Loading...
HomeMy WebLinkAbout45831-Z o�OS0EF0l Town of Southold 10/15/2022 P.O.Box 1179 oc 53095 Main Rd y,��l dao Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43501 Date: 10/15/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 14380 Oregon Rd, Cutchogue SCTM#: 473889 Sec/Block/Lot: 84.-1-12.5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/4/2021 pursuant to which Building Permit No. 45831 dated 2/18/2021 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 Longdog Acres LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 22-85096 9/27/2022 PLUMBERS CERTIFICATION DATED - 0 .A or zed S'g afore ��SUEfotp-�oTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o �,¢ SOUTHOLD, NY a 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#: 45831 Date: 2/18/2021 Permission is hereby granted to: Longdog Acres LLC 530 Orchard St Orient, NY 11957 To: construct an in-ground swimming pool as applied for. At premises located at: 14380 Oregon Rd, Cutchogue SCTM #473889 Sec/Block/Lot# 84.-1-12.5 Pursuant to application dated 2/4/2021 and approved by the Building Inspector. To expire on 8/20/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector Certificate ofCompliance ...................................:..................................................................................................................:........................................ - CERTIFIED ELECTRICAL INSPECTIONS; INC.' 188 PARK AVENUE. . AMITYVILLE, NY.11701 P: (631) 598-5610: .................................................... ....................................................:......... -CERTIFIES THAT Upon•the application of Upon premises-owned by LC Electrical Contracting Long Dog Acres LLC. 22 Woodbine Lane 14380 Oregon Road " East Moriches, NY 11940 Cutchogue; NY 11935 Located at: 14380 Oregon Road, Cutchogue, NY 11935" Application Number#: 22-85096"'Certificate#:.22-85096 Electrical:License,#: ME=3804.3 Section: Block: Lot: Building Permit#: 45831 Described as a Residential occupancy;wherein the premises electrical system consisting of . electrical devices-and wiring,-described below, located Won the premises at: . Inground Swimming Pool A-visual inspection of the premises electrical system, limited to electrical devices-and.wiririg to the extent detailed herein, was conducted in accordance with the requirements of the applicable code/or standard'promulgated by the State of New.York,.Department of State Code Enforcement and Administration, or other authority having jurisdiction, and:found to be incompliance therewith .on the-27th day of September 2022 Name QTY Time.Clock ' 40 Amp, 220V 1 GFI Circuit Breaker, 20,Amp, 220V 1 Swimming Pool-Bonding 1 Pool'Receptacle.=20 Amp, 240V- 1' Salt Generator- 15 Amp', .120V -1 Switch - 15 Amp, 120V I GFI.Receptacle- 15•Amp, 120'V 1 Pool Fixture- 15 Amp, 120V , 1 EI ct '�al,lnspec r: Sal Frangipane JL OCT 0 9 2M . =a APPROVEDIZ5 . . .°a • - ; . _ 'yam 'This certificate is not valid unless raised seal is present. Certificate of Compliance .................................................................................................................................................................. CERTIFIED ELECTRICAL INSPECTIONS, .INC. 188 PARK AVENUE AMITYVILLE, NY 11701 P: (631) 598-5610 .............................................................................................................!.................................................................................. CERTIFIES THAT `Upon the application of Upon premises owned by LC Electrical Contracting Long Dog Acres LLC. 22 Woodbine Lane 14380 Oregon Road East Moriches, NY 11940 Cutchogue, NY 11935 Located at: 14380'Oregon Road, Cutchogue, .NY'11935 Application Number#: 22-85096' Certificate M 22-85096 'Electrical License#: ME-38043 Section: Block: Lot: Building Permit#: 45831 Name QTY Heat Pump- 60 Amp, 240V Ep9trical Inspector: Sal Frangipane, .............. This certificate is not valid unless raised seal is present. u- ho��OFSOUIyO� l 3 94 orle * # TOWN'OF SOUTHOLD BUILDING DEPT. 