HomeMy WebLinkAbout45983-Z of SouTyo`o Town of Southold
* * P.O. Box 1179
r c9 53095 Main Rd
`y�ouxrr� , Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 45826 Date: 12/12/2024
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1985 Peconic Ln Peconic, NY 11958
See/Block/Lot: 74.-5-7
Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 03/08/2021
Pursuant to which Building Permit No. 45983 and dated: 03/25/2021
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 with spa fenced to code as applied for.
The certificate is issued to: Kevin Meyers , Christine Meyers
Of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL:
ELECTRICAL CERTIFICATE: 45983 11/20/2021
PLUMBERS CERTIFICATION:
9ut
o ' ed ignature
��OFSOUr�O TOWN OF SOUTHOLD
BUILDING DEPARTMENT
`� • TOWN CLERK'S OFFICE
olr�UUN1V N��
SOUTHOLD, NY
BUILDING PERMIT
RENEWED
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 45866 Date: 03/02/2021
Permission is hereby granted to: Renewal Date: 12/04/2024
Kevin J Meyers
59 Wellington Rd
Garden City, NY 11530
To:
construct additions and alterations to existing single-family dwelling as applied for.
Premises Located at:
1985 Peconic Ln, Peconic, NY 11958
SCTM#74.-5-7
Pursuant to application dated 02/16/2021 and approved by the Building Inspector.
To expire on 12/04/2026.
Contractors:
Fees:
Renewal Fee $176.60
Total S176.6
ing Inspector
o�SUFFQc,t� TOWN OF SOUTHOLD
aye BUILDING DEPARTMENT
y x TOWN CLERK'S OFFICE
"may + 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#: 45983 Date: 3/25/2021
Permission is hereby granted to:
Meyers, Kevin
59 Wellington Rd
Garden City, NY 11530
To: construct accessory in-ground swimming pool as applied for.
At premises located at:
1985 Peconic Ln., Peconic
SCTM #473889
Sec/Block/Lot# 74.-5-7
Pursuant to application dated 3/8/2021 and approved by the Building Inspector.
To expire on 9124/2022.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO- SWIMMING POOL $50.00
Total: $300.00
Building nspector
pF SOUry�l
Town Hall Annex ~ Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 Q sean.devlinl-town.southold.ny.us
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICAL COMPLIANCE
SITE LOCATION
Issued To: Kevin Meyers
Address: 1985 Peconic Ln city,Peconic st: NY zip: 11958
Building Permit#: 45983 Section: 74 Block: 5 Lot: 7
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Pro-Line Electric License No: 32279ME
SITE DETAILS
Office Use Only
Residential X Indoor X Basement Service
Commerical Outdoor X 1st Floor Pool X
New X Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt 1 Ceiling Fixtures Bath Exhaust Fan
Service 3 ph Hot Water GFCI Recpt 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
Transformer 100W UC Lights Dryer Recpt Emergency Fixtures Time Clocks
Disconnect Switches 1 4'LED Exit Fixtures 11 Pump Ed
Other Equipment: Pentair Easy Touch, Pump 220GFI, Heater, 3 Lights on AJ 100W Pool Tranny
Notes: Pool
Inspector Signature:
Date: September 20, 2021
S.Devlin-Cert Electrical Compliance Form
ho�a0FS0Ujy��
# # TOWN OF SOUTHOLD UILDIN"pcg
G DEPT.
765-1802
INSPECTION
[ ] 'FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] 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 7 1 INSPECTOR- c
i
Q
TIG
�,/TOWN OF SOUTH L DEPT.
765-1802
-INSPECTION
[ ] FOUNDATION 1ST [ `] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS.ULATIOWCAULKING
[ ] FRAMING/STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ " ] TIRE SAFETY INSPECTION
] FIRE RESISTANT.CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
DATE c �� INSPECTOR
o�aOE SO(/Ty�
f # TOWN' OF SOUTHOLD BUILDING DEPT.
