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HomeMy WebLinkAbout47287-Z �o�OSu�Focs Town of Southold 7/12/2023 P.O.Box 1179 0 o _ 53095 Main Rd 4w, Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44262 Date: 7/12/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 380 Homestead Way, Greenport SCTM#: 473889 Sec/Block/Lot: 40.-2-12 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/7/2021 pursuant to which Building Permit No. 47287 dated 1/3/2022 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 Laureano,Lemarie of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47287 7/29/2022 PLUMBERS CERTIFICATION DATED Au or ed i ature TSz TOWN OF SOUTHOLD oo�g1)FFot� � BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY W � 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#: 47287 Date: 1/3/2022 Permission is hereby granted to: Laureano, Lemarie 2621 Palisades Ave Apt 12A Bronx, NY 10463 To: construct accessory in-ground swimming pool as applied for. At premises located at: 380 Homestead Way, Greenport SCTM # 473889 Sec/Block/Lot# 40.-2-12 Pursuant to application dated 12/7/2021 and approved by the Building Inspector. To expire on 7/5/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Bui ding Inspector �o��pf SO(/r�ol 0 Town Hall Annex 'Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlinCM-town.southold.ny.us Southold,NY 11971-0959 OIyCpUIY 1►e�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Lemarie Laureano Address: 380 Homestead Way city:Greenport st: NY zip: 11944 Building Permit#: 47287 Section: 40 Block: 2 Lot: 12 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 100W UC Lights Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches 4'LED Exit Fixtures Pump 2 Other Equipment: Pump 220GFI, Waterfall Pump 220GFI, Pentair Intellitouch 10 Circuit/ 6 Used, 100W Tranny x2 w/4 Lights, Heater Notes: Pool Inspector Signature: D Date: July 29, 2022 S.Devlin-Cert Electrical Compliance Form O��OF 50(/l�0 -72-6-7 -3 &0 - # TOWN OF SOUTHOLD BUILDING. DEPT. `yco 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: DATE -612,2 INSPECTOR O��OF SOUIyo �`� `��� ��✓' ,�������C� # 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 CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: ' Vol,, DATE l INSPECTOR �o _ ` vvq # # TOWs (44 S,& f so OF SOUTHOLD BUILDING DEPT. cou631-765-1802 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: OA y DATE 22 INSPECTOR OF S0UlH0� - H / - # TOWN OF SOUTHOLD BUILDING DEPT. / °ycou631-765-1802 '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) [y�, ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: Al" f&g&v2l el C/K DATE Z Z INSPECTOR u �� ho�aOF SOUIyO� l� TOWN OF SOUTHOLD BUILDING DEPT. Cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/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 REM ICS: pv3o &J— D 4011" ID* v Vv, _ u� Vii , q(t clami DATE Iii L?i INSPECTOR I rjf SO(/T,y�� -- "Il TOWN OF SOUTHOLD BUILDING DEPT. couto 631-765-1802 . INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] KULA 7 N/ HULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL MARKS: oi(4 L� DATE INSPECTOR 1 e s o � e • e � � FOUNDATION FOUNDATIOD):,. �. PLUMB&& STATE 00 mWEA ! / , ' 7' % �1 1 _ FRU Mme' �Ir-.1 - r MWIMPIM P� — i• !1� R • MMa ML -I MOM ��/,tel RAWtl vo°�rf�{k°4 TOWN OF SOUTHOLD—BUILDING DEPARTMENT n `v 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.;ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use OnlyAll PERMIT NO. Building Inspector: LI / I D DEC 7 2021 ID Applications and,forrris niusfibe filled out in their,prItitetyAncomplete BUILDING DE�� applications will not be accepted, Vhere the Applicant is not the owner,an TOM OF-MMOLID Owner's Authorization form:(Page 2)shall be completed., Date: 7� ,OWNER(S). F PROPERTY:. Name:LeMarle Laureano SCTM# 1000- _ Project Address:380 Homestead Way, Southold, NY 11971 Phone#:914-479-919111 Email:lemarielaureano@gmail.com Mailing Address:380 Homestead Way,, Southold, NY 11971 .CONTACT.PERSON:: Name:Jason Simmons Mailing Address:P.O. Box 1331 , Hampton Bays, NY 11946 Phone#:631-324-7844 Email:officeasons ools.com @J.. p _ _..