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HomeMy WebLinkAbout47789-Z o�OgUEFOt�co Town of Southold 7/7/2024 a Gym P.O.Box 1179 0 o _ 53095 Main Rd d Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45333 Date: 7/7/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 275 Sleepy Hollow Ln., Southold SCTM#: 473889 See/Block/Lot: 78.-1-38 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/5/2022 pursuant to which Building Permit No. 47789 dated' 5/6/2022 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: in ground swimming pool fenced to code as applied for. The certificate is issued to Gilbert,Jonathan&Courtney of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47789 8/1/2022 PLUMBERS CERTIFICATION DATED I. yhrw Auth ize ignature gOfFD! o TOWN OF SOUTHOLD �cay� BUILDING DEPARTMENT cox TOWN CLERK'S OFFICE oy 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#: 47789 Date: 5/6/2022 Permission is hereby granted to: Gilbert, Jonathan 275 Sleepy Hollow Ln Southold, NY 11971 To: Construct in ground gunite swimming pool at existing single family dwelling as applied for. Minimum 15 foot setback from property lines is required for pool and equipment. At premises located at: 275 Sleepy Hollow Ln., Southold SCTM # 473889 Sec/Block/Lot# 78.-1-38 Pursuant to application dated 4/5/2022 and approved by the Building Inspector. To expire on 11/512023. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector oF so�ryol , Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.deviinCaD-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Jonathan Gilbert Address: 275 Sleepy Hollow Ln city:Southold st: NY zip: 11971 Building Permit#: 47789 Section: 7$ Block: 1 Lot: 3$ WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1 st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Surrey 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 A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED F� Exit Fixtures Pump Other Equipment: AquaLink Pool Panel 10 Circuits / 9 Used, Pumpx 2 220GFI, Heater, 6 Lights 120GFI Intermatic Pool Tranny 300W, Hayward Salt Generator Notes: Pool Inspector Signature: Date: August 1, 2022 S. Devlin-Cert Electrical Compliance Form OF SOUtyo� * 1 PT. TOWN OF SOUTI�OLD BUILD NG D cou 631-765-1802 k. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ ] ,FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE.SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESItTANT;PENETRATIONe, [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) a [ ] CODE VIOLATION F q [ ] ,PRE C/O �,�[ ] RENTAL REMARKS: `' dt11i r v DATE INSPECTOR - 01 1-11111-1 It"or, 000 Qv �� A o 4A ho�aOF SOUlyo6 TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/C ULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PREP C/O [ ] RENTALREMARKS: 60ac. IaJ6 2S - be, o ooze 5Ccvtq DATE J���S�'a INSPECTOR Jeffrey Sands Architect April 28t" , 2022 Property/swimming pool location: Jon Gilbert 275 Sleepy Hollow Lane Southold, NY RE: Swimming pool rebar and dWyell 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, _1. i• t-_.= Jeffrey Sands Architect DE EE W E AUG 2 3 2023 Building Department Town of Southold 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—Jeffrey sand s(cD hotmai 1.com FIELD INSPECTION REPORT I DAjrE COM ENTS FOUNDATION(1ST) ------------------------------------- N'C FOUNDATION (2ND) y ROUGH FRAMING& PLUMBING or r INSULATION PER N.Y. STATE ENERGY CODE V� 5S/5•.