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of SOUr Town of Southold * * P.O. Box 1179 1 � �0 53095 Main Rd COUN Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45742 Date: 11/09/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1375 Smith Dr S Southold, NY 11971 See/Block/Lot: 76.-2-3 5.1 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 05/07/2024 Pursuant to which Building Permit No. 50898 and dated: 07/02/2024 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: David Russell, Sondra Russell Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50898 10/16/2024 PLUMBERS CERTIFICATION: tho iz d S gnature �sufFot�'c�. TOWN OF SOUTHOLD moo- BUILDING DEPARTMENT co :$ TOWN CLERK'S OFFICE • 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#: 50898 Date: 7/2/2024 Permission is hereby granted to: Russell, David 1375 Smith Dr S Southold, NY 11971 To: . construct accessory in-ground swimming pool as applied for. Must maintain a minimum rear yard setback of 5 feet. At premises located at: 1376 Smith Dr S, Southold SCTM #473889 Sec/Block/Lot# 76.-2-35.1 Pursuant to application dated 5/7/2024 and approved by the Building Inspector. To expire on 1/1/2026. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $300.00 CO-SWIMMING POOL $100.00 Total: $400.00 Building Inspector OF SO!/T�ol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G ,�► • �o sean.devlinC&-town.southold.ny.us Southold,NY 11971-0959 ���OUNT`I,Nc� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: David Russell Address: 1375 Smith Dr S City:Southold st: NY zip: 11971 Building Permit#: 50898 section: 76 Block: 2 Lot: 35.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Bethel Electrical Contr. License No: 40557ME 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 2 Wall Fixtures 1 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 2 4'LED Exit Fixtures Sump Pump Other Equipment: Pool Panel, Pump 220GFI, Heater, Lights 30OW Trans 120GFI, Step Lights Around Pool 30OW Trans 120GFI, Waterbond Notes: Pool & Light on Outdoor Shower Inspector Signature: Date: October 16, 2024 1375SmithDrSPool r1f so 0&9 1-3 76 Sn//A # # TOWN OF SOUTHOLD BUILDING DEPT. 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: <\ !P�V-IY m &q el----)� �o klo (t DATE INSPECTOR OF SOUTyo� # TOWN OF SOUTHOLD BUILDING DEPT. I00 631-765-1802 �.jjs INSPECTION [ ] FOUNDATION 1 ST/REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I UL TION/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: (1) Ec ViU � h (o ry" vla� n4 V[34N:� K�& �vory Al wrA IgoP!46� - DATE -INSPECTOR . OF SOUIyo� �/�eA 13 75TOWC�IOOUTHOLD BUILDING DEPT. . �. °y�o��►� 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: I vor) l �-POIA."r-- 6�f:: car 0��1� ' n��2� 4/y DATE INSPECTOR / Of 50/¢�,0� # TOWN OF SOUTHOLD, BUILDINGDEPT. co 631-765-1802 $ INSPECTION ' ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND - [ ] IN L TION/CAULKING [ ] FRAMING/STRAPPING [ INAL [ ] -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ "] FIRE RESISTANT CONSTRUCTION [" ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: qwvl` 6!t G DATE INSPECTO Kt J D .A dewenMls {(t OSL05« FOUMTAIN,SWI4YINGPOOL OR SPA RAN TSFORMER :� c�o•i+���;�wa�,�.••r.crowv., n..w,<a.Drwno-.aMn...n 1 . - � ut�0.�n.rz u.>1rYNauro,nnrtr+,W0.M.r 'r �w��Ir•nr JMI.Mr,.,t ��• .w.rr.0.r.,,.DrM arprn..D • I a CAUTNNI',,nuar N�wcxes:o+DDancc�«crow,M.o�awaw 4 I O4IIE EM OIJIDE'..+ .. � �rw.o.c.c�i.�nc�on�Vya•W+Dru�[.,v+.nevn.rar GcAunox.,D.. ..onw...wo,or�.ww r.,..Nrz,na 0417EEMGARDE.csr OCAUTidI'.nwin ` . �MUiElX6AAGE:r.uca.,cn,owaunuvw�r.nrwc i � ..orirtSW c.n�No.IYWEDMO.