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HomeMy WebLinkAbout44722-Z SV=r— � TOWN OF SOUTHOLD BUILDING DEPARTMENT y TOWN CLERK'S OFFICE . ,' 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#: 44722 Date: 2/21/2020 Permission is hereby granted to: Robinson, Barnaby 31 Washington St Apt 3 Brooklyn, NY 11201 To: construct accessoryinround swimming-g g pool as applied for. At premises located at: 6620 Horton Ln, Southold -30 -al VV (-)T &A1 CT SCTM # 473889 Sec/Block/Lot# 54.-3-14.3 Pursuant to application dated 2/13/2020 and approved by the Building Inspector. To expire on 8/22/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Buil g ector I Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial building, industrial building,multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957)non-conforming uses,or buildings and "pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial $15.00 Date. New Construction: Old or Pre-existing Building: (check one) Location of Property: 6 6 o—j % &2CAV� House No. Street Hamlet Owner or Owners of Property: TW N P13 1_� * _�o r—C-AFf _UQ ojW (j Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ Si ature ESLD INSPECTION REPORT -DATE COMMENTS r� FOUNDATION (1ST) H ----------------------------------- FOUNDATION (2ND). C c� y ROUGH FRAMING& E+,� PLUMBING yam'1 INSULATION PER N,Y. �, y STATE ENERGY CODE FINAL ADDITIONAL COMMENTS c� 300 .0 11 �w A07 AA. ft lb V2 o d TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631)765-1802 Planning Board approval FAX: (631)765-9502 Survey Southoldtownny.gov PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined .20)b Single&Separate Truss Identification Form Stone-Water Assessment Form Contact: Approved 2046 Mail torr"5 A�'L( Disapproved a/c �t,��(���Lu,sF.6?uokUftA- l6Q2 Phone-.L- -37�-. YC7 f .Expiration. __.,20 Augaln'qg' Inspector FEB 1 3 2020 APPLICATION FOR BUILDING PERMIT Date ,20 2� INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months. Thereafter,a new permit shall be required. 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,or 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 for necessary inspectio4fe applicant or name,if a corporation) iu irerp Lu, (Mailing address of applicant) State whether applicant is owner,lessee'agent, architect engineer,general contractor,electrician,plumber or builder Name of owner of premises [1j�(LN�r{�{ Ja t '(�j'�CzG�( 113 i OSO t3 (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: Sok'o H-a C-0 House Number Street Hamlet County Tax Map No. 1000 Section �;LA BlockLot �l Subdivision Filed Map No. Lot 2. State extsting use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy 'S1 I A Lf-- 'rAi 1 l,`( b. Intended use and occupancy S�N k W!F 1FA V",%LJ1-< 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work SIy1W4iQ1j�d�i_- 4. Estimated Cost 'S 1 O© Fee (Description) (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. c 1 1 7. Dimensions of existing structures,if any: Front -jL Rear Depth '2 Height Zi I Number of Stories -2- Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front �� f Rear_ 4 1 Depths®/ 10. Date of Purchase '011201 u Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13. Will lot be re-graded?YES NO�Will excess fill be removed from premises? YES NO 3t 1o,�5Ht� 14.Names of Owner of premises� Cs�t Address ga cQy,�;V I go I Phone No.04 6 JAI D 3221 Name of Architect 30W SAWS ° -Ad dress602"4er*J CP,6Awhg-W Phone No 6,31 -3-7S-S11104-1 Name of ContractorGgr IAwJ r0001,S �ajQ&. Address ISMtu�.relltR�,PA Phone No.631 294 IoLo 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES&D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16. Provide survey,to scale,with accurate foundation plan and distances to property lines. ✓ 17. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO� * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) AAZS being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, CONNIE D.BUNCH (S)He is the Notary Public,state of New York fdn A-1-81.16:185050 (Contractor gen orporate Officer,etc.) Qualified in Suffolk County Commission Expires April 14,2 da(� 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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to b_Afore mth'. A f e day of :11���. 20 3 U � K\ Notary Public gnature of Applicant CONSENT TO INSPECTION 2!tAg/` 6EY K OIZ l 6(,S /�V ,the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersigned(is) (are)the owner(s) ofthe premises in the Town of Southold, located at b-600 H p e (m Q S LA17C— , dpi i , which is shown and designated on the Suffolk County Tax Map as District 1000, Section 5i( , Block S_, Lot I L4 .3 . That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: iia,►r a� ����t��c�L . tS�� That the undersigned do(es)hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon,to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances,rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances,rules or regulations of the Town of Southold. Dated: (Pri Rt Name) (Signature) .E-Wire M-eAi1\jc-- (Print Name) MEDINA ELVIRA No"f Public,State of NewYbflh No.0f MF-6370740 Qualified in Kings county Commission Expires February s,2022 Dal le/goao. Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) 1�� 610I'1Sdi lresiding at �b•� Yftl (Print profperty owner's name) (Mailing Address)) do hereby authorize -CS C,I'LRS (Agent) to apply on my behalf to the Southold Building Department. 12-0 (Owner's Signature) (Date) (Print Owner's Name) Scott A. Russell S0FRZ /f SUPERVISOR AMIANAG SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING: (CHECK ALL THAT APPLY) Yes .No ❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. ❑R) B. Excavation or filling involving more than 200 cubic yards of material ` J within any parcel or any contiguous area. ❑�J C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑[3 D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑�] E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑q F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT: (Property Owner,Desio ofessional,Agent,Contractor,Other) S.C.T.M. #: 1000 ate _rte+ District c r NAME: GT T t��r J l� Ll 4/00 Section Block Lot FOR BUILDING DF_.PARTNIENT USE ONLY Contact Information: rrd,pho Nwnbro Reviewed By: — — — — — — — — — — — — — — — — — — Date: Property Address/ Location of Construction Work: — — — — — — — — — — — — — — — — — h C� )t —�is /��l'i„ ❑ Approved for processing Building Permit. �Q ( Stormwater Management Control Plan Not Required. — - - - — — — — — — — — — — — — — f�kTl �" ) ❑ Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 APPLICANT: S.C.T.M. '�: 1000 CHAPTER 236 (Property Owner,Design Professional,Agent,Contractor,Other) — — b1 s Ir 5'4 3 14.1 Stormwater Management Control Plan CHECK LIST NAME: Section Block Lot z S M C P -Plan Requirements: Provide ONE copy of the Building Permit Application. pke P" Date: � � The applicant must Provide a Complete Explanation and/or Reason for not Providing )375-0 a 2i D all Information that has been Required by the following Checklist! �Igi 1 Telephone Number. I. A Site Plan drawn to scale Not Less that 60' to the inch MUST If You answered No or NA to any Item, Please Provide Justification Here! YES NO NA If you need additional room for explanations, Please Provide additional Paper. show all of the following items: A P a. Location & Description of Property Boundaries 0� b. Total Site Acreage. ERI=1= c. Existing - Natural & Man Made Features within 500 L.F. OO of the Site Boundary as required by §236-17(c)(2). d. Test Hole Data indicating Soil Characteristics&Depth to Ground Water. e. Limits of Clearing & Area of Proposed Land Disturbance. 