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HomeMy WebLinkAbout50852-Z of Solo/ Town of Southold * * P.O. Box 1179 0 53095 Main Rd lrepUNM Nay Southold, New York 11971 i CERTIFICATE OF OCCUPANCY No: 45730 Date: 11/03/2024 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 515 Moose Trail Cutchogue, NY 11935 See/Block/Lot: 103.-4-48 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 05/03/2021 Pursuant to which Building Permit No. 50852 and dated: 06/21/2024 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: Charles Quigg,Linda Quigg Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50852 09/09/2024 PLUMBERS CERTIFICATION: thor ze Si ature �SVFFat,( TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE "� • SOUTHOLD, NY fl� 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#: 60852 Date: 6/21/2024 Permission is hereby granted to: Quigg, Charles 14 MaKanna Dr Huntington, NY 11743 To: construct accessory in-ground swimming pool as applied for. Replaces BP#46273 At premises located at: 516 Moose Trail, Cutchogue SCTM #473889 Sec/Block/Lot# 103.4-48 Pursuant to application dated 5/3/2021 and approved by the Building Inspector. To expire on 12/21/2025. Fees: PERMIT RENEWAL $200.00 Total: $200.00 Building Inspector TOWN OF SOUTHOLD moo r BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE 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#: 46273 Date: 5/19/2021 Permission is hereby granted to: Quigg, Charles 14 MaKanna Dr Huntington, NY 11743 To: construct accessory in-ground swimming pool as applied for. At premises located at: 615 Moose Trail, Cutchogue SCTM # 473889 Sec/Block/Lot# 103.-4-48 Pursuant to application dated 5/3/2021 and approved by the Building Inspector. To expire on 11118/2022. Fees: SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector o��pF SOUj��l � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 11971-0959 �oly� � �o sean.devlinCaD-town.southold.ny.us RUNTY, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Charles Quigg Address: 515 Moose Trail city:Cutchogue st: NY zip: 11935 Building Permit#: 50852 Section: 103 Block: 4 Lot: 48 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: First Choice Electric License No: 45014ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor 1 st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 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 2 4'LED Exit Fixtures Sump Pump Other Equipment: Intermatic Pool Panel 8 Circuit/ 5 Used, Heater, Pump220GFI, (2) Lights AJ Pool Trans.100W 120GFI, Waterbond on Pipe Notes: Pool Inspector Signature: <Z77 ate: September 9, 2024 S.Devlin-Cert Electrical Compliance Form Copy - ho�apESOUTyo� L) # # TOWN OF S U ,.OLD BUILDING DEPT. `ycourm��'' 765-1802 E INSPT1'• N - C O [ ] FOUNDATION 1ST [ ] 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 rn [ ] PRE C/O REMARKS: '!`�Cs� _ �N y► N o DATE 2 I INSPECTOR � � t— # # TOWN OF SOUTHOLD BUILDING DEPT. `ycoutm��' 765-1802 -INSPECTION .. [ ] 'FOUNDATION 1ST [ J ROUGH PLBG. [ -I' FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ]. FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE'&'CHIMNEY [ '_] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: �� - DATE INSPECTOR �- _ �o�F SOpj /' 3p1a-,-! * # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm,a�`' 765-1802 INSPECTION [: ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULATION/CAULKING -] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL-(ROUGH) - [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: v r DATE 0zry /o Z 2-- INSPECTOR ` a SOUIyo� # # TOWN OFSOUTHOLD BUILDING DEPT. 631-765-1802 S,$SVINSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ NSUL ION/CAULKING [ ] FRAMING /STRAPPING IV] .FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O- [ ] RENTAL REMARKS: I N ylker�- r � `� nil - 1 I '' �ry & �el cJ 0�k lvwol aim -,mus u C . 