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HomeMy WebLinkAbout45822-Z �o�OS�FF y Town of Southold 7/22/2023 P.O.Box 1179 cz ca 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44350 Date: 7/22/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 24775 Route 25,Cutchogue SCTM#: 473889 Sec/Block/Lot: 109.4-20.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/3/2021 pursuant to which Building Permit No. 45822 dated 2/16/2021 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 Beebe,Thomas&Virginia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45822 6/9/2022 PLUMBERS CERTIFICATION DATED h riz ignature TOWN OF SOUTHOLD o�goFFDtKCOP, BUILDING DEPARTMENT H TOWN CLERK'S OFFICE oy • o� SOUTHOLD, NY ,dol '0. 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#: 45822 Date: 2/16/2021 Permission is hereby granted to: Beebe, Thomas 24775 Route 25 Cutchogue, NY 11935 To: construct an in-ground swimming pool as applied for. At premises located at: 24775 Route 25, Cutchogue SCTM # 473889 Sec/Block/Lot# 109.-1-20.2 Pursuant to application dated 2/3/2021 and approved by the Building Inspector. To expire on 8/18/2022. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Buil ing Inspector Form No.6 TOWN OF SOUTHOLD. BUILDING DEPARTMENT TOWN HALL 765-1802. APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings;property lines,streets, and unusual natural or topographic features. 2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9.form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I Wlead. . 5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6: Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957)non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and*unusual natural or topographic features. 2. A properly completed.application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building$50.00, Additions,to accessory building$50.00, Businesses$50.00. 2- Certificate of Occupancy on Pre-.existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date. New Construction: Old or Pre-existing Building: (check one) Location of Property: Main &kkQka House No. , r Street Wmlet Owner or Owners of Property: _ 110 tio-S 0- Suffolk Suffolk County Tax Map No 1000, Section Block r Lot .0. 2. Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ V(A Appl' ant Signature SOUT�,QI 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlin(-town.southold.ny.us Southold,NY 11971-0959 Q couffm BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Thomas Beebe Address: 24775 Route 25 city:Cutchogue st: NY zip: 11935 Building Permit#: 45822 Section: 109 Block: 1 Lot: 20.2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Platinum East Electric License No: 34091 ME 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 2 Disconnect Switches 2 4'LED Exit Fixtures 11 Pump 1 Other Equipment: Heater 220GFI, Pump 220GFI, 1 Light on 100W Deckbox Tranny 120GFI, Salt- Generator Notes: Pool Inspector Signature: C Date: June 9, 2022 S.Devlin-Cert Electrical Compliance Form OF SO!/thp�o � �� -7 7 # # TOWN OF SOUTHOLD BUILDING DEPT. `ycomm, ' 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: L �� ,�.•—�, n Zo t., L ( n -r NZrI4& !&L62 7/ 7 DATE INSPECTOR - pf 50UTy0� # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] 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: �T/wu d ..f�� G6C i .10k Co^pw -°a Coo Cod& DATE 114-7,z- INSPECTOR o��OF SOUTyoI q T4 7-7 5 # TOWN OF SOUTHOLD BUILDING DEPT. y o,rm��o �, 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: �L Z7 DATE INSPECTOR OF SOUTyO f� cYj 2 elL17-75" - # # TOWN OF SOUTH.OLD 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: c �y _ J' ACV - are 4cA 11v 1!506 , e j 11vtl-e&, Vey ? DATE L INSPECTOR i�•' r T. Y S L c f' r ,byy ~' S ;� •; � �. � �. � r `. / M� ` ,.rte � � C �•� � 1. ff i f ftm ��� lOWT _ `- ice• ,,y _ MELD;INSPDtTXON REFOiT DATE FOUNDATIQN(ZND) � o ROUGH FRAMING PLUMBING y IN9S .kTION•PER N..Y. STATE EN°ERCrY COI}P, NJ TINAx, •:oo _ . � . 