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HomeMy WebLinkAbout46220-Z �o�0g11EFOl�Cot Town of Southold 3/7/2023 P.O.Box 1179 N 53095 Main Rd oy�� 'p Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43904 Date: 3/7/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 3005 Grand Ave.,Mattituck SCTM#: 473889 Sec/Block/Lot: 107.-1-22 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/22/2021 pursuant to which Building Permit No. 46220 dated 5/11/2021 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 Johnson,Laurie&Bilotti, Sandra of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46220 6/4/2021 PLUMBERS CERTIFICATION DATED fi -4/k\-, A o ize ignature SUFE l,1tr TOWN OF SOUTHOLD BUILDING DEPARTMENT H x TOWN CLERK'S OFFICE 'oy • 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#: 46220 Date: 5/11/2021 Permission is hereby granted to: Johnson, Laurie PO BOX 72 Mattituck, NY 11952 To: Construct in ground vinyl swimming pool as applied for. At premises located at: 3005 Grand Ave., Mattituck SCTM #473889 Sec/Block/Lot# 107.-1-22 Pursuant to application dated 4/22/2021 and approved by the Building Inspector. To expire on 11/10/2022. Fees: CO- SWIMMING POOL $50.00 SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 Total: $300.00 Building Inspector OF SO(/Tyo! Town Hall Annex ~ Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Q sean.deviinCcD-town.southold.ny.us Southold,NY 11971-0959 oly�0UM�1,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Laurie Johnson Address: 3005 Grand Ave city:Mattituck st: NY zip: 11952 Building Permit#: 46220 Section: 107 Block: 1 Lot: 22 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electrical Contracting License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New 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 Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures 11 Pump Other Equipment: Heater, Salt Generator, Pump on 220 GFI Notes: Pool Inspector Signature: ��j � Date: June 4, 2021 S. Devlin-Cert Electrical Compliance Form.xls OF SOUIb 2..,2'0 5 Avg, # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ] FOUNDATION 1ST [ ] 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: DATE INSPECTOR OE SOUlyO� # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ .INSUL TION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] ' CODE VIOLATION _n ] PRE C/O REMARKS: ov-4wf,4 Mff cloy,-- w(/ ,l a�✓ w� V�tiol�- ��S vv 4"- - yvoS�' DATE INSPECTOR s a f TOWN OF SOUTHOLD BUILDING DEPT. ycou631-765-1802 INSPECT-ION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] SUL10 A IIN [ ] FRAMING /STRAPPING [ FINA �a�_ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 0 _ �f DATE Y?/ INSPECTO dir fw ID 1� IV/ MAR U 3 2023 7 OWN OF$OU7F 6w FIELDINSPECTION REPORT 'DATE NTS : FOUNDATION(1ST) O . FOUNDATION(2N)?) J ROUGH FRAMING:& PLUMBING. . • r INSULATION.PER N.Y. STATE'ENI;RGY CODE t' �.. Pel • . . . � . . FINAL. , ADDMEN ITIONAL COMTS Ov Z El (ZeC q iG o Z m H TOWN OF SOUTHOLD-BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. 0.Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 hqps://www.southoldtownny.ROV Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMITNO. &220 Building Inspector: L! APR 2 2 2021 1 L_"" Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name:Sandra Bilotti & Laurie Johnson Project Address:3005 Grand Avenue, Mattituck, NY 11952 Ph..one..#:2.08-70.9-5269-- ------ -J Email:sand rabi 1otti@yahoo.co_m­_ Mailing Address:PO Box 72 Mattituck, NY 11952 CONTACT PERSON: Name:Ann Southard Swim Tech Pools, Inc. Mailing Address:467 Miller Place Road,.Miller.Place, NY 11764 Phone#:631-9�2.8-.2693 X1 00 Email:annie@svVimtechpools.