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HomeMy WebLinkAbout45684-Z Town of Southold 10/15/2022 o P.O.Box 1179 o • 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43486 Date: 10/15/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 50 Wabasso St, Southold SCTM#: 473889 Sec/Block/Lot: 78.-3-41.3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/28/2020 pursuant to which Building Permit No. 45684 dated 1/19/2021 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 Goldfarb,Jason&Kowalski,Robin of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45684 6/16/2021 PLUMBERS CERTIFICATION DATED l Au i ed Signature TOWN OF SOUTHOLD 4�o�S�FF01P��49 BUILDING DEPARTMENT TOWN CLERK'S OFFICE • fig 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#: 45684 Date: 1/19/2021 Permission is hereby granted to: Goldfarb, Jason & Kowalski, Robin 142A 31 st St#1 Brooklyn, NY 11232 To: construct an in-ground swimming pool as applied for. At premises located at: 50 Wabasso St, Southold SCTM # 473889 Sec/Block/Lot# 78.-3-41.3 Pursuant to application dated 12/28/2020 and approved by the Building Inspector. To expire on 7/21/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buil ng In pecta[ oF so�ly�l Town Hall Annex ~ Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Q sean.devlinCD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Jason Goldfarb Address: 50 Wabasso St city:Southold st: NY zip: 11971 Building Permit* 45684 Section: 78 Block: 3 Lot: 41.3 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electrical Contr 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 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 4'LED Exit Fixtures 11 Pump 1 Other Equipment: Heater 260GFI, Pump 220GFI, (4) Lights 120GFI, Salt Generator, Intermatic Pool Panel 8 Circuit- 5 Used Notes: Pool Inspector Signature: tel/` Date: June 16, 2021 S.Devlin-Cert Electrical Compliance Form.xls SOUIyp ��V Gv WASA J v # TOWN OF SOUTHOLD BUILDING DEPT, 765-1802 INSPECTION [ . ].. FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] `FRAMING/STRAPPING [ ] FINAL [ .] FIREPLACE'& CHIMNEY. [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE INSPECTOR f OF 50(/lyO� q sq, # # TOWN OF SOUTHOLD BUILDING- DEPT. 765-1802 1 NSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. ,[ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ ] FINAL f ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION, [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O REMARKS: '�� (Ad-FZ, t DATE INSPECTOR V its how o� TOWN OF SOUTHOLD BUILDING DEPT. �0 • �O `ycourm?�` 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] -ROUGH PLBG. [ ] FOUNDATION 2ND /] FINAL SUL TION/CAULKING. [ ] FRAMING/STRAPPING [ ] FIREPLACE & CHIMNEY j ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: J&/hv�. �ea vt WA �-- woo (AM IAafiz v- - (X) V, ;L; .. DATE INSPECTORy JU li ''rc'FIELD"]INSPECTION REPORTDATE COMMENTS FOUNDATION IST ` ------------------------------ FOUNDATION(2ND) ROUGH FRAMING,.& y PLUMBING' ' Vv INSULATION PER N.Y. STATE ENERGY CODE ti FINALLode ooll , / ADDITIONAL'COMMENTS. 0o �" z TOWN OF SOUTHOLD—BUILDING DEPARTMENT :r Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 .: Telephone (631) 765-1802 Fax (631) 765-9502https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT N0. �� � Building Inspector: ' r� Applicor s an f rms rra .BIled obit ori etr.sntt xlricomplete '. DEC 2 8 2020 a plica�orjs 1 nc t �ccepted I�fher+ th A/�+�ylicantpts°nM. e q�vner,an �, .,.,. '^ '.r' o"�' 't,',x' h'v _ z :S x u •Vim,.:, Date: Z Z0-'v '�%3ri. ,a�'..5:a •. �..