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HomeMy WebLinkAbout46771-Z ,r Siffat C19 010 . Town of Southold 8/14/2022 P.O.Box 1179 o o 53095 Main Rd �,jj0 ao�YiSouthold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43331 Date: 8/14/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 920 Moores Ln N, Greenport SCTM#: 473889 Sec/Block/Lot: 33.-2-42 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/20/2021 pursuant to which Building Permit No. 46771 dated 9/2/2021 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 Clarke,James&Conway,Laura of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46771 4/6/2022 PLUMBERS CERTIFICATION DATED s th rize ignature e fei�,co TOWN OF SOUTHOLD k BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE oy • �� 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#: 46771 Date: 9/2/2021 Permission is hereby granted to: Clarke, James 140 7th Ave Apt 6L New York, NY 10011 To: construct accessory in-ground swimming pool as applied for. At premises located at: 920 Moores Ln N, Greenport SCTM #473889 Sec/Block/Lot# 33.-2-42 Pursuant to application dated 8/20/2021 and approved by the Building Inspector. To expire on 3/4/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector hO,*pF SO(/T�OIo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 Southold,NY 11971-0959 �� • �o sean.deviin(aD-town.southold.ny.us �yC4UN1`I,�c� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: James Clarke Address: 920 Moores Ln N city:Greenport st: NY zip: 11944 Building Permit#: 46771 Section: 33 Block: 2 Lot: 42 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043ME 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 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 11 Pump 1 Other Equipment: Intermatic Pool Panel 8 Circuit/4 Used, Salt Generator, Heater, 1 Light 120GFI, Pump 220GFI, Pool Cover 120GFI w/ Keypad Notes: Pool Inspector Signature: Date: April 6, 2022 S.Devlin-Cert Electrical Compliance Form �aoFsn�ryo l0 (X/ t3'^�`Q� 'lrA/ AJ # # TOWN OF SOUTHOLD BUILDING- DEPT. • io �`�couxn� 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 REMARKS: a DATE INSPECTOR OF SO(/lyplo 0971 L,,� # TOWN OF SOUTHOLD-BUILDINGDEPT. co,rm��'a� 765-1802 INSPECTION ' [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ . ] FOUNDATION 2ND- { ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL -[-. ],- FIREPLACE-& CHIMNEY [' ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] .FIRERESISTANT PENETRATION ELECTRICAL (ROUGH) 71 ] CODE VIOLATION PRE C/O REMARKS: �O `e Cie AAe, DATE It ZZ INSPECTOR *`� 71 NOF SO(/TyO ", ✓1`1 f # TOWN OF SOUTHOLD( UILDINd DEPT: 765.4 802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [. ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ` ] FIREPLACE &-CHIMNEY [ ] FIRE SAFETY INSPECTION [ ]'-FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) K&ELECTRICAL (FINAL) [ ] CODE-VIOLATION q, [ ] PRE C/O REMARKS: RVI: Ae AAtk�-.,J DATE Z INSPECTOR s r• / Z OE SOUTyOIo TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL e J� [ ]. FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 1 DATE S INSPECTOR 1174 4�-7-71 Jeffrey Sands Architect October 25, 2021 ® E c � � Y E APR 2 2 2n92 BUILDING DEPT: Property/swimming pool location: TOWN OFSOUTHOLD Laura Conway 920 Moores Lane North Greenport, NY RE: Swimming pool rebar inspection Attention Town of Southold Building Department: Upon inspection of swimming pool rebar and drywell at above mentioned property, I find all to have been installed to meet current building code requirements. Sincerely, Aq (P r2789� OF N Je rey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands _hotmail.com FIELD:TNSPL+�CTION REPORT DATE TS FOUNDATION(1ST)' ----------- FOUP'ATION MID.) 77 RQUG$FRAMING:& y' t PLUM-BIN.G.: INSUL�TIO'NPER N.Y. STATE'ENGY CODE FINAL'. =gyp-i Qe 1 z sx� o�gUfFO( COG TOWN OF SOUTHOLD—BUILDING DEPARTMENT y z Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy • o�� Telephone (631) 765-1802 Fax (631) 765-9502 hgps://www.southoldto=.