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HomeMy WebLinkAbout49262-Z r � SUFFOt,f�pG Town of Southold 11/4/2023 P.O.Box 1179 o - 53095 Main Rd y oar' Southold,New York 11971 zrir1zG'. CERTIFICATE OF OCCUPANCY No: 44717 Date: 11/4/2023 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 55 Knollwood Ln,Mattituck SCTM#: 473889 Sec/Block/Lot: 107.-6-12 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/24/2021 pursuant to which Building Permit No. 49262 dated 5/17/2023 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 fenced to code as applied for. The certificate is issued to Uklanski,Piotr&Alison of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46397 9/24/2021 PLUMBERS CERTIFICATION DATED 0 Au o 'ze S gnature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o . SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 49262 Date: 5/17/2023 Permission is hereby granted to: Uklanski, Piotr 55 Knollwood Ln Mattituck, NY 11952 To: Construct accessory in-ground swimming pool as applied for. Replaces BP #46397. At premises located at: 55 Knollwood Ln, Mattituck SCTM #473889 Sec/Block/Lot# 107.-6-12 Pursuant to application dated 5/17/2023 and approved by the Building Inspector. To expire on 11/15/2024. Fees: PERMIT RENEWAL $150.00 Total: $150.00 Building Inspector TOWN OF SOUTHOLD BUILDING DEPARTMENT C2 x TOWN CLERK'S OFFICE oy • o��r 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#: 46397 Date: 6/10/2021 Permission is hereby granted to: Uklanski, Piotr 55 Knollwood Ln Mattituck, NY 11952 To: construct accessory in-ground swimming pool as applied for. At premises located at: 55 Knollwood Ln, Mattituck SCTM #473889 Sec/Block/Lot# 107.-6-12 Pursuant to application dated 5/24/2021 and approved by the Building Inspector. To expire on 12/10/2022. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Bui ding Inspector of so�ryol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.deviin(cD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Piotr Uklanski Address: 55 Knollwood Ln city:Mattituck st: NY zip: 11952 Building Permit#: 46397 Section: 107 Block: 6 Lot: 12 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electrical 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 1 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 4'LED Exit Fixtures Pump 1 Other Equipment: Intermatic Pool Panel 8 Circuit/ 3 Used, Hayward Salt Generator, Pump 220GFI Heater, (1) Light 120GFI Notes: Pool Inspector Signature: Date: September 24, 2021 S.Devlin-Cert Electrical Compliance Form *�5 all tOP SOblyolo Ll V ��� k �VG.�(.� `-� # * TOWN OF SOUTHOLD- BUILDING DEPT. �ycpe�` 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 REMARKS: J% SDA-/ tt&eTtZie_kc, LN,y je�nG,A) DATE INSPECTOR oP souTyo� - # # TOWN OF SOUTHOLD BUILDING DEPT. °ycourm��'�� 631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2NDXFINAL SULATION/CAULKING FRAMING /STRAPPING wt--� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: Ufa Irk S� U 105 I PL, g-, Dn Dogo% O VL oft_ DATE INSPECTOR V son # # TOWN OF SOUTHOLD BUILDING DEPT. �p . �o `ycou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL O 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: ( - � 1 V � hoc,► A--D t DATE 0 IQ INSPECTOR k n5 y�3� Jeffrey Sands Architect August 8, 2021 Alison Residence 55 Knollwood Mattituck, NY 11952 RE: Swimming pool rebar inspection *TAT-MO-L Attention Town of Southold Building Department: Upon inspecting swimming pool rebar and drywell at the above mentioned property I find all to have been installed to meet current building code requirements. Sincerely, BRED 02739A OQ� QF NES y Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sands()-hotmail.com Jeffrey Sands Architect August 8, 2021 Alison Residence 55 Knollwood Mattituck, NY 11952 RE: Swimming pool rebar inspection * PfL�— Attention Town of Southold Building Department: Upon inspecting swimming pool rebar and drywell at the above mentioned property I find all to have been installed to meet current building code requirements. Sincerely, RED ARC �� ON ) F NE`N Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—Jeffrey sands@hotmaii.com FIELD INSPECTION REPORT DATE COMMENTS, FOUNDATION(1ST) ------------------------------------ C FOUNDATION(2ND) 11 �O ROUGH FRAMING& PLUMBING y INSULATION PER N.Y. STATE ENERGY CODE Co � 1� VV" i Irir��f-� Mph P,p, FINAL. DA,Q e f O,�Sti n oTk L Pl ADDITIONAL OMAJENTS 2q 1 cip4r1c, oo te Ms r"P- re-c, m G ' �l H H x d b H QgUff0lg�� 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://www.southoldto)VM.