Loading...
HomeMy WebLinkAbout47730-Z cuEFOiKc r� Town of Southold 10/2/2023 a P.O.Box 1179 o T., 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44619 Date: 10/2/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 800 Midfarm Rd., Southold SCTM#: 473889 Sec/Block/Lot: 70.4-38 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/22/2022 pursuant to which Building Permit No. 47730 dated 4/22/2022 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 with spa as applied for. The certificate is issued to Kneuer,John&Mimi of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47730 8/8/2022 PLUMBERS CERTIFICATION DATED Authoriz d S'g ature o�SufFQt,t�o TOWN OF SOUTHOLD BUILDING DEPARTMENT y TOWN CLERK'S OFFICE "� • SOUTHOLD NY a� 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#: 47730 Date: 4/22/2022 Permission is hereby granted to: Kneuer, John 800 Midfarm Rd Southold, NY 11971 To: construct accessory in-ground swimming pool with spa as applied for. Pool equipment must have a minimum setback of 10 feet from all lot lines. At premises located at: 800 Midfarm Rd., Southold SCTM #473889 Sec/Block/Lot# 70.4-38 Pursuant to application dated 3/22/2022 and approved by the Building Inspector. To expire on 10/22/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 wilding Inspector oF so�ryol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �e sean.devlin(Qtown.southold.ny.us Southold,NY 11971-0959 Q�yCOU�,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: John Kneuer Address: 800 Midfarm Rd city:Southold st: NY zip: 11971 Building Permit#: 47730 Section: 70 Block: 4 Lot: 38 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043ME 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 1 Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 3 4'LED Exit Fixtures Pump 2 Other Equipment: 100A Sub Panel 12 Circuit/ 8 Used, 3 Lights on 30OW Intermatic Pool Tranny, Salt Generator, Heater, Pump 220GFI x 2, AutoCover 120GFI w/ Key Locked Switch Notes: Pool Inspector Signature: Date: August 8, 2022 S.Devlin-Cert Electrical Compliance Form r t + i- t � Thank you, Lennie Cancellire LC Electrical Contracting PO Box 231 East Moriches NY 11940 Cell: 631-445-4482 Office/Fax: 631-874-0485 www.Icelectricalcontractinginc.com from my Whone This email may contain material that is confidential, and proprietary to LC Electrical contracting Inc, for the sole use of the intended recipient. Any review, reliance or distribution by others or forwarding without express permission is strictly prohibited ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 3 o�aOF SO(/l�o 9 7 7V 60 MIJ&--m )Zld # # TOWN 6F SOUTHOLD BUILDING DEPT. cOVUM'1 N� 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 .M ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: o I d � Gam- 4ioLCA 1,r I A Yl*o')/e aA tAl ►�ni�� GOr4 df DATE INSPECTOR -7 ,�OE Sol C m --- - * * TOWN OF SOUTHOLD BUILDING DEPT. `ycourmN�' 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: S DATE INSPECTOR ho��OFSOUIyOIo W7-7 #30 600 M194VI), # # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 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) N4 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: A 1.S- 4 a 9: � � r iL C44 r d ran n is ev✓ La tS cn s DATE Fi 2 INSPECTOR OE SOUI,�°lo # # TOWN OF SOUTHOLD BUILDING DEPT. couto, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ dFINAL )4� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: /2e jlzleA,, Ok, 5/,6A eeVewZ Dk- Fmcc ha glzli, n&a-5 e Szewogez A.V4 A . 6e-// w & DATE -023 INSPECTOR pF SOUTyo� -- f # TOWN OF SOUTHOLD BUILDING DEPT. �ycoo631-765-1802 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: ��- �(�— d�� O. DATE INSPECTOR Jeffrey Sands Architect April 28th , 2022 Property/ swimming pool location: John Kneuer Residence 800 Midfarm Road Southold, NY RE: Swimming pool rebar and dDMell inspection Attention Town of Southold Building Department: Upon inspection of swimming pool rebar and drywell at above mentioned property, I find all to have been installed to meet current building code requirements. Sincerely, s" D MmE D Jeffrey Sands Architect AUG 2 3 2023 EURMIIVG DEPT: TOWN OF SOUTHOLD 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—jeffrey sands(d)hotmail.com FIELD INSPECTION REPORT I DATE COMMENTS J