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HomeMy WebLinkAbout47281-Z Z.- Town y Town of Southold 7/1/2023 a P.O.Box 1179 o - 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44250 Date: 7/1/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 230 Kouros Rd,New Suffolk SCTM#: 473889 Sec/Block/Lot: 117.-6-16.6 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/3/2021 pursuant to which Building Permit No. 47281 dated 12/29/2021 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. Maintain grass at gates so self close hinges function properlL. The certificate is issued to McNamara,Brian&Lynn of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47281 7/12/2022 PLUMBERS CERTIFICATION DATED Auhignature TOWN OF SOUTHOLD ��o�SofFo�K�oya BUILDING DEPARTMENT TOWN CLERK'S OFFICE CR oy�• a��gr 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#: 47281 Date: 12/29/2021 Permission is hereby granted to: .McNamara, Brian 1557 Berkeley Ave Baldwin, NY 11510 To: construct accessory in-ground swimming pool as applied for. At premises located at: 230 Kouros Rd, New Suffolk SCTM #473889 Sec/Block/Lot# 117.-6-16.6 Pursuant to application dated 12/3/2021 and approved by the Building Inspector. To expire on 6/30/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 u ding Inspector pF SOUTyolo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlinCD_town.southold.ny.us Southold;NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Brian McNamara Address: 230 Kouros Rd city:New Suffolk st: NY zip: 11956 Building Permit* 47281 section: 117 Block: 6 Lot: 16.6 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043ME 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 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 FixtureTime Clocks X Disconnect Switches 4'LED Exit Fixtures Pump X Other Equipment: Intermatic Pool Panel 8 Circuit/ 3 Used, Pump 220GFI, Lights 120GFI, Heater, Salt Generator, AutoCover 120GFI w/ Key Locked Switch Notes: Pool Inspector Signature: Date: July 12, 2022 S.Devlin-Cert Electrical Compliance Form o�aOF 50Ulyo H -7 02...-6 1 46 # TOWN OF SOUTHOLD BUILDING DEPT. �o • io `ycourm� 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) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: co DATE d INSPECTOR SOUlyO6 H -72,-E . , 1,50Kouros ------ TOWN OF OUTHOLD BUILDING DEPT. °`�couun� 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 (ROUGH) [� ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: T-0 0 1.- DATE INSPECTOR ho��Of SOUIyo� # # TOWN OF SOUTHOLD BUILDING DEPT. °�courme�' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL ��t [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: ,"s5 W&-s 5o 5elr do=k AA5es v0dzo el Olt, DATE INSPECTOR `���- -- q 7,2g Jeffrey Sands Architect January 25, 2022 X17 APR 2 2 2022 Property/swimming pool location: -DD BUILDING DEPT. Lynn McNamara TOWN OF SOUTHOLD 230 Kouros Road New Suffolk RE: Swimming pool rebar inspection Attention Town of Southold Building Department: Upon inspection of swimming pool rebar and drywell at above mentioned property, 1 find all to have been installed to meet current building code requirements. Sincerely, ED ARC M.Sq NE`N Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands(ahotmail.com FIELD:INSPE.CTIUN":1 RT. I?'ATE•... .' FOUNDATION(1ST); --- -------------- -------- .FOUNDATION , ROUGH FR ZlING; y PLUM_,B G INSULATION.PER N. STATE ENERGV C-ODE 12"ce FINAL iA 64 AA_ CSF; r6z , Q $UffDlx TOWN OF SOUTHOLD—BUILDING DEPARTMENT G"O� �OGx y. Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 y • o��f Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny_gov Date Received APPLICATION FOR BUILDING PERMIT QJFor Office Use Only PERMIT NO. �02 Building Inspector: 2021 ID DEC 0.3 Applications'and'forms must,be filled out in their entirety.Incomplete BUILDING DEPT. .applications will-not be accepted: Where.the Applicant is not the owner,an TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall'be completed. Date: 'OWNER(S)OF--PROPERTY: ' Name: L fflo-NayY)Ctrot, SCTM#1000- 1 Project Address: 1"1 Yd , SUrt-p\ Phone#: Email:MC h l L em Mailing Address: a3Q. KUU./©S CONTACT PERSON: Name: Kwl�na Mailing Address: y-v AV �Vl qqc l Phone#: 3��.(� y.®... . .- Email: Ylrl " DESIGN.PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR.INFORMATION: Name: Mailing Address:�10 au 0 oc MN aq4 k Phone#:( (�6 _—� Email: J \S Cd DESCRIPTION OFPROPOSED'CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Esti ated Cost of Project: 10 ther New PfcLPSSD>ns� dgye 1 6.L4;1- C,V.. SU-) mmin $ 8►Soo Will the lot be re-graded? ❑Yes 'N' Will excess fill be removed from premises? es ❑No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: 0$t6 Zone or use district in which prerpises is situated: Are there any covena is nd restrictions with respect to this property? ❑Yes L�f Jao IF YE�, PROVIDE A COPY. heck Box After Reading:"The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by hapter 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,autho"rized inspectors on premises and in building(s)fornecessary inspections.False statements made herein,are punishable as a Class A misdemeanor,pursuant to Section 210AS of-the New York State Penal Law. Application Submitted By(print name): (,��,, HjE v' P6uthorized Agent ❑Owner Signature of Applicant: 6A Date: STATE OF NEWcY`O[RKK)) I/ COUNTY OF ga4—vrl fl Q.Ir.„u r being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Aae��� (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 '�,�, J day of,,f CJS , 20 2. 1 , Notary Public MICHELE A MEDUSKI Public,State of New PROPERTY OWNER AUTHORIZATION No Reg.No.01MES393343 York 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 r--- J •t y , f �.. lj 4, i, Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) � - I s i YA1C41a C4� "residing at j (Print property owner's name) Qviailing Address)N do hereby authorize koI r 1 ►� C-'lCG{ /C� (Agent) ' i - I Pp Y on m a 1 behalf to the O- . Y i Southold Building Department. 1 Zdl ' (Owner's ignature) (Da ) i i (Print Owner's Name) i i i i i i F BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(c�southoldtownny.gov - seanda-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4/11/2022 Company Name: LC Electrical Contracting Inc. Electrician's Name: Lennie Cancellire License No.: ME-38043 Elec. email:office @ Icelectricalcontracting.com Elec. Phone No: 631-874-0485 El I request an email copy of Certificate of Compliance Elec. Address.: 22 Woodbine Lane East Moriches, NY11940 JOB SITE INFORMATION (All Information Required) Name: McNamara, Brian Address: 230 Kouros Rd, New Suffolk Cross Street: Phone No.: Bldg.Permit#: 47281 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool Square Footage: Circle All That Apply: Is job ready for inspection?: FV YES ❑ NO ✓0 Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES FV-] 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 Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y F1N Additional Information: PAYMENT DUE WITH APPLICATION � t 0 Ad d a �oguFFat/( BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 P" Southold, New York 11971-0959 C� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr _southoldtownny.gov — seand D_southoldtownwgov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4/11/2022 Company Name: LC Electrical Contracting Inc. Electrician's Name: Lennie Cancellire License No.: ME-38043 Elec. email:office@Icelectricalcontracting.com Elec. Phone No: 631-874-0485 01 request an email copy of Certificate of Compliance Elec. Address.: 22 Woodbine Lane East Moriches, NY11940 JOB SITE INFORMATION (All Information Required) Name: McNamara, Brian Address: 230 Kouros Rd, New Suffolk Cross Street: Phone No.: Bldg.Permit #: 47281 email: Tax Map District: 1000 Section: Block: Lot: (�• (D BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO ✓❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES 0 NO Issued On Temp Information: (All information required) Service Size 1-11 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 FJ2 H Frame M Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION /0d a PERMIT# Address: l of Switches Outlets GFI's .� Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon . Micro. Generator: ' .......... - Coo top Tra nsfer AC AH J Mini Special: Comments: ' 0) L�dCT r C ,1'r�- C _ b =-,,,S Y�O�'RK I Workers' CERTIFICATE OF srArE Board Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE `� I Board 1a.Legal Name&Address of Insured(use street address only) v 1 b.Business Telephone Number of Insured 631-996-4687 Patricks Pools Inc PO Box 3024 1c.NYS Uneniployn tent Insurance Employer Registration Number of East Quogue NY 11942 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.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 (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold NY 11971 _ WWC3528513 3c.Policy effective period 05/13/2021 to 05113/2022 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/olficersinduded) []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`1a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3 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 ". The insurance•carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled 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 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 aut ized representative or licensed agent of insurance carrier) Approved b . ( 6ature) (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.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation Is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-108.2(9-17) REVERSE A�o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYW) `--"' 105/1012021 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(les) 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 631 941-4113FAX 631 941-4405 100 Oakland Ave,Ste 1 E-MAIL . certificates brookhavena enc .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 11942 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER /DD M DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE �OCCUR DAMAGES( RENTED $100,000 x Contractual Liability X X PHPK2229439 02/28/2021 02/28/2022 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY FX PRO- JECT F LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $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 HIREDAUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS'LIABILITY Y/N STAT[ITF FIR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBER EXCLUDED? Fy] N/A WWC3628513 05/13/2021 05/13/2022 (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 25(2014/01) The ACORD name and logo are registered marks of ACORD NEW I workers' STATE CoCERTIFICATE OF INSURANCE COVERAGE mpensation 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 it co•erege 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 Requestinc Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"1 a" 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: Q A.All of the employer's employee:eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or class Bs 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 Fai illy Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 _ 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;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 3 checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily Leave Benefits Law,It must be mailed for completion to