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email CONTPACTOR INFORMATION: Name:Ann Southard - Swim Tech Pools, Inc. Mailing Address:467 Miller Place Road, Miller Place, NY 11764 Phone#:631-928-2693xl 00 Email:annie@§wimtechpools.com DESCRIPTION OF PROPOSED CONSTRUCTION E]NewStructure EJAddition DAlteration E]Repair EJ Demolition Estimated Cost of Project: El Other Inground Vinyl Swimming Pool $38,320.00 Will the lot be re-graded? E]Yes R No Will e.xcess fill be removed from premises? WYe*s ONO PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ONO IF YES,PROVIDE A COPY. B Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 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(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted B .{print nam );Sand a I ttl Lr lognnDAuthorized Agent BOwner Signature of Applicants Date:�j/ZZ�Z.f STATE OF NEW YORK) SS: COUNTY OF ) GL ABing 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 day of M&r[k1 '2091 Notary Public ANN E SOUTHARD NOTARY PUBLIC,STATE OF NEW YORK PROPERTN' OWNER AUTHORIZATI N Registration No.01S06372105 Qualified in Suffolk County (Where the applicant is not the owne Commission Expires March 12,20a 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 F ; , BUILDING DEPARTMENT- ElectCi I sn pec or Ro co ,t �O�' TOWN OF SOUTHOLD` A Town Hall Annex - 54375 Main Road - PAL 1 N021 CI' - Southold, New York 11971-0959 -T. Telephone (631) 765-1802 - FAX (631 78' -�v� .ro. rogerr(o-),southoldtownny.gov - seandsou oldtoWnriy'.gov--­­ APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: !L-7 Company Name: 9VT" •L nLJEJ C--Mk CAL CO NA-RAa'I N C� LTD Name: k?c-1AR_9- 1 U License No.: N/\E email: e, Address: o L),nco� -e AM 0 1A O74-1 Phone No.: JOB SITE INFORMATION (All Information Required) Name: R1C.0T_'1 J- L1U0C_ 'f0.14NS©N Address: k)-ttALA i )nd< � ) Cross Street: I r-"AAAv2v�vt� Phone No.: -T-66--- J0 —• (o C�ai�e�►'?� Bldg.Permit#: -ZITO email: Tax Map District: 1000 Section:. Block: I Lot: Z� BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES NO Issued On Temp Information: (All information required) Service Size 1 Ph 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: 1 k20'd S� C 411) Oclr f Qf-P i(e. W'i . AA ►A� f 'p. � '� --° Gi �� , - PAYMENT DUE WITH APPLICATION \C) Request for Inspection Form.xls Vn o��� . � p F BUILDING DEPARTMENT - Electe iInspe 6T ��O�O C y. TOWN OF SOUTHO LP UU CZ Town Hall Annex - 54375 Main Road - POORx 1 N021 -a-- r1r, - Southold, New York 11971-0959 VFP. M PT Telephone (631) 765-1802 - FAX (631 - N • rogerr(cDsoutholdtownny.gov -- seand6d�! f0 APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information R6quired) Date: Company Name: 9VT"EL nL-F-C-TRICAL_ CONT-RACTINC2 .1 UlD . Name: ?.I LON License No NA5. email: G5 e- AV- aD 0 0 ' A iA2,-J\?-t Address:. 1-2 — 0 L-)A c o &,qt AkA 74-1- Phone,No.: (0 2; JOB SITE INFORMATION (All Information Required) Name: 5ANDR-k g]C-0-r-r1, 4- ii LWSIC '—TO J�N Of V M F Address: \AAtA c9mAA Ac �a J )4d< Cross.Street: AN J C-"AAA Phone No.: Bldg..,PerMit-#. emaV; Tax-Map , Bloc ax aplDistrict: 1000 Lot: 'BRIEF.DESCRI-PTION OF WORK (Please Print Cl6arly) Circle A[I 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 I Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals s 1 2 H Frame Pole Work done on Service? .