Loading...
HomeMy WebLinkAbout50353-Z og�FFOi,rcoG Town of Southold 7/25/2024 P.O.Box 1179 o _ _ 53095 Main Rd y o�d Southold,New York 11971 viol- �a. CERTIFICATE OF OCCUPANCY No: 45396 Date: 7/25/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 45805 Route 25, Southold SCTM#: 473889 Sec/Block/Lot: 75.-2-14 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/18/2022 pursuant to which Building Permit No. 50353 dated 2/20/2024 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. The certificate is issued to Sona LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50353 8/24/2023 PLUMBERS CERTIFICATION DATED 0 u on Signature gQFFat/( TOWN OF SOUTHOLD �oo� cOay BUILDING DEPARTMENT y TOWN CLERK'S OFFICE "oy • 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#: 50353 Date: 2/20/2024 Permission is hereby granted to: Morrissey, James 2333 Schermerhorn St Ph 54L Brooklyn, NY 11217 To: replaces bp#47478 construct accessory in-ground swimming pool as applied for. At premises located at: 45805 Route 25, Southold SCTM #473889 Sec/Block/Lot# 75.-2-14 Pursuant to application dated 1/18/2022 and approved by the Building Inspector. To expire on 8/21/2025. Fees: PERMIT RENEWAL $200.00 Total: $200.00 Building Inspector g�FF01 c TOWN OF SOUTHOLD �o� gay 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#: 47478 Date: 2/23/2022 Permission is hereby granted to: Gorman, William PO BOX 1447 Mattituck, NY 11952 To: construct accessory in-ground swimming pool as applied for. At premises located at: 45805 Route 25, Southold SCTM #473889 Sec/Block/Lot# 75.-2-14 Pursuant to application dated 1/18/2022 and approved by the Building Inspector. To expire on 8/25/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Bui din pector oF so�ryol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.deviin(aD-town.southold.ny.us Southold,NY 11971-0959 �Q�y COU BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: James Morrissey Address: 45805 Route 25 City,Southold St: NY zip: 11971 Building Permit#: 47478 Section: 75 Block: 2 Lot: 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: LC Electric License No: 38043ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Intermatic Pool Panel 10 Circuit/ 3 Used, Salt Generator, Pump 220GFI, Heater, 1 Light 120GFI, Bond Integrity Test Notes: "AS BUILT NO VISUAL DEFECTS " POOL Inspector Signature: Date: August 24, 2023 S.Devlin-Cert Electrical Compliance Form East;End InsRection-Agency,"LLC =' pO�. Boz:35EE 'l -East Q4ggue,New Y6tk, 11942 ,594-�272 Fasi•(fi3 , East,End [ns ect:ian A• enc ' offfce�@eaisfendinspectic►nagency:cvon A..�:. -.:� 9..-�. :Y { CERTIFICATE OP ELeCTRICAL.•COMPLIANCE 'his_Cectificate'of.Cornpliencc is llmited to-the ihspEctioii and campliance;of electrical;equipnt'ent aritllo�work desci ed:beloW, Instalidd bythe appli'-'rt-and fiotafterthe.flnal,inspection.date4sted; M1C mate. Ast,2�t Owner Gorman ugu Address, 45805 Main Rd' � C;ei til i60e No: .23a737' 7„ Southold',NY, r Location of;F�raoer#v iris'0ected' .45$05 Main Rd:SQUtl2otd Mew York- '-DW Section; 75, Block:-2 t t. 14 Permit Number -NIA <y: [Xj Electrical Survey [X].Residential [X]Swimri7ing Pal_ [X-Bond 1nteg0 ty 'test using-.a cable locator GFCi Receptacles-1 4-C6riiers 96rided Swimming.Pool--1-ingrouhd Tempo 501,Cable-locator, Time Clock-l-20 Amp .04 Ohms of Grounding Resistance 5witcfire5- 1 GFCI Breakers-.2• Pao!Pumps-1 1hp .00-Ohms f 0rounding :Special Rec.= 1-20,Amp Pooh l -2 low voltage Date of Rouging Inspection; Date ofFinal Inspection:- Y9 023 Certificate fnr•Cbde'Compliance Only, Not intended-for the Certificate;of Occupancy Prot ess The electrical work'anct./or equipPn®nt descriiz®d:above.were inspected-and appear to be in compliance with local, state:.