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HomeMy WebLinkAbout46934-Z �O�S�FFOIX oy Town of Southold 1/12/2023 a P.O.Box 1179 o _ r 53095 Main Rd 6 Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43755 Date: 1/12/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1320 Willow Dr.,East Marion SCTM#: 473889 See/Block/Lot: 22.-5-17 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/27/2021 pursuant to which Building Permit No. 46934 dated 10/7/2021 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 Manolangas,George&Elizabeth of the aforesaid building. ' SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46934 12/10/2023 PLUMBERS CERTIFICATION DATED A t ri ed Signature SOUR/( TOWN OF SOUTHOLD BUILDING DEPARTMENT y TOWN CLERK'S OFFICE "oy • o�g 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#: 46934 Date: 10/7/2021 Permission is hereby granted to: Manolangas, George 147-71 6th Ave Whitestone, NY 11357 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1320 Willow Dr., East Marion SCTM # 473889 Sec/Block/Lot# 22.-5-17 Pursuant to application dated 9/27/2021 and approved by the Building Inspector. To expire on 4/8/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buirding Inspector pF SO(/r�ol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.deviinP-town.southold.ny.us Southold,NY 11971-0959 COMM BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: George Manolangas Address: 1320 Willow Dr city:East Marion st: NY zip: 11939 Building Permit* 46934 Section: 22 Block: 5 Lot: 17 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Owner License No: SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 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 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 Transfer Switch UC Lights Dryer Recpt Emergency StrobeHeat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Intermatic Pool Panel 8 Circuit/6 Used, Timeclock 2, Heater 220 GFI, Pump 220 GF Salt Generator, Hayward Deckbox Tranny 120GFI, Water Bond Notes: POOL Inspector Signature: Date: May 23, 2022 S.Devlin-Cert Electrical Compliance Form 50UTyp� # # TOWN OF SOUTHOLD BU LDING DEPT. �yco 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (FINAL) ] CODE VIOLATION ] PRE C/O [ ] RENTAL REMARKS: At - N e, r l AIA-'� ti-.191CIT2,01 C DATE 12 INSPECTOR ho�aq SOUIy�� # # TOWN OF SOUTHOLD BUILDING DEPT. ,M1,O • i0 765-1802 INSPECTION . . [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ]- FOUNDATION-2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [vie-FINAL [ ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ '] FIRERESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: P ell DATE INSPECTOR l l� �o�aOF SOUTyolo - - ` # * TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] ULATIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL 7 [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O ( ] RENTAL REMARKS: 0 04�1� C ad i ?S� � (p6lq e DATE INSPECTOR Pontino, Susan From: GEORGE Manolangas <RHODESNYC@outlook.com> Sent: Tuesday,January 3, 2023 9:58 PM To: Pontino, Susan Subject: 1320 willow drive pool inspection/George manolnagas Hi Susan Below is the description of the pool alarm that was inspected and is in question. it's from the manufacture "briidea" official-website. It states the gate alarm system meets the UL 2017 standards for child pool safety. 