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HomeMy WebLinkAbout35782-Z g11FFQ1,1. Town of Southold Annex 4/11/2011 C�ay 54375 Main Road C= Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 34893 Date: 4/11/2011 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 4745 Rocky Point,New York 11939, SCTM#: 473889 Sec/Block/Lot: 21.4-17 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 8/9/2010 pursuant to which Building Permit No. 35782 dated 8/16/2010 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 Vasilantonakis,John&Vasilantonakis,Eve (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 35782 3/30/11 PLUMBERS CERTIFICATION DATED 12 Aux-of-zed 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. 35782 Z Date AUGUST 16, 2010 Permission is hereby granted to: JOHN VASILJ~NTONAKIS 4745 ROCKY POINT ROAD E MARION,NY for : CONSTRUCTION OF AN ACCESSORY INGROUND SWIMMING POOL FENCED TO CODE AS APPLIED FOR at premises located at County Tax Map No. 473889 Section 021 pursuant to application dated AUGUST Building Inspector to expire on FEBRUD~RY 4745 ROCKY POINT RD EAST MARION Block 0001 Lot No. 017 9, 2010 and approved by the 16, 2012. Fee $ 250.00 /~~ut hor~i z~ed/~S ignat ur e ORIGINAL Rev. 5/8/02 TO~Tq OF SOUTHOLD Il ~'~'~l ~ 'row .At, Iu UI ;n, Ill I APPLICATION FO~ CERTIFICATE OF OCC~NCY This ~pplication mu~t be fill~d in by typewriter or ink ~nd ~ub~itted ~o the Building ~a~mu with th* 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. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). (~ Approval of electrical installation from Board of Fire Underwriters. 4. Sworn stateroom from plumber certifying that the solder used in system contains iess than 2/10 of 1% lead. 5, Coramea'eial building, industrial building, multiple residences and similar buildi~s ~nd installations, a certificate of Code Compliance fi'om architect or engineer responsible roi' the building. 6. Submit Planning Board Approval of corapletcd site plan requirements. B, For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pr~-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 consenl to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons theretbr in writing to the applicant. C, Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Altexafions to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of OccupancY- $.25 4. Updated Certificate &Occupancy - $50.00 5. Tomporary Certificate &Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of prope~: House No, ~treet Owner or Owners of Prope~' ~'X -¥ ~ Suffolk County Tax Map No 1000, Section ~ { Subdivision Old or Pre-existing Building: (check one) Hamle[I Block I Lot / -~ Pcrmit"N~ ~ Date of Permit. Filed Map. Lot: Applicant: Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: S -.~, ~) 0 Underwriters Approval: Final Certificate: " '~ Applicant Signature g 'd ~E[L~LLI~9 'ONI'IIZ'O'a'a ~¥ 6§:~[ LOOg-gg-~d? Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (63 I) 765-9502 ro.qe r. richert ~,,town.southold .ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Eve, John, Vasilantonakis Address: 4745 Rocky Point Rd City: East Madon St: NY Zip: 1193c. Building Permit#: 35782 Section: 21 Block: I Lot: 17 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Raymond Elec Cont License No: 5141-me SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Se~iceOnly ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCl Recpt Main Panel A/C Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures [~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures ~ CO Detectors Fluorescent Fixture ~ Pumps Emergency Fixtures!.