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HomeMy WebLinkAbout47175-Z o�OSUFFO Town of Southold 10/20/2022 P.O.Box 1179 o �' - 53095 Main Rd Southold,New York 11971 . CERTIFICATE OF OCCUPANCY No: 43523' Date: 10/20/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2705 Eugenes Rd., Cutchogue SCTM#: 473889 Sec/Block/Lot: '97.-3-20.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/16/2021 pursuant to which Building Permit No. 47175 dated 12/3/2021 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 Zuhoski,William&Stephanie of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL .ELECTRICAL CERTIFICATE NO. 47175 9/29/2022 PLUMBERS CERTIFICATION DATED Author' e S gnatur o�sueenl�.�o TOWN OF SOUTHOLD Gym BUILDING DEPARTMENT C* x TOWN CLERK'S OFFICE "oy • o� SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 47175 Date: 12/3/2021 Permission is hereby granted to: Zuhoski, William 2705 Eugenes Rd Cutchogue, NY 11935 To: construct accessory in-ground swimming pool as applied for. At premises located at: 2705 Eugenes Rd., Cutchogue SCTM # 473889 Sec/Block/Lot# 97.-3-20.2 Pursuant to application dated 11/16/2021 and approved by the Building Inspector. To expire on 6/4/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 B I n Inspector . , o��pF SOUjyol ti o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 a� sean.devlinCaD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: William Zuhoski Address: 2705 Eugenes Rd city;Cutchogue st: NY zip: 11935 Building Permit* 47175 Section: 97 Block: 3 Lot: 20.2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Platinum East Electric License No: 34091 ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 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 2 Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: Pump 220GFI, Heater, Salt Generator, Lights 120GFI Notes: Pool Inspector Signature: Date: September 29, 2022 S. Devlin-Cert Electrical Compliance Form OF SO(/T�o t-1 1175 Q, # TOWN OF SOUTHOLD BUILDING DEPT. �O • �O �ycourm��' 765-1802 INSPECTION ,. [ ] FOUNDATION 1-ST [ ] 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: tar 0 1\ k/ oa 0 IQ G- Cal - 1/ 0 Al Cil DATE Z7i INSPECTOR ' SOUlyolo TOWN OF SOUTHOLD BUILDING DEPT. `ycou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL �i-0/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: s,& o s rz A-S s • �o�I �af�.Gr� �� r ✓t �6v I . • �/�.l�!�G,� C�Z.��C��C.. J�-�(�I/Lem, . • ��-n�v� rr�s ern. ��.��- r�,r�l e�ws 7 DATE `��IS- �� INSPECTOR Awl4 a q_l q SOUIyOIo 2,,� 1491 * # TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 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 [ ] RENTAL REMARKS: Z Z Z l DATE INSPECTOR �O��pF SOblyo� # TOWN OF SOUTHOLD BUILDING DEPT. °`ycourmN�' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATIOWCAULKING [ ] 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: /L s.j �' dosp G.o. DATE INSPECTOR FIELD;INSP C 'ION Ti P' RT`'. DATE:;: ' Cb.M1bLC;TS' FOUNDATTON:-(1ST)� :::+;,.,..,:.• .. ly FOUNDATION(2NA.). ` ... • J Y`i••V,l ROUMINO;& t� , ..... .GH.FRA....... .; • PLUMBINGON. : . INSULATIPO NE' RN.. STATE ERGY`COD . .�•1 .S .: o' d S FINAL ADDIT.dNSLs:,`,OI ,N.TS: S _ �.A rj a -a q rl - rn • z TOWN OF SOUTHOLD—BUILDING DEPARTMENT g Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631)765-9502 hftps://www.southoldtom=.gov Date Received APPLICATION FOR BUILDING; PERMIT For Office Use Only ® _ C E l! PERMIT NO. Building Inspector: NOV 1 b 2021 DD Applications and forms must be filled out in their entirety.Incomplete BUILDING DEPT. Pp Y p TOWIUOFSOUTHOLD applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: .c S7E�NRiV/C ZuNtIS SCTM#1000- CIS_ _'9O,oog Project Address: �7Us EU� s �iZ�, L'ur'C�aC�E Phone#: &3 - 9J6-_x-866 Email:�u�oSK Alec a7gr��,1 ,e vn--i Mailing Address: CONTACT PERSON: Name: (&)ILLI AIM ZA-0540 Mailing Address: 9705- Phone 70SPhone#: 631 - 9,;26- 6-E-66 Email:Zul-+vsKi�oal eor���rY�o.t l ,��r►�► DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: -CONTRACTOR INFORMATION: Name:� •�I:TI1i�'nj .SLS L� Mailing Address: 7p.O, 3X 9 -Phone 4: _�3l� y�`/-�,/�2ys Email: act,,,"o:)cF?