`ycommN�' 765-1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG. {
(- ] FOUNDATION 2ND [ r SULATII ,O�,WCAULKING
FRAMING /STRAPPINGNAL f V V
`[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ' ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS: 1caii-g ..Aim_
uJ ��
DATE �-� �Z� INSPECTOR
ho�aUF SOUTyOlo
# TOWN OF SOUTHOLD BUILDING DEPT.
coorm,��` 631-765-1802
I.NSPECTION
[ ] FOUNDATION 1 ST/ REBAR [ . ] ROUGH PLBG.
[ ] FOUNDATION.2ND [ ] SULATION/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, I y INSPECTORwk2
RAY DONER,ARCHITECT
ARCHITECTURAL DESIGN
INTERIOR DESIGN
PLANNING&DEVELOPMENT
RESIDENTIAL-COMMERCIAL-INDUSTRIAL
95 RICHMOND AVENUE
S.AMITYVILLE, NEW YORK 11701
Phone/Fax: (631)691-1718 EMAIL:RDARCHITECTa@YAHOO.COM
® E
_--___-_____ ---------_ __----___ ------ ----- -_ _- - - -- --- - - - ----- MAR.2 1 2022
ED
�1.
BUILDING DEPT
TOWN OFSOUTHOLD
r
March 12, 2022 -
Southold Building Department
54375 Rte. 25
Southold,New York 11971
RE: CERTIFICATION of POOL RE-BAR „
1995 Peconic Lane,Peconic
_ !� D GPER1VJ(T:,NO 459.$3
To Whom it May Concern:
This Letter is to Certify that as.per,My Inspection All Re-bar was installed to the Walls and `Floor' of the
In-ground Pool before the Pouring of Concrete.
I Acknowledge that the Southold Building Department is relying on this Affidavit to issue a Final
Certificate of Occupancy for the above Construction. _
Sincerely,
Ray Doner,.Architect. �� D A ?,10
C'�5 BOND OpN
sc
N'y�, 0248�a y0�
�OF NEB
FIELD INSPECTION REPORT DATE COMMENTS
c t� i
FOUNDATION(1ST) w y
---------------------------------
'FOUNDATION(2ND) t4
_ z
ROUGH.FRAMING& m
PLUMBING H V)
^f
INSULATION PER N.Y: H
STATE ENERGY CODE
a y1 A✓ Y Prtl'iG VS*l
L `�/►� ,,JJ
l '�.
5KN w
FINAL ito ui A cd'
ADDITIONAL CQMMENTS
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t4`. BUILDING DEPARTMENT- Electrical Inspector
' MAY 2 8 2021 TOWN OF SOUTHOLD
Town Hall Annex - 54375 Main Road - PO Box 1179
Southold, New York 11971-0959
Tele hone 631 765-1802 - FAX 631 765-9502
rogerr(@_southoldtownny.gov - seand(a7southoldtownny.gov
APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date:
Company Name: I P ILA VS I -1D W r 10 E 6 L E CT?,,L
Name: _
License No.: ?) 220 9 M F email: 0 FE 1 — @ PRO-L1 PUULECTete .CO&
Phone No: 1 ? 51 1 ❑I request an email copy of Certificate of Compliance
Address.: nivL PLOY, (�
JOB SITE INFORMATION (All Information Required)
Name: V l
Address: ? IV(C L N = I
Cross Street:
Phone No.: 2
Bldg.Permit#: 45-Y83 email:
Tax Map District: 1000 Section: '7q Block: 5 Lot:'-7
BRIEF DESCRIPTION OF WORK (Please Print Clearly). Q-pc�e C&C,'4n-J!r.
