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HomeMy WebLinkAbout46475-Z �o�Og11fEQ1�c0 Town of Southold 8/9/2023 a Gy< P.O.Box 1179 o - W m.� 53095 Main Rd �oy?j! �oo� fir Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44423 Date: 8/9/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2545 Henrys Ln,Peconic SCTM#: 473889 Sec/Block/Lot: 74.4-44.4 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/16/2021 pursuant to which Building Permit No. 46475 dated 6/23/2021 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 Hardy,Stefan&Singhal,Mridu of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46475 6/2/2023 PLUMBERS CERTIFICATION DATED AultriLjj Signa `gpFFOIK TOWN OF SOUTHOLD BUILDING DEPARTMENT C x TOWN CLERK'S OFFICE "o • �,' SOUTHOLD, NY t� 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#: 46475 Date: 6/23/2021 Permission is hereby granted to: Hardy, Stefan 144 N 8th St Apt 2B Brooklyn, NY 11249 To: Construct in-ground vinyl swimming pool at existing single family dwelling as applied for. At premises located at: 2545 Henrys Ln, Peconic SCTM # 473889 Sec/Block/Lot# 74.-1-44.4 Pursuant to application dated 6/16/2021 and approved by the Building Inspector. To expire on 12123/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector OF SO!/r�ol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 i� sean.devlin(Dtown.southold.ny.us Southold,NY 11971-0959 OIyCOUIV BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Stefan Hardy Address: 2545 Henry's Lane city:Peconic st: New York zip: 11958 Building Permit#: '4&4-15 Section: Block: Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: License No: SITE DETAILS Office Use Only Residential X Indoor Basement Service commerical Outdoor X 1st Floor Pool X New 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 Transfer Switch UC Lights Dryer Recpt Emergency StrobeHeat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 1 pump , 1 cleaner, 2 time clocks, lights,1 intermatic panel 8 space 4 used, 1 salt gen Notes: Inspector Signature: Date: June 2, 2023 2545 henrys In - Ll b 47 � 25 4� Ya, c �O��oF soujyo6 # * TOWN OF SOUTHOLD .BUILDING DEP' . Citi rim � 7654802 INSPECTION - [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION 10 ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O ` n REMARKS: ` DATE __7 � INSPECTOR c OF SOOj,�olo P7 LA # TOWN OF SOUTHOLD BUILDING DEPT. `yco 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"'�e� k L-2 f- M41PS -.01 II-C, hain cl a ck r DATE of INSPECTOR OF50GtyOlo # # -TOWN OF SOUTHOLD BUILDING DEPT. °`yrournr, ' 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) ELECTRICAL (FINAL) [ ] CODE VIOLATION [/ ] PRE C/O REMARKS: DATE d INSPECTOR c�� l"J�f hoy��OF S0Ulyo6 ` Y/o l "'1►► !!! * TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL pnt--� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ PR C/O [ ] RENTAL REMARKS: [ 6v L ky4,,. yrtcs�tS — +►� Sl • r DATE INSPECTOR OF SOUTLf q75 # # TOWN OF SOUTHOLD BUILD114G D PT. 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: DATE Z 2� INSPECTOR ' 0f SOUTy�6 # # TOWN OF SOUTHOLD BUILDING DEPT. `�couHtv��' 631-765-1802 X15 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ 1i]"FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: O21�Gv C I . mo d I A o � -aR--�r GVA ,/L GC,4 A►tel I��C_5 �J2P�1ti 'e'l DATE INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS � ►e FOUNDATION(IST) U � ------------------------------------ C .FOUNDATION(2ND) � O H ROUGH FRAMING& y ' PLUMBING .