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HomeMy WebLinkAbout37045-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 2/26/2013 CERTIFICATE OF OCCUPANCY No: 36151 Date: 2/26/2013 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 13920 Soundview Ave, Southold, SCTM #: 473889 Sec/Block/Lot: 54.-3-3 Subdivision: Filed Map No. conforms substantially to the Application for Building Permit heretofore 3/7/2012 pursuant to which Building Permit No. Lot No. filed in this officed dated 37045 dated 3/7/2012 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 inground swimming pool fenced to code (per New York State Variance Petition #2012-0492) as applied for. The certificate is issued to Smith, Patrick & Smith, Judy (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37045 4/11/12 Aut hOf[~ Signature~ 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 #: 37045 Date: 3/7/2012 Permission is hereby granted to: Smith, Patrick & Smith, Judy 13920 Soundview Ave Southold, NY 11971 To: construct an accessory inground swimming pool fenced to code as applied for At premises located at: 13920 Soundview Ave SCTM # 473889 Sec/Block/Lot # 54.-3-3 Pursuant to application dated To expire on 9/6/2013. Fees: 3/7/2012 and approved by the Building Inspector. SWIMMING POOLS - ABOVE-GROUND WITH REQUIRED FENCING CO - SWIMMING POOL ELECTRIC Total: $250.00 $50.00 $100.00 $400.00 spector Form No. 6 ·OWN OF $OU~HOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to tile Building Department with the following: A. For new building or new use: I. 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 eertifyiug that tile solder used in system contains [ess than 2/10 of I% lead. 5. Commeroial buildiilg, industrial buildiog, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Hamfing 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: I. Accurate survey of property showing all property lilies, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to iuspect sigued by the a0plicant. If a Certificate of Occupancy is denied, the Buildiug Inspector shall state the reasons therefor in writing to the applicant C. Fees I. 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 Certificate of Occupancy on Pre-existing Building - $ 100.00 Copy of Certificate of Occupancy - $.25 Updated Celtificate of Occupancy - $50.00 5.Temporary Certificate of Occupancy - Residential $15:00, Commercial $15.00 l~ew ~nsf~ruction: , ? Location of Property: House No OWner or Owners of Property: suffolk coun~ T~ Map No 10~, S~tion Date. Old or Pre:existiq6 Bui!d!n~.~ St2eet (check one) Health Dept. Approval: Planning Board Approval: Temporary Certificate Request for: Hamlet (check one) Fee Submitted: $ ~) , ff..) Filed Map. ~-6 '75 Applicant: Underwriters Approval:. F hal Certificate.~//// Lot: Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971 0959 Telephone (631 ) 765-1802 Fax (63 I) 765-9502 ro.qer, richert~.town southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Patrick Smith Address: 13920 Soundview Ave City:Southold St: NY Zip: 11971 Building Permit #: 37045 Section: 54 Block: 3 Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electric License No: 2880-me SITE DETAILS office Use Only Residential ~ Indoor ~ Basement ~ Service Only [~ Commedcal Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Servicelph ~ Heat ~ DuplecRecpt ~ Service 3 ph Hot Water GFCl 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: Ceiling Fixtures J~ HID Fixtures Wall Fixtures ~.~ Smoke Detectors Recessed Fixtures ~.~ CO Detectors Fluorescent Fixture ~ Pumps Emergency Fixtures~ Time Clocks Exit Fixtures L.