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HomeMy WebLinkAbout47792-Z ��o�ogllFFQL Town of Southold 8/11/2022 a � l P.O.Box 1179 y ? 53095 Main Rd y�ow �oo� ¢r Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43319 Date: 8/11/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 200 Hyatt Rd., Southold SCTM#: 473889 Sec/Block/Lot: 50.-3-8 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/6/2022 pursuant to which Building Permit No. 47792 dated 5/6/2022 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 GCG Bayberry LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47792 8/8/2022 PLUMBERS CERTIFICATION DATED 0 Autkfcorized i nature TOWN OF SOUTHOLD o�SufFocK�oG. y BUILDING DEPARTMENT y TOWN CLERK'S OFFICE o . 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#: 47792 Date: 5/6/2022 Permission is hereby granted to: GCG Bayberry LLC c/o Glen Ravn 81 Harvard Ave Rockville Centre, NY 11570 To: construct accessory in-ground swimming pool as applied for. At premises located at: 200 Hyatt Rd., Southold SCTM #473889 Sec/Block/Lot# 50.-3-8 Pursuant to application dated 4/6/2022 and approved by the Building Inspector. To expire on 11/5/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buil g Inspector OF SO(/l�ol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 a� sean.devlin(aD-town.southold.ny.us Southold,NY 11971-0959 COUlm'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: GCG Bayberry LLC Address: 200 Hyatt Rd City,Southold st: NY zip: 11971 Building Permit* 47792 Section: 50 Block: 3 Lot: 8 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Johnson Electrical Contr. License No: SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Surrey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt 1 Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 4'LED Exit Fixtures Pump 1 Other Equipment: Pump 220GFI, 1 Light 120GFI w/ 10OW J&J Tranny, Heater Notes: Pool Inspector Signature: Date: August 8, 2022 S.Devlin-Cert Electrical Compliance Form i , H20oV44- OF SOUI,yOlo � �q2 # * TOWN OF SOUTHOLD BUIL G DEPT. °`ycourm��' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: ep f DATE INSPECTOR -� �apF so o # Q.-- TOWN OF SOUTHOLD BUILDING D PT. �ycouto, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR ' ���]„�1�o1��OF SOUTyOIo TOWN OF SOUTHOLD BUILDING DEPT. couto, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: Wr DATE 9 J0 )0 v INSPECTOR I �� _ `` =•�r�';^c` t � !moi -`•,-` y � m. FIELD INSPECTION REPORT7 DATE COMMENTS .� J b FOUNDATION(1ST) ------------------------------------ O ❑ O FOUNDATION(2ND) z A� p O U ROUGH FRAMING& y PLUMBING O'C 7d V' O c. r � H INSULATION PER N.Y. �- STATE ENERGY CODE FINAL ADDITIONAL COMMENTS 9 VD f/-) z m � r V� y O z x H � C b N � ilfFot co�. TOWN OF SOUTHOLD-BUILDING DEPARTMENT 4 Town Hall Annex 6437 Main Road P. O. Box 1179 Southold, NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 h_,.}tt 2s:/h5jnnv.southalcitosvnny aov Date Received t APPLICATION FOR BUILDING PERMIT For Office Use Only APR p 6 2022 PERMIT NO. (aq�LBuilding Inspector: _ gUl OF SOUiiiOLo Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owners Authorization form(Page 2)shall be completed. Date: 312912 Z OWNER(S)OF PROPERTY: Name: ,�CO) A, Y ,L LG SCTM#1000- 50 3 " g Project Address: 1 'T SQA I �� i �'/ r�� `fi-I�n1 t Phone#: b2 G 63 Email: Mailing Address: X SOUTH 2 0 i S\J V 112-7 0 CONTACT PERSON: Name: k(0N Ch AlE&05� Mailing Address: ](� S�<�}22�,(, i P_ 7 >✓��jf C�t (� (J� t/ �( �Gf Phone#: -7 �' �J 5 Email: H 0tJ—,BE_�,J(T 60 RS A), C DESIGN PROFESSIONAL INFORMATION: Name: Go 07V t9 WEE D N CET d C -E C. Mailing Address: (s " Z V (2 Q Q (., Email: Phone# - jl_.,"4 4J,�J� `'1 "� CONTRACTOR INFORMATION: '4 L 2P Name: 0�2�•''..