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HomeMy WebLinkAbout46434-Z aQ'0f004 y Town of Southold 6/17/2023 P.O.Box 1179 0 o - 53095 Main Rd y oma,:t� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44182 Date: 6/17/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2795 Cox Neck Rd.,Mattituck SCTM#: 473889 Sec/Block/Lot: 113.-7-20 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/3/2021 pursuant to which Building Permit No. 46434 dated 6/16/2021 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 2795 Cox Neck LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46434 6/3/2022 PLUMBERS CERTIFICATION DATED 0 t 0r' ed Signature TOWN OF SOUT'HOLD ��o�sOFF01 BUILDING DEPARTMENT cc TOWN CLERK'S OFFICE "may • � ;5 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#: 46434 Date: 6/16/2021 Permission is hereby granted to: Chadha, Deepika 83-09 Talbot St Apt 4D Kew Gardens, NY 11362 To: construct accessory in-ground swimming pool as applied for. At premises located at: 2795 Cox Neck Rd., Mattituck SCTM #473889 Sec/Block/Lot# 113.-7-20 Pursuant to application dated 6/3/2021 and approved by the Building Inspector. To expire on 12/16/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 tal: $300.00 Building Inspector *pF SO(/j�,Ql 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.devlina-town.southold.ny.us Southold,NY 11971-0959 Q COM,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: 2795 Cox Neck LLC Address: 2795 Cox Neck Rd City,Mattituck st: NY' zip: 11952 Building Permit* 46434 Section: 113 Block: 7 Lot: 20 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: MD Power License No: 33345ME SITE DETAILS Office Use Only Residential Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph 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 Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Pump 220GFI, Heater, Lights 120GFI, AutoCover 120GFI Notes: Pool Inspector Signature: Date: June 3, 2022 p 9 S.Devlin-Cert Electrical Compliance Form / OF SO -7 Q/ # # TOWN OF tOUTHOLD BUILDING DEPT. Cou765-1802 INSPECTION = [ ] .FOUNDATIONAST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND. [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL ] -FIREPLACE &CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE-RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: _ � �sac DATE INSPECTOR ���_ SOplholo # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST . [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL TION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ]` FIRE-SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: no (�✓ lr n y ; ul, w I :;,- rd0007 DATE )/ INSPECTORAA x, 0 v 4 HM ENGINEERING P.C. P.O.Box 914 EAST NORTHPORT,NY 11731 TEL:516-476-5392 EMAIL:HMARNIKA@OPTONLINE.NET May 27, 2021 Town of Southold Building Department Town Hall Southold,N.Y. 11971 Dear Sir/Madam: This is to certify that the drainage facilities to be used exclusively for the construction of a swimming pool on the premises of. Chadha Residence 2795 Cox Neck Road Mattituck,N.Y. 11952 will not require draining because the pool is constructed with a vinyl liner. The pool water will be continuously recirculated through the filter and will be reused from year to year. Since this pool will have a cartridge filter, there will be no backwash. There will be no interference with the public water supply system, existing sanitary facilities, adjoining property owners,public highways or private roads. 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Ao- ` `yJ / .. h:<//'• / '/ry', j,f�y �j • s,' o�f� ( yd' ,ns-,;yl > rE a ,. � ,� ylSl / 11� ', ���/✓ S4 �! fll, �/ , :`,•'�,��'���'��I���ap�� y}��/ N,�J' I ';:, ♦'- N / / �/ / Y. d l '�J�'sj ,, .! I '• '' ' 7 �jj, •lr I'''� 1 it V IVY ��► � •��w//�/ i �` ��� .