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Home My WebLink About36433-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 11/22/2011 No: 35296 Date: 11/22/2011 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 500 Jacksons Landing, Mattituck, NY 11952, SCTM #: 473889 Sec/Block/Lot: 113.-4-7 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 5/18/2011 pursuant to which Building Permit No. 36433 dated 5/31/2011 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 ~round swimming pool with fence to code as applied for. The certificate is issued to Tsoumas, Vasilios & Tsoumas, Kathy (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36433 7/11/11 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF occUP~td~cy Ti~ application must b~ 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, sOeets, and unusual natura} or . topographic fcatur6s. 2. Final Approval from Health D.ept. of water supply and scwerage~disposal (8-9 form). 3.. Approval of electrical installation from Board 0f Fire underwriters. ' 4..~w.~mstat~mentfr~mp~umbercor~fyingthatth~s~deru~edin~y~temcon~alv`s~essthan2/~f~%~ead. . 5. Commeroiat building, indmtrial building, multiple residences and similar buildings and kn~stallations, a certificate of Code ComPliance'from architect or engineer responsible for the buildiag: .6. Submit Planning Boant Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957~ ~ion-eanforming uses, or buildings and ~pre~existing" laud uses; 1. Accurate survey of property showing all property linc~,'strcets, building and unusual natumi or topographic features. 2. ^ Properly ~mpleted application and consent to inspect signed'by the applicant. Ifa Certificate of Occupaucy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. C, crtifica!¢ of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00; Swimming po01 $50.00, ACCessory building $50.00, Additions to accessory building $$0.00, Businesses $50.0(~. 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 l',lew Construction: /~ Old or Pre-existing Building: Suffolk .County Tax Map No 1000, Section. Subdivision Permit Ho. Date of Permit. Planning Board Approval: Request for: Temporary Certificate _ Foe Submitted: $ .L.~ , O (x~ / (check one) mec Fried Map. Underwriters Approval: Final Certificate: Lot (check one) Hamlet ~'Appli/cant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 ro,qer, richert~,town.southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Kathy Tsoumas Address: 500 Jackson Landing City: Mattituck St: NY Zip: 11952 E~uilding Permit #: 36433 Section: 1 1 3 Block: 4 Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Raymond Electrical Cont License No: 5141-me SITE DETAILS Office Use Only Residential [~ Indoor ~ Basement ~ Service Only ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Servicelph ~ Heat ~ DuplecRecpt ~ 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 Other Equipment: I-GFCI circuit breaker Ceiling Fixtures [~ HID Fixtures Wall Fixtures ] ] Smoke Detectors Recessed Fixtures[~ CO Detectors Fluorescent Fixture [~ Pumps Emergency Fixtures~._.~ Time Clocks Exit Fixtures [~ TVSS in ground swimming pool to include, bonding, 1-pool light, 1 pool heater Notes: Inspector Signature: Date: July 11 2011 81-Cert Electrical Compliance Form 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 #: 36433 Permission is hereby granted to: Tsoumas, Vasilios & Tsoumas, Kathy 15-38 150th St Whitestone, NY 11357 Date: 5/31/2011 To: construct an inground swimming pool fenced to code as applied for per Trustees & DEC permits At premises located at: 500 Jacksons Landing, Mattituck, NY 11952 SCTM # 473889 Sec/Block/Lot # 113.