FOR BUILDING PERMIT I� ' Date � 20 RUT-LN,D1G DF, INSTRUCTIONS TOW* onC T be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 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 the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. 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,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code, d-regulations,and to admit authorized inspectors on premises and in building for necessary inspections. T. (Signature of a phi ant or name 'f-a orporation) 5Q911 (Mailing address of applicant) Warloyl, State whether applicant is owner, less e, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premisea ^ 1\4 U (As on the tax roll o latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of�orgte gff�er) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location o land on whichDpropos d work wills be d=e: Nitto House Number Street O Hamlet County Tax Map No. 1000 Section �' Block U b Lot 1 i Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and inten d use and occdpancy of proposed construction: a. Existing use and occupancy r b. Intended use and occupancy_ 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost �EDD� Fee (Description) (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 Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 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? YES NO_!)4 13. Will lot be re-graded? YES NO Will excess fill be removed from premises?YES NO 14.Names of Owner of premise uIWW Addres� ��'�E Pho e Phone No� 1 ��r�.� 3 � Name of ArchitechV15 LLIy AddresawY-errs Phone No 31 Name of Contractor) R614,�42CAddressiaRPe, : A-Phone Noll 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO *IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BFB REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO *IF YES,D.E.C. 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. 18. Are there any covenants and restrictions with respect to this property? *YES N� *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) r U being duly sworn,deposes and says that(s)he is the applicant (Name of mdividua signing contract�abo �ed, (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 q�efore m x "� day o EVE B MILLNER r TARP PUBLIC STATE DF YOR SUFFOLK COU No Public UC.# 1MI62 1657 Signature of Applic COMM.EXP. w-� •-7 r iff ti'' � To Telephone(631)765-1802 5437 Road ' -� ' N (631)765g116. r.0. o�c 1 2 7. 201a �o roger.richertCatown.souton��.us Southold, 11971-0 ,u:T• BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION tEQUESTED BY: I�0 FJV� Veli.. l�lrC e 4C Date: - ` la 8 ;ompany Name: ��' Q ec:?-r�Cof "�'1 p, i' L dame: -.lA.r,i 0V\ .icense No.: — �d dress: LIJA ec n AU , IOBSITE,INFORMAL"ION: (*Indicates required information •Name: :, IfigY `�iaYl2 �v�yGne ]FIt Address: 225. a ri on LC1ri� LOIS— arl o�n NY Crass Street: (- Q Phone.No.: j1. 410'�$3�Co31 "ermit No.. BPH307q 22 �O31 5�� 783 ax-Map District: - 9000 Section: 3----�_._._.. Block: Lot: Lel BRIEF DESCRIPTION OF WORK (Please Print Clearly) -- �f;�•1.A�lV} /��� 00,1 �.�r�.� �_ P'fease Circle All That Apply) Is job ready for inspection: YES N0. Rough In Final Do.you need a Temp Certificate; �� YES QN amp Information (If.needed) Service Size: 1 Phase 3Phase 00 -u360 40,0.... ; Othe 900 960 200 3 _ ...,..,.. ...,z .a:.. . .. ;,. ..... .. :.. ., ..... .. ..0. ,... . . r.. ,. Vew Service: Re-connect Underground Number of Meters Change of Service Overhead, dditionallnformatlohi �' ,c 7 PA T DUE WITH APPLICATION C O, �� V� D 1- ! LAJ Gln, •16" - I .82=Request for inspection Form A. a�tt . us' e1t. ° "]C'O]E I� ('��'> 7ClIE . SUPERVISOR' 1 r1 SOUTMOLDTOWNHALL-p'C3..Sdg >l�'19 ��`\� \ r1� M--]E \. JL 59095 Mahn Rbad-9OUMOLD;,�M YOLK i1hTi To wfn. oci+o: d CHAPTER 236 - STORMWATER..MANAGEMENtWORK SHEET .( T.0, BE COMPLETED:BY THE APPLICANT) DOW�'THIS I'ROMT INVOLVE~ANY OF TI3E FOLLOWING Yes No :fCNECIC ALL THAT"PLY) :❑0 A. Clearing; grubbing, grading or stripping.of 'la'nd which affects. more than•5;000.sclua,re feet:of 'ground s'urface., ❑ B: Exca.vat.iorl o.r fi1'r ,ng involving-mate: tl�an.200 cubic yards'of*Xnatetial within any parcel'or any contiguous .area. ❑ C. -Site preparation on sk es VV ch exceed- J-0,feet vertical q.s.. to :10.0 -feet of horizontal.dis'tance: o D. Site preparation within 100 feet of Wetlands beach b tuff or coastal erosion .hazard area. M�E. Site preparation within -the. one-hu'nd:red-y,ear floodplain.