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HomeMy WebLinkAbout47745-Z �o��Sj�FFDL Town of Southold 10/29/2022 o P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43 544 Date: 10/29/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 705 Lighthouse Rd., Southold SCTM#: 473889 Sec/Block/Lot: 54.-3-26.9 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/24/2022 pursuant to which Building Permit No. 47745 dated 4/27/2022 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 Parker,Sheri of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47745 8/9/2022 PLUMBERS CERTIFICATION DATED AuAio 'ze SignaVel 'SUFE- TOWN OF SOUTHOLD BUILDING DEPARTMENT N z TOWN CLERK'S OFFICE oy • ��: SOUTHOLD, NY sol � Sao ;s 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#: 47745 Date: 4/27/2022 Permission is hereby granted to: Parker, Sheri 705 Lighthouse Rd Southold, NY 11971 To: construct accessory in-ground swimming pool as applied for. At premises located at: 705 Lighthouse Rd., Southold SCTM # 473889 Sec/Block/Lot# 54.-3-26.9 Pursuant to application dated , 3/24/2022 and approved by the Building Inspector. To expire on 10/27/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE. $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector pF SOUT�oI Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.devlin(cD-town.southold.ny.us Southold,NY 11971-0959 OI�CQU�s�� BUELDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Sheri Parker Address: 705 Lighthouse Rd city:Southold St: NY zip: 11971 Building Permit#: 47745 Section: 54 Block: 3 Lot: 26.9 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 2 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 G Transformer UC Lights Dryer Recpt Emergency FixturesE Time Clocks Disconnect Switches 2 4'LED Exit Fixtures Pump Other Equipment: Intermatic Pool Panel 8 Circuit/ 5 Used, 2 Lights 120GFI, Heater, Salt Generator, 22 Pump 220GFI, Auto Cover 120GFI, w/ Key Locked Switch Notes: Pool Inspector Signature: Date: August 9, 2022 S. Devlin-Cert Electrical Compliance Form SOF SO', l L/ li-AAOUS2 ho� o�o H-7 7 115 .� * # TOWN OF SOUTHOLD BUILDING DEPT. °yCIOU �'' 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: d ot, CA l I � DATE Z INSPECTOR o�aOF SOUIyo 7 q,;7 �O L, TOWN OF SOUTHOLD BUILDING DEPT. `ycou631-765-1802 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 ?01 PRE C/O [ ] RENTAL REMARKS: O�-ti DATE INSPECTOR ooe UP SOUTyo� * TOWN OF SOUTHOLD BUILDING DEPT. courm, 631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ WFINAL fid� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION �1 [ ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR Jeffrey Sands Architect May 14, 2022 [ECROVE Property/swimming pool location: OCT - 5 2022 Sheri Winter Parker 705 Lighthouse Road BUDDING DEPT. TOWN Off'SO OILD Southold, NY RE: Swimminq 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, E ARc Y M,, S�2o �C) a —{ (PP o27894 OF N ENN Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—Jeffrey sandsD-hotmail.com FIELD INSPECTION REPORT I DATE COMMENTS ro FOUNDATION (1ST) I ^ � ------------------------------------ C FOUNDATION (2ND) z �o G (� y ROUGH FRAMING& PLUMBING y 1 N r INSULATION PER N.Y. �3 STATE ENERGY CODE ak- � FINAL ADDITIONAL COMMENTS b o � X o ro x d ro �coGy TOWN OF SOUTHOLD-BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 y�o as Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldto=.gov Date Received APPLICATION FOR BUILDING PERMIT 4 F r Office Use Only R PERMIT NO. Building Inspector: MAR 2`4 2022 V_/ - Applications and forms must be filled out in their entirety. IncompleteTOWN F G D HOLD applications will not be accepted. Where the Applicant is not the owner,an , Owner's Authorization form(Page 2)shall be completed. Date: ��q OWNER(S) OF PR PERTY: Name: ( ,/ „ (D.t JY SCTM# 1000-�� -3 - aG� r V 1 Project Address: Phone#: �;l -B49 Email:(E�k •fir Mailing Address: CONTACT PERSON: , Name: KnAnV� �r �n o v Mailing Address: i 1 r 119 [ Phone#: 0� I , _/ l Email: l 1 `'t lY um) ( �<C —1 Div DESIGN PROFESSIONAL-INFORMATION: Name: Mailing Address: Phone#: Email- CONTRACTOR INFORMATION: Namelafig(_Vs Mailing Address: I w J Phone#: I _ Q? lc Email: S l C DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑ Ilteration ❑Repair ❑Demolition Estim a ostofProject: 0-70 Will the lot be re-graded? ❑Yes No 1.4 Will excess fill be removed from premises? es ❑No 1 PROPERTY INFORMATION ' Existing use of property: )� Intended use of property: 15,rvey h,0LWkK— u' ki, V1 Zone or use district in which premises i ituated: Are there any covenants and restrictions with respect to Athis property? ❑Yes ENO 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( rint name): in ��`��Y `o authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF-k6 ) Ina I'YIucuyi-D being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the An�Al� - ontractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this � 2ya"I" 0 day of /IC(/� 20 ��� Notary Public £ZOZ'LL aunt sajidxE uoissiwwoo Ajunoo�iognS ui pa le £b££6MIA1,0'ON•69�1 )Pa1.MON 40 81e1S'oiignd tielON PROPERTY OWNER AUTHORIZATION Ixsnoaw v HiaH31w (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 Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) residing at .� lyL► <1 `20/ (Print property owner's name) (Mailing Address) do hereby authorize Katrina Mercurio (Agent) to apply on my behalf to the Southold Building Department. � l (Own is ignature) (Date) (Print Owner's Name) BUILDING DEPARTMENT- Elect i nspector � TOWN OF SOUTHO JUN 0 6 2022 Town Hall Annex- 54375 Main Road - PO �c„1,,'�J9 Southold, New York 11971-095wN of say nHoLo Telephone (631) 765-1802 - FAX (631) 765-9502 roger r(&-southoIdtownny.gov — seand(cD-southoldtownny.gov 3.. APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 5/26/2022 Company Name: LC ELECTRICAL CONTRACTING INC Electrician's Name: LC ELECTRICAL CONTRACTING INC License No.: ME-38043 Elec. email:OFFICE 9LCELECTRICALCONTRACTING.COM Elec. Phone No: 631-874-0485 01 request an email copy of Certificate of Compliance Elec. Address.: 22 WOODBINE LANE, EAST MORICHES, NY 11940 JOB SITE INFORMATION (All Information Required) Name: PARKER, SHERI Address: 705 LIGHTHOUSE RD., SOUTHOLD Cross Street: Phone No.: Bldg.Permit#: 47745 email: Tax Map District: 1000 Section: 5 Ll Block: 2) Lot: , BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): IN-GROUND POOL Square Footage: Circle All That Apply: Is job ready for inspection?: YES 0 NO ❑✓ Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES 0 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 Reconnect❑Underground❑Overhead # Underground LateralsF11 2 H Frame Pole Work done on Service? Y F1N Additional Information: PAYMENT DUE WITH APPLICATION � po 11fF01 BUILDING DEPARTMENT- Elect ica'I<Inspector TOWN OF SOUTHOLID ® - Town Hall Annex - 54375 Main Road - PO Southold, New York 11971-096'q'1! ;'\1 C '�''}` 4,' Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrCcDsoutholdtownny.gov - seand(a southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 5/26/2022 Company Name: LC ELECTRICAL CONTRACTING INC Electrician's Name: LC ELECTRICAL CONTRACTING INC License No.: ME-38043 Elec. email:OFFICE@ LCELECTRICALCONTRACTING.COM Elec. Phone No: 631-874-0485 0 I request an email copy of Certificate of Compliance Elec. Address.: 22 WOODBINE LANE, EAST MORICHES, NY 11940 JOB SITE INFORMATION (All Information Required) Name: PARKER, SHERI Address: 705 LIGHTHOUSE RD., SOUTHOLD Cross Street: Phone No.: Bldg.Permit#: 47745 email: Tax Map District: 1000 Section: Block: '�t) Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): IN-GROUND POOL Square Footage: Circle All That Apply: Is job ready for inspection?: YES 0 NO 0 Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES F&�/] 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 Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION LDO PERMIT # Address: Switches , Outlets GFI'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 rl �� e r � S.C.T.M. N0. DISTRICT: 1000 SECTION: 54 BLOCK: 3 LOT(S):26.9 I L07 2 N 48 055'10 E 450.45' POST/WIRE FENCE ALONG LINE 0.4'S 0.2'W x O O � A ELEC. OO C METER r N x i 0.7'W C) H O VEL DRIVEWAY z G� �,10.3' GRA X w 18.0' w 37.6' o z y y o �y Io 1.5' 0.7'W m 2.0'> ' 20.0' U 13.1 o �O1 I� CI tp 0 l 0 1 8N FRAAiE =o -i rt LOT 3 a o DWELLING 0 \ O �- LOT 4 x Z I Q 3 Sri I oo 1705 C-) ( 3 x ^ 5.3 G m 00 m L8.2'- 11.5' G•0 m IV m O I 10.3' o F`' Z (Z) 2 . > o n ~ O 8.9' 9.8-3.1' 6' 173.4. �/ r ►r TIR ENCLOU RE GRAVEL20.0' O O � o 12.3' W U.P. 6.8'N °�,° SHE 20.9'E x O O S ' RE FENCE ALONG LINE POST/ WIRE FENCE 3.2'NPI61 /WX X X X X X X X X XX X TAT X X X S 48°55'10" YY ASPHALT DRIVEWAY LOT 4 450,45' ASPHALT DRIVEWAY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - = - - - - - - - - - - - - - - PIPE THE WATER SUPPLY, WELLS DRYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. AREA: 76,575.91 SOFT. or 1.76 ACRES ELEVATION DATUM: _________________________ UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ' ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES. ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE STRUffURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY ® CSURVEY OF: LOT 3 FNEIy, CERTIFIED TO: SHERI WINTER PARKER; MAP OF:LIGHTHOUSE ROAD 26, LLC `P tN M WO 0 FILED: AUGUST 1, 2001 No.10656 _�� yy�� MAR''2 4 2U1 -DD * r a BUILDING DEPT. SITUATED AT: SOUTHOLD o TOWN OF SOUTHOLD TOWN OF: SOUTHOLD a SUFFOLK COUNTY, NEW YORK �s 0s 0682J� KENNETH M WOYCHUK LAND SURVEYING, PLLC F N J� Professional Land Surveying and Design P.O. Box 153 Aquebogue, New York 11931 FILE #221-103 SCALE:1"=40' DATE:AUG. 5, 2021 N.Y.S. LISC. NO. 050882 PHONE (831)298-1588 FAX (631) 298-1588 , ,i DATE CERTIFICATE OF LIABILITY INSURANCE 03101/2022 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 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 Nicholas Zulkoiske Brookhaven Agency,Inc. PHONEAn. 631 941-4113 FAX x(631)941-4405 100 Oakland Ave,Ste 1 EMAIL s: certificatesQ)brookhavenagency.com PortJefferson,NY 11777 INSURERS AFFORDING COV G NAI !! INSu E • Philadelphia Indemnity Insurance Co. INSURED INSURER 13• Merchants Mutual Insurance Co. Patrick's Pools,Inc -INSURER C: Wesco Insurance Co. PO Box 3024 INSURER D-: East Quogue NY 11942 INSURER INSURER F: 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. INR TYPE OF INSURANCE irdnn min,_ADOL SUBR D UM ER POLICY FF POLICY EXP LIMITS X I COMMERCIAL GENERAL LIABILITY A H CCURR NCE 1.000.000 DAh1AGE A CLAIMS-MADE X OCCUR Sr.G TO RENTED S 100,000 x Contractual Liability X X PHPK2386555 02/28/2022 02/28/2023 -MEQ EXP(Any one person) $5,000 P£R A 8 APV INJURY $1 000 000 £N'L AGER GATE LIMIT APP IES PER: GENERAL AGPREGATR s2,000,000 POLICY LijJGCT LOC PRODUCTS-COMP! P ACG s2,000,000 OTHER• S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 500 000 cideiW) B X ANY AUTO BODILY INJURY(Per person) S ALL AUTOS OWNED SCHEDULED X X CAP9267113 07/12/2021 07/1212022 80DILY INJURY(Per accident) $ X MIRED AUTOS X NON-OWNED PROPERTY DAMAGE S AUTOS _ S UMBRELLA LIAl3 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I R:.TF TI N S WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY N _­RTAT.1 ITE ANY PROPRIETORIPARTNER/EXECUTIVE WWC3528513 0511312021 05/13/2022 C E.L.EACH ACCIDENT $100 000 OFFICERIMEMBER EXCLUDED? YY NIA(Mandatory in NH) E.L.DISEASE-EA£MPL Y£E 5100:000 s T�. II os,describe under D SCRIPTION QF OPERATIONS bolo E.L.DISEASE-POLICY LIMIT I S r,00.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more apace Is required) Town of Southold is included as additional insured per written contract CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hall Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <NSZ> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD —�jTOAtc Compensation i Workers' CE R TIFICATE OF INSURANCE COVERAGE rarE� Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1,To be completed by Disabi ity and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 [OAST QUOGUE,NY 11942 1 c.Federal Employer Identification Number of Insured Work Location of Insured(only roqutrod if co•erase is spoGltoarry ttmited fo or Social Security Number corfain locations In New York Sfaro,to.,Wrap-U( Policy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Mc Ider) SheitorPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"1a" PO Box 1179 DBL318565 Southold,NY 11971 3c,Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: A.Both disability and paid family le ave benefits. (� B.Disability benefits only. 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 class es of employer's employees: Under pens ty o pe ury, certify that I am sn authoilzed representative or licensed agent of the insurance carrier re eraneed above and that the named insured has NYS Disability and/or Paid Fat lily Leave Benefits Insurance coverage as described above. Date Signed 3/1/2021 By �lJr (Signature of Insurance carrier's authorized represantative or NYS Ucensed Insurance Agent of that Insurance carrier) Telephone Number 516.