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HomeMy WebLinkAbout50721-Z 0�0 CpG Town of Southold 5/31/2024 o� Ad P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45240 Date: 5/31/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 505 Longview Ln, Southold SCTM#: 473889 . Sec/Block/Lot: 88.-5-6 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/15/2020 pursuant to which Building Permit No. 50721 dated 5/21/2024 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 per ZBA#7634,dated 4/21/2022. The certificate is issued to Samaan,Andrew&Mollie of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44621 1/26/2021 PLUMBERS CERTIFICATION DATED rN 0. u o ' d Signature �o�g�fFO��co TOWN OF SOUTHOLD ay 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#: 44621 Date: 1/24/2020 Permission is hereby granted to: Cavagnaro, George c/o Linda Matteini 3067 Lancaster Dr#4 Naples, FL 34105 To: construct an in-ground swimming pool as applied for. At premises located at: 505 Longview Ln, Southold SCTM #473889 Sec/Block/Lot# 88.-5-6 Pursuant to application dated 1/15/2020 and approved by the Building Inspector. To expire on 7/25/2021. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 $300.00 Building Inspector OESOGTyO� - # # TOWN OF SOUTHOLD BUILDING DEPT. couto, 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]. INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ]. ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O- REMARKS: m DATE Z INSPECTOR ;Z �oy�00E SOUlyolo # # TOWN OF SOUTHOLD BUILDING DEPT. �ycourm,��' 765-1802 1 NSPECT101% [ ] FOUNDATION 1ST [ ] -ROUGH PLBG. [ ] FOUNDATION 2ND , [ ] =LATIOWCAULKING FRAMING /STRAPPING [ L PW� [ ] FIREPLACE & CHIMNEY- [ ] -FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: n, a • rz� rh DATE INSPECTOR 44 Of SOGry�� # # TOWN OF SOUTHOLD BUILDING DEPT. cu 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULAT WCAULKING [ 1 , FRAMING /STRAPPING [ FINAL 1 [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ]- RENTAL REMARKS: 61el? DATE a INSPECTOR OF SOUryol Town Hall Annex ~ Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G Q sean.devlin(EL-)town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Andrew Samaan Address: 505 Longview Ln city,Southold st: NY zip: 11971 Building Permit#: 44621 Section: $$ Block: 5 Lot: 6 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electric License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X 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 Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 4'LED Exit Fixtures Pump 1 Other Equipment: Heater, Pump on 220GFCI Breaker, (4) Circuit Intermatic Pool Panel Notes: " AS BUILT NO VISUAL DEFECTS " POOL - Did Not See Bonding Inspector Signature: Date: January 26, 2021 S.Devlin-Cert Electrical Compliance Form.xls FIELD INSPjtCTIO§REPORT -DATE COMMENTS FOUNDATION (IST) ------------------------------------ ci FOUNDATION (2ND). 0 P ROUGH FRAMING& PLUMBING .y oo LA INSULATION PER N,Y. y STATE ENERGY CODE yAVN fQiv fib^ o FINAL �j Wi WIA . Lk W- wt Moo-, D LA ADDITIONAL COMM NTS JET T N K V • I e o�og�fF01/��OG TOWN OF SOUTHOLD—BUILDING DEPARTMENT y� y Town)Full Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631) 765-9502 https://www.southoldtgmnnygov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ® 2 PERMIT NO. f40,Z1,9 Buildinglnspector: W, BU1LL7iivG DEPT. Applications and forms must be filled out in their entirety. Incomplete TO%JVN OF sOUTHOLD applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:- �i I�,I �-'L OWNER(S)OF PROPERTY: Name: C 10,016 CA&-i&Z I SCTM#1000- 104 - ( 2- 2- Project Address: Phone#1� ' � I 1p � 22�� Email: Sa a'1'1 �.a�In � �a,�►v�. cc�,�- Mailing Address: 12 S &R'0 -C)IWA102-s ROAD Ci, 7C' 001 q'V 1 l 3S CONTACT PERSON: v Name: Mailing Address: �Z � � (�b (`(�T—Gj��C; /•t/ `l q 3,S Phone#: '�� � ZZ 6$ Email: C Sa,VY► DESIGN PROFESSIONAL INFORMATION: Name: C rZ 1 71'1K Mailing Address: 1 56�5 )(1 r7-6A,1 i d kl—o :e1 1111 4 Phone#: l -7 -- 7q te S Email: 0 CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: .J:JOther f'0 u L $ 1 d, M Will the lot be re-graded? ❑YesXNO Will excess fill be removed from premises? ,Kyes ❑No 1 PROPERTY INFORMATION Existing use of property_ I Intended use of property: Zone or use district in which premises is situated: Are there any covenants a restrictions with respect to this property? ❑Yes Mf4 o IF YES, PROVIDE A COPY. 10 Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water Issues as provided by Chapter 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 210.45 of the New York State Penal Law. Application Submitted By(print name): C a4 n t ❑Authorized Agent Ldwner Signature of Applicant: Date: S/Z 2Z STATE OF NEW YORK) SS: COUNTY OF V Lbeing duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the D �� (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 20 otary Public SETH G BANK ENotary Public-State of New York PROPERTY OWNER-AUTHORIZATIONN0.01BA6427783 alified in Suffolk County mission Expires Jan 3,2026 (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 J - / o�g�FFOrk�OG TOWN OF SOUTHOLD—BUILDING DEPARTMENT s= Town Hall Annex 54375 Main Road P. O.Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631)765-9502 https://www.southoldtgMLnny.gov Date Received APPLICATION FOR BUILDING PERMITor A}. ; /S z &I RO For Office Use Only PERMIT NO. Building Inspector: DEC 2 12021 Applications and forms must be filled out in their entirety. Incomplete BUILDING DEPT. applications will not be accepted. Where the Applicant is not the owner,an TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed. Date: A kz i OWNER(S)OF PROPERTY: -a -JD-�1 Ar q --C I NF_ . SCTM#1000 Project Address: ►-�5- w_ C - - oC� 9 - Phone#: b �Z Y Email: G - ^- Mailing Address: _lq o- _ CONTACT PERSON: Name: Mailing Address: G - - ----.get— Phone#: Email:. CSGGW1Gt,GG.� q,h e0, G.w� DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑N w Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Prother Pay L- $ 4 . �91J0 Will the lot be re-graded? Ves ❑No Will excess fill be removed from premises? es ONO 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this-property? ❑Yes, o IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water Issues as provided by Chapter 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 210.45 of the New York state Penal Law. CTf n{ �nC� S ❑Authorized Agent [_Oner Application Submitted By(print name): �� w _ Signature of Applicant: V% Date: 1 2� STATE OF NEW YORK) �SS: COUNTY OF L�. ) being duly n, 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. Swor before me this '^ day of_ 200�02-1 Notary Public TRACY KARSCH PAWMBO PROPERTY OWNER AUTHORIZATION Notary Public,State offilew York No.02PA6087274,Suffolk County (Where the applicant is not the owner) Commission Expires March 30,aw 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 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT SOUTHOLD,N.Y. NOTICE OF DISAPPROVAL DATE: January 13, 2022 TO: Catherine Samaan 125 Broadwaters Road Cutchogue,NY 11935 Please take notice that your application dated December 21, 2022: For permit: to construct an accessory swimming pool at: Location of property: 125 Broadwaters Road, Cutcho ug e,NY County Tax Map No. 1000—Section 104 Block 12 Lot 8_2 Is returned herewith and disapproved on the following grounds: The proposed accessory swimming pool,on this conforming 55,140 sq. ft. lot in the R-40 District, is not permitted pursuant to Article III, Section 280-15, which states accessory buildings and structures shall be located in the required rear,yard. The accessory structure is located in the side ,yard. Authorized Signature Note to Applicant: Any change or deviation to the above referenced application may require further review by the Southold Town Building Department. CC: file,Z.B.A. BOARD MEMBERS Leslie Kanes Weisman,Chairperson 30 Southold Town Hall � 53095 Main Road v P.O. Box 1179 Patricia Acampora Southold,NY 11971-0959 Eric Dantes Office Location: Robert Lehnert,Jr. \® Town Annex/First Floor, Nicholas Planamento 54375 Main Road(at Youngs Avenue) Southold,NY 11971 http://southoldtownny.gov u EE C E N'V E D ZONING BOARD OF APPEALS TOWN OF SOUTHOLD APR 2 a 2022 Tel.(631) 765-1809•Fax (631)765-9064 SOUthol FINDINGS, DELIBERATIONS AND DETERMINATION 6d Town Clerk MEETING OF APRIL 21, 2022 ZBA FILE: 7634 NAME OF APPLICANT: John Carter& Catherine Samaan PROPERTY LOCATION: 125 Broadwaters Road, Cutchogue, NY SCTM No. 1000-104-12-8.2 SEQRA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type 11 category of the State's List of Actions, without further steps under SEQRA. SUFFOLK COUNTY ADMINISTRATIVE CODE: This application was not required to be referred to the Suffolk County Department of Planning under the Suffolk County Administrative Code Sections A 14-14 to 23. LWRP DETERMINATION:The relief,permit,or interpretation requested in this application is listed under the Minor Actions exempt list and is not subject to review under Chapter 268. PROPERTY FACTS/DESCRIPTION: The subject property is a 55,140 s ft. 1.26 acres q- ( ) parcel located in an R-40 Zoning District. The property is a corner lot with a 191.59 feet irregularly shaped frontage on Broadwaters Road along the northerly property line, then turns south for 218.59 feet along Vanston Road, turning west for 188.00 feet, before returning 284.6 feet north back to Broadwaters Road. The property is improved with a one story single family dwelling, as shown on site plan depicted as a proposed, prepared by Robert A. Steele, LPE, dated January 21, 2022. There are currently additions and alterations to the dwelling being constructed under building permit# 46754. BASIS OF APPLICATION: Request for a variance from Article III, Section 280-15 and the Building Inspector's