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HomeMy WebLinkAbout49521-Z �gtlFFO(,f�oGy Town of Southold 8/4/2023 a P.O.Box 1179 o - �' T 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44374 Date: 8/4/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 565 S Harbor Rd Southold SCTM#: 473889 Sec/Block/Lot: 75.4-1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this,office dated 2/4/2021 pursuant to which Building Permit No. 49521 dated 7/26/2023 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 Nardi, Simone of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45824 9/2/2021 PLUMBERS CERTIFICATION DATED A hor' d Signatur �SnEF to kco, / TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE x 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#: 49521 Date: 7/26/2023 Permission is hereby granted to: Nardi, Simone 20 Henry St Apt 6CS Brooklyn, NY 11201 To: construct accessory in-ground swimming pool as applied for replaces by 45824 At premises located at: 565 S Harbor Rd Southold SCTM #473889 Sec/Block/Lot# 75.4-1 Pursuant to application dated 2/4/2021 and approved by the Building Inspector. To expire on 1/24/2025. Fees: PERMIT RENEWAL . $150.00 Total: $150.00 Building Inspector o�SUFFn TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy i SOUTHOLD, NY Qom„ 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#: 45824 Date: 2/16/2021 Permission is hereby granted to: Nardi, Simone 20 Henry St Apt 6CS Brooklyn, NY 11201 To: construct accessory in-ground swimming pool as applied for. At premises located at: 565 S Harbor Rd, Southold SCTM #473889 Sec/Block/Lot# 75.4-1 Pursuant to application dated 2/4/2021 and approved by the Building Inspector. To expire on 8/18/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $300.00 Bui or pE SO(/jyol Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 c Q roger.richert(a)-town.Southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD. CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Simone Nardi Address: 565 South Harbor Rd City: Southold St: New York Zip: 11971 Building Permit#: 45824 Section: 75 Block: 4 Lot: 1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: LC Electrical Contracting License No: 38043-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1 st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: In ground swimming pool to include, bonding, control panel, gas pool heater, 1-pool filter pump, 1-spa blower, 1-spa recirculator,3-single use recpticles for pumps and blower,salt generator, low voltage pool lights. Notes: Inspector Signature: Date: September 2 2021 81-Cert Electrical Compliance Form.xls hod*OF SOUlyolo # # TOWN OF SOUTHOLD BUILDING DEPT. �ycouto, 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 'f/ `2I INSPECTOR �� of SOUIyO # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 ee� Z INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]. INSULATION/CAULKING [ ] -FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE &-CHIMNEY A ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ CODE VIOLATION [ ] PRE C/O REMARKS: — 1 DATE j l 21 INSPECTOR OF SOUTyolo 1 # # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ✓r FINAL [ ] FIREPLACE &-CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE g- 0�3 INSPECTOR 8 2- Jeffrey Jeffrey Sands Architect August 8, 2021 Daiena Residence 565 South Harbor Road Southold, NY 11971 RE: Swimming pool rebar inspection A'D-F—VaLA, 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, Y N � 027891% ypQ` OF NE`N Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—Jeffrey sandsa-hotmail.com FIELD'INSPEC IO2�I REFDAT' DATE T FOUNDATION(1ST) ~ ' FOLNDA,TION(2ND) . 