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HomeMy WebLinkAbout50129-Z �4g11FFal�cp Town of Southold 7/8/2024 ao Gym P.O.Box 1179 o _ 53095 Main Rd y o� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45335 Date: 7/8/2024 THIS CERTIFIES that the building HOT TUB Location of Property: ' 560 Fawn Ln, Cutchogue SCTM#: 473889 Sec/Block/Lot: 103.4-29 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/22/2023 pursuant to which Building Permit No. 50129 dated 12/14/2023 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 hot tub as applied for The certificate is issued to Gordon,Paul&Shui Man of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50129 5/22/2024 PLUMBERS CERTIFICATION DATED fik ho ' e Signature �O�gUFFOI,��o TOWN OF SOUTHOLD ay 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) / r Permit#: 50129 Date: 12/14/2023 Permission is hereby granted to: Zoumas, loannis 2050 N Country Rd Wading River, NY 11792 To: Install an accessory hot tub to an existing single-family dwelling as applied for per manufacturers specifications. Must have a minimum setback of 5' from lot lines. At premises located at: 560 Fawn Ln, Cutchogue SCTM #473889 Sec/Block/Lot# 103.-4-29 Pursuant to application dated 11/22/2023 and approved by the Building Inspector. To expire on 6/1412025. Fees: ACCESSORY $300.00 CO-RESIDENTIAL $100.00 Total: $400.00 Building Inspector SO!/�yQl Town Hall Annex . Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q -�► • �o sean.devlinO-town.southold.ny.us Southold,NY 11971-0959 Q couffm BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: loannls Zoumas Address: 560 Fawn Ln city:Cutchogue st: NY zip: 11935 Building Permit#: 50129 Section: 103 Block: 4 Lot: 29 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Prime Electric License No: 52402ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub X Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel ' A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect 50A Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 50A GFI Disconnect , Motor is Grounded Notes: Hot Tub Inspector Signature: Date: 5//22/24 S.Devlin-Cert Electrical Compliance Form rqjf so # # .TOWN OF SOUTHOLD. BUILDING DEPT. coum, 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR .]- 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: C� DATE INSPECTOR i hO�aOF SOUly�lo # TOWN OF SOUTHOLD BUILDING DEPT. comm, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ rSLATIOWCAULKING U FRAMING /STRAPPING [ NAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE JVYID01, INSPECTOR GELD INSPECTION REPORT DATE COMMENTS t� FOUNDATION (1ST) ----------------------------------- - FOUNDATION (2ND) Q z � o a ROUGH FRAMING& PLUMBING l r r� INSULATION PER N.Y. STATE ENERGY CODE l FINAL ADDITIONAL COMMENTS otcl1614430 etc s H _ � O x - x - _ d b . T }oOSOfFoIK�?oGr TOWN OF SOUTIiOLD —BUILDING DEPARTMENT y Town Hall Annex 54375 Main Road P. Or Box 1179 Southold,NY 11971-0959 am ab�� Telephone (631) 765-1802 Fax (631) 765-9502 https://ivww.sotittioldto,,viiny.gov '�>nOP - For Office Use Only Date Received PERMIT NO. 15 O I a Building Inspector: �6 D Applications and forms must•be filled out in their entirety. Incomplete applications NON will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. �n�yd'eng�e���tment , LOIN' of aoJ'ho3d UI:� P -AT-1 Date: -fown� ;'. OPER r.•OWNE 'PR '•�.: i � Name: Tax Map#: SCfM#1000-)O3-4 . . -2� -4� . . ' . .. ... Physical Address: Phone 1 r- ®� Email: _. . Mailing Address: F-n i-CY)i% ,•l,.i L�r: E SON"r .:: '• `:.: .:,,• '°�: , Name: _... Mailing Address: Phone#: Email: p O ••J ESIG ..R F SS /AL.I T °s •,:: .N,� _';' .D '�P Q N NF M Name: Mailing Address: Phone#: Email: 7: 'GONTRAC' O ;INFORMATLON: `�:: �•. w, ��;�:::�••..! Nam.e: . .. .. .