January 13, 2022 Notice of Disapproval based on an application for a permit to construct an accessory swimming pool; at 1) located in other than the code permitted rear yard; located at: 125 Broadwaters Road, Cutchogue, NY. SCTM No. 1000-104-12-8.2. RELIEF REQUESTED: The applicant requests a variance to construct an accessory swimming pool in a side yard where it'is required in the rear yard. ADDITIONAL INFORMATION: The dwelling sits on a corner lot and faces Broadwaters Road. There is currently construction taking place under BP#46754, at the rear of the house. The pool is to be located at the rear of the house, and a variance is only required due to the corner lot placement. Letters of support have been received from the adjoining neighbors. The property is-heavily wooded from the dwelling to Page 2,April 21,2022 #7634, Carter-Samaan SCTM No. 1000-104-12-8.2 Vanston Road eliminating potential issues of adverse visual impacts and lack of privacy from neighbors' properties and from Vanston Road to the swimming pool. FINDINGS OF FACT/REASONS FOR BOARD ACTION• r The Zoning Board of Appeals held a public hearing on this application on April 7, 2022 at which time written and oral evidence were presented. Based upon all testimony, documentation, personal inspection of the property and surrounding neighborhood, and other evidence, the Zoning Board finds the following facts to be true and relevant and makes the following findings: 1. Town Law 5267-b(3)(b)(1) Grant of the variance will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. The proposed pool is located in the architectural rear yard of the house on this corner property.The property is a double lot which resulted from a merger and there is a very large wooded buffer between the subject dwelling, the'proposed pool and Vanston Road, which, given the road's higher elevation and the large setback of the proposed pool, will prevent any adverse visual impacts to either Broadwaters or Vanston or any adjoining property. 2. Town Law 267-b(3)(b)(2),The benefit sought by the applicant cannot be achieved by some method, feasible for the applicant to pursue, other than an area variance. Due to the corner lot location, there is no legal rear yard for the-placement of the pool in a conforming location, therefore any pool would require variance relief. 3. Town Law 267-b(3)(b)(3) The variances granted herein is mathematically substantial, representing 100% relief from the code. However, due to the corner lot location of the property there is no functional . rear yard in which to place an accessory pool in a conforming location. The proposed pool also meets all of the setback requirements for an accessory pool, and is located close to the subject dwelling where it has the least impact on neighbors and is in the most functional location in relation to the layout of the house.. Also, the pool is proposed to be sited on relatively flat open land where no tree removal is required. 4. Town Law $267-b(3)(b)(4) No evidence has been submitted to suggest that a variance in this residential community will have an adverse impact on the physical or environmental conditions in the neighborhood.The applicant must comply with Chapter 236 of the Town's Storm Water Management Code and conditions of this board. 5. Town Law 267-b(3)(b)(5) The difficulty has been self-created. The applicant purchased the parcel after the Zoning Code was in effect and it is presumed that the applicant .had actual or constructive knowledge of the'limitations on the use of the parcel under the Zoning Code in effect prior to or at the time of purchase.. 6.Town Law&267-b. Grant of the requested relief is the minimum action necessary and adequate to enable the applicant to enjoy the benefit of an accessory swimming pool while preserving and protecting the character of the neighborhood and the health, safety and welfare of the community. RESOLUTION OF THE BOARD: In considering all of the above factors and applying the balancing test under New York Town Law 267-B, motion was offered by Member Lehnert, seconded by Member Planamento, and duly carried, to GRANT the variance as applied for, and shown on the site plan prepared by Robert A. Steele, LPE, dated January 21, 2022. . Page 3,April 21,2022 #7634, Carter-Samaan SCTM No. 1000-104-12-8.2 SUBJECT TO THE FOLLOWING CONDITIONS: 1. Pool pump equipment/mechanicals must be located a minimum of 20 feet from any property line or be contained in a shed type enclosure with a lot line set back that is in conformance with the bulk schedule for accessory structures. 