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HomeMy WebLinkAbout47543-Z �OSufFOI'e o Town of Southold 8/17/2023 P.O.Box 1179 53095 Main Rd i1roy o� ) Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44458 Date: 8/17/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 7400 New Suffolk Rd.,New Suffolk SCTM#: 473889 See/Block/Lot: 117.-6-30 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/11/2022 pursuant to which Building Permit No. 47543 dated 3/14/2022 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. i The certificate is issued to Barry Jr,Robert&Joyce of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47543 6/27/2022 PLUMBERS CERTIFICATION DATED 0 Auth ed i ature "= TOWN OF SOUTHOLD �surFo��- ��o c�ay BUILDING DEPARTMENT TOWN CLERK'S OFFICE "oy • o� '� SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 47543 Date: 3/14/2022 Permission is hereby granted to: Barry Jr, Robert 7400 New Suffolk Rd New Suffolk, NY 11956 To: Construct in ground vinyl swimming pool at existing single family dwelling as applied for. Must maintain 10 feet minimum setback as required from rear and side property lines for pool and equipment locations. At premises located at: 7400 New Suffolk Rd., New Suffolk SCTM #473889 Sec/Block/Lot# 117.-6-30 Pursuant to application dated 2/11/2022 and approved by the Building Inspector. To expire on 9/13/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector so�ryQl 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlina-town.southold.ny.us Southold,NY 11971-0959 QIyCOUn�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Robert Barry Jr Address: 7400 New Suffolk Rd City,New Suffolk st: NY zip: 11956 Building Permit#: 47543 Section: 117 Block: 6 Lot: 30 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Elec Tec Inc License No: 4814ME 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 FixtureTime Clocks [12 Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: Intermatic Pool Panel 8 Circuit/6 Used, Pump 220GFI, Cleaner Pump 220GFI, Heater, 1 Light 120GFI, Salt Generator Notes: Pool Inspector Signature: Date: June 27, 2022 S. Devlin-Cert Electrical Compliance Form vs yoL--► 7 5-'01 7100 Ats vJG� f TOWN OF SOUTHOLD BUILDING DEPT. `ycou631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] 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 rl PRE C/O [ ] RENTAL -REMARKS: OK DATE INSPECTOR pf sobTyolo # # TOWN OF SOUTHOLD BUILDING DEPT. �ycoutm, 631-765-1802 �5 �3 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL /00-o-r [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION '"[ ] PRE C/O b54ek [ ] RENTAL REMARKS: �u � 6c (Na-w�vc- aukam a-s LOCAOYES . DATE 7-/0-a? — INSPECTOR OOF SOUTy� 1A" q� # # TOWN OF SOUTHOLD BUILDING DEPT. couto, 631-765-1802 INSPECTION [ ] .FOUNDATION 1ST [ ] R GH PLBG. [ ] FOUNDATION 2ND [ ] NSULAT N/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: I ) Mv 01� d DATE INSPECTOR y . FIELD.- PEC "' P' tT." -T GO . INS CTI, RE "77'A.E > :;,::,.:�1..�: '�1�I�S . i;,:. ;ti;>..:. FOUNDATION:(QST) ,..—:..;::.: y . h FOUNDATIO.N...(.2. ' .2ND. 11 , ..:, v' �. )' .. lA- : S : , • - 71..(- � "a',-"N..r ?' ^i ` ,,.i , l , . . . . .. '� -�,:-; ,Y.. - .% " I...,.;..,.-. - ., . , �, ... : I . . s : t}fit;:::.,.: ,::, - a;:,:. :4::: y r.:'•:_ ham,.,•.;; ,,a„ % ROUGH F.. ,;:. M Y-..X.. 3...;,, •.�: PLUMB u,_,:;�;'3':'%i7:::' y . .,i<,.:'.:t tn't� ! 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'.j:t - `-.^ ;`Sri';'•":':c h..;4. ,�.}l.r ,Yom" `.<`” •'�S i;`� �'i}i?�y�Iqzifs:.' 4ii O f:;.,.,:,... :'4'Y^ i.5--!, r{�:,-;i•.a.,.,.:: .. �:.:::' ;: .. . �. . .. . �;� - {.,:� .hl yi.e"I,iti� t•.4 } y,-!.. qN" .,'i'ia:t'>'�ii'°'L:' '}i¢.i,i;is 'Z• ' .. t`2'r'.• ....k':' `ril+',r�Aifi,r,Y'1t•��1�.''S-:•.`,:!':.. 'a•. l ,.� .h'1 x+• ,l(yy�ryJ i'::= `'_�iii }�J•:''. _ ryy v.A:': .,r'.. •',,.:.':Ili:' ,`S:t ,;:SM'.` I. ;,.I . 'ill:'^.. 1::`'.)i`-t,'::`. " .. .. 'a. r ;r_ :., t:>.. . ...� '% ::;..G '' . . Fro :,,...t.•.,.. . •,r, s�; ::sib•. =�•.. x r`rir ,;,:'e,;.':. . ,i;: -`}iLI i>'`c' Vis:,; . r,;':, .