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Home My WebLink About47784-Z ¢yo�StlFfO1K�Q� Town of Southold 10/4/2023 a !tl P.O.Box 1179 C" x 53095 Main Rd � Southold New York 11971 CERTIFICATE OF OCCUPANCY No: 44634 Date: 10/4/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2205 Grandview Dr., Orient SCTM#: 473889 Sec/Block/Lot: 14.-2-3.19 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/1/2022 pursuant to which Building Permit No. 47784 dated 5/5/2022 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. The certificate is issued to 2205 Grand View Orient LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47784 9/18/2023 PLUMBERS CERTIFICATION DATED ut oriA Signature TOWN OF SOUTHOLD SUFFn�k�, BUILDING DEPARTMENT yx TOWN CLERK'S OFFICE WSOUTHOLD, 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#: 47784 Date: 5/5/2022 Permission is hereby granted to: 2205 Grand View Orient LLC 1157 Willis Ave Ste LL3 Albertson, NY 11507 To: construct accessory in-ground swimming pool as applied for. At premises located at: 2205 Grandview Dr., Orient SCTM # 473889 Sec/Block/Lot# 14.-2-3.19 Pursuant to application dated 4/1/2022 and approved by the Building Inspector. To expire on 11/4/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Bu ing Inspector pE SO(/jyQl ` 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 Q Jamesh a�southoldtownny.gov Southold,NY 11971-0959 �Q • �O �yCOUNT`I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Theo Verios Address: 2205 Grandview Drive city:Orient st: New York zip: 11957 Building Permit#: q�7 S q + 47465 Section: 14 Block: 2 Lot: 3.19 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: AXIOs Electric Corp Electrician: Mike Lignos License No: 45299ME SITE DETAILS Office Use Only Residential X Indoor X Basement X Service X Commerical Outdoor X 1st Floor X Pool X New X Renovation 2nd Floor X Hot Tub Addition Survey Attic X Garage X INVENTORY Service 1 ph 300 Heat Duplec Recpt 120 Ceiling Fixtures 12 Bath Exhaust Fan 4 Service 3 ph Hot Water GFCI Recpt 12 Wall Fixtures 18 Smoke Detectors 6 Main Panel 2 A/C Condenser 2 Single Recpt Recessed Fixtures 95 CO2 Detectors Sub Panel 1 A/C Blower 2 Range Recpt Ceiling Fan Combo Smoke/CO 3 Transfer Switch UC Lights 20ft Dryer Recpt 1 Emergency StrobeHeat Detectors 1 Disconnect 2 Switches rjg 4'LED 5 Exit Fixtures Sump Pump Other Equipment: 2 garage door openers,1 well pump, 300amp service,2 main panels 150amp each panel#1 30 space 18 used, panel#2 30 space 25 used Notes: POOL 1 heater,1 pump,1 pool light, 1 chlorinator, 1 panel 4 space 3 used WHOLE HOUSE/POOL Inspector Signature: A Date: September 18, 2023 2205 grandview dr OF SOUIyO� 14 # # TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] 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 I Z INSPECTOR l �o��OF SOUIyO� -_ L # # TOWN OF SOUTHOLD BUILDING DEPT. courm NF'' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULA ION/CAULKING [ ] FRAMING /STRAPPING [ FINAL W/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ]. FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: �04uC49 .!