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HomeMy WebLinkAbout46331-Z Su Foci �0�0 coGy, Town of Southold 7/22/2023 a � P.O.Box 1179 H T�, 53095 Main Rd o4% ao�g' Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44336 Date: 7/22/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 5305 Narrow River Rd., Orient SCTM#: 473889 Sec/Block/Lot: 27.-2-2.3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/28/2021 pursuant to which Building Permit No. 46331 dated 6/2/2021 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 with spa fenced to code as applied for. The certificate is issued to Bostic III,Henry&Ambriel of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46331 3/18/2022 PLUMBERS CERTIFICATION DATED Aut rize gnature � suF TOWN OF SOUTHOLD y�o BUILDING DEPARTMENT C* TOWN CLERK'S OFFICE "oy • o� 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#: 46331 Date: 6/2/2021 Permission is hereby granted to: Bostic III, Henry 246 Warren St Brooklyn, NY 11201 To: construct accessory in-ground swimming pool as applied for. At premises located at: 5305 Narrow River Rd., Orient _ SCTM #473889 Sec/Block/Lot# 27.-2-2.3 Pursuant to application dated 4/28/2021 and approved by the Building Inspector. To expire on 12/2/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector \!"�oF so�ryolo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlinCaD-town.southold.ny.us Southold,NY 11971-0959 �QIyCOUo'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Henry Bostic III Address: 5305 Narrow River Rd city,Orient st: NY zip: 11957 Building Permit#: 46331 Section: 27 Block: 2 Lot: 2.3 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Rocky Point Electric License No: 32644ME 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 80A 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 Pump 2 Other Equipment: Aqualink, Hayward Salt Generator, Pump 220GFi, Booster Pump 220GFI, 4- Lights 120GFI, Blower, Pool Cover 120GFI w/ Key Locked Switch, Heater Notes: Pool w/ Spa Inspector Signature: L Date: March 18, 2022 S.Devlin-Cert Electrical Compliance Form �aOF SOGtyo - * # TOWN OF-SOUTHOLD BUILDING DEPT. 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) [ LECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: Tot rk LNf DATE 7-6 INSPECTOR C A � �j souryOlo y �.� d+� /V Gt1'/'G'!i✓ �C 1 vel- TOWN e/TOWN OF SOUTHOLD BUILDING DEPT. cou765-1602 I=NSPECTION [ ] 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: d� DATE INSPECTOR hO�aOF SOUT��� * # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 ��033.1 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [Vf FINAL P&V740 [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE �r�'/-o' 3 INSPECTOR Jeffrey Sands Architect August 9, 2021 Bostic Residence 5305 Narrow River Road Orient, NY 11957 RE: Swimming pool rebar inspection_k '�l Attention Town of Southold Building Department: Upon inspecting swimming pool rebar and drywell at the above mentioned property I find all to have been installed to meet current building code'requirements. Sincerely, EDA (P 9)` 02769� OQ� FOF NES Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands@hotmaii.com FIELD INSPECTION REPORT DATE COMMENTS , �►o FOUNDATION(IST) ---------------------------------- FOUNDATION (2ND) 6,07 z �o ROUGH FRAMING& . J PLUMBING e1 • N 1 � W r INSULATION PER N.Y. y STATE ENERGY CODE v 7- 40642, Z FINAL ADDITIONAL COMMENTS o. ola n MIA, AIA ° y- 00 .0 e) 1 I'S vs- ro ✓a v�� Voe' Pb vb H N z TOWN OF SOUTHOLD—BUILDING DEPARTMENT a Gyp N 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 PERMIT NO. qbs3(— Building Inspector: APR R- 8 2021 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:3/30/21 OWNER(S)OF PROPERTY: Name:Henry and Ambrie l Bostic SCTM#Z000-473889 27.