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HomeMy WebLinkAbout46792-Z gUFFOi�-�-� �0 CpG Town of Southold 3/23/2023 a y� j P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43934 Date: 3/23/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 400 Youngs Rd., Orient SCTM#: 473889 Sec/Block/Lot: 18.-2-19 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/30/2021 pursuant to which Building Permit No. 46792 dated 9/8/2021 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 Baruh,Dogan&Karen of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46792 6/13/2022 PLUMBERS CERTIFICATION DATED Aut ize nature �SofFotKc TOWN OF SOUTHOLD ��o o BUILDING DEPARTMENT. H z TOWN CLERK'S OFFICE "o • SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 46792 Date: 9/8/2021 Permission is hereby granted to: Baruh, Dogan 233 Pacific St Apt 2A Brooklyn, NY 11201 To: Construct in-ground gunite swimming pool at existing single family dwelling as applied for. At premises located at: 400 Youngs Rd., Orient SCTM #473889 Sec/Block/Lot# 18.-2-19 Pursuant to application dated 8/30/2021 and approved by the Building Inspector. To expire on 3/1012023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector oF so�ryolo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlin(,atown.southold.ny.us Southold,NY 11971-0959 QIyCOUffN'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Dogan Baruh Address: 400 Youngs Rd city:Orient st: NY zip: 11957 Building Permit#: 46792 Section: 18 Block: 2 Lot: 19 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Yannucci Elec License No: 50592ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Surrey 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 1 Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency FixtureTime Clocks 1 Disconnect Switches 4'LED Exit Fixtures Pump 1 Other Equipment: 2 lights 120GFI, Heater, Pump 220GFI, Salt Generator Notes: Pool Inspector Signature: , Date: June 13, 2022 S.Devlin-Cert Electrical Compliance Form *pF SO!/lyO� Lf to 71 s �� �o- �_ # * TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION - FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [` ] FIREPLACE & CHIMNEY [ ] FIRE-SAFETY INSPECTION [ ] FIRE RESISTANT CONS RUCTION [ ] FIRE RESISTANT PENETRATION -j���ICAL (ROUGH) [ ELECTRICAL (FINAL) [ ] 'CODE VIOLATION ] PRE C/O REMARKS: 34 4e" DATE Z.2 INSPECTOR a0F SOUIy Lq 6 7 q 0.a J.J �o� opo Cy^G� J # # TOWN OF SOUTHOLD BUILDING DEPT. �o • �o `y^ou631-765-1802 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) 00 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL . c REMARKS.. / DATE lt771q-?-- INSPECTOR SOGTyo� - # TOWN OF SOUTHOLD BUILDING DEPT. `ycou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ FINAL pwtl� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ]' RENTAL REMARKS: DATE INSPECTOR .. . ; . ..`:..;.: . .' ;::, '�. ; ,'�;,: :... `.• '., .,`.MTS .., • . FIELD:INSP CTION REPORT 'DATEDRIM FOUNDATION (IST) -------------J- -------- - --- --� . , FOU�O ATTO N-'(2ND. ) �... ROUGH FRAIYIIN : P UMBIN.G. INSULATION TER N.Y. STATE pNFRGY CODE FINAL. .. 10 , � . . .. �� . . . ; .• �. . � ;•.•; . . �' Off. rn TOWN OF SOUTHOLD—BUILDING DEPARTMENT a� sit' Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT o For Office Use Only D . 1 PERMIT NO.. / aZ Building `\`_/�� Ins Pector: . AUG 302021 I . . Applications and forms must be filled out in their entirety:Incomplete T applications will not be.acc6 t6d. Where the Applicant is not the owner,an P�DI10G DF1�T' pp p Pp TOWN OF SOIJTllOLD Owner's Authorization form(Page 2)shall be completed. - Date: $ Q a0a OWNER(S)OF PROPERTY: Name: t� SCTM#1000- 6lb,00 - Oa•U - 1Qi 0 Project Address: `rt u® �bV YOB V1 - r Phone#: q I y-I V_qct J Email: Mailing Address: a33- 'Q Y� CONTACT PERSON: Name: 90:61 J "1 - Mailing Address: S�� Phone#: Rs 3_ Email: UVI via Ck DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: W 1.