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HomeMy WebLinkAbout36222-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 6/24/2011 No: 35022 Date: 6/24/2011 THIS CERTIFIES that the building 990 DUCK POND RD CUTCHOGUE, N.Y. 11935, Sec/Block/Lot: 83.-4-12 1N GROUND POOL Location of Property: SCTM #: 473889 Subdivision: Filed Map No. conforms substantially to the Application for Building Permit heretofore 3/8/2011 pursuant to which Building Permit No. Lot No. riled in this officed dated 36222 dated 3/8/2011 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 as applied for. The certificate is issued to Lamonica, Jennifer (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 8144 4/2/08 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 36222 Date: 3/8/2011 Permission is hereby granted to: JENNIFER LAMONICA 219 BEEBE ROAD MINEOLA, N.Y. 11501 To: CONSTRUCT AN INGROUND SWIMMING POOL IN THE REAR YARD, FENCED TO CODE AS APPLIED FOR. REPLACES BUILDING PERMIT #33739. At premises located at: 990 DUCK POND RD CUTCHOGUE, N.Y. 11935 SCTM # 473889 Sec/Block/Lot # 83.-4-12 Pursuant to application dated To expire on 9/8/2012. Fees: 3/8/2011 and approved by the Building Inspector. PERMIT RENEWAL $250.00 Total: $250.00 Building Inspector 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. 33739 Z Date MARCH 17, 2008 Permission is hereby granted to: JENNIFER LAMONICA 990 DUCK POND RD CUTCHOGUE,NY 11935 for : CONSTRUCTION OF AN INGROUND SWIMMING POOL IN THE REAR YARD, FENCED TO CODE AS APPLIED FOR at premises located at 990 DUCK POND RD CUTCHOGUE County Tax Map No. 473889 Section 083 Block 0004 Lot No. 012 pursuant to application dated MARCH 6, 2008 and approved by the Building Inspector to expire on SEPTEMBER 17, 2009. Fee $ 250.00 Authorized Signature COPY Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN 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 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 1% 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. Bo For existing buildings (prior to April 9, 1957) non-conforming 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 shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations 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 of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date· New Construction: Old or Pre-existing Building: (check one) Location of Property: House No. Owner or Owners of Property: ,~. Suffolk County Tax Map No 1000, Section Subdivision Permit No. Street Block Health Dept. Approval: Filed Map. DateofPermit. 3 "~ -- t / Applicant: Hamlet Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ l~ c ,~ Final Ce~ificate: Lot Lot: Nassau Suffolk Electrical Inspectio] P.O. Box 549, Aquebogue, New York + 11931 Tel: 631-591-3097 Fax: 631-591-3098 Application: Issued to: Address: Village: 8144 Date: 4/2/08 Lamonica 990 Duck Pond Rd Introduced By: Beth~ Cutchogue License #: 2880-ME JUN 2 3 2011 BLDG. DEPT. Electric TOWN OF SOUTHOLD Residential [] Commercial The following was examined and approved up to the above date and found to be in compliance with the NEC: Attic 1~t Floor 2'a Floor 3rd Floor Garage Conversion Basement Hot Tub Addition Detached Garage Pool [] Switches Receptacle Fixtures GFI Heat Pump Time Clock Fans Dishwasher Washer/Amps Drser/Amps Oven Range/Amps Carbon Monoxide Furnace Oil Gas Heat Zones Whir}pool Bell Transformers Rough Insp II Final ]nsp. Meter Amps Phase Motors Other Equipment: Salt Generator Permit #: Section: 83 Block: 4 Lot: 12 This certificate must not be altered in any manner TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [~FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRA110N REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 FOUNDATION 1ST FOUNDATION 2ND FRAMING / STRAPPING FIREPLACE & CHIMNEY m~m~ mlr~ ~tmwctm~ INSPECTION [ ] ROU~PLBG. [ ] IN/SULATION [ ~J~INAL [ ] FIRE SAFETY INSPECTION [ ] RRE RESISTANT PENETRATION REMARKS: /? DATE ~///~©///'/ INSPECTOR ~~/~ FYELD INSPECTION REPORT ] DATE [ COMk'VI~NTS FOUNI)ATION (1ST) FO~DATION (2ND) ROUGH F~'G & I LNSULATION PER N.Y. - STATE ENERGY CODE ~DITION~ COUNTS z BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 Examined Approved Disapproved a/c 7//7 PERMIT NO. Do you have or need the follo~g, before applying Board of Heal~ 3 sets of B~ing Plans S~ey ,/ Check~ [~kll 5 Septic Fo~ N.Y.S.D.E.C. Trustees Contact: Mail to: Building Inspector APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date 5 ' (o' O& , :0 a. This application MUST be completely filled in by ¢2pewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to sghedule. b. Plot plan showing location of tot and of buildings Cn'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 tkroughoFt'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 cbnstruction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to co:reply with all applicable laws, ordinan/es, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necess~i-y inspections. ',...~,, ~,'/~, ~, · .. ~ (Si~"~t~re of applicant or name, if a corporation) ,,,.-..,-,'., *'.',:-y,, USE IS UNLAWFUL ... F ~ ,~, * . ENi~fiC~)OMOpL&I~i~NODE WITHOUT CERTIFICATE - BEFORE "WATER' F'~r~ t~F't~l I m A MmV . State whether applicant is owne~;-4~s~,~e~,r~c~n~t~c[, engineer, general contractor', electrician, plumber or builder If signature of duly a~ho ad o.fficer 7~:t .... 8.,-L,I :© 47M POR THE , ALL CONS':~LE~x~ l,*; FC~ POURED CC;qCRETE Builders LicenseNo. ~ ~E~THE REQOlt¢:~'-t¢'.~,ur~:'T'' /r~/'~'M]NG a PLUMDNG Electricians License No. Other Trade's License No. V'~ - 7.~ ERWRITERS CERTIFICATE 1. Location of land o~n which l~roposed^v~ork will b~ done: ~/c)o Ou~' {~4~ t~. ' House Number Street County Tax Map No. 1000 Section Subdivision 'Block BE C©M?LEiE FOR C.O. ALL CONSTRUST;ON SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONS',BLE FOR BESIGN OR CON~:~L~A~I~.oERRORS. RM WATER RUNOFF r - . ,.......-PURSUANT TO CHAPTER 236 4 uo~ i~ Filed Map No. Lot (Name) State existing use and occupancy of premir~qs and intended use and occupancy of proposed construction: a, Existing use and occupancy., b, Intended use and occupancy Nature of work (check which applicable): New Building Repair Removal Demolition Estimated Cost if'dwelling, number of dwelling units If garage, number of cars Fee Addition Other Work -~>-.~tl0~ (Descr/ption) (to be paid on filing this application) Number of dwelling units on each floor 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 Stories Rear Depth Dimensions of same structure with alterations or additions: Front Rear Depth Height_ Dimensions of entire new construction: Front Height Number of Stories Number of Stories Rear Depth Size of lot: Front Rear Depth 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 premises: 4, Names of Owner ~).~.~p. remises~.~qff-eg [J~l~ Address~ ~.~"-Phone No,~$l{~1742.- {~.~/~9 Name of Architect[3~ ~/~'Y. ac-I Address .r'~,.. ~.~/~',~t~; No Name of Contractor[JOg ~t~ ~ Address 300 ~ ~ ~ {~t~hone No, 5, Is this property within 100 feet of a tidal wetland? *YES NO ~ · [F YES, SOUTHOLD TOWN TRUSTEES PEPaMITS MAY BE REQ~D 6. Provide survey, to scale, with accurate foundation plan and distances to property lines, 7, If elevation at any point on property is at I0 feet or below, must provide topographical data on survey. TATE OF NEW YeP. X) :OUNTY O F ~-t~)S: ~ ~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, ~)He is the (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; ~at 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, wom to be,fore me this ~'~, day of ~ 200~ ' PE'rER BOOTH Notary Public, State of New York No. 01BO6092004, Suffolk County Term Expires May 12, 2011 ~ Siqatfire ot~Applicant 3510 Veterans Memorial Highway Bohemia, New York 11716 Phone: (631) 585-1616 (Bohemta) Phone: (631) 543-1616 (Smithtown) Fax: (631) 585-0253 Southold Town Building Department 54375 Main Road Southold, New York 11971 (631) 765-1802 Parcel ID: 83.