FOUNDATION (1ST) V1 G ------------------------------------ �I c FOUNDATION (2ND) 11-lyO O ROUGH FRAMING& ¢ , PLUMBING . � 1 r INSULATION PER N.Y. y STATE ENERGY CODE 5AI-c 6A ole, h4,2rL4.eti nu-As s / S ga Cam// wheh FINAL 902 f a —QjO RAJI jil5lP—I&4e. )tg�,MOle— A* ADDITION41,CqMMENTS Z y m 1S• �3•a3 C �20 �02 2al�irz• � a � b au Wz x r� �d b H 0.00��00� TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy • o�y� Telephone (631) 765-1802 Fax (631) 765-9502 hgps://www.southoldtownny.RoV Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only � nr PERMIT NO. �J� _ Building Inspector: Applications and forms must be filled out in their entirety. Incomplete MAR 2 2 2022 applications will not be accepted. Where the Applicant is not the owner,an BUILDING DEPT. Owner's Authorization form(Page 2)shall be completed. TOWN OF SOUTHOLD Date: OWNER(S)OF PROPERTY: Name: J O�Y) ; yy)°\ K SCTM# 1000- 04 —3& Project Address: M n l Farm rCJ S 0 J�O`� v Phone#: U�IJ� �-�®�1 400 Email: eir� L�yy)- Mailing Address: CONTACT PERSON: Name: CU�� Mailing Address: \( urq I1(� " Phone#: 3 i_(C'2_ �J U-, EM'ail- ,Dk&PAM DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email. CONTRACTOR INFORMATION: Name: VW _ Pab S -Tin L `` Mailing Address:Y`0 6� Zo ay ST v O Je 11-CI` I oZ Phone#: W JN_(�� -7 uPS— Email:t S t-COvyl DESCRIPTION OF PROPOSED CONSTRUCTION Struture ❑Addition ❑Iteration ❑Rpir ❑Demolitn ?py�3bW�Zx1 $st �edCProject: S� G� l��XOtheNe � � Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? es ❑No 1 PROPERTY INFORMATION Existing use of property: )tam Intended use of property: W Zone or use district in which premises is situated: Are there any covensis nd restrictions with respect to ® this property? ❑Yes o IF YES, PROVIDE A COPY. 31 Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by apter 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 rint name): yl 1D uthorized Agent ❑Owner Signature of Applicant: Date: 3'as STATE OF NEW YORK) S• COUNTYOF 1k ) �rIna me' u )1- 16 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Aqcxv+- (Contr or,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 ZVi" day of 1V I c�,v�h , 2o2-2— Notary Public MICHELE A MEDUSKI i Notary Public,State of New York - Reg.No.OIME6393343 PROPERTY OWNER AUTHORIZATION Qualified in Suffoli<County (Where the applicant is not the owner) Commission Expires June 17,2023 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 Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, w residing at �Io Y� Itr)j 0 (Print property owner's name) (Mailing Address) V do hereby authorize t I'�,� CAAr-" (Agent) to apply on my behalf to the Southold Building Department. I 1 (O is Signature) (Date (Print Owner's Name) i I k I �171 �a CO) N� q� w III 6Uyra4 I ✓fie c�acAt � 1�nAa..+"c� c �i�d Lpector BUILDING DEPARTMENT- Elect . TOWN OF SOUTHO JUN 0 6 2022 Town Hall Annex - 54375 Main Road - PO Qg?c,14,79�; , r - WN OF SCIbTHOLD Southold, New York 11971-095 's Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD-southoldtownny.gov — seandp_southoldtownny.Aov APPLICATION FOR ELECTRICAL.INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 5/3/2022 Company Name: LC ELECTRICAL CONTRACTING Electrician's Name: LENNIE CANCELLIRE License No.: ME-38043 Elec. email:OFFICE@LCELECTRICALCONTRACTING.COM Elec. Phone No: 631-874-0485 El I request an email copy of Certificate of Compliance Elec. Address.: 22 WOODBINE LANE EAST MORICHES NY 11940 JOB SITE INFORMATION (All Information Required) Name: KNEUER Address: 800 MIDFARM RD SOUTHOLD Cross Street: Phone No.: Bldg.Permit#:47730 email: Tax Map District: 1000 Section: `1 Q Block: Li Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): POOL Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES ✓] NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES ❑ NO Issued On Temp Information: (All information required) Service Size❑1 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service[:]Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground LateralsF-1 F12 H Frame M Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION -` b rat ND.,19994 TNT MIDFARM ROAD MAP OF y 0. 