0 f. Existing & Proposed Contours of the Site (Minimum Z Intervals) ►4V1 g. Location of all existing & proposed structures, roads, driveways, sidewalks, drainage improvements &utilities. h. Spot Grades & Finish Floor Elevations for all existing& proposed structures. I. Location of proposed Swimming Pool and discharge ring. F_ j. Location of proposed Soil Stockpile Area(s). T SfibLKPtU13'1 k. Location of proposed Construction Entrance/Staging Area(s). 0© C0 Te`kC1)o` V_ f40Ge 1. Location of proposed concrete washout area(s). 77 77 FT M. Location of all proposed erosion&sediment control measures. 2, Stormwater Management Control Plan must include Calculations showing that the stormwater improvements are sized to capture,store,and infiltrate on-site the run-off from all impervious surfaces generated by a two(21 inch 0� rainfall/storm event. 3. Details&Sectional Drawings for stormwater practices are required for approval. Items requiring details shall include but not be limited to: a. Erosion & Sediment Controls. b. Construction Entrance & Site Access, O0 c. Inlet Drainage Structures (e.g.catch basins,trench drains,etc.) d. Leaching Structures (e. . infiltration basins,swales,etc.) _....._......_._.._._._.-_.__._.........- -- -- -- -- . _...............-..._.__..._..-- - __........_..._.........._._............__._...._....._................. - I VY.) 1. DNGINE I::RING DEPAirrMENT USE ONLY**** El Additional Information is Required. I Reviewed & I Stormwater Management Control Plan is Not Complete. Approved By: — — — — — — — — — — — — — — — — — — — — — — — — Stormwater Management Control Plan IS Complete. Date: i SMCP has been approved by the Engineering Department. FORM * SWCP Check List -TOS MAY 2014 5 U RV EY O F F RO F E RTY PROPOSED LOT COVERAGE INFORMATION 51 T U AT E : 5 O U�JT H O L D P-40 A#.20%COVERAG� 1000-54-3-14.3 TOWN : �O d Y N • 5 O U 1 � (OLD {� AREA COVERAGE 48,250 S.F. 'pl,� � �\ E V U 1 f�J L K COUNTY, 1 V Y EXISTIING St10ED E 2.036.7 S.F. SURVEYED 09- 15-2014 MODIFIED STOOP 144.85.F. PROPOSED GARAGE 640.7 S.F. PROPOSED GARAGE OG-27-2018 PROP05EDBREEZEWAY 70.8 S.P. REV.,08- 13-2018 PROPOSED ADDITION 5G.7 S.F. PROPOSED DECK/ 1,211.8 S.F. XIIIIIIIIIIIIIIII REV. 12-02-2019, 02-03-2020 FROF05ED I.G.POOL 720.0 S.F. TOTAL PROP05ED COVERAGE 4,93 1.8 S.F.or 10.2% SUFFOLK COUNTY TAX # 1000 - 54 - 3 - 14.3 CERTIFIED TO: BARNABY ROBINSON TORREY ROBINSON JPMORGAN CHASE BANK, N.A. \ S LEGAL ABSTRACT, LLC F SG STEWART TITLE INSURANCE COMPANY 0 ;,0 0- ° ° °&.o 4'�j �m ° �F F d °m f•/ t \� cP4�o / \�'2�'h,9O �� F3r.�, \ �° p •per Qati.W�l.C' 011 ' J SO'17 n 0 s ij�y lL r Al QG0, Al oF��� / O\ sa\Fops /�P�O boy O� G ��K FEB 1 3 �0 2020 'DRAINAGE CALCULATIONS PROVIDED FOR 2"(O.1 7) RAINFALL DRAINAGE SYSTEM CALCULATIONS: ROOF AREA= 2,819 5a, Ft. 2,819 5q. Ft.X 0.17= 480 480142.2= 1 1.4 VERTICAL FT. OF 8' DIA. LEACHING POOL REQUIRED PROVIDE(2)8' DIA. x G' STORM DRAIN POOLS NOTES: "Unauthorized alteration or addition to a survey �y pp�r,� mop bearing a licensed land surveyor's seal is o ® MONUMENT FOUND JON^I C. E H LE RS LAND SURVEYOR t 9� ��'• violation of section 72or subt dEdu n Education or the JOHN I V / Plew York Slate Education Low.' PROPOSED POOL �✓�C+•EI�CE' "Only copies tram the original of this survey ENCLOSURE FENCE fi g+ �Q� marked with on a ca.l of the land surveyor's 'Q x y stampetl seal shall he considered to ha valid true " copies G EAST MAIN 5TREET N,Y.5. LIC. NO. 50202 Cerlihcations indicated hereon signify that this survey was prepored in accordance with the ex- Area = 48,250 Set. Ft. RIVERHEAD, N.Y. 1 1901 3G9-8288 Fax 3G9-8287 ' 4 ,. bytheNew of York Practice eState Afor Lad r P(adopted Area = 1. 