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HomeMy WebLinkAbout51138-Z oF souryol° Town of Southold * * P.O. Box 1179 ag 53095 Main Rd arm, Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45680 Date: 10/24/2024 THIS CERTIFIES that the building OTHER Location of Property: 900 N Sea Dr Orient, NY 11957 Sec/Block/Lot: 15.-3-39 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 06/28/2024 Pursuant to which Building Permit No. 51138 and dated: 08/28/2024 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: pool fence to code, as applied for The certificate is issued to: Donald Brudie Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: PLUMBERS CERTIFICATION: i Oth i d Signature '�oFSooryolc TOWN OF SOUTHOLD BUILDING DEPARTMENT ' 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#: 51138 Date: 08/28/2024 Permission is hereby granted to: Donald T Brudie 5 Cathedal Ave Garden City, NY To: Install fence to comply with pool barrier requirements. Premises Located at: 900 N Sea Dr SCTM # Section\Block\Lot# 15.-3-39 Pursuant to application dated 06/28/2024 and approved by the Building Inspector. To expire on 02/27/2026. Contractors: Required Inspections: Fees: ACCESSORY $125.00 CERTIFICATE OF OCCUPANCY $100.00 Total $225.00 Building Inspector OF SOUTyo� # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 o," INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SUL ION/C ULKIN�a [ ] FRAMING/STRAPPING [ FINAL q-rvlP�v [. ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] -FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMAR S: J $WPLa1 t�A L �f�A y - DATE 110D ANSPECTOR � �`�� II IIII I �� ��I! I Illlllll,!�'�% i�ll(� �f ���� IIIIIIII �P � i ,, , � � , III � R, FIELD INSPECTION REPORT I DATE COMMENTS yT' FOUNDATION (1ST) ------------------------------------- C FOUNDATION (2ND) t� O ROUGH FRAMING& y PLUMBING c i INSULATION PER N.Y. STATE ENERGY CODE 3IL i h 0 FINAL ADDITIONAL COMMENTS 010 ep o Z �rn c Q ® y O x d m b y TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(63,1) 765-1802 Fax(631) 765-9502 https://www.southoldtoLAM.gov Y Date Received a ; For Office Use Only - `�,(� PERMIT NO. 113 V Building Inspector: DI��* ' Applications and-forms must be filled out in their entirety.Incomplete B per- applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:. 41 Aq OWNER(S)OF PROPERTY: Name: nalt,ld T, &uat;a sum#s000- 15-3— 3�) Project Address: q00 tjot - Sea Dr, q, '©r;ew4 �•��(� q 5 7 J, Phone#: 5l L , 330 �(73g9 Email: bra d1 6 ' ,ni✓"1 Mailing Address: 5 CGl.-� Ldu�0. o fJlvl,(� 6-aw�p(�py G'�'�' 0� . 15 3 0 CONTACT PERSON: Name: ()0 n)t�LD Cit-13 ws. ►RrhN�i�l�ou�cS��'/� G Mailing Address: 10$r4 st lkt';S L. Hwy. ��y,,.(t? Ny) /r 70( phone#: 6 7 - �' - SOC7 1 �o— rJ 3 Email: DESIGN PROFESSIONAL INFORMATION: arJ Name: _ I Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: 01�J Mailing Address:4o gCkP{r;s,,P J?sv�,• Vv p Nay!