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HomeMy WebLinkAbout47063-Z �o�SHFF01q�1p . Town of Southold 11/5/2022 G � P.O.Box 1179 o - C 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43574 Date: 11/5/2022 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 480 Oakwood Ct, Southold SCTM#: 473889 Sec/Block/Lot: 90.4-3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/18/2021 ,pursuant to which Building Permit No. 47063 dated 11/1/2021 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 with spa fenced to code as applied for. The certificate is issued to Adimey,Jarijo&Lugris,Veronica of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47063 4/18/2022 PLUMBERS CERTIFICATION DATED uth ri d ignature �o�S�4fs��co TOWN OF SOUTHOLD �$ BUILDING DEPARTMENT N x TOWN CLERK'S OFFICE 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#: 47063 Date: 11/1/2021 Permission is hereby granted to: Zoumas, loannis 2050 N Country Rd Wading River, NY 11792 To: construct accessory in-ground swimming pool as applied for. At premises located at: 480 Oakwood Ct, Southold SCTM #473889 Sec/Block/Lot# 90.4-3 Pursuant to application dated 10/18/2021 and approved by the Building Inspector. To expire on 5/3/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 du/11d'i—ng Inspector *pF SO!/lyol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlinCcD-town.southold.ny.us Southold,NY 11971-0959 OIy1000%�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Marijo Adimey Address: 480 Oakwood Ct City,Southold st: NY - zip: 11971 Building Permit* 47063 section: 90 Block: 4 Lot: 3 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 Spa X 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 Fixture Time Clocks Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: Aqualink Pool Panel 12 Circuit 9 Used, Salt Generator, Pump x2 220GR' Blower, Heater, 4 Lights 30OW Tranny 120GFI, Autocover 120GFI Keylocked Switch Notes: Pool Inspector Signature: Date: April 18, 2022 S.Devlin-Cert Electrical Compliance Form OF SOUTyO� * # TOWN OF SOUTHOLD BUILDING DEPT. f co 765-1802 0 �V INSPECTIONLX [ ] 'FOUNDATION 1ST [ ] .ROUGH PL13G. [ ] FOUNDATION 2ND. [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION ( ] FIRE RESISTANT PENETRATION [�(J ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [`'] CODE VIOLATION [ ] PRE C/O REMARKS: DATE 2v 2 INSPECTORO) aG:SOGIH 1 CI - # # TOWN 01 SOUTHOLD BUILDING DEPT. 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: oa elee, r a DATE 4 �� 2� INSPECTOR OF SOUTyo� # # TOWN OF SOUTHOLD BUILDING DEPT. `ycouffov, 631-765-1802 . INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINALP t, [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: IJ 0 40► 'L I/C�� 7 Vol- k-vvwv�� DATE INSPECTOR =" `tib�3 Jeffrey Sands Architect /DJ December 8, 2021 LI APR 222022 LD) �owv'o�so�HoLn Property/swimming pool location: Marijo Adimey 480 Oakwood Ct Southold, 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, D ARC a F OF NES Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands0hotmail.com FIELD.INSPECTION'REPORT.. DATE COMMENTS , ►o C� FOUNDATION(IST) y ---------------------------- . W � FOUNDATION(2ND) d ROUGH FRAMING;84' y Q PLUMBING' 1 INSULATION PER.N.Y. STATE ENERGY CODE Sr Co-I FINAL, rY14�tC11 ✓bo: g iA ' Loll r ' ADDITIONAL, COMMENTS COD Jc77� �cl Z 1.1x ... rn -�e t � V >1W ° . d b f"g�yF��FOIA'4 oma° e ' TOWN OF SOUTHOLD—BUILDING DEPARTMENT - y. x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownn.gov Date Received APPLICATION FOR BUILDING PERMIT D E C EE VE ,3For Office Use Only PERMIT NO. �D -Building Inspector: OCT 1 a 2021Di- BUILDING DEPT. Applications and'1orms'.rn--"be4illed out.in,their entirety. Incomplete TOWN OF SOUTHOLD applications will.not be:accepted:,1"ere.the-Applicant is not the owner,an Ow'ner's Autho iiation'form`(Page'4'shall be completed. Date: ,OWNER($),0F,0 Name: FcTm# 1000-090,CO — 04, 00 — Qp3.�3- Project Address: IVB A� 1i Phone#: Email: 1v Mailing Address: CONTACTARSON:_..::_ Name: Mailing Address: Phone#: Email: 1.- �-1�.. 1 i[�Ca DESIGN PROFESSI.ONALJNFORMATION:' ' Name: Mailing Address: Phone#: Email: :CONTRACT0R" NFORMATI.ONd Name: Mailing Address: O U N Phone#: (� U� Ema' - DESCRIPTION OF'PROPOSED-CONSTRUCTION El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition -(yn Estimated Cost of Project: %Other N eW sAtCSSG 5; Come- ��p (-,�n�le-�nc�i $ 11 cam., L4 QD Will the lot be re-graded? ❑Yes' No Will excess fill be removed from premises?VYes ❑No 1 r` PROPERTY INFORMATION -20'KqO Existing use of property: Intended use of property: Pooh w� 5e ..._.._,_ Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to _1 1 Dthis property? ❑Yes o IF YES, PROVIDE A COPY. heck Box'After`"Reading: The"owner/contractor/design professional is responsible for all drainage and storm water issues'as-provided:byj apter 236 of the.Towri 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,4 '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 Cla' A.inisdemeanor,`pursuarit to Section 210.45 of the New York State Penal Law. Application Submitted B (print name): muc o Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEWCYORK) COUNTY OF JAI ) T�l n<L meeco Ir 0 being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the Aceni- (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 U CTDbQ� ;20 2. t Notary Public MICHELE A MEDUSKI Notary Public,State of New York Reg.No.01ME6393343 Qualified in Suffolk County PROPERTY OWNER AUTHORIZATION Commission Expires June 17,2023 (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 BuildineMenartment Aanlication • AUTHORIZATION (Where the Applicant is not the Owner) S zu,*45 residing at (Print property owner's name) (Mailing Address) do hereby authorize '`�!�;x1 (Agent) to apply_on my.behalf to the SoutholdSuilding Department. ( wner's Signature) (Dfate) (Print-Owner's Name) ' D 1 1 g 2021 OC • BUILDINU TOWN OF SOUTH"!; c� . . BUILDING-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 ' rogerrCaD-southoldtownny.gov - seandCa)-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ali Information Required) Date: t Company Name: Electrician's Name: i License No.: - Elec. email: j+ _C�.1; Elec. Phone No: ;i•- � 'LII.request an email copy of Certificate of Compliance Elec. Address.. . JOB SITE INFORMATION (All information Required) I Name: Z 0 V A rl-,-3 Address: qco pay ,wp C—_1 Cross Street: Phone No.: BIdg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): a SWI AAM ILA— f I�Do k Square Footage: Circle All That Apply: Is job ready for inspection?: YES 0 NO F-]Rough In FIFinal Do you need a Temp Certificate?: F� YES❑ NO Issued On Temp Information: (All information required) Service Size[]1 Ph❑3 Ph Size: A # Meters Old Meter# New Service[]Fire Reconnect[]Flood Reconnect E]Service Reconnect DUnderground EOverhead ii # Underground Laterals 1 M2 n H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION � ,C 0 `0 of SuffQ(� BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD C* Town Hall Annex- 54375 Main Road - PO Box 1179 o • ,, Southold, New York 11971-0959 4 .