HomeMy WebLinkAbout32964-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
Date: 08/12/08
No: Z-33213
THIS CERTIFIES that the building ACCESSORY
Location of Property: 855 STANLEY
(HOUSE NO.)
County Tax Map No. 473889 Section 106
RD
(STREET)
Bl.ock 8
MATTITUCK
(HAMLET)
Lot 12
Subdivision
Fil.ed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
fil.ed in this office dated
MAY 2, 2007 pursuant to which
Buil.ding Permit No. 32964-Z
dated
MAY 10, 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 ACCESSORY IN GROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR.
The certificate is issued to EDWARD C & MELISSA HASSILDINE
(OWNER)
of the aforesaid building.
SOFroLK COU..-r1" DEPAR~ OF HEALTH APPROVAL
N/A
06/07/07
ELECTRICAL CERTIFICATE NO.
7669
N/A
PLUMBERS CBRTIFICATIOlII DATED
~~
Rev. 1/81
Fonn No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFlCATE OF OCCUPANCY
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 we:
I. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natura1 or
topographic features.
2. Final 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. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance 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-confonning uses, or buildings and "pre-existing" land uses:
I. 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 sball state the reasons therefor in writing to the applicant.
e. Fees
1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00,
---7Swinuning pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00.
2. Certificate ofOccnpancy 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
Date. 3-/1- 08
New Construction:
Location of Property:
[(55
House No.
Old or Pre-existiog Building:
S-f-t7J'? Ie:! Ron.rJ
Street
(check one)
rYllJ.. H/.J.u c..k
Hamlet
Owner or Owners of Property: Gdward of- n1~.J"sra. I-I-a .(S /1 d /n f'
Suffolk County Tax Map No 1000, Section In&' Block 08 Lot 01.J..
Subdivision )U(l~-(.,f- tnotl ~ Filed Map. Lot: 10
Permit No. 3f).qu,'1 Date of Permit. 5-{O-07 Applicant: '-kJ{.c;/~d.".n-(
Health Dept. Approval:
Planning Board Approval:
Request for: Temporary Certificate
Fee Submitted: $ :J. 5. uo
Underwriters Approval:
Final Certificate:
v'
(check one)
c.o b 33:1-!3
R..t <:...-1 ~J lo I
lIk.u.i./,. 41.U.)dAA-f
Applicant Signature
Nassau Suffolk Electrical Inspections, Inc.
P.O.Box 549. Aquebogue, New York 11931. Tel: 631-591-3097. Fax: 631-591-3098
Application: 7669
Date:6/7/07
Issued to: Hasseldune
Address:855 Stanley Rd
Village: Mattituck
Introduced By:: Bethel Electric
License#:2880-ME
was examined and approved up to the above date and was in compliance with the NEe
Bas :n1ent
1st Roor
2nd floor
ResidentiallRl
Ccnrrercial
PooIlRl
Hct Tub
De! C?aage
f>ddtioo
New t-IJrre
Switches Receptacles Fixtures G.F.1. Timeclock Smoke
Detectors
2 3 1 1 1
Fans Dishwasher Washer/Amps Dryer/Amps Oven Carbon
Range/Amps Monoxide
Furnace Oil Gas Heat Zones Whirlpool Bell
Transformers
Rough Insp: Meter Amps Phase Motors
6/5/07
Finallnsp: 6/7/07 2
Other Equipment: Inground Pool
Out Res
.JV'=;([uI!l>a 0!ect:riazi.'Tn..rj> Vw_ &>
7.4(~~ ~
This certificate must not be altered
In any manner
Section: 106
Block: 08
Lot:012
"
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.
32964 Z
Date MAY
10, 2007
permission is hereby granted to:
EDWARD C III HASSILDINE
855 STANLEY ROAD
MATTITUCK,NY 11952
for :
CONSTRUCTION OF AN IN-GROUND SWIMMING POOL IN THE REQUIRED REAR
YARD AS APPLIED FOR
at premises located at
855 STANLEY RD
MATTI TUCK
County Tax Map No. 473889 Section 106
Block 0008
Lot No. 012
pursuant to application dated MAY 2, 2007 and approved by the
Building Inspector to expire on NOVEMBER 10, 2008.
Fee $
250.00
ORIGINAL
Rev. 5/8/02
roWN OF SOUTjj(.
BUILDING DE PARTlY...
