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Home My WebLink About37146-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 9/25/2012 CERTIFICATE OF OCCUPANCY No: 35971 Date: 9/25/2012 THIS CERTIFIES that the building Location of Property: SCTM #: 473889 Subdivision: IN GROUND POOL 1910 The Long Way, East Marion, Sec/Block/Lot: 30.-2-128 Filed Map No. Lot No. conforms substantially to the Application for Building Penmit heretofore filed in this officed dated 4/10/2012 pursuant to which Building Permit No. 37146 dated 4/18/2012 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 in ground swimming pool with fence to code as applied for. The certificate is issued to Galanakis, Emmanuel & Minardo, Marie (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37146 6/13/12 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 #: 37146 Permission is hereby granted to: Galanakis, Emmanuel & Minardo, Marie 69 78th St Brooklyn, NY 11209 Date: 4/18/2012 To: construct an Inground swimming pool fenced to code as applied for At premises located at: 1910 The Long Way, East Marion SCTM # 473889 Sec/Block/Lot # 30.-2-128 Pursuant to application dated To expire on 10/18/2013. Fees: 4/10/2012 and approved by the Building Inspector. SWIMM1NG POOLS - 1N-GROUND WITH FENCE ENCLOSURE CO - SWIMMING POOL Total: $250.00 $50.00 $300.00 Building Inspector Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPAdNCY 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 insmllation 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 ceifificate 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 rises: 1. Accurate survey of property showing all property lines, strects, building and:unusual natural or topographic features. 2. A properly completed app}ication 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. UpdatedCertificateofOccupancy- $60.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of Property: Owner or Owners of Property: ~-I~ltll0?ll~t Suffolk County Tax Map No 1000, Section Old or Pre-existing Building: House No. Street Subdivision Permit No. Health Dept. Approval: · Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ ¢~'D, ~/ DateofPermit. [/- i~; -~ ! ~ Date. 12 (check one) Hamlet Block ~ Lot Filed Map. Lot: Applicant: ~/blCa:~ Underwriters Approval: Final Certificate: /' (check one) A~plicant Signature Town Hall Anncx 54375 Main Road P.O. Box I 179 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 mued To: Galanakis ~,ddress: 1910 The Long Way City: East Marion St: NY Zip: 1193.c ~uilding Permit #: 37146 Section: 30 Block: 2 Lot: 12.~ WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE 3ontractor: DBA: USI Electric LicenseNo: 2740-e SITE DETAILS Office Use Only Residential I~ Ind°°r l~ Basement [~ Service Only~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage Service 1 ph Service 3 ph Main Panel Sub Panel Transformer Disconnect Other Equipment: 1-heat pump INVENTORY Hot Water GFCl Recpt NC Condenser Single Recpt NC Blower Range Recpt Appliances Dryer Recpt Switches Twist Lock Ceiling Fixtures ~8 HID Fixtures Wall Fixtures I I Smoke Detectors Recessed FixturesR CO Detectors Fluorescent Fixture ]-----I Pumps Emergency Fixtures[__I Time Clocks Exit Fixtures [__l TVSS ~n ground swimming pool to include, bonding, l-pool light, 2-GFCI circuit breakers Inspector Signature: Date: June 13 2012 81-Cert Electrical Compliance Form.xls TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 / INSPECTION [~/] FOUNDATION 1ST [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ [ ] FIREPLACE & CHIMNEY [ [ ] FIRE RESISTANT CONSTRUCTION [ [ ] ELECTRICAL (ROUGH) REMARKS: [ ] ROUGH PLBG. [ ]INSULATION ]FINAL ]FIRE SAFETY INSPECTION ]FIRE RESISTANT PENETRATION [~)~ ELECTRICAL (FINAL) TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] RO~I PLBG. [ ] FOUNDATION 2ND [ ]/~I~RJLATION [ ] FRAMING/STRAPPING [~/] FINAL ( ) FIREPLACE & CHIMNEY [ ) FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION ( ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [.~ ELECTRIC~AL (FINAL) REMARKS: ~'~-- ~~~ ~ ~~ _ DATE T~WN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 PERMIT NO. Examined q[[?, 20 [Z Approved q/Il(, 20 t ~" Mail to: Disapproved a/c V.,~t~ ~O/(,q ~3 Phone: 't Building Inspector BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying ? Board of Health 3 sets of Building Plans Survey. Check Septic 7orm N Y S.D.E.C, Contact: APR 1 0 20!2 FOR BUILDING PERMIT -- Ctli/; ~dq.- Date . .,~., ,20 a. This application MUST be completely filled in by typewriter or in Iffk and subraltted 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 tiffs application may not be commenced before issuance of Building Permit. d. Upon approval of tiffs application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspedtion throughout the work. ¢. No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the ~ssuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, ~nd other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein descri'bed. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and.xegulations, and to admit authorized inspectors on premises and i, Al~i~in, g for necessary inspections. ut,,,: ANC oa "! ,, 35E i<; MlaED! T_ E_L_Y_'_ , ,: UNLAWFL.. (Signature ofa~p~~o~oration) ENCLOSE POuL/U BEFORE "WATER" ': ' ~ - State whether applicant is owner, lessee, agent, architect, engineer, gene*al contra ; ~ftt"~r~C~r..l~ilder Name of owner of premises If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) to~.~.uZ 8 AM-TO 4 ~M ¢Off-Ti~E '- FOLLOWING INSPECTIONS: ~tflffiOndCc. gar J fltl/}l~.l<~ 1. rn~ i~D~,~,,' .... .... zz'~r ..... (as on the tax roll or mtes~¢OURED OONCRE¢E ~, ROUGN.FRAMtNO, ~LUMBiNO, STRAPPING, ELECTRICAL i ~AULKING 4 FINAL. CONSTRUCTION & ELECTP~Ca[ MUST Builders LicenseNo. Plumbers License No. Electricians Lice~_se No. -n/o -mE ,~L CONSfRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. Other Trade's License No. 1. Location of land on which proposed work will be done: House Number ~treet ' t County Tax Map No. 1000 Section Subdivision (Name) RETAIN STORM WATER RUNOFF PURSUANT T2 CHAPTER 236 ~ ,/~l~J:~:.~ CODE. Hamlet Block ~ ELECTRI~o~L State existing use and occupancy of premises and intended use and occupancy of provosed constmctilon: a. Existing use and occupancy ~\~o b. lntended use and occupancy g4.~q~00Ml'tm ~14~t~ 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 Alteration Other Work"~",,~ ~q~;~o ~' (Description) (to be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height Number of Stories Rear ~ Depth__ Dimensions of same structure with alterations or additions: Front Rear Depth Height 8. Dimensions of entire new construction: Front ] ~'~ ~{0 Height Number of Stories 9. Size of lot: Front ~0' Rear ~0' Number of Stories Rear _Depth _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: 13. Will iotbere-graded ~O0c ~ (2~ · 14. Names of Owner of premises ~../~1.~4~ Address NameofArchitect"Th,mqt~ B l~t. fl~ ~ Address Name of Contractor/~ t~9~,~m ~ Address 15. Is this property within 100 feet of a tidal wetland? *YES · IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED Will excess fill be removed from premises: (YES 'h NO ql0 to, wq ~ M4-e..,o~ Phone No. g ~ ~ ~hone No 16. Provide survey, to scale, with accurate foundation plan and distances .to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF~Of'"'~-x~ ) ~ ~J ~O~4ct..l~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the 0__.O~ (Contractor, Agent, Corporate Officer, etc.) · of said owner or owners, and is duly authorized to perform or have performed the said work and to ~nake 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. Sworn to before me this a , day of ~' Notary Public 1 MARGARET A. KIDNEY Nolary Public - Stale of flm. t York No. 01KI6021111 Qualified in Suffolk County My Commission Expires March 8, Town of Southoid Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM ~ :;= PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A