� on n+..rie+ DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: other1#O Q2u01t4> .5LZi""iAe7 $'2y, oocl Will the lot be re-graded? Mes 0 N Will excess fill be removed from premises? ❑Yes k'NO 1 PROPERTY INFORMATION Existing use of property: - Intended use of property:.:2 S9"zy ZC�� Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to 'this property? ❑Yes;KNo IF YES, PROVIDE A COPY. (�Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(pri name): �(J7Authorized Agent EJ Owner Signature of Applicant: Date: ,", STATE OF NEW YORK) SS: COUNTY OF Ci.;G,Pb\C ) 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/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. i Sworn before me this I L day of 4yem6e20 al tary Public EVE L.GAU-SCHWAMBORN NOTARY PUBLIC.STATE OF:NEW YORK PROPERTY OWNER AUTHORIZATION Registration No.OIGA6274028 Qualified in,Suffolk County (Where the applicant is not the owner) Commission Expires Dec.24,20-251- I, 4,20251- I, ,]�1 1� �1Y,OS1� residing at aq4p:!� V-- Lge(`e-<� Z� do hereby authorize l'�/9�K 7ey(ZS --7'z>- to apply on my behalf to the Town of Southold Building Department for approval as described herein. - f ,7,�, Owner' Signa� re Date Print Owner's Name 2 lu.�,� ILDING DEPARTMENT- Electrical Inspector MAR TOWN OF SOUTHOLD f3U1��NG 0EP_r- Vown Hall Annex - 54375 Main Road PO Box 1179 o • TOW , Southold, New York 11971-0959 1p� Telephone (631) 765-1802 - FAX'(631) 765-9502 roger.richertCcD-town.southold.n .us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: "3 Company Name: — — CC-C l . .1V . Name: License No.: m/:- 3 YD 9 �. .email: Address: .131n /2 vvcD �7 Phone No.: - J1 U JOB SITE]NFORMATION: (All Information Required) Name: Address:.' D 'Cu Te,4(O Ute' Cross Street: Phone No.: x,31 - &tc- 09 u 6 Bldg.Permit#: 4717 . email: 9jc�frnu�t7�+s� I Fax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Roo Circle All That Apply: a Is job ready for inspection?: .YES / O Rough In Final Do you need a-Temp Certificate?:- YES / NO Issued On- Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service'- Fire Reconnect- Flood Reconnect- Service Reconnected - Underground -Overhead #Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Request for Inspection Form-As p v .� :A �uFFC ,� •�•� ILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Bu `� H01-Town Hall Annex - 54375 Main Road - PO Box 1179 roan.;, Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 roper.richert(a-)town.southo ld.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: ellA Date: 3 Company Name: 6-C l Name: License No.: mr- 3 YO 91 email: a rYmi ee4 s{ .2 &40. (' Address: 3 _ ov7focD Ply 5`71 Phone No.: - ria JOB SITE INFORMATION: (All Information Required) Name: (Ll Z Address: Nf�- D CuT ¢(O UC' Gross Street: Phone No.: Cn,3 I BIdg.Permit#: `17 I '� � email- Ic��lnu��as1 1: Fax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Poo Circle All That Apply: Is job ready for inspection?: YES /LI�O Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A #Meters Old Meter# New Service - Fire Reconnect- Flood Reconnect- Service Reconnected - Underground -Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Request for Inspection Form-As ��/ � n PERMIT# Address: Switches Outlets G F I's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven W/D Smokes DW Mini Carbon Micro Generator Combo Cooktop Transfer AC AH Hood Service Amps Have Used Special: Comments SO(/Tho �� f 75' 2-7o5-V" ✓4�� # TOWN OF SOUTHOLD BUILDING DEPT. co 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLDG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ '] FINAL [ ] FIREPLACE & CHIIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: ®� a Lh r C[ Qn DATE Z7i INSPECTOR ���� � �-� � z� �r )N5)SHOWN HEREON FROM THE 5TRUCTURE5 TO THE A55TRACT OF TITLE AND EASEMENTS FOR 5UBJECT PARCEL SPECIFIC PURP05E AND USE AND THEREFORE ARE NOT AND ADJOINING PARCELS NOT PROVIDED FOR THE °CTIONO F FENCES, RETAINING WALLS, FOO1.5, PATI05, PREPARATION OF T1115 SURVEY. ABSENCE OF EASEMENTS lit S. C. 7'. # 1000-97-3-20. 