-4-7 Pursuant to application dated To expire on 11129/2612. Fees: 5/18/2011 and approved by the Building Inspector. SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE CO - SWIMMING POOL Total: $250.00 $50.00 $300.00 Building Inspector TOWN OF~G DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ]ELECTRICS_ OUGH) [ ]ELECTRICAL(FINAL) REMARKS: "~/P~ /~/~//~ ~'~- /~'~/~-~ ! DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROU~'PLBG. [ ] FOUNDATION 2ND [ ],~ISULATION [~,'~ FINAL [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] fiRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION []ELECTRICAL (ROUGH~ ~'~ [/]ELE~i.I/C~AL (FINAL) REMARKS: DATE BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: [631) 765-1802 FAX: (631) 765-9502 www. northfork, net/Southold/ Examined .~'/ Approved Disapproved PERMIT NO. 433 Do you have or need the following, before applying? Board of Health 3 sets of Building Plans Planning Board approval Survey Check Septic Form N.Y.S.D.E.C. Trustees C°ntact:Mail to.~2F~T. ~ ~ Phone: -~%Or --g ~_ Expiration ~)~i! ~ INSTRUCTIONS Date ,20 t[ a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be conmlenced 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 code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections.,/'// "IMUEDIATELY" OCCUPANCY OR ENCLOSE POOL TO CODE ~ ...... ~ (Sianatur%-of"an~lic~int or name ii' UPONcOMPLETION LL,:"~ IFUNI AWFJL \ ~ ........ rr-'~7 ....... ' ..... Y ........ BEFORE"WATER" t ':"*'~ ,. -, " (Mailing address of applicant) Gl ' uCL;UPANCY state whether appncant owner, lessee, a ent, architect, engineer, seneral contr g;, or builder FEE: ~0, BY~ Name of owner ofpremises ~3~ (As on the tax roll or If applicant is a corporation, signature of duly author/zed officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. NOTIFY BUILDING DEPARTMENT AT l~;~d'~ ~ TO 4 PM FOR THE POLLOVVIN[3 INSPECTIONS: 1. FOUNDATION. TWO REQUIRED FOR POURED CONCRETE 2, ROUGH - FRAMING, PLUMBING, STRAPPIN~ ELECTRICAL & CAULKING 3 INSULATION 4 FINAL-CONSTRUCTION&ELECTRICAL MUST ~tE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. 1. Location of land on w..~_hich proposed work will be done:, , I I ~q~[F~Ill~l.q~ WATER RUNOFF House Number S}reet - · ,. ~ mm~e~F THE TOWN CODE. ~2~[~i~;~ Map No 1000 ~a~p~TION RE~RED State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy :~,¢~,~ ~ ~ . r'--~-~' t~l,~-_,- b. Intended use and occupancy ~ Nature of work (check which applicable): New Building Repair Removal Demolition Estimated Cost I ~, ~-~¢:~ Fee If dwelling, number of dwelling units If garage, number of cars Addition Other Work Alteration (D~scription) (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 Stories Rear Dimensions of same structure with alterations or additions: Front Depth Height Number of Stories Dimensions of entire new construction: Front Height, Number of Stories Depth Rear Size ofl0t: Front Rear _Depth 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 13. Will lot be re-graded? YES__ NO~ Will excess fill be removed from premises? YES&NO 14. Names of Owner Name of Architect' ~,.,CJ~';~'~->~ 'k'B~c::~q Address :[~r'4---'~'--octc Phone No Name of Contracto~l}r'~_, ~q-, 1~ _cCJ.~' ,~--~f-Address ~ pC) tv',~-t- Phone No.Z?~:'o 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES O * IF YES, SOUTHOLD TOWN TRUSTEES &.D.E.C. PERMI, T/S MAY BE REQUIRED. '-' b. Is this property within 300 feet ora tidal wetland? * YES '", NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. ~ q- "Tt'x,t.