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HomeMy WebLinkAbout51009-Z o�SUFFOI,f�oG Town of Southold 9/28/2024 a� y� P.O.Box 1179 0 53095 Main Rd �o4, Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45598 Date: 9/28/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 580 Gin Ln, Southold SCTM#: 473889 Sec/Block/Lot: 88.-3-8.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/12/2022 pursuant to which Building Permit No. 51009 dated 7/31/2024 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 Orsini,Mark&Benarrach,Joseph of the.aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47807 7/27/2022 PLUMBERS CERTIFICATION DATED /7 n R�" ho 'z Si ature gOFFOLIr TOWN OF SOUTHOLD �oo� may BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE "o • SOUTHOLD, NY y�al �a ss 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#: 51009 Date: 7/31/2024 Permission is hereby granted to: Orsini, Mark 560 W 45th St Apt 1807 New York, NY 10036 To: Install in ground vinyl swimming pool at existing single family dwelling as applied for. Must maintain minimum 110 feet from edge of pond to pool or Trustee approval will be required. Minimum 10 foot setback from property lines to pool and / or pool equipment. At premises located at: 580 Gin Ln, Southold SCTM #473889 Sec/Block/Lot# 88.-3-8.1 Pursuant to application dated 4/12/2022 and approved by the Building Inspector. To expire on 1/30/2026. Fees: IN-GROUND SWIMMING POOL ` $200.00 Total: $200.00 Building Inspector �suFFoa,r�o TOWN OF SOUTHOLD �o ay BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE "oy • o� SOUTHOLD, NY pi+pl .a S 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#: 47807 Date: 5/11/2022 Permission is hereby granted to: Orsini, Mark 550 W 45th St Apt 1807 New York, NY 10036 To: Install in ground vinyl swimming pool at existing single family dwelling as applied for. Must maintain minimum 110 feet from edge of pond to pool or Trustee approval will be required. Minimum 10 foot setback from property lines to pool and / or pool equipment. At premises located at: 680 Gin Ln., Southold SCTM #473889 Sec/Block/Lot# 88.-3-8.1 Pursuant to application dated 4/12/2022 and approved by the Building Inspector. To expire on 11/10/2023. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector e Yf Yak��ii4�.�✓Id{..ilyl Jr Form No.6 TOWN OF SOUTHOLD s 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-,�ns talfdtibn;from Board of Fire Underwriters:' J 4. Sworn statement from plumbe = ertifyii'that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial buildi � iridustrial liuilding�multiple residences'and�snnilarbuildings and,installations,a certificate of Code Compliance froii darbhite ofngine� �esponsible for the buildings, 6. Submit Planning Board Approval te plan requirements. ,r 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..,1,'9properly 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. New Construction: V VPL7 Old or Pre-existing Building:, -.< (check one) Location of Property: ��� ct h~r �uti? _ cSo t�� ta� House No. Street,,'- Hamlet ?wner or Owners of Property: Suffolk County Tax Map No 1000, Section Block J Lot " S4bivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ - Ap "ant o�'�'oF so�ryol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlina-town.southold.ny.us Southold,NY 11971-0959 COm'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Mark Orsini Address: 580 Gin Ln city,Southold st: NY zip: 11971 Building Permit#: 47807 Section: 88 Block: 3 Lot: 8.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electric License No: 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 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 CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches• 4'LED Exit Fixtures Pump 1 Other Equipment: 2 Iights120gfi, intermatic pool panel 4 circuit/4used, pump220gfi, heater250, chlorsync Notes: pool Inspector Signature: Dater July 27, 2022 S.Devlin-Cert Electrical Compliance Form o�aOE SOGtyo Li -7 0 1 I v L-,j ti <o TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] 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: l MA-L-- -5l.