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HomeMy WebLinkAbout47268-Z �OS�EFOIy Town of Southold 9/24/2023 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY J No: 44560 Date: 9/24/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1055 Rosewood Dr.,Mattituck SCTM#: 473889 Sec/Block/Lot: 113.-2-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/3/2021 pursuant to which Building Permit No. 47268 dated 12/27/2021 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 Elmokian,Edmond&Ashhen of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47268 5/2/2022 PLUMBERS CERTIFICATION DATED 0 Au ori ed ig ature �o�SUFFot,�� TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o • SOUTHOLD, NY ,y O� 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 #: 47268 Date: 12/27/2021 Permission is hereby granted to: Elmokian, Edmond 64 Clinch Ave Garden City, NY 11530 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1055 Rosewood Dr., Mattituck SCTM #473889 Sec/Block/Lot# 113.-2-5 Pursuant to application dated 12/3/2021 and approved by the Building Inspector. To expire on 6/28/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 ilding Inspector OF SOUryol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlin(c)-town.southold.ny.us Southold,NY 11971-0959 �Q OWN, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Edmond Elmokian Address: 1055 Rosewood Dr city:Mattituck st: NY zip: 11952 Building Permit#: 47268 Section: 113 Block: 2 Lot: 5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: TRC Electric License No: 46689ME 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 1 4'LED Exit Fixtures Pump 1 Other Equipment: Intermatic Pool Panel 8 Circuit/ 3 Used, Pump 220GFI, Salt Generator, Hayward De( Box Transformer Notes: Pool r Inspector Signature: Date: May 2, 2022 S. Devlin-Cert Electrical Compliance Form pE SOUTL4 2 `ZcTowoo6( * # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ I 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) 11-4 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 10a� Ok DATE INSPECTOR q7)4 ho��OP SOGTyO� # # TOWN OF SO UTHOLD BUILDING DEPT. courm��'` 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULA [ ] FRAMING /STRAPPING [ FINAL rULKING [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMAR S: Q �/� �/ win r 1 � f DATE II INSPECTOR OP SOUTyOIo - -- ��� # # TOWN OF SOUTHOLD BUILDING DEPT. courm, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] NSULIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL pal. J:�� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION . [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 5v . Z DATE INSPECTOR WOM w ml 0 M z MD MAIM I.1 UV&f. ... 0 to �► f t } 10 AA of d" r � , AL- 1 r' • I . . • ' I • 7VF !mss a Ow mv .ti aM► ;. 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AV i .y., .r� •1 ILI ter Ir . Y ••• • • 1 • -� •• •1- • 1 • • '•'• :•� •• t r r • � ® � e y e oT— • r • • r • ° r ROUGH 11 PLUMBING � • STATE El�ilkdV er _ M mop-- Wo : _ M;T4 rffAr�%AW2TM IMM Milt �P�ye',��'���di�� � �_ ;►,"'moi � MUM DE 7TM lob Wv ' s r^crtq+, ���oSUFfot r�oGz�', TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy�0 ao� Telephone(631) 765-1802 Fax(631)765-9502 https://www.soutlioldtownny.gov Date Received APPLICATION FOR BUILDING PE MIT For Office Use Only PERMIT N0. q-12 Building Inspector: `J DEG3 2021 Applications`.and`a'r'ms mdst`be:filled ouf�'irr.their=entiretV' Incomplete `application's will riot tie a'ccepted.