� a. uE.c,bk4 e6IO S ov b-poie he oe ho v d so,2.s O!� Avoeon c•t, FINAL , .� ��L t..-�• ADDITIONAL C MMENTS 10 Ua °z H x d b y =o�gtlf folk �, d TOWN OF SOUTHOLD—BUILDING DEPARTMENT y Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownngov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only D PERMIT NO. d Building Inspector: APR O:� 20i2/2 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 OFSOUTHOI.D Owner's Authorization form(Page 2),shall be completed. Date: Gra- — OWNER(S OF PROPERTY: Name: } Guy+he,\j TSCIM#1000- 16 -1-.-35 Project Address: 971 `cc ha 0 Phone#: �11)U .. "®` V66 Email: ou �►'1 Y ad...coal Mailing Address: CONTACT.PERSON: Name: i M ,acu - . Mailing Address: ,JP— - u� . - oY 1 \1� -. Phone 1 3_ Ul�CU._1 - Email: ` K1U .ry DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION:. Name: C O()\S a:� C_ Mailing Address: -- Phone#: �?J I �j �j Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Pro ject: Other 0 a0�SD SW�m m G" $ Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? Yes El No 1 PROPERTY INFORMATION Existing use of property: pry Intended use of property: aS Gunt Zone or use district in which premises is tuated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES, PROVIDE A COPY. Zaeck Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided"by pCh ter 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): Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF SW"--lk-k*ivla MbAm, o) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Ham+ 0 (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 // c ^I day of �ri� , 209d- Cq-e� Notary Public SUSAN DOEINCK Notary Public-State of New York No.o1D0629 PROPERTY OWNER AUTHORIZATION Co Qualified in Suffolkk County My Commission Expires Noy 4,202 (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 DING DEPARTMENT: Electrical Inspector -I- TOWN OF SOUTHOLD AUG' 1 1 2022 0 o II Annex- 54375 Main Road - PO Box 1179 BUILDING DEPT. Southold, New York 11971-0959 TOWS!OF SOUTH^+_ETelephone (631) 765-1802 - FAX (631) 765-9502 rouerr@southoldtownny.gov - seanda-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date:7/24/2022 Company Name: LC Electrical Contracting Electrician's Name: Leonard Cancellire License No.: ME-38043 Elec. email:office@Icelectricalcontracting.com Elec. Phone No: 631-874-0485 El I request an email copy-,of-Certificate-of Compliance-- Elec. Address.: 22 Woodbine Lane, East Moriches, NY 11940 JOB SITE INFORMATION (All Information Required) Name: Gilbert, Jonathan Address: 275 Sleepy Hollow Lane, Southold, NY 11971 Cross Street: Phone No.: Bldg.Permit#:47789 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): In-ground pool Square Footage: Circle All That Apply: Is job ready for inspection?: � YES❑NO �Rough In ✓� Final Do you need a Temp Certificate?: YES❑NO Issued On Temp Information: (All information required) Service SizeF11 Ph❑3 Ph Size: -A #Meters Old Meter# ]New Service[]Fire Reconnect[]Flood Reconnect[]Service Reconnect[]Underground[]Overhead #Underground Laterals 0 1 n2 H Frame Pole Work done on Service? 0 Y N Additional Information: �� PAYMENT DUE WITH APPLICATION SSET op,�spa 1 IJ� O�G�, 1D�y�o N GIP1 S830164011 E e o WE 47.86' EqN 1 CA ss Me-CA FENCE PV6E N� A'CLiG� f ���,� 1 os w. �'()(J 0 0 osed 40' Iz Tr fRAATE 0 AV 1 Lo 1�rOQoseLlt 2, (_ _ � H O= 0 I h MASOWV (�j PLAT uj O z W a) '' SYNTNETM Z n SCREENED DS7EPS J O a PORCH O0b'CIFE WALL b Oi z n. Q' EJIY.'