HomeMy WebLinkAbout48529-Z O��FF�tic Town of Southold
p� oG 12/20/2022
P.O.Box 1179
CO
C.,
- 53095 Main Rd
foo fid' Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 43710 Date: 12/20/2022
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1445 Green Hill Ln,Greenport
SCTM#: 473889 Sec/Block/Lot: 33.-2-25
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
3/30/2018 pursuant to which Building Permit No. 48529 dated 11/23/2022
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 Maintain proper self-closing of both gates.
The certificate is issued to Lilikakis,Demetrius
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 42542 7/19/2018
PLUMBERS CERTIFICATION DATED K�\ 0
Au ori ed S'g tore
�o�SUFFot,��o TOWN OF SOUTHOLD
ry BUILDING DEPARTMENT
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#: 48529 Date: 11123/2022
Permission is hereby granted to:
Lilikakis, Demetrius
7911 Colonial Rd
Brooklyn, NY 11209
To: construct accessory in-ground swimming pool as applied for.
Replaces BP #42542 .
At premises located at:
1445 Green Hill Ln, Greenport
SCTM #473889
Sec/Block/Lot# 33.-2-25
Pursuant to application dated 3/30/2018 and approved by the Building Inspector.
To expire on 5/24/2024.
Fees:
PERMIT RENEWAL $150.00
Total: $150.00
Building Inspector
OL TOWN OF SOUTHOLD
BUILDING DEPARTMENT
o - TOWN CLERK'S OFFICE
oy_. 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#: 42542 Date: 4/6/2018
Permission is hereby granted to:
Lilikakis, Demetrius
7911 Colonial Rd
Brooklyn, NY 11209
To: construct accessory in-ground swimming pool as applied for.
At premises located at:
1445 Green Hill Ln., Greenport
SCTM # 473889
Sec/Block/Lot# 33.-2-25
Pursuant to application dated 3/30/2018 and approved by the Building Inspector.
To expire on 10/6/2019.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
ector
Form.No.6
TOWN OF SOUTHOLD.
BUILDING DEPARTMENT
TOWN BALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings;property lines,streets, and unusual natural or
topographic features.
2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. .
5. Commercial building, industrial building,multiple residences and similar buildings and installations,a certificate
of Code Compliance from architect or engineer responsible for the building.
6: Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9, 1957)non-conforming uses,or buildings and"pre-existing"land uses:
1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic
features-.
2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is
denied, the Building Inspector shall state the reasons therefor in writing to the applicant_
C. 'Fees
1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling $50.00,
Swimming pool$50.00, Accessory building $50.00, Additions.to accessory building$50.00, Businesses $50.00.
2. Certificate of Occupancy on Pre-.existing Building- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential$1.5.00, Commercial$15.00
Date. 3 2Q—1 V
New Construction: Old or Pre-existing Building: ' V_/ (check one)
Location of Property: �'l"7j���— &A AI.
House No. Street Hamlet
!Owner or Owners of Property: 61 e J f I U S LL 1 U S
Suffolk County Tax Map No 1000, Section J3 Block 01 Lot
Subdivision Filed Map. Sa34 Lot: 132
Permit No. L5 2Date of Permit. Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted: $ V
r
Ap ure
SO(/lyolo
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 �Q roger.richert(D-town.southoId.ny.us
Southold,NY 11971-0959 Q
couffm
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Lllikakis
address: 1445 Green Hill Lane city,Greenport st: New York zip: 11944
Building Permit#: 42542 Section: 33 Block: 2 Lot: 25
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Standard Electric License No: 43098-ME
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service Only
Commerical Outdoor X 1st Floor Pool
New Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks
Disconnect Switches 1 Twist-Lock Exit Fixtures TVSS
Other Equipment: Inground Swimming Pool to Include: Bonding, Control Panel, 2- GFCI Circuit Breaker
Salt Generator, Heat Pump, 2- Low Voltage Pool Lights.