7.7 ' ROUGHSRAIV IING&. MUMBING i INSL7,,4TION:PER N..Y. STATE EWER CGCODE' • � �' � �a3� 'cod- :::er���J:•' • .. • . . . � •. ' • ' �. ::FINAL {,r S V ,,�,},rrxuvrc,y DS°fF°�X�o 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 htlps://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only t_;: ] •,_ _ws J i_:-+ [+Cx; PERMIT NO. Building Inspector: FEB 4 2.021 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. m ' Date: a L1 a�a OWNERS)OF PROPERTY: Ala j_dl Name: T) QS C I Q rc_I I I . FCTM #1000- (4_ 1 Project Address: 5595- U-V\ bav Y Soum-\f::,1 Phone#: _ a Sb,�T Email: 'mosc-tar fewC41� Mailing Address: CONTACTPERSON: Name: r Mailing Address: ` ` lq4 q Phone#!Q�1_QS3-(A o olr k0'61-S�la -(Waq�Pt�i Email: 'no L "DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: -Z"C- . Mailing Address: l? Phone#:� �.q53 (ayol Emal : C��-�� So1es@ s oafs , cram DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration []Repair ❑Demolition aoxL4D Estimated Cost of Project: Pother Ncw CA\WC Su.),mmiPool $ Will the lot be re-graded? ❑Yes C*O Will excess fill be removed from premises? es El No 1 PROPERTY INFORMATION Existing use of property: IStcofr-� Intended use of property:c fia�. 40us r l7w I mil ri svo- 1j Zone or use district in which premises is situated: Are there any covenan s and restrictions with respect to Q _ _ this property? ❑Yes o IF YES, PROVIDE A COPY. 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 buildings)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): ( IIt'1Q Y��YC.u��� Q *uthorized Agent []Owner Signature of Applicant: Date: a/L4 J a o a l STATE OF NEW YORK) LAUREN PARENTE S Notary Public-State of New York rr rr NO.OIPA6262470 COUNTY OF �l�i L. ) NO. in Suffolk County /� /� My Commission Expires May 29,2024 Ko4riu �(�r(�i(,�/ (� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the (Contra t r,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 —, 200/ Notary Public PROPERTY OWNER AUTHORIZATION ,(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 Buiidina Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, % r C'` .a C 1 residing at <G ' ,t r:4- "1 '� (Print property owner's name) (Mailing Address) do hereby authorize � 51., y Pr) AUK„S (Agent) (' Aftej&DtO apply on my behalf to the. Southold Building Department. (Owner's Signature) (Da e) &\("/C (Print Owner's Name) BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD APR 1 g 2(} bwn Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Tele hone 631 765-1802 - FAX 631 765-9502 :.. P ( ) ) 'rogerrAsoutholdtownny.gov seandCa�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: y 7 Company Name: LC Electrical Contracting Name: License No.: ME-38043 email: office@LCElectricalcontracting.com Phone No: ,� �._ ,..y.._ �5 ZI request an email copy of Certificate of Compliance 'Address:: ,�� �✓®dA�3i�� L.a-.��- !��-s��la�«��� �5�6 JOB SITE INFORMATION (All Information Required) Name: A,e=lJi oto Address: r6 f i -.goy lob ��' o/ Cross Street: Phone No.: Bldg.Permit#: s g a-'t email: office@LCElectricalcontracting.com Tax Map District: 1000 Section: Block: Lot: BRIEF.DESCRIPTION OF WORK (Please Print Clearly) Check All That Apply: Is job reatly for inspection?: OYES ONO ❑Rough In ❑Final Do you need a Temp Certificate?: OYES ONO Issued On . Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑;Underground ❑Overhead # Underground Laterals ❑1 ❑2 ❑H Frame ❑Pole Work.done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx �Ir7Q IZ� YORK Workers' CERTIFICATE OF srATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-9964687 Patricks Pools Inc PO Box 3024 East Quogue NY 11942 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a W_rap-Up Policy) Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 54375 Main Rd vWVC3465462 PO Box 1179 SoutholdNY 11971 3c.Policy effective period 05/1312020 to 05/13/2021 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partnersfofricers Included) QX all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"l a"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 above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or Its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded 6y the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Nicholas Zulkofske (Print name of authorized representative or licensed agent of insurance carrier) Approved by: -� /71zv (Signatur (Date) Title:Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering Into