~ TVSS in ground swimming pool to include, bonding, 1-pump, 1-GFCI circuit breaker Notes: Date: April 11 2012 81-Cert Electrical Compliance Form.xls /'~ ~TO'~N OF SOUTHOLD BUILDING DEPT. ~///-- 765-1802 '/ INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE RESISTANT CONSTRIJCrlON [ [ ] ELECTRICAL (ROUGH) [ REMARKS: [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION ] ELECTRICAL (FINAL) DATE ~INSPECTO~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROU~-BG. [ ] FOUNDATION 2ND [ ] IN/,SULATION [ ] FRAMING / STRAPPING [i/~INAL ~ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION ] ELECTRICAL (FINAL) [ ] FIREPLACE & CHIMNEY [ [ ] FIRE RESISTANT CONSTRUCTION [ [ ] ELECTRICAL (ROUGH) [ REMARKS: ' ~-~, '-~/¥ DATE ~" INSPECTOR ]-OWN 0l; .tic tI~HOLO BUILDING DEP,kRTMENT TOWN HALL SOUTHOL~, NY 11971 TEL: 765-1802 Approved Disapproved ~c Do you hav~ or need the follo~g, before applyln~ Board of Hoal~ 3 sets of Building Plans S~ey ~heek Septic Fo~ N,Y,S.D,E,C. Trustees Conifer: Mail to: Phone: guilding Inspector APPLICATION FOR BUILDING PERMIT D ate INSTRUCTIONS 'zT. of b, Plot pla~lshowing location of lot and of building~ on'premises, relationship to adjoining premises or public streets or areas, and watep.va,~s. "' c. The wor~ covered by this application may not be commenced before issuance of Building Permit. d. Upon aptb~,oval of this applicat on, the Building Inspector will issue a Building Permit to the applicant Such a permil shall be kept on thelpremises available for inspection throughout'the work . e. No buildlng, t shall be occupied or used in whole or in'part for any purpose what-so-ever until a Cert ficate of Occupan is issued by the Building Inspector. . . APPLICA'~ION IS HEREBY MADE to the Building Department for the issuance of a Bui d ng Permit pursuant to the Building Zone Ord~hance of the Town of Southold, Suffolk'~ohnty, New York, and other applicable Laws, Ordinances or Regulations, for thd c'onstrucfion of buildings, additions, or~Mterations or for removal or demolition as herein described. The applicant agrees to ~oinply with all applicable laws, ordinan6es, building code, housing code, and regulations, and to admit authorized inspect~s on premises and in building for ne~s,~:~3' inspections, ,. · . {~'(Signature of applicant or name, if a corporation) '" (Mailing addre~ o f applicant) State whether applicant is owner, lessee, agent, m'chiteet, ~ngineer, general contractor, electrician, plumber or builder Name o f owner 'emises ot .nL , (as ~n the tax roll or latest deed) ] '! If applicant is a cbrporation, signature ~,~ duly authorized o/~_~ (Name and title of corporate officer) Builders License!No.. Plumbers License Nc. Electricians Lice,nsc No. Other Trade's LiCense No. 1. Location ofl~nd on which proposed work will b~ done: House Numbar ~ Street unty Tax ~ap No, 1000 Section Co Hamlet Block Filed Map No._ Lot Lot (.9 b. interfded rise and occupancy Nature of work (c~heck which applicable): Repair [ Removal L Estimated Cost ! I0~ OOo ;. If dwelling, numL~er of dwelling unit~ If garage, number of cars _ State existing us{ and occupancy ofprq.~ises and intended u~e and occupancy of proposed construction: a. Existing dsc and occupancy k/..-~, .~ ,'ko,a k:¢~ Fee New Building_ Demolition_, Addition Alteration OtherWork ~',-'~¢,;~,,~A. '~'~..-i.-~-,'....) ~¢~l [~ ~':~q ~.,~ ~Descnptmn) (to be paid on filing this application) Namber of dwelling units on each floor ,. If business, comrdercial or mixed occupancy, specify nature and extent of each type of use. ,. Dimensions of existing structures, if any: Front Rear Depth Height - I Number of Storie.s Dimensions of game structure with alterations or additions: Front Rear Depth I Height Number of Stories ;. , Dimensions of en[tire new construction: Front Rear Depth Height i .Number of Stories -- "Size°fl°t:FrontI 195- _Re< lqt-/.<~9 Depth. 2-")S ,-23 0' Date °fPurchasei Name of Fonner Owner 1_., otc 1. Zone or use distri t in which premises are situated 2. Does proposed c~ns ruction violate any zoning law, ordinance or regulation: 3. Will lot be re-gra~led ..-~ d9 Will excess fill be removed from premises: ~ NO 4. Names of Owner lo f premises .~o~M,c..~ '~ v,,,.'J,,~ Address/'~'20 ~',...., I ~ ~--,4~ Phone No. Address'Ifc, O~'er ~....~, PhoneNo 7"/H -7:t ~'~ 5. Is Ns property wpthm 100 feet of a tidal wetland? *YES NO · IF Y~S, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE RF,~ED 6. Provide survey, t~b scale, with accurate foundation plan and distances to property lines. 