2. Drywell for pool de-watering shall be installed. This approval shall not be deemed effective until the required conditions have been met.At the discretion of the Board of Appeals,failure to comply with the above conditions may render this decision null and void. That the above conditions be written into the Building Inspector's Certificate of Occupancy,when issued. The Board reserves the right to substitute a similar design that is de minimis in nature for an alteration that does not increase the degree of nonconformity. Any deviation from the survey, site plan and/or architectural drawings cited in this decision will result in delays and/or a possible denial by the Building Department of a building permit, and may require a new application and public hearing before the Zoning Board of Appeals. Any deviation from the variance(s)granted herein as shown on the architectural drawings, site plan and/or survey cited above, such as alterations, extensions, or demolitions, are not authorized under this application when involving nonconformities under the zoning code. This action does not authorize or condone any current or future use, setback or other feature of the subject property that may violate the Zoning Code, other than such uses, setbacks and other features as are expressly addressed in this action. IMPORTANT TIME LIMITS ON THIS APPROVAL Pursuant to Chapter 280-146(B) of the Code of the Town of Southold any variance granted by the Board of Appeals shall become null and void where a Certificate of Occupancy has not been procured,and/or a subdivision map has not been filed with the Suffolk County Clerk,within three (3)years from the date such variance was granted. The Board of Appeals may, upon written request prior to the date of expiration, grant an extension not to exceed three (3) consecutive one(1) year terms.IT IS THE PROPERTY OWNER'S RESPONSIBILITY TO ENSURE COMPLIANCE WITH THE CODE REQUIRED TIME FRAME DESCRIBED HEREIN. Failure to comply in a timely manner may result in the denial by the Building Department of a Certificate of Occupancy, nullify the approved variance relief,and require a new variance application with public hearing before the Board of Appeals. Vote of the Board: Ayes: Members Weisman(Chairperson) Dantes, Acampora, Planamento and Lehnert. This Resolution was duly adopted(5-0). _ ,�/L'`-�- Gam'. ' J• 4�trrr�--� Leslie Kanes Weisma Chairperson Approved for filing /d-�/2022 ��g�ffO1K�O BUILDING,DEPARTMENT- Electrical Inspector �O Gy TOWN OF SO.UTHOLD CDTown Hall Annex - 54375 Main Road - PO Box 1179 C#' - Southold, New York 1 1 971-0959:- oy�o� Telephone (631) 765-18:02 -FAX (631) 765-9502 rogerr(c�southoldtownny.gov sea nd(southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN- INFORMATION (Au information Required) Date: Company Name: 9VT"CC_ ML&C1-RI C L CO NrTZACTI.N& L D Name: IJ'Tv1f'L..S. L-0 License No.: Q .. email:- t 64C,. iD Q A111A0e1 A Address_: :..(�i�nc:o V2 A oRL: is-A 113 . Phone.No.: JOB SITE INFORMATION (All Information'Required) Name: � � 1p/dOU-1 E SA AAN Address: LOA .0 kW L Cross Street: Phone No:: Lot: ,: . . Block: .(>. r:-:Tax.(U�ap.�,istri.ct :.._.,::..1,.0,.,:0 ._._:_ ,._Section:. � .. BRIEF DESCRIPTIONN O'F"WORK (Please Print Clearly) wv i Y\A,NM,./'A N P—O0 L11`� 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=F-ire-R-econnect FFlood-Reeonneet-service-Reconnected--U-nder-ground-�Overh ad # Underground Laterals... 1 2 -,H,Frame.- - - Pole- Work done on Service?-- Y-- N - - - Additional Information: Dv+l~ ;ce: wi AA fA C �,oUI a:r U P PAYMENT.DUE WITH APPLICATION—— ....... --- .... . pp N\Q Request for Inspection Form.xls �i� �� PERMIT# Address: Switches Outlets GFI's Surface J —Swnees H H's LIC Lts _ Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Combo Cooktop Transfer AC AH Mini Special: f Comments: / / / r • •I ` a 13 I LEGEND: 4 PROPERTY LINEBR\ ©AV A RS�—23? EXISTING CONTOUR —22--� /EXISTING M PROPOSED CONTOUREXfA(NGSCWA� WATER N roadway G\ fa •�-..�L1• /\`_,�_^-�'--�'if l `•PROPOSED CIRCULAR SEPTIC TANK PROJECT Q_ _ -_ LOCATION �„F '-•�" l i LR 1� PROPOSED SANITARY LEACHING POOLrr'AVEA4E / rUT�L, r / I - - G \ ll _� 11 - ' '_ _. �• F f4� �( _-'- — -21— PROPOSED SANITARY PIPE PROPOSED FUTURE EXPANSION GLJL �� E S ate, N�'��/,^., 7 �2�" -4 Al —w— PROPOSED WATER SERVICE - \ ' �IJN `\ —OH— EXISTING OVERHEAD ELECTRIC SERVICE '\ �/ , PROPOSED POOL SETBACK •�'�'-'�"� '\ \ \ IV I MIN. \ y \ PROPOSED WATER \ I V FE\ ?s \ \ .tL SERVICE LOCATION MAP \ I�\1 7 •V L 10'MIN. P h � y d I \' EXISTING WATER /I �✓ i•►,v SCALE: 1"=400' a \ 7qC \ \ I WELL TO BE / Il Q o 700 400Fext . REMOVED / — CC I Date: 6128/21 I sT a, /,I y I° b 77�� \ / \ I` ' / / / i _/ / ELEV. DEPTH 10'MIN. 21.50' 0' Po z ' &ovm silty santl SM 1 f \ PROPOSED cp N f ti I / — BUILDINGS: 1 STORY ¢ / L�1 i 18 50 ------- EXISTING 1 STORY RESIDENCE / BASEMENT n,. BEDROOM RESIDENCE '� "—�'•..' / ` `3 j r1 3' W I \ 1N 25' Y EXISTING SANTARY STEM 3 `,J PROPOSED 1 STORY ADDITION f BASEMENT ..l'Z•:'�. W/ BASEMENT (4 BEDROOMS) I F \ 4 TO BE COLLq'PSED,& / 1 / ABANDONED AN PLACE AS GARAGE F.F.