Sec~on Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCllON ITEM # / WORK ASSESSMENT I Yes No a. What is the Total Ama of the Project Parcels? Will this Project Retain All Storm-Water Run-Off (include Total Area of all Parcels located within ~ ~1000 ~ Generated by a Two (2") Inch Rainfall on Site? the Scope of Wor~ for Proposed Construction) (S.F. I Ac~s) (This item will include all mn-off created by site b. What is the Total Area of Land Clearing cleadng and/or construction activities as Well as all and/or Ground Disturbance for the proposed ~:)1~ ~ ' Site Improvements and the permanent craaEon of construction activity? impervious surfaces.) (s.F.,~,,) 2Does the Site Plan and/or Survey Show All Proposed PROV'E)E BRIEF PRO. TECT DESCR[YTION (P~V, de.~dd~o,~ ~. N*~ded) Drainage Structures Indicating Size & Location? This / r~ -- Item shall include all Proposed Grade Changes and 0 ~ J~l X: 3~3 I n~~0Ji~c) Slopes Controlling Surface Water Flow. ·' ' · 3Does the Site Plan and/or Survey 0escdbe the erosion ~J~ I~ ~/,., ,,"/31~h,/t%l'~lN 0~ t~OC)L .J~ ~T~ and sediment control practices that will be used to control site erosion and storm water discharges. This Construction Period. 4 Will this Project Require any Land Filling. Grading or Excavation where there is a change to the Natural r~ Existing Grade Jnvolving mare tha~ 200 Cubic Yards of Matedal within any Parcel? 5 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand~ (5,000 S.F.) Square Feet of Ground Surface? 6 is there a Natural Water Course Running through the Site? IsthlsProjectwithintheTrusteasjurisdictionW V/' General DEC SWPPP Requirements: or within One Hundred (1 Off) feet of a Wetland or Submission of a SWPPP is required for al~ Construction acttvi~es thvolvisg soil Beach? disturbances of one (1) or more acres; lacluding disturbances of I~s than one ac~e that 7Will there be Site preparation on Existing Grade Slopes are part of a larger common plan that will u~mately disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical PJse to ~ including Conslructton activities involving ~ disturbances of less than one (1) ac~e where one Hundred (100') of Horizontal DistanCe?~ -- the DEC has determined that ar SPDES permit is required for storm water discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES Generat Permit 8 Will Driveways. Parking Areas or other Impervious for Storm Water Discharges fTom Construction activity - Permit No. GP-0-10-001.) Surfaces be Sloped to Direst Storm-Water Run-Off ?. The SWPPP shall be prepared prk~ th the submittal of the NOL The NOI shall be into and/or in the direction of a Town right*of-way?~ __'v submitted to t~e Deparbnent prk~ th the commencement of c,o~s~uction activity. 2. The SWPPP &hall describe the erosion and sediment control p~ac#ces and where 9Will this Project Require the Placement of Material, required, post-cons~uctton storm watsr managernent practtces that wal be used and/or Removal of Vegetation and/or the Constructien of any N constructed th reduce the poiluthnts in stom~ water discharges and th ~,~sum Item Within the Town Right-of-Way or Road Shoulder compllan(=e with the tem~ end condi~ons of this permit. In additfon, the SWPPP shall~ stATE OF NEW YORK, ~ coum ......... ............. ss ThatI, ~ ~-13b/h'#.O$ bein dui swom de osesalldsasthath tsheis .... - And that he/she is the ........................................ Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statement~ conta~ined in this application are tree to the best of his knowledge and beliefi and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; ~) FORM - 06/10 <100211 I I 0ua#fled i~ ,~ff01k County Town Hall Annex 54375 Main Road P.O. Box 1179 Sou&old, NY 11971-0959 Telephone (631) 765-1802 ro.qer richertd~w(~n !