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HomeMy WebLinkAbout50552-Z ��o��S�FF01Xc Town of Southold 9/23/2024 P.O.Box 1179 0 o 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45570 Date: 9/23/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1140 Park Ave,Mattituck SCTM#: 473889 Sec/Block/Lot: 123.-8-1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 7/10/2018 pursuant to which Building Permit No. 50552 dated 4/12/2024 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: "as built"accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to Stork,Ryan of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50552 5/15/2024 PLUMBERS CERTIFICATION DATED Autloriz d Signature o�SOFFo�,�� TOWN OF SOUTHOLD BUILDING DEPARTMENT y :z TOWN CLERK'S OFFICE VA 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#: 50552 Date: 4/12/2024 Permission is hereby granted to: Stork, Ryan 275 W 10th St Apt 5B New York, NY 10014 To: legalize "as built" accessory in-ground swimming pool as applied for. Additional certification may be required. Replaces BP#43M At premises located at: 1140 Park Ave, Mattituck SCTM # 473889 Sec/Block/Lot# 123.-8-1 Pursuant to application dated 7/10/2018 and approved by the Building Inspector. To expire on 10/1212025. Fees: PERMIT RENEWAL $325.00 Total: $325.00 Building Inspector 4r ' TOWN OF SOUTHOLD �a BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy . SOUTHOLD, NY BUILDING PERMIT t (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH"ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 42868 Date: 7/17/2018 Permission is hereby granted to: Stork, Ryan 55 E 52 St F 112 New York, NY 10055 To: legalize "as built" accessory in-ground swimming pool as applied for. Additional certification may be required. At premises located at: 1140 Park Ave., Mattituck SCTM # 473889 Sec/Block/Lot# 121-8-1 Pursuant to application dated 7/10/2018 and approved by the Building Inspector. To expire on 1/16/2020. Fees: AS BUILT - SWIMMING POOL $500.00 CO - SWIMMING POOL $50.00 Total: $550.00 B spector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957)non-conforming uses,or buildings and "pre-existing"land uses: 1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00, Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy- $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential $15.00, Commercial $15.00 Date. 21 0 /-s New Construction: Old or Pre-existing Building: (check one) Location of Property: 1 140 AU mLy_ nmrFITU6k, House No. Street Hamlet Owner or Owners of Property: ay At Suffolk County Tax Map No 1000, Section 2.�j Block of j Lot D I Subdivision ( O ! rJa-mowA PAak- Filed Map. 4150 Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: A)IA Underwriters Approval: Planning Board Approval:ln)1A Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 60100 Applicant Signature jf SOUryo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sea n.deviinAtown.south old.ny.us Southold,NY 11971-0959 0 �yDDUNT`I,Oc� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Ryan Stork Address: 1140 Park Ave city:Mattitck st: -NY zip: 11952 Building Permit#: 50552 Section: 123 Block: 8 Lot: 1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Wildwood Electric License No: 4836ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New 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 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 Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Aqualink 12 Circuit/ 12 Used, Pump 220GFI, Heater 220GFI, Salt Generator, (3) Lights 120GFI Notes: " AS BUILT NO VISUAL DEFECTS " POOL Inspector Signature: Date: May 15, 2024 S. Devlin-Cert Electrical Compliance Form OF SOOTyolo # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTIO N [ ] FOUNDATION 1ST [ ] ROUGH PLBG. 7s� [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING ( ] FINAL [ ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE 13 INSPECTOR f pF SOUlyolo o J ✓ Cgum,�� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG: [ ] FOUNDATION 2ND [ ] SULAT N [ ] L_ FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: w4�0vi- DATE INSPECTO NOF SOUIyO# G � � g T�&N O �THOLD BUILDI G DEPT. °`ycou 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ 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: DATE INSPECTOR / Uf SOUIyO� TOWN N O F SOU O TH LD BUILDING DEPT. 631-765-1802 