__. DESIGN PROFESSIONA4INFORMATION; Name: Mailing Address: Phone#: Email: CONTRACTOR INFO+RMATIION ; Name: i Mailing Address: 'fop, Phone#: ^7 Email: ea ` DESCRIPTION OF,PROPOSED"CONSTRUCTION: ❑New Structure_ ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: EOther swimming pool $73,050.00 Will the lot be re-graded? ❑Yes VKio Will excess fill be removed from premises? es ❑No 1 6 PROPERTY INFORMATION'.,. Existing pro use of prty: I .. .. .._. e .... ....___Re„sl,dtia.l ... __.. .. ... .ntended.._ . ... . use_ ....._.of. _p..ro ert :. p,.._ywreside.ntial .__ .. _.... . .. Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes El No IF YES, PROVIDE A COPY. n,check Boz After Reading: The owner/contractor/design professional is responsible forall drainage and storm water issues as provided:by Chapter 236 of the Town Code. APPLICATION 15 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'otherapplicable Laws,'Ordinances'or Regulations,for the construction of buildings; additions,alterations or#or removal or demolition as herein described.The applicant agrees to comp(y�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 By(print name):Jason Simmons BAuthorized Agent ❑Owner Signature of Applicant: Date: f STATE OF NEW YORK) SS: COUNTY OF ) _l ( -Tcen ) t�•'� -0 el? C' being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the C'a► ,�'t (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 1.PM Y om✓ , 20 ��Ao2A,1 <hotary Public F I Scye,,,�,, `\\���5•NOTARY 9C, PROPERTY OWNER AUTHORIZATION NO.OlFI641385o':y QUALIFIED IN _ (Where the applicant is not the owner) ; SUFFOLK COUNTY COMM.EXP. P 02-01-2025 OU B LAG I, LeMarie Laureano residing at 380 Homestead Way'�,,FpF'N��,ly,,,�� Southold, NY 11971 Jason Simmons do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's SignatureDate 1 , Print Owner's Name 2 i Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) LoLi-Are-a -,p residing at 380 Harnc-sAeod VVCsy, (Print property owner's name) (Mailing Address) do hereby authorize J c(10 f-► (Agent) to apply on my behalf to the Southold Building Department. y (Owner's Signature) (bate) P-Mnrle— Lou n() (Print Owner's Name) tiffat 1P 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 southoldtownny.gov — seand(a-southoldtownny.Qov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 2/24/2022 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 NY 11940 JOB SITE INFORMATION (All Information Required) Name: LeMarie Laureano Address: 380 Homestead Way, Greenport NY 11944 Cross Street: Moores Phone No.: 914-479-9192 Bldg.Permit#: 47287 email:LeMarieLaureano@gmail.com 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?: R1 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 Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y F1N Additional Information: PAYMENT DUE WITH APPLICATION .tip �\Cp �� r 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(cD-southoldtownny.gov - seand b-southoldtownny gov .APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date:2/24/2022 Company Name: LC Electrical Contracting Inc. Electrician's Name: Lennie Cancellire License-No.: ME-38043 Elec. email:office@lcelectricalcontracting.com Elec. Phone No: 631-874-0485 Q1 request an email copy of Certificate of Compliance . Elec..Address.: 22 Woodbine Lane, East Moriches NY 11940 JOB SITE INFORMATION (All Information Required) Name: LeMarie Laureano Address: 380 Homestead Way, GreenportNY 11944 Cross Street: Moores. Phone No.: 914=479`-91:92 _ L _ :Odg.Permit#: 47287`.' email . eManeLaureano@gmail;corn' Taz Ma District: 1'Q'00: ` Section:. .., _ . p..... Block:: ot: BRI; F,DESCRIPTION"OF;.WORI<, INCLUDE S:QUARE`FOOTAGE (P,Lease"Print Clearly)::,.". - P-ooF :.. Square Footage: . Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑✓ Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES ❑ NO Issued On Temp Information: (All,information required) Service Size❑1 Ph❑3 Ph S'ze: A # Meters Old Meter# F-1 New Service[:]Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals n 1 2 n H Frame Pole Work done on Service? Tly FIN Additional Information: PAYMENT DUE WITH APPLICATION CQly 6D .tip �� 'P { PERMIT# Address: Switches Outlets GFI's Surface Sconces : H H's UC Lts .. . Fans :. .._. ,.,...... . _: ...:.•.FF'ift' . HW Exhaust Oven W/p •' smokes. :. DW Mini. C rb¢n micro...... :Genera'.or, ., -... Com e _ r-:; tea.... . ... .. .. . . .. .. _. ...... ......... ..