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Home My WebLink About47607-Z ��o�c�11EFULKco Town of Southold 7/22/2023 P.O.Box 1179 C* x 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44339 Date: 7/22/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 3705 Breakwater Rd.,Mattituck SCTM#: 473889 See/Block/Lot: 106.-3-27 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/28/2022 pursuant to which Building Permit No. 47607 dated 3/28/2022 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 Thomas,Walter of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47607 6/27/2022 PLUMBERS CERTIFICATION DATED th rize S gnature TOWN`OF SOUTHOLD BUILDING DEPARTMENT y x' TOWN CLERK'S OFFICE "o • SOUTHOLD, NY ' rx 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#: 47607 Date: 3/28/2022 Permission is hereby granted to: Thomas, Walter 116 Juniper Ave Smithtown, NY 11787 To: construct accessory in-ground swimming pool as applied for. At premises located at: 3705 Breakwater Rd., Mattituck SCTM #473889 Sec/Block/Lot# 106.-3-27 Pursuant to application dated 2/28/2022 and approved by the Building Inspector. To expire on 9/27/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 ilding Inspector pF SOUIyo! 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.deviinCaD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Walter Thomas Address: 3705 Breakwater Rd city:Mattituck st: NY zip: 11952 Building Permit#: 47607 Section: 106 Block: 3 Lot: 27 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Island Power Electric License No: 52729ME 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 Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures 11 Pump Other Equipment: Sub Panel 8 Circuit/ 5 Used, Salt Generator, Pump 220GFI, 1 Light Hayward- Deckbox Tranny Notes: Pool Inspector Signature: Date: June 27, 2022 S.Devlin-Cert Electrical Compliance Form �'J 7 SOUTHOIo 47 / 160 3 7 Q - f # TOWN OF SOUTHOLD BUILDING DEPT. 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: oo" ) I v c /r-f2L` ri n JA; -C7('77 Ar- Q j;cMq UJA IS- ori cc 'Par- j IS or k ell - Or4;�r cpJ G� 2 'atA d A DATE �� INSPECTOR hO�aOF SOUTyo� l -7 &b-7 -5 7 05- <areakpv . ----- # TOWN OF SOUTHOLD BUILDING DEPT. 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 [ ] RENTA REMARKS: ,-Q f.ac1l fg c, r i c- 41 1 DATE INSPECTOR r TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUI-AjPOWCAULKING [ ] FRAMING/STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLAT_ION [ ] PRE C/O [ ] RENTAL REMARKS: - AR� ' Ir'2> . Ki wVL, �J: j2Z Q AlDATE INSPECTOR pFSOUIyOIo (/11,•1��(/J�vJ f # TOWN OF SOUTHOLD BUILDING DEPT. couff 631.765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULAT ON/CAULKING [ ] FRAMING /STRAPPING [ FINAL PbW j�� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: nn 5 � DATE INSPECTOR �/ � fV t '_ ti� �y .� I - � c � /� — _� �� r� �_ — _� i Si �� , * � y �� 1 -� a "� _--^� _� 1 y �� ..-•� _- 1 .�" t� �� r AL �..�.. � � i FIELD INSPECTION REPORT DATE COMMENTS �b FOUNDATION(IST) O -------------------------------------- FOUNDATION -----------------------------------FOUNDATION (2ND) � z _ o y � ROUGH FRAMING& y PLUMBING INSULATION PER N.Y. STATE ENERGY CODE i. Covit- 12, 1 h FINAL Cady ADDITIONAL COMMENTS a c �,� � �o tea- zl-z m C'0 H Q� O W z x E� y x d b H TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 https•//www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only R PERMIT NO. D� Building Inspector: FEB- DD °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: -a -a� OWNER(S)OF PROPERTY: Name: � � � �� Cl� `�fMas SCTM#1000- Project Addre4W &-i?AI<WO,� 90 Pk+- eV- �l`f )l9SZ Phone#: 5lb- 319- 2,0 Email: :J1CS P.p C�40L.L43m Mailing Address: 1� 2 A4. e-- ltd$-7 .-CONTACT PERSON:, =, Name: Jt ��hlfl�� LS Mailing Address: q2A jQ - 2'�A I 17dV Phone#: �3�'7��--71$S )C— ( Email: PA-.e PDDI S)(Jrfi DESIGN-PROFESSIONAL INFORMATION: _ Name: —F)\'3 r od Vie►I l� Mailing Address: )4 &2-ec- L-iJ �)m�`l� ► 61-1 7 Phone#: (g3� �/2�F- 57� Email: c6NTRACTOR INFORMATION:: . - -- Name: Attixic &Jh1A,a)s Vy,'cS Mailing Address: gjcp A±- 2S-A PI 11-6— qau- Phone#: Email: 6(7r(ee()4e—,OW e,}y,- DESCRIPTION OF PROPOSED CONSTRUCTION Y❑New Structure^❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: i other I�A(Wvoy►A\jIL Z 01Mmin101 1921)c $ JLI'D--x)r Will the lot be re-graded? 1gYes El No (�,) A . I Will excess fill be removed from premises? )DYes El No 1 -PROPERTIVINFORMATION.,, Existing use of property: Ie�2Q Intended use of property: (rl41nlg Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes i[No IF YES, PROVIDE A COPY. ,; w Y.contractor,desi1 n •rofessionaiiis.res onsibie:for all drainage and stonm.water issues as providedtiy ?