- Y N Additional Information: FVwse— c0l otAr OFJP')c e w i A A I A C>' Mk< . da PAYMENT DUE WITH APPLICATION \C) Request for Inspection Forrn.xIs PERMIT# Address: Switches — - Outlets - - - - - - -------------- ------ C-FI's :Surface- Sconces SurfaceSconces HH's UC US Fans. Fridge i H-W Exhaust :Oven. Dryer SmQlies.. DV�f: "Service - .. - �. A ; artioq:- -- --._._ - 7Viir+ -..- -- t__.:.- _. rteratar. ...:. . Cortti.bo Cooafop. :. , T.r. nsfer. . ` AC AH . Mini -Special: Comments- , tow 2- NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 112855800 SWIM TECH POOL SERVICES,INC 467 MILLER PLACE ROAD ❑E MILLER PLACE NY 11764 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SWIM TECH POOL SERVICES, INC TOWN OF SOUTHOLD 467 MILLER PLACE ROAD 53095 MAIN STREET MILLER PLACE NY 11764 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12406522-9 452665 12/19/2020 TO 12/19/2021 4/19/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2406 522-9, 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 HTTPS://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 AS A 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: 136898206 U-26.3 Client#:1095 SWIMP002 ACORD., CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 1/29/2021 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 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMNACT E: Commercial Support Edgewood Partners Ins.Center ocNO -390-9700 cNo: -390-9790a/ Ell:631 631 40 Marcus Drive E-MAIL 3rd Floor ADDRESS: certificates@cookmaran.com Melville,NY 11747INSURER(S)AFFORDING COVERAGE NAIC If INSURER A:Hartford Fire Insurance Company 19682 INSURED INSURER B SwimTech Pool Services,Inc. 467 Miller Place Rd INSURER C: Miller Place,NY 11764 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY 12UUNOZ8766 2/01/2021 02/01/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE a PR OCCUR EMISEEgqaEoNccTurrence $300 000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 X POLICY F I ECT —1 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COM Ea accidBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/NIER TATUTEANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Main Road PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S2914650/M2914633 CPRAV 4SY� Workers' CERTIFICATE OF INSURANCE COVERAGE TATE 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 SWIM TECH POOL SERVICES INC (631)928-2693 467 MILLER PLACE ROAD MILLER PLACE,NY 11764 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage Is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 112855800 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) TOWN OF SOUTHOLD 53095 MAIN STREET 3b.Policy Number of Entity Listed in Box"l a" PO BOX 1179 DBL 5394 18-5 SOUTHOLD,NY 11971 3c.Policy effective period 02/01/2021 to 02/01/2022 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 4/19/2021 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Melissa Jensen,Director of Disability Insurance Unit IMPORTANT: If Box 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, DB 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 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 (10-17) Certificate Number 639420 Additional Instructions for Form 1313-120.1 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 Worker's 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 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 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 notwitKstanding 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. DB-120.1 (10-17)Reverse t Suffolk County Dept.of i Labor,Licensing'&Consumer Affairs HOME IMPROVEMENT LICENSE Name MICHAEL G HCMERICK' Bus iness.Name _ This.ert es that the SWIM TECH POOL_SERVICES INC bearer is duly.licensed bY the County of suffolk License Number:H':12781' Fra,4., ardzUe; Issued: 08/01/1986 Commissioner 'Expires: 08/01/2021; This license is the property of Suffolk County t r Department of Labor,Licensing&.Consumer Affairs. 'P Possession of this license does not guarantee its validity_. Additional Business Name License Category H26-Pools 8 Spas i Certified;H1--GC;H3-Pools/Spas APPROVED AS NOTED OCCUPANCY OR DATE:_` B.P.# �?D USE IS UNLAWFUL FEE: � BY: WITHOUT CERTIFICATE NOTIFY BUILDING DEPARTIVI 'dT AT OF 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. �7ANMEDIATE0`4 ALL CONSTRUCTION SHALL MEET THE ENbLOSt POOL TO CODE REQUIREMENTS OF THE CODES OF NEW UPON COMPLETION YORK STATE. NOT RESPONSIBLE FOR BEFORE "WATER" DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF E.ECMCALtVsMnH REQMRW NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTHa D TOIAIN ZBA EEtSOUTHOLD TOWN PLANNING BOARD RETAIN STORM SOUTHOLD TOWN TRUSTEES ��jSpANT TO HAPTER WATER R 23 OFF N.Y.S.DEC HE TOWN CODE.pov -,If I flj� 6 L4 vS-� GENERAL NOTES 1.Install pool in accordance with approved site plan,local zoning and construction Z °O codes,2020 Residential Code of New York State and 2020 Energy Conservation POOL DECK Qv��� �i r Construction Code of New York State. '/e'x t' BOLT WITH NUT w z Q 2.Locate patio,pool,pool equipment and fencing as specified on approved plot plan. & 2 WASHERS 4D-D" MIN. 6"THICK \\ (7 PER JOINT REO'D.) Install all products in strict conformance with manufacturer's instructions. All warning F- v labels to be permanently affixed. CONCRETE COLLAR \\\/\\\ WALL - STEEL 14 GA. -' a r °z 3.Install pool in free draining sub rade. Backfill with clean select ranular fill. REO'D.AT BASE OF _ >• " W/2oz. (G235) `} P g g g WALL PANELS i o .. //// =w o Z 4.Water treatment plant to conform to the following minimums specification. Pum to /\\j\\ GALVANIZING Z o W o Q z ...: //\// %"x2y" BOLT < m P g P P DRIVE RODS THROUGH ,�.;-,_, \\\\ tum I volume in 18 hours. Filter to pass no more than 5 gpm/sf. 1 skimmer. \ i ' HOLES IN PANELS to' W/NUT o 5.Provide potable water supply in pool area. \ INTO UNDISTURBED /\\/\\ v o 6.Provide dedicated electric circuits of capacity sufficient to service water treatment — — ' I EARTH %\�/ REINF. 3 P P P y g P I 2' SAND OR VERM. /\\ \j\\\/ ROD Q o plant. All electric in pool area to be protected b round fault interrupt. Install all CON C.. electric in accordance with the N.E.0&local requirements.There shall be no o verhead I m electric lines within 10'of the pool. I I UNDISTURBED EARTH UIN ANY OFF THE PPORT SUPPORT MAY BE m 7.Slope deck 14"per foot away from pool. All concrete to be 3,500 psi,5-7%air � BACKFILL SHALL BE FREE-DRAINING CLEAR BRACE SUPPORT BOLTED THE ANGLE z entrained unless otherwise noted. I I o GRANULAR MATERIAL SUCH AS SAND, TRACE PRE-PUNCHED HOLES a" J $•Install a temporary 4'high construction barrier about the pool during its installation. - - - - - b Maintain such barrier until a permanent barrier is in place. - - CLAY OR TRACE SILT �� 0- w TYPICAL LINER INSTALLATION DETAIL TYPICAL WALL BRACE ASSEMBLY zee --1 9.Install erosion controls prior to the start of construction as required and specified � � ) 1 O hereon.Maintain such controls during construction. I I I �/g'x1" BOLT W/NUT& CONCRETE DECK REO'D. /� }>> d 10.The permanent barrier about the pool area shall comply with local ordinance,the ( WASHERS CORNER BRACKET (NP. 14 EA. CORNER) J�v Residential Code of NYS Chapter R326-Swimming Pools,Spas and Hot Tubs — X12-14x1" SELF DRILLING —RIM-LOCK