-as depicted. on FII3M Map of any watercourse.. EIR F. 'Installation of new or.-resurfaced Impervious surfaces of' 1,000 sq uare I feet or,moire, Unless prior approval of •a•Storm.water M.Ana-gernent control Plan was :received by fheTown and the -proposal includes in-kind replace rnen.t of :impervious surf aces.. If you'answered.NO to all of the gir'estions a>ioVC;'STOP! CbMpiete•the Applicaut sectiort•below 0-M,y'gpr Dante, Signatures.contact.Informatiotu,Date &•Couhty.Tax.1 o Spimbetr.1 "Chapter 23.8 doe&not apply to you.project. If you.answered"YFS tb one,br more of the above,please sub'mit Two copies•of a Stormwater Management Control Plan and a completed:Check List Form to-the Building.Department witg—your Building Permit AppHeation. APPLICANT: (PK4Rer¢y,OeVhen'.Desig Professl nal,pgErii,Qonttactm,Qther� NAME: J N4tron IWk Lot I ` Contact)hrormmion �� I *rQR BUILDING DEPA1tTMEN1'•U E ONLY ' n'ekghDne Numhvi � Reviewed.By: i - - - - - - - - - - - - - - - -- i Efterty Address/Location.of 4Constracti n'Wo k• D_ ate_: or SApproved•for processing Building.Permit. I ❑ tmwater-Mans erne — — , 8 nt�ControYPlan.lNot'Re. aired. I Stormwater'Management:Contioi:P;lan..'is'Requ:ired.: (F.orwat`d to Engineering Department for.Review.) FORM * SMCP-TOS MAY 2014 — --'— _ -- --•a � 3c)-2 9 APPLICANT: S.C.T.M.# 1000CHAPTER 236 (Property Owner,Design Professional,Agent,Contractor,Other) bQ 9tlFFQ � �8 (2►d1 � NAME: t� c -S Section Block Lot I�: o - STOMWATER - DRAINAGE Date: INSPECTION REPORT FORM Slgna[Ure Telephone R_=—b- DESCRIPTION OF SITE WORK TO BE COMPLETED COMPLETED Indicate All Site Work that has been completed Checking Yes/No or NA YES NO NA Submit Documentation for Compliance to the Engineering Department for Review&Approval. a. Maintenance of Erosion&Sediment Controls 00= b. Limits of Clearing&Area of Proposed Land Disturbance. c: Condition of Stockpiled Soils. 00 0 , d. Verification of Size&Depth of Leaching Pools. 00 e. Verification of Drain Pipe Installation/Concrete Parging. �0 f. Driveway Installation within the Town ROW-Highway Specifications ==F-j r c,-Fu pts RM By g. Final Site Grading-Effect on.Adjacent Property h. Inspection of.Gutter& Leader System-Drainage Piping . 0� i. Instalation of proposed Swimming Pool and discharge ring. I L ! i :^ j. Inspection of Construction Entrance/Staging Area(s). =1=F= k. Location of proposed concrete washout area(s). A Final Inspection Report must be completed prior to issuance of Certificate of Occupancy. The applicant has three options for certification of dr a e instal al ns I. 8 r * OPTION,3: 1. Certification of Drainage Installation with As-Built drawings prepared&Sealed by a Registered Design Professional Licensed in the State of New o- 19 OPTION*:2. Photographs showing placement of all drainage structures with appropriate background indicating location of all structures and drainage piping. OPTION#:3: Site Inspection of open excavation prior to complete backfill and,a written approval from the Town Engineering Department: ;,•.__;r,r„Tr., �;,� OPTION*: 1. OPTION$:2. ``" :77 D Provide Certification of Drainage Installation with As-Built drawings prepared Submit Photographs to the Town Engineering Department showing placement &Sealed by a Registered Design Professional Licensed in the State of New York. of all drainage structures with appropriate background indicating location Professional Certification&As-Built Drawings must be submitted to the of all installed structures and drainage piping&site grading. Town Engineering Department. TOS Review NOTES: TOS Review NOTES: ****FOR ENGINEERI G EPART gENLY**** Additional Work is Required for Approval. Reviewed& ❑ SMCP Installation is Not Complete. (See Notes.Above) Approved By: — — — -- - — — — — — — — — —.- — — — — — — — Stormwater Management Plan Installation has been Date: d — , ( Inspection#: Completed & Approved by the Engineering Department. FORM # SWC spection Report Form-TOS October.2014 6;O FEB 2 3 2009 ' 10� oo dr P 19 ��2a• aye ��� / cam.• 0 , �� \ X1.0 0 �m 5 9. ,1 Np V\2• r { \ ... �\G� \ 9 ,f, . ZONING DISTRIOT; R 40 FIRM ZONE X 'IES- •VISION �' A 1EAD WIRES o�`� �yti ��� 4 C WATER i• ,�� � AREAS 1000- 31-08- 12.4 = 34,194 sq.11. 