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: GG Q P a� DATE Z INSPECTOR �oy�00F SOGIho� , TOWN OF SOUTHOLD BUILDING DEPT. �ycnurm,��' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ rULATIOWCAULKING FRAMING /STRAPPING [ AL 66� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: to r ink, ol,Z4 �a l DATE L INSPECTOR -* X631 Jeffrey Sands Architect D August 30, 2021 APR 2 2 2122 BUILDING DEPT TO Wei OF S0U-rH5,p Property/swimming pool location: Courtney Hoblock 14380 Oregon Road Cutchogue, 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, EDA Y N � �• 0 8 O¢ .F NE�y Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrev sands(W-hotmail.com l FIELD'INSPECTI0IV REP013T DATE k. FOU"ATION(1ST) FOLMATION(SND) tZ ROUGH IFRA11]NG PLUMBING INST;1 41`ION!PEA N..Y. STATE ENERGY COD-E': . 1 ,Y)N'AL , . .. N � o o. ffp . rn '.s'• �. U c., SofFntXc 1q, o� TOWN OF SOUTHOLD—BUILDING DEPARTMENT y2� y x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownnM.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only �31 - PERMIT NO. Building Inspector: FEB — 4 2021 Applications and forms.must be filled out in their entirety.Incomplete - applications will not be accepted: Where the Applicant is not the owner,an :Owner's,Authorizationyform(Page 2)shal l°be completed. • 1 Date: OWNERS)OF:PROPERTY: . S Name: C SCTM# 1000-46 a r— Project Address I L� Q�, t,)N ' '� Phone#: rJ 1 � _5 —C C� � Email: Mailing Address: m -CU+cKO t , q�5 -CONTACT PERSON: Name: W V1 Mailing Address: J11 q 0 Phone#: Email: 1P31-q-S3-(a40..1. .ov 1031 -5,9q -Ko q(p I Q l -DESIGN-PROFESSIONAL INFORMATION:.,, Name: Mailing Address: Phone#: T!mail: CONTRACTOR INFORMATION:., Name:Tnt o - S- -TC_ Mailing Address: _F &\J, O-K0-9 \tcr f, a Phone#• mail• `-1 (03.1_--9 - D a a SGS `DESCRIPTION OF PROPOSED CONSTRUCTION' ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: %other e NQC o S UC .m 1axSZ $ L09 i DOC) Will the lot be re-graded? ❑Yes `No Will excess fill be removed from premises? Yes ❑No . 1 TROPERTYINFORMATION Existing use of property: +DA Intended use of property:C_ f aXS Zone or use district in which premises is situated: Are there any covenants and restrictions gith respect to this property? ❑Yeslo IF YES, PROVIDE A COPY. - , 1 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 ISMEREBY MADE to the Building Department for the issuance-of a Building Permit pursuant to the Building Zone Ordinanceof the Towri;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 a rees,to comply with all applicable laws ordinances building code, housing code and regulations and to admit authorized inspectors on premises and in buildings)for necessary inspections.False statements made herein are. punishable as a,Class A misdemeanor pursuant to Section 210.45 of•the New York State Penal Law. Application Submitted By(print name): kg y I na MQX CINt O N 4uthorized Agent ❑Owner Signature of Applicant: Date: p�) ab a 1 STATE OF NEW YORK) LAUREN PARENTE Notary Public-State of New York S NO.01PA6262470 COUNTY OF ( lJ Qualified in Suffolk County �/y OF /� ) My Commission Expires May 29,2024�1 C / Aa M�� �{�/b being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the (Contracto 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. re me this 7:Of ,20 a1 . 