Loading...
HomeMy WebLinkAbout45844-Z {siit:Fe[k =opo coGy Town of Southold 9/17/2022 P.O.Box 1179 co 53095 Main Rd Southold New York 11971 CERTIFICATE OF OCCUPANCY No: 43416 Date: 9/17/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1235 Cedar Dr, East Marion SCTM#: 473889 Sec/Block/Lot: 22.-2-44 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/5/2021 pursuant to which Building Permit No. 45844 dated 2/25/2021 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 Menzel,Adam&Johanna of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45844 11/10/2021 PLUMBERS CERTIFICATION DATED Authorized i nature �osuFFvt,t�o. TOWN OF SOUTHOLD aye BUILDING DEPARTMENT N z TOWN CLERK'S OFFICE Wo • 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#: 45844 Date: 2/25/2021 Permission is hereby granted to: Menzel, Adam 18 Litchfield Rd PortWashington, NY 11050 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1235 Cedar Dr, East Marion SCTM # 473889 Sec/Block/Lot# 22.-2-44 Pursuant to application dated 2/5/2021 and approved by the Building Inspector. To expire on 8/27/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 z $300.00 Bu' ng Inspector oF so�ryol Town Hall Annex ~ Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Q sean.devlin(aD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Adam Menzel Address: 1235 Cedar Dr city:East Marion st: NY zip: 11939 Building Permit#: 45844 Section: 22 Block: 2 Lot: 44 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: South Electric Inc License No: 58024ME 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 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 2 Other Equipment: Intermatic Pool Panel 8 Circuit/ 7 Used, 2 Lights 120GFI, Pumps 220GFI, Heaters 2, Cleaner Pump 220GFI, Salt Generator Notes: Pool Inspector Signature: Date: November 10, 2021 S.Devlin-Cert Electrical Compliance Form SOUTy�Io L4 S-V L 2- CgvA-r--> # # TOWN OF SOUTHOLD BUILDING DEPT. `ycoum, 765-1802 INSPECTION .1 [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] ,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: P.OwD f ly!a DATE INSPECTOR 0E SoUlyolo L4 ( Lf 12,—3 # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] -.ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 'INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION= [ ] ELECTRICAL (ROUGH) A ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: T at . DATE INSPECTOR 0E S0Ulyolo Sp q y r 2�s C c. A-mV,e # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION . [ ] FOUNDATION 1ST , [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] "INSULATION/CAULKING - [ ] FRAMING /STRAPPING [ ] FINAL [ ' ]:-FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] -FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [DELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE INSPECTOR OE 50(¢yO� TOWWOF SOUTHOLD BUILDING DEPT. 765-1802 �- INSPECTION , . [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND' [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [o q FINAL 106;a- FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [. ] FIRE RESISTANT CONSTRUCTION- [ ] FIRE RESISTANT PENETRATION, [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: rlCs�Zdl� F�LltY.e Garr �iLo CerTw ot, y Ai a P.,-4 s- «Esinac na s cti tvx4ibc,u-s /bye s Fc� 6ar-O-6E. CTAM FILE DATE - - INSPECTOR /� vl / 1 ho��Of SOUTyO6 - - 1 # # TOWN OF SOUTHOLD BUILDING DEPT. courm, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ rSUL ION/CA FRAMING /STRAPPING [ NAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY IECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: U s DATE �f If d INSPECTOR OF SOUIy�� - - - # # TOWN-OF SOUTHOLD BUILDING DEPT. cnu631-765-1802 INSPECTION ' [ ] FOUNDATION 1ST [ ] 'ROUGH PLBG. [ ] FOUNDATION 2ND [ ]. INSULATIO CAULKING [ ] FRAMING /STRAPPING [ 1KFINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: SIL G. o. , DATE INSPECTOR 4;4t(;D4-ZL FIELD JWPE.. • ON REPO., ' DATE g.. FoiflvD.b.pN(IST) : . ---------------------rte 7. FOLMATION(ZND) rn. ROUGH FRAMING& PLUMBING INSL7,,XTION PER N..Y. : STATS ENERC,Y CO3? j. -uwf. Ali f Zil &-i No 64,G 5:s Gam. , .i:rl s :: . 77 . , ' : .. o�suiF°tx�oG_ TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall-Annex 54375-.Main Road P. 0. Box 1179 Southold;NY 11971=0959 Telephone (631)765-18.02 Fax. (631) 765-9502 https' nny //www southoldtow .>;oy Y Date Received; .... ...... ::::APPLICATION FOR: BUILDING PERM For OfficeUse.Only - - - -- PERMIT NO. Building Inspector: _ -- `�.J fi S 2021. F.EB0 Applications and forms must-be filled out in their entirety. Incomplete . - . -------- p M,v applications will not be accepted. ,Whe.re.the Applicant is not the owner an •�•,_,-_:.,...;-. r Owner's Authorisation form`(Page 2)shall be completed. ry 4 D' .:: .Date:,: OWNERS)OF PROPERTY: - SC TM.#1000- �"�3 '��-� �: Name: R { M Mean zelk -- - �..: Physical Address: Phone# l 4S�p �C�1 Email: Qrhn ------ .. Mailing:Address:: : . CONTACT PERSON: ... ------ Name: Nlailing.Address:. . . .. Erriail: _ Phone#: - 'DESIGN PROFESSIONAL INFORMATION:, Name: �c�r�n � r�e� �C c� SSS ....... .... . ....... ::.(�� V:VC( Mailing Address: J�—'�.���: :�0:\►1 �� - - Phone.#: \ c�G�CC3�� l r 3� Email: - �P 'CONTRACTOR INFORMATIQW _- Name: c�.(1 S Q CA Mailing Address: r- .. :` � S_ ��:::... Phone#: DESCRIPTION OF PROPOSED-CONSTRUCTION Estimated Cost of.P.roject: �lNewStructure DAddition:.:DAlteration ❑Repair.❑Demolition $ E1Other Will the lot be re-graded?- LSes.ONo = Will excess fill be_removed from premises? ❑Yes kgNo .. 1 PROPERTY INFORMATION -Existing use of ro ert : Intended use- of property: Zone or use district in which premises.is situated.: Are there any covenants and restrictions with respect to - - - - this property? (]Yes MNo IF YES, PROVIDE A COPY. . lCheck Box-After Reading: The owner/contractor/design professional1s-responsible for all drainage and storm water issues as,provided by apter236oftheTowriC6cle. APPLICATION IS HEREBY MADE to4he 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 orrRegulations,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 admitauthorized Inspectors on premises and in building(s) necessary inspections.False statements made herein are . punishable as a Class'A misdemeanor pursuant to Section 210A5 of the New York State Penal Law. - `lp►uthorized Agent ❑Owner Application Submitted By(print name): _ - ._ , Signature of Applicant: .. ...... Date STATE OF NEW YORK) SS: - - COUNTY OF ) 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 fife 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 - :20day of _ Nota Public ... ...