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HomeMy WebLinkAbout50253-Z tOF SOUIyo`o Town of Southold * * P.O. Box 1179 G oQ 53095 Main Rd °���nurm Nei Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45675 Date: 10/23/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1425 N Sea Dr Orient, NY 11957 Sec/Block/Lot: 15.-5-27 Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 12/21/2023 Pursuant to which Building Permit No. 50253 and dated: 01/25/2024 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: Frank Schlecht Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50253 4/30/2024 PLUMBERS CERTIFICATION: A tho Ve Signature �g�FFDL�� TOWN OF SOUTHOLD ao. aye BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE oy • o� SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 50253 Date: 1/25/2024 Permission is hereby granted to: Schlecht, Frank 257 N Queens Ave North Massapequa, NY 11758 To: construct accessory in-ground swimming pool as applied for. At premises located at: 1425 N Sea Dr, Orient SCTM #473889 Sec/Block/Lot# 15.-5-27 Pursuant to application dated 12/21/2023 and approved by the Building Inspector. To expire on 7/26/2025. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO SWIMMING POOL $100.00 Total: $400.00 Building Inspector OF SO!/j�ol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 11971-0959 •old �o Ja mesh l'a�southoldtownny.gov COU��N BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Frank Schlecht Address: 1425 N. Sea Drive city:Orient st: New York zip: 11957 Building Permit#: 50253 Section: 15 Block: 5 Lot: 27 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electec Inc. Electrician:.Frank Zambrishi License No: 4814-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt 1 Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 1 4'LED Exit Fixtures Sump Pump Other Equipment: 1 pool panel with time clock, 1 240v pool pump, 1 120v pool heater, 1 120v salt gen, 1 300watt transformer for 3 Iv pool lights Notes: POOL Inspector Signature: Date: April 30, 2024 1425 n sea dr Of SOUTyolo N � TOWN OF SOUTHOLD BUILDIN DEPT.. °ycoorm,��' 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] .FINAL [ ] .FIREPLACE & CHIMNEY [ ] FIRE-SAFETY INSPECTION [ - ] FIRE RESISTANT CONSTRUCTION.- f ]. FIRE RESISTANT PENETRATION �JVELECTRICAL (ROUGH) ELECTRICAL (FINAL) ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: nJJ4- � DATE . INSPECTO �o��OF SOUryp`o \J I v'v fV TOWN OF SOUTHOLD BUILDING DEPT. COY�m�i� 631-765-1802 INSPECTIO-N [ ] 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: ton i - PK DATE INSPECTOR SOUTyolo # # . TOWN OF SOUTHOLD. BUILDING DEPT. cOU 631-765-1802 , ' 1 N'SPECTION [ ] FOUNDATION 1ST/REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ eFINAL SULATION/CAULKING FRAMING /STRAPPING [ ] FIREPLACE & CHIMNEY [ ] :-FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE 101A "1A INSPECTO FIELD,INSPECTION REPORT DATE COMMENTS lb FOUNDATION(1ST) H I 1 C FOUNDATION(2ND) • O S vl � y ZA ROUGH FRAMING& y PLUMBING • _ t INSULATION PER N.Y. y STATE ENERGY CODE m L low f7Oti' Ll FINAL ADDITIONAL COMMENTS J VAX A G � 'Y 22 Z 12S / `7 o Ns i� 0 � z - r _y n �Ffotgrc TOWN OF SOUTHOLD-BUILDING DEPARTMENT oy� Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 • ov a` Telephone(631) 765-1802 Fax(631) 765-9502 https://www.southoldtownny.gov W Date Received APPLICATION FOR-BUILDING PERMIT - -' - For.Office Use Only .. i s J \ PERMIT NO. ` 'Building Inspector: I i DEC 2 1 2023 `r^ �"s.`muY"':b' ill�'•'�out'ina;eir'ntiret5t'%loco let��"���z"'Apptcatlons a d forrnl st s f d h ��,A y ritp e�r �,� �, ,app{icai�on�wUl not 6e accepted' 1Nhere the Applicant is;not,tl�e owneg an,r' f ,�,� .r,,.�n,.f., �,�^�, Ownei's:Aiihorizaton�,fori�i, Pa e:2�'sliall be coin leted:`�r�`��`�`r=f�'- •�'w 3 �"�"� °•'°�-'� ��'°'��° !^ r'f. ,.:ti 1! ':;r'� ".�4<" >,1.. �'ii}'••"Y? "'.t�.,. ti�Y'��'" '.fir t'��r'.{, i;,�v"i.. ! ,� .0 Date: :'rF^ of-,;s. ^'SW.;,?