1000- 31" 08- 13 = 8,334 sq.fl. NEW PARCEL I = 30,448sq.ft. 1 Qp� \ PARCEL 2= 12,080 sq.ft. APPROVED BY 'VIP, x� v1 1k� PLANNING BOARD TOWN OF SOLITNOLD Jj . - 9y mss` p�P DATE AUG 1 12009 N'NERS, 1000-31-08-12.4 \ �1,Lp � pi1_ IANE 8 SCOTT MULVANEY --y=-- "wt/i - 25 MARION.LANE \\ / �Ia�E �aFNearr 'AST MARION, N.Y. 11939 yT`s rnel�evz�' gS7"rY .I RRFSLnF�: N� Workers! CERTIFICATE OF STATE C ritatlon NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Fence King of Rocky Point.Inc. 631-744-8100 DBA Swim Kings Pools&Patios 471 Route 25A Rocky Point,NY 11778 1 C.NYS Unemployment Insurance Employer Registration Number of Insured 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 Yak State,i.e.,aWrap-Up Policy) Number 11-3008276 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Sentinel Insurance Company Town of Southold 53095 Rt.25 3b.Policy Number of EntityListed in Box"1 a" 7 PO Box i i79 2 Southold.NY 11971 12WEOJ677 30.Policy effective period 09/01/2018 to 09/01/2019 3d.The Proprietor,Partners or Executive Officers are QX 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"T'insures the business referenced above in box"1 a'for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of insurance to the entity listed above as the certificate holder in box 7'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a 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: Bethany Frabizio (Print name of authorized representative or licensed agent of Insurance carrier) Approved by: �.lX .nt�, OJ�►-a � 1rt� ( nature) (Date) Title:Account Executive 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 C405.2.Insurance brokers are NOT authorized to issue it C-105.2(9-17) www.wcb.ny.gov oYOY T Workers' CERTIFICATE OF INSURANCE COVERAGE T Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.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 specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 113008276 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 53095 Route 25 DBL37154 P.O. Box 1179 3c.Policy effective period Southold, NY 11971-0000 02/01/2018 to 01/31/2019 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. E] 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. E] B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 2/2/2018 By "d Ulf (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part i has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 11111111Q iii1u111iiiiuii°°1°11°11°°°�IIIIII APP OVED AS NOTED DATE: B.P:# FEE: r��� RETAIN STORM WATER RUNOFF PUSUANT TO NOTIFY BUILDING 1)EPARTM . OF TOWN C DETER 236 AT 765-1802..8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1.,FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH --FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST ELECTRICAL BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE INSPECTION REQUIRED REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES 7MMVIEDI T ELY"_._ AS REQUIRED AND CONDITIONS OF ENCLOSE POOL TO CODE ''t7PON.COMPLETION { "BEFORE,°.WATER'`-, JXUl0VvNP1qWNGt0APfD tOUTRaFT—OW—N TMES OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY NOTES 1. NO SOIL SURCHARGE PERMITTED WITHIN 4 FEETOF EXCAVATION AT THE SHALLOW END,OR 6 FEET OF EXCAVATION ATTHE DEEP END. 0 2. THIS POOL MEETS THE REQUIREMENTS OFAN51/NSPI-5 'AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROVND SWIMMING O POOLS'AND 1996 BOCA CODE-SECTION 421. DIVING EQUIPMENT 15 NOTALLOWED. a 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED LAW REQUIREMENTS OF a 5ECTI0N 8326.53 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD t� TOWN CODE. ACCESS GATES SHALL COMPLY WITH SECTION R326.5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY H2OHzo LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED. ALL GATES ARE TO OPEN AWAY FROM THE POOLAREA. OD 0 'A O 4. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROUND THE EXCAVATION IAW THE CODE OF THE �< TOWN OF SOUTHOLD. Q 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING A CHILD ENTERING THE WATER AND SOUNDING v AN AUDIBLE ALARM WHEN DETECTED THAT 15 AUDIBLE ATPOOL 51DE AND ATANOTHER LOCATION ON THE PREMISES WHERE THE POOL 15 LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS. Z Q Z THE ALARM MUST MEETASTM F2208 "STANDARD SPECIFICATION FOR POOLALARM5. THE DEVICE MU5TOPERATE INDEPENDENT(NOT N c 1� ATTACHED TO OR DEPENDENT ON)OF PERSONS. S.O CONC.WALLS Y � �a 6, POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI O B A112.19.SM ORA MINIMVM 18"x 23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH °L u ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN. SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH A5ME A112.