0 SL,40, 04! R&, V DATE 4110 - INSPECTO UF SOUT 2, TOWN OF SOUTHOLD BUILDING DEPr. 631-765-1802 I -NSPECTION ] 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: n G - DATE INSPECTOR rsf s0 yOIo V # # TOWN OF SOUTHOL-D-BUILDING DEPT. o�+N 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: DATE INSPECTOR pF SOUIyOlo # * TOWN OF SOUTHOLD BUILDING DEPT. °`����►�,� 631-765-1802 �a-,,e/,)..-ANSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULA O CAULKING [ ] FRAMING/STRAPPING [ FINAL [ ] FIREPLACE &'CHIMNEY [: ]' FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ .] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: I l 1/ $uv fl D DATE h0ff INSPECTOR t� L 1 r i i J, t f 41 ' moro eTIM)NDS FOUNDATION UST) • • e . • PA PL UMBING ' INSULATION STATE ENERGY CODE der ?� ZVO v • ea ® • as �10 �� � � o . YA �'�7�� s TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING .P RMIT For Office Use Only r t PERMIT NO. � t Building Inspector: MAY 3 2021 F Appl►catians and farms must b-filled out 1n their entirety Incomplete i?U? �applications will ngt$be accepted>Where the Apphcant'is nat•the'oeivner,an '�'g�`:`-* � F . Qv_ner's Author�zadon form(Page 2)Sha116ecompleted r Date: P_q Zt 011UNER(Sj OF PROPERTY Name: 'Cal �LCS - �' .(� aC3 SCTM# 1000- poo Project Address: I t-- M Phone#: 6 2O �; � �- %�j Mailing Address: CONTACT'PERSpN =�- q� "�,--. Name: O N 1 rh H.. 1 CD! [ D Mailing Address: 2J �'j�� CJJ �'� ?CJL V 06Uu / N f // 42 Phone#: 975Y Email: C_� ��Oy/7G PS CC)" DESIG N"PROFESSIONAL,I FOR N NATION:° - Name: SO 7 ► � lDl�1 /��Iltl'L��/Il�� Mailing Address: L✓__�(S'�7r�©��� r1 �i'�/JU�t�fj(�(�� �� l` c�j�� _ Phone#: ��_ 2v f� sV Email: � - l ,CONTRACTt�R°li'►1FORMi4T10N - Mailing Address: PO p,Y ��h/� P7-D� &Z1 /! L6 Phone M COS/_ zf2— 5838 Email: L p 7VE2 pCXy S DESCRIPTIOffid R ED CONSTRUCTION _ _ Zi ❑New Structure ❑Additio ❑Alteriition ❑Repair ❑Demolition Estimated Cost of Project: &40ther &'X,s� P $ 2A Will the lot be re-graded? ❑Yes DAO Will excess fill be removed from premises? E!lY6s ❑No 1 PROPERTY INFORMATION Existing use of property: /f fk(OuAfu Intended use of property: refe O&CC0 <fal Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to L—�0 this property? ❑Yes ❑No IF YES, PROVIDE A COPY. Check Box After Reading: 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 Gass A misdemeanor pursuant to section 210.45 of the New York State Penal Law. Application Submitted By(print name): Po/V)tc* L4duthorized Agent []Owner U Signature of Applicant: Date:- STATE OF NEW YORK) COUNTY OF 5QAD ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the CCD h 01P J (Contractor,Agent,Corporate Officer,Pic.) 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 c that the work will be performed in the manner set forth in the application file therew' NAYMA SIDDIQuA Notary Public -state o 11ew York Sworn before me this Qualified in Queens County n My mission Expires Dec 16,2021 "1 day of I .20 of Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) residing at �-r5 koos. , `TT e=a ) ( �( ,PQ01 U b ftj X do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. -&i ( n / - 1,R-DGQN Of_wner's Sig ature Date Print Owner's Name 2 16 2022 , .