-y'.,�`,,;',�•YO,L �r���C Mailing Address: � � (CJ��J SD U j_#4"/-/O� �/f /j�6 i Phone 0PC2 1 S 6DC?���C C DESCRIPTION OF PROPOSED CONSTRUCTION w Structure Addition ❑Alteration ❑F epair ❑Demolition Estimated Cost of Project: Other 1�)0 0221 2,,0 ® $ Will the lot be re-graded? Zyes 1:1 No Will excess fill be removed from premises? EKes. ONO 1 PROPERTY INFORMATION Existing use of property: Vis( 441' Intended use of property: 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 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 pass A misdemeanor pursuant to Section 220AS of the New York State Penal Law. Application Submitted By(print n e)• gAAuthorized Agent OOwner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (Name of indivi I signing contract)above named, (S&'�s the l0C,7,I--(o 10k-) (Contractor,Agent,(torporate 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 the application file therewith. Sworn before me this / day of\� lel ,2O—Z7. Notary P lic PROPERTY OWNER AUTHORI711AUREIDNIN r DAWN 0. (Where the applicant is not the NOZrH49 8373 NEW YORK SUFFOLJ(COU sslFWM MAY 26 ),— C1C--Q7L8y- residing at do hereby authorize 10 A/ 1+(C�- �-(r9 7�;L S,- �% to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's ignaturec�� Date Print Owner's Name Z BUILDING DEPARTMENT- Electrical Inspector r ,oma® IV/ 2TOWN OF SOUTHOLD Hall Annex - 54375 Main Road - PO Box 1179 2 4 2022 Southold, New York 11971-0959 r; 410 k� ®� 1' phone (631) 765-1802 - FAX (631) 765-9502 �1 w�o so�THoEA r gerr(c�southoldtownnv.gov seand&southoldtownnv: ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date--2 h 1 Company Name: � e;tzTr C jmtA LLc- Electrician's Name: . . License No.: ,�� _ Elec. email: "�,,; e l��a b c.. �j , I Elec. Phone No: 5.1,6 -Lti. Gcq 50I request an email copy of Certifica a of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: �9;" '_T Address: B Cross Street: ;,, Phone No.: Bldg.Permit#: _ email: Tax Map District: 1000 Section: '50 Block: 3 Lot. 8' BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE]FOOTAGE (Please Print Clearly): Square Footage: -- -__.___._ Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: 1_71 YES E] NO Issued On , ' n . Temp Information: (All information required_) Service Size F-11 PhF—]3 Ph Size: __ A # Meters Old Meter# LJ New Service0 Fire Reconnect[]Flood Reconnect OService Reconnenderground❑Overhead # Underground Laterals')7, 1 M2 LJ, H Frame Pole Work done on Service? N Y RN Additional Information: PAYMENT DUE WITH APPLICATION BUILDING DEPARTMENT- Electrical Inspector ,6 0 TOWN OF SOUTHOLD fOWN11 H a I I Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 L�L-dle'phone (631) 765-1802 - FAX (631) 765-9502 80ILD1 No�OFr,-r OWN go seand&south ldtownnv.aov _gerrfl south oldtown ny.gov 0 APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date-- '2Z3 2-2-- Company Name- Electrician's Name: License No.: Elec. email: 'FLL J Elec. Phone No: I request an email copy of CertificaYe of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: 6. ,, Address- Z k L'i-7 Cross Street: Phone No.: BIdg.Permit#- — Lf 7719, email: Tax Map District: 1000 Section: 6r) Block- 3 Lot-, BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly).- 'flUD5 yy, yvn 1 0 V Square Footage: J Circle All That Apply: Is job ready for inspection?.- F,-] YES 7 NO F_]Rough Ia. ❑ Final Do you need a Temp Certificate?