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HomeMy WebLinkAbout47520-Z ����g�1FFDlea Town of Southold 11/10/2022 P.O.Box 1179 o _ 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43584 Date: 11/10/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 6580 New Suffolk Rd.,New Suffolk SCTM#: 473889 Sec/Block/Lot: 117.4-33 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/8/2022 pursuant to which Building Permit No. 47520 dated 3/3/2022 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 Winward Partners NY LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47 20 10-25-2022 PLUMBERS CERTIFICATION DATED A ori e Si ature TOWN OF SOUTHOLD �FFOIK BUILDING DEPARTMENT Co z TOWN CLERK'S OFFICE 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#: 47520 Date: 3/3/2022 Permission is hereby granted to: Winward Partners NY LLC c/o Steve M Figari PO BOX 237 New Suffolk, NY 11956 To: Construct in-ground gunite swimming pool at existing single family dwelling as applied for. Minimum 5 foot setback from rear and side property lines must be maintained for pool and equipment. At premises located at: 6580 New Suffolk Rd., New Suffolk SCTM #473889 Sec/Block/Lot# 117.4-33 Pursuant to application dated 2/8/2022 and approved by the Building Inspector. To expire on 9/2/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector pF SO(/j,�,Ql � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 Q sean.deviinCab-town.southold.ny.us Southold,NY 11971-0959 Q OUNTI,�� . BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Winward Partners NY LLC Address: 6580 New Suffolk Rd city:New Suffolk st: NY zip: 11956 Building Permit#: 47520 Section: 117 Block: 4 Lot: 33 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: YE$S Electric License No: 50592ME 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 Disconnect Switches 4'LED Exit Fixtures 11 Pump Other Equipment: Intermatic Pool Panel 4 Circuit/ 3 Used, Pump 220GFI, Heater, Salt Generator, 1 Light 120GFI Notes: Pool Inspector Signature: Date: October 25, 2022 S.Devlin-Cert Electrical Compliance Form �o�,�,u�sooryo6 Ll "J, S 2C) # # TOWN OF SOUTHOLD BUILDING-DEPT. �imnm•�''� 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 REMARKS: TCCJ a DATE ZZ INSPECTOR ��- i apF SO�Tyo6 1 [ 7 Z (.v S-& "a^r 5u Fr- # # TOWN OF- SOUTHOLD BUILDING DEPT. `ycouhm '' '765-1802 IN:SPECTION_ , [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] 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 4t REMARKS: �o►es✓ NA DATE 10 INSPECTOR " 1-4 _T5D Jeffrey Sands Architect D ECF 9 �q ' APR 2 2 202.2 April 5, 2022 TO"U'LDING DEPT OFSOU OLD Property/swimming pool location: 6580 New Suffolk Road New Suffolk, NY RE: Swimming pool rebar inspection Attention Town of Southold Building Department: Upon inspection of swimming pool rebar and drywell at above mentioned property, I find all to have been installed to meet current building code requirements. Sincerely, M. AR 27 OF Jeffrey Sands Architect e 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands(,hotmail.com FIELD'INSPECTION REPORT' '- D'AT'E G01121VtENTS FOUNDATION(IST) ' ------------------------------- FOUNDATION -FOUNDATION(2ND) 03 ROUGH FRAIVIIN.G& PLUMBING y INSL:LATION:PER N..Y. STATE ENERGY CODE: FINAL :� : •. . .. AD MME` .. .... .. ....... 300: co. :' + :�Q ..: .��:.. .. � • QLo O vS . m su i, TOWN OF SOUTHOLD—BUILDING DEPARTMENT ;,. Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 https://wwu,.southoldtoo�l�.Q�o_v Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ® E C E Ll PERMIT NO. Building Inspector: �V�J LI FEB 07 8 209 . "G'pg',�M1•x'•.,��, ;`kFi4• -4,�;'�'s_f..,r __ _ :,te,,, :'f .ie,,; _ - .. Applications and farms must be filled out m their,entirety Incomplete- BUILDING DEPT. TOWN OF SOUTHOLD apphcat�ors will not be accepted Where the Applicant is not the owner,an F+Owner's Authonzation'form(Page 2j shall be completed T , Date: a pat. ",�,WNER(5}O�PROPERTY Kik 4, - : NameSCTM# 1000- ..._.m _._.. ., Project Address: �ZoaA Phone#: -) Email: Mailing Address: Dw, 10 �CONTACTf,�PERS.ON . , Name: Mailing Address: Phone,# ..:t11..:J\...'