� SAS ~ to l Fu 8'WTE ti CLFE O 0 ZO PROPAHE 2 STORY ° = S METAL FENCE DEW TAW FRAME 31 FFE Z Z DWELLING - CCMAR 0. E ENITRAWA 0 p Lj NO.275 'u y J OTd' O(H'GaKAETE OVER , 0 c O W I Sim N 2 $ O 9 41.6' PUT A ►� STEPS 48.0' o Lu IJi.I r! C7 7 WDFE SRUNINOUS (n ONLINE PAVEMENT (n 1t! Z EAM WAUc Wr MONRY W pj T PVCFE POINT OF BEGINNING UY 0.7E �vATER F3L ), CONCRETE S76'08'S0'E 200.00' raMa d T� PAN0. MONUMENT MOE OF PAVEMENT N76D08'50"W APRON 165.00' SLEEPY HOLLOW LANE (50'PRNATE ROAD) U1r AREk'°B4OTTSF.J=Ar- YOIE REPORT NOTPROYMED Fat PPEAARAYION DFSLVKY. TNEOFFSETS(DROWWWONS)SHOWN HEREON FROM THE 51RUOTTIRFSTOTHEPIROPERTY UNFS ARE FOR ASPWFIC PURPOSE ANO USE AND THEREFOREARE NOT DIMNOEO TO GUIDETHE E RECTIONOF FENCES.RETAMNOwaM POOLS, PIANIDIGAREAS.WDNGS,BULMOADOMONS AND CONSTRUCTION OF ANYMER WROVEMEMM ® 2 Rn 2 MNOEnG OUND.ovEwFADAwGRaw+DervEaummESARLWoWGUAnANTEmAS A000RACY.ErACTUXATIM, IS �Yf LSDtTPE OR uEEAcVENPN:AnDN u MANDATORYWTMMUtOCFALAGENOESAND.ORPUBUCORPRIVATE MM COMPAMM MM TD 0DWMLCTKW .=ROEO EASE]ENFS ORRp F.NfSOWAY,IF ANY. AR ANT.NOTSHOWE NOT C(31TDTFD APR 0 a 2022 G TEAoN oNT»A =OF � sTWTEW8rORwwIABUILDING EuuEOTnmwumob TOWN OF SOUTHOLD BE CONSI"LLREDTO0EA VALID TRUECOPY GUARANTEES INDRAIF IRE=SHAU.RUNONLYTO THE PERSONFOR WHOM THE MAP 6 PREPARED.NW ON THEIR BEHAU'TO THE TRLE rdtPIVG'.DOYERHMENTALAGETW MA MOM P1lMgo.4U$IEDFMON.ANDTOT"EASVCNEESOFTNELEMMWZTRU"ON GUARANTEESARENOT TRAICiFrtARTE TDADornotMNSn1UIg DRSUBSEOVENTDYOIpt4 ._ ALL PIDFrTS RESERYE011D VART Of na90RAu7FM WY BE RFPRGDIJCfDBYP1IOTOCOVGND,RCOORDMMORDY ANY - _ OTHER YEAN3:OR STORED.PROCESSED OR TMNSErI1TEDUr OiIBYAIfl'CCIZQUIEROROTNERDYSTEMWIT"OUT T"E _ - -�'TNIS MAP WAS PREPARED FOR YUNICIPALRIPPO$ES ONLY. PRIOR WRrrrM PERMISSID)GFTNE SURVEYOR. ANY OTHER USE SUCN ASOONVETND.INSURN0.AND 7PANSFERRNO MLE IS NOT AUD/OR= NOR GUARANTEED BY THE SURVEYOR SCTM:DISTRICT 1000 SECTION 78 BLOCK 1 LOT 38 DATE:MAY 16,2021 �0� NE'"r0 SURVEY OF PROPERTY pLAN Ao .Q AS DESCRIBED IN o DEED LIBER 12817; r y PAGE 253 05 03 ,4Q SITUATED AT SOUTHOLD Tr�+EwA.8 ST,PLS TOWN OF SOUTHOLD, SUFFOLK COUNTY, NEW YORK. 2LESTER AVENUE PATELStB-315.9977 72 JOB N0.21021 SCALE:1"=40' SHEET; 1 OF 1 AT SETl QD vj cly �OP'G �0�5 01 �`5 k� y ti S CLFE Sg3 15: ` SET O,T E. " 47.86 3 S ;E 1set.o 3* PVCFE 3 gTOCKADE CO ETE2.r IL F O �fj 1 er'Cf- .1'N. 1 Dsw. �q D❑ r�X17, ( LL. FRAME 0 SHED. N 60 CIA,/,�IL�9 ��� � ; o U. U T, c,0 :a o o.,it. ou MASONRY PLAT J. Z W 22,T \ z W-m :srNTHiEnc 11 SCREENED' O:S AND PS Z Z z O L,> S CLFE WILLl _ M t0 0 .� o W IJI ON LINE' •, 1t0: GATE EJW4 ea fff . 8a - ' CLFE } Z' PROPANE Z STORY �• • -- _ 6 METAL FENCE D.B W. TANK c� 7 PVCFE U ,CD FRA +fE Z_X I DWELLING CECELLAR o.sE 40 N01-275 tsx C) d_w ...1 Q^ i3)ACLtNTfS ZNDSTY. UJ . J f" ONCOIICRETE OVER m L7 ' O, 41.6' 13• ONRY �+ � ` �S., O 48.0' W r' W WDFE BrrmI!NQUS r: T•-- _ ONLINE' MASONRY 'IIAI PAVEMENT a EJW..' WI tAMONRY LA^4` Z- I `f ! EDGE .7. T- a"� -�- - -r ram-°-• - - g - -_ •T FWFE- P0II4T OF BEGINNING-\ WATERL. CONCRETE, 200. 