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HomeMy WebLinkAbout47516-Z ��o�OSUFFotkcp�y Town of Southold 2/4/2024 a P.O.Box 1179 N 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44922 Date: 2/4/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 57856 Route 25, Southold SCTM#: 473889 Sec/Block/Lot: 66.-2-2.5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/4/2022 pursuant to which Building Permit No. 47516 dated 3/2/2022 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to Schaefer,Karin&Michael of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47516 12/21/2023 PLUMBERS CERTIFICATION DATED r Au on ed i nature SoFK TOWN OF SOUTHOLD �o�° 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 #: 47516 Date: 3/2/2022 Permission is hereby granted to: 57856 Main Rd LLC c/o Giovanni Marciano 100 Garvies Point Rd Unit 1246 Glen Cove, NY 11542 To: construct accessory in-ground swimming pool as applied for. At premises located at: 57856 Route 25, Southold SCTM #473889 Sec/Block/Lot# 66.-2-2.5 Pursuant to application dated 2/4/2022 and approved by the Building Inspector. To expire on 9/1/2023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector pF SOUr��l 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlinO-town.southold.ny.us Southold,NY 1 1 97 1-0959 Q�yCOUNT`I,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Karin Schaefer Address: 57856 Route 25 City,Southold st: NY zip: 11971 Building Permit#: 47516 section: 66 Block: 2 Lot: 2.5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: Electrician: Island Power Electrical Corp License No: 52729ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 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 2 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel 100A A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 2 4'LED Exit Fixtures Sump Pump 11 Other Equipment: 100A Sub Panel 20 Circuit, Pump 220GF1, Cleaner Pump 220GF1, Heater, Salt- Generator, Timeclock, Lights On Hayward Deckbox Transformer 120GFI, Fence Bonding, Bond Te Notes: " AS BUILT NO VISUAL DEFECTS " Pool Inspector Signature: Date: December 21, 2023 S.Devlin-Cert Electrical Compliance Form �oy�00F 50GTy�� - # # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINALll?oto� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: in 66 A1' Q DATE la INSPECTOR r4_c� ho��OF SOUTyo� l �j f/� ( V t7 �* T WN OF SOUTHOLD BUILDINtl DEPT. �o • �o 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: b(3►i f r 00 l ,41 - ;7 r a I cl, pa z oz /p or, 1 r, cA IrrA lo,\4T -Jbr- mozol /J- aaj�g 4� DATE (J' ZZ INSPECTOR hO�aOF SOUIyO{o � -� � r � �-7 f # TOWN OF SOUTHOLD- BUILDING DEPT. co 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: r� ' /-an - S In Jo c�f If // - 1 � � DATE INSPECTOR s Ai i, r i s � �► T_ � � � � I �-;� 1 � � � �; .� . :t� J , ► � . , � ! � � � � , _ i '-; , t y� Alt ilk a 'NN r r d pF 50Glyo� # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm,��' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULATJI_ON/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: ✓ ✓LC W .� DATE INSPECTOR � • • C.® e FOUNDATION --------- ROUGH lNG,: MUMBING STATE ENERGY • B — WE NOW, WIN ! � w • TOWN OF SOUTHOLD BUILDING DEPARTMENT a 'Town Hall Annex 54375 Main Road P. O:Box.1179.Southold,NY..1197i-0959 . Telephone(631).76514902. Fax.(631) 765-9502 httns %%www.southoldtownny.;?ov 'Date Received APPLICATION.FOR BUILDING PERMIT. For office Use only . . V PERMIT NO: Building Inspector:' . . FEB 0 4 2022:• BUILDING DEPT. .. Applications and�form's must be filledgowt in�tfirei�enti� ty:lc�omplete" TOVIIi OF S s .' fir.y .: .s d:,cc�rC tT ,.