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Home My WebLink About46767-Z �O�OS1lfF0t Town of Southold 8/23/2022 P.O.Box 1179 �o� • ,� 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43354 Date: 8/23/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 205 Knapp Pl., Greenport SCTM#: 473889 Sec/Block/Lot: 34.-2-18.1 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. 46767 dated 9/1/2021 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 gunite swimming pool fenced to code as applied for. The certificate is issued to Acri,Gabriel&Katherine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46767 4/6/2022 PLUMBERS CERTIFICATION DATED uth rize S gnature i ��gQFFO� TOWN OF SOUTHOLD BUILDING DEPARTMENT cz co 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#: 46767 Date: 9/1/2021 Permission is hereby granted to: Acri, Gabriel 71 Carroll St#2D Brooklyn, NY 11231 To: Construct in-ground gunite swimming pool at existing single family dwelling as applied for. At premises located at: 205 Knapp PI., Greenport SCTM # 473889 Sec/Block/Lot# 34.-2-18.1 Pursuant to application dated 8/20/2021 and approved by the Building Inspector. To expire on 3/3/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector Of SO�jyOl 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.devlin(cD-town.southold.ny.us Southold,NY 11971-0959 CQUIY BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Gabriel Acri Address: 205 Knapp PI city:Greenport st: NY zip: 11944 Building Permit#: 46767 Section: 34 Block: 2 Lot: 18.1 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 Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 4'LED Exit Fixtures 11 Pump 1 Other Equipment: Intermatic 8 Circuit/ 6 Used, Heater 260GFI, Pump 220GFI, Salt Generator, 2 Lights 120GFI, Pool Cover 120GFI w/ Keypad Notes: Pool Inspector Signature: Date: April 6, 2022 S. Devlin-Cert Electrical Compliance Form 1 �,gg� SOUly�lo LI IV�!' # # TOWN OF SOUTHOLD BUILDING DEPT. �ycourm, 765-1802 INSPECTION [ ] FOUNDATION TST [ ] 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: �®"'�6. �[��y-� i �IJ 4* ow,#J DATE -. INSPECTOR ��' r=- �o��,oF &OUT' HOLD )TOW OF BUILDI G PDEPTr . 765-1802 INSPECTION [ ] FOUNDATION IST [ ] 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 F SO(/ � < f ` / �q 6-TOWN OF OUTHOLD B�JVD INYD PT. 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: bid_4:4__ n ?zA DATE INSPECTOR 5n a OP SO(¢�0� TOWN OF SOUTHOLD BUILDING DEPT. �`y�ou►m ' 765-1802 INSPECTION [ ] `FOUNDATION 1ST [ ] ROUGH PLBG. [ " ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [DQ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY`INSPECTION [ ] FIRE RESISTANT CONSTRUCTION . [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUG ) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATI [ ] PRE C/O REMARKS: Alabg To - -,Tr oo- FCR- 5466 r Y S P&��66 s roz 02;f- L14I'"r-q s 1'7 <-'�� /l/6C-bS COME� 6 E�t/E C— :TA/ Ifd ,.011, ' CAA/'r --f7,f&,e,- Z �C& I EEb�s Gccic Lccic 60t,z LE6 Get/ O If EAA-rr int -9/17,c—, DATE -r - vz INSPECTOR l I� Of SOUTy�� ' TOWN OF SOUTHOLD BUILDING DEPT. °`�courmNe'' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAU G [ ] FRAMING /STRAPPING [V(FINAqot [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ .] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: tS cn/ DATE Z INSPECTORtAljzi,-t—) Jeffrey Sands Architect October 15, 2021 Property/swimming pool location: Gabriel Acri 326 Knapp Place 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, RED A&P SPE M.S 3 N 9 02 y F OF NES Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—jeffrey sands(a)-hotmail.com FIELD.'INSPCT. • ION REPORT 'I?ATE .. •• •CON,IIV�N�S .- - 77 FOUNDATION(IST) 7777 ...... FOUQTD,ATION(2ND):' ROUP$FRAMINQ:& H . P lu.1 INSULATION.PER N.Y. y STATE•ENtRGY CODE 1�a _t �Y FIN L' opmlc AD ?� Gt, { hi: c i ro . : .. . ..... .. . .. . VVIFOLte TOWN OF SOUTHOLD—BUILDING DEPARTMENT . Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southo"ldtownn.g_o_v Date Received APPLICATION FOR BUILDING PERMIT M D For Office Use Only D PERMIT NO. Building Inspector: AUG 2 0 2029 Applications and#orms°inust 6erfilledout in their;entir'.ety:`Incomplete . h$UI][.I1IPJG DEPT. =applications will not be accepted: Where".th"e Applicant"is not,the"ov+rner;an0N OF SOIfTRDLD Owner's Authoniatfon forr»i(Page 2)'sfiall be`comple#ed Date: 01NNEWS OF`PROPERTY Name: � SCTM #1000- 3�_ 1 Project Address: �5 w _..Fu..w... _.._ . . ._ f- .._C, e 205. _. Phone#: -lAl a Email: Mailing Address: ONT T C AC PERSON Name:Ke ( _.11.o Mailing Address: Y Its 1 C( Phone# Email: - - rDESIGN-PROFESSIONALINFORN1AT10Nc`"`.¢�� ° - Name: Mailing Address: Phone#: Email: O.N RACTOR INFORMATION: 4 Name: Mailing Address: 'Eas-V V6011 u2 NN I 1 Phone#: Email: o U - S S L�. DESCRIPTION OF PROPOSED CONSTRUCTION .. _ ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: OtherC C, he 3C) Gun t W- Sia omrc.1 nR $ ILQ s-- Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? es ❑No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants-and restrictions with respect to this property? ❑Yes NZI o IF YES, PROVIDE A COPY. heck Box After Reading"'The owner/contractor/design professional is responsible for all drainage and storm water issues at provided by C'apter 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--omply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A'misciemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted B (print name):�- Yl V\e if1-V.r(1 Xuthorized Agent ❑Owner. Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF s_ Vim U1 k ) L<G±ri r\(:),, A" I PJ1rGV�� being duly sworn; deposes and says that (s)he is the applicant (Name of individual signing contract)above named, (S)he is the e—n (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 19'II day of 20 2 Q Notary Public MICHELE A MEDUSKI PROPERTY OWNER AUTHORIZATION Notary Public,State of New York Reg.No.01ME6393343 (Where the applicant is not the owner) Qualified in Suffolk County f"-sbfflmisslon 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�e�� nt A�pIlication dere the Applicant is not the Owner) I.Katherine Acri Gabriel Acri,residing at 326 Knapp Place(205 Knapp Place), Greenport, New York 11944,do hereby authorize Katrina Mercurio to apply on my behalf to the Southold Building Department,to obtain a permit relating to a pool project. E I f. } August 5; 2021 Katherine Acri Gabriel Acri �l 4� f� V . U DING DEPARTMENT- Electrical Inspector DEC 0„2 2021 TOWN OF SOUTHOLD BUILDING DEP own Hall Annex - 54375 Main Road - PO Box 1179 '* TOWN OF SOUTHOLD Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD-southoldtownny.gov seandCa�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: G - h---M,.-'A-1C�v-z2,��"iuv� �• Electrician's Name: License No.: _ Rp4 Elec. email: �F�rCo:u;y�v�c,� ,t . ElePhone No: _0 5� re - � email copy of Certificate of Compliance— C. �oxt Elec. Address.: .1-_ mo , /j /1o JOB SITE INFORMATION (All Information Required) Name: C Address: ,,,App PL A-t-4 3 Poe-7 Cross Street: Phone No.: Bldg.Permit#: Ly b 7 6,-7 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 5L10- Square Footage: Circle All That Apply: is job ready for inspection?: YES ❑ NO Sough In Ami ❑ Final Do you need a Temp Certificate?: ❑ YES ❑ NO Issued On Temp Information: (All information required) Service Size❑1 PhF-13 Ph Size: A # Meters Old Meter# F]New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals M 1 2 D H Frame Pole Work done op Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION oo� < U ING DEPARTMENT- Electrical Inspector DEC 0„2 TOWN OF SOUTHOLD BUILDING own Hall Annex - 54375 Main Road - PO Box 1179 'TOWN OF SOUTHOLD Southold, New York 11971-0959 : Telephone (631) 765-1802 - FAX (631) 765-9502 roger r _southoldtownny.gov - seandAsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail Information Required) Date: Company Name: �, s✓c Com i i2 ��l>v A." Electrician's Name:. License No.: fyF_ - x.804 3 Elec. email: 0 .r_j_ �G �Lrc-rp -A- Co 7 4�. Elec. Phone.No: _ _o re email copy of Certificate of:Compliance C'&p Elec.-Address.:" " " l.