~ 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation ~t _an`.y, point,on,, prQpcrty is at 10 feet or below, must provide topographical data on survey. STATE OF NEW ¥OR_~ : ...... COUN YO ),, (Name of individ~l~i~ing ~ontraot) aboOe named, (S)He is the (C, ontractor, Agent, Corporate Officer, etc.) of said owner or 01,vnerS; and is duiy authorized to perform or have-performed the said work and to make and file this application; that all statements ~onthin, ext in this applio~tion are true to the best of his knowledge and belief; and that the work will be performed in the manner apt forth,ir~.the application filed therewith. ~re of]~pplicant t./ BOARD :OF SOUTHOLD TOWN TRUSTEES SOuTHOL~; NEW YORK PERMIT NO. 7533 DATE: APRIL 20, 2011 ISSUED TO: KATHYTSOUMAS PROPERTY ADDRESS: 500 JACKSON'S LANDING~ MATTITUCK SCTM# 113-4-7 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on April 20, 2011, and in consideration of application fee in the sum of $250.00 paid by Kathy Tsoumas and subject to the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits the following: Wetland Permit to install a 16'x32' in,ground swimming pool, patio and surrounding fence; and as depicted on the survey prepared by Peconic Surveyors, P.C., last dated March 8, 2011, and stamped approved on April 20, 2011. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Br~odemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF $OUTHOLD CERTIFICATE OF COMPLIANCE # 0695C Date: October 18, 2011 THIS CERTIFIES that the installation of a 16'x32' in-ground swimming pool, patio and surrot~nding fence At 500 Jackson's Landing, Mattituck, New York Suffolk County Tax Map # 113-4-7 Conforms to the applications for a Trustees Permit heretofore filed in this office Dated March 11,2011 pursuant to which Trustees Wetland Permit #7533 Dated April 20, 2011 was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the installation ora 16'x32' in-ground swimming pool, patio and surrounding fence The certificate is issued to KATHY TSOUMAS owner of the aforesaid property. u~t'horized Si)~at~u New York State Department of Environmental Conservation Division of Environmental Permits, Region One SUNY @ Stony Brook, 50 Circle Road, Stony Brook, NY 11790-3409 Phone: (631) 444-0359 ]Fax: (631) 444-0360 Website: www.dec.ny, qov May 12,2011 Joe M~r~ens Commissioner Ms. Kathy Tsoumas 500 Jackson's Landing Mattituck, NY 11952 RE: Permit ;41-4738-01555/00003 Dear Permittee: ~AY ~. 2011 Bt [}G DEPL In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please carefully read all permit conditions and special permit conditions contained in the permit to ensure compliance during the term of the permit. If you are unable to comply with any conditions, please contact us at the above address. -~-- ......... '"--,,~ Also enclosed is a permit sign which is to b~ con~ posted at the pr& site and protected from the weather. //~ · ]//~' ~/~istrator~ JAW/dj Enclosure NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 1-4738-01555 PERMIT Under the Environmental Conservation Law (ECL) Permittee and Facility Information Permit Issued To: KATHY TSOUMAS 500 JACKSON'S LANDING MATTITUCK, NY 11952 Facility: TSOUMAS PROPERTY 500 JACKSON'S LANDINGISCTM 1000-113-4-7 MATTITUCK, NY 11952 Facility Application Contact: SWIM KING POOLS INC 471 ST RTE 25A ROCKY POINT, NY 11778 (631) 744-8100 Facility Location: in SOUTHOLD in SUFFOLK COUNTY Facility Principal