002 TO BUILDINGS AND ANY OTHER CONSTRUCTION. DOE5 NOT DENY THE EfC15TENCE OF SAME. N 07°51 00" W 370.861 Proj. # 17055 Lot 2 Map of Minor Subdivision Prepared for Scott Kaufman 0 Situated at �y s vJjj4AA14 East Cutchogue z Town of Southold Iv �" Suffolk County, New York s.a W CE O iz ` o N Lot 2 _ � = Surveyed 10 N s 1 1.r o I C9 N 2 so A 16.a December 18th, 2017 W ;�27os - .a 41, Rev. 4/13/21: Add Detached Garage 3 -------- --���` N --- 7.a 76.7' Nage MUNICIPAL LAND SURVEY, P.C. 213 10 SYLYIA LANB >iI ! NZDDLTs ISLAND, NEW YORK, 11953 I ----------- (631) 945-265e ---`.------- P------ ����� NISI " 1X�5t'D I —�� Asp. I ^' az' y' y' 2C $ Pn D*y. Q arage _ wcy 30.1' ' 21.8 �t9E� cct> wJ lUJ L II lV� S vR N NOV 1,6 2021 351 . jD 97' lron>�n BUILDING DEPT. 5 07°5 ' 100" 6'Me,Fence 0.5'Ca. Fe t=ne TOWN OF SOUTHOLD 4.2' Ea. n Lot 3f O I. —r:T iY P 1 v 'Atin gU Banks Btre�t yr I.� ui n+-4- i C-' n1vC-- I 9nAG1r On A�® CERTIFICATE OF LIABILITY INSURANCE DA�/1B2D02� THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER 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 polioy(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 endorsemer*s). PRODUCER CONTACT Lauren Murphy Roy H Reeve Agency,Inc. PHONE c (631)298 4700 ac No: (631)298-3850 PO Box 54 E-MAIL Imurphy@rbyreeve.com ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE 'NAIC# Mattituck. NY. 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED ' _ INSURERB: Chituk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 1,1935 INSURER F: COVERAGES CERTIFICATE NUMBER: CL213414038 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AUULSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2021 03/15/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑JECT LOC PRODUCTS-COMPIOPAGG "$ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIABHCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U more space Is required) Re: William Zuhoski 2705 Eugene's Rd Cutchogue,NY 11935 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD _k ', workers' CERTIFICATE OF INSURANCE COVERAGE sTa Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la.Legal Name&Address of insured(use street address only) 1 b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245.- PO BOX 9. , CUTCHOGUE,NY 11935 1c.Federal Employer.Identification Number of Insured. or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations In New York State,I.e.,Wrap-Up Policy) 11330634.7 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity'.Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town'of Southold PQ Box 1179.' 3b.Policy Number:of Entity.Listed.in Box"1 a" Southold NY 1.1971 DBL614067. 3c.Policy effective period 05101/2021; to 04/30%2023'. 4. Policy,provides the following benefits: © A.Both disability and paid family leave benefits. 0 B.Disability,benefits only. El .: C.Paid family leave benefits only. 5. Policy,covers:. © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/16/2021 B � 19i UWWI/ y (Signature of insurance carrier's authorized representative of 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 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 513 of Part i 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) IIOIIP!uiiii1�211�11111111681pi17)ii�l�l ` CERTIFICATE OF 1 'Or�CeS< NYS WORKERS' COMPENSATION INSURANCE COVERAGE T :>: ori erisai, `ri Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) 16.