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HomeMy WebLinkAbout36736-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 8/31/2012 CERTIFICATE OF OCCUPANCY No: 35929 Date: 8/3 l/2012 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1030 Jacobs Ln, Southold, SCTM #: 473889 Sec/Block/Lot: 79.-7-34 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this ofllced dated 9/23/2011 pursuant to which Building Permit No. 36736 dated 10/5/2011 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: accessory inground swimming pool, fenced to code as applied for. The certificate is issued to Neese II, Robert & Neese, Laurie (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36736 11/12/11 " Autl~rized 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 #: 36736 Date: 10/5/2011 Permission is hereby granted to: Neese II, Robert & Neese, Laurie 1030 Jacobs Ln Southold, NY 11971 To: construct an accessory Inground Swimming Pool, fenced to code as applied for At premises located at: 1030 Jacobs Ln, Southold SCTM # 473889 Sec/Block/Lot # 79.-7-34 Pursuant to application dated To expire on 415/2013. Fees: 9/23/2011 and approved by the Building Inspector. SW1MM1NG 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 OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board 0f Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commemial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6, Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and: unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelting $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of Property: Old or Pre-existing Building: (check one) House No. Street · - Owner or Owners of Property: ~0ff/stOc o /./'t~lq[ ]~ff'~ · Suffolk County Tax Map No 1000, Section rT~ Subdivision Permit No. ~('g-) D~(o Health Dept. Approval: Plann/ng Board Approval: Date of Permit. __ Block r~ Filed Map. Applicant: Underwriters Approval: Hamlet Request for: Temporary Certificate Fee Submitted: $ I~-0 - / Final Certificate: (check one) Applicant Sign~tul-e Town Hall Annex 54375 Main Road P.O. Box 1179 Southold. NY 11971-0959 Telephone (631) 765-1802 Fax (63 l) 765-9502 ro,qer, richert~town.southold.n¥.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Robert & Laurie Neese Address: 1030 Jacobs Lane City: Southold St: NY Zip: 11971 Building Permit #: 36736 Section: 79 Block: 7 Lot: 3,1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric LicenseNo: 2740-me SITE DETAILS Office Use Only Residential f~t Ind°°r ~ Basement l~ Service Only~ Corn merical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI Recpt Main Panel A/C Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures r~l~l HID Fixtures Wall Fixtures I I Smoke Detectors Recessed Fixtures I I CO Detectors Fluorescent Fixture~ Pumps Emergency Fixture Time Clocks Exit Fixtures ~ TVSS in ground swimming pool to include, bondin9, 2 pump recpticles, 2 GFCI circuit- breakers, 1 pool light, 1 control panel Notes: Inspector Signature: Date: Nov 23 2011 81-Cert Electrical Compliance Form TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INS~.UJ.ATION [ ] FRAMING/STRAPPING ~ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONS'I'RUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: ~ ~'-'-0'¥ ~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE TOWN OF SOUTHOLD BUILDING DEPT. ~l 765-18O2 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: ~-/"~ ~--'~ ~:~/q- ~/~/~/~TOWN OF SOUTHOLD BUILDING DEPT. */ _,~ / 765.t802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ~ELECTRICAL (FINAL) REMARKS: DATE ~INSPECTOR~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 Examined Approved Disapproved a/c /)/~, 20 r/ PERMIT NO. BUILDING PERMIT APPLICATION CHECKLIST Do you have 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: Mail to: i,.~.~~ ((} [~ ~ ~ ~ ~ Buildinglnspector }L~l SEP 21 2011 [~P[LICATION FOR BUILDING PERMIT Btl)~ DEPI.' Date ~/).O/I I ,20 T0W~ 0F S0¢~U0LD ] INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspedtion 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, ~nd other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein descn'bed. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code,~d regulations, and to admit authorized0cc~?A?,j~ ?inspect°rs on premises0F{ and in building for necessary inspections. USE IS UNLAWFUL "IMMEDIATELY" ENCLOSE POOL TO CODE (Signat~'~'~ ~pplic~]{~r name, ifa corporation) WITHOUT CERTIFICATE OF OCCLIPANCY (Mailing address of applicant) ' State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises ~('~g_X '. Z'~t.