- Mailing Address: �i a�, ISvU N \ 42 Phone#: �3�: q�3- 11C��� Email: 1eS @ Ov\S CO DESCRIPTIONOF PROPOSED'CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition EstimatedCost ofProject: Other 4aL 0, kW-S-kY"% $ -7 5-400Q Will the lot be re-graded? ❑Yes V0 Will excess fill be removed from premises?>3as El No 1 PROPERTY INFORMATION ?,-apos a& , Existing use of property: Intended use of property:aNC_%1t�q y Sedrvo-"Z i 1.y C . Swwm , Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to E, -- ­0__. -1 1 - I - this property? ❑Yes<No IF YES, PROVIDE A COPY. �haCheck Box After Reading: The owner/contractor/design professional is,responsible for all drainage and storm water issues as provided by pter236 of the,Town 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, housing code and regulations and.to admit authorized inspectors on premises and in building(i)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penial Law, Application Submitted By(print name): Ori n *uthorized Agent DOwner Signature of Applicant• Date: I I C1 STATE OF NEW YORK) COUNTYOF 5J4tI4, ) I<o,+v-lr)O,. Mefcuy-I 0 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 manner set forth in the application file therewith. Sworn before me this Q , l +day of AL)gys+ 126Z Notary Public MICHELEAMEDUSKI Notary Public,State of New York PROPERTY OWNER AUTHORIZATION Reg.No.01ME6393343 Qualified in Suffolk County (Where the applicant is not the owner) Commission Expires June 17,2023 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 Building-Department Application AUTHORIZATION (Where the Applicant.is not the Owner) -1,___1GrarLF-n1 ' A2 H residing at #,ao lou►jG-S ot,- or-leN'T (Print property:owner's name) (Mailing Address) 141 I1Q dahereby authorize VA-70-10A Meg-CUe l b . (Agent) x�ari2t�1L'ScottiS to apply on my behalf to the Southold Building,Department. (Owner's Signature). (Date) (Print Owner's Name) �\ BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex - 54375 Main Road - PO Box 1179 v' '* Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 " rogerr(aD_southoldtownny.gov— seand()southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4.1.22 Company Name: Yannucci Electrical Services Inc Electrician's Name: Vincent Yannucci License No.: 50592-ME Elec. email:Vinny@yeselectricalainc.com Elec. Phone No: 631-258-7324 Com]I request an email copy of Certificate of Compliance Elec. Address.: PO Box 638 Shoreham NY 11786 JOB SITE INFORMATION (All Information Required) Name: Dogan Baruh Address: 400 Youngs Rd., Orient Cross Street: Main Road Phone No.: Bldg.Permit#: BP#46792 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): BP#46792 In-Ground Swimming Pool 1 timer, 1 pump, gas heater Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES FV_1 NO Issued On Temp Information: (All information required) Service Size❑1 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals D 1 2 H Frame M Pole Work done on Service? Y FIN Additional Information:In-Ground Swimming Pool BP#46792 PAYMENT DUE WITH APPLICATION Z CP �p 'Q 'Su FOLk - BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o =` Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 5„. rogerr@southoldtownny.gov - sea nd(aD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4.1.22 Company Name: Yannucci Electrical Services Inc Electrician's Name: Vincent Yannucci License No.: 50592-ME Elec. email:Vinny@yeselectricalainc.com Elec. Phone No: 631-258-7324 Ev]I request an email copy of Certificate of Compliance Elec. Address.: PO Box 638 Shoreham NY 11786 JOB SITE INFORMATION (All Information Required) Name: Dogan Baruh Address: 400 Youngs Rd., Orient Cross Street: Main Road Phone No.: Bldg.Permit#: BP#46792 email: Tax Map District: 1000 Section: Block: -,,Itot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): BP#46792 In-Ground Swimming