`.Where.the Applicant is not the'owne,r;an (303 3�Ri�DEPT Owner'sAuthori ation,.form:(Page,2)ahall be;completed. 'TOVV el OF SOUTHOLD Date: 'OWNER(S)OF PROPERTY:;­" Name: SCTM#1000- ._ ...IIac�JD_ I rl<.l,4i� .. ._ - Physical Address: ��SJ� osa Phone#: ti Email: X16 .._, , 0 / ._,. . . _ Mailing Address: d.�.!�.L-�. .. , . . J .��.. Vft1.. . �- _ �..... ,0NT4CT P ERSON: r� Name: Mown Expediting UNiM Mailing Address: Suiite,212 Phone#: I..CViUDwn,NY11756 Email: jY7pl�f'1t7 ��2t�i�ln �cJw!-�sD CovYr NFORMATI o : `;DESIGN�PROFESSIONALYI N , Name: e1. Mailing Address:._ .._. .. 0•.. OX..._ �.�f....�Ge�So `� . 31 Phone#: Email: ax, - M ION :.CONTRACT R .......::.. ....:. .- . . , - r, Name: Mailing Address:.. 5y _ 1, l_ C u(1iyL4_)2Cora .. ..n. . . /"12--^7 Phone#: Email: r:®ESCRIP..TIO,f�`OF PROPOSED'GON,STRUCTION :.` ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estirpated Cost of Project: Mther , 1 po ilrol.t.Y1.d $ 60, 000. Will excess fill be removed from premises? Les ElNo Will the lot be re-graded? D'Yes W"D 1 PROPERTY INFORMATION` ;" Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes o IF YES, PROVIDE A COPY. i?Ck.BOX After'Readin" '',The owner' contractor,de'si n rofessional'is res�onsible forill'dralnage,and storm water,issues;as,�pro%ded by:: "Chapter 236,of the,Town'Code:�APPLICATION IS HEREBY MADE16the Building Department for the issuance'of,a Building Permitpursuant to the Building,Zone:,, Ordi6anc6of the Town,of Southold;Suffolk,County,,,New York,and bihher applicable'Laws,`Ordinances,or.Regulations,for the construction of buildings;'; ,'additions;alterations or,for removal or'demolition as Herein described.Thea pplicant,igrees to complywith-all applicable"laws;ordinances;building code', housing code and.regulations and to_admit authorized inspectors,on premises andein building(s)-for.necessary Inspections:False statements made herein are . punishable'as a Class A rnisdemeanor,pursuant to Sectiom210:45-of the'.New;York State Penal.Law.,+ Application Submitted By(print name): ❑Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTYOF Thi M l3 I(. y.�� )�l q:►-, being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the-- own ti( (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 la day of N etc -f/ .20 o-I Nota Public DANA MAULTSBY Notary Public-State of New York NO.01MA6163015 PROPERTY OWNER AUTHORIZATION Qualified in Queens County My Commission Expires Mar 19,2023 ■ (Where the applicant is not the owner] A 47waw C'my residing at " r Ll / / //15-30 do hereby authorize A&4 do hiond LAS )s to apply on "behalf n of Southold Building Department for approval as described her inl1 /�- �2nature ate r5Al o/WD FL-M oklo/ol/ Print Owner's Name 2 ��S�F. APR 4 2422 UILDING DEPARTMENT- Electrical Inspector B No s°�No�Town Hall Annex -O 4375 Main Road - PO Box 1179 �- ^ft Southold, New York 11971-0959 o. 4� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(@southoldtownny.gov - seand(aD_southoldtownny aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: T7Z7 Z Company Name: , , 4-1cC%11264-- . CIC92-p Electrician's Name: :n2 M45 ckm vt,�.eq-5 License No.: t1g6<R7, WtG Elec. email:- Elec. Phone No: 3) g Yg_ 7-55-�- %I request an email copy of Certificate of Compliance Elec. Address.: 16 11=L .,-*,d p7s:5- JOB SITE INFORMATION (All Information Required) Name: Address: off' o5e wog, Cross Street:. Phone No.: 06 d _ Z6 a-6 Of 7 . Bldg.Permit#: L�7�.