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HomeMy WebLinkAbout36271-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 8/1/2012 CERTIFICATE OF OCCUPANCY No: 35851 THIS CERTIFIES that the building 1N GROUND POOL Location of Property: 1425 Jacobs Ln, Southold, Date: 8/1/2012 SCTM #: 473889 Sec/Block/Lot: 79.-6-4.4 Subdivision: Filed Map No. conforms substantially to the Application for Building Permit heretofore 3/28/2011 pursuant to which Building Permit No. 36271 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issuod is: accessory in ground swimming pool with fence to code as applied for. Lot No. filed in this ofliced dated dated 3/28/2011 The certificate is issued to Mohr, Christopher & Gianfrancesco, Shanno (OWNER) of the aforesaid building. SUI~I~OLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36271 6/24/11 Au~/~ ri~ Sig~atur-~/ 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 #: 36271 Date: 3/28/2011 Permission is hereby granted to: Mohr, Christopher & Gianfrancesco, Shannon 1425 Jacobs Ln Southold, NY 11971 To: construction of an inground swimming pool, fenced to code as applied for At premises located at: 1425 Jacobs Ln SCTM # 473889 Sec/Block/Lot # 79.-6-4.4 Pursuant to application dated To expire on 9/26/2012. Fees: 3~8~011 and approved by the Building Inspector. SWIMMiNG POOLS - IN-GROUND WITH FENCE ENCLOSURE CO - SWIMMING POOL Total: $250.00 $50.00 $300.00 TOVfN OF SOUTHOLD. BUILDING DEPARTMENT TOWN HALL 765-1502 APPLICATION FOR CERTIFICATE OF ocCUPANcy This ~pplioation must be filled/n by typewriter or/nk and submitted to the Building Department with the folloWinE. A. For new building or new use: 1. F/nal survey °f Pr°perrY with accdrate'location of all buildings, property lin~, street~, and ~ual na~} or · topographic features. 2. Final Approval from Health D.opt. of wat*r supply and sewerage-disposal (8-9 forml. 3. Approval ofolectrieal imtallation from Board 6fFne Underwriters. 4. 'Sw. om ~tatoment from plumber certifying that the mlde~ ~; ............. ' -~. - ,-' ~omw,~-mai ouuamg, ma.~ braiding, mulhple ~lde~e, and sumlar buildings and instal'latiom, a cet~ificat~ of Codo Co .~iiatme'from amhitect or engineer re~on~ible for the building~ .6.' 8ubmit planning Boand Approval of comple, ted site phn requirements. Il'or existing bailding$ (prior to April 9, 19571 ~ion.-eonforming us~, or balldtngs am/"pre-existing" lind 1. Accurate ~orveY °f Pr°pert¥ sh°wing all property lincz,'streots, building and unusu~d natural or topographic fe~itures. - . . 2. ^ properly c~mpleted application and consent to inspect signed.by the applicant If a Certificate o~ ~c'cu nc ' - pa y~s denied, the Buikting Inspector shall sta~e the reasons therefor in writing to the applicant. 2. Fees - 1. Certificaie of Occupancy - New dwelling $50.00, Addition, to dwelling $50.00, Alterations to dwelling $50.00, Swimmirig poql ~50.00; Accezsory building $50.00, Additions to accessory building $50.00, Businesses $50.00,. ~. Ci:.rtifieate of Occupancy on Pm-existing Building - $100.00 3_ Copy o.fCertificate of. Occupancy - $:25 ' · 4. UpdatcxfCcrtificate of Occupancy - $50.00 · 5. lemporary Certificate Of Occupancy - Residential $15.00:, Commercial $15.00 Iew Comtruction: oeation of Property: ' Date. Old or Pre-existi~g Building:.' House No. Street "(check one) ~ . Haml~ ~folk .C:~. tyTaxMapNo'lOOO,$ectio, n. ~7 (5) ' ~odivision ~,,!m D~t. Approval: mmirlg Board Approval: Underwriter~ Approval: XlUCZt for: Temporary Certificate _ Final· Certificate: (check one) Apl~licanl Sb, nature 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 southo d ny us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: C&S Mohr Address: 1425 Jacobs Ln City: Southold St: NY Zip: 11971 Building Permit #: 36271 Section: 79 Block: 6 Lot: 4.4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric License No: 2740-e SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commericai 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 NC Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures [~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures [~ CO Detectors Fluorescent Fixture ~.