` $��:Check Box;'Aft`er:Reading:;:rhe•o ne,/ / g I? p, , . �? ..- _ r .�� Y Chapter 236 of the Town Code.-APPLICATION'IS'HEREBY NiADE.to the 8uilding;Department•forthe issuance:of a,Building Permit'pursuant to tFie,B_uilding Zone{ Ordinance of the.Town of Southold,Suffolk,County,New York and other.applicable Laws,;Oidinances or Regulations;for the construction of buildin Bs.; ,faddltions,akerations or for removal or demolition as,herein desctibed.'The;applicant agrees to comply with.all applicable laws,,ordinances,building+code; h`ousing•code and:regulations and.to:adnik authorised inspectorion premises and'in building(s]for_necessary,inspei tiions.,False statements made,herein;arp�,-! punishable;as a Class A misdemeanor pursuant to Section.21o.45'of th@ New YorkState Penal,Law:' ;r. Application Submitted By(print ame) ❑Authorized Agent Owner Signature of Applicant: f(J / Date: STATE OF NEW YORK) SS: ' COUNTY OF ��t=�' ) Y ALA-''?—� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing.contract)above named, (S)he is the �hlrv�22' (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 2o22- wai— MARGAREr A. KIDNEY Notary Public Notary Public State of New York No. O l K160211 11 Qualified in Suffolk County PROPERTY OWNER AUTHORIZATION My Commission Expires March 8,20a (Where the applicant is,not the owner) 1, 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 �o�Og�fFOA4�oGy BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD C* Town Hall Annex - 54375 Main Road - PO Box 1179 o _ Southold, New York 11971-0959 y o� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr6a southoldtownny.gov - seandCD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: (� pew GII4t\C Electrician's Name: License No.: Elec. email: Elec. Phone No: ❑I request an email copy of Certificate of Complance Elec. Address.: P d - JOB SITE INFORMATION (All Information Required) Name: Wool 2r- -T V- Q V-e-)A 5 Address: d 5 Yeak t,✓AJzr 1"A4 i CIS (ll Cross Street: a �� V� Phone No.: >I b— 3( R— ?-'160 Bldg.Permit#: L1 -7 6 GJ email: j K 54P(2 6to p Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 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 Size: A # Meters Old Meter# r-1 New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? DY N Additional Information: P �s �l ```'` � RI PAYMENT DUE WITH APPLICATION JUL 15 2022 r BUILDDtPl ING TOWN OF SOU'V;AO LF SU�Fpj�. BUILDING DEPARTMENT- Electrical Inspector �O� cOGye TOWN OF SOUTHOLD C* Town Hall Annex - 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 44 Telephone (631) 765-1802 - FAX (631) 765-9502 1 " rogerr(c)-southoldtownny.gov -- seand(a)southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Electrician's Name: License No.: Elec. email: Elec. Phone No: ❑I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 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 PhF—]3 Ph Size: A #Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 FJ2 H Frame Pole Work done on Service? Y RN Additional Information: PAYMENT DUE WITH APPLICATION � �a Jae SwI ` ry � s U Jq4 ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FEB 2 6 2022 FAX-744-0174 H 0 BUILDING DEPT APPLICATION FOR A SWIMMING POOL PERMIT: SOUTH&by°FSOUTHOL0 TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: j APPLICATION FOR OUTDOOR POOL PERMIT [ V CERTIFICATE OF WORKER'S COMPENSATION [ CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE OF DBL INSURANCE [ SUFFOLK COUNTY LICENSE 4 SETS OF STAMPED PLANS �l 3 SURVEYS with FILTER LOCATION j $400.00 CHECK FOR PERMIT FEE 77 i�M-1 1 � 1 1:7 1 IL P4 tp MUM ir I/A _zz \L-4 (MMM �►co CERTIFICATE OF LIABILITY INSURANCE DATE 1212212021 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 la an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,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 endorsemen a. PRODUCER ; Matthew Ruperto Liberty Risk Management,Inc. PHONE (631j569-5633 FAx N,):(631)5694M6 2333 Route 112 Jibortyriskorg Medford,NY 11763 INSURER(S)AFFORDING COVERAGE NAlcs INSURERA: NIP Greenwlch INSURED Arthur J.Edwards Mason Contracting Company Inc. INSURERS: DBA Arthur J.Edwards Pool&Spa Centre MURERC: I929 Route 25A MURER D: Miller Place,NY 11764 N86 ERE: NSURER F COVERAGES CERTIFICATE NUMBER: 00000005.1323810 REVISION NUMBER: 23 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 LTR TYPE OF INSURANCE SU OR POLICYNUMBER OEM POLN:Y EXP Ulm A X COMMERCIAL GENERAL LIABILITY NPC4 004300-01 01/01/2022 01/0112023 EACH OCCURRENCE $ 1. 