� app' Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(E�southoldtownny.gov- seand(a�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) ',. Date: Company Name: Electrician's Name: License No.: Elec. email: ,Y Elec. Phone No: ❑I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: Phone No.: email: - --------- ----------- --- - -- ----- Tax Map District:-. 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE.-(Please..Print Clearly): Square Footage: Circle All That Apply: .Is job ready for inspection?: ❑ YES ❑ NO ❑Rough In. -.❑-Final Do you need a Temp Certificate?: ❑ YES❑ NO Issued On Temp Information: (All information.required) Service Size❑1 Ph n.Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 0 1 F12 n H Frame Pole Work done on Service? Y N Additional Information: - ----PAY-MENT-DUE-WITH APPL-ICA-T-ION--- ob n nr CGUe � 1LL 27t�1 7r s c�J�'cJ c,.Rroat� PATRICIA C. MOORE Attorney at Law 51020 Main Road D E C E � V E Southold,New York 11971 Tel: (631) 765-4330 OCT 2 5 2021 Fax: (631) 765-4643 BUILDING DEPT. TOWN OF SOUTHOLD October 25, 2021 By Hand Mike Verity,Building Inspector Southold Town Building Department Town Hall Annex, 54375 Main Road, Southold,NY 11971 Re Owner: Marijo Adimey (Zoumas property) Premises: 505 Lakeside Drive North, Southold Dear Mike: Nancy Dwyer reviewed this file with you. The property is owned by Joannis Zoumas (builder) and he is building a house and Patricks Pools Inc. is building the pool for Marijo Adimey. The property is located on Lakeside Drive North,to the west is an unopen road(Clear View Road) and behind the property is Lakeside Drive. Enclosed with the building permit application for the pool is a Covenant and Restriction, to be recorded on the property. The C&R's state that this parcel will not have vehicular access on Lakeside Drive. Without vehicle access on Lakeside Drive, the building department can issue a building permit for the pool located in the rear yard, as an accessory structure. Please confirm that the C&Rs are acceptable and I will have the C&R's recorded. /Ve raly�, ricia C. Moore Cc: Marijo Adimey Patrick's Pools Inc. PCM/bp Encls. PRIVATE ROAD COVENANTS DECLARATION OF COVENANTS AND RESTRICTIONS 6 T IS DECLARATION made by IOANNIS ZOUMAS, this Z0 day of e� , 2021, residing at 2050 N COUNTRY ROAD, WADING RIVER NY 11792, hereinafter collectively referred to as the DECLARANT, as the owner of premises described in Schedule "A" annexed hereto (hereinafter referred to as the PREMISES) desires to restrict the use and enjoyment of said PREMISES and has for such purposes determined to impose on said PREMISES covenants and restrictions and does hereby declare that said PREMISES shall be held and shall be conveyed subject to the following covenants and restrictions : 1 . The DECLARANT hereby extinguishes and abandons the right to vehicular use of a private road which abuts his property on the South side of the parcel, known as Lakeside Drive, Southold; and 2. the DECLARANT reserves the right to use Lakeside Drive for pedestrian access, including but not limited