-. Notary PROPERTY OWNER AUTHORIZATION - W ) (Where the_applicant:is not the:owner _..-.. .. - :residing at do hereby authorize. to apply on -my behalf to the Town of Southold Building:Dep me.t oval as.described herein. Owner'sSignature :-::..: ..... Date: ._ Print Owner's Name :: . .2 r a:;5' RUPERTY INFORNIA'TION r1ry c. intdc i use of property: Are there terry covenants and restrictions with respect to ch prern�ses s si>ua Ged ;.; * x" this property? OYes ONo IF YES,PROVIDE A COPY. 1r r .=a ad by Sy 6 ?t0�11SHlpy�EBYMAOf1latAe6ulmnaDtpart iemfortheIssuanceofaSundtn�►mn:tcnwarrto Idn�zone : n Cfitllfiy ;W'ybPii Rd otl wj*pwobla ta^ordirnnces or Regulations,for Lhe consuuci on C o� q litfelY��detol6od:Ilvi'Wkanla`rtestocmplywithagapplicable laws,ordmancesr code, iA ^ sary fnspectlon,ialse statements er—are AuthorixedAeent 7—Owner no d' sworna edosesand saysthat(s)heisS eapplicant Co U rrrOtrhave:per�orme SHe said 'or and to m ke and file this in arearueto the_best of his/ knowledge and belief;and to apply on Scanned with CamScanner ee -2AoS .OSvf1►jCO� BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD ® 1` si - _Town Hall Annex-54375 Main Road - PO Box 1179 co Southold, New York 11971-0959 Telephone (631)765-1802 - FAX.(631) 765-9502 roaerrasoutholdtownny.gov - seanda-southoldtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All-information Required) Date.: Company Name:.. �o lc :. Name:. License No. . 5 z 1-kG email: Phone:No: (o3i._ g:� lQ request an email copy of.Certificate of Compliance Address.: f-e noj. q 11-7q JOB SITE INFORMATION (All Information Required) Name: cid.r`n _ tf� cszx Ad d rests.: Cross Street: Phone-No.:-- Bldg.Per:mit#::- ,4 S R 44 -email: Tax Map District: 1000 Section:. 2Z Block: Z Lot: 4 q- BRIEF. DESCRIPTION OF.WORK (Please Print Clearly) Check All That Apply: Is job ready for inspection?: EBI(ES ❑NO ❑Rough In ❑Final Do you need a-Temp Certificate?: OSS ❑NO Issued On Temp Information. -(All information required) Service Size: ph:'_❑3 Ph Size: A # Meter Old Meter# New Service 0 Service Reconnect ❑ Underground Overhead # Underground Laterals 01- ❑2 .:❑H Frame:❑Pole Work done on Service? ❑Y ❑N Additional Information: - PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx BUILDING DEPARTMENT- Electrical Inspector OG R TOWN OF SOUTHOLD `� _... . ' : -Town Hall Annex- 54375 Main Road - PO Box 1179 ' Southold, New York 11971-0959 y01p ' ,• ` ''` Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr cCD-southoldtownny.aov seandC�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: 455o Name: License No.: = email: Phone No: 31 —Egg _ l0 request an email copy of Certificate of Compliance Address.: Y nc1 (��R JOB SITE INFORMATION (All Information Required) Name: Address: �� Cross Street: Phone No.: 5l —.44516— L{O l S Bldg.Permit#: &4 S S 44 email: Tax Map District: 1000 Section: Z'Z Block: Z Lot: .4 .BRIEF DESCRIPTION OF WORK (Please Print Clearly) IC-0 NJ Check All That Apply: Is job ready for inspection?: [B*V'ES ❑NO ❑Rough In ❑Final Do you need a Temp Certificate?: E]-(gS ONO Issued On Temp Information: (All information required) Service Size Ph .