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only j �j PERMIT NO. ✓ Building Inspector: 4M AY 2 4 2021 •- Applications and forms must be.filled out in their entirety. Incomplete applications'will not be accepted:' Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: �VoZ I laoa-1 OWNERS)OF PROPERTY,1:,, Name: A'1 V F Ans.9`�l SCTM#1000- I p—I . LO- la Project Address: rJ_5--. An.01iw00c-A Vane,, tAOt+�-\J%,cX Phone#: Email: a �n �� 1MG1fr� C.OYV1 Mailing Address: .CONTACT,PERSON: Name: Mailing Address: _5 oI .Phone#: IAI-_ q_53'.L0401_ .. _ Email: V-dIJl1Y%YIOI :b(tQ\. s O 1S Q- yymaXt ox m DESIGN PROFESSIONAL INFORMATION:, Name: Mailing Address: Phone#: I .Email: .-CONTRACTOR INFORMATION: Name: Mailing Address: � bOY4 301a\41 SOS ' QUO or-, Ny 1\ol4'a- Phone#: (QEmail: sa\e.sis krtL)gLspoo\s ► co►y-1 DESCRIPTION:OF PROPOSED CONSTRUCTION- ❑New Structure ❑Addition ❑Alteration ❑Repair I%Demolition� t, sQ�� Estimated Cost of Project: Other N C Sw�rnw•: 6o1 a3t.5y oL $ -151000 Will the lot be re-graded? ❑Yes-Vo Will excess fill be removed from premises? Aes [:]No 1 PROPERTY-INFORMATION Existing use of property: '4 ouSQ Intended use of property: �'$ rnt' �S Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to p° tA AR—. this property? ❑Yes WNo IF YES, PROVIDE A COPY. heck Box After—Reading:,The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by hapter.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 21085 of the New York State Penal Law. Application Submitted By(print name): IZaAYl h a Me-VCUY10 Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SSS: COUNTYOF-_civalV_ ) 6�mna Me-y U n O being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract)above named, (S)he is the (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 bA a I 20—IL MICHELEAMEDUSI< Notary Public Notary Public,State of New York Reg.No.01 ME6393343 Qualified:in Suffolk County Commission Expires June 17,2023 PROPERTY OWNER AUTHORIZATION (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 Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, AllSorl z. Piot-v- UKLANSK1 residingat 55 Kho(Iwood Latie (Print property owner's name) (Mailing Address) Ma fh k G k-, N\/ 1051- do hereby authorize 7R fy I e S Pods /h c, K A T K l N/A (Agent) Il.,fE R C v i21 0 2 ` 1l-1Yz P o.a ex 3 a Z y �kf r C>vo� to apply on my behalf to the Southold Building Department. /Z /"AY (Owner's Signature) (Date) (/K 1414 s K Ot- (Print Owner's Name) FI /( t BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD CD Town Hall Annex - 54375 Main Road - PO Box 1179 o Ze _ Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(cbsouth oldtownny.gov — seand(aD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: x_21~al Company Name: e,-.,\ Name: �� erZ License No.: email: Phone No:Z 3t-,Vy,S, ❑0equest an email copy of Certificate of Compliance Address.: JOB SITE INFORMATION (All Information Required) Name: U )( !� 1e- �o-}1L Address: )e-,d 0 1 �.-- o� 7 ..�7 �� i 4 J Cross Street: Phone No.: Bldg.Permit#: Y6 S ci :?- email: Tax Map District: 1000 Section: Block: . Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) (Qrrn 1 Check All That Apply: Is job ready for inspection?: YES ❑NO ❑Rough In Final Do you need a Temp Certificate?: OYES ONO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead # Underground Laterals 01 02 ❑H Frame Opole Work done on Service? ❑Y ONII 'Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx �/ �Ca �� cp BUILDING DEPARTMENT- Electrical Inspector Gy TOWN OF SOUTHOLD y ? Town Hall Annex- 54375 Main Road - PO Box 1179 ^� Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(_southoldtownny.gov seand(aD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 9_21--a( Company Name: / Name: License No.: 3 © y3 email: Phone No:431-1/�°S^ ❑�request an email copy of Certificate of Compliance Address.: JOB SITE INFORMATION (All Information Required) Name: h �- 1�,.1S Ic' Address: 9e—,d 0 1 w os� .