0. S47o8'10 E DESCRIBED PROPERTY x}8.2 8771' SITUATE ` SOUTHOLD TOWN OF SOUTHOLD, SUFFOLK COUNTY N.Y-AREA = 26,569 SO. FT. In N �A gyp, DATE: MARCH 8, 2010 SCALE: 1'-30• to tn � of5 q ' :n7 7 ID9 r W y o cT] w. �my�1' CL^ 3 0 0 3 0 * � � o -- 1n � � � F 013 ly 1 p� o � bdSL'�C�th 1 •n �mzol' Y ocl Z< w 1 Q�AH L Ic�ii yW 1. U Ao O Si��n,y y ZQZ W O 1 •.r - e'? Z -V O - JO C) • 19.7 L � "Y 0 GARAGE 11J "Ci7L11R I i' .�•. d' Ii CERTIFIED TO. Z 4 9.T• vJ J RICHARD KNOriLDEN MARGARET KNOMDEN I Q FlDEUTY NATIONAL TITLE INSURANCE COMPANY .a•..P P..w+, U CUC MORTGAGE CORP. ..Not•r4•Iw Ln IND o•�d »: _ _ _•_ _ „D PREPARED BY -"""•'°°"" " "Y N55'17'00"w • PDSTnNDNALrENZ • rc 17s 176.14' SCHNEPF & MURRELL, P.C. N µw LAND SURVEYORS - LAND PLANNERS ,,, ,„„�:,.,...,.,P•••-•� LAND NOW OR FORMERLY OF. 126 MAIN STREET, SAYVILLE. NY 11782 +•� ""�""°N" �`"'� ARLENE Z RYAN TRUST 631-589-1322/631-589-1779(FAX) °"�"'•''"""P"•'NJOHN J. RYAN TRUST.pw:M� ��••T+,N I.F�wWNw TAX YN DL9OIA7101 FND ewl.y,.v.w P•,..••r..P.., pISTIrR SCIIOII i00K lDT p. v'e .r•P"�.:. 1000 70 04 38 R CERTIFICATE OF LIABILITY INSURANCE °ATE'MM`°°"'""' A os/01/2022 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Nicholas Zulkofske Brookhaven.Agency,Inc. PHONN.E 631 941-4113 FAx 631 941-4405 100 Oakland Ave,Ste 1 E-MAIL certificate$ brookhavena enc .com Port Jefferson,.NY 11777 INSURER(S)AFFORDING COVERAGE N IC# INSURER : Philadelphia Indemnity Insurance Co. INSURED INSURERS: Merchants Mutual Insurance Co. Patrick's Pools,Inc INSURER C•Wesco Insurance Co. PO Box 3024 INSURER 0: East Quogue NY 11942 IN RER E: IN E COVERAGES. CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL UBR POLICY NUMB POLICY EFF POLICY EXPLTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE ®OCCUR DAMAGE TO RENTED $100,000 x Contractual Liability X X PHPK2385555 02/28/2022 02/28/2023 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2 00O 000 POLICY[j]PROJECT F-1LOC PRODUCTS-compt6P AGG s2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $6001000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE D I I RETENTION$ $ WORKERS COMPENSATION X I PER IT, 1 10 AN AND EMPLOYERS'LIABILITY STATI ANY PROPRIETORIPARTNER/EXECUTIVE Y E.L.EACH ACCIDENT $100,000 C OFFICERIMEMBEREXCLUDED? Y NIA WWC3528513 05/13/2021 05/13/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 r) es, IPTION OF OPERATIONS e E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as additional insured per written contract CERTIFICATE HOLDER CANCELLATION Town of Southold,Town Hail Annex SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <NSZs ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Y i workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disabi ity 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 PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only regtrHecl ileo Yrrage is spedlteatry umttearo or Social Security Number certain locations In Now York state,i.e.,Wrap-U, Percy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Ht Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Fid. 3b.Policy Number of Entity Listed In Box"1a" PO Box 1179 DBL318565 Southold,NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: A.Both disability and paid family It eve benefits. S.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or dose as of employer's employees: Under penalty of pe ury,I cerbVthat I am an authorized representative or licensed agent of the Insurarm canter referenced above and that the named insured has NYS Disability and/or Paid Fal illy Leave Benefits insurance coverage as described above. Date Signed 3/1/2021 _ By " (5igmture of insurance cardees authorised representative or NYS licensed Insurance Agent of that insurance carrier) Telephone Number 516-629-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A.ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Ucensed Insurance.►gent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B i;checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily Leave Benefits Lew.