=25.1) f'� PER SCDHs STAY ARDS/ I \GNEU / / t SITE DATA: T Q SDTM#: 1000-104-12-8.2 SITE AREA: 1.2658 ACRE —31 \\�jT tiny J / / ° / "^I "� GENERAL NOTES —24 1r, �� N Pale brown fie sand SP 1. NO EXISTING SURFACE WATER WITHIN 100' tu Q 2. NO PRIVATE WATER WELLS ARE LOCATED WITHIN 150' OF THE PROPOSED SANITARY SYSTEM. NO PUBLIC �- WATER WELLS ARE WITHIN 200' OF THE PROPOSED SANITARY SYSTEM DRAINAGE 4. PROPOSED ANITARY SY WITHIN R STEM SDESGNED FORITATO AL OF 4 BEDROOMS. \� ��oU ' / I I / / / 1 I� / SURVEY NOTES: q / 1 1. MEASUREMENTS ARE IN ACCORDANCE WITH U.S. STANDARDS. `34\ �I, PGO�`f // / // I �% / / //// i / I 1 I P / ^ , 2. BEARINGS SHOWN ARE IN NEW YORK STATE PLAN COORDINATE SYSTEM, LONG ISLAND ZONE. SANITARY SYSTEM NOTES: 2. SEPTICSED TANK TO DWELLING L BE TO 1,250AGALLON 5- DIA. MAXIMUM. 4.50' 17' 3. CAST IRON SANITARY PIPE SHALL EXTEND THROUGH FOUNDATION WALL A MIN. OF 2'. O 4. SANITARY PIPE TO BE 4"SDR 35 PVC PIPE O/ / 1 5. PITCH OF PIPE FROM HOUSE TO SEPTIC TANK TO BE}" PER FOOT MIN. ` / Comments: No water encountered 6. PITCH OF PIPE FROM SEPTIC TANK TO LEACHING POOL TO BE J"PER FOOT MIN. ( ) 7. USE TWO (2) 8' DIAMETER, 6' HIGH PRECAST CONCRETE LEACHING POOLS. „J HIGHEST EXPECTED GROUNDWATER = 0.80' 3 / D {.` / /ti / 1 B. PROVIDE ROOM FOR FUTURE EXPANSION. • / / I 1 I I I -� / / / t� / !„ 9. SLOPE OR GRADING AROUND SEPTIC SYSTEM TO BE 1/20 S 0' MIN. TEST HOLE 10.BACKFlLL MATERIAL SHALL BE COARSE SAND AND GRAVE �r 11.BOTTOM OF POOLS SHALL BE A MINIMUM OF 3'ABOv F9�G UP 0_ \ / _2e_ — / I 1 N.T.S. AND \L \ ,Jv? \ \ / / / / ; \ 12.SANITARY SYSTEM SHALL BE INSTALLED AS PER TH ChiI A !0 / _ _ // ' 0 ! y I ' �,•�` 2� \3\3p� C I OCn / W copy from ZBA SS`� \ — — \ \ \ Q[aD p^ \ I r Final reviewed doc ments 3 \ \ —39— ` \ \ \ \ p ZBA Fli #'J Date: 1 1 21 22 FP POOL SETBACKS ADDED RAS \ / DATE BY DESCRIPTION APPROV. BY REVISIONS �� \ `Nc50 RT \ \ \ \ I / / / / /1/ 125 BROADWATERS ROAD NASSAU NT, NY 11935 PROPOSED I RENOVATION j m ' /�� PROPOSED SANITARY PLAN SITE PLAN ' /' O 1 rt L. K. McLEAN ASSOCIATES, P.C. V O SCALE: 1"=40' 1 CONSULTING ENGINEERS 437 SOUI I COUNTRY RD..BROOKHAVEN.NEW YORK 11719 O (Vtwumx w or me srRr[or xn mRR RRaxRers -m �nrou.u�+c uarnu+e ,,,� 0 70 ao Designed By: MF/CFD Sccle: AS NOTED Sheet No. '4 O Ave/oR TE NmNRNrv9rG SRECRFIIbIb.Vpf55 R•e Feet C N sup are Drown By: MF Dote: JANUARY 2022 S 1 o/ xscxo£RxC r�u rannr or txE.umnax tw 1xC �mM xE exi--— SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES Approved By: RAS F.I.Ne. 21092.000 a.�1 •• �V,'��/ �I^ LEGEND l\ ,� - I --„-- EnsnND mNmDR `� p ��\-• o p a Jfi V —�Dx c snu\ rwrA r I�An � ysphatt roadaaY / ✓�—Y J C,,—� PPOPOSm CaxCUUR SEPTIC V VII 1 ':�.� \• r� c C71/PAV \— 5 ZO13 10° f0 t'•-.— —r— ,pn , (rt, PPDPOSm MVRE C+�KroN _ 1 S�D/"h[FU/✓£q y—---i— . PROPosm lm sERACE • �\ 1 ���ENO 1—`Jy I � —�,— PnsGvc DVExe,EaO EtFLFRIC smYCE � 4 __ \ \ /•\ ����..; N 0 / ��. F6¢ / ———PRorosm Pom sETetcN £} •,o \1 � \ I S• 'J \ PR°Posm Yr00t / ,; LOCATION MAP \ \I 1 �° \ \ J �•w�'FLM.TN00 t� S :1•_4.' REUIRMO Mra \ I ..`.,. , / t\a,E Bane,etlPPx°0 SIA \ PROPOSED 1 ORY Jr' M1 I /I�j I / J BUILmOFINGS: ,sfORr IRSo�sE w/e15EYFM\ I I \; BEORGDM RC�� l .�.: 11 / / F ,(A50' __—__— S pnecL Y `� SArd S�slFal 1 MFF^ rx'?.. .. I.•.: / E[6nN0 U.�PTARP o RroPOSm STORx WDm(4 \I \ GE-33.1) •ti`:•:" AA9Ar°.N+sE�-// (O1 ( w/e+sFYmr(e eEoa°wly / 1I \9NED GARAGE F.F.c25,1) �'I'�:'•s`•i••-••:••� / Pm scoS ,/ 1 �' V SITE DATA, '' � 511E ARFA 13658 ACRE Ila // / •—) GENERAL NOTES `\ 1 \ ®\ / // O �333 PYeb°+m.emN 6P ,.NO Dt61W0 51°iFHY VA,EA WRI@1,OY ///] 2 NO PRNAIE NNFA 119E ARE LOWm,IRmN 1'A'n TIIE PRnaSm SANRARY SY'iEN.NO Wt4& N�0 P0�SNOICIUR6 WIINW 1V OF SNi0.Qf SYSIEL mSuavEY NDTEs: tlD / I t O rAL1PExRNis IJE IN ACCORCNICE MM US.SLNYADS. /\ �� .5.. / i / Ir ' //// �/ / i / n/ 2 EffAIIaICS SIWm,ARE¢ILLN PORK sfATE PLW WOROaIA,E MIEI(U1N°¢4ND LONE I��JI LL. SANITARY SYSTEM NOTES: x,—1 I OR ro�PIFE G4LIAN e'DIA J.CAST RON SANIGRY PIPE SHALL FXIFNJ THRn1GN iD11NDOlON WALLA Lm1 OF W. O 1.54Na4xY PPE ro eE f•mP]S PVC PPE /O/ l ( tl J S.PRCN R PPE MOM IroIISE ro SEPTIC TANK TO eE)•Pm mor IaLL / , Commenlx No water ewwrWeO 0.PRn1 OF PRE m0Y SEPTC TAKK ro IUDCNO PoOL TO EE L'Pm EDGE Yal ,4 / (MONEsr ExPEOtm GROI DRAM m OXW) T.USE TRD(a)°'OuuEIER.°•xOe MEGST MNG¢TE It CxPNc PDOti 1 B PROYOE R G FOR MIME E:RANSION. v `\\ 1 / / I / J I I •! ,// / / , J !� SmPE OR GRAC ING AROUND sEPOO SYAIEx,ro DE 1/a.S—FOR FLRSf a0.1aN. J TEST HOLE ,°•eACRFn1 UATERIu sluLL ee co°ASE sANo AIm cRAvu. \ � / / / \\` l I\ \\_9_x I— /,/// // / I'i S\ � N.rs. ,,.emEw w Pans suu eE A�uu of a•C O way cRoumrATos 97 u \ I � I / / �1 \ \ / // / , I 12 SANRARr SrSItL SxWl�INSLWID AS Pm 4 El D.Aos @@ppip FINAL MAR 1 21 2z POOL- O�DED RAS p gQaL� aTE er °EscwPnoN APPRov.er o \ \ — ^\\\ \ \ \ \ \ , / 4➢4 REVISIONS REVIEWEt Y ZSA `�'� � 125 BROADWATERS ROAD RR \uu \ \ I / / /� /f/ p� �G+� „onQF NASSAU POINT NY 9R "l\O /1 //�tE , /!g8• I J // J / SEE eg��IV� W"' PROPOSED RENOVATION DATED / PROPOSED SANITARY PLAN Y; t SITE PLAN / ��/ L K McL PAN�ASSOCIATES,P.C. MF/CFO AS 110 Dram „nxw JANUARY 2022 S l a r SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES wPa.aPr. RAS n.N,.21092.000 �OS�fEOt,�- BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD - Town Hall Annex - 54375 Main Road - PO Box 1179 CD all � - Southold, New York 1 1 971-0959 4,� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(a-),southoldtownny.gov - sea nd cDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: 9V7r"E_rL Le-_LF—C-1-R b CAL O W-R ACCI N C2 LTD , Name: 4ZTs'Arz--S, I LX License No.: 40,55 MS email: 9- d-ec_ OJ aA'iI/\e-- n Address: n co v2 �,_ >J.