�TI2`6 - C,l DATE Z Z INSPECTOR r OF SOUIyO� t - # TOWN OF SOUTHOLD BUILDING DEPT. ^ou�m 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] NSUL ION/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: r �lhg& Nvylay v ca1 h �n5 • �n� wl � AAA DATE I 'INSPECTOR 5 oe souryolo * # TOWN OF SOUTHOLD BUILDING DEPT. co�rm��' 631-765-1802 Siva INSPECTION ' [ ] FOUNDATION 1 ST/ REBAR [ : ] ROUGH PLBG. [ ] FOUNDATION 2ND- [ ]-. OULATIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL ?o� -- E0.,, [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL - -= --- REMARKS: DATE INSPECTOR FIELD INSPECTION REPORT TDATE COMMENTS , pp b O FOUNDATION(IST) -9 y ------------------------------------ (.A ran FOUNDATION(2ND) z l ° ROUGH FRAMING& -0 y V' PLUMBING O INSULATION PER N.Y. STATE ENERGY CODE C, Q.� r WtaP Vll/20\�' �� Ll FINAL C ADDITIONAL COMMENTS '7 la 6?It S re. l a ce S P 147 80-7 -� 77- y rr , O z x d m b I TO'JVN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey Southoldtownny.gov PERMIT NO. v7eolCheck Septic Form N.Y.S.D:E.C. Trustees C.O.Application Flood Permit Examined ,20 Single&Separate R E C E Truss Identification Form �J Storm-Water Assessment Form APR 1 2 2022 Contact: Approved ,20 Mail to: v%r t e 4>-A S Disapproved a/c BUILDING DEPT. TOWN OFSOUTHOLI� �SIO UeS �wy Phone: S ��jd oo I� 1 Expiration 120 I Building Inspector APPLICATION FOR BUILDING PERMIT Date , 20 Z-Z INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets 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 areas,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 shall 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 issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property 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 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,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 kf applicant or name,if a corporation) ti v1 L (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premises „/�/� G (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. �, S Plumbers License No. Electricians License No. 0 5 SFl — —144 Other Trade's License No. 1. Location.o land on which oposed wo k will be don House Number Street Hamlet County Tax Map No. 1000 Section Block Lot - 1 S'ibdivision -Filed Map No. Lot 2. State existing use and occupancy of premis sand intended use and occupancy of proposed construction: a. Existing use and occupancy S; 4 2�4,11c� b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work ' (Des ripti ) 4. Estimated Cost o �( R G Fee (To be paid on filing,this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 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 9. Size of lot: Front Rear Depth 10. Date of Purchase Z Z3 Name of Former Owner 11. Zone or use district in which premises are.situated 12. Does proposed construction violate any zoning law, ordinance or regulation?YES NO 13. Will lot be re-graded?'YES NO�Will excess fill be removed from premises?YE�r NO Siaar Yl�al� 14.Names of Owner of premises 44 cr r- O,51 h : Address SOU ci, �Pl( ec.N��o-)1 Name of Architect ''c—s -(),&&i leafle-,- 'Address of /4-w /u Rhone 1Vo G --7 556 Name of Contractor O VVNrI 4-`c.�)aals Address 351C, l/e4-5_ 14-K y Phone No. .58.?-i 30o ho� ,g 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES 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 :�!s- * IF YES,D.E.C. PERMITS MAY BE REQUIRED. 