❑3 Ph Size: A # Meter Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground Overhead # Underground Laterals ❑1 ❑2 ❑H Frame❑Pole Work done on Service? ❑Y ❑N Additional Information: . PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.x1sx V\ PERMIT# Address: Switches Outlets ----- .— .---------- -- GRIS. Surface Sconces HH's UC Its Fans:. Fridge HW Exhaust :Oven Dryer Sm-okes... : . '. 'DW Service . - - = --- - -- - . .. :......- -.... - - - Car►io .___- --= -- ..__._..._ - -- _- - -1VI�c��. Combo - Cooktop Trarsfe AC AH Mini Comments: 2 ►>>vip `CE1 'IFI: ATE'OFLI .�.L�T1('..INSURA�L�E �%� 20. 'THI TIFICATE:'IS.ISSUED?AS.II::MATTER OF iNFORMA110N;;bWLY'AND;CONFERS; 63`,RIGHTS";.UPON'THE"CERTIFICATE HOLDER.THIS' CERTIFILATE:;:DOES NOS:AFFIRMI�TIVEL�f OR NEGAT11lEL1F AMEND;:EXTEtdD:aR ALTER THE;:CONEitAGE';AFFORDEQ BY"THE POLICIES BE40Y, THIS GERTIF1ChTE.:OF 1NSURANCE,t30E5 htOT. ONSTI7EUTE A'•:CONTRACf BETWEEN:THE_13St)ING'::INSURER(S); AUTHORIZED "12ERRESEI+1`T�FT`iVE>:OEt RRODUCER<ANE3�-�°HE�C1=R'TIFI�A'�E:`I:IIE3L'QER:•: IMIiOR7AN1 • R.diel:.cetEticat '.libldlais„an?AIDITIQNAL::1I�15iURED;tt :;RoN_ l'l !)mt fir®ADDITIONAL,INSURED;provtns` iow be.endorsed. If StIBi�1CiATlON IS WANED.dub t'to tltaterm ond:csnditigna of the po)icy;c itain•.poUcka>maygpquiro an.endaraement :A:stdtem®M on. ttiPe�iattilfcete '.`' fesl'cWtf 'ht .t�b =clii#iiCa' k:ii�''It6..�f; Yr=arido �ieri-s ;. _ : o f g,y R I? `BiX z . 95T Cil iNBU itllc Op ;f `Iti6tll RL's :. :. w. IN6UR "'O . . .... ....... . .. k��►"��IItUMR�.:: . `REVISION NUMBEI ��V a.Ti-Y::THaT YH ;pa. �s o ;:INSUf3ANGE L(� E©6EL01M,kIA1/E.BEEN.I3SUE[y rtU'lHE INSURED NAMED Mgyrz EOR THE P,0_U..6..-Y.PERIOD jN1iSFTER,.:N1f1NJTHS7ANDiNd ANif.TiC�lf1EEMENTTiRM COINi�(7TON l}F•<ANi .GtSNTKAG�t3R OTHIS ER DOCUIUIENT'W17H RESPEC ]`O WHICH�Fi ?t,EFiT IiTA E-tJl ";BE 1SS.ti1t:D OR;INAY;,F'EEt f1lN, I i :1�IS1fW#t1GE 1E+F0IiDEi .BX:>1iE I Irlxx DES iil6E[)HE�iEIN 13 SI)g.fECT Td ALL THE TERM' .. ES.. R_ OVVN:MAY'#��I�:SEE�+I�tEC�t10ED;13?i��A1D E�.iA1M$." . :;t�c�ilsioi��Vt�c�an+,D1�NS,pF su�l�r��r�t, lu�T- _ rd�idva - t11h19Ep: BY�� E N 't011xi4){3l'►. At#VlR- Pi `mss; Nth= 'I< RtQM..PElIS/471P1 ., a ►X11: 7f 1C^ ft►. :: `p `��IB�t,�; . •-._:-,.: _:,. ;E L'6'bi��Ar�E-Pti ICiFLI�l1C1' �'... ok ?t?�str�!!;W`app!►rpit►.a"aw :y�ku�i:�;IRR^a1�1ala±Eiei�i;Ria►,urt�pi3a�ir�!lx�i: i�:e ;yfp�+:t�aii4�iti+) . S#1R 1 O7 7 [I ±C3filIPAt�IY'MFtMS'�1+If3i1id1�15"AND�GLI31{)N CER"I1 :' AM OLDER :CANCELLA7`019: S»!flflSi�: ED.P.,OL<;IES'BE;¢ATIGELIR;BE�oRE: . 4A 'A . . >3ulklung> m�,,c;, . i}fE`:' EX ft 4 QN: PiE. 'iHEREQF NOME: 1. BE•`DELIVERED;:IN . AC4���W:�EWITkk.:'[F(��'b,C(D�:'Pl#OVISIOtI$: 'Tc:Swrit'Ia�;Atrn88 " F"b-t3oxrt79 rl . ATNE i911>Y*2043°ACORD C. TI :. , ', AC.OR 2120 $t03} The::ACORD 4iho.-hd:logo:are: gistereei marke:cT`ACbRD `..