-....... ans Hood: Service - .,:Hove.p :S " '`Comments`. t - .... r I 1�J- O �d',, i S.C.T.M. NO. DISTRICT: 1000 SECTION: 40 BLOCK: 2 LOT(S): 12 #R10-15-001 E C E " W W W W W DEC 0 7 2021 ' FRESHWATER WETLANDS" W W W W W W AS DETERMINED BY' W W W W BUILDING DEPT. SUFFOLK ENVIRONMENTAL CONSULTING INC. W TOWN OF SOUTHOLD W ON AUG. 28, 2014. W W W W W W W W W W W W W W W W W W W W W _.._.. _ .. _ . ._. . _ ' WAY CL 7.7 HOMESTE�D i moo' EDGE OF PAVEMENT S66"09'10"w ��'P' 7469"02'10"E 50.00' IRON PIN (jQ,QQ' E 8.0 j W.M. GUTTER DRAIN EL 8.8 300.0' 0 D O /' y ' FL TK 000 ,Q 3 I3 i z ./ U U D c>, WEL CPORCH CONC' STONE WALK m 7.3'x 4.0' 26.2' ':::•::'29.4'::::'::::': ....... ?:t 1.5' t+� EL 8.8 ...?R:1:•::::: :�.... EL 8.3 w.e.: tp oi:•::•:::•::•::::::::::.DWELLING•::::•::•:•::::•:::• N• FFL 11.2 LAND N/F C12 EL 9.0 4' NK CE B2.P': :: :: : :... STK. OF CRAID & MARINA BLEIFER CONC./STONE EL 9.0 6' 14' STOOP 28' S.T. 69' 79. 68' CONC./STONE L.P. 31' PATIO � 44' L.P. 84 � w � U L.P. w O z 3-4 BEDROOM O � FlR�PR SANITARY SYSTEM c, O 1000 GAL. S.T. U (3) WDIA x4' DEEP L.P. io STONE WALL U to o h >c oL 0.1;74 o.3'N EL 15.3 6' STOCKAD FENCE 0.3'N 0.1 E o.3'w 110.00' STK. STK. S66009'10"W ASPHALT NORTH ROAD C.R. 48 UPDATED 10-03-21 REVISED SANITARY MEASURMENTS 04-23-17 THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL FINAL SURVEY 04-10-17 LOCA77ONS SHOWN ARE FROM FIELD OBSERVA77ONS AND OR DATA OBTAINED FROM OTHERS. AREA: 22, 192 S.F. or 0.51 ACRES ELEVA77ON DATUM: NAVD88 UNAUTHORIZED AL7ERA770N OR ADD177ON TO THIS SURVEY IS A WOLA77ON OF SEC77ON 7209 OF THE NEW YORK STATE EDUCA77ON LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID 7RUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TU77ON LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INST/7URON, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO 774E STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT 774E PROPERTY LINES OR TO GUIDE 774E EREC77ON OF FENCES, ADD177ONAL S7RUCTURES OR AND 0774ER IMPROVEMENTS. EASEMENTS AND/OR SUBSURFACE STRUC-TURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY OF:DESCRIBED CERTIFIED TO: LEMARIE LAUREANO; MAP OF: FILED: SITUATED AT:GREENPORT TOWN OF.-SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design P.O. Box 153 Aquebogue, New York 11931 „ , PHONE (831)298-1588 FAX (631) 298-1588 FILE #16-159 SCALE: 1 =30 DATE:SEPT. 20, 2016 N.YS. LISC. NO. 050882 maintaining the records of Robert J. Hennessy & Kenneth M. Woychuk Workers` CERTIFICATE OF NEW NYS WORKERS'COMPENSATION INSURANCE COVERAGE YQRK sr�,T� Compensation Burd Insured Detail Is.Legal Name and address of insured(Usc street address only) lb.Business Telephone Number of Insured MaryMeg,inc, 631-324-7844 P.O.Box 1331 Hampton Bays,NY 11946 le.NYS:Unemployment Insurance Employer DILA:BillsPools,Bills Pools,Service,Jasons Pools,Jason,and Dills Pool Registration Ntimber,of lnsured Service id:Federal Employer Identification Number of insured or Social"'ecurilyNumber 113168202 Work Locetion`ot'Tnsurdd(Only:reyuit:ed.lf•coverage is-specifically limited Yo: certain loceliair.i'n.New,Ybrk State,.l.e.,.&Wrap=Up.policy). 2,Name and Ad'd'ress of,thc;Entity Re questing'Proof of Coverage 3a:Namc of.lnsursnce,Csrrier (Entity:Being Listed as.tHeCertif(cate liolde�) Technology;insurance Company,Inc. TOWN;OF;SOUT�MOLD BUILDING DEPARTMENT TOWN HALL 3b.PolicyNumhcr of entity listed In box"la": SO,UTHQLD,+NY'119.71 TWC3965837 31c.:Policy eilective.period: 3/23/2021.to 3/23/2022 3d,The proprietor,Partners or Executive Officers are: ,`�i Included(Only.chcckbox!fall partners/officers included)' Li i all excluded.or certain partners/ofLcers excluded This certitles-thaf the insurance carrier indicated above in box"311:insures,the business referenced above in box"la":for Workers'coml iensation under the.New York State Workers'Compensation Law.