TOWN HALL
SOUTHOLD, NY 11971
TEL: 765-1802
PERMIT NO.
3~qb3c
tiUlL1J1.N1.i J:'bKlYlll AJ:'J:'LiCAfl(JN CH.cCKLIS
Do you have or need the following, before applying
Board of Health
3 sets of Building Plans
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
/()
Examined
Approved
Disapproved alc
,20-4
,20-1-
Mail to:
Phone:
r ----
!
I ,
,
MAY - 2.
\ L T'j<M2-_~ .~_)! APfLICA TION FOR BUILDING PERMIT
Date
,,^-I\:~
l~-r
2001
, -
INSTRUCTIONS
a. This application MUST be completely filled in by iypewriter or in ink and submitted to the Building Inspector with 3
sets of plans, accurate plot plan to scale. Fee according to scliedule.
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 througho\ltthe 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;Coimty, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions, or'a:lterations 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 for nece~sary inspections.
P~.
Signature of applicant or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, ~ngineer, general contractor, electrician, plumber or builder
c~~~
Name of owner of premises EDWI\RD Hf\9)ILDltJE"" 855' S1A..:Jte1 R.o~
(as on the tax roll or latest deed)
.'
I-\A-TT IfMJ( tJ. y.
I
Builders License No. Hr 3.S6S
Plumbers License No.
Electricians License No.
2880 M.c
Other Trade's License No.
I. Location of land on which proposed work will b~ done:
e ~5" STAt..)Ll::;;""'1 Qt>A-1) .' . .'
House Number Street
N. ~lTw.oc::-
Hamlet
t-J '~S'2..
County Tax Map No.1 000 Section
Subdivision
10,",
. Block 8
Filed Map No.
10 t --.l 'Z..
Lot
(Name)
~
b, Intended use and occupancy
Resl \) ~-'D A-L
State existing use and occupancy of premises and intended use and occupancy of pro
a, Existing use and occupancy" Re5 _
l. Nature of work (check which applicable): New Building
Repair Removal Demolition
Addition Alteration
Other Work~llcw\l() VINYL ~lL/llM\lX. k
(Description)
I, Estimated Cost
ICl/lf1fD .
Fee
" If dwelling, number of dwelling units
If garage, number of cars
(to be paid on filing this application)
Number of dwelling units on each floor
I, If business, commercial or mixed occupancy, specify nature and extent of each type of use,
-
Dimensions of existing structures, if any: Front
Height Number of Storie,S
Rear
Depth
Dimensions of same structure with alterations or additions: Front
Rear
Depth
Height
I b )C 34
Number of Stories
:t)~~ ulM1L..suJ~~ ~
Rear IJepth
" Dimensions of entire new construction: Front
Height Number of Stories
,
0, Date of Purchase
Rear
8{,'
Depth
19.8 I
, Size of lot: Front
Name of Former Owner
I, 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 f\jO Will excess fill be removed from premises: ~ NO
m~mTUO(
4, NamesofOw~erofpreiniSeS~Address_85S'S~~ _ PhoneNo.~e-OOO@.
Name of ArchItect TI'ttou:s. 1)~ic'1 Address2bo1lEc~. ~utJ( Phone No-.1:9.~' 71110
Name of Contractor tlltJRITl: P!lCt.S Address ~e<;II~ ~Phone No. :\9S' ,,, 110
5. Is this property within I 00 feet of a tidal wetland? *YES NO k
. 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 YORK) ,
~'
:OUNTY OF ~F
ell rFoRD BA-R:04 MI\'W being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
3)He is the
Ce t-9TR.PtC-WL
(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;
lat all statements contained in this application are true to the best of his knowledge and belief; and that the work will be
:rformed in the manner set forth in the application filed therewith,
worn to before me this
~dayof ~
(:
Notary Public
20 01
~--;
PETER BOOTH
Notary Public, State of New York
No, 01806092004, Suffolk County
'fjlrm Expires May 12, 2007
3 ?-?, If z...
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
] FOUNDATION 1 ST
] FOUNDATION 2ND
] FRAMING I STRAPPING
] FIREPLACE & CHIMNEY
] FIRE RESISTANT CONSTRUCTION
f'~~
~ OK)
REMARKS:
[ ] ROUGH PLBG.
[ ] INSULATION
rtX'FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
~ /)~ -I-Jr.~ ' ~
<......; ~"""'-"C., ~f"1)
~. ~Yi,
DATE 7.-} I .- () 'I
INSPECTOR ~~
II
"
.
