Loading...
HomeMy WebLinkAbout46552-Z po�O �ly, Town of Southold 12/3/2022 0 P.O.Box 1179 53095 Main Rd oy pe� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43650 Date: 12/3/2022 TRIS CERTIFIES that the building IN GROUND POOL Location of Property: 25500 Route 25,Orient SCTM#: 473889 Sec/Block/Lot: 18.-6-10 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/28/2021 pursuant to which Building Permit No. 46552 dated 7/9/2021 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 Sutton,Alexander&Tracy of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46552 11/4/2021 PLUMBERS CERTIFICATION DATED A or zed i ature Su Foir�, TOWN OF SOUTHOLD �s,ro`p c�ay ,UILD1\11G '' E P A R 7 Ph,`-1-N!T C* x TOWN CLERK'S OFFICE o • ��r SOUTHOLD NY BE �LDiNG PERP411T (THIS PERMIT DUST BE KEPT ON THE PREMISES WITH ONE SET OF APFFIOVED PLACES AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 46552 Date: 7/9/2021 Permission is hereby -gra vecl T urturro, Joan 2550n Main Rd Orient, NY 1195 consz tic`° adcesse.1 in-ground swiimr-ni;..g fool as -applied for. At premises located at: 25500 Routs 25, Orient SCTIM ?t 4- '31®69 Sec/BIock/Lot 18.-G-10 Pursuant to appiicaiion da-'L-ed 0/28/2021 and approved by the Building Inspector. To expire on 11 12023. Fees: SV;'IN4MING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 uilding nspector OF SO(/r�ol Town Hall Annex ~ O Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 � • @ sean.deviin(D-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Alexander Sutton Address: 25500 Route 25 city:Orient st: NY zip: 11957 Building Permit#: 46552 Section: 18 Block: 6 Lot: 10 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Paul Burns Electrical License No: 3897ME 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 X 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 Pump Other Equipment: Intermatic 8 Circuit Pool Panel / 4 Used, Pump 220GFI, Lights 120GFI, Heater Salt Generator Notes: Pool Inspector Signature: Date: November 4, 2021 S.Devlin-Cert Electrical Compliance Form SO//lHp� L4 Co5 z # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] 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 REMARKS: der DATE -9 INSPECTOR lad souyo� 4 X 552 2 55oo OT,4- 2-_5- TOWN STOWN OF SOUTHOLD BUILDING DEPT. " �`ycourme�' 765-1802 INSPECTION [ -1 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: � f c DATE INSPECTOR ' i y OF SOUTyOIo # # TOWN OF SOUTHOLD BUILDING DEPT-.765-1802 - INSPECTION . [ ] ,FOUNDATION 1ST [ ] ROUGH PLBG. ] FOUNDATION 2ND [ _ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ WolFfoelNAL [ ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] TIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ` ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: Zk• r -DATE , INSPECTOR l.T �Of SOGIy - - --- - �-� # °# TOWN OF SOUTHOLD BUILDING DEPT. courm N 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL TION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 1t1►'�l �P( `�- (�Vl� ON E om DATE INSPECTOR �' of`�. sn fir♦ ) + f r Sent from my iPhone § > a & H e > w 2 d / % 0 / ° . t = � m ] 3 � o & ' n \ � \ % < .. 7 CD aN r B. \ / § °CD d ( \ C \ o _ § 5 2 ± -Ti a CD / / o / CD e A / y U) \ / \. \ J } \ \ \ ? 0 9 . \ / ° o $ . . 