-_...t Y. ., .. ... .. .... .......... ...... ,..._. ...., _.. _.-_... Mailing Address: RD i� Phone#: Email: 1 Y 1 CTI ON 'I)ESCRI .TIO .OF�RR •�;�:-P _N '•74 r'7'"t G .r. ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other / — $ Z)C)Cc) Will the lot be re-graded? ❑Yes El No Will excess fill be removed from premises? ❑Yes El No PERTY..INFORMAT •N:;.:-;: 'sy?�•., 1.+. - ,f':,pR0 IO ',.;:. _ .%,.,'.,:. .1.1':1�r,•�i:Ya'ai•• r 1.n_ y Existing use of property: Intended use of property: Date of Purchase: Name of Former Owner: • 1 . Zone or use district in which premises is situated: Are there any coven is and restrictions with respect to this property? ❑Ye No IF YES, PROVIDE A COPY. heck 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): horized Agent ❑Owner Signature of Applicant: Da e: p STATE OF NEW YORK) SS: COUNTY OF ) —Kuvs� — —�—v- —r — being duly sworn, deposes and says that (s)he is the applicant (Name of indivi al signing contract) above named, I (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. Sworn before me this c'yy of No ary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) 1, 42w r 1 residing at9A-. r Qr k-11+ do hereby authorize ��7--- to apply on my behalf to the Town of Southold Building Department for approval as described herein. W+M jsr`G`� \�N\\nnlrirrrrri�i J/" / �',23 MILL/U Owner's atu e �` �' �'S' �� �� p�ARI ''• %� Date JJ �3 1g5-I 441.N GOP\F\( •' Print Owner's Name BUILDING DEPARTMENT- le trical Inspec r k TOWN OF SOU HAD pY 1 2 Town Hall Annex- 54375 Main ad - PO Box 1,1.7;9i(a4e� Southold, New York 11971�95.9t'° qz �;, ��'l ` . . Telephone (631) 765-1802 - FAX (63'i+-7t!=9502 jameshCab-southoldtownny.gov seandCc�southoldtownn rLclov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 5/8/2024 Company Name: prime electric Electrician's Name: michael, hunter - License No.: me-52402 Elec. email:mike@primeli.biz Elec. Phone No: 6313875650 El I request an email copy of Certificate of Compliance Elec. Address.: 1380 broadway ave hol brook ny 11741 JOB SITE INFORMATION (All Information Required) Name: Paul &jackie gordon Address: 560 fawn lane cutchouge 11935 Cross Street: Phone No.: 6313875650 Bldg.Permit#:497i5t 50�-2.R email:mike@primeli.biz Tax Map District: 1000 Section: Block: , Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE,FOOTAGE (Please Print Clearly): need inspection on hot tub Square Footage: Circle All That Apply: ---- - - - - Is job ready for inspection?: 0 YES ONO ❑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 # Underground Laterals 1 F2 H Frame D Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION ' -SUBJECT .TO, CO�fENANTS: AND. :,RESTRfCTIQ�IS, SIJBDIVISION.11rtAP E)F I AS ,PER, LTBER 7.425, ,PAGE :t78 TASTE NOT' LISTED ON FILE MAP :_NOR, :IN ;DEED). MC)Q COVE AT T�:CUTCHC�GUE F1LED AUGUST'3U,:.196Q.A$..MAP:IVO::32'3r7 i rSTTUATE•AT o. : -cuTcxoGUE FA`:I N L�4I IE (50 SLTFF0LK C6A�.o�sou�)i.I ;NEW"YoR AREA: 4F PARCEL 1:$ 9... ,si „FT: OR Q:;459f ,ACRE :PAllEN.ENr'... - s .EEGEND `KYrl11'-, -. ,. r.::;'. ,rCl7NIF6RIlUS SFtRI13'. __..;N I _ BM=2t5d ' � E7'ER .1 ..- ,��: i w: ;tnzs:• - • ..;:'SPO.T EL'EVAII©N, '•�' I �!- � t!t1� � :'-tYI1PD1Iil�idEY;L. :..AIR`'CONDITI�fJE4 ..:_OVE.HEAD f✓IRES= �.: I ,,p -3, ;FF•fL:• . - � Fr7?ST FLODf?-.ECEV%xTIDN' GF £G.d ,:GARAGc,FLDGR.ELEC/A11L71J, - I .. M NOTES _ f j ww! 1tLDF'l7VE?HA;VG;: _ L, 1. hfFASUREhfENTS 4REtNACCORDANCE:WITH,U.'S.STANDARDS 9 F'- 0 48 4'� ' �`-R f — 2.. 