0 TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION,CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health. _ SOUTHOLD,NY 11971 3 sets of Building Plans TEL: 765-1802 Survey PERMIT NO: �,�: Check Septic Form N.Y.S.D.E.C. Trustees Examined 20C Contact: Approved 20 Mail to: Disapproved a/c Phone: Spector m _`e, APPLICATIONFORBUILDING.PERMIT Date � ) , 20 ?� INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupancy is issued by the Building Inspector. 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,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances-,building code,housing code, an ations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature oiYpplicant or ndne,if a corporation). ON A2+- 2rW- Pt&_,X PIO U bY (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premises U►iUrJ1 Q. &.e (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No.- �-fb Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: .24q-7s, "am F. House Number Street Hamlet r';v! County Tax Map No. 1000 Section 10q Block I Lot ; o:f20. Z Subdivision Filed Map No. L;of 'ti:pct; (Name) : . ; 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy kes\n]"a b. Intended use and occupancy. 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work_ I n y„n„A U►nf m yvy� ,tel (Description) 4. Estimated Cost L0013" Fee (to be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures,if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation: K11Q) 13. Will lot be re-graded &C A-a,4 cw4 Will excess fill be removed from premises:6ES NO 14.Names of Owner of premisesV1�31N►a &-e1 2 Address-2q--M Atn (0 Phone No. 0)-4-9- 21k7 Name of Architect Address Phone No Name of Contractor Address Phone No. 15. Is this property within 100 feet of a tidal wetland? *YES NO IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE IRED 16. Provide survey,to scale,with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF&A:�Lk ) V1 A being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the ©KWIL-- (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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this 24, V— day of 202_� Notary#ublic S' ature of Applicant MARGARE'f A. KIDNEY Notary Public-State of New York No. 01 K16021 1 1 1 Qualified.in Suffolk County My Commission Expires March 8,209 t , i BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD uN 2 5 2021 Town Hall Annex - 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 '0q-T lephone (631) 765-1802 - FAX (631) 765-9502 roger.richert(citown.southold.ny.us .t APPLICATION FOR ELECTRICAL INSPECTION -REQUESTED BY: k Date: Company Name: v j- C-C l Name: License No.: Mel-_ 3 YO email: u fltir>oas� .2 G`fov. (' Address: 3 !— Phone No.: (e S - JOB SITE INFORMATION: (All Information Required) Name: P\ 6 vv-z ems. Address: Cross Street: Phone No.: 31 " _ PhoneBldg.PNo.: : y �g�2 email: �U�mu".easI' • u 10�c Tax Map District: 1000 Section: Block: Lot: a0 BRIEF DESCRIPTION OF WORK (Please Print C early) job 6ip1 db L Circle All That Apply: Is job ready for inspection?: YES / Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A #Meters Old Meter# New Service - Fire Reconnect- Flood Reconnect - Service Reconnected - Underground -Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Oall � �0 �,.. Request for Inspection FormAs �' 7BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD u� 2 2021 Town Hall Annex - 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 113V hone (631) 765-1802 - FAX (631) 765-9502 roper.riche rtp_town.south old.ny.us APPLICATION FOR ELECTRICAL INSPECTION 'REQUESTED BY: Date: Company Name: T- T- Name: License No.: M/:- 3 YQ 91 email: u V"eu s{.2 G*oo_ ( Address: 3 - l� ICDvv- J 57 Phone No.: 61 " JOB SITE INFORMATION: (All Information Required) Name: �"v'r w" Address: 14 1�'_ CU TC Efc.UC Cross Street: Phone No.: 31 email: lov,,ea&I � u oe.