105 Acres Load Surveyors. Said certifications shall run only je5urvey@optonllne.net ,%) to the person for whom the survey is prepared, GRAPHIC SCALE 1 40' Q f and on his behalf to the title company.governmen- -sj.`/I/ 5O2� �? tot agency and lending institution listed hereon.and LAD o the ossignees of the loading institution. Cerlifico- 14-1 Or '4''-�+ n lions are not transferable to additionoi institutions — � r u �oo+�mAu.u wr m,u,v-iws NYSIF New York state Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE a 0 ^^^^^^ 813943811 RICHARD ROSSI INSURANCE AGENCYINC 204 MEDFORD AVE PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER CROSS ISLAND POOL SERVICES INC SOUTHOLD BUILDING DEPT 415 MUNSELL RD 54375 MAIN RD EAST PATCHOGUE NY 11772 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12399982-4 765000 09/27/2019 TO 09/27/2020 1/29/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2399 982-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/iWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT KIMBERLY VIGGIANO OF A ONE PERSON CORPORATION 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:241473211 U-26.3 ACC>Rb® CERTIFICATE OF LIABILITY INSURANCE ATE(M'1/'29/2'010 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(fes)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 NAME: SPECIALIZED INSURANCE&SERVICES PHONE Fax631-758-6781 204 RTE.112 E-MAIL INC No PATCHOGUE,NY 11772 ADDRESS: SRUt7a SPECIALIZEDINSURANCE.COM Auto-Home-Business-cycle-etc. INSURERS AFFORDING COVERAGE NAIC# INSURER A.ATLANTIC CASUALTY INSURANCE CO 42846 INSURED INSURER B: CROSS ISLAND POOL INSURER C• SERVICES INC • INSURER D 415 MUNSELL RD INSURER E EAST PATCHOGUE,NY 11772 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. 1NSR TYPEOFINSURANCE OD SBR POLICY NUMBER MMIUDDY YYY POLICY EXP LIMITS LTR A COMMERCIAL GENERAL LIABILITY Y N L0680243739/12/2019 9112/2020 EACH OCCURRENCE $ 1,000,000 D GE o RE r CLAIMS-MADE ®OCCUR PREMISES Ea occurrence) S 100,000 MED EXP aneparson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑SECT LOC PRODUCTS-COMP/OP AGG $ 2,000000 OTHER: $ AUTOMOBILE LIABILITY COBI EaMacoiNED SINGLE LIMITde t $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Par Pe accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ST TUT ETH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEMEXECUTIVE YN/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E:L DISEASE-EA EMPLOYE $ If qes describe under DES3RIPTION 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) REMODELING;CARPENTRY AND DRY WALL OR WALLBOARD 1NSTALLATION,LANDSCAPE GARDENING,MASONRY,SWIMMING POOL SERVICING,SWIMMING POOLS-INSTALLATION,SERVICING OR REPAIR-ABOVE AND BELOW GROUND BELOW ARE LISTED AS ADDITIONAL INSURED AS PER WRITTEN CONTRACT OR AGREEMENT. CERTIFICATE HOLDER CANCELLATION SOUTHOLD BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 MAIN RD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY VISIONS. SOUTHOLD, NY 11971 AUTHORIZED REPRESENTATIVE ` +n ©198 -2015 ACORD COMPdRATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD NYSI F New York state Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE D C"3 All A"^^ 813943811 '� RICHARD ROSSI INSURANCE AGENCYINC 204 MEDFORD AVE 0 PATCHOGUE NY 