�do N -P-�ts-r" Mo A /19q- 0-. JOB SITE INFORMATION (All,information Required) Name:. . C . A ._ ddress: Phone No. , . . Pe ema'il: .' °..TaX.Map.District ... . .1000 Section: , ` Block: ;:Lot :. BRIEF": ESCRIPTION OF WORK,"INCLUDE:SQUARE FOOTAGE(Please°Pdht Clearly): ; Square Footage:.:: `:Curdle All That'Apply: : . is.lob:'ready":for-inspection?.. . .... ..";;....:,:, _ =.VES NO. . ough,"In Final Lir J— . Do you need a Temp Certificate?: YES NO Issued On Temp Information: i(AII information required) Service Size�1 PhF13 Ph Size.: 'A #Meters Old:Meter# " ; . J7New Service0 Fire ReconnectOFlood ReconnectEjSer#'e ReconnectDUnde'rground averhead # Underground Laterals 1 2 H Frame Pole Work done on"Service? Y N Additional Information: PAYMENT DUE.WITH APPLICATION " N OO. ,`)> `G 3 Address: nes utlets GFI s Surface. Sconces H H's UC Lts Fans.:... Fridge ',._:........:....,._.:.__..:..,.:.....:... .,..,, HV1/ Exhaust Oven W/D Smokes DW Mini Carbon :... :.......... :_.. ..._.,:... IVlicro .... _,.,..._...._... Generator Combo.: _.: : ...._ ;,....>-._ . ......._::._:. Coolttop Tr-ansfer AG- AH Hood .Service :.. Amps . 'ka-ve 'used Special:...: _.. ...... _ Comments: . s. V W �t . , �voRKSTATE Compensation Workers' CERTIFICATE OF INSURANCE COVERAGE 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 Ia.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 LOCallen of Insured(Only required if co'erage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Ur 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) 5heltorPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"1a" 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. F1 B.Disability benefits only. n 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 claseas 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 Fai lily Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 By (W101,UGt (Signature of insurance carrier's authorized representative or NYS Ucensed 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 i,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;ad to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance canters are auth prized to issue Form OB-120.1.Insurance brokers are NOT authorized to issue this form. D13-120.1 (10-17) Ilfl IP!°��[df�2Ill[Ifl1llll(l1[0ioi1[7)iiln101 YORE NYS WORKERS'CO O'tP' ' CERTIFICATE OF MPENSATION INSURANCE COVERAGE Insured Detail la.Legal Name and address of Insured(Use street address only) lb.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 ld.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 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"la": Southold, PO Box WWC3528513 ,NNY 11971 3c.Policy effective period: 5/13/2021 to 5/13/2022 3d.The Proprietor,Partners or Executive Officers are: -11 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"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"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 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) AA _" Approved By: 5/5/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it 605.21(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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 YORK °alters` CERTIFICATE OF C-- srATE Compensation NYS WORKERS` COMPENSATION INSURANCE COVERAGE Board Ci a.Legal Name 9 Address of Insured(use street address only) _ 16.Business Telephone Number of Insured f 631-996-4687 Patricks Pools Inc 11 PO Box 3024 East Quogue NY 11942 1 c.NYS Unemployment Insurance Employer Registration Number of Insured r I Work Location of Insured(Only required if coverage is specifically limited to id.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number t 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"1a" Southold NY 11971 WVVC3528513 3c.Policy effective period 05/1312021 to 05/1312022 3d.The Proprietor,Partners or Executive Officers are included.