- ",1....... .',.....lY4D..`:...... ..._..-,............... ... Email:. : DEStGN PRQFES�IQNAL INFC1R1Vii41'ION `;:'. - J YYt. '�.t � � �` f Name: Mailing Address: Phone#: Email: r, [ TRACCOR`ItVFC3RMATlON h5 r l J Name: Mailing Address: Phone#: Cox TEmail:�` 4S �1 DESCRtPT1ON OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition �vr�m` Estimated Cost of Project: x3a G�� �o�� $ Y �o they N , - Will the lot be re-graded? ❑Yes FO Will excess fill be removed from premises? s ❑No 1 INFORMATION Existing u e of property: Intended used property: �es�cmnNnw W j N Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to am 1f us n tss this property? OYesONo IF YES, PROVIDE A COPY. i Z 'UAf owner/contractor/design professional 1sresponsjolLjrfor'ajjdrainage and storm water issues as provided by: ' Ch'ap.tO'e23'66f,th,ie T6wriCode APPLICATION FS HEREBY MADE to the,Buildiiig;D6partinent-fcie-'thL-isstfAncEiijfa"Buildiilg-Permit.-p,ir�si"t�to.,""" th6'Building' Ordinance of the T.OWR..'Of,SbuthiDICI,,,96ffdlk,CbUht AeW Yoe and 6tconstruction ofibiiildings, Ili'61 L Watibris,,for tM,` additions,alterations or for removal or demulrtwn as herein described.The applicant agreesao comply with all applicable laws,ord+nances,,bGrlding code, �;�.'- Application Submitted_!yfprint name): Me_VQ_UV11b 16uthorized Agent ElOwner Signature of Applicant: Date: 01 -311- STATE OF NEW YORK) COUNTY OF lk ID+rA r1'CIL, M 4?,CC-U YlQ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the �Jntractor, 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 KU CLV_ , 20 2_2 Notary Public PROPERTY OWNER AUTHORIZATION MICHELMAMP-DUSKI Notary Pwbllo,State of Nqr York (Where the applicant is not the owner) Reg,No.01ME639334..3 Quallflod In Suffolk Go'" ty U commlsolon Explres Jun"e,'l 79,2023 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 :..' : . .: :: .epartment.�U�ai� a�ut�.:. . . . ... . . .....:...::. ...:.::...:...... .... .. .: ...........: .::.: .'. { .. . Ap1. An. s.dot. li (>cx net)`': :.:.:: :.::.:• .. . .. .. :. ..... .... .•:: :....,:...... .:. . .. .'... . . . :. ...:... :.::. .: . . ....-.... ... ..... .. . .. .- : ::: : :.... .. .. ;. W. _ .-..� M. :.. fit. :w.l .,:; ' : ; ::.;:-:: l?r`'t, e a . .o 'r:: o,.I . e .:':...:::.'. •.'.::.'.' •. 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'.: .:,:': : t . `:: :.' ..: :.. :. i. ..... .t..: . .....:.... . .: . ... .... ..:. ........ o��guFFDL/�C,O" BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex- 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 1 " - rogerr _southoldtownny.gov- seandCa)_southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4.15.22 Company Name: Yannucci Electrical Services Inc Electrician's Name: Vincent Yannucci License No.: 50592-ME Elec. email:Vinny@yeselectricalainc.com Elec. Phone-No:-631=258-7324 Eli request an email copy of Certificate of Compliance Elec. Address.: PO Box 638 Shoreham NY 11786 JOB SITE INFORMATION (All Information Required) Name: Winward Partners NY LLC c/o Steve M Figari Address: 6580 New Suffolk Rd., New Suffolk Cross Street: George St. Phone No.: Bldg.Permit#: BP#47520 email: Tax Map District: 1000 Section:117. Block: -4 Lot:-33 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): BP#47520 In-Ground Swimming Pool 1 timer, 1 pump, gas heater SCTM # 473889 F Square Footage: Circle All That Apply: Is job ready for inspection?: FV-] YES ❑ NO F-]Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES 0 NO Issued On Temp Information: (All information required) Service Size❑1 PhF_13 Ph Size: A # Meters Old Meter# EJ New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect[-]Underground❑Overhead # Underground Laterals F1 1 2 H Frame Pole Work done on Service? Y N Additional Information:In-Ground Swimming Pool BP#47520 SCTM#473889 PAYMENT DUE WITH APPLICATION �'1O� CA oSgFO(/CBUILDING DEPARTMENT- Electrical Inspector 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 a_�southoldtownny.gov - seandCa�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4.15.22 Company Name: Yannucci Electrical Services Inc Electrician's Name: Vincent Yannucci License No.: 50592-ME Elec. email:Vinny@yeselectricalainc.com Elec. Phone No: 631-258-7324 Lv i request an email copy of Certificate of Compliance Elec. Address.: PO Box 638 Shoreham NY 11786 JOB SITE INFORMATION (All Information Required) Name: Winward Partners NY LLC c/o Steve M Figari Address: 6580 New Suffolk Rd., New Suffolk Cross Street: George St. Phone No.: Bldg.Permit#: BP#47520 email: Tax Map District: 1000. Section:117. Block: -4 Lot:-33 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): BP#47520 In-Ground Swimming Pool 1 timer, 1 pump, gas heater SCTM # 473889 F Square Footage: Circle All That Apply: is job ready for inspection?: YES ❑ NO '❑Rough In [] Final Do you need a Temp Certificate?: ❑ YES 0 NO Issued'On Temp Information: (All information required) Service Size -11 PhF-13 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 FIN Additional Information:In-Ground Swimming Pool BP#47520 SCTM#473889 PAYMENT DUE WITH APPLICATION C� VA eco \�� PERMIT # Address: Switches I Outlets GFI's I 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 ,ir 19-217 LOT AREA = 14,912 SQ. FT. ( 0.342 ACRES ) 21-34 DATUM N_A.V.D. 1988 21-276 1 STY FR ACCESSORY STRUCTURE (NO OCCUPANCY) NOW OR FORMERLY NOW OR FORMERLY TUTHIL MARK AND DIANA SCHWATKA 10.10 I ° N 07°01'20"E 89.04' 1.4'W N 0459'00"E (15.3') fo 1.4'N (12.3' —, 3' fd mon / chain link fence fd pipe _v- --� • x fc 1.8'S' is 1S 8= �' r edge of grUvel / 12.3' fc 0.7'S 0.7'E 1.o's 1 STY ©® I 0.5'E fr shed ro FR BLDG. N I 1 0.7'S o rvfi 13.7_ Z7.� 1 !•Ita'Az 00 m 12.3' -Wof1,%%yn O'� o CO o N CtI m � a y fencee� m1�"'® 'o ' V O n m O = zo ,Fc I 1 13.5' m o C: 0.3'5 I m :;u m O pole 6.0' 30.6' x O O FOUNDATION 14.6' fc i.1'N m Z n 1 x 00 < o a t b 0 00 14 7' X 4_ .I. � I m Ix D CD 21.0' -P :U O (A / + wall. 9 � Q 1.2'N Q R'I co I x � 0 l 4 8:w D I 1.4'S 200.10'(deed) O fde i fd mon 200.00'(aCt) P P fd stk !. drive .3014 - - S 0705'20"W 101.29 C h overhead wires (8.4') NEW SUFFOLK .ROAD (10.4') pole O 12-16-2021 FOUNDATION LOCATION 9-8-21 STAKE BUILDING 4-5-2021 REVISED 2-11-2021 REVISED PROPOSED DWELLING 1-7-2020 REVISED SEWER/WATER LINE SEPERATION 11-6-2019 ADDED HEALTH DEPT. INFOMATION THE OFFSETS (OR MIENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT JOB No. 19-75 FILE No. 987 F INTENDED TO GUIDE THE ERECTION OF FENCES, RETAINING WALLS, POOLS. PATIOS, PLANTING AREAS,ADDITION TO BUILDINGS OR ANY OTHER cONSIRUCTION. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION SURVEYED FOR WINWARD PARTNERS NY LLC 7209 OF THE NEW YORK STATE EDUCATION LAW. GUARANTEES INDICATED HEREON SHALL RUN ONLY TD THE PERSON FOR WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY. GOVERNMENTAL SITUATED AT NEW SUFFOLK AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF 1HE LENDING INSTIMON. GUARANTEES ARE NOT TRANSFERABLE TO ADDITIONAL.INSTITUTIONS TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y. OR SUBSEQUENT OWNERS. COPIES OF THIS SURVEY MAP NOT BEAJUNNG THE LAND SURVEYOR'S INKED SEAL OR SCALE I" = 30' DATE 4-11-2019 EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. E (� FILED MAP No. DATE C E CERTIFIED ONLY T0: ,'",, TAX MAP No. 1000-117-4-33 CRD. 16-234 ` DISK 2019 t FEB o 8 91199 41;_r HAROLD F. TRANCHON JR. P.C. LAND SURVEYOR BUILDING DEPT. TOWN OF SOUTHOLD ;t P.O. BOX 616 t �M1 1866 WA DINGRIVER—MA NOR RD. WADING RIVER, NEW YORK, 11792 I . -.N.Y' LI' -. No. 048992 631-929-4695 HAROLD F. TRANCHON,'JR: PENN.11C. No. 2115—E CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD"'"Y). '✓ 10511012021 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 Brookhaven Agency,Inc. PHONE 631 941-4113 T.FAx, 631 941-4405 100 Oakland Ave,Ste 1 E-MA,rSIL certificates brookhavena enc .com Port Jefferson, NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Philadelphia IndemniInsurance Co. INSURED INSURER B: Wesco Insurance Co. Patrick's Pools,Inc INSURER C: Merchants Mutual Insurance Co. PO BOX 3024 INSURER D: East QUogue, NY 11942 INSURER E: 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. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP ' LTRPOLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 PR A CLAIMS-MADE ®OCCUR DAMAGE TO RENF FS TED $100,000 x Contractual Liability X X PHPK2229439 02/28/2021 02/28/2022 MED EXP(Any oneperson) ' $5,600 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY PEC LOC PRODUCTS-COMP/OP AGG s2,000,000 OTHER, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $50(),000 C X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2020 07/12/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X' NON-OWNED PROPERTY DAMAGE $ AUTOS (Per arrident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION �( PER OTH- AND EMPLOYERS'LIABILITY 11ITI FR ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBER EXCLUDED? ® N/A WWC3528513 05/13/2021 05/13/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S100,000 If yes,describe under DESCRIPTION OF OPERATIONS be ow E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES,(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold is included as additional insured 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 REPRESENTATNE /f <> �L��l� Ps�Jl6r ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD YORK j ComWorkers' CERTIFICATE OF INSURANCE COVERAGE s7AT£ Compensation `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 EAST QUOGUE,NY 11942 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if co'erege is specifically limitedor Social Security Number to certain locations in New York State,i.e.,Wrep-IJ, Policy) 262929943 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He[der) ShelterPoirit Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"l a" 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 Ie ave benefits. B.Disability benefits only. E] 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. C] B.Only the following class or class es 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 Fat illy Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 ByjU'G� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A i ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.kgent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 413,4C or 5B 1;checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily 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 f IYS Workers'Compensation Board(only If sox 4C or ss of Part i has been checked) State of New York Workers' Compensation Board According to information maintained b/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 Emptoyee) Telephone Number Name and Title Please Note:Only insurance carriers licen red to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt.:4zad to issue Form OB-120.1.Insurance brokers are NOT authorized to Issue this form. DB-120.1 (10-17) III�I�P1QIl�I�2IIgI1IIIU(I10Ial1U7f[lll�i� APPROVED AS,NOT D OCCUPANCY OR DATE: �3 �B.P.# USE IS UNLAWFUL FEE- WITHOUT_ WITHOUT CERTIFICATE NOTIFY BUILDING DEPARTMENT AT OF OCCUPANCY 765=1802 i-�W TO 4-PM FOR .THE FOLLOWING:INSPECTIONS: 1. FOUNiDATION:=_TWO'REQUIRED: FOR POURED CONCRETE` 2. ROUGH FRAMING & PLUMBING 3. INSULATION .4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O: COMPLY WITH ALL_CODES OF ALL CONSTRUCTION SHALL MEET THE NEW YORK_ STATE & TOWN CODES REQUIREMENTS OF THE CODES OF NEW AS REQUI D"AND:CONDITIONS OF YORK STATE.. NOT RESPONSIBLE FOR DESIGN OR ,CONSTRUCTION ERRORS. SOUTHOLDTOWNZRA SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES N.Y.S.DEC WE IaATELY" ENCLOSE POOLTO:CODE up,ON C4�!lP1,�TION �3Et ?NVTI=R".� RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. necMCALMOEMM REQUMM ° '{�`'k ` - �.I o. t. S 1C1� _ T ► T�__!_ __ f_ _�__`_ f ivjw _ a I I f UT I { Iviotibe �� .r { 1 _ _ l { ; ; _ WIF _F FEB— 01 21177- } - I i BUILDING DEPT,, - { a-rJR-SOUL TNOL-D-- I + _J yy l I !moi u. f + I - I — i i — I I � T — -- --�-----} '�l-- ' I T) I� I }.���.r��...`Y_r�. - - l _�--._._�_.✓._.,�_ -� T _ PF -rl, ej -� --j-- y +' T-- � ! t �� '� { �