�.� �,�♦:dttN.{.l Wu,�..�. - .D.,.nlM�nwGED�a v8- f 4 li tt� 7 , i D. �� ' � �AV' fit.. ONP or 4wo OW R Z� t ---------- ` 1 J WR L FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) -------------------------------------- -- ------ FOUNDATION (2ND) ROUGH FRAMING& PLUMBING ------------ ------- INSULATION PER N. Y. STATE ENERGY CODE • 4r,, wk, r FINAL ADDITIONAL COMMENTS f4e czV- 1007 --�c�-1 a�.l_a�---- ��S---rep.- _—���_�—��---�---------- - -- d rn S'l- TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 'y • o� Telephone(631) 765-1802 Fax (631) 765-9502 hgps://www.sotitholdtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector: PIP *A'' lica`tionsariehfirms'`must-'b„e:'fHed:'ouf`-iri liei °enti'ret"'; ?:.': r,,�-... ., ..•..t :r.,.' •:.,.•.JJ:.,�.ti?"str' �,,•u.. �y ,>.J. :n.:'[ ,j�5' -'.:ka� ...• � ,4 A;� aji' licationswillnot'be`acceOted:',3,WhdretiieApplican't'is„notithe:cwner;an • ''O:w`ner•s''Authorization':.for""m �QaQ�e�2�•'Sia11'<tie.corn'{{"���leted��;>;:::;";':.=';v.',;,':,. `';.';:;•:,�.° "6t%' :thy �..':..`. ',�,.'a:tn.' r;,z" .tryi4,-,ne)•'R� •��. -t`!:'::t�' ';�j;: ',,-1:%:�'j�'� FP','4''t�;�:.�:.a^J,.,4 jy�, 'w:v Y4.•1':r,jrS' 1�'7_`�v J.h�:�1 . A .,i:., j,. ,<a?�a. t: -�..:�t+,�c..». .,».. S^ ,r..t ,.d-�:'-115..�.ra d..i•`t;__d.�r<v �_i Dat I 2,b j - - --7:'",u`)i!'§��,.:_ "r,•,m— 'zei;;i7a;�14'.g '.'8'rth','- 'a..t. rw 1a ':(H... - ::"'r; _r,-- `F+`r `+• .�' e �'F„�C�., ','t'-;ur :tl•ir. iar..v';;r.��:' ,:4'.. Aj p 7 ) ' 01NNER/S\''OF:P OPERTY: h, ',. :::•.:," i�•r .: .::.. , . ; ...,- ';w :,, ;'.r: .: ..�i� ..ai:.. �.,?.';'tEir:. ;.'r,.".°:��w`n.,Y �r.. ,::.:F::� .'.fr ....Z'.Y i7.�,x::.i::%„�9's_°^.';..� -:i`�:.s."`.t.::...:S;pu1�:.,.ta�,:'.i..:. .,..X,�:., .t't'_•�.s.; Name: SCTM#1000- r Project Address: Phone#: Email: Mailing Address: .r,.� •,.;.t, �.y.. .,it.. _ .��..,,Y*," ,,•t^,„*� - - r+• .4:'' .,.ri.n• _ :f'E.'s.•-,,,, ,wt r.,r ,,.••,: r., qr � ew%y_ eta:,%;..r_ ,si � k'r'�'r;: ,k•.,ri dg�}": ..b�%'%� n,Y. :'C^^; .1r.-.+::r„'�,'r,• �q_W.•.•.�.._o,-_,'....a-,. .,s.:'t ,:- ;�:::. A'��N'^.•._.... •S»hti..l,N.-..t.`rsFi':}_........._,J:'L::.r._ • :.c: �a..£:-..,_.s.,_�G'• .✓ax�.:i:i:.lt�;'LM.•'; tea.k:�:%.,,... .,+•�.__�:.,,, :.U,nstvl. i.�..,>.. '•d�;.�:.,u6.i�,�,:¢:2.......ti,!.�...ra7t.x,%_tr..,c... u3k�. c.�..,:., Name: to Mailing Address: LM Phone#: Email: I - _ - - �.M'�_':�r'. - -`-'!4�x'+� i°1• t4"' .?'..""' 't:S.ti .'L`,�- - - — - - '4M"J^,�":: >'P_s ::•�`* :,1._ ;'."t_.�„ _'r':�", .i4:. ;:}r:. ;';3. �td71-` c�, {;c�•. ,>.,J`" 1, �7 h. FESSIONAL_INFO MATfON''�:� � :�:,•„ r ,�,wi, .�:�:;,� ;��,,"';nw- .,.r,:�.�:...':�<<,._ r„�-�r-'< •>�_<<' =„'` :DESNGN: RO - NSbliz.:.:.u.:t..„l�s n:sa:.::r..;r ...GY-.'ti'`;.§- �,,:�sGtr.;I_�a�: al+"•'i1=::n*>-',++: ,;"•b,�' :.1:&':^.":�':::.s,r.:._, a. r_st.��,:tai:^4'��':,:a,a>,!�'f:,:SS.«.. .��.�,.. ,ai�n"s:.:...+.4�i:;'w:.,.a c'G=:�.6R:� Name: Mailing Address: Phone M, Email: , £r- � �t O ^INFO MATIONa:" �:�':'.CONTRACT. R, R r,' ::?£:� .��t� •..�-,.., ^r r:::f t2..h^.>„a.':;is�c',;3':�` .;:�`"n"..•.�aJ',.,.,: ,c*Mi.";,_ �«t L':.kr_=:i.: - ..,._}.'•C.S. a,�.'.:u. t.�...J>,ii::'h,kt`a".;.i _�a�'i..aa...:..,..:45LS�^:'i,_.. .:.1� Name: Mailing Address: Phone .•.;i' _ .�i:�-..:.�-t.�,�...r..... -_;.�..,,..,...4'�: ):<+:':l: .,tt'9:"i -•.T r.�� �r'f� t'Y.SF'_. .:�..•'E.'.! '%t'[::� ,a ,•M:L..-U._ .,:1'v. „It `-1 'h' •Y'' ,M, •`�:�-:.,,.,-. E:t:,�w ,.>I"-°:t+ =',a'u' :` "-w��,• 2?.�t'''-`i., ,DESCRIPTION QF PROPOSED`�CONSTRUCTI;ON'.;,.''�;�:,;,-';�, .,.rasut-1':.. •+' .,:n�-5.'',-•,5.'c-=.',;. +1,;�,g: ;y :L.r, .,-,!ti i?