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only D PERMIT NO. � Building Inspector: Ah L=v D AUG 2 0 2021 Applications and forms:must.be filled out in-their entirety. Incomplete applications.will not.be accepted:`Where the Applicaht"is not the owner,an- BUILDING DEPT. Owner's Authorization form(Page 2)shall be completed. TOS OF SOU'1'Ili®LD Date: j q ap; OWNERS)OF;PROPERTY: - Name: Y }. avra COY-, SCTM# 1000- Project Address: --m fCs ' A Phone#: Email: 0 ` Mailing Address: CONTACT PERSON: Name: 1 Acy-w-n Mailing Address:W Y 11 OI LAq Phone# Email: DESIGN PROFESSIONAL-INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR 1 N FORMATI ON, Name: _ -�- --_, GyS Mailing Address: �j Phone#T .�j� �j ^-���. Email:C-t coen DESCRIPTION'OF PACIPOSED-ZONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Mstima d Cost of Project: ther O S _ r 3 }n�E2 P $ " I a Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? es ❑No 1 PROPERTY:I14FORMATI ON' Existing use of property: astOY4 FMrne' Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to ____--_ u\r"'c� -- .- • --• this property? ❑Yes o IF YES, PROVIDE A COPY. heck Box,After Reading: the"owner/contractor%design professional isresponsiblefor all drainage and storm water issues as provided by Chapter236 of the Town Code.:APPLICATION IS-HEREBY MADE to the Building Department'for the issuance of a Building Permit pursuant to the-Buiiding`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 ort premises and in building(s)for necessary inspections.False'stateinents'rriade hereiin are " punishable as a Class A'misdemeanor'pursuant to Section 210.45 of the Newyork State Penal Law. Application Submitted By(print name): ❑Autho'rized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF ) a-�--r(Ina M ie rcua o being duly sworn,-deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Aq P- (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 the application file therewith. Sworn before me this IIday of AU 61 u 20 21 Q Notary Public MICHELE A MEDUSKI PROPERTY OWNER AUTHORIZATION Notary Public,state of New 3343 c Reg.No.01ME6393343 (Where the applicant is not the owner) Qualified in Suffolk County Commission Expires June 17,2023 I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 Building Department Annlication AUTHORIZATION (WhCre Ihc.lppficsant is not the.O-wner) 1. Laura Conway_ resid ng al. 920 Moores Lane, Perth Greenport (Print properly im-ners name.) 4i�iai(in� :�tfdre5+,i _ do hereby authorize. Patricks Pools °e;I y�� He-,(CL)V1 D (rlgenf 1 to apply (in my behalf to the Southold Building Department. jvvL, 08/17/2021 (Owner's Slgt]aillrC} (Uiile`)��__~� Laura Conway (Print Owner's Name) v t fat& I ING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD TipgU1LDING D-fH wn Hall Annex - 54375 Main Road - PO Box 1179 TOWN OF SOUTHOLD Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrCa),southoldtownny.gov - seand@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: L6_ f=1 C- Electrician's Name: I FI�c�—fzc G/� l P L �d„�, e- e - License No.: r A - 380ii "3 Elec. email: d r-r-tC ��jecj-a,C, ' (OAA �,rJtl- Elec. Phone No: 01- 6 7 —©4 %S' request an email copy of Certificate of Compliance o LovA Elec. Address.: WU© L, JOB SITE INFORMATION (All Information Required) Name: C It p VL _ Address: qac) IA cc�s p G ����✓�0Q IJ Cross Street: Phone No.: Bldg.Permit #: -7-7 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): POO) Square Footage: Circle All That Apply: Is job ready for inspection?: ES NO Rough In Final Do you need a Temp Certificate?: EJ)YESNO Issued On Temp Information: (All information required) \ Service Size 71 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals F 1 F2 R H Frame Pole Work done on Service? Y MN Additional Information: PAYMENT DUE WITH APPLICATION CP \\ \�o �rp) I ING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD :.: TT wn Hall Annex - 54375 Main Road - PO Box 1179 BUILDING DEPS TOWN OF SOUTHOLD Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(cD_southoldtownny.gov — seandRsoutholdtownhy.