__~ Time Clocks Exit Fixtures ~ TVSS swimming pool, bonding, I GFCI circuit breaker, heat pump, pool lights Notes: Inspector Signature: Date: March 30 2011 81-Ced Electrical Compliance Form INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [,J~ELECTRICAL IFINAL) REMARKS: DATE ~/'~/// INSPECTOR~-~~~ TOWN OF SO~TH~)LI)BUILDING DEPT, (_~5-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN~TION [ ] FRAMING / STRAPPING [./] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ l nm~n~Sl'Amrrco~muc~ [ ] mm~SWT, u,n'm~.N~nA'rmoN REMARKS: ~~.~ ~ / TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork. net Examined ~/[,/a, 20 /o Approved Disapproved PERMIT NO. Expiration ~_Q ~/i/~,,, 20 g' ~' /~.~/~ _ [ Building Inspector BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey. Cheek Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Form Contact: q-7/ zs/ f/ a,. .k j /9/- APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets ofplaus, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relafionslfip to adjoining premises or public streets or areas, mid 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 slmll be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or ha part for may purpose what so ever until the Building Inspector issues a Certificate of Occupaucy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 1 8 months from such date. If no zoning amendments or other regulations affecting the propeay have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for au addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Departmaat for the issuanco of a Building Permit pursumat to the Building Zone Ordinance of the Town of Southold, Suffolk Cotmty, 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 n:'F'r':"6;'~-~""m~'~'i'and'hlvlill41~'nll~!~f°~necessarYm~ctlOns' ( agrees to comply with all applicable laws. z ordinancos, building code,J~tng code, mad regulations, and to admit ~ .... Il : ' ~ t- - * 0Mailingaddressofap, l~liean. D State wl ~"ther a~Pl~l~O~lgl~..1._O_ ~.nnamuen,,,, ~, ,~ ~Lj~l~[,~.._.~.Ta.~z,.~',~~ general contractor, e'lectnclan, plmnber or bmlder u~ cOMPLETION REQUIRED APPROVED AS NOTED Nameofownerofpremises /~J//~.. ~'JO/.gk'] 7t/f/J, cl'l/'J~.,tglOl"~.~.~ ' (As dn th~'i~ rbll'or latest dee~E. If applicant is a corporation, signature of duly authorized officer NOTIFY BUI~ D~LI~EN'r (Name and tide of corporate officer) Builders License N 2-1 q l o2J-¢1 Plumbers License No. Electricians License No.~f Other Trade's License No. - FOLLQWING INSECTIOtl8: 1. TIO RED ' -- - / ' ~ .... /'""'~' 2, ROUGfi4RAMING, PLUMB/I~,~),., ] ~:::~,~"'"~--.~~ ,~J//Z~'--'-' - J "'"" - 1. ,"~--'~_TRAP, PING, ELE~RIC~II- .... , .. / 4 FINAL- CONSTRUCTION & ELEC,R,~AL MUST BE COM~.ETE FOR CO. Ly3tiff/~n,~of land 99 whic. h propo~d work will/bp done/ Fi i Fo/,a fl House Number ' ~S~eet' ' ' County Tax Map No~ 1000 Section Subdivision AL!: CONSTRUCTION SHALL ,M~. ET THE Block O/ Lot /q Filed M~ No. Lot 2. State existing use and occupancy of premises andjntended use and occupancy of proppsed construction: a. Existinguseandoccupancy ~l r'~ L¢ -~'l/k3q i {,l l r ~-~ A~l /~ d-m2 _ b. Intended use and occupancy. 3. Nature of work (check which applicable): New ~ I Addition Alteration Repair Removal Demolition Other Work Estimated Cost Fee If dwelling, number of dwelling units If garage, number of cars (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Heigh[ Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Depth Height Number of Stodes Rear 8. Dimensions of entire new construction: Front Height Number of Stories Rear .Depth 9. Size of lot: Front Rear .Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES__ NO/, 13. Will lot be re-graded? YES NO__Will excess fill be removed from premises? YES__ NO__ 14. Names of Owner of premises Name of Architect Name of Contractor 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES__ NO ~, * IF YES, D.EC. PERMITS MAY BE REQUIRED. Address Phone No. Address Phone No Address Phone No. No 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO/~ · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF V\//~ ,-X/t~ (;)/'g '/r~l///~ ~.~being duly sworn, deposes and says that (s)heis the applicant ~'oF~divi~lual ~-gfiin'g'~.~hfi'dc~ ab ov~ flamed, (S)He is the (Contractor, Agent, Corporate Officer, etc.) of said owner or ovmers, and is duly authorized to perform or have performed the said work and to make m~d file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the rammer set forth in the application filed therewith. Sworn to befoxe me this / / · DEIRDRE E. TOUHEY Notary Public, State of New YorI~ No. 01TO6018045 Qualified In Kings County Commission Expires Dec. 21,200~- LAND 72~ Tillable 1 Tillable 2 Tillable 3 Woodland Swam?land Brushland House Plot Tota'l SEAS. VL [MP. J TOTAL .~. & Acre Tg-g'gG Value Per ' Acre FARM DATE Be PROPERTY RECORD VI LLAGE E W COMM. CB. MISC. CARD ,DISTt SUB. ~ LOT / ~ AR. TYPE OF BUJLDIN~ Mkt. Vatue /2 II FROI'4TAGE ON WATER FRONTAGE ON ROAD DEPTH BULKHEAD DOCK ~.xtensTon Extension Porch Porch ~reezewoy ! ~ Patio Total /Foundot[on J Bosern ant Ext. Walls Fire Place Bath F[dors [nterror Finish Heat Type Roof Rooms Ist Floor Recreation Room Dormer Driveway Rooms Q o, Erosion~ Sedimentation & Storm-Water Run-off ASSESSMENT FORM ~_~O~0~P/~I~TY LOCATiIOI~/~S~C.T.M.S: ~ ~PHE ~OLLOWHO ACTmNS MAY aaeume ~.e susm.m, o~ A (~/~ /v~ (~/I I~ ' 8..TOKM'W~KK'GRADING DRAINA,GEANDEROSIOHCONTROLPLAH I "~-~- ~ BloCk '"L~ I ~Kterer'uBYADF'SIGHPKOFESSEONALINTHESTATEOFNI~YYOIIIC' Item Number: (NOTE: A Chask Mark (~) far cash QtmsEoe ts Required for a Complete Application) Yea No WIll this Project Retain All 8tcrm-Waisr Run.Off Generated by a Two (2") Inch P~nfall (This item will include all rUn-off created by Rite cleating antler ¢onstm~ion a ~Mlies as we~l as all Site -- I~1 improvements and the permar~nt oreatloa of Impervious suriaces.) Does the Site PISn and/or Survey Show Ail Profiosed Dmbu~ge Struotums fndicctfng Size & Lasat~on? This Item shall include a,~ Proposed Grade Cheeses and Slopes Conb~[ing SuKace Wafl~rFIowi 3 4 5 6 7 8 9 Will this Pmjout Require any Land FItiir~. Grading er Excavation where them Is a change to the Nature[ Existing Glade Involving more than 200 Cable Ya~s of MatodsJ within any PameJ? Will this Appllastion Require Land Disturbing A~Mtlas En~ompaasMg an Area In Excess of Five Tt~ousand (5,000) Square Fe~ of Greu~cl Sudaee? Is there a Natural Water Coume Running through the Site? Is thts Project within the Trustees Judadictioa or within One Hundred (10{7) ~eet of a Wetland or Beach? Will there be Site prepar~tion on Existing Grade Slopes which Exoeed FReen (15) feet of Ver~cal Rise to One Hundred (lg0') of Horizontal Distance? Wti( Dflveways, perldng Areas er other Impervioas Suriacas be Sloped to Direct Stere-Water Run-Off into and/or in the dlreclEm of a Town right-of-way? Will this Project Require the Piacernent Of Material; Removal of vegetaUon and/or the Conslruct{on of any Item Within the Town Right-of-Way or Road Shoulder Area? (This Item wtll NOT include the Instillation ~3f Driveway Aprons.) Wtil Ihis Project Require Bite Preparation within the One Hundred (t00) Year Floud~alo of any Watercourse? ~ NOTE: If Any Answer to Questlofle One through Nine Is Answered with a Cheek Mark in the Bex, a Btorm-Water, Gradingt Drathage & Erosion Contel Plan Is Required and Must be 9ubml~c[ for Review Prior to Issuance of Any Building Perfflitl EXEMPTION.' Yes No Does this p~oJe~t meet the minimum standards for cJasslflca~on as e~,~ficuituml Project? Note: If You Answered Yes to thts Question. a Slerm.Wster, Grading, Draisage & Emston Control Plan ts NOT Requlmdl STATE OF NEW YORK, COUNTY OF ........................................... SS &~d that hdshe is the ..,i ..................................