- S�ffQ�,f.0 MAR BUILDING DEPARTMENT- Electrical Inspector a�O� �Gy� Bum�p►��N -�jpt_o TOWN OF SOUTHOLD o - TowH Down Hall Annex- 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 yg� a4� Telephone (631) 765-1802 - FAX (631) 765-9502 1 ' rogerr(cD-southoldtownny.gov - seand(a-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: .�sT �oiL-e \eC�s Electrician's Name: e �C, n License No.: t Elec. email: �t5�c� :ceT; ver�•�n.�e Elec. Phone No: �� �S�-1Sa ❑1 request an email copy of Certifica a of Compliance Elec. Address.: 7a- 11a,`R; �. s JOB SITE INFORMATION (All Information Required) Name: C �� Address: 5 Cross Street: �� e Phone No.: - p Bldg.Permit#: `A�PWT '3 email: . o . _ Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): _�c,r-> Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO ❑Rough In Final Do you need a Temp Certificate?: YES❑ NO Issued On Temp Information: (All information required) Service Size0 1 Ph 3 Ph .Size: A #Meters Old Meter# New Service0 Fire'ReconriectOFlood Reconnect.QService ZeconnectOUnderground DOverhead #Underground Laterals 1 n2 H Frame Pole Work done on Service? Y F1N Additional Information: PAYMENT DUE WITH APPLICATION �J 1 0l � cO S,afFOL/r BAR 6 20�BUILDIN13 DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD CD Te°� OF l own Hall Annex- 54375 Main Road - PO Box 1179 o * Southold, New York 11971-0959 9��• �ap�� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(ab-southoldtownny.gov - seand0)-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: <i�vcsr C`no;L-e E Electrician's Name: -_�,e QC, �, License No.: C0 t Lk., Vj Elec. email: Elec. Phone No: » �S�-\5 ❑1 request an email copy of Certifica e of Compliance Elec. Address.: 7a s� e -� JOB SITE INFORMATION (All Information Required) Name: � 'X-- a, Address: " Cross Street: Phone No.: - Q Bldg.Permit email: ..C, �D ��, Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑Rough In Final Do you need a Temp Certificate?: ❑ YES❑ NO Issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 F12 D H Frame Pole Work done on Service? Y nN Additional Information: PAYMENT DUE WITH APPLICATION �J ud" rc a S kaja r y L"ny Ioc) UI 2 Iris V\J-� Y 4 A16-� — F C"Rv® CERTIFICATE OF LIABILITY INSURANCE DATE(M 4/22/2o 1 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER ONTACT GIACIZZO INC/GIACALONE INS.AGY PHONE - FAX 57 EAST MAIN ST,UNIT 3 /uc No E GIACIZ70INC@GMAIL.COM RIVERHEAD, NY 11901 CONTACT:JEANINE GIACALONE INSURERS AFFORDING COVERAGE NAIGP INSURER A:ATLANTIC CASUALTY INS CO 42846 INSURED LOPEZ A POOL SERVICE CORP INSURER BINSURERC: PO BOX 6053 INSURERD: SOUTHAMPT.ON,NY 11969 INSURERS: IN9UR£RF: ` COVERAGIES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICYFF POLICY OLI Y EXP YM LIMITS COMMERCIAL GENERAL LIABILITY L088026693.0 EACH OCCURRENCE $ 1,000,000 A 4M 9/2021. 4/19/2022 CLAIMS-MADE ®OCCUR -PREMISES(Ea occurrence) $ 100000 MED EXP(Any one rson $ 5 000 PERSONAL s ARV INJURY 3 1.000 000 C!G GEN'LAREGATE LIMIT APPLIES PER. GENERALAGGREdATE $ 2,000.000 POLICY JECT LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY OMB EQ S NGL LIMIT $ ANY-AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERLY DAMAGE AUTOS ONLY AUTOS ONLY s $ $ UM9RELLALIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED: RETENTIONS S WORKERS COMPENSATION STERTUTr I O_TH AND EMPLOYERS'LIABILITY Y I N ANY PROP IETORIPARTNERIEXECUTNE OFFIC EMBER EXCLUDED? NIA E.L.EACH ACCIDENT S (Mandate In NH) E.L.DISEASE-EA EMPLOYEE S IF yes describe O� E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS belay DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached U more space Is required) POOL SERVICE/INSTALL CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE;DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHOR REPRESENTATIVE "I ' 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Yo K. Workers` Aix Compensation CERTIFICATE OF INSURANCE COVERAGE g Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by 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 LOPEZ JR POOL SERVICE CORP (631)252-583$ 945 N,SEA MECOX RD WATER MILL In 1 976 1 Federal Employer Identification Number of insured Worst Location of Insured(Only required if coverage Is specifically c. eera limited to certain,6cations in New York State,i.e.,Wrap-tip Polley) or Social Security Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carder (Entit'r Being Listed as the Certificate Holder) TOWN;OF SOUTHOLD Standard Security Life Insurance Company of New York 53095 ROUTE 25 3b.Policy Number of Entity Listed in Box"I a" L$6113=000 PO BqX 1179 SOUT' OLD,NY 11971 3c.Polley effective period 4/1 912 0 1 8 to 4/21/2022 4. Polley provides the following benefits: XD 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. El 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,tas NYS Disability and/or Paid Family Leave Benefits insura coverage as described bove. Date Signed 4/22/2021 By (Signature ofllnsuraiiie carrier's auto zed"riminve-orNYS-CrerLke4lnsurance Agent of that insurance carrier) Telephone Number (212)3554141 Name and Title Bebi Ishmail,Supervislor-DBUPoilcy services 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.Mall 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 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 4C or 58 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 with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Tide Ptease Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed Insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (1047) IlMhuBiiii1i2�0i�i1iii�(i1�0iiii17i)�7111 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"I a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance 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 my be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c,whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a 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 business must.provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family leave Benefits Coverage or other authorized proof that the business Is complying with the mandatory coverage requir6ments of the New York State Disability and Paid Family Leave Benefits Law. 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 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 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. DB-120.1 (1047)Reverse N YS 1 F New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE C] A A A A A 824530810 GIACIZZO INC-T/A GIACALONE INSURANCE AGENCY 57 EAST MAIN ST �t<' RIVERHEAD NY 11901 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LOPEZ JR POOL SERVICE CORP TOWN OF SOUTHOLD PO BOX 6U53 53095 ROUTE 25 SOUTHAMP'TON NY 11969 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE M406 069-1 465121 1212k020 TO 12/23/2021 4/22/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2406 069-1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT ALDEMAR LOPEZ LOPEZ POOL SERVICE,CORP.- A ONE PERSON CORPORATION(1 OF 1) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE: AFFORDED BY THE.POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:821394175 SURVEY . of PROPERTY Lot 10 Map.of = . Little Neck Properties iI r5,ut N Always on FIieCi: . Nov.30, 1973 -Map No:6048 110 SOUTH 4th STREET SITUATE Lindenhurst, New York MJScalice®mjslandsurvey.com EAST. CUTCHOGUE Pc631-95772400 F:631-226-2400 TOWN OFSOU.THOLD, SUFFOLK COUNTY, NEW YORK FSURVEYEDBY:C.S. --,JOB'NO.S76-073 6 DRAWN BY:S.V. - - ®: ® Suffolk Tax Map No::soon-z0,30o-04'00-048000 LOT ®®� O DATE SURVEYED:07-22-2oi6 8 CE SCALE: 1°=30' . _ PE S pA 1 5.0 0 .S ON . g.3 CONjmo 8c 30 0 30 60 �� �I ��'.��' WOODED 7 600 ''� �'"� 9.as 4 w\�EFE. WOODED N _ AREA o•�'� ` GRAPHIC SCALE: 1 INCH = 30 FEET. E }�® O 0 COL, .p V 91 LOT ,..� .a 10 y ,. LOT ` 9 r WOOD WOODED ' STEPS. `: AREA 1 1. l WOOD 1 LOT DECK (28") 1 26.5� CONG WOODED �� STY. . . 23,0' N AREA 2�. 'FR. .RES. GAR is #515 23.0 �. 3�.a OV 1 0- 5.6 •c 2 4 V c0 e WOODED � Q AREA o s _� 42, �. . p:O:B: �45� LOT AREA 0 � 40,020 S.F: 0.92 ACRE(S) it 5 .O � PAVEMENT �F EDGE OF 8, . 13''_ . . . .' . L ��pF..EWY�. •s 5 A �P ��- s7600 T S E GUARANTEED. TO 0 CHARLES J, QUIGG AND LINDA J." QUIGG - 90. . 50 STEWART TITLE INSURANCE COMPANY REVISIONS UPDATES ADDITIONS l�C No AT COST ABSTRACT, INC. F,y 0508 TITLE# 'ACNY-2849-16 , DATE:: DESCRIPTION: : CHECKED BY: SF� LAND' 2 . (1) UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY:MAP BEARING A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION 7209, SUB-DIVISION 2, OF NEW YORK STATE,EDUCATION,LAW.,(2) ONLY BOUNDARY SURVEY MAPS WITH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND CORRECT COPIES OF THE SURVEYOR'S ORIGINAL WORK AND OPINION. (3) CERTIFICATIONS ON THIS BOUNDARY SURVEY-MAP SIGNIFY THAT THE MAP WAS PREPARED IN ACCORDANCE WITH THE,CURRENT EXISTING CODE OF � PRACTICE FOR LAND SURVEYS,ADOPTED BY THE NEW YORK"STATE"ASSOCIATION OF-PROFESSIONAL:LAND SURVEYORS,.INC. THE CERTIFICATION IS LIMITED TO PERSONS FOR WHOM THE BOUNDARY SURVEY MAP IS PREPARED, TO THE TITLE COMPANY,TO THE LU GOVERNMENTAL AGENCY,AND TO THE LENDING INSTITUTION LISTED ON THIS.BOUNDARY SURVEY MAP_..(4) THE CERTIFICATIONS HEREIN.ARE NOT TRANSFERABLE. (5) THE LOCATION OF UNDERGROUND'IMPROVEMENTS OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND• O OFTEN MUST BE ESTIMATED. IF ANY.UNDERGROUND IMPROVEMENTS OR'ENCROACHMENTS.EXIST OR ARE SHOWN, THE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THIS SURVEY. (6) THE OFFSET(OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES- TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND'USE AND'THEREFORE•ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES, RETAINING WALLS;POOLS, PATIOS PLANTING AREAS, ADDITIONS TO BUILDINGS, AND ANY OTHER TYPE'OF CONSTRUCTION. (7) PROPERTY CORNER MONUMENTS WERE NOT SET AS PART OF THIS SURVEY. (8) THIS SURVEY WAS PERFORMED WITH'A SPECTRA FOCUS 30.ROBOTIC TOTAL STATION. t VA � z r ENCL:QSE p.004.TO.0 :,��PON C0MPL'ETt01�1 o N ,� w °" "V1[AT � 04 loo Z o APPROVED AS NOTED 33'-aa DATE: 7�; B.P.