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HomeMy WebLinkAbout45803-Z �o�OSUfFUt Town of Southold 10/15/2022 o P.O.Box 1179 o _ 53095 Main Rd oma. Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43500 Date: 10/15/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 590 Bayberry Ln., Greenport SCTM#: 473889 Sec/Block/Lot: 52.-3-18 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/29/2021 pursuant to which Building Permit No. 45803 dated 2/9/2021 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: accesso , in-ground swimming pool fenced to code as applied for. The certificate is issued to Marinucci,Arita of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45803 9/15/2022 PLUMBERS CERTIFICATION DATED A or e S afore o�SUFFot��o TOWN OF SOUTHOLD a aye BUILDING DEPARTMENT C, TOWN CLERK'S OFFICE "�y • ,� . 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#: 45803 Date: 2/9/2021 Permission is hereby granted to: Marinucci, Arita 140-44 Qunce Ave Flushing, NY 11355 To: construct an in-ground swimming pool as applied for. At premises_located at: 590 Bayberry Ln., Greenport SCTM # 473889 Sec/Block/Lot# 52.-3-18 Pursuant to application dated 1/29/2021 and approved by the Building Inspector. To expire on 8/11/2022. Fees: SWIMMING POOLS,-IN-GROUND WITH FENCE ENCLOSURE $250.00 677tal: L $50.00 $300.00 Building Inspector ` 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). 1 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 1%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. Certificaie of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations 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. New Construction: Old or Pre-existing Building: (check one) Location of Property: Sq'® bi House No. Street Hamlet Owner or Owners of Property: Otpu�q Har;nuac1 Suffolk County Tax Map No 1000, Section 52 Block 3 Lot Subdivision Filed Map. Lot: 13 Permit No. .Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 64 Applicant Signature o�'�\OF SO!ll�ol ti o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �o sean.devlinCaD-town.southold.ny.us Southold,NY 11971-0959 coum,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Arita Marinucci Address: 590 Bayberry Ln city:Greenport st: NY zip: 11944 Building Permit* 45803 Section: 52 Block: 3 Lot: 1$ WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Island Power Electric License No: SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub - Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches 4'LED Exit Fixtures Pump 2 Other Equipment: Pumpx2 220GFI, Salt Generator, Heater, pool light Notes: " AS BUILT NO VISUAL DEFECTS " Pool Inspector Signature: Date: September 15, 2022 S.Devlin-Cert Electrical Compliance Form OE SOGTy�� # # TOWN OF SOUTHOLD BUILDING DEPT. Comm 631-765-1802 INSPECTION [ . ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING ( INAL P"I [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: • L-11 v.2 -C 0 6n Joublc 2, 106 e., &�Ax a I lo v GD (4-b ' h f4UVl DATE aZ'!� INSPECTOR 1�-N` OF SOUTyolo # # TOWN OF SOUTHOLD BUILDING DEPT. `ycou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] ,JNSULA3jON/,CAIJkWM [ ] FRAMING /STRAPPING [ FINAL Q� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE '?/ INSPECTOR a ie W WAN vz "Xv A`iPcol°Borcfin rite WX C kip mm UZI 1 15" 7 Say to. 0, - -'W " Qj m my-W cafe~" . ' ll A 1, , � -0 P,N. ON; idiiinini _too t�ttif lfs ow M�G Of S_ MOW Mom mtsw d" PmW lit, 0 *11cens I e >ew"-­d'c j 4 nwa ,gqr. ce,n' m nicePa eas. sur .d" A, W , d colie eastgmhftea Oi* 0-� icatile nts such as>fr a� WwhaW� ceInc Oa TO� to :1.............. "TWIT low" e� W-A- 1 5P�rPl AQ Say,104 A- -- is W=4 -W g Ue V Twx d OT, -WN, POW Y� I'll".WFN I ".qk# W a Ott e OF, ,.and''{ a' N., m MAN] dI tzi vp I ZY.i 'Pal- OWN:IN- "cap e= ......... ........ e • � e 1 TOWN OF S.OUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following_,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 3 sets of Building Plans TEL: 765-1802 Survey PERMIT NO. _/ Check Septic Form N.Y.S.D.E.C. P [7; Trustees Examined �w i't s ! J ` Contact: y Approved— 20 ( .>' `'�y PP ; j`� y r Mail to: Disapproved a/c LJ � i JAN 2 9 2021 Phone: _ ^-7 7".fit�in+..;r iYy :.4 Building Inspector APPLICATION FOR BUILDINGYERMIT Date I'Zg ' , 20_?=L INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 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 a Certificate of Occupancy is issued by the Building Inspector. 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;and ations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of ahlicant or e,if a corporation) kt 2s� (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premises ap,tV 0, Ptlr'InUeel (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name'and title of corporate officer) Builders License No. WE Plumbers License No. Electricians License No. Other Trade's License No. 1. Location ofland on which pro .osed work will be done: '51c) k5o� Lir - ��-►�0 I el w. House Number Street v3' � , (13 .,.Hamlet E)F17 "All' County Tax Map No. 1000 Section 52- Block 31` ` ` ' Lot Subdivision Filed,Map No. Lot �3 (Name) y 2. State existing use and occupancy of premi es and intended use and occupancy of proposed construction: a. Existing use and occupancy .51deri—a b. Intended use and occupancy. 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work i%fwwo 6NimMvy (Description) 4. Estimated Cost Fee (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 lb X 3b Rear Depth 3'12- Height '1zHeight Number of Stories 9. Size of lot: Front ILK 1 Rear 145► Depth I q 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: N<3 13. Will lot be re-graded Poo I AQq ONIA Will excess fill be removed from premises: YES NO k\Aa 1404W Ouina Ae- 14.Names of Owner of premises �knpdee► Address Fi..,�shwy4 W 113Ss Phone No. qk7-b03 4 4'7) Name of Architect Address Phone No Name of Contractor Eelw&ds ball Address q�A 9-t-2A Phone No. 6S)--M--71kr . . _ M�1 �P►e�e.e 9M 117rv� 15. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES 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. STATE OF NEW YORK) SS: COUNTY OF ) 'UO.- H(Lr I r1Je being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (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 workwill be performed in the manner set forth in the application filed therewith. Sworn to before me this day of :JnJ'" 202-1 NVtAry hblic Signature of Applicant MARGAREf A. KIDNEY a Notary Public—State of New York No. 01 K160211 11 Qualified in Suffolk,County My Commission Expires March 8,20ia •`L Scott A. Russell '01 'r S�C'�0)][�l��l WA\T]EIR. SUPERVISOR MANAGEMENT SOUTHOLDTOWN HALL-P.O.Box 1179 � Town of Southold 53095 Main Road-SOUTHOLD,NEW YORK 11971 0 CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES 11M PROJECT INVOLVE ANY OF THE FOLLOWING: (CHECK ALL THAT APPLY) Yes No ❑©'A. Clearing, grubbing, grading or stripping of land which affects more than 5,00&square feet of ground surface. ❑ ffB. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑9C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. [][YD. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑[TE. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑[•�F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #' 1000 Date: District NAM: Ri_ a ari!�►6 52 3 1B -2$--Z( Section Block Lot ****FOR BUILDING DEPARTMENT USE ONLY**** Contact Informatiom 1,_ 6 03_ 14-71 7 rrel,#0W MMb.) . Reviewed By: — — — — — — — — — — — — — — — — Date: Property Address/Location of Construction Work: — — — — — — — — — — — — — — — — — 5,�� �w��^w -� ��� Approved for processing Building Permit. Ua [ eae Stormwater Management Control Plan Not Required. Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 rwQ rvr+...{/..vim-w{.vn10J YI'►ti�i � - a F'Qope2`rY r� JA,�1. suaveyeoPce t - � f G t * _ t,-�i f ��-'-i _ 6 �j �t�.�1 Com.. �_ STA__T�_ANT OF INTENT - - - THE WATER SUPPLY AND SEWAGE.Di j A"r" SYSTEMS FOR TH!$ RESIDENCE CONFORM TO THE STANDARDS j wowN oF= zsoI-n-i L_D,.hv. SUFFOLK CO. DEPT. OF HEALTH SE (S) APPLICANT • c:�s i SUFFOLK COUNTY DEPT. OF 1 SERVICES -- FOR APPROVAI CONSTRUCTION ONLY r� } l� 'r H.S.REF. NO.- - 3 `� •` �tira�artt j i I APPROVED: SUFFOLK CO.TAX MAP DESIGNAT s DIST. SECT. i3l.00lC t90.0 1000 052 to @ iron OE�iG OWNERS ADDRESS: aG E FL+w- x h �► i l��3- # E3vie Ave. p 4D 12-.s m- •� . DEED. R.. 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EJ v tc' v "V .I S i �/ <: i e/^ J ' ti/�',', �vl., t !I/. �\�r - ,' ?.i'.k sf,•/ \.?-..Y+� , \ r :r!/ \'4`° _, <i ,r., ,f%\�' -•Y' "'. r \w'.c. .' ,i; �ti,,�t:- }_,�^k".µ. - s "0�, t 1Y+` U1 :►-. 3+4 ��+a `��� ,�h����.`aF�31'�►''�i'��.I I .yam''*:+.. +7tx`,t• ,��-lY'•�'*r*fiYac a•✓ i4`,� J y �� ��ay..'��� `1"i�'j�*Y3'{� C '�'r���`�+1�` '�#! .U�r�e� _S,.i�-- t.f 'f,��,r^�;, •.'t ,.��y.'�r _r.. .rdjU z'.�}�„"r li NY S ' F 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112377925 mm LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491-9 308232 06/29/2020 TO 06/29/2021 06/18/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK,EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 730432298 IIEIIIINWII�00000000000083456E9E2i5lI�IIlig Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-24384919] U-26.3 57 [00000000000083456925][0001-000024384919][AtG][15408-10][Cert_NoP-CERT_I][01-00001] YORKATE Compensation Workers' CERTIFICATE OF INSURANCE COVERAGE ST Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE, NY 11764 Work Location of Insured(Onlyrequired if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York TOWN OF SOUTHOLD Y P Y PO BOX 728 3b.Policy Number of Entity Listed in Box"l a" SOUTHOLD, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/22/2021 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. F1 B.Disability benefits only. 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 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 descyi7ed above.' Date Signed 6/23/2020 By Aa�t (Signature of insurance carrier's authoriz d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 1212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY 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 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) 1111111111°°1°°°°1°°1°��a111°11°111°111111 Additional Instructions for Form 1313-120.1 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. 1313-120.1 (10-17)Reverse +AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 01/05/2021 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Gene Romano Liberty Risk Management,Inc. ADNN : (631)569-5633 AIC No:(631)569-5636 664 Blue Point Road,Suite A E-MAIL ADDRESS: gene@libertyrisk.org Holtsville, NY 11742 INSURERS AFFORDING COVERAGE NAIC# INSURER A: NIP/Greenwich INSURED INSURER B Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J. Edwards Pool 8r Spa Centre INSURER C: 929 Route 25A INSURER D: Miller Place, NY 11764 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000005-963374 REVISION NUMBER: 1 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR /Y POLICY NUMBER MM/DDYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY NPC-1004300-00 01101/2021 01/01/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE-TO_7CLAIMS-MADE �OCCUR PREM SES E-RENTED occu encs $ 300,000 MED FRCP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT FILOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acddent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOWPARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under 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) Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 728 Southold, NY 11971 AUTHORIZED REPRESENTATIVE GGR ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by GGR on January 05,2021 at 03:12PM ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY. 11764 516-744-7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: APPLICATION FOR OUTDOOR'POOL PERMIT [ EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM [A CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF LIABILITY INSURANCE [ SUFFOLK COUNTY LICENSE PLUMBER LICENSE -- OUNTY ELECTRICIAN LICENSE rb 4 SETS OF PLANS - (3 STAMPED), �,A 3 SURVEYS with FILTER LOCATION- [ ] APPLICATION FOR ELECTRICAL INSPECTION APPLICATION FOR CERTIFICATE OF OCCUPANCY C.O. TAX BILL $400.00 CHECK FOR PERMIT FEE AP ROVED AS NQTED DAT P4 B.P.#!4 COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES FEAS REQUIRED ANI)LG. NS OF "IMMEDIATELY"NOT Y BUILDING CL'.a �MENT AT ENCLOSE POOL TO CODE 765-1802 8 APA TO " PM FOR THE SOUTHOLD TOWN UPON COMPLETION FOLLOWING INSPECTIONS: SOUTHOLD T PLANNING BOARD BEFORE"WATER" 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE SOUT D TOWN TRUSTEES 2. ROUGH - FRAMING & PLUMBING N.Y .DEC 3. INSULATION 4. FINAL - COINISTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE rC0P NOY OR ELEcIRICALINS?EcIION REQUIRED REQUIREMENTS OF THE CODES OF NEW 0 YORK STATE. NOT RESPONSIBLE FOR IS UNLAWFUL DESIGN OR CONSTRUCTION ERRORS. i� � TOUT CERTI�ICAT Or OCCUPANCY A O ® FJ*.M H B' AhmVirium F To Fftw From F9hr R Rip To Wats -T� FbMd WcM F Plan A Py Was OPH-0 Piping.. Arrangement f4ftbm 42" OF NEW C-) Section B—B r 3SOO P.51 c...ft W 10" T l ,off X43595 Section A—A �•cal Wall Section OP S, SIZE A B C_ D E F G H AREA CAP Pmrobmw FEET FT FT FT FT FT FT FT FT SQ. FT GAL. e =�Qr15 X 34 15 34. 14 12 5 3 3 9 510 17,200 `' 8Z SPA CENTREAddrem 16 X 36 16 36112114 6 4 4 8 576 21,600 ! PERMACRETE WALL SYSTEM &j4,hD CI s Py MLY 36 Em4 6ElItsjIlm wggm r-411-300 929 Route 25A Miller Place NY 11764 20 X 48 20 48 14 14 6 4 5 10 800 33,000 (631) 744-7185 FAX (631) 744-0174 ��71 24 X 44 24 44 18 14 8 4 8 10 798 35,000 , Suffolk License #4436—HI Phem Nassau License #HI74450000 24 X 48 24148120116 8 4 6 10 900 38,500