�g email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUA E FOOTAGE (Please Print Clearly): /j/`j jLOu N� ®O� / j�JT .v"� t cel�j�17 Square Footage: Circle All That Apply: Is job ready for inspection?: � YES ❑ NO ❑Rough In ® Final Do you need a Temp Certificate?: F-1YES NO Issued On 1-00 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 2 H Frame Pole Work done on Service? Y DN Additional Information: PAYMENT DUE WITH APPLICATION v OSVf QR 2422 UILDING DEPARTMENT- Electrical Inspector GpVpT. TOWN OF SOUTHOLD o B��0F:so H°Town Hall Annex - 54375 Main Road - PO Box 1179 C-0 • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 � P rogerr(�.southoldtownny.gov — seandCcDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Z� n z Z Company Name: _ Electrician's Name: :n'v A45 Ck+t Vk,--eR-5 License No.: PAG Elec. email: C yyZc> `' �,•vf�1 -��4+-t Elec. Phone No:,Q)_� Yg_ 79 s--Y 01 request an email copy of Certificate of Compliance Elec. Address.: 16 V!z:�!-z-,.v Air .64.W ,v /�7Ss— Ir JOB SITE INFORMATION (All Information Required) Name: C1J M u.U, L=/yam X-��,✓ Address: off' o5e-wob, ` ;)Pg k Cross Street: Phone No.: S-26 r V26 -6-0 1 Bldg.Permit#: Z�7o2 6V email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUA E FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: IR YES NO ❑Rough In Final Do you need a Temp Certificate?: ❑ YES NO Issued On Temp Information: (All information required) . Service Size n1 PhF—]3' Ph Size: A # Meters Old Meter# EJ New Service❑Fire Reconnect❑Flood Red onnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame r7l Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION \° \cls PERMIT# Address: Switches f Outlets ` G FI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini e Special: Comments. , �6-` �V L �, � V �� ,��, ter�� I SURVEY OF LOT 17 :p AS 5HOWN ON A MAP ENTITLED"P,05EWOOD E5TATE5a N FILED IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY,JAN. 24, 1969 AS MAP NO.5240 51TUATE: MATTITUCK w TOWN : SOUTHOLD E SUFFOLK COUNTY, NY SURVEYED 08-26-2020 S SUFFOLK COUNTY TAX # 1000 - 113 - 2 - 5 CERTIFIED T0: i Bdmond Elmokian 0 v' Ashben Elmoldan Langdon Title Agency LLC LTA-8772 Stewart Title Insurance Company �-••"�� � �Zz United Nations Federal Credit Union, ISAOA/ATIMA -50 N 9� GN�M ADA` N0 � •63 lZ. O r Q� 12d \a.\' ZN 70 N n, A Q r � 7 o �VAN 7-A 2B•3 `y 6 rv�o : � o .ts I.:.t.•... > 0- M 1 r.'.. "Unauthorized alteration or addition to a survey maP Dearing o licensed land amwyor's seal fs o "p, violalion of seel1.7209,sub—division 2,of the \\ ,•, ,,`\.��.r.::-,`r,�.,;�'�._•:`,, New York Slate Education Law." O '.'.J "', -''I �•� 'r,.;-:`�d., 'only eo ias tram the original of this survey \ Y P 2 marked with an original of the land surveyor's �f103 stomped sect shall be considered to be valid true G6 Ij VQ` copies" J '1 •'•' "Certilications indicated r' hereon signify that This survey was prepared in aeeordanee with the '�n /c",••1,?. fisting Code of Praallco for Land Surveys adopted by the Now York Stola Asaoclation of Proressionol Land Surveyors. Said certincallans shah run only to the person for whom Iha survey is prepared, and an his behalf to the title company,qavern non— . lal agency and lending Inslllullon listed hereon,and , to the assignees of the lendingg Ins111ullon. Cerllflca— 1 tions ore not transferable to additional Institutions fl NOTES: + MONUMENT FOUND JOHN C. E h LE R5 LAND 5 U RVEYO R ` I I 6 EAST MAIN STREET N.Y.S, LIC, NO. 50202 Area = 20,101 5q. Ft, RIVERHEAD, N.Y. 1190 I 369-8288 Fax 369-8287 j Area = 0.46 Acres GRAPHIC SCALE! 