11772 SCAN TO VALIDATE AND SUBSCRIBE i i POLICYHOLDER CERTIFICATE HOLDER 7 CROSS ISLAND POOL SERVICES INC SOUTHOLD BUILDING DEPT 415 MUNSELL RD 54375 MAIN RD EAST PATCHOGUE NY 11772 SOUTHOLD NY 11971 i i POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12399982-4 765000 09/27/2019 TO 09/27/2020 1/29/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2399 982-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. '�• I IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:NWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT KIMBERLY VIGGIANO OF A ONE PERSON CORPORATION 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 i THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:241473211 U-26.3 oa APPRQ M AS NNED DATE: p FEE: rD _ BY: NOTIFY BUILDiNT ur--??,R T HENT AT The barrier must completely surround the swimming 765-1802 sAM `�-4;�,, FOR T;-'E SWIMMING POOL ENTRAPMENT PROTECTION P Y g FOLLOWING INS ".,I,� JS. CD pool and must obstruct access to the swimming pool. 1. FOUNDATION - FOR POURED cR;^ REQUIRED r I I I Suction outlets must be designed to produce circulation 2. ROUGH - FRAMING LUMBING 3. INSULATION - throughout the pool or spa The barrier must be at least 4 feet (48 inches) high. 4. FINAL - CONS RUC IO�I'' MUST Single outlet systems, such as automatic vacuum cleaner BE COMPLETE FOR C.O. systems, or other such multiple suction outlets whether ALL CONSTRUCTI N SHALL MEET THE y p A building wall can form part of the required barrier. REQUIREMENTS F THE CODES OF NEW isolated by valves or otherwise must be protected against YORK STATE. N T RESPONSIBLE FOR However, where a wall of a dwelling serves as part of DESIGN OR CON (RUCTION ERRORS. user entrapment the barrier, at least one of the following requirements DUAL ANTIVORTEX In ( Suction Fittings: All pool and spa suction outlets (exceptmust be satisfied: COMPLY TVITH ALL CODES OF NEW YORK BTATE & TOWN CODES � ( VGB COMPLIANT I I surface skimmers must be provided with: MAIN DRAINS. p the pool must be equipped with a powered safety AS REQUIRED AND CONDITIONS OF 1 40"� PLUMBING TIED I I a cover that conforms with reference standard cover WITH "T" ANSI/ASME A112.19.8 Suction Fittings for Use in all doors with direct access to the pool through that ED Swimming Pools, Wading Pools, Spas, Hot Tubs, and wall must be equipped with an alarm or other means r-s C u i ' Whirlpool Bathtub Appliances, or of protection, such as self-closing doors with a drain grate that is 18 inches x 23 inches or larger, or self-latching devices, which are approved by the 40'-0" - an approved channel drain system governing body OCCUP NCY OR Atmospheric vacuum reliefs stem required: All pool and In the case of an above-ground pool, the pool� 6'—a" p y q p g p p USE IS UNLAWFUL - spa single- or multiple-outlet circulation systems must structure itself can serve as a part of the required WITHOUT CERTIFICATE L 4'-0" IFlCATbe equipped with atmospheric vacuum relief should grate barrier, provided that the pool structure is sufficiently OF OCCUPANCY NCY I LL, - ' covers located in the pool become missing or broken rigid to obstruct access to the pool. However, where _ — — — — — — — — — — — — — — — — — — — - - — — — — — — The vacuum relief system needs to include at least one an above-ground pool structure is used as a barrier RETAINS ORM WATER RL►°l�+FF- COPING _ _ J y g p PURSUA T TO CHAPTER 236 � — — — — — — — — — — — — — — — — — — — — - - — — — — — — — — — — — — — — — — of the followingtwo approved or engineered methods: or where the barrier is mounted on to of the pool pp g p p OF THE TOWN CODE. 0 TE- o Safety vacuum release system conforming to ASME