~te (as on the tax roll or If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: House Number Street DATE /~/~//1 _R P. latest dee.d) FEE: .J,5 [/- By NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: f. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2, ROUGH-FRAMING, PLUMBING, STRAPPING. ELECTRICAL & CAULKING 3. INSULATION 4. FINAL. CONSTRUCTION & ELECTRICAL MUST BE COMPLETE FOR C O. ALL CONSTRUCTION SHALL MEET THE ELECTRICAL REQUIREMENTS OF THE CODES OF NEW ' ...... YORK STATE NOT RESPONSIBLE FOR INSPECTION HE~IUlHI:IJ~slGN OR ~J0NSTRUCTION ERRORS. Hamlet County Tax Map No. 1000 Section Subdivision (Name) Block 7 Filed Map No. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~/,co~cetoe~ · b. Intended use and occupancy ~g&O0fibtc 3. Nature of work (check which applicable): New Building. Repair Removal Demolition 4. Estimated Cost ~/-~: 003- 5. If dwelling, number of dwelling units [f garage, number of cars Fee Addition Alteration Other Work~'~-'rl~qoo,uo ~,mrm,'r4. (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 ~55~ Rear 3~ Depth Height Number of Stories I Dimensions of same structure with alterations or additions: Front Rear Depth Height. 8. Dimensions of entire new construction: Front 20 Height Number of Stories 9. Sizeoflot: Front ]00' Rear 100' Number of Stories Rear 20 ' Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 13. Will lot be re-graded 14. Names of Owner of premises Name of Architect ~ Name of Contractor 12. Does proposed construction violate any zoning law, ordinance or regulation: ~J© Will excess fill be removed from premises: (~ES~ NO Address 1{353 0qe06~L4 Phone No. 031-7(o5'-- O"bi7 Address 4 Address 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 fgundation 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 JJ~-0C¢- ) j~7[~ ,.~ 'ff'~JktOS-'~ being duly swom, deposes and says that (s)he is the applicant (Name of individual-~L~nl~-txlnW4et~., ~elnamed - (S)He is the , i ~ , (ContmcWvi Agent, Corporate Officer, etc.) of said owner or owners, and is dulS, aUthorize~t tO perform or have performed the said work and to make and file this application; that all statements contained in this alJl~ii~h'tion are tree to the best of his knowledge and belief; and that the work will be performed in tt~e manner set fortl~ m the apphcatlqn filed therewith Sworn to before me, this , ~_,: ~~ee o~~ ~ Notary Public Si MARGAREt A. KIDNEY ~ Public - State o~ ~ Yod~ No. OI KI60211 II Qualified in Suffolk County My Commission £xpif~s March 8, ~lt Town of Southold' Erosion, Sedimentation & Storm'Water Run-off ASSESSMENT FORM  PROPERTY LOCATION: $.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF/I ~/~ '7 ,.~ STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN seca6n Dish,ct Block CERTIFIED BY A DESIGN PROFE~iONAL IN THE STATE OF NEW YORK. SCOPEOFWORK - PROPOSED CONSTRUCTION ITEM# / WORK ASSESSMENT -[ Yes No a. What is the Total Ama of the Project Parcels? (Include Total Area of all Parcels located within /'~t 0(~ ~' I Will this Project Retain Ail Storm-Water Run-Off the SCOpe of Work for Proposed Consbuction) Generated by a Two (2") Inch Rainfall on Site? b. What is the Total Area of Land Cleadng (S.F.l,~s) (This item will include all mn-off created by site / r~ clearing and/or construction activities as welt as all and/or Ground Disturbance for the proposed ~)~ ,~' Site Improvements and the permanent creation of construction activity? impervious surfaces.) PROVZDE B~E~ PROJ'EC~ D,~.~C]~J~IION (P~d,~P=~,.N,~,~ 2 Does the Site Plan and/or Survey Show All Proposed Drainage Stmcturas Indlcaitng Size & Location? This ) , Item shall Include all Proposed Grade Changes and 20~ ~ Ifi~.~J~ VIfl,~ C Slopes Controlling Surface Water Flow. ~t'~fil~3 I~ ~L I~J ,'T~ ~..~ 3 D°es the Sits Plan and/°r Survey des°dba the er°si°n and sediment control p~citces that will be used to V/ .~ ~ control site er6slon and storm water discharges. This item must be maintained throughout the Entire Construction Period. 4Will this P[oject Require any Land Filling, Grading or Excavation where there is a change to the Natural ~'~ Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? 