©~jO'~o;......~7;....~,7....,,...~..g;.jd.;,jj,_.,_,_ .................................... : ............................ ' Owner and/or vepresenlallve of the Owner of Owner's, and is duly authorized m perform or have performed the said work and to m:tke and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the ma~n/~r set forth in the application filed herewith. Swom to before me this; FORM - 06/07 DEIRDRE E. TOUHEY ....... Notary Public. Stat~ of New York N~ 01TO~bleO~ .............. Qu,a~ified in Kings County /o Commisoion Expires Dec. 21, 20~ Town Hall Am~x 54375 Main Road P,O. Bo~ 1179 Somhold, NY 11971-0959 Telepho~: (631) 765-180~ ro~er BUILDING DEPARTMENT TOWN OF SOUTHOLn APPLICATION FOR ELECTRICAL INSPECTION JOBSITE INFORMATION: (*Indicates required information) *Cm~ Street: ~. ~, Z ~ ' Pe~ No.: Tax Map Dis~ct: 1000 Section: 0 J I Block: ~ I Lot: I '-7 *BRIEF DESCRIPTION OF WORK (Please Print Clearly) (Please Circle All That Apply) *l$ljOb ready for inspection: ,Do you need a Temp Certificate: (~/NO YES/~' Temp Information (If needed) l *Service Size: 1 Phase 3Phase 100 *New Service: Re-connect Underground Additional Information: Rough In Final 150 200 300 350 400 Other Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION CONSENT TO INSPECTION Owner(s) Name(s) That the undersigned (is) (arO the owner(sLof the j~relnis~in the Town of · Southold, located at /,[--/~ ~ ~/J ~/ ~- ~ ~--~1~-- }V~LkDO~ which is shown and des{gnitted on the Suffbll~i~oun~ TaXx Map a~Di~tttict 1000, ' Section c2-~/ , Block O ]' Lot / r~ That the undersigned (has) (have) filed, or cause to be filed, an. application in the Southold Town Building Inspector's Office for the following: That the undersigned do(es) hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon, to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances, rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances, rules or regulations of the Town of Southold. Dated: (Signature) . (Print Name) STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) RANDY T. RODECKER, INC. DBA: SWIM KING POOLS 471 ROUTE 25A ROCKY POINT NY 11778-8985 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, i.e., a Wrap-Up Policy) lb. Business Telephone Number of Insured 631-744-8100 lc. NYS Unemployment Insurance Employer Registration Number of Insured Id. Federal Employer Identification Number of Insured 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD 53095 ROUTE 25 PO BOX 1179 SOUTHOLD NY 11971 or Social Security Number 11-3092960 3a. Name oflnsurance Carrier VALLEY FORGE INSURANCE CO. 3b. Policy Number of entity listed in box "la" 2094735086 3c. Policy effective period 09/01/2009 - 09/01/2010 3d. The Proprietor, Partners or Executive Officers are [] 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 "la" 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 will also notify the above certificate holder within 10 days IFa policy is canceled due to nonpayment of premiums or within 30 days 1F 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. 