/� -.. �At f 1 ffa4wk6wol Q4rf /r,> DATE INSPECTO ■ f w / C \ SYN P00 F �� IIIII�1��1�11111��lllllllllilill lott�� Tit.- 1, 1 1 Pool Alarm Safety Made Easy Alarma Segura Y be Ficil lnstalaci6h f MEETS ASTM F2208 08(2019) CAS MI LAB CERTIFIED Model PA-30 Meets Requirements of ASTM Standard F2208 Modelo PA-30 Cumple requerimientos de la ASTM F2208 �00 Q ��A vv--, FIELD INSPECTION REPORT I DATE COMMENTS •o FOUNDATION (1ST) OC'� ------------------------------------- C FOUNDATION(2ND) No V1 `— c y ROUGH FRAMING& PLUMBING 1 b r INSULATION PER N.Y. Dy STATE ENERGY CODE 2viwg b2 c C FINAL t y3 OKAY ADDITIONAL COMMENTS s1VLz � it Z ti O Z Em l t� y O H x V m b H TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179-Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 https•/iwww.s6uthbldtomM.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only D PERMIT NO. Building Inspector: BUILDING 0 •1 2022 __ - _ .. - ,._ r,.•I-.r•� - .SQL"'-�'.,- TOIDEpr a. r�;� a fiilled oufin�therrr entiretyc,lncomplete - N OFg Applieatioris arid�forrns must.6: _ ` O'JrHOLD �ap,�pli�,ca�tionsdwill not�be aec�pted. Where the7Applieant�,�sno�t'�the�owner an�,�=�:- -O;wner's,Authorizatorn foim.jFage�2),sha"Ilibelcomp el ted: Date: - -22 _ Name: u'e(L��S SUM#1000- I -2 ' 3, 1 -f Project Address: 2-ZO (LQine�U1�1�1 tacky-(_ lC�enf Phone#: Cl vi- 2 - �0.�Is Email:` f 5-iwf— Mailing Address: 521, �j XtdJ6b,, , VI -�CONTACT.PERSON: -- Name:M `�ha2._ w"A-cos ��LS Mailing Address: QI Phone#: �3�-�1�I�(-�IBs Email: �eC� e DESIGN'=RROFESSIONAL.INFORIVI- Name:` N` 'H.as Mailing Address: P Z2L �Ul`t"t41 Phone#: (p3�- lZ�� 5717 - Email: Name: Mailing Address: `I �ZQ.I kt- 2-V- I � plQU 1176VPhone#: (Q31-.7�4-��' Email: C-2 _ ONSTRUCTI - PT. OF_PROP µ'ED�COS _ �.,.�.;1-.��• _- - _ ❑� V New Structure ❑Add1i1t// ❑ ion Alteration ❑Repair ❑ emolition Estimated Cost of Project: E Other Ill EWN2 VN L- 5 %1 M(ru'V uy� $ 31,Ch1y— Will the lot be re-graded? ) Yes El No � LWill excess fill be removed from premises?$Yes ONO � y 1 - - '�- �PRO ER ATIOIV.`, M - f P TY 1 FORN Existing use of property: Intended use of property:_4�Jn Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? DYes-$No IF YES, PROVIDE A COPY. r Il dreina e'and � storiri•water issues as: roiriile.., y. "M D+�Clieck�BoxAft�rzReaiing�:,The,owner/contractor/design,profess"oneliis:responsiblefo P _ "` a .HEREBY MADE.to the,Buildin �De ar�tment,foi tfie�issuance.'of`a'Building Permit pursuant;ta�thi6 BdildiniiZ e','; Chapte�'236 of the Town Ctide; APBLICATION'IS HE _ g...P :- - c6nep ;Ordinarice 'the'Town.of.Southold,Suffolk,,County;New York and;otfier apohiia le,laws„O?dinancesor Regulations,for flip construction,of buildings,; t� 4 additions,alterations or for remova'I or demolition as;herein described.The applicant agrees to comply with.alla`ppticatile laws,ordinances;bwlding�cotle ¢', < liousmg cdde and.regulations end.to admd authorized inspector's`on premises+antl'in:building(s)'for necessary,inspections Felsestatements made;he`rein averts punishable as a Clas's A�misdemeanor. urs,ant,to.Section 210:45 of the New York'State,-Perial'Law. '. ” '4 `Y , Application