INSPECTION ' [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [- ] FOUNDATION 2ND [ ] I SULATI WCAULKING [ ] FRAMING /STRAPPING [ FINAL [ ]' FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION ] "FIRE RESISTANT CONSTRUCTION [ j FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 4—mm�d 4-02 C. 19 DATE •�1 o� - INSPECTOR Jeffrey T. Butler, P.E., P.C. 206 Lincoln Street Riverhead, New York 11901 631-208-8850 Licensed Professional Engineer d _ September 4,2024 S E P 9 2024 BUILDING DEPT. Building Department TOWN OF SOUTHOLD Town of Southold 54375 Main Road Southold,NY 11971 RE: 1140 Park Avenue, Mattituck(Building Permit#50552) Stork Pool To Whom It May Concern, Please note the following concerning this application: • I had inspected the rebar for the swimming pool prior to the gunite being applied. This included all footings,floor and side walls. My inspection concluded that the rebar installation was consistent with the plans and the anticipated soil loads to be imposed on the side walls based on the soil conditions observed. Should you have any questions please do not hesitate to call. 'ncerely, 0�: NEW,_ T. �r Jeffrey . Butler P.E. 0 w ��< 073495 OA ROFESSIO r FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(1ST) UN H 'FOUNDATION (2ND) . l�C a ROUGH FRAMING& PLUMBING H INSULATION PER N.Y: H STATE ENERGY CODE A Le .. W+�- . Fvio FINAL oq ADDITIONAL COMMENTS �- o � 1- 1 00 1c ° y' 2• t 3 < rn 3 N z b H GOWN OF SOUTHOLD E BUILDING PERMIT APPLICATION CHECKLIST COWNHALL WILDING DEPARTMEN"�.'�:. Do you have or need the following,before applying? GOWN � Board of Health 'OUTHOLD,NY 11971 4 sets of Building Plans CEL: (631) 765-1802 Planning Board approval {AX: (631) 765-9502 ` Survey )outholdtownny.gov PERMIT NO. (j2 Check Septic Form N.Y.S.D.E.C. Trustees D [EC50V C.O.Application Flood Permitxamined ,j 0 D Single&Separate JUL 1 0 2018 Truss Identification Form Storm-Water Assessment Form , I I g BUR DING DEPT. Contact: kpproved 20 .( ,OWN OF '$OLD ' � Mail to ffloj,�, 2u jea )isapproved a/c 206 1Gl60 4)65`r. lt��f/ASS Phone:16�&) ,xpiration 20 Bui ' ector APPLICATION FOR BUILDING PERMIT Date lh ar e"- .�ff�', 20 . INSTRUCTIONS a. This application MUST be completely filled in by typewriter or hi ink and submitted to the Building Inspector with 4 ets of plans, accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or yeas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit hall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector ssues a Certificate of Occupancy. £Every building permit shall expire if the work authorized has not commenced within 12 months after the date of ssuance or has not been completed within 18 months from such date. If no zoning amendments or'other regulations affecting the )roperty have been enacted'in the interim,the Building Inspector may authorize, in writing,the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the 3uilding Zone Ordinance of the Town of Southold, Suffolk County,New York, and other applicable Laws, Ordinances or Zegulations,for the construction of buildings, additions, or 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 for necessary inspections. (Signature of applicant or name,if a corporation) aob t ISO Al ; a11,f��t ffi. ,W ))9_01 (Mailinj address of applicant) State whether applicant is owner.Alessee, agent, architect, engineer, general contractor, electrician,plumber or builder -game of owner of premises A; (As on the tax roll or latest deed) [f applicant is a corporation, signature of duly authorized officer . a (Name and title-of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of 1 don which proposed work will be done: - 0 PNkAW;PjL- -nTu b, House Number Street County Tax Map No. 1000 Section 9s ' . Bl`o`''cl '" ' : � y Lot Subdivision t A/U<- Filed Map No. Lot 2. State existing use and occupancy of premises and is ended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy !:�;f- 5)0EAL, 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal o2i#ic r 'F� %,�.)Ofhef ork� � �j-�J y i (Description) i0 4. Estimated Cost '�(� D �� � ¢ Fee 6f;la �1 0 r L c ( o be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor �r� If garage, number of cars j _ �Wy,�uu.:'Rl•'�t � ',c. sS.aA' 6. �If business, commercial or mixed occupancy, spe,cify nature and extent of each type of use. A))A 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height `Number of Stories i 9. Size of lot: Front 2 , ��6 ar-11,27, r Depth 10. Date of Purchase ` �'� 9 Name of Former Owner Vie✓ d1���1? z 11. Zone or use district in which premises are situated )�z Li o 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 1--' 13. Will lot be re-graded? YES NO VWill excess fill be removed from premises? YES NO 55 E, 52"'"'ST. 12- 14. Names of Owner of premises —114A) � Address c Phone NoCZ12 a81 o S3D0 Name of Architec Address b N s Phone Nod,")Zo8-SSSo Name of Contracto Address Phone No.