(To use t)tis form;New York(NY)must belisted under,Item 3A on.the INFORMATION PAGE of the workers'compensation insurance.policy).:The Insurance Carrier•or its Ifcensed agent will:send this Cert ficate of insurance to the entity listed above.;as the certificate holder in.box 17% The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within.10.days:IF a.polley.is canceled ue to nonpaymenrof premiums._or iviihin 30 Clays IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate,the insured front the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise;this-Certifcateis valid foroneyea[ er this form is approved by the insurance carrier or its licensed agent,or until,the policy expiration date listed.in box u3c',whicheveris earlier. This certificate Is issued as a matter of information only and confers no rights upon the certificate,It older.This certificate does not amen 1,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in.the,referen_ed 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,l certify that i am an authoriued 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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) .A Approved By: 4/9/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of nuthorized representative or licensed agent of insurance carrier:CarrierPhone Please Note.Only iusura u'e carriers and their licensed agenb are authorized to ivae the C-10S.2 form.Insurance brokers are NOT authorized to issue it. YR 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 la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured MARYMEG INC DBA BILL'S POOL SERVICE 631-324-7844 DBA Jason's Pools P.O BOX 1331 HAMPTON BAYS,NY 11946 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 1131.68202 2.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 Building Department 3b.Policy Number of Entity Listed in Box"l a" Town Hall Southold, NY 11971 DBL446593 3c.Policy effective period 01/01/2020 to 12/31/2021 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. n B.Disability benefits only. LTJ( 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 employers 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 11/9/2020 By r (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 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit,PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 4C or 513 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-920.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111°°��°�°�°°1°1°°u111°11°°I°Inl�l APPROVED AS NOTED DATE: 3 B.P.# . L� .RETAIN STORM WATER RUNOFF _ FEE: BY: PURSUANT TO CHAPTER 236 NOTIFY BUILDING DEPARTMENT AT . OF THE TOWN CODE. 765-1802 8 AM TO 4 PM FOR THE , 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 ELECTRICAL REQUIREMENTS OF THE(,ODES OF NEW INSPECTION REQUIRED YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ,,IMM IATELY„ 'EW'C LOSE POOL TO CODE SC' BOARD `. ;WPbN COMPLETION SOUTH USTEES 'BEFORE"WATER" OCCUPANCY OR ed u(pnyl 9n+ USE IS UNLAWFULmusmQ,�ri4arh WITHOUT CERTIFV1 OF OCCUPANCY �D ' se-�bQ� III/ 40' SUCTION Bonding Wire connected to all LIGHT L>:GKf hardware d DEC 0 7 2021 WASTE FILTER Heater BUILDING DEPT. PUMP SKIMMER TOWN OF SOUTHOLD WATER LINE i MAW 2"RETURN TO INLET. DRAIN b MIN N 3'APAR LO PIPING SCHEMATIC PUMP 1. s-,ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA70(NEC), FILTER PRINCIPALLY ARTICLE 680.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY GROUND FAULT CURRENT INTERCEPTORS �? 2'2" RETURN ! HORIZONTAL4/8':. 2 POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE DETECTING A CHILD ; }y REBAR . 4 PLACES ENTERING THE WATER AND SOUNDING AN ALARM AUDIABLE AT POOLSIDE AND ATANOTHER £ LOCATION ON THE PREMISES WHERE THE POOL IS LOCATED.THE ALARM MUST BE INSTALLED, `= " " UNDISTURBED EARTH MAINTAINED AND USED IN ACCORDANCE WITH MANUFACTIRER's INSTRUCTIONS.THE ALARM 10: ., 45" '* MUST MEET ASTM F2208'STANDARD SPECIFICATION FOR POOL ALARMS'.THE DEVICE MUST ;4{ OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSON. k z.- F CONC.MIN.3500 PSI VINYL LINER. VERTICAL3/8"REBAR PLACED 3"O.C. 3. WATER SOURCE FILLING THE POOLSHALLBE EQUIPPED WITH A BACKFLOW PROTECTION P SYSTEM. 14' 14' 8' 4' ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED.ALL PIPING TO BE POLYETHELYNE. WALL CROSS SECTION 4. NTS 5 POOL SHALL BE GREATER THAN 10 MEASURED HORIZONTALLY FROM ALL OVERHEAD WIRING. POOL DESIGN INCLUDING DRAINS WILL MEET ALL 2020 NYS RESIDENTIAL CODES. �EW Complies With: * q o r 3 .;;,- � Jasons Pools Section 11326 of the 2020 Residential '— Code of New Yorke 2 - 4 380 Homestead Way ct Section.N1103.12(11403.12) Residential �FOAQ° . 2 Southold,NY Pools ©FESSx P Section R326A Barriers POOLTYPE:20x40 Rectangle REV SCALE: NTS Section R326.5—R326.6.5 Entrapment JAMES DEERKOSKI, P.E. I Avoidance DATE: 12/6/2021 260 DEER DRIVE MATTITLIK, NEW YORK 11952 DRAWING NUMBER 1. OF 1