-. [7] YES ❑ NO issued On Temp Information: (All information required) Service Size F-11 PhF-]3 Ph Size: A # Meters Old Meter# New Service[:]Fire Reconnect[:]Flood Reconnect[:]Service Reconne' ndergrou"nd[:]Overhead # Underground Laterals�]1 []2 L] H Frame r-1 Pole Work,done on Service? r N Additional Information: PAYMENT DUE WITH APPLICATION PERMIT # Address: Switches I Outlets G FI's Surface Sconces H H's UC Lts Fans Fridge ., „ ... HW Exhaust Oven W/D Mini Smokes DW Micro G6i 6.. tqr. Carbon .. Combo Cooktop Transfer AC AH Hood Service ... Amps 'Ha've Used Special: AlComments 1 'S <NTEREWorkers! CERTIFICATE OF �Tlt oa�pansation Board ,NYS WORKERS' COMPENSATION INSURANCE COVERAGE h ia.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LOPEZ JR POOL SERVICE CORP 631-252-5838 PO BOX 6053 ic.NYS Unemployment Insurance Employer Registration Number of Insured Southampton, NY 11969 N/A Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in hlew York State,i.e.,a Wrap-Up Policy) Number 82-4530810 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wellfleet New York Insurance Company TOWN OF SOUTHOLD 3b.Policy Number of Entity Listed in Box"1 a" 53095 ROUTE 25 N9WC366977 PO BOX 1179 3c,Policy effective period Southold, NY 11971 11/13/2021 to 11/13/2022 3d.The Proprietor,Partners or Executive Officers are Included,(Only check box if all partners/officers Included) X❑ 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 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"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage Indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate Is 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 after 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'Compensatlon 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: Rakesh Gupta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 03/28/2022 (Date) Title: Chief Operations Officer Telephone Number of authorized representative or licensed agent of insurance carrier: 844-472-0967 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 i ACC)RV CERTIFICATE OF LIABILITY INSURANCE DATE(M 3/2'8/2M2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pol(cy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policles may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT GIACIZZO INC/GIACALONE INS.AGY NAME: :PHONE 57 EAST MAIN ST,UNIT 3 E t No RIVERHEAD, NY 11901 ADDRESS: GIACIZZOINC@GMAiL.COM CONTACT:JEANINE GIACALONE INSURERS AFFORDING COVERAGE MAIC 0 INSURERA:ATLANTIC CASUALTY INS CO 42846 INSURED LOPEZ JR POOL SERVICE CORP INSURERS: PO BOX 6053 INSURER C: SOUTHAMPTON, NY 11969 INSURER D: INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER LTR TYPE OF INSURANCEJIM WVD POLICY NUMBER MMIDDfyYYI POLICY YY LIMITS COMMERCIAL GENERAL LIABILITY L068026693-0 EACH OCCURRENCE $ 1,000,000 A 4l19/20Z1 4/19/ZO22 DAMAGE O RENTED CLAIMS-MADE ® OCCUR PREMISES Ea occurrence $ 100,000 MED EXP Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEPRCT O- ❑ LOC PRODUCTS-COMP/OPAGG $ 000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO OWNED SCHEDULED BODILYINJURY(Perperson) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION STATUTE OT - AND EMPLOYERS'LIABILITY Y/N STAT TE ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? D N I A E.L EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) POOL SERVICE/INSTALL CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD, NY 11971 " AUTHORIZED REPR5E ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD i I 4 mYO.. Workers' are 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 la,Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured LOPEZ JR POOL SERVICE CORP (631)252-5838 945 N.SEA MECOX RD WATER MILL NY 11976 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 82-4530810 2.Name