1 3: 17 ad ii briidea.com Description IDEAL FOR POOL SAFETY: Meets UL 2017 standari for Child Pool Safety Law. The Driidea peel alarm prevents children from entering the pool area unsupervised . The alarm goes off immediately wh triggered , and continues to sound even the door is closed, which keeps children away from your pool the wire is cut or damaged, the anti-tamper mechanism can also trigger the siren . EXTREMELY LOUD: 120 DD alarm, super loud enOL to be heard up to 750ft120m . Alert you of 3 Thank you George You're email came up when I started typing it in so we must have emailed before... Anyway please send me the info on the alarms so I can check with John when he gets back next week. Thank you! Sl tsaVL 7>0wt%w0 Sew%or Dffia Assistawt susanp@southoldtownny.gov Southold Town Building Department PO Box 1 179 Southold NY 11971 631-765-1802 Sent from my Phone ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 4 Pontino, Susan From: GEORGE Manolangas <RHODESNYC@outlook.com> Sent: Tuesday,January 3, 2023 10:29 PM To: Pontino, Susan Subject: 1320 willow drive George Manolangas Hi Susan In addition to the last email, I would also like to submit the description from Amazon. From which the alarm was purchase and it also states in the description that it is UL 2017 pool safety compliant. Thank you again 1 Q Search Amazon Briidea Gate Alarm System PASS TEST PASS RESE 1 RESET ' 1 I ' I � , i , 3 C, Search Amazon r -1 uj Brand Back to Top Power Source a ery owered Noise Level 120 dB About this item • IDEAL FOR POOL SAFETY: Meets UL 2017 Stan for Child Pool Safety Law. The Briidea pool alarm prevents children from entering the pool area unsupervised. The alarm goes off immediately wh triggered, and continues to sound even the door i; closed, which keeps children away from your poo the wire is cut or damaged, the anti-tamper mech; can also trigger the siren . • EXTREMELY LOUD: 120 DB alarm, super loud ei Sent from my Whone ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 6 FIELD INSPECTION REPORT 'DATE COMMENTS FOUNDATION(IST) H . ------------------------------- FOUNDATION(2ND) �1 C ROUGH FRAMING& t� PLUMBINGCD y CD INSULATION.PER N.Y. H. STATE ENERGY CODE 1 1 FINAL tee- l "G to vii .t0 � ARM LIONAL COMMENTS Gam. e� . 000 Qb 0 .. Q�j ►d 0 0 W yW H FOL't TOWN OF SOUTHOLD=BUILDINGDEPARTMENT w Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,'NY 1197:1-0959 Telephone(631)765=1802..Fax.(631) 765-9502 hgps:%/www.s6uth6ldto.MM'.gov. Date Received APPLICATION, FOR BUILDING PERMIT. . or;Office Use Only D .� PERMIT NO. Building Inspector. SEP .2 7 2021. BUILDING DEPT. :Applications and forms must.be,filI' out in their enfirety Incomplete' ::';; TOWN OFSOUTHOLD applicatioris will not bd-accepted.,,Where;the Applicant is not th'e owner:"ari °Owner's Authorization form-(Page`2)shall be.complete Datd, Iw t TYi'`- 01NNER S,OF PRO R - - Name: �SCTM# 1000- e� e: (Yl�nol ,� l3- . 1� Ilor► . - Project.Address. Phone#: Email: h�re dv`f��7aK, n. Mailirig Addrss: -147 _ --e- - - '1.1 E - •�CON TACT P RSON� Name:,:. h/ DS _P MaillhgAddress: �r :Z�'A .. . 1 Il .. laee `:. :�.� by.:. Phone.#: :b31=7L/(-/=7lg ee Ae c s,0jM Email � - - DESIGN PROFESSIONAL INFORMATION:,'` Name: Mailing Address: Phone#: :CONTRACTORINFORMATION" _'- Name: -- Mailing Address: q2 �t-Z�'/� r JI II ef_: PY Email: Phone#: ?I�� wiet Aepx , , DESCRIPTION OF'PROPOSED'CONSTRUCTIOW :_. ❑New Structure ❑Addition ❑Alteration _111 pair ❑Demolition_ Estimated Cost of Project: Other 13" 1 L $ 2U,0Go- - - _ 77 Will the lot be re=graded? IXYes El No Will excess fill be removed from premises? Oves El No, PoOcArew1 1 PROPERTYINFO.RMATION'' Existing use of.property: Intended use of property: .. _ rnm� Zone or use district.in,which premises is situated: Are there.any covenants and restrictions with respect to this property? ❑Yes INo IF YES, PROVIDE A COPY: Check.:f3.ox Atte"r Reading: The'owner/contractor/design professional•is:respondible for all drainage.and storm,water.issues as provided by; ?J. Chipter,236 of the Town Code.'APPLICATION IS HEREBY MADE to the Building Department forthe-issuance of a.Building Permit,pursuaet to the.Building Zone'.' Ordinancwof'the Town of Southold,Suffolk,County,_New York and other applicable Laws,Ordinances or Regulations;for the construction of buildings;- -alterations or for removal or demolition.as herein described:The:applicant agrees to comply with all_appliwble laws;ordinances,building code, .'