to, recreational access; and 3. the DECLARANT reserves the right to use Lakeside Drive for all utilities, including, but not limited to, electric, cable, natural gas, and public water; and 4 . The DECLARANT, its successors and/or assigns shall set forth these covenants, agreements, and declarations in any and all leases to occupants, tenants and/or lessees of the above- described property and shall, by their terms, subject same to the covenants and restrictions contained herein. Failure of the DECLARANT, its successors and/or assigns to so condition the leases shall not invalidate their automatic subjugation to the covenants and restrictions; and 5. These covenants and restrictions shall run with the land and shall be binding upon the DECLARANT, its successors, and assigns . Ioannis Zoumas ACKNOWLEDGMENT STATE OF NEW YORK ) . ss. . COUNTY OF SUFFOLK ) On the 20 day ofAakl� in the year 2021 before me, the undersigned, personally appeared IOANNIS ZOUMAS personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual or the person upon behalf of which the in ivid 1 acted, executed the instrument. Nota y Public MARIJO C'MILLE ADIMEY Notary Public,State of New Yo[ No.02AD6230835 3lified in Now York County �fiiitiiti9l l9 !es NOVZ 86 20J ACKNOWLEDGMENT STATE OF COUNTY OF J41 ) : ss . : On the ';-e)- day ofj'hko in the Fear before me, the undersigned, personally appeared 4 /*" �%r1�S personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the, individual or the person upon beh if of which the individual acted, executed the instrument. No ry Public MARIJO C'MILLE Ai7HEY Notary Public,State of New`1e-i" No.02A06230835 ilified in New York County r,gMIj11pI4t9 moires Nov.8, PROPERTY ON THE SUBDIVISION MAP OF CEDAR BEACH PARK - - - - - - - - LOT 67 FILED DECEMBER 20,1927 AS MAP NO.90 L7AKWDgD DRIVE SITUATE AT £30' aTDE) BAYVIEW S 41'59129' E 200.'170' TOWN OF SOUTHOLD SUFFOLK COUNTY,NEW YORK aa� s ,.aro AREA OF PARCEL = 29,0123 SQ.FT. OR 0.666± ACRE \ I 1 arph t I 1 1 Tr FDP DF FVUNDA r1M i x22.:,1 SPDi ELCVA ilpN !r2E'g� CLIC^.,roGS. •a�G �� �E �`O O P lig CDNCRETE ( NOTES z Wim® � FDUNDATTDN ?. MEASUREMENTS AREINACCORDANCE KITH U.S.STANDARDS. \ LLIT AR 2. LONGI LAND ZWNAREIfl NEW YORK STATE PLANE COORDINATE SYSTEM NAD83, LONG ISLAND ZONE. 3 F 6 58q u ll6J T•$'--_"-' 3. ELLVADONS REF[R[NCE NAVD foes(G[OtOt A). W�•IRK W r"T Y Ilei vlMi� uL•7w vm.L .DIJAtt ` 4• UNAUTRORIZEDALTEREON OR ADDITION TO A SURVEY MAP SEARING A LICENSED p, 46.4" I OLAND SURVEYORS SEAL IS A VIOLATION OF SECTION 7209,SUBDIVISION 2 OF THE (D� NEW YORK STA TC EDUCATION LAW �,`'�' e 5 THE LANONLY PIESFROM YORS TAIBOS LOFTHISSURSPAL$ALL BE CONSIDEREDAL v VS THE LAND E COREORS'FMHOSSED'OR'INKEO'SEAL SHALL 8E CONS/CERED TO BE \ �'"' VALID TRUE COPoGS. Z 0- CERTIFICATIONSDA INDICATED HEREON SIGNIFY THAT THIS SURVEY WAS PREPARED UI -.yuf♦,Tt A�`r_ ACCO RDANEEHE N WY DasTINa STAT CODE OF PRACTICE FOR LAND SURVEYORS ADOPTED S THE NEW YORK SIONS SKAU R DON L PROFESSIONAL LAND \\ CU adX yo 1�ro(posed ' SURVEYORS,SAID CERTIFICATIONS TO TTO HE OL#PAN. MOW THE SURVEYIS PREPARED AND ON NIS BEHALF 70 THE TITLE COMPANY. 1,[-I - / GOYERNESOF7AGEND'NGISTITUtON.CTU'DONLISTSD HER EON AND TOFRA TOADDEESOF TNT"WING IOR SUBSEQUENT NTOWNERS.TIONS ARE NOT TRANSFERABLE ' ♦�r"� ��_,g�a TOADDIirONAL fNSitttITIDN50R 5UBSE0UENiOwNERS p\,_ Rroms-OF-warxorserowry arrc+vor eeRnr•rea. E. THE SURVEY CLOSES M INFUiTICALLY. rrtla I _ 1 N 40'31'39' W 116.17 r� A,Qp01 ca•.r a'SrD+c aat� 2 �3' LAKESIDE DRIVE NORTH DATB DY I DKNCRIPTIOK �APFRDY.DY (30' HIDE) REVISIONS / a 4;"';IE Tnwn of Snuf.hnld .