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HomeMy WebLinkAbout49246-Z 2=1. F04�O , Town of Southold 11/4/2023 G y� P.O.Box 1179 0 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44715 Date: 11/4/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 7955 Nassau Point Rd, Cutchogue SCTM#: 473889 Sec/Block/Lot: 118.4-7 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/11/2023 pursuant to which Building Permit No. 49246 dated 5/15/2023 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 fenced to code as applied for. The certificate is issued to Hollis,Peter&Christine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 49246 8/18/2023 PLUMBERS CERTIFICATION DATED A ized i ature �o�gUffDtK TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE Wo 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#: 49246 Date: 5/15/2023 Permission is hereby granted to: Hollis, Peter 120 Kensington Rd Garden City, NY 11530 To: construct accessory in-ground swimming pool as applied for. At premises located at: 7955 Nassau Point Rd, Cutchogue SCTM # 473889 Sec/Block/Lot# 118.4-7 Pursuant to application dated 4/11/2023 and approved by the Building Inspector. To expire on 11/13/2024. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector oF so�ryolo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlin(a)-town.southold.ny.us Southold,NY 11971-0959 �yCOUNTY,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Peter Hollis Address: 7955 Nassau Point Rd city:Cutchogue st: NY zip: 11935 Building Permit#: 49246 Section: 118 Block: 4 Lot: 7 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Bethel Electric License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor Basement Spa X 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 2 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures 11 Sump Pump Other Equipment: Aqualink RS Powercenter, Hayward Salt Generator, (2) Pumps 220GFI,BIower220GF 5 Lights 30OW Transformerl20GFI, Heater Notes: Pool & Spa Inspector Signature: Date: August 18, 2023 S.Devlin-Cert Electrical Compliance Form �o�aOF SOUTyOIo LE a # # TOWN OF SOUTHOLD BUILDING DEPT. lourm,�� 631-765-1802 INSPECTI ON [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) t>47ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: - L DATE INSPECTOR OF SOUIyO� - - - TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL TIOpWCAULKING [ ] FRAMING /STRAPPING [ FINAL Utfl/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: l DATE I1 l Y INSPECTOR Jeffrey Sands Architect June 9t" , 2023 Property/swimming pool location: Peter Hollis 7955 Nassau Point Road Cutchogue, NY RE: Swimming pool rebar and drywell 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, cjn i r Jeffrey Sands Architect R® EC EE VE AUG 2 3 2023 Building Department Town of Southold 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sand s(�hotmai1.com FIELD INSPECTION REPORT DATECOMME S FOUNDATION (IST) ------------------------------------ u C FOUNDATION (2ND) -44 � O tlN H ROUGH FRAMING& PLUMBING � J 0 r INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS o� a S gice23 a`Qk O �oS/ u► q t 'Pockw 5-06 r W � � o z x _ x Cl m b G�oSUfFOI rho TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 i Way • o� Telephone(631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny.g`ov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector: APR 1 12023 BUIWINGDEPT `Applications and-forms:must be.filled'out in their entirety:Incomplete' `����®F��IUTInGLD P will not be,"acceptedr' Where.the Applicant is not,the:ow`n'er,an - " Owner's.Authorization;form(Pa"ge 2)s,tiall-be cbmpteted:; Date: 'OWNERS OF PROPERTY: - Name: �, I ( � SCTM# 1000- �? ,_it 1 Project Address: SS KasmLu 30 1 u "I Phone#: J Email: h ` cn Mailing Address: 10-% 5 C e, ,` N\4 �15 