Reference Point: NYTM-E: 705.5 NYTM-N: 4541.3 Latitude: 41059'49.2'' Longitude: 73033'24.3'' Authorized Activity: Install a 16' x 32' inground swimming pool with permeable apron. Install a drywell for swimming pool discharge. Remove portions of the driveway and rear yard walkway to accomodate the swimming pool installation. Project to be in accordance with survey/plan last revised 3/8/I 1 by John T. Metzger and stamped NYSDEC approved on 5/12/11. Permit Authorizations Tidal Wetlands - Under Article 25 Permit ID 1-4738-01555/00003 New Permit Effective Date: 5/12/2011 Expiration Date: 5/11/2016 NYSDEC Approgal By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, and all conditions included as part of this permit.I~I~ ~ Permit Administrator: JOHN A WI._/~ ~.D, Deputy ~1 Permit Administr Address: N fSDEC I~ION 1 HEAfl~QUARTERS ~ ~,IY ~ONY BR )~[50 CIRCLE RD ~S' ~OOK,~ ~790~9 AuthofizedSi~a~e: L' [ ..~ t/ ~ . . Page 1 of 5 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 1-4738-01555 Distribution List SWIM KING POOLS INC Habitat - TW $OHN A WIELAND Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: TIDAL WETLANDS 1. Conformance With Plans All activities authorized by this permit must'be in strict conformance with the approved plans submitted by the applicant or applicant,s agent as part of the permit application. Such approved plans were prepared by John T. Metzger and stamped NYSDEC approved on 5/12/11. 2. Notice of Commencement At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days &completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 3. Concrete Leachate During construction, no wet or fresh concrete or leachate shall be allowed to escape into any wetlands or waters of New York State, nor shall washings from ready-mixed concrete trucks, mixers, or other devices be allowed to enter any wetland or waters. Only watertight or waterproof forms shall be used. Wet concrete shall not be poured to displace water within the forms. 4. No Construction Debris in Wetland or Adjacent Area Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in wetlands and/or protected buffer areas. 5. No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activities. 6. Storage of Equipment, Materials The storage of construction equipment and materials shall be confined within the project work area and/or upland areas greater than 100 linear feet' from the tidal wetland boundary. Page 2 of 5 Town of Southol Erosion, Sedimentation & Storm-Water Run-off A: ~1 :~SI~I~N I~O ~ ~ ~ ~ STO~WATE~ G~ING, D~IHAGE ANI ~COPEOFWO~ - PROPO~ CONdUcTION l'r~ / WO~S~ a~ G~ D~a~ ~r t~ pm~ed ~/~ Site Im~v~en~ and ~ .~an~t ~ of ~ } / Item shall i.~ude all P~ ~e C~nges and con~l site e~bn and st~ ~ter discharge. Th~ item must ~ main~in~ ~mug~t ~e Entire C~stm~bn Pe~. 4 ~11 ~is Pmj~ R~im a~ Land Filling. Grading Excava~on where there is a ~nge Existing Grade Involving mom ~an ~0 Cubic Yards of Matedal w~hin any Pamel? 5 ~[I ~is ~li~on R~uire Land Disturbing Ac~es ~ ¢ (5,000 S.F.) Square Feet of ~nd Sudace? 