�� m aknt ��x,v�q,� r �`z" e,,..� � r r�.,"�`:f', xrf r '' v ««z.'t. Name: c I SCTM#1000- ` © � -� Physical Address: ......, _ µ_ .,. Phone#: C 1..11.1.. .�..�..�1 .,... Email: # �b ._ ,� Mailin Address• JL4 .,. ........._ .... .... .. :. _. .1 —.. -........_ :.:.._...... d. . ._.__ L.._._..�..e _ --------------- `"/.4},,x '`'glr�;'y �- oj< u'z='v� rg < ,a- "•; ` T - . .� ...,... .. z ,. x 1>� s<,.,r S;..Y,...x^��.<�y' „.fi45 '.3��'� �"•< Name: Mailing Address: X 1� a I - I-}Gt�rn ►'J ►'� Q)0� c-4 �p Phone#• Email: w_,__._.:...._,3.,f..w_._ _,.2�-�.•....'l_.. _. 1.._.,�......,.... vim;c� GZ. .U�cS od I S , Lori, 16 4P(ItID- S ICIIItA <1fw < v�`t."v4'F'>':J"' i t'r''.A.• •.. �. ."r✓r<y�. .' ..'.'!'raraY'�x,.x .rhv.p� yl „x A Name: Mailing Address: Phone#: Email: !� ...<w '".g�o-'y�,'�'�'? �<;�'%.. m.�_ ,��y tzar<•5"�:'`v'�a"<- '�'f'x;'�:.�. xx�„ v>...r,. - '�a> � � R. S> � ��'��`�e�".>f+h3'R• �C-�vl N`x�y �;??Z+!'.<z5 �^`i".:,', �v J" 'c.> '�k„3'�'�(�2 5 Name: Mailing Address^...�....Q_ .1X. ...1.. ....-u ,..... Phone#: Lo w...J...... .. _....�L.. -�. ., ...:... .. ................ Email .0 (''�Ge.. ..,..... .G1 SU..✓l S d...........Gorr'1...... <��, :a:r.<4... �?� >� z �,u�, .,�M.=s�Y.�.xA �r'? ,.;,k�ub.,�" .r• ^�`k' �'t�`r .�'� ,� ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition- Estimated Cost,of Project: `Other l�llC�1'Ult.{RG� llo` sc �I l�j � Sl.1J 1m� t�t� ,�ci�'! � $ 5 C� � ci �C� • c� V _--------- -------------------..."e.-.",..._............ Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? [KIYes ONO 1 ' "��„�y� ���*,?,�����7�"F�`a �5',�'C�,`��"�`�'��C� �-p,'�Au3Fyi*��T�v�T�' why l?"�l�,,,� ;s'.�%�,.�";'r�,- �^moi^��-'��,, �''�'�•�£�� " �� ecy �si��i�4"T`:�r�.,9'u?r.,,a t+.z���%�,«•�� r. �T1tV,F"LRF•F i1V�aJl�l�l7+1 'i`71�ry,; S.=' ���, .,< ;� -� �Fz:,m�.�vn��.zz'r,•iz " '...'".3"*.,:��'S'=»'':.�'.'3�"x '° ;�_.'.A. ''"''s�'s�'" �"�.,vax�'.�az.`t�+.�_ ;�:�':�.�'''..�e�',.3cas?:;5.^.•v`. Existing use of property: CeS. .L.. :GL..�..._...-_-_._ Intended use of property: -Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to �3 U AA01 GI this property? ❑Yes ®No IF YES, PROVIDE A COPY. ec 1 �� eti� wne`Ca1tr$ a i7i4 tM Jdes yp•°fesst6661:10.esponsible far'0 c�rai, ge:an tarm grater 3sswes as pkavtd�d r}� p x 6 of to role C de;z A' w��4�`lra i�iY nnAcit thi l�ii'1dtii l ar#hser t far tti spa ne #f ui tr P ri p�s nt is ktie ulldfrf�2o ;�;.x r}�{ ncg�afthe'fown`af 5aiutltiold,Scfffalk,�Cay,�ew Vol%arr�:otf�er'appkicable tativs;Orcti#��i�ces or�egula�ions,"�ar<tii�'coristriri:tiar�af�illdings, �� �a •Ctlat�� tte�ratians�tir� orremtovat£o�eie�oliElor►'�herefn escrihe'd'7�e�appi#ic�nLagrees�tacQmp�Yu��that{$pplfr� (�;lauv ard�na es;hull�(ing'c,„ade,Y: ,;x. g�r�d�.��' re`ulaitla sand to�d,�ry�kt,�a,uthnl " Insp otors p�p�rni�se'�snd tn>�uild�(s):.a �,!����!Y<irispe�tl�glts False slateinentz rn h�l�n�3,a�e;.=. y�Ut1,��F��85,8�G18�5�,A�II��I'f1e�lf�tp��3tJ�5tl�l�R�Cln��4�i�#the�N��k�ork,State,Punat�aV� �cb����?��y"`,"�, �,'�„�•�•.;s Application Submitted By(print name): cid n CgAuthorized Agent ❑Owner - ._.,.._.. . - _.._._.... _._._._ o .. �..rnnm�? s. _._._..�.............. _...