00.000 CLAIMS-MADE r—..I OCCUR PREM ES Ee oo rtenee $ 300,000 MED EXP(Any one S 10,000 PERSONAL&ADV INJURY S 1,000,000 GEIYLAGGREGATELIMIT APPLIES PEP: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT F1 $ OTHER Ewa BB I E SINGLE LIMIT S AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY(Par pemon) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS PROPERTY DAMAGE $ HIRED NON-OWNED Per AUTOS ONLY P AUTOS ONLY $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMSAME AGGREGATE i S DED RETENTION PER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITYYIN ELL EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA A OFFICER/MEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE S (Manddm in NH) If yep deacrlbe under EL DISEASE.POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddlOcnal Rernaptps SeMdule,mry be alled"N more space Is required) Town of Southold Is included as an Additional Insured,ATIMA,as requrled by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall P.O.Box 728 AUTHORIZED REPRESENTATIVE Southold,NY 11971 1 uAw4toz L, MJR 1988-2015 A13ORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by MJR on 1212212021 at 01:26PM oAtE workers' CERTIFICATE OF INSURANCE COVERAGE 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 ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE,NY 11784 Work Location of Insured(Only required If coverage is specifically limited c.Federal Employer Identification Number of Insured limited to or Social Security Number certain locations in New York State,i.e.,Wisp-Up Policy) 11-2377925 2:Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier Town of ngListed outhos the Certificate Holder) Standard Security Life Insurance Company of New York PO Box 728 3b.Policy Number of Entity Listed in Box°1a" Southold, NY 11971 Z06874-000 30.Policy effective period 7/1/2020 to 6/9/2022 4. Policy provides the following benefits: 0 A.Both disability and paid family leave benefits. F1 B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: ❑x A.All of the employers 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 descylged above. Date Signed 6/10/2021 By (signature of Insurance writer's authoriz d representative or NYS Licensed Insurance Agent ofthat Insurance wrrler) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES 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 sox 4C or 5B of Part t 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 autho►tzed to Issue this fbrlin. DB-120.1 (1047) ioiiuiuiiii(iiiiiiiio)ii� �0 Additional Instructions for Form 10113-120.1 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 Workers'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 my 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 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 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 NYSIF199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund nyslfcom CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A 112377925 �0 '0 LEVITT-FUIRSTASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 m r SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE 25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438,491-9 633479 06/29/2021 TO 06/29/2022 06/16/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW.YORK STATE INSURANCE FUND UNDER POLICY NO. 2438 491-9,, 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: 391287892 I®MIN00000000000094�420936111UMID Form WC_aRT-NOPRM Venion 3(082912019)[WC Policy-24384919] U-263 LOCATED AT 7X LOT MAS Of SCALE 1"- 3-• POD IoJ �`',• � � G:l ; 40, PIP ?bt •arcs► �ti iL. w iiw 1 t v ns' • ff Y X ` •J MAR - 1 2022 Ct: • art:.... . . . ..;. -... fT/L/ � � � � # �- � �akc,�o. � � r•�.,,�f �•4�js4�� /!/DQ Q,Q,r�E ��u�o s�`' ..mow IIeF A ,,may HL SURVEYED Zg,, 19 -- BY 3 � OOD ASD � EAST IKP,LI..PLY.11700 ' ' � (51G)SM-low FOC(51IA M-IM od JAP R® ® AS NOTED DATE: B.P.# FEE: ` �® BY: OCCUPANCY OR NOTI 765-1862.BUILDING 4 N PM FOR THE USE IS UNLAWFUL FOLLOWING INSPECTIONS: ELECTRICAL 1. FOUNDATION - TWO REQUIRED WITHOUT CERTIFICA, INSPECTION REQUIRED FOR POURED CONCRETE OF OCCUPANCY 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTICN SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. RETAIN STORM WATER RUNOF1= PURSUANT TO CHAPTER 236 ENCLOSE POOL TO GODS COMPLY WITH ALL CODES OF OF THE TOWN CODE. ®N GflMIN PLETI� "WATER",_- NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ,SOUTHOLD TOWN?BA Su .�_ G BOARD SOUTHOED 6�TEES N.Y, - A B. Rsbmrn MD >to <J- B Fm B Aman m EO F � .. - To FVh. From FMw A Puny To To Rt. ft WA RaWWN F Plan A Piping.. Arrangement ,wry, w R.Oor 42" 5E p,TE OF � SOMAS D.R {- 1. 0 Section B—B �. 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