�„ w t 'e? ,x- Ar '' t" i-�' ':�," ,.;1:,-6.,w>✓x, {1 a' �`�>' ;'tW -',..F7;>..f,-,,'" , w'��"� �:'s..;y'+. 'w•% :;OU4INER PROF�ERTY:-` ,. , A•... . . . A r x s E 1 k 4 */5e."C' i'� :3. ..tS. c:G. =V't:rc' fJ � -.ti.z-?y.1 >Y� ✓w"' 1,.,. .,...t ( �,.� S<' � Kure Name:V�K Au6i�� hle�Fr�- SUM#1000- ���Jr,�� Project Address: �y� N � - dr,f� � -IV% 119.6-7 Phone#: S�Ln��%2- �9v3 Email: /(-�-b leGh+�oc�nf Mailing Address: /y�s , , 5 U,--�n�, �l/cr /I 9S,7 r{:t a; ^S. d .r CONT CT.PE N..•A - �-y Name: Mailing Address: X13, Phone#: �0 3I _ 73y_766S Email: <DE5IGIV P90 ESS[t1111AL<I111F�Ri1AATION Name: Mailing Address: Phone#: Email: 7 .CONT O T� Name: L- Mailing Address: �oX 9 ) CLAC,6o L",� Phone#: Email: ►tee+ -UCT - ~=� EC 1PT10 OF R N S - - ?i. x4Gr;, 5: ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: NOtherzz::-M Scc�,r»►vr�►-�e ��y� $ 2�&D00-06 F the lot be re-graded? LYes El 'No Will excess fill be removed from premises? Ce []Nos No 1� s. Existing use of property: 2e:5i"tiC-4 Intended use o propert &�q Zone or use district in which premises is situated: Are there.any covenants and restrictions with respect to this property? E]YesKNo IF YES,PROVIDE A COPY. ri" M ft—upg., pr-- 'Kv °ieavi bid. :80(Al Coe. 1 left V APEiAv MA', Obbor"WA 0,� W� PP­­­­0`r-'­ SMk Ne"040k"46d" ;7" 77*1 A", OMAN 10MA LJ e_ Application Submitted IBIV(pri name).: (L,,.!:33*Pe I n- EfAuthorized Agent 0 Owner t. Signature of Applicant: Date: STATE OF NEW YORK) COUNTY OF &L)fier-Lc being duly sworn,deposes and says that(s)he is the applicant (Name of ndividual 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/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 S+d-ay of Nota l MyPE-ic L.GLEW Notary Public,State of New York No.01 GL4879505 PROPERTY OWNER AUTHORIZATOON Qualified in Suffolk CpunI4 (Where the applicant is not the ownef)ommission Expires Dec. 8, residing at do hereby authorize Aa.It LL to apply on my behalf to the Town of Southold Building Department for approval as described herein. wnees sigipaturp Date fc&iL)4 1,01- Print Owner's Name 2 J' J'r BUILDING DEPARTMENT-Electrical Inspector � T` 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 ., rogerre-southoldtownny.gov- seand rJsoutholdtownny aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORM ATiON (Ail Information Required) Date: a Company Name: Electrician's Name: License No:. PC6!I-+_ m C, Elec. email: a C© rn Elec. Phone No: _ 9 01 request an email copy of Certificate o Compliance Elec. Address.: 2 JOB SITE INFORMATION (All Information Required) Name: SC 12 daft Address: [It-D il Cross Street: t- Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: ) Block: Lot: 02 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Foo e: Circle All That Apply: . K Is job ready for inspection?: YES®NO ❑Rough In Finaq/30 Do you need a Temp Certificate?: YESP�VO Issued On Temp Information: (All information required) Service Size01 PhF-13 Ph Size: A #Meters Old Meter# [-]New ServiceE]Fire ReconnectM Flood Reconnect®Service Reconnect®Underground QOverhead # Underground Laterals 1 02 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Ef JztJ 24 a%a( 1 b1 V2-7 PERMIT# Address: Switches I Outlets 0 GFI's I Surface Sconces H H's UC Lts Fridge HW POOL vvQ'r Fans Mini Fr. W/D PanelPump 2i � �� d Exhaust Oven Sump Heater 1 Z� Trnsfmr Smokes DW Generator Salt Gen. ?C-41) Carbon Micro GrbDis Water Bond vo'* Lights Heat Pucks ERV HOT TUB/SPA Inst Hot DeHum Transfer Disc Combo Cooktop Minisplit Blower AC AH Hood Blower Service Amps Have Used Sub Amps Have Used Comments C& 3 L GCS 1 6W Can F If ET. - E t.E V'/)*j I C)N. 17AT611A 1494 Rg�tor Feinn Lars well 'a p TttZT. � Y,1 V t' f ,8 00 . rote ut�aurHORYLE4;AtTERA'[It?N;hB:kM)TiO� i ..