$29-6100 Name and Title Richard White, Chief Exeeutiye Officer IMPORTANT: If Boxes 4A and 6A i tri checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.%gent of that carrier,this certificate is COMPLETE.Mail It directly to the certificate holder. If Box 4B,4C or 69;1 s chocked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F smily Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Accept ince Unit,PO Box 5200.Binghamton,NY 13902.5200. PART 2.To be completed by the f IYS Workers'Compensation Board(only If sox 4C or 58 of Part 3 has been checked) :state of Now York Workers' Compensation Board According to information maintained b I the NYS Workers'Compensation Board,the above-named employer has compiled 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 Emproyoel Telephone Number Name and Title Please Note:Only Insurance carders/ices rad to write NYS disability and paid family leave benefits Insurance policies and NYS licensed Insurance agents of those insurance carders are suit Ddzed to issue Form DB-1211.1.Insurance brokers are NOT authorized to Issue this form. DB-120.1 (10-17) II�IIPIaeQ1u2l0a�1llii(�1�0l�l1l7)ly�e� YORK V1�arlcei s' CERTIFICATE OF STATE Compensation M WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name S Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-9964687 Patricks Pools Inc Pd Box 3024 1c.NYS Unemployment Insurance Employer Regislration Number of East Quogue NY 11942 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a I4'rap-tip Policy) Number 262929943 2.Name and Address of Entity Requesting Proof of Cowraglo 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 54375 klain Road 3b.Policy Number of Entity Listed in Box-"9a" Southold NY 11971 WWC3628513 3c.Policy effective period 05f1312021 to 05113/2022 3d.The Proprietor.Partners or Executive Officers aro Included.(only chock box 9 oll.partnerslotficors indudod) QX all excluded or certain panders/officers excluded.. This certifies that the insurance carrier indicated above in box"3"Insures the business referenced above in box"1 a`:for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York,(NY)rnust,ba Ilsted enderltern'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.carrfer must notify the above certificate,holder and the Workers'Compensation Board within.10 days IF.•a policy is canceled dueto 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.Cartificate.(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 listad 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 certiftcate-does not,arnend, 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 contractissued 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 cortify that I am an authorized representabve or licensed ardent of the insurance carrier referenced above and that thm named Insured has the coverage as depleted on this form. Approved by: Nicholas Zulkofske (Print name-pt au zed representative or licensed agent or insurance carrier) i Approved r ( aturo) (Dote) 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-106.2.Insurance brokers are NM authorized to(,nue it. C-106.2(9.17) www:wcb.ny.gov 7141ED AS NOTED DATE: B.P.# 7 RETAIN STORM WATER RUNOFF FEE: BY: PURSUANT TO CHAPTER 236 NOTIFY BUILDING DEPARTMENT AT - OF THE TOWN CODE, 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION ELECTRICAL 4. FINAL - CONSTI PU'710N MUST BE COMPLETE FCJ C.O. dNSPECTION REOUIRED ALL CONSTRUCTION 'rTALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. ENCLOSE POOL TO 0&j-' COMPLY WITH ALL CODES OF ,.UPON COMPLETIQIV,' NEW YORK STATE & TOWN CODES . ORE Ary AS REQUIRED AND CONDITIONS OF J -n S ',,kB�6�P1Hd0 BOARD SOIJTb��STEES WH—.DK - JCCUP.�NCY 4R_ USE IS -UNLAWPU;L WITHOUT CFRTIFICA- OF OCCUPMCy U, mom► lam n, t ► -l_ f�w 1 •4 C s. _ z�=, �r 'rias. .•{ }{ f �- L~ _ _� _ t in dvou 1, 7177 - 3n LE -1 R�2 a, .. — —Iw BUILDING DEPT. i Pl TOWN OF SOUTfiO D ! - nye , -'S ff ear s•' 4 r � - it all k tor Co— Ua DO `Ip lI _ t , �r ,+_������ "' ��'y_,,{fi t - IV _ _ _ �� � + ' -�► -o- X89-��-o� -�-