Submitted By(print name): veto ❑Authorized Agent xowner Signature of Applicant: Date: 4-1-22- STATE -1-22STATE OF NEW YORK) SS: COUNTY OF J Ri-DLK ) --Ike-a Vee-k,35 being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the OVJ � (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 day of �-t� , 20 2.2 Notary Public MARGAREF A. KIDNEY Notary Public-State of New York No. 01 K16021 I l I Qualified.in Suffolk County PROPERTY OWNER AUTHORIZATION My Commission Expires March 8,20,L (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 Stu OL't BUILDING DEPARTMENT-Electrical Inspector jo COGy� TOWN OF SOUTHOLD o Town�Hall Annex- 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 ` Telephone(631)765-1802-FAX(631)765-95M rogerr_ southoldtownnv.aov - seanda-southoldtownnv.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: I o I a3 Company Name: CQea� Coc ElectnciaWs Names -- Limnse No.: LA,:r) M i�- Bea email: - a7 ec Zo e Elec. Phone'No: 51 ®I-request an email copy of Certificate of Compliance Elec.-Address.: o�c,t� �- JOB SITE INFORMATION (A11,110m, %MwRequlred) Address: 'a,�� Gco. v'�ew ��'. os'k a N Cross Street: Phone No.: 63N Bldg.Permit#: 1� email: L h h o Tax Map DLclWct -.-1000 Section: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE(Please Print Clearly): Square Footage: Circle All That Apply= 1115 joi%rear fix,-dupe rffv U T'r s"'NU �kough to t=ttt� Do you need a Temp Certificate?: YES E]NO Issued On Temp Information: (All information required) Service Size0l Ph M3 Ph Size: A #•Meters Old Meter# QNew ServiceoFire Reconnect)]Flaod Reconnect.r_-beEvice ReconnectanderWound[--jPverhead #Underground Laterals . 1 2 H Frame Pole Work done on Service? My FjN Additional Information: PAYMENT DUE WTrH APPLICATION bill: LOT 6 G� ILT FENCE AND/OR / ✓� RES . FLOW i I LOT 14 Y BALES AROUND ,� RE LOT.SEE DETAIL / . P� YO t� VACANT • / • / • / TEST ` ��\v / �� 4" VERTICAL FACE PROPOSED SEPTIC SYSTEM HOLE WELL II SEPTIC TANK: 8 DIA.xS L.D /• • �c' 26• LP's: 2-8' DIA.x8' L.D • / , �' ` TEi,4,a YCO 5TFjx--n N BEDDING DETAIL / 2 ENTIZAI SEE AIL' WELL NOT TO SCALE 0 / . .0.0 . / DRAINAGE AREA NO MORE THAN 1/4 ACRE PER 100 FEET ° >�� • 5'0'•MIN. / / OF STRAW BALE DIKE FOR SLOPES LESS THAN 25%. �\ ��j �� • / • / / ` 23' \�` �0 • / RooF / / L 0 T 7 ANGLE FIRST STAKE TOWARDS aPREVIOUSLY LAID BALE. S / �` V-` , FLOW , / / 20MIN ' 5 h O 24 , o h 0 n O 6(,'�0 ° ' '� BOUND BALES PLACED ON CONTOUR. / / 4. 6 39 5' zio0 4" DIA. CROSSOVER PIPE. , AX. 1/2 EFFECTIVE DEPTH �� 10 MI ` �\ ��- 2 RE-BARS, STEEL PICKETS OR 2"X2" STAKES PLACED N 1 / / �P MIN P = 1 1 /2' TO 2' IN GROUND. 2 ' / / `' 8' �0 o - DRIVE STAKES FLUSH WITH m Ayp. Via ' o �-�\ �o TOP OF BALE. ANCHORING DETAIL 50' NOT TO SCALE / TO PORCH \ h ` o P PROPOSED a Q 2-STORY (5 BEDROOM) �`b 7A 9�1� FRAME DWELLING `L CONSTRUCTION SPECIFICATIONS OG�, 6$ FF EL=29.0 50' a 7oZ� 2nd FLOOR EL=40.0 ETBACK BALES SHALL BE PLACED AT THE TOE OF A SLOPE OR ON THE CONTOUR AND IN A $ 122.6 0 BASEMENT 28.0 o 1. ROW WITH ENDS TIGHTLY ABUTTING THE ADJACENT BALES. 