Notes:
Inspector Signature: G, Date: July 19, 2018
0-Cert Electrical Compliance Form.)ls
SOUTyO�
* TOWN OF SOUTHOLD BUILDING DEPT.
courm��' 765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG. '1
[ ] FOUNDATION 2ND [ ] INSULATION Z T
[ ] FRAMING /STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
Q,
DATE ` INSPECTOR
� yq
oF SOUTyo<o
f * TOWN OF SOUTHOLD BUILDING DEPT.
courm, 631-765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ ] I SULATION/CAULKING
[ ] FRAMING /STRAPPING [ FINAL-�ov Q
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O [ ]' RENTAL
REMARKS:
DATE INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS
FOUNDATION (1ST)
---------------------------------
'FOUNDATION (2ND)
1"
ROUGH FRAMING& y
PLUMBING
INSULATION PER.N.Y-. y
STATE ENERGY CODE
FINAL
ADDITIO COMMENTS
A 05 �o
g,614t z
22 ZZ r e c 10-514L, z
I
S� .. •�V�GvJ'ct�
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TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT `7°' -
Do you have,or need the following,Before applying?
TON_HALL.. Board , Health
'''-SOUTHOLD,NY 11971
3 sets of Building Plans
`:TEL: 765-1802 Survey
PERMIT NO. Check
�(� n Septic Form
D ��`�t�`.-�LE�� N.Y.S.D.E.C.
Trustees
Examined ,20 Contact:
Approved '.20
w
Disapproved a/c MAA 3 0 2018,- laqq-cl
PP S iP✓a- .C-&
Phone: (J 31 —744'Q -I t g S—
.e)(p a-s, I bI46,L1q TOWN OF SOUTH (f M14cl re+)
Building In
APPLICATION,FOR:BUILDING;PERMIT
Date 20
INSTRUCTIONS
a.This application MUST be completely filled in by typewriter or in ink and-submitted to the Building Inspector with 3
sets of plans,accurate plot plan to scale-.'Fee according to'schedule.
b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises orpublic streets or
areas,and waterways.
c.The work covered by this application may not be commenced before issuance of Building Permit.
d.Upon approval-of this application,lhe Building Inspector will issue a Building Permit to the applicant. Such a permit
shall be kept on the premises available for inspection throughout the work.
e.No building shall-be.occupied or used in whole or in part for any'-pur'po'se wliat-so-ever until a Certificate of Occupancy
is issued by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance ofthe,Town oMouthold; Suffolk=County;-New,York,and other applicable Lawa,Ordinances or
Regulations,for the construction of buildings, additions,or alterations or for removal or demolition as herein described.The
applicant agrees to comply w,#4,.a11 applicable laws,ordinances;;building code,housing code, regulations, and'=to admit
authotized-iinspectors on premises,anddn building for necessary;inspections.
(Signature of applic :name;Ta corporation)
e
(Mailing address of applicant
State whether applicant is owner,lessee, agent,.architect, engineer,rgeneral.contractor, electrician,.plumber,or.builder
Name of owner of premises �2(ylQ��'IUS I 1�A-I�l S
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No. - CT Z
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
House Number Street Hamlet
County Tax Map No. 1000 Section 33 Block Lot
Subdivision Filed Map No. SQ 3y
(Name)
2. State existing use and occupancy ofpremises and intended use and o cupancy of proposed-construction:
a. Existing use and occupancy S,
b. Intended use and occupancy
3. Nature of work(check which applicable):New Building Addition Alteration
Repair Removal Demolition Other Work_010 00�eo Jeno o Oily('.` `' (Description)
4. Estimated Cost U =f ee + (61
(to A) 'd on filing this application)