0 / \ _. '»~ $ / \ \ / j - - ' D = . # J \ $ 0 G ? / \ $ 3 = v % . . ƒ \ § CD 0 i'. _l Ia•w � K• Lltl �t•.c • -Taut au e FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) y T A C FOUNDATION (2ND) o O ROUGH FRAMING& A PLUMBING ` N rn INSULATION PER N.Y. �y STATE ENERGY CODE Af ol FINAL vt Iwo � 1ADDITIO AL COMMENT u, 9y 3c/ 7 2y 2-1 rZb UjA Vee- rrc' s� m 1X . b O x �x d H 5�ffOi,Y X191% 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 httl)s://www.sotitholdtownii.gov Date Received APPLICATION FOR BUILDING PE IT For Office Use Only PERMIT N0. 55, Building Inspector: JUN 2 $ 221 ',ii`iti4-"+A;;: rrF�'ii1p�7�i{,c+:; -- r`ta:-'. :=il1J'r ;,t'��t=',:r,!:�j• - ' - =A•� `lcations`;"and.#ofrrjs'must=be'';filled'out�in'aleir,:e'-'fi`"et" .Incom°-le'fe`:� -'�`�`���r���-1• T�,�a_pppp li�c,a�LLtio��n,,s:4'w-�•-i�I=h,:nr..o,�t;_.`b.�e:=�'.`a.-cc�eti p�tedt�;Fx1>N-=h�;��::- •:,;i_;;=;::n_r.,`Y-�.' ,.,,:''.,•p_:,}" _''P_ �� -B xJ ��!J$ rN 5 DEPT, )t:..._ �;,:!-. .CSS:: -.:::t:'.: `.: - :i F.1;Ar +°ry1-'_ S `=Y' - �•v's,'.rt:.h;ia M-'�i �: - :;�;,F�. : •9 "r.t v, -r •r•rTrsw �Owrier''s{^ onzatlon`fo'r'm' e'2 s IP `• ` p - - .1 g. ); ha 'be`com leted•`-';r'- r:�= _�,',:;_:;��._:,�� �' sr (P : .:1:• a%4 .,;; ip., 7?"Y`...,t,�P .,5� - - 461::r. 'OWNERS 'OF-. ko �u� �Y'- ,�,._ _ .�s.,:].<^5•:,'�•w..,� - - - {:?:_L��`!'a-x rFr-' --'?,•,=-rys �at ;:•�;ya^. _. -_. __ - - -__ ....�-.,:-_-�• ..K...r,.� _.4:fi:ira,��,...ya;�=.r,_.:�r3w�,5";4-=,:k`:GY.:ne�r��.: - ^:-+,!�:::'e':-=^'=';-':24 \ Name: SCTM Project Address: Phone#: L� 1j� Email: �� ,,.S Mailing Address: CONTAG•T'P.E SON' ;':'t,. ., '�';�` �`z. ��;-'; .-;:ass, :;�.', .1 R `+c;,t`t:;e. �'t__,. :�:..n• - a •,a:*:`,f'::`:i. ,p.}inr. -.v.1:}�t: - - -,f'. - - - ';J: .,,�- ✓'�;,�rw:v„.. .at3�'[�:;,.:�5�a._L:.ilei':-:::.:,cF.:afiS+c:1.:7: Name: - --� ` Mailing Address: ll Phone#: Email: - ---- — 1��� - - -- d:DESIGN I?MATION .ROFESSIONAL`u`INFO � .,.fz - - -'•�;-• �'�._ -�:,r,... �,.._ �<��: -- :,.,,:r,,. ,;,�:: ;�� .-. _,;• :.39-, .:ai_y<�J:a:,..,.; �s,-`a:8c .,�i:��,;a�;:r '•t;:x'4 r.'�v:ur.,n:,,�.>.:�..";'=... ..:,{':P,l:n. ,:.p..-� +.ti*. '�' � - - - - sit_ - - s,r' .}.;.•�:4.;::, - -t. ,y�....,. �'T_.'..r.=- ,S..,r�,��-•,,,.,. ez Name Mailing Address_ Phone#: I v _ Email: N RAT R;INFORIVIATI ON. L-u�•f.��. =sr�;,>�;r�f.; . . - .>.,. s� :.:�-,:.- ..,�:.,..,x. x�:� .,�. _ _>= L% - .:[z;i'' � �x.7. - ..Rhin`•. ?zr`,'- ;.w-. ,k�..'t{, oEYa., �� .ayn - :.,?� ._i,.- ..:z_... ,:>?:, ,s.T=.r -- ,:Y„.�.�r ui'! fx.�h?-� ''�`: ! ._•4'y? ..,1, .S.3_C '=�r3•- ..v: - - -- - - n ;r; x:�. _ tas, :;rr:::;.,:�; >:;i:�:i.:F;:x��sf= .::NJ:��L'caf1��:-�:'-,�_::�,=,k..,ht'1�7.:x-�.',,,t:,=.S?:£,'�s_;a::x::•S° Name: y Mailing Address: Phone#: I Email: C1� '^7!P...J':��zi•u?=:.r,:err., ..F::" .is 'iy^:'” '%1'.V= :C�c..r .Iz . STRUCTIO,'DCRI T10NOF�PROPOSEDCON '!'._r..t�.,.r_:.�r ,5t r ft[. -`'�`�'1-�f.i�:;;.,,. :•�.4F� �� .} �r,l•�5, -'h,, " F r� 'a.,...a::.-':'_ <.:�s.-*._� . .-:.-,oa..': ...:�:5 �•:.,_ :':.,:,_•: -_.�. .. _ - :.1��-� - '+'s4'f`i _4.,..,:. .r,'-i;:,.r' _Sa._.. rfs,.d`�,, ..1�r if[ _kt.i,r..�::t. . ..�.. .,..>!..r..__s..-r_...,..._.�k,^cA....l1s. a+,__.-_"ty_ro:,.. in..5...d..,.f,.'v_.-+.L:..��it::,n.n:.:?`:�r ::Y.... i,r•s, iaR - a.4 .k -�!'.S'.�::i... e.- n� zi4. El New Structure ❑Addition ❑Alteration El Repair []Demolition Es mated Co t of Pro' ct: heQ $ � Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes (Where the applicant is not the owner) �8 ILDING DEPARTMENT-Electrical Inspector 'It ®� TOWN OF SOUTHOLD ,•.,' 5EQ Town Hall Annex- 54375 Main Road - PO Box 1179 ,:.V Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 ^ .{ -`bgerr(asouth oldtownny.gov. 