111= 301 je5urvey@optonhne:net 2020-143 LONGI-7 OP ID: EI ACORO� �,,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDryrrY) 11/19/2021 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 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). PRODUCER 631-669-3434 CONT ACT Brennan P.Regan Regan Agency,Inc. PHONE 631-669-3434 FAX 631-669-3035 463 Deer Park Ave (AIC,No,Ext): (Arc,No): Babylon,NY 11702 ED DR AILss• Regan Agency,Inc. INSURERS)AFFORDING COVERAGENAIC# INSURER A:American Casualty Company 20427 IN D INSURER B:State Insurance Fund 36102 Long FfsIand Pool 8 Patio,Inc. 543 Middle Country Rd. INSURER C: Coram,NY 11727 INSURER D 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 DDL UBR POLICY NUMBER POLICY MIDDIYEFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1'000'000 CLAIMS-MADE �OCCUR X 5099218546 12/2012021 12/2012022 PREMISESO a occurrrence $ 100'000 MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2'000'000 X POLICY 1:1 JECT F—I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMB(Ea LIMIT $ ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED rPROPERTY AMAGE AUTOS ONLY AUTOS ONLY er accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY ST6TUTF Y/N 12439791-1 04/1012021 04/1012022 100,000 ANY PROPRIETORIPARTNERIEXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICERlMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100'000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Property Section 5099218546 1212012021 12120!2022 BPP 150,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Certificate Holder is additional insured. CERTIFICATE HOLDER CANCELLATION SOUTHOL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Route 25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE �w ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4. Suffolk County Dept. of er Affairs- bor Licensing & Consum, La. HOME IMPROVEMENT LIC-EN E NaMe .MI-"C, flAELJ DOM-1 NIC I This certifies that the bearer i d tlY Ii ense ON ISLAND PMOL PATIO INC by the Count' of suffol License Nw"rrber H4 5107 Rosalie Drago 2212000 Issued ., 04/ 0��i,saajoner E=x. res. � 1 / 112{ � T LONGI-7 OP D• E ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/03/2020 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 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). PRODUCER 631-669-3434 CNOAWCT Brennan P.Regan Regan Agency,Inc. PHONE 631-669-3434 FAX 631-669-3035 463 Deer Park Ave (Arc,N. Ext): (A/c,No): Babylon,NY 11702 E-DMAIL DRESSm Regan Agency,Inc. INSURERS AFFORDING COVERAGE NAIC# INSURER A:American Casualty Company 20427 INSUR D INSURER B:State Insurance Fund 36102 Long FI-Iand Pool&Patio,Inc. 543 Middle Country Rd. INSURER c Coram,NY 11727 INSURER D 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 DDL UBR NSIDPOLICY NUMBER POLICY EFF POLMMIICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY '1,000,000 EACH OCCURRENCE CLAIMS-MADE OCCUR X 5099218546 12/2012020 12/2012021 DAMAISES Ea occu a ce $ 100'000 MED EXP(Any oneperson) 15'000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 X POLICY El PES F-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBIcN 8D SINGLE LIMIT $ ANY AUTO BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOSyy BODILY INJURY Per accident r 1 1 $ AUTOS ONLY AUTOS ONLY PeoacEclRdent AMAGE $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ B WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY STATUT ER _ 12439 791.1 