.
.
FIELD INSPECTION REPORT DATE I COMMENTS uJ",
9.)t'l
FOUNDATION (1ST) ...o~
(')...,
-+-'It
-----.---------.-------------------- N1
-c:
FOUNDATION (2ND) . lb~
z
~
cO",
Cl\ ...,
f;l
ROUGH FRAMING & \ t'l
PLUMBING ...,
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-.--------- c----- . ~~
--------
INSULATION PER N. Y. -- -- ~~
STATE ENERGY CODE
;3
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FINAL
~
::t:--
ADDITIONAL COMMENTS s::>
~
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Erosion, Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM
.. ,......, ~-....
t) O-;J"- d--
Yes No
EXEMPTIONS:
A. Does this project meet the minimum standards for classification as an Agricultural Project. >:
Note: If you answered Yes to any of the above, a Storm-water, Grading, Drainage & Erosion Control Plan is not required.
ACTIONS REOUIRING THE SUBMISSION OF A STORM-W ATE&. GRADING. DRAINAGE & EROSION
CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE. STATE OF NEW YORK.
Item Number: (A Check Mark (J) for each question is required for complete application)
1.
Will this project retain all Storm-Water Run-off generated on Site?
(This will include all run-off created by site clearing and/or coristruction activities as well as all
Site Improvements and the permanent creation of impervious surfaces.)
Yes No
Kg
bl~
gk
[;]k
Idk
gk
[;]-\-
blX
Note: If any answer to questions one through eight is answered with a check mark In the Box, a Storm-water, Grading,
Drainage & Erosion Control Plan is required and must be submitted for review prior to Issuance of any building permit.
2.
Will this project require any land filling, grading or excavation where there is a change to the
natural existing grade involving more than 200 cubic yards of material within any parcel?
STATEOF~~~~F ~HHIHHSS
That I. ... c.oc-f:~ .~.. ... being duly sworn, deposes and says that he/she is the applicant for Permit.
And that::::::d::ualS1~ln.g~~~....................................................... ................. ..................
(Owner, Contractor. Agent, Corporate Officer, etc.)
Owner and/or representative of the Owner or Owner's, 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 tme to the best of his knowledge and belier; and that the
work sill be performed in the manner set forth in the application filed herewith.
3.
Will this application require land disturbing activities encompassing an area
of five thousand (5,000) square feet of ground surface or more?
4.
Is there a Natural Water course running through the site or is this project within
One hundred (100) feet of wetlands or a beach?
5.
Will there be site preparation on slopes which exceed fifteen (IS) feet of vertical rise to
One hundred (100) feet of horizontal distance?
6.
Will driveways, parking areas or other impervious surfaces direct Storm-Water Run-off
into and/or in the direction of a Town Right-of-Way?
7.
Will this application require the placement of material, removal of vegetation and/or the
.construction of any item within the Town Right-of-Way or road shoulder area?
(This item does not Include the Installation of driveway aprons.)
8.
Will there be site preparation within the one hundred (100) year floodplain of any watercourse?
Sworn to before me this; \t
................ .... ......4 ..7:Hday of ....~.................H 20.0J
NotaryPubuc: Fe...,"",,, ~ ................PETI!ASOOTH....H
Notary Public, State of New York
No. 01806092004, Suffolk County
Term Expires May 12, 2007
o
TOWN OF SOUTHOLD PROPERTY RECORD CAR
-[>-/2
S
FARM
IMP. TOTAL
MO .260
(;J (/ -J '-
,- F~
)) 0"
h t -7'00 /,,Zoo
W
/'1- J '1
(~~
DIST.
COMM. CB. MICS. Mkt. Value
REMARKS
'^~
v0 Or\{ ^ v::1
AGE
NEW
FARM
BUILDING CONDITION
NORMAL
BELOW
ABOVE
Value
~
Acre
Value Per
Acre
House Plot
FRONTAGE ON WATER
FRONTAGE ON ROAD
DEPTH
BULKHEAD
Tillable
Woodland
Meadowland
Total
DOCK
-......
.....-
'" ,I[.
