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Home My WebLink About50368-Z of soulyo� Town of Southold * * P.O. Box 1179 2 0 53095 Main Rd COUNMV.�`� Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45678 Date: 10/24/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 45 Oakwood Dr Southold,NY 11971 Sec/Block/Lot: 70.-13-1 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 01/24/2024 Pursuant to which Building Permit No. 50368 and dated: 02/23/2024 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: James&Cynthia Traina Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50368 09/26/2024 PLUMBERS CERTIFICATION: _YA� Authorized qignature �o�SOFFo�,t�oG TOWN OF SOUTHOLD y BUILDING DEPARTMENT x TOWN CLERK'S OFFICE �y • �� 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#: 50368 Date: 2/23/2024 Permission is hereby granted to: Horne, Karen 45 Oakwood Dr Southold, NY 11971 To: construct accessoryin-ground swimming g g pool as applied for. At premises located at: 45 Oakwood Dr, Southold SCTM #473889 Sec/Block/Lot# 70.-13-1 Pursuant to application dated 1/24/2024 and approved by the Building Inspector. To expire on 8124/2026. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $300.00 CO- SWIMMING POOL $100.00 Total: $400.00 Building Inspector SO(/r�o! Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlin(cD-town.southold.ny.us Southold,NY l 1971-0959 cDUNr1,N BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Karen Horne Address: 45 Oakwood Dr city:Southold st: NY zip: 11971 Building Permit#: 50368 section: 70 Block: 13 Lot: 1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Elec Tec Inc License No: 4814ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1 st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: Aqualink RS Intermatic Pool Panel 4 Circuit/4 Used, Pump 220GFI, Hayward Salt- Generator, Heater, (2) Lights 1 OOW Trans. 120GFI, AutoCover 120GFI, Waterbond on Pipe Notes: Pool Inspector Signature: Date: September 26, 2024 S.Devlin-Cert Electrical Compliance Form Copy OFSo(/lyO� Lf 5- 0 Cuk # # TOWN' OF SOUTHOLD BUILDING DEPT. co 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ 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: �'�— un4 b- and'a )-a cnite-1Atlo cQue/ is cal, J\e ISA� /all DATE - I - INSPECTOR OF SOUTy�� .r S L/�/`'t Ll/ D Q•/� -- # # TOWN OF SOUTHOLD BUILDING DEPT.. o m, �o . 631-765-1802 'INSPECTION [ ] FOUNDATION 1 ST/ 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 [9XI ] PRE C/O [ ] RENTAL REMARKS: 451 o4 le 14 /' Coe- 0 R Z- DATE 2 INSPECTO . 500 7(P !! # # TOWN OF S.OUTHOLD 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) L4 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ]' PRE C/O [ ]- RENTAL ti REMA�KS:�� POO otjo ooer f be 5 ac._d nod ,twt,e_ br-ea er DATE 0 �" INSPECTOR SOUIyOIo &0 36- - 15 — # # TOWN OF SOUTHOLD BUILDING DEPT. cou 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: kJ in oo l� �C1ZJam®,, `e� ce-A 1 „ t,� �r DATE INSPECTOR L so # WN OF SOUTHOLD BUILDING" DEPT. cou�m� 631-765-1802 INSPECTI.O'N [ ] FOUNDATION 1 ST/REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ "] FIRE RESISTANT CONSTRUCTION [ ] TfIRE RESISTANT PENETRATION [. ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR 50 3& 41:1 Ofr SOGTyol10 # TOWN OF SOUTHOLD BUILDING DEPT. `yco . 631-765-1802 INSPECTION ] FOUNDATION 1 ST/ 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: 61ec,&C* Ki� A et ta. C c. tit e d%w n rs#4 �v he o/� inside. 'al, Vo:,d a-g� a.le"s m vs� scw/ oo�- �w /L8A-: ),21/; cJ; �a- 4 ,rU4 4e- l2tw�d W , 5 LahO a "W has2kos.