structure, and the means of access is a ladder or SKIMMER SKIMMER SKIMMER A112.19.17; or steps, then: ELECTnICAL �tl1pSPE�T10N REQUIRED 31_o POOL PLAN An gravity drainage system the ladder or steps shall be capable of being secured, 10" 10" Dual drain separation: Single or multiple pump circulation locked or removed to prevent access, or the ladder or 2" THICK STONE COPING systems must have: steps shall be surrounded by a barrier sLy� NOLOS _ POOL TO CODE`= at least two of the approved type of suction outlets, and when the ladder or steps are secured, locked or }FOI COMPLETION C19a minimum horizontal or vertical distance of 3 feet removed, any opening created shall not allow the aF ' E,° arER 4 Uo MARBLE DUST FINISH �o o between the outlets, and passage of a 4-inch-diameters here. LED •.I : P g p SIJ. the suction outlets piped so that water is drawn through Barriers shall be located so as to prohibit permanent e•.. •.. i,. - ., '1;. •: ''•' :. ..:' . ," :• r a `i POOL them simultaneous) through avacuum-relief--relief-protected structures, equipment or similar objects from being LIGHTING p1 9 . I:• line to the pump or pumps used to climb the barriers. Pool cleaner fittings: Where provided, vacuum or pressure #4 REBAR 12"OC EACH WAY ' cleaner fittings shall be located in accessible positions at • �'' r,_� Q° ._:' . .fa least 6 inches and not more than 12 inches below the SWIMMING POOL ALARM REQUIREMENTS NOTES: POOL SHALL MEET POOL BARRIER minimum operational water level, or REQUIREMENTS AS STATED IN SECTION AG105 as an attachment to the skimmers s capable of detecting a person entering the water at any point NYS BARRIER REQUIREMENTS PNEUMATICALLY APPLIED on the surface of the pool and giving an audible alarm CONCRETE MINIMUM to provide detection capability at every point on the surface of a MASONRY SHALL BE DESIGNED IN ACCORDANCE 300DPS1 AT 28 DAYS swimming pool, it may be necessary to install more than one SEAL fia., . �, •• ,_-�.„,y WITH PROVISIONS OF SECTION R606 OF THE NYS RESIDENTIAL COADE 0R IN ACCORDANCE WITH pool alarm SECTION PROVISIONS OF ACI 530/ASCE 5/TMS402 is audible poolside and at another location on the premises where ; ,`� �` the swimming pool is located ; is not an alarm device which is located on a person, or which is dependent on a device located on a person for its proper operation ARCHITECT SWIMMING POOL BARRIER REQUIREMENTS meets ASTM F2208 JEFFREY SANDS ARCHITECT 2" THICK STONE CO ING NOTES: POOL SHALL MEET ALL SWIMMING POOL 6EVERGREENLANE EAST QUOGUE, NY 11942 ARBLE DUSTyFI ISH RELATED CODES IN THE 2017 NYS UNIFORM CODE PHONE 631.375.5997 FAX 631.576.8916 EQUIPMENT LIST: SUPPLEMENT SECTION 326 EMAIL:JEFF( ''° ALL PIPING 2" SCHED 40 PVC =III-111- i- q :i =�1_�-1►_�- PUMP: HAYWARD VS SUPER PUMP SP2603VSP MASONRY SHALL BE DESIGNED IN ACCORDANCE PROJECT HEATER: RAYPACK 406A WITH PROVISIONS OF SECTION 8606 OF 2015 IRC ROBINSON --III :._i I •• ii -i_�1 : l• :: rA: �: . . ;; .� : =1�1 FILTER: PENTAIR CLEAN AND CLEAR CARTRIDGE FILTER OR IN ACCORDANCE WITH PROVISIONS OF ACI RESIDENCE -=��i_._ �.� -� -, =. =►I►= AUTOFILL. 1 530/ASCE 5/TMS402 6620 HORTON'S LANE _� iii:- i1 IliiTi I ►i -�� liili Iii- DEEP HEAT RETURNS: 2 SOUTHOLD PNEUMATICALLY APPLIED WALL RETURNS: 5 SWIMMING POOL SHALL MEET ALL SWIMMING POOL NEW YORK CONCRETE MINIMUM 4 REBAR 12"OC DEEP END DRAINS: 2 DRAWING TITLE 400aPsl AT 28 DAYS # CODES AS STATED IN SECTION 85-891 OF THE EACH WAY SKIMMERS: TOWN OF BROOKHAVEN ZONING CODE. SWIMMING S P A ECTION ECHANICALLY COMPACTED OR NO FLO DRAIN VI GIN SOIL POOL AND SPA DETAILS S� a►�a -�--- j//�.2�M 1,4- SC�7s11=11-011 i"27-Zo2o IDRAWING NUMBER I Opp Ilra+7d nIll 11500 A