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HomeMy WebLinkAbout47671-Z V7 _ =� ��g11FFQi�� � Town of Southold 5/14/2024 P.O.Box 1179 (04,% *w ' 53095 Main Rd a � Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45179 Date: 5/14/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 155 Broadwaters Rd, Cutchogue SCTM#: 473889 Sec/Block/Lot: 104.-12-8.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/14/2022 pursuant to which Building Permit No. 47671 dated 4/12/2022 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 appled for The certificate is issued to Sharma,Rahul&Isaac,Veena of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47671 07/21/2023 PLUMBERS CERTIFICATION DATED 0 h iz d Signature suFFot,t TOWN OF SOUTHOLD BUILDING DEPARTMENT 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#: 47671 Date: 4/12/2022 Permission is hereby granted to: Suffolk County 330 Center Dr Riverhead, NY 11901 To: construct accessory in-ground swimming pool as applied for. At premises located at: 155 Broadwaters Rd, Cutchogue SCTM #473889 Sec/Block/Lot# 104.42-8.1 Pursuant to application dated 3/14/2022 and approved by the Building Inspector. To expire on 10/1212023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 uilding Inspector oE so�ryQl 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.devlinls'-town.southold.ny.us Southold,NY 11971-0959 Q �yeou BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Rahul Sharma Address: 155 Broadwaters Rd city:Cutchogue st: NY zip: 11935 Building Permit#: 47671 section: 104 Block: 12 Lot: 8.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: LC Electric 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 Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 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 Sump Pump Other Equipment: Intermatic Pool Panel 4 Circuit/ 3 Used, Hayward Salt Generator, Pump 220GFI, Heater, 2 Lights 120GFi, Waterbond Notes: Pool Inspector Signature: ate: July 21, 2023 S.Devlin-Cert Electrical Compliance Form # # TOWN OF SOUTHOLD BUILDING DEPT. p`ycourm��' 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: DATE o l Z INSPECTOR < � -74 OE SObT40 y�lo # # TOWN OF SOUTHOLD BUILDING UE�T. 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) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] JPRE C/O [ ] RENTAL REMARKS: i I/ W184erl Z-ecl DATE INSPECTOR 1i' ho�aOF SOUIyO� -- "� # # TOWN OF SOUTHOLD BUILDING DEPT. courm, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] ULAr N/ HULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL 77 KS: Q� b4c,", v . -a f--7 DATE" y INSPECTOR souryo� —1 lo7 ( J•.7 /' - - # # 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: ( s ov U� bon I X ran al a� DATE INSPECTOR Of SOUTyo6 L1-7 V—7 * * TOWN OF SOUTHOLD BUILDING DEPT. 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 REM ARKS: vV l DATE Z�' INSPECTOR Jeffrey Sands Architect April 13, 2022 D DD Property/swimming pool location: OCT - 5 2022 Rahul Sharma 155 Broadwater Road BIDING DEFT. Cutchogue, NY TOWN OF SOUTHOLD RE: Swimming pool rebar 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, RE D q ��PEY M 9�F 02789� OF'NE� Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—ieffrey sandsCcD-hotmail.com y .e7J - 21.1 ` �. �4 a* R s - 'r� __ � - • �:'s Jam' t♦ = �{I1 � �� lt� �•.r• `rid .�` �� r4 .A ��;; •� :,�.� = . �, psi, �.' '4 0,,�o'' Air— r r� �• i�:.p S' I w � Y j a„ • ; •� {-y -_fix �� •.a , ;��' u�;., � ;,`,, „�a �! -' ,. ., �� l Oyu y �3s 4�.5r•�.,' �. Y r; li i ;� S` ` <ST < ► i ;Y is �� A1 ;, IF X �' ' ti;� at � v,rq. ^L t T. R� •per",�� �' ,l�- .'i` ,�, ti •• �}, ai ...t _LyT�i ili �GF�\'4�1 •-Y�`yIJ �'`�'111 t� ��y.! 4... Sa+� ,ert +v���� p+.,r 1�. Y.Yi �a c` "'J�•'�� > 't1�Sj� ♦� � �'"S " FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) �-y ------------------------------------ �., C _ FOUNDATION (2ND) z -- o V1 �C ROUGH FRAMING& PLUMBING t INSULATION PER N.Y. STATE ENERGY CODE v�✓1��- oo- w� FINAL AD ITIONAL COMMENTS ©/ aJ6b i V1 2l¢c 1 0 0 R Z. H x d b 113-guFFn 0't o�y TOWN OF SOUTHOLD—BUILDING DEPARTMENT x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 o� • Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtomm.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ® E C E � n Vn E PERMIT NO. Building Inspector: MAR n"0 .909 Applications and forms must be filled out in their entirety.Incomplete, applications will not be accepted. Where the Applicant is not the owner,an BUILDING DEPT. pp p pP � TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY:: Name:. gah,� _ ' E) SCTM # 1000- Project_Address: 0 1 S Min _ Phone#: -L � Lo _ a� Email: r Mailing Address: CONTACT ERSON: Name: 6a-)h no, Mailing Address: V - Phone# q Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: Phone :�31 �_ Email: S rl DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑AlltCte--ra--tion ❑Repair ❑Demolition Estimated C st of Project: Other aD N 4d C U1n t c f YY1 Vl�Lln 0l � $_ _�` l C)Will the lot be re-graded? ❑Yes O Will excess fill be removed from premises?Xes ❑No 1 ,:,;. . .......; ... . ... ...,.;. PROPERTY INFORMATION Existing use of property: + Intended use of property: vn� . _ r .. __ .. _ ..._.... __. ... .. - .,. .o2A �p.. Zone or use district in which premises is situated: Are there any coven nts and restrictions with respect tom (f this property? ❑Ye o IF YES, PROVIDE A COPY. Check-B,ox-Afitar Reading: The owner/contractor/desigrrprofessional,is responsible for.all drainage and storm water issues'as provided;by";`' , apter236 of the Town Code.`APPLICATION-Is HEREBY MADE to the Building Departnien#-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 demolitiorras herein described.The applicant agrees to comply with ail applicable taws,ordinances,building code,, housing code and regulations and to admit authorized inspectors on premises and in buildings)for nece`ssarOnspections.False statements,made-herein are punishable"as a Class"A`misdemeanor'pursuant to section 2 10.4 5;of the New"York State Penal Law. Application Submitted By print name): I �I)C �y CUV1 thorized Agent ❑Owner Signature of Applicant: Date: -,a> STATE OF NEW YORK) SS: COUNTY OF b-) 1� ) )'na � )ir( � being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract)above named, (S)he is the ontractor,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 MaP-� 20 22 ` Notary Public MICHELE A MEDUSKI Notary Public,State of New York PROPERTY OWNER AUTHORIZATION Reg.No.OIME6393343 (Where the Qualified,in Suffolk County applicant is not the owner) Commission Expires June 17,2023 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) Rahul Sharma&Veena Isaac residing at 155 Broadwaters Rd, Cutchogue, NY 11935 I, (Print property owner's name) (Mailing Address) do hereby authorize Katrina Mercurio (Agent) to apply on my behalf to the Southold Building Department. March 4, 2022 (Owner's Signature) (Date) Rahul Sharma (Print Owner's Name) i BUILDING DEPARTMENT- Electrical Inspector 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 rogerr(&southoldtownny.gov' seand(Dsoutholdtownny. ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4/13/2022 Company Name: LC Electrical Contracting Inc. Electrician's Name: Lennie Cancellire License No.: ME-38043 Elec. email:office@Icelectricalcontracting.com Elec. Phone No: 631-874-0485 01 request an email copy of Certificate of Compliance Elec. Address.: 22 Woodbine Lane East Moriches, NY11940 JOB SITE INFORMATION (All Information Required) Name: 9tIII0IK GetH4Y J�l 011'IYaQ: L� �p �� Address: 155 Broadwaters Rd, Cutchogu ,CouOv Cross Street: Phone No.: Bldg.Permit#: W76,11 :email: Tax Map District: 1000 Section: I'oq Block: '� Lot: �. BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES ✓❑ NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES 0 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 # Undergrouna Laterals r1 i 12 H Frame " Pole vvork done on Service'! L_Jr'Y IIN Additional Information: PAYMENT DUE WITH APPLICATION Ck cS� 2rf En,joyttys ' Vu . 