-. MEW ',Workers' :_: CERTIFICATE OF INSURANCE COVERAGE TAT_ C±a rgt*nsatlgn IB"4DISABILITY 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 Cartier 1a:Legal Name&Address of Insured(use street.address only) 1b.Business;Telephone Number ofinsured LONG ISLAND POOL CARE CORP 631=765=8285' 50000 MAIN ROAD• SOUTHOLD,NY 11971 1c.Federal.Employer Identification Number of Insured ..... :or Social;S6curity Number Work Location of Insured(Only required if coverage is specifically limited to. certain locations in New York State,i.e.,Wrap-Up Policy)''' '' ' 275174033 2.Name.and Address:of Entity Requesting Proof:of Coverage 3a.'Name ofinsurance Carrier (Entity Being Listed as the Certificate Holder) .... ShelterPoint Life Insurance Company Town-of Southold " Policy N4mber of.Entity-Listed in Box:"1:a". DBL35:7404 c Policy,effectiye:period 1.04j-19020:-, to 04/18/2022 , 4. Policy provides the,following,benefits: A.Both disab'ility-and:paid family leave benefits.: El B.Disabilitybenefitsonly: C..Paid family leave benefits only. 5.; Policy-covers: m A.All of the employer's employees eligible under the NYS:Disability and Paid Family Leave Benefits Law. Q B.:Only the following class or classes of employer's employees:-' = Under penalty of.pedury,1 certify.that I am an authorized.representabve.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:atiove. .1/12/2021. ... r ' Date Signed BY " (Signature:of Insurance carrier's authorizgd representative or MYS Licensed Insurance Agent of that.ln�urance carrier) Telephone Number 516-829-8100 Name and Title.��Rlchard'White, Chief ExecutiVe Off der IMPORTANT: If Boxes 4A and 5A are checked,and.this form-is signed by the insurancecarrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is CO.MPLETE:.Mail it directly to the certificate holder. If.Box 46,4C 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 completiori to the Workers'Compensation Board,Plans Acceptance Unit;PO Box 5200,Binghamton, NY 1.3902-5200.-_ -. PART 2.To be completed-by the NYS Workers'Compensation Board (Only if Box aC 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 withsespect 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. I IIIII�IIIIIIIIIIUIII IIII IIII>III�IIIII AI III I DB-120.1.(10-17) IDB 12 0 1 (10-117) �I III 11/1212020 Certificate of NYS:Workers'Compensation Insurance Coverage ,,.,: CERTIFICATE OF r 7 ` 1 NYS WORKERS'.COMPENSATION INSURANCE COVERAGE - i '1Fl Insured Detail la.Legal Name and address of Insured(Use street address only) lb.Buslness.Telephone Number of Insured ;LongiIsland Pool Care Corp . 631=765-8285 .50009 Main Rd. PO Box 1690 Soutliold,:NX 11971 .. : lc.NYS'Unemployment Insurance Employer . Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Secu`ty Number. Work Location of Insured(Only required if coverage is specifically_limited to 27-51,74033 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 (EnOiy.Being-lasted as the Certificate Holder)) Wesco InswtanceCompany Town of SoutholdBuilding Depar pidnt Town Hall Annex 54375 Main Rd. 3b.Policy.Number,of entity listed in box!'la": RO..$ox 1179 ... ... C3465186 Southold,.NY 11971 3c.Policy:effectiveiperiod: 4/19/2020,to 4/19/2021 - 3d.The'Proprietor,Partners or Executive Offcers are: - _ included(Only check box f.all partners/officers included) all excluded or certainP artners/offcers excluded ... This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"!