/� Q Phone,#: Email: Cd DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: OpOther ibrePO'P, wo, Will the lot be re-graded? ❑Yes 9�No Will excess fill be removed from premises? [yYes 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is Situated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES, PROVIDE A COPY. ❑ The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal.law. Application Submitted By(print name): iV-1m M C 6o -5(PRA k%J9(aS r'W 1IAuthorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF JQ X-T,5& 1-t ) R9/1QW Qkb, C, (n6a Q 6,f Nct Co) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)abovl(e'named, (S)he isthe(Cc9✓1�1'ilt`�/'�tfJr" ,f�lY)Al IG1� rAActo a 1 (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 d n . day of �9 r, 203 Lj MAUREEN E.MAN Notary Public,State of New York Notary Public No.4955616 Qualified in Nassau County / Commission Expires Sept. (Where the applicant is not the owner) I, �4 �� i residing at 960 0(cn—�' ,���/� 11 q S7 do hereby authorize o apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 77. �:,+ qi " _ , ;o r�� F�#; ✓." ;,t:;r;. lJ ,S,.is:., �- ,,,.as ': ` .q�;ia... ^�1:. i., ~\ T:,t,;,; �L• •. f'..:a„ '���, ��. IA dill• .,r ,+ 1 1pll`''':+; !lll1.�;�r •',��111\� a, i, ,,,1lIIt��� ,,;'=' iii�'� � :�� '(AI1 �n; � llll `f�• +_i'�`�- __,Ef_:,� P]'�'�.1 Y:� ✓.,fli'.'$I`iF'a;'.1ti'11:"1Vi•�"p(,Y,1•(; '`tr t•pP,:,t�i,t ,�V„e „i 3.;:�.,,,i�:,;•' �:••, ..., �� �•W',r-..• 7 ...._...t.J..._t„.se.,.i�:J?!w41�!.,�.x..,t i•,U �It2I.3.i{`•tttial.t,.t,Jiti.,i,t.;, .{.t.i,„xt;;. .rfl„}'t;t..r i„t i, �n n;;t t t n irrrtrr:rt%u ttu ;tt, i t�+�r �,r.^:s; ;rt 1-,.i i.n mr. � -�`, �,. -, ........._s.....�.1.a.1.,.,,....,�•.�'9l....tt!).t. l ....... iti. 1;4: ,,.l;�tj,ylj;'a�jfLti:;iYf1 t,16 .r.�"U1-}.F•r`,L'+.2 )» E� 3 w-Su o lkvCounty Executive's-0ffice_of-onsu airs==-= -�-�--�---------=-VETERANS N�MORIAL—HIGHWI�Y*—HAUPPAUGE—_NEW�ORK I-L7.8.8—�,—�---_ _ "DATE=ISS:IJED,-----__-- .._.---_L.��._..-,_.�___-..�_---_._..-.--..__-- --•_�:Y. �--=��._��= _This is to certi£V�that Y - - ---_ — - - _ .� � --------_----..----_�---._---__- rCHAEL:JAIVIENDOL-A - - -�-- <.' - - -:::.�AMENDOI:AINDUSTRIE,S-INC----�_ r ��havinfuini'shed thele utrements�Oet_fort rin-accordance with and-sub'ectt_ to provisions of applicable laws;rules--- ~> -- - -les _- __—--�an�reguld�- at on of the_Coun_tyof-BuffoIlc,SState-o, Newt'Yorkjs-hereby licensed-toC-condu-c business �- - "��-= -—�-IIvIMROVEMEN CONTRA — - - _ CT012-_in the.,CouIti of Suffolk �.---� icense_ ate ory try. -�--�.- �< <._ �- __ ,_ :i,.� • —NOT-VALID-WITHOUT--Additional-Businesses- 9- �- t. --'--DEI'ARTMEK•i-A-L.-SEAL--.-•—�--------'•--• _p7`•D:—A-EQRREL�7 `--rA:IvIENDOLA�_INDUSTRIES—` ------ - :-_�MRER-AFFAIRS AMENDOL-ASrFENC-E-CO— _ -- ENDOLA-INDUSTRIES-INC-DBA---- --t�-AME 1DOL'A-FENCE-GO irector�� :.. -.. .::�:u.,,•.� •r„r.���.,;..;.r.:.,1..:�,-.�..r n•,�r•t(�;....%r„ �•��fi�., r.,�,r,.�,1.,., � � i f .,tC.,r�},n, „tr,� i.u,.,u,.rfNu•r...r..,l,n.,t�},i.r,. ,r,i,t,,,,i�t,r,A,;n,lru:; ,.�Il,,.i.,G;u;.i.l.r;se: ;!tams.�.a�:rl?i61`lin:i;,:!r�.�t,t.,"iir�„t�„li;, r,31..t.,iic�r:7s7.:, i, :,i�,:• :"�•;v rn•.�;,�.J,:�•, a r ,} _ 1111/. ,,., Ilff ,,' ,,,•„ -,�• a,. III r,a� 3,.� 1 / y 'Vr ;c �, t�3. ,: .!•3. ,• f� ��;�p�i•'tip �! s Nlll„ '•+ 1 '! III �-�1U%> �.:_ 1111/ _!%' � _ ,IIU .,•, t :,IIIt c,�. Ilf(/ :,�e• �y,<, Ifl11�"*�' ,} `r I Suffolk County Dept.of Labor,Licensing&Consumer Affairs w EOME IMPROVEMENT LICENSE Name i `.. .' VICNAEL J AMENDOLA Business Name This cerifies:hat the nearer is duly licensed AMENDOLA INDUSTR;ES.MC DBA :y the County of suffolk License Number:H-6244 Rosalie Drago. Issued: 09/01/1980 Commissioner Expires: 09/01/2024 } I Client#:171 AMENIND ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE,MMlDDlYYYY} 11/13/2023 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 