[6S1 53-&yg 3u2G, A41 f 196v 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES vl"NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES ✓ NO * IF YES,D.E.C. PERMITS MAY BE REQUIRED. r 16. Provide survey,to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or'below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO_Ae!-:�- * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF51694L MELu5gm bAn being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)He is the1IT (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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this z Z day of Z f it _ f Tara E Farrell Notary.Public,State of Neuir Y Suffolk County No.01 F Notary Public commission Expires Juiy 18, o •='Signature of Applicant OWNER AUTHORIZATION I I residing at 97' P NV I OD (Owner of Property) (Owner's Current Mailing Address! %l d —5 3a'D ,owner of the property-located-at 1 1 9 O fA K A"E .. (Ow nees Telephone Number) (Property Address). 6 /8j: {'iC-k, . /V .SCTM No.. Z a V —01 (Property A dress) f 2 give permission for j_ts . RAA 1 _,located at 2.t 6 L(/► ,P)L-J GT` (Agent) (Address) VEtU 'F—AD A U, POL to file for a building permit on my behalf. (A ) i AIGNATURIVFPRO ERTY OWNER Sworn to before a this, day of 0� t. NOTARY PUBLIC CORA ANN PEZZELLO Notary Public,State of New YA No.olPE6251234 Qualified in Queens County Commission Expires November 14 w CONSENT TO INSPECTION the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersi ned(is) (are)the owner(s) of the premises in the Town of Southold, located at l Tyu�. �T)' which is shown and designated on the Suffolk County Tax Map as District 1600, Section 2 3,Block 0, Lot D That the undersigned(has) (have)filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: P�rzC That the undersigned do(es)hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property,including any and all buildings located thereon,to conduct such inspections as they may deem necessary with respect to the aforesaid application,including inspections to determine that said premises comply with all of the laws, ordinances,rules and regulations of the Town of Southold. The undersigned,in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances,rules or regulations of the Town of Southold. Dated: igna e) (Print Name) (Signature) (Print Name) New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40-SUNY,Stony Brook, New York 11790-2356 Phone: (631)444-0365 • FAX: (631)444-0360 Website:www.dec.state.ny.us Denise M.Sheehan Commissioner LETTER OF NON JURISDICTION TIDAL WETLANDS ACT November 6,2006 Jack Farnsworth P.O. Box 397 �`Mattituck,NY 11952 `Re: Application#1-4738-03633/00001 Farnsworth Property, 1140 Park Avenue,Mattituck, Southold 11952 SCTM# 1000-123-08-01 Dear Mr. Farnsworth: Based on the information you have submitted the Department of Environmental Conservation has determined that the property landward of the pre-existing bulkhead and gazebo, as shown on the historical survey prepared by Van Tuyl&Son dated June 2, 1970, is beyond Tidal Wetlands Act(Article 25)jurisdiction. Therefore,in accordance with the current Tidal Wetlands Land Use Regulations(6NYCRR Part 661)no permit is required. Be advised, no construction,sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary;as indicated above,without a permit. It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Article 25 jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and your project(i.e. a 15'to 20'wide construction area)or erecting a temporary fence,barrier, or hale bay berm. Please note that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies or local municipalities. Sincerely, Mark Carrara Deputy Permit Administrator cc: Environmental East, Inc. BMHP file Scott A. Russell SUPERVISOR AMIA NA\(G IEMLENT SOUTHOLD TOWN HALL-P.O.Box 1179 Q 53095 Main Road-SOUTHOLD,NEWYORK 11971 Town of Southold CHAPTER 236 -. STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOS ')('1H[IS IPIROJ ECr INVOLVE ANY OF T)E3[]E FOLLOWING OWING 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. ❑13"13. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑[ C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. 00'a Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑0, E. Site preparation within the-one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑BT. 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. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. : 1000 Date: District NAME: 3 Section Block Lot 61g urel **** FOR BUILDING.DEPARTMENT USE ONLY **** Contact Information � ���) frelephone Numbed Reviewed By: _ - - - - - Date_ - - - _ — PI•operty Address/Location of Construction Work: — _ _ � O��g�, �S �� fl � Approved for processing Building Permit. !dt� Y�9 /1 Stormwater Management Control Plan Not Required. 1 -52— Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM SMCP-TOS MAY 2014 fdi,(co BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 �.y Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX(631) 765-9502 roger.ric hert(a?.town.southold.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: 9"PR PAssprNTrat) --I2 Date` (9-011- 1 8 Company Name: W I LDW oo-D ELUGT2VC- Name: PorSS 9 Nv SC- License No.: 4?36 email: f-0 h r (W—W ILDwO-ao E-LEC cuc. C2 r"- Address: . O . Gow Boo wfto1N� VZ.•vaar— NY. It-742. Phone No.: b 1- 9 2. 9- 1420 C 3i-,.3 G -as I ) JOB SITE INFORMATION: (All Information Required) Name: 621� Address: J j 4 v0 M 61►%Tv C- Cross Street: A4(Z R-r0bKA e0tz Phone No.: Bldg.Permit#: 2 2!c I 't` -� email: �a1pti Ic wljDwoo1� a t.r ,c .Gem Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK(Ple rint Clearly) � A cMm R2Af W TN LO-FT (3Oksi ?NGaCOCIND aoL S/DO 0W,cla 100 . Circle All That Apply: Is job ready for inspection?: YE - NO— Rough In Final Do you need a Temp Certificate?: (YES / NO Issued On , Temp Information: (Ail information required) Service Size 1 Ph 3 Ph Size: b _A #Meters ( Old Meter# 9q 364ZZ3 New Service Fire Reconnect- Flood Reconnect-Service Reconnected Under round Overhead #Underground Laterals 1 2 H Frame Pole Work done on Service? ( N Additional Information: PAYMENT DUE WITH APPLICATION /0 1 00 \�� ct\ xrp 82-Request for Inspection Form.As M n � fp��co BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD w Town Hall Annex - 54375 Main Road - PO Box 1179 '� • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 roger richert antown.southoid.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: +ila "1�2 Date: (9 Company Name: W I L.DWOOD ELL-6'Fa%C- Name: ( ¢%_-fVk PAsspxrJ)%Nv Sa- License No.: Wg 3 b email: avo EL c—c CC. C Address: , O . Go Phone No.: b /— 9 2 9 — JOB SITE INFORMATION: (Ali Information Required) Name: ST62K Address: 1140 P()06, A-40 MHO►1 i v G Cross Street: AU-A I dbKP, (�090 Phone No.: BIdg.Permit email: Q`�P�j�c W t�DWac>� E t�G�uL •c a'"'- Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF VI/ORK(Ple ,rjn lea W 'rN LOFT G&Vi :ri<r ou.�: 5�r r,.r„nt mar. �lDO mcv,c� ll VD-0 :t s 3 y firLV Circle Ail That Apply: _ Is job ready for inspection?: YE NO Rough In Final Do,you need a Temp Certificate?: (ES / NO Issued On Temp Information: (All information required) 4 A # Meters ( Old Meter# -1 36QZ23 Service Size CD 3 Ph Size: _ ff#Undnerground Fire Reconnect- Flood Reconnect-Service Reconnected Under round Overhead Laterals 1 2 H Frame Pole Work done on Service? 0 N Additional Information: PAYMENT DUE WITH APPLICATION '0 00 82-Request for Inspection FormAs PERMIT# Address: Switches i Outlets I G F I's . 2S� Surface Sconces H H's UC Lts Fridge HW POOL Fans Mini Fr. W/® Panel 4r..Pump Exhaust Oven Sump Heater Trnsf / Smokes DW Generator Salt Gen.v� Carbon Micro GrbDis Water BondLights Heat Pucks ERV HOT TUB/SPA Inst Hot DeHum Transfer Disc Combo Cooktop Minisplit Blower AC AH Hood Blower Service Amps Have Used Sub Amps Have Used Comments r i H LOT RM3ER5 REFER TO TRAP OF MARRATOOKA PARK'FILED IN THE SUFFOLK COUNTY CLERKS �, ys o OFFICE ON NOV.I,IgO5 AS MAP No.450 AREA OF DISTURBANCE: �� F o i2 FLOOD ZONE FROM FIRM MAP 3610360482H ±2,300 50 FT. SITE PLAN BASED ON ORIGINAL SURVEY BY: PARK AVENUE �� P y 5 G �i r 3 PECONIC SURVEYORS,P.G. „5 o u T H ROAD" / U t 1230 TRAVELER STREET JAMESPORT,NY IIg4l PROP. ER05ION CONTROL MEASURE: / RYAN STORK /OWNER: m SURVEYED: APR q,IggB SILT FENCE BARRIER TO BE MAINTAINED PROP05ED RYAN STORK ° �n UNTIL JOB COMPLETION(APPROX.206 L.F) 5WIMMIN5 POOL JUL 9 0 2018 LAST UPO: MAR.22,2011(GERTIFIGATION5) UTILITY AREA: GOO S.F. v p;}:.''