H
I, .0 ~
1(. 1M 4-
", 0"
I. S ~. iI3 It fe I 'Y. ~
4 j.l Y. 111 Ii
~-- -
, ~~ F,
, tJ ,
. - -
/
106-8-12 2104 L, I.. f'lo~ Do IUl ''''- Q. {',
, , ~ 4' , 1'" I"'"
M. Bldg. 'I ij,.. 28 :; 1232 ' ,.ra /',"f"/(,. I
Extension
Extension .
-
Extension
Foundation ,v/, Bath Dinette
P~~h ~ tt .I( .,r (., ~2/'-''I , \,"0 I ~2. Basement f" {/ Floors K.
Porch Ext. Walls i/y ,(jAIl Interior Finish LR.
Breezeway Fire Place {es Heat DR.
Garage 2- 2...,< 2.. 'i ;:. 1) 2/? /.2, t:w Type Roof Rooms 1 st Floor BR.
Patio Recreation Room Rooms 2nd Floor FIN. B
O. B. I Dormer Drivewoy
I /' .,~, oV ~J.>f 300
Total I , , 7568 ..
i ,4 5Ses5d. r/...~C' /1"'700 -; Uti
. "' /!I'.."/1 t/4(', n
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OR
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UNE Of f1l..EO MAP
Subdivision -
Suffolk
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2 STORY FRAME HOUSE
& GARAGE
Lot 1
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PATIO
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"IMMEDIATELY"
ENCLOSE POOL TO CODE
UPON COMPLETION
BEFORE "WATER"
~WATER MAIN
EDGE OF PAVEMENT
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Survey for:
755.00'
EDWARD C. HASSILDINE III
& MELISSA HASSILDINE
Lot fO, "Sunset KnoUs"
At
Mattituck
Town of
Southold
Suffolk County, New York
S.C.T.M.: 1000-106.00-08.00-012.000
MO.29'
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o.:ts
R= 18.50'
L=34.S4'
NOTES:
1. AREA = 22.828 S.F.
2. . = MONUMENT FOUNO, A = STAKE FOUNO.
. 0 = SPIKE SET.&. = STAKE SET.
3. SUBOIVlSION MAP "SUNSET KNOLLS" FILED IN
THE OFfICE OF THE CLERK OF SLFFOLK COUNTY ON
JAN. OS, 1968 AS FILE NO. 5023.
30
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SCALE: 1"=30'
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AUG. 28, 2D03 """- sua-.<Y
JUNE 11, 2003 FOUNDAllOIol LOCAlKH
MAY 20. 2003 Rfl.OCJoTED PROP. HOOSE
MAY OS, 20U3 AllOOl CEIl""""'.
APR. 30, 2003 !ill(. FOR CC>OS1RUC1JON
DEC. 13, 2002 AllOOl CE111>FlCA"'"
OCT_ 21. 2002 N"J. PROP. WAlER SIR~CE
OCT. 01, 2002 AMENDED PROP_ S7Ruc.
SEPT. 17, 2002IND_ Pft(F Sl'RUC.
DATE: AUG. 21. 2002
JOB NO: 2002-453
O~UPANCY OR
USE IS UNLAWFUL ALL CONSTRUCTION SHALL
WITHOUT CERTIFIC;\T~EET THE REQUIREMENTS OF THE
OF OCCUPANCY CODES OF NEW YORK STATE.
3:
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"Anthony Dris &- Helen Dris"
County File No. 8995,
APPROVED AS NOTED
DATE:~ B.P. ii'~<3bL(-I
FEE:~":>5t> BY~
NOTIFY BUilDING DEPARTMENT AT
765.1802 8AM'TO 4PM FOR THE
FOllOWING INSPECTIONS:
1. FOUNDATION. TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
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.
CERTIFIED TO:
EDWARO C. HASSILDINE III &
MELISSA HASSILDINE
ULSTER SAVINGS 8ANK
FIDELITY NA TImlAL TITLE INSURANCE
COMPANY OF NEW YORK
___-.. I
~v1'\1/
\,,_/~
DAVID H. FOX N.Y.S.L.S. #50234
FOX LAND SURVEYING
PO BOX 224
SPEONK, N.Y. 11972
(631) 325-2902
U"'...Ul'l-lQRI2E:O ...t,.~R""T'IOl"l Of! ...OOlnON TO THIS SURVEY
IS ^ VlOL...nON OFSEcno,," 7:209 OF n~E NEW YOI'lK sr...TE
EOUCATION L,o,W. COPtf"S Of' n-tIS SlJRV(Y M~ NOT BC...RI"'C
""E I....NO SURVEYOR"S INKEO SE...L OR EMBOSSED SEAL
Sl4ALL NI)1 BE CONSJOF:RED TO BE " VA.L!O lRve CO"'Y.