� , � • . T0,.7k15 SURYFj-AT Ew .tS'`gi:N10tAT1�`i OF ([ , �,V}�K�Y��.'':.T+O�iG SECTION 72C9 OF tTHE'NEW-;YCfiK 57ATE i 4 0-)El CF.THIS SURVEY AAAP-NOT®EARING "tfYOR'S'INxD:EAIOR •• '•« •r••: - � .. h16�:Sti+. ,. NALL NOT 8E CONSIDERED } IWO TO BE A 11a4a, I::"COPY. ClAy" j pwsAR 10-N q UAs?!T::S :!Ct�1:1_mitiON'Sfl a RNMt � lP.. d _rr Pkiii ac:.,I:,:' 't•7IiL :%LF TO,THE f -- - _ ITLE COIAFA;I- o•.t Y.IN:h.A�AGENCY ..A LE/ ING IN32iTUriv.:r.yi37 H.a.J�1,;AND' TO THE ASSIGt4Qi'0E;TFSt.I:iONG INSTI; ; T vwf.GUARANTEES;' 0J q ItANSFE_ ORIENT ,. N. tl • TO ADDTIOHAL tNSTEEU.105:OR SOUMUMN OWNERS. 3celet �a'+��•' GLI�►fCt�MT1r+TrG �b ANfiCaG�Eetit .'l�t!'T4�g.. a ce si ,elegy 2t1MV&VLbD III JAvUAMEY it is :. ... NotcLot momtwes owwn rafeEr 40 Mop of Drieti4 tom; thr 5- a— ; .-...`' '' .. ..... 5Ertion'rw&?-, iitad ieq 1110 6of**iiC t ____.._....�.._ Li"ndfJ Ladd 'r ury c to ws Cs. C Itx rk OF re-0 4% PACIp W�444. DATE(MMIDDIYYYY) A►COORo® CERTIFICATE OF LIABILITY INSURANCE 2023 -z/zo/---- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO NT CT Lauren Murphy Roy H Reeve Agency,Inc. PH (631)298 4700 FAX (631)298-3850 A/C NONEo Ext: AIC No PO Box 54 E-MAIL Imurphy@royreeve.com ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B: Chituk Pools Ltd. INSURER C: PO Box 9 INSURERD: INSURER E: Cutchogue NY 11935 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2321518551 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. POLI TR TYPE OF INSURANCE INSD WVD POLICY NUMBER MOMIUDD EFF MMMD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ©OCCUR PREMISES Ea occu DAMAGE TO RENTEence $ 100,000 X Contractual Liability MED EXP(Any one person) $ 15,000 A 6018146726 03/15/2023 03/15/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ E,,,dent ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Par., UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH. AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Re: Frank Schlecht,1425 North Sea Dr,Orient,NY 11957 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. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 --1 � ©1988-2015ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 6/13/23,2:36 PM Certificate of NYS Workers Compensation Insurance Coverage CERTIFICATE OF '' `orkors, NYS WORKERS'COMPENSATION INSURANCE COVERAGE Insured Detail la.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 la NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is spec*ally limited to 2.Name and Address of the Entity Requesting Proof of Coverage 3aName of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold PO Box 1179 3b.Policy Number of entity listed In box"la": Southold,NY 11971 W9NC3623614 3c.Policy effective period: l/1/2023 to 1/Y2024 3d.The Proprietor,Partners or Executive Officers are: FED 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 113"insures the business referenced above in bog"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 lilted ABovd fig the dertifidafe-B61116f iu B61"2". The insurance carrier must nodfy 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 ofpremiums drat cancel the policy or eliminate the insured from the coverage indicated on this Cer4 icate-(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 slier the coverage afforded by tMe 06lidy`listed,fior does it doiifer airy rfghte or i eap aiffifiifia my—aind fffose lidwained in Ilia ireferenced 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 its complying with the mandatory coverage requirements of the New York Sfafd Wdr-M's'Co"iiipens"afiofi L8Vv. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) a f. Approved By: 6/13/2023 (Signature) (Date) Title: Senior Vice President httpsd/wc.amtrustgroup.com/ANAWC/PolicyNYCertificateOtWclns.aspx?Indexld=418222&instanceld=853ce09d-fccb-4330-a5b5-24bccf8ad5fb 112 6/13/23,2:36 PM Certificate of NYS Workers'Compensation Insurance Coverage Telephone Number of authorized representative or licensed agent of insurance carrier:877-528-7878 Please Note.,Only Insurance carriers and their licensed agents are authorized to issue the G105.2 form.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering contracts unless compensation is secured. 