C) .r CONTACT PERSON. Name: Mailing Address: 5pek� vAn n �I cm Phone#: b'6 ' `_ S'3,_ (P(i�� Email: G `S `` DESIGN PROFESSIONAL INFORMATIONt' `" Name: Mailing Address: Phone#: Email: .777. . . ., .. ... CONTRACTOR.IN FORMAT ION; Name: P60 �S -Tn c Mailing Address: Phone#: 1 ® Email: CO DESCRIPTION,OF,PROPOSED CONSTRUCTION, ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition fi�-l)c-1 Estimated Cost of Project: C OtherNPt� ACCeson,f S�N1'iyf� IexGEI �� ns IP, 5lA3•VYIUYlU1Cl $ 11 Q14Do Will the lot be re-graded? ❑Yes)INo Will excess fill be removed from premises? Pes ONO 1 PROPERTY;iNFORIVIATION:. Existing use of property: [? �,�� Intended use of property:Sf, W1 yu POON , , 52 Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes�iVo IF YES, PROVIDE A COPY. rCheck Box,After Reading:' The owner/contractor/design professional is responsible for all drainllag__e;and storm water issues as provided by hapter,236,'of the Town Code. APPLICATION IS HEREBY MADE to the Building'Departme'nt 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_a's 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(e)for necessary inspections.False statements made hereii are,' " punishable as a Class A'misdemeanor pursuant to Section 210.45 of the,New York State Penal Law. Application Submitted By( rint name): �( Ylna me0C_UV-U0 L�uthorized Agent ❑Owner Signature of Applicant: � � Date: V / 11 ja s STATE OF NEW YORK) SS: COUNTY OF �511��LIti ) k'Al r&,ek' ./ 4ve (-L.,' X10 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is theI-Ijn T (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 1 ` o 1 day of 40 Gt , 20 0 Notary Public VICTORIA A FERREMI PROPERTY OWNER AUTHORIZATION Notary Public-State of New York NO.01 FE6430360 (Where the applicant is not the owner) Qualified in Suffolk County My Commission Expires Mar 14,2026 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 i Building Department Application AUTHORIZATION (Where the Applicant is not the owner) i I, Pet Ek `u S residing at (Print property owner's name) (Mailing AddreA) 6rdm `h iqA I 5-30 do hereby authorize KA�YNjNh I vEA.G(I (Agent) to apply on my behalf to the Southold Building Department. I i ( er's Signature} ; (Date) t-cc (Print Owner's Name) 4,14 #.}�.. :t'f,.•" a:": ..��f 4";.�g� _fit I i ! I 3 2023 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD K gJ-lall Annex- 54375 Main Road - PO Box 1179 1aiJ�..I9�3G �0 .N ,.:,�cO�"�`�=r'� - Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD-southoldtownny.gov - seand(aD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: Viateur.Pilon License No.: ME-40557 Elec. email: Bethelec@optonline.net Elec. Phone No: 631-750-6555 ❑✓ I request an email copy of Certificate of Compliance Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) Name: E:E;—> - hQLA-IS Address: jNassottx PojoaSS Cross Street: Shu Phone No.: BIdg.Permit#: 43 Vemail: ; S C-D© iyw all Tax Map District: 1000 Section: Block: Lot: '7 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring Square Footage: Circle All That Apply: Y L_M W W1 P Is job read for inspection?: . y p � YES❑ NO ❑Rough In f Final Do you need a Temp Certificate?: ❑ YES 7N issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Servicer-1 Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead #Underground Laterals 1 R2 0 H Frame Pole Work done on Service? Y N Additional Information: Please call our Office with an inspection date and the Homeowner for inspection access -Thank you! PAYMENT DUE WITH APPLICATION re C4 10b/ 69 j BUILDING DEPARTMENT- Electrical Inspector AUG Y TOWN OF SOUTHOLD x5 T-gwmJ-fall Annex - 54375 Main Road - PO Box 1179 corte :v�i ��"e.'f¢_�.