Check All That Apply:
Is job ready for inspection?: DYES dNO ❑Rough In ❑Final
Do you need a Temp Certificate?: DYES fNO Issued On
Temp Information: (All information required)
Service Size ❑1 Ph ❑3 Ph Size: A # Meters Old Meter#
❑New Service ❑ Service Reconnect ❑ Underground [—]overhead
# Underground Laterals ❑1 ❑2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N
Additional Information:
PAYMENT DUE WITH APPLICATION
Electrical Inspection Form 2020.xlsx �(� �
BUILDING DEPARTMENT- Electrical Inspector
5 MAY 2 8 2021 TOWN OF SOUTHOLD
{ Town Hall Annex- 54375 Main Road - PO Box 1179
Ne:T,T 11. Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 765-9502
rogerr(a7southoldtownny.gov seand(a�southoldtownny.gov
APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date:
Company Name: Cf) PILA P.S I 7 W - 1 N E L CTeL
Name:
License No.: ?) 2Z-7 9 M F email: I - 21p- w - .COIN
Phone No: ? _ I ! ❑I request an email copy of Certificate of Compliance
Address.: T/wr PLOY (-( ritlll
JOB SITE INFORMATION (All Information Required)
Name: — V I �.
Address: fqIVtC - 1
Cross Street:
Phone No.: S 2
BIdg.Permit#: email:
Tax'Map District: 1000 Section: '7q Block: 5 Lot
.7
BRIEF DESCRIPTION OF WORK (Please Print Clearly) ; PCX. ep-640
Check All That Apply:
Is job ready for inspection?: ❑YES D60 ❑Rough In ❑Final
Do you need a Temp Certificate?: ❑YES ffN 0 Issued On
Temp Information: (All information required)
Service Size ❑1 Ph ❑3 Ph Size: 'A '#•Meters Old•Meter#
❑New Service ❑ Service Reconnect ❑ Underground []overhead
# Underground Laterals ❑1 ❑2 ❑H Frame ❑Pole Work done on Service? ❑Y ❑N
Additional Information:
PAYMENT DUE WITH APPLICATION
Electrical Inspection Form 2020.xlsx
PERMIT# _ - Address:
Switches
Outlets I
G FI's
Surface
Sconces
H H's.. .
UC Lfs
' Fans Fridge -H1N ..;<. ..
Exhaust Oven W/D
H`
Smokes DW Mini
Carbon :" Micro Generator
Combo:. _._,.....,_ . ..w ..._.. . Cooktop Tr..ansfer'
AC AH Hood Service
Amps `' . Have Used
Special.;..,. .. ..... _. �. .-.. . .
Comments: I G
� �
s�S+�fFock o TOWN OF SOUTHOLD—BUILDING DEPARTMENT
y x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax(631) 765-9502 https://www.sotitholdtownny.gov
a
Date Received
APPLICATION FOR BUILDING PE MIT r
For Office Use Only i j ['•.7', •I ' ; l� �:•;m i
93
�4
PERMIT NO. Building Inspector: ,
- -.. -. MAR 2021
Applications and forms_must be filled out'in their entirety.Incomplete '
'applications will;not�be•accepted: Where the Apphcintjs not the owner,an
,Owner s;Authoriiation_form(Page 2)'shall be completed _
Date:3/5/21
'.OWNER(S)OF PROPERTY,. • � - �• -
Name: �[V i h1____._.-.C [5T f tit _ scTM#1000- 1 Lt_-___0
Project Address: O p
�_._lC-_cs _-------.-.---- -
Phone#: Email:
Mailing Address: s A a V E.
CONTACT PERSON
Name:Adrian Konior
Mailing Address:87 sandy Ct_,Riverehad NY 11901
Phone#:646 413- 4604 Email:adkoninc mail.com
@9 a_____ M --
DESIGN,PROFESSIONAL;INFORMATION -
Name: !f, L_V6_(-6�11�.5_�_G.1
Mailing Address: —
Phone# --�?�� 2 g-7-, 23 9�..-___ Email:
CONTRACTOR NNFORMATION:
Name= --��!_g� s- - (UJ�_U-!� �' O W&P --
`�r
Mailing Address._.__ S U L.U E7
Phone#: Email:
.DESCRIPTION,OF PROPOSED;CONSTRUCTION
�ONewStructure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
ther 2 F '� 4 $ Z4 0
Will the lot be re-graded? ❑Yes 0WO Will excess fill be removed from premises? Ples ONO
1
}p
ROPERTY INFORMATION
i
Existing use of property: i U,%IR MAr�Lj Intended use of property: &LA"61jl?