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 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: __ Thomas P. Terry, CPCU (Print name of authorized represcntativ~ or licensed agent of insurance cagier) 05/24 2010 Approved by: (Signature) (Date) Title: ._Authorized Representativ~ Telephone Number 6f authorized representative or licensed agent of insurance carrier: (631) 283-8000 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. www.wcb.state.ny .us C- 105.2 (9-o7) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment ofemployeas in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head ora state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such enntrant unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C- 105.2 (9-07) Rev arse DATE (M M/DO/Y~fY} ACORI . CERTIFICATE OF LIABILITY INSURANCE I o5/24/2olo PRODUCER (631)283-8000 FAX (631)287-2207 THISCERTIFICATEISISSUEDASAMATTEROFINFORMATION Maran CoPpo~ate Risk Associates ONLY AND CONFERS NO PJGHTS UPON THE CERTIFICATE HOLDEf~ THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 300 ,Hampton Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Southampton, NY 11968 INSURERS AFFORDING COVERAGE NAIC # INSURED Randy T. Rodecker, [nc. INSURERA: Valley Forge Tnsurance Co. 20508 DBA: Swim King Pools INSURERS: 471 Route 25A INSURERC: Rocky Point, NY 11778-8985 INSURERD: I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS. INSR ~DD'L POLICY EFFEC~VE PO[JCY EXPIRATION LTR NSRD ~PFPEOFINSURANCE POUCYNUMBER DATEiMM~DD,%'Y'Y*Y~ DATEiMMIDD/~rYYY] LIMITS GENERAL~BI[JTY 2094735072 09/01/2009 09/01/2010 EACHCCCURRENCE $ DAMAGE TO RENTED ~-- COM M ERCIAL GENERAL LIABILITY PREMISES (Ea occuffence I CLAJMS MADE []OCCUR MED EXP (A~y one pemon) S 10~ 00( A __ PERSONAL & ADV INJURY $ 1 ~ 000100( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/DP AGG $ 2,000 ~ 00( LI PRO- AUTOMOBILEL[ABlUTY 2094735069 09/01/2009 09/01/2010 COMBINEDSINOLEUMIT ~-- ANY AUTO (ES acciden~ S 1,000,00( ALL OWED AUTOS BODILY INJURY -- SCHEDULED ~UTOS (Per Pemon) $ A -- -- HIRED AUTOS SOCiLY iNJURY $ NON~WNED AUTOS (Per aC~dent) WORKERS COMPENSATION 2094735086 09/01/2009 09/01/2010 HORYL'"'*EI ANY PROP RIETOR~PARTN E R~XE CUTIV~ I E.L EACH ACCIDENT $ 500,00( A / I E.L e,SE~SE-EAE~PLOYE~ S SO0,O00 CERTIFICATE HOLDER CANCELLATION T~n of Southold 53095 Route 25 PO Box 1179 Southold, NY 11971 ACORD 25(2009101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAI~ THEREOF, THE ISSUING INSURER WiLL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ARY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTA3WES. AUTHORIZED REPRESENTATIVE ~. ~ Thomas Tepr¥/ALTCTA © 1988-2009 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this ~rtiflcate does not confer dghts to the certificate holder in lieu of such endorsement(s). if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cer'ain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER This Cedificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009101) ~ LOT 8 t~OSENB£RG ~'ACANT \ \ sTR~ Tt4oR$ 10T 9 VACANT R OA Ok \ FRAI~E DWG." ~" '-~.x in,peet e~ ~ LOT/o MAP OF STRATMOR$ ESTATES FILE N~ ~7,E$',, FILE FEB, GITUAT~ AT EAST MARIOIV- town OF $OUTYOLO SUFFOLK CO., N. Y. riv~ new york ftgOI (5t6)~9-17t 7 Apr, 27~ 1986 dob N°- 85-845 I000- 021-01-17 Scale: I"= :50' TO PlSPO~L/~ ~ , DRYWELL ~ NOTE5 0 ~ ~ 1. ALLCONSTRUCTIONISTOBEINACCORDANCEWI~ERBIDEN~ALCODEOF ~ .~ ~ x = O~ TH E WATER TO ~CEED BACKFILL BY MORE THAN 8~· SECTION A , , ~q , ,~c~o~c~.o.~,.~o~o~o,~ ~,~o~..~.o~,~ ~ ~ ~ COMPACT S~LE: 1/8' = 1'-O" ~ g ROLLEP FOAM B~EEN~J ~,N"~ D. WAL~ TO BE SMOOTH, NON SKIP ~PE SLOPEPAWAY FROM POOL ~ 7. ~o plw~ ~p. 0 ~ ~ Z ~ , , ~ ~v~o~ 5 ECTI ON B ~ALL SECTION ~,. A TEMPO~RY ENCLOSURE, OR, ~ F[NCE SHALL BE INSTALLEDAND REtaIN IN P~CE