-4-12 Permit #: Permit Date: Expiration Date: 33739 3/17/2008 9/17/2009 BUILDING PERMIT RENEWAL LETTER Applicant: Location: Work Description: Dated: 2/26/2011 JENNIFER LAMONICA 990 DUCK POND RD CUTCHOGUE, N.Y. 11935 IN GROUND POOL CONSTRUCTION OF AN INGROUND SWIMMING POOL IN THE REAR YARD, FENCED TO CODE AS APPLIED FOR. A FEE OF $250.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT, THANK YOU. Owner: Address: JENNIFER LAMONICA 219 BEEBE ROAD MINEOLA, N.Y. 11501 The permit listed above has expired. Please contact our office as soon as possible to begin the renewal process. All work on the project must stop on the expiration date. No work is permitted or authorized beyond the expiration date. THANK YOU, SOUTHOLD TOWN BUILDING DEPT. Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. #: 1000 ~,3 4 t District Section Block Lot THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER; GRADING; DRAINAGE AND EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. Item Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application) 1 Will this Project Retain All Storm-Water Run-Off Generated by a Two (2') Inch Rainfall on Site? Yes No 2 3 4 5 6 7 8 9 (This item will include all mn-off created by site cleadng and/or construction activities as well as all Site Improvements and the permanent creation of impervious surfaces.) Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and Slopes Controlling Surface Wated:low! 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 Matedal within any Pamel? Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000) Square Feet of Ground Surface? Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction or within One Hundred (100') foot of a Wetland or Beach? Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15) feet of Vertical Rise to One Hundred (100') of Horizontal Distance? Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off into and/or in the direction of a Town right-of-way? Will this Project Require the Placement of Matadal, Removal of Vegetation and/or the Constmctioo of any Item Within the Town Right-of-Way or Road Shoulder Area? (This item will NOT include the Installation of Driveway Aprons.) Will this Project Require Site Preparation within the One Hundred (100) Year Floodplain of any Watercourse? r l_v/ NOTE: If Any Answer to Questions One through Nine 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 EXEMPTION: Yes Does this project meet the minimum standards for ctassiflcation as an Agricultural Project? Note: If You Answered Yes to this Question, a Storm-Water, Grading, Drainage & Erosion Control Plan is NOT Required~ No STATE OF NEW YORK, COUNTY OF ........ ~..~..~....0.....[~............. SS That I, .......~....L..[...~....~.~...~....~.......~.~.~...~.....~....t~... .......... being duly sworn, de'poses ,and says that he/she is the applicm~t for Permit, (Name of individual signing Document) that be/s .e ............................. .......................................................................................... (Owner, Contractor. Agent. Coq3orate Officer, etc.) Owner and/or representative of the Owner of Oua~er'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 true to the best of Iris knowledge and belief; and that the work will be perforated in the manner set forth in the application filed herewith. Sworn to before me this; ....................... ..