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HomeMy WebLinkAbout48076-Z �o�guFFO[,�cpGy� Town of Southold 1/14/2024 o - P.O.Box 1179 co 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44866 Date: 1/14/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2015 Stillwater Ave., Cutchogue SCTM#: 473889 Sec/Block/Lot: 103.-8-3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore . filed in this office dated 6/14/2022 pursuant to which Building Permit No. 48076 dated 7/15/2022 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: accesso in-ground swimming pool fenced to code as applied for. The certificate is issued to Quinn,Brian&Tepshi,Ingrid of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 48076 4/18/2023 PLUMBERS CERTIFICATION DATED A/utho&ed Sign re Q1 TOWN OF SOUTHOLD �SufFo�� BUILDING DEPARTMENT y x 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#: 48076 Date: 711512022 Permission is hereby granted to: Quinn, Brian 10 Anpell Dr Scarsdale, NY 10583 To: Construct in-ground swimming pool at existing single family dwelling as applied for. At premises located at: 2015 Stillwater Ave., Cutchogue SCTM #473889 Sec/Block/Lot# 103.-8-3 Pursuant to application dated 6/14/2022 and approved by the Building Inspector. To expire on 1/14/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector 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: l. 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: CMG Old or Pre-existing Building: (check one) -Location of Property: __ �O �C„ e r 4G L, uz. House No. Street Hamlet Owner or Owners of Property: C-, a — Suffolk County Tax Map No 1000,Section 1 G 3 Block Lot 3 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: $ Applicant Signature Of SOUI��I � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 o sean.devlin(a-town.southold.ny.us Southold,NY 11971-0959 Q couff I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Brian Quinn Address: 2015 Stillwater Ave city:Cutchogue st: NY zip: 11935 Building Permit* 48076 Section: 103 Block: 8 Lot: 3 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Bethel Electric License No: SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 1 st 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 1 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 Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures 11 Sump Pump Other Equipment: Int ermatic Pool Panel 4 Circuit/ 3 Used, Hayward Salt Generator, Light 11513171, Pump 220GF1 Notes: Pool Inspector Signature: Date: April 18, 2023 S.Devlin-Cert Electrical Compliance Form ho�aOE SOUt (�('J 70 TOWN OF SOUTHOLD BUILDING DEPT. cou 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) fAELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE I INSPECTOR �n1a�m.9ec- 4 - 3 i ho�apF SOUlyo6 * f TOWN OF SOUTHOLD BUILDING DEPT. �ycoulm", 631-765-1802 #o/v INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ti' FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: /� in ti`t alovAs &eA^*lc1 soll so bo&m 4,ACe- /-5/ wl,�Alw d1fiaLe-5 or, qgA_,,�o �4.o. DATE ������3 INSPECTOR FIELD INSPECTION REPORT I DATE COMMENTS FOUNDATION (1ST) ------------------------------------ kA FOUNDATION (2ND) "O � � O cny ROUGH FRAMING& PLUMBING �6 Oki W r INSULATION PER N.Y. v y STATE ENERGY CODE �•�a3 /ass � �•�C �►. a.,d! ,�(.av�.s �v on ��• � s / ock � �ik�c.l ate/ a� 010�hLL ,50i l 550 / D rl Anex- i5 wiAih flLoft0� �o(L C•o• FINAL 04 L' - AD ITI NAL COMMENTS C 71� lOo ale c ` Yela�a�3 � m . ■o s ►� Z � x d b H '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. a Check Septic Form N.Y.S.D.E.C. Trustees r C.O.Application Examined ��✓��� Zp Flood Permit , Single&Separate I� r Truss Identification Form ® yl I Storm-Water Assessment Form JUN 1 4 2022 C tact: Approved 120 BUIL _ Mail to: D� aG� C�iR6-A 0 IG Disapproved a/c TOWt�!.������i�� Phone:51 't7 Expiration ,20 Building Inspector APPLICATION FOR BUILDING PERMIT Date , 20 2 Z 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 i 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 inspections. ® (Signature of applicant or name,if a corporation) 2015 541 :4 Lr- (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder r Name of owner of premises 2 U/s (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. 