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HomeMy WebLinkAbout33111-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-32536 Date: 08/20 07 THIS CERTIFIES that the building DECK W/ INGROUND POOL Location of Property: 620 WUNNEWETA RD CUTCHOGUE (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Sectioa 104 Block 11 Lot 14 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 25, 2007 pursuant to which Building Permit No. 33111-Z dated JUNE 6, 2007 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 DECK ADDITION WITH INGROUND SWIMMING POOL FENCED TO CODE AS APPLIED FOR. The certificate is issued to BASIL ASCIUTTO (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAI. N/A ELECTRICAL CERTIFICATE NO. 7302 07/23 07 PLDPffiERS CERTIFICATION DATED N/A uth~rized Signature Rev. 1/81 - - _ ~„at¢ ~~?d I,J.ummpwe~ ~ Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCI' This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Fina] Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I % lead. 5. Corrunercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Cornpliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is ~ denied; the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees ] . Ceiiificate of Occupancy -New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Switrnning pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 Dat New Construction: Old or Pre-existing Building. (check one) Location ofPropeny: 6oZ0 Wt.IyI/yl/I~W~'fA' Rfl Ct{'TGyu6eyE House No. Street Hamlet Owner or Owners of Property: ~~-S ~J4 j ~ Suffolk County Tax Map No 1000, Section ~ Block Lot Subdivision Filed Map. Lot: Pertnit No. 33 t 1 ! ~ Date ofPennit. ~ 07 Applicant: IL d~$G!_W~ ~yNI>%r~ ~d~ Heahh Dept. Approval Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Pee Submitted: $ L ~ ~ I ~ Applicant Signature ~r IF3U~~A~J 3+ SUF..~LK E. F ~ 'r,. ~ ~ ,~F%CC-, a iC. 40 Nottingham Drive, Middle Island.E--Mai SBEIGS~gmail.com Telephone: 631495 8136 Fax: 6319806455 CERTIFICATE OF ELECTRICAL COMPLIANCE Certificate No.: 7302 ' Apptitartt: B Eiectrtcai F.~ ItrspeKtiort per; July 3 ,2007 Rough In Inspection Date: l~Y 3 ,2007 Appla~on No.: 7302 euiid'mg Perrmt No.: _ - xx,,,, ar,,.:' 104_12 .14:;x.. This Certificate of Electrical Compliance is limited to the inspection and compliance of electrical equipment and/or work described below, irtsYalted by the applicant named above, located at the premise of and not after the final inspection date above: ()venter: ISasit Attu .Site LDOt~n: 6~ yfhuMayre~a Rda CutihO4tru, Tit' 11935 awne~s address t;f different): ; k { J OO.`!G„IP,i '-'Service '1. Residential Indoor ; 0 Outdoor i~ First Floor iwrj pod _i FlotWb ?Commercrc7aal ~1, 0 New ~ Renovation ~ Second Floor ~ Affic ~ ~r~` OSurve Other. F ? Addfion y _ _ - INVENTORY Dupkz Recpt 220v Ceflireg FixWre HID FixWres . Single Phase Hest OFCI Recpt 1 Waft FocWra Smoke Three Phase Hot Wafer Single Recpl Recessed Feature CO Detect Main Parcel AC Cond Punps 2 Sea PU,e itlq AC Bbaer _ Raepe Recpt _ E Time Cbcic 1 ~P~~ pryef Recpt SwiVCI~ p Twist Lack Exit Fotlures