-_.. _._........ Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTYOF&Xf )� ) 19,so ri S 1 f h ryLcyv1-' being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is theit:7 (Contractor,Agent,Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this �. day of Lu ' � , 20j:n Rotary' Public ,�` �NOTojftYOB sz _: LIC; PROPERTY OWNER ,AUTHORIZATION (Where the applicant is not the owner) �'s '°. ...• ' ti�.��`` I, - ci5on QUo46 residing at '9'0 "46550 S#QQ,} •�! Io�c�1d IN v\ I �q] I do hereby authorize Jason c51 M mo n-S to apply on my behalf to tke Town of Southold Building Department for approval as described herein. MARC LEWI S.SURWAK i Z l Q_ Owner's ignature Notary Public-State of New Yorpa e ��T r�"'� No. 02SC6230555lyl � Jot Sar\ G81ualified in Nassau County Print Owner's Name Commission Expires November 1,2022 2 F BUILDING DEPARTMENT- Electrical Inspector APR 1 9 2021 TOWN OF SOUTHOLD Town Hall Annex 754375 Main Road - PO Box 1179 d Southold, New York 11971-0959 Tele hone 631 765-1802 - FAX 631 7 - �� p ( ) ( ) 65 9502 rogerr(&-southoldtownnV.gov - seandasoutholdtownn ..gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: y�/X/2�22 Company Name: L C _�-n c 6-,v7 Name: License No.: email: Phone No: G _o,V g5- ® request an email copy of Certificate of Compliance Co � Address.: F uJ say Lr Zai 1,(*eI�c Xly 11�qo JOB SITE INFORMATION (All Information Required) Name: �i lcr� Address: Cross Street: Phone No.: Bldg.Permit#: � 610 email: Tax Map District: 1000 Section: __7q Block: Lot:'V 3 BRIEF DESCRIPTION OF WORK (Please Print Cle ly) , n I Check All That Apply: Is job ready for inspection?: DYES ❑NO ❑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 ❑ Service Reconnect ❑ Underground ❑Overhead # Underground Laterals 01 ❑2 ❑H Frame [—]Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION y`7� )OD Electrical Inspection Form 2020.xlsx 2'�I� I Tilt BUILDING DEPARTMENT- Electrical Inspector APR 1 g 2021 TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765=9502 rogerr(cD-southoldtownny.gov seand(a�southoldtownny.gov , APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: L C 4c & / - !& Name:_ License No.: _ 3 SD �f 3 email: _r r LL iG7/u c y}L ✓ ►j✓f� Phone No: _off ff D�gl request an email copy of Certificate of Compliance Cos Address.: Gl ,��.,,� ; o�,.c o1/ s/ ' JOB SITE INFORMATION (All Information Required) Name:.' ar�Tr�rJ Address: sp Cross Street: Phone No.: Bldg.Permit#: z1�-694 email: Tax Map District: 1000 Section: Block: Lot:7 F13 BRIEF DESCRIPTION OF WORK (Please Print Cle ly) ;n Check All That Apply: Is job ready for inspection?: OYES ONO ❑Rough In ❑Final Do you need a Temp Certificate?: ❑YES ONO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# . ❑New Service ❑ Service Reconnect ❑ Underground 0 Overhead #,Underground Laterals ❑1. 02 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx 2A,I� I PERMIT# Address: Switches Outlets I GFI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini Special: Comments: rA 0 r ct-V A 1 �� C�►`�ey • = ai':w.:,�.=:.;Workers' , Y AYE ' Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 77 . 1a.Legai Name:and address of insured(use street address only) 1b.Business Telephone Number of Insured MARYMEG INC DBA JASON AND BILLS POOLS 1c.NYS Unemployment Insurance Employer .PO:.BOX 1331 Registration Number of Insured .HAMPTON BAYS NY 11946 1d.Federal Employer Identification Number of Insured.or Work Location..of lnsured.