CEFlTI~Ir:J\nofi. "OI)J<::ATED HEFlEClN $l~J1lL RUN ONLY TO n-lE
"[1'>;0'1 reR ....,e... n..'e SI)F!".If.Y ,S f"I./EI'''F.EO "'''0 '.>N IllS ..
Elf:H"'F" TC "'f l1n.e: COI~;-"'J"'. r.UVf:P.~II~I':'H'<'I. "'Cf:NCA<
",.n l..l':f.lqIN:; ,.,:;" nJ TlQH '_''!';TCO I 'E f(F.:l'" . ;...m 1 Q ll~r.
~:;~'J~""II':C'" (".... n'l" l.t.'.CU.r. "J$ "1\J ncv-~. t:(FI II' I-...Il"'.r:!,.." \
,.Rr .,:)1 11>""1.,11 R.:.AI.r: T'l "OCll1Ot!':'.l !~J~.lIP~ 11:)1.1', f'-.. ........
tll'> ~'.'FI...r:.~IJ(" I 'lV"Jrl<:-; 8'--":"-::;:'
DWG: 2002-453
..
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STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
la. Legal Name and address ofInsured (Use street address only)
Dunrite Manufacturing Corp
Dumite pools
351 0 Veterans Memorial Highway
Bohemia, NY 11716
lb. Business Telephone Number ofInsured
631-588-1300
Ie. NYS Unempioyment Insurance Employer Registration
Number ofInsured
0592920-5
Work Location of Insured (Only required if coverage is specifically
limited to certain locations in New York State, i.e. a Wrap-Up Policy)
Id. Federal Employer Identification Number ofInsured
11-2245133
.
2. Name and Address of the Entity Requesting Proof of
Coverage (Entity Being Listed as the Certificate Holder)
3a. Name of Insurance Carrier
State Insurance Fund
3b. Policy Number of entity listed in box "la":
Town of Southhold
Bldg. Dept
Main Street
Southold, NY 11971
WC1883215
3c. Policy effective period:
04/01/07 to 04/01/08
3d. The Proprietor, Partners or Executive Officers are:
KJ included. (!.?nly check box ifallpartners/officers included)
o all excluded or certain partners/officers excluded.
3e. Demolition is: (Definition of Demolition on Reverse)
o included.
o excluded.
This certifies that the insurance carrier indicated above in box "3" insures the busines~. referenced above in box "la" for workers' compensation
under the New York State Workers' Compensation Law. The Insurance Carrier or its licensed agent will send this Certificate ofInsurance to
the entity listed above as the certificate holder in box 1<2".
The Insurance Carrier will also notify the above certificate holder within 10 days IF apolicy is canceled due to nonpayment a/premiums
or"within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insuredfrom.the coverage
indicated on this Certificate. (I'hese notices may be sent by regular mail.) Otherwise, this Certificate is validfor a maximum of one year
after this form is approved by the insurance carrier or iU licensed agent. .
Please Note: Upon the cancellation ofthe workers' compensation policy indicated on this' form, ifthe business continues to be ~a'm~d 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 proofthat the business is complying with the mandatory coverage requirements oftbe New York State Workers'
Compensation Law.
Under penalty of perjury, I certify that! 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:
Kf':vin Mr.T1nnrmgh
j ~~~f authonzed representative or licensed agent of. insurance carrier)
{I( ()ffC-/)rNc.!-- 111()/?007
(Signature) (Date) .
Approved by:
Title:
President of Walter Rose Agency, Inc
Teiephone Number of authorized representative or licensed agent of insurance carrier: (845) 783-2555
Please Note: Only insurance carriers and their.licensed agents are authorized to issue the C-I05.2form. Insurance brokers are NOT
authorized to issue it.
C-105.2 (9-01)
r
PRODUCER
Wal~se Agency,
8 Stage Road
Monroe NY 10950
Phone: 845-783-2555
INSURED
Inc
OP 10
DUNRI-1 04 02
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 POLICIES BELOW.
ACORD.