~.....~.'.. ........ day of ~ ,20I~' -- /~/~ ........ /- ~otary Pubbc: ~ ~'Y "('""~;~mg~;'Suff°lk CSaffiY''~''''''''s~''~~ ' -[ 't _ . FORM - 06/07 New York State Insurance Fund Workers' Compen~atian & Disability Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (888) 997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE DUNRITE MANUFACTURING CORP T/A DUNRITE POOLS 3510 VETERANS MEMORIAL HIGHWAY BOHEMIA NY 11716 POLICYHOLDER CERTIFICATE HOLDER DUNRITE MANUFACTURING CORP T/A TOWN OF SOUTHOLD DUNRITE POOLS BUILDING DEPARTMENT 3510 VETERANS MEMORIAL HIGHWAY MAIN STREET BOHEMIA NY 11716 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 1477 156-2 772811 04/01/2007 TO 02/28/2009 12/7/2007 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1477 156-2 UNTIL 02/28/2009, 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. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 02/28/2009 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 SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 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 cedificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 608625908 9R/C;D1764R-20/489 ACqR. j CERTIFICATE OF LIABILITY INSURANCE OP,D DATE M.,BD I · .~- DUNRI - 1 I 04/02/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Walter Rose Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8 Stage Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Monroe NY 10950 Phone: 845-783-2555 Fax: 845-783-2425 INSURERS AFFORDING COVERAGE NAIC # ~NSURED INSURERA: Twin City Fire Ins Co 347 INSURER B Hartford Dunrite Manufacturing Co~p INSURERC 3510 Veterans Memorial Highway INSURERD: Bohemia NY 11716 INSURER E I 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 WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRJBBD HERE N S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS ~rsR Rq:rD.~ ] POLICY EFFECTIVE POLICY EXPIRATION LTR INSRI TYPE OF INSURANCE POLICY NUMBER DATE (M M/DD/T7) DATE (MM/DD/~Y) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ i / 000 ~ 000 B X COMMERCIALGENERAL LIABILITY 01SBAAI5151 04/01/07 04/0~/08 PREMIsEsL)'%I%qAL~b IU H:~nltU(Ea occurence) $ 50 fO00 ~, I CLAIMS MADE ~ OCCUR MEDEXP(Anyoneperson) $ 5, 000 PERSONAL & ADV INJURY $ 1~000~000 I GENERAL AGGREGATE $ 2 , 000 ~ 000 GEN'LAGGREGATELIMITAPPLIESPER:~ I I PRODUCTS COMP/OPAGG $ ltOOOtO00 A~UTOMOBILE LIABILI]7 I COMBINED SINGLE LIMIT A __X ANYAUTO 01UECTI6053 11/20/06 11/20/07 (Ea accident) $ i / 000 / 000 ALL OWNED AUTOS -- BODILY INJURY ! SCHEDULED AUTOS (Per person) , I (Per accident) $ I GARAGE LIABILITY i I ~UTO ONLY EA ACCIDENT $ OTHER THAN AUTO ONLY: AGG i $ EXCESSIUM B RELLA LIABILITY ! EACH OCCURRENCE $ AGGREGATE $ i $ r DEDUCTIBLE $ RETENTION $ $ CERTIFICATE HOLDER CANCELLATION SOUTH-7 Town of Southold Building Dept Main Street Southold NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX PIRATIOh DATE THEREOF, THE ~SSUING INSURER WiLL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO TNB CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL iMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2001/08) ©ACORD CORPORATION 1988 STATE OF NEW YORK WOP-XERS' COMPENSATiON BOARD CERTIFICATE OF NYS WORKERS' COiVfP]BNSATIOI~ I]NSUtLtNCE COVERAGE la. LegalName and address of Insured (Use street address only) Duarite Manufacturing Corp Dunrite pools 3510 Yeterans Memorial Highway Bohemia, NY 11716 Work Location of Insured fOnly required if coverage is span~eally limited to certain locations in New York State, £ e a Wrajo- Up Policy) lb. Business Telephon~, Number of Insured 631-588-1300 1 c. NYS Unemployment Insurance Employer Registration Number of Insured 0592920-5 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder Town of Southhold Bldg. Dept Main Street Southold, NY 11971 Id. Federal Employer Identi~ation Number of Insured 11-2245133 3a. Name of Insurance Carrier State Insurance Fund 3b. Policy Number of entity listed in box "la": WC1883215 3c. Policy effective period: 04/01/07 to 04/01/08 3d. The Proprietor, Partners or Execut~e Officers are: ~J included. (Onlycheckboxifallparmem/offieeminclnded) [~J all excluded or certain partners/officers excluded. 