# Q m m" 32'-m" m" ol FEE: B`/• w z J NOTIFY BUILDING D'; +RTMENT AT 8'-m" 16'-m" 8' w -m° < 765-1802 8 AM TO 4 PM FOR THE Q ❑ ❑ FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQ — — — — — — — — — — — — — — — — — — FOR POURED CONCRETE a .. :.,, T. :. ... 2. ROUGH - FRAMING & PLUMBING 3. INSULATION I': ".I FRET ICJ RETURN I. I 4. FINAL - CONSTRUC-ION M ST BE COMPLETE FOR ALL"CONSTRUCTION SHALL MEET HE U)r' REQUIREMENTS OF THE CODES OF z EW I " 4'-m" 'r YORK STATE. NOT RESPONSIBLE FOR I I W a DESIGN OR CONSTRUCTION Efimu IS. =m' I w :3 00 I I W o = w O � n M ) a. I I W-O" X 32'-0" I I c 0 � o - I - DRAIN I I a U-, U U a I .':I )CCUPANCY OR L JSE IS UNLAWFUL L I I I •L W NITHOUT CERTIFICATE D�'" " U �j� I I A a u Lu L ? N)F OCCUPANCY oN En ,DETAIN STORM WATER RUNOFF I ..'I OF NEW E a`) W°'�,� PURSUANT TO CHAPTER 236 I I LIGHT LIGHT' I. :I _ "' i - I LIGHT �Q�� �;� O 'A � � OF THE TOWN CODE. SKI R SKIMMER I `:I ' — — .— � � A �.".. �.. r �. L - — Z .:.�. w COMPLY WITH ALL CODES O1: 0 _z NEW YORK STATE & TOWN CODES L--- ='" �_ w AS REQUIRED AND CONDITIONS OF 4'-m" 4'-m„ s'-ma N�o os9go5 ~ a Sal ITHO D TOWN ZBA ROFESSx�� m" 32'-0" ma Sgl gL-2?$tP}R p A !4Nf�BOARDA A z z -,, �RUSTEES POOL NOTES ° 1-ALL GUNIIE SHALL HAVE A MIN.28 DAY SIRENGHT OF 45M PSI. W 2-STEEL.REINFORCQVENT SHALL BE GRADE 60 CONFORMING TO ASIM A615 3-WELDED WIRE FABRIC REINFORCEMENT SHALL BE COLD DRAWN CONFORMING TO AST 185 7-ALL WORK SHALL BE IN ACCORDANCE WITH THE LATEST ACI CODE ELECI'RlCd4L POOL PLAN 81EE1Rainaus 9R-SHALL' m�BE REPaIRm io RauoRE cSoR INSPECTION REQUIRE® 1 AMND WALL 10-ALL DIMENSIONS GIVEN SHALL BE CONSIDERED A MIN.CONTRACTOR MAY INCREASE SCALE:1/4' a V-0" TO PROVIDE FOR DRAINS&COPING > 11-ENGINEER CONTROLLED INSPECTION REQUIRED 12-POOL BARRIERS AND ALARMS TO BE COMPIJAN`WITH TOWN OF SOLI HOLD CODE AND NYS 2020 BUILDING CODE 32'-0" 01 O ✓ �, 0u V-0° 12'-0u 12'-Ou Z C\j ° TOP OF WATE w LL o /\\i O POOL ¢ o \/ IS'-0"X 32'-0, w z ✓//\/ //\//\//\//\//\//\//\//\//\//\//\//\//\//\//\/ v \ \/\j v� j j\\j\\j/\\jam\j�\/\\\ \% to 1 SECTION A O U SCALEd/4' = P-0' Z LV I-- LL N J 40 F- O O Z O n M U iL loll IS'-0" loll o a Lb V U 12" COPIW-i 12" COPING SAND OR j % �'// \ SAND OR CLEAN FILL 5X5 TILE 5X5 TILE /\ GLEAN FILL TOP OF WATER---I loll X loll P.C. ''//\ 'F� "4 REBAR FOR 04 REBAR FOR f '/ / 10" X loll P.C. c o M M BEAM \ :' WIDTH OF POOL WIDTH OF POOL �\\\ BEAM a z N N REBAR a 12 O.C. 04 REBAR 0 12" O.C. \\//. L U - 3 ui o N EACH WAY O EACH WAY = N N MARBLE DUST - 18'-0" X 32'-0" MARBLE DUST w 'L N fn fn \/ M a I LL. l"GUNITE uo l" GL NITE / ,. MAIN DRAIN STONE OR SAND BASE �\ \ STONE OR SAND BASE Q ° \//\//\//\% -fit..-..�4.��•���1• .�-: �j� ; 1 e ... •: ��.is .'�:•ter.^+•�L4'd \\ \ \ POOL NOTES -- CD ,�� 9 �� 1-ALL GUNRE SWILL HAVE A MN.28 DAY STRENGHT OF 4,500 PSI. W 2-STEEL REINFORCEMENT SHALL BE GRADE 60 OONFORNING TO ASTM A615 3-WELDED WIRE FABRIC REINFORCEMENT SHALL BE COLD DRAWN CONFORMQIG TO AST 185 7-ALL WORT(SHALL BE IN ACCORDANCE WITH THE LATEST ACI CODE r 1 s,"., W 8-LEGS OF MBAR ACCESSORIES SHAM BE ROC TIPPED.ALL SNAKES AND WAIL S E C T 1 O N B _�, . I z KNETRAWa S 9-SHALL BE CLEANED&(2W REPAIRED TO PRELUDE CORROSION 2 10-ALL D01E NSIONS GMIEN SHALL BE CONSIDERED A MIL.CONTRACTOR MAY INCREASE SCALE:3/8' ■ I'.0° �� a � 0 h �� TO PROVIIIE FOR DRAINS&COPING 11-BONER CONTROLLED INSPECTION REQUIRED 12-POOL BARRIERS AND ALARMS TO BE COWLIANT WITH TOWN OF SOUIHOLD CODE AND NYS 2020 BUIDIVG CODE