- � � /l / to : '�j//��,�J��IJV: ��'� � •��= ' ._�'., �-, 1 y )� mis-1; R3 FIELD INSPECTION REPORT, DATE COMMENTS FOUNDATION(1ST) ------------------------------------ .FOUNDATION(2ND) � z ROUGH FRAMING& y PLUMBING V n G INSULATION PER N.Y. STATE ENERGY CODE a L �t�2✓'' FUCA b¢„ �A ►S W — t v FINAL ADDITIONAL COMMENTS 3 AO 2 ^dZT, H O z x 0-4 d M N TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold,NY 11971-0959 V, Telephone (631) 765-1802 Fax(631)765-9502 hLtps://www.Southoldtomm.gov Date Received APPLICATION FOR BUILDING PERMIT LECIEff F Office Use Only PERMIT NO. t3qBuilcling Inspector: JUN 3 2021 I ou ti ii hA�ir; ritirky I 't �'!'ApOli�ptions'and, 6rehsrny#bq f a0pliqa'iiq�q�"��yi,h r�otpp'a�c P�'Ika�ui:n6tth'- Wheirethd,A e�owner.an, 6Wneei Auth6fliavdh f6rin(Pa 6 2)"shalfb6 cdmp e�ed-; Date: ' 9W E RTY Name,: 0- SCTM -1100 1,13--'..1 Project Address. -PrhOne 19, Email: akeepic-�&4 %A cow Cr pi.* Mailing Address,,: Kew 121Df -s( 0 oNTAcT.PERS Name: _0, "0 Mailing Address: i4vi-Vtoovi"R(Al i6 Phone#: 02 Email: ,)o v) j�6XP-eA%A i AOL-10--IL49!-�60- ONFORMAT Oi'�,` DESIP'N PROFES' S'i6kA' to Name: n Mailing Address: -al- P 73) ,.Phonle#: 51 Emai.l.: n- Jr-W1Q00P--�VnL'iAE-i�neF-- F ATION:�"��,' , ONTRACTORIN 014�4 Name: nVA0 -Poov- Pei vo ,Mailing Address:, CORCA, Phone#: mail: I)ESCAIPTION OF PROPOSED-CONSTRUCT10h EINewStructure nAddition ElAlteration DRepair ElDemolition Estimated Cost of Project: �Atlh e1r---- Will the lot be re-graded? E]Yes)(No Will excess fill be removed from premises? �Oes El No Pro p qs e y\!�hvro%&0%ip Doo Zvq D' w4h hez4cr lip,A -Vinci) b cod-L) P' Air F � T t�' PROPERTY,'INFORMATION, Existing use of property: Intended use of property: rltlY Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? []Yes *o IF YES, PROVIDE A COPY. CheckBOX After:ReadIng::'The owner/contractor/design professional is responsible for,all drainage and stoat,water issues.as provided by, Chapter 23li.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,.alteratione or for.remo'val or demolition as,hereiri described.The applicant agrees to.cornply with all applicable laws;ordinances,building code, housing code and`.regulaiions:ancl to ad' inspectors on premises.arid:in,:building(s)for necessary inspections,False statementsmade herein are P as a'Class A'rriisdemeanorpursuant,tolSection 210.4s.ofQhe'New'.York State"Penal Law.. 11__ I Application S!abrnitte .By(p-int n?.t^.e): I`CCt �Q n C�Latnorized Agent. Lwner :. ..... _........ ... , . ee. ...... C... d . I Signature of Applicant: Date: STATE OF NEW YORK) SS. COUNTY OF ) ,021421 VCU CSV)&Ah,cL2 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named,(S)heisthe � - C1l aWhe (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 forin airatii&n jtherevuithVETLANA KALANTAROVA Sworn before me this ary Public-State of New York NO.01KA6290eK Qualified in Queens Countyday of -6x 2� Commission Expires Oct 1.202 Not Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I, NPDAea CVlli 6a residing at $3-01 -fQtbot St j4C ke!Ld G 1nl) do hereby authorize �f�1r1L-1 eynow; a to apply on my behalf to the Town of Southold Building Department for approval as described h rein. n ignature Date Prirk Owner's Name 2 J �� �7 N O�O g�ffO ^3 �-�' In BUILDING DEPARTMENT- Electrical Inspector(.,� O j l l TOWN OF SOUTHOLD C* P 1 4 2021 Town Hall Annex - 54375 Main Road - PO Box 1179 CIO ^ Southold, New York 11971-0959 sy T,DTNG DEAM Telephone (631) 765-1802 - FAX (631) 765-9502 ro terr _southoldtownny.gov seand(a)-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: ©-L}J