8111/23 4:04 PM John , pool gate locks were reversed at 1 ,55 Broadwater as requested . The electrical -work was also completed as requested but have not h,eard - from that inspector. Thank You as always . Frank Buonaiuto Thanks OC77 v BUILDING DEPARTMENT- Electrical Inspector 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 ro erKc_southoldtownny.aov — seand@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4/13/2022 Company Name: LC Electrical Contracting Inc. Electrician's Name: Lennie Cancellire License No.: ME-38043 Elec. email:office@Icelectricalcontracting.com Elec. Phone No: 631-874-0485 0 I request an email copy of Certificate of Compliance Elec. Address.: 22 Woodbine Lane East Moriches, NY11940 JOB SITE INFORMATION (All Information Required) Name: Stfff e y Sh qrmcL IS U fo l k Address: 155 Broadwaters Rd, Cutchogu Cross Street: Phone No.: Bldg.Permit#:4W4=76 14 r](D-1 1 email: Tax Map District: 1000 Section: r .014 Block: I;Z Lot: Ob. BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Pool :Square Footage: Circle All That Apply: Is job ready for inspection?: 11 ,YES ❑✓ NO ❑Rough In El Final Do you need a Temp Certificate?: ❑ YES FV—] 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 Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION 0�'�� CP Southold Town Building Department P.O.Box 1179 Permit#: 47671 53095 Main Rd Southold,New York 11971 Permit Date: 4/12/2022 (631)765-1802 Expiration Date: 10/12/2023 �X, Parcel ID: 104.-12-8.1 BUILDING PERMIT RENEWAL LETTER Dated: 5/3/2024 Applicant: Suffolk County Location: 155 Broadwaters Rd, Cutchogue Work Description: IN GROUND POOL- construct accessory in-ground swimming pool as applied for. A FEE OF $200 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Suffolk County Address: 330 Center Dr Riverhead,NY 11901 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee.made payable to the Town of Southold. Mail to the Town of Southold Building Department,P.O. Box 1179, Southold,New York 1'1971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. AC R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) th.� 03/01/2022 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 Nicholas Zulkofske Brookhaven Agency,Inc. PH 631 941-4113 FAx (AIONE 631 941-4405 100 Oakland Ave,Ste 1 E"MAIL , certificatesA brookhave nag enc .com Port Jefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURERA: Philadelphia Indemnity Insurance Co. INSURED INSURER B: Merchants Mutual Insurance Co. Patrick's Pools,Inc INSURER C: Wesco 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 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. IL SR TR TYPE OF INSURANCE ADDL SUBR ton vvvr) POLICY NUMBER POLICY EFF PIYYYYI OLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1 000 000 A CLAIMS-MADE X� OCCUR DAMAGES( RENTED $1 OO 000 x Contractual Liability X X PHPK2385555 02/28/2022 02/28/2023 MED EXP(Any oneperson) $5 000 PERSONAL&ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY X ] PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG s2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $5OO OOO B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ hD)E CESS LIAB CLAIMS-MADE AGGREGATE $ D RETENTION $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $100 000 C OFFICER/MEMBEREXCLUDED? F 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 $50O 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 <NSZ> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD NEW I workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation 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 1a.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 , 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required it co•erage is specifically limited 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 He[der) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box"la" PO Box 1179 DBL318565 Southold,NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: © A.Both disability and paid family le 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 class as 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 Fai illy Leave Benefits insurance'coverage as described above. Date Signed 3/1/2021 _ By (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 i ire checked,and this form,is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.