~ Pumps Emergency Fixturesl.~ Time Clocks Exit Fixtures [~ TVSS in ground swimming pool to include, bonding, 2 pool lights, 2 GFCI circuit breaker.. 3 pool pumps, 1 pool heater Notes: Inspector Signature: Date: June 24 201'1 81-Cert Electrical Compliance Form 3A 71 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ~'FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] RRERESISTANT~ [ ROUGH PLBG. INSULATION FINAL FIRE SAFETY INSI~ ]ImE RESISTANT I,BEn,ATK)N REMARKS: DATE ~"--~ ~-- I I INSPECTOR ? TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SA,-.-. '/INSPECTION [ ]mEREmT,~'r~ [ ]F~EREmTJ~n'PE.ET~'rl~ [ ] ELECTRICAL (ROUGH) ~,~'JxELECTRICAL (FINAL) REMARKS: DATE ~ / ~__~.~__ INSPECTO~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]/INSULATION [ ] FRAMING/STRAPPING [~/] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESl~rANT CONSTRUCTION [ ] RRE RI~iS'I'ANT PENE'rRATION [ ] ELECTRICAL (R~)IJGH) ~, .. [ ] E'~=~nTRICAL (FINAL) REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSU~,A?~N FRAMING/STRAPPING [~'FINAL / FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: m ~ DATE ~/~_~/~~''/ INSPECTOR ~/~ TOWN OF SOUTHOLD BUILDING DEPARTM'ENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 PERMIT NO. Examined ,20_ ApproVed ''F4/~, 20 ( ( Mail to: Disapproved BUILDING PERMIT APPLICATION CHECKLIST Do you hav~ or need the following, before applying ? Board of Health 3 sets of Building Plans Survey. Check Septic Form N.Y.S.D.E.C. Trustees Contact: JAN 3 1 2011 BLDG, DEPT. Building Inspector ~PPLICATION FOR BUILDING PERMIT Date ,201 I TO~N OF s0uT~0t0 INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 se!s of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relatitnship 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 tkis 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 a Certificate of Occupancy 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 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, fl . _ ~ d',~?~i~ ~ . (Signature of appli~q[t or name, ff a corporation) /qi/'H()LtT CERTIFICATE ..... ,.. <. "II I ,IEDIAT£t.y" (Mailingaddressofapplicant¢ !Jr U,..JU, !PANCY ENCLOSE POOLTOCODE State whether applicant is own~i', lessee, a~l~~eer, general contractor, electrician, plumber or builder A R0¥£D N01B · (as on the tax roll or largE, deed) N()llgY BUILDING DEPARIMENT AT If applicant is a corporation, signature of duly authorized officer 7~5-~802 $ AM TO 4 PM FO~ 11-t~ (Name and title of corporate officer) Builders License No. .Plumbers License No. Electricians License No. Other Trade's License No. I;L~GIHIGAL 1. Location142¥ofland on whic ._~p~l[~ ~'~N~,, ,,.,,~Lal 1R~IClRED House Number Street County Tax l~ap No. 1000 Section '-7~ Subdivision (.~O-ILtq. (Name) FOLLOWING 'NSPECTIONS ~('iUND,~TiON. TWO REQUIRED oCR POURED CONCRETE 2 "~OL,G~. FRAMING PLUMB;NG. S*R~.PPlNG ELECTRICAL & CAULKING 3 .'¢¢ULATION z. z:N:,! . CONSTRUCTION & ELECTRICAl. MUgT BE COMPLETE FOR CO. ALL CONSTRuCTiON SHALL M~ET TH~ F EOdlREMENTS OF THE CODES OF NEW YORK STATE NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~SItTt~ b. Intended useandoccupancy ~51~k-t~ ~,/~t~,d~ ~iT Nature of.work (check which applicable): New Building_ Repair Removal Demolition Estimated Cost ~O000 - Fee If dwelling, number of dwelling units If garage, number of cars · Addition Alteration Other Work~o~ :~m/~. ~ u (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 ~;~ ~ Rear ~'0 ~ Height Number of Stories ,,2 Depth 2(0' Dimensions of same structure with alterations or additions: Front Rear Depth Height 8. Dimensions of entire new construction: Front [~7¢0~J )~,¥J~LRear Height Number of Stories 9. Size of lot: Front I ~O ~ Rear l ~ ' Depth Number of Stories 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 lot be re-graded ~O~f,~d 0~c~ Will excess fill be removed from premises: ~ NO 14. Sames of Owner of premises ~.,hllS~.c ~0~[ Address ~2qf'~63 ~ ehoneNo. ~--~}~ NameofArchitect'-~C,~ ~X~e, tl~ i~£. Address~ ~l~2_/c,~,l ~tm-a:~ PhoneNo Name of Contractor ~.'