-arid riattanal'elecIndal code requirements at'the time of inspection: Installer:LC Electrical Contracting Llcenseftmlagr: 180443' 22 Woodbine La: East Moriches, ICY 11.940 Electrical Inspector. Edward Seltenreich -�i'` Of SO(/l - -7 L-4 5 -- - # # TOWN OF SOUTHOLD BUILDING DEPT. Iy�OUNi1 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: a4 c fI C LA4 , MzaQ J--& -s-gg DATE INSPECTOR Jeffrey Sands Architect June 6 , 2022 EQ°pC I V E JUL ' 9 2024 Property/swimming pool location: James Morrissey IQ.tAtmi"Department 45805 Main Road NY route 25 Town,of Southold Southold, NY RE: Swimming pool rebar and drywell 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, 02 720 � �Q Jeffrey Sands Architect 6 Evergreen Lane, East Quogue, New York 11942 phone-631-375-5997, fax, 631-576-8916 email—Jeffrey sands _hotmail.com Pontino, Susan From: BILL GORMAN <neweng land barns@aol.com> Sent: Tuesday, July 9, 2024 11:08 AM To: Pontino, Susan Subject: "4 pool fence inspection r�s doh n 5-0 ,553 P tl� ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. . s v JUL ' 8 2024 x # ' Building Department Town of Southold , P 1 } ' S �r ♦, r.. 4 • _i ^ F 1 s ;ar,�. +fin,• WIL - •r , � ,,' �,��� y ,tip, :�, � �,� ���'" :,� Buil • Town of Southold w if .yc t 14 � Sent from my Whone J U L - 8 2024 Building Department Town of Southold 6 -� OE SOUlyolo * # TOWN OF SOUTHOLD BUILDING. DEPT. coum, 631-765-1802 O� INSPECTION ' [ ] FOUNDATION 1 ST/ REBAR" [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ S.ULATION/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: P✓ v [ -WVk-,l i9n DATE &P 0 INSPECTOR FIELD-TNSPECT`ION REPQRT DATE GOhIMENTs • Cx! FOUNDATION(1ST) V- ---------------- FOUNDATION(ZND) .i` CA ,I ROUGH FRAMING& (� PLUMBING y . TNSL-LATION:PER N..Y. STATE ENERGY CODE, .FINAL. : .:: . 0 `� Li `,r �o�g FF0IKCOG TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O.Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631)765-9502 https://ww .southoldtgm=.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ® EC E � W E 'PERMFT NO. C Building Inspector: JAN 18 2072 Applications and farms must be filled out in their entirety:Incomplete BUILDING DEFT. applications will not be accepted Where the Applicant Is not the owner,an TOWN OF SOUTHOLD Owner's Authorization for m'(Page 2)shall,be completed. „ Date:1.14.22 OWNER(S)OF PROPERTY:, Name:Bill.Gorman ISCTM#1000-75-02-14 Project Address:45805 Main Rd. Southold Phone#:631-445-1461 Email:newenglandbarns@aaLcom -Mailing Address:PO Box 1447 Mattituck CONTACT PERSON: Name:Joan Chambers MailingAddress:PO Box 49 Southold NY 11971 Phone#:631-294-4241 Fa—i!-joanchambersi O@gmail- com DESIGN PROFESSIONAL INFORMATION; Name:Jeffrey Sands Mailing Address:East Quogue, New York., Phone#:631-375-5997. Email:lnfo@jsa-ny.com CONTRACTOR INFORMATION: Name:Patrick Pools Inc Mailing Address;PO Box 3024 East Quogue NY 11942 Phone#:631-903-7665 Email: DESCRIPTION OF PROPOSED CONSTRUCTION RNeuv Structure I]Addition 0Alteration DRepair ❑Demolition Estimated Cost of Project: QGther in-ground swimming pool&enclosure Will the lot be re-graded? ❑Yes BNo Will excess fill be removed from premises? IiYes DNo 1 t I ' .' 1. 'a, :, _ •. , PROPERTY INFORMATION" Existing use of property: Residence - Intended use of property:Residence Zane or use district in which premises is situated: Are there any covenants and restrictions with respect to AC this property? DYes BNo IF YES, PROVIDE A COPY. IQ Check,Box:After Reading: The owner/contractor/design professional is responsible far all drainage and storm'water Issues as provided by Chapter 236 of the Town Code.'APPUCATION IS HEREBY MADE to the Building Departmentlor the issuance of a Building Permit pursuant to the Building Zone �Ordinance'of the Town of Southold,Suffolk,County,New York and other appti�able taws,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 puntsha6le as a pass A mtsdemeanor,pursuarrt to Section 210.45 of the.New York State Penal taw. Application Submitted By(print name):Joan Chambers BAuthorized Agent ❑Owner Signature of Applicant: Date: _ IQ 101 STATE OF NEW YORK) SS: COUNTY OF 5U-Pfb l*- 1 JOan Chambers being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Ag a nt (Contracto ,Agent, orporate Officer,etc.) of said owner or owners,and is duly authorized to m 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 �h 1 day of r 0 ary Public TRACEY L. lj ER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW6306900 PROPERTY OWNER AUTHORIZATION QUALIFIED IN SUFFOLK COUNTY (Where the applicant is not the owner) OMISSION EXPIRES