~o~ u~o~, ny, u,~ BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Company Name: D.. ~ ."f- Date: Name: License No.: Address: Phone No.: JOBSITE INFORMATION: *Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: (*Indicates required information) S lq o '-rae toaq 1000 Section: *BRIEF DESCRIPTION OF WORK (Please Print Cleady) Block: ~ Lot: (Please Circle All That Apply) *Is.job ready for inspection: *Do you need a Temp Certificate: ' Temp'lnformation (If needed} - *Service size: 1 Phase *New Service: Re-connect Additional Information: YES / NO Rough tn 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 ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: [~¢ APPLICATION FOR OUTDOOR POOL PERMIT EROSION SEDIMENTATION & WATER RUN ASSESSMENT FORM CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF LIABILITY INSURANCE SUFFOLK COUNTY LICENSE SUFFOLK COUNTY PLUMBER LICENSE SUFFOLK COUNTY ELECTRICIAN LICENSE 4 SETS OF PLANS - (3 STAMPED) 3 SURVEYS APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK APPLICATION FOR CERTIFICATE OF OCCUPANCY C.O. TAX BILL $300.00 CHECK FOR PERMIT FEE Suffolk County Executive's Office of Consumer Affairs VETERANS MEMORLAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 SUFFOLK COUNTY Master Electrician License No. 2740-ME This is to certify that EDWARD S REIFF doing business as .............. _UN?ERGROUND SP_ E_C_IAL~!ES INC having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN m accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York. by,he C 2740-ME ] Additional Businesses ! ) hector 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 Carrier 1 a. Legal Name and Address of Insured (use street address onlyl A[thur J. Edwards Mason Contracting Company Inc. 929 Route 25A Miller Place, NY 11764-2700 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of SouthoJd Town Hall, PO Box 728 Southold, NY 11971 lb, Business Telephone Number of Insured (631) 744- 4455 lc. NYS Unemployment Insurance Employer Registration Number of Insured 24 - 10871 ld. Federal Employer Identification-Number of Insured or Social Security Number 11 - 2377925 3a. Name of Insurance Carrier The Guardian Life Insurance Company of America 3b. Policy Number of entity listed in box "la": 00984424.- 0000 3c. Policy effective period: 07/01/1986 to 06/30/2012 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 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 Signed: 07/07/2011 By: ~ ~ ~ Stuart J. Shaw, FSA, MAAA Telephone Number: 1-888-278-4542 Title; Vice President, Group Insurance IMPORTANT: If box 4a Is checked, and this form Is signed by the Insurance carr er s authorized representative or NYS L cansed Insurance Agent of that carrier, this cartlflcste Is COMPLETE. Mall It directly to the cartlflcate holder. If box "4b" Is ohecked, this certificate Is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of Part I has been checked) State Of New York Workers' Compensation Board According to information maintained by the' NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefit~ Law with respect to all of his/her employees. Date Signed: By: (Signature of NYS Workers' ComDensaiion Board Emoloyee) Telephone Number: Title: ~lease Note: Only insuran.ce carriers ficensed to write NYS disability benefits insurance policies and NYS licensed ~ao~iCzee(~gt~t~sOufetht~se /~Sr~ance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT DB-120.1 (5/06) ~ OP ID: VM CERTIFICATE OF LIABILITY INSURANCE aATE .M,OO YV 01/12/12 -THIS CERTIFICATE IS ISSUED AS A MA'I-rER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AL~ER THE COVERAGE AFFORDED SY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), ·AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADD~T]ONAL INSURED, the policy(ies) must be endorsed, if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policie~ may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(st. PRODUCER :Bagatta Associates, Inc. 823 W Jericho Turnpike Ste lA Smithtown, NY 11787 Bagatta Associates, Inc. INSURED ArthurJ Edwards Mason Conti'acting Co Inc DBA Arthur Edwards Pool & Spa Center 929 Route 25A Miller Place, NY 11764 631 ~864-1 lll 631-864-8274 CONTACT NAME: PHONE FAX CUSTOMER ID #: ARTH U-I INSURER(SI