~r~ 7::t~rt~g P~ooc..x Address ~2ot £~'2fA PhoneNo. 15. Is this property within 100 feet of a tidal wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 16. Provide survey, to scale, with accurate foundation pl~ ~d distances to property lines. 17. If elevation at any point on property is at 10 feet or bel0w,:must provide topographical data on survey. STATE OF NE~ YORI~i · ¢OUNn' ]'~ * ~_g~O.5 being duly sworn, deposes and says that (s,he is the applicant (Name of individual.signing contract) abo~ve named, (S)He is the (Contractor, Agent, Corporate Officer, etc.) of said oxy.~p, ~ or owners and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work Will be perfonned~t,fl~e'manuei: set forth in the application filed therewith. Sworn to be,f,o,~rnle'/his I N~tary Public~ ' A. KIDNEY No, OI KI6021111 . ~l~i~ in Suff~ Coun~ My ~iss~ Ex~ Mar~ 6, ~ Town of Southold' ~ Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORu PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SU_~!_e._e!ON OF A Lo~ (;I:KTIff'IED BY A Di&i~N PROF~,i~iAL IN THE STATE OF NEW YORK. SCOPE OFWORK - PROPOSED CONSTRUCTION ITEM # / WORK,t~F,.S,SME~IT a. What ts the Total Ama of the Project Parcels? (thclude Tots[ Ama of all Parceis located within I Will this PmJent Retain AJI Sturm-Water Rur.,.Off the Scope of Work for Propcoed Constmc~on) i 0~I#~.'jl Genemtsd by a Two (2") Inch Rainfall on Site? and/or Ground Disturbance for the proposed ~ ~ ~( , clearing end/or constTuctlon activities as well as all Site improvements al~d the permanent creation of Impe~cos surfaces,) construction ao~vity? (~.~.,)~.~. 2 Does the Sits Plen end/or Survey Show NJ Pro~ PRO3~D~. B~' P~OJT.,CT ])ESCUdOs'ION ~P,g,,=N.d,e Drahaga Strocluros IndlcaUngSlze& LouaUon?Thls _/ Item shell I~clude all Proposed Grade Cha~as end and sediment conf~ol practices that wUI be ~ control site erosion and storm water discharges. This item must be n~aintained throughout the Entire Constmclion Pedod. 4 Will this I~ect Require any Land Fi ng, Grading or Excavation where there is a change to the Natural / Existing Grade involving more than 200 Cubic Yards of Material within any Parcel? , 5 Will this Application Require Land Disturbing Ac~vities Encempaasing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Sudace? 6 is there a Natural Water Course Running through the Site? Is this Project within the Trus~as ju~ aeneral DEC SWP~.- OF within One Hundred (100~) feet of a Wetland or Submission of a SWPpp is requ;r6d f~. ail Construction ac'UvJtths Involving soil Seach? ampart~f~a~gerc~n1rn~npisnthatw~u~tle1eth~ydi~turb~ne~m~r~isnd;disturbancssof~ne(1~)~m~reacms;~ecled~ngd~torbar~cesof~ee~than~neacre~hat 7 Will there be Site preparation on Existing Grade SIopes l..--.I which Exceed Fiff.,e,,en (15) feet of Ver~cel PJse to /heincludingDEC hasC°~structl°odeth~nlned~that a SPOESflw°k'legbem~t so~ dlsturba,cesls required fo~°f ~ormleSs thanwater o.edlscha~ges.(1) a~e where One Hundred (100 ) of Horizontal Dista.n. Ce? SWPRP'. Shall meet. the Minimum Requlmmeof~ of the 8PDES General I~wat~ 8 Will Driveways, Parking Areas or other Impen. ioua f°r St°nn WB~r Dleehsr~H from C"~tnJctlce ~ ' P'rmlt N°' GP'O'~O'O01*) Surfaces be Sl°l:~d t° Direct St°rn~Water Rutl'Off $. The SWPPP shatl be pmbemd lalor th the submitthl of the NOI. The NOi Mwii be subeated to me Depalmeat lator to me co.,ren~rmmt of censmic~n aceaty. ' into end/or in the direction of a Town right-of-way? 2' '~e SWPPP "bell bescC~e Ibe ematm and~mt c°ntr°l IxaCUce~ and where 9 Will this Project Require the Ptscement of Material, required, poet-con~ructlon atmm v,~thr management pmcUce~ that wE be used and/er RemoVal of Vngetat~on and/or the Conslrucliou of any consm~ed to reduce the ~ is ~ wa~r o'l,cha~ges a~d to ~aum Item Within the Town Right*of-Way or R°ad ShoUlder STATE OF NEW YORK, COUNTY. OF ........ c~.[~.,.: ......... SS ~'~ ~v~u~ ~ ~i ....... ys fl~t he/~he i~ the applicant for Permit, And that he/~he i~ the ............................................. i . .~...