7. If elevation at an~ point on property is at 10 feet or below, must provide topogTaphical data on survey. TATE OF NEW ¥Ot~K). I gs: f '~'~-~"' ~ t'4"/"vx ~ ~ being duly sworn, deposes and says that (s)he is the applicant (Name of individdal signing contract) above named, (Contractor, Agent, Co;porate Officer, etc.) said o,.vner or owne?s, and is duly attthorized to perform or have performed the said work and to make and file this application; mt all statements contained in this application are true to the best of bis la*owledge and belief; and that the work wilt be :rformed in the manngr set fortb in the application filed therewith. worn to before me thi's gn ture of Apphcant NOTARY ICBUC, STATE OP Iql~ YO~.K FEEl 19 2013 STATE OF NEW YORK DEPARTMENT OF STATE ONE COMMERCE PLAZA 99 WASHINGTON AVENUE ALBANY, NY 12231-0001 MENT OF STATE In the Matter of the Petition of: Patrick Smith For a Variance to the New York State Uniform Fire Prevention & Building Code CESAR A. PERAI ES DECISION PETITION NO. 2012-0492 Upon the application of Patrick Smith, filed pursuant to 19 NYCRR 1205 on October 19, 2012 and upon all other papers in this matter, the Department makes the following determination: NATURE OF GRIEVANCE AND RELIEF SOUGHT The petition pertains to the installation of an in-ground swimming pool for a one-family dwelling, located at 13920 Soundview Avenue,, Southold, Town of Southold, County of Suffolk, State of New York. Relief is requested from: 19 NYCRR Part 1220, Residential Code of New York State, (2010) Section AG105.3 section 8.2, which requires, in part, that all gates shall be self latching, with the latch handle located within the pool enclosure (i.e., on the pool side of the enclosure) and at least 40 inches above grade. In addition if the latch handle is located less than 54 inches from the bottom of the gate, the latch handle shall be located at least 3 inches below the top of the gate. [ The Petitioner request permission to permit a latch handle for a pedestrian gate as a part of a pool enclosure, located 54 inches above the bottom of the gate, to be located on the outside of the pool enclosure.] FINDINGS OF FACT An in-ground swimming pool was installed at the subject premises. In doing so an enclosure was provided around the pool itself with a pedestrian access gate~ The pedestrian access gate swings outward from the pool and has a latch handle that is located at least 54 inches above the bottom of the gate. However the latch handle has been located on the outside of the gate. WWW.OOS.NY,GOV E-MAIL: INFO~DOS,NY.GOV Petition No. 2012-0492 Psge 2 10. The previous, 2003 and 2007, Residential Codes of New York State allowed the latch handle to be placed on the outside of the pool enclosure as long as the handle was located a minimum of 54 inches above the bottom of the gate. The current 20'~0 Residential Code of New York State requires that even if the latch handle is 54 inches above the bottom of the gate that it must be located on the pool side of the enclosure. The provisions for barriers around swimming pools are to protect young children. Less than 5 years of age, according to the International Residential Code Commentary. The 2006 International Residential Code, on which the 2010 New York State Residential Code ~s based, allows a latch that is 54 inches above the bottom of the gate to be located on the outside of the enclosure. The commentary for the International Codes states that the "54 inch latch height requirement limits the potential for small children to reach and activate the latch." If the latch is located lower than 54 inches then the Code requires that the latch be located 3 inches below the gate on the inside of the enclosure. Section 303.2, Part 8 ,of the current, 2010, Property Maintenance Code of New York State has retained the language about pool latches that was in the previous Residential Codes of New York State and still allows a latch that is located 54 inches above the gate to be located on the outside of the enclosure. Based on the above findings, it is the assumption that the 54 inch height of the latch above the bottom of the gate is adequate to protect the children thCt the Code has identified from reaching the latch and gaining entrance to the swimming pool regardless on which side of the enclosure the latch is located. The latch used for the subject gates is manufactured by "Magna-Latch" which approves the installation on the exterior of the enclosure as long as it is set a minimum of 54 inches above the bottom of the gate. On some gate configurations it may be possible to reverse the latch to be in compliance with the current Code requirements. However in this instance the enclosure and the gates would have to be Petition No, 2012-0492 Page 3 completely reconfigured or replaced to reverse the latch. The Petitioner has stated that this would bo[h physically and financially impractical. 