{Onlyrequired if coverage 1S.speciflcally ._ Social SecurityNumber. lir»ited to_cerfa'irr�locations in:New<York States`i:e.a Wrap�Up Policy) 114168202 " Name.and;Address of tbEi Entity Requesting Proof of 3a:•Name of Insurance Carrier Coverage(Entity l3eing Listed as the Certificate Wolfler)' Property and:Casualty Insurance Company of Towr%:ofoutbold '.. Hartfor. _,. : : __!Building_l7epartment`.::: 3b:Policy.Number.of.Entity Listed.in Box"1a": Y, 1K1 12:WE OJ2629 3c..Policy:effective:penod: 03/23/2020 to 03/23/2021 3d.-rhe Proprietor;Partners or Executive Officers are 'El Included:(Only check,box if all partneisloffc'ers included). D all'excluded�dr certain partners/officers excluded.. This certifies-ttiat 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)must -lie-listed under 'Item. 3A on.the'INFORMATION PAGE of the.workers' compensation insurance policy). The lnsurarioe.'Carrier.or its aicensed,agent will send this Certificate.of Insurance,to.the entity listed above as the certificate - holder<n,:box.2": :. the insurance carrier must notify the above certificate holdef and the Workers'Compensation Board within 10 days IF a .policy is:canceled:due to'nonpayment miu of prems or within.30 days..IF there.are-reasons other than nonpayment of pre,miums.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 cert ificate-is`issued as a matter of'information only and•confers no rights upon the certificate holder. This certificate tloe§not.amend,:extend.or.alter. the coverage afforded.by the.policy listed, nor does it confer any rights or responsibilities beyond,:triose:;cgntained,in the re feienced policy.. ::,•:.: This certificate.may be used as evidence of a Worker's Compensation contract.of insurance only while the'-underlying pol'icy:is.in'effect:' Please IVote: 6..pon cancellation of the workers' compensation policy.indicated on this form, if the business continues to`Eie named on 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 in coverage requirements .of the New York State, Workers' Compensation Law. Under penalty of perjury, i certify that lam an authorized representative or.licensed agent of the insurance carrier referenced::above and that the named insured has:the--coveragd-is depicted onthis-form. 'Approvedby: :Danielle;Glauserr. (print name of authorized_representative or licensed agent of insurance carrier) Approved by: r,Irn .�. .x. :04101/2020 (Signature) (Date) .Title: _Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877)853-2582 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 (0A7)-' Form WC 88 3121 F Printed in U.S.A.- www.wcb.ny.gov Page 1 of 2 CERTIFICATE OF LIABILITY.INSURANCE DATE(MAUDDIINM 1012612020 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(tes)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 NAMS BARSON ASSOCIATES INC PHONe (631)689-6160- IF (6311689-6084 689-6084 207 Hallock Rd Ste 1 E-MAIL. Stony Brook,NY 11790 INSURER -AFF.ORDINO COVERAGE NAIL 0 INSURERA: XL S QC,faltylnSurahce 37885 INSURED BURESRR Marymeg,Inc dba.Jason Pools INSURER PO Box 1331 INSURERD: Hampton Bays,NY 11945 : 'INsURERe: INSURERF• cova ARES CERTIFICATE NUMBER: REVISfON NUMBER: THIS.IS:TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED HAMMED.ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY-CONTRACT OR OTHER.D000MENT 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 CONDMO.NS OF SUCFI OLIMES LIMITS SHOWN MAY HAVEBEEN REDUOED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADOIL DPOLICY'NUI176ER MM UDY EP•Fm Ina .P Y.EXP LIMITS X COMMERCIAL GEIERALLIABILITY EACH OCCURRENCE S 1 OOO OOO CLAI{i7S MADE OCCUR SES-Ea ezunenee 3 2,600,000 MED EXP I ane parson S 16,000 A NPC-1003117.00 - 312312020. •312312021 -PERSONAL aADviwuRY s 1 0.00000 GENLAGGREGATE LIMIT APPLIES.PER: GENEPALAGOREGATE S 00000.0 X poucY JECROr LOC " PRODUCTS-COMProP AGG $ 1000,000 :OTHER $ AUTOMOM.E.UABILfrY B,Eo sl G $ 1000`000 X ANY AUTO. 80DILY INJURY(Perye(son) $ OWNED SCHEDULED A AUTOS ONLY AUTOS NBA-1003121-00 3/23/2020 3123112021. -BODILY INJURY(Per*dderll) $ AINIONLY ABUT 04}1Y PROPERTYDAMAGE. S r UMI3RELLALUI600CUIR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE 3=12020 312312021: AGGREGATE S DED RETENTIONS 8 1NORKURS COMPENSATION MUTE 4 EOTH- ANQ'FMPLOYERV L)AmIL"y . Y f.N ANI?PROPRI�rORIPAR NEMXI!CUT11lE E.L.EACH ACCICENT S OFFICt76ry.In EREXCWDED? NlA' E.LDISSEASE'-€AEMPLOYE S (Maadatoryln NF) �- I�y�,deseribeuntlar of SCRIPTION OF OPERATIONS Mlow E.L.DISEASE-POLICY.LIMIT -S DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES.(ACORD 101,Additional Ramaft Sah.adula;may be attabhed U more space 18.required) 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 BUILDING DEPARTMENT ACC4RbAN0E WITH THE POLICY PROVISONS. TOWN HALL AUTHORIZED REPRESENTATIVE SOUTHOLD,NY 11971 '11660-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marcs of ACORD i Workers! 11111�����a� CERTIFICATE OF INSURANCE COVERAGE ompeI -CBoard '�—y nsation_- "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&Address of Insured(use street address ionly) 1b.Business Telephone Number of Insured MARYMEGINC PBA BI1r M POOL-SERVICE631-324'-7844 DBA Jason's.Pools .P.'O BOX 1331 HAWMN BAYS,NY 11946 I 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifica fly limited to certain locations in New York State,i.e.,Wrap-Up Policy) -1131158202 , 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 Sou ttfid Building:Department 3b.,Policy Numl erof Entity Listed in Box"1 a" Town HBII S ttthold, NY:11871 QBL06593 3c:Policy effective period. 01/01/2020 to 12/31/2021 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 employer's employees eligible under the NYS Disability IndPaFamily Leave Benefits Law. 0:B.:Only the following class or classes of empioyer' employees: Under penalty of pequry,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' 11/9/2120. By (SI nature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number '51"29-8100 Name and Title RlChard White: Chief.aecutive 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,POf 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 Wgrkers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave.Benefits Law lwith respect to-all of his/her employees. I Date Signed By I (Signature of Authorized.NYS Workers'Compensation Board Employee) Telephone Number Name and Title i 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. n DB-120.1 (10-17) DB-iiiiiioiiiiii�iii�iiniiiii����� i I SURVEY OF PROPERTY NIOIF SIT UA TE N101F ;� PETER BRAN5FIELD JOSEPHS O U T H O LD L CHURCH TOWN OF SOUTHOLD & MARIANNE m 115.80 '51 '00"N 87°51 '00" E SUFFOLK COUNTY, NEW YORK FRAME ?1,0 m Z 30.46' ° SHED