� INSULATION PER N.Y. y STATE ENERGY CODE cvewbic- vd ( FINAL A ._. IL ADDITIONAL COMMENTS ql l 3 UD =� f � � — 3� 1 2� o I 'G r ^ 0 z rn H y� t" H C[ d H o�SlaFF174COG TOWN OF SOUTHOLD—BUILDING DEPARTMENT a y� Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 https://www.southoldtowmi�gov f Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector: \\\� C_a \3 JUN 1 6 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 Win___ T r TN7"Pm Owner's Authorization form(Page 2)shall be completed. " Date: OWNER(S)OF PROPERTY: Name: � , SCTM#1000- -Iti Physical Address: J,LAs Phone#: Email: Mailing Address: CONTACT PERSON: Name: L-(DV- 5`S��c�v�a Mailing Address: 50c>oc) Phone#: 62) ---7 ksoj O a-95 FEmail: LT. q06`Cc,fo�— � • ' DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: n_ - --airp /� Name: �--O'n C Lr\A \p C CXR\ , Cod Mailing Address: b ooc) Ve &k-n Phone#: �3\ -) � Email: L� e(�O r�� W)a � 1 DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther PC50 $ X904) Will the lot be re-graded? 'LL.Yes ❑No Will excess fill be removed from premises? lkyes ❑No 1 PROPERTY INFORMATION Existing use of property: e S •�n k 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�ANo IF YES,PROVIDE A COPY. 14 Check BOX After Reading: Tho 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,Ordlnances 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 210.05 of the.New York State Penal law. Application Submitted By(print name): �1� U�``� authorized Agent ❑Owner Signature of Applicant: Q Date: STATE OF NEW YORK) COUNTY OF fA A l ) �`S� Eel Oma!tib- being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, \ (S)he is the �4�e,+r��— L'�``n�SS��G� �C p vim` (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 thisjk -� �)j /qtr day of " l lel 20a I �' o ary Public TRACEY .DWYF_R (VOTARY PUBLIC,STATE OF NEW Y K PROPERTY OWNER AUTHORIZATION NC.01DW6306900 (Where the applicant is not the owner) QUALIFIED IN SUFFOLK COUNT COIU[L4ISSION EXPIRES JUNE 30,2 02 I, S7lkN � iD -residing at S5 ��,J I.nmf.r� dA�!^G. do hereby authorize USpt d iri to apply on my behalf to 6e To n of Southold Building Department for approval as described herein. 0111024 / jws Signa Date Print Owner's Name 2 Cy-,-qoR— vzO(5-0 :1:17-AC)TO Z, Ur BUILDING DEPARTMENT- Electrical ljr�spector TOWN OF SOUTHOLD MAR' 2021 C= ma` Town Hall Annex - 54375 Main Road - PO Box 11'(9 co • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631)'765-95.02,, rogerr(cb-southoldtownny.gov - seandasoutholdtownny.%ly APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: 7 q Company Name: S- O� Eleck-< Lc'-, Name: License No.: Lk 1--k email: L-:—L Phone No: 219(,- request an email copy of Certificate of Compliance Address.: \ CS JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: Phone No.: C( k Lk I.VZ� '3u Bldg.Permit#: +5 4\S- email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Check All That Apply: Is job ready for inspection?: UES ❑NO 2�Rough In E]Final Do you need a Temp Certificate?: YES [:]NO Issued On Temp Information: (All information required) Service Size F-11 Ph F-]3 Ph Size: A # Meters Old Meter# FINew Service FiService Reconnect [] Underground []Overhead 1# Underground Laterals Ell F - _]Y F-1 N ]2 E]H Frame [❑]Pole Work done on Service? Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx ,. �SUF �(� BUILDING DEPARTMENT- Electrical Inspector j�� CQ� TOWN OF SOUTHOLD ii Q =` Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 ap Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrCcDsoutholdtownny.gov - sea ndCc�southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Name: License No.: email: Phone No: 01 request an email copy of Certificate of Compliance Address.: JOB SITE. INFORMATIO (All Information Required) Name: S'�� Address: Z SL 5 P(eru- S Cross Street: Phone No.: Bldg.Permit#: 1 j email: Tax Map District: 1000 Section: 7 Block: Lot: , BRIEF DESCRIPTION OF WORK (Please Print Clearly) Check All That Apply: Is job ready for inspection?: ❑YES ❑NO ❑Rough In ❑Final Do you need a Temp Certificate?: DYES 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 cRMIT# Address: . Switches Outlets GFI's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven W/D Smokes DW Mini Carbon Micro Generator Combo Cooktop Transfer AC AH Hood Service Amps Have Used Special: Comments. i i • s '0I' / 1_6 n�Di W 'pvTi 37o s Baa c •y� "'•p. �eg • '0 00 el-0 c i Q .a. J15�Ot' �A 0 mA SURVEY FOR F. V/TO LOPEZ 8 ANGELA M. BAT i AGL LOT •NO, 3 , a PECON/C KNOLLS /A d AT PECON/C TOWN OF SOUTWOLD IIAYEj NOV. /B, 1997 !� SUFFOLK COUNTY, NEW yoftSCALE I " 2 SO NO, 97.0730 _ FQ�AI,T.C� •1AMUMORtZ LO AL/WT#1-OR A00,11oa TC fUllV[T 4A VIOLATION O/fLCTIOp 1!101 O/TN[Is A'SRT/fl OTO: Mt1[•TOM 7TAT([ OATIDN LAr VIM LOP6Z a C0►IItI C/ Mlf'TIpV[Y NOT �[IUIMO 7Nt LAMO ANGELA AL M.M.40LIA aunVtt011A It0tl0 fLIL OR lNIo[ff0 tGIL 1NALL aOT K Cb11ftOERtO TO K A YALIO TRUL told- R/OGEK'000 SAV/NGS HARM HEALYH DEPARTMENT-OATAFOR APPNQ1tIl TO MauAMRTtU W014TIC Ntmoa IIv L tuna T t0 F/O$LI7Y NArIO11abL t/TLf/NS(/RANCE M N[ARtt1T RAI ML CON'3TRUCT AND cm Mg ArYALP IT" M6 fUMttt 11 PRllAtttO COMPANY O/'Mf1r vnnv ttliLltC�ai.a.n... r tt to w+��..-...... A ® DATE(MMIDD/YYYY) �� IC CERTIFICATE OF LIABILITY INSURANCE 06/09/2021 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). CON PRODUCER Morstan General Agency NAME CT P O Box 9005 AI_CC,No Ext; (631)578-0890 AIC No): (631)582-1412 New Hyde Park NY 11040 AD RIESS: INSURERS AFFORDING COVERAGE NAZCA INSURER A. Century Surety Company 36951 INSURED Long Island Pool Care Corp.G INSURERS: PO Box 1690 INSURER C: INSURER D: Southold NY 11971 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. 'I�SR TYPEOFINSURANCE DLSUBR POLICYNUMBER POLICY Mf DmFF MMIIDIYYYY LIMITS I( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAO RENTD CLAIMS-MADE II OCCUR PREMISES Ea occurrence $ 100,000 A CCP970688 04/30/21 04/30/22 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE UMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 x JECT POLICY❑PRO- ❑LOC PRODUCTS-COMPIOP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMEa eBocINEDSINGLELIMITklenl $ ANY AUTO BODILY INJURY(Per parson) $ OWNED SCHEDULED BODILY INJURY(Per aocidont) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Por accident $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS'LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y 7 N STATUTE ER OFF CERIMEMB REXCLUDED9ANYPROPRIETORIPARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ (MandatorjinNH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may bo attached if more space is required) SUBJECT TO COMPANY TERMS,CONDITIONS AND EXCLUSIONS CIER711FICATE HOLDER CANCELLATION Town of Southold jf3ulid(ng Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEL VERED IN Town Hall'Annex ACCORDANCE WITH THE POLICY PROV N FO Box:1,179• Southold,NY 11971_ AUTHORIZED REPRESENTATIVE Lgel ©1988-2015 ACORD C TION: is reserved. 