%gent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 513 1;checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F dmily Leave Benefits Law,It must be mailed for completion to.the Workers'Compensation Board,Plans Accept ince Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the f IYS Workers'Compensation Board(only If Box 4C or 58 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained b,f the NYS Workers'Compensation Board,the above-named employer has compiled 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;led to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are auth:rized to issue Form OB-120.1.Insurance brokers are NOT authorized to Issue thisform. DB-120.1 (10-17) 1U2i0ml1Uiiu(i1�0io1W11ii10�� UEw Workers' CERTIFICATE OF. �--.� STATE 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 Patricks tools Inc Po Box 3024 1 c.NYS Unemployment Insurance Employer Regislration Number of East Quogue NY 11942 Insured Work location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security cor#oin 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 Co Town of Southold 1 54375 Main Road 3b.Policy Number of Entity Listed in Box 1a" Southold NY 11971 WWC3528513 3c.Policy effective period 05/13/2021 to 05/13/2022 3d.The Proprietor,Partners or Executive Officers are included.(only chock box if all partnerslofricers included) X❑ 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 41 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"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 (lamed 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 aut zed representative or licensed agent of insurance carrier) Approved b . ( ature) (Dale) 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 C-105.2.Insurance brokers are NOT authorized to Issue it, C-105.2(9-17) www.wcb.ny.gov 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 compensation 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 duty 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 STREET ADDRESS 155 BROADWATERS ROAD HEALTH DEPT. REF, NO. R10-98-0037 N SURVEY OF. PROPERTY AT NA SSA U POINT TOWN OF SO UTHOLD SUFFOLK COUNTY, NY 1000-104-12-8,1 SCALE: 1"=40' DEC. 19, 2001 DEC. 26, 2001 (prop, hse.) JAN. 14, 2002 (s tk. fn d.) APRIL 14, 2003 -(conc. fndtn.) O MARCH 17, 2004 (final) yc \41' o RNEwAY `w cryr tAR �'fy �` K DIRT O \Tlie �v 96' ''oco V �Ir o. 7 20 'o o• 3�0 41 ft 75/ PI PO50— m Pool Fh(e n LEACHING'PbOLS ARE 150 FEET FROM ALL N6S` Ig. WELLS FOR POTABLE WATER SOT 1 jg \ AREA=35,77E SF, TO TIE LINE I am familiar with the STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE LOT NUMBERS REFER TO AMENDED MAP 'A'OF NASSAU DISPOSAL SYSTEMS FOR SINGLE FAM/L.Y RESIDENCES POINT'FILED IN THE SUFFOLK COUNTY CLERK'S OFFICE and' will abide by the conditions set forth therein and on the AS MAP. NO. 156. permit to construct. The location of wells and cesspools shown hereon are ., from field observations and or from data obtained- from others. � N-Y:,. C<l�''rN�{ 49618 ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION ECONIC U YOF7S•v t', 'lI OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. ;� . C631) 765 020P�;, .-1",°�)�rC6 1') 765-1797 EXCEPT AS PER SECTION 7209-SUBDIVISION 2 ALL CERTIFICATIONS k v;..-- ,,Iri rr HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF P. 0. BOX 909, SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR ■=MONUMENT 1E30 TRA VL�EF S�TRtiFFT �:2 WHOSE SIGNATURE APPEARS HEREON 0=PIPE SOUTHOLD, NY,. sC. i APPROVED AS NOTED DATE: B.P.# FEE: BY: NOTIFY BUILDING - GhRTMENT AT 765-1802. 8 AM TO µPM FOR THE RETAIN STORM WATER RUNOFF FOLLOWING INSPECTIONS: PURSUANT TO CHAPTER 236 1. FOUNDATION - TWO REQUIRED OF THE TOWN CODE. FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTR'Ir _10N MUST BE COMPLETE j. ALL CONSTRUCTl:,n --HALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. ELECTRICAL INSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ...S S0 6WN PtANNNd BOARD Sa ITH GI HOWN TRI ISTEES NYSDEC - ENCLOSE POOL TO CODE,. UPON COMPLETION BEFORE,WATER �:)000PANCY OR 0 �•f USE- IS UNLAWFULP601 -,� WITHOUT CERTIFICA-►- rn a- km- OF OCCUPANCY rmu,vy) ` - I I' n,es :7 (y'4 - ..ham _ '.ff✓- -nh•s, <k� } •S` .A f r =g}h F� t FT I •9 FT 4 _ _ n 4 - ` s BUILDING DEPT. TOW OF-SOUTtiOLD__.. r — 1 _ --� spar � TI 01 ELL �yx Y I —ILL, Avet � •� I I I � I I i I I t � � 1 � � t i ► I • � ( .