�,aii_L. •:;;e1� .ir: :;.�,i1r.: ,e r>w,S:St :.::...,..,i` ..N','.Xa.. o;k,_r,:or'.M,?':' _ae, �JF,l..JZ.u',:wads�6.r• e.:.Sk:..1.,�.A}Sa ,'.�.W?::..+:.,.:.A wn'4. ..a..,.t,.F.W.w «.:`M."w�. .,7.,}:^- :'."i..L.e.iF:::S:,>'«h .,:1}.i.t..L..a ..)s. - - .�.'i'.�''::�.:$.7., .��.K-.r,. ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther l $ Will the lot be re-graded? ❑Yes O Will excess fill be removed from premises? s b NO 1 1 l '77,• _ - _ _ PROPERTY*INFORMATIO Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenknts^ restrictions with respect to this property? ❑Yes o IF YES, PROVIDE A COPY. Check Biix i4fter heading?'fifie owner/cantrac`tor/design professional is responsible for all drainage and;stornrwateC issues as.provided by apter 236 of the"Town Code. APPLICATION IS HEREBY.MADE to the-Building Department for the issuance of.a Building permit.pursuant to the Building Zone Or ante of the Town of Southold,5dffoik,County,New York and otherapplicable Laws,Ordinances or Regulations,for the construction afbuildings, additi s,alterations or for removal.dr deniolitidn as herein described:The,applicant agrees to comply with'all.applicable Iaws,ordinances;building code; housing code and regulations'arid to admitauthorized inspectors on premises and in buildirig(s)for necessary inspections.False statements made herein are , punishable as a Class A misdemeanorpursuant to Section 21D.b5,of the Nd%York State Penal Law., Application Submitted tint name : 'f, ,. I ❑Authorized Agent ner Signature of Applica t: Date.tk.__.___. 1 STATE OF NEW YORK) SS: �jOTA,*k'-<�'P/�� COUNTY OF ) .:NO.01M16231657. QUALIFIED IN SUFFOLK COUNTY COMM P. being dul}swarn,1100m. VO says that(s)he is the applicant (Na of individual signing contract)abov named, %may' Ugl�c p //F 0 F 1N E�,\ (S)he is the (Contractor,Agent,Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me,this day of ivi N tary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I residing J>0 d [2��j at �M� Dr ' " e S" g I�A � 1 � C L(Jt do hereby authori I bo_ S to apply on my eh f to the To no outhold Building Department for approval as described herein. 7,� Owner's Signa ure ������•'N°TART � 'X ate ,•'NO.0IMI6231657. ' QUALIFIED IN SUFFOLK COUNTY COMM. Print , Owner's Name = �, 11=2s N E\N D EC� E0VE JUL 2 2 2024 BUILDING DEPARTMENT- Electrica nspector TOWN OF SOUTHOLD Building Department Town Hall Annex- 54375 Main Road - PO BgbgSouthold Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrCaD-southoldtownny.gov - seandCa)-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: viateur Pilon License No.: ME-40557 Elee_emaiI Bethelec@optonline.net Elec. Phone No: 631-750-6555 ��'request_an email copy of Ce.t'ifica�e of'Com�p{ian- Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) N� Name: PMJD $- �����A t SSE-CrC_ Address: J brl SAA; ' <,- 01AJk Cross Street: Phone No.: Bldg.Permit#: email: a'Ujck nAS3e1 M ., ,co Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring Square Footage: Circle All That Apply: Is job ready for inspection?: W YES❑ NO ❑Rough In ❑✓ Final Do you need a Temp Certificate?: ❑ YES F✓ 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 2 H Frame Pole Work done on Service? Y N Add iti6—R-a1 I!'lfOrmatiOn:-Please call our Office with an inspection date and'the Homeowner for inspection access � shank you! PAYMENT DUE WITH APPLICATION PORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured / (631)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1 c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Rocky Point,NY 11778 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest National Ins Co Town of Southold 3b.Policy Number of Entity Listed in Box"la" 53095 Rt.25 SW5W000205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 to , 11/05/2024 3d.The Proprietor,Partners or Executive Officers are QX included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation Insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I rn an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: a. A-- 11/03/2023 (Signature) (Date) Title:President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Sa workers' CERTIFICATE OF INSURANCE COVERAGE TA E Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A ROCKY POINT,NY 11778 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required d coverage is specifically limited 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 53095 Rt. 25 3b.Policy Number of Entity Listed in Box"1 a" P.O. Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. , C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/7/2023 By Al 4t (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) i Telephone Number 516-829-8100 Name'and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C or 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 513 have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to Issue this form. D13.120.1 (12-21) �I�IIPiuim1�2i0oi1iiii(i12iu2i1)ii01� A CC?R D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/06/2023 THIS CERTIFICATE IS ISSUED AS A MATTER.OF INFORMATION ONLYAND 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 CONTACT K m O'Gara NAME: y AssuredPartners Northeast,LLC. HCONN Ext: (631)465-4000 FAX No 100 Baylis Road E-MAIL kym.ogara@assuredpartners.com ADDRESS: Suite 300 INSURER(S)AFFORDING COVERAGE NAIC# Melville NY 11747 INSURER A: Philadelphia Indemnity Insurance Co. 18058 INSURED I INSURER B: Everest National Insurance Co 10120 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios INSURER C: ShelterPoint Life Insurance 81434N 471 Route 25A INSURER D: INSURER E: Rocky Point NY 11778 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2382314181 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWD POLICY EXP DY EFF MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ©OCCUR PREMISES Ea occurrence $ 300,000 X Contractual MED EXP(Any one person) $ 5,000 A X AI incl Comp Ops/WOS/PNC PHPK2595157 09/01/2023 09/01/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X JEa LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident IX ANYAUTO BODILY INJURY(Per person) $ AOWNED SCHEDULED PHPK2595157 09/01/2023 09/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS RT HIRED X NON-OWNED PROPEY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER �/ OTH- AND EMPLOYERS'LIABILITY YIN STATUTE V ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBERExCLUDED? N/A SW5WC00205-221/222 11/05/2022 11/05/2024 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,000 NY Disability C DBL37154 02/01/2023 02/01/2024 Statutory&Continuous DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) The following are included as additional insured if required by written contract subject to the terms and conditions of stated policies:Town of Southold CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 RL 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ` _ ;.L� ..t.". •:r; fix.. i:� _ ;wi•.`'� <:• : �; _ ; m LOTS 106, /•fey 12, If 3 FUBAYVIEW 1�i.!!d3 F A3.ti /CiedER 2b 39dd � TOW OUT14OLD F... - •-� �,�_ � TOWS ESF YORK 5UFFC)LK•. CXPN4LW •N gp-34���w £ j', ,..,' `:o. 76 S.E. TAX "* .02-34.3 1 ~••• • - •� :!