16i1A I Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) 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 Buildinp,Department Application AUTHORIZATION (Where the Applicanrissnot the Owner) l L, YOL toy L�- kestdtng at (Print property owne s name) (Mailing Address) do hereby authorize kap yi p a M e r-L)A 6/ (Agent) _ lRf h G�S -pc)ol S to apply on my behalf to the Southold Building Department. (Ow er's Si ature) (Da ) (Print Owner's me) SUEFot,� NOV 2 �U�1 BUILDING DEPARTMENT- Electrical Inspector O TOWN OF SOUTHOLD oE}� Town Hall Annex- 54375 Main Road - PO Box 1179 *► Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(absoutholdtownny.gov - sea nd(cDsoutholdtown ny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: — Company Name: V Ito+-j WC-1 Electrician's Name: d ZZU License No.: �= �-pp Elec. email: e /i G pL. GO Elec. Phone No:^ .' �-a S'3 P3I request an email copy of Certificate of Compliance Elec. Address.:36-S-F G-eti Pia) e, .(3 A L 4 JOB SITE INFORMATION (All Information Required) z' Name: O�/061 C Address: N-320 o 801 GU a 11 3s Cross Street: r/ Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section:. Block: ® Lot: a,, 15- BRIEF DESC IPT4E)N_-_OF W-.Ql_K,-, CLUDE SQUARE FOOTAGE (Please Print Clearly Cal w PSI Qo rid l �R1i P) Square-Footag ,_` Circle A at Apply: . Is job ready for inspection?: ® YES❑NO Rough In Final Do you,need a Temp Certificate?: ® YES❑NO Issued On Temp Inforni tlo ,: (All information required) Service Size�.1� 3 Ph Size: 30C� A # Meter ­61-dMeter# .Z New Service Fire Recon`hec. ood Reconnect ice Rec6nnectIgUnderground 00verhead #Underground Laterals 1 2 F]a -VV rk done on Service? Y N Additional Information. Sed- 3 ti PAYMENT DUE WITH APPLICATION rp BUILDING DEPARTMENT- Electrical Inspector �p TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 CM r"' Southold, New York 11971-0959 �y • p!� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrC@.southoldtownny.gov gov - seand(cDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information,Required) Date: a� �I Company Name: U fo" 6_`eL r1C_1 C1 Electrician's Name: ,N 19rVd ZZU License No.: S-06 6 Elec. email: e /ig C, fia, GO Elec. Phone No: � - S3 [�91 request an email copy of Certificate of Compliance Elec. Address.: $SF Ceti PA) JUL) -Rthe M 11714 JOB SITE INFORMATION (All Information Required) ` Name: f_ Hob/06Ijj C Address: 3g Md Gv �h° U� ' 11?3 Cross Street: r/ Phone No.: Bldg.Permit#: LA 3 I email: Tax Map District: 1000 Section: Block: © Lot: a,, BRIEF DE_S_C_,RIPT-ION_--OF-W-ORK.—I.NCLUDE SQUARE FOOTAGE (Please Print Clearly): e rl_ rl vvi lit �;G Square.Footag Circle A-f�`I` at Apply: J� ,. _ Is job ready for inspection?- i-'Z YES-F-] NO '.O,Rough In. Final Do you need a Temp Certificate?: ® YES ❑NO Issued On Temp Inform_plio.n: (All information required) -�—� Service Size 1 3 Ph Size: 300 A #Meters- _'Old Meter# New Service Fire Reconnec._ loo Reconnect[].Service:ReconnectSUnderground DOverhead # Underground LateralsZ1 2 ~ Fi'F`tam_e-- Work done on Service? Y N Additional Information: ' SC� -` � nj �Ul7 . �'' PAYMENT DUE WITH APPLICATION PERMIT# Address: Switches ` Outlets GFI's 1 Surface, Sconces H H's UC Lts Fans Fridge HW Exhaust Oven W/D f,. Smokes DW Mini Carbon Micro Generator. Combo Cooktop Transfer AC- AH Hood Service Amps Have Used Special: � Q -rrPJ Comments: nn be. P Cif v e -� V e e 1 S o i` -BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD APR 1 9 20091Nn Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 - •` r -Telephone (631) 765-1802 - FAX (631) 765-9502 ,lid rogerr _southoldtownny.gov — seand(aD-southoldtownny.gov APPLICATION FOR ELECTRICA INSPECTION