(Only check box it all partners/officers included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures,the business referenced above in box"1a'.for workers' compensation under the New York State Workers'Compensation Law.,(To use this form,New York(NY)must be,listed under item 3A on the.INFORMATION PACE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agentwill send this Certificate of Insurance to.the entity listed above as the certificate holder in box"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled I 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 cbverage indicated on this Certificate. (These notices n-iay 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 irntil 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: Nicholas'Zulkofske {?rind name of aur (reed representative or licensed agent of insurance carrier) '2 4 - -- Approved b . ( ' fratwe) (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 authorized to issue.it. C405.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation Is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17) REVERSE Certifications indicated hereon signify that this plot of the propery,depicted hereon was made in accordance with the existing Code of practice for Land Surveyors adopted by the New York State Assaciolion of Professional Land Surveyors. This certification is only for-the lands depicted hereon and Is not certification of title,zoning or freedom of encumbroncel. Said certifications shall run only to the persons and/or entities listed hereon and are not transferable to additional persons,entities or svbsegvent owners. TAX LOT 1 _MAP N 741,32110" E .72.Q))eQMoNUMENr i rouNV LINE FE ♦3AM800 14'5 EP WIN 0 Z yC!O Far ;0 e w tjJf d LOT P/tom 1 A �&j CS f 3g L07' 5 ✓0 `�,,,�,�rj 40 C) X07 001 ?� a 4�`LMASONSY r DuILDI C tm ' � 76 2' '1 GARAGE ;OFAA v LOT P/0 as LOT OT. 40 luo FE a� 0.2'E - FE GAR 2,4'E t CCGK 1.2 0.31W 11.2' 8.2'fa 12.5' PAVY i• ON GA.RA^£ m WHE a � Gh1 FE 2 .+0.1' o.a'w a'ia 5t W tiff � i Z_ to A i 1 � v gal m � t 165.00' FE ON t : PIPE PAV7 0.8' r I yN 2.2E FJ� :KrAh1CF16TG'WACK� O,449S F, 5 0 S 72`44'40" W 80.00' KNAPP PLACE VI Sultver VIM, su"v DEED REFERENCE LIBER 11821 PAGE 489 The offsets or dimensions shq vn from strvoures to the property lines ore for o specific pvrpase and use,and therefore,ore not intended to guide in the erection of fences,retcining walls, pools,patios,planting areas,additions to buildings and any other construction. Subsurface and errvironmemal conditions were not examined or considered as o part of this survey. Easements,Righls4Way of record,if any,are not shown.Property comer monuments were not placed as a part of this survey, Q 2010 BBV PC BYMBClrrett Tax Map: DISTRICT 1000 SECTION 34 BLOCK 2 LOT 18 BOnacci & Ma of: 60 LOTS OF LAND BELONOINO TO JOHN 0.CHAMPUN unauthorized alteration or addition,to ap this survey is o Viafotion of Section Van Weele, P� 7209 o1 Now Yolk State Education law Civil Engineers 175A Commerce Drive Map Lot: 39,P/O 40 Map Block-, -- Surveyors Hauppauge, 111788 County:Filed: 10/23/1873 No.; 337 Coon SUFFOLK Planners r 631.435.1022 www.bbvpc.com Situate: GrREENPORT,TOWN OF SOUTHOLD t Irtiffed to: Titlrh No.: TAI{08) 172 Revision By Date GABRIEL ACRI Copes of this survey mop not bear- KATHERINE IRENE ACRI ing the land surveyor's embossed on- STEWART TITLE INSURANCE COMPANY seal and signature shall not iia sidered to be a nue and valid copy TITLE ASSOCIATES sury : lk, Drafted by, D.W. checked b : A.M. Scale: V= 30' Dote:6.MAYS 2010 Project No,; A100175 M:\DA10\A10017WwgV1100175.d*g,Modal,5/6120101:41:34 PM,\lfpvbl14Pl1 CADj7,Barrett,Bono&van wome/DW APPROVED AS NOTED OCCUPANCY OR DATE:91 . B.P.# USE IS UNLAWFUL FE 2�-OD BY: WITHOUT CERTIFICATE 7 5-1$02881 MINTOIFY ULDGD4 PMR FOR THE- OF OCCUPANCY FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. COMPLY WITH AILL CODES OF ALL CONSTRUCTION SHALL MEET THE NEW YORK STATE & TOWN CODES REQUIREMENTS OF THE CODES OF NEW AS REQUIRED AND CONDITIONS OF YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. SOUTHOLD TOWN ZBA SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES "JMIIA ibtff tLY�'. N.Y.S.DEC ENCLOSE POOLTQ CODE.:' UPON icbmOLETION 'BEFORE"WATER" RETAIN STORM WARP ER 23�4i, PURSUANT TO CH OF THE TOWN CODE. Additional Certification May Be Required. EL,,mCAb N REQUIRED V'