Q_ Name: i License No.: 33 3 y email: Y^ Phone No: k ] GH 10 \41 14 request an email copy of Certificate of C mpliance Address.: �-L N)A_O C' O (' -A JOB SITE INFORMATION (All Information Required) Name: N 1S Address: Cross Street: Phone No.: L7910 14 (10 BIdg.Permit#: �-} (o�-}- `3 email: 1 -1��P� i5 '�j �ti•�' Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print,Clearly) Check All That Apply: Is job ready for inspection?: YES g ❑Rough In ❑Final Do you need a Temp Certificate?: ❑YES Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead # Underground Laterals ❑1 ❑2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT,DUE WITH APPLICATION G �8 Electrical Inspection Form 2020.xisx C�' tqu 7-73nUILDING,DEPARTMENT-Electrical Inspector TOWN OF p o y p 4 2021 SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 oy •- �' Southold, New.York 11971-0959 Telephone (631) 765-1802 FAX (631) 765-9502 r(a_s wtholdtownny aov seand(c�southoldtownny aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFOR ATION (All Information Required) Date: Company Name.: Name: License No.: 33 3\4 5 r�(1 em il: Phone No: C CL'A d C)h/ 31 0`�— 0 request an email.co of Certificate cate of C mpliance Address.: JOB SITE INFORMATION (All Information Required) Name: N�S Address: Cross Street: Phone No.: 11 114 BIdg.Permit#: 4 email: ra�) Tax Map District: 1000 Section: �� t 5 �ti•�t Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print.Clearly) . , Check All That Apply: Is job read for inspection?: �r7 y . . YES Do you need a Tem Certificate?: �ro ORough In Final Temp DYES Issued On Temp Information: (All information required) Service Size Q1 Ph 03 Ph Size: A # Meters Old Meter# New Service Service Reconnect [] Underground E]Overhead # Underground Laterals 01 M2 []H Frame Opole Additional Information: Work done on Service? []y DN PAYMENT,DUE WITH APPLICATION Electrical Inspection Form_2020.xlsx - �O ✓� C1 - : S.C.T.M.NO. DISTRICT:1000 SECTION:I13 A BLOCK: 7 LOT(S);A UN 1 5. 2021 LAND N/F OF TOLD KOULOU60UDIS , CL 32.7 VACANr ! 1 C o ¢'lie ti 14 s W DWELLINGr� _ 35 O• CLJ _ I { CL 32.6 . - W/WER WATERi rs 'i Np• _ >t ovER,150' � r (33.0) •A'35,6 1 m f 133.0) ,,,- y�dPtrt•,nme ;�\�,1}��•1 or7+y 1wN TB' ,.e1 $ N CL 5'.a ,a$ , 4 1. 9 .v. ,'C. °'•,'°' (33:0) • wE%� c t, �'"Cg` (3so) DeR 4 ovER 150 3/ LAND N>F 0 CA7HER24E Uh&q Y'RmNOMUTER ;c `:. \, 1 CL 30.8 MREVOC6lP TRUST `r_...•. i" ' DL �0 D1 0.8' / r Su sum :2:6' Vit" 1 i ISO B80MN UED1 1T 1 FRANCLK NMDSAY _ // SP SN ✓• DwrwNG f, DRAWL 13.6' S,4? 36a V11 W OVER WATER N0 WATER ZONED ZONED R-40 DCT.2.MG-17 ` NON—CONFORMING LOT K.WOYCHUK Ls FRONT YARD: 40'MIN ' DRAINAGE CALWWON REAR YARD: 50' MIN PROPOSED DWELLING W/aWERED PORCH:3085 SO.Fc SIDE YARD: 15' MIN, 35' TOTAL 3085 s 0.166-512cT REPUIRED THE WATER SUPPLY, WELLS DRYTIELLS AND CESSPOOL (2)8'DIA a 6'DEEP ORYWELL-537tH PROVIDED . LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS. AND OR DATA OBTAINED FROM OTHERS AREA:30,608.57 SOFT. or 0.70 ACRES FND. LOC_ 03-26-21 ELEVATION DATUM: NAVD88 UNAUTHORIZED ALTERATION OR ADDITION 7D THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY 15 PREPARED AND ON HIS BEHALF TO THE 177L£COMPANY, GOVERNMENTAL AGENCY AND LENDING 1N577TU7ION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INS77TUTION• GUARANTEES ARE NOT TRANSFERABLE THE OFFSE75 OR 01MENSTONS 5NOM HEREON FROM THE PROPERTY LINES 70 THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY UNES OR TO GUIDE THE ERECTION OF FENCE$ ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS r ANO/OR SUBSURFACE S7RUCRIRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY SURVEY oF:DESCRIBED PROPERTY CERTIFIED T0:MANISH CHADHA;DEEPIKA