contracts unless compensation Is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or,office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)REVERSE aco' CERTIFICATE OF LIABILITY INSURANCE DAT E(MMIDD/YYYY) `.i - 07/13/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Brookhaven Agency,Inc. PHONErt 631 941-4113 Fax 631 941-4406 pic N.100 Oakland Ave,Ste IE-MAILnng . certificates brookhavena enc .com Port Jefferson,NY 11777 INSURER(SI AFFORDING COVERAGE NAIC d INSURER A: Philadelphia Indemnity Insurance Co. INSURED INSURER B.Wesco Insurance Co. Patrick's Pools,Inc INAUgEgc,• Merchants Mutual Insurance Co. PO BOX 3024 INSURER D: East Quogue,NY 11942 INSURER E: INSURER : 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 DL SUER POLICY NUMBER POLICY EFFbIMMDNYYYI POLICLTRIMMIDOY EXP LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE �OCCUR DAMAGE TO RENTED $100,000 X X PHPK2103006 02128/2020 0212812021 MED EXP(Any one n $59000 PERSONAL&ADV INJURY $1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 X POLICY EJ PRO-JECT ED LOC PRODUCTS-COMP/0P AGG $2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $600000 C X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07112/2020 07/12/2021 BODILY INJURY(Per accident) $ AUTOS UTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per greirlAnt) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS4ME AGGREGATE $ D RETENTION S $ WORKERS COMPENSATION X PER AND EMPLOYERS'EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACCIDENT $100,000 B OFFICERIMEMBER EXCLUDED, Y� NIA W WC3465462 05/13/2020 05113/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $100#000 1 s,d-pqlbe under I E.L.DISEASE-POLICY LIMIT s600,000 NO CERATIONSbaow DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may ba attached If more space Is required) Town of Southold is included as additional insured CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 64376 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE <CC> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD Yid workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART'I.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name P Address of Insured(use street address only) 1b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required lfcoverage ls specifically limited to or Social Security Number certain locations In New York State,i.e.,Wrap-Up Policy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) SheiterPoint Life Insurance Company _ Town of Southold 54375 Main Rd 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL318565 Southold NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2021 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © 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 described above. 7/17/2020 B C�U, Data Signed Y (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 carriers 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 JNYS Workers'Compensation Board(only if sox 4C or 56 of Part i 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. DB420'.1 (10-17) IIOIIPmuuiuQum iiii(i10im17)°[UI�I V v APPROVED AS NOTED DATE:, B.P.# oC q FEE: RETAIN STORM WATER RUNOFF NOTIFY ,BUILDING DEPARTMENT AT . PURSUANT TO CHAPTER 236 765-1802 8 AM TO 4 PM FOR THE OF THE TOWN CODE. FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH-- FRAMING & PLUMBING .3., INSULATION 4: FINAL - CONSTRUI-TION MUST BE COMPLETE F" = _.0, ELECTRICAL ALL CONSTRUCTIOP: SHALL MEET THE INSPECTION REOUIRED REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ARD LY•• �OLITW°IEES > °;; Dill O CODE ENC�:OSE POO _® NQS-BEC �;,, UPON CON,PtET10 : EFORE WATER" ; OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICAr::' OF OCCUPANCY i�� i QU\ Y`�,f Yt�•• ,_. ��-L3�'�CEIC`cl-s {Ei\\j J U�� :l• G , 1 - OA I i , .• oo IS rn 1 it a l V ` ' 1/ �! 1M IIJ 4! Jre � r Sc�1�. , I - _ Cc P..._.._..._ 't✓(�S^t t �__ �r�'fir � -� -sw�,�.: ,c:x��...--rtn:,. •:'.e..�,....�.zs,.�.,.azv�N;�'.ta s%,<.c-=^��:.,., .� .. .� :..,.;..,v,.'� j; , ` 9 , D' ARE ,AA? �7C:i1 '1r1 1� 4`1'J`(1 _. .. `,' V V��1� `'-, - ._ - - �� � -. .... `y-:.s.