-2-2.3 Project Address:5305 Narrow River Road, Orient, NY 11957 Phone#:917-340-0396 TEmail.hawes.bostic@gmail.com Mailing Address:246 Warren Street, Brooklyn, NY 11201 CONTACT PERSON: Name:Hawes Bostic Mailing Address:same as above Phone#:same as above Email:same as above DESIGN PROFESSIONAL INFORMATION: Name:Patricks Pools Inc Mailing Address:P.O. Box 3024, East Quogue, NY 11942 Phone#:631-599-6529 Email:katrinapatrickspools@gmail.com CONTRACTOR INFORMATION: Name:Patricks Pools Inc Mailing Address:same as above Phone#:same as above Email:same as above DESCRIPTION OF PROPOSED CONSTRUCTION ®New Structure ❑Addition .❑Alteration ❑Repair ❑Demolition Estimated'Cost of Project: ❑Other $132,000 Will the lot be re-graded? ®Yes ONO Will excess fill be removed from premises? ❑Yes ©No . 1, PROPERTY INFORMATION Existing use of property: 1 family home Intended use of property: 1 family home Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to r=200 _ _. . _- .. -- - this property? ❑Yes 0 No IF YES, PROVIDE A COPY. B Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 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 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 na RC—,NP- ❑Authorized Agent 32"Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF_kkVAG S ) being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract)above named; (S)he is the Diw//�� (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 ii (� day of O car- l , 201. l/ Notary Public t &i;Eo XAVIERSLAYNE +'A a = Registration#O1LA638255T Qualified ir:Kings County My Commission�i:es ,,IPROPERTY OWNER AUTHORIZATION oP,'. October 29,2022 !� (Where the applicant is not the owner) 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 D � V �- D UILDING DEPARTMENT-Electrical Inspector AUG 2 3 2021 TOWN OF'SOUTHOLD own Hall Annex- 54375 Main Road - PO Box 1179 DAG DE ®�SOS IT. Southold, New York 11971-0959 Telephone (631) 7651802 - FAX (631) 765-9502 rogerrCa�southoldtownny.gov seand(c�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATI (All Information Required) Date: Company Name: o&IC oj-,xi7- �Ci/zl'c Name: zxi� -,757�J,/jo/J License No.: ,�(OLIC �� email: c/ Po��+iT �lcCTiZT �ko©•cows Phone No: 1L/-cJcP57 01 request an email copy of Certificate of Compliance Address.: & i2,& )- P7/7S--` JOB SITE INFORMATION ' (All Information Required) Name: H gq(A S -6D S-r-j_-C_ Address: E?3 0 s O1Z T Cross Street: T 1 --rT-- Phone No.: Bldg.Permit#: (Q3 3 email: Tax Map District: 1000 Section: -7 Block: 1 Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) S w� al-A-)(y— 1p,�:,C Check All That Apply: Is job ready for inspection?: MIYES [3NO PRough In ❑Final Do you need a Temp Certificate?: ❑YES PNO Issued On Temp Information: (AII inform 'on required) Service Size [31 Ph [ ]3 Ph Size: Aeet"rs Old Meter# ❑New Service ervice Reconnect nderground Overhea ;—����� # Undergroun aterals []1 2 QH Frame Pole Work done on Service? QY ❑N Additional Information: PAYMENT DUE WITH APPLICATION ct ��o� u Electrical Inspection Form 2020.x1sx ,(�,� D D ffU ILDING DEPARTMENT-Electrical Inspector :AUG 2 3 2021 TOWN Oif SOUTHOLD P own Hall Annex 5.4375 Main Road - PO Box,11.79 . DI1�IG DE Southold, New York 11971-0959 ' •" OF SOUTHOLD Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD-southoldtownny.gov seand(a�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATICV (All Information Required) Date: Company Name: oc 0'7w7- Name: �j 6. —7o.A-,)wjo11J J License No.: email: E'+goo•co t4? Phone request an email copy,of Certificate of Compliance Address.: i2 JOB SITE INFORMATION (Ali Information Required) Name: H Aq u S Address: 53 0 6 IV LK4?