CERTIFICATE OF LIABILITY INSURANCE
07
Fax:845-7B3-2425
INSURERS AFFORDING COVERAGE
Dunrite Manufacturing Co~
3510 Veterans Memorial Highway
Bohemia NY 11716
INSURER A:
INSURER B"
INSURER c:
INSURER 0:
INSURER E:
Twin Cit
Hartford
Fire Ins Co
NAIC#
347
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 ANY CONTRACT OR OTHER DOCUMENT VlJlTH 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 PArD CLAIMS
LTR NSR TYPE OF INSURANCE POLICY NUMBER DAT~1MMI~8~E pgk!fEr/r=Jjb~J!rqN UMITS
~NERAL LIABILITY EACH OCCURRENCE .1 000 000
B X COMMERCIAL GENERAL LIABILITY 01SBAAI5151 04/01/07 04/01/08 1 ~=~~~ (E~~Cr~ncel . 50,000
l CLAIMS MADE ~ OCCUR MED EXP (Anyone person) . 5,000
~ PERSONAL & ADV INJURY .1,000,000
~ GENERAL AGGREGATE .2,000,000
~'l AGG~EnE LIMIT APnS PER: PRODUCTS - COMPIOP AGG .1,000,000
POLICY ~f8T lOC
~TOMOBllE LIABILITY COMBINED SINGLE LIMIT .1,000,000
A ~ ANY AUTO 01UECTI6053 11/20/06 11/20/07 (Eaaccident)
- ALL OVolNED AUTOS BODilY INJURY
.
- SCHEDULED AUTOS (Per person)
~ HIRED AUTOS BODilY INJURY
.
~ NON-OWNED AUTOS {Per accident)
- PROPERTY DAMAGE .
(Peraccidenl)
~RAGE LIABILITY AUTO ONLY- EA ACCIDENT .
ANY AUTO OTHER THAN EAACC .
AUTO ONLY: AGG .
~ESSIUMBRELLA LIABILITY .. EACH OCCURRENCE .
OCCUR D CLAIMS MADE AGGREGATE .
.
==1 DEDUCTIBLE .
RETENTION . .
WORKERS COMPENSATION AND ITORYLlMii'S I IO~~-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.l. EACH ACCIDENT .
OFFICERlMEMBER EXCLUDED? E.l. DISEASE. EA EMPLOYEE .
If yes, describe under
SPECIAL PROVISIONS below E.l. DISEASE - POLICY LIMIT .
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
SOUTH-7
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAil ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLlGA nON OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTH IZ PRES TATlVE
Town of Southold
Building Dept
Main Street
Southo1d NY 11971
@ ACORD CORPORATION 1988
ACORD 25 (2001108)
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STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
NOTICE OF COMPLIANCE
DISABILITY BENEFITS LAW
TO EMPLOYEES
1. If you are unable to work. because of an illness or injury not
work-related. you may be entitled to receive weekly benefits
from your employer, or his or her insurance company, or
from the Special Fund for Disability Benefits.
2. To claim benefits you must filA a claim form within 30 days
fr.Qm..k~da.te..m..~disabilitv but in no event more
than 26 weeks from such date.
3. Use one of the. following claim forms:
-If, when ,your disability begins, you are employed or are
unemployed for four weeks or less. use WHITE claim form
(Form OB-450). which you may obtain from your empioyer.
his or her insurance carrier, your health provider or any
office of the Workers' Compensation Board. and send it to
your employer or the insurance carrier named below.
-If. when your disability begins, you have been unemployed
more than four weeks, use the GREEN claim fonn (Form
0B-300). which you may obtain from any Unemployment
Insurance Office, your health provider, or any office of the
Workers' Compensation Board. Send completed claim form
to the Workers' Compensation Board. Disability Benefits
Bureau. Albany, New York 12241.
IMPORT ANT' Before filing your claim, your health provider
must complete the "Health Care Provider's Statement.. on
the claim form. showing your period of disability.
4. You are entitled to be treated by any physician,chiropractor,
dentist, nurse-midwife, podiatrist or psychologist of your
choice. However, unlike workers' compensation, your
medical bills will not be paid unless your employer and/or
union provide for the payment of such bills under a
Disability Benefits Plan or Agreement.
5. If you are ill ar injured during the time you are receiving
Unemployment Insurance Benefits, file a claim for Disability
Benefits as soon as you sustain the injury or illness, by
following the instructions outlined above.
6. If you are out of work in excess of seven days, your
employer is required to send you a Disability Benefits
Statement of Rights (Form OB-271).