%",'.,.,. ,l,•"i,"+ern 1,,.7> ";:? :�_... , ;;.,: ;:;i:E.. t ,,,. . . �og11FF0! TOWN OF SOUTHOLD—BUILDING DEPARTMENT y�o Gyz Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownnygov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only i U , F151 PERMIT NO. Building Inspector: EC Applications and forms must be filled out in their entirety. Incomplete FEB 1 1 2022 applications will not be accepted. Where the Applicant is not the owner,an TOWN BUILDING DTHOLD Owners Authorization form(Page 2)shall be completed. Date: .4zg�� :A OWNER(S)OF PROPERTY: Name:2vr s�`zCE SCTM# 1000- X17_ p�, -90 Project Address: 7,&,0 Ue-Z,0 �i -� Phone#: �, 3 J_ gyk- 93Co R Email: Mailing Address: CONTACT PERSON: Name: Mailing Address: Phone#: 31^y�y-yzys Email: gch (c�F�,� �n 1 s ne,rre DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: "i-ruk'-' q?ccv-S L-7>. Mailing Address: �?v any G, C_c»c�+c�C�u�, Ny' /j5 3 S Phone#: �, 1 ygy-�2vS Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ®Others/� Will the lot be re-graded? M Yes El No Will excess fill be removed from premises? Yes ❑No 1 PROPERTY INFORMATION Existing use of property: S� tel, Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to "'4e5i . this property? []Yes lgo 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 building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): KAuthorized Agent []Owner Signature of Applicant: � /� Date: y/a'� STATE OF NEW YORK) SS: COUNTY OF --Scg;;iA ) e0lC76;;UC G(-f 17v1< being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the �'ON7ZAC-2-4)2 (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 qday of relo r.L-'O-r K , 20 lu Woa Public .0 V. - STEVEN L. HARKED Notary Public State of New York PROPERTY OWNER AUTHORIZATION No.O1hA6071848 (Where the applicant is not the owner) Qualified inSuffolk County Commission Expires March 3, �ad.a I, -,J o�s4r P-0 rYLI residing at -7-A 0o Kew New SUl do hereby authorize a}a 17UK'Pux,S to apply on my behalf to the Town of Southold Building Department for approval as described herein. it 4 Qw-,� ala /aoaa. 0 e 's Signature Date Joyce ]ar r Print Owner's Name 2 oi'I'm ; W D G DEPARTMENT-Electrical Inspector 2 ����Iallkinex- TOWN OFSOUTHOLD {< Town 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 TOWN OF S01,, ,Ci;_0 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrO-southoldtownny govseand(—Dsoutholdtownnv c�ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail information Required) Date: — Company Name: Electrician's Name: 2a.Y,nba� License No.: (L+_ Elec. email: �c�n e( inc ma4 <<d Elec. Phone No: I request an email co of Certificate ofCompliance Elec. Address.: 6( JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: „J Peo Phone No.: Bldg.Permit#: qF2 email: Tax Map District: 1000 Section: ka Block: Lot: s BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES��VO Issued On Temp Information: (All information required) °°'' Service Size❑1 Ph❑3 Ph Size: A #Meters Old Meter# ❑New Service[]Fire Reconnect[]Flood Reconnect ElService Reconnect[:]Underground[ ]Overhead # Underground Laterals 1 2 H Frame 0 Pole Work done on Service? -.FIY nN Additional Information: PAYMENT DUE WITH APPLICATION pa oin a� �- pir-pa-fir rD ' '- BUILD I�G DEPARTMENT-Electrical Inspector F!DTOWN OF SOUTHOLD '"Y �.. To vun Hall Annex- 54375 Main Road - PO Box 1179 E9Southold New York 11971-0959 .. �4 O = Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrOsoutholdtowl�rly.ciov seand(Jsouihoidtownny APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail Information Required) Date:. Company Name: Electrician's Name: ��� , ` License No.: 0� QL� ® c�� Elec. email: � � �9e �� I'a9 .fie Elec. Phone No: I request an email copy of Certificate of Compliance Elec. Address.: 0 JOS SITE INFORMATION (All Information Required) Name: Address: may, Cross Street: j Phone No.: BIdg.Permit#: 1i email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: (InYESO NO Rough In OF I Do you need a Temp Certificate?: YES�PO Issued On Terr>tap Information: (All information required) Service Size®1 Ph®3 Ph Size: A #Meters Old Meter# ®New Service®Fire Reconnect®Flood Reconnect®Service Reconnect®Underground®Overhead # Underground Laterals D 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION pa - V<L Ain a � ��- I I� �,�-� rZ� qr' ��� �� r �'�1���� yea �� F . Mec b� k Y � S � � � ( N SURVEY OF PROPERTY AT NEW SUFFOLK N/0/F T p y{rN OF . SO UTHOLD JONI FRIEDMAN ANDIjEW TORGROVE S SUFFOLK COUNTY, N. Y. 83'43 3o E 1000-117-06-30 GMF SCALE.