-0UJ VEJ�-- F. oorN Oar/JT" Cross Street: `ir�--�— Phone No.: Bldg.Permit#: 03 31 email: Tax Map District: 1000 .Section: -7 Block: 91 Lot: .3 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Check All That Apply: Is job ready for inspection?: \VJYFS ❑NO ARough .In ❑Fin1.al Do you need a Temp Certificate?: ❑YES PNO Issued On Temp Information: (All inform 'on required) Service Size M1 Ph []3 Ph Size: A ers Old Meter# ❑New Service ervice Reconnect nderground Overhea # Undergroun aterals [D 2 H Frame ole Work done on Service? QY ❑N Additional Information: PAYMENT DUE WITH APPLICATION rp �� Electrical Inspection Form 2020.x1sx �r 6/3/21 JUN 4 2021 r i Sue, Please find the enclosed check for the fees associated with permits 46330 and 46331. You may contact Tom Kraebel at Peconic Bay Contracting to pick up the permits. His cell phone number is: 516-398-$051: I CP Thanks, �1 Hawes Bostic 12 Brook Farm Group June 16th,2021 Amanda Nunemaker Building Department Town Hall Annex Building 54375 Main Rd PO Box 1 179 Southold,NY 11971 Dear Ms.Nunemaker, Per your request,I have enclosed one copy of the revised Proposed Pool Location Plan for the Bostic Residence,dated June 11,2021. This is a hard copy of the pdf that I emailed to you on June 15th. Sincerely, ��'�g°j"-4 Kathleen Bakewell Landscape Architect encl:Proposed Pool Location,Sheet L-04, I I x 17" Hawes and Ambriel Bostic j L" ; JUN 1 7 2021 7 -;R,•, TnT. . 161 C h r y s t i e St # 3B New York NY 10002 212 . 461 . 4243 b r o o k f a r m g r o u p . c o m YORK Workers' CERTIFICATE OF STATE Com NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996-4687 Patricks Pools Inc PO Box 3024 East Quogue NY 11942 io.NYE Unemployment Insurance Employer Registration Number-of Insured Work Location of insured(Only required if c werege is specifically limited to 1dFederal Employer Identification Number of insured or Social Security certain locations in New York State,Le.,a�rep-Up Policy) d.F Number 262929943 2.Name and Address of Entity Requesting I'roof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holde) Wesco Insurance Co Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 54375 Main Rd. WWC3465462 PO Box 1179 Southold,NY 11971 3c.Policy effective period 05/13/2020 to 05/13/2021 3d.The Proprietor,Partners or Executive Officers are E] included.(Only check box if all partners/officers included) 0 all excluded or certain partners/officers excluded. .This certifies that the insurance carrier it dicated 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 3A 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"2". The insurance carrier must notify the ab,the certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or with 130 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 t tis form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whi-.hever Is earlier. This certificate is issued as a matter of it formation only and confers no rights upon the.certiftcate 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 contras It issued by a_certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compens;ition Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of:he 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 hat,the coverage as depleted on this form. Approved by: Nichola: Zulkofske ()rint name of authorized representative or licensed agent of insurance carder) Approved by: 7//1 -Z/ (Signature) (Date) Title:Authorizr:d Agent Telephone Number of authorized represt!ntative or licensed agent of insurance carrier. 631-941-4113 Please Note:Only insurance carriers a nd 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 if permits and the entering into contracts unless compensation is secured. 