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes UXo IF YES, PROVIDE A COPY.
�]Check'Box After Reading The owrter/contractor/design professional is respons�bie for all drainage and storm water issues as prov1ded by
Chapter 236 of the Town Code<APPLICATION l HEREBY,MADE to the iuildmg aepartmer►tfor the lgsuance'of a 96if ing permit pursuantao tiii b iiiiiiiig Zone 4
odmance of the Town of Southold,Suffolk,County,NewYork and other applicable taws,Ordinances or Regulattons,:for the construction of buildings,
additions;alteragons or for removal or;demoiitiori as herein described The applicant s to cdmply ply-wit applicable law;;.ordina
agree "nces,budding code,
housing code and regulations and to admit authorized msp@ctors on q�emtses artd n buMiri (s)for,necessary inspections Faise3statements made herein are,
punishableas a ClassA misdemeanor pursuant to Section 210 45 of he New Yolk State Penal Law:" _
Application Submitted ByN(print name): A PP2.f4tJ �i� 1 � ^�`YY NMAuthorized Agent ❑Owner
Signature of Applicant: / T Date: - --- - _
Monika Majewski
STATE OF N E W YO R K) NOTARY PUBLIC,STATE OF NEW►YORK
SS: Registration No.OIMA6392440
CO U NTY O F C,(/M-2 LJ C- ) Qwtified in Suffolk Couoty
Commiiwion Expires 05/28I2023
Q LIA CJ "N 10/L- being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the �•0
ontractor,Agent,Corporate Officer,etc.)
of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this
application;that all statements contained in this application are true to the best of his/her knowledge and belief;and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
day of lUae,CIA ,202
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, r—L V/N & Cffei Sjl A)E ki=YCf0f residing at J��� ��C2�/U1G' f T%� ,�P�✓�C
do hereby authorize t�p /�} I<fcAjlC/L- to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
r. REYEZ S '?/,(Zr
Owner's Signature Date
-cyI /y offyGPs
Print Owner's Name
2
OF SO(/T�QI
� o
Town Hall Annex Telephone(631)765-1802
54375 Main Road
P.O.Box 1179 G • Q
Southold,NY 11971-0959 �Q
�yC4UNT1,�
BUILDING DEPARTMENT
April 28, 2022 TOWN OF SOUTHOLD
Meyers, Kevin
59 Wellington Rd
Garden City, NY 11530
RE: 1) Pool release latches (2) must be poolside of the barrier.
2) Bottom fence"rail' (guy wire/tension wire) is required at bottom of pool barrier.
3) A separate building application needs to be submitted to obtain a building permit for t
raised patio/deck attached the the dwelling.
TO WHOM IT MAY CONCERN:
The items marked below are required to obtain your Certificate of Occupancy
Application for Certificate of Occupancy. (Enclosed)
Electrical Underwriters Certificate.
X Surface Water Alarm Required ( Comply with ASTM F2208).
Final Survey with Health Department Approval.
Plumbers Solder Certificate or Pex Affidavit
Trustees Certificate of Compliance. (Town Trustees # 765-1892)
Final Planning Board Approval. (Planning # 765-1938)
Final Fire Inspection from Fire Marshall. (631-765-1802)
Final Landmark Preservation approval.
Final Elevation Certificate required.
Energy Test Results.
Spray Foam Insulation certification from a NYS licensed architect or
Engineer
BUILDING PERMIT: 45983-Z In-ground Swimming Pool.
CORD,,
DATE(MMfDD)YYYYj
ORDry CERTIFICATE OF LIABILITY INSURANCE
PRO07UCER 10/30/2020
D 516-564-5656 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
NORTH FRANKLIN BROKERAGE INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
13 N FRANKLIN ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
i
HEMjPSTEAD,.NY 11550
........ INSURERS AFFORDING COVERAGE NAIC#
INSURED
INSURERA,.AMERICAN EUROPEAN INSURANCE
CUBIAS CONSTRUCTION CORP
INSURER 8z
76 GARDNER AVE INSURER C;
HICKSVILLE, NY 11801 INSURER D:
COVERAGES INSURER I—
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
T1NS R_AD_D'
EFFECTIVE POLICY EXPIRATION-"UMBER POUIIATCI'EFFEC YM LIMITS
GENERAL LIABILITY
EACHOCCURRENCE $1,000,000
A 1 ..
I 17—V COMMERCIAL GENERAL LIABILITY AwGrro-Rtffe
PREMISES(Epoccurence)—.— 100,000
CLAIMSMADE 06e OCCUR I MED EXP(Anyone person) S5,000
II SKP2007842 10 10/21/20 10/21/21 1 PERSONAL&ADV INJURY IS1,000,000
GENERAL AGGREGATE s 2,000,000
GEN'L AGGREGATE LIMITAPPLIES PER; PRODUCTS-COMPIOP AGG s 2,000,000
p,,,,y PRO-
LOC JECT
UTOMOBILE LIABILITY CO SINED SINGLE LIMIT
ANYAUTO (Ea m.cddent) is
ALLOWNEDAUTOS BODILY INJURY
S CHEDULEDAUTOS (Perperson)
�AM
f I — I
I HIREDAUTOS
BODILY INJURY
NON-OWNEDALTOS I(Peraccident)
�PROPERTYOAMAGE
1H (Peracadent)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT is
.ANYAUTO ----
EAACC I S0ERXNAUToFY_
AGGIS
j EXCESSIUMBRELLALMiu'rY EACHOCCURRENCE Is
POCCUR CLAIMS MADE AGGREGATE
0 DEDUCTIBLE is
I RETENTION S $
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT Is
OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPL2YEE S
i
it yes,describe,under I
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT IS
iOTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
According to policy terms and conditions certificate issued for proof of coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town Of Southold DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAR 30 DAYS WRITTEN
53095 Route 25 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 30 SMALL
PO -'kOX 1179 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Sothold, NY 11971 REPRESENTATIVES. 4
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108) @ACORD CORPORATION 1988
orr RK workers'srAfE Compensation CERTIFiCATE OF iINSURANCE COVERAGE
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 8 Address of Insured(use street address only) 1 b.Business Telephone Number of Insured
CUBIAS CONSTRUCTION CORP 516 439-3s70
76 GARDNER AVENUE
HICKSVILLE,NY 11801
1c.Federal Employer Identification Number of Insured
Work Location of insured(Only required itsoverage is specificaDy 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 Carrier
(Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company
Town Of Southold
53095 Route 25 3b.Policy Number of Entity Listed in Box"la"
Po Box 1179 DBL605178
Southhold,NY 11971 3c.Policy effective period
12/18/2019 to 12117/2021
4. Policy provides the following benefits:
tJ A.Both disability and paid family leave benefits.
B.Disability benefits only.
C.Paid family leave benefits only.
5. Policy covers:
Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law.
0 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 Disabitity and/or Paid Famity Leave Benefits insurance coverage as described above.
n
10/6/2020 'f d 4t
Date Signed By
(Signature of insurance carrier's authorized representative or NYS Licensed insurance Agent of that insurance carrier)
Telephone Number 516-$2"10p 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 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 SB 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.
Data Signed- By
(Signature of Authored 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 OB-120.1.Insurance brokers are NOT authorized to Issue MIS form.
DO-120.1(10.17} 81QIIPiBii-i1�2i0�i �iiit�a �-ii ill�l�
y
A?PPRO ED AS NOT D
DATE:V B.P.#
FEE: BY:
NOTIFY-.BUILDING DEPARTMENT AT .
765-1802 ' 9 AM TO 4 PM FOR THE
FOLLOWING.INSPECTIONS:
1. FOUNDATION, - TWO REQUIRED =RETAIN STORM WATER RUNOFF
FOR POURED CONCRETE :PURSUANT TO CHAPTER 236
2. ROUGH FRAMING & PLUMBING OF THE TOWN CODE.
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
DESIGN OR CONSTRUCTION ERRORS.