�` . OUTHOLD agplieationskwillnotbelaccept�d �Wherethe�Ap�plicant;isinot,the!owner;.ari T� Owrier's Authoiiiation form'(Psoe� )bshall;be�con p teal, -. Date: OWNER(_S):'OF'PROP.ERT`� ' Name: SC�1/12.��2. SCTM#:1000= a ':!X;S, . :. :Project Address: ?�. :. 57 ��(� : Win . ►20 Phone-#:.. �O=qbS=' JJ//312 � Email:- G. 11 -39.z� .: Mailir' 'Address':� .40•A e Stearn ;XONTACT PERSONc Name: -Mailing Address: Phone:#: Email: . DESIGN PROFESSIONAL INFORMATIONe Name:,. . Mailing Address:. :• Phone# Email: CONTRACT OR`INFORMATION:;' _ Name: -�i2`fhtlrL-En,jr�ros Mailing Address: QZ�. �ti— 2S/� r117w. .: Email: CC p agc3 !'C 3>%r :. Phone DESGRIP,TION OF PROPOSED CONSTRUCTION I]New.Steucture..QAddition: DAlteration ORepair Demolition Estimated'.Cost&.Projec' .. Ego ther I/1QR�1rvp 1�1�Vi` �N�m�rri�✓g' Av: -- $ Ibi00lJ:� Will-the lot be re-graded? Yes.�No. Will extess fillbe removed from premises? Yes ONo �. . ��L A reams c�nl�t PROPERTY_IN FORMATION' - Intended use of property: Existing use oy:: ory: : .. f pro pert.. :.__:. .._.. ... Sleleiie.�. . �. :: -• .::..:...: ._ ... . ... _ 1�._.. . _. . ►mine.. : . Zone or use districtin which premises is situated: Arethere any.covenants and,restrictions:with:respectto, _ this property? D.Yes- lo IF YES, PROVIDE.A'COPY: -. ❑ Check Box After Reading: The owner/contra'ctor/design professional is Iresponsiblerfoi alfdrainage and stanri;aater issues es pro4iile`d.by:}:•':,, "'Chapter 236 of the:Town Code.APPLICATION IS HEREBY MADE to the Building Department for the issuance,of a Building Permit.pursuant,to•tlieaBulldin&Une";• Ordinance of.'the Town of Southold,Suffolk;,County,New York'and other applicable Laws,'Ordinances orReguiations,for the.construction of buildings;.­;,:­,,:`­- . additions,alterations'or for removal or demolition as herein described.The•applicant agrees,to comply with alLapplicable laws,.ordinances,buildingcode, housing code and-regulations and to admit authorized inspectors on premises and in buiiding(s)for necessary.inspections.False statements.made herein punishable as a;Clas's A misdemeanor pursuant.to Section 210.45 of the New.York State Penal'Law: Application Submitted By.�(pri.nt na. _ DAuthorized Agent : Owner. Signature of Applicant:. Date: : STATE'OF NEW.YORK).. SS: COUNTY OF ., J'�Ckc Scm 2FF being duly.sworn' deposes and-says that(sft is the applicant (Name' individual signing,contract)above named; (S)he-is the. Q YJ�l2. (Contrac tor,Agent,..Corporate.Officeri etc.) of said owner or owners, and.is duly'8uthorized 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.o.f his/her,knoWledge and.belief;and that the work will be performed in the manner set forth in:the application file therewith Swiorn before me this 1 day of T�brLy, 20Z MARGARE I- A. KIDNEY Notary Public „ Notary:Public=State of New York No. O:I.K1G021 1 H Qualified.An Suffolk County PROPERTY OWNER AUTHORIZATION_ My Commission Expires March 8,20 (Where the applicant:is not the owner) . 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. . .•'''df¢a�KC BUILDING DEPARTMENT- Electrical Inspector 0* ;R� TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrCcDsoutholdtownny.gov - seand c(D.south old town nV.