� 049�1- DATE - INSPECTOR �� aOF SO(/T�° 205&9 # TOWN OF SOUTHOLD BUILDING DEPT. Couffov, 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATII�ON/CAULKING [ ] FRAMING /STRAPPING [�INAL (!" O/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETYINSPECTION [. ] FIRE RESISTANT CONSTRUCTION [ ] 'FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: /*/7y'c� — Zm� v oewtlu� A D!G Ae �. • DATE /o a3 ��. INSPECTOR Nir,Lil INSPECTION REPORT DATE COMMENTS •o FOUNDATION (1ST) CA — -- - -- .� -------------------------------------- CA -FOUNDATION (2ND) ----- -- ,2 O ROUGH FRAMING& — - PLUMBING � r INSULATION PER N. Y. STATE ENERGY CODE �0'a •02 Qiyj� "T�- 5 I�W�Q e �. .� 2 f2lc�0___cte • hQed�e2. �D'� �� M�c�iiis st-swim auk K aw vAit ems/ hsic es 46 cf�a- a,/ Side FINAL U�-�- e hazoicf._ — 4� Ito �'le�c��o� Q�i�'✓ a�dctk._ ADDITIONAL COMMENTS � �01 - -- - -- - - — — x TOWN OF SOUTHOLD—BUILDING DEPARTMENT y i Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 hLtps://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT Q V E �� 50 For Office Use Only PERMIT NO. Building Inspector: JAN 2 4 2024 Bull ing DRPZ1T1M19nt Applications and forms must be filled out in their entirety.Incomplete `irowc,,®jl�cautt�old .applications will-not be accepted.,_Where the Applicant is:not the,6wner,an' x Owner's Authorization form(Page 2)shall be completed.- Date: .OWNER(S)OF PROPERTY:- Name: - --- � "T �r -- - SCTM#1000- ___--- Project Address:w -_------------- Phone#: �' .3�f1' Email: ' im4rco nc%cZ)ue,tzv n. niA- Mailing Address: CONTACT PERSON: Name: e.r-1 _- Mailing Address:r `30 C �- Ai 9 3S - - --- - -- -- - -- - — --------------- Phone#_-C�31-73`7��7L?Lo --- -- - ---- Email DESIGN PROFESSIONAL-INFORMATION:. Name- Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: � � iU y' /1935 _ Phone#: &31 ;73y'7&6S Email:c:�Ch�� DESCRIPTION OF PROPOSED CONSTRUCTION' ❑New Structure ❑Addition ❑Alteration ❑Repair [I Demolition Estimated Cost of Project: VOther��C- e ►-r,n-,,ne. PqD) $ Will the lot be re-graded? kyes El No Will excess fill be removed from premises? >Yes El No 1 r `PROPERTY`INFORMATION Existing use of property:.../ ,. `lL�s�2�ncA 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 -o IF YES, PROVIDE A COPY. 4Checki.Box�After�Readittg:�The'owner/contractor/design'- fessional,is respongible for alf drainage and storm water issues as'provided.by i; Chapter�236 of the Town'Coae.APPLICATION I5,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, addition`s,alterations or for removal or demolition as herein,described.The applicant agrees to compty with all applicable laws,ordinances,building code, a r r, a a housing,code and'regulations and to admit authorized inspectors on premises,and in builiiing(s)for necessary inspections.False statements made,herein are, punishable as a Ciass A misdemeanor pu,6ant'to Section 210.45 of the New York State Penal Law..- ' • d Application Submitted By(print name): (J�E� GJ�/71�f; Authorized Agent ❑Owner Signature of Applicant: Date: -------- _-______._ _ _-- -. __ .____-_._._. STATE OF NEW YORK) CONNIB D.BUNCH Notary Public,State of New York SS: No.01 BUG165050' COUNTY OF ) Qualified In Suffolk Coup".. Commission Expires April 14,2 y being duly sworn, deposes and says,that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to.make and file this application;that all statements contained in this application are true to the best of his/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 hday of At)UL�- , 20 0'� `-�(T� t �`^f 4 Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) s— residing at ?S CJc KLU 0 d Ck d{i do hereby authorize �A//zUe 2�Z L7� to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signaturd Date l c-. GI r/lC,— Print Owner's Name 2 BUILDING DEPARTMENT-Electrica pector TOWN OF SOUTHOLD JUN 2 0 2024 Town Hall Annex- 54375 Main Road - Box 1179 Southold, New York 11971-0959 ► Department Telephone (631) 765-1802 - FAX (631) Southold roger rnsoutholdtownny.gov p seand(�sauihoidto rnny,c ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: ( ,� Electrician's Name: b rcfZ6i License No.. Elec. email: Elec. Phone No: �(� MI request an email copy of Certificate of Comp lance Elec. Address.: qo I JOB SITE INFORMATION (All Information Required) Name: r Address: Cross Street: Phone No.: Bldg.Permit#: email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply. 1 ,, Is job ready for inspection?: YES❑NO ®Rough In Final Do you need a Temp Certificate?: ® YES 1�3 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 El H Frame Pole Work done on Service? MY N Additional Information: PAYMENT DUE WITH APPLICATI®N re- 1 -77r,7 `1 to4- S-5�-)�08 PERMIT# Address: Switches Outlets G F I's Surface IM r. . 4 -" Sconces rl� H H's UC Lts Fridge HW POOL r ' Panel r�.9��e Fans Mini Fr. W/D pump 6 Exhaust Oven Sump Heater i Gig Trnsfmr Smokes DW Generator Salt Water BonGen., WeAt ��r d '��/ Carbon Micro GrbDis 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 AC R" CERTIFICATE OF LIABILITY INSURANCE DAT 01/24/24//2024 Y) 024 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 N NT CT Lauren Murphy Roy H Reeve Agency,Inc. NCNNo Ext: (631)298-4700 Nc No: (631)298-3850 PO Box 54 AE IESS: Imurphy@royreeve.com 13400 Main Road INSURERS)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Valley Forge Insurance Company 20508 INSURED INSURER B Chituk Pools Ltd. INSURERC: PO BOX 9 INSURER D: INSURER E: Cutchogue NY 11935 INSURER F: COVERAGES CERTIFICATE NUMBER: .CL2321518551 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. POLICY TR TYPE OF INSURANCE INSO WVD POLICY NUMBER MMOIUDD E� MMIDD ExP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $0NIT?-�E TO RENTED 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 PET LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED,SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LLAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORMARTNERIEXECUTIva ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: James&Cynthia Traina,45 Oakwood Drive,Southold,NY 11971 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 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF W Workers' NYS WORKERS' COMPENSATION INSURANCE COVERAGE RK sTOATC Compensation Board 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 Id.Federal Employer Identification Number of Insured certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name 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 to l/1/2025 3d.The Proprietor,Partners or Executive Officers are: 0 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"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF 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 th is 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 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 carver) Approved By: / 12/20/2023 (Signature) (Date) Title: Senior Vice President N"w 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 carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured CHITUK POOLS LTD 631-484-4245 PO BOX 9 CUTCHOGUE, NY 11935 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required If coverage Is specifically limited to or Social Security Number 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 barrier (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"I a" Southold, NY 11971 DBL614067 3c.Policy effective period 05/01/2023 to 04/30/2024 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 6/13/2023 By . Wj , ht (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat 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 sox 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 DS-120.1.Insurance brokers are NOT authorized to issue1I this'Ifonn. DB-120.1 (12-21) �I�II�II�IIN��2 �I0 11�fi��ll('�'I'�2®I�'I� ...... .... ................ *-NI. rW WJIOVW� Z� !AW, aw ekvl y% Area- 14.65mm ej. 45 f0f Cut Y I- !r.V 7• 'Pit 'k,n" ww Pine Neck Road CW OV E 9937* f 148lwtr 01 sea t. Sir Um r" 0 K V x 0 caOAS% b CL uPi or b- craw . dy mow eR411 Q 01 4.15 Id IIK* Certified to: &ney of Described.property OAKEN L HOC situate at WIRY Rkwiq TRE W;xm WWm LLC WXKWD-T OW&ACC tlou Pine Nee.k Town of- Southold Michael W. Minto, L.s.P.C. Suffolk County, NtW York mvism P*Orrssx*fx UWV SUFVCMR hX* VOW STATC UCCWW KAMER OWN)PI District 1000 Section 7.0 -Block 13 Lot 1 67 Woodview Lane Scale V= 10' Surveyed August 2.9, 2019 Centerench. N.Y. 117:30 I`I1KWV./fAX.- (631) t.W-1202 011APHIC EXALF.' WILWI. (631) .......... APPROVED AS NOTE ��WBUILDING B.P. -; 8 FEBY: RETAIN STORM WATER RUNOFF NODEPARTMENT AT PURSUANT TO CHAPTER 236 631765-1802 8AM TO 4PM FOR THE OF THE TOWN CODF. FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO REOI TIRED FOR POURED CONCRETE 2. ROUGH-FRAMING&PLUMBING 3. INSULATION 4. FINAL-CONSTRUCTION MUST ELECTRICAL BE COMPLETE FOR C.O. 'NSPECTION REQUIRED ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTON ERRORS COMPLY WITH ALL CODES OF 171WA iVI D;AT LLY:', . NEW YORK STATE&TOVVN CODES ENCLOSE POOL TO.CODE; AS REQUIRED AND CONDITIONS OF _l--,<UPON COMPLETION:; SOUTHOLDTO A : ::BEFORE WATER; _._..._...__SOUTHOLD WN PLANNING BOARD SOUTH TOWN TRUSTEES N.Y , EC UTHOLD HPC SCHD OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICA- OF OCCUPANCY POrLSQ� '•wthsFep:. A. t.8. .. C . ':D:. E. F. C' 8 '.'K '•'L. M N:: Oral' 14�CJ0: 14m: 14 ,a0 •0' ..:6 6.. •.'6 ,14' 6. ::4 4: 6•, . . 12900 ,:. 16 26: 3 �..;CS' :::G.. .,.I .?:6.'. ::4:.::-4,, -•8.•.: • W' :rAC �3TOo 1DQ0'::: 16104 16 'lll;. ia•4't i6 6"' ::%.'4_:':$:.'.4.: .4 4. :- _' 4.0•'Tao` :8,500 1h5Gi05',: •-., 6id{:' :AG. i:30.'_ fi.;; :: :."•: .• -...�• :. ,•. . • 10ielfi+::':. 1 ..•''. �O�t.•�E�-�3�4•i;:'4':.:6;. -'s.:.. r '•. •:.•-2 .lnae-•" •1Zi0D'• .1z:�.:zs: .a-a�: 's`a,< .-s: :;yo- :•6:• -<`¢•• r'44: ::.�•.•. - 167Qb: c.IWO:'. .i1G: '-'1b.; '4{' :�6_ :6: 1Pti �:6? '•4:' -.4.: :8 i°A' _ :T 4�• 13000 �o�; .��" � ;a. ••'6;"•.�•.a::. :.a_. •:a.,�•fi:=�a'-o...•ram-:`� ? '/ •��'t1�!�:� �_:��:•':• - :.: :.TO".t��:'3'?}'. :'8S. :14._ :'i14::.� ,..4_• y 4�.;;12. +4'•0': •4'.'. 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POOL SECTION z_A • Complies With 2020 Code Section 3032-1'=3014 Swifnming Pools,Spas and Hot Tubs AROFF �O P� Sdction'R326 of ftie'Re W46tial Code of New York -----------'-=_i'y------------- Section 3109 of the Building Code of Newyork r Section N1103.12(R403.12)Residential Pools and Permanent Residential Spas POOL WPE:NECTANGL . REV. SCALE: :NTS: s• Section 31093.12-3.109 7.4•Pools and Spas Gates,Barriers _ Section G106 Entrapment Protection .. JAMES DeERKOSKI,P.E. TYPICAL P • EI: FFNER 'Section G107 Alarms 260 DEER®HIVE ®ATE: Section W01-E4312 FJectrital Connections fot Pools MAWffUK,NEON YORK 11952 DRAWING NUMBER • _ 1 OF i 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 Al 12.19.8M OR A MINIMUM 18'X23"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 ANSUNSPI-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 ADJUST WATER 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 EASY ACCESS 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.COMPLIES 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 O Ew - 20.2 THE ENERGY CONSERVATION CONSTRUCTION CODE OF NEW YORK STATE(2020)SEC R403.10 �' g4'q Qs 20.3 THE FUEL GAS CODE OF NEW YORK STATE(2020) 21 � 4 (�•-i�::,`� "f' � 20.4 THE NEW YORK STATE SANITORY CODE. n eZ ;'- •;I`, ay 20.5 ANSI/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. POOL NOTES SCALE: NTS 20.6 BOCA CODE SECTION 421. �F��fl• 0 2 '6J JAMES DEERKOSKI, P.E. 20.7 CODE OF THE TOWN OF SOUTHOLD ROFE � P 260 DEER DRIVE DATE: 10/2/2020 MATTITUK, NEW YORK 11952 DRAWING NUMBER 2 OF 2 i