~ Owner and/or reprasentafive of the Owner or Owner~, and i~ duly authorized to perform or have performed the ~aid work and to make and file this application; that all ,tatements contained in ~ application are tree to the be~t of.h/s knowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before this; .............. .......1,, .................. ................... , I / .............. ......... ......... ......... No. 01KIE021111 ~ you need' a TemP Certificate: YES / NO Temp information (If needed}, *$el~tJoe $1'~.e: ' 1 Phae~ 3Phase 100 *New Service: Re'~onneot Underground Additional Information: 150. 200 Number of Metem R,ough In' ' ~ 30~ 380. Change Of Serv ce .PAYMEN'I; DUE WITH APPLICATION 400 Other Overhead~ .~ 54375 Main Ro~d P.O. Box 1179 Sou~hold, NY 11971.0959 Telephone (63t) 765-1802 BUH .r~ING DEPARTMEIx~F TOWN OF $OUTHOLn APPLICATION FOR ELECTRICAL INSPECTION BY: Company Name: ~), Name: License No.: No,: Date: JOBSITE INFORMATION: (*Indicates. required information) *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: 1000 Section: ."~ *BRIEF DESCRIPTION OF WORK (Please Print Clearly) Block: (Please Circle All That Apply) *Is. job ready for inspection: *Do you need a Temp Certificate: Temp-lnformation (If needed). *Servtce Size: 1 Phase 3Phase *New Service: Re-connect Additional InfOrmation: yEs~ YES / NO Rough In Final 100 Underground 150 200 300 350 400 Other Number of Meters Change of Service Overhead pAYMENT DUE WITH' APPLICATION ~ \oD. o o 82dqeque~ for Inspection 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: LJ [] 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 C.O. TAX BILL $300.00 CHECK FOR PERMIT FEE PLEASE CALL OUR OFFICE IF THERE ARE ANY QUESTIONS REGARDING THIS APPLICATION. This certificate is an original. State of New York Worker's Compensation Board CERTIFICATE OF PARTICIPATION IN WORKER'S COMPENSATION GROUP SELF INSURANCE la. Legal Nnme and Address of nmthess Participating In Group Self-insurance (Use Street AddreSs Only) Arthur J. Edwards Mason Contractor, Inc. DBA: Arthur Edwards Pool & Spa Centre 929 Route 25 A Miller Place, NY 11764 lb. Effective Date of Membership in the Group 4/24/2002 Issue Date 7/27/2010 Expiration Date 7/26/2011 (631) 744-7185 lc. NYS Unemployment Insurance Employer Registration Number of Business Registered in Box "la". 24108715 If. Federal Employer Identification Number of Business Heterenced la Box lc. The Proprietor, Parmers, or Executive Officers are ] lnciuded. (Ohiy check if all partners / officers'inluded. ] Ati exciuded or certain partners / omcers excluded. 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as Certificate Holder). Town of Southold Town Hall PO Box 728 Southold, New York 11971 111277925 3. Name and Address of Group SeE Insurer. Special Trades, Contracting And Construction Trust 6250 South Bay Road Syracuse, NY 13039 Policy: W521504 This certifies that the business referenced above in box "1 a" is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law as a participating member of the Group Self-Insurer listed above in box "3" and Participation in such group self-iusurance is still in force. The Group Self-Insurers Adminis~ator will send this Certificate of Participation to the entity listed above as the certificate holder in box "2". The Group Self-iusurer's Administrator will notify the above certificate holder within 10 days IF the membership of the Participant listed in box" la" is terminated. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer.'. /f this certificate is no longer valid according.to the above guidelines and the business referenced in box "la" continues to be named on a permit, license or contract issued by the certificate holder, the business must provide the certificate holder either with a new certificate or other authorized proof the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation £aw. Under penalty of perjury, I certify that I em an authorized representative of the Group Self-insurer referenced above and that the business referenced in box "la" has the coverage as depicted on this form. Certified By: Certified By: Title: Telephone Number: (315) 699-8475 GSI-105.2 (2-02) Worker's Compensation Law Worker's 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 required by law to issue any permit for or in connection with'any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carder is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall 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 if so employed. 