6 is ~ere a Natural Water Coume Runni~ ~mugh Site? Is ~is P~ea ~in ~e Trustees judsdic~n ~ DEC ~Ppp ~1~: or wi~in One Hund~ (100') f~t of a WeOand am ~d o~ a ~ co~ p~n t~i ~] ulli~e~ db~ ~e or ~m a~ o~land; ~ich Exceed Fifteen (15) feet of Veffical Rise toPmparati°n on Existing Grade SI~ ~PPP's S~II ~t l~ ~nlmum Re~m~ ~ ~e SPDE8 ~e~al Petit 8 Wi~ D~, Pa~ng ~eas or ~her Im~us STA~Z OF NEW YO~ Q~ ~d I~ 0~ ~or rep~senmfive of ~e ~er or 0~, ~d is duly au~o~d m ~o~ or have m~ ~d rde ~ application; ~at ~1 s~t~ con~ed in ~i~ app~mfion ~ ~e m ~e best offs ~owled~ ~d ~t ~e ~rk MIl ~ peffomed in ~e m~ner set fo~ ~ ~e apphcafion filed ~ ....... da or ~ 2''jj FORM - 06/10 =~ To~n l. bll Annex ,f4375 Main Rind P.O. B~t 1170 · Soudl~d. NY IIF/i-0~9 Telejdmae (6~1) 76,S-180~ BuH.nlNG DEPARTMENT TOWN OF 8OUTliO~n APPLICATION FOR F[FGTRICAL INSPECTIOH JOBSITE INFORMATION: (*Indicates required Information) ~ooo sc..mo,: %%-% amc. k: q *BRIEF DESCRIPTION OF WORK (Please Pffnt Clea~y) Lot: (Ptuse CJrcb Nt That App.) *Is job ready for inspeclfon: *Do you need a Temp Certificate: (~! NO Tomp'lnfomutlon (If needed)- *Sm'vice Size: 1 Phase 3PMme 100 *New ~:- Re-~o,nect U.dergro,~ A~dlflonal Information: Rough In Final 150 200 300 350 400 Other Number of Metem CtmngeofSewfce Overhead PAYMI=NT DUE WITH A-PPLICATIO~; Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 November 21,2011 BUILDING DEPARTMENT TOWN OF SOUTHOLD Telephone (631) 765-1802 Fax (631) 765-9502 Vasilios & Kathy Tsoumas 15-38 150th St Whitestone, NY 11357 Re: 500 Jacksons Landing, Mattituck TO WHOM IT MAY CONCERN: The Following Item(s) Are Needed To Complete Your Certificate of Occupancy: ~Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of $56.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) Final Planning Board Approval. __ Final Fire Inspection from Fire Marshall. - Bob Fisher __ Final Landmark Preservation approval. BUILDING PERMIT: 36433 - In Ground Swimming Pool STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1 .To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Cart er 1 a. Legal Name and Address of Insured (Use street address only) RANDY T. RODECKER, INC. DBA SWIM KING POOLS 471 ROUTE 25A ROCKY POINT, NY 11778 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 1 t971 tb Business Telephone Number of Insured lc, NYS Unemployment Insurance Employer Registration Number of Insured 8561753 Id. Federal Employer Iderldfication Number of Insured or Social Security Number 113092960 3a. Name of Insurance Carrier The First Rehabilitation Lif~ Insurance Company of America 3b. Policy Number of Entity listed in box "t a": DBL37154 3c. Policy effective period: 02/01/2011 to 01/31/2012 4 Policy covers: a, [] All of the employer's employees eligible under the New York Disability Benefits Law b [] Only the following class or classes of the employer's employees: Under penalty of perjury, I certi fy that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above (Signature ¢ insura~ ~ie~'~ a~hotiz~ ~se~;(i~ or Telephone Number. ~ 6Z~:~ ~Q Title Chief Executive Officer IMPORTANT: If ~x "4a" is c~ked, and U~is form is sign~ by the insuran~ carrier's auth~iz~ representative or NYS [icen~d Insura~e Agent oft~t carrier, [his ~lficate Is COMPLETE, Mail It dirtily to the e~ific~e If ~x "4b" is ~ecked, this ceAifi~te is NOt COMPLEfE for the pur~s of S~ion Zzo, Subd, 8 of the Di~bili~ Benefits Law. It must be ma il~ ¢~ completion fo the Worker's Component ion Board, DB Plans ~cepta~e Unit. 20 Park St~ec Albany, NY 12207. PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board According to Intormation maintained by He NYS Worker's Compensation Board, the above-named employer has complied wi~h the NYS Disability Benefits Law wilh rmpecl to all of his/her employees, Date Signed By (Signature of N YS Worker's Compens,~Bon Beard Employee) lelephone Number .... Tit e ...... Please Note: Only insurance carriers licensed to write NYS Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carriers ar(! authorized to issue Form DB-120,1 Insurance brokers are NOT authorized to issue this form DB-120.1 (5-06) LOCATION MAP ~ LOT COVERAGE HOUSE, DECK &. WALKS AREA ' 3378 sq. fl.