1. The head of a state or munk--ipal department, board, commission or office authorized or required by law to issue any permit for or in connection w th any work involving the employment of employees in a hazardous employment defined by this chapter, and notwith:tanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit L Mess proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensatio i 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 a,y 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, notwi;hstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contre,ct unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensatic n for all employees has been secured as provided by this chapter. C-106.2(9-17) REVERSE DATE(MM/DD/YYYY) A�o• CERTIFICATE OF LIABILITY INSURANCE 03/02/2021 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(ies) 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 endorsemeat(s). PRODUCER CONTACT Brookhaven Agency,Inc. PHONE 631 941-4113 FAX 631 941-4405 100 Oakland Ave,Ste 1 E-MAIL certificates@brookhavenagency.com Port Jefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURERA: Philadelphia Indemnity Insurance Co. INSURED INSURER B: Wesco Insurance Co. Patrick's Pools,Inc 19SURERC: 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 M DD /DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS MADE 1 OCCUR DAMAGE TO 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[�]PRO-'O LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $SOO,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 HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE - AGGREGATE $ DED TETENTION $ WORKERS COMPENSATIONX PER OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTNEY❑ E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBER EXCLUDED? NIA A WWC3465462 05/13/2020 05/13/2021 (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 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. PO Box 1179 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 17 YOR I workers' CERTIFICATE OF INSURANCE COVERAGE Board STATE Compensation 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 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required it co•erage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrep-U, Policy) 262929943 I 2.Name and Address of Entity Requesting 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"ia" 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 k ave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. Q B.Only the following class or class as 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 Fal lily Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 By (Signature of insurance carrier's authorized representative or NYS Ucensed 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;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 5B 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 licen ped to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt prized to issue Form OB-120.f.Insurance brokers are NOT authorized to Issue this form. tI DB-120.1 (10-17) III I�IItfI�O�pItI��I�UI�III(�II�IIQIIIIIIffII�IQI CONTRACTOR TO VERIFY ALL CONDITONS AND DIMENSIONS IN THE FIELD AND REPORT ANY DISCREPANCIES TO KDS,LLC. ' 8'X 4'POOL EQUIPMENT TO BE \\ LOCATED WITHIN SETBACKS �, '� 2S'8-- \• ti`' !I FLOOD ZONE X SEE LANDSCAPE PLAN FOR DRIVEWAY- - 0" 1A �• / AND GRADING DETAILS j T �T6gc \vim//� ,� _ NEW 40X20' POOL WITH POOL TERRACE SURROUNDED BY 4'TALL FENCING, PER CODE. EXISTING TWO STORY HOUSE- 0, i 2�°Ivo op O� /• '' ° p•p� I NEW FRONT SETBACK FROM DECK \�\ FRONT PORCH ADDITION IN �pN2°°PopO — \ p�0 �F\ FRONT DECK ADDITION / T0111- /• Q\ c� 00" N LL \ / max/ HO / N U.Lu LjjZ \\\ ) \\\ / / ,\'\ %59' O Z / O \ \ APPROXIMATE LINE / ' �' •\ I Q i N \ \ �Q \\ OF WETLANDS /- •\ Q APPROXIMATE LINE '\ '\ OF WETLANDS L/s; OND '\ ✓ 01- 78 kl o o' '\ — 231.58,IRE 27 --TIVV / N 78001 POND Il � o / � rlr, ILij f • 6 0 O/ � �,\ 383 ,�•� �� 00 ° o ' �� — --- SON \.