�� Con�� 1'�1' i 1 74-1 Phone No.: 15 �; JOB SITE INFORMATION (All Information Required) 1� Name: A NDZEA/ a, M OLU SA M PAN Address: So t; LqAovU I-Qw LOtAeL, (AA 01 A "7 Cross Street: ���, ,-ew -:013111 Phone No.: — —76 r' S-500 Bldg.Permit,#*. 4-(DZ J email: Tax.Map District: 1000 Section:. g45 Block: Lot: ro BRIEF DESCRIPTION O'F"WORK (Please Print Clearly) �vv,n�1AA/PO )rJ 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 Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: 1ec�S� e�11 oar © F;c� w', AA ,n a; .� .. . � o•w-. PAYMENT'DUE WITH APPLICATION �C o0 m�Cb Request for Inspection Form.xls Scott A. Russell ,��°Suf '� ST01R.MWAT]EIK SUPERVISOR ' z MA\NA\G]EM]ENT SOUTHOLD TOWN HALL-P.O.Box'1179 0 53095 Main Road-SOUTHOLD,NEW YORK 11971O Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS ]PROJECT INVOLVE ANY OF THE ]FOLLOWING: — Yes No (CHECK ALL THAT APPLY) ❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. ❑ B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑0 C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. 1:10 D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. [IFE. Site-preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑ F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. If APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 100 Dat12 e: �i ' M rfct I (� NAME: ll L•'' 1�--xf-gp ( 1 IN(lI J Section Block t g� 35 i ****FOR BUILDING DEPARTMENT USE ONLY**** Contact Information: ITe4pMrc Num6erl I I i — Reviewed By: — — — — — — — — — — — — — — — 11Y Pro ert Address/ Location of Construction Work: I —Date_ 1'1r Approved for processing Building Permit. lY Stormwater Management Control Plan Not Required. OKI— �) (; ❑ Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM. # SMCP-TOS MAY 2014 — — SURVEY OF LOT 193 * 194 AS 5HOWN ON A CERTAIN MAP ENTITLED'AMENDED MAP A OF NA55AU POINT" OWNED BY NA55AU POINT PROPERTIE5,INC.FILED IN THE SUFFOLr,COUNTY j CLERC5 OFFICE ON AUGUST I G.1922 A5 MAP NO.156 V SITUATE: CUTCHOGUE TOWN: SOUTHOLD s SUFFOLK COUNTY, NY 5URVEYED OG-27-2014 5UFFOLh COUNTY TAX# 1000- 104- 12-8.2 p 3 CERTIFIED TO: BRD CRIGAGO TITLE INSURANCE COMPANY D"•�T� - �� JOHN CARTER CATHERINE SAMAAN ` '\ ROAD AD Q'.IVQe asphalt madly w r ' O n�•• I 533��ryo ', N� '3j a"Eo n eG91�hO4s ? Ifv 44V o Ad 0, , 11 D W O F I O Na o , �0` —�iz /' cry / Z epee o clx .INc � h� m' , , O i �95 ; , , i I.r1TP�i Lww„mv,<e d,„m:n.n eu°.iw,°a aver � MONN/ENT POUeW O� N�� „° M•„na v,comma,n•a m°aewr i aea b° o SF14EFou+D JOHN C. EHLERS LAND SURVEYOR GE ` °""'°""„n„�•n"-sMa°''°„n' New me Siw,e rawmu°w lw: Q� yC c�O� ear c p uom IN, • y 7 (dP) wr °+eroeo ua u,°e ew unamea,°I.c.ab,.ur rede.- 6 EA5T MAIN 5TREET N.Y.5f UC.NO.50202 N P.IVERHEAD,IJ.Y. 1190I 369-8288 Fax 369-8287 y r.oa �d L_ "+ Area =1.2 140 5 Ft. 1, -- 7 raao coao°+i�.o<, n lone smm� Area a I.2658 Acres � O¢ eTine Nw rmr se,�acmma,o,,Yw•�d G P IC 5C =30' Ionglslandlandmveyorxom �, E'' `+_+h� �'� �;air„�•d So � w,W m nn Mnn,+°Ne„tle aany,mp SFOLAND F'Ve' F.� `om>a 14-158 ,tea„ m,lna+w°Pw omn :,:emus° Jul ze 1.9, Ug:SZa Harold Tranchon Jr. P.C. 6319291426 p.2 LOT AREA = 17,500 SQ. F T.4 'go� 0 4 LOT NUMBER 48 S. 51053'30"rE FC f 75.OD' F,c f0.3'N 0.3'N J 'Post and wits fence D.#`W � a N O pipe Q fd t,J P;pe C� r' n stoop ant) 0 �r-� a F` walkLi `� 8t �G CulyYlf7� '` O wood. r� a 40 deck . r►�+.t C7 � � +.� 18.E _ � - 6Ik Cureen r� rtin ° w anct. M fl. © asphalt driveway o GAR 13.7' M N 4Q Lu 411' _ ca fd , pipe N 51453'30"UV 75.00 re—bar LOT NUMBER 46 a r THE EXIMENCE OF R"T OF WAYS ANQ OR WSAENTS OF RECORD. IF ANY. NOT SHOW ARE NOT GLWWtTFI;D. o . TIME OFFSETS (OR DIMENSIONS,) SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY ONES ACE FOR A SP�CIfiC PURPOSE AND USE AND THEREFORE ARE NOT INTEhIpEp TO GUIDE THE ERECJION OF FE?rCES, RtrTNN1HG WN.lS, POMS, PATIOS, JOS No. 19-189 FILE No. TERRY WATERSPLANTING AREAS, ADDITION TO SUILDINGS Oft AW OTHER CONSMCnoti. 7U4MTH0RI2ED ALTU;AAMN OR ADDITION TO TM SLIRVFY IS A VIOLATION OF SECDON SURVEYED FOR ANDREW SAMAAM SAND MOLLIE SAMAAN 209 OF THE NEW yM STATE EOUCAHOR LAW. LOT NUMBER 47 CiUARMITEES -WINCATED HEREON SHALL RUN ONLY To THE PERSON FOR WHOM THE MAP OF' TERRY WATERS SURVEY IS Frt ED, AND ON HIS BEHALF To THE TE COMPW GOVERNMENTAL SITUATED AT BAYVIEW AGENCY AND LENDING IN MEU11ON USTED 11MEON, AND TO MC ASSICNI=ES OF THE LENDING 'NSTITUAON. 