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: 1_6._ 1-le cT-Ix-I c� C0­17_A-Af. r&AI, a:W Electrician's Name: License No:; j�A := 3 80 4 3 Elec. email- Fi Elec. Phone No. G31_6 74. t�4 request an email copy of Certificate of Compliance � Elec. Address.: JOB SITE INFORMATION (An Information Required) Name: .- Address: Cr a(7. ILA . :s - ..`- ,Cross_Street: o. .. -• - Phone No: .; BIdg.Permit"#: -q(..-77,v'­7:-:.:. r. ' email:: Tax Map District:- 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly)': - Square Footage: Circle All That Apoly: p Is job ready for inspection?: ES NO Rough In,. Final Do you need a Temp Certificate?: YttS]R NO .: Issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph .Size: A # Meters Old Meter# EJ New Service Fire ReconnectlFlood ReconnectElService ReconnectE]UndergroundE]Overhead-' # Underground;Laterals M 1 FJ2 F1 H Frame Pole, Work done-on..Service? ... .. Y N.-. - Additional Information: PAYMENT DUE WITH APPLICATION ( Oirtlk 4cr kc / 1 _ YORK i Workers'Compensation CERTIFICATE OF INSURANCE COVERAGE STATE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1,To be completed by Disabi ity 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 PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured Work LOCallgn of insured(Only required it cq,*erage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-U, Policy) 262929943 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"l a" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: n A.Both disability and paid family le ave benefits. B.Disability benefits only. E] C.Paid family leave benefits only, 5. Policy covers: Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or class as 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 Fal illy Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 By Ivaof,hk (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A;Ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance,kgent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B 1,checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily 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 f IYS 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 b/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 licen;ed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autf prized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issue this form. DB.120.1 (10-17) IIIIIIP1°�—°1u2°0°I1°1°1�1�11°�1' 1°/alai CERTIFICATE OF NEW Workers! NYS WORKERS' COMPENSATION INSURANCE COVERAGE STd�TE I�9�"t"llr'i15i00 Insured Detail Ia.Legal Name and address of Insured(Use street address only) 1b.Business Telephone Number of Insured Patrick's Pools,Inc. 631-831-0816 5 Petes Path Manorville,NY 11949 lc.NYS Unemployment Insurance Employer Registration Number of Insured 1d.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number 262929943 certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 54375 Main Road 3b.Policy Number of entity listed in box"1a PO Box 1179 Southold,NY 11971 WWC3528513 3c.Policy effective period: 5/13/2021 to 5/13/2022 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) 21,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"la"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 112". 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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 5/5/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Nate:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it fe NEW Workers' r YORIC CERTIFICATE OF --•••---STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address.of Insured(use street address only) A� 1b.Business Telephone Number of Insured 631-996-4687 Patricks:Pools Inc PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Oubgue NY 11942 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d Federal Employer Identification Number of Insured or Socia!Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 262929943 2.Name and Address of-Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate:Holder) Wesco Insurance Co Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold'NY 11971 WWC3528513 3c.Policy effective period 05/13/2021 to 05/13/2022 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all parinerslofficuis 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"1a"for workers' compensation under the New.York State Workers'Compensation Law,(To use this form,New York(NY)must be listed under.It 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 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 mast provide that certificate holder with a new.Certiffcate of Workers'Compensation Coverage or,other authorized proof that the business is complying with the mandatory covei•a'ge 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: Nicholas Zulkofske (Print name of autp§died representative or licensed agent of insurance carrier) / I""A Approved b . ' Vj/ =s-rL-- ( ' 6ature) (Date) Title:Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authohzedi to Issue it. _ C-105.2 (9-17) www.wcb.ny-.gov i s Workers' Compensation Lave Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17) REVERSE SURVEY OF PROPERTY INLET POND ROAD LOT 100-MAP OF SECTION 3 EASTERN SHORES AT GREENPORT FILED:SEPTEMBER 27, 1965-MAP NO.4475 SITUATE w GREENPORT a TOWN OF SOUTHOLDa SUFFOLK COUNTY, MY, �� LOT 89 130.00 N69'02'1 0"E O6T 6'S70CKADEFENCE 0.9'N r TAX MAP NO.: 1000-033.00.02.00-042.000 T 'PIPEFNo. N LOT AREA:19,500.00 S.F.(0.448 ACRES) 0 °m y� O O DATE SURVEYED:FEB.10,2020 o �`e [p ��a\ D DEED REFERENCE:LIBER 12822 PAGE 074 0 ° m 0 30 60 to ��f+1 g WATER \ Feet }'[•t I METER - (2J❑0 o UNITS Z �, SCALE: 1 INCH= 30 FEET 32-3 39.9' N m m = CERTIFIED TO: m i 51.7' 0 D JAMES CLAKF.&LAURA COl`IWAY y m m 5.1 m m .'FIDELITY NATIONALTITLE INSURANCE COMPANY r` 3 ° m o IR 2 STORY TITLE N0.7404-007566 -" I FRAME1 D ~ LOT 100 x RESIDENCE •#'920 nno o N m � IT{ Z O T LAj Z m y..,kA�Nores: I D 2NO STORY m to CAPYRILM so m,vc w+o surr+rnNe.u„e Au wcN,s/¢swum. zuruumoaam�noN ORAeomaNroTus svRrn•MirscwNenuerAwmu.rosumcr°assE.iuAufOunonorsernon Ties. �' o E` ER Z O NflvYORKSTAT[DVCATONUw. Y N s.ow.rnwno.Rrm.,,ver.wswaNrME wnvcrw.s asossm sPxARE eENurNETFueANocowmcPeonEs oFn+Eavxcorssown*av_ GARAGE 11.0 -D WORKANDOPIMON, (n 0 4CERi4sK:ATON.ONTnILeOUNOARYSIRVEY WJSOMrYTYT'ME MAry/AL PPEPAaEDwACCOa01HCC wnllTlie cURRTTpCS'INOGOpEOP PMCnG£soaVNOSURVEi5A0o1rED sr'MENcwreu:sraEAsswwnoN oePnoPEsmaNawmsuRvsroas.we.YKEeum�uneN�suMnm � 0 209 m A YOrEPsoNs roRwrcMTMcaouND.aravRrnsw�srRv�cD,10 TNEmvecoNrem.TOTNE eovnc'Nv+TA�Acwcc.Nsron+cv owo ELLAP. wzTmnrpnuL+m onTnmeouraAm svmavMAP, j [NTRANCE ].•lMZeemineAnorrvMo�EnARENOi>tran2venAnic a or aT1L L[KFIION OFUNOERO•YOUNOO/PROVW�Oq WCaOAaWEn{L MENOTLLv/ATS]wowNwNOOcitNNUSTaE[pTwYFD.IFM+f y T UNDEPOROUNO WPaOY[NErI50RE�+0ACNNEN}L CASTCRARESNOWKTH£n+PacvLv�OR PHCRO/aYaENiS AHENOYCOvsJLpeYYMS A==� Q p wa cr. L. z T.TNEOFs.'�E'r"..foa OMElGtONmsnOwNnERLONPAONTiESTiwcrvRESYO n+EPRDPERrtl1N[3ARC FCpALPECIPICPURPOLEnm ULEARD 3 s7l DAN -ct T.ERtsORCAnGNOT�Urn+OCOYo GUIDETNE kAernaN OF sfN¢AlETNMNewNJ.n.PootS.PATOSPWmnSAReAS,ADO1nONeYn eUitDiNd,AND .� ANramERYrvcoFc°rGYaurncN. �� � Z DRAIN ASPHALT ORMINAY n.ow.r sum'crs sEau.vcTr,cNArm�sENDrmsEe�sxeu�neER rto uroN sv.