Disconnect Pool Luminelre 1 Exhaust Fan k, GFCI Bn:eker Heat Pump 1b0 Ektctrre Heat Ottmr Equipmerd: The electrical work and/or equipment described above were inspected and appear to be in compliance with local, state and national electrical code requirements and this office. License No.: 2880ME Applicant: Bethel Electrical Cont pate Of Certificate: Jul 23 , 2007 Inspected By: Gene Surdi r ::Signature: FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 33111 Z Date JUNE 6, 2007 Permission is hereby granted to: BASIL ASCIUTTO 620 WUNNEWETA RD CUTCHOGUE,NY 11935 for : DECK ADDITION WITH INGROUND SWIMMING POOL AS APPLIED FOR at premises located at 620 WUNNEWETA RD CUTCHOGUE County Tax Map No. 473889 Section 104 Block 0011 Lot No. 014 pursuant to application dated MAY 25, 2007 and approved by the Building Inspector to expire on DECEMBER 6, 2008. Fee $ 450.00 ~<J.A &1~ ~ Authorized Signature ORIGINAL Rev. 5/8/02 ho~y,OF SOUTy~6 33111 ~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION FOUNDATION 1ST ( ]ROUGH PLBG. ( ]FOUNDATION 2ND [ ]INSULATION FRAMING STRAPPING ~~FINAL [ ] FIREPLACE ~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ] FlRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION ~IIa~ ~e~-~e, d~/~ie~.ai REMARKS:~~ d L --Z-~l- ~-C-~. . DATE ~ ~ INSPECTOR - FIELD INSPECTION REPORT DATE ~ COMMENTS FOUNDATION (1ST) ~ ~ ~ I ~ ~ / ~ , ~ y a C FOUNDATION (2ND) z 0 7 ~ ~ ~ ~ y ROUGH FRAMING & - PLUMBING - _ - - _ _ L~ - - 2 - _ - p." INSULATION PER N. Y. - y STATE ENERGY CODE _ \ FINAL ADDITIONAL COMMENTS ~ , - - - - ~ O - - - - _ _ - _ _ - - ~ m - - - - j~~ z - - - T'~ v 1 Q ~ °S' °z Z-~ x e b y TOWN OF 6QUTd0l,>4 tsuu,lluvu YbK1v111 AYYLIC;A'11UN CHJ?CKL1S BUILDING DEPARTMENT Do you have or need the following, before applyin@ TOWN HALL Board of Health SOUTHOLD, NY 11971 ~ 3 sets of Building Plans TEL: 765-1802 Survey PERMIT NO. 33///-~/ Check Septic Form N.Y.S.D.E.C. ~ Trustees Examined ((I , 20~ Contact:. Approved , 20_~ ~ Mai] to: Disapproved a/c ~ Q g Phone: - - - Building Inspector MAY 2 5 r_..~ l ' ~PP~.ICATION FOR BUILDING PERMIT t-! ' - _J Date Z~~ , 20~ INSTRUCTIONS a, This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout'the work. e. No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupan is issued by the Building Inspector, 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, or~alterations or for removal or demolition as herein described. The applicant agrees to comply with al] applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. DU1.~RITE its) (Signature of applicant or name, if a corporation) (Mailing ddress of ap- ph t) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ~'A~A1~Gci ~1'~, Name of owner of premises 'SAS aSC(u.TTO (as on the tax roll or latest deed) If ap lica is ~t co oration,ls~ignature of duly authorizCd officer ( e and title of1corporate officer) - Builders License No._ ~[1 35Q~j~ Plumbers License No. ~ ~j Electricians License No. I~JQ(J M Other Trade's License No. 1. Location of land on which proposed work will be done: 62o WUNIJGWETA RD ~ CuTCNoGuE House Number Street Hamlet County Tax Map No, 1000 Section I ~4 Block ~ ~ Lot ~ 4 Subdivision Filed Map No. Lot (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~ ~ ~I~ b. Intended use and occupancy_ fl>^ ~`T'~ 1. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work S_t._16Qhif11.}~ ~i9lMMl t-~, ~o~ I Q (Description) I. Estimated Cost y Fee (to be paid on filing this application) If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars If business, commercial or mixed occupancy, specify nature and extent of each type of use. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories ~Zx 7~} T'?.~~"~-A4~ f9 G ~N'1?1M X70 ~Cn- Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories Dimensions of entire new construction: Front Rear Depth Height Number of Stories r Size of lot: Front ~9 Rear ~ ~ ~ Depth X46 ~ 0. Date of Purchase ~ Name of Former Owner 1. Zone or use district in which premises are situated 2. Does proposed construction violate any zoning law, ordinance or regulation: ' 3. Will lot be re-graded Will excess fill be removed from premis YES NO 4. Names of Owner of remise ~ {U Address 20 Phone No. 7~-$10$ Name of Architect ~ l g Address Phone No_ zr~$ -7 b Name of Contractor_iR(fE Address - hone No. ~,S- 5. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 6. Provide survey, to scale, with accurate foundation plan and distances to property lines. 7. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. TATE OF NEW YORKS)8 OUNTY OF~U,F~h~JC) ~ 1 C~F~9RD being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, i)He is the _ ~ ~~j (Contractor, Agent, Corporate Officer, etc.) f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; iat all statements contained in this application are true to the best of his knowledge and belief; and that the work will be erformed in the manner set Forth in the application filed therewith. worn to before me this 7.~~day of ~ 20Q~ Notary Public S' lure of Applicant PETER ECC''N Notary Pubfk, State of fVew'!~rk No. Ot 606092004, Suffo6; C ,ur~ty Terre Expires May 12, 2017 i s, I i . „ a . ~ ~I ~ ~ tip, ~ I' Y~._ r w ~ ' ~.xN. ~ y~,• LLB, ~ ~ r~ ` a _ ~ a'". ti's' 7 .F € ~ 5r. 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V. x Y ~ F ! i ~ H ~tii "'-"db ~j /d:. : , i. } - A • . + _ v _ _ ~ - r y ~ E _ w ~s, . may;''- ~ ~ ~ ~ ~ a . .r ~ ~ y, .y ~tF -,ivy s~ q y A. t~ v . ~ _ . r ~ n , , ter... ,ads- sue. \ 'i~...~~. • • • ~-7 _ _ OWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET VILLAGE DIST. SUB. v LOT#-Z9 I~ ~ sdd. C~ f~ ~a ~ ~ ~ Nd sad ~ ~~r~~~-, , FORMER OWNER N E ACR. •6 (~,~}.~Q~G(w~y~ r'S~Y1~ S W TYPE OF BUILDING tES. SEAS. L. 9 ARM OMM. CB. MISC. Mkt. Value LAND IMP. TOTAL DATE REMARKS L ~ a / ~s c .ry„ t.. ~ w d s a e .~o fJ- ~,2 7~ ,1 ,~'=',2 , ~.S'O A / S-a d l` ~~6G ~'o /u~ ~of'.29 b', ~d o2~ S_G d Q,l~.PS Q ~8u:~ ~Y6 U a ~0 C, 13 ~ S°4 '~,79csc~, la/ r"~AdDY,=f/d ~ WF To W. T3Pt oN.-~~a_ r"r~220 ~S'7/(! S-aQ 1 /2a ~l r^ ~ a .3Sax~~ 13r~ ~ -T'o ~7fir2.`z~ L- ~~~`-c~ r 5~1 7.:+0 ,~2.oc.~ % 5e/c?u ~ 2-~z7 fsS~ 7~ ~L ~rZ. l I ~l O o I AGE BUILDING CONDITION ! ~--~aD~S~L7a.~'i"!.1`FFC.