04/10/2020 04/1012021 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT OFFICE JIM MgER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Property Section 5099218546 12/2012020 12/20/2021 BPP 150,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate Holder is additional insured. CERTIFICATE HOLDER CANCELLATION SOUTHOL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE I OF� I ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t NYSIF New York state Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE � O R` = A A A A A A 112590890 r REGAN AGENCY INC _ 463 DEER PARK AVENUE 0 BABYLON NY 11702 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND POOL&PATIO INC TOWN OF SOUTHOLD 543 MIDDLE COUNTRY RD 54375 MAIN RD CORAM NY 11727 SOUTHOLD NY 11791 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12439791-1 190110 04/10/2021 TO 04/10/2022 11/23/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2439 791-1, 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, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. 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 POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT MICHAEL DOMINICI LONG ISLAND POOL&PATIO INC (ONE PERSON CORP) 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 STAT SUR NCE FUND STAT lei DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:384507745 U-26.3 voRK workers' CERTIFICATE OF INSURANCE COVERAGE srAre I 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) 1 b.Business Telephone Number of Insured LONG ISLAND POOL&PATIO INC 543 MIDDLE COUNTRY ROAD CORAM,NY 11727 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 112590890 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1a" 54375 Main Rd. DBL575672 Southold, NY 11971 3c.Policy effective period 01/01/2020 to 12/31/2021 4. Policy provides the following benefits: 0 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 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 described above. Date Signed 10/7/2020 By W40'.4f (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B 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) DB-120.1 (1017) I01111 'HMINGINEERING`P.C., EAST NORTHPpx ORT,_NY 11731 EM AIL':,HMA RNIKA@OPTONLINE.NET November 22; 2421 Town of;Southold, Building Depart'mI ent Town Hall Southold;N.YA 1071 Dear;Sir/Madam: - , This,is to certify,that the.drainage facilities to.be used exclusively for the construction of a swimming pool on,the.preiliises,o£ 'Elrnokian.Residence . 1055'Rosew06d Drive . 1Vlattituck,N.Y. 11952 will-n6f tequire :draining;because; the;'po61 is ,constructed ,with .A vinyl liner: The pool 'water,will :be'' continuously recirculated through the filter Arid will be reused,from.year,to,year, S"' flus;pool'will:have a cartridge filter, there will be no backwash: There wily be no,,interference.with.the.public water supply systein;existing sanitary facilities;adjoinng'prope�rty,owners;.public:highways or<private,roads' Sincerely; MgneeringP.C. 7z, aikaPE,n kal APPRO ED AS NO ED DATAE: O9 B.P.# RETAIN STORM WATER RUNOFF FEE ,� BY: PURSUANT TO CHAPTER 236 NOTIFY BUILDING DEPARTMENT AT OF THE TOWN CODE. 