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Electrician's Name: License No.:N,6,6 4j;?7o EIec. email: �1t,4�pdu/�.2 C 0 G-&W Elec. Phone No: 7(0 ❑I request an email copy,of Certificate of.Compliance Elec. Address.: Z6 a Aly '79 JOB SITE INFORMATION (All Information Required) Name: Address: 7 6- ry41rf V&r a r/aL� Cross Street: Phone No.: Bldg.Permit#: ���(o email: Tax Map District: 1000 Section: ell (o Block: I Lot: BRIEF,DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES rjo 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❑Underg round❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y FIN Additional Information: PAYMENT DUE WITH APPLICATION sad 2� �4cfc9cc �oy j� ASwimming pool Bonding Integrity Test iVame i VttECX� y Date: 12 ) Address: 67B &tj4hold. fQ. ,jQ71 Inspection of swimming 600ls—No certificate of compliance will be issued without a valid bonding integrity test performed by a licensed electrician and/or qualified testing agency. A low impedance instrument capable of measuring.01 ohm shall be used. The lead conductor used in the measurement shall be calculated and deducted from readings. A test of applicable test points such as filter motors housing,ladders,diving board,safety line eyelet, water heaters or any other associated metal components shall be performed at least twice and tabu- lated. Readings in Ohms Readingsin Ohms Point of Test Point of Test TEST 1 TEST 2 TEST 1 TEST 2 e -000 -000 `,Po( .000 .000 aM o :nog p. er Tnnrf •000 'coo .000 -WD Tool I.o� mf AD WD. Loddy .601 .001 The resistance between any one points shall be low enough to eliminate any voltage gradients in the pool area as prescribed in Article 680.26 Equipotential Bonding. Spas and Hot Tubs shall comply with the provisions of Parts-I and II_of Article 680 except as modified by 680.42(A)and(0),680.43.fountains,.Signs Part V,Therapeutic Use Tubs and Pools Part Vi. Test Data must be verified by electricians signature,license number and date. .g 2 77-4 12 zl Electrician Print Na a License Number Date fi (�.JRM Sat MOUL4,LU Irt33 Electrician i ature Address Mail resui to: Electrical Inspectors,Inc.,300 East Meadow Avenue,East Meadow,NY 11554 or Fax(516)794-5854 E C E � U M E DEC 2_, 2023 BuIldiineg ovVii OR,Southold ARTHUR:EDWARDSPOOL &:SPA.CENTRE 929. ROUTE 25A MILLER PLACE; NY, 11764. : 516-744=7185 FAX-74:4-0174 APPLICATION.FOR A SWIMMING POOL PERMIT: SO UTHOLD:" TOWN OF SOUTHOLD - MAIN.ROAD (P.O .BOX:1179) SOUTHOLD; NY .11971 (631) 76.5-1,802.' ; PAPERS ENCLOSED: APPLICATION FOR OUTDOOR:POOL PERMIT; CERTIFICATE.OF WORKER'S COMPENSATION. . [ :. . CERTIFICATE-OF LIABILITY INSURANCE: . . CERTIFICATE:OF:DBL.IN.SURANCE-- [�} SUFFOLK'COUNTY LICENSE 4.SETS OF:-STAMPED:PLANS 3, SURVEYS-with FILTER LOCATION [ C.O., ---TAX BILL'.'. �. _ -:$400.00 CHECK FOR PERMIT.FEE RZ, 117:7 4WF m X4K13 las WI -!A n.j ------- - 440 199 CHURCH STREET;NEW:YORK�N.Y:;10007-1100 New:York state insurance Fund .�nySif.Com CERTIFICATE"OF.WORKERS'.COMPENSATION INSURANCE n n n n n. .1.12377925 .. a .o LEVITT=FUIRST ASSOCIATES:LTD. 520 WHITE PLAINS ROAD;2ND FL TARRYTOWN NY 10591. . SCAN TO VALIDATE AND SUBSCRIBE CERTIFICATE HOLDER POLICYHOLDER". :� . . ER. ARTHUR.J EDWARDS MASON.' TOWN OF SOUTHOLD - CONTRACTING COMPANY INC.' P.O::BOX 728 929 Wit 25A. HOLD.NY'.11971 SOUT_ MILLER PLACE-NY 11764. . 'POLICY-NUMBER CERTIFICATE NUMBER -POLICY PERIOD.` DATE. G 2438 491=9. 633479. : 06%29/2021:. TO..06/29/2022 .06/16/2021 THIS IS TO.CERTIFY THAT THE HOLDER, ABOVE:I$ INSURED WITH THE-NEW YORK STATE:'INSURANCE,': FUND.UNDER POLICY NO::2438:491=9,. COVERING.TFIE'ENTIRE.OBLIGATION'OF„THIS..POLICYHOLDER FOR-WORKERS' ... COMPENSATION.UNDER.THE.NEW•YORK WORKER S.'.COMPENSATION LAW WITH RESPECT.TO ALL OPERATIONS.IN THE STATE OF.,NEWYORK;EXCEPT AS.INDICATED BELOW. IF :YOU- WISH: TO RECEIVE.'NOTIFICATIONS REGARDING_ SAID .POLICY,. INCLUDING ANY NOTIFICATION , OF. CANCELLATIONS, OR. TO,.VALIDATE .THIS .CERTIFICATEj-VISIT.OUR WEBSITE,AT HTTPS://WWW:NYSIF.COM/CERTI CERTVAL-ASPi,THE'NEW YORK.STATE INSURANCE FUND IS NOT LIABLE IN .THE:'EVENT OF. FAILURE._'TO'GIVE SUCH...: NOTIFICATIONS... . . . . . 