~~?~ ~L.~-{,~ HSr,~,ld 7"~~G~171~1X~ NEW NORMAL BELQW ABOVE FARM Acre Value Per Value Acre tillable 1 tillable 2 -illable 3 Voodland swampland FRONTAGE ON WATER 3rushland FRONTAGE ON ROAD ~ louse Plot DEPTH 3 pQ BULKHEAD d "otal v DOCK COLOR iz r --y ~ .e• I U~ 1 Z 1 I jj?? ~ ~ ~ I TRIM o~ . s: ~~l Vy ,`(lam 1 ~ y x ~ z s* i w ~1 ~I~~ _ I~- ~~~JJJ z _ ~ { ism io _ _ , . ,-1 2 Dinette T Bath `1 I Foundation , M. PJ~dg. txz~ _ .~}G»'2- 5,50 2~4~~ - _ 2391 / asement i:`;,, ~i,~ Floors OAK, K. Extension 7.~.x ~ = f~~`~' 3.7.5 a x ~Z = a4 ~ / t. Walls "'v`- Interior Finish ~j,~l 'c LR. Extension i.z 2,SU y0 ~~-i~~a - Extension ire Place ' Heat ~ , r~ DR. ype Roof < ~ G~ Rooms l st Floor 3 BR. ~ Porch 50 ~7/ ecreation Room Rooms 2nd Floor Z FIN. B. C~ ~-M - I ~ ^3~ = ' ~ ~ ormer Breezeway _ r iveway Garage u~U~u."t.. Patio - O. B. Total -1 ~ e • • • STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured Dunrite Manufacturing Corp 631-588-1300 Dunrite pools lc. NYS Unemployment Insurance Employer Registration 3510 Veterans Memorial Highway Number oflnsured Bohemia, NY 11716 0592920-5 Work Location of Insured (Only required if coverage is specifically ld. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e. a Wrap-Up Policy) 11-2245133 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Ilolder) State Insurance Fund 3b. Policy Number of entiy listed in box "la": - - Town of Southhold WC1883215 Bldg. Dept 3c. Policy effective period: Main Street 04/01/07 to 04/01/08 Southold, NY 11971 3d. The Proprietor, Partners or Executive Officers are: ~l included. (Only check box ifah partners/officers included) ? all excluded or certain partners/officers excluded. 3e. Demo]ition is: (Definition ojDemolitian on Reverse) ? included. ®excluded. This certifies that the insurance carrier indicated above in box" 3" insures the business referenced above in box "1a" for workers' compensation under the New York State Workers' Compensation Law. 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 /nsurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ojpremiums or within 30 days IFthere are reasons other than nonpayment ojpremiums that cancel the policy or eliminate the insured from.the coverage indicated on this Ceri~cate..(These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of oneyear after this form is approved by the insurance carrier or its licensed agent. Please Note: Upon the 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 cerfify 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: KPVIn MrT)nnrnrgh ~Gj~(Pf/~nJ,t(~/n~~/o)f„a~u~thonzed representative or licetued agent of insivance carrier) APProvedby: ~9`~ U+~~I~Y`o`~-- ~/~Q/2007 (Signature) (Date) Titre: President of Walter Rose Agency, Inc Telephone Number of authorized representative or licensed agent of insurance carrier: (845) 783-2555 Please Note: Only insurance carriers and theirlicensed agents are axdhorized to issue the C-105.2 form. Insurance brokers are NOT aaahori__>ed to issue it. C-105.2 (9-O]) ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE (MM/DD/YYYY) DUNRI-1 