CHADHA MAP OF: SECURITY TITLE GUARANTEE CORPORATION OF BALTIMORE; FILED: ASK ABSTRACT INC.; SITUATED AT:MATTITUCK CITIZENS BANK; TOWN OF:SOUTHOLD KENNETH M WQYCITUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design .I �,___ ff P.O. Box 153 Aquebogue, New York 11931 jT�tr..1>'f a/QYfP"` PaaNe IBaL)z08—Lsee PAX(GSI)zas—Esse FILE #220-157 SCALE:1"=30' DATE: OCT. 2, 2020 N.Y.S. L1SC. NO. 050882 vaola,e Wg,ha.kora.or Rohr,T.H--y C Kenneth 1L Raychuk -C. be r Y ng ons r er f# yrs 'H--''., -.L C-EN I'l VEM-f T G, ,H- ,, .L , YN�t� This certif: s t, , #i bearer ts duly I�:� _ , _ by the - o►unt f of su b s t� 12 �1 LONGI-7 OP ID: El '4�o�2om CERTIFICATE OF LIABILITY INSURANCE DATE(M3/20 12!03!20 0 20 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 631-669-3434 coNTAcT Brennan P.Regan Regan Agency,Inc. PHONE 631-669-3434 FAX 463 Deer Park Ave (Arc,No,Ext): (A/c.No):631-669-3035 Babylon NY 11702 E-MAIL Regan Agency,Inc. INSURERS AFFORDING COVERAGE NAIC# INSURER A:American Casualty Company 20427 INSUR D INSURER B:State Insurance Fund 36102 Long Ffsland Pool&Patio,Inc. 543 Middle Country Rd. INSURER C: Coram;NY 11727 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 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. ILTR I NSR 1 1 TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE X OCCUR 5099218546 12/20/2020 12/2012021 DAMAGE TO RENTED 100,000 X MI S a occurrence) $ MED FRCP(Any oneperson) $ 15,000 i PERSONAL&ADV INJURY 1,000,000 GEN-L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 �:THER, OLICY CT LOC PRODUCTS-COMP/OP AGG 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUpTOpSyy Ep � AUTOS ONLY AUTOS ONLY PPerr acGdent AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B AND EMPLOYERS COMPENSATION Y/N �( STR I ER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE 12439791-1 04/10/2020 04/1012021 100,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If. es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Property Section 5099218546 12/20/2020 12120/2021 BPP 150,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate Holder is additional insured. CERTIFICATE HOLDER CANCELLATION SOUTHOL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 Southold,NY 11971 AUTHORIZED REP RESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �Yo�K Worker-s' CERTIFICATE OF INSURANCE COVERAGE �� rs,TATE' :Ctll'tipQl1Sdti.G41 �- .B:nard. 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) 1 b.Business Telephone Number of Insured LONG ISLAND POOL&PATIO INC 543 MIDDLE COUNTRY ROAD CORAM,NY 11727 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 112590890 �.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as-the Certificate Holder) ShelterPoint Life Insurance Company TOWn Of Southold 3b.Policy Number of Entity Listed in Box"1 a" 53095 Route 25 DBL575672 i Southold, NY 11971 3c.Policy effective period. 01/01/2020 to 12/31/2021 d. Policy provides the following benefits: M A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. i 5. Policy covers: . 0 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: i 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. i . Rate Signed 10/7/2020 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 413,4C 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 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. m� oB-120.1 (10-17) IIUIIIIIIIIIIIIIIIIIIIIIIIIIII(I1III�IIIIIIIIIIIII�I D� APPROV D AS NOT D DATE::. B.P.