'nPE , METER ELE EL bJ ONUMENT ST6 080 E. 40' FourlD FOUND 'APRON' N76608'.50"W. 165. '' SLEEPY H LL+0�W, LANE NOTES: (50' PRIVATE ROAD) LOT A4A--40.QU SF,Io=AC.. TrrLE REPORT NOT PROVIDED FOR PREPARATION of SURVEY. , THE OFFSETS(OR 011tE11S10NSl'SHOWN HEREON FROM.THIE STitUCTURESTO THE PROPERTY LINES ARE FORA SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES,RETAINING WALLS,POOLS; pLaNTMG AREAS.,W,LOINGS.BURRING ADDITIONS AND CONSTRUCTION OF ANY OTHER IMPROVEMENTS. R I7 UNOERGROUND.OVERNEADND.A GROUND.LEVEL UTILITIES ARE NOT GUARANTEED AS TO ACCURACY,D ACT LOCANON: 11vwJ TYPE OR USE.'ACTTYE OR NIACTIVE.VERIFICATION IS MANDATORY WITH MUNWALAGENGESANMR PUBLIC OR PRIVATE UTILITY COMPANIES PRIOR TO commmTHM., -, APR 0 5 2022 RECORDED EJL ME n.%OR RIGHMOr-WAY,IF ANY,NOT SHOWN.ARE NOT CERTIFIED, uKkUTHdRUEDALTERAn6N'ORADDMONTOTHlSW1APiSA066kTIOHO sECTIONT30DbF`Tti6iEh YORKSTATE:., BUILDING DEPT. EDUCATION LAW.COPIES OF THIS MAP NOT BEARING ND THE LA SURVEYORS WISED SEAL OR ElAXWEDSEAL'SHALL NOT TOWN OF SOUTHOLD SE CONSIDERED TO BEA VALID,TRUE COPY.GUARANTEES INDICATED HEREON'SHALL RUN ONLYTO THE PERSOPI FOR:. wHOM,THEMAPIS.PREPARED.-AND ONTHEIR.SEHALF•TO7HE:Tff E PiAPANV.GOVERNMENTALAGENCYANDLENDRIG ,B1STMn nON USTED HEREON;AND TOTHE ASSIGNEES'OF THE,LENDING INSTMMOM GUARANTEES:ARE NOT TRANSFERABLE M ADOMONAL W STRUTIONS OR SUBSEQUENT OWNERS,. _. . t_ RIOHTS RESERVED.NO VAw-OF-Im ORAvmG MAY DE REPRO-M)CED BY PHOTSIOOp!ANO-PECORDING-OR DY.AN�_= •_OTHER MEMP5-OR STORED PROCESSED OR TRANSMITTED IN OR S ANY WbiPLITER OR OTHER SYSTEM WITHOUT THE •THIS PAARWAS PREPARED FOR MOMCIPAL P<iRPOSES OkLy, PRIOR WRITTEN PERMISSION OF-THE SURVEYOR ANY OTHER USE,SUCH AS CONVEYING,iNSUR1NG AND TRANSFERRING TITLE;IS NOT AUTHORED NOR GUARANTEED BY THE SURVEYOR SC TM: DISTRICT` 000 SECTION 78 BLOCK 1 :LOT:38' DATE:MAY 'i.6, 2021 � N E Q 'l l RVU EY 0"F P P ERTY ,pN AS.DESCRIBED IN co D EE D Ll BE 1� 2817 ci PAGE 2.53 as a3 SITUATED AT i SOUTHOLD' TTHEW.A: BORST, PLs "TOWN Op SO:UTHOLD, SUFFOLK,.00UNTY; NEW YO,W 2 LESTER AVENUE PATCHQ'GUE, NY 11772 TE:.516-31.5:9977 JOB NO: 2'102,1 SCALE: '� 40' SHEET: 1-0F ') f A�R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 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). ONTACT Nicholas Zulkofske PRODUCER NC Brookhaven Agency,Inc. PHONE 631 941-4113 FAX 631 941-4405 100 Oakland Ave,Ste 1 EAI -ML certificates brookhavena 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 INSURERC: 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 POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1 000 000 A CLAIMS-MADE X OCCUR DAMAGE TO RENTED $1 OO 000 x Contractual Liability X X PHPK2385555 02/28/2022 02/28/2023 MED EXP An oneperson) $5 000 PERSONAL&ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2 000 000 POLICY X�PRO- POLICY LOC PRODUCTS-COMP/OP AGG $2 OOO OOO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea ancirlent) $5OO OOO B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS X X CAP9267113 07/12/2021 07/12/2022 BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS%LIABILITYTIIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $10O 000 C OFFICER/MEMBER EXCLUDED? ❑Y N/A WWC3528513 05/13/2021 05/13/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold is included as additional insured 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 Y RK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-996-4687 Patricks Pools Inc PO Box 3024 1 c.NYS Unemployment Insurance Employer Registration 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 certain 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 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold NY 11971 WWC3528513 3c.Policy effective period 05/13/2021 to 05/13/2022 3d.The Proprietor,Partners or Executive Officers.pro Included.