'D outholdtownnv.gov ' O APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: 9 /21 121 Company Name: Paul Burns Electrical Contractors Inc Name: Bob Burns License No.: 3897-ME email: pburnsjr@optonline.net Address: PO Box 1061 Southold,NY 11971 :r Phone No.: 631-365-4735 JOB SITE INFORMATION (All Information Required) Name:. Sutton Address: 25500 Rt 25 Orient Cross Street: Phone No.:' Bldg.Permit#: 46552 email: Tax.Map District: 1000 ., Section: Block:. Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Wire swimming pool Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp Certificate?: YES /60) Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter#, New Service- Fire Reconnect- Flood Reconnect- Service Reconnected- Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: .PAYMENT DUE WITH APPLICATION 2� tiV Request for Inspection Formals Eptk . \` lam g `BUILDING DEPARTMENT-Electrical Inspector ° . M1 2 221 TOWN OF SOUTHOLD o �,•,. 5Ee Towp Hall Annex- 54375 Main Road - PO Box 1179 ua . -g:) Southold, New York 11971=0959 Telephone (631) 765-1802 - FAX (631) 765-9502 roaerrCc-southoldtownnv..gov.�-seand -southoldtownny.gov. -APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: 9./21 X21 Company.Name: , Pau1,Burns Electrical Contractors Inc Name: Bob Burns License No::- 3897-ME email:- . pburnsjr@optonline,net- - Address: PO Box 1061 Southold,NY 11971 Phone No.:- : 631-365-4735 JOB SITE INFORMATION (All Information Required) s ' Name: Sutton t Address: 255:00 Rt 25 Orient Cross Street: Phone No.: Bldg:Permit#: 46552 email ............. _-M•.. .TaxDistrct:,,......:.1 .., ion; _ :...BRIEF DESCRIPTION OF WORK (Please Print Clearly) ._.._: - - Wire swimming pool:..:...._ ... Circle All That Apply: Vk, aaw�� Is job.ready for inspection?: YES / NO Rough In Final Do you need a Temp.Certificate?: YES Issued On;,. . .,. , Temp Information: (All information required) Service Size 1 Ph. 3 Ph Size::... ., .. A # Meters ,.OId,Meter#., Kew Service ' Fire Reconnect- Flood Reconnect- Service Reconnected- UndergGound,-Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? .':Y N Additionallnformation: 'f .PAYMENT.DUE WITH APPLICATION O Request for Inspection Form.xls \C� ���0\ PERMIT# Address: Switches Outlets G F I's Surface Sconces H H's UC Lts Fans Fridge .. HW Exhaust Oven W/D Smokes DW Mini Carbon Micro Generator. Combo Cdoktop Transfer AC AH Hood Service Amps Have S Used Special: Comments. r • UNAUTHORIZED ALTERATION Note:'ALL•SUBSURFACE STRUCTURES; TO THIS.SURVEY IS A VIOLA Area, �. �. WATER SUPPLY,;SANITARY. SYSTEMS, SECTION 7209 OF THE NEW DRAINAGE,.DRYWELLS AND UTILITIES,' EDUCATION LAW. /� �} SHOWN ARE'FROM FIELD OBSERVATIONS 40,314 sq.l cc ME 09e W='011 AND OR DATA OBTAINED FROM.OTHERS. COPIES OF THIS SURVEY MI THE.LAND.SURVEYOR'S INNE SHALL NOT 0.93 acres 1>�d 21\ 10 ATHE ETENCE OFND/OR EASEMENTSROF ECORDIF TO BEA VAUDIGHTS OF WY EMBOSSED LTRUE COPY. ANY,NOT SHOWN ARE NOT GUARANTEED. GUARANTEES INDICATED HER ONLY TO THE PERSON FOR IS PREPARED, AND'ON 'HIS _ Promises known as: TITLE COMPANY, GOVERNMED LENDING INSTITUTION USTgp 1 25500 Main Rood. Orient TO THE ASSIGNEES OF THE' +TUTION. GUARANTEES ARE N 4 ' PSN ��•• �. tONID g _ ��ap�A►i � u vP F . d� 4R � •+'yQ, i 0 �. � e► IMS �� oP. 116 Lie oa NP 107 Ee0" 'Po arRL y OF ed to: nder L. Sutton M. Sutton fy;National Tifle Insurance Services, LLC Survey of Property situate at Orient Town of Southold LAND SURVEYING - Suffolk County, New Yoi Mlnbovtlle�aol:com `� 'Tax Map #1000-18-06-10 SUBDIVISION S S. � { nT1F a MORTGAGE SURVEYS ` 0 Scale 1"=--W March 10, TOPOGRAPHIC SURVEYS LAND PLANNERS + GRAPHIC SCALE SITE PLANS 30 0 15 30 to OHN MINTO, k8. PHONF1 (631) 724-4e32 'D •LAND SURVEYOR FAX.