0 G� �� GARAGE EL=28. � R \ 130.2`' o GROVNp 0 2. EACH BALE SHALL BE EMBEDDED IN THE SOIL A MINIMUM OF (4) INCHES, AND UNpER SNE ,:j: PLACED SO THE BINDINGS ARE HORIZONTAL. \ ° c �GC� P�� / \ PROPS Eo R\GP-�• / U TI LI TYS 3. BALES SHALL BE SECURELY ANCHORED IN PLACE BY EITHER TWO STAKES OR /f RE BARS DRIVEN THROUGH THE BALE. THE FIRST STAKE IN EACH BALE SHALL P1 10 PP \,�� , / � BE DRIVEN TOWARD THE PREVIOUSLY LAID BALE AT AN ANGLE TO FORCE THE PROPOSED �P-y- 15' / '/ BALES TOGETHER. STAKES SHALL BE DRIVEN FLUSH WITH THE BALE. G a� WELL 0 A . / 4. INSPECTION SHALL BE FREQUENT AND REPAIR REPLACEMENT SHALL BE MADE �� • / PROMPTLY AS NEEDED. / • 'Y��""� 5. BALES SHALL BE REMOVED WHEN THEY HAVE SERVED THEIR USEFULLNESS SO , / WIRE LOT.SEE DETAIL. AS NOT TO BLOCK OR IMPEDE STORM FLOW OR DRAINAGE. / ss J ADAPTED FROM DETAILS PROVIDED BY: USDA - NRCS, NEW YORK STATE DEPARTMENT OF TRANSPORTATION, STRAW BALE 0 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION, 0- \ ' �,�. / NEW YORK STATE SOIL & WATER CONSERVATION COMMITTEE DIKE / \ / / O, &ENERAL NOTES LTHEOINEER5 CERTIFICATION APPLIES ONLYOSTRATING THE DESIGNS CONFORIMANCE TO THE BUILDING CODE OF THE STA TO DEMONSTRATING TE OF NY. � ° 2. ALL MATERIALS,ASSEMBLIES,CONSTRUCTION AND EOIUIPTMENT 15 TO BE IN ACCORDANCE WITH THE BUILDING CODE OF THE STATE OF NY Q ) Q� AND MANUFACTURER'S INSTRUCTIONS. 3. VERIFY ALL DIMENSIONS BEFORE AND DURING CONSTRUCTION, NOTIFY ENGINEER OF DISCREPANCIES. DO NOT SCALE DRAWINGS. 4. DEVIATION FROM THESE PLANS,UNAUTHORIZED DUPLICATION OR REUSE WILL NEGATE ENGINEERS CERTIFICATION AND IS A VIOLATION OF NYS LAW. DRAWINGS ARE THE COPYRIGHT OF THE ENGINEER. 5.THE ENGINEER 15 NOT RE5PON5113LE FOR THE DISCOVERY,PRESENCE,PREVENTION, REMOVAL OR HANDLING OF ASBESTOS, HAZARDOUS XHAZARDOUS MATERIALS,GA55E5,FUMES, MOLD AND/OR MILDEW. L 0 T 16 b. THE ENGINEER A55UME-5 NO RESPONSIBILITY FOR CONSTRUCTION, MEANS METHODS, TECHINIGUE5,5EGUENCE5, PROCEDURES OR SAFETY PRECAUTIONS AND PROGRAM IN CONNECTION WITH THE WORK. THE ENGINEER SHALL NOT BE RESPONSIBLE FOR ERRORS OR OMISSIONS OF RES . THE OWNER,CONTRACTOR OR SUB-CONTRACTORS. 1. THESE FLANS ARE OF LIMITED SCOPE AND ARE INTENDED FOR USE BY EXPERIENCED OHNER5/BUILDER5 FOR CONSTRUCTION ON OWNERS PROPERTY WITH FINAL SPECIFICATIONS SELECTED BY THE OWNER. THE ENGINEER, NOT CONTRACTED TO CONTROL THE CONSTRUCTION t PROCESS 15 NOT RESPONSIBLE FOR ASSURING THE FINAL AS CONSTRUCTED BUILDING AND SITE 15 IN COMPLIANCE WITH ALL BUILDING CODE5, �O LOCAL LAWS,REQUIREMENTS OR SUITABILITY FOR A PARTICULAR USE. THE ENGINEERS LIABILITY TO OWNER OR ANY THIRD PARTY 15 THEREFORE LIMITED ONLY TO THE FEE PAID FOR 5ERVICE-5 RENDERED. Q &. USE OF THE DRAWINGS INDICATES BINDING ACCEPTANCE OF THE ABOVE CONDITIONS d ,ARE A PART OF AGREEMENT WITH THE ENGINEER WELL q. ELEVATIONS BASED ON NAVD (N55),U5C 3 GS DATUM 10. METES # BOUNDS d TOPOGRAPHY FROM A SURVEY BY PAUL BARYL5KI L5. DATED 10/BO/20 O 11. NOT MORE THAN I ACRE DISTURBED. SANITARY CALCULATIONS: w TIN. 5EPTIG 5Y5TEM: FLOW .0` �fr-0"MAX c"`°` smaw ON Im 5EPTIG TANK: 5 BEDROOM MIN= 1500 GAL (TABLE 2A IN 5GDH5 MANUAL) ;�PMY!6AW/dt -�► i RA :•�4':- . p: ; ; � .�.►,-rK mtj REGU I RED: 1,500 GAL -',_�L .