'AGORD•25(2016/03) The ACORD name and logo are registered marks of ACORD t , DATE(MMIDDIYYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCEF 06114/2021 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 pollcy(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 CONTACT Laura FButeux NAME: McMann Price Agency,Inc. PH(AIONE, ExII: (631)477-1680 FAXAICNa; (631)477-8930 828 Front Street E-MAIL lsura@mcmannpdce.com PO Box 2065 INSURER(S)AFFORDING COVERAGE NAIC 0 Greenport NY 11944-0876 INSURER A: Wesco Insurance Co. INSURED INSURER B: Long Island Pool Care Corp INSURER C: 50000 Main Rd INSURER D: INSURER E: Southold NY 11971 INSURER F: 'COVERAGES CERTIFICATE NUMBER: CL2161403146 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. ITR TYPE OF INSURANCE D POLICY NUMBER POLICY EFF MMIDD E'(P LIMITS COMMERCIAL GENERAL LUIBILRY ' EACH OCCURRENCE $ DAMAGE TO RENTEff'_ CLAIMS-MADE F-1 OCCUR PREMISES Ea occurrence S MED EXP(Anv one person) S -PERSONAL BADVINJURY S GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S POLICY a JECT LOC PRODUCTS-COMPIOPAGG S OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S e accident ANYAUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per.Man. S S UMBRELLA UAB HOCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I I RETENTION$ S WORKERS COMPENSATION PER OT' AND EMPLOYERSLIABILITYYIN STATUTE I I ER A ANY PROPRIETORIPARTNERIEXECUTIVE [wyj NIA WWC3521424 04/1912021 04/1912022 E.L.EACHACCIDENT s 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If vas,describe DE.L.DISEASE-POLICY LIMIT S�600,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall Annex PO Box 1179 AUTHORIZED REPRE A Southold NY 11971 61988-2015 ACORD C TION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD YORK workers' CERTIFICATE OF INSURANCE COVERAGE STATE compensation DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LONG ISLAND POOL CARE CORP 631-765-8285 50000 MAIN ROAD SOUTHOLD,NY 11971 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 275174033 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 Building Department-Town Hall Annex 3b.Policy Number of Entity Listed in Box"1a" P.O. Box 1179 DBL357404 Southold NY 11971 3c.Policy effective period 04/19/2021 to 04/18/2022 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: 0 A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] 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 6/9/2021 By Aho, hf (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) VIII I Il III I III DB-120.1 (10-17) I` YORK workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured LONG ISLAND POOL CARE CORP 631-765-8285 50000 MAIN ROAD SOUTHOLD,NY 11971 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 275174033 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 Building Department-Town Hall Annex 3b.Policy Number of Entity Listed in Box"1 a" P.O. Box 1179 DBL357404 Southold NY 11971 3c.Policy effective period 04/19/2021 to 04/18/2022 4. Policy provides the following benefits: 0 A.Both disability and paid family leave benefits. E] B.Disability benefits only. E] 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 6/9/2021 By w4 4I (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 sox 4C or sB 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. 