1;UARAN EES ARE NOT TFLWSFERABLE TD ADDITIONAL. INSi1TUTI0N9 ��• TOWN OF SOUTHOLD COPIES OF THIS SURVEY MAP NOT BEARING THE LAND sURVEMWS Imea SSA. OR SCALE 1 " EMBOSSED SEAL. SHAD. NUT BE O NSIMM Tao BE A VA1JO TRUE COPY. DATE DATE 7--23-201 9 FILED MAP No. 2901 HATE 12--29-1958 �ERDFIED ONLY TO: ,�IRST AMERICAN TITLE INSURANCE COMPANY TAX MAP No. 1000-8$--5-6 CRD, 16-335 Labor, Licensing&Consumer Affai 1 a HOME IMPROVEMENT LICENSE Name f RANDY RODECKER • Business Name FENCE KING OF ROCKY POINT INC i This certifies that the bearer is duly licensed License Number H-21412 by the County of Suffolk "06/01/1992 _ Issued: Commissioner Expires: 0610112020 r i i PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE j la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-744-8100 Fence King of Rocky Point,Inc. 471 Swim King Pools&Patios 1 c.NYS Unemployment Insurance Employer Registration Number of 471 Rt.26A Insured Rocky Point,NY 11778 I Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations In New York State,he.,a Wrap-Up Policy) Number 113008276 i 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest Indemnity Insurance Co. Town of Southold 3b.Policy Number of Entity Listed In Box"I a" 53095 Rt.25 SW5WC00205191 PO Box 1179 Southold NY 11971 3c.Policy effective period 11/05/2019 to 11/05/2020 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"1 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 mall.)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. ` 11 - Approved by: �i Vmkum (Print n - of aut z r resentaflve or licensed agent of Insurance carrier) Approved by: Un UnderwrItInx Vice PresIdeni 19 (Signature) (Dat ) Title: U J�V y Y P ?� ^ I Telephone Number of authorized representative or licensed agent of insurance carrier:- U �� J `�� 0 Please Note:Only Insurance carriers and their licensed agents are authorized to Issue Form C-106.2.Insurance brokers are N authorized to Issue It. C-105.2 (9-17) www.wcb.ny.gov i root Workers'Compensation CERTIFICATE OF INSURANCE COVERAGE 31•wre 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 1a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 471 ROUTE 25A ROCKY POINT,NY 11778 1c.Federal Employer Identification Number of Insured Work Location Of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York state,i.e.,wrap-up Policy) 113008276 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 53095 Rt.25 3b.Policy Number of Entity Listed in Box"1a" PO Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2019 to 01/31/2020 4. Policy provides the following benefits: © A Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 2/1/2019 By ;.���;t^�*w•t�:L. : (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be 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 1 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 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 (10-17) IINIIP1°°�1°211°°1°1°(11111°�1�7)°INI{0 10, 40' 10, NOTES "IMMEDIATELY"'.- 1 1. NO SOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END,OR FEETOF EXCAVATION AT THE DEEP END. ENCLOSE POOL TO CODE ; ° 2. THIS POOL MEETS THE REQUIREMENTSOFANSI/NSPI-5 AMERICANNATIONAL5TANDARD FOP,RESIDENTIAL INGROUNDSWIMMING O �u�p'yON COMPLETION-c POOLS'AND 1996 BOCA CODE-SECTION 421. DIVING EQUIPMENT15 NOTALLOWED. k'U FOR IIVA a L_* 3. SWIMMINGPOOLSHALLBECOMPLEELYANDCONTINUOUSLYSURROUNDEDWITHABARRIERCON5TRUCTEDIAWREQUIREMENTSOF p- SECTION R326.5.3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE 5OUTHOLD 6 TOWNCODE.ACCE55GAES SHALL COMPLY WITH SECTION 9326.5.2OF THE]PC AND BE SELF CLOSING,SELF LATCHING AND BESECURELY ��� � P } - � a s s o A LOCKED WHEN POOL 15 NOT IN USEOR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOLAREA v1 J 00 sy I 4. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROUND THE EXCAVATION LAW THE CODE OF THE Q ems^ TOWNOF5OUTHOLD. O y )T I;Y BUILEI NL=, i._ i rim!? G I Imo. o y' `'- �$QZ Si��I TOPM FOR TI;E S. POOL MUST BE EQUIPPED WITH AN APPROVED POOLALARM CAPABLE OF DETECTING A CHILD ENTERING THE WATER AND SOUNDING >- AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE ATPOOLSIDE AND ATANOTHER LOCATION ON THE PREMISES WHERE THE POOL V 3 di 1 I ( h h.;' !�ICPrf`� I�,' 15 LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS. v LLO'NIN. ,I nS EU i0t,'S o Z Q z THE ALARM MUST MEET F2208 "STANDARD SPECIFICATION FOR POOL ALARMS. THE DEVICE MUST IN (NOT FOU MT ON - T vV01' FECQUI ED ATTACHED TO ORDEPENDENTON)OFPERSONS. N _� CONC.WALLS O FOR POtJFAEU COf,iCRE:TE B 6. POOL SUCTION FITTINGS(EXCEPT FOkSU`PF.ACE SKIMMERS)MUST BE PROVIDED WITH A COVER THATCONFORMS TOASME/AN51 a �. OLI�+ii - Fti.1;`vlI!, u 'LU11'l 5f1: A112.19.SMORAMINIMUM18'x23"DRAINGRAEORACHANNELDRAINSYSEM. POOL CIRCULATIONSYSEMMUSTBEEQUIPPED,WITH °� Y tp�-. Ii a--tr..I PLAN ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATECOVER5 LOCATED WITHIN THE POOLBECOME M155INGOP BROKEN.SUCH n O 3. 