S.C. TAX No. 1000-78-03-41 .3 90 N 86031930 30 E b ,ep HED CONC. MON. SCALE 1 "-2O' e. SOO W o PICKET FENCE FENCE r' 1-2-SED JUN16, 2017 e ... a.' TnZ Q STOCKADE FENCE 1.5'5. .8'E. Ln s oo /�� �z 25.3' o Wq✓K Qvl� _1 ° d No Nm z > Y^V 5,F- N AREA = 9,621 sq. ft. 0.221 ac. O o . •• r,i� v' r / � � _ :::GONG. � d Uo =0 ? _ ,I n 0 BRICK WAS w rn ENTRANCE � FENCE 0.5'W. .d •v e O O f f A WOOD o oS 10.5- S Z CERTIFIED TO: TITLEVEST AGENCY, LLC Al o — — — _ _ _ _ 897,_ — _ _ _;_ FIRST AMERICAN TITLE INSURANCE COMPANY Nm ve LOANDEPOT.COM, LLC ISAOA/ATIMA 2B.o_ _ ROOF OVER ,� JASON GOLDFARB ly WOOD PORCH Q' m ROBIN KOWALSKI o ' ^ e 16.4' FENCE O U`J v T a OVERHANG n a 22.4' \ A e m "1 4. FRAME Ii! ro a H V Ll v $ GARAGE A v. 22.4' 26.8' ONC PREPARED IN ACCORDANCE THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED v• APRON BY THE LIALS.AND APPROVED AND ADOPTED 4 e I ,v. FOR SUCH USE BY THE NEW Y92K STATE LAND > + d J TITLE ASSOCIATION._ v" e•. 04 OF Neft", .•q00N _ e e. w I d•• a a7 Gd 'jAFr a Q ,m A •v. .e •S :'v d v i t FENCE °.. N 8505890 099 o.sE. N 85'58'00�+ yy A 80.00 v \ FOUND FOUND e e 13 9.9 g' CONC. MON. CONC. MON. \ L F Y '^ tic. No. 50467 ed. ^.t:. •..�: •.... a A '• ,�tt ' -A. :d ° < UNAUTHORIZED ALTERATION OR ADDITION Nathan Taft-- _ Orwin III TO THIS SURVEY IS A VIOLATION OF v a a d A'. ° SECTION 7209 OF THE NEW YORK STATE EDUCATION F`"W Land Surveyor e. vG .v ed e° d " e e v e ' a EDGE OF PAVEMENT e ' . m • �e• . v ,v '. a, ' d•' ' °• d' ' v• . . ' ' , . e .. e ' ' °v .•.e �, � . . ..d -0., . • v .. ',w COPIES OF THIS SURVEY MAP NOT BEARING Y a a d d THE LAND SURVEYOR'S INKED SEAL OR . e d 9 d e e d EMBOSSED SEAL SHALL NOT BE CONSIDERED v•e Al a TO BE A VALID TRUE COPY. v�" NOKO " da• e ° v CERTIFICATIONS INDICATED HEREON SHALL RUN b ONLY TO THE PERSON FOR WHOM THE SURVEY Trtle Surveys — Subdivisions — Site Plans — Construction Layout IS PREPARED, AND ON HIS BEHALF TO THE TIRE COMPANY, GOVERNMENTAL AGENCY AND PHONE 631 727-2090 Fax 631 727-1727 IS ROAD LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INS11— TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. OFFICES LOCATED AT MAILING ADDRESS THE EXISTENCE OF RIGHTS OF WAY 1586 Main Road P.O. Box 16 AND/OR EASEMENTS OF RECORD, IF Jamesport, New York 11947 Jamesport, New York 11947 ANY, NOT SHOWN ARE NOT GUARANTEED. 37-146 SURVEY OF PROPERTY N/0/F' N/O/F SITUATE JOSEPH F. CHURCH PETER BRANSFIELD S O UTH O LD & MARIANNE L. CHURCH TOWN OF S O U T H O L D m N 87"51 '00" E SUFFOLK COUNTY, NEW YORK N 86°31 '30" E 1 15.85 ED ?m o P c =.10.46 �, S.C. TAX No. 1000-78-03-41 .3 v n CONC. MON. e •• N,oZ SHED SCALE 1 =20 v, Nn d A tn PICKET FENCE I 1 -SHED _ JUNE 16, 2017 1.2'S. " " STOCKADE FENCE t.5' . ,T 13QB'E. MARCH 1 , 2021 CORRECT LOT AREA % o 25.3'4 t4 �r� viz St47vF kA `1_ _ d oZ �m Pg om O AREA = 17,496 sq. ft. •v �� om �, �� 0 o.s'E. N 0.402 ac. z zn r a r fv%% :..CONC. O 0 u- 0 ca ° P �-c u O BRICK WAS w m ENTRANCE x FENCE 0.5'W. v e On o IT7 v o 0 10.5' STEPS ij CER TIFIED TO: 0'flm `j o � TITLEVEST AGENCY, LLC o '— — '— — FIDELITY NATIONAL TITLE INSURANCE COMPANY W N 147. — LOANDEPOT.COM, LLC ISAOA/ATIMA a _ 28.0'_ _ WOOD POR H JASON GOLDFARB am ROBIN KOWALSKI o t�110 e � 16.4' FENCE 00 ROO t B'W a d �o OVERHANG n v 22.4' T FRAME z H Ii! GARAGE m t� e 91.1' —I — — v. 22.4' 26.8' � ONC. i PREPARED IN ACCORDANCE WITH THE MINIMUM ° n• j APRON STANDBY THE ESTABLISHEDDS FOR TITLE SURVEYS AS L.IAL .S. ANQ_APPROVED-AN ADOPTED d. W e FOR SUCH USE IWITHE BYO STATE,LAND I TITLE ASSOCIA OR.