• �1.T's�i -t'r1„`b••+t~SS��r.t..Lt�;`+�?.t•�. ♦.w..Mij Y•:�'.r+:.� �fi LL lai. QI I _ _ C/ x 5 L.D. 5EPTIG TANK GAL PROPOSED: DIA. !1500 ) y 1 yxTABLE 4 5GDH 5TANDA( RDS) �N 4 =LL y �► "1` ~rY_ ;' `.;{_ 4{ LEAGHING POOLS: „ �► y � r SLOPE VERTICAL X : FACE REQUIRED: 2-8 DIA x 8- DEEP L.P.5 � ��O � '�;;~:- ��'. ~�'��'- .. ";5` ,a.;..,:;�;-. � o b PROPOSED: 2- 8' DIA. x 8' DEEP L.P.5 PERSPECTIVE VIEW S BEDDING DETAIL ROOF DRAINAGE GALGULATION5: APR 0 1 2012 _ ROOF DRAINS A, B, G AREA: 4,300/3=1,300 50. FT. EACH POOL .,.,�. ANGLE FIRST STAKE TOWARD 7 �' 36" MINIMUM 2 X 2 rENc R,7cTxwrNTRANrT-m ruo^nnNormml PREVIOUSLY LAID BALE. FENCE POST 3.a•sTONERIrNvoRNY5TATTD°T M'Mrn4nRCA RUNOFF=1,433 50. FT. x 1.0 x .Il = 244 CU. FT. BUILDING DEPT. ER11731R'(NMC1Y .fAREEx,j71NGGRA(KFOItDRA1NAGE N!TOWOFSOUTHOLD 10I DIA. RIN65 = 68.4 CU. FT. FLOW WOVEN WIRE FENCE REOD.: 244 CU. FT. / 68.4 = 4 L.F. (EACH POOL) s x s - 10110 wwFl PLAN wEw PROP05ED: 10' DIA. x 4' DEEP L.P. (EACH POOL) ANOELO FILTER CLOTH S . NIGOSIA, P .E . N NOTES: Engineering Design 71 I. LOT AREA=45,2gq.2 s ft=1.04 acres 42 Hayward Avenue NY 11-766 q. y Mt. Sinai, `�"�a... 631-g28-2112 BOUND HAY BALES EMBED FILTER CLOTH 2. DATUM=N.A.V.D (1g88) Fax 631-cl28-2163 - - GROUND PLACED ON CONTOUR MIN. 6" INTO Z 3. FIVE BEDROOM DWELLING 4r `r.' , rnNSTOVBIr 0Rnvrr.urC1(ITAPMCN.Rf--k n 4I /approved: ;.; 4..! wr �°t rRETOW(Nx'iNfAR°ovEEXISTINGC&ADEFORCHtAJ c 4. FLOOR AREAS: �� 2 RE-BARS: STEEL PICKETS OR 2"x 2"STAKES 1.5'to 2' IN GROUND. NOTE: IST = 2,3g8 5 f t f ,� DRIVE STAKES FLUSH WITH TOP OF MAXIMUM DRAINAGE AREA CROSS SECTION HAY BALES. 1/2 ACRE / 100 LINEAR FEET 2nd = 2,38DRIVE V� SLG 1 soft v' ��\r(\ �� . -- ANCHORING DETAIL Open to below= T18 5gft 2205 ORANDVIEW DR., ORIENT ",r SECTION DETAIL Garage = 802 5gft TEMPORARY CONSTRUCTION ENTRANCE 5. PROP05ED SANITARY 5Y5TEM: STRAW BALE DIKE DETAILS SILT FENCE DETAILS EROSION GONTROL PLAN 1500 al 5EPTIG TANK \ SCALE:NTS SCALE.Nib 9 SCALE Fill 2-8' DIA x 8' DEEP LEAGHING POOL SGTM# 1000-14-2-3.Iq 1. 5GTM# 1000-14-2-3.lq Drawn b : A5N Job No.:Rev.: Sheet: REVISIONS 5ca le:I"=20' Date: 4/Iq/21 21-050 1 Of ARTHUR RDS POOL & SPA CENTRE 929 ROUTE 25AD 2 C L�2 � nn 2 MILLER PLACE, NY 11764 I� VIS 516-744-7185 APR 0 12022 FAX-744-0174 BUILDING DEPT. APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: APPLICATION FOR OUTDOOR POOL PERMIT y� CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF LIABILITY INSURANCE [ CERTIFICATE OF DBL INSURANCE SUFFOLK COUNTY LICENSE [� 4 SETS OF STAMPED PLANS 3 SURVEYS with FILTER LOCATION [ C.O. [ ] TAX BILL' $400.00 CHECK FOR PERMIT FEE MAP`, A -t' Al" §RN Al DO I Iasi 11 EN IN, TE ACOO O® 212? 1 12021 CERTIFICATE OF LIABILITY INSURANCE D2127IDDJ 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 AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUT REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certfficate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUAROGATION 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 Ileu of such endomemen s. CONTACT PRODUCER NAME: Matthew Ru rto Liberty Risk Management,Inc. PHONE 631 5695633 FAx Nal.