- 1 =30 WIRE FEN.END HEDGE 199.40' 0.1'E 6 9. dwcOOD LANDING S COLUMN 22.3 OCTOBER 9, '2020 CMF N2 STY.BUILDING.n N tt A N yl PPu7t� 5.8' __ 4.2' a ^1 F>•7tnZ Loeviiar/ �o r !i � VINCENT MICHAEL & FLORENCE CARUSO TRUST 12.4' WONC./STONE W wax xy �3ia 18UILDING U. o' _ ASPHALT DRIVEWAY 'f 2i ttr�Sc�P ��'xtc�� Jy� - T�C'jSw.r+rHl.Yy Wvi .�QpL 1.5' CANTILEVER O FEN COR y�r �. 25.•4 NC. 2.3'W 'el i r IN x �L. � GS 2 STY. a J r R/0 CONC. PORCH 13'1 FR.' is 4 O LU /9 CE FiOUSF n R/O w p LL CONC. WALlE. 10.7' " PORCH CONC. yy 0 ALK LOU LL OI Y 7.4' 5.9'M Q X5.8 R/0 CONC. X8.9' //��� z PATIO PA710 62.9' vJ N/O/F O W ALEC HEMER ELISA URBNELLI FEN, 2.1 &D� E C E N83.57'00v FEB 1 12022 I HEDGE CMF 199.70BUILDING DEPT KEY I N/O/F j TOWN OF SOUTHOLD SYMS FAMILY TRUST 0 = REBAR co ® = WELL M 4 A = STAKE M '(SOF NEtV rO = TEST HOLE CERTIFIED T0: ��P -c. nn�r�O ' - = PIPE .ROBERT BARRY AND JOYCE BARRY FIRST AMERICAN TITLE INSURANCE COMPANY ■ = tilonluMENr SPANO ABSTRACT SERVICE CORP. NEW. SUFFOLK J ` = WETLAND FLAG CITIZEN'S BANK N.A. AVE. CQ, = UTILITY POLE �. .S. LIC. NO. 49618 PEC P.C. ANY ALMRAnON OR ADD177ON TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE (631) 76-5-5020- FAX (631) 765-1797 NEW YORK STATE EDUCATION LAW. EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL AREA= 30,326 SO. FT. P.O. BOX 909 CER77RCA77ONS HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR 7HE IMPRESSED SEAL OF THE SURVEYOR WHOSE SIGNATURE 1230 TRAVELER STREET ,20-062 • SOUTNOLD, N.Y 11971 CJ CERTIFICATE OF NEW YORK Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE STATE 'Compensation Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) Ib.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 lc.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 113306347 certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold PO Box 1179 3b.Policy Number of entity listed in box"la": Southold,NY 11971 WWC3563869 3c.Policy effective period: 1/1/2022 to 1/1/2023 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) 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"la"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 insterance 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 maib)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c';whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a 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: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 2/3/2022 (Signature) (Date) Title: SVP,Workers Comp Production Management Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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 YTAT 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 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245 PO BOX 9 CUTCHOGUE,NY 11935 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) 113306347 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 PO Box 1179 3b.Policy Number of Entity Listed in Box"l a" Southold NY 11971 DBL614067 3c.Policy effective period 05/01/2021 to 04/30/2023 4. Policy provides the following benefits: R] A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑X A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. F1 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 bove. Date Signed 11/16/2021 By wil,i (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 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. DB-120.1 (10-17) 111111111°°°1°1°1°°1°1°111°�°�!