3e. Demolition is: (]Definition of Demolition on ~everse) [~ included. ~ excluded. This certifies that the insurance carder Lndicated above in box "Y' insures the business 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 Cel-dficate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notif~ the above cert~cate holder within ]0 days IF a.~olicy is canceled due to nonpayment offlremiums or within 30 days IF there are reaso~ other than nonpayment of premiums that cancel the policy or eliminate the insured from.the coverage indicated on this Certificate. (These/lotices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximura of one year after this form is approved by the insurance carrier or its licensed agent. Please Note: Upon the cancellation of the workers' compensation polky indicated on this form, if the business continues to be named on a permit, license or contract issued by a ce,~rtifi cat e holder, the busin ess must provide that certificate holder with a new Certificate of Workers' Compensation CoYerage 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 1 am an authorized representative or licensed agent of the insurance carrier referen ced above and that the named insured has the coverage as depicted on this form. Approved by: Approved by: Title: Kevin McDc~nancrh (P)~nt-n amex° f authored representative or heemed agent of insr~ance carrier) q/qO/2007 (Signature) (Date) President of Walter Rose Agency, Inc Telephone Nurnber of authorized representative or licensed agent of insurance carrkr: (845) 783-2555 Please ]Vote: Only insurance carriers and their licensed agents are authorized to issue the C-]05.2 form. ]nsurance broJcer~ are WOT C-105.2 (9-01) AREA: 40,36.5 sq,ft, ' 150,00' 1 i · N.39,OO'OO"W, 12~,;bOr o DUCK POND ROAD I g J;~:4'~Gg FOUNDATION 'LOCAT:ION . I ~LD'F, T~0N JR. ~. LIC, NO. 211.15-E I , ~E.eTIC TA~K & WELL rlie exiStence of rigfit of ways ana or easemen~ of record,.if any, not shown are not gUaranteed. ~o.~. e7-26~' ' ~,LE No. wo~,'~' SURVEYED FO~ LOT NO. 1~ ~AP OD W~INE ~ANOR ' SITUATED AT CUTC HOGU"E TOWNOF $OUTHOLD~ ---SUFFOLK COUNTY, N.¥ SCALE I" ; ,GO' DATE 7. 23~ lgg7 FILED MAP' NO. 8239 DATE 12 TAX MAP NO. 1OOO- 83= 4 - 12 (REF, ONLY) DISK HAROLD F. TRANCHON JR. P.C. LAND SURVEYOR WADING RIVER-MANOR RD. WADING R ',:~, NEW YORK, I 1792 $16-9~g-4695 AREA: 4,0,365 sq.ft, (,¢'¢~ $,3g"00'00" E, 7 © · 150.00' well 8 · DUCK POND ROAD Ld Z _J C.F.,alHXL, ~,FI'IC TANK & WELL . ~TEe existence of rigtit of ways an:d or easements · :of record,.i,f any, not shown are'not guaranteed. · : JOB~NO. 97-26c~' FILENO. WOOD~INI:' MANOR SURVEYED FOR LOT NO, 1~ MAP OF' WOO~E~INE MANOR SlTIJATED AT CUTCHOGUE TOWN OF SOUTHOLD ~ ~- SUFFOLK COUNTY, N.¥ SCALE I" ~, .GO' DATE 7- 23-1997 FILED MAP NO. 8239 DATE 12 - 1.5 - lg~G TAX MAP NO. 10OO- 83- 4 - 12 (REF, ONLY) DISK 176 HAROLD F. TRANCHON JR. P.C, LAND SURVEYOR 1866 WADING RIVER-MANOR RD. WADING q' NEW YORK, 11792 5 $ 6'-9.~9-4695 POOL DIMENSIONS TYP. PANEL STIFFNER FRAME BASE STEEL ANGLE DRIVESTAKE THICK VERMICULITE AGGREGATE MIX kLARD BOTTOM 18' LONG STEEL REINFORCING ROD HOLES IN BOSOM OF PANEL TYPICAL WALL SECTION AT '__A' FRAME Al POOL PLAN A2 B2 C2 MIN. 2" THICK VERMICULITE AGGREGATE TAMPERED D2 SECTION B1 TOP CORNER r~.l ,x~., ,_~r,,u.~, ~/ CORNER CONNECTION DETAIL DESIGN IS ACCEPTABLE FOR ~OOL TYPE: RECTAGLE I REV. S~ALE N.T.S. o.