5EncompassingWill this ApplicatiOnAreaRequire Land Disturbing Activities an 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? Is this Project within the Trustees jurisdiction !General DEC SWPPP Requlremenl,~: or within One Hundred (100!) feet of a Wetland or Submission ~f a SWPPP is required for all Consl~cSon activities Involving soil Beach? disturbances of one (1) or mom ac, ms; includisg disturbances of less than one acre that 7Will there be Site preparation on Existing Grade Slopes ~ are Part of a target common plan that will ultlmatMy disturb one or mom ac~es of ~and; which Exceed Fifteen (15) feet of Vertical Rise to J inctuding Conseucflon actNIliss i~voN~g soil disturbances o{ )ess than One (1) acm where One Hundred (100') of Horizontal DistanCe9 ~ the DEC has detmmined that e SPDES permit is required for storm water discharges. . SWPpp's Shall meet. the Minimum Requlmment~ of the SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious for Storm Water Discharges from Construction aetfv!ly. Permit No. GP-0-10-001.)Surfaces be Sloped to Direct Storm-Water STATE OF NEVv' YORK, And dar be/she ~s the ...................................................... (Owrter, Co~hactor. Agent, Co~' ~[~t:,' ~i 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 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 me this; Noea~ Pu . . .. ~ ~ , c/ {;s~gnatureoJ/.~ppacant) Oualified in Suffolk My Commission Expires Mamh 8, Town Hall Annex 54375 Main Road P.O. Box 1179 Sou&old, NY 11971-0959 Telephone (631) 765-1802 ro.qer, ric he r t (~,~.~ u~o~], ny. u,s BUILDING DEPARTMENT TOWN OF APPLICATION FOR ELECTRICAL INSPECTION BY: Company Name: Name: Date: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: ~.Z.'t o L/~i~ ~J~':~.. *Address: 10~0 ~$ ~_n *Cross Street: J.~¢~J/~r~ [~ ~. *Phone No.: ~1-'~b-- ~(~[~7 Permit No.: Tax Map District: 1000 Section: , ~7~ *BRIEF DESCRIPTION OF WORK (Please Print Clearly) Block: Lot: (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Tamp Certificate: Tamp 'Information (If needed} - *Service Size: 1 Phase 3Phase *New Service: Re-connect Additional InfOrmation: 100 Underground YES / NO Rough In YES / NO Final 150 200 300 350 400 Other 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: --H-- 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 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 onty) Arthur J. Edwards Mason Contracting Company !nc. 929 Route 25A Miller Place, NY 11764-2700 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed a.s the Certificate Holder) Town of Southold Town Hall, PO Box 728 Southold, NY 11971 4. Policy Covers: 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. Poticy Number of entity listed in box "la": 00984424 - 0000 3c. Policy effective period: 07/01/1986 to 06/30/2012 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: ~haw~', FSA,~M~-A 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 carrier's authorized representative or NYS Licensed Insurance Agent of that carder, this certificate Is COMPLETE. Mail it directly to the certificate holder. If box "4b" is checked, 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 1 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 Benefits Law with respect to all of his/her employees. Date Signed: By: (Signature of NYS Workers' Compensation Board Employee) Telephone Number: Title: Please Note: Only insurance carriers licensed to write NYS disabifity benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB- 120. 1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5/06) Additional 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, license 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.Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 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 if 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 connect[on 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-120.1 (5/06) Reverse 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 Name and Address of Business Participating In Group Self-Insurance (Use Stree! 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 ef Membership in the Group 4/24]2002 Issue Date 7/11/2011 7/10/2012 Expiration Date Id. Business Telephone Number of Business Referenced in "la". (631) 744-7185 le. NYS Unemployment Insurance Employer Registration Number of Business Registered in Box "la". 24108715 I f. Federal Employer Identification Number of Business Referenced in Box lc. The Proprietor, Partners, or Executive Officers are ] Included. (Only check if all partners / officers inluded. ] AIl excluded or certain partners / officers excluded. 2. Name and Address of the Entity Requesting Proof af Coverage (Entity Being Listed as Certificate Holder). Town of Southold Town Hall PO Box 728 Southold, NY 11971 112377925 3. Name and Address of Group Self 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 "la" 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-insurance is still in force. The Group Self-Insurer's Administrator will send this Certificate of Participation to the entity listed above as the certificate holder in box "2". The Group Self-insurer'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.) Other~vise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer.'