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 * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) ,.X/A G! �C �S i ►� being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his 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 day of Art, 20 otary u Mc Signature of Applicant CONSENT TO INSPECTION cvL m T the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersigned(is) (are)the owner(s) of the premises in the Town of Southold, located at J5 which is s o and designated on.the Suffolk County Tax Map as District 1000, Section ,Block , Lot That the undersigned(has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: 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. r' Dated: pp �(Signature) (Print Name) GREGORY PINTO CAL—K e-1 NOTARY PUBLIC,STATE OF NEW YORK NO.01-PI6090455 (Signature) QUALIFIED IN SUFFOLKCOUNTY MY COMMISSION WIRES APRIL%20?3 (Print Name) �{ \ CCA �wN PA Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, residing at (Print property owner's'name) (Mailing Address) do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. (Owner's Signature) (Date) (Print Owner's Name) ��gwJfFOLKc 2 U ING DEPARTMENT- Electrical Inspector O 1C TOWN OF SOUTHOLD own I Annex - 54375 Main Road - PO Box 1179 co - Southold, New York 11971-0959 oy�o� �o � t,'-oFs o J phone (631) 765-1802 - FAX (631) 765-9502 rogerr southoldtownny.gov — sea nd(aD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: 13 d I J ee�r`►cg Cooit` t Name: IA -PwT"' 0✓\ License No.: Me--40GS'7 email: 6& QCG7 p 0� i/12,✓1t? Address: iS g Z vQnv�� nll�rao t l� l . Phone No.: (`p�� 7�Q fj JOB SITE INFORMATION (All Information Required) Name: -Tor-- (BEN i\RP<-oc-H MAPJ-- OIE!SI N I Address: G80 &A, ���� Ga of A Cross Street: Phone No.: —i-7S " )2 � Bldg.Permit#: 50-1 email: Tax Map District: 1000 Section: E6 Block: '� Lot: . BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: Is job ready for inspection?: Q'D� NO Rough I CFDinal Do you need a-Temp Certificate?: NO Issues On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: O,M►eow✓V� to C-00.r 1. e- Ae 9•^ .e- (,A q PAYMENT DUE WITH APPLICATION Request for Inspection Form.xls 0 � fQ� StfF01,� t t BUILDING DEPARTMENT- Electrical Inspector b L' SJ� 1: 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 _ r rogerr&southoldtownny.gov — seand(c-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION Information Required) Date: Company Name: / Electrician's Name: License No.: Elec. email: Elec. Phone No: ❑1 request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: n ' - . nl Address: Cross Street: Phone No.: Bldg.Permit#: �'0'7 email: Tax Map District: 1000 Section: �j' Block: 3 Lot: �. BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): pc�,o ;YYA 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 Re'connect❑Underground'❑Overhead # Underground Laterals 1 FJ2 H Frame Pole Work done on Service? D Y N Additional Information: PAYMENT DUE WITH APPLICATION PERMIT# Address: Switches�� Outlets t GFI's Surface Sconces H H's LIC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator _ _. . ...- ---.._.... .- - -_. _. _.. .._._... ... Transfer Combo Cooktop AC AH Mini Special: Comments: - / Southold Town Building Department P.O.Box 1179 Permit#: 47807 53095 Main Rd Southold,New York 11971 Permit Date: 5/11/2022 (631)765-1802 Expiration Date: 11/10/2023 Parcel ID: 88:3-8.1 BUILDING PERMIT RENEWAL LETTER Dated: 5/31/2024 Applicant: Orsini,Mark Location: 580 Gin Ln., Southold Work Description: IN GROUND POOL Install in ground vinyl swimming pool at existing single family dwelling as applied for. Must maintain minimum 110 feet from edge of pond to pool or Trustee approval will be required. Minimum 10 foot setback from property lines to pool and/or pool equipment. A FEE OF $200 IS REQUIRED TO RENEW THIS BUILDING PERMIT. s Owner: Orsini,Mark Address: 550 W 45th St Apt 1807 New York,NY 10036 The permit listed above has expired.No work is permitted or authorized beyond the expiration date.Please submit the above fee made payable to the Town of Southold.Mail to the Town of Southold Building Department,P.O. Box 1179, Southold,New York 11971 C THANK YOU, SOUTHOLD TOWN BUILDING DEPT.