°°°�IIIIII DATE(MM/DDIYYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 02/11/2022 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 CONTACT Lauren Murphy NAME: Roy H Reeve Agency,Inc. PHONE (631)298-4700 FAx (631)298-3850 AIC No Ext: A/C,No PO Box 54 E-MAIL Imurphy@royreeve.com ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURER A: Valley Forge Insurance Company 20508 INSURED INSURERS: Chituk Pools Ltd. INSURER C: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 11935 INSURER F: COVERAGES CERTIFICATE NUMBER: CL213414038 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLISUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMBS LTR INSD WVD POLICYNUMBER MMIDD MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO_7CLAIMS-MADE �OCCUR PREM SES Ea occuE e100,000 nce $ Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2021 03/15/2022 PERSONAL a ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 JECT POLICY PRC ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accidE $ ent UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER I I OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Re: Robert Barry,7400 New Suffolk Rd,New Suffolk,NY 11956 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 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 f ��+r—� @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD -ti OCCUPANCY OR APPROVED AS NOTE USE IS UNLAWFUL DATE: �' �a�B.P. 3 WITHOUT CERTIFICATE FEE ,00 BY: OF OCCUPANCY NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION TWO REQUIRED FOR POURED CONCRETE 2. ROUGH FRAMING & PLUMBING 3. INSULATION `COMPL`t WITH ALL CODES OF 4. FINAL • CONSTRUCTION MUST VIEW YORSTATE & TOWN CODES BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE i4S REC) ED AND CONDITIONS OF REQUIREMENTS OF THE CODES OF NEW SOUTHOLD TOWN ZBA YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES N.Y.S.DEC ENCLOSE POOL,TO-Co0E UPON,COMPLETION BEFCSRE,:'WaTEFt RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. RECMM papWMN MWMa I P006812E vMbdep' R. -.B•. .. C . .:D E.' F. .G'. H K' '-'L.' :.'M • 1430 1444: 14: '..30:' 3'4" 6 6• Q 14' 6. :4.- '4: 6;:4'-0" 4' 11900 S.: pa,' {pQ6 16X#2: `28',' 3'•4'.-'6�`. ::6' :.12: .::6' .4. -:4 g, a•: T44 13100 i6fo`: 16><!a - 16 , '20. ;S'•4';:6';6''-:•r-4"-: B�` .'4. -4.; 4. :,.8_..4:Ar••:T-�{`•:'9�0Q . :. •.. - V411., 6' •:4.... 8 -4`-0"'•7 ` 11000 '. .: .. .. • .. - 16t©A� :>.', b)Gid:' :'i6.. ..30.'• �". :.8. 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BUILDING DEPT. TOWN OF SOUTHOLD ' : POOL SECTIO ' CO j e;S1w ' 2020 Code Section 3032.1 303A Swimming Pools,Spas and Hot Tubs Sdcfon'R326 of the Residential Code of New York 1 ---------- , . - Section 3109 of the Buildirlg'Code of Newyork Section N1103-12(8403.12)Residential Pools and Permanent Residential Spas ®®�, PE:I ECTAN(kE . REV° " SCALE; ;NTS Section 31093.12-3.109.7,4 Pools and Spas Gates,Barriers JAMES ®EERK®SK PZ Nk Section G706 Entrapriment Pro#ecgon . " I TYPICAL P EL SWONER 'Section G107- Alarms 260 DEER®RIVE DATE: Section E4201—E4312 Electrical Connections for Pools MA ffU(C,NEW YORK 11952 DRAWNO NUMBER - 1 ' OF 1 NOTES: 1. DIVING BOARD TO CONFORM WITH ANSI/APSP/ICC-5 SEC 6 2. NO SOIL DISCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION 3. POOL MUST BE SURROUNDED BY A CONTINUOUS BARRIER CONSTRUCTED IAW REQ.OF SEC 326.4.2.1-R326.4.2.6 OF THE NYS RESIDENTIAL CODE(2020)AND ALL SECTIONS OF THE SOUTHOLD CODE 4. WALLS MAY SERVE AS PART OF THE POOL BARRIER AS PER SEC 326.4.2.8 AND ALL WINDOWS HAVE A SELF LATCHING DEVICE 5. ACESS GATES SHALL COMPLY WITH SEC R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY LOCKED WHEN POOL IS NOT IN USE OR SUPERVISED. ALLL GATES ARE TO OPEN AWAY FROM THE POOL AREA. 6. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECT A TEMPORARY BARRIER AROUND THE EXCAVATION IAW CODE OF THE TOWN OF SOUTHOLD. 7. POOL MUST BE EQUIPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER AND SOUNDING AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE AT THE POOLSIDE AND INSIDE THE DWELLING.THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH TEH MAUFACTURERS INSTRUCTIONS.THE ALARM MUST MEET ASTM F2208"STANDARD SPECIFICATION FOR POOL ALARMS".THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSONS. 8. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIIMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI Al 12.19.8M OR A MINIMUM 18"X23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM.POOL CIRCULATION SYSTEM MUST BE EQUIPTED WITH ATMOSPHERIC VACUUM RELEIF.SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME Al 12.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD.POOL SALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE.THE SUCTION FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS).VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENT TO THE SKIMMER/SKIMMERS. A REQUIRED POOL ATMOSPHERIC VACUUM RELEIF SYSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE R326.6.3(2020)AND IN ACCORDANCE TO TOW CODE 9. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC),PRINCIPALLY ARTICLE 680 AND THE NYS•RESIDENTIAL CODE SECTION 4102 THROUGH 4106.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GOUND FAULT CURRENT INTERRUPER(GFCI).CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5. ALL METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. 10. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608. 11. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 12. WALKS,IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM THE POOL EDGE. 13. A MEANS OF EGRESS FROM DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/NSPI-5 SECTION 6. 14. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. 15. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. 16 THE DESIGN IS BASED ON A DRAINAGE SOIL WITH<10%SILT.GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION.IF GROUND WATER EXISTS WITHIN 60"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. 17 ALL GAS AND OIL WATER HEATERS(IF INSTALLED)FOR THE IN-GROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT.POOL HEATERS SHALL BE TESTED IAW ANSI 221.56 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726.POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECTAGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS.POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES.A BYPASS LINE SHALL BE INSTALLED FROM THE INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HATER.POOL HEATERS SHALL BE PROVIDED WITH THE FOLLOWING ENERGY CONSERVATION MEASURES: 17.1 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE PILOT LIGHT. AT LEAST ONE THERMOSTAL MUST BE PROVIDED FOR EACH HEATING SYSTEM.HEATED SWIMMING POOLS SHALL BE EQUIPTED WITH A POOL COVER.(exempt FROM THIS ARE OUTDOOR POOLD)DERIVING 20%OF THE ENERGY FOR HEATING THE POOL FROM RENEWABLE SOURCES OVER AN OPERATING SEASON. ® E (C E 17.2 CLOCKSTIME SHALL BE INSTALLED SO CONDITION IAW THE PUMP ABLE SN BE SET TO ODE NEW YORK STATE.N DURING ELECTRICAL DEMAND PERIODS,AND CAN BE SET TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A `. FFR 1 12022 CLEAN ANDfN a a„ :,u[L' �'G OF7"T 18 BACKFILL WILL BE DONE WITH CLEAN EARTH FREE OF ROOTS AND DEBRIS. BACKFILL HEIGHT AND WATER LEVEL TO BE WITHIN 8"OF EACH OTHER. PLACE CONCRETE ON SANDY LOAM SOIL. CLAY TO BE REMOVED AND �:z: s., ,;nT: REPLACED WITH SANDY LOAM. 19 THERE ARE MAIN DRAINS IN THIS POOL.THERE ARE TWO APPROVED SUCTION OUTLETS WITH A MINIMUM OF 3'OF SEPARATION. THE SUCTION OUTLETS ARE PIPED SO THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM-RELEIF-PROTECTED LINE TO THE PUMP.COMP I WITH ENTRAPMENT PROTECTION AS PER CODE. 20 THE POOL WAS DESIGNED REFERENCES AS THE FOLLOWING: 20.1 THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE(2020)SEC R326 �F EP/Yv 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 �P S\ D ERCc in �O 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) 20.4 THE NEW YORK STATE SANITORY CODE. r' ° Lu 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. POOL NOTES SCALE: NTS 20.6 BOCA CODE SECTION 421. Ftp 07 JAMES DEERKOSKI P.E. 20.7 CODE OF THE TOWN OF SOUTHOLD ROg$\ DATE: 10/2/2020 260 DEER DRIVE MATTITUK, NEW YORK 11952 DRAWING NUMBER 2 OF 2