1t SU_1 A' ll.Py VACUUM RELIEF SYSTEMS SHALL CONFORM WITH A5MEA112.19.17ORBEA GRAVITY SYSTEM APPROVED BY THE TOWN OFSOUTHOLD. N IC4 4. i iNAL - CGNd_ST.;UCIIOiN MUST N.T.S. POOL SHALL BE PROVIDED WITHAMINIMUMOF2SUCT10NFITTINGSOFTHEABOVEMENTIONEDTYPE.THESUCTIONFITTINGSSHALLBE _ SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A BE COMPLE I_ FOR O 1 C.O. 20'VINYL COVERED CONCRETE END STEP VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCE551BLE n L ('OIVSTRj 7!O' Si„`�.LL ME l Ti POSITION,MINIMUM OF 6'AND NO GREATER.THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO o THE SKIMMER/SKIMMERS. R .`�1UI1 =111F�!TJ OFTHcCO�ESOFNc 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTSOFNFPA70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRCSECTIONS YI RK ST:1TE. NO1 RESZPO' SIBLE FOR 4201 THROUGH 4206. ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIESANDBE PROTECTED BYA ',� SIGN OR COrJJ I t�i�CTIGPJ ERRORS. I'to4'SANDBOTfOM GROUND FAULT CURR ENT INTERRUPTER(GFCI) CURRENTCARRYING ELECTRICAL CONDUCTORS EXCEPTFORTHO5E PROVIDING POWER V TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEETTHE SEPARATION REQUIREMENTS OF TABLE E4203.5.ALL METAL ENCLOSURES, u FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT QJ WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. SECTION A B. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NYS PLUMBING CODE 608. QJ 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. `p p TOP OF WALL WATER LINE 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. Q/ Z 0 `> 4' 12' 4' 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED LAW AN51/NSPI-5 5ECTI ON 6. v In p 0 12. CONTRACTOR TO PLACE THE POOL LAW TOWN OF SOUTHOLD CODE SETBACKS. 0 J O O 13.' ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUB)ECT PROPERTY. p THE DESIGN IS BASED ON ACOMPLY WITH ALL CODES OF 154 WATER EXSTSWITHIN 6'0"DFROIMGRADE,DE ATERINGFACILI ES WILL BEREQUIREDOT EXIST WITHIN THE EXCAVATION. IF GROUND - F�CTRI �C77 SECTION B NEW YORK STATE & TOWN CODES 16. ALL GAS AND OIL HEAERS(IF INSTALLED)FOP,THE INGROUND SWIMMING POOL SHALL BENATIONALAPPLIANCEENERGY p CAL INSp AS fit=CCU I R tD A CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED LAW AN51 Z21.56 AND SHALL BE INSTALLED IAW N OM�QUIRQO N.T.S. NS OF MANUFACTURERS SPECIFICATIONS. OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR II GVARDEDTO PROTECT AGAINSTACCIDENTAL CONTACT OF HOT SURFACES BYPERSONS. POOL HEATERS SHALL BE PROVIDED WITH CHECK VALVE SOU HOLD TrTOWNTRUSTEIES ' TEMPERANRE AND PRESSURE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SY5TEM.A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE PUMP FROM SKIMMER SOUTHOG BOARD FOLLOWING ENERGY CONSERVATION MEASURES: 16.1 AT LEAST ONE TH ERM05TAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. Gda SOUTHO 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHVH TING OFF THE 00 N.Y.S. OPERATION OFTHEH EATER WITHOUT AP)UST]NGTHE THERMOSTAT SETTING AN1)TO ALLOW RESTARTING WITHOUT RELIGHTINGTHE yUI o DR w�V N DE 16.3 HEA ED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTARE OUTDOOR POOLS ,"�"� C / DERIVING 20%OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) 16.4 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE 5ETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET W DIVERTER COPING ANND WALKWAY 10" TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE W ¢r w c VALVE O SANITARY CODE OF NEW YORK STATE. y WATER LINE GRADE ^ p .c* A 17. TH15 DRAWING 15 FOR STRUCTURAL SHELL ONLY.ALL ACCE55ORI E5 AND APPURTENANCES ARE DEFINE[)BY OTHERS. Ita FILTER _ - r�IE w w p rn UNDISTURBED EARTH 18. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHTOF THE Kr Z a M C-Q cd • WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" 41 n o:�.r, E 3500 PSI POURED CONC. 4 N 0 ,» 3/9"REBAK 2)NP. a 19. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL. W tc- VINYL LINER 20. THERE 15 NO MAIN DRAIN IN THIS POOL. SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY. THIS MEET5 V G z roa'sAND / REQUIREMENTS OFTHE IRC-SECTION R326.6 FOR ENTRAPMENT PROTECTION. 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: O F NE ft DER rN TO RETURNS 21.1. THE INTERNATIONAL RESIDENTIAL CODE'I RC)-CHAPTER 42(2016) � �Q �21 CHECK VALVE 21.2. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION RA03.10(2015) 21.3. THE INTERNATIONAL FUEL GAS CODE(2015) �1 VERTCAL3/Bor 'REBAR©3'O.0 21.4. THE NEW YORK STAECODE SUPPLEMENT-SEC11ONP326 (2017) 1I (NsHowN) 21.5. THE NEW YORK STATE SANITARY CODE. C �a a g r P Il O 21.6. AN517 NSPI-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. � L� ` � yI u � CC r I•�� P 1 ¢ q 21.7. BOCA CODE-SECTION 421, CU PLUMBINGSCHEMAT-% I _&N1L�311 �"� WALL SECTION 21.8. CODE OF THE TOWN OFSOUTHOLD. }? e tauAT>-J E fP 22. ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. ^ �� N.T.S. ��r°U d b G'ni „ p IT N.T.S. � 088475 �6 OF ANCY CL V IFICATE �OcESSIONP