- AREA OF UPLANDS = 19505 S~l. fI. 3378/19505 ~, 1.7.3% ~ PROP. POOL? 51Z',~q. ff'o~ °O ~ 512119.505 .. &,6% .' '_ ,/ ~' 8 - LOt CO'V~Sm; ~ ~0~ A = WETLANDS FLAG WETLANDS A'S DELINEA TED BY SUFFOLK 'ENVIRONMENTAL CONSUL TING, /NC. JUNE E4, 2009 ELEVA T/ON,~ AND CONTOUR LINES ARE REFERENCED TO N.G. V. Ddum. FI~OOD ZONE' FROM FIRM COMMUNITY PAN:EL NO. 560813 0112 E AREA = 23,570 sq. ft. to tie fines SCDHS EeL# R10-96-0112 The locations of wells' and cesspools shown hereon ore from field observations and or from data obtained from olhers. I ~m familiar with /he STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES and will abide by fhe. conditions set forlh therein and on the permil to consfruct. /O/-Op I o ~ ,~ .~,,,71~.~ Test Boring ~,.9' "~ o'el /o,/ · 0£ ~ oj Br. ~y ~oam ---- - ~ ~ B to medium S~nd Woler In pole br. fine 1o medium Sand LOT 5 JACKSON'S LANDING" FILED MAR. 28,1969. FILE NO. 5280 A T MA TTITUCK TOWN OF SOUTHOI-D SUFFO/'K COUNTY, NY. 1000- 113- 04 - O? Sca/e: 1" = 30' Jan. 27,1997 JUL Y ~, 2009 JUL Y I$, ~00~ O%~OP. POOU JCl_)'_ zz, _'~_o_ s. (~o~_ ~T? / ) SEPT. I, ~U,~ ~op. pe'o SEPT. 15~ EOOS [revldo~] OCT. 15, 2009 (r~vl~lonl ,' · ANY ~L TERA T/ON ~ ADDITI~ TO T~ SURVEY I$ A VIOLA TI~ OF SECT~E09 OF T~ NE~ Y~K ST~ ~ ~ TION L~ ~ S~OWHOSE~PS~NAOR TuRECOP~ESAPPEARSaEAR ~EHEREON.~RE~EO S~AL OF ~ SURVEYOR.~ t ~A~ ] 6 20~] ~ ~ ' ~631) 765 ' 50~0 ~ ' ~. O. BOX 909 ADDITIO~ALLY TO COMPLY WITH SAID LAF T~ TERM 'ALTERED ~Y' MUST 8E USED 8Y ANY AND ~LL SURVEYORS UT[~ ~ COPY ~,~ ., ~ I~0 TRA V~L~R OF ANOTHER SURVEYORS M~P. TERMS SUCH ~$ '~SPECTED' AND 'BROUgHT-TO-DATE' ARE NOT IN CO~L~NCE FITH THE LA~ 49~18 STREET ,,~l 96-2 4LgO' L 0 T CO VERA GE SCDHS Ref.# R10-96-0112 L A L. HOUSE, DECK & WALKS AREA = 3378 ,~I./L~-~ AREA OF UPLANDS = 19505 sq. fl. PROP. POOLL= ~ · .E (,.-.) k ) ~-- WETLANDS FLAG WETLANDS ,4S DELINEA TED BY SUFFOLK 'ENVIRONMENTAL CONSUL TING, INC. JUNE 24, 2009 Test Boring 4-/ I0.1 Dr. ~. Loom Br. Sony Lo~m Br. Loamy Son~ fo medium Sand ELEVAT/ONS AND CONTOUR L~NES ARE REFERENCED TO N.G. V. Dolum. COMI~UNITY PANEL NO. 5608/5 0112 E shown hereon ore from field observations and or from data obtdned from o/hers. FEOOD ZONE' FROM FIRM ' ' LOT AREA = 23,570 sq. ft. to tie lines JACKSON'S LANDING" FI&ED MAR. 28, ~ FILE !~. 5280 The Ioodions of we/is' *nd ce,spools A T MATTITUCl~ TOWN OF SOUTHO[~E~ SUFFOLK COUNTY, I ~m familiar ,,/th /he STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES and w/It ab/de by the, conditions set forth lhere/n and on the perm// to cons/ruct. JUL Y 2~ 2009 JUL Y I~ £00~ ~OP, POOD .~T. i,'.~o~¢,~:-~rr OCT. 15, R~9 (6~) 765 - 50gO FA (G311 765 - 1797 P. O. BOX ~9 96-2 7C ANY AL TERA T/ON OR ADDITION TO THI~ SURVEY I~ A VIOLA TION OF $ECTION'~Z09 OF' THE NEW YORK STATE EDUCATION LAW, EXCEPT ,45 PER SECTION ;~09-SUBDIVIEION ~. ALL CERTIFIC4TIONS HEREOI~ ARE VALID FOR THIG 1~4P AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR WHOSE SIGNATURE APPEARS HEREON. ADDITIONALLY TO COMPLY WITH SAID LAW THE TERM 'ALTERED BY' MUST 8E USED BY ANY AND ALL SURVEYORS UTIL4ZlN~ A COPY OF ANOTHER SURVEYORS MAP. TERMS SUCH AS 'iNGPECTED' AND 'BROUGHT-TO-DA TS' ARE NOT IN COMPLI4NCE WITH THE LAW. 1000- 113- 04 - 07 Sca/e: 1" = 30' Jan. 27,1997 ~ ,,~1~ ~ P~N PLUMBING FORMED CONCR~E S~PS ~ ~LLED FOAM B~EEN ~ : ~ 5500 PSi POVRED CONCR~E WALL SECTION SECTION A NOTES , VARIES ~ 4-' TOP OF WALL WA1 ER LINE ~' 4' VARIES 4-'