`-.._..v-`• a ---1 m- � � ,� al *_ - ...i '.,.5 1i� }� 'F. 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P. � f 1 - 3 s , ( ' I l v , : 6 , i 1 � r , i : I t j i3 i } ) i i - - - _ • 1, LU i 'Poo'-Y-, C-\�,s 'k. 0() vz� 7 t I � } , : , ; , , , , E i } , 1 , i 3 F w , , , S i , , r • , f , �__..._��-.��.-,._.-.�:�.,._� ._�._v.�.,,z..,.�,�:....�__.,.w ���=__.,r_•w:_�r�_.,u�...�:.�.4w�.,...._-0�..�._..__.v.�__._� ..�:.,d....�...�..,_•..a.._�_.._.�_.�_,..__..-...�.�,.-.y�,�.�___.a.._..___d�....._.�..r_._�.�.__�,._.._.�..�._-_.�..�...�.�.:..��,. ._.,�.,__-__-��.._..�,-w:.�.r .__- �,__�.w._�___.__._��.__-�-_�..°:.....�..w__ .�n�.Y�....___._._�,�_-.�,-.:�..��_�_�_:.�_._..�. 5URVEY Of PKOFERTY 51TUATE: 50UTHOLD TOWN : 50UTHOLD 5UffOLK COUNTY, NY 0F SURVEYED 10-27-2020 tO , )\o-t SUFFOLK COUNTY TAX # 0 M.W— ?-00- 1000 - 75 4 - I ?CT CSS + 0 CERTIFIED TO: POLY 0 \ 130 0 Simone Nardi ?I Daiena Masciarelli > Spano Abstract Service Corp.; Title No. SP44373—S Westcor Land Title Insurance Company VIA Citibank, N.A. 0 0 FR�Nlf eb ox 0 0 76 C;ocw G��Gt - 0 O O =-- q z GO—oc- _ } r' 0 0 0 o -7 V 0 -7- 70 ---------- 713 . ZOO 00 0 011 5-75 F,vo?UAI:FL- " . GING NOTES: MONI 1MENT MUND map hearing licensed land s—yr*i seat a Viclatian of section 7209.-b-&v'Sla.2,of the JOHN C. E�ILER5 LAND 5L New'fork State Education Low.' STOCKADE MUND r "Only copies 1`11.1 the original of lhls survey WRE FOUND ked.;th an original at the land brv,)-'s stamped s.ol shall be—alde,ed to be�01!d J,�, G EAST MAIN STREET N.Y.5, LIC. 1,10. 50202 'Certifications indicated hereon signify that this survey was procured in-1c-1 d--with the 1cling rode a(P-=11,- Land Surveys adopted Area = 28,70 T RIVERHEAD, N.Y. 1 1901 3G3-(5285 Fax 3CO-8257 e for by!h,New York St.t.A—c;atft- of P-fe-1-1 Area = O.G59 Acre, Land Said -,hdt—­jy —Sury (S—ay—. 1. he person'or h—the survey h prepared, JP e,,/(,@cptonline.net P-1KAPHIC 1GALE 301 and tat oo He behalf to the title C—pa.y,gDvernmen- to the assignees and e dl'girstfhjtloa 1W ad " 17-176 o�s9iqnf the,end;"i-!t. on Ce,Iffc- -- tions-a not t--fer.ble to addiUanal natit.licas j . SURVEY OF PROPERTY N 51TUATE: SOUTHOLD Op,� TOWN : SOUTHOLD SUFFOLK COUNTY, NY M goer°�;�,�, SURVEYED 10-27-2020 t PN© tGriE�ti N )tt�R' Poll S SUFFOLK COUNTY TAX # W alt N_ Z00.7 UTI_ 1000 - 75 - 4 - 1 sn — — — POS (� i uriL• -4" O. CERTIFIED TO: Pow Q V3Ott f W m Simone Nardi7I O \ t j Daiena MasciarelIi N + 5 lip O Spano Abstract Service Corp.:Title No.SP44373-5 ;Q I Westcor Land Title Insurance Company Citibank, N.A. Zee ll 1 O I _ GON GWp Gb p %4 � z z __ CpNG• r n tmg I -C < g� _ 1 0 ;�; 0+ Z �� s f -'.. -n j it •s.s -6 1A'& r4Vs ! in `Yj67Y O 7-0 . _': APR 2 6 2021 _ ' Dc�`r—``°''�.Y � 13 �! pE.A1014G 00.0 2 57 5015 �w-Y OF: �FOS A lA1`tfl� L GING�A GtNGO ! NOTES: r Vnoulhorized alteration or addition to o wrvey 4s e�J mop bearing o licensed land surveyors seal is a ® MONUMENT FOUND JOHN C. E H LE R5 LAND 5 U RVEYO R _ .�, ,�G.E,�� a �rolatron of section 7209,wb—di•Asion 2,of the —�- STOCKADE FOUND O[' .� dw ,� New'York Stole Education Law. 'P Only copies from the original of this survey —X—X— WIRE FOUND °j✓ morked with an original of the land surveyor s m f, "� staped seal shnll be considered to be valid true G EAST MAIN STREET N.Y.S. UC. NO. 50202 I v��''<;. aaple rea = 28,708 sa. Ft. RIVERHEAD, N.Y. 1 1901 3G9-8288 Fax 3G9-8287 orwy -Certifications indicated hereon signify that this I < —+,b ro ming was prepared m or Land with the ted F) �e�.uti; isling Code of Practice for Lond Surveys adopted rea = O.G59 Acres >i? by the New York State Association of Professional je5urvey@optonl!ne.net y 5G2 J3+ Land Surveyors. Said certifications shall run only oRAFMIC SCALE III=301 I 11'`� �� to the person far whom the survey if prepared. L——MI 005 �C{�11) and an his behalf to the title company"gavernmen— 17-!76! t?Z+L tel agency and lending institution lialed hereon,and to the assignees of the lending institution. Certifico— lions we not transferable to additional nslitutians i