-� :• 1 ',t O3 s':c.r'YAx kC' �'3rJ ayosz c saa F �g ,c,•' /ERA If�[Td €Jut Ka. Iffy-sW ft- `ri0 i8 Y>3 c .t• f » TAX it • - �.._ � �-• � �V 1�14•-'7b-02-�.'� ":.CwlSt ec tcs ;•;;t:.. n x 4 sq t S ox Po brib'q` LA 4.. i. A . '�. .sue ' r• c •- '31'tr�. * is 0' BQ_3p y 4 is u V .`j• E c1 ms 14 JUL ti: .Y•.,.. � �i r.r r)e ti t* ,.F,. • `• 4 hhh�' Town of �ab�f en oamm $L ��`sSDIA$d�otd fir: Vw�''� �• o Qi s.7 • , ;;.. .N;, _UK ...rj !�)..'7', - F tS a ++ i 6?�.,2•"- _ :F� <arc _ - 'Y::. __y�.Y>.r:::.:`w�:.-n..-g,��,i�..t�'��s�',i�"r���, ,:.Y�_t:^ 'i„';•=. 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THIS POOL MEETS THE REQUIREMENTS OFANSI/APSP/ICC-5 AMERICANNA110NALSTANDARDFORRESIDEIJTIALINGROUNDSWI MT11G vU �.. O POOLS"AND1996BOCACODE-SECTION421.DIVINGEQVIPMENTISNOTALLOWED. •.._BEFORE WATE(�.. - .:� �i S. SWIMMING POOLSHALL BE COMPLETELY AND CONTINVOVSLY5VRROUNDED WITH A BARRIERCONSTRUCTED LAW REQUIREMENTS SECTION R326.4.2.1 THROUGH R326.4.2.6 OFTHE NEW YORK STATE RESIDENTIAL CODE(2020)AND IN CONFORMITY WITH ALLSECT APP VED AS NOTED 18' 10" OF THE TOWN OFSOUTHOLD CODE.DWELLING WALL(5)MAY SERVE AS PART OF THE POOL BARRIER ASPERSECTIONR326.4.2.BAN CONDITION(1)ARE MET.OPERABLE WINDOWS IN THE WALL(5)USED AS A BARRIER SHALL HAVE A SELF LATCHING DEVICE.ACCESS SHALL COMPLY WITH SECTION R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECUR DATE B.P.# o LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. � co aQs�t V V 2'BENCH 4. DURING CONSTRUCTION THE CONTRACTORSHALLERECTATEMPORARY BARRIER AROUND THE EXCAVATION LAWTHECODEORTHE v1lon TOWN OF SOVTHOLD ST u�,hO`� FEE BY-. u . low NOTIFY BU DING DEPARTMENT AT H2O z A 5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER AND SOUNDING AN } _ AUDIBLE ALARM UPON DETECTION THAT15AUDIBLEATPOOL5IDEANDINSIDETHEDWELLING.THE ALARM MUST BE INSTALLED, V v 631 765-18 8AM TO 4PM FOR THE MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS.THE ALARM ML15T MEET ASTM F2208 Z Q z 2'BENCH "STANDARD SPECIFICATION FOR POOL ALARMS.THE DEVICE MUST OPERATE INDEPENDENT(NOTATTACHED TO OR DEPENDENT ON)OF ry FOLLOWIN INSPECTIONS: o PERSONS. ,4'0 1. FOUND TION-TWOREOUIRED 6. POOL SUCTION FITTINGS(EXCEPT FOP,SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THATCONFORMS TO ASMEIAN51 0 T FOR P RED CONCRETE B A112.19.8MORA MINIMUM I8"x23"DRAINGRATEORA CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH . ATMOSPHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN.SUCH V1 2. ROUG -FRAMING&PLUV!31. G VACUUM RELIEF5Y5TEM5 SHALL CONFORM WITH ASME A112.19.17 OP,BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. PLAN POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTI NG5 OF THE ABOVE MENTION ED TYPE.THE SUCTION FITTINGS SHALL BE 3. INSU ION SEPARATED BYA MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A 4. FINAL- 30NSTRUCTION MUST N.T.S. VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCE551BLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO - BE COA PLETE FOR C.O. THE 5KIMMER/SKIMMERS.A REQUIRED POOL ATMOSPHERIC VACUUM RELIEF SYSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE ALL CONS UCTION SHALL MEET THE r ID'VINYL COVEREDSTEP5 24'BENCH R326.6.3(2020)AND IN ACCORDANCE WITH INC.VILLAGE CODE. REQUIREM NTS OFTHE CODES OF NEW 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE NY5 IF N RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND -----------M ------- y YORK STA NOT RESPONSIBLE FOR BE PROTECTED BY A GROUND FAULT CUP RENT INTERRUPTER.