�->> -.-1- 1 4 1 Cross Street: Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: . Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) (pn-rn 1 Check All That Apply: Is job ready for inspection?: ]YES ❑NO ❑Rough In Final Do you need a Temp Certificate?: DYES ❑NO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead # Underground Laterals ❑1 ❑2 ❑H Frame❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx PERMIT# Address: Switches Outlets G F I's Surface Sconces H H's UC Lts Fans Fridge HW Exhaust Oven W/D Smokes DW Mini Carbon ' Micro Generator.. Combo . _........ nsf _.,....... Cooktop Tra er AC AH Hood Service `A mps Have used Special: . __.... . �.... .. U . .. Comments N SURVEY OF PROPER AT MATTITUCK TO WN OF SO UTHOL, SUFFOLK COUNTY, 11 1000-107-06-12 SCALE. 1'=30' JANUARY 28, 2022 4' 0 CT 5 2023 y E i ' AN ppb KL t MON. Ba APRON w m C) Q MM Q� p ^ v C-RAVEI, %LFo IX1, STONE & 1g$ �q 20 to WALK b DRWY FE.COR. RAMP 2.3'W. 2 26-�' S�0OJSE 0 1�. s 00 .N 1a� DEG (J1 o 0 o -,4 STONE COPING g� �' 6' �� c� 11 IF=, 0 L DRIVEWAY u, 16 6' \ STAKE 0 SET STAKE SET m� a z • -n z n m O CP \ tD O Os A = STAKE MON. • = REBAR \ STAKE 003' \ SET X13 ■ = MONUMENT FE.END O = UTILITY POLE O.a'E ST — WA TER METER C• ERN NEW � RICNAR ERNST �� ,. �� NI�� R� n� �� .. RIONA -N u4� AREA =38,195 SQ. FT. N.YS. LIC. Nc ANY ALTERATION OR ADD/TION TO THIS SURVEY IS A VIOLATION Y.S LIC. N0. 05 pE S, P.C. OF SECTION 72090F THE NEW YORK STATE EDUCATION LAW. EXCEPT AS PER SECT/O.N 7209-SUBDIVISION 2. ALL CER70CA BONS (631). a FAX (631) 765-1797 1.-1 ..-.- 1u m .--- -.... ..A- ..... w ......1 .- D n DnY 0/10 'Q 0 CPO CIO t.A � ' Retest O� � o G n I �1 n ST/ Kt ` 3g 7-10 c SE T J3 oA01 Z PROF uAaafwama 5' L £ZOi; S 100 n �9 J ID I / A / E- \ 1000 0 L K Off" N uj •� a Cn 3e p =4 O � h �2. A Y� 5g.1 S.�pNE 4ZOOK o X81 V4 P� ^ 'Py J 1�04{, O NO 26a Zy�o�,E�cE cA ❑ G e� J� R �� v 51? to C%Cn Q p m OO ,g0 ZZD�pE Gp� in m P a2 SLATE PATIO pP 2� 2 38,045 Sq.Feet 0.873 Acres N C° MR �2 m TAX TAX LOT LOT 12 11 . N r � O F fT p ' O SURVEY OF PROPERTY �? - C SUFFOLK COUNTY TAX MAP m DISTRICT 1000 SECTION 107 BLOCK 6 TAX LOT 12 AT MATTITIJCK N TOWN OF SOUTHOLD �1o0aA0' ° w SUFFOLK CO. N.Y. S 1309 0 TAX m LOT OODc`1�� OR 13 l'r<En 1 0p GUAR.TO: 7404-009015 r' �.p tz.=''"1•:X"' T' FIDELITY NATIONAL TITLE INSURANCE COMPANY ;,, •; f�� PIOTR UKLANSKI ALISON UKLANSKA r •�\ `�' PETER'J;,�R,ENNAN JR. TREUMAIVS=L--0 TS INC. LAND SURVEYOR N.Y.LIC.50679 PO BOX 229 SELDEN N.Y.11784 (631)698-4429 SURVEYED AUGUST 14,2020 SCTM 1000-107-8-12 009 - 0 1 �1'f 15p pp w Q w u 3e IPS O� Z� W co G ? m� �. Of S��NE 66.E .p VAP U, ) � ❑ 26 25�yp.�`EN�� �' Z ❑ G a° w�, R�56 � 51.1 D � � 4 # 5ul Z 'fN<ly9P� O m 00 ase pyo 0 of GpC� ' C 6• 0 ' 38 5 Sq. Feet 9 2 73 Acres >. -•4 eoa��4�� ow TAX TAX LOT LOT 12 11 ° N y � 2 .R SURVEY OF PROPERTY i o SUFFOLK COUNTY TAX MAP �' m DISTRICT 1000 SECTION 107 BLOCK 6 TAX LOT 12 AT MATTITUCK TOWN OF SOUTHOLD 1o0��t�p 9k 90 SUFFOLK CO" N.Y. S� p9' 0 m TAX IFF pR. LOT 13 V GUAR. TO: 7404-009015 i i' s t�,•, r. FIDELITY NATIONAL TITLE INSURANCE COMPANY �--- PIOTR UKLANSKIb<` ALISON UKLANSKA , t .ry PETS ,J;�;, L,NNAN JR. TREUM ks L•--AYOIJTS INC. LAND SURVEYOR N.Y.LIC.50679 PO BOX 229 SELDEN N.Y.11784 (631)698-4429 SURVEYED AUGUST 14,2020 SCTM 1000-107-8-12 Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ,% - 05/10/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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- Brookhaven Agency,Inc. PHONE(AIC No 631 941-4113 (AIFAX 631 941-4405 100 Oakland Ave,Ste 1 E-MAIL certificates@brookhavenagency.com PortJefferson, NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Philadelphia Indemnity Insurance Co. INSURED INSURER B: Wesco Insurance Co. Patrick's Pools,Inc INSURER C: Merchants Mutual Insurance Co. 