¢o°+mowNwoosLEo,ca�ccv,EswrconrNN * 00°z ® WMi BLOCK CURB m UNAUtHcw 90NOUNDC BLENODM1CAnOa5.0ELlTO,E.A➢DmONSANO CNpNcp. LL RCPYRtt CORNCHNWnMENTL NM1A[NDrs[YALPAar OPTV„-SUiM'TUn,.E58 OT�UrW4ENOiTA. * �jr 4 IO.AU.MEALUnD/PJJri3PvfAYO iLVRVEYSOo*, `A_J'l �' N vl J r� al o PIPEFND. 31CHAIN UNK FENCE 0.1'N MON.FND. In S:''.... <YsAND 57: YYXIi`C& ?LAI*1`i G} - I ,Ire..... s<.. 1 30.00 W ;.•;. :.:,..-.. :• p.• 1� :i.",;,.,..;__b'.;Y < t' ' a S69°02'1 UW A ny77 Si'COL 1=[_vI1Sk ClZPAb ' 0CENTEIE KGI I.;:I�I1';�7>-2 _ i, LOT 101 r4EIvIAIL.' ,TE2 � OPTONNLII�IE. E7 ANG � � NII PR O IONAL LAND SURVEYOR I � O JOSEPH CECERE i SCDHS Ref # RIO-13-0064 AREA= 19,500 SO. FT. SURVEY . OF PROPERTY A T GREENPORT N TOWN OF SO UTHOLD ROAD- SUFFOLK COUNTY, N Y. P014D 1000-33-02--42 CAro �� zo 0' ISLEy Iro APRIL 1, 201* (FgUNDAVdV LOG) I AUG. 5, 2014 (RNAL) �n N AUG. 2A 2014 (REW570NS) NG��g`VG why i MAY 27.20151�.ERTIFICATIONS) 99 /� 0 •c — CEO 5 ay.�� 69 ��O•E Z9., 0 7iA�� N RAIN RUNOFF CONTAINMENT ,N 0� HOUSE 1920 sq. ft. 1920 x Ix 0.17- 326 cu. ft. Fy30� 0N' 1i"� 'i• t� G 328/42.2 7.7 vf. 1q�y��". • v PROVIDE 2 — 8'0 x 4' deep DWs. O,Ey2� H• "tRS OO , \� '� N DRIVEWAY DRAINS: 2 — 8'p x 8' deep PRECAST DWs. - NE' ICA �a cov` p+ y k CA d 7� 0. IESTHOL E `Q ��\ + R $f 9 CERTIFIED TO: tP 30.8' Nom' o ps A SCOTT KORTGARD ?� �o a g' �ti�• ca`6 'P,� '00. EMILY KORTGARD `r$- O y Stifps Sri xFIDELITY NATIONAL TITLE INSURANCE 0.� EVER BANK �G 5t.d o "05. fY103 4c00 90- VICepM C QR Q O V' kro.A •�O+w N sgg�0? - - - 7 - o, WT HOLE \ Vol a 3o.Ls' 9p9/i013 \r UL SM PALE BROoy�a�IP'�e SEPTIC LOCATION anrSM J' q' g' ST 27' 44' PALE BROW AND BROW SILTY SAND SW LP .10' 40' SFPW SMIM to' [1]a FT. L>kx 12 FT. IOGN PRECAST CONALEIE LEWONG Rare SWOML MATERIAL CMM SAND AAD GRAM(J'CUJM) BROW FINE TO COARSE SAND SW (1]1,000 GALLcw PRECAST SEPRC TAW iHTH IDX GRAVEL 1r LOT REFER TO 'MAP OF EASTERN SHORES AT GREENPORT, SECTION 5' FILED IN THE SUFFOLK COUNTY CLERKS OFFICE ON 12/31/68. AS FILE NO. 5234. • o PIPE _ AT GREENPO ■ o MONUMENT LOT RESECTION 3' FILED NTO -MAP OFEASTERN THEE SUFFOLK COUNTY CLERKS T. OFFICE ON 09/27 S FILE NO. 4475 1 or..• familiar with the STANDAROS FO•R APPROVAL �P��OFNEIy),O� AND CONSTRUCT.!ON OF SUBSURFACE SEWAGE g ��r.MET{c DISPOSAL SYSTEWS FOR S%NGL C l AMIL Y RESIDENCES ar,a ++Il abide by the corditicrls set forth therein and cn the y1e' permit to construct. The location of wells and cesspools shown hereon ore from field observotions and or from data obtuined from others. $ �.Y.S UC. N0. 49618 ANY AL IM VON OR AODIVON Til THIS SURVEY IS A KOLA DON AECORS, P.C. OF SECDON 7209OF THE NEW YORK STATE EDUCADaW LAW. (631) 765-5020 FAX (631) 765-1797 EXCEPT AS PER SECR N 7209—SUBDIVISION 2 ALL CFR17h70ADON5 P.O. BOX 909 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY W SAID NAP OR COPIES BEAR 7H£IMPRESSED SEAL OF THE SURVEYOR ELEVATIONS ARE REFERENCED TO 1230 TRAVELER STREET f NNOS>=SI&WA7URE APPEARS HEREON. AN ASSUMED DATAM. SOUTHOLD, N.Y. 11971 F1 Ri I V I { I r APPR VEDAS NOTED DATE; B.P.# FEE-: Li..d BY: NOTIFY BUILDING C. :-,4RTMENT AT . RETAIN STORM WATER RUNOFF 765--1802 .9'AM TO d PM FOR_THE PURSUANT TO CHAPTER 236 FOLLOWING-,INSPECTIONS: Of THE TOWN CODE, l'..�FOUNDATION TWO REQUIRED FOR POURED CONCRETE 2: ROUGH .'FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONS-•? ­N MUST BE COMPLETE D. ALL,CONSTRUCTi'.,,, ::.­TALL MEET THE REQUIREMENTS OF[HE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. (ELECTRICAL INSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF �' QC�T6Gtl — G BOARD --9GUT+0tDfiWRUSTEES `Id:Y:S-DEQ- pi UMEDIATELY =� ;; .EQb6SE POOL TO CODE "U06N COMPLETION OCCUPANCY OR 1BEFORE "WATER USE IS UNLAWFUL WITHOUT CERTIFICV )F OCCUPANCY „� � ` i F t I I ? � •.--_! I.c.>_._.-:._.�.,1-.... F f t i� g f t ti � � � � � s � � P� - � - `}� :4 .i'- .T moi.=v - •F_�: i. gib:” ,.,n.' - "...�"-""."*"_"_' _ .v: F- - S f' J'. 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