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. PLAN POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 5UCTION FITTINGS OF THE ABOVE MENTIONED TYPE. THESUCTIONFITTING55HALLBE SEPARATED BYA MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM 51MVLTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE 19'VINYLCOVERED CONCRETE END STEP POSITION,MINIMUM OF 6-AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO THE SKIMMER/5KIMMERS. rn m o. Q N 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRC SECTIONS r ° 4201 THROUGH 4206. ALL ELECTRICAL DEVICES MVST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BYA U GROUND FAULTCURRENTINTERRUPTER(GFCI) CVRRENTCARRYINGELECTRICAL CONDUCTORS EXCEPTFORTHOSEPROVIDINGPOWERSZ Z c2-to 4'SANDBOTfOM ' TO POOL LIGHTING AND POOL EQUIPMENT5HALL MEETTHE SEPARATION REQUIREMENTS OF TABLE E4203.5. ALL METAL ENCLOSURES, 91 c FENCES OR RAILINGS NEAR ORAP)ACENTTO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT .L•0 WITH AN ELECTRICALCIRCUIT5HALL BE EFFECTIVELY GROUNDED. SECTION A 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE608. � LLI IV qj 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. `O TOP OF WALL WATER LINE 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. 0 T, 2- O M 4 10' 4 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/NSPI-5 SECTION 6. C t o Yi G P m 12. CONTRACTOR TO PLACE THE POOL LAW TOWN OF 50UTHOLP CODE SETBACKS. f� A L ,.-C N 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE 5VB)ECI'PROPERTY. F" N 15. THE DESIGN 15 BASED ON A DRAINAGE 501L WITH<10%SILT. GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IF GROUND WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. o� SECTION B 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY b CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED LAW MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726.'.POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECTAGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRE55VRE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPA55 SYSTEM. A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO AP)UST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE FOLLOWING ENERGY CONSERVATION MEASURES: tn r- CHECK VALVE 2'-2" 16.1 AT LEAST ONE THERMO5TATSHALL BE PROVIDED FOR EACH HEATING SYSTEM, 0. FROM SKIMMER COPING AND WALKWAY 10„ 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE pop PUMP (BYOTHERS) OPERATION OF THE HEATER WITHOUTAWL15TING THE THERMOSTATSETT'ING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE � GRADE PILOT LIGHT Z t WATER LINE a 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTARE OUTDOOR POOLS C DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) z .•. 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE 5ETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET W w VNDI5TVRBED EARTH TO DIl yt. TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION IAW APPLICABLE W Q P Coco R \DRYWELLly 3500 PSI POURED CONC. .4" - SANITARY CODE OF NEW YORK STATE. 7 3/6"KEBAB.2)TYP. GI \ v 17. THIS DRAWINS FOR STRUCTURAL SHELL ONLY. ALL ACCESSORIES AND APPURTENANCES ARE DEFINED BY OTHERS. ~i as.4 °vaivE R O vINYLLINER ad \ 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHTOFTHEZ s Y w N z Toa^sAND . WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN B" W N g ffi 0 FILTER �••' ••• �, / j •/\\ 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL O 20. THERE 15 NO MAIN DRAIN IN TH15 POOL. SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY. THIS MEETS IEW y o REQUIREMENTS OF THE IRC-SECTION 8326.6 FOR ENTRAPMENT PROTECTION, 0 �O y VERTICAL 3/8'REBAR®3'O.C. (NOT5HOWN) 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: H MSS r 21.1. THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER42(2016) 21.2. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2015) .0. WALL SECTION 21.3. TH E INTER NATIONAL FUEL GAS COPE(2015) (n fn TO RETURNS N.T.s. 21.4. THE NEW YORK STATE CODE SUPPLEMENT-SECTION R326 (2017) ( I a . / 21,5. THE NEW YORK STATE SANITARY CODE, y y CHECK VALVE 21.6. ANSI/NSPI-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. 21.7. BOCA CODE-5ECTION 421. c DE OF THE 22. ALL BAC WASH0TOBESELWN OF SOUTHOLD. � F-ONAINEDON-SITE. < S �881� P PLUMBING SCHEMATIC °ROFESS�� N.T.5.