�, - • /•./ //�, co N 6 F \ ` R\ �-`- UTfLITYpp�E SS \ ' k 0 1 -+- WITH GUYVVIRE \ s KIDS, LLC \ \ 1437 KING STREET, #5 CHARLESTON, SC 29403 N81 o0 0 2' orjW BOSTIC RESIDENCE 50.00 f \\ SITE PLAN / 1 "= 40' / 03 28 21 / A 0. 1 \ \ \ rSo " eo L2 pie ctl _ ! {. fr•a�: f,\.e i \\�.:r r�-v..;.t �;�` ,-T"r "�"�y•G�.r-f. `� 1 o 8 -0r r { i \ .�`\ w �m \#. 1T „� .� xzj t'� •tf \ o�^�l- L r 7-1 POND 1 POOL <Y Ilk" �� ��~� / / � _ � • � _ ' � • EQUIPMENT ` _• `� �.w r... �\�.�:k�: �.M�,,.,`.,.� IZ- {rF 4 H\ SELF-CLOSING, f� ,� �:n. ��.�0 POND TCHING LOCKABLE :\ \ SELF- j �� 1 IF a f . -•^.,\ r s � �__ � I � � � ~ „_. .. "� { I `� �''`"^",.„ �`.,,�x�,� „,,,may t� � "�..u•I GATE _ • _ , f P v r ....�v ems.T t CONTEXT PLAN / Scale: N.T.S. F _ 35 10.35 i _ 10.35 CD am _._ ' I 2 ._ a. _,. 1 _ _ 201-011 NIP " IN 10 FIR 1 _ , ! ° l I FIN" 1 I_ r„ APPROX. LOCATION OF BORING o TEST PERFORMED ON 1 .27.22021 i I of 10Till 7(( � I �^ k PROPOSED POOL LOCATION. SEE POOL P . DESIGNERS DRAWING. PROVIDE 4' H. FENCE , ! n ri ;1 .. �\ AT PERIMETER, ALL SIDES. FENCE OPENINGS ria\\\ \�\'� I I , `_,,,,,,,, „ �' ���^�•�� � NOT TO EXCEED 4 i 1 � x „. =: _ , FRONT YARD SETBACK .., t \ ROPO\SED SCK 10.35 '' -� (1 2) — ff 4°/D 10.35 0 � r 2% ;fir DN t --------- ---------- EXISTING i1 k6) - _ � __ CONTOUR, _ ._..__._,._ $ TYP \ . 0 1 PROPOSED 1 d ONTOUR, TYP. . \ i1 1 POOL SITE PLAN ,• „ DATE REVISIONS DWG DWG NO. BROOK FARM GROUP LLC TITLE F, P LANDSCAPE ARCHITECTURE �\ a �0 0 1. A[r BOSTICRESID' EINCE 0 \ 161 CHRYSTIE STREET SITE NEW YORK,NY 10002 917-747-7406 - 5305 NARROW RIVER RD. DEC ID# 1-4738-04532/00001 ORIENT, NY 11957 2000 M SEAL& SIGNATURE SCALE: AS NOTED DATE 03.22.21 DR BY: KB CHKD BY KB Km- AS7RUED AS NOT ID RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 DATE: B.P.# OF THE TOWN CODE. FEE: ` BY: NOTIFY BUILDING DEPARTM T AT 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 - CONSTRU"7ION MUST BE COMPLETE FOF" 0.0. ALL CONSTRUCTICk SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. 9iVSP�C 0®N� AL COMPLY WITH ALL CODES OF REQUIRED NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF G BOARD -SGUTtf6 TRUSTEES ..! . . ,DEC BvflVllWEDl TE-LVlv. ENCLOSE POOL f(J CQODa,, OCCUPANCY OR :uP°N CO,�PLETION BEFORE "WATER" USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY �. ..._ Ao, IP00 , oo i r 11 r-IT { 3 AY M. RCS, `� c)` t �- e (Anttj D C , o27�gA y�Q V�v1CQ c�tCrCt� ( OFNE`N I J ' ,i ' ' PROPOSED POOL WITH DECK LINE FINISHED GRADE OF DECK TO BE FLUSH TO ADJACENT GRADE PROPOSED � STONE 2 WA LINING �U —� PROPOSED PARKING AREA \\ I / ��/ � ��' •. i 4-H SELF-CLOSING, SELF-LATCHING,LOCKABLE i 10.35 GATE �G 6.-0.' 20'-0" 10.35', i _}0.35} LINE OF - .\ EXISTING RESIDENCE \\\ \\\ PROPOSED CONIC. I 4 \ \ - ._-- _, RETAINING Tw \\ - SHALLOWEND WALL 82 I PROPOSED POOL LOCATION SEE POOL 4:-0., _ DESIGNER'S l7RAWING. PROVIDE 4'H.FENCE AT 2. PERIMETER,ALL SIDES i FENCE OPENI�'G.NOTT EXCEED4' 1 _ I _I POOL EDGE NOT TO —��- �� \ PROJECTiPAST LINE OF EXISTING _PTOUR, PROPOSED DECK \ f =— ! DEEP END �. I b 103.5! 10.35 i EDGE OF DECK FLUSH TO + 'DOL EQUIP. ADJACENT FINISHED _ GRADE PRO OIEI { CONTOUR,TYP. 1 1 ST e REAR YARD J 1 PROPOSED POOL AREA PART PLAN Scale:l'=10' \ Q� I JUN 1 7 2021 1 YARfJ�EFINITI�N ALAN _ I BRO OAPE ARCH GROUP LLC - -- - - — ��++T �+ RESIDENCE BRGOKFARI4 EcrupE PROPOSED POOL LOCATION ®�71 I!� iaESI®E8�CE SITE-- 'BEETL04 117 7477. 5305 NARROW RIVER RD DEC ID#1-4-,35-0.532100001 ORIEIJr NY 1195.7 2000 M hs uorec KB ------------