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 OFINSURANCE 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/DDIYYYYI (MM/DDfYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE F OCCUR DAMAGE TO RENTED $100,000 x Contractual Liability X X PHPK2229439 02/28/2021 02/28/2022 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICYX❑ PRO LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Fn arnidpnt) $SOO,000 C X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2020 07/12/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS IX NON-OWNED PROPERTY DAMAGE $ AUTOS UMBRELLA LIAB R EACH OCCURRENCE $ HCcLcAMuS-MADE EXCESS LIAB AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITYIFR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $100,000 B OFFICER/MEMBEREXCLUDED? Y❑ N/A WWC3528513 05/13/2021 05/13/2022 (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 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 �> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF y0 �. Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE STATE C€'lift`I'ensatlon Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Patrick's Pools,Inc. 631-831-0816 5 Petes Path Manorville,NY 11949 lc.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number 262929943 certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 54375 Main Road 3b.Policy Number of entity listed in box"la": PO Box 1179 Southold,NY 11971 WWC3528513 3c.Policy effective period: 5/13/2021 to 5/13/2022 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 daysJF there are reasons other than nonpayment ofpremiums 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"3c';whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 1 r� 5/5/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it. YORK Workers'STATE Compensation CERTIFICATE OF INSURANCE COVERAGE 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 Ia.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 ic.Federal Employer Identification Number of Insured Work Location of Insured(Only required if co•siege is specifically lirnifed to or Social Security Number certain locations in New York State,i.e.,Wrap-U, Policy) 262929943 I 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate H(Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 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: - Q A.Both disability and paid family Ic ave 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 clasE es 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 Fal illy Leave Benefits insurance coverage as described above. Signed 3/1/2021 Byva of,ht (Signature of insurance carrier's authorized representative or NYS Ucensed 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;Ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.kgent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B 15 checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F amily 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 f IYS Workers'Compensation Board (only if sox 4c or 58 of Part i has been checked) State of New York Workers' Compensation Board According to information maintained b/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 licen;ed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt Drized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issuethisform. DB-120.1 (10-17) IIIIII�IQlinll2l0llll[IIIIIII1IIIaIII7IIIII�I�I 19 toad LW6 D AS NOTE DATE: /B.P.# FEE: BY: NOTIFY BUILDING DEPARTMENT AT . 765-1802 8A TO 4 PM FOR-THE FOLLOWING.INSPECTIONS: 1. FOUNDATION TWO REQUIRED RETAIN STORM WATER 236 TER RUNOFF FOR POURED CONCRETE: . 2. ROUGH - FRAMING & PLUMBING PURSUANT TO CHAP 3. INSULATION OF THE TOWN CODE. 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. ELECTRICAL COMPLY WITH ALL CODES OF INSPECTION REQUIRED NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF BOARD SOUTkBEB quTEES I`:IMMEMA 'EL Y �Q�ME POOL TO.CODE- PON COMPLETION BEFORE"WATER" OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY