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HomeMy WebLinkAbout50981-Z of souryo`o Town of Southold * * P.O. Box 1179 io 53095 Main Rd ��'COUxn. Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45870 _ Date: 01/06/2025 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 720 Stanley Rd Mattituck, NY 11952 Sec/Block/Lot: 106.-7-31 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 06/03/2024 Pursuant to which Building Permit No. 50981 and dated: 07/24/2024 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: "as built" accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to: Michael Schneider Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50981 07/31/2024 PLUMBERS CERTIFICATION: Autho ized gnature �o�suEF `: TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE SOUTHOLD, NY Woy�o 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#: 50981 Date: 7/24/2024 Permission is hereby granted to: Schneider Jr, Michael 720 Stanley Rd Mattituck, NY 11952 To: legalize "as built" accessory in-ground swimming pool as applied for. Additional certification may be required. At premises located at: 720 Stanley Rd, Mattituck SCTM #473889 Sec/Block/Lot# 106.-7-31 Pursuant to application dated 6/3/2024 and approved by the Building Inspector. To expire on 1/23/2026. Fees: AS BUILT- SWIMMING POOL $600.00 CO- SWIMMING POOL $100.00 Total: $700.00 B g Inspector pF SO(/ly�l Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �Q sean.devlin(cL-)town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Michael Schneider Jr. Address: 720 Stanley Rd city:Mattituck st: NY zip: 11952 Building Permit#: 50981 Section: 106 Block: 7 Lot: 31 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Bethel Electrical License No: 40557ME SITE DETAILS Office Use Only Residential. X Indoor 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 Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 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: Intermatic Pool Panel 8 Circuit/ 3 Used, Pump 220GFI, (4) Lights On 30OW Trans. 120GFI, Chlor Synch Salt Generator 120GFI, Skimmer Plate Water Bond Notes: Pool Inspector Signature: te: July 31, 2024 S.Devlin-Cent Electrical Compliance Form *of SO TOWN :OF SOUTHOLD BUILDING DEFT. 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 (FINAL) [ ] CODE VIOLATION ] PRE C/O [ ] RENTAL REMARKS: -- °rr Iw S/" / o .Q 41 DATE IALLI INSPECTOR pF SOUIyO� # TOWN OF .SOUTHOLD BUILDING DEPT. IOU 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ . ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ q"'FINAL yq&( [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY.INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION. [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL'(FINAL) [ ] CODE VIOLATION [ . ] PRE,C/0 [ ] RENTAL REMARKS:- 0007 4XA- AS4,11 lo6k-, sil sagaobl�_ _*�e ve, 0�0. �10�Glle �.• Sy��ce.. w GUst-� �aSlc..0 As OIL 4z C-o . DATE INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS b FOUNDATION (IST) y ------------------------------------ c� C FOUNDATION (2ND) z � o ROUGH FRAMING& y PLUMBING S INSULATION PER N.Y. �y STATE ENERGY CODE on A/� �.0 /�S�x,�/ (N lea, on e,e-'r big /4ee ve or "loLo b& .61f4e . Sy i4cc.t wxkA 4"ot llaA- �S -- //a0�r-�Co,�µ. FINAL P C.�. . /Wf'� d� `.0- on /.g•,� O,rL Q . 0, coo ADDITIONAL COMMENTS mk�qj c � QAM� � y O z x . y x d b y oo�SurFn�t�oGy TOWN OF SOUTHOLD—BUILDING DEPARTMENT w. Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 https://wvuw.southoldtownny ov Date Received APPLICATION FOR BUILDING PERMIT n E C1 0 V E For Office Use Only V PERMIT NO. Building Inspector: J U N - 3 2024 Applications andxforms must"be'' 'filled out.it�their entiretyi Incompletet `� � °r. Building Department applications will ngt`be accepted tA/here.the Applicant is nod thi:�owner,an t 'town of Southold '"Owner's-Authorization`form'`(Page 2)shall be completed' r .J Date: I 2Z OWNERS OF PR PERTY '" _5_...C. ......: ...a.._.......�.�....,._....__.. ...+-_.:.. .t.......s... ,..s...:ah(..,.i. :rM. . G �r ..,i—.:.;:w..i:�).? �,�>.:.._..e. ......_..... .r j.�,.....�..µ..�,........sR x>.,4e�..�k....1_,._,_.,.w s. .,.�4t[.: Name: SCTM#1000- 1 ' Project Address: Phone#: Email:� Q.0 V . Mailing Address: Y.:.,.....,�.tt_h....a.Y.` ._..1.,,_.:�C..A.r_.+. .. Name: Mailing Address: . Phone#: Email . _ sDESIGN PROFESSIONAL _.x� .-t».r�i_. _ _G�,..:,...a_ rl.,a. ,H...:,sa±.a..aw,,:.w,*z:N. .ems .<.,�.:eia.:r�, �".�YJx..�.t.�, .5-- fs 7 s..a:..?�.a�s�z;l_.-d...✓2..;.1:',.�!,,,! k3kn Y41. Name: Mailing Address: AuL­ Phone#: Email: CONTRACTOR INFORMATION � � � ` � � i Name: Mailing Address: Phone#: Email: Yf)ESCRIPTION OF`PROP;OSED'CONSTRUCT1 N , r W h[k u qr ...w+w.'.(�.. P wStructure ❑Addition ❑Alteration ❑Repair.❑Demolition Esti ted Cost o Project: her $ Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? s ❑No 1 • - PROPERTY.INFO lVIATION� Existing use of property: Intended use of property. Zone or use district in which premises is situated: Are there any cove ant and restrictions with respect to this property? ❑Yes o IF YES, PROVIDE A COPY. ~ C eCk BOX After Reading ;The owner/contractor/design professional is responsible for all amage.and storm.water issues as provided by Chapter 236 of the Town'Code.-APPUCATION IS HEREBY MADE to the Building-Department for the issuance of a Building Perrrmtt pursuant to,the Building Zone R. 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[einoval or demolition as herein;described The applicant:agrees to comply,with ell applicable laws,ordinances;building code, 'housing code and;reguletions and to admit authorizedinspectors on,pre,mises and n building(s)'for necessary inspections.False statements•made herein are punishable as a Class A misdemeanor pursuant to Section 310 45 of the New,York State Penal Law , 4 t Application Submitted By ri name): thor'zed Agent ❑Owner Signature of Applicant: . te:(�5 STATE OF NEW YORK) SS: COUNTY OFP-aYJQT i9::2&(___kaA1__being duly sworn, deposes and says that(s)he is the applicant (Name of individual si ning contract)above named, (S)he is the (Contractor,Agent,Ccrrporate 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 M&4__1 \\01111liiii "�� otary Public E R M= PROPERTY OWNER AUTHORIZATION w �od��o� (Where the applicant is not the owner) i�WWdIng at 1 �I•'� \ _2 do hereby authorize Wto apply on AbeylfXtheynoSouthold Building Department for approval as describe herei � /7 0� Owner's Signatur ff Date Print Owner's Name 2 1 F BUILDING DEPARTMENT-Electrical Inspector �y TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 �!8 . ,��` Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr -southoldtownny.gov — sea ndCcD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECT N ELECTRICIAN INFORMATION (All Information Required) Dat - Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: Viateur Pilon License No.: ME-40557 Elec. email: Bethelec@optonline.net Elec. Phone No: 631-750-6555 ❑✓ 1 request an email copy of Certi ica a of Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) Name: MJ` n— Address: -Z�© S gn\p ZoA Moftbck Cross Street: Rlrt r- Ti,�,0 Phone No.: V�,Ail< S 6-6 Bldg.Permit#: email: Tax Map District: 1000 Section: I CX0 Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring Square Footage: Circle All That Apply: Is ob read for inspection?: NO Rou h In �51,7 Y P j ❑ ❑ g F Do you need a Temp Certificate?: ❑ YES ✓0 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 M H Frame Pole Work done on Service? Y FIN AdditionalI formation:Please call our Office with an inspection date and the Homeowner for inspection access PAYMENT DUE WITH APPLICATION A I nG y� BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD o - Town Hall Annex - 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 ' OZ Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(a_southoldtownny.gov - seand(ab-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECT N ELECTRICIAN INFORMATION (All information Required) Dat - j f Company Name: Bethel Electrical Contracting, Ltd. Electrician's Name: Viateur Pilon License No.: ME-40557 Elec. email: Bethelec@optonline.net Elec. Phone No: 631-750-6555 ❑✓ I request an email copy of Certificate of Compliance Elec. Address.: 1337-8 Lincoln Avenue Holbrook, NY 11741 JOB SITE INFORMATION (All Information Required) Name: M CI= 3- T��zx `I'b.N `;C N�—: l brPZ, Address: zo %,, zv fi:oA VA, k 1 -a Cross Street: P-= (`2 LAJ r- r,0 Phone No.: 1L/IjI-e -S j '0_�5 ., 10 1 Bldg.Permit#: 50-1 g/ email: rAc.'v-eop jma d ,celv\ Tax Map District: 1000 Section: Block: -7 Lot: S I BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Swimming Pool Wiring ` - Square Footage: Circle All That Apply: Is job ready for inspection?: W] YES ❑ NO ❑Rough In WI 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 R2 M H Frame Pole Work done-on Service? Y MN Additional Information: Please call our Office with an inspection date and the Homeowner for inspection access -Thank you! PAYMENT DUE WITH APPLICATION ,voiA 4 • PERMIT# Address: Switches Outlets GFI's Surface . Sconces H H's UC Lts Fridge HW POOL Panel ] Fans Mini Fr. W/D Pump Exhaust Oven Sump Heater Trnsfmr �-r cc,'�0 � � Smokes DW Generator Salt Gen. C,k l� r s Carbon Micro GrbDis Water Bond � ���., F�G� 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 j. 'c' ,F. "` f.'; _ :r-': .. " _�._ . I. 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C 5 'Y'� R�Y,54Sd.11...i 'fX�q-1`;�4'ir A'Xt:i•r�l ...._ ,-...,•{:.., ...<.-.. .,,.- ,t..:.1'<,..]1yf t.:•..,4-b,-IT". jla. r..-�A ri.7_.• Y STATE Compensation workers' CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC.DBA SWIM KING POOLS&PATIOS 631-744-8100 471 ROUTE 25A ROCKY POINT, NY 11778 1c.Federal Employer Identification Number of Insured 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 Rt. 25 3b.Policy Number of Entity Listed in Box"1 a" P.O. Box 1179 DBL37154 Southold, NY 11971 3c.Policy effective period 02/01/2023 to 01/31/2025 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. 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 11/7/2023 By w4a 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 413,4C or 513 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. DB-120.1 (12-21) IIIIIIP>!uiiu1ii2i0oi1iiii(i12iui21)ii01� A�o E IY ® CERTIFICATE OF LIABILITY INSURANCE DAT (.WDDYYY) 11/06/2023 ,THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 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 CONTACT m K O'Gara NAME: Y AssuredPartners Northeast,LLC. PHONE (631)465.4000 FAX AIC No Ext: A/C No 100 Baylis Road E-MAIL kym.ogara@assuredpartners.com ADDRESS: Suite 300 INSURERS)AFFORDING COVERAGE NAIC q Melville NY 11747 INSURERA: Philadelphia Indemnity Insurance Co. 18058 INSURED INSURER B: Everest National Insurance CO 10120 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools$Patios INSURER c: ShelterPoint Life Insurance 81434N 471 Route 25A INSURER D: INSURER E: Rocky Point NY 11778 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2382314181 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDD MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN CLAIMS-MADE FXR OCCUR PREMISES Ea occurrence $ 300,000 X Contractual MED EXP(Any one person) $ 5,000 A X Al ind Comp Ops/WOS/PNC PHPK2695157 09/01/2023 09/01/2024 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�jEa LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED PHPK2595157 09/01/2023 09/01/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per.accident H 1 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER �/ OTH- AND EMPLOYERS'LIABILITY YIN STATUTE /� ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICERWEMBEREXCLUDED? NIA SW5WC00205-221/222 11/05/2022 11/05/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 if yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ NY Disability C DBL37154 02/01/2023 02/01/2024 Statutory&Continuous DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The following are Included as additional insured if required by written contract subject to the terms and conditions of stated policies:Town of Southold 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. 53095 Rt.25 PO BOX 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD vORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (631)744-8100 Fence King of Rocky Point,Inc.,DBA:Swim Kings Pools&Patios 1c.NYS Unemployment Insurance Employer Registration Number of 471 Route 25A Insured Rocky Point,NY 11778 Work Location of Insured(Only required if coverage is specifically limited to 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Everest National Ins Co Town of Southold 3b.Policy Number of Entity Listed in Box"I a" 53095 Rt. 25 SW5WC00205-222 Southold, NY 11971 3c.Policy effective period 11/05/2023 to 11/05/2024 3d.The Proprietor,Partners or Executive Officers are ❑X 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"1 a"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 a policy is canceled due to nonpayment of premiums orwithin 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or 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: Philip Colletta (Print name of authorized representative or licensed agent of insurance carrier) Approved by: a 2* 11/03/2023 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-465-4000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov NOTES (� 1. NO SOIL SURCHARGEPERMITTEDWITHIN4 FEETOF EXCAVATION AT THE SHALLOW END,OR 6 FEETOF EXCAVATION AT THE DEEP END. 2. THIS POOL MEETS THE REQUIREMENTS OFANSI/APSP/ICC-5 AMERICANNATIONALSTANDARDFORRESIDENiIALINGROVNDSWIMMING 10• 40, i0' POOLS'AND1996 BOCA CODE-SECTION 421.DIVING EQUIPMENT 15 NOTALLOWED. O 3. SWIMMING POOL SHALL BE COMPLETELYANDCON71NVOt5LYSURROVNDED WITH A BARRIER CONSTRUCTED LAW REQUIREMENT5 OF SECTION R326AZf THROUGH R3216.4.26 OF THE NEW YORK5TATE RESIDENTIAL CODE C2020)AND INCONFORMITY WITH ALL SECTIONS ''<xe BENCH OFTHE TOWN OF SOVTHOLD CODE.DWELLING WALLC5)MAY5ERVEA5 PARTOF THE POOL BARRIER AS PEOTECTION R'a26.4Z8 AND n' ° CONDITION(I)APE MET.OPERABLE WINDOWS IN THE WALL(S)USED ASA BARRIER SHALL HAVEA5ELFLATCHING DEVICE.ACCESS GATES 46 APPROU 0 S NOTED SHALL COMPLY WITH SECTION R326.52OFTHENYS RESIDENTIAL CODE(2020)AND BESELFCLOSING,SELF LATCHINGAND BE SECURELY tL�/� LOCKED WHEN POOL 15 NOT IN USE OR SUPERVISED.ALL GATES ARE TO OPEN AWAY FROM THE POOLAREA. J F �A m 3-4 b aa• 4. DVRINGCONSTRVCTION THE CONTRACTORSHALLERECTATEMPORARYBARRIERAROUND THE EXCAVATION WWTHE CODE OFT14E O e- ��491HxS Hza TOWN OF SOVTHOLD, i S. POOL MUST BE EQUIPPED WITH AN APPROVED POOLALARMCAPABLEOF DETECTING ENTRY INTO THE WATERAND50VNDINGAN d } �� - a AUDIBLE ALARM UPON DETECTION THAT 15 AVDIBLEAT POOLSIDE AND INSIDE THE DWELLING.THEALARM MUSTBE INSTALLED, V 6 BY: MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS.THE ALARM MUST MEETASTM F2208 Z QZ NOTi BUILDING DE ARTMENTAT 'STANDARD SPECIFICATION FORPOOLALARMS.THE DEVICEMUSTOPERATEINDEPENDENT(NOTATTACHEDTOOP.DEPENDENTON)OF ][ri n c PERSONS, < 631-765-1802 8AMTO PM FOR THE 6. POOL SUCTION FIT71 NGS(EXCEPT FOP.SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORM TO ASMEIAN51 < ��T FOLLOWING INSPECT 0(tiS: A112.19.8M ORA MINIMUM I8'x23'DRAIN GRATE OR A CHANNEL DRAIN SYSTEM.POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH _ B __ ATMOSPHERICVACWM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN.SUCH 1. FOUNDATION ; i ;4 ~� PLAN VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME A112.19.17 OR BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. FOR POURED i 10; ��E"." SEPARATED BYA L SHALL BE MINIMUM OF3 ANVIDED WITH A ID MMVST)BE PIPESUCTION V<H THAT WATER IS wa DRAWN ETMi IRAVCH n THEM TYPE. MVLTANEOVSLY THROUGH AE SUCTION FITTINGS SHALL BE _ N.TS. VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OP.PUMPS)VACWM/PPE55VRE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE 2. ROUGH-FHAM3N POSITION,MINIMUM OF 6'AND NO GREATER THAN 12'BELOW THE MIN IMVM OPERATIONAL WATER LEVEL OR BEAN ATTACHM ENT TO 3. INSULATION THE SKIMMER/SKIMMERS.A REQVI RED POOL ATMOSPHERIC VACUUM RELIEF SYSTEM SHALL BE INSTALLED AS PER NY5 RESI DENTIAL CODE A�1 19"ONYL COVERED STEPS R326.63(2020)AN I N ACCORDANCE WITH INC.VILLAGE CODE, 4, FINAL-CONSTRU TIONML1,ST 7. ALL ELECTRICAL WORK SHALL COMPLY WITH TIE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE NYS QJ BE COMPLETE F C.O. cri RESIDENTIAL CODE SECTIONS 4201 THROUGH 4206.ALL ELECTP[CAL DEVICES MUST BE APPROVED BYVNDERWPJTEP,5 LABORATORIESAND BE PROTECTED BY A GROUND FAULT CVRRENT INTERRUPTER(GFCV CURRENT CARRYING ELECTRICAL CONDUCTORS EXCEPT FOR THOSE ALL CONSTRUCTION HALL MEET HE PROVIDING POWERTOPOOLLIGHTINGAND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5.ALL -v METAL ENCLOSVRES,FENCES OR RAILINGS NEAR OP ADJACENTTO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED REOUIREMENTSOFT CCDESOFNCVU rrorSANDROITOM y DUE TO CONTACTWITIANELECTRICALCIRCVIT5HALLSEEFFECTIVELYGROUNDED. Ql YORK STATE. NOT Ill SPONSIRLE FOR8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE 609, 06 Ln DESIGN OR CONSTRU TON ERRORS SECTION A 9. ALLPIPING 15 DIAGRAMMATIC VNLESSOTHERWI5E5TATED. `0 N.T.5. 10. WALKS IF PROVI DED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. 8 Z Addition WATER LINE TaPOF WALL 11. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW AN5I/APSP/ICC-5 SECTION 6. 4 Ln c 3 4. 1O, 4, 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOVTFIOLD CODE SETBACKS. 0 0 NO R Certificati n 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. May Be Req red. m 15. THE DESIGN IS BASED ONA DRAINAGE SOIL WITH:tO SILT.GROUNDWATER SHALL NOT EXISTWITHIN THE EXCAVATION.IFGROVND WATER EXISTS WITHIN 6'-01 FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. OCCUPANCY OR 16. ALL GAS AND OIL HEATERS(IF INSTALLED)fORh1EINGROVNDS'NIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY SECTION B CONSERVATION ACT(NAECA)COMPLIANT.POOL HEATERS SHALL BE TESTED IAW ANSI=.56 AND SHALL BE INSTALLED IAW- MANVFACTURERS SPECIFICATIONS.OIL FIRED POOL HEATERS SHALL BE TESTED IAW VL726.POOL HFATERS SHALL BE LOCATED OR T^ USE IS UNLAWFU N.T.S. GUARDED TOPROTECT AGAINST ACCIDENTAL CONTACT OF HOT SURFACESBYPERSONS.POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES.FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM.A RYPA55 UNE SHALL BE /� INSTALLED FROM INLETTO OVTLETTOAD)V5TWATER FLOW THROUGH THE HEATER POOL HEATERS SHALL BE PROVIDED WITH THE V FOLLOWING ENERGY CONSERVATION MEASVRES: WITHOUT CERTI CATr <HECK VALVE 2'-2' /� COSY OTNND WALKWAY 10• ib.i AT LEAST THERMOSTAT BE PROVIDED FOR EACH HEATING SYSTEM. 000E CSY OTHERS) 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE PUMP Fw' M5KIMMER GRADE OPERA71ON0FTHEH EATER WITHOUT AD)USTINGTHETHERMOSTAT SETTING ANDTO ALLOW RESTARTING WITH OUT REUGHTINGTHE m # �F OCCUPANCY WATERLINE HEATLIGHT. "T E i63HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH APOOLCOVER(EXEMPTED FR.OMTHIS REQUiREMENTAREOVTDOORPOOLS �L m.-m m TO DISPPAV DERIVI NG 20:OF THE ENERGY FOR HEATING FROM RENEWABLE SOURCES AS COMPUTED OVER AN OPERATING SEASON) m DRYWELL / VNDISTVRRED EARTH : - 16A TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET � >} 3500 PSI POURED CONC a� - TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER IN ACLEAN AND SANITARY CONDITION IAW APPLICABLE ¢ 3R o DIVERTER r \ SANITARY CODE OF NEW YORK STATE Y Z V o p RETAIN STORM WATE RUNOFF °�"� ° 'AT REBA0."�' �r m a VHIYLLINER n. THIS DRAWING IS FORSTRVCTURALSHELLONLY.ALL APPURTENANCES ARE DEFINED BY OTHERS. = c o m PURSUANT TO CHAPT R 236 FILTER z•ros SAND 18. BACKFILL WITH CLEAN F.ARTH,FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHTOFTHE W `s o D o -�' _ WATER IN THE POOL BY MORE THAN B',OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8' Of THE TOWN CODE. 19. PLACE CONCRETE ON 5ANDYTO LOAM SOIL.REMOVE ANY CLAY DEPOSITAND REPLACE W/COMPACTED CLEAN BACKFILL CHECK VALVE 20.THERE 15 NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY.THIS MEETS REQUIREMENTSOFTHENYSRE5MENTIALCODE-SECTIONR32b5FOP.ENTRAPMENTPROTECTION.'' 'V PLVMB(NGSCHEMATIC 21. THE POOL WAS DESIGNED IAW THE FOLLOWING: THo/�J N.T.S. WALL SECTION 21.1. THE NEW YORK STATE RESIDENTIAL CODE-SECTION R326(2020) COMPLY ALL CODES OF N.T.S. 21Z THE NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2020) 213. THE NEW YORK STATE FUEL GAS CODE(20'_0) •� CO NEW YORK STA &TOWN CODES 21.4, THE NEW YORK STATE SANITARY CODE - * 1`I 21.5. AN51/APSP/ICC-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. _1} fS 21.6. BOCACODE-5ECTION421. U I fit AS REQUIRED A CONDITIONS OF 21.7. CODE OF THE TOWN OFSOUTHOLD. OLD MAz,- ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. 'LS F� Q. oaa�1 0 TOWN PLANNING BOARD FESS0400 SO TOWN TRUSTEES N.Y. EC DIATEL S OLD HPC ELECTRICAL ' ;GEtSE POOL TQCODE 'IVSPE^'T.O�V REQUIREC PO(V COMPLETION CHD - - 'BEFORE"WATER°