COPING Section R326.4.2 and conform to the following minimum specifications. ` I FASTENER (18" O.C.) EXTRUDED ALUMINUM a: a.The top of the barrier shall be at least 48 inches(1219 mm)above grade measured / ¢ o Z on the side of the barrier which faces away from the swimming pool. The maximum ` ` I PLASTIC CORNER VINYL LINER (HUNG) 0 vertical clearance between grade and the bottom of the barrier shall be 2 inches(51 INSERT � U) Z mm measured on the side of the barrier which faces awayfrom the swimming pool. RADIUS CORNER o M rn g P COPING POOL WALL PANEL Z y� Q z_ Where the top of the pool structure is above grade,such as an aboveground pool,the 3 w a TYPICAL DETAIL RIM-LOCK COPING DETAIL �/ F E L C -L barrier may be at ground level,such as the pool structure,or mounted on top of the P� pool structure. Where the barrier is mounted on top of the pool structure,the POOL PLAN �P�v TA maximum vertical clearance between the top of the pool structure and the bottom of WALL DETAILS the barrier shall be 4 inches. SCALE:NONE �� . b. Openings in the barrier shall not allow passage of a 4-inch-diameter(102 mm) _ sp.Solid barriers which do not have openings,such as a masonry or stone wall,shall 2 WALL DETAILS O �'' (' I" not contain indentations or protrusions except for normal construction tolerances and tooled masonry joints. d.Maximum mesh size for chain link fences shall be a 2.25-inch(57 mm)square DIVING PROHIBITED A_1 NONE \ 077 unless the fence is provided with slats fastened at the top or the bottom which reduce ONE PROFILE NOT CONFIGURED FOR THIS POOL \� P�, < the openings to not more than 1.75 inches(44 mm). 7 n fir_r r 1 //a e. Gates in the barrier shall be self closing,self latching and be secured with a key orJ w F o combination lock or other approved child proof mechanism. Pedestrian gates shall �,Z w 0 o open away from the pool. Where the self latching mechanism is less than 54 inches HEIGHT OF WATER 0 K 0 B,o a on amoo$ 0above the bottom ofthe gate the latching mechanism shall be on the pool side ofthe o , >Z5 o �w-w w?Zw barrier and the gate and barrier shall have no opening greater than q'within 18"of theme HEATER WITH TIMER SWITCH. o Z a o =m�<a s v o latch and its release mechanism. M PUMP WITH TIMER PROVIDE THERMAL POOL w 3 0 0^ o o$ f.The permanent barrier shall be erected and functional no later than 90 days after the �7 z _ SWITCH w m Z> m u N M o FILTER -COVER. O Z ww- mZ�- completion of the pool. �i `o.< o z o i 3 X ao to CHLORINE GENERATOR wo J- `-own 11.Where the design uses a wall of the dwelling as a part of the permanent pool 0 0 o w o=o 0 0 0 a o barrier installer shall provide one of the following access control measures. WASTE RETURN JET SKIM MER 5 E i < w z o w s o a.Operable windows within the wall shall have a latching device located no less than Z o 5 0 3 z 368 8zUo o a s o 48 inches above the floor.Openings in operable windows shall not allow the passage 0 a w 5 <2D7,< u M w u of a 4 inch diameter sphere when the window is in its largest open position. 4'-0" 6-0" 14-0" 16'-10" b.All doors with direct access to the pool through that wall shall be equipped with an alarm which produces an audible warning when the door and its screen,if present,are s_------__--- opened. The alarm shall sound continuously for a minimum of 30 seconds 2"0 SCH40 O U immediately after the door is opened and be capable of being heard throughout the AFFIX TAG PVC, TYP. jyj J W ti house during normal household activities. The alarm shall automatically reset under all STATING "MAIN O F-K conditions. The alarm system