�� 4 _ r "S.-C.TiM. NO. DISTRICT: 1000. SECTION: 88 BLOCK: 3 LOT(S):B.I Np is 1 " s s �0.�/,, ob •— .—FRESH WATER' r-- �OO• r•PONQ.— �+ 2 r D's o �t \ PIPE 3 Ile r� N ��ti Z 00 hd 00. . GARAGE UNDER e C' iu M�rl. age_r Ira W.N. O a 'PIPE S U.P. e APR 1 2 2n72 a i9 e � BUILDING DEPT. TOWN OF SOUTHOLD .I THE WATER SUPPLY, WELLS, DR.YNELLS AND CESSPOOL q LOCATIONS.SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. AREA: 28,615.65 SQ.FT, or 0.66 ACRES ELEVATION DATUM: UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A NOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A' VALID TRUE COPY, GUARANTEES INDICATED HEREON SHALL RUN 3 ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION b LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE, THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADD/710NAL STRUCTURES OR AND OTHER IMPROVEMENTS. EASEMENTS AND/OR SUBSURFACE STRUfURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY .,'SURVEY OF: P/O LOT 2 & LOT 3 INCL. ,CERTIFIED TO:ARTHUR 0. WELLS; :'MAP OF: BAY HAVEN ROSE M. WELLS; FILED: JAN. 22, 1959 No.2910 .,FIDELITY NATIONAL TITLE INSURANCE ° 3 LLC; sITUATEo AT: SOUTHOLD SERVICES, • - 1 ,TOWN OF: SOUTHOLD KENNETH M VOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design - P.O. Box 153 A uebo ue,q g New York 11931 ''FILE # 16-69-1 SCALE:1"=40' DATE:JUNE 5. 2016 .. .._ .._. .._ ______ PHONE (631)296-1588 PAX (631) 298-1688 A A DUNRI-1 AS YY) 0 (MM/D(MMD/YYDfYY CERTIFICATE OF LIABILITY INSURANCE DATE 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 pollcy((es) 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 endorsements. PRODUCER 845-783-2555 c TACT Walter Rose Agency Inc Walter Rose Agency,Inc PHONE 8 Stage Road A/C No Ext:845-783-2555 ac No:845-783-2425 Monroe,NY 10950 E-MAI lisa@walterroseagency.com INSURERS AFFORDING COVERAGE NAIC# --INSURERA:Central Mutual 20230 Dunrite INSURED Manufacturing Corp E B.Utica National of Texas 43478 Dunrite pools INSURERC 3510 Veterans Memorial Highway Bohemia,NY 11716 INSURER 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 7CLP TYPEOFINSURANCEPOLICYNUMBER POLICYEFF POLICYEXP LIMITSA XCOMMERCIAL GENERAL LIABILITY 1,000000 F1�CH OCCURRENCE $ +CLAIMS-MADE �OCCUR864 04/01/2021 04/01/2022 DAMAGE TO RENTED $ 300,000 MED EXP(Any oneperson) $ 5,000 j PERSONAL&ADV INJURY $ 1,000,000 1 GEN'L AGGREGATE LIMIT APPLIES PER:EJ POLICY❑JECT GENERAL AGGREGATE $ 2,000,000 LOC OTHER: PRODUCTS-COMP/OP AGG $ 2,000,000 B $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO 4822099 12/31/2020 12/31/2021 Baaccident) Per person) $ $ ODILY OWNED SCHEDULED AUTOS ONLY AUTOS HIRED ��N� EE BODILY INJURY Per accident $ AUTOS ONLY AUTO ONLD PROPERTY AMAGE Per acci ent $ UMBRELLA LIAR OCCUR EXCESS LIAR HCLAIMS-MADE EACH OCCURRENCE $ DED I I RETENTION$ AGGREGATE $ WORKERS COMPENSATION Is PER OTH- AND EMPLOYERS'LIABILITY YIN A Tr I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Swimming Pools -Installation,Servicing Or Repair-Below Ground CERTIFICATE HOLDER CANCELLATION SOUTH02 SHOULD ANY QF THE.ABOVE DESCRIBED POLICIES BE,CANCELLED BEFORE, Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 530950 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED(�r+"��REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YoPa Compensation workers' CERTIFICATE OF INSURANCE COVERAGE rre 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 Carrie Ia.Legal Name 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured DUNRITE MANUFACTURING CORP 3510 VETERANS MEML HGHWY BOHEMIA,NY 11716 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required coverage or Social Security Number ( lY e9 g pecihcallyGmrted to certain locations in New York State,i.e.,Wrap-Up Policy) 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 530950 Route 25 3b.Policy Number of Entity