5. If dwelling, number of dwelling units uml?,er:ofidweling umt each floor
If garage, number of cars
6. If business, commercial or mixed occupancy, speci j.�a e aiid� x erit.o e ch type of use.
byKa fSi" i�ear�,
7. Dimensions of existing structures, if any: Front Rear. (D O Depth 25
Height Number of Stories ) a
Dimensions of same structure with*,=alterations-or.additions: Front Rear
Depth (( Height Number of Stories
8. Dimensions of entire new construction: Front _MJ Rear J43 Depth 3'/z.`7
Height Number of Stories
' 1 �
9. Size of lot: Front 160 Rear. Depth 230
10. Date of Purchase Name of-Former Owner
11. Zone or use district in which premises are situated,
12. Does proposed construction violate any zoning law, ordinance or regulation: No
13. Will lot beye-..graded w, (11, Will excess fill be removed from premises: F)
YES NO
1li
�Yt1�{YIUS ItfS�r�en iTl.n/ ]�6 -���-J(O'7�j
14. Names of Owner of premises Z i I k►cA-u •s Address �-een wt Phone No.
Name of Ak 't-'1 :)Ha s b Rel liu Address 4 4e,),j 5 Phond No '724-5740
Name of Contractor_Ac}uc- 'LP(*4wo s Address 41 (Lt 2: -Ak Phone No. (031-7W-701
Ptcll,u- R010-
15.
0,015. Is this property within 100-feet of a tidal=wetland? *YES NO
o IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE QUIRED
16. Provide survey,to scale,with accurate foundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet:or below,must provide topographicaldata on survey.
STATE OF NEW YORK)
SS:
COUNTY OF
/tltt-`� ��r✓�CS being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the e36�40L-
(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 knowledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.
Sworn to b fore me this
_day of 1 I l/stfn 201
.fl
otary Public §Wfiature o licant
MARGARET A. KIDNEY
p Notary Public-State of New York
No. 0l K16021 1 1 1
Qualified in Suffolk County
My Commission Expires March 8,20-N
Southold Town Building Department
boy Qg�FFOLq 04 P.O.Box 1179V. Permit#: 42542
53095 Main Rd
Southold,New York 11971 Permit Date: 4/6/2018
#ao (631)765-1802 Expiration Date: 10/6/2019
Parcel ID: 33.-2-25
BUILDING PERMIT RENEWAL LETTER
Dated: 7/30/2021
Applicant: Lilikakis,Demetrius
Location: 1445 Green Hill Ln., Greenport
Work Description: IN GROUND POOL
construct accessory in-ground swimming pool as applied for.
A FEE OF $150.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT.
Owner: Lilikakis,Demetrius
Address: 7911 Colonial Rd
Brooklyn,NY 11209
The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please
submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building
Department,P.O. Box 1179, Southold,New York 11971
THANK YOU,
SOUTHOLD TOWN BUILDING DEPT.
Town Hall Annex J Telephone(631)765-1802
54375 Main Road
roger.richertla' towli.) li015.nv.us
N� 4
P.O..Box 1179 4�;. O
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY: Date:
Company Name: iC
Name: 4I 0. o 91- o
License No.: dqg_
Address- �5� l O� lC ePY ti W1
Phone No.: 5I - 4 J 9.735
JOBSITE INFORMATION: (*Indicates. required information)
*Name:.. hp r-nAr I VS 1 ICA 6,S
*Address: 1445- Af;eea N 1 I U
*Cross Street: �� 1,\r
*Phone No.:
Permit No.:
Tax Map District: 1000 Section: 3 Block: Q Lot: '25-
BRIEF
2SBRIEF DESCRIPTION OF WORK(Please Print Clearly)
_Pw C
(Please Circle All That Apply)
*Is job ready for inspection:
YES / NO Rough In Final
*Do you need a Temp Certificate: YES / NO
Temp Information (If needed) -
*Service Size: 1 Phase. 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH-APPLICATION
82-Bequest for Inspection FormI
Scott A. Fussell
SUPERVISOR
z IM[A
SOUTHOLD TOWN HALL-P.O.Box 1179 \NG]EM1EN
7
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT)
DOES TMS PROJECT EWOLVE ANY OF TM FOLLOWING:
Yes No (CHECK ALL THAT APPLY)
❑(� A. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
❑[,� B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑ C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑(,� D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
❑ E. Site preparation within the one-hundred-year f loodplain as depicted
on FIRM Map of any watercourse.