(Only check box if all partners/officers included) Q 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"1a"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,yntil the policy expiration date listed In box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Nicholas Zulkofske (Print name of avu4illzed representative or licensed agent of insurance carrier) 1 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-106.2 (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 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. C-105.2(9-17) REVERSE SNTA Ew I Workers' CERTIFICATE OF INSURANCE COVERAGE TE 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 PO BOX 3024 EAST QUOGUE,NY 11942 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required irco erage is specifically Ilmiled to certain locations in New York State,i.e.,Wrap-U, Policy) 262929943 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate He Ider) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd. 3b.Policy Number of Entity Listed in Box 1a" PO Box 1179 DBL318565 Southold,NY 11971 3c.Policy effective period 05/13/2020 to 05/12/2022 4. Policy provides the following benefits: a A.Both disability and paid family Ic ave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: X❑ A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. rj B.Only the following class or class as of employer's employees: Under penalty of perjury,I certify that I am 3n authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Fai lily Leave Benefits insurance coverage as de scribed 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;ire checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance.kgent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 513 i 3 checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F 3mily 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/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 Authorised NYS Worker'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licen.ed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are autt prized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issue this form. DB_120.1 (10-17) IIIIIIP!uiio1o2i0ai1iiii(i10mi17)Ey01D1 APPROVED AS NOTED OCCUPANCY OR DATE:9—& g,p.# 9-9 USE IS UNLAWFUL FEE: $ 3ev- ,0i)BY: WITHOUT CERTIFICATE NOTIFY BUILDING DEPARTMENT AT OF OCCUPANCY 765-1802 8 AM TO 4 PM FOR.THE FOLLOWING INSPECTIONS: 1. FOUNDATION -TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4.-FINAL.= CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE 'COMPLY WITH ALL,'CQDcS OF REQUIREMENTS OF THE CODES.OF NEW ;NEW YORK STATE & TOWN CODES YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. AS REQUIR D AND.CONDITIONS OF SdbOLD TOWNiBA 8,00OLD TOWN PLANNING BOARD SOUIHOLD TOWN TRUSTEES "IMRIHEPATELY MY:s.DEG E40L6SE POOL TO CODE:' :UPON.d0MP,LETION tt!701111 EI MMIGL OWK. ON REQUlM RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. _77 I Ifib` i I ! ( I I 1 1 4 I I I I ! 1 I P_ __. I _ I-_ Ieqv � i;. 4 ""1 —J— n�lhl n in VaFns I B ILDI qG EjEPT. '0 QE SOUTHO L D_ Mlq e ct U4. 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