11. The PetitioneP hss proposed that the pool enclosure and pedestrian gates will be in compliance: with all other applicable provisions of Appendix G of the Residentia! Code of New York State. 12. The local code enforcement official has been consulted in this matter and does not object to the granting of a routine variance under the provisions of 19 NYCRR 1205. CONCLUSIONS OF LAW Strict compliance with the provisions of the Uniform Fire Prevention and Building Code would be unnecessary in light of the fact that the latches as configured will be a minimum of 54 inches above the bottom of the gate and should be out of reach of the children that the Code provisions are trying to protect and would ensure the achievement of the Code's intended objectives more efficiently, effectively or economically such that granting a variance would not substantially adversely affect the Uniform Code's provision for health, safety and security. DETERMINATION WHEREFORE IT IS DETERMINED that the application for a variance from 19 NYCRR Part 1220, Section AG105.3 section 8.2, to permit a latch handle for a pedestrian gate as a part of a pool enclosure, located 54 inches above the bottom of the gates, to be located on the outside of the pool enclosure; hereby PROPOSED TO BE GRANTED with the following condition: 1. That the latch handle be located a minimum of 54 inches above the bottom of the pedestrian gates. 2. That the pool enclosure and pedestrian gate will be in compliance with all other applicable provisions of Appendix G of the Residential Code of New York State This DECISION is issued under 19 NYCRR 1205.6. Unless obiected to by the petitioner in writinq received by the Department, the decision shall become FINAL after fifteen days of receipt of the decision by the parties. Petition No. 2012-0492 Pa9e 4 This decision is limited to the specific building and application before it, as contained within the petition, and should not be interpreted to give implied approval of any general plans or specifications presented in support of this application ~Administration ~AT~: ~ Jlsh ¢- RAS:sg NYS DEPARTMENT OF STATE DIVISION OF CODE ENFORCEMENT AND ADMINISTRATION Variance Attest List Petition No: 2012-0492 The persons below are advised to TAKE NOTICE of the attached document. The attached document pertains to a petition for relief related to code requirements. If there are any questions, call (518) 474-4073 and ask for the Variance Unit. Please refer to the petition number in all related conversations or correspondence with us. GARY FISH / TOWN OF SOUTHOLD BLDG DEPT 53095 MAIN ROAD P O BOX 1179 SOUTHOLD, NY 11971 PATRICK SMITH 13920 SOUNDVIEW AVENUE SOUTHOLD, NY 11971 10/23/2012 Page 1 of 1 Town Hall Annex 54375 Main Road P.O. Box 1179 $outhold, NY 11971-0959 Telephone (6~1) 765-1802 ro · (631) 7 5 ,qer. nchert('~.t~ (w~6~.sou~5o(~.n¥.u~ B[.R~ .]31NG TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION !REQUESTED BY: .~.~/~A v',' ~-~ [~ 00,1 ~ Date: ~License No.: % ~0 ~ ~ JOBSITE INFORMATION: (*Indicates required information) *Cross Street: ~_ ~ *Phone No.: Permit No.: Tax Map District: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) '-/65 - % I qS 1000 Section: ~'q Block: Lot: (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Tamp Certificate: Tamp Information (If ~eeded) *Service Size: 1 Phase *New Service: Re*connect Additional Information: YES/~__~ Rough In Final 3Phase 100 150 200 300 350 400 Other Underground Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C,T.M. #: 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) Yes No 1 2 3 4 5 6 7 8 Will this Project Retain All Storm-Water Run-Off Generated by a Two (2") Inch Rainfall on Site? (This item will include all mn-off created by site clearing 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 nd eating Size & Location? This Item shall include all Proposed Grade Changes and Slopes Controlling Surface Water'Flow! WiJl 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 F ve 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') feet 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 Sudaces 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 Material, Removal of Vegetation and/or the Construction of any Item Within the Town R ght-of-Way or Road Shoulder Area? (This item will NOT include the Installation of Driveway Aprons.) 