`'` m C� CL DATUM: NAVD88 18 IS 6°5�'OOnE X.SPLIT RAIL FENCE 254.50' POLE - Menem°ka von C2. TT�� g�T�1 t�rq G ox �x 0 --� atriwck� i'.a.;.'''r" m = :; Y'IJIL IHl\lT T:Y f x o POOL DRAINAGE r u: g Q s T_, 7 W,,T 7 ,7. LD 5TORAGE _ { Ok DEDICATED TO: POOL °` J Q x m < n N I BACKWASH d STORAGE ,mac �-•;�.;-�, USE � Q \ n STORM WATER LEACHING FX BRICK PAD ,,. N O J o POOL(SOLID COVER) aP °v� P ���f +'? O p TO REMAIN PROPOSED { { I °P SITE o tP 4 HIGH POOL FENCE — ' L00,ATION W { { { 20' MIN { '^ x.I .W.. ..,ae sue. s,. .1. ...-. • ,n 18 rn { ( { 1 LOT 14 LOCATION MAP: „ rm P/O LOT I3 ° { { { POOL EQUIP EX SHED NOT TO SCALE 123'x 12.3', r W c 1 31.0' 151 50.FT. SITE PLAN - p.., o LOT 12 S { I x ° PROPOSED SWBMING POOL m PROPOSED 51TUATE AT: 0 � {CIS POOL EQUIPMENT MATTITUCK,NY I o 30.0' ° TO BE LOGATED ' TOWN OF 50UTHOLD ' Q 5UFFOLK COUNTY,NEW YORK LU{ X Z LL EXI5TINC7 p o { IN51DE EXISTING SHED 5GTM NO.: 1000-123-08-0I GVRD PATIO ni ZONING DISTRICT: RESIDENTIAL'R40' Q IT ° 420 SQ.FT. ° 1 0 t USE: RESIDENCE I N Ex NG:DATA: I5TI : PROPOSED: ^ _ W 10.0' 10.0' AREA OF SITE: 131p81 5.F.(3.1411 AC) N.G. Q PROP05ED Ib EX. 3 GAR GAR. W. STOR (TO TIE LINE) Q dJ PROP05ED 5-� 4'HIGH POOL FENCE FIN.FL.EL. = 12.8' ° tom, �sfl O EROSION CONTROL MEASURE: 1 ` N AREA: 1,428 SQ.FT. LEGEND: W SILT FENCE BARRIER TO BE ERECTED PRIOR TO START OF AND MAINTAINED DURING ALL W PROPERTY LINE 10. PHASES CON5TRUGTION. " IbA ° / 10.0' 38.0' N 0' EA%11I 16 SANITARY PIPE 55 55 SEE DETAIL,TH15 DWG { I { EXI5T]%WATER 5WGE w O x o 1 101, E45DI6 OVERIEAD UTILITY LINE: —a — { Pp P { EX. GRAVEL SURFACE �, EXISTING U/6 ELEGTRIGAUTAMMJNIGATION ° x ° 582VI6E LIIE5: —Ue Lie U6 — M� e'24' x 6Fj' PROP05ED STORM DRAINAGE STRUCTURES I rI I - G5 - FOR POOL BAGKWA5H AND 5TORA6E (�: L ic�i E ic: Ig o EX PATIO ° 70�' S-I�j°41' "W SITE PLAN - ENLARGED VIEW oPEN coves TO GRADE71 ` \ EX.GAR. 20 l0 0 20 40 EXISTING SPOT ELEVATION x6.0 �'�P�P� ��0,9 � 6RAPHIG 5GAE- I'=20'-0" R05ION CONTROL LEGEND: n rn SILT FENCE BARRIER x x n T► : W n \ SEPARATION D15TANCE REGI MNT5 FOR POOL Z - z BAGKWA5H AND 5TORA6E LEAGHIN5 �p IT 1 EX.6RAVEL o AND PIPIN IDENTI �� "S 3 DRIVEWAY '• ' W 1 Q HORIZONTAL SEPARATION D15TANCE5 FOR 5TORM SIONP� w IT O DRAINAGE LEACHING POOLS: PROPERTY LINE=5'MINIMUM .IEFFREY T.BUTLER P E. 1" BUILPIN65 WITH CELLAR= 10'MINIMUM t] OF W Y &I t I�ANn 1 � BUILOIN65 ON SLAB=5'MINIMUM � 800-2�2-��80 81 I rn ' WATERS LINEMTERALS/MAINS= l0'MIN O p ?` ' WOVEN WIRE FENCE SYMBOL { 1 EX.% r\r UNDERGROUND UTILITIES=5 MINIMUM (MIN.14 I/2 6AU6E W/MAX.6"MESH — x x — ^ � .. c� `Cu�� CAST IRON FRAME All 6RATE../GOVER 10'MAX G.TO G. 1�1 SANITARY SEPTIC TANK=20'MINIMUM O o i�E 5T UTILITY SANITARY IFAGHIN5 POOL=20'MINIMUM CAMP13ELL 1162 G OR APPROVED EQUAL z J www.dignetnycli.com 3 EX.GAR PORT ` i ' o STORM WATER LEACHING POOL=8'MINIMUM (� POLE orwrother18tates) 1 140' PUMP STATION=20'MINIMUM O 3b'MIN.LENGTH FENCE (for other states) ' _ FY : FINAL GRADE - POSTS DRIVEN MIN. 16" LL_ v F oUT. e % MANHOLE=20 MINIMUM }- — EX.6RVL DRVWY A o 5HH �� 8 TRAFFIC INTO 6ROUND. z O 0 By law,excavators and contractors working in A 1t V° PRIVATE WELLS=50'MINIMUM " the five boroughs of New York City and Nassau A _1 1a' �1q G -r RETAINING HALLS= 10'MINIR M -= BEARING SLAB WW*R OF FILTEP (I1 Z and Suffolk Counties on Long Island must TTt Q �� EX UIG ELECT 5ER LINE 225 ` FUEL 5TORA6E TANK5(BELOW GROUND) =20'MIN 4'PIPED I (WHERE III w •16'MIN ' 1 ,\ "J contact Dig Net,1-800-272-4480 or 811,at least 9CD �;—� ur, IA Mlli APPLICABLE) �Y y a LL, \d �V Q Q Q Z EX 2 STY.FIR OWL6 p M lI REC�11PmJ v 48 hours but no more than 10 working days � U� / VERTICAL SEPARATION DISTANCES FOR POOL/ per, 1 1 y y�O�y y y O.r' y y y ao F- I ~ � (excluding weekends and legal holidays)prior O 18 a AREA:2110 SF. POOL EQUIPEMNT HATER/DRAINA6E LINES: HIGH DMITY POLYETRYLENE HDPEI ® ® ©I �` y y y z m to beginning any mechanized digging or 1 F.FLPL.20.4' �0�, WATER SERVICE LINES= IS'MINIMUM SIZE' ® ® ® ®I 1 y LU N Z Q excavation work to ensure underground lines 0 , POOL EQUIP.COM€CAM=4'0 MIS. ® ® ® ® ® i