7. Other information about Disability Benefits may be obtained
by writing or calling the nearest Workers' Compensation
Board Office.
WORKFRS' COMFJENSATION BOARD OFFICES
Albany. 12241 -100 Broadway-Menands- (518) 474-6681
Binghamton, 13901 - State Office Bldg.-44 HawleySt.- (607) 721-8353
Buffalo, 14202 - Statler Towe~ - 107 Delaware Ave. - (716) 842-2166
Hauppauge. 11788 - 220 Rabro Drive - Suite 100. (631) 952-6000
Hempstead, 11550 - 175 Futton Avenue - (516) 560-7745
New Yori< City, 1.1248-0005 - 18Q Livingston St.- Brooklyn - (718) 802-6964
Peeksklll. 10566 - 41 North Division $1. - (914) 788-5775
Rochester, 14614 - 130 Main Street West - (716) 238-8300
Syracuse. 13203 - 935 James St.- (315) 423-2934
ESTADO DE NUEVA YORK
JUNTA DE COMPENSACION OBRERA
AVISO DE CUMPLlMIENTO
LEY DE BENEFICIOS POR INCAPACIDAD
A LOS EMPLEADOS
1. Si usted no puede trabajar debido a enfermedad 0 lesion no
relaeionada con el trabajo, podria tener derecho a recibir
benefieios semen ales de su patron 0 de la compania de
seguros. de eVella 0 del Fonda Especial para Beneficies par
Incapacldad.
2. I r n fi . t f
I r I I
~ In pero en mngun caso mas
die a ee a.
3. Use una de las siguientes formas de reclamacion :
.Si, cuando comience su incapacidad usted e5m empleado 0
ha estado desempleado par cuatro semanas 0 menos, use la
forma de reclamaci6n BlANCA (fonm OB-450). la cua Ruede
obtener de su patron 0 de la campania de ~uros de el/ella,
o de su proveedor de cuidados de salud, 0 bien de cualquier
oficina oe la Junta de Compensacion Obrera, y enviela a su
patron 0 a la compania de seguros nombreda abajo.
-Si cuandc comience su incapacidad, usted ha estado
desempleado mas de cuatro semanas, use la forma de
reciamaci6n VERDE (fonm 0B-300). ta cual puede obtener en
cualquier Oficina de Seguro de Oesempleo. de su proveedor
de salud, 0 bien de cualquier oficma de la Junta de
Compensacion Obrera. Envle la forma de reclamacion.
debidamente terminada, a Workers' Compensation Board,
Disability Benefits Bureau, Albany, New York 12241.
IMPORTANTE- Antes de presentat usted su reclamacion, es
necesano que su proveedor de salud comptte la declaracion
del medico ("Health Care Provider's Statement") en la forma
de relamacion indicando el periodo de su incapacidad.
4. Usted tiene derecho a ser tratado por cualquier medico,
quiropractico, dentista, enfermera-partera, podiatra 0
psicologo que usted ellla. Pero. contrario a la compensacion
obrera, sus cuentas medicas no seran pagadas a menos que
su patron y/o Union haga el pago de tales cuentas medicas
bajo un Plan 0 Convenio ae Benelicies por Incapacidad.
5. Si estuviera usted enfermo 0 lesionado durante el tiempo que
este recibiendo beneficios del Segura de Desempleo,
presente una reclamacion para Beneficios por lncapacldad,
siguiendo las instrucciones arriba descritas, tan pronto como
surra la lesion 0 la enferrnedad.
6. Si usted esta desempleado par mas de siete dias, su patron
esta obligado a enviarle la Declaracion de Oerechos de
Beneficios par Incapacidad (Form 08-271).
7. Otras informaciones relativas a Beneficios por Incapacidad
pueden obtenerse escribiendo 0 llamando a la oficina mas
cercana de la Junta de Compensacion Obrera.
/l~ /Z. .r;. ~ /# <:.(
Robert R. Snashatl
Chainnan (Presidenle)
The undersigned employer is in compliance with the provisions of the Disability Benefits Law (EJ patron abajo firmante esta en conformidad con las
disposiciones de la lay de BeneflCios por Incapacidad).
Disability Benefits, when due. will be paid by (Los Beneficios por Incapacidad. cuando debidos. seran pagados por):
Zurich American Insurance Company
Disability Operations
P.O. Box 9102
Plainview, NY 11803-9002
(800) 887-9111
(631) 845.2200
Effec!ive:4/ohI97
(En Vigor Desde)
PolicyNo1717?Cj?.