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 lc.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically Social Security Numbercally limited 113306347' to 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 PO Box 1179 3b.Policy Number of entity listed in box"la": Southoold,NY 11971 WWC3505094 3c.Policy effective period: 1/1/2021 toi1/1/2022 3d.The Proprietor,Partners or Executive Officers are: ❑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 bog 113"insures the business referenced above in bog"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"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within IO days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other titan nonpayment ofpremiums 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 73c';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: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) ri_.iit�-rrr_----r-1 --_!_c_tfl,-_r--.-/rinenninnm_---._ninn-.cninnn_--..t-ice7_�___r tnnnI Approved 11/16/2021 By: (Signature) (Date) Title: SVP,Workers Comp Production Management 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. C-105.2(9-17) www.wcb.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.o. 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 ,C1_.///T_/T T_ _t—_._id-i nr, nn/num______n�nn_.Ql/nn['�___al_ W..a APPROVED AS NO ED RETAIN STORM WATER RUiuOh- �I PURSUANT TO CHAPTER 236 DATE: 307 B.P.# ( OF THE TOWN CODE. FEE:3� NOTIFY BUILDING i EPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH '- FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ELECTRICAL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW INSPECTION REOUIRED YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIPED AND CONDITIONS OF SOIff R0,-07-1 O-W-N (BOARD ENCLOSE POOL TO COPi;;-` SQ�USTEES *.-UPON COMPLETION OCCUPANCY ORtA; m.�n- USE IS UNLAWFUL ` ��� �� WITHOUT CERTIFICATr rY1+�t�' �� a OF OCCUPANCY rAI, nl,mLtftn O-r a l6�q(n.s .. � PODLSQE •wifh3te0`' 'R.I•..6•. C . :D E. ' F; .G'. H 'K '•'L.' :-67 .. N` .Gal.. 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TOWN OF SOUTHOLD asmumcoamm POOL SECTION s� •..• .,. :. � ' ... .. '• � . '?�`.-• =ter � • Compfies.With F� o. 1 2020 Code Section'3032.1`=303A Swimming Pools,Spas and Not Tubs Section-11326 of the Residential Code of New York ' -----.bi1--- --------- - ------- Section 3109 of the Bliilding'Code of Newyork Section N1103.12(11403-12)Residential Pools and Permanent Residential Spas POOL WFE:REC'G'ANra� " SCALE. ;NTS- �, Section 31093.12-:3."1097.4.Pools and Spas Gates,Barriers 1AES® ERK®SK!D °� ro Section G106 Entrapthent Protection -. TYPICAL P M EL$11vFNER Section G1o7Alarms 960 DEER DRIVE _ ��`�� Section E4201-E4312 Electrical Connections for Pools MATTITUK,NEW YORK 11952 DRAWIMS NUMBER • .. -_ ... . 1 ®F �' 1 Ir ^ l NOTES: 1. DIVING BOARD TO CONFORM WITH ANSI/APSP/ICC-5 SEC 6 2. NO SOIL DISCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION I. 3. POOL MUST BE SURROUNDED BY A CONTINUOUS BARRIER CONSTRUCTED IAW REQ.OF SEC 326.4.2.1-R326.4.2.6 OF THE NYS RESIDENTIAL CODE(2020)AND ALL SECTIONS OF THE SOUTHOLD CODE 4. WALLS MAY SERVE AS PART OF THE POOL BARRIER AS PER SEC 326.4.2.8 AND ALL WINDOWS HAVE A SELF LATCHING DEVICE 5. ACESS GATES SHALL COMPLY WITH SEC R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY LOCKED WHEN POOL IS NOT IN USE OR SUPERVISED. ALLL GATES ARE TO OPEN AWAY FROM THE POOL AREA. r 6. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECT A TEMPORARY BARRIER AROUND THE EXCAVATION IAW CODE OF THE TOWN OF SOUTHOLD. 7. POOL MUST BE EQUIPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER AND SOUNDING AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE AT THE POOLSIDE AND INSIDE THE DWELLING.THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH TEH MAUFACTURERS INSTRUCTIONS.THE ALARM MUST MEET ASTM F2208"STANDARD SPECIFICATION FOR POOL ALARMS".THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSONS. 8. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIIMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI Al 12.19.8M OR A MINIMUM 18"X23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM.POOL CIRCULATION SYSTEM MUST BE EQUIPTED WITH ATMOSPHERIC VACUUM RELEIF.SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME Al 12.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. POOL SALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE.THE SUCTION FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS).VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENT TO THE SKIMMER/SKIMMERS. A REQUIRED POOL ATMOSPHERIC VACUUM,RELEIF SYSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE R326.6.3(2020)AND IN ACCORDANCE TO TOW CODE 9. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC),PRINCIPALLY ARTICLE 680 AND THE NYS RESIDENTIAL CODE SECTION 4102 THROUGH 4106.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GOUND FAULT CURRENT INTERRUPER(GFCI).CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5. ALL METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. 10. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608. 11. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 12. WALKS,IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM THE POOL EDGE. 13. A MEANS OF EGRESS FROM DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/NSPI-5 SECTION 6. 14. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. 15. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. 16 THE DESIGN IS BASED ON A IiRAINAGE SOIL WITH<10%SILT.GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IF GROUND WATER EXISTS WITHIN 60"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. 17 ALL GAS AND OIL WATER HEATERS(IF INSTALLED)FOR THE IN-GROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT.POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726.POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS.POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES.A BYPASS LINE SHALL BE INSTALLED FROM THE INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HATER.POOL HEATERS SHALL BE PROVIDED WITH THE FOLLOWING ENERGY CONSERVATION MEASURES: 17.1 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE PILOT LIGHT. AT LEAST ONE THERMOSTAL MUST BE PROVIDED FOR EACH HEATING SYSTEM.HEATED'SWIMMING POOLS SHALL BE EQUIPTED WITH A POOL COVER.(exempt FROM THIS ARE OUTDOOR POOLD)DERIVING 20%OF THE ENERGY FOR HEATING THE POOL FROM RENEWABLE SOURCES OVER AN OPERATING SEASON. 17.2 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS,AND CAN BE SET TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITORY CONDITION IAW APPLCIABLE SANITORY CODE OF NEW YORK STATE. 18 BACKFILL WILL BE DONE WITH CLEAN EARTH FREE OF ROOTS AND DEBRIS- BACKFILL HEIGHT AND WATER LEVEL TO BE WITHIN 8"OF EACH OTHER. PLACE CONCRETE ON SANDY LOAM SOIL. CLAY TO BE REMOVED AND REPLACED WITH SANDY LOAM. 19 THERE ARE MAIN DRAINS IN THIS POOL-THERE ARE TWO APPROVED SUCTION OUTLETS WITH A MINIMUM OF 3'OF SEPARATION. THE SUCTION OUTLETS ARE PIPED SO THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM-RELEIF-PROTECTED LINE TO THE PUMP.COMP I WITH ENTRAPMENT PROTECTION AS PER CODE. 20 THE POOL WAS DESIGNED REFERENCES AS THE FOLLOWING: 20.1 THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE(2020)SEC R326 QF EW y v 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 �� R 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) r , '..,_•'Ps,:s:° Y 20.4 THE NEW YORK STATE SANITORY CODE. 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. y1 = v �=C? POOL NOTES SCALE: NTS 20.6 BOCA CODE SECTION 421. ��p 07 P� JAMES DEERKOSKI, P.E. 20.7 CODE OF THE TOWN OF SOUTHOLD260 DEER DRIVE ROFESS� DATE: 10/2/2020 _ MATTITUK, NEW YORK 11952 DRAWING NUMBER 2 OF 2