# FEE: RETAIN STORM WATER RUNOFF NOTIFY ..BUILDING ^r PA 'TTENT AT . PURSUANT TO CHAPTER 236 7651802 8 AM TO 4 PM FOR THE OF THE TOWN CODE. FOLLOWING..INSPECTIONS: 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. ELECTRICAL INSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF en 'iftWl ZBA ARCMU9 SW;WQL-;0WXT_RUSTEES II��n G --- rvIMMEDCATELY91 .ENCLOSE POOL TO-CODE 3, UPON COMPLETIPN OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY i NOTES: CONTINUOUS 1.POOL AND PROPERTY TO CONFORM TO 2020 NYS UNIFORM FIRE PREVENTION AND BUILDING CODE,TOWN BRACE CONCRETE COLLAR OF SOUTHOLD CODE AND 2017 NATIONAL ELECTRIC CODE. (TY'-) (ENTIRE PERIMETER) 2.POOL SHALL CONFORM TO ANSI/APSP/ICC 5 STANDARDS R326.3.1. SEE DETAIL THIS 3.SECTION R326.7 POOL ALARM REQUIRED. SHEET 4.ENTRAPMENT PROTECTION REQUIRED SECTION R326.5. 5.POOL SHALL COMPLY WITH BARRIER REQUIREMENTS SECTION R326.4. 6.POOL SHALL COMPLY WITH 2020 ENERGY CONSERVATION CONSTRUCTION CODE OF NYS SECTION R403.10: ..�;' •.•.• '' : : '• • ; ':. POOLS AND PERMANENT SPA ENERGY CONSUMPTION(MANDATORY). ~ '' SECTION R403.10.1 HEATERS BENCH SECTION R403.10.2 TIME SWITCHES SECTION R403.10.3 COVERS SWIM—OUT :, 7.SLOPE PATIO SURFACE 1/4"PER FOOT(MIN.)AWAY FROM POOL. I 8.LOCATION OF PROPOSED SWIMMING POOL AND POOL EQUIPMENT BY OTHERS.LOCATION TO COMPLY WITH LOCAL ZONING REQUIREMENTS. ' 9.BACKFILL MATERIALTO BE FREE DRAINING GRANULAR MATERIAL(NO CLAY OR LARGE ROCKS). I 10.FILL POOL WITH WATER PRIOR TO BACKFILLING. V1wL I b 11.POOL TO REMAIN PERMANENTLY FILLED. 20' $ MING L 12.ALL DRAIN COVERS TO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME BAKER(VG B)POOL AND SPA I I SAFETY ACT. 800 S.F. :'; 13. NO DIVING EQUIPMENT PERMITTED. I 14.CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR TO INSTALLATION OF POOL. I 15.THIS PLAN IS FOR CONSTRUCTION ON PROPERTY AT 2795 COX NECK ROAD,MATTITUCK,N.Y.11952 I JI_ ONLY. / .':•.. 16.HM ENGINEERING,P.C.SHALL NOT BE RESPONSIBLE FOR CONSTRUCTION MEANS,METHODS,TECHNIQUES / OR PROCEDURES UTILIZED BY THE CONTRACTOR,NOR FOR THE SAFETY OF THE PUBLIC OR CONTRACTOR'S / EMPLOYEES,OR FOR THE FAILURE OF THE CONTRACTOR TO CARRY OUT THE WORK IN ACCORDANCE WITH THIS PLAN. 17.SUCTION OUTLETS SHALL BE DESIGNED AND INSTALLED IN ACCORDANCE WITH ANSI/APSP/ICC 7. 18.NO SURCHARGE ALLOWED WITHIN 4'OF SHALLOW END AND G OF DEEP END. 40' FILTER PUMP BRACE (FILL 6" POOL PLAN CAVITY WITH GRAVEL NOT TO SCALE NOTE: AGGREGATE OR SKIMMER CONCRETE) THIS IS A NON-DIVING POOL. 2'4 (TYP.) DUAL MAIN DRAIN WITH 3.0' STRAINER (VGB (MIN.) SAFETY ACT = = O VINYL LINER APPROVED O SWIMMING POOL — FIBER HIGH VIEW ACROSS CENTERLJNE OF HOPPER O FIBER—REINFORCED COMPOSITE PANEL 62 0 _ 8' X36' 2" SAND BOTTOM — CONTINUOUS TAMPED ROLLED FILTERED WATER DRIVE STAKE CONCRETE COLLAR RETURN, NUMBER OF :F.':i;' a� O (ENTIRE PERIMETER) NOZZLES VARIES PERIL ^T' :""'• ' ::: ;' ' POOL SIZE _ 17- 14' s' 3' MAIN DRAIN PIPING SCHEMATIC 40' NOT TO SCALE LEVELING BASE UNDISTURBED NOTE: EARTH DRAWING CONFORMS TO ANSI/APSP-7 SUCTION ENTRAPMENT AVOIDANCE CODES. WALL SECTION AND BRACE SYSTEM POOL SECTION NOT TO SCALE NOT TO SCALE NOTE: BACKFILL MATERIAL TO BE SAND,GRAVEL OR OTHER PREPARED FOR: NON-EXPANSIVE MATERIAL CHADHA RESIDENCE GENERAL NOTE: 2795 C OX NECK ROAD ALL MANUFACTURED ITEMS AND CONSTRUCTION SHALL COMPLY WITH THE 2020 MA UCK, N.Y 11952, RESIDENTIAL CODE OF NYS,INCLUDING THE SPECIFICATIONS IN SECTION R326. fr NOTE: �/O HM ENGINEERING, P.C. DATE: 0512712021OWN SCALE: AS SHOWN THESE PLANS ARE AN INSTRUMENT OF SERVICE AND ARE THE PROPERTY OF HM ENGINEERING P.C.UNAUTHORIZED �� �7 �� SHEET: 1 OF 1 ALTERATIONS OR ADDITIONS TO THESE DOCUMENTS ARE A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE P.O.BOX 914,EAST NORTHPORT,NY 11731 EDUCATION LAW.INFRINGEMENTS WILL BE PROSECUTED. Tel:(516)476-5392 Fax:(631)980-7671 Email:hmamika@optonline.net RESIDENTIAL SWIMMING DID HOURAISED SEALAND BLUE SIGNATURE POOL PLAN