(poliza No.)
To INDEFINITE
(Hasta)
THE WORKERS' COMPENSATION BOARD EMPLOYEES AND SERVES
PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
LA JUNTA DE COMPENSACIQN OBRERA EMPlEA Y SJRVE
Prescribed by Chalr
OB-120 (S-OO) wo<"'~''''''-u''"Bo'''
StilteofN_Yortr;
nn. . '.
The benefits provided are (Los beneficios provistos son)
o Statutory D Under a Plan or Agreement
Class(es) of employees covered (Clase(s) de empleados amparados)
ALL
Name of employer (Nombre del Patron)
OUNRITE MANUFACTURING CORP,
THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND
ABOUT THE EMPLOYER'S PLACE OR PLACES OF BUSINESS_
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. POOL DIMENSIONS
, 6' A e e 0 . , G H ~ ,
""'. .-0 "'-0 .. -0 ...0 ...0 ... -0 ..0 04-'
e><71 e-o -0 .. .. ., ,.. ... -0 -0 ,
.."" 16-0 >2-0 .. -0 ... I'" .'-3 -0 ..0 .'.3
..- "-0 ...., .. .0 10... ".. .., -0 ..010-3
20><'" -0 -0 .. -0 12" 13.. "'., -0 -0 .,
lOX>< ~oO )04-0 .. -0 to.. ".. .., -0 -0 &-,
""'" "-0 -0 .. .. "1'" N -0 -0 n-,
>P"",, -0 -0 .. .. -0 -0 .s.... .. 21-3
""'" 14-0 ...0 .. -0 ...0 12-0 .., -0 -0 6.,
10 lONG WELDS ON
SIDE OF PANeL
WELDED TOP & BOTTOM
AS SHOWN AND COVER
OVER waDS WITH
AlUMINUM COAl1NG
TTT
AAA
M N ~ III:
-0 6+1/8 ~-4 2'1..)
-0 6+V8 ,.. 21-2-61160
-0',,,, 104-10 16.113'.
-0 ,... \.4-10 .,_
..0 ,"'"' \04.10 1-0-11/16-
-0 ,... \04.10 J -10-1/16
-0 '-'1-1/16 l~-o No-2-lIe
.. 84-3/' 1to-&-1I. .,..
-0 oS-V,," l2-ll-lIe 3 -'T-IlI16
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"'-
16."110
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20,_
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'16.HO
0,100
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TYP. PANEL STIFFNER
1o.32X518" SELF ORILUNG SCREWS
SPACEDQ 12"O.C.
CONCRETE OR WOOD DECK UP TO
COPING (BV OTHERS)
SLOPED AWAY FROM POOl PANEL
STIFfENER (BEYOND)
lONG STEEl ANGLE
-
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, /
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ALUMINUM COPING
1" lONG WELD
w1lYP. AlUMINUM COA. TlNO
20 mil. VINYL UNER
STEEL WALL PANEl
3J8".1l>xl"BOLT, NUT, (2) WASHERS
2" THICK VERMICULITE "'GGREGA TE MIX
HARD BOTTOM
180LONQ STEEL REINFORCING ROD
INTO UNDISTURBED EARTH THROUGH
HOlES IN BOTTOM OF PANEL
TYPICAL WALL SECTION AT 'A' FRAME
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DIVI G BOARD , / B1
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POOL PLAN
F
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02
MIN, 2" THICK VERMICULITE
AGGREGATE TAMPERED
A2
B2
C2
SECTION
5118'"0"'- CARRIAGE BOLTS
wlWASHER & NUT
..4"
~.,1l"'""
CORNER CONNECTION DETAIL
DIVING BOARD
N.T,S,
DUNRITE POOLS, INC.
POOL COMPLIES WITH ANSI 514, APWNDIX G
DESIGN IS ACCEPTABLE FOR
ALL COMMON SOIL CONDmONS
3510 VETERANS MEMORIAL HIGHWAY
BOHEMIA, NEW YORK 11718
(631) 585.1618
POOL TYPE: RECTAGLE REV.
JAMES DEERKOSKI, P,E.
260 DEER PATH
MATTITUCK, NEW YORK 11952
N,T.S.
SALE
DATE
DRAWING NUMBER
OF