1313-120.1 (10-17) �IIIIII1111°°1°1°1°1°°1°11°111°11°111°�IIIII OCCUPANCY OR USE IS UNLAWFUL APPROVED AS NOTED WITHOUT CERTIFICATE DATE:&'�3'--rB.P. OF OCCUPANCY �_ B . ANCY FEE: 2 D,� BY: NOTIFY BUILDING DEPARTMENT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS; 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 111MMEDIATELY'' 2. ROUGH - FRAMING & PLUMBING ENbLOSE POOL TO'CODE 3. INSULATION UPON COMPLETION 4. FINAL - CONSTRUCTION MUST BEFORE-VATEF' BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUI ED AND CONDITIONS OF ���"���ui� SOUTHOLD TOWN ZBA SOUTTH/OL�D TOWN PLANNING BOARD Sn�,"'7ll�li Tnrr4r+� r�Tr_,. N.Y.S.DEC NOTES w 1. NO SOIL SURCHARGE PERMIT-ED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR6 FEET OF EXCAVATION AT THE DEEPEN P. < 2. THIS POOL MEETS THE REQUIREMENTS OF AN51/AP5P/ICC-5"AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUNDSWIMIMING v B POOLS"AND 1996BOCACODE-SECTION421.DIVING EQUIPMENT I5NOTALLOWED. J 3. SWIMMING POOL SHALL BE CDMPLETELYANDCONTINUOUSLYSVRROUNDEDWITH ABARRIERCONSTPUCTEDIAW'REQUIREMENTS(OF Q o SECTION R326.4.2.1 THROUGH R326.4.2.6 OF THE NEW YORK STATE RESIDENTIAL CODE(2020)AND IN CONFORMITY WITH ALL SECTIONS O OF THE SOUTHOLD TOWN CODE.DWELLING WALL(5)MAY SERVE AS PART OF THE POOL BARRIER AS PER SECTION 8326.4.2.8 AND CONDITION(1)ARE MET.OPERABLE WINDOWS IN THE WALL(5)VSED AS A BARRIER SHALL HAVE A SELF LATCHING DEVICE.ACCE55 GATES a SHALL COMPLY WITH SECTION R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BESECMELY LOCKED WHEN POOL 15 NOT,N USE OR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. 7Q 3•-b^ a-o^ 4. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROUND THE EXCAVATION IAVIITHECODEOFTHE A H2O ^ H2O r TOWN OF SOUTHOLD. iT 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATERANID SOUNDING AN N AUDIBLE ALARM UPON DETECTION THAT 15 AVDIBLE AT POOLS DE AND INSIDE THE DWELLING. THE ALARM MUST IBEINSTALLED, w Z MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFA;TURERS INSTRUCTIONS. THE ALARM MUST MEET ASTM F2208 ~ 35 "STANDARD 5 PECI FICATION FOR POOL ALARM5. THE DEVICE MVST OPERATE INDEPENDENT(NOT ATTACHED TO OORDEPENDENTON)OF V O PERSONS. Z C O 4 6. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THATCONFORMS TO ASME/ANSI O 10" 10" A112.19.8M ORA MINIMUM 18"x 23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH O ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN. SUCH N PLAN VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME A112.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. POOL SHALL BE PROVIDED WIFH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE. THE 5UCTI0N FITTINGS SHALL BE N.T.5. SEPARATED BY A MINIMUM CF3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM 51MULTANEOUSLYTHROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE POSITION,MINIMUM OF 6-AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE:AN ATTACHMENTTO THE SKIMMER/SKIMMERS.A REQUIRED POOLATMOSPHERIC VACUUM RELIEFSYSTEM SHALL BE INSTALLED AS PER NY5 RESIDENTIAL CODE VINYL COVERED R326.6.3(2020)AND IN ACCORDANCE WITH TOWN CODE. CONCRETE STEPS 7. ALL ELECTRICAL WORK SHALL COM PLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRI NCI PALLY ARTICLE 680 AND THE NYS ° y RESIDENTIAL CODE SECTIONS 4201 THROUGH 4-206.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GROUND FAULT CURRENT INTERRUPTER(GFCI)CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FORTH(OSE v c PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT5HALL MEETTHE SEPARATION REQUIREMENTS OFTTABLE E4203.5.ALL V 21'TO 4"SAND BOTTOM METAL ENCLOSURES,FENCESDR RAILINGS NEAR OR AD)ACENTTO THE SWIMMING POOLTHATMAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT WITH AN ELECTRICAL CIRCUITSHALL BE EFFECTIVELY GROUNDED. N '-CS 8. WATER SOURCE FILLING THE 2001_SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NYS PLUMBING CODE 608. Q) QJ SECTION A o ��tn 9. ALL PIPING is DIAGRAMMATI:UNLESS OTHERVNISESTATED. w. N.T.S. 