❑ F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project.
If youanswered YES to one or more of the above,please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
APPLICANT: (Property Owner,Desig rofessional,Agent,Contractor,Other) S.C.T.M. #: 1000. Date:
District
NAME: L°YY1� IU Z` IS 33 a �S 2q1)S
Section Block Lot
FOR BUILDING DEPARTMENT USE ONLY****
Contact Information
RNep6one Numbvl
Reviewed By:
Property Address/Location of Construction Work: _ _ _ _ _ Dates_
it 4, _ C&A I L f „ i Approved foMina—gement
rcessing Building Permit.
�Iv Stormwater Control Plan Not Required.
Stormwater Management Control Plan is Required
(Forward to Engineering Department for Review.)
FORM SMCP-TOS MAY 2014
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SUFFOLK COUNTY DEPT OF LABOR,
LICENSING6 CONSUMER AFFAIRS
MASTER
ELECTRICIAN
CALOGERO G BRUTTO
This certifies that the
bearer Is duly STANDARD ELECTRIC CORPORATION
licensed by the
County of Suffolk ""'�"�1°" °'"' "
43098-ME 0711 gr"7
ocw.n.rmr ¢Ynunwwn' 07/01/2019
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'+1KWo�rkersf
C pe ,fin CERTIFICATE OF INSURANCE COVERAGE ,
a UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. To be completed by Disability Benefits.Carrier or Licensed Insurance Agent of that Carrier
1 a. Legal Name and Address of Insured•(use Street address 1b. Business Telephone"Number of Insured
only) (631) 744-4455
Arthur J Edwards Mason Contracting Company
Inc 1c. NYS Unemployment Insurance Employer Registration
929 Route 25A Number of Insured
Miller Place, NY 11764-2700 24-10871
1d. Federal Employer Identification Number of Insured or
Work Location of Insured (Only requited if coverage is specifically. Social Security Number
limited to certain loca'tlons in New York State,Le.,'a Wrap-Up Policy) 11-2377925
2. Name and Address of the Entity Requesting,Proof of 3a. Name of Insurance Carrier-
Coverage (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America
Town of Southold
P.O. Box 728 .3b."Policy Number of entity listed in box 1 a":
Southold, NY 1197100984424-0000
3c. Policy effective period:
07/01/2017 to 07/01/2018
4. Policy Covers:
a. ® All of the employer's employees eligible under the New York Disability Benefits Law
b. ❑ Only the following class or classes of the employer's employees:
Under penalty of perjury, [certify that I am an authorized representative or licensed agent"of the insurance carrier
referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above.
Date Signed:07/07/2017 By: Stuart J.Shaw, FSA,MAAA
(Signature of insurance carriers authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number: 1-888-278-4542 Title:. Vice President,Group Insurance
IMPORTANT: If Box"4a"is checked,and this form is signed.by the insurance,carrier's authorized representative orNYS Licensed
Insurance Agent of that carrier,this certificate is COMPLETE.Mail it-,directly to the certificate holder.
If Box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability
Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328
State Street,Schenectady,NY 12305
PART 2. To be completed by NYS Workers'Compensation Board(Only if box"4b"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 Benefits Law with respect to all of his/her employees.
Date Signed: By:
(Signature of NYS Workers'Compensation Board Employee)
Telephone Number: Title:
Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed
insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT
ARTHU=1.
DATE.(MM/DDIYYYY)
CER IfFIC/�tT�E Qr ;,LIABI_ ," I: IS.URA 10E
.,•..,+,s..,.vo..:ny:;a�,.,--:•..:•, ~.�4..-y,-.. :..,.^.w.•.,.......•.,,wsn:r�.•H•s'-.:,•.r.-..-.. .'. : s
THIS CERTIFICATE IS'ISSUED'AS,A,Mi4TTER30E%I`EOR(tgAT10N� IVI Y?AIIID i ONFEFt:Sr. O t;1GH., UPO TH GEFtiIEJCATEs HOLDE 2:rTH13
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CERTIFICATE,DOES:NOT"AFFIRNIATIVELI(:.:Oit:IVEGA'ItY�ll'�1f1Vl NQ; EJ(7END°40j ttiTER'�t7HtcCOVER11Gl5AF.FOREI) BY,¢1HEnPOIICIES
BEL"OW.:,THI3;CERTIF,KATE`QF'INSURANCE',DOESz NOT'CONSi11TUTE:'A'.:CONTRACTETY1iteEN�TtfiE�IS_SUINO INSURER($j;.°AUTHORIZED-.