(631)569-5636 2333 Route 112 ow@OlbeftdsLorg Medford,NY 11763 INsu a AFFORDING COVERAGE NAIC+ INSURERA: NIP/Greenwich INSURED UISURER B Arthur J.Edwards Mason Contracting Company Inc. INSURERS: DBA Arthur J.Edwards Pool&Spa Centre INSURERD: 929 Route 25A Miller Place,NY 11764 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000005.1323910 REVISION NUMBER: 23 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. INSRLIR TYPE OF INSURANCE R POLICYNUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY NPC-1004300-01 01/01/2022 01/01/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RE $ 3OO000 CLAIMS-MADE �OCCUR PREMISES Ee oc rm w MED EXP one n $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENLAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2000000 PRODUCTS-COMPlOP AGG $ 2.00 OO OOO POLICY❑X JECTPRO. LOC OTHER ECOMBIN SINGLE LIMB AUTOMOBILE LIABILITY : ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per sedderd) $ AUTOS ONLY AUTOS PROPERTY DAMAGE S HIRED NON-OWNED Perecdderd AUTOS ONLY AUTOS ONLY $ UMBRELLA LW! OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION PER S STATUTE EOR AND EMPLOYERS'LIABILITYYIN E.L.EACH ACCIDENT 5- ANY PROPRIETORIPARTNER/EXECUTIVE ❑ H/A EM OFFICERIMSER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S pbnddM In NH) [fps desa�eundor EL DISEASE-POUCYUMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional RsmoM Sehsdrde,maybe atfacfrsd H mon space Is rsqulreA Town of Southold is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall P.O.Box 728 AUTHORED REPRESENTATIVE Southold,NY 11971 44 W&�, MJR ©1966 2015 A ORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/2212021 at 01:26PM IWI Workers' CERTIFICATE OF INSURANCE COVERAGE C^ srAre Compensation �- I 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 8 Address of Insured(use street address only) 1b.Business Telephone Number of insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE,NY 11784 1c.Federal Employer Identification Number of Insured Work Location of Insured(only required it coverage Is speciflOW limited to or Social Security Number certain locations In New York State,i.e.,Wisp-Up Policy) 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Bein Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold Town 728 3b.Policy Number of Entity Listed in Box"'I a• Southold, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/9/2022 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: ❑X 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 insurence carrier referenced above and that the named Insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as descylged above. Date Signed 6/10/2021 By (Signature of Insurance carrier's authoriz d representative or NYS Licensed Insurance Agerrt of that Insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carders authorized representative or NYS Licensed Insurance Agent of that,carrier,this certificate is COMPLETE:Mail it directly to the certificate holder. If Box 413,4C 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 ff Box 4C or 59 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) IIIII'iBiio1�2i0ii1iiii(i10iii17)ii�lU Additional Instructions for Form 1313-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is cancelled 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 coverage indicated on this Certificate.(These notices my be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in Box 3c,whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article.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 disability benefits to any such employee if so employed. (b)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 employment as defined in this article and 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 the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17)Reverse .N Y S ' F 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 Flew York state Insurance Fund nysifcom CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A All 112377925 km LEVITT-FUIRST ASSOCIATES LTD 520 WHITE PLAINS ROAD,2ND FL TARRYTOWN NY 10591 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ARTHUR J EDWARDS MASON TOWN OF SOUTHOLD CONTRACTING COMPANY INC P.O.BOX 728 929 RTE'25A SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 2438 491=9 633479 06/29/2021 TO .06/29/2022 06/16/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2438.49.1-9, 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. IF. YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR.WEBSITE AT HTTPS:IIWWW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. 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 STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 391287892 "000000000009�4420936 11111 Fozm WC.=T-NOPRAT Veroion 3(08292019)[WC Policy-043849191 U-26.3 god APP p, 0,VED AS NOTED DATE: �7� P.# FEE: `-� BY: NOTIFY. BUILDING DEPARTMENT AT RETAIN STORM WATER RUNOFF 765-18b2,:_8 AM TO 4 PM FOR THE PURSUANT TO CHAPTER 236 FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED OF THE TOWN CODE. FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FO;-' C.O. ALL CONSTRUCTKA: SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR ELECTRICAL. DESIGN OR CONSTRUCTION ERRORS. INSPECTION REQUIRE[ COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF G BOARD SOI ' NTRUSTEES ni v r " 10,,LCfSE POOL TO.CODE;. ; 77. '° JI?( N COMPLETION �,.�i "WATER" . OCCUPANCY OR, USE, I;' UNLAWFUL WITHOUT CERT-IFICA-l'" of OCCUPANCY A B /AlonfYrin ` TO R r" RYaa R1Er i Pww To T®Rib w �Wd"4 A---J POW v r PlanPiping . Arrangement X§4 ftbw 420 �P�e OF NFA 5 o�NS D.RFS Section B—B H 039 (P A 3595 Section A—A Typical Wall Section ssloNN\-� SIZE A B C- D E F G H AREA CAP V �js FEET FT FT FT FT FT FT FT FT SQ.FT GAL. Pnrdb� ezl 14 X 20 14 20 8 .8 2 2 2 8 280 9,5002-265qra4ov)ewAe V FOOL?[SPA CWM f 16 X 36 16 36 112114 6 4 1 4 8 576 21,600 PERMACRETE WAIL SYSTEM !' 18 X 36 18 36 12114 6 4 5 8 648 24,300 929 Route 25A _ Miller Place NY 11764 20 X 44 20 44 20 14 6 4 5 10 880 36,300 (631) 744-7185 FAX (631) 744-017421b on" j Plbm� 24 X 44 24 44 18114, 8 4 8 10 798 35,000 Suffolk License #4438—M Nassau License #M74450000 - 24 X 48 24 48 201161 8 4 61101 900 38,500 .