shall be equipped with a manual means,such as touch LATERAL SECTION THROUGH POOL DRAIN" pad or switch,to temporarily deactivate the alarm for a single opening. Such z `� Z deactivation shall last for not more than 15 seconds. The deactivation switch(es)shall 'f I °' U ui be located at least 54 inches(1372 mm)above the threshold of the door;or W v c.Other means of protection,such as self-closing doors with self-latching devices, 18X23 BOTTOM 3'-O" z 0 >- g DRAIN, TYP. OF 2 21 which are approved by the governing body,shall be acceptable so long as the degree of" — N w protection afforded is not less than the protection afforded by Items 4.a or 4.b O = � described above. W :i 12.Install all suction fittings in accordance with Section R326.6 "Suction Outlets". O o Single and multiple outlet systems shall be protected against user entrapment as m a of detailed herein or ANSI?SPSP/ICC 7. POOL DETAILS 3 WATER TREATMENT z_ _ Q w a.Single and multiple pump systems shall have a minimum of 2 suction outlets „- F- c separated by a minimum distance of 3 feet. A_1 1/8 -1 A-1 NONE -1 12 U g L b,Suction outlets shall be equipped with a cover conforming to ANSI/ASME Q r 'o W Al 12.19.8 or have a drain grate with a minimum projected dimension of 18"by 23"or O C- Lu have an approved channel drain system. .J c.Provide Atmospheric Vacuum Relief System conforming to ASME A 112.19.17. to z M d.Pool cleaner fittings,if provided,shall be located in an accessible area and be located between 6 and 12 inches below the minimum operational water level or be an Cn attachment to a surface skimmer. y , S o. . (31 00„E N o / d 52.3' � m O- t v v C m G Oi c �N N� o - Q6)& 0 0 S � � O `o IJ l SURVEY OF PROPERTY SITUATE MATTITUCK,' TOWN OFSOUTHOLD SUFFOLK COUNTY, NEW YORK Suffolk Tax Map No.,:1000-107-01-022 DATE SURVEYED:2/8/203-4 J NOTE. 20"snow at time of survey. Walkways and patios not shown orguaranteed. 1. UNAUTHORIZED ALTERATION OR ADOTRON TSS SURVEY MAP BEARING A LICENSED LAND SURVEYOR'S J Q SEAL IS A VIOLATION OF SECTION 7209, SUB-DIVISION 2, OF NEW YORK STATE EDUCATION LAW. ff,,�� (�"°'' 50PVf!yl% 2. ONLY BOUNDARY SURVEY MAPS WITH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND `_ �CC� [AND CORRECT COPIES OF THE SURVEYOR'S ORIGINAL WORK AND OPINION. 3. CERTIFICATIONS ON THIS BOUNDARY SURVEY MAP SIGNIFY THAT THE MAP WAS PREPARED IN ACCORDANCE WITH THE CURRENT EXISTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE ' NEW YORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS, INC.THE CERTIFICATION IS LIMITED , . TO PERSONS FOR WHOM THE BOUNDARY,SURVEY MAP IS PREPARED, TO THE TITLE COMPANY, TO THE GOVERNMENTAL AGENCY, AND TO THE LENDING INSTITUTION LISTED ON THIS BOUNDARY SURVEY MAP. 4. THE CERTIFICATIONS HEREIN ARE NOT TRANSFERABLE. 11O So-uth 4th Street, Lindenhurst, NY 5. THE LOCATION OF UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND OFTEN MUST BE ESTIMATED: IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS EXIST OR ARE M S Ca-I I Ce I•Y1�S I a n d S U rVey.COI•Y1 SHOWN, THE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THIS SURVEY. 6. THE OFFSET (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE �: 631-957-240o F: 631- 226-24'00 FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF ' FENCES, RETAINING WALLS, POOLS, PATIOS PLANTING AREAS, AQDRIONS TO BUILDINGS, AND ANY OTHER TYPE OF CONSTRUCTION. 7. PROPERTY CORNER MONUMENTS WERE'NOT SET AS PART OF THIS SURVEY, SCALE:1°=20� SURVEYED BY:M.S. ,JOB NO.S14-0029 B. THIS SURVEY WAS PERFORMED WITH A SPECTRA FOCUS 30 ROBOTIC•TOTAL STATION. MAPPED BY:A.C.