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 f IYS Workers'Compensation Board(only N Box 4C or 58 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained b f the NYS Workers'Compensation Board,the above-named employer has compiled 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 Worked'Compensation Board Empiorae) Telephone Number Name and Title Please Note.Only insurance carriers))can red to write NYS disabOy and paid famUy leave benefits Insurance policies and NYS licensed Insurance agents of those insurance carolers are aW..262ad to Issue Form tie-720.t.insurance brokers are NOT audtortzed to issue this Iti m. DB420.1(1047) IidIIPDu�ia1a20o�miiun10iui17)a�l� wor(ers' v"oRlc ( CERTIFICATE OF STATE Compertsatiort NYS WORKERS' COMPENSATION INSURANCECOVERAGE Boo 1 a,Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996.4687 Patricks Pools Inc PO Box 3024 East t]uogue NY 11942 1 c.NYS Unemployment Insurance Employer Registration Number of ue Insured Work Location of Insured(On7yrequired it coverage is specifically limited to 1d Federal Employer Identificatlon'Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of insurance Carrier . (Entity Being Listed as the Certificate Holder) Wesco Insurance Co Toven of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold NY 11971 . WWC3628513 3c.Policy effective period 05/13/2021 to 05/13/2022 3d.The Proprietor.Partners.or Executive Officers are included.(Only chock box if all partners/officers inducted) ® all excluded or certain partners/of8cers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business-referenced above in box"1a"4or workers' compensation under the NeW York State Workers'Compensation Law.(To use this form,New York•(NY)must be listed under ttem 3A on the INFORMATION PAGE of the workers_'compensation insurance pollcy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box'2". The insurance carrier must notify-the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that.cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)0,therwise,this Certificate is valid for one year afterthls form is approved by the insurance carrier or Its licensed agent;or,untll 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,1.certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Nicholas Zulkofske (Print name'of au dzod representafive or licensed agent.of insurance.carder) r Approved b . ` �- ( ature) (Date) Title:Authorized Agent Telephone Number of authorized representat'ive•or licensed agent of insurance carrier: 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-106.2'(9.17) www.w6b.ny.gov T, D AS NOTEDDATE: nn-B.P.# 3v FEE: ll dU BY: NOTIFY BUILDING U( RETAIN STORM WATER RUNOFF 765-180,-AAM TO 4 PM FOR THE PURSUANT TO CHAPTER 236 FOLLOWING INSPECTIONS: OF THE TOWN CODE, 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH "-,-FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOP C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR ELECTRICAL. DESIGN OR CONSTRUCTION ERRORS. INSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF POOL TO'GBOARD O D COMPLETIONSnl "@-T8 eti4°USTEES � RE."WATER" .. N. - OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICA i OF OCCUPANCY , o ; I , i I i 1 I f i 1 i i I r i I 1 I ; I I i z_ e i- 1 , , T t i t l'. � r�l�Y� 0. 1 E Qf i - 1 I I :i Er'' i• - I - 7 - - I , `,` ' , I , t I i" { E I , p O s 00 l ! I i E F I , 1 i t i I 1 , r I. I" I 1 t , G I �\D Q Qdi I i _ i I i , , i , r ; ; , r , 1 t I 1 1 0 kI , i „ , i 1 I t -_ I I , _ _- ..1.^:;!':-..-';c.":r:c•-�". , i 1 1 I i r e 1 _ It ._ , , I I , I 7 , 1 C V j V i 1 I --i � .+ i i _..1 ,_.i { ..i ._i ,s —.i r— --I -'�' � •- ��:�' t , � , � E I L a t K6 � Y , r I -i 1 1 , j 1 : , I t ___ ----- __._---- ___- i it" i f;� , I 1` - 1 I i 1 I � I I i i i 1 I ,J\ ! i I : , , I ! i 2 n- - - - - - - - - - - - - - ' -MAR2 � � i i � r , ; , DE 1 i \ TOW JI Or$G PT. , i _ _ _ t i _ _ 6 i ! I i I ppY\iOLD �1!IIL.�1 -. :.I�_ I I rzi` - —I l U�_S�6 CV_ 1' i _ , r i — 3 eg 9 Y ;- Nmui e� t � r• 1 , 1 _ 1 I r , , ._..-__•—_ --. .,.__ ._ _- — -._-_ y'q , 1 i , , ,! �,....�.,--..�.. ., . --�-:>--2-�- .,, _ . .. ... _. - _< �• _ .::�Wiz•<.. __ _ __ - ' - —_. .. _ _.. .._.. .----__ - - - ,-. _. ,u r i y�, i I � 1 i t i 1 i 1 i `_ -'-_ i i-- I .—., i } � ' 1 i C y 1-1 lt..-' i✓0:..•6.h�e�- I d ! < I I i i , , I i 1 , 116 ( , , Y , r 1 r I f I I i , , r E D i I I- pp P r ! i 1 ' s A <t,, r'� 1 I 5 } 1 I I 1 r s I < , 4_lcoi , , I , i. r i , i 1 YC s x , OF NE`s �_ � t 4 ' -- - „k L �,�.....�.,�.,,s-„�.... -m.�.e®..�..��.�..r.,��e.,�._ .....-a.�..,._. .®.w.a.��e.,�m.e.�..-�� - ��..m._.•,.�A.--.e�-_,-.�”.�,.-,..�,e.�,.>..�...ze-.,�•..�,.�.�..� -..�..�,�.e�.._-�_-..._-,.�—r....,,�.,-...�__...�._.-.-,s.e,..-�..!...,.e,Ta..s.sm_-.A..•.�•.--3