ELECTRICIAN\NFORMATION (All Information Required) Date: Company Name. LC Electrical Contracting Name: License No.: ME-138043 email: Affice@LCElectricalcontracting.com Phone No: ❑✓ I requeo an email copy of Certificate of Compliance Address.: ,-)� u1v� I.hv,� 0, Iter (� JOB SITE INFORMATIONII Information Ret ired) Name: �6,.,c�cot� {� ti L LI Address: d p �NrJ 1411) %i-ro 0 Cross Street: Phone No.: Bldg.Permit#: Li email: office@LCElectricalcontracting.com Tax Map District: 1000 Section: Block: ILot: ,> BRIEF DESCRIPTION OF WORK (Plea a Print early) Pc'.I Check All That Apply: Is job ready for inspection?: ❑YES ❑NO ❑Rough In [:]Final Do you need a Temp Certificate?: ❑YES ❑NO Issued On Temp Information: (AI information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service econnect ❑ Underground ❑Overhea\on # Underground Laterals ❑1 2 ❑H Frame ❑Pole Work doervice? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION l Pa,4 l Electrical Inspection Form 2020.xlsx �/ Ili pp • � ... � AB.TfY�'RpM•� . .. a'vlF�y� NN SOP Pik JAI .ry ^ 1~- GAP16g �7ry. � "�-.198,21' �� � � : � � �. •, 1 � •. . or fIn mem •. o . . •i ��" �t ..��,.� �� �•'�� � • - hQmro�nsf�:oa - P _ r 'oda eg1'.. l formerly r .' Tf'rofiAS.Uhtfn . :� ' • LIM c CILTIV;170 ger r . Karen UhIlmger. r J now or.. r :. �'o7;zP,uHt. °�'"'�''' foi-mert r. Vl rA 1; i r0W..ar for °rmerty V It ` . Development �fgFits1 • off' �. � �. _ - . � � �. . :. . • � � . . - . . . . 400 Ostrander Avenue, Riverhead, Naw York 11401 tal. b3l.-12-%2505 fax. 631.7-77.0144 admir@youngengincering.com Howard W. Young, Land Surveyor Thomas G. No►pert, Professional Engineer Douglas E Adams, Professlonal Enginaar Robert G. Tast, Architect 5 nv n� NOV 222010 A DEPT OF LAND P ESERVATION S FIS r ' SURVEY wx F f ' no;q or J! Lleb Vineyard LLC r T �Svb�ect to LLKEY >z4i=' I° M OWh SCALE= =600' neyelopman* Raid ` j/� tr►�or:cisnvnrroM ��vrt�,y� "'"`_ "'C 560■g2 Y4"!_ � ��--- 0 - �_ L Sty gyp. '33�4J pr"Ov� n�] Z s '4 UIS1 rya 0 �a�r s rA `1 'T'ON 0 ary AREA c 26.6717 ACRES o} w Y� s• I sob FARPq a 1_ 7',4INb'n PA m +N6 t0,1� 1 In m -� noWWir for erly 010 - _�onghue zry_ " - 04 00 ',W- ` a�' 50.� r -`� _ SITE DATA SroF >xtry y,r `�4q.gl' �A.1r; 1h R1'IQrY pl., form@rl oQ obert A. Graeby 1 nota or formerly 1 TOTAL AREA = 33.1810 ACRES nary or for t'hylls A. Gree � Thomas G Thomas U mer ly 1 UM P,cWrW�7rdk M6$ b ( DIone 4 , hj[,,,,, r ane GrQe(' I ACOU151TION PARCEL AREA 26.6717 ACRES - wren �tlinger 1 72.61 ! ! 1022601 1 RETAINED PARCEL 'A' AFZEA - 4.6669 ACRES 1 N6l•O = ,+Y4 � Ed a d F, Hughes j '�O^�+w+r � De o; or former! t 27121°F t 0? Natur@ LLG RETAINED PARCEL 'B' AREA = 2.6214 ACRE5 or formerly Lleb � �� •�� I-LC \ 441.51 NbO°5558„� 962,25,51 11E J 449.8x' —�' (5Llblerit to 1 � ! $IGYra p 1 RETAINED P'��EL 0.82' t$r �r- IRAILS �i w oWn Of Southold 1 REA = 2.6274 ACRES m Development Rights) - _ • N60.55'5WN `.`. r . sy' ! nON or formerl �7s6' 657.3q' Z 1 Mlcha@I Lot 6 Nbo•g0�2„ Q� ,� Hary or form REFUTED ONNER = MICI14AEL PEMGHAK 4 MARIA DEMGHAK Demchq� � � • erly Ma+"lcr Demcho vr ` TI-romas -mom GARNOUSTIE COURT 1 (Sub.ject to � psOn RIVERI-EAD, NEW YORK 1140{ '' Town of Southold 0 now or Development Rl9hts) v o- Mattltvrk (S rl C b lnc, f0. y 1 h r SURVEYOR'S GERT11=10ATION Jd NE HEREBY CERTIFY TO TOWN OF SOUTHOLD, UNITED a t STATES OF AMERICA (USDA-NRCS)* MICHAEL o' 1 � DEMCHAK, MARIA DEMCHAK & STEWART TITLE INSURANCE COMPANY THAT THIS SURVEY WAS PREPARED t / IN ACCORDrANCE WITH THE CODS+ OF PRACTICE FOR LAND SURVEYS N 1 f a Ur ` / t ADOPTED BY THE NEW YORK STATE A550GIATION OF PROFESSIONAL LAND SURVEYORS s i. q) IT JI �}ID 97 0 '141 11 4r fiU' Q �/, � / ` `� /� t ++ONARD W.YOUNG, N.Y.5. L.5. NO. 458419 a 11 4por 14 0 k- a Q0y '/ ' 5URVEY FOR GIp,��S o 1111N--1N11%LANZ � *�� / 1 TOJNN OF SOUTHO D $ `0 NY at Gutchogue, Town of Southold 14 .; Suffolk Gountlg, New York X61°33'08 yv / 27:78, ACGtU 151 TI ON MAS' 1000 &4 01 11 OX'S 1 GOunttq Tax Mop Urstrlct 1000 section 84 Block 01 Lot 12.1 a ~•7 f�' MAP PREPARED NOV. 16, 2010 a Record of Revlslons RECORD OF REVIVON5 DATE 100 O 50 100 200 300 9sr-010. 