� Suffolk County New York / 505 Lakeside Drive North 10 SOITTROLD, NEP' YORK SUFFOLK COUNTY REAL PROPERTYTAXMAP Ihereby certify that this map was made from an actual survey ( FOUI\DATION AS—BUILT DISTRICT 1000 completed by me on 03/1912021. I L. K. McLEAN ASSOCIATES, P.C. SECTION KH 090.00 I�aT soLrcovxrRY xoAn BRODAY&NG,NRR YORK BLOCK 04.00 LUI 003.003 TAMARA L.STILLMAN,P.L.S. su•»r^� CO I s.«.: 31" NYSPLS No.50528 rro�aY nx. .«a xAeot ez ) I ._I P�zerb2.w6 5D5 Loxe.�ae L•NASI+y.D—'Proas�MCSW r-4 As-awsmp 62MFW 417PN T—Sce;.+un i acc-�«e ev.res. n.re Nrt2am PROPERTY OWN THE SUBDIVISION MAP OF - CEDAR BEACH IPARK LOT 67 FILED DECEMBER 20. 1927 AS MAP NO t..1AKWELJD 11RI V SITUATE AT tap` 11,11DE7} BA x r�'h7 e.7a - -L_.t _ .-.,..�. se - s .� 41`501'29' r� �t�C:IIO' TOWN OF Sc�UT�I�I.D — — .�1 _ m.._......._.. SUFFOLK COUNTY,NEW YORK AREA DE PARCEL = 29,012± SQ.F-T. OR 10.666: 'so 1 Ey O E (C E /7 rr T,'Yf= :�' t'LL'r;`�r:,'iu7v •� .c%Tf _ ...__�IF-'c{.4 �'/�.� � IIv.. Il `L1(/J OCT 1 S 2021 i coo BUILDING DEPT. TOWN OF SOUTHOLD C2NCRF_7EFDUNDA TION ZJ1 ti rrQ r s MEASUREMENTS ARE IN ACCORDANCE W1TH'US.STANDARDS_ BEARINGS SHOWN ARE 114 N15W YORK STATE PLANE CGORDWATE SYSTEf'N. LONG ISLAND ZONE, 51 EVAi70f•!S R£rlh�7.1C£'hIAUZ?"168(GBO1DfJi. VA k tJNAUZHORI?EG ALTEF T1OPJ C-ADD!TION TOA SUP VSY MAP BEARING A UC LAND SURVEYOR'S SEAL 1SA'VIOLA 7tOH-OF SECTION 7209.SUED!WSION III G MEW'i 0RX TA i E EDUCA FICA;LA''V. -• ONLY COPIES"ROA4 7r1E OPIG1NA.L OF 1:F115'SjPV-Y MARKED WMq AI4 OP;Ge 7HE�LAND SURVEYOR'S`E;VBL:SSED'CR'.'NK.8tD-SEAL SHALL 8E CONSIDEPL 'JAUD T!'i;.iE COPIES. X..� ,p(� 5. CE'R iTIFiCATIONS INDICATED HE.- 51GN1.F'f7'i•1nT'FH15 Si1I2�Y VV'.4S PRE ` fro os---4 ACCORDANCE WlI'H TPE rXIS'rING CODE Or PRACTICE FOR LAND SURVEYC: y.\V I ADOPTED BY 7 HE:tip vV YORK S TA"TE ASSOCIA TION OF PROFESSIONAL LAW- SURVEYORS. AW-SU RVEYORS. SAW CER'rJr,CATi011S Si•iALi RUN OULY TO THE PERSON FOP' I:-fE SURVEY!3 PPE PARED AND ON HIS BEHALF M THE T1 TLE COMPANY. e/ / GO N6RhIRf6h17:+5L:5G1='11CYtLPtDLE.IL�IPIG thlSTfrir710N G'S7'�rJ 7-1ER6Clt'F,T7D7 !� ASSIGNEES OF THE LENDING INS rTUTiC^I. CERI'FiCAVONS ARE NO7 7RAN. • ���� ;;z!s '+'.%AGD1TiOMAL 11JSYTrU77GN5 OR SL1HSEdLfENT v^'v'r7i'ERS_ 7. FIGHTS-°7�-VYAY:tOT SHCWM ARE rVQT Gi_RTIFIF�. f 3 "HE SURVEY CLIOSES MATHEMATICALLY. AOL— llp 60f N 40'3'1`39` W 11617 .:� arLz13 I lay � ossrxzPr;orr REVISIONS TS7V4T1 i} fZ17 r1 Suffolk County New � 505 I,B1Ceslc#e Drive Nc SOUTHOL , NZ EW YoT S-UF;70LfC y OU'LlTvREAL PROPERTY TAX;WAP F hereby certify that thismap was:Made frau an aCtU,rrt Sarvey FOUNDATION AS—t C315TRIL; 7©d0 compha&zd by rap on 0311_/2021. ! L_ R_ Nlc-LE it\ .iSSOCIAT: ICO'_ti&t:LTTtiG rmr-INEERS & LAND SECTION 090.0013:17 80. COUNTRY ROAD, BROORRAVE: 3LOCK 04.W � I L1.,1 003.1103 TAMARA L. S-,iLLMAN, P.L_S_ j ! enn rn x. •- ' �!v �yf f1 O ;ar 54D i_Gvo5lav er' _ _ - _ _ r'7 1'SPLv No. 5052:1 I i ar�.n a.�. �:.4 �.� 4dr7::r•'3:i,_ !i &..f"v4v _ t�27r:�ungcl 11724•?