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE ELECTRICAL REQUIREMENTS OF THE CODES OF NEW 'INSPECTION REOUIRED YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF °rP�r d ED,10t'LY".: ENCLOSE POOL TO'C.QDE. z,UPON COMPLETION .._vSggliP�_ ARD ''. FORE."WATER" S N Y e nGr OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE )F OCCUPANCY NOTES: 1.POOL AND PROPERTY TO CONFORM TO 2020 NYS UNIFORM FIRE PREVENTION AND BUILDING CODE,TOWN 4' x 8' CONTINUOUS CONCRETE OF SOUTHOLD CODE AND 2017 NATIONAL ELECTRIC CODE. STEP COLLAR (ENTIRE 2.POOL SHALL CONFORM TO ANSI/APSP/ICC 5 STANDARDS R326.3.1. PERIMETER) SEE DETAIL 3.SECTION R326.7 POOL ALARM REQUIRED. THIS SHEET 4.ENTRAPMENT PROTECTION REQUIRED SECTION R326.5. 5.POOL SHALL COMPLY WITH BARRIER REQUIREMENTS SECTION R326.4. I " ' �` •� .': .:;.t :_.'"' •.';' 6.POOL SHALL COMPLY WITH 2020 ENERGY CONSERVATION CONSTRUCTION CODE OF NYS SECTION R403.10: POOLS AND PERMANENT SPA ENERGY CONSUMPTION(MANDATORY). 8' ` SECTION R403.10.1 HEATERS SECTION R403.10.2 TIME SWITCHES I SECTION R403.10.3 COVERS 7.SLOPE PATIO SURFACE 1/4"PER FOOT(MIN.)AWAY FROM POOL. 8.LOCATION OF PROPOSED SWIMMING POOL AND POOL EQUIPMENT BY OTHERS.LOCATION TO COMPLY WITH LOCAL ZONING REQUIREMENTS. 22' VIN)nL I I ' ''? 9.BACKFILL MATERIAL TO BE FREE DRAINING GRANULAR MATERIAL(NO CLAY OR LARGE ROCKS). 10.FILL POOL WITH WATER PRIOR TO BACKFILLING. 18' SVVMMNG PCXDILI I 11.POOL TO REMAIN PERMANENTLY FILLED. 680 S.F. I I - 12.ALL DRAIN COVERS TO MEET ALL REQUIREMENTS OF THE VIRGINIA GRAEME BAKER(VGB)POOL AND SPA I SAFETY ACT. 13. NO DIVING EQUIPMENT PERMITTED. = 14.CONTRACTOR SHALL VERIFY SOIL BEARING LOADS PRIOR TO INSTALLATION OF POOL. t-.`• 15.THIS PLAN IS FOR CONSTRUCTION ON PROPERTY AT 1055 ROSEWOOD DRIVE,MATTITUCK,N.Y.11952 ONLY. 16.HM ENGINEERING,P.C.SHALL NOT BE RESPONSIBLE FOR CONSTRUCTION MEANS,METHODS,TECHNIQUES OR PROCEDURES UTILIZED BY THE CONTRACTOR,NOR FOR THE SAFETY OF THE PUBLIC OR CONTRACTOR'S EMPLOYEES,OR FOR THE FAILURE OF THE CONTRACTOR TO CARRY OUT THE WORK IN ACCORDANCE WITH THIS PLAN. 36' 17.SUCTION OUTLETS SHALL BE DESIGNED AND INSTALLED IN ACCORDANCE WITH ANSI/APSP/ICC 7. 18.NO SURCHARGE ALLOWED WITHIN 4'OF SHALLOW END AND 6'OF DEEP END. FILTER - POOL PLAN BRACE BRACE (FILL 6- NOTE: NOT TO SCALE (TYP•) Fpu7MP CAVITY WITH GRAVEL THIS IS A NON-DIVING POOL. AGGREGATE OR CVINYL LINER ONCRETE) 2.0 (TYP.) SKIMMER STRAINER (V DUAL MAIN RAIN WITH = _ -- o 36' SAFETY C - (MIN.) APPROVED DRAINS) O 3'-4' HIGH O 3'-4" VIEW ACROSS CENTERLINE OF HOPPER SWIMMING POOL COMPOSITE PANEL 6' 0 6* x 36' CONTINUOUS CONCRETE COLLAR 2' SAND BOTTOM DRIVE STAKE r.:•':.,'- O (ENTIRE PERIMETER) TAMPED & ROLLED FILTERED WATER RETURN, NUMBER OF NOZZLES VARIES PER 17' 10 6' 3' POOL SIZE — — — — — — MAIN DRAIN PIPING SCHEMATIC LEVELING BASE UNDISTURBED NOT TO SCALE EARTH POOL SECTION NOTE: WALL SECTION AND BRACE SYSTEM NOT TO SCALE DRAWING CONFORMS TO ANSI/APSP-7 SUCTION ENTRAPMENT AVOIDANCE CODES. NOT TO SCALE GENEL NOTE: ALL MANUFACTURED ITEMS AND CONSTRUCTION SHALL COMPLY WITH THE 2020 - BACKFILL MATERIAL TO BE SAND,GRAVEL OR OTHER=® C E RESIDENTIAL CODE OF NYS,INCLUDING THE SPECIFICATIONS IN SECTION R326. PREPARED FOR: NON-EXPANSIVE MATERIAL. DEC 012021 ELMOKIAN RESIDENCE BUILDING DEPT. 1055 ROSEWOO 11 DRIVE TOWN OF SOUTHOLD MA (TUCK, N. 11952 DATE: 11/22/2021 NOTE: -,-v-0 HM ENGINEERING, P.C: SCALE: ASSHOWN THESE PLANS ARE AN INSTRUMENT OF SERVICE AND ARE THE PROPERTY OF HM ENGINEERING P.C.UNAUTHORIZED _ )/ SHEET: 1 OF 1 ALTERATIONS OR ADDITIONS TO THESE DOCUMENTS AREA VIOLATION OF SECTION 7209 OF THE NEW YORK STATE C [ 2-1 P.O.BOX 914,EAST NORTHPORT,NY 11731 EDUCATION LAW.INFRINGEMENTS WILL BE PRosEcuTED. Tel:(516)476-5392 Fax:(631)980-7671 Email:hmarnika@optonline.net RESIDENTIAL SWIMMING VO WITH RAISED SEALAND BLUE SIGNATURE POOL PLAN