9 Wirl this Project Require Site Preparation within the One Hundred (100) Year F oodp ain of any Watercoume? O ~ 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 Pr or to ssuance of Any Building PermR~ EXEMPTION: Yes No Does this project meet the minimum standards for classification as an Agricultural Project? Note: If You Answered Yes to this Question, a Storm-Water Grading, Drainage & Eros on Control Plan is NOT Requiredr STATE OF NEW YORK, ~ ~ COUNT oF ................. ss ThatI, .~.t ~¢~.- ..~,~,~'¥1,~,~'~ be' ' ' ..................................................................... mg duly sworn deposes and sa3 s that he/she Is the applicant for Pernnt, (Name of individual signing Document) And that he/she is thc ......................... .,.~....~...~3..:.~....~..,~.....~.. ..................................... '. ........... (Owner, Contractor, Agent, Corporate Officer, etc.) Owner and/or representative of the Owner of Owner's, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before rne this; Notary Public: ...... FORM - 06/07 OP ID: ML CERTIFICATE OF LIABILITY INSURANCE 03/15/11 THIS CERTIFICATE IS ISSUED AS A MATrER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CER'I1FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'rWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endomem ent(e~ coerrACT PRODUCER 845-783-2555 NAME: FAX Walter Rose Agency, Inc 845-783-2425 CAIc.PRONENc~ ~Xt): 8 Stage Road E~4A~L Monroe, NY i0950 AOORESS: PRODUCER DUNRI CL~TOMER ID · ' INSURER(S) AFFORDING COVERAGE NAIC ~.su~o Dunrite Manufacturing Corp INSURERA: Twin City Fire Ins Co 347 Dunrite pools ~NSURES e:Central Insurance Companies 20230 3510 Veterans Mere orial Highway ~NSURES C: Hartford 34690 Bohemia, NY 1i716 INSURER D: INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT ~IE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVVITHBTANDING ANY REQUIREMENT, TERM OR CONDiTiON OF ANY CONTaACT OR OTHER COCUMENT 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. LIMiTS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS. INSR ADDL SUBI~ POLICY EFf= POLICY EXP GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A ~- COMMERCIALGENERALLIABIUTY 91UENQS9371 04101111 04/01/12 DA~ETOREN~U P~EMISES fEe occurrence) $ 300~000 I CLAIMS~ADE [~ OCCUR MED E,V~ (Any one person) $ 10,000 PERSONAL & ADV IN JURY $ %000r00( ~ PopUp GENERAL,aGGREGATE $ 2,000,00( AUTOMOBILE LIABILII~f COMBINED S~GLE LIM~T {Ea ecddent) $ 1~000,00( E~ ~ ANYAUTO SAP 8880739 i2/31110 12131/11 ANYPROPRIETOR/PARTNER/EXECUTIVE YIN~ )IWECJX2028 03/27/11 03/27/12 !EL EACHACCIDENT $ 1D0,00t C Swimming Pool Installation Service or Repair CERTIFICATE HOLDER CANCELLATION SOUTH-7 Town of Southold th Building Dept ~ Main Street Southold, NY ii 971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NO'riCE WILL BE DELIVERED IN ACCORDANCE WITH TI'IE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BI~NEFFfS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of tl~ai Carrier la. Legal Name and Address of Insured (Use street address only) Dunrite Manufacturing Corp Dunrite pools 3510 Veterans Memorial Highway Bohemia, NY 11716 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) I b. Business Telephone Number of Insured 631-588-1300 .lc. NYS Unemployment Insurance Employer Registration Number of Insured 0592920-5 1 d. Federal Employer Identification ~arnber of Insured or Social Security Number 112245133 3a. Name oflnsurance Carrier Hartford Town of Southold Building Dept Main Street Southold, NY 11971 3b. Policy Number of entity listed in box "la": 01WECJX2028 3c. Policy effective period: __03/27/11 to _03/27/12_ 