{%.pxx .:S-cup:s.rar;y .c9.i Mt) -N7 R4 ra .:!rn0>''` ' ACd CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �105/10/2021 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 631 941-4113I(AIC FAX 631 941-4405 100 Oakland Ave,Ste 1 E-MAIL certificates@brookhavenagency.com PortJefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Philadelphia Indemnity Insurance 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 SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER M/DD DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE �OCCUR DAMAGE TO RENTED $100,000 x Contractual Liability X X PHPK2229439 02/28/2021 02/28/2022 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY�jE F LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $500,000 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 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB I I CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY Y/N STAT ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBEREXCLUDED? N/A WWC3528513 05/13/2021 05/13/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below 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 REPRESENTATIVE <> ©1988-2014 ACORD CORPORATION. All rights reserved. . ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD NI:W Workers' S YORIC CERTIFICATE OF :f,_ srATr Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE -- Board 1a.Legal Name&Address of Insured(use street address only) _ + 1 U.Business Telephone Number of Insured 631-996-4687 Patricks Pools Inc PO Box 3024 - ic.NYS Unemployment Insurance Employer Registration 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 Nein York State,i.e.,a Wrap-Up Policy) Number ¢ 262929943 2.Name'and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"18" Southold NY 11971 VWVC3528513 3c.Policy effective period '05/13/2021 to 05113/2022 3d,The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) ❑X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3'insures the business referenced above in box"1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under jtelp 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 carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled i due to nonpayment of premiums or wittiin 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 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 certificate is issued as a matter bf information only and confers no rights upon the certificate holder.This certificate does not amend, 'extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named.on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation-Law. Under penalty bf perjury,1 ceftify that I am an authorized representative or licensed agent of the insurance carrier referenced above a'nd,that the named insured has the coverage as depicted on this form. Approved by: Nicholas Zulkofske (Print name of aut r'ized representative or licensed agent of insurance carrie) Approved b . Ly , ( ' azure) --- (Date) 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-105.2. Insurance brokers are NOT authorized to•issue,iit. C-105.2(9-17) www.wcb.ny.gov y 1 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into 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 APPR VED AS NO ED DATE: B.P.# �( FEE:. 3 - BY: NOTIFY BUILDING DEPARTMENT AT . 765-1802.`; 8 AM TO 4 PM FOR THE RETAIN S TOR WATER RUNO FOLLOWING INSPECTIONS: PURSUANT TQ CHAPTEF R 2 1.. FOUNDATION - TWO REQUIRED 36 FOR POURED CONCRETE OF THE TOWN CODE, 2-.-ROUGH;=,FRAMING & PLUMBING 3, INSULATION 4. FINAL -'CONSTRUCTION MUST BE COMPLETE FOR C.O. 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