COMPLY WITH ALL CODES OF ELECTRICAL
NEW YORK STATE & TOWN CODES I�lStPECTI®IN REQUIRED
AS REQUIRED AND CONDITIONS OF
rS01LTHQLD TOWN 7RC
6�Ndi't�IdMSIG BOARD
RUSTEES
S- ECG
"NV E IATELY
ENCLOSE POOL TO CIJJDE,;
UPON COMPLETION
BEFORE"WATER
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
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POOL NOTES
1-ALL GUM S1U4LL HAVE A MIN.28 DAY STRENGHT OF 4,500 PSI.
2-Sf n REINFORCEMENT MALL BE GRADE 60 CONFORMING TO ASIM A615
s c T I O N 7-ALL WOR-WEL.DED K ZU BE IN REINFORCEMENT
WITH THEE LAATTEST�"C DEE "c TO AST 185
8-LEGS OF REBAR ACCESSORIES SHALL BE PLASTIC TIPPED.ALL SNAPRES AND WALL
PENELRCONS 9-SHALL BE CLEANED&MITREPAIRED TO PRELUDE CORROSION
10-ALL DIMENSIONS GO SHALL BE CONSIDERED A MIN.CONDtACTOR MAY INCREASE
TO PROVIDE FOR DRAINS do COPING
11-ENGINEER CONTROLLED INSPECTION REQUIRED
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1-ALL GUNBE SHALL HAVE A MIN.28 DAY SfRENGHT OF 4X PSI.
2-SM REINFORCEMENT SHALL BE GPADE 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
8-LEGS OF REBAR ACCESSORIES SHALL BE PLASTIC TIPPED.ALL SNAPBES AND WALL
PENETRATIONS 9-SHALL BE CLEANED&GROUT REPAIRED TO PRELUDE CORROSION W
10-ALL DWQiSONS GNEN SNAl1 CONSIDERED A MIL CONTRACTOR MAY INCREASE �
TO PROVIDE FOR DRAINS&C OPING
11-ENGINEER CONTROLLED INSPECTION REQUIRED
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PLOT PLAN OF PROPERTY o��
SI T UA TE
PECONIC g' ` s
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
6.y0 O�t`OPG�• ;�� •fit• ����`
S.C. TAX No. 1000-74-05-07 y� 06 o
SCALE 1 "=40'
FEBRUARY 11 , 2021
4.0'
tiy6 1.S�pJSF. ryk i �,o
AREA = 72,923 sq. ft. NOO
OPTS
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CERTIFIED TO:
KEVIN J. MEYERS -o
CHRISTINE P. MEYERS
oo�
CHICAGO TITLE INSURANCE COMPANY e�
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of 0y9 COO
of �
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4�co�ZG
UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF THE NEW YORK STATE
EDUCATION LAW.
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED
TO BE A VALID TRUE COPY.
CERTIFICATIONS INDICATED HEREON SHALL RUN
,+ v ONLY TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED, AND ON HIS BEHALF TO THE
+� TITLE COMPANY, GOVERNMENTAL AGENCY AND
.N LENDING INSTITUTION LISTED HEREON, AND
T� LENDING
TNE CERTIFICATIONS ARE NOT TRANSFERABLE.
THE EXISTENCE OF RIGHTS OF WAY
AND/OR EASEMENTS OF RECORD, IF
ANY, NOT SHOWN ARE NOT GUARANTEED.
ti Q�
PREPARED IN ACCORDANCE WITH THE MINIMUM
STANDARDS FOR TITLE SURVEYS AS ESTABLISHED Nathan Taft Corwin
BY THE LI.A.LS. AND APPROVED AND ADOPTED III
CO FOR SUCH USE BY THE NEW YORK STATE LAND
NG o�, hy� Yp� ,OD TITLE ASSOCIATION.
0�
Land Surveyor
S
Title Surveys — Subdivisions — Site Plans — Construction Layout
Z
PHONE (631)727-2090 Fax (631)727-1727
OFFICES LOCATED AT MAILING ADDRESS
1586 Main Road P.O. Box 1931
4 ' N. .S. Lic. No. 50467 Jamesport, New York 11947 Riverhead, New York 11901-0965
41-006