AFFORDING COVERAGE INSURERA :Worcester Insurance Company INSURER B: I 26182 COVERAGES C~:A¥iFICATE NUMBER: THIS IS TO CERTIFY THAT 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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS EACH OCCURRENCE $ '~ ,000, 00( A MPA00000038801H DAMAGE TO RENTED __ 01/01/12 01/01/13 PREMISES (Re occurrence) 100,00( j CLAIMS-MADE [~ OCCUR $ PERSONAL & ADV IN JURy $ 1,000,00[ __~- BLANKET ADDITIONA GENERAL AGGREGATE $ I PRODUCTS- COMP/DP AGG 2,000,00( / CERTIFICATE HOLDER CANCELLATION 0000000 THE EXPIRATION DATE THEREOF, NO~CE WILL BE DELIVERED IN Town of South old ACCORDANCE WITH ~ E POLICY PROVISION~]. Town Hall P.O. Box 728 AUTHORIZED REPRESENTATIVE ® 1988.2009 ACORD CORPORATION. All rights reserved. · ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WOI~.EP~S' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) Arthur J, Edwards Mason Contractor, 929 Route 25 A Miller Place, NY 11764 Work Location of Insured (On~ required ~f coverage is ~peofficaliy lisslied to certain iocatlon~ in New York ~tate, L ~, a ~Frap-Up Policy) ' 2. Name and Address of the Entity Requmflng Proof of Coverage (Entity Being Listed as the Certificate Holder) Town ofSouthold P,O, Box 728 Southold, NY 11971 lb. Business Telephone Number oflnsured 631-744-71g$ I~N-T$ Unemploymentlnsuranee Employer 24108715 Id, Federal Employer Identification Number of Insured or Social Security Number 11-237792S Name of lnsuranee Carrier UIIt¢o Casualty Insurance Company 3b, Policy Number of entity listed in box "la" WCS-70009'~-00 Policy effective period ~ to 01/01r2013 above and that the named insured has the coverage as deplet~ on this form. T~I=:~ Proprietor, Partners or Executive Officers are [ x ] included. (Ouly cheek box If all parlnera/offieer~ included) [ ] all excluded or enr~n;., par~ers/offieers excluded. This certifies that thc insurance curner indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation Lmder the New York State Workers' Compensation Law, (To use this form, New York (NY~ must be listed under ~on the I,NFORMATION PAGE eftbe workers' compensation insurance policy), The Insurance Carrier or agent will send this Certificate of Insurance to the entity listed above ns the certifi;ate holder in box "2". its licensed Thc Insurance Carrier will also notify the above certificate holder within 10 days IF apo/icy is canceled due to nonpayment of premlurns or within 30 days IF there are reasons other than nonpayment of premiun~ that cancel thepollcy or eliminate the insured from the Coverage indicated on this Certificate. ffhese notlce~ may be sent by regular mail.) OtherWise, ~tls Cert~qeate is ~alid for one year ql~er this form is aPProved by the Ins#raaco carrier or 1~ 1 '3e"~ ~. L ceased agent, or Until the policy explratinn date listed tn box Please Note: Upon the eaneellaflon of the workers' compensation policy indleated on this form if the bus named on a permit, Ileenen or contract Iss--a t. .... .~,, ......... ; ~ . , iness continues to be new Certttleate of , u provide that eertifl Workers Corn easation Cove eate holder w~th a mandatory enveraee re~ui men~nrth, m,,~ ~ge or other.auth, o~ proof that the business is eom I n with _ -- re ............ Yo.k State Workers' Compensation Law. p yi g the Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the lasurance carrier refereneed Telephone Number ofeathorized representative or licensed agent of insunmce :an/er: o~ - ~ ~d' "~?/ Piea.~e Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers.are NOT authorized to issue it. C-105.2 I9-07) www.wcb.state.ny.us STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSIYRANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) Arthur J. Edwards Mason Contractor, Ina, 929 Route 25 A Miller Place. NY 11764 Work Location of Insured (On/~ required ~ eoverale is spec~fleatiy limited to certain locations In New York State, I.