1” = 100' Joe NO. 2010-0250 DWG. 2010_00%-2010_0250^6s OF ] 0= MONUMENT 5r--r 0= MONUMENT FOUND D°sTAKE 5ET A=57A�FOUMO Y workers' Compensation' CERTIFICATE OF INSURANCE COVERAGE srarrc Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name tf Address of insured(use street address only) 1b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-9414113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required 11 coverage Is specUfca!!ylimlled to or Social Security Number certain locations In New York State,i.e.,Wisp-Up Policy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate H";Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL318565 Southold NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2021 4. Policy provides the following benefits: ® 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 employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employers employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date signed 7/17/2020 By (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 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,410 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 OB-120.1.Insurance brokers are NOT authorized to Issue this form. DS-120.1 (10_17) iInIIP!uuuioQum1 (iouimi�ii�l�l YO K Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-9961687 Patricks Pools Inc PO Box 3024 East Quogue NY 11942 1 c.NYS Unemployment Insurance Employer Registration Number of Insured c Work Location of Insured(Only required it coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social 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 3b.Policy Number of Entity Listed in Box"1 a" 54375 Main Rd WWC3465462 PO Box 1179 SoulholdNY 11971 - 3c.Policy effective period 05/13/2620 to 05/13/2021 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partnerslofficers included) QX 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"l 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 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 (Print name of authorized representative or licensed agent of insurance carrier)) Approved by: -7/17/2-u (Signatur (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. C-105.2(9.17) www.wcb.ny.gov DATE (MMID A 0' CERTIFICATE OF LIABILITY INSURANCE 07/132020 DnYYY) 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(les) must 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 Ileu of such endorsement(s). PRODUCER CONTACT Brookhaven Agency,Inc. PHONE 631 941-4113 FAX 631 941-4405 100 Oakland Ave,Ste IE-MAIL Annizip.gs, certificatesC@-brookhavenagency.com PortJefferson,NY 11777 INSURER(S)AFFORDING COVERAGE NAIC a INSURER A; Philadelphia Indemnity Insurance Co. INSURED INSURER B•Wesco Insurance Co. Patrick's Pools,Inc JNSURER C• Merchants Mutual Insurance Co. PO BOX 3024 INSURER D: East Quogue,NY 11942 NSURER E: IN URE 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 TYPE OF INSURANCE DL UBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIm rs X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 NTED A CLAIMS-ME �OCCUR DAMAGES( n owm $100P000 X X PHPK2103006 02/28/2020 02128/2021 MED EXP(Any one on $5,000 PERSONAL&ADV INJURY $1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY❑PRO JECT ❑LOC PRODUCTS-COMPIOP AGG s2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $SOO OOO C X ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED X X CAP9267113 07112/2020 07/12/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGEAUTOS (Per aceidant) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAS CLAIMS-MADE AGGREGATE It D RETENTIONS $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS LIABILITY ST ANY PROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACCIDENT $100,000 B OFFICERIMEMBER EXCLUDED? NIA WWC3465462 05/1312020 05/1312021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE 100,000 Ms,dW*be underOF 0 belowERATIONS E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached if more apace is required) Town of Southold is included as additional insured CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE <CC> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD -. ,. '++.�- r�r�.-'• .,,; _ ..h-.• { %f= 7- M. N CQ bc r' ^, }• ..F H �S 5, t•: t ;,; ��� � Vii'= `Y. �•f-. _ . _ r t ri� I r I t I t I I 4 I -t i t s g��7 t i 71 NTED ' ., APP ..__ - Z 3 1� ' I DATE: /� &P.#1 �J t CC�iEVfPL`l WITH ALL CODES•OR `® BY: NEW YORK STATE & TOWN CODES ' ! " FEE: - coy-rvp)a dn. QI i NOTIFY' BUILDING DEPARTMENT AT i i i ,r •' I I' AS REQUIRED , 765-1802 8 AM TO 4 PM FOR THE , FOLLOWING-INSPECTIONS: - --_---. _ ON.-.TWO-REQUIRED ? 1. FOUNDATION. FOR I•POURED CONCRETE' S USTEES ` 2. ROUGH - FRAMING &( PLUMBING ` � � 3. INSULATION 4. FINAL - CONSTRUCTION_MUST BE COMPLETE—FOR—C-.,0 - - — — --- — ---- �- --'-- - - X11 ��23 - , } .�---�` � �,• � I i $ i ALL CONSTRUCTION_SHALL MEET THE ; , ?J. v' i -- — - :. r: C , a i - , .L.. �F.N 1 ~'S -DES } r t THE C �?OF E UIR M ENTS' -�- } �"4• 'I - A - - - -i ' i I s<FO Fi i .NS{ BLE '-; 'RO �T . N9T-° I DE IGN OR CONST UG,TION ERRORS. �jj1 IPfSPEMON t I I occ E�EcrRI I i m ! I�>�h ��+�C Mi..gY 1 i o U...-E.J.S.-UN wil MEDIATELY ! f i IIS ENCLOSE POOL TO,COgE� OCCU ' N (9 ! + j UPON COMPLETION I I ! t t I ,;', I BEFORE"WAST ER _-- �_-:,._ -- . -_,r,,,�r .,.:-.4.> -..ins -�-..� �..,•_«.. ,�,�%p.v -.••-.o••.,•.- ..�+.--"�:-X�';�''�'�a!>'e'�...'_��'.�^��N:�RtfiY�'�.+,'a.�..:r�-.,tom. T:,��* _,K—^`.��t b `+°tip•+ Jx�'x__��R?��_�-�. �C.• ^.,s_:_:=...,� .._....,.._. r•=".C'-...5".`.°`t,.es<o:����*`"2�""'�s-"�'• .""'�'w"..�.i'�:II.a!�s:az..,....�-.s".........::�....+.,rr,•e"' 'x,...._._�•:.� .a,._.,.. ...,._.... � :-^+.f�.+•*.,:�f � !1 "�"` ,E� I -•--}-,_ _...j. i } I \ i J` -- ---- - i ._..o,_..,_u.--�• a - -o---' o-• --i ^-.-`a-•-^•.c--�-o--`---a-..w. a.._::.. __..�_�.,�.. Q,�.�_ I I _.j_._ t ---1- -� ,..m..•...,....-,.e'B sl�.,.,..-.-„�-...„,,n-..,,�_,.°-..-.,..,,. ....._.�,-'.,..��.-.��._..�_.r.tr-��y� � .,�,.°..._.._p_.._.� ;--o--, ._,._,._.--_..,._ i °._._....__'� a_'i.._° �.��... t �-.� � .. � _�•�� .�.�x„1!1 .—.�� { ! ~p,ED Aq PrD?.OS PC70� �j v 0F E __��__..�__'I�`��.�{`���.�i�i` ��:'`•�t'��`�~i �__._-..__ Via, C�A.`J�ic ri ti �. ��.g� �� _� � _. � - l •----. � � i - ----- --- _�_______ I.___ M____ _ __ i1 � _______ �__._._._.__ - , _ t _ ____,_..�._. I f + A , , I i i , + ! _ j o; I i .. , j I ._.r...._..,__,..—r._...... �..rr..._.,..-..,- ,.......__...-v._-..�......_. .._...,�. ".,.,,_,...,..... , � f � .r,....v ,-._ ... ._ .. _._....... _ _-__.._..- _.«.-+-a-....._. .n......env- _.._.,.-_ -- -t___ _ _ .�-..,_.—. .....__..-......._.r...._ _ _....._...... -.... i V , i . , Ii -k ' I j v Ck E RED 41 COD 14 , : 1 f t r N , { i i , r �`''� ! 4 } 4 ' 1 , pp qq >894AV CV5.` •14�.V.'i..J i "^—'v j . . i : • i � i + ' � � f k ; � �.__...,------• it - i �� ` j � 'L5 � �.L.'7 i _ _ i ! p _.- _t._.__........._-,-�—...-,__t_.-....--,.,-.....-._-v-.__-_a -•.__ a { f I