PERSPECTIVE VIE" Q OI are marked.Excavators and contractors can EX. ti SANITARY WASTE L1NE5= 18 MINIMUM I _ r 42.1' ® ® ® t� InCL N I 56"MIN.FENCE POST V' also submit locate requests online,through ._ ® ® ® CL ITIC.If you do not currently use ITIC,please II.b' ( ® ® ® ® ®I 3'MIN. WOVEN WIRE FENCE(MIN.14 1/2 W 0 Q d call 1-800-524-7603 for more information. ' EX.COVERED DECKI GAUGE W/MAX.6'MESH N (31 MIN. I ® I� ® ® ® 1LI0® ® ® Z ® ®I SPACING)WITH FILTER CLOTH O >, For safety reasons,homeowners are strongly T'Tt I ® � ® ® ®I I N = 0-( encouraged to call as well when planning any Z 8 ZONE X Z I I ® � ® < G Q t1NDISTURBED GROUND O Q 1- type of digging on their property.Homeowners 1rn COMPACTED SOIL LL V z Q can contact us directly at 1-800-2724480 or by Trt 10 calling 811,the national call before you dig s -t ® ® ® ® WRAP STRUCTURES EMBED FILTER CLOTH 1�1 Q 0 1 EX 00,T.O.RKFD @ EL. .b' I® ® ® ® ® I A MIN.OF 6" IN GROUND. Q number.For excavation work completed on � r WITH FILTER FABRIC 4" t � � LL � dJ personal property,it is the contractor's Z EX NG.5TAIR 1® � o ® 1 (USE 6EOTEX 351, SECTION VIEW C LL Q fV responsibility-NOT the homeowners-to rt EX RICK ® ® ® contact DigNet.Having utility lines marked prior TOP OF BANK EX AZ�O TOP80F BANK 1 1 ® ® ® I I BY PROPEX) CONSTRUCTION SPED I F I GATI ONS k6 to digging is free of charge. I.WOVEN WIRE FENCE TO BE FASTENED SECURELY TO FENCE P05T5 WITH WIRE TIES 1 12 I0 �9� z NON-RATEABLE OR STAPLES.PO5T5 SHALL BE STEEL EITHER"T'OR'U'TYPE OR HARDWOOD. ^ FLOOD ZONE LINE _ __ ,_ �FLOOD ZONE LINE s e'DIAMETER SOIL - F+1 Z '_ 8 2.FILTER CLOTH TO BE TO BE FASTENED SECURELY TO WOVEN WIRE lb'x 16-I PjGj xT.' GROUND WATER FENCE WITH TIE5 5PAGED EVERY 24"AT TOP AND MID 5EGTION. LANDWARD EDGE OF TIDAL WETLAND5 58-I°36'S1"W LIAR MATERI FENCE SHALL BE WOVEN HIRE,12 1/2 6AUGE,6'MAXIWM MESH OPENING. ALONG M.H.W.M AS DETERMINED BY SUFFOLK ZONE VE,EL8 6 MIN. f a� ENVIRONMENTAL CON5ULTIN6, INC.ON JULY 10,2014. EX.METAL 5TAIR (PENETRATIOW 3.WHEN TWO 5EGTION5 OF FILTER CLOTH ADJOIN EACH OTHER THEY SHALL BE OVER- V O Q EX HOOD DECK RATEABLE 501L LAPPED BY 51X INGHE5 AND FOLDED, FILTER CLOTH SHALL BE EITHER FILTER X, MIRAFI IOOX,5TABILIWA T14ON,OR APPROVED EQUIVALENT. TIE LINE ALONG SEA WALL 4,PREFABRICATED UNITS SHALL BE 6EOFAB,ENVIROFENGE,OR APPROVED EQUIVALENT. /� ` M.H W M.ALONG SEA WALL GREAT PECONIC BAY UNDERLYING SAND AND GRAVEL STRATA 5.MAINTENANCE SHALL BE PERFORMED A5 NEEDED AND MATERIAL REMOVED WHEN D I- A O E :. SITE PLAN "BUL6E5'DEVELOP IN THE 51LT FENCE. , POOL BACKWASH AND 5TORAOE U.S.VWARTMM OF AGRICULTURE SILT LEAGHING POOL LEE DETAIL NATURAL REsoTHIW Oot+WPON 1oN 5 L WN FENCE NEW YORK STATE DB'ARTMENT OF B�MROf#�ENTAL C011UERVATtON 50 25 0 50 100 NEN YORK STATE 501L 4 KATER CONSERVATION C01•HMITTEE 6RAPHIG 5GALE 1'=50'-0' NOT TO SCALE THESE DRAWINGS AND AGGOMPANYING 5PEGIFIGATION5,A5 INSTRUMENTS OF 5ERVIGE,ARE THE EXCLUSIVE PROPERTY OF THE ARCHITECT AND THEIR USE AND PUBLICATION SHALL BE RESTRICTED TO THE ORIGINAL SITE FOR WHICH THEY WERE PREPARED. REUSE, REPRODUCTION OR PUBLIGATION BY ANY METHOD, IN WHOLE OR IN PART, O f { 15 PROHIBITED EXGEPT BY WRITTEN PERMISSION FROM THE ARGHITEGT. TITLE: TO T'HE5E PLANS SHALL REMAIN WITH THE ARGHITEGT.VI51JAL GONTAGT WITH THEM SHALL GON5TITUTE PRIMA FN( IE EVIDENGE OF AGGEPTANGE OF THESE RESTRIGTIONS. �1 FLAWPOO-01 GBUCKLEY ACORO® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE F07/10/2018 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#BR-$76726 NAMEACT Execu Ins Broker Fin Ser Inc PHONE 515 Johnson Avenue (AIC,No,Ext):(631)563-8433 (A/C,No):(631)563-7706 Bohemia,NY 11716 E-MAIL certificates@eifsonline.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Continental Casual Company INSURED INSURER B:Merchants Mutual 23329 Kevin C.Norden Inc.Dba Flawless Pool Service INSURER C:Continental Insurance Company P.O.Box 867 INSURER D: Remsenburg,NY 11960 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR IN SD WVD MMIDDIYYYY MMIDD YYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F_X�OCCUR 05/23I2018 05/23/2019 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL BADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OPAGG S 2,000,000 OTHER: JEMPLOYEE BENEFI $ 2,000,000 B COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea accident $ X ANY AUTO CAP1048066 03/31/2018 03/31/2019 