(BIdg.Permit #: Tax Map District: 1000 Section: Block: Lot: a0 2 BRIEF DESCRIPTION OF WORK (Please Print C early) loo (AM,-1 vb 1. Circle All That Apply: Is job ready for inspection?: YES /��' Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect- Flood Reconnect - Service Reconnected - Underground-Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION � ryti Request for Inspection Form.xls t l c PERMIT# Address: Switches Outlets GFI's I Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer- AC H Mini -Special:- - Vi - - - Comments:' �Q.! 't/1�6. I koyol, Y--*' l-&-pov CJ r " Scott A. Russell d°Su`FQ/r S'7C'0]KMWA\T]E1K SUPERVISOR AMIANAG]EMIENT SOUTHOLD TOWN HALL-P.O.Box 1179 v' 53095 Main Road-SOUTHOLD,NEW YORK 11971 o Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING Yes No (CHECK ALL THAT APPLY) ❑� A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. ❑91 B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑P C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑9 D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑[3 E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑[ F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date: D)strict �^�-� NAME: kp-ltj\&, &� j01Q I X.Z (Pond Section - Block Lot gou 6— �31 ?� 1� **** FOR BUILDING DEPARTMENT USE ONLY**** Contact Information (Telephone Numbed Reviewed By: — — — — — — — — — — — — — — — — - - - - - - - - Date- - - - - Property Address/Location of Construction Work: — — — E Approved for processing Building Permit. Stormwater Management Control Plan Not Required. — — — — — — — — — — — — — — — — — ❑ Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 , v. -` .1✓ n .` ��\,� ..���.. >. /�:\ j ;,.., �.,;o-{�./.�..;•�.3�C.. �i�t!� ,� �.14'a� 1�`:. X"1'''.�"�'��.�..��� -',�t 'C�. �1` .l G�f -�. �'iJ�•� _�-_.-- -- -- �. ti �/\�r„i,_;;:w'", --Ta:,,iti:. ,- - .- y, t. .a..-¢ "'u_ ..a,...+:' ::��'s,Ti "_,•.� v's,:"�S:-' a� r�. • _ • •I 1' M A 1 ILVA711 4 1 r _ l" ►,�" '�• t I � i N04 , fi n yE/ `�r•�T,. _ .-.s_,., —._ �.: ,,r �'-i_.—.._._-. �_�..:.;-tom_>�xo.rte,�L,�fW c r�i'c'..k _ —_ _ i'�n.-_ __ ___ '.. — _J�/_ \,, ! �� •� __ ..sC_ �._ .i / .i.' Ms � — ). V;'r';"i� �.> -:F� y. � L. �y 1 � c �Y•^� ��-,- T, .�'.'•. `,i �`l .�_ .�'.� i�U cF .'f. ,'4? -,•1��.- .�."�. .� ����' _.'7'4�F'.r- �5��f. + .��w��. r'� � �.. ✓� t - .F' r!�. � ,�'/`] i�,� �[<. •'}Yt- �i��v` ,.��•%� \fir r. ✓'- :�% \J,� �� °�/ \' ��/J �� ° �7 Vf �/ \` �/• -7 �// �\ � '� J ��/,'/=�v/Iv��� `/� �'� �• � r/J �� � \ ;.tl �\ , i .rye /r_�\�-•_.:_= �''' .,�,-/�� I �� �� IyI �� �,�". I y • t u- F; -� V '1,� 1' •r LMa...F .V Y 4'� V '1•lr'1 , -. 1 � � i u '1 1 v ter- .r-�I,fes �\,.,r 'y:3'�, F 1 \.�Yez`,_�.• �� _.i f rJ`.e'r /�' \�_ _.y .ba? , ,.y"•:' S+i.'J.� ��V jr �� -� - ./ `��'.,� ! ��'_ A� NYSIF199 CHURCH STREET,NEW YORK,N.Y.10007-1100 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 112377925 0 LEVITT-FUIRST ASSOCIATES LTD R 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 �• Y 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 308232 06/29/2020 TO 06/29/2021 06/18/2020 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: 730432298 limill0000000000008345692511II111I1 Forth WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-243849191 U-26.3 57 [OOOOOOO 0063456925][0001-000024384919][r!G][15408-10][Cert-NoP-CERT_3][01-00001] RK 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 1 