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",irt, :/iL'GE ems••' : .. _ _ _ --. .. ..,.-. .:.... .,....., x PIPE ,� '�"+`�` t , - ANYERSEM_ENTS;:CONOITIONS QR ENCUMBRANCESAN UPDRTE!},F1TLE SEARCHA WY �' l s REVEAL PIN'' a3 N - 7 0 �nN. I S' 2,30 W 2QQ+00 CAP' cettltirations zTC S. ;2PN' O{DATB ._,. 3 '.T:L.S:: tt`ddei7 ION LQT 52 CERTIFIED TO. 1._�1lnencanHimes.TftleAgency,LLC �, � Sj �e T.o_.tvn. of. .SauthoId :y a �! 2.41d Repub7ic'Naffonaf Trfie lrtsuranCq Company ,ti' , t�� 't' I� Suffolk County,--Ne�+r - � ;�,haul Gorclori an_d.Shu1 Man Gonion : #, �! _ ' -.y= -.*• 560:"Fawn• Laae I :4:TD:Bank,:N.A. I - i �� Cu -Y tcIo •v:e, 1\tew' or1� I .. 'I I I I AS-BUILT SANITARY. PROPERTY TAX MAP A FROM OWNERS Of.BUILDING l hereby Ceialfy'.hat this map was made from:8t}abfaal Survey SUFFOL1c COUNTY REAL DISTANCES FR c COmpleted,byme on 09/2212022. L . K. MoLEAN .ASSOP. DISTRICT MOO ! � C: A ' B _ Q�52�. .. o CONSULTING.ENGINEER§ d�i.-- YQRS SECTION'103.00 ST 24' 20.5' .CENTER OF Jrd,COVER 437,SO. COTJNTRY'R01D.:•BROOKHAVEN: NE1P'.YORI{ f BLOCK .64.00 69 31.5' '24' CENTER OF:SMUCNRE Q�dfk�l*i�.. :!` Surf rd'Bg'J.t✓J.P.L .. :Seder' .}'^ 20' Shwt'Po. LQT 029.000 :L? 35.5` 20' CENTER_OF COVER '... - - - ..- - . .. IAMARAC.STILLMAN_P.LS. u,•ar,;err' _BX._ oat�•s�ote,+be�:a�2oza. :�' : . NYSPLS No..50528 1 S:\Shared With WIRroject's\21185A00'560 Fa,rn Lane, Cutchogue\Survey AepttfTrarings\21185000 Final as bjfxfl g 5/25/2023 19 AM T4,,, ea-s-Nlnan Approrea err'TLS FJe Ho. P1185000 vTAT workers' :CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrieii 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM_ KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A. ROCKY POINT, NY 11778 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 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 71a" P.O. Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. E] C.Paid family leave benefits•only. 5. Policy covers: . © A.All of the 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 11/7/2023' 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 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 emailed to'PAU@wcb.ny.gov or it can be.mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board,(only if Box 413,4C or 5B have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Pie ase 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 DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) �IIIIIPiiiiiii1ii2i0iii1iiiiu1ieiui2i1oiil�l�l SNEw workers' CERTIFICATE OF INSURANCE COVERAGE TATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A ROCKY POINT, NY 11778 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 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"1 a" P.O. Box 1179 DBL37154 - SOuthold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 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 11/7/2023 By wid 1/ f (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 413,4C or 513 is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 46,4C or 5B have been checked) State of New York Workers' Compensation Board; According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and,Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their 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 DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 111111°1°1°°°°1°°°°1°°�1°°I�I�I Workers' PORK 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)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Rocky Point,NY 11778 Insured i 