. lf this certificate is no longer valid according to the above guidelines and the business referenced in box "Ia" 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 Law. Under penalty of perjury, I certify that I am 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: David F,rance¥ 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 t~roof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation'for all employees has been secured as proyided by this chapter. Nothing herein, however, shall be construed as creating any liab/llty'~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 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 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 Group Self-insurer. At the expiration of those dates, if the business continues to be named on a permit or contract issued by the above government entity, the business must provide that government entity with a new Certificate. The business must also provide a new Certificate upon notice of cancellation or change in status of the policy. GSI-105.2 (2-02) Reverse OP ID: VM ACORD' CERTIFICATE OF LIABILITY INSURANCE I DATEIMM O YYY oi tt/ THIS CERTIFICATE IS ISSUED AS A MATTER 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 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 AI:)D~TIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION I$ 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 endorsement(sT PRODUCER Bagatta Associates, I nc. 823W Jericho Turnpike Ste lA Smithtown, NY 11787 Bagatta Associates, Inc. 631-864-1111 631-864-8274 ArthurJ Edwards Mason Contracting Co Inc DBA Arthur Edwards Pool & Spa Center 929 Route 25A Miller Place, NY 11764 CONTACT NAME: PHONE IFAX CUSTOMER ID it ARTHU-1 INSURER(.~) AFFORDING COVER~'GE iNSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 26182 THIS IS TO CERTIFY THAT THE POLICIES OF iNSURANCE LISTED BELOW HAVE SEEN 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS NSR ADDLSUB~ POLICY EFF POLICY EXP J GENERAL LIABILITY COMMERCIAL GENERAL LiABILITYI( PREMISES (Ea occurrence)J~,~A~EACH OCCUR~ENCEE T o ~e~ I bo $$ 1,000,000 A ~- MPA00000038801H 01/01tll 01t01/12 100,000 J j CLAIMS-MAOE [] OCCU~ [ MEDEXP(Anyo~epers0n) $ 5'000 __X- BLANKETADDITIONA I J G/NERALAGGREGATE $ 2,000,000 i ALL- OWNED AUTOS I SCHEDULED ALTOS i I ~ R'3F ERTY ~)AkIAG E I I CERTIFICATE HOLDER CANCELLATION Town of Southold Town Hall P.O. Box 728 Southold, NY 19971 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3~IE EXPIRATION DATE THEREOF, NOllCE WILL BE DELIVERED IN ACCORDANCE WITH ~'IE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1999-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD 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 No. 2740-ME SUFFOLK COUNTY Master Electrician License This is to certify that EDWARD S KEIFF doing business as_ UNDERGROUND SPECIALTIES INC having given satisfactory 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. This ce~fies that the bearer is duly licensed by the County of Suffolk ...... OF CONSUMER AFFAJR$' MASTER ELECTRICIAN 2740-ME 111980 Additional Bush~esses Suffolk County Executive's Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 7/1/78 No. 4436-H SUFFOLK COUNTY _t-[oz~ e h~pro veto en t Con tractor License This is to certify that ARTHUR J EDWARDS doing business as ARTHUR EDWARDS MASON CONTIL~.CTING INC l~aving ctmfisl~ed the requ.i~'emeni:; sci £orth in accordance with and subject to the provisions of applicable laws. rules and cag, nlalSons of ~he Coun~; of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. ~ iS dui,/ C~unit~ =f Suffolk Donis MoElligotl SUFFOLK COUNTY DEPARTMENT 07/0111978 07/01/2e~12 Additional Businesses Director h, 3'4 k C A D Plan Section B-B Section A-A SIZE A B C D E F G H AREA CAP. FEET FT. FT. l~. FT. ~. FT. Fr. FT. SQ.FT. GAk 16x3Z' 16' 32' §' 14' 6' 4' 4' 8' 5i2 19,000 16'x36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600 18'x36' 18' 36' 12' 14' 6' 4' 5' ~' 648 24,300 20'x40' 20' 40' 16' 14' 6' 4' 6' §' 800 30,000 24'x44' 24' 44' 18' 14' §' 4' 6' 10' 798 24'x48' 24' 48' ~.0'i6' §' 4' 6' i0' 900 ~0,000 lB 0 ) Typical Wall Piping Section PERMACRETE W_AT.T. SYSTEM 929 Route 25A Miller Place NY 11764 (631) 744-7185 FAX (631) 744-0174 Suffolk License #4436-HI Nassau License #HI74450000 Arrangement