Pool 1 timer, 1 pump, gas heater Square Footage: Circle All That Apply: Is job ready for inspection?: Ft/1YES ❑ NO []Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES Ft/� NO Issued On Temp Information: (All information required) Service Size❑1 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service[:]Fire Reconnect[—]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y RN Additional Information:In-Ground swimming Pool BP#46792 PAYMENT DUE WITH APPLICATION ,v PERMIT# Address: Switches Outlets G F I'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 �� YORK Workers'' CERTIFICATE OF C--"" YORK c,STATE l Compensation - NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only)�J 1b.Business Telephone Number of Insured _ 631-996-4687 Patricks Pools Inc PO Box 3024 1 c.NYS Unemployment Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured(Only required if coverage is specifically limited to id.Federal Employer Identification Number of insured or Social Security certain locations in New 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 v (Entity Being Listed as.the Certificate Holder) Wesco Insurance Co Town of.Southold 54375 Main Road 3b.Policy NuViber of Entity Listed in Box 1 a" Southold NY 11971 WWC3528513 3c.Policy effective period 05/13/2021 to 05/13/2022 3d.The Proprietor,Partners or Executive Officers'are included.(Only check box Wall 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"1 a"for workers' compensation under the New York Stare Workers'Compensation Law.(To use this form,New York(NY)must be listed tinder,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.non0ayment 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: Nicholas Zulkofske (Print name of aul dzed representative or licensed agent of insurance carrier) Approved b " ( ature) (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 it. C-105.2(9-17) www.wdb.ny.gov Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 05/10/2021 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 631 941-4113 FAX . 631 941-4405 100 Oakland Ave,Ste 1 EMAIL . certificates@_brookhavenagency.com Port Jefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURERA: 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 11942INSURER 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 NUMBER POLICY EFF POLICDY EXPLTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE �OCCUR DAMAGES( RENTED $100,000 x Contractual Liability X X PHPK2229439 02/2812021 02/28/2022 MED EXP(Any oneperson) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY 10 PRO JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea accident) $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 (Per amident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONX PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBER EXCLUDED? FY I N/A WWC3528513 05/13/2021 05/1312022 (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(2014101) The ACORD name and logo are registered marks of ACORD YORK STATE Compensation i Workers' CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disabi ity and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured Work Location Of Insured(Only required if co erage is specifically limited to or Social Security Number certain-locations in New York State,i.e.,Wrap-U, Policy) 262929943 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Maid Rd. 3b.Policy Number of Entity Listed in Box"1a" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: A.Both disability and paid family Ic ave 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 class as 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 Fal illy Leave Benefits insurance coverage as described above . Date Signed 3/1/2021 By V 1, Ude (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;Ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.kgent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B