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HomeMy WebLinkAbout35956-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 5/1/2011 CERTIFICATE OF OCCUPANCY No: 34926 THIS CERTIFIES that the building Location of Property: Date: IN GROUND POOL 5/1/2011 435 Bay Road, Cutchogue, NY 11935, SCTM #: 473889 Sec/Block/Lot: 116.-2-11.1 Subdivision: Filed Map No. conforms substantially to the Application for Building Permit heretofore 10/7/2010 pursuant to which Building Permit No. 35956 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. Lot No. filed in this officed dated dated 10/20/2010 The certificate is issued to Robertson, Mark & Robertson, Ann (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 35956 4/4/11 ed 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. 35956 Z Date OCTOBER 20, 2010 Permission is hereby granted to: for : ANN D TOBIN 520 FRANKLIN AVE GARDEN CITY,NY 11530 CONSTRUCTION OF ANACCESSORY INGROUND SWIMMING POOL FENCED TO CODE AS APPLIED FOR at premises located at 435 BAY RD County Tax Map No. 473889 Section 116 pursuant to application dated OCTOBER Building Inspector to expire on APRIL CUTCHOGUE Block 0002 Lot No. 011.001 7, 2010 a/id approved by the 20, 2012. Fee $ 250.00 Authbrized Signature ORIGINAL Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOED BUILDING DEPARTMENT TOWi~ HALL 765-1802 APPLICATION FOR CERTIFICATE 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 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 sewerageqtisposal (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 1% lead. 5. Commemial 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-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 applicat/on and cor/sent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the rea.sons therefor in wr/ting to the applica ~t. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alten Swimming pool $50.00, Accesso~ building $50.00, Additions to accessory building 2. Certificate of Occupm~cy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Oocupancy - Residential $15.00, Commercial $15.00 o dwelling $50.00, BLDG. DEPT. IOWN OF SOUTHOLD Date._ 4- 2a,.It Hamlet ~pplicafna(ure Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ ~ 0 -~ Subdivision Permit No. Health Dept. Approval: Filed Map. Date ofPermit, l~-2~O- / (-.-) .Applicant: Underwriters Approval: Final Certificate: / (check one) Lot: New Construction: '/ Old or Pre-existing Building: (check one) Location of Property: ~ ~ Iq? R ~ . ~ VT-&~F~F_,¢O~. House No. Street Owner or Owners of Property: ~qLSL5 'T' ~'~ g~9~t'~-~I~-'T;C::~ Suffolk County Tax Map No t 000, Section ] 1 (o Block ~ Lot lt. t To,m lta[[ Annex 54375 M;fin Road P.O. Box 1179 Soudmld, NY 11971-0959 Tclcphonc (631) 765-1802 l:ax (63 I) 765-9502 ro.qor, richert~town southo d nv us 1½UILI)ING 1)EPARTMENT TOWN OF $OUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION ssued To: Robed[son Address: 435 Bay Rd City: Cutchogue St: NY Zip: 1193~ 3uilding Permit #: 35956-35876 Section: 116 Block: 2 Lot: 11.001 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE 3ontractor: Tim Meskill DBA: License No: 5211-e SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commedcel Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI Recpt Main Panel A/C Condenser Single Recpt Sub Panel A/C Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Ceiling Fixtures [~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures [~ CO Detectors Fluorescent Fixture ~.~ Pumps Emergency Fixtures~._~ Time Clocks Exit Fixtures ~ TVSS Other Equipment: swimmin9 pool and shed, pool includes-bonding, 2 lights, 2 twist lock recpticles fo~ pumps, 1 control panel, 1 GFI recpticle, 1 dead front GFCI, 3 GFCl circuit breakers, 1 heat pump,1 cover motor Notes: Inspector Signature: Date: April 4 2011 81-Cert Electrical Compliance Form TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING / STRAPPING [ ]FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]RRE RESISTANT CONSTRUCl10N [ ]FIRE RESISTANT PENETRATION ~d~CTRICAL (ROUGH) [ ] ELECTR~AL (FINAL) REMARKS: __ INSPECTO~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH~LBG. [ ] FOUNDATION 2ND [ ] 1~ISULA'I'_ION []FRAMING/STRAPPING ['~FINAL ~ FIRE SA~-,- ~ 'f INSPECTION [ ] FmRE~CE & cHmm~' [ [ ]FIRERESm'AHTC0m'TRUCTHX4 [ REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPARTMENT TOW1N HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined Approved Disapproved a/c Expkafion {0 sets area. PERMIT NO. ~ ,~"' ~ BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans planamg Board approval Survey Check Septic Form N.Y.S.D.E.C. Tmstees Storm-Water Assessment Form Contact: Mail to:~ Building Inspector PPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS tletely filled in by typewriter or in ink and submitted to the Building Inspector with 4 e according to schedule. lot and of buildings on premises, relationship to adjoining premises or public streets or 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 the Building Inspector issues a Certificate of Occupancy. 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 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. 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 all applicable laws, ordinances, building code, housing c)~37and regulatio2~% ag~ to admit authorized inspectors on premises and in building for necessary inspecti~.)/// ,~ ...... A/,0~n¢,/ ENCLOSE POOL TO ~DE UPON13 E F©.RCOMPLETtONE "WATER" (Mailing address of applicant) t~q/ State whether applicant is owner, lessee, agent, architect, engineer, genera] contractor, electrician, plumber or builder ~)bd ~ ~ UNDERWR TER$ C~RTIFICAT'_- (As on me tax roll If applicant is a cterporation, signature of duly authorized officer (Name find title of corporate offi~g}~(,3 Il ~ ~ U ¥ U H '!'-" ;: AWF[' Builders License No. C~./q/ f/~/-' , , ?'. ...... Plumbers License No. , : ' Electricians License No. z Other Trade's License No. [df' kdkaka U F'/.~NC~ f Location of land on which.proposed work will b~ done: House Number / Street County Tax Map No. 1000 Section Subdivision (Name) Block Filed Map No. FFF .~ 5-O. BY.~.~._;,~ N()ilFY BUILDING DEPARTMENT AT 7:,5 ~802 c AM TO 4 PM FOR THE ~JL ~ ',','i~'~O INSPECTIONS' r2t'~ '?N TWO REQUIRED S~;~PP!NG ELECTRICAL &CAULKfNG 3INSULATION 4FNAL · 30NSTRdCT~ON & ELECTRICAL ~c C O~,~PLETE FFR C 0 ALE CONSTRUCTION SNALg MEET THE REQUIREMENTS OF T..~ ~.: OF NEW B~ STATE NOT ~ESPONSIBLF ..... PURSUANT T APTER OF THE TOW CODE. 2. State existing use and occupancy of premises and intended use and occupancy of proposed constructions. a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work (check which applicable): New Building_ Addition Repair Removal Demolition Alteration OtherWork ~]ttO~t! Lt~a POor.. I - (DesCription) 4. Estimated Cost ~,,~ ~.,, 5. If dwelling, number of dwelling units If garage, number of cars Fee (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 Height_ Number of Stories Rear _Depth Dimensions of same structure with alterations or additions: Front Depth. Height Number of Eltories 9. Size of lot: Front 10. Date of Purchase Dimensions of entire new construction: Front Height Number of Stories I°t/. Rear ('SO. -)r/~ q~OOr) Name of Former Owner Rear Depth Depth / ~' ~ Rear l 1. 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- aded9 YES NO .)(/Will excess fill be removed from vremises9 YES J~' NO 14. N~esofOwn~ofpremise~ Ro~dAddress~r ~o~ ~0neNo. N~e of Arc~tect Address Phone No Nme of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES __NO * 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.E.C. PERMITS MAY BE REQUIRED. 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 d~t~lorfsm'vey. 18. Are there any covenants and restrictions with respect to this property? * YES__ NO__ · IF YES, PROVIDE A COPY. STATE OF~~.. VC~c: COUNTY OF ~/~_ ,7 ~ ~ '.t~ being duly swam, deposes ~d says that~heis theapplic~t (Nme of individ~l si~ing contract) above named, ~e is the (Con.actor, Agmt, Co¢orate 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 tree to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Swam to before me this Notary '_Public ~ ~, UMMER t Notary PuBlic - 8tote of New York ,,. bio. O1 U6182676 QualiFied in Suffolk County · : My Commission Expires March 3, 2012 Tovm I-bll Annex 54375 M~&~ Road P.O. ~ 1179 · Sou~oM, NY 11971-0959 Telephone (631) 765-1802 roRer, dchedd~w(~.~s) oTur~o~, ny. us BUII J]ENG DEPARTMENT TOWN OF SOUTHOLB APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Company Name: Name: License No.: ~ddress: Phone No.: Date: lO-~7, lO . JOBSITE INFORMATION: (*IndiCates required information) *Name: /~)-A'/<' ~oa~"3 7go.J'., ~.* · ~d,~ *Address: ~g ~ ~ Ro. CuZ~ uw *Cross Street: ~ ~ 5~ & d ~ ~ ~ *Phone No.: C¢~c : ~o~ - ~/ -/qOl Tax Map District: 1000 Section: ) I ~ Block: oOO ~ // tqO ~ Lot: oIl. OOt *BRIEF DESCRIPTION OF WORK (Please Print Cleady) (Please Circle All That Apply) *Is job ready for inspection: ~Do you need a Temp Certificate: YES / NO Rough In YES / NO Final Temp'lnformation (If needed} - *Service Size: I Phase 3Phase 100 *New Service: Re-connect Underground ^dditional Information: 150 200 300 350 400 Other Number of Metem Change of Service Overhead WITH APPLICATION PAYMENT DUE ~ ~ 82-Request for Inspection Form Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 BUILDING DEPARTMENT TOWN OF SOUTHOLD April 21, 2011 Mark Robertson 172 Argyle Road Stewart Manor, NY 11530 RE: 435 Bay Road, Cutchogue TWO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of 50.00. __ Final Health Department Approval. __ Plumbers Solder Certificate. (AII permits involving plumbing after 4/l/84) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) __ Final Planning Board Approval. __ Final Fire Inspection from Fire Marshall. __ Final Landmark Preservation approval. BUILDING PERMIT: 35956-Z swimming pool Clio n~. 19835 VINCEL 4CORD. CERTIFICATE OF LIABILITY INSURANCE PRODUC~ THIS CERTIFICATE 1818$UED A.S A MATTER OF INFORMATION ONLY AND CONFER8 NO RIGHT8 UPON THE CERTIFICATE Bradley & Parker Ins HOLDER. THIS CERTIFICATE DOEB NOT AMEND, EXTEND OR P,O. Box 677 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Syoseat, NY t'1791 INSURERD AFFORDING COVERAGE HA. lc # ~N.UP~D ~.su~ Peerles~ Insurance Co Vlncen Electric Co Inc ~DUR~R~ State Insurance'Fund 188 Quality Plaza ~suR~ e Hloksvllle; NY 1'1801 COVERAGES A GENERAL LIABIUTY CCP5227286 07/04/2010 07/04/2011 EACH OCP-4Jf~EHCE X COMM EROAL GENERAL UABL]TY FREMIsEBT~. er, mamn~m ~,000. PERSONAL & ADV IN,IUay t1~000~000 A A__mo~om~ u~mu~i BA8227586 07104/2010 07/04/2011 COMB~;ED SINGLE UM/i' $'1,000,900 X__ ~Y ~u~o A ~xcEss / U~RErL~ ua~cnY CU8227886 07/04/2010 07/04/2011 ~c~ OCCU~RENC~ ~.000.000 X~ occu~ [] c~.~ M~. ~c~ ~S,000,000 PzT~mo~ $10000 $ B WO;KaRSCOaP~,S~Tm.~ 20900619 0t/01/2010 01/01/29~1 Im.vu~ml I°~'~ ~FIm~;~'~ ~XCC~-D?L~ State Ins Fund ;~_ mgEA~E.EAEMFt. OYE~ $110001000 s ~"~ w. ~RO~aSIO~p b.~ Cert form to follow E.L. mseAse - mucv uMrr $1,000~000 Re: Electrical work at 435 Bay Road Cutchogue NY 11935 related to service upgrade and pool related work. Mark Robertson & Nancy Tobln Roberlson end Town of Southold {53095 Main Road $outhold) addltlona! Insured aa respects operations of named Insured aa required by written contract. Waiver of subrogation applies In favor of additional insured aa respects operations of named Insured. Cutchpgue, NY 1'1935 ~EPREBEK~rATNE8- ACORD 25 (2009/01) I of 2 #S167804/Mt 59559 · 1988-2~09 ACORD CORPORATION. All Hghts reserved. Tho ACORD name and ]o~o ~re registered marks of ACORD . New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since. 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 P/~lte: (885) 997-38~3 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 112994904 VINCON ELECTRIC CO ]NC 188 QUALITY PLAZA HICKSVILLE NY 11801 POLICYHOLDER VINCON ELECTRIC CO INC 188 QUALITY PLAZA HICKSVILLE NY 11801 CERTIFICATE HOLDER MARK ROBERTSON & NANCY TOBIN ROBERTSON 435 BAY ROAD CUTCHOGUE NY 11935 POLICY NUMBER Z 2090 06%9 CERTIFICATE NUMBER 297722 PERIOD COVERED BYTHtS CERTIFICATE DATE 01/01/2010 TO 01/01/2011 10/25/2010 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS iNSURED WITH THE NEW YORK STATE iNSURANCE FUND UNDER POLICY NO. 2090 061-9 UNTIL 01/0t/20t1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, oR CHANGED PRIOR TO 01/01/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAiL BO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOTASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GtVE SUCH NOTICE. THiS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLYANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER~ THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U-26.3 NEW YORK STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysff.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 1055811912 AC~/g'~:~eV CERTIFICATE OF LIABILITY INSURANCE I ~ (631) 283-8000 ~: (631) 287-2207 THIS CER~FICA~ IS ISSUED AS A ~11~ OF INfuSiON ONLY AND CONFE~ NO ~GH~ UPON THE CE~FICA~ ~ran Co--rate ~sk ~so=ia~s, Inc. HOLDE~ THIS CE~IFICA~ ~ES NOT AMEND, ~ND OR 300 ~p~n R~d ALTER ~E COVE~GE AFFO~ED BY THE POLICIES BELOW. SouPcOn ~ 11968 INSURE~AFFO~ING COVE~GE NAIC~ 471 ~u~ 25A INSURERD: ~ P~int ~ 11778-8985 I~ER~ COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTW~THSTAN DiNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VMTH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UMITS SHOWN MAy HAVE BEEN REDUCED BY PAID CLAIMS. IN~R M)Dt POUCY P.~Pl=~vE POLICY E)~IRA~ION GENERAL LIABIUTY EACH OCCURRENC~ $ 1 t 000 t 000 A ICL~JMSkL~DE [~ OCCUR !094735072 9/1/2010 9/1/2011 MEOEXP(Anyofleperton} $ 5,000 FERSON~ & ADV ~I~JURY $ 1~000~000 AU__TOMOBILE LIA~IUTY COMEIINEO SINGLE UMJT X ~AUTO (E~ ~=c~mt} $ 1,000,000 A __ N-L OWNED AUTOS ~094735069 9/1/2010 9/1/2011 ~oo~Ly ~NJURY S am, ~m'~m~=~c~r~ ~00 ~ 000 OFFIGERMEMBEg~iM~d~Oejln NH} EXCLUDED? ~ 2094735086 9/1/2010 9/1/2011 E.L DISEASE- EAEIdPt. OYEE S $00~000 CERTIFICATE HOLDER CANCELLATION Town of Southold 53095 Rou~e 25 P0 Box 1179 Southold, NY 11971 ACORD 25 (200910t) INS025 Terry, CPCU, AAI/ED © t988-2009 ACORD CORPORATION. All fights reserved. The ACORD name and logo are registered marks of ACORD 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 DBA: Fence gang of Rocky Point 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, Lc., a Wrap-Up Policy) lb. Business Telephone Number of Insured (631)744-8100 lc~ NYS Unemployment Insurance Employer Registration Number of Insured ld. Federal Employer Identification Number of Insured or Social Security Number 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being lasted as the Certificate Holder) Town of Southold 53095 Route 25 PO Box 1179 Southold, NY 11971 11-3092960 3a. Name of Insurance Carrier Valley Forge Insurance Co. 3b. Policy Number of entity listed in box "la" 2094735086 3c. Policy effective period 09/01/2010 - 09/01/2011 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 can'ier 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 IF a policy is canceled due to nonpayment of premiums or within 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 pollcy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cencelintion 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 certffirate 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. Apprevedby: Appmved~: Thomas P. Terry. CPCU (Print name of authorized representative or lic,~nsed agent of irtsurance c,~riex) 'n~'~'n~n~ 08/25/2010 (Signatu~) (Dm) Title: Authorized Renresentafive Telephone Number of authorized representative or licensed agent of insurance carrier: (63 I) 283-8000 Please Note: Only insurance carriers and their licensed agent~ are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C- 105.2 (9-07) www.wcb.state.ny.us ~T I' L,~L..f"-- L..,'~/'~I"~I I, I'N.I 5:,dFFOLK COUNT'( TAG< ~, 1000-[16-2-11.1 NOTES: N'iO NUI'dI~NT FOUND AP-~A = 26.241 S.F. cc 0.80 AC, IRE ®P-,APHIC 9CALE I"= 30' Lc:lnd Now or Por'mecl~ ot:: Norf. h Pork d,~ounb'"t.j Club S89°42' 10"E 153.78' House ,/ / /. / / / / JOHN C. EHLERS LAND SURVEYOR 6 EAST NL~[N STREET N.Y.S. LIC. NO. 50202 RIVERH~AD, N.Y. 11901 369-8288 Fax 369-8287 REF.\\Server\dkPROS\05-239.pro 20' H20 PLAN SECTION A TO?O 10' SECTION MIN. DIM. SECTION I5' WATER LINE MIN. DIM. SECTION WATER LINE MIN. DIM. SECTION NOTES FROM SKIMMER CHECK VALVE PLUMBING SCHEMATIC COPING ~ DON E BY O I'FIEP~S DIVING BOARD DETAIL CBy OTHERS) GRAPE · g WALL SECTION