1.The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however,shall be construed as creating any liability on the part of such state or municipal department,board,commission or office to pay any compensation to any such employee if so employed. 2.The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for ail employees has been secured as provided by ibis chapter. C-105.2(9-17)REVERSE httpsJ/wc.amtrustgroup.com/ANAWC/PolicyNYCertificataOfWclns.aspx?lndexld=418222$Instanceld=853ce09d-fccb-4330-a5b5-24bccf8ad5fb 212 CERTIFICATE OF O I�r�CerSr NYS WORKERS'COMPENSATION INSURANCE COVERAGE vTE r rnp�rasatiata Sciard Insured Detail la.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Chituk Pools Ltd 631-734-7665 PO Box 9 Cutchogue,NY 11935 le.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured certain location in New York Slate,i.e.a Wrap-Up Policy) 2.14ame and Address of'ihe Entity Requesting Proof of Coverage JaAame of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold PO Box 1179 3b.Policy Number of entity listed in box"la": Southold,NY 11971 W WC3688012 3c.Policy effective period: 1/1/2024 fo l/l/2025 3d.The Proprietor,Partners or Executive Officers are: ❑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"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"T'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to HohpdyiHent of pre"m mim or WitlfiH 30 ddyg IF lit f g dre t'easM olfief Ilia"ii Iiotipayiiiehf of pMMii1l37f lliat edheel Ili&policy of elimit7die[lie 111511Fad 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 axpiration 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 insuranee 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 am an authorized representative or licensed agent of the insurance carrier referenced above and that #lie named insured liar the coverage as depicted on this form. Approved By: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) -2 Approved By: 12/20/2023 (Signature) (Date) Title: Senior Vice President Telephone Number of authorized representative or licensed agent of insurance carrier.877-528-7878 Please Note:Only insurance carriers and their licensed agents are auduonzed to issue the GI052 forin.Insurance brokers are NOT authorized to issue it C-105.2(9-17) wmvwcb.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering contracts unless compensation is secured. 1.The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however,shall be construed as creating any liability on the part of such state or municipal department,board,commission or office to pay any compensation to any such employee if so employed. 2.The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)REVERSE Yo K workers CERTIFICATE OF INSURANCE COVERAGE srA'; Compensation ._I i oard NYS DISAMUTY 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 carrle 1 a.Legal Name 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245 POBOx9___ ____ CUTCHOGUE,NY 11935 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required coverage Is specifically limited to or Social Security Number certain locations in New York State,La.,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 PO Box 1179 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL614067 3c.Policy effective period 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. C.Paid family leave benefits only. S. 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 6/13/2023 By �4hd 4f (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(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. 013-120.1 (12.21) 1111111111111111iiaiiiuliiiiiiniimi"IIIII Additional Instructions for Form 1313-120.1 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(Certificate)to the entity listed 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 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 responsibilities Beyond fFi d confaindd 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 IJUSIHeee Must:provide that:ceFt'ifrcete holder with a rfiew C&TiificatO df InSi M06 CdOM&fof NYS C1199 Ilty 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 §226. 