��1 � N, ° T� Ii y 'A W..u N Vl C3 y l.. d m ! W e.•.v .'° ,.• d.. W °. i 6NEE N 85"58'00„ W a -• vdN 85'58 > oopSo. 67 FOUND r•� A. ° 1 ,39-981 CO MON. CONC. MON. N. S. Lic. No. 50467 4v 'e° •4 °v It I v .v ° o e vn•° a a d ° d : ' ALTERATION ADDITION d TO 'MIS SURVEY IS A VIOLATION OF Nathan Taft Corwin orwin III ° d ° °v SECTION 7209 OF THE NEW YORK STATE v• ° , EDGE OF PAVEMENT EDUCATION LAW. 4. a a THE LAND COPIES OF THIS SURVEY MAP NOT BEARING Lan Surveyor d v -.v SURVEYOR'S I5� d A. . d EMBOSSED SEAL HALL NOT BE CONSIDERED .d ° e TO BE A VALID TRUE COPY. A. v CERTIFICATIONS INDICATED HEREON SHALL RUN I I NOKOMIS ^ v ONLY TO THE PERSON FOR WHOM THE SURVEYTitle Surveys — Subdivisions — Site Plons — Construction Layout ;,e �,1 �__..�' IS PREPARED, AND ON HIS BEHALF TO THE M A R 1 2 2021 A D TITLE COMPANY, GOVERNMENTAL AGENCY AND PHONE 631 727-2090 FOX 631 727-1727 i LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE OFFICES LOCATED AT MAILING ADDRESS _J.; f V :• .:„^:_,,r,• THE EXISTENCE OF RIGHTS OF WAY 1586 Main Road P.O. Box 16 AND/OR EASEMENTS OF RECORD, IF Jamesport, New York 11947 Jamesport, New York 11947 Y , q i,;:;+"!; ;;`,{,);{t;y ANY, NOT SHOWN ARE NOT GUARANTEED. 37-146 L, Jason's Pools Estimate PO Box 1331 Hampton Bays, NY 11946 Date Estimate No. 631-324-7844 Fax 631-329-5127 12/10/2020 3640 Jason Goldfarb Jason Goldfarb 142A 31 st St 50 Wabasso St. Brooklyn, NY 11232 Southold,NY 11971 Date Description Qty Rate Total Installation of a 16'x 36'Vinyl Swimming pool. 28,600.00 28,600.00 Pool Includes: Liner Color of choice(27 Mil) Standard 45"Shallow end with an 8'deep end Rounded or Diagonal comer steps(Additional sundeck/steps listed below) 2 Skimmers&5 Returns 1 Pentair Variable Speed Pump 4 Pentair Glo-Brite Color LED lights including transformer 1 350 Sq. Ft.Sta-Rite Cartridge Filter Loop-Loc Green Mesh Winter Safety Cover. No upcharge for color change 5'Deep End bench 475 gallon drywell 1 pool alarm Pool includes all plumbing 2"poly underground and 2"rigid above ground. "Final grade of affected area around pool is included in base price"' Additional 8'x 8'sundeck outside of the pool rectangle with 1 step onto 1 5,000.00 5,000.00 sundeck and 2 8'steps after. Sand/Cement hardbottom(Instead of sand bottom) 1 1,500.00 1,500.00 Pentair IC20 IntelliChlor salt system with power supply. Includes initial salt 1 2,300.00 2,300.00 start up(750lbs) Removal of roughly 120 cubic yards of fill.TBD 0 24.00 0.00 Installation of 2"coping 124 22.00 2,728.00 2"x 12"thermal bluestone coping(Additional coping options available) 124 18.00 21232.00 Aqua-Cal SQ125 Electric Heat Pump 1 5,500.00 5,500.00 Stamped engineer plans required by Southold Town 1 600.00 600.00 Subtotal before tax 48,460.00 ""*Due to the large machinery used during this process,access to pool area is needed.We do not re-install fences,gates etc..Due to the large machinery used during this process your landscape,grass and irrigation will get damaged.We will do our best to limit the damage caused but repair work(to be done by others)will be required after we are done.