&, a P/rap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of Sonthoid P.O. Box 728 ~ Southold, NY 11971 I b. Business Telephone Number of Insured 631-744-7195 1 e. NYS Unemployment Insurance Employer 24108715 Id. Federal Employer ldentifiention Number of Insured or Social Security Number 11-2377925 3a. Name oflnenrance Carrier Ullico Casualty Insurance Company 3b. Policy Number of entity listed in box "la" WCS-700093-00 Policy effective period 0/01~ to 01/Olr2013 Proprietor, Partners or Executive Officers are £ x ] included, (Only check box Ifall partner#officers Included) all excluded or certain gartners/offlm,~ excluded This certifies that thc insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under thc 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). Thc Insurmlce Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as thc certificate holder in box "2 ". The Insurance Carrier will also notify the above certificate holder within 10 days IF a pollcy ts canceled due to nonpayment of premiums or within $0 days IF there ar~ reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indlcated on th/z Cert~cate. (These notlces may ba sent by regular mall.) Otherwbe, thb Cert~fleate is valid for one year ofter thb form ls approved by the Ins#raaco carrier or its licensed agent, or until the pollcy expiration date listed In box "Se'; ~. Please Note: Upon the caneelintion of the workers' eompensntion poUcy 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 enrtlfleate kolder with n new Cerflflente of Workers' Compensation Coverage or other nuthori~ed proof thnt the business is complying with the mandnto~y coverage requirements of the New York State Workers' Compensntton 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 depict~ed on this,for,re. 'nt n~e of a ~zed.~rf, se . lye or, lic;nscd agent of hsurancc carrier) crafted by: ~ / / Telephone Number of authorized representative or licensed agent of insurance carrier: Please Noto: Only insurance carriers and their licensed agents are author/zed to issue Form C-105.2. /n~urance brokers are authorized to izsue it. C- 105.2 (9-07) www.wcb,state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or requirad by law to issue any permit for or in connection with any work involving thc employment of employeas in a h0~mrdous empinymen~ definnd by this chapter, and notwithstanding any §choral or special statute raquh~ng or authorizing the issue of such permits, shall not issnn such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to thc chair, that compenSation for all employees has been secured as provided by this chapter, Nothing herein, however, shah be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee ifsu empinycd. 2. Thc head of a slate or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving tho employment of employens in a hs?~rdous employment defined by this chapter, notwithstanding any general or special s~atute requiring or authorizing any such contract, shall .*:.ct enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employacs has been securad as provided by this chapter. C~105.2 (9-07) Reverse B B Plan Section B-B Section A-A Typical Wall 5qZE A B C D E F G H AREA CAP. FEET FT. FT. FT. FT. FT. Fr. Fr. FT. sq.Fr. ~L. 1§x32' 16' 32' 8' 14' 6' 4' 4' 8' 512 19,000 16'x36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600 18'x36' 18' 36' 12' 14' 6' 4' 5' 8' 648 24,300 20'x40' 20' 40' 16' 14' 6' 4' 6' 8' 800 30,000 24'x44' 24' 44* 18' 14' 8' 4' 6' 10' 798 30,000 _24'x48' 24' 48' 20' 16' 8' 4' 6' 10' 900 30,000 PERMACRETE WAIJ. SYSTEM 929 Route 25A Miller Place NY 11764 (631) 744'-7185 FAX (631) 744-0174 Suffolk License #4436-HI Nassau License #HI74450000 Piping Section Arrangement SERVICES APPLICANT ........ Lot 47 vAc,~N'[ 45 Lot 4~9 sCl. ft. AreO ¢ 258 44 ,, OF THE CLERK OF SUFFOL ~ COUNTY ON JUNE II, 1975 ~S ~1~E ~ ~: STAKE L YOUNG & 400 OSTRANDER AVENUE, ALDEN W, YOUNG SURVEY FOR: WILLIAM SAUSMER 8~ PEARL. Sl LOT 46"PEBBLE BEACH ^T EAST MAR I 0 N YOUNG SUFFOLK CO., N.Y. I IN~[~TITU'T~ON$ OR SUBSEQUENT OWNERS. I = 40 JAN. 13, 1981 81 - 6