1NSURERiS),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 any rights to the certificate holder In lieu of such endorsement(s). PRODUCER NRNTACT ME: Commercial Support Edgewood Partners Ins.Center AICON o Ext:631-390-9700 A/C Ne:631-390-9790 40 Marcus Drive E-MAIL 3rd Floor ADOREss: NEcertificates@epicbrokers.com Melville,NY 11747 INSURER(S)AFFORDING COVERAGE NAIC a INSURERA:Pennsylvania Lumbermens Mutual Ins CO 14974 INSURED INSURER B:Zurich American Insurance Company 16635 Amendola Industries,Inc. INSURER C-The North River Insurance Company 21106 D/B!A Amendola Fence Co. INSURER D:The Travelers Indemnity Company 25658 1084 Sunrise Highway Amityville,NY 11701 INSURERS: INSURER F' t 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 CONTRACTOR 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. LTR TYPE OF INSURANCE N R WVD: POLICY NUMBER BR MMIDCY EFF MPMIIDDCDYYEYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 31A5600523 1/13/2023 11/1312024 EF7vACH OCCURRENCE s1000000 CLAIMS-MADE OCCUR PREMISES EaEocCuDenpa $100000 X Contractual Liab. MEDEXP(Any oneOMM) $5 000 PERSONAL&ADV INJURY $1 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY F_X1 ECT LOC PRODUCTS-COMPIOPAGG s2,000,000 OTHER: 5 A AUTOMOBILE LIABILITY 31A5600323 1/13/202311/13/202 EaMBIINdDtSINGLEL?MIT 51,000,000 X ANY AUTO BODILY INJURY(Per person) 5 AUTOS ONLY AUTOS`)LED BODILY INJURY(Per occident) 5 X AUTO S ONLY X NON-0NMEO AUTOS ONLY PROPERTY DAMAGE 5 Per etddent 5 A X UMBRELLA LIAR X OCCUR 31A5600423 1/13/2023 11/13/202 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE 11156,000,000 DED I X1 RETENTION510000 I I5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYIMF ANY PROPRfETORIPARTNER1EXECUTIVE YIN E.L.EACH ACCIDENT: 5 OFFICERIMEMBEREXCLUDED? N!A (Mandatory In NH) E.L.DISEASE-EA E4PLOYEEI S Iles,describe under DCRIPTIONOF OPERATIONS belcw E.L.DISEASE-POLIC'YLIMI7 S B 12nd.Layer Excess AEC869412102 1/13/2023 11/13/202 95MM Ea Occl 55MM Agg C 3rd Layer Excess 5228117199 .1/13/2023 11/13/202 $1OMM Ea Occ/.S10MM Agg D 4th Layer Excess EX9SO8545423NF 1/13/2023 11/13/202 55MM Ea Occ!S5MM Agg DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) '5th Layer Excess Liability Firemans Fund Insurance Company NAIC#21873 Policy#1USL015019225 11/13/2023-11/1312024 a5MM Ea Occ/S5MM Agg. CERTIFICATE HOLDER CANCELLATION Village of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Mail Rd ACCORDANCE WITH THE POLICY PROVISIONS:; Southold,NY 11971 AUTHORIZED REPRESENTATIVE • 1 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S60292851M6029098 CPRAV 4 EWEW Workers' CERTIFICATE OF a1KE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name Address of Insured(use street address only) 1b.Business Telephone Number of Insured Alcott HR Group LLC DBA:Alcott HR Labor Contractor,for leased workers (631)420-0100 to: Amendola Industries Inc dba:Amendola's Fence Co 1c,NYS Unemployment Insurance Employer Registration Number of insured 1084 Sunrise Highway Amityville,NY 11701 1d.Federal Employer Identification Number of Insured or Social Security Number Work Location of insured(Only required if coverage is specifically limited to certain ;locations in New York State,i.e.,a Wrap-Up Policy) Carrier Listed as the Certificate Holder) American Zurich Insurance Company rVllage of Southhold 3b.Policy Number of Entity Listed in Box"I a' '53095 Mail Rd i WC 98-38-269-07' Southold, NY 11971 3c.Policy effective period 1/1/2024 to 1/1/2025 Id The Proprietor,Partners,or Executive Officers are x included.