(GFCI)CURRENTCARkYING ELECTRICAL CONDUCTORS EXCEPT FOP,THOSE V PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENTSHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5.ALL c: DESIGN OR ONSTRUCTON ERRORS 2'TO4'SANDBOrrOM\"/ METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED 91 DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUN DED. s 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NY5 PLUMBING CODE 608. SECTION A 9. ALL PIPING 15 DIAGRAMMATIC UNLE55 OTHERWISE STATED. 1O v T:: o V, o-Z N.T.S. 10. WALKS IF PROVIDED,SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. s -cs _ ,�[perq,, pp ^ WATERLINE 24'BENCH TOP OF WALL 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW AN5I/APSP/ICC-5 SECTION 6. v s !lCC�I�H 11 ®� 10' 12. CONIRACTORTOPLACETHEPOOLIAWTOWNOFSOVTHOLDCODESETBACKS. Q S ^ 3 VC _ -- •- ,'na LAWFUL 1 '�•"� 13. ALL DRAINAGE FROM THE POOLSHALLBE MAINTAINED ONTHESVBJECTPROPERTY. � a USEIS U 15. THE DESIGN 15 BASED ON A DRAINAGE SOIL WITH<10;SILT.GROUND WATER SHALL NOT EXI5T WITHIN THE EXCAVATION. IF GROUND WITHOU CERTIFICV WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. �} 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY N SECTION B CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW ANSI Z21.56 AND SHALL BE INSTALLED IAW rl-A MANUFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR OF OCC N.T.S. GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPA55 SYSTEM.A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE V ' FOLLOWING ENERGY CONSERVATION MEASURES: 2'2" a :� CHECKVALVE 16.1 AT LEAST ONE TH ERM05TAT SHALL BE PROVIDED FOR EACH H EATI NG SYSTEM. -. = 00 COPING AND WALKWAY 00 10, 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCE55 TO ALLOW SHUTTING OFF THE MOTHERS)PUMP FROM SKIMMER GRADE OPERATION OFTHEHFATERWITHOUI-ADJVSTINGTHE THERMOSTAT SETIINGANDTO ALLOW RFSTARIING WITHOUT RELIGHT]NGTHE n .� WATERLINE PILOT LIGHT. C ti E 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQVIREMENTARE OUTDOOR POOLS �L d v m v 74 roDI5P O5AU ,4 - DERIVING 207OF THE ENERGY FOP HEATINGFROMRENEWABLESOVRCE5A5COMPVTEDOVERANOPERATING5EASON) m DKYWELL VNDISTVRBED EARTH - = 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET >} .-a / _ TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE ^ ¢ 3�0 J/ 3500 DSI POURED CONC. a - y C_ d m a cs SANITARY CODE OF NEWYORK STATE. Z�p DIVERTER 3/8'REBAR 2)TYP. a Y VALVE O N m a VINYL LINER - 17. THIS DRAWING 15 FOR STRVCTURAL5HELLONLY.ALL ACCESSORIES AND APPURTENANCES ARE DEFINED BY OTHERS. - = E c m ro- v o d R E 2'T04'SAND 16. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHTOF THE .. W FILTER -' _ WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" o F cc E4 ' 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL. L p, ro RE vRNs 20. THERE 15 NO MAIN DRAIN IN THIS POOL.SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY.THI5 MEETS C� COMPLY ITH ALL COD%Q REQUIREMENTS OF THE NYS RESIDENTIAL CODE-SECTION R326.5 FOR ENTRAPMENT PROTECTION. C NEW YORK TATE&TOWN CODES PLUMBING SCHEMATIC 21. THE POOLWAS DESIGNED IAWTHEFOLLOWING: AS REQUIR AND CONDITIONS OF N.T.5. WALL SECTION 21.1. THE NEWYORKSTATE RESIDENTIAL CODE-SECTION P326(2020) 21.2. THE NEW YORKSTATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2020) - /N.Y.S, C ZBA N.T.5. 21.3. THE NEW YORK STATE FUEL GAS CODE(2020) B 21.4. THE NEW YORK STATE SANITARY CODE. OF NEW PLANNING BOARD - 21.5. AN5I/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. '�� rO 21.6. BOCA COPE-SECTION 421. 5�oQag !fo"ayS��-* TRUSTEES RETAIN STORM WATER RUNOFF 21.7. CO D E OF TH E TOWN OF SOUTH OLD. * n PURSUANT TO CHAPTER 236 ELECTRICAL z2. ALL BACKWA5HTOBE5ELF-CONTAINED ON-SITE. u ' m r INSPECTION REQUIRED OF THE TOWN CODE. 1p