`�r C, ,�1 z'u �o . ft, �4 . : ,, ;,. Southold, New York 1197170959 �✓,fj� ap�fir a Telephone (631) 765-1802 - FAX (631) 765-9502 rogerre-southoldtownny.gov - seandCaD-southoldtownny.gov `r��24,1LYr ri APPLICATION FOR ELECTRICAL INSPECTfON ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: Viateur Pilon License No.: ME-40557 Elec. email: Bethelec@optonline.net Elec. Phone No: 631-750-6555 ❑✓ I request an email copy of Certificate of Compliance Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) Name: 5-F,>,- HLILL-I's Address: t I NJSS Cross Street: Phone No.: ) 'o — Bldg.Permit#: ztO Vemail: p ; � t- ij ivw ..h Tax Map District: 1000 Section: I 1p> Block: - Lot: 7 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring Square Footage: Circle All That Apply: L.WI pV M -74-/ Is job ready for inspection?: YES❑ NO ❑Rough In 7Final Do you need a Temp Certificate?: ❑ YES NO issued On Temp 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:Please call our Office with an inspection date and the Homeowner for inspection access -Thank you! PAYMENT DUE WITH APPLICATION Z/(4122-16 611.l�( r�� re) C 4 1 o5,1 tog 4 T 2(4-cp I IV �� II SURVEY OF LOT #(91 AMENDED NEAP A \ OF NA55AU POINT, GLUS PROPERTIES, ING." FILED OCT. 4, laid \ AS FILE # 745 ° SITUATE: NASSAU POINT TOWN OF SOUTHOLD SUFFOLK GOUNTIr, NY SURVEYED OG-2b-9b SUFFOLK GOUNTY TAX MAP �O �d� / �g \\O I000 - Ilb - 4- -1 �Q 3� ° 0\6, GERTIFIED TO: DOUGALL ERASER Jr. GAROLINE FRASER NOTES: QQ� _ overhead _ o 00 O - — utilitle5 / ■ MONUMENT FOUND O PIPE FOUND - —°—°— WOOD FENCE N ° `, 1 _ — vw qo a , �2� Q� o O �Q O Q — cr,teE al tareticn c enitecn to ° e,.i;saao]ene�ew_.a,Pr.e ar:le: t State�Eeucet t9\ zte Ore seal tsnel l°neec°ns° cloeeet54en uz. o (o2 OClstnn9rtse'sPk'Prac f°rrWnen a ste° teflon Serf o sslone] N \O'`` � ��o� I��JLi t LenE Su enal�e!°rtn�t[liletc°oaannalltrt °nIY Vt1 �G.F`yy4e`! `O elaas ara natel�.nrtr'l.att�°e°entlt,tra�n eoM1�"ea r�.palno t°atttYo�.�'1.€]t°t,ent \, Co i g v c o ® F F'HT: _-.Lt 1 = �' N.Y.S. LIC. NO. 50202 JOHN B SURVEYOR 6 EAST '- T RIVERHEAD.N.Y. 1Y901 369-8288 Fax ;Rq-RPR7 RF-FFRFNCF * qR-nP9R -4�o (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE DATE 02/24/2023 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. PHONE 631 941-4113 FAX 631 9414405 100 Oakland Ave,Ste 1 E-MAIL . certificates brookhavena enc .com Port Jefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURERA: Philadelphia Indemnity Insurance Company INSURED INSURER B: Merchants Mutual Insurance Company Patrick's Pools,Inc. INSURER C: Wesco Insurance Company PO Box 3024 INSURER D: East Quogue NY 11942 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER (MM/DQ/YYYY1 (MM/DDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE X OCCUR DAMAGE TO RENTED $10Q000 X Contractual Liability PHPK2517025 02/28/2023 02/28/2024 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY Y]ECT —1 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER, $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Fa ann't1pnt) $500,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2022' 07/12/2023 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS FX NON-OWNED PROPERTY DAMAGE $ AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONg WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EE.L.EACH ACCIDENT $100,000 XECUTIVE C .OFFICER/MEMBER EXCLUDED YI N/A WWC3687728 05113/2022 05/13/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 Hall 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 <BS> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD STYORK workers' AVE I Compensation CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 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 required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 262929943 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 54375 Main Rd 3b.Policy Number of Entity Listed in Box"I a" PO Box 1179 DBL318565 Southold, NY 11971 3c.Policy effective period 05/13/2022 to 05/12/2023 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. B.