-housing code and regulations and to:admit authoriied inspectors on premises and in-building(s)for necessaiy,inspections:False statements madefierein-are:.;,' .punishable as a Class A misdemeanor,pu�suent.to Section 210.45.of the New York State.Penal:Law: ( ❑Authorized Agent : Owner Application Submitted By(print me): ��a QnJ1:Qn661s g K Signature of Applicant: Date:: STATE OF NEW YORK) COUNTY OF &VML 1 � h,&171,gAS. : being duly sworn;deposes and says that(s)he is the.applicant (Name of individual signing contract)above named; :. (S)he is the.. . .(Contractor;Agent,Corporate'Officer,etc:) of said owner or owners, and is duly authorized_to.perform or have.performed the said work-and to make and 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 manrier set forth in the application file therewith. Sworn before me this : Nom` day of �`�'}2�ubee. , 20 2L _ 4ryP Nlic MARGARE�f.A. KIDNEY Notary Public-State of New York . Ifo: o I K1602i I 1-1 PROPERTY OWNER:AUTHORIZATION 0tialified in Suffolk County, `My Commissioil.Expires March 8,2093 - (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 Z S�FFpLK. BUILDING DEPARTMENT-Elect Inspector TOWN OF SOUTH D MAY 0 6 2022 cf, Town Hall Annex- 54375 Main Roa - POQ 1179 . Ef 1N - 79 r. Southold, New York 11971-09WN of SouTHOLD Telephone (631) 765-1802 - FAX (631) 765-9502 d rogerr(a-southoldtownny.gov — seand@southol_dtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail Information Required) Date: 5/5/2022 Company Name: N/A (Owner applicant) Electrician's Name: License No.: Elec. email: Elec. Phone No: ❑I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: George Manolangas Address: 1320 Willow Drive East Marion NY 11939 Cross Street: Cedar Ct& Cedar Dr Phone No.: 347-242-6659 Bldg.Permit M y61 3� POOL Permit email:Rhodesnyc@outlook.com Tax Map District: 1000 Section:22 Block: 5 Lot: 17 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool Permit in place, Scope of work will involve electrical supply to pool subpannel/pool equipment. 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 Pha3 Ph Size: A #Meters Old Meter# ❑New Service0 Fire Reconnect[]Flood ReconnectOService ReconnectQUnderground[-]Overhead # Underground Laterals 0 1 n2 M H Frame R Pole Work done on Service? 0 Y MN Additional Information: PAYMENT DUE WITH APPLICATION \�D r BUILDING DEPARTMENT-Elec thc AV AFF94- Inspector S TOWN OF SOUTH LDS Town Hall Annex- 54375 Main R ad PO. Bob 11 79 � Southold, New York 11971-0959V% -,,Psooco Telephone (631) 765-1802 - FAX (631) 765-9502 ✓ V rogerrP_southo1dtownny.qov - seandt,@-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail information Required) Date: 5/5/2022 Company Name: N/A (Owner applicant) Electrician's Name: License No.: Elec. email: Elec. Phone No: ❑I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: George Manolangas Address: 1320 Willow Drive East Marion NY 11939 Cross Street: Cedar Ct& Cedar Dr Phone No.: 347-242-6659 Bldg.Permit#: W 3'/ POOL Permit email: Rhodesnyc@outlook.com Tax Map District: 1000 Section:22 Block: 5 Lot: 17 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool Permit in place, Scope of work will involve electrical supply to pool subpannel/pool equipment. Square Footage: Circle All That Apply: F Is job ready for inspection?: 1-1 YESFV NO _]Rough In E] Final Do you need a Temp Certificate?: F❑I YES FV-]NO issued On Temp Information: (All information required) Service Size F11 PhE]3 Ph Size: A #Meters Old Meterft 0 New Service®Fire Reconnect r-1 Flood Reconnect®Service Reconnect ElUnderground ElOverhead # Underground Laterals[]1 n2 M H Frame r-1 Pole Work done on Service? DY E]N Additional Information: PAYMENT DUE WITH APPLICATION �D i `o C) 1010 PERMIT# Address: Switches �. Outlets G FI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini Special: Comments �` I SURVEYED FOR:GEORGE&ELIZABETH MAIyOLANGAS � . LOCATED AT E.