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 Insurapce to the entity•listed above as the certificate holder in box.':'211. 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 Yhis.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 7ieensed 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 olic .... . .... . 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 oli:this form. Approved By: Henry C.Sibley (Print name of authorized,representative or licensed agent of insurance carrier) >y __,,:.-;:•.:,.,. 11/12/2020 Approved By. . .. (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative.or licensed agent of insurance carrier:CarrierPbone 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. https://wc.amtrustgroup.com/anawc/PolicyNYCertificateOfWclns.aspx?lndexld=315660&I nstanceld=7cebO8fe-6c8b-432d-bb5d-f7Od8dfde5l 7 1/2 11/12/2020 Certificate.of NYS Workers'Compensation Insurance Coverage 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 on 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 https://wc.amtrustgroup.com/anawc/PolicyNYCertificateofWclns.aspx?lndexfd=315660&lnstanceld=7cebO8fe-6c8b-432d-bb5d-f7Od8dfde5l7 2/2 ONUM£NT N79'14 00 120.00' c. SOUTHERN &VO. O ASPRALf ' L'ONC. �CARIGE b �u i rj 3 MONUMENT FOUND 0.4'£AST io >,3o h rpm` FENCE 0.7 EAST i Ooe Q 2� r Qe b b O b� ii?6.J'ts i p % 0 Or .y N Sl.zl• A NB�Is?O`Il NUMENf 4 11?9j N88.161p;p FENCE elmne 0.7(AST nem nr,t ae avasm emc ree.rr erne cwnmw-- ne moe eae mower .eo � wtwaw--' ner s.aet ser. SHED SNEO UAN w en" V rr et .l V. �rYMef ,r ex m VMDV r MUM /.7 NORTH iw u, emef rir , GRAPHIC SCALC ON LINE E/W ii n.r aeur 'II, u�r�n roit - 7 /NCH:JO fCET MAP OF LOT 11 AS SHOWN ON "MAP OF AQUAVIEW PARK AT EAST MAR/ON" SITUATED AT EAST MAR/ON, TOWN OF SOUTHOLD ANAP NO.5621 FILED 7/30/1971 SUFFOLK COUNTY, NEW YORK TAX MAP DESIGNAT/ON 1000-022-02-014 REFERENCE NO: 16776 DATE 7/02/2016 CHRISTOPHER HENN, L.S SURVEY SOLUTIONS Z Gl Z- c� CERTIFIED TO: ADAM MENZEL `^ JOHANNA MENZEL LA V RS MKM ABSTRACT SERVICES, INC. 46 HUNT/NG H14L DR. FIRST AMERICAN TITLE INSURANCE CO. DIX HILLS, NY 11746 MB FINANCIAL BANK, N.A. (631) 858-1675 TITLE NO.MKM-S-32589 Fox 858-1676 N.Y.S. LIC, NO. 49857 (C)COPYRIGHT Scanned with CamScanner i NOTES B W 10" 40 10„ 1. NO SOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR 6 FEET OF EXCAVATION AT THE DEEP END. 2. THIS POOL MEM THE REQUIREMENTS OF AN5I/APSP/ICC-5"AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING o POOLS"AND 1996 BOCA CODE-SECTION 421.DIVING EQUIPMENT 15 NOT ALLOWED. ,- :r 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED IAW REQUIREMENTS OF O SECTION 8326.4.2.1 THROUGH R326.4.2.6 OF THE NEW YORK STATE RESIDENTIAL CODE(2020)AND IN CONFORMITY WITH ALL SECTIONS APPRO ED AS NOTED OF THE SOUTHOLDTOWN CODE.DWELLINGWALL(S)MAY SERVE ASPART OFTHEPOOL BARRIERASPEP SECTION R326.4.2.8AND CONDITION(1)ARE MET.OPERABLE WINDOWS IN THE WALL(5)USED AS A BARRIER SHALL HAVE SELF LATCHING DEVICE.ACCESS GATES Q. SHALL COMPLY DA E: as B.P.# LOCKED WHEN POI OL IS HOTH OT IN USE OR SUPERVISED.ALL GATES26.5.2 OF THE NYS AREARE TOIAL CODE(OPEN AWAY FROM TH2020)AND BE SELF E POOL AREA NG,SELF LATCHING AND BE SECURELY Q 3'-6" R'W A z FE N IizD Hf 4. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECT ATEMPORARY BARRIERAROUND THE EXCAVATION IAWTHECODEOFTHE 3Y TOWN OFSOUTHOLD. NO FY BUILDING E ti•'ARTMENT AT 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATERAND SOUNDING AN V1 N } 765 802 .8 AM TO 4 Phi FOR THE AUDIBLE ALARM UPON DETECTION THAT IS AUDI BLEAT POOLSIDEANP INSIDE THE DWELLING. THE ALARM MUST BE INSTALLED, .._. Lu z FOL OWING INSPECTIONS: MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURER5 INSTRUCTIONS. THE ALARM MUST MEETA5TM F2208 S "STANDARD SPECIFICATION FOR POOL ALARMS.THE DEVICE MUST OPERATE IN TO OR DEPENDENT ON)OF `' V o 0 1. F UNDATION - TV,,C RE o PERSONS. REQUIRED 2'x6'BENCHz o S F R POURED C 0)IN.'"=ATE 6. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO A5ME/ANSI O O 2. R UG - FRa,t�ii?Y r, LUMBING A112.19.8MORAMINIMU,M18"x23"DRAIN GRATE ORACHANNELDRAINSYSTEM. POOL CIRCULATION SYSTEM O H O 3. I UL H -F ATMOSPHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN. SUCH -� PLAN VACUUM RELIEF SYSTEMS 5HALL CONFORM WITH A5ME A112.19.17 OR BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. 4. FI AL - CON--. MUST N.T.S. POOL SHALL BE PROVIDED WITH AMINIMUM OF2SUCTION FITTINGS OFTHE ABOVE MENTIONED TYPE. THE SUCT10N FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH 7 HAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A ( J VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE B COPdPLE it POSITION,MINIMUM OF6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO ALL ONSTRUCT;',;ti° SHALL MEET THF TFiE SKIMMER/SKIMMERS.A REQUIRED POOL ATMOSPHERIC VACUUM RELIEF SYSTEM SHALL BE INSTALLED AS PER NYS RE5IDENTIALCODE z0'VINYL COVERED STEPS 8326.6.3(2020)AND IN ACCORDANCE WITH TOWN CODE. REQI IREMENTS OF THE CODES OF NEV, YOR STATE. NOT RESPONSIBLE FOR, � 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OFNFPA70(NEUPRINCIPALLYARTICLE680AND THE NYS RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND QJ DESI NOR CONSTRUCTION ERRORS. BE PROTECTED BYA GROUND FAULTCUkRENT INTERRUPTER(GFC0 CURPENTCARRYING ELECTRICAL CONDUCTORS EXCEPT FOR TH05E V PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT5HALL MEETTHE SEPARATION REQUIREMENTS OE TABLE E4203.5.ALL COMPLY WITH ALL CODES OF 21*TO 1'5ANDBOTTOM 4 METAL ENCLOSURES,FENCES OR RAILINGS NEAP,OkAP)ACENTTO THE SWIMMING POOLTHATMAY BECOME ELECTRICALLY CHARGED .� DUE TO CONTACT WITH AN ELECTRICAL CIRCUITSHALL BE EFFECTIVELY GROUNDED. Ln NE YORK STATE & TOWN CODES S. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH ABACKFLOW PROTECTION DEVICE LAW NYS PLUMBING COPE 608, tz ASR QUIRED AND CONDITIONS OF SECTION A 9. ALL PIPING 15 DIAGRAMMATIC UNLE55 OTHER WISE STATED. ti QJ j J N •- Z o o 501 n VAIN 7R� N.T.S. 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. 