JUNE 30, I, Bill Gorman residing at 45805 Main Rd. Southold do hereby authorize Joan Chambers to apply on my behalf to the Town of Southold Building Department for approval as described herein. ae�6� 1 .14.2022 Owner's Signature Date -BI L�,L C-D Print Owner's Name 2 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr@southoldtownny.gov — seandasoutholdtownny.c ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: LC Electrical Contracting Inc Electrician's Name: Leonard Cancellire License No.: ME-38043 Elec. email:office@lcelectricalcontracting.com Elec. Phone No: 631-445-4482 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: Gorman Address: 45805 Route 25, Southold NY Cross Street: Phone No.: H Bldg.Permit #: 47478 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 'IN-GROUND POOL I 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 Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 R2 F1 H Frame M Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION to 110192 160 e-C-4 1 �29 5tr SURVEY OF PROPERTY - cplo ���P�- SITUATE v"�, SOUTHOLD EYAgD5 �10 TOWN OF SOUTHOLD kp SUFFOLK COUNTY, NEW YORK � S.C. TAX No. 1000-75-02-14 SNP METAL c I ��. N o SCALE 1 "=30' SHED FEB.RUARY 11 , 2008 s, rd NOVEMBER 18, 2008 ADDED PROP. ADDITION Id MAY 25, 2010 ADDED PROPOSED PARKING SPACES ti0 '' 4z APRIL 3, 2018 ADD PROPOSED ADDITIONS ca JUNE 22, 2018 ADD STORMWATER NOTES NOVEMBER 17, 2018 AS—BUILT SURVEY FOR ADDITION ,lpo N0 aA E.�}► ,, oi„ AREA 21,695 sq. ft. �F , J }' .. '� -r 0.498 cc.. .e► No \ \ 9 \ '4 .0-1 cz C IJ JAN 18 2022 DD BUILDING DEPT. �-�. ��f �'C` \. \\ OK��jSF.�,(�P� '' .;. o •. ,r. ��y TOWN;OF SOUTHOLD •X,��. - �+:, ;\ \ �• F���o st`�o ry o ��t' ate. �coa� ��A�� - • a0 s lb. .G Onq. Q. Z58 Eqp Q f �, - `t Gp .•: ' r PAIN ,NE ammm yt ` By THE c `,`� �,o ,. I _ •.•.... � � FOR /u�•-. TME NW QL S � ? Uc. No. 50467 UNAUIDIORIZED Fj9�'g$ TION OR ADDITION TO S5AA VIO 47M SECTION 77OD OF THE NEW VORIC STATE • E,x>GTION I.M. Nathan Taft Corwin III 5 COM OF TM SURVEY NAP NOT BE W �. THE`T SSE sM SHAUURVEYORS NOT BE%AL ORLand Surveyor ` TO BEA V"TRUE COPY. BE COId9DERE0 of Ot �HEWN SIMLL RUN 7 ON TMwE�P suavEY } 6 PR£PARiD,AND ON HIS BEHALF TO THE Sutxxsmr To: SEon�y J. Lsalaen,Jr.L.S. T11LE COMPANY,OOVERNMETCIAL AGENCY AND Jo 1 A.Ingegno LS. � T07W A OF W LENW R MTURON LISTED HEREON.�- TRIe Surreys-subdirtslorrs - Me Plane - CcnshucU-Layout TUnON.CEt11FIGATIONS ARE NOT 7PANSFERABIE PHONE (631)727-2090 Fax (631)727-1727 THE EIOSTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF OFFim LOCATED AT ATAILM ADDRESS ANY, NOT SHOWN ARE NOT OUARAHTEEO. 1566 Main Road P.O. Box 16 JamesporL Now Yak 11947 Jamesport, New York 11947 61 1 50' - - - - - - 00 „ E 18 2 . 10' - - - � I I SHED SHED a j GARAGE ON—GRADE PATIO ' 1 Z'-0" 36--0" -0" i i SEPTIC o PROPOSED ' LOCATION zo 3 6x 16 ' I IN-GROUND o SWIMMING POOL 01 ,r.. PROPOSED POOL ENCLOSURE ' I AS PER CODE co ! r- r I POOL I EQUIP. 2 11695 SQ. FT. NOTE: o MEETS & BOUNDS AND EXISTING I W STRUCTURES REFERENCED FROM SURVEY BY NATHAN CORWIN M I EXISTING 2 STORY FRAMED HOUSE EXISTING , 0 DATED FEBRUARY 11 , 2008 ACCESSORY 0 SCTM # 10 0 0 - 7 5 - 0 2 - 14 I STRUCTURE I Ln SITE PLAN FOR LOCATION OF POOL, 2: SITE ENCLOSURE AND POOL EQUIPMENT I � _ r__ ONLY I � ' I Cn MAIN HOUSE 1918 .5 SQ.FT. GRAVEL PARKING AREA I FRONT PORCH 161 . 9 & DRIVEWAY L _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J STORAGE BLD. 876 .04 I GARAGE 222 . 3 SHED 100.0 SHED 65.7 PROP. POOL . 571v TOTAL I 3��a a 39ab,4�38\,k 44 DIVIDED BY 21 , 695 X7 , l o 1 �7 . /o LOT COVERAGE I r I . - _ _ _ _ _ - _ _ _ _ - _ S 59 29 00 w 18 6 . 8 o PROPOSED SWIMMING POOL A/ & POOL ENCLOSURE 25 ) 45805 MAIN RD MAI N ROAD SmRm Y SOUTHOLD 1 /8 - 1 '- O" 12 . 7 . 2 1 EDAy, FEB 17 2022 F NEON y BUILDING DEPT TOWN OF SOUTHOLD ,{�Ntaw Worl<ers' YOItI< CERTIFICATE OF C—_. STATE Barr ensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE �-=� Boart! 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 East Quogue NY 11942 1 c.NYS Unemployment Insurance Employer Registration Number of , Insured Work Location of Insured(Only required it coverage is specifically limited to 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Molder) 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 are included.