(Only check box if all partners/officers inclued) 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 vnll send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier most 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 unfit 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 po'icy 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,froese or ombar3Issued by a certificate holder,fha business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the busiress is complying with the mandatory coverage mquireirients of the Now York Steta Workers'Compensation Law. Under penalty of perjury,i certify that I am an authorized representative or licensed egertt of the insurance carrier reeeniced above and that the named insured has the coverage as depicted on this form. Approved by: Douglas Jones _ (Print name of authorized representative or licensed agent of insurance carrier) d Approved bv: � z�''� _ 12/19/2023 (Signature) (Date) Title: Vice President _ Telephone number of authorized representat3we or licensed agent of insurance carrier. (480)951-4177 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) ww.vvcb.ny.gov vo K workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured AMENDOLA INDUSTRIES INC. D/B/A AMENDOLA'S FENCE CO 1084 SUNRISE HIGHWAY 17162214109 AMITYVILLE,NY 11701 Work Location of Insured(Only required ifcoverage is speolticaliylimited to 1 c.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) Standard Security Life Insurance Company of Ne York Village of Southold P y W 53095 Mail Rd 3b.Policy Number of Entity Listed in Box 1a Southold, NY 11971 35079-75 3c.Policy Effective Period 2/16/2016 to 2/9/2025 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. Polipy 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 descr d above. Date Signed 2/11/2024 By (Signature of insurance carrier's authorded representative or NYS licensed insurance agent ofthat insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY SERVICED 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.hy.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 56 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(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.Fo'm' DB-120.1. Insurance brokers are NOT authorized to issue this forma D13-120.1 (12-21) IIIIIIIIIIIIIIIIIIIIIIIIII1IIII(I12Ilili1)Ill�llll Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificatg)to the entity listed as the certificate holder in Box 2. The in carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled 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 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 responsioilities beyond those contained in the referenced policy. This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy.is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the busines must provide that certificate holder with a new Certificate of Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory; coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employee in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an in carrier is produced in a-form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided;by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benTfits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first;two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. D13-120.1 (12.21)Reverse 0 TIED TO: LOT �� CERTIFIED 25 SURVEYOFPROPERTY DONALD T. BRUDIE & BARBARA T. BRUDIE AT89°30 'n00" LOT 76 MAP OF E� 2o'1`� �M°N ORIENT-BY THE-SEA FAO"4'S -FE 0.3'S LOT7° � SECTION TWO 145.13 P FILED OCTOBER 26, MAP #:3444 ��� Li FILED °58 2 SOUTHOLD 14 7 9, TOWN OF SOUTHOLD `° SUFFOLK COUNTY, N. Y. o � - 1 SURVEYED: SEPTEMBER 8, 2023 M0N i[ INGR. SWIMMING POOL I NOTES: • Lei o 1. PROPERTY KNOWN AS TAX MAP# 1000-15-03-039.0 `L N Cfl 2. LOT AREA =23,643 SQ.FT. (0.543 ACRE(S)) =3 Q 3. THIS SURVEY WAS PREPARED USING A TRIMBLE t, ,}4,0' 35.9 S3 ROBOTIC TOTAL STATION. _ 4. PROPERTY CORNER MONUMENTS WERE SET L MAS' STANDARD NOTES: I - _ 75 7. COPYRIGHT 2023 MICHAEL K. WICKS LAND SURVEYING _ I LOT 2, UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY MAP GEARING A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION 7209. (161 TREX DECK BELOW SUB—Di VISION 2, OF NEW YORK STATE EDUCATION LAW. 1 .Q (15.504-5�) 3. ONLY BOUNDARYAND SURVEYMAPS THE SURVEYOR'S EMBOSSED SEALI J� f� ARE GENUINE TRUE ANO COO COPIES COPIES OF THE SURVEYOR'S ORIGINAL WORK ACID OPINION. �•�L v_ C _ 4. CERTIFICATIONS ON THIS BOUNDARY SURVEY MAP SIGNIFY THAT THE MAP •� TRpC DECK ABOVE (4'X482�) '' 40'6" I l�� WAS PREPARED IN ACCORDANCE WITH THE CURRENT EXISTING CODE OF `co PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE W ASSOCIATION OF PROFESSIONAL LAND SURVEYORS, INC.THE CERIFICATION IS 48.Z' O LIMITED TO PERSONS FOR WHOM THE BOUNDARY SURVEY MAP IS PREPARED, TO THE TITLE COMPANY,TO THE GOVERNMENTAL AGENCY, AND TO THE LENDING INSTITUTION LISTED ON THIS BOUNDARY SURVEY MAP. 2 ? 5.THE CERTIFICATIONS HEREIN ARE NOT TRANSFERABLE W W Story.a m, I 6. THE LOCATION OF UNDERGROUND IMPROVEI.:ENTS OR ENCROACHMENTS ARE / N Z ReStialP'7 c!' w NOT ALWAYS KNOWN AND OFTEN ldUS7 6'c ESTIMATE 1F ANY UNDERGROUND In= L+'rgme ,� IMPROVEMMENTS OR ENCROACHMENTS EXIST OR ARE SHOWN. THE N JJ. 9 O 0 IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THIS SURVEY. jrt ,1 7.THE OFFSET (OR DIMENSIONS) S40YIN HEREON FROM THE STRUCTURES TO A/C THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES. RETAINING WALLS, O �`t't 1I POOLS, PATIOS PLANING AREAS.ADDITIONS TO BUILDINGS,FWD ANY OTHER pMLT DRNEWAY 32.7' ' `I o TYPE OF CONSTRuOTION- AS 0 1� a4 PVC FE ELL NOTED OH. m ENCL FRONT " c<�"`� -'•* /%' w-� 40,6. Ti` 3� �:: PROVED AS ENTRANCE 8 D AT "ZII Z 1 B.P.# MAS. PL. FEE Y: CD MAS. WALK NOT BUILDING DEPARTMENT AT 631— 65-1802 8AM TO 4PM FOR THELn FOL WING INSPECTIONS: �„ —; �, It COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED OUNDATION—TWO REQUIRED i e'�€ rl. r low Ifli-91I.7 OR EMBOSSED SEAL SHALL NOT ECONSIDERED TO BE A VALID COPY. i ' OR POURED CONCRETE I ' MICHAEL K. W KS, P.L.S. 50390 OUGH—FRAMING&PLUMBING zi ' MICHAEL K WICKS SULATION IN AL MusT LAND SURVEYING E COMPLETE FOR C.O. '` T 'S� �-�"-'� _ 15 FROWEIN RD — SUITE E2 ALL ONSTRUCTION SHALL MEET THE DN E r—" CENTER MORICHES, NEW YORK 1i934 A DU W ES J r� ��i�I h � VOICE: 631.874.0156 — FAX. 631.909.3845 RE IREMENTS OF THE CODES OF NEW ;DN _ _ CALIFORNIA www.wicksl¢rdsurueying.com YO STATE. NOT T `T E IIcl a E /fj L * .f RECORDS OF RICHARD C. DRAKE DE GN OR CONSTRUCTION ERRORS T ro j� -_ �`�� SCALE: SURVEYED BY: DRAWN BY: SHEET: 1 v 1 e �oIll �J d/ 1°=20' M.W. J.W.W. 1 OF 1