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 classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 6/23/2022 By wddh� (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 emailed to PAU@wcb.ny.gov or it can 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 46,4C or 5B have 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(Article 9 of the Workers'Compensation Law)with respect to all of their 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 (12-21) DB-120.1 (12-21) YORK Workers' CERTIFICATE OF sTATt: Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996-4687 Patrick's Pools,Inc PO Box 3024 1c.NYS Unemployment Insurance Employer Registration Number of East Ouogue NY 11942 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification 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 Company Town of Southold,Town Hall Annex 3b.Policy Number of Entity Listed in Box'1a" 54375 Main Rd. WWC3587728 Southold,NY 11971 3c.Policy effective period ristint2n22 : to nsf vnm�,zi 3d.The Proprietor,Partners or Executive Officers are E] included.(Only check box If all partnerarofficers included) Qx 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"l a"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 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.)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 13c",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: Nicholas Zulkofske (Print name of authorized representative or licensed agent of insurance carrier) Approved by: -S/11 Z Z (signature) (Date) Title: Authorized Agent Telephone Number of authorized representative or licensed agent of Insurance carrier. 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C405.2.Insurance brokers are) authorized to Issue it. C-105.2(9-17) www.wcb.ny.gov r i � Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into 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 compensatlon 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 Aj oil it APP ® ED AS NOTED DATiff B.P.# FEE: gy. RETAIN STORM WATER RUNOFF NOTIFY,BUILDING DEPARTMENT AT PURSUANT TO CHAPTER 236 765-1802 8 AM TO 4 PM FOR THE OF THE TOWN CODE. FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING €; PLUMBING 3. INSULATION 4. FINAL - CONSTRUC TION MUST BE COMPLETE FOP ';0. ALL CONSTRUCT!ON SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. TAf�1,CM1. g pyo ;d;,�iJU�r'�:r 9allO�F1 J'll�i��'�Jtl��AJ COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF u ZSA glaS D 9 ATELY, ��--- SOUTE'!11 n mU��,pl q iAu;ia BOARD ENCLOSE POOL TO,`CQD; APP NED AS NOTED DATE: S B.P.# RETAIN STORM WATER RUNOFF FEE: � . BY: PURSUANT TO CHAPTER 236 NOTIFY. BUILDING DEPARTMENT AT OF THE TOWN CODE. 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONICRETE .2: ROUGH - FRAMING 8: PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ELECTRICAL ALL CONSTRUCTION SHALL MEET THE ��,,SpcC-TJON REQUIRED REQUIREMENTS OF THE CODES OF NEW "A YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ENCLOSE POOL.TQCDF NG BOARD UPON COMPL'.ETI�1 SUU T HOLD TOWN TRUSTEES '' Q N.Y.S.GFS OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICA I )F OCCUPANCY I , , i - t I- { , ' •T 1 ' '1' r' I .,yam , 1 , t ' ! I 1 I • i I { I o c i I , coI , Soot �2&u , I t _ ._. ..- - -..._ __ .. ,r:.- --'� - - '- - - - i -- - --jam -- -' '- -- -'- -- -- -' - --- .- - _.. _.__ __ ..- � - ----- --- — •'-'-•-- "-' -- -- --:-.- ---- r - - _ -m�-- --- - - .--�—'--- --------- --- --'- - ----- -- -,----- ---- - '------ - _ --- i 4 I I I I i : II I I l4 tea,. ,a _ . ' I ' I 1 " I ' i ; ; � 1 i i I i I i I I I I I " I _ I I i I i i p ; , -3- I _ 7710611( , ' ,