2. The head of a state 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 the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute mqu'u'ing or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carder is produced in aform satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. ,please Note:This Certificate is valid only through the policy dates indicated above, OR a maximum of one year after this form is approved by the authorized representatives of the Cn'oup Sclf-iasurer. At thc expiration of those dates, if the business' continues to be named on a permit or/~0ntract issued by the above government entity, thc business must provide that government entity with a new Certificate. Thc business must also provide a new Certificate upon notice of cancellation or change in status of the policy. GSI-105.2 (2-02) Reverse STATE OF NE'W YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by DI#bill~ Beneflta Carrier or Licensed Insurance Agent of thet Carrier la. Legal Name and Address of Insured (u. ~w.a~. ~. Arthur J Edwards Mason Contracting Company Inc. 929 Route 25A lc. Miller Place, NY 11764 2. Name and Address of the Entity Requesting Proof of Coverage (Enlily Being Listed as the cenillcMe Hol~e~) Town of Southold 53095 Main Road PO Box 1179 Southold, NY 11971 lb. Business Telephone Number of Insured 631-744-4455 NYS Unemployment Insurance Employer Registration Number of Insured 24-10871 ld. Federal Employer Identification Number ~ Insured or Social Security Number 11-2377925 3a. Name of Insurance Carrier ' Guardian Ute Insurance Company of America 3b. Policy Number of entity listed in box 'la': 984424-0000 3c. Policy effective pedod: 07/0111986 to 06/30/2011 4. Policy Covers: a. I~ Atl of the employers employees eligible under the New York Disability Benefits Law b. [] Only the following class or classes of the employer's employees: Under penalty of pe~ju~, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS D~urar~ce~coverage as described above. Date Signed: September 29, 2010 ay~,,/~ ! ~ Telephone Number: (212) 964-2150 Title: President IMPORTANT: if box '4l# II ehedted, lee thil form Is dgned by the in~uranoe oarrlor's auamC4ed rep~nthtlve or NYS Lk~nNd thl~mee J~eM M thM eenlw, thls cMtlflCMe IS COMPLETI~ MMI It dlrlcey te the eorlfllcate holder. ff hex "4b" 18 eheck~l, this eMeeoMe Is NOT COMPLETE thr PlJqmM. of Section 220, SuIxI. e M the DiWlty ~ law. It rnuat he ma#ed for oompldton to the WOd(MS' Compenaatlon 8oard, DB Plans Acceplinoe Unit, 20 Pad( Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only If box "4b" of Part I has bee~ checked) State Of New Yolk Workers' Compensation Board According to information maintained 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: Title: PM~e Note: Only insurany'e careers li~.nsed to wr~..e NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance careers are aumo#zed to issue Form DB- 120.1. Insurance brokers are NOT authorized to I~ue this form. DB-120.1 (7/09) Additionat Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced in box "la" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box "2". This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box "3c". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, licenee or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220.Su1~1. 