a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE,NY 11764 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier TOnWN eOFLSOUTHOLD ed as the to Holder) Standard Security Life Insurance Company of New York PO BOX 728 3b.Policy Number of Entity Listed in Box"l a" SOUTHOLD, NY 11971 Z06874-000 3c.Policy effective period 711/2020 to 6/22/2021 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. E] B.Disability benefits only. E] C.Paid family leave benefits only. 5. Policy covers: Qo A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as des d above.. Date Signed 6/23/2020 By 4Avpt (Signature of insurance carrier's authorizlid representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY 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 46,4C or 513 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-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) IppoI111111111 11111iiiniimoiill11 Additional Instructions for Form D13-120.1 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. D13-120.1 (10-17)Reverse 1 a DATE(MMIDDIYYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 01105/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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). UUMI PRODUCER NAME: T Gene Romano Liberty Risk Management,Inc. PHONE (631)569-5633 FAX No:(631)569-5636 664 Blue Point Road,Suite A E-MAIL ADDRESS: gene@libertyrisk.org Holtsville,NY 11742 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: NIP/Greenwich INSURED INSURERS: Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J.Edwards Pool&Spa Centre INSURERC: 929 Route 26A INSURER D: Miller Place,NY 11764 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000005-963374 REVISION NUMBER: 1 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 AD n WVnSUER POLICY NUMBER MMIDDY EFF MMfDD EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY NPC-1004300-00 0110112021 0110112022 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEEk OCCUR PRAENES E TOE.%%ante $1 300.000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY❑X JEC LOC PRODUCTS-COMPIOPAGG $ 2 000 000 OTHER $ ND AUTOMOBILE LIABILITY CEO,,.dd.nII SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acdtlent Is UMBRELLA LAB HOCCUR EACH OCCURRENCE Is EXCESS LIAR CLAIMS-MADE AGGREGATE Is DED I I RETENTION$ Is WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YN 1 A E.L.EACH ACCIDENT Is OFFICERIMEMBER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYE $ Kes,descr be under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Town of Southold is included as an Additional Insured,ATIMA,as requried 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 Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 728 Southold,NY 11971 AUTHORIZED REPRESENTATIVE GGR ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by GGR on January 05,2021 at 03:12PM °a. SUBJECT-,,\ PREMISES Tl O �h Oma, F � g MI� I' 4V _ �6 SCALE 1 "=600' SSP `r'v`° s, moo, oyc Baa kayo "0 BOUNDARY LINK ALTERATION NEAP 0 �R��~ c° � 9 SITUATT'D X17' �� C-U T C H C� G ' ` . •�6 ����� �� `1� g�° �o ;�y �90 TOWN OF SOU�i ' OLD 6 � �,Lo• cp. � aF° �G ��, SUFFOLK COUNTY, SFW YORK ',0 � o S.C. TAX No. 1000— ' 09 -01 - 18 1000 - 109 — 01 — 19 41p Sr° 1000._ 1 09 - 01 —20. 1 C7. 9 F • 70. W004,D �% f°°�� 9 ��P °y` SCALE 1 "-20' \A f �o� � OCTOBER 28, 2003 o ,� �o` �✓a^ �T, MARCH 25, 2005 PROPCSLE',, ; A/- U'; : tVA-• �F-r-OCA?