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 employees 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 insurance 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 benefits 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 noiwithstanding 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. DB-120.1 (12 21)Reverse .1 D (/vnV APPROVED AS NOTED LATE! .P# FEE BY: RETAIN STORM WATER ER 236FF NOTIFY BUILDING DEPARTMENT AT PURSUANT TO 631-765-1802 8AM TO 4PM FORTH E OF THE TOWN CODE. FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE 2. ROUGH-FRAMING&PLUMBING 3. INSULATION 4. FINAL-CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR ELECTRICAL DESIGN OR CONSTRUCTON ERRORS MSPECTION REQUIRED COMPLY WITH ALL CODES OF NEW YORK STATE &TOWN CODES AS REQUIRED AND CON ITIONS OF SOUTHOLD TO N ZBA SOUTHOLD WN PLANNING BOARD ��I F-DIATPLY�� SOUTHO TOWN TRUSTEES ENCLOSE POOL TO;CODE N,YS.D W�UPON COMPLETION SO OLD HPC `-.BEFORE"WATER" . SC OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICAT. OF OCCUPANCY M p• --- _ :4�0 T 4� 12s88 POOL&QE wMstbi R. ..B-. C . :D E-.' F, . �'. H 'K -•'L. • 1440 ' 14Y34• 14. .:30 -T 4" 6 6• 6 14' 6 :4_ '4: 8 16' `28' 3`•4r. :$^6•. -•:�.. .:.1t: 6',..:.g. ;-A "S., ''4'-0":••Td:� t04¢:• 16�1 16 '20: .3'4".- iO'W'':.--A.., 4. :..8•: q:0•`Tr4_:9500 • 1bfl0`•; :+.',a6iC3A: 16: ..30:% 3'd"; 6 4' :,8: '.12:. : ::4:: .4.•..:'8: 4-0° :r 4"'1/000 :•.....-. 4�A ._ .. -... . . '.:•. - tOsifi... 10i¢U ... j8.: ..96,E�3.4";'::4'�::6':. '.4.:..�":4'� �.:2:"• :•:Z-. 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'. .et1SR- 6095014 'wil GOP DMNG BOARD ep NNW FRWI TYPICAL ew P CONNER C0N CH0IN GEML a®s ------------- y am um roasam �Y� EEpy FOOL SEMON • Complies With .." �`�d' /,! - __ �J`•�tv'' • � .. . . . . - . .. ...� .•- .. ..�.:..�.:�. ,- .. F� o. 2 Pam. 2020 Code Section 3032.1'=303A Swimming Pools,Spas and Hot Tubs ARp��gS1 � SdctionR326 of the-Residential Code of NewYork ------------=' `�------------- Section 3100 of the Buildingtode of New York + Section N1103-12(R403.12)Residential Pools and Permanent Residential Spas POOL�f E:RECTANG� . REV. u SCALE: :NYS' x Section 31093.12-3109 7 4 Pools and Spas Gates,Barriers 1AMES'®EERK®SK'a P.E. : - Section G106 Entrapment Protection .- ®ATE: . PIC EL� PANE Section G107 Alarms 960 BEER®RIVE Section i 4201—E4312 Electrical Connections tot Pools MA.T f•UK,NEW YORK 119S2 DRAWING DUMBER 1 OF 1 NOTES: 1. DIVING BOARD TO CONFORM WITH ANSI/APSP/ICC-5 SEC 6 2. NO SOIL DISCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION 3. POOL MUST BE SURROUNDED BY A CONTINUOUS BARRIER CONSTRUCTED IAW REQ.OF SEC 326.4.2.1-R326.4.2.6 OF THE NYS RESIDENTIAL CODE(2020)AND ALL SECTIONS OF THE SOUTHOLD CODE 4. WALLS MAY SERVE AS PART OF THE POOL BARRIER AS PER SEC 326.4.2.8 AND ALL WINDOWS HAVE A SELF LATCHING DEVICE 5. ACESS GATES SHALL COMPLY WITH SEC R326.5.2 OF THE NYS RESIDENTIAL CODE(2020)AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY LOCKED WHEN POOL IS NOT IN USE OR SUPERVISED. ALLL GATES ARE TO OPEN AWAY FROM THE POOL AREA. 6. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECT A TEMPORARY BARRIER AROUND THE EXCAVATION IAW CODE OF THE TOWN OF SOUTHOLD. 7. POOL MUST BE EQUIPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING ENTRY INTO THE WATER AND SOUNDING AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE AT THE POOLSIDE AND INSIDE THE DWELLING.THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH TEH MAUFACTURERS INSTRUCTIONS.THE ALARM MUST MEET ASTM F2208"STANDARD SPECIFICATION FOR POOL ALARMS".THE DEVICE MUST OPERATE INDEPENDENT(NOT ATTACHED TO OR DEPENDENT ON)OF PERSONS. 8. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIIMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/ANSI.A112.19.8M OR A MINIMUM 18'%23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM.POOL CIRCULATION SYSTEM MUST BE EQUIPTED WITH ATMOSPHERIC VACUUM RELEIF.SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME Al12.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD.POOL SALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE.THE SUCTION FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS).VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN ACCESSIBLE POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENT TO THE SKIMMER/SKIMMERS. A REQUIRED POOL ATMOSPHERIC VACUUM RELEIF SYSTEM SHALL BE INSTALLED AS PER NYS RESIDENTIAL CODE R326.6.3(2020)AND IN ACCORDANCE TO TOW CODE 9. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC),PRINCIPALLY ARTICLE 680 AND THE NYS RESIDENTIAL CODE SECTION 4102 THROUGH 4106.ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GOUND FAULT CURRENT INTERRUPER(GFCI).CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER TO POOL' LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5. ALL METAL ENCLOSURES,FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT WITH AN ELECTRICAL CIRCUIT SHALL BE EFFECTIVELY GROUNDED. 10. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 608. 11. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 12. WALKS, IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM THE POOL EDGE. 13. A-MEANS OF EGRESS FROM DEEP AND SHALLOW ENDS MUST BE PROVIDED-IAW ANSI/NSPI-5 SECTION 6. 14. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS. 15. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. 16 THE DESIGN IS BASED ON A DRAINAGE SOIL WITH<10%SILT.GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION.IF GROUND WATER EXISTS WITHIN 60"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. 17 ALL GAS AND OIL WATER HEATERS(IF INSTALLED)FOR THE IN-GROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT(NAECA)COMPLIANT.POOL HEATERS SHALL BE TESTED IAW ANSI Z21.56 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726.POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS.POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES.A BYPASS LINE SHALL BE INSTALLED FROM THE INLET TO OUTLET TO ADJUSTWATER FLOW THROUGH THE HATER.POOL HEATERS SHALL BE PROVIDED WITH THE FOLLOWING ENERGY CONSERVATION MEASURES: 17.1 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASYACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE PILOT LIGHT. AT LEAST ONE THERMOSTAL MUST BE PROVIDED FOR EACH HEATING SYSTEM.HEATED SWIMMING POOLS SHALL BE EQUIPTED WITH A POOL COVER.(exempt FROM THIS ARE OUTDOOR POOLD)DERIVING 20%OF THE ENERGY FOR HEATING THE POOL FROM RENEWABLE SOURCES OVER AN OPERATING SEASON. 17.2 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS,AND CAN BE SET TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITORY CONDITION IAW APPLCIABLE SANITORY CODE OF NEW YORK STATE. 18 BACKFILL WILL BE DONE WITH CLEAN EARTH FREE OF ROOTS AND DEBRIS. BACKFILL HEIGHT AND WATER LEVEL TO BE WITHIN 8"OF EACH OTHER. PLACE CONCRETE ON SANDY LOAM SOIL. CLAY TO BE REMOVED AND REPLACED WITH SANDY LOAM. 19 THERE ARE MAIN DRAINS IN THIS POOL.THERE ARE TWO APPROVED SUCTION OUTLETS WITH A MINIMUM OF T OF SEPARATION. THE SUCTION OUTLETS ARE PIPED SO THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM-RELEIF-PROTECTED LINE TO THE PUMP.COMP I WITH ENTRAPMENT PROTECTION AS PER CODE. 20 THE POOL WAS DESIGNED REFERENCES AS THE FOLLOWING: 20.1 THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE(2020)SEC R326 OF p EW Y�Q 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 5 1. RHO 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) � ��F.. •`¢ ` Y�r r x 20.4 THE NEW YORK STATE SANITORY CODE. 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. V; �'vc+� POOL NOTES SCALE: NTS 20.6 BOCA CODE SECTION 421. Fop 07 - P� JAMES DEERKOSKI, P.E. 20.7 CODE OF THE TOWN OF SOUTHOLD R�FE 260 DEER DRIVE DATE: 101212020 MATTITUK, NEW YORK 11952 DRAWING NUMBER 2 OF 2