-MARION,T/O$OUTHOLD;SUPR;CO:N.Y: LOT 17 . MAP OF "HIGHPOINT AT-EMAR:ION" SCALE 1"—.50" S.C.T.M:.01000-22=05-017 .. ,LC 9ataen X \ X. e. 00, •\ ,ash � '. . • ovaP ?)� o 041,, 6� hb'� a ve o AN - .. 0'Sd�-ty0 so '��6' '`�b^ •�� OS PJ�fdS,� d Y Vj J yn i • l CERTIFY•TO: amended ` "Y . AN GEORGE & ELIZABETH MANOLANGAS 4/16/2013 - ti�v� FIDELITY NATIONAL TITLE INSURANCE CO. FILE NO.48755 (#12-7405-66245SU FF) WILLIAM R-SIMMONS III,L.S:P.C. . 128 CARLETON AVE.EAST ISLIP,N.Y.11730 . .- FH. 631 581-1688 FX. 631 581-1691 DATE:•2/15l2013SCALE:1" .50' DRAWN BY:.WRS IV . ARTHUR EDWARDS POOL_ &.SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 . 516-744=7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD, TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 . PAPERS ENCLOSED: [�¢ APPLICATION FOR OUTDOOR POOL PERMIT [) CERTIFICATE OF WORKER'S COMPENSATION, CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE OF DBL INSURANCE SUFFOLK COUNTY LICENSE L� [ 4 SETS OF STAMPED:PLANS 3 SURVEYS with FILTER LOCATION [ ] C.O. TAX BILL $400:00 CHECK FOR PERMIT FEE l a DATE(MMIDDIYYYY) A�V CERTIFICATE OF LIABILITY INSURANCE 01/0512021 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 have ADDITIONAL INSURED provisions or 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 NAME: T Gene Romano Liberty Risk Management,Inc. PHONE (631)569-5633 FAX No:( 1)569-5s36 664 Blue Point Road,Suite A E-MADDRESS: gene@llbertyrisk.org Holtsville,NY 11742 INSURER(S)AFFORDING COVERAGE NAIC k INSURERA: NIP/Greenwich INSURED INSURERB: Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J.Edwards Pool&Spa Centre INSURERC: 929 Route 26A INSURER D: Miller Place,NY 11764 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000005.963374 REVISION NUMBER: 1 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. INSRTYPE OF INSURANCE ADDL SUBR POLICY NUMBER MI UUDDY EFF POLICYMIDEXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY NPC-1004300-00 0110112021 01/0112022 EACH OCCURRENCE $ 11000,000 CLAIMS-MADE OCCUR PREM ET RENTED PREMISES Fa occurrence $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ 2,000,000 POLICY®jECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Fa accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per acddent UM13REL A LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE Is DED I I RETENTION$ Is WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETORIPARTNERIEXECUnVE —1 NIA E.L EACH ACCIDENT Is OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.LDISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 728 Southold,NY 11971 AUTHORIZED REPRESENTATIVE GGR ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by GGR on January 05,2021 at 03:1213M Mi NYSIF199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State 16suran4e Fund I Oy51/.0011'1 CERTIFICATE OF WORKERS' COMPENSATION.INSURANCE A A A A A 112377925. LEVITT-FU IRST ASSOCIATES LTD 520 WHITE PLAINS.ROAD,2ND.FL TARRYTOWN NY 10591. r ■ 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.1.1971 MILLER PLACE.NY 11764 POLICY NUMBER C. RTIFICATE'NUMBER POLICY PERIOD DATE G 2438 4914 633479. 06/29/2021 TO' 06/29/2022- 06/16/2021 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 EXCEPTAS INDICATED BELOW. 1F YOU : WISH TO RECEIVE NOTIFICATIONS-.REGARDING . SAID POLICY, INCLUDING- ANY.