-+0'�: MAY 26, 2006 SET PROP" �L -1O I �o NEW PARCEL 2 $ = �o A_PPLI C'A N I. yy ae`' r �oJa� AREA = 35,530.41 sq. ft. ti� CONSTANC.:- PEC?E �y f/ N`�1 Jj a�Fp t^ 'pJ, \ 6 `�°._ 2477 MAlP: ROAD r CUTHOGUf U.Y. 11935 c O S Op e s a. G�, �O >, •�7, -T. ''SAO \ �'- s- Lill C�a NEW PARCEL 7 c9� AREA = 40,361 .93 sq. ft. O 9 OQ,, c wa00 , 0. LOT AREA DATA La v `- At : S11, vtN� EXISTING LOT AREAS �2 2 `����' > •'o 1, c��w °p TAX MAP No. AREA e 0'' Q°�� °► 1000-109-01-20.1 33,908.30 sq.ft. 0.778 ac. r� a v► i° a ,p�� \ J O p 1000-109-01-19 19,492.97 sq.ft. 0.448 ac. r� °.' �. F % ► ° 1000-109-01-18 22,491.07 sq.ft. 0.516 ac. °_° • - > ° 1' 0L ^, OR/�'�0/'OS . . +I °�� ° - - . °- ..; TOTAL 75,892.34 sq.ft. 1.742 ac. VV °. tOC Ery > . a ° . NEW LOT AREAS ° yore �9 rLCJ� c° �iL �T�ON , "' •. NEW PARCEL No. AREA NEW PARCEL 1 40, O �e �``.Y - � y \ r�� 361.93 s ft. 0.926 ac. ti sy ° ► �.4 O V ° q Fo pAr> �O 19 J 9��O = q cF ° a• ° NEW PARCEL 2 35, q. �o 530.41 s ft. 0.816 ac. y s y , ° ,p TOTAL 75, Fy ��v>,. o ; O� l.T� F �1 • � � 892.34 sq. ft. 1.742 ac. Ck -10 F° oo . a s s. \F' p r ys° • O PRt PARI' I�;''. :':-. ir.l;CE WITH. INF \ ° > ° + SSANDAP' 0'i SURV-YS AS FS;AHLIS I D slp •p °> 7 Y H'+' TjIF `. ��.`�". APPROVED ANO A:jOD'10 P� ° 'p �� 1 ° > ° v FVQ SGL SL n'' '.,I NFW YORK SATE AND° �$• �F T T vel O Lf ASS=; A":)N v bb ° > , N� ° { I �~ > O �nF V ° 7 �\f �YPa�f> > > p ,. • � N.Y.S. i-1c. No. 49668 ro FOV�pN �� G i v - -- — ° ° l UNAUTHORIZED ALTERATION OR ADDITION e a_ \ TO THIS SURVEY IS A VIOLATION OF UTi raj((P481 a - °° a. ° a SECTION N LA OF THE NEW YORK STATE �\ - ^ ° .O, • EDUCATION LAW. `j `f COPIES OF THIS SURVEY MAP NOT BEARING °' ° °° • ► THE LAND SURVEYOR'S INKED SEAL OR _► ` - EMBOSSED SEAL SHALL NOT BE CONSIDERED Land urveyor • ► TO BE A VAUD TRUE COPY. • ► .p CERTIFICATIONS INDICATED HEREON SHALL RUN ---- --.--- - .--.--------- ---.--.-- --- ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Title Surveys -- Sut,-visi;;ns Site Plans Construction Layout TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND 10 THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-209v Fax (6.31)727-1721 TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. OFF/CIS LOCAiFD A[ KIA111NC ADDRESS THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF 322 ROAN0< AVr-N,, r.0. Box 1931 ANY, NOT SHOWN ARE NOT GUARANTEED. RIVERHEAD, New York ' ='1 Riverheod, New York, 11901-0965 23-42( ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: y APPLICATION FOR OUTDOOR POOL PERMIT [� EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM 0 CERTIFICATE OF WORKER'S COMPENSATION [ CERTIFICATE OF LIABILITY INSURANCE [ SUFFOLK COUNTY LICENSE -{-]� SUFFOLK COUNTY PLUMBER LICENSE -[-J---SUFFOLK COUNTY ELECTRICIAN LICENSE 4 SETS OF PLANS - (3 STAMPED) [ ] 3 SURVEYS with FILTER LOCATION APPLICATION FOR CERTIFICATE OF OCCUPANCY C.O. [ ] TAX BILL _ $400.00 CHECK FOR PERMIT FEE f APPROVED AS NOTED � DAT� � B.P.# B'FEE: �� * C` e �� T— L'UiL%iNG DEaPRTkitvT AT c nN 765-180 a A'rt TO ,., PM FOR THE S�L.�dd p �O✓J� FOLLOWING INSPEC,TiONS: FOUNDA T IUB! - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUNONG 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 pOp O`p'' j\ N' DESIGN OR CONSTRUCTION ERRORS. P �����. S COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED A NS OF SOUTHOLD TOW A SOUTHOL WN PLANNING BOARD SO LD TOWN TRUSTEES N.Y .DEC I © 1 jell • 1 B O B To FRW R1. F1Er•Pww s ft N�hn wa�� To is i Plan A F Piping . Arrangement f4 ftbw _ OF NEV 42" ' c� P�D.RF�� O Section B—B. r Mw PJU 1on X43595 OFFS S I ONP� Section A—A Typical Wall Section SIZE A B C D E F G H AREA CAP. FEET FT. FT. FT.FT.FT.FT.FT.FT.SQ.FT. GAL. 12 X 20 12 20 8 9 0 3 3 6 240 8,000 �� (;4r7-75- Hall, R 16 X 36 16 -36 12 14 6 4 4 8 576 21,600 rML&SPA CENTRE 18 X 40 18 40 16 14 6 4 4 8 720 28,500 PERMACRETE WALL SYSTEM �,�}} ►��Y-e— ;929 Route 25A Miller Place NY 11764 ff 20 X 40 20 40 16 14 6 4 6 8 800 30,000 ' (631) 744-7185 FAX (631) 744-0174 I q,35- 24 13s24 X 44 24 44 18 14 8 4 6 10 796 30,000 Suffolk License #4436-M 24 X 48 24 48 20 16 8 4 6 10 900 31,000 Nassau License #M74450000 I