04 02/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Wal er Rose Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 Stage Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Monroe NY 10950 Phone:645-763-2555 Fax: 645-783-2425 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Twin Cit Flre InSi CO 347 INSURER B: HaltfOrd Dunrite Manufacturing Corp INSURER C: 3510 Veterans Memorial Highway INSURER D: Bohemia NY 11716 INSURER E' COVERAGES 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 ANV 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 7HE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OFINSURANCE POLICY NUMBER E TIVE POLICY E%PI DATE MM/DD/YY DATE MMIDD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 B X COMMERCIAL GENERAL LIABILITY OISBAAI5151 04/01/07 04/01/08 pREMISES(Eaoccurance) $ 50,000 CLAIMS MADE X~ OCCUR MED EXP (Any one person) $ 5 ,QQQ PERSONALSADV INJURY $1, QQQ, QQQ GENERAL AGGREGATE $2,000, QQQ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $1,000, QQQ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY A X ANY AUTO OlUECTI6053 11/20/06 11/2Q/Q'] COMBINED SINGLE LIMIT $ 1 Q00 QQQ (Eaa¢itlent) r r ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (PerawitlenQ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: qGG $ E%CESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ g WORKERS COMPENSATON AND TORY LIMITS ER EMPLOYERS' LIABILITY E. L. EACH ACCIDENT $ ANV PROPRIETOR/PARTNER/E%ECUTIVE OFFICER/MEMBER FXGLUDED? E.L. DISEASE-EA EMPLOYEE $ If yes, tlescriba untler SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ' CERTIFICATE HOLDER CANCELLATION SOUTH-7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL l O DAYS WRITTEN TOwn Of Southold NOTCE TO THE CERTIFICATE HOLDER NAMED TO THE LER, BUT FAILURE 70 DO SO SHALL Building Dept IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Main Street Southold NY 11971 REPRESENTATIVES. AUTH IZ PRES TATVE ACORD 25 (2001106) ©ACORD CORPORATION 7988 STATE OF NEW YORK ESTADO DE NUEVA YORK WORKERS' COMPENSATION BOARD JUNTA DE COMPENSACION OBRERA ~ NOTICE OF COMPLIANCE AVISO DE CUMPLIMIENTO DISABILITY BENEFITS LAW LEY DE BENEFICIOS POR INCAPACIDAD TO EMPLOYEES A LOS EMPLEADOS ~ti 1. If you are unable to work because of an illness or injury not 1. Si usted no puede trabajar debido a enfermedad o lesion no work-related, you may be entitled to receive weekly benefits relacionada con el trabajo, podria tener derecho a recibir from your employer, or his or her insurance company, or beneficios semenales de su patron o de la compDania de from the Special Fund for Disability Benefits. seguros de el/ella o del Fondo Especial pars Beneficios por ' 2. To claim benefits you must file a claim form.within 30 days Incapacidad. 1 2. P r r l r o f i t f fir m t~fir date ,your disability, but in no event more m I n n r I Ir n than 26 weeks from such date. ~~In pero en ningun caso mas semanas e 3. Use one of the following claim forms: tlic a ec a. ~~--.k -If, when your disability begins, you are employed or are 3. Use una de las siguientes, fortnas de reclamacidn : '1~1 F"' unemployed for four weeks or.less, use WHITE claim form -Si, cuando comience su mcapacidad usted esta empleado q , 7 (Form DB-450), which you may obtain from your employer, ha estado desempleadD por cuatro semanas o menos use la forma de reclamacidn BLANCA (Form DB450), la coal puede his or her insurance carrier, your health provider or any obtener de su patrdn o de la compania de seguros de eUella, ; office of the Workers' Compensation Board, and send tt to ode su roveedor de cuidados de salud, o been de cualquier your employer or the insurance carrier named below. oficina de la Junta de Compensacidn Obrera, yy enviela a su -If, when your disability begins, you have been unemployed patron o a la compania de seguros nombreda abajo. more than four weeks, use the GREEN claim form (Form -Si cuando comience su Incapacidad, usted ha estado DB-300), which you may obtain from any Unemployment desempleado mas de cuatro semanas, IISe la forma de Insurance Office, your health provider, or any office of the reclamation VERDE (form DB-300), la coal puede obtener en ~ Workers' Compensation Board. Send completed claim form cualquier Oficina de Seguro de, Desempleo, de su proveedor de salud, o bien de cualquer oficina de la Junta de to the Workers' Compensation Board, Disability Benefts Comppensacidn Obrera. Envie la forma de reclamacidn, Bureau, Albany, New York 12241. debidamente terminada, a Workers' Compensation Board, IMPORTANT: Before filing your claim, your health provider D~i~s~a~bi~lity Benefits Bureau, Albany, New York 12241. must complete the "Health Care Providers StatemenC' on LmPUR iANIE: Antes de presentat usted su reclamacidn, es ) the claim form, showing your period of disability. necesario que su proveedor de salud comptte la declaration del medico (Health Care Providers Statement') en la forma ; 4. You are entitled to be treated by any physician chiropractor, de relamacion, indicando el periodo de su intzpacidad. ~ dentist, nurse-midwife, podiatrist or psychologist of your q, Usted tiene derecho a ser tratado por cualquier ,medico, choice. However, unlike workers' compensation, your quiroppractico, dentists, enferrnera-parte2, podiatre o medical bills will not be paid unless your employer and/or psicdlogo que usted elya. Pero, contrario a la Compensacidn , union provide for the payment of such bills under a obrera, sus cuentas medicas no seran pagadas a menos que ~'q ~ Disability Benefits Plan or Agreement. su patron ylo Unidn hags el pa ode tales cuentas medicas 5. If you are ill or injured during the time you are receiving bajo un Plan o Convenio de Beneficios por Incapacidad. Unemployment Insurance Benefits, file a claim for Disability 5. Si estuviera usted enfermo o lesionado durante el tiempo que este recibiendo beneficios del Segguro de Desempleo, ~y Benefits as soon as you sustain the injury or illness, by presente una reclamacidn pars Benefcios por Incapacdad, Imo, following the instructions outlined above. slgqwendo !as instrucclones amba descritas, tan pronto Como 6. If you are out of work in excess of seven days, your sufra la lesion o la enfennedad. employer is required to send you a Disability Benefits 6. Si usted esta desempleado por mas de siete dias, su patrdn 1 Statement of Rights (Form DB-271). esta obligado a enviarle la Declaracidn de Derechos de Benefcios por Incapacidad (Form DB-271). 