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 certify 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. Date __03/16/2011 __ By ~~ (Signature of iasurancc carrier's authorized representative or NYS Licensed [osurancc Agent of that iasur~cc carrier) Telephone Number..845-783-2555 Title_President IMPORTANT: If box "4a" b checked, and this form is signed by the insurance carrier's authorized representative or NYS Lkenstd Imuranee Agent of that carrier, this certificate ta COMPLETE. Mail It directly to the certificate holder. If box "4 b' is checked, this certificate is NOT COMPLETE for purposea of Section 220, Subd. 8 of the Disahilit~t Bets ~tlL~ Law. It must he mailed for completion to thc Workers' Compensation Boardt DB Plans A¢ceptane/~ Unit, 10 Park Street, Albafl~l NM York 12107. PART 2. To be completed by NYS Workers' Compensation Board (Only if box -4b,, of Part 1 has been checked State Of New York Workers' Compensation Board According to information mainta/ned by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed. By Telephone Number Tit}e (Signature of NYS Workers' Compensation Board Employee) Please Note: Only insurance carriers licensed to write NY$ disability benefits insurance policies and N YS llcer~red insurance agents of those insurance carriers are authorized to Lrsue Form DB-120. I. Insurance brokers are NOT authorized to Issue this form. DB-I20.1 (5-06) STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) Dunrite Manufacturing Corp Dunrite pools 3510 Veterans Memorial Highway Bohemia, NY 11716 Work Location of Insured (Only requlred ~f coverage Is specifically limRed to certain locations in New York State, La, o Wrap-Up Policy) lb. Business Telephone Number of Insured 631-588-1300 lc, NYS Unemployment Insurance Employer Registration Number of Insured 0592920-5 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 Building Dept Main Street Southold, NY I 1971 or Social Seeuri~ Number 112245133 3a. Name of Insurance Carrier Hartford 3b. Policy Number of entity listed in box "la" 01 WECJX2028 3c. Policy effective period __03/27/11 __ to 03/27/12 3d. The Proprietor, Partners or Executive Officers are [] included. (Only check box if all partners/officers included) X 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 pulley). The Insurance Carrier or its licensed agent will send this Certificme of lnsarance to the entity listed above as the certificate holder in box "2". The lr~vurance Carrier will also notify the above certificate holder within 10 days IF a policy ia' canceled due to nonpayment oJpreminms or within 30 days IF there are reasons other than nonpayment of premiums thal cancel the policy or eliminate the insuredJkom the coverage indicated on thin' Certificate. (These notices may be sent by regular mail.) Otherwtse, this Certificate is valid for one year after ems form is appeoved by lite Insurance carrier or Rs 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 bolder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory cuverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, 1 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: Ke¥in McDoq9ugh (Print nam~ of authlxizad representative or licensed agent of insuuu~c* cartier) (Signature) (Date) Title: President of Walter Rose Agency, 10c Telephone Number of anthorized represeotative or l icensed agent of lnsurance ~arrier: 845-783-2555 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT attthorized to issue it. C- 105.2 (9-07) www.wcb.state.ny, us A~ ' ~.~OOTt,tOL ,ck. ~, B POOL DIMENSIONS TYP. PANEL .GTIFFNER I - TYPICAL WALL 6ECTION AT 'A' FRAME r.~ . N0~FY BUILDING DEPARTMENT ~ ~ ~ '- ~ 76~.1802 8 ~ TO 4 PM FOR T~ ~ ~0 .LO~NG INSPECTIONS 1. ~ATION - TWO RE~UIR~D ENCLOSE ~ TO CO~ ;TRAP"q~G ELECTRICS. U~ ~~ ~ ~SULATION ~ ALL CONST- ENTRAPMENT PROTECTION IN COMPL ANCE UJ TH 8,EOT. A~- 0~, ucSIGN OR CONo, RuG ~b N :--~ J~(t POOL PLAN ~,ET,~!N STORM WATER RUNOFF PURSUANT TO 6HAPTER 236 Of THF Tnw~f nnnE ELECTRICAL ~WICK. %'ERMICULITE mOOLT'I'PE~ RECTAGLIE I~Ev. JAMIE~ IDi=,'-~K. OSKI, ~ Di=m-',< PATt-I HA'ITl'TUCK, NB/J POOL COMPLIANCE !.UITW ANS, I BT4, ~:::)IO APPENDEX ~. DE~,IGN IN ACCEPT~I~LE F--Ol~ ALL COP'Ih'ION ,~,OIL CONDITION8, N.ToE~.