Listed in Box"1a" PO Box 1179 DBL593730 Southold, NY 11971 3c.Policy effective period 01/01/2021 to 12/31/2022 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 12/15/2021 By �r + (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 4B,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(Artide 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 - y j 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) �Illll�i'ii1o2ii0mi1iiii(i1i2io21)ii01� NEW Workers' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE s°ATE Compensation COVERAGE Board 1a.Legal Name&Address of Insured(Use street address only) 1 b. Business Telephone Number of Insured 516-543-1616 Dunrite Manufacturing Corp 3510 Veterans Memorial Highway 1c.NYS Unemployment Insurance Employer Bohemia,NY 11716 Registration Number of Insured Work Location of Insured (Only required If coverage is specifically limited to certain locations in New York State,i.e.,a 1d.Federal Employer Identification Number of Insured wrap-up Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) AmTrust Insurance Company of Kansas Inc Town of Southold 3b.Policy Number of entity listed in box"I a!' 530950 Route 25 KWC1223367 PO Box 1179 Southold,NY 11971 3c. Policy effective period 10/20/2021 to 10/20/2022 3d. The Proprietor,Partners or Executive Officers are included.(Only check box if all partners/officers included) x 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". The Insurance Carrier will also notify the above certificate holder 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 the 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, 1 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: Kevin McDonough (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 10/13/2021 (Signature) (Date) Title:- President of Walter Rose Agency,Inc — --—" - Telephone Number of authorized representative or licensed agent of insurance carrier: 845-783-2555 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.state.ny.us RIM 12 R- Te U d --n7............. ........... g A. SYffolk County D opartment of Lab -or, Licensing & 03 D Y Co irs nsumerAffa IQ VETERANS MEMORIAL HIGHWAY HAUPPAUGE NEW YORK 11788 DATE ISSUED: 3/1/1977 ------- NO. 3585-H -------------- SUFFOLK COUNTY 6 110me Improvement Contractor License In This is to certify that : doing XF.N7Vr4,ry-y business as TBARTHMAN tj Q1, J)UN.RI having furnished.the TE MANUFACTURING CORP R11 requirements set forth in accordance with.and subject to the p 4? and regulations of the county of Su.ff6lk- provisions of applicable laws,rules 15 State of�Tew York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOk, in the County of Suffolk. --------- -- Category AdditionalBusinesses Au V. Pools/Spas Ui Fio-;-'sit:en4 onsum6rAff6aes. DUNRIT- ,E.p00LS E, MAN Fh' Co :'Y'he:Oddhii. '1r/'1!977 6 C o rd m re� R-:r 23 ..... ....... OCCUPANCY OR APPROVED AS NOTEP USE IS UNLAWFUL DATE l B.P.# S,0 7 WITHOUT CERTIFICATE NOTIFY BUILDING DEPA RTMEW AT OF OCCUPANCY 765-1862 8 AM TO 4 PM FOR THE FOLLOWING.INSPECTIONS: 1. FOUNDATION:- TWO REQUIRED FOR POURED CONCRETE 2. ROUGH = FRAMING & PLUMBING 3. INSULATION 4. FINAL CONSTRUCTION MUST COMPLY WITH ALL CODES OF BE COMPLETE FOR C.O. ;NEW YORK STATE & TOWN CODES ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW AS REQU D AND CONDITIONS OF IR YORK STATE. NOT RESPONSIBLE FOR SOUTHOLD TOWN ZBA DESIGN OR CONSTRUCTION ERRORS. SOUTHOL..TOWN PLANNING ROAN SOUTHOLD TOWN TRUSTEES- N.Y.S.DEC "IMMEDIATELY" ENCLOSE POOL TO CODE UPON COMPLETION , RETAIN STORM WATER RUNOFF BEFORE"WATER" _ PURSUANT TO CHAPTER 236 OF THE TOWN CODE. ELECTRICAL INSPEMON REQUIRED POoksks'mwjs t •A: -:8 G 1% !_: P G H K L tY- ,a4L , TOXI6- 1:J?a0 :16 .-16 PLO 4 4 Z .7 6 b'0' sj,,op PAD lCJe78: 1MC•s2;- -to... ?8' _6'-b` 6 12• b +i 1• .usco. How 3/8'I OS-0�ANC ROp d ' -t??a�€ •-;17.}C16. 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