8 (a) The head of a state or municipal department, b~ard, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiting or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee il so employed. (b) The head of a state 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 the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-t20.1 (7/09) Reverse ~ · OP ID: VM CERTIFICATE OF LIABILITY INSURANCE CER~FICATE ~ES NOT ~FIRMA~VELY OR NEGA~VELY AMEND, EXTEND OR ALTER THE COVE~GE ~FORDED BY THE POLICIES BEL~. THIS CER~FICA~ OF INSU~NCE ~ES NOT CONS~TE A CONT~T BE~EEN THE ISSUING INSURER(S), ~THORIZED REPRESENTA~VE OR PRODUCER, AND ~E CER~ FI~ HOLDE~ IMPORT~T: If the ce~EicMe holder is an ~O~ INSURED, the policy(ies) mu~ be endorsed. If SUBR~A~ON IS W~VED, subje~ to the te~s and co~)tions of t~ policy, ce~ain ~licies may require an endorsement A statement on this ce~ificate does not confer rights to the c~te holder in lieu of such endom~ent(s~ PRODU~R 631-8~-1111 C~ACT W Jericho Turnpike Ste lA 631-864-8~4 ~*~.PHO~No. ExU: Smit~ow~ ~ 11 ~7 C~TO~m~ ~ ARTHU-~ Contracting Co Inc DBA A~hur ~NSU~S: Edwards Pool & Spa Center 929 RE ute 25A ~NSU~ c; Miller Place, NY ~ ~ 764 ~NSU~S~ ~: INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POMCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WFfft 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 ~,DDL ~UBI POLICY EFF POLICY EXP A ~ ! COMMERCIAL GENERAL LIABILITy MPA00000038801H 01/01111 01/01/12 CLAIMS-MADE ~L~ OCCUR '~IED EXP (Any 0ne person) $ 5,000 PERS©NAL & ADV iN JJRy $ 1,000,000 --~-BLANKETADDITIONA GENERALAGG~EGATE $ 2,000,000 OFFICER/MEMBER E~CLU DED? ~ NIA CERTIFICATE HOLDER CANCELLATION 0000000 Town of Southold Town Hall P.O. Box 728 Southold, NY 19971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WiLL BE DELIVERED IN ACCORDANCE WITH TI-IE POLICY PROVISIONS. ALrFHORIZED RE PRE~Et~rTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORp name and logo are registered marks of ACORD Suffolk County Executive's Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 SUFFOLK COUNTY Master Electrician License No. 2740-ME This is to certify that ................................ E_p_WARD S KEIFF ........... doing business as ......... U-NDERGROUND_SPE_C_~_I~L_~_TIE~S INC ........... having given satisfactoc~ evidence of competency, is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York. SUFFOLK CO[JNTy DEPARTMENT OF CONSideR A~FNR~ MASTER ELECTRICIAN EDWARD S REIFF 2740-ME ~"~"~ Additional Businesses DLrector Suffolk County Execu~'ve's Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 7/1/78 No. 4436-H SUFFOLK COUNTY _blon~ e .[;npro vein en t Con tractor License This is to certify that ARTHUR $ EDWARDS doing business as ARTHUR EDWARDS MASON CONTRACTING INC having _~u:~a~e~ ne req~fizement~ se~ forth in accordance with and subject to the provisions of applicable laws, rt~c~ and ~ cg~alanons c,t thc Coumy of Suffolk, State of New York is hereby licensed to conduct business as a ~ HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. Denis Mdgtli~e, tt SUFFOLK COUN~t' I~EP~TMEN T Additional Businesses Director 11 Yds. Conc. 155 Form Ties 15 Rebar , Perimeter 99 Area 568 sq.ff. 40" DEEP 16' Plan ~ ~' ~-'~ ~iping ~rangement Typical Wail SectionM Section A-A -- 16~' 16' ~' 8' 14' 8' 4' 4' 8' 51~ 19,~~,~L~AC~ 1~'~'18' ~' 1~' 14' 6' 4' 4' 8' 576~,~ PE~C~ETE W~ 18'~' 18' ~' 1~ 14' 8' 4' ~' 8' ~ ~,~ 929 Boule 25A Miller Place ~ 11764 ~ ~'x~' ~' ~' 18~ 14' ~' 4' 8' 8' ~ ~,~ (631) ?~-7185 Y~ (~31) ?~-0174 ~ ~'z~' ~' ~' 18' 14' 8' 4' 8' 10' ~ ~,~ S~fo~ Meenee ~36-~ ~'z~' ~' ~' ~' 18' 8' 4' E lO' ~ ~,~ Nassau Mcense ~7~50000 N.Y.S. Lic. No.. 5~67 aan Taft Corwin III Land Surveyor ~e~ts -- Subdivisions -- Site Plons -- Construction Loyout 51)727-2090 Fox (631)727-1727 LOCATED AT I~{AILING ADDRESS ~oke Avenue P.O. Box 1931 UNAU~OR[ZED N_'rE~TK)N OR ~moN TO ~S ~ mS A ~ON OF ~C~ 7~ ~ ~E NEW YORK STA~ THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED, FIDEUTY NATIONAL TITLE INSURANCE COMPANY OF NEW YORK THE SUFFOLK COUNTY NATIONAL BANK CHRIS MOHR ROBERT T. MOHR LOT 4 MAP Of CROWLEY ESTATES FILE No. 8236 FILED DECEMBER 12, 1986 SITUATED AT BAY-VIEW. TOWN .OF SOUTHOLD' SUFFOLK COUNTy, NEW YORK S.C. TAX No..1000-79-06-4.4 SCAb[ 1 "--50' JULY 29, '1 998 .ECRU,E" 22, ~999 ADDEo ..oPosED .ousE ~ B.O... APRIL 1~, 2000 FOUNDATION LOCAnON DATA. MAY 20, 2000 ADDED PROPOSED BARN AREA = 102,448.51 sci. ft. ~ 2.352 ac.