and Address of Entity Requesting Proof 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 3b.Policy Number of Entity Listed in Box"la" 53095 ROUTE 25 L86113-000 PO BOX 1179 SOUTHOLD, NY 11971 3c.Policy effective period 4/19/2018 to 3/27/2023 4, Policy provides the following benefits: FXJ A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. [] B.Only the following class or classes 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 insuran coverage as described above. Date Signed 3/28/2022 By (Signature o Insurance carrier's aut orized r eta iveAINYS-M—enle4 Insurance Agent of that insurance carrier) Telephone Number (212)355-4141 Name and Title Bebi Ishmail,Supervislor-DBL/Pallcy 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 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 compiled 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 5mployee) 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-121).1. Insurance brokers are NOT authorized to Issue this form. DB_120.1 (10.17) 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, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first,two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (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 carrier 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. 1136-120.1 (10-17)Reverse I °1 ' \' ��° SURVEY OF PROPERTY 0 SITUATE f <�<ti,o � ; . , j o o SOUTHOLD �s N TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX N0. 1000-50-03-08 t SCALE 1 "=30' y DECEMBER 12, 2020 AREA = 32,388 sq. ft. �F<< �� 0.744 ac. �' NOTES: 1. ELEVATIONS ARE REFERENCED TO N.A.V.D 1988 DATUM — �4j X sOl/j ��S°" �/� ? EXISTING ELEVATIONS ARE SHOWN THUS: �j' 60.7 mac, Py, �. ? EXISTING CONTOUR LINES ARE SHOWN THUS:XX————XX ,9� tS�J+ '(. 'ry. MINIMUM SEPTIC TANK CAPACITIES F R A 6 EDROOM HOUSE IS 1,80P G LLONS. ��. �`. I �.� F .a, � �; �.�•a✓_ 1 TANK;- ��, ��� i L� P/ . A cr ` 4 �+ Q ` %' T•".x 3. MINIMUM LEACHING SYSTEM FOR A 6 BEDROOM F�OUSE IS 400�sq ft SIDEWAUL AREA. ci ' `xz1 tC! °i" �oF. as l'i r _. " ,r ti ,r` 2 POOL: 18' DEEP, 8' dia. ,�/ A� �y� I ' / ��\ 0� a ^�'� •f" { •:v ' PROPOSED FUTURE 50X EXPANSION POOL PROPOSED 8' DIA. X 8' DEEP LEACHING POOL ��y\� F PROPOSED••1-9e9-GALLON SEPTIC TANK c� v 1 / I 59.9 1 / • s2.2 / •. .��° `, s'h°� 'e, X XO°F ��� 4. THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD <j OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS. S �A \\\y"0 �p� DRAINAGE SYSTEM CALCULATIONS /D � I / /x�� $��'} kP � `\ ROOF AREA: 2,125 sq. ft. Q, \ 2.125 sq. ft. X 0.17 = 361 cu, ft. �0 61.s .:. `I �`i �' ' \ o �� 9� \\ 361 cu. ft. / 42.2 = 8.6 Vertical ft. of 8' dia. leaching S8.7X x /� `�\` /Q�� S � PROVIDE (2) 8' dia. X 5' high STORM DRAIN POOLSyj Pool required f- ...... "`'.' ...' X81 \ PROPOSED 8 DIA. X 5 DEEP DRYWELLS FOR ROOF RUN–OFF ARE SHOWN THUS: : I' .D� hQp \ QA'::::::I::. V \ \ \•�.. : 1 0 C iso X 58.6 ,� 61.0 ,q ro ss 1 x/ \ \ \ I TEST HOLE DATA '\h I 0 (TEST HOLE DUG BY SHAWN BARRON ON JANUARY 8, 2021) :.170 0 58.0\X ::0 i �j_�1�::: .......: 0 ,•` 111E , 1 j q I fFp_ cPy / 1' SANDY LOAM (SM) \ 1 Q+ x ST�� I 700, - IZ-10 \ .I (� (� 2 n 1 n n "rO, \ \ 57.0 x Q \ I�, �' \\ I / SANDY SILT WrrH GRAVEL (ML) EL 41.5' r 1 r �lF �lc ♦ ` 1 \ X 18.0' GROUND WATER ENCOUNTERED APR F 2Qi2 ,50 \ `\ \\"o °�S/,yX —60 <,Z��ti , o O \ \ \G O s \ ID 0\)��0 , / WATER IN SILTY CLAY WITH GRAVEL (SC) G 1 i 30.0' BUILDING DER\i' \ ` \\ `\\\ /� �����•¢0 �� �� / TOWN OF Sol 1TI-(3t\ ' 6g�10 WATER IN BROWN FlNE TO COARSE SAND SP � R c \ \ TEST HOLE ' \ \ 36.0' 1 UVdDtOi i lils) ,� �° d \ \ \ X 58.3 `\r 9 ` j / OG EL 1.6' '.1$El rvices. ���9 °yam 55.9' .-+ I.