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: E . NEW YORK.STATE INSURANCE FUND . " DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:. 39,1287892 � I®�WII00000000.000094420.� � 3b11®1�� Form WC-CERT-NOPRm Version 3(0&29)2019)[WC Policy-24384919j. : U-263. f"'aE Compensation workers' CERTIFICATE OF INSURANCE COVERAGE �Y AT Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING COMPANY INC 929 ROUTE 25A 6317440174 MILLER PLACE,NY 11764 Work Location of Insured(onlyrequired ifcoverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations In New York State,le.,Wiap-UP Policy) or Social Security Number 11-2377925 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier TOWn Bel of nS�Lis t d as the Certificate Holder) Standard Security Life Insurance Company of New York PO BOX 728 3b.Policy Number of Entity Listed in Box"I a" Southold, NY 11971 Z06874-000 3c.Policy effective period 7/1/2020 to 6/9/2022 4. Policy provides the following benefits: M A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Q A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employers 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 descy. d above.. Date Signed 6/10/2021 By . (Signature of Insurance carrier's authoriz d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICES 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 413,4C 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 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 4C or 5B of Part i has 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 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 carders 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 (1047) IIIII'iuiiiiiuiiiiiuiiii(iiiiiiiiu)iillll� Additional Instructions for Form D13-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed. (b)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 employment as defined in this article and 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 the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (10-17)Reverse A`o® CERTIFICATE OF LIABILITY INSURANCE DATE(IdN 12/22/202202Y1r) 1 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 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 WE: Matthew Ruperto Liberty Risk Management,Inc. PHONE 631)569�633 FAx No:(631 569.5636 2333 Route 112 ADDRESS: matthew@ilbertyrisk.org Medford,NY 11763 INSURERS AFFORDING COVERAGE NAIL: INSURERA: NIP/Greenwich INSURED INSURER B Arthur J.Edwards Mason Contracting Company Inc. DBA Arthur J.Edwards Pool&Spa Centre INSURERC: 929 Route 25A INSURER D: Miller Place,NY 11764 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000005-1323810 REVISION NUMBER: 23 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 NUMBER POLICY EFF PLTR OLI pY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY NPC-1004300.01 01/01/2022 01/01/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO FMWMD— CLAIMS-MADE I X]OCCUR PREMISES Ea occurrence $ 300 000 MED EXP(Any oneperson) S 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2 000 000 POLICY PR - LOC PRODUCTS-COMPIOPAGG; $ 2,000,000 $ HOTHER: AUTOMOBILE LIABILITY Ee accident) LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED Peraccident $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LJAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y❑ NIA EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mom apace Is required) Town of Southold Is included as an Additional Insured,ATIMA,as requried by written contract,subject to policy terms, conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. P.O.BOX 728 AUTHORIZED REPRESENTATIVE Southold,NY 11971 404V iLpgt� MJR ©1988 2015 A ORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by MJR on 12/22/2021 at 01:26PM l _ _ S.C.T.M. NO. DISTRICT: 1000 SECTION: 66 BLOCK:: 2 LOT(S):2.5 MAIN ROAD N LAND N/F OF I "(p RUSSELL KARSTEN 457.30' N 87055'30"E 00 PAVER PAip ARVAT DRAMY PQt00lA - PAVER PA71D �, k li/)b• SMOP ' y ... �'B' tsar.:. 