REPRESENTATIVE OR PRODt10ER AND vi}�ER7IFICA'tE�t�OLa0ER3 s' - = - t;4Y:L...;. t
IMPORTANT;If the Ce y., s >�x.r,.:: :�
rtlticate Fioltler'is`an ADDIT10�li4t 1�15URR'E ytf�iespolicy{le ?�rjiust ha�!e.ADD177 t�AL:IKSIJRED` rovislon-S,6i+tie e�iorse�d.•
s'• > '?'..F'7''a%,N'N.�...�'y' �,�..� ,,<.,. y r.: ., .,ctic:=•..,. . . p,...
IUSUBROW610N IS.WAIVED;,subject.to,the terms*and co�dl Ions of.th"ploolic ;�;cer a(ii-Dollales iria .requlre:an>,endors®ment "A�statement•on
this certiflc"ate does nait•corifer:rI tits to:the cerftticaC®fi )deillieu ofstiehl�h7dbrseme�f s `k :: _ K_', ,: :'
PRODUCER B3IS4=111.1 r` ;" ,'` ;`'x= BaattBAssuCla �I"ncz; '
Bagatta_Assocla a
t s�Inc.
823:W'Jerlcha.*1dhipike:Ste 1A ', (AlG o E -z63' 015A F�.X1;631'=864=8274.;
Smithtown,NY=11787 ,_ gg,3 ;�:- ry;- ;_ .
Bagatta Associates,Inc. .,.,,,..,,•• ... ;
MsiiReii s' F D G c
Cna<insurafi%ceGotnpany' 20443
INSURED Arthur:J Edwards;Mason
Contracting:Company Inc. INsuRERB::.,
929 Route 25A 'irisuiieiTc . .
Mlller'Plac®,NY 11764 1INSUR-ik6:
:RISURER'E
:MSURERF�: '
COVERAGES. CERT) IC :E:-NUMB `. REVIS O' • UM ER:.
THIS IS.TO CERTIFY THAT.THE POLICIES_OF;INSCi 'ANCE'i'L' TED:-BELQW;tfAVE-BEEN�ISSUED:TO THE�INSURED,•NAMED�A80VE^FOR•THE;POLIGY•,*P.ERIOD'
INDICATED. NOTWITHSTANDING'ANY:REQUIREME NT,TERM;Olt`;C;ONDITION OF ANY,CONTRACT:OR':OTHER-.DOCUMENT.WCfH'RESPECT TO,WHICH THIS ;
CERTIFICATE''MAY BE ISSUED OR'MAY PERTAIN aTHE INSURA'NctYAPO.FKDED�BY kH POLICIES'DESCRIBED'HElt8lN:IS-SUBJECT TO-ALL.THE TERMS,--
EXCLUSION&AND.CONDITIONS OF SUCH POLICIES LIMIT$SHOWN;MAY.HAVE BEENIREDUCED:BY P.AIbCLAIMS:
MS TYPE OF INSURANCE PDUCY,NUTdBER., 'POLICY EFF': POL'ICY.EXP.z i, LIMITS.
A - X COMMERCIAL GENERAL LIABILITY
'EACH OCCURRENCE $ 1000;000
:PREMISES(Ea occurrence)
CLAIMS-MADE 0 OCCUR 6043396248.' D1'/O1I2018 :01/O1Y2Ipt9>tDAMAGETO RENTED. $. ' 100;00;0
- E o rson
X BLANKET AD'DITIONA ' . 1000'000'
PERSONAL.& ADV,INJURY $ -.. :.! .r
GEN'L AGGREGATE LIMIT APPLIES PER: DENRAL AGGREGATE'
POLICY.�:JEC7 ❑LOC 2;00.0',000
ER
AUTOMOBILE LIABILITY COeBIINEDSINGL'ELIMITen
$
ANY AUTO E` ''NJURY R arson .
OWNED. SCHEDULED
AUTOS ONLY AUUT�OpSyy�t p BODILY'INJURY Penaccident $
AUTOS ONLY AUTOS ONLY. ePER��a.AMAGE $
•UMBRELLA LIAR OCCUR = EACH:OCCURRENCE $
EXCESS'LIAS CLAIMS-MADE 7 AGGREGATE $
DED.',; 'RETENTION$
WOq�ERg�pMPE�gAJO ;P OTH.
AND EMPLOYERS'-L'IABILITY ER
YIN
ANY PROPRIETORIP.ARTNERIEXECUTIVE 11.EACH ACCIDENT- $ '
FIC EXCLUDED? N)Lj
Janda cry n' t .E.L.-DISEASE.-EA'EMPLOYEE $
If yes,describe under '
DES I O 0 PERATIONS belowE:L. ' $E CY L T
z
DESCRIPTION OF OPERATIONS)LOCATIONS'I VEHICLES.(ACORD 101,Addltlonal Rem®ilii Schedule,maybe d ht hed F mon space's required' ;*
0000600 >.. ...::
SMOUI DL�ifdY;GP:THE ABOVL;OESC9fBED P•,OOCIES BE CANCELLED 8EF0RE
i1iEE7tPiRttON':01�TE„x`�HEREOF+;+N071'CE:..VIIILL BE DELIVERED''IN `
ACCORDANC�WITH Tlil'POL'ICY'PROVISIONS: ' .
Town:of Southold
TownsHail :
P'O:'Box 728 'nunaol3»�p`kEi�s�A.i, ' •` ,
Southold,W 11971
ACORD 25'(20113/03) RD CORPORATION. All"rigtits reserved.
'fir.. •� _ ,•:��.x. ;:: ,1:�.• ra- .., ..r•
The AC ORD Name anthlogb'are:'r'.egisterddt"ma�ks;of AORD:'
® New York State Insurance Fund
Workers'Compensation&Disability Benefits Specialists Since 1914
199 CHURCH STREET,NEW YORK,N.Y.10007-1100
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
%0P .nnAnnn 112377925
LEVITT-FUIRST ASSOCIATES LTD
520 WHITE PLAINS ROAD,2ND FL
TARRYTOWN NY 10591
SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD
CONTRACTING COMPANY INC P.O.BOX 728
929 RTE 25A. SOUTHOLD NY 41971
MILLER PLACE NY 11764
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
G2438 491-9 328250 03/02/2018 TO 06/29/2018 3/8/2018
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2438 491-9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTP8://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.
NEW YORK STATE INSURANCE FUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:767045530
U-26.3
s -i
APPR VED AS.NpTED
DATE: g p: 5 ELECTRICAL
FEE:- INSPECTION REQUIRED
BY-
-'NOTIFY..BtJRbING DEPARTME _ 'AT
768-t802 - 8 AM TO 4 PM: FOR THE,
FOLLOWING-.INSPECTIONS; ..
1. FOUNDATI.N TWO REQUIRED
FOR .POURED:CONCRETE
2. ROUGH FRAMING & PLUMBING. � l�� `' " ' '
3. INSULATION ENrCLOSE POOL O :,ObL
4. FINAL - CONSTRUCTION MUST UPON,COMPLETION
BE COMPLETE FOR C.O. 6EFORE"WATER"
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
-I$ 8 T6WN Pb fdhfl BOARD
��6EE�� iS�EES
ISS-BEE-
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICA
OF OCCUPANCY
RETAIN STORM WATER RUNOFF
PURSUANT TO CHAPTER 236
OF THE TOWN CODE.
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