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. O 'i } A WATER LINE TOP OF WALL ..Q Z 11. A MEAN5 OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSVAPSP/ICC-5 SECTION 6. t N a: _ ,u 0Qj a' 7' 4' l �I 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. p p j a d I Na e Y 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON TH E SUBJECT PROPERTY. 15. THE DESIGN IS BASED ON A DGAINAGE SOIL WITH<10%SILT. GRDUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IFGROL/ND WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILT TIES WILL BE REQVIRED. 16. ALL GAS AND OIL HEATERS 01 INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY SECTION B CONSERVATION ACT(NAECA)COMPLIANT. FOOL HEATERS SHALL BE TESTED IAW ANSI 721.56 AND SHALL BE INSTiALLED IAW MANUFACTURERS SPECIFICA-.IONS. OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR N.T.S. GVARPED TOPROTECTAGAINST ACCIDENTAL CONTACT OFHOT SURFACES BYPERSONS. POOL HEATERS SHALL BEIPROVIDEDWITH TEMPERATURE AND PRESSURE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM. A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OJTLETTO AD)VST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE N 2„ FOLLOWING EN ERGY CONSERVATION MEASURES: 40. V 00 CHECKVALVE COPING AND WALKWAY 10• 16.1 AT LEAST ONE THERMOSTAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. 00 (BY OTHERS) FROM 5KIMMER 16.2 ALL POOL HEATERS SHALL BEEQUIPPED WITH AN ON-OFF SWI-CH MOUNTED FOR EA5Y ACCESS TO ALLOW SHUTTING OFF THE Ut PUMP O GRADE OPERATION OF THE HEATER NITHOUT AD)US-1 NG THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTINGTHE `Z WATERLINE a PILOTLIGHT. �. C TO DISPO$AV 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTARE OIUTDOOR POOLS �. m v DRYWELL • DERIVING 20%OFTHEENERGYFORHEAT]NGFROM REN EWABLESOURCES ASCOM PUTEDOVER AtNOPERATINGSErASON) W ml: UNDISTURBED EARTH > co W q a 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SET TO RVN DURING OFF-PEAK ELECTRICAL DEMAND PERIIODS AND CAN BESET W Q r d y 3500 PSI POVRED CONC. 4 TO RUN THE MINIMUM TIMENECESSARY TO MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION IAWAPPLICABLE Z O SANITARY CODE OF NEW YORK STATE. z Z cb VALVE R 5/9'REBAR 2)TYR \ '7 .Y r n i cd Uy 3 (�co a a VINYL LINER ',fid \ 17. THIS DRAWING 15 FOR 5TRUC-URAL SHELL ONLY. ALL ACCESSORIES ANDAPPURTENANCESARE DEFINED BY OTHERS. f� = EPP 2"TO 4"SAND w h 44 w CD is O FILTER 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS. DC NOTALLOW THE HEIGHT OF BAC KFILLTO EXCEED THE HEIGHT OFTFHE "`-' WATER IN THE POOL BY MOR.THAN 8", OR THE WATER TO EXCEED BACKFILL BY'MORE THAN 8" 3 Nem A p F \ 19. PLACE CONCRETE ON 5ANDYTO LOAM SOIL. REMOVE ANY CLAY DEPOSIT AND REPLACE W/COMIPACTED CLEAN BACKFILL. W m `� R TO RENRNS 20. THERE I5 NO MAIN DRAIN IN THIS POOL.SUCTON FOR POOL WATER CIRCULATION IS PROVIDED B;Y THE SKIMMERS ONLY.THIS MEETS U CHECK VALVE VERTICAL 3/8"REBAR B 3'O.C. REQUI REMENT5 OF THE NYS RESIDENTIAL CODE-SECTION 8326.5 FOR ENTRAPMENT PROTECTION. G O F NES PLUMBING SCHEMATIC (NOT 5HOWN) P 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: QNER T/ya� N.T.S. WALL SECTION 21.1. THE NEWT'ORKSTATE RES]VENTIALCOPE-5ECT10NR326(2020) O 21.2. THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-5ECTION 8403.10(2020) N.T.5. 21.3. THE NEW YORKSTATE FUELGAS CODE(2020) _r Lc 21.4. THE NEW YORK STATE SANITARY CODE. C7 DO U I 0 r D 21.5. AN51/APSP/ICC-5 STANDAR)FOR RESIDENTIAL IN-GROUND SWIMMING POOLS" TC1 EY 21.6. BOCA CODE-SECTION 421. 2 i�y UJ 21.7. CODE OF THE TOWN OF 50VTHOLD. 22. ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. Q 8847 5 0 ��FES S I ON P�-