11 G S-5 E Other Trade's License No. 1. Location.of land on which proposed work will be done: \ 1 House Number Street I Hamlet County Tax Map No. 1000 Section ` 0 3 Block S Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy e"; ; ke l b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost 'J G o OW Fee (Des 'ptn) (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. A,, 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories 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 Rear Depth 10. Date of Purchase -L 1"-LName 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 X NO 14.Names of Owner of premises c vc AddressZ� Name of Architect��s O e tGo�I� �Address2.6c,'Q.ea, Q�����.�1 O'we No 5 Ss s- Name of Contractorf), v,r%k-e Addres3sl r Le Is N. .► h�Phone No. -1 2 9 --7-3 SS g 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 x * 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)Z * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OFSy"Ir!,) ir �y ''� 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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this / day of 20 2 GRE QORY PI N ublic NOTARY PUSUC,STATE OF NEINVOR Signature of Applicant NO.0"16090455 QUALIFIED IN SUFFOLK COUWW-- MY COMMISSION EXPIRESAPRIL 14,20— e CONSENT TO INSPECTION t C� '^ V v, ,the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersigned(is) (are)the owner(s) of the premises in the Town of Southold, located ate I S 11 ,c ct -e1, 4U,<- C v Nc��05 ,,- which is shown and designated on.the Suffolk County Tax Map as District 1000, Section 103 , Block `6- , Lot _. That the undersigned(has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: C*,\j e D a 5� �- 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 9 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: 3 )6 Z Z (Signature) \-1f Av, C3?li P . (Print Name) (Signature) (Print Name) o��SUFFUt `, BUILDING DEPARTMENT- Electrical Inspector K TOWN OF SOUTHOLD c Town Hall Annex- 54375 Main Road - PO Box 1179 �, • Southold, New York 11971-0959 ti O� Telephone (631) 765-1802 - FAX (631) 765-9502 rog-erra-southoldtownnygov— seand(cDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: I1-5 Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: viateur Pilon License No.: ME-40557 Elec. email: Bethelec@optonli,ne.net Elec. Phone No: 631-750-6555 ! Ei request an email copy of Certificate of Compliance Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) Name: BPAN Q 11�(INN J N b P,1D { -.PS H 1 Address: �LQ) ; �✓�1 AveV1 Re- C I0 0 e- Cross Street: &AA - Route- Phone No.: °� ,�,; — -7 Q 4-- Bldg.Permit#: -7 email: Tax Map District: 1000 Section: I C7 Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑Rough In Final Do you need a Temp Certificate?: ❑ YES 7 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 1 2 H Frame D 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 l� 23 GLk- 0 b p L4 U �O��sUFFO�,�CO BUILDING DEPARTMENT- Electrical Inspector ti Gy TOWN OF SOUTHOLD z Town Hall Annex- 54375 Main Road - PO Box 1179 N �o Southold, New York 11971-0959 p� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr aiDsoutholdtownny.aov- seand(pD-southoldtownny.aov 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 M 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: INNJ N OP-1 D {m-j�S H Address: 'c-Q i� ; ��) Aq W1 fA . Cross Street: r-O• A - M, e , _to� Phone No.: & j Qp; — { n 04-- Bldg.Permit#: email: Tax Map District: 1000 Section: I 0'_�> Block: Lot: , BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring 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 Ph❑3 Ph Size: A #Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame D Pole Work done on Service? Y DN Additional Information: Please call our Office with an inspection date and the Homeowner for inspection access -Thank you! PAYMENT DUE WITH APPLICATION ` Lf( lZ DUNRI-1 OP ID-AR CERTIFICATE OF LIABILITY INSURANCE D 0311212//2021Y) 021 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 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 endorsements. PRODUCER 845-783-2555 CUT Walter Rose Agency Inc Walter Rose Agency,Inc PHONE 845-783-2555 FAX 845-783-2425 8 Stage Road A/c No Ext: A/C,No): Monroe,NY 10950 E-MAIL ,lisa@walterroseagency.com ADDRESS INSURERS AFFORDING COVERAGE NAIC# INSURER A:Central Mutual 20230 INSURED INSURER B•Utica National Of Texas 43478 Dunrite Manufacturing Corp Dunrite pools INSURER C: 3510 Veterans Memorial Highway INSURER Bohemia,NY 11716 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. IITP NSR TYPEOFINSURANCE ADDLSUB pOLICYNUMBER POLICY EFF POUCYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR CLP9791864 04/01/2021 04/01/2022 DAMAGE TOREcTED 300,000 PR MISE currence)— $ MED EXP(Anyoneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY DJECT PRO- ❑ LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO 4822099 12/31/2026 12/31/2021 BODILY INJURY Perperson) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS AUTOS ONLY AUUTOS ONLY PerraccidenDAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION 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) Swimming Pools -Installation,Servicing Or Repair-Below Ground CERTIFICATE HOLDER CANCELLATION SOUTH02 _ _SHOULD.ANY OF THE ABOVE..DESCRIBED P,OL�CIES,BE-CANCELLED BEFORE„__- Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 530960 Route 25 PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Yoe Workers'Compensation CERTIFICATE OF INSURANCE COVERAGE TA7E 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 carrie 1a.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured DUNRITE MANUFACTURING CORP 3510 VETERANS MEML HGHWY BOHEMIA,NY 11716 1c.Federal Employer Identification Number of Insured Work Location of Insured(Onlyrequired if coverage is speciftcallylimited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 112245133 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 530950 Route 25 3b.Policy Number of Entity Listed in Box 1 a" PO Box 1179 DBL593130 Southold, NY 11971 3c.Policy effective period 01/01/2021 to 12/31/2022 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. E] C.Paid family leave benefits only. 5. Policy covers: ® A-All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following ciass,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. l� Date Signed 12/15/2021 ByWr (Signature of Insurance carrier's authorized representative or NYS Licensed I nsurance 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 Bois 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 413,4C or 56 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(Artide 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYSWorkere'Compensation Board Employee) Telephone Number y Name and Tolle 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 DS-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 111111DB-120.1 (12-21)iidl� gI I� 11' • ir l nL Ri •M"M; iUMa -§ R1 R" n , �I 11M M M -ffi,MI A Syffolk County Department of.Labor, Lic'en: sing & M. C o n s um" e r Affai r s N­ VETERANS MEMORIAL BIG , W DATE ISSITED: 3/1/1977 No. SUFFOLD COUNTY M Home Improvement Contractor License This is to certify that KE,NNE TH J BARTHMAN doling.business as FACTURING CORP DUNRITICi MANU h ing furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules and regulations of the County Of Su JMPROVEMENTCONTRACTOI�, in the County of Suffolk. ffilIC, State-of New York is hereby licensed to conduct business as a HOME r p License CateRory. Pools/ Additiona],Busitiesses 'S(iff-dik-Cidu f b-, DUNRM-PooLs n L onsurner.Atrairs- M IMMOVI-M: ruo-W r sl _:� .,.R m Odm-�;B' TH AN M`a* Commissioner R4WffACTvRINGZC'0RP-DBA, H L - PH Pq �71 c. Cbrarnl'i 1671". M OCCUPANCY OR APPROVED AS NOTED USE IS UNLAWFUL DATE: 76-:219 B.P.# Lo WITHOUT CERTIFICATE FE3� BY: NOTIFY BUILDING DEPARTMENT AT OF OCCUPANCY 765.1802 9 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CCYAPL`{' Wl I [ . Al.L. OF CODES. NOT RESPONSIBLE FOR NEW YORK STATE & TOWN CODES DESIGN OR CONSTRUCTION ERRORS AS REOU17D AND CONDITIONS OF SOUTHOLD TOWN ZBA SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES "JMMEDIATELY" N.Y.S.DEC ' El POOL TO COGE :QPON,.COMPLETION 'BEFORE."WATER" RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. �cnoN 'POOk 66E WMAljs£ -A ':8. 6- F G a K L tt• :C-�tL t0)Ob. •10?00 :T6 .-16 =4' 4 6 i .F 2 Z• 6 Y'O' SSOO s�1� .�M . 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