-'NOTIFICATIOW..'OF CANCELLATIONS,. OR.TO VALIDATE,THIS CERTIFICATE, VISIT OUR WEBSITE AT .HTTPS:/IWWW.NYSIF.COM/CERT/ CERTVAL:ASP: THE NEW YORK'STATE INSURANCE FUNDIS NOT LIABLE_IN.THE .EVENT_ OF ,.FAILURE_TO:GIVE : SUCH NOTIFICATIONS. . : : . THIS =CERTIFICATE.IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR .INSURANCE. COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOESNOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE:POLICY: NEW YORK STATE INSURANCE FUND .Qp DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 391287892 11111H100 00 00000®�420931II1NJJ Foim W6CER-r-NOPRINT Version 3(08129/2019)[WC Policy-24384919) U-263 AQ - .,,,. ..,. ,....,. ..,....-... Y s' workerAse CERTIFICATE OF INSURANCE COVERAGE Compensation 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 ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE,NY 11764 Work Location of Insured(only required rf coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations In New York State,i.e.,Wrap-Up Policy) or social Security Number 11-2377925 2:Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold PO BOX 728 3b.Policy Number of Entity Listed in Box"l a" Southold, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/9/2022 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. F1 C.Paid family leave benefits only. 5. Policy covers: ❑X A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employers employees: Under penalty of perjury,I cerfify 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 desc d above. Date Signed 6/10/2021 By (Signature of Insurance carrier's authoriz d representative or NYS Licensed Insurance Agent ofthat Insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES 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 5B of Part i 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. DB-120.1 (1047) 111111'°°°11°2111111°°I�10-171°�IIII Additional Instructions for Form D13-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed. (b)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 employment as defined in this article and 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 the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (10.17)Reverse OaJ APPOWED ED AS NM3�DATE: A B.P.# FEE: U BY: NOTIFY BUILDING DEPARTM AT . ELECTRICAL. 765-1802' 8'AM TO 4 PM FOR THE FOLLOWING'INSPECTIONS: INSPECTION REQUIREC 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2'. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. ENCLOSE POOL TO CODE; `4JPONCOMPLETION `- T§'gEFbRE,"WATER" COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTHOLD TOWN ZBA s SGA4 ING BOARD SO6THG@i0Wid %STEES S.DEC OCCUPANCY"OR USE IS UNLAWFUL IVITHOUT CERTIFICI OCCI �FR'� . , RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. 3 z• . . " H H SEP �7 2 � . . 2021 BUILDING DEPT. cu TOWN OF SOUTHOLD. F . . CU CU cu SUN DECK 17: CU 28CU , cu !a 5' . . . . . . _ . . . . CU 3cu 3' D _CU _ p ft 4,. . . cu W. 40' DEEP a.. .' C . . . . c CU Ct CU T5 � 2420' lArthurldwards Pool@ .17 PAbAM Fft - From. .Rodd F7ai F :.Plan Piping Ar' - t `<;' REIL�yA�. R,*w*. �Q e-) 42" y .IX� „y? w Section .8—$. . �eoo'PS4 .r 0 \� �iS 3595 H 0" �•�F ES�No. F Section.'A-A. . . . Typical Wall. Section SIZE : A ,B. :C D. .E F' G H AREA CAP purdba a FEET 'FT FT_ FT 'FT FT FT .FT FT SQ.,FT GAL:.' 15 X 30 15 -30 11 11 S. 3 3 9 450 15,000 POOL&SPA CENTRE 16 X 36 1 16136, 12 14: 6 4'. :4' 8 576 21,600 . PERMACRETE WALL SYSTEM 18 X 36 18 36 12 14 .6. •4 '5. 8, :64824,300 929. Route' 26A'Miller Place NY. 11764. 20"X 4 20 44 20 14 6 4 5 10 880 36,300! (831) 744=7185 FAX'.(831).744=0174 DD "— Suffolk license #4438—HI " 24.x 44 1 24'1 44 18 14 :8 4 :8 10 .798 35,000 Nassau' License #HI74450000 24 X 48 1241. 8 20 16 8' .'4 6 10 900 36,500