117.2 : ::::. •: LAND N F OF :::::.:::::2,w..................... ,TOSEPH KRUKOWSKI \\ .. o; . ..17�;...: °ALN. \ °MJI. 0 ALL \ N72o�9�00' W @QG T DRrW AY P Z5� 7HE WA7FR SUPPLY, MELM DRYWELLS AND CESSPOOL RI G N LOCA77ONS 9f01NV ARE FROM RELD 019SERVA7IONS 0-p `' 00 AND OR DATA 68TAINED FROM/ OTHERS q� IA tr AREA:79,998.62 SQ.FT. or 1.84 ACRES ELEVATION DA7UM: UNAWHO ZED ALRMUON OR ADDIAON 70 7HIS SURVEY IS A YOLAMW OF=11ON 7209 OF IRE NEW YORK STA7E EDUCANON LAW. CQWES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT SE CQN9M ED 70 BE A VALID 7RUE COIPY. GUARANTEES INDICA7ED HEREON SHALL RUN ONLY 70 THE PENSON FOR NHOY WE SURVEY 1S PREPARED AND ON HIS BEHALF 70 THE RILE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSI17UIXW ZS� US7ED HEREON, AND 70 THE ASSIGNEES OF 1HE LENDING INS717UR01M, GUARANTEES ARE NOT 7RANaMiABLE � 7HE 0073M OR bIMENSICWS SHOW HEREON FROM 7HE PROPERTY LINES 70 THE S7RUCTURES ARE FUR A SPEaRC PURPOSE AND USE 7HEREFW THEY ARE NOT IN71NDED 70 MONUMENT 7HE PROPERTY LINES OR TO GUIDE 1HE EREC7/ON QF FENCES, ADD171ON&SINUCAIRES OR AND.07HER/AIPROMdENM EASE)WENIS AND/OR SUB.SYURFMCE SIRWWWS RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY ENDENT LW 7HE FRI WSES AT 7NE 77AE Q:*SURVEY � � 0.7'W stiRvEy ORDESCMBED PROPERTY CERTIFIED TO: MICHAEL E. SCHAEFER; MAP OR KARIN L SCHAEFER; Fly: FIDELITY NATIONAL TITLE INSURANCE COMPANY; SITUATED Ar:SOU1"FiOLD EMINENT ABSTRACT, INC.; I TOWN OR SOUTHOLD tF1LE K COUNTY, NEW YORK EENNETH M WOYCEUH LAND SURVEYING. PLLC Professional Land Surveying and Design —153 sCl►LE 1"=40' DATE SEPT. 1, 2021 ' PAz�169 Aquebogue, New York 119SL -- N.Y.S, U51G�NO. oMEWm PUM ( Y�-1588 FAX(831)298-1588 AP VED AS NOTED DATE: B.P.itFEE:- BY: NOTIFY. BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE ELECTRICAL FOLLOWING INSPECTIONS: INSPECTION REQUIRED 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 CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. EICLC-SE POOL TO CODE UPON COMPLETION —'c"-.. COMPLY WITH ALL CODES OF "'BEFORE"WATER" NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF 4DI 91:10I n WNI of ANAII G BOARD SOl1�tifiRtlSTEES OCCUPANCY OR USE ,I-S UNLAWFUL WITHOUT CERTIFICAT OF OCCUPANCY . . . . O. - H -: B Auminum " E. To.Fftw' F— (FWr-t-Pump To V , "J To FE�4wr �Y III�II 0our4�: A RoIMd WoY,F. �.. .Plan Piping Arrangement wd ; :. �+.R.ea.: 42" . . . : ' Section B=B. �. PSl X X �]a r® Cn �:0». : BUILDING DEPT 043595: �C? Typical Wa11 Section ff TOWN OF SOUTHOLD SeCtiO.n. A'-A FSSIONP L� . SIZE : A. B C 'D . E F G --H .AREA CAP nn FEET, FT 'FT' FT FT: ,FT. FT: FT: FT: :SQ.,FT GAL.- 14.X 20'. .14::20. 8 &. 2' 2-. 2: 8. 280... 9,500 �aF/ i7i`�Q�fO�QriL� 1 �O : I"l i.�► �(J: FOOL&SPA CENTU ' . Adder ' 16 X 36. 16 36 12 14. -6-, 4.'T 4• 8. 576 '21,600 PERMACRETE WALL, SYSTEM. : & ow �.�. . ' . 18 X 36' 18 36 ,12. .14 , 6. 4 5' .8 648 y24300 29 Route..25A�.Millen Plaice NY 11764, 20�Xr44 .4.4 �201 5r °10 880- 36,300 (631 . 744-7185 FAX : 631. 744-0174 �: > ( ��4i ,0 Suffolk. License 4436 24'X 44 24'. 44L20 14 8'. 4 8 10. 798' 35,000 # Nassau License #HI74450000 24 X 48 24 :48' :16 8 4 . 6 10 _.900 38,500 -