(Only check box if all partnerstofficers included) xC 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 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 No 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,t 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 a Ized representative or licensed agent of insurance carrier) Approved bI�A ( ature) (Date) Title:Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-941-4113 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov, Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connectior 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 YORK workers' CERTIFICATE OF INSURANCE COVERAGE STATE I 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 I 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 Mein 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: © A.All of the employer's employeeE eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or class?s 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 Fat illy Leave Benefits insurance coverage as described bove. Date Signed 3/1/2021 By (Wo G (Signature of insurance carrier's authorized representative or NYS Ucensed 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 5B i s checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid F smily Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Accept rose Unit,PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the r 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 Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers ficen:ed to write NYS disability and paid family leave benefits insurance policies and NYS licensed Insurance agents of(hose insurance carriers are auth prized to issue Form DB-f 20.f.Insurance brokers are NOT authorized to Issue this form. D13-120.1 (10-17) IIiIIIP1°°�1°2°0��'1°1uli1i0►ui17i�ilnlQl A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/10/2021 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). ME PRODUCER CONTACT Brookhaven Agency,Inc. PHONE 631 941-4113 1(AlFAX. 631 941-4405 100 Oakland Ave,Ste 1 EAI -ML , certificates@brookhavenagency.com Port Jefferson,NY 11777 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Philadelphia Indemnity,Insurance Co. INSURED INSURERB:Wesco Insurance Co. Patrick's Pools,Inc INSURER C: Merchants Mutual 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER DD1YYYY) (MMIDDrCYYYI LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE FXI OCCUR DAMAGE TO RENTED $100,000 x Contractual Liability X X PHPK2229439 02/28/2021 02/28/2022 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY Z PRO ❑LOC $2,000,000 OTHER: JECT PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $SOO,000 C X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X X CAP9267113 07/12/2020 07/12/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION AG $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY ANY - B OFFICER/MEMBER ER EXCLUDED?ECUTIVE N/A WWC3528613 05/13/2021 05/13/2022 E.L.EACH ACCIDENT $100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $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 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 64375 Main Rd. ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE <> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD APPROVED AS NOTED DATE: 3 S.P.# FEE: � BY: NOTIFY :BUILDING DEPARTMENT AT 765-1802�.:8 AM TO 4 PM FOR THE ELECTRICAL FOLLOWING INSPECTIONS: INSPECTION REQUIRED 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE. 2. .ROUGH FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRU"710N MUST BE COMPLETE l p, ALL CONSTRUCTI"t% SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. it w_. . C08E POOL TO CODE 'MON COMPLETION +81s-ORE-"WATER" COMPLY WITH ALL CODES OF s, NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SO IAA S SEES -N Y S DEr 0CCI RfANCY 0R USE lS- UNLAWFUL WITH, CERTIFICA OF OCCUPANCY ---------- 'kit- LDL a\ IE I 'r sjs-lo� em e��Q -Al I -T -4-JAN-11-8-2022i-I - ILDING EPT So 0-D-- VVI 42h -17 47% jvv CNI Lj IF MID E I floi,- E N-