i 5 checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amity Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton, NY 13902-5200, PART 2.To be completed by the f IYS Workers'Compensation Board (Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained b I 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 licen ted to write NYS disability and paid family leave benefits insurance policies and NYS licensed Insurance agents of those insurance carriers are auth arized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) IIII IP1°LIQ[I2f0[Illllllll(l1[IIOIIIIIIIIII�I�I SURVEY OF DESCRIBED PROPERTY SITUATE AT ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY,NEW YORK AREA OF PARCEL 23,903± SQ.FT. OR 0.5.49± ACRE N/F ANN- M,gRIE 'SOI T L1 NOTES 1. MEASUREMENTS:ARE.INACCORDANCE WTT14U.S STANDARDS: PIPE N' 8,50451530 E 200.00. 2. BEARINGS SHOWN ARE IN NEW YORKSTATEPLANECOORDINATE SYSTEM"NAD83; q: LONG ISLAND ZONE . O: ^s: ' 3:. .EL'E.VA770NS REFERENCE7VAVD 1988:(GEOtD12A):. 4. UNAUTHORMEDALTERATIONORADDIJrIONTOA SURVEY MAP:BEARINGALICENSED ' o FDtUlOA710N c : LAND,SURVEYOR'S-SEAL ISA VIOLATI6NOFSECTION7209,SUBDIVIS1ON2,OFTHE_ NEW YORK.STATEEDUCATIONZAW. a N ° N b Q (� LkQ 5. ONLY COPIESFROM THE.ORIGINAL OF THIS SUR VEY MARKED.WITH AN ORIGINAL OF �. 040! i V THE LAND SURVEYOR'S''EMBOSSED'OVINKED:SEALSHALL.BECONSIDERED'TOBE �' rcErso' I iIAIJD TRUE COPIES 6: CERTIFICATIONS INDICATED HEREON SIGNIFY THAT THIS.SURVEY WAS PREPARED IN. ACCORDANCEMTH THE-WaSTING CODEOF'PRACTICE FOR LAND•SURVEYORS o• rao ti. rADOPTEDBYTHENEWYORKSTATEASSOc1AnoNOFP.ROFESSioAtALLAND_ O 1 � C SURVEYORS..SA1D'CERTIFICA77ONS:SHALL RUN ONLY TO THEPERSON FOR WHOM" } p i �; THESURVEY IS PREPARED AND ON HIS BEHALF TO THE PILE COMPANY, 3 N'Z. ' • f GOVERNMENTAL:AGENC.YAND LENDING•INSTITUTION LISTED HEREON AND.Tr'—1. ' ASSIGNIEES'OF THE LENDING INSTITUTION.:CERTIFICATIONS ARE NOT TRAM: LE, FDUNDATTDIVI, � TO'ADDITIONAL IN$T�T MONS.OR SUBSEQUFMWO4ERS. C-) a "� _ 7:. RIGHTS-OF-VlAYNOTSHOWNARE,NOTCERTIFIED: - 8,. .THES&RVE.YCLOSES'MATHEMATICALLY.: A,. v. m,57�. 'a vi "' .A0 CV) i LE(END z- - — CDNCRETE POST !. — S 89°4555'` V : 193.88' - 'i�flf NEW f M; cr: . - 1 DATE" BY DESCRI=ON JAPPROV.,.BSG REVISIONS ; cs.Qs2s , <<" Town of South-old MAIN. ROAD s�'o` .- 5� Suffolk County; New York- 400 Youngs Road I ORIENT, NEW YORK FOUNDATION A5-BU,` i SUFFOLK-COUNTY REAL.PROPERTY TAX MAP l hereby certifythat:this map Was made from an actual survey ^-= completed by.me.on 04/26,1 N'2021.. L. K: McLEAASSOCL4TES DISTRICT. 1000' COrrSULTING ENGINEERS & LAND .SURVEYORSI. j SECTION 018.00437 SO. COUNTRY ROAD, BROOKHAVEN. NEW,YORK. ��..� + BLOCK. 02.00 Q- s�yed er• PL/AR Scats !'_ .iD" 9+eet Na - LOT- .- 019.000. - --...-.. - - - - - ------ --TAMAPA_L...-STILI MAN,.P.LS . .... nx Dots o4/2>rzo2 - - --- - . ---prc.n ay. 1 8121045000 400 Youngs Rd%Siur ey Dept\B,..n9S%21045.000 Found.AS—b.,tdrg 6/29/2011 447 PH lialw Natonfen'e NYSPLS No:.50528i Approved By. TLS. Fie Na. 2104.5000 � A e OCCUPANCY OR APPROVED AS ANNOTD USE IS UNLAWFUL DATE: B.P.# WITHOUT CE�TI�I FEE: �Y: ®� CATL NOTIFY BUILDING DEPARTMENT AT OCCUPANCY 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: I. 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 COIMPLY WITH ALL COUPS OI- REQUIREMENTS OF THE CODES OF NEW NEW YO YORK STATE, NOT RESPONSIBLE FOR AS kEOUR ED AND CONDITION DES DESIGN OR CONSTRUCTION ERRORS. SOF SOUTHOLD TOWN ZBA SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES N.Y.S.DEC EN,LOSE POOL TO CODE UPON IE .COMPLETION 'gEFORERETAIN STORES WATER RUNOFF ;�y�i4TER�� PURSUANT TO CHAPTER 236 OF THE TOWN CODE, MA=CALVZrr.Cn0N REQUMO 0 A,lzq j -To-Poo v. 7'-'T. 17 771 � l , 6- yV IV- +berl Dar) 0 A z TI IJIn rc- t. 4 i- ca\c 1 -{ t ate-^ W • ea• .. ........ 771 j. D A -m -d- I 14 ' n -Y�d 'T� 6 'pw-iA L pb� A 6 20 G 3 0 " N DEPT. BUILDIT OLD