•:• 0 y TEST HIGHEST EXPECTED GROUND WATER I✓a'aiI rJ��'3�(_.-•'.�'.gI CI�..�, r^}j'� 1•,.l l.r::G�.'\\e Advance, , `— WELL No. ucrc 4105040724&',t901 c 8�+ ^.1 0 / ___._._–.._......_._...__–....—..........�•c\ `c�,p;�•yc ��'Y•�tfl !s \�1 � \\ S8 i \ i ...._- ALT1� -rEi'.V1cE£+ p,7iAENT OF A \ SUFFOLK OOUI+iTY DEPAI: \ FOR A AL ©: CONC' T STRU114 \ F ' PERGIIT FOR APPROV \ i SINGLE n-,i�`; PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED \\ OD / BY THE LI.A.LS. AND APPROVED AND ADOPTED -t n2lFOR SUCH USE BY THE NEW YORK STATE LAND -' - \ \\ ' °O\' TITLE ASSOCIATION. _ -- � •,•�, Iri_t .... i'•;0. \\\ \ ,moi� 2 •� • ROOMS Or`\` \ve BED \\ �. OVAL L1A,E OF APPR sem, N.Y.S. Lic. No. 50467 O\' UNAUTHORIZED ALTERATION OR ADDITION Y ' O TO THIS SURVEY IS A VIOLATION OF GF�c�R Excavation Inspection Required � SECTION 7209 OF THE NEW YORK STATE ! �S �i"(� / -\ EDUCATION LAW. Nathan Tait Corwin III �ty� COPIES OF THIS SURVEY MAP NOT BEARING For Sanitary i QP���� Xt' EMBOSSED SEAL SME LAND HALL INOT BE CONSIDERED By health Department OF � TO BE A VALID TRUE COPY. Land Surveyor ONLY TO THEPERSONFD HEREON SHALL RUN V OR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Successor To: Stanley J. Isaksen, Jr. L.S. TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND Joseph A. Ingegno L.S. X TOTHE ASSIGNEES RTIFICAT ONS ARE NOT LENDING NTRANSFERABLE. Tittle Surveys 640 ys – Subdivisions – Site Plons – Construction Layout PHONE (631)727-2090 Fax (631)727-1727 THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILING ADDRESS AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16 ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947 AAP�PRD AS NOTED DATEB.P.# 2 FEE: !�v: RETAIN STORM WATER RUNOFF NOTIFY BUILDING DEPARTMENT AT PURSUANT TO CHAPTER 236 765-1802- 8 AM -10 4 PM FOR THE OF THE TOWN CODE, FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH -. FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTR1.iCTION MUST BE COMPLETE ALL CONSTRUCTION SMALL MEET THE REQUIREMENTS OF THE CODES OF NEW ELECTRICAL YORK STATE. NOT RESPONSIBLE FOR d�����CTI®9!q REQUIRED OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF >— ,. ,•�-- -- ENCLOSE PO% TC}';CiOD r 110M T=?L" G BOARD ,"UPON COMPLE�LC��1; Srn ITHGL9 STEES BEFORE,NW T Pi-y—g PEG OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICf OF OCCUPANCY ol 201-011 cm Lu 0 O Q o co co} R1=TUR RETURN J Z 40i_0m co 0 0 T 13'-0'1 10 Q co DRAIN 0 Z Z VINYL OO H � a a 20'-0" X 40'-0" . �, � Q = O } w O i 2 a C) z 00 o n. N co U DRAIN cn •� w 10 0 C d az Lu co 0 3j (A Lu 3�co0 LI r LI t LI Hr 0 u z o SKIMMER SKIMMER p. ? v,a°tD :. ', N Lu I— I— u. l +°" Q 1 l.. I I F (VES = w 0 I_ i `A D m coLn , w ?�s990 -.,'<; ' ESSIQ��I''`" 1 POOL PL AN z sca�e: iid� = i'-m' o POOL NOTES w ® EcE � WE - ALL WOI?I�SMALL BE IN ACCOi�ANCE WITH THE LATEST NY STATE t LOCAL APR n F 2022 BUILDING CODE -ALL DIMETISIONS GIVEN SHALL BE CONSIDERED BUILDING DEPT. A MIN.CONTRACTOR MAY INCREASE TO TOWN OF SOUTHOLD PROVIDE DOR DRAINS 1 COPMG -CONTRACTOR TO PROVIDE POOL FENCE t ALARMS AS REQUIRED BY LATEST NYS BUILDING CODE ,U - ' O z C\l 0 2" COPIWs TOP OF WATER F W N U- VINY o~ ¢ o 00 L z co 20'-011 X 401-011 ¢ } m Z U � Q CD o 0 16'-0" 'i'-0" 4'-0" 40'-011 r- U) z 0 � O } H SECTION A 0Z w 0 SCALE: I/4" = I' -0" f- J -J � � z O 0 O = z d a. N (O QU cn C •L W N V � � 000 C: Q. � z tri LU W co d. CO� N TOP OF WATER �O U W 0 M M TEMPLATES TEMPLATES a M o,%D ko VINYL E uj LC O O CONCRETE (� U CONCRETE a W 201-011 X 'fY/01-iG//SII - - 4-JSAND � 6 I� - ," 0 u ' W of NEW , �v� D cn z �r /v ' i� cn > SECTION 5 SCALE: i/4" s I'-0" �,��"""-.--"-'�` bfESSIC" '-- > LU