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident S $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 EXCESS LIAB CLAIMS-MADE 5099706301 06/23/2018 05/23/2019 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Commercial Property 05/23/2018 05/23/2019 20,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Proof of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Town Main Road ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i NEW Workers' / STA7E Compensation CERTIFICATE OF INSURANCE COVERAGE 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured KEVIN C NORDEN INC. DBA:FLAWLESS POOL SERVICE 7 ROGERS LANE 6314843242 REMSENBURG,NY 11960 Work Location of Insured(Only required ifcoverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder)Town of Southold Standard Security Life Insurance Company of New York 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 D96780-000 3c.Policy effective period 1/3/2008 to 7/9/2019 4. Policy provides the following benefits: 7 A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Q 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 de sc' d above. Date Signed 7/10/2018 By (Signature of insurance carrier's authoriz d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES 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 513 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 DB-120.1. Insurance brokers are NOT authorized to issue this form. 1313-120.1 (10-17) 1�1 11 l 1111 1�1 DB 120.1 (10-17) IdicidY. Workers' ST TE Compensation CERTIFICATE OF �! Board NYS WORKERS'COMPENSATION INSURANCE COVERAGE / la.Legal Name&Address of Insured(use street address only) lb.Business Telephone Number of Insured Kevin C.Norden,Inc. (631)484-3242 dba Flawless Pools Service lc.NYS Unemployment Insurance Employer Registration PO Box 867 Number of Insured Remsenburg,NY 11960-0867 1 d.Federal Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier Being Listed as the Certificate Holder) Continental Indemnity Co. Town of Southold 3b.Policy Number of Entity Listed in Box"la" 54375 Main Road 46-359127-01-03 Southold,NY 11971 3c.Policy effective period 04/01/18 to 04/01/19 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers included) 0 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"la"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'. Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? W YES ❑ NO 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 Certifi- cate 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: Todd Brown (Print name of au horized representative or licenced agent of insurance carrier) Approved by: 07/10/2018 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: (877)234-4424 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(9-15) AF R VED AS NOTED g, ,DATE: _ It 1 6.P:�# � � RETAIN STOR v�6�j M WATER RUNOFF "FEE'% BY: .PURSUANT TO CHAPTER 236 NOTIFY._ BUILDING DEPART TT OF THE TOWN CODE. 7fi5-f802.;_9 AM TO 4 PM FOR THE FOLL{3WING INSPECTIONS: 1. :F..OUNDATION -.TWO REQUIRED FOR POURED CONCRETE 2. ROUGH = fRAMING & PLUMBING 3. INSULATION ELECTRICAL 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. INSPECTION REQUIRED ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. ,ENCLOSE POOL TO CODE COMPLY WITH ALL CODES OF uPON.coMPLETION NEW YORK STATE &TOWN CODES BFOR�:;'_WAT)=FF'M AS REQUIRED AND CONDITIONS OF SOUTHOLD TOWN ZBA SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES N.Y.S.DEC OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY GENERAL NOTES: POOL NOTES: I. ALL WORK SHALL BE PERFORMED IN ACCORDANCE WITH ALL STATE,MUNICIPAL, ALL EQUIPMENT AND THE INSTALLTION OF SUCH EQUIPMENT TO MEET THE 2015 IRC WITH 2O1-1 LOCAL ZONING AND BUILDING CODES AND ORDINANCES HAVING JURISDICTION AND NYS SUPPLIMENT, ALL LOCAL CODES AND THE VIRGINIA GRAEME POOL AND SPA SAFETY ACT BEST STANDARDS OF CONSTRUCTION PRACTICE. THE AMERICAN INSTITUTE OF R326 AND CHAPTER 42 SHALL BE COMPLIED WITH, n > ARCHITECTS CONDITIONS SHALL APPLY TO ALL WORK PERFORMED ON THIS PROJECT, (A" 1, ALL REBAR TO BE GRADE 40 STEEL,USE k4 REBAR AT 10" O,C, VA > 2. THE CONTRACTOR SHALL VERIFY ALL CONDITIONS AT THE SITE. ANY DISCREPANCIES BOTH WAYS TO A DEPTH OF 4'-0",AT GREATER THAN 4'-0" DEPTH ` MUST BE BROUGHT TO THE ATTENTION OF THE ENGINEER PRIOR TO COMMENCEMENT USE 44 REBAR AT 5" O.C. VERTICAL BY 10" O.C. HORIZONTAL. `4 OF CONSTRUCTION. THE CONTRACTOR SHALL BE RESPONSIBLE FOR CORRECTIONS NOT 2, ALL REBAR SPLICES WILL HAVE A MINIMUM OVERLAP TO BE 20 BAR DIAMETERS, "" REPORTED ONCE HE HAS STARTED WORK EXCEPT FOR HIDDEN JOB CONDITIONS. 