the Workers'Compensation Board,Plans Accept ince 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 58 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained b/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 ficen ped to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt Drized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issue this ppform. DB-120.1 (10-17) 0lla�iii<< 0iuiill7l��l�l� p0 V SYMBOL LEGEND Ljo El MONUMENT FND pa 0 I.P. /I.B. FND a W I.P. / I.B. SET Z z ,, oysa SPOT ELEVATIONS LL J s 1y �o Q UTILITY POLE > GUY WIRE ' O Qa C>==='p 6 W UTILITY POLE W/LIGHT . y' Y' 0S zg's LIGHT POLE S BEARINGS SHOWN HEREON ARE BASED 1 * L �� o N SIGN ON LIBER 12685 PAGE 0571 a= FIRE HYDRANT u i a -o- PVC FENCE (PVC) w W u STOCKADE FENCE (STK) N W o z -x- CHAIN LINK FENCE (CLF) —•— WRE FENCE JOJRC ROAD a o 0 MANHOLE o o Q w o m n N "A"-INLET (50' WIDE) Q "8"-INLET (� zoo z o n�Z N r W °• YARD INLET o o a 4 EDGE OF PAVEMENT ----------- EDGE OF PAVEMENT -------- YARD INLET ------- ------- Z A/C UNIT I m J O ® ELECTRIC METER S81021 30"E 150.00 © GAS METER _ _ _ _ _ ---- a o .,zo O WATER METER �— SETFND i zona z / BAR — W pQ GAS VALVE �{ 159.80' REPIPE I o i w WATER VALVE " a I I T Qf TEST HOLE ^i € I 3 ® (D Co ? tt TREE N z O Z U Q SHRUB • BOLLARDQ { ( I a z N 3 Z O W LL x WETLAND FLAG I $ J x o D.C. DEPRESSED CURB 1 pp 3 I PVC I a w FE. FENCE w ^ FENCi I poo p MAS. MASONRY A " 1 -HI 0oa PLAT. PLATFORM O o 3' PVC FEN. W.W. WINDOW WELL O ' I w 3 x B/W BAY WINDOW O o C/E CELLAR ENTRANCE m a a z o- 0/H OVERHANG M'�►� M '`_1 ':1 FLAG STONE " PVC W R/0 ROOF OVER s o FEN w s BRICK CANT. CANTILEVER i A/C'S WALL 3 0.6'± o 0 0 G.O.L. GENERALLY ON LINE 1 i"R/o To CANTILEVER O o a 0 Q STAKE t 28.2' �N U F Q o CROSS CUT � � o. 37 2 a o 0/L ON LINE 0'4' E. CAMPBELL z o'er r 2 STORY TAX LOT 17 '_s v I FRAME RESIDENCE b` > u F 1 CONC. M aow> I #230 � W�U0 W o � �oFu 144.5' --� :ONC'-+SUNROOM TREX PLAT. 2ND STORY '� " m w i BRICK B/W n w DRV 1 WALL (n - W n>3 �� O naow -� ono V 1 wl O ��4 FM LOT 1 ,(� p)l TAX LOT 16.2 u al :r 1 K^' e I �a mac. zo � W0-578034'00"E 100.0 PIPE Q0 07 r 3'WIRE FEN SET O (I 3 r J/YJ 3'PVC FEN, w, (� PV FEN PVC WRIF WRF REBAR o z o N 0.9'tt 1.9'ft �D o a i rw z 'P FM LOTS X yY1S� I O J Q oOz� ( T X LOT 16.6 oo1} O O O vW o W N (� . 5m , Z W Qazo 0 o�o t; p W�x� ' o �o�� o cD �g � x ory LLJ O P/0 FM LOT 5 I >- (, Z W O U1 TAX LOT 19.3 w o (N � U) Ngo 6'PVC FEN. o N w c'71 p 0 V) w e 1 FND PVC Z c) dopa � MON FEN W 5 O PR FrN oz N ''t�` I - � � o woo REBAR �"+ 6+8e PoSrDILAP, 4' PR 36 o__ &RAIL FFN. 0 FtN PVC ON ►0FEN 9'B LOCK 10Joo PVC- F_=-I M ..5FEN DRY GRAVEL DRIVEWAY0.6't O N PVC FEN,13 Fy 0N87e500" LOT 2 MO" FD Qo TAX LOT 16.3 Goowo O Nw TAX zor 1 4 1 1V784384 0..W Ld (n oz Cf) W 3 z I W a LI- FM LOT 4 z 11os TAX LOT 16.5 F— LL Q 00 W z o m IL o Cy) < 000z —J o z Woxo O `y ^ iooa LL OO J mgn~ Y w o K a Z W f W J WW o Q �OgON o 0pa¢a0 LL o r Ld LL 000no GRAPHIC SCALE V) Z.12 o f 'Z'3 W 30 0 15 so z ozar- LOT AREA o 1 1 � N 1 �<1. ( IN FEET ) 40 96t}ACF ~ Wpz En, W3Zoz 1 inch = 30 ft. W o W o= 1 z�Ott3 1 110/06/2 T J.H. J.L. REV DATE DESCRIPTION BY CHK asp VA rVad APPROVED AS NOTED DATE: B.P.# 02 FEE: BY: ELECTRICAL NOTIFY BUILDING DEPARTMENT AT INSPECTION REQUIRED 765-18 021.8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH --..,FRAMING & PLUMBING 3. INSULATIN 4. FINAL - CONSTRiLICTION MUST BE COMPLETE r.0 0.0. ALL CONSTRUCTICw' SMALL MEET THE REQUIREMENTS OF THE CODES OF NEW °� 6� e 'IATELY": YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. 'ENCLf!SE POOL TO CODE UPON COMPLETION >BEFORE "WATER" COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTHOtUTOWITItAW BOARD SOTN8t6 i6tftlt<tfiRUSTEES TS. EC RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. 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