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 11 3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest National Ins Co, Town of Southold 3b.Policy Number of Entity Listed in Box"la" 53095 Rt.25 SW5WC00205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 to 11/05/2024 3d.The Proprietor,Partners or Executive Officers are ❑X 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"T'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 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 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: Philip Colletta (Print name of authorizedrepresentative or licensed agent of insurance carrier) Approved by: �U"t - 11/03/2023 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 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) y9 www.wcb.n ov I i ORK Workers'. CERTIFICATE OF STATE Compensation NYS WORKERS' .COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (631)744-8100 I: i Fence King of Rocky Point,Inc.,DBA Swim Kings Pools&Patios 1c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Insured Rocky Point,NY 11778 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 11 3092960 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity.Being Listed as the Certificate Holder) Everest National Ins Col Town of Southold 3b.Policy Number of Entity Listed in Box"la" 53095 Rt.25 Sw5WC00205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 l to "11/05/2024. i 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Onlylcheck 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"I 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]F 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 belsent 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 thisl form,if the business continues to be named on a permiti 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: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 11/03/2023 (Signature) (Date) Title: President j Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 l 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) ' i www.wcb.ny:gov 'Rom APPROVED AS NOTED DATE: a1 3 B.P.# 5 I . .�. . A DO•d BY: COMPLY WITH ALL CODES OF VORK &TOWN CODE NOTIFY BUILDING DEPARTMENT AT N R QUIR DTATE AND CONDITIONS OF 631-765-1802 8AM TO 4PM FOR THE SOUmT=Zm FOLLOWING INSPECTIONS: FOUNDATION-TWO REQUIRED $OIIiNOlDTOWN pIANNING BOARD FOR POURED CONCRETE SOUiiIOL =NTRUSTEES ROUGH-FRAMING&PLUMBING NX3.DEC INSULATION SDAW HFC FINAL-CONSTRUCTION MUST DD BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS ELECTRICAL INSPECTION REQUIRED All exterior lighting installed,replaced or repaired shall conform to chapter 172 OCCUPANCY OR of the Town Code USE IS UN LAWLFU L WITHOUT CERTIFICATE OF OCCUPANCY ST11 Island a +" nasY;•!�A=�-fix'. �sGwT^iwE.,. yc+w.=:'_'a,..y'y3�".=:?mac.* _—„':"-';' _ ti _ _ _ Te Double, fir . na' _ --,The, Barbados Ives ou' le- g _y nt of reasons to'�relaz: With multi'le 3]', 14 jet arrangements, two loungers and open':barrier seating this'spa is designed for you and your guest to•lounge back and enjoy'_a,soothing.- yet powerful hydrotherapy experience. 7-7 >_ t µ.*i - -^•� �'�.� - �h'" - �mow'' '''' - �`� �+r� 6� �p ._..:,,,,::.n..� - 7 - '- , t n.,ff, 'J! :.,e.y e..^' ..` H.+_,".rw •. �� ,h�1' _ '.^t`m`' [� C)16�;,. ,'`•', - so MV two ' � I '.*°: ~�h:�'.,'V✓...,- `•�^ �y��,:�i ,�v'- "'.'�'.�•t.. "-_"�"t�, �`4`.. __ _- _••tiny _ ^�?'0.-,� .. ^`"""w;o; - � . r- 4 --�� •;���_--n.��.:, _'tip'=�' _ s�:'• •� � ,:;�'.. --� %_` mc . -narbados 91 in. x 91 in. x 36 in. 231 cm x 231 cm x 91 cm L Seating Capacity 5 61 Jets I Acrylic:White Pearl