3, ALL FOUR CORNERS WILL HAVE REBAR EXPOSED AT POOL BEAM FOR-CONNECTION NEW YO OF ELECTRICAL GROUND AS PER TOWN CODE. REBAR TO BE RAISED 'A > 3. CONTRACTOR SHALL GUARANTEE TO THE OWNER THAT ALL MATERIALS AND A MINIMUM OF 3" WHEN SHOOTING GUNITE" ALL GUNITE SHALL BE A MINIMUM 4000 PSI,8" n" EQUIPMENT INCORPORATED IN THE WORK WILL BE NEW,AND THAT ALL WORK WILL BE THICKNESS THROUGHOUT WITH 12" BOND BEAM. > Q 1 d OF GOOD QUALITY,FREE FROM FAULTS AND DEFECTS FOR A PERIOD OF ONE YEAR FROM 4, POOL TO BE FORMED OUT OF USING DUG FUR LUMBER TO ALLOW FOR STRAIGHT �L THE DATE OF THE FINAL CERTIFIGATE OF OCCUPANCY, WALL CONSTRUCTION. 5, POOL LOCATION AS PER SITE PLAN BY THIS OFFICE- "" > - � 4. THE ENGINEER SHALL NOT BE RESPONSIBLE FOR THE CONSTRUCTION MEANS, METHODS, 6. THE LOW-END OF THE POOL WILL RANGE FROM 42 TO 45" IN DEPTH FROM TOP OF ^ TECHNIQUES,SEQUENCES OR PROCEDURES OR FOR THE SAFETY PRECAUTIONS AND BEAM TO THE FLOOR WHILE THE DEEP END WILL BE --'^5" FROM TOP OF BEAM TO FLOOR. "n >" w PROGRAMS IN CONNECTION WITH THE WORK,AND HE SHALL NOT BE RESPONSIBLE FOR THE LOW-END IS TO HAVE A CUSTOM SET OF STEPS, ALL OF WHICH WILL BE CONSTRUCTED THE CONTRACTOR, FAILURE TO CARRY OUT THE WORK IN ACCORDANCE WITH THE ENTIRELY OUT OF GUNITE. i " Ct CONSTRUCTION DOCUMENTS. THE ENGINEER SHALL NOT BE RESPONSIBLE FOR THE ACTS 1. POOL TO HAVE THE FOLLOWING INSTALLED: INTELL:6.FLO SVRS VARIABLE-SPEED PUMP 3 HP, v" ' no' OR OMISSIONS BY THE CONTRACTOR. NO CHANGES SHALL BE MADE IN THE DOCUMENTS MODULAR 3 450 SQ FT STA-RITE CARTRIDGE FILTER„ THREE 250 WATT LIGHTS UNDER EACH AND/OR THE BUILDING AS DESIGNED WITHOUT THE EXPRESSED WRITTEN CONSENT OF THE SKIMMER,3 SKIMMERS,3 RETURNS, I AUXILIARY LINE FOR FUTURE USE, v" ' ENGINEER. ONE FLUID MASTER AUTO FILLER WITH SUPPLY LINE CONNECTED BY PLUMBER,TWO 12"X12" - LIGHT GREY MAIN DRAINS WITH DEEP HEAT RETURNS!AND SUCTION LINES EACH T'D TOG-ETHER,AND >" 5. THE CONTRACTOR AND ALL SUBCONTRACTORS SHALL MAINTAIN CONTINUOUS A 400,000 BTU STA-RITE DIGITAL ELECTRONIC- NAT::�;AL GAS OR LIQUID PROPANE HEATER, INSURANCE COVERAGE'INCLUDING STATUTORY POLICIES (WORKER COMPENSATION, ETC.) S, ALL UNDERGROUND PLUMBING WILL BE DONE IN 2':NCH BLACK POLLY PIPE,ABOVE GROUND v A AND GENERAL LIABILITY IN AN MOUNT NOT LESS THAT s5 MILLION AND AUTOMOBILE WILL BE 2" SCHEDULE 40 WHITE PVC WITH SWEEPING P-BOWS AS PER THE CODE. ALL PUMPS m LIABILITY AND DAMAGE COVERAGE NOT LESS THAN s2 MILLION" THE ENGINEER SHALL BE WILL HAVE 2" UNIONS FOR EASY WINTER STORAGE ADD VALVES WHERE NECESSARY. ^ m A NAMED INSURED ON ANY AND ALL POLICIES. 9, TILE ENTIRE TOP(o INCH SECTION OF SWIMMING-P(=.)L WITH Fi" X 12" FROST FREE ' rj SLATE TILE OF HOMEOWNERS CHOICE WITH A 1/2"-3/4` �OP JOINT 10. SUPPLY A JANDY POOL ONLY SYSTEM WITH POWi R CENTER,SURGE PROTECTION,ONE > I I 1 Fi, ALL ELECTRICAL WORK TO BE IN ACCORDANCE TO THE RULES AND REGULATIONS OF TOUCH REMOTE, AND SERIAL OR IAQUALINK. INSTALL PER NEC REQUIREMNTS BY LIG ELECTRIAN, 18'X 50' THE N.Y.B.F,U, AND A N,Y.B,F,U. CERTIFICATE IS TO BE PRESENTED TO THE OWNER AT THE PROPOSED GUNITE COMPLETION OF THE JOB. POOL ' li 1. PLUMBING INSTALLATION TO COMPLY WITH STATE AND LOCAL CODES ° mll 8, DO NOT SCALE DRAWINGS. USE FIGURE DIMENSIONS ONLY. S. THESE DRAWINGS AND SPECIFICATIONS ARE INSTRUMENTS OF SERVICE AND SHALL REMAIN THE PROPERTY OF THE ENGINEER WHETHER THE PROJECT FOR ^" �- WHICH THEY ARE MADE IS EXECUTED OR NOT. THEY MAY NOT BE USED " Q) LL- ON ANY OTHER PROJECT EXCEPT BY WRITTEN AUTHORIZATION OF THE ENGINEER v . ^ ' 10. THE ENGINEER HAS NOT BEEN RETAINED FOR SITE SUPERVISION,ON-SITE - - v"" > INSPECTIONS AND CERTIFICATIONS AS REQUIRED OR REQUESTED BY THE OWNER, CONTRACTOR OR LOCAL BUILDING DEPARTMENT. Is'X 50, JA " ' ° II. THE DESIGN IS BASED ON AN ASSUMED BEARING-CAPACITY OF THE SOILS OBSERVED o PROPOSED GUNITE " (SW)WITH 2500 PSF CAPACITY, a POOL "n > > Q --------------------------------------------------- -, Q m SECTION A-A ; "" Lu> "n > "^ PROPOSED 8WIMMING POOL FOR: STORKRESIDENCE --------------------------------•-------------------- -----------.--------Li ,^" 11-40 PARK AVENUE "" > MATTITUCK, NEW YORK I8'X 50, PROPOSED GUNITE- v n \`, SCTM 1000-123-00-01 POOL ' vn > jA' "" 5ECTION B 5 "A ;