0 c cl- 0 Qj WATER LINE TOP OF WALL v'R T TOWN PLANNING-BOADn 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MU5T BE PROVIDED IAW ANSI/AP5P/ICC-5 SECTION 6. Af7LJ 4' 12' 4' ! ry 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. O O -C M SQUTHG68;9 : TEES 01 " `� W� 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. N. 15. THE DESIGN 15 BASED ON A DRAINAGESOIL WITH(10%SILT GROUND WATER SHALL NOTEXI5TWITHIN THE EXCAVATION. IFGROUND WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. N 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOLSHALL BE NATIONAL APPLIANCE ENERGY SECTION B CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED IAW N MANUFACTURERS 5 PECI FICATION5, OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR N.T.S. GUARDED TO PROTECT AGAI N5TACCI DENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH TEMPERATVREAND PRE55URE-RELIEF VALVES, FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM. A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE (� 2'-2- FOLLOWING ENERGY CONSERVATION MEASURES: A' r- 00 = q N �n ° : CHECK VALVE COPING AND WALKWAY 10, 16.1 AT LEAST ONE THERMO5TAT SHALL BE PROVIDED FOK EACH HEATING SYSTEM. 00 $tJ �F.L;. (BY OTIIER5) 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE (� JR F_ PUMP FROM5KIMMER GRADE OPERATION OFTHEHEATERWITHOUTADJUSTINGTHETHERMOSTATSETTINGANDTOALLOWRESTARTINGWITHOUTRELIGHTINGTHE 7y a� ENCLOSE PO LTQ ^OD �: :, E WATERLINE a PILOTLIGHT. q UPON CoIti LET:.ION 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTARE OUTDOOR POOLS ELL DENVING20%OFTHEENERGY FORHEATING FROM RENEWABLE SOURCES ASCOMPUTED OVER ANOPERATING SEASON) W h��y `� w-7 BEFORE" „ATEFt VNDI5TVRBED EARTH 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET W 5500 P5I POURED CONC. d; TO RUN THE MINIMUM TIME NECE55ARY TO MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION IAW APPLICABLE z 2DIVERTE Z e0 d) i° SANITARY CODE OF NEW YORK STATE. ��n+ o rt VALVE R O 3/B"REBAR.2)TYP. '� V�y 3 A caw 01 VINYL LINER 17. THIS DRAWING 15 FOR STRUCTVRAL SHELL ONLY.ALL ACCESSORIES AND APPURTENANCES ARE DEFINED BY OTHERS. Fr = n__U w '.1 Y p� FILTER 2°TO a"SAND 18. BACKFILLWITH CLEAN EARTH,FREE OFSCOTS AND DEBRIS. DO NOT ALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHT OF THE W N p'�"�'' o WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" Y y u R/I Ll MAN \ • \ 19. PLACE CONCRETE ON SANDY TO LOAM SOIL, REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL. ~ 44 ro RET)PAS lz 20 THERERECUT 15 NO MAI N DRAIN IN THIS POOL.THE NYS RESIDENTIAL CODE SECTION WATER FOR EIRCRAPMON 15 PROVIDON Y THE SKIMMERS ONLY.THIS MEETS U y CHECKVALVE VERTICAL3/e°REBAR©'a'O.G. P'EW Yp�, � ( PLUMBING SCHEMATIC (NOT5HOWN) OCC PANCY O R 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: • �,�i �HpMgS N.T.S. WALL SECTION 21.1. THE NEW YORK STATE RESIDENTIAL CODE-SECTION 8326(2020) USE I UNLAWFUL N.T.S. 21.2• THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION 8403.10(2020) r.1 �.� 21.3. THE NEW YORK STATE FUEL GAS CODE(2020) !: j !Z• L W 21.4. THE NEW YORK STATE SANITARY CODE. 6 ° WITH UT CERTIFICATE / 21.5. ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROVND SWIMMING POOLS. C `k, fn Z 21.6. BOCA CODE-SECTION 421. ' E���'�R�VN� 21.7. CODE OF THE TOWN OFSOUTHOLD. t. % A� OF 0 CUPANCY RETAIN STORM WATER RUIVIC' v Y �.i 1� �N����'�''®� REQUIRED 22. ALL BACKWASH TO BE ON-SITE. y�.� � �-�5 PURSUANT TO CHAPTER 236 �K�J flG s' �o�a� OF THE TOWN CODE. PP - FESs�°