7. Other information about Disability Benefts may be obtained 7, Otras informaciones relativas a Beneficios por Incapacidad ~ by writing or calling the nearest Workers' Compensation pueden obtenerse escribiendo o Ilamando a la ofcina mas Board Office. cercana de la Junta de Compensacidn Obrera. WORKERS' COMPENSATION BOARD OFFICES Albany, 12241 - 700 Broadway-Menands- (518) 474-6661 ' .Binghamton, 13901 -State Offce Bldg.-44 Hawley St: (607) 721-8353 y {I~ BuHafo. 14202 - Statler Towers - 107 Delaware Ave. - (716) 842-2166 q Hauppauge, 11788 - 220 Rabro Drive -Suite 700 - (fi31) 952£000 r - w/ Hempsteatl. 7 7550 - 175 Fulton Avenue - (516) 560-7745 New York City 11248-0005 - 1 BO Livingston St.- Brooklyn - (718) 802-6964 I Peekskill, 10566 - 41 North Divisbn SL - (914) 788-5775 Robert R. Snashall Rochester, 14674 - 730 Main SVeet W est - (716) 238-8300 Chairman (Presideme) Syracuse. 73203 - 935 James SL- (315) 4232934 1a The undersigned employer is in compliance with the provisions of [he Disability Benefits Law (EI paVOn abajo fionante esta en conformkiad mn las (~1 disDOSiciones tle la lay de Beneficios por Ingpacidad). Disability Benefts, when due. will t>e paid by (Lw Benefcios por Inppacidad, cuanoo debitlos, seran pagados por): Zurich American Insurance Company (800) 887-9111 The benefits provided are (Los Denefcios provistos son) Disability Operations (631) 845-2200 P.O. Box 9102 Statutory Under a Plan or Agreement Plainview, NY 11803-9002 X EHective¢~ojryi97 To TNDFFTTdT TF Class(es)ofemployees covered (Clase(s)de empleados amparados) (En vigor Desde) (Rasta) ALL Policy NO~~{.~~7-2>~3 . (POliza NO-f Name of employer (Nombre del Patron) THE WORKERS'COMPENSATION BOARD EMPLOYEES AND SERVES DUNRITE MANUFACTURING CORP. PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. LA JUNTA DE COMPENSACION OBRERA EMPLEA Y SIRVE (~f iti" DB-120 8-00 "°'°1°`auycnair THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND wonen'ewra><sauoeeoara ABOUT THE EMPLOYER'S PLACE OR PLACES OF BUSINESS. SIiW a! New York 1 rvvL 1111'ICN51VN5 I a 1 1 1 - \ 1 - \ \ ~ / i 1 -1 \ \ i 1 \ ~ 1 1I t E dt116 1 - 1- -11/ ,100 ~ ~ \ / C• - - \ ~ ~ ~ v 0~~JI/~ ~ry~d I \ \ \ t~ v \ > I DIVI G BOARD Q/ BI eorFon: t n J T T T ~ I ' \ ~hOA9'~Mt / / \ ' I ~ / \ \ 1 + ~ \ \ I I II \ I I ~ I I RPtP ! _ I _ _ _ I nOr~ -f -~aKInnER I dICTKM I AI I 1 . POOL PLAN I I I . I I -------------A~~----- F4 Tl'P. PANEL STIFFNER ~ _ _ ~ ^ - - - ~ - MIN. 2" TNIGK VERMICULITE ~ - K>39(9/e' aE! c DRiwr~ acReus ~ AGGREGATE TAMPERED ePACED . IY o.c. CANCRETE OR WOOD DEDK OP TO COPMG BY OTNERSJ _ _ - - aLOPEO Awar rROn PcaL PANEL AL1nINW1 OGPING B2 C~ ' D2 anrxENex BEYOND) AY - - - _ LaNG aTm ANGLE o o i \ 1'LONG WWED ~ SECTION ~ - / ~ v TYP, auwlWln coAnNG l e/la' DIA CARRIAGE B0.Ta: _ m nn. vINYL LMER w wAeNER 1 wr. . I~I D x / T CORN `ter {-E~~v~ - :L4' FRAHE BdaF~ O STEEL WALL PANEL / r r . t aTm ANGLE 3/e'-16x1' BOLT. WIT, Z WAEHER9 ~ (///@///j~ ~ , . DRIVE eTAKE - ~ ~ i GIIRVETI FLLER ~ M'1 p TO RELIEVE LINER ~ a~ l n b w BOLT®W a/la' D16 ~ nowlo wlrN, CARRIAGE BoLra , Sn /w 3 CU. FT. CONGREfE el10RT _ L. ~ V elm D / \ ANGIE 3' TYCK VERnILULJTE AGGREGATE nU( i/~O ~`1 . O HARD 80TTOn FN. V - - _ - _ _ _ _ _ _ _ _ _ CORNER CONNEGTIOA9~F P _III~Ir III~II=1il~ll=_III~II=III IL-III~IIJIIE311=III= `III=III III 11=III=IIIE?III I0 111 III- I III=III-III~II_111.-III` '~~-1- f~~_I_I~II f~~II=III _=11 ~IIEI~~113 b' LONG 6Tm REINFOROMG ROp -III=III III- U18JIeTIRBED EARTH 111=11 - _ RRO IlND10T1IRBED EARTH TNROOfW 'll-III 1=111=III=Ills NOLE6 M BOrtOH aF PANEL ail= i=Lan-J~u-'llail=III l T~TI_ ;1111 JII=II ICI III IIiI~II ~I IIII~II II IlI~pIII111111=' III=III=III=III=IIIJII=IIIJIIBIIIJII3111= TYPICAL Wi4LL SECTION ,4T 'A' FRAME PODL TYPE: REGTAGLE REY.~ SCALE N.T.S. JAMES DEERKOSKI, P.E. DATE Z60 DEER PATH DRAWING NUMBER MATTITUCK, NEW YORK 11957 OF M _ - - s , ~J "~t _ / , - , `r - « 1 Lo~ .2.97 (Ve/ca,~ - - r Ci ~ _ ~ nl ~y { _ r' THE WATER SUPPLY AND SEWAGE DISPOSAL ~ r' 1 N ~i6` ~,S 4L~~~. ~4 T_ ~~+~'i. 7'<? ~ b SYSTER~IS F4R TFfJE RE&IL?ENCE WILL ~ S ~ o ? ~ _ _ ~ COtlFaft#~A TO THE STANDARDS OF THE ~ g1iFFOLK Cd. DEPT. OF HEALTH SERVICES, +i _ ~_j weal! -gas... k t p J y ~k ~_'t. big - y OS SUFFOLK COUNTY DEPT- OF HEALTH . • .c, ~ v - ~On•~ ~ ? - s1~- ~ I SeRY1C£S - FQR APPROVAL OF ~ ~ ~Q - \ b 2~ ~''~~vr><C ; f ~ ~ r g. ' DA~'1f6~+CTFpM (j1JLY a _ ~ ~ ~ '`'rR . ~ ~ ~ U APPRtiHfD: Vl '7/G ~a ~ ~ • ~ SW~'FOi.iC,CO. TAX MAP DESIfNAT10N: m.. _:~':E?,~.~. f.~ d ~C. ' f9 BiST. SECT. STACK !'CL. .n l~oU I~~ f/ /4 ~ , j a ~ ttS At~DR SS. E~ ~ I 9 - Y f S ^ DEED: L. -i3' 3c7 P. 2 S k„~~ 'i~ ~ r ' ~~~=;L~ , J~,/'~ 1 lea+EEroeW unwn+. v,.wi l0~~~..-,G'=- 1 t_ t~-~ r- ~ r i r r~ H, I"C.. a.~ ~J~ G i~QU H P ~ Wt suaKr u •w8.wrnw w /teEOU rn? a nuriiW row an ~ T Ri~xnaFEAw. (A Atl5 $UAYf! xe~v rWE ~ }ttA~ ~ 4 1485 R. D. Ate. ~ . f' r ; C' ~ r ~ I/ " -lnp -•n : ( IA10 etlAYEYOes seem su. e• ~t SNALL NOE ee eawi•r~ ~eSa ai goeal and •at.n '_!r - ~ ~ ~ VM® RIIE COZY. 7 ,q ~ t ~ LEI !T"it~ r7 i .l ~'yi C' Yt ~ - eor<.rro ~Eaa+ .uu +w faeilitira fnr thin' lga`tiaunt ~ ~f~~. / ~3 V`!n! G7f .~f7(CIL. I Y• J~': ='f Cj s / /'QYI _ tT~ r9 C ~o n~E rEasa+vac wit or Elydn LG6P.Qtea b7, this depaR me ~ K f f pRMa uo a+ nis taw ro #Yt .i,.. ~>f~l'JL, rS ~ CCUrvAIf., GOVawtIr+EAt r•OrE1C~ Mo • ~ ~tiRtaatot'TQ~ ,,IIJJ ~ /U R ~ ~Yr+ wuinmon usrm Mtxaa ,w ~vis~ Moir. f , f 9$~ iq.s ~ n,E t~•o errwrc Ere7leR Y SEAL NO~e's: ~G~~ l1C~,7J~GY5 ;`~1Cat~f, ~1 rf~Cr 7'r~ :=-!%~''7[14`~ _ / 11' ~~s-f-6,~1~ .~virrc~s E~arslr ~cr-st-~ sa,',d :'~C?~' ~ " r^,iG7~ ~ c.~'c! +:.Z/r° ~ fi' r H fY'C ~l ~ 7-7~Fi<K L Cac"m~i1 ~i~'rk s <%s lYla~' /'~~~mh~'r /~'S6. .1~ ~u,v~c~~ G--+. t`7, rr_~8-i. ~ ~ . E/~va~/~~s shawrr`~+Y~ /rr r`~~a~: tr:,~l ~c'~E~c' - - - v ~ u~rl<., ~n Su~{v!k ~Qurl~ tD ~ V1L des-,'a~ sf_rr?~ f. r - _ - i . - LLp. tJF1~G S tiiRr~i~'!RT fill YCARic