-'(631) 724-3475, YOIC1 RATE UG HM 45a60 (.IN FEET ) (PPM,,N 9DULSVARD skj Tw prm N.Y.. 11787 I Inch o 30 IL Labor,Licensing&Consumer Affai n v1 HOME IMPROVEMENT LICEN4 r Name 'EE RANDY T RODECKER • i ��u:c; 'Business Name This certifies that the FENCE KING OF ROCKY POINT INC DB, bearer is dufy licensed by the County of suffolk License Number:H-21412 Rosalie Drago Issued: 06/01/1992 Commissioner Expires: 06/01/2022 1 e J r YYORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-744-8100 Fence King of Rocky Point,Inc. DBA:Swim Kings Pools&Patios 1 c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Rocky Point NY 11778 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11-3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest Indemnity Insurance Co. Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 53095 Rt.25 SW5WC00205-201 PO Box 1179 Southold,NY 11971 3c.Policy effective period 11/5/2020 to 11/05/2021 i 3d.The Proprietor,Partners or Executive Officers are X❑ included.(Only check box if all partners/officers included) E] all excluded or certain partners/officers excluded. i This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)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 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 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 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 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 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 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 on this form. Approved by: Philip Colletta (Print name of of authorized representative or licensed agent of insurance carrier) Approved by: a. ' (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 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(9-17) www.wcb.ny.gov 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 NEW. Workers' � YORK rs eomper►sation CERTIFICATE OF INSURANCE COVERAGE Board 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 only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS &PATIOS 471 ROUTE 25A ROCKY POINT,NY 11778 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number � certain locations in New York State,i.e.,wrap-up Policy 113008276 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 Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL37154 3c.Policy effective period 02/01/2020 to 01/31/2022 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 and Paid Family Leave Benefits Law. B.Only the following class or classes 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 Family Leave Benefits insurance coverage as described above. Date Signed 1/27/2021 B Y (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 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, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (Only if Box 4C or 56 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 with respect 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. OB-120.1 (10-17) IIIIIIPiiiiiiuiiiiiiiiiiiiiiii(iiuiiiiiiiiii)iilllllll P06LJ ELECTRICAL INSPECTION REQUIRED NOTES O 1. NO501LSURCHARGEPERMITTEDWITHIN4FEETOFEXCAVATIONATTHESHALLOWEND,OR6FEETOFEXCAVATIONATTHEDEEPEND. Q 10" 10"36' a, 2. THIS POOL MEETS THE AMERICAN NATIONAL STANDARD FOP, _ty 4, POOLS"AND 1996 BOCA CODE-SECTION 421.DIVING EQUIPMENTIS NOTALLOWED. ��YYJJ PP �VEDAS NO ED 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTI NVOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED IAW REQUIREMENTS OF O -'�• o SECTION R326.4.2.1THROUGHR326.4.2.6OFTHE NEW YORK STATE RESIDENTIALCODE(2020)AND IN CONFORMITY WITH ALL SECTIONS z'x 'BENCH OF THE SOUTHOLD TOWN CODE.DWELLING WALL(5)MAY SERV_AS PARTOF THE POOL BARRIERA5 PER SECTION R326.4.2.8AND O /) a CONDITION(1)ARE MET.OPERABLE WINDOWS IN THE WALL(5)USED ASA BARRIER SHALL HAVE SELF LATCHING DEVICE.ACCESS GATE5 LZ. } DATE:' B.P.# o`/ SHALL COMPLY WITH SECTION R326.5.2OFTHE NY5RESIDENTIAL CODE(2020)AND BE SELF CLOSING,5ELF LATCHING AND BE SECURELY LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED,ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. v a FEE: BY: 4. DURING CON5TRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIERAROUND THE EXCAVATION IAW THECODE OFTHE Z 52NOTIFY BUILDING ?ARTMENT AT A TOWNOFSOVTHOLD. x ry H2O H2O w.O 765-180 8:AM TO �P11� FOR THE 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATERAND SOUNDING AN 30 AUDIBLE ALARM UPON DETECTION THAT 15 AUDIBLE ATPOOLSIDEAND INSIDE THE DWELLING. THE ALARM MUST BE INSTALLED, K-T OLLO ING`INSPECI IONS: MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS.THE ALARM MUST MEET ASTM F2208 u F FLOU• bATiON NT "STANDARD SPECIFICATION FOR POOLALARM5. THE DEVICE MUST OPERATE INDEPENDENT(NOTATTACHED TO OR DEPENDENT ON)OF N 0 /O REQUIRED PERSONS. CRETE FOR OUFiED CON6. POOL 5UC11ONFITTING5(EXCEPTFOP,SURFACE SKIMMER5)MUST BEPRO"PED WITH ACOVER THAT CON FORMS TOA5ME/ANSI 2. ROU H -..FFtA CON & PLUMBING A112.19.8MORA MINIMUM IB"x23'DRAIN GRATE OR A CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH ATMOSPHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN.SUCH 3. INSU TION B VACUUM RELIEF SYSTEMS SHALL CON FORM WITH A5M E A112.19.17 OR BEA GRAVITY SYSTEM APPROVE[)BY THE TOWN OF SOUTHOLD. POOL SHALL BE PROVIDED WITH A MIN IMVM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE.THE SUCTION FITTINGS SHALL BE 4. FINAL - CONSTPUCTInhI MUST PLAN SEPARATED BY A MINIMUM OF3'AND MUST BE PIPED SUCH THAT WATER 15 PRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A BEC MPLETE r!' N.T.5. VACUUM RELIEF-PROTECTED LINE TO THE PUMP COR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE 0. POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENT TO ALL CO STRUCTIOti 5�?ALL MEET THE THE 5KIMMER/5KIMMERS.A REQUIRED POOL ATMOSPHERIC VACUUM RELIEF5YSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE 8326.6.3(2020)AND IN ACCORDANCE WITH TOWN CODE. QJ REQUIRE MENTS OF THE CODES OF NEW V 12'VINYL COVERED STEPS S_. YORK S ATE. NOT RESPONSIBLE FOR 7. RE51PE ELECTRICAL SEC IONS42O THROUTHTH 6.ALL REM TICAL NFPA7M(NECEAPPR PALLY QJ RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND 'CS DESIGN R CONSTRUCTION ERRORS. `= v BE PROTECTED BYAGROUN1)FAULTCURRENTINTERRUPTER(GFC0CURRENT CARRYING ELECTRICALCON DUCTOR5EXCEPT FOP,THOSE rn PROVIDING POWER TO POOL LIGHTING AND POOL EQVIPMENTSHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5.ALL Ql METAL ENCLOSURES,FENCES OR.RAILINGS NEAR OR AD)ACENTTO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED -ti• \/ DUE TO CONTACT WITH AN ELECTRICAL CIRCUITSHALL BE EFFECTIVELY GROUNDED. m� • 2'TO 4"SAND BOTTOM•" O O cc Cn 8. WATER 50URCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608. O } Ln v CO PLY WITH ALL CODES OF 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. v to Z NEW ORK STATE & TOWN CODES SECTION A 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOLEDGE. s AS R U I R E D AND CONDITIONS O F N.T.S. 