*** 10%to apply for permits,40%to start,25%after coping,20%after finer install,5%when complete Subtotal Tax(8.625%) Date: Signature: age 1 Total r• Jason's Pools Estimate PO Box 1331 Hampton Bays, NY 11946 Date Estimate No. 631-324-7844 Fax 631-329-5127 12/10/2020 3640 Jason Goldfarb Jason Goldfarb 142A 31 st St 50 Wabasso St. Brooklyn, NY 11232 Southold,NY 11971 Date Description Qty Rate Total *If cement mixer can't access both sides of pool,a boom pump will be 0.00 0.00 needed:$1300 Patio(Estimated at 500sgft) Installation of paver patio on 4"concrete base reinforced with wiremesh. 500 12.00 6,000.00 Sqft TBD Estimated cost of paving stones(Cambridge,Techo etc.) 500 5.00 2,500.00 Electric not included.Can provide referral if needed. -Rough estimate is$3,000 for pool,heat pump will add more. 10%to appiy for permits,40%to start,25%after coping,20%after liner install,5%when complete Subtotal $56,960.00 Tax(8.625°/x) $0.00 Date: Signature: age Total $56,960.00 "j� Bonding Wire connected to all ENCLOSDrp r0 hardware UPON COMPLETION DE WASTE FILTER HAIR& R RN R RN RE URN BEFORE"WATER"' i PUMP SKIMMER LIGHT LIGHT FILTER WATER LINE PUMP _ 2"RETURN TO INLET !G I� F,� �'�� ; N OR MAIN DRAIN 3 T PIPING SCHEMATIC ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF 2015 IECC � L-1 1. ° 2'2" „ POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE DETECTING A CHILD HORIZONTAL 4/8 2 r REBAR 4 PLACES ENTERING THE WATER AND SOUNDING AN ALARM AUDIABLE AT POOLSIDE AND AT ANOTHER SUCTION SUCTION M s n•j sem;',• LOCATION ON THE PREMISES WHERETHE POOL IS LOCATED.THE ALARM MUST BE INSTALLED, 36 10 ' UNDISTURBED EARTH MAINTAINED AND USED IN ACCORDANCE WITH MANUFACTIRER'S INSTRUCTIONS.THE ALARM r;�y 45” MUST MEET ASTM F2208'STANDARD SPECIFICATION FOR POOL ALARMS'.THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSON. VINYL// CONC.MIN.3500 PSI LINER t.rY FL VERTICAL 1/2"REBAR PLACED 4'O.C. 3 WATER SOURCE FILLING THE POOLSHALL BE EQUIPPED WITH A BACKFLOW PROTECTION i,',. SYSTEM. 12' 14' 6' WALL CROSS SECTION 4. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED.ALL PIPINGTO BE POLYETHELYNE. COMPL`! WITH ALL CODES Old NTS NEW 'CORK STATE & TOWN CODES ,� �°' S POOL SHALL BE GREATERTHAN 10 MEASURED HORIZONTALLY FROM ALL OVERHEAD WIRING. AIS RO ED AS NOTED AS REQUIRE7Spas S OF POOLDESIGN INCLUDING DRAINS WILL MEET ALL 2017 CODES. DA rE: r Z� B.P.#.t L SG FEE.. 1 BY:�- �— LANNING.BOARD of NEW y N T -Y B1111_C�ING -;� AR I MENT AT -._...--.. --- ..-_ 7Q-1802 8 AM TO 4 rFVi FOR THE RUSTEES �P�S '�EER�o.Q�- V F 'LLOWING INSPECTIONS: Complies With ' � ` °�� lasons Pools 1. FOUNDATION - TWO REQUIRED I r- "'=' "`'''� "' Uj FOR POURED CONCRETE .,Pools, ZiI 2020 Code Section 303.2.1—303.4 Swimand Hot Tubs to Z 2. ROUGH - FRAMING & PLUMBING Section R326 of the Residential Code of New York ,yo 3. INSULATION Section 3109 of the Building Code of New York ! Op 72 �� 4. FINAL - CONSTRUCTION MUST Section N1103.12(11403.12)Residential Pools and Permanent Residential Spas RQFES r1P BE COMPLETE FOR C.O. Section 3109.3.1.2-3109.7.4.Pools and Spas Gates,Barriers ELECfRICALINSPECTION REQUIRED b' ection G106 Entrapment Protection POOL TYPE: 18x36 Rectangle REV SCALE: NTS A L CONSTRUCTION SHALL MEET THttionG107Alarms JAMES DEERKOSKI, P.E. R QUIREMENTS OF THE CODES OF NE\yection E4201-E4312 Electrical Connections for Pools DATE: 12/24/2024 260 DEER DRIVE - Y RK STATE. NOT RESPONSIBLE FOR D SIGN OR CONSTRUCTION ERRORS. MATTITUK, NEW YORK 11952 DRAWING NUMBER 1 0F. 1