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW AN5I/AP5P/ICC-5 SECTION 6. Z ~ N WATERLINE TOP OF WALL �nl- nl n mtivtd 7BA 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. W 4' 10, 4' SOUT WIq�tAi�N#NG BOARD 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE 5VB)ECT PROPERTY. 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH<10%SILT. GROUND WATER SHALL NOT EX15T WITHIN THE EXCAVATION. IFGROUND S-O OLD GOWN TRUSTEES ^ WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY N• • C' CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR SECTION B GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL H EATERS SHALL BE PROVI PEI)WITH n• TEMPERATUREAND PRESSURE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM.A BYPASS LINE SHALL.BE IL � N.T.S. INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE 00 FOLLOWING ENERGYCON5ERVATION MEASURES: rvy RETAIN STOR WATER RUNOFF 16.1 AT LEAST ONE THERMOSTATSHALL BE PROVIDED FOR EACH HEATING SYSTEM. z PURSUANT T CHAPTER 236 2-2 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE h CHECK VALVE COPING AND WALKWAY i0" OPERATION OF TH E HEATER WITHOUT AD)USTI NG THE THERMOSTAT 5ETTI NG AN D TO ALLOW RE5TA RTI NG WITHOUT RELIGHTI NG THE w ;h�N BvoTNERs) PILOTUGHT. %-W c 9 OF THE TOWN CODE. PUMP O FROM SKIMMER GRADE 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THI5 REQUIREMENTARE OUTDOOR POOLS w H d WATER UNE DERIVING 20%OF THE ENERGY FOP,HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) z G I a 16.4 TIME CLOCKS 5HALL BE INSTALLED 50 THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET V � $ a To PISPo5AL TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION IAW APPLICABLE V E p m PRY wELL UNDISTURBED EARTH ?• / 5ANITARYCODEOFNEWYORK5TATE. M 0 ij j Ud 3500 P51 POURED CONC. .4 17. THIS DRAWING 15 FOP,5TRUCTURAL SHELL ONLY.ALL ACCESSORIES AND APPURTENANCES ARE DEFINED BYOTHERS. W N c •• X DIVERTER 3/B"REBAR 2)TVP. Imo' C F'"W p VALVE O 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOT`.AND DEBRIS. DO NOT ALLOW THE HEIGHT OF BACKFILL TO EXCEED THIE HEIGHT OF THE w a y VINYL LINER ',fie \ WATER 1 N THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN B" nA a 2"TO 4"SAN W FILTER 19. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEPOSIT AND REPLACE W/COMPACTED CLEAN BACKFILL. U �+ 'C 20. THERE IS NO MAIN DRAIN IN THI5 POOL.SUCTION FOR POOL WATER CIRCULAITON IS PROVIDED BY THE SKIMMERS ONLY.THIS MEETS \ REQUIREMENTS OF THE NYS RESIDENTIAL CODE-SECTION R326.5 FOR ENTKAPMENTPROTECTION. C ��W YOR� OCCPANCY OR / TO RETURNS 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: HO Al ELK VALVED/ VERTICAL 3/8'REBAR 9)3'O.C• (NOT SHOWN) 21.1• THE NEW YORK STATE RESIDENTIAL CODE-SEC110N 8326(2020) USE I UNLAWFI�L PLUMBING SCHEMATIC 21.2. THE N EW YOP K STATE EN ERGY CONSERVATION CONSTRUCT-ION CODE-SECTION R403.1D(2020) WITH UT CERTIFICATE 21.3. THE NEW YORK STATE SANITGAS YCOCODE(2020) +- ` n LLu 'J N.T.S. WALL SECTION 21.4• THE NEW YORK STATE SANITARY CODE. � � � V• \ n Z Q9 F' rr� qA �� 21.5. AN51/AP5P/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. Mo NE •"� +� 1 •:; N.T.S. 21.6. BOCA CODE-SECTION 421. C '" '�� ) C9 OF O CUPANCY 21.7. CODE OF THE TOWN OFSOUTHOLD. - ENCLp`OSE FOOpL.TO�.CEDE>' ti-,,,W ON,COMI-LE'1•ION 22• ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. OIIafa�I� �n �,. ��'�BEEORE"WATER'`:'": pRC,r�ss