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HomeMy WebLinkAbout36967-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 8/28/2012 No: 35919 Date: 8/28/2012 Location of Property: SCTM #: 473889 Subdivision: THIS CERTIFIES that the building IN GROUND POOL 750 Clearview Ave, Southold, Sec/Block/Lot: 70.-9-61 Filed Map No. conforms substantially to the Application for Building Permit heretofore 1/30/2012 pursuant to which Building Permit No. Lot No. filed in this offlced dated 36967 dated 2/2/2012 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 Blume, Laura & George (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36967 5/14/12 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 #: 36967 Date: 212/2012 Permission is hereby granted to: Blume, Laura & Blume, George 584 Henry St Brooklyn, NY 11231 To: construct an accessory InGround Swimming Pool fenced to code as applied for At premises located at: 75OClearview Ave, Southold SCTM # 473889 Sec/Block/Lot # 70.-9-61 Pursuant to application dated To expire on 813/2013. Fees: 1/30/2012 and approved by the Building Inspector. SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $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 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 certificate of Code Compliance from amhitect 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 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 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. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of Property: Date. ] '2b' Old or Pre-existing Building: (check one) House No. Street Owner or Owners of Property: ~,~..Olg~ e ~ Suffolk County Tax Map No 1000, Section r7 0 Subdivision Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Foe Submitted: $ ,~/9, q~¢- Date of Permit. ~ ~_,-- ]'2- Hamlet Block q Filed Map. Applicant: Underwriters Approval: Final Certificate: Lot Lot: (check one) Town Hall Annex 54375 Main Road P.O. Box I 179 Southold~ NY 11971-0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 ro.qer, richer~town southold.ny, us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Blume Address: 750 ClearviewAve City: Southold St: NY Zip: 11971 Building Permit #: 36967 Section: 70 Block: 9 Lot: 61 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric LicenseNo: 2740-e SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Servicelph ~ Heat ~ DuplecRecpt ~ Service 3 ph Hot Water GFCI Recpt Main Panel NC Condenser Single Recpt Sub Panel A/C Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: I-pool light Notes: Ceiling Fixtures e~[~[~ HID Fixtures Wall Fixtures j j Smoke Detectors Recessed Fixtures CO Detectors Fluorescent Fixtur Pumps Emergency Fixture~l Time Clocks Exit Fixtures TVSS in ground swimming pool, to include, bonding, 1 control panel, 2 GFCl circuit breal Date: May 14 2012 81-Cert Electrical Compliance Form.xls TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ~}~FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ [ ] FIREPLACE & CHIMNEY [ [ ] FIRE RESISTANT CONSTRUCTION [ [ ] ROUGH PLBG. [ ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ~F.J. ECTRICAL (FINAL) REMARKS: TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ] I~LATION [ ]FRAMING/STRAPPING [J,~ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRIC~OUGH) [ ]ELECTRICAL (FINAL) REMARKS: /~_~c_ /~ ~1 ~ //~, .c/ DATE r'/ /' -~//~ I l~/ INSPECTOR /~~ /~~/~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]~ULATION [ ] FRAMING/STRAPPING [//] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) _~~ ]~E~CTRICAL (FINAL} REMARKS:_ ~-~~ ~_ ~ DATE ~/~'-S// ~ INSPECTOR~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 Examined o//~ , 20 709- Approved Disapproved a/c PERMIT NO. Building Inspector j'0 JAN 3 0 2012 ~ BI DO DEN. .... ~,~m~j~¢u~xp BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying '? Board of Health 3 sets of Building Plans Sup,,ey_ Check Septic Form N.Y.S.D.E.C. Trustees Mail to: - n ,~ ~_~I[ APPLICATION FOR BUILDING PERMIT Date 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 ;o 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 pm'pose what-so-ever until a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuauce 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,,~d regulations, and to admit authorized inspectors on premises and in building for necessary inspections.~...~/,){ .....,. ,.,:"' ~dFl' ,m · !i ~ i~/r-t (Signatu ' ' ' n) "IMMEDIATELY" i.,..,~vvru,_ ENCLOSEPOOLTOCC~ ,LyiDTiF..,~,Tr_.q~ ~_ 2f,~ M, lle,: tgo,r UPON COMPLETION :; ~ i¢=.,-2~! ' L~." ' BEFORE "WATER" (Mailing address of applicant) State whether applicant is owner, lessee, agent,' architect, engineer, general contraq~l~l~l:~O~ or builder D*TE~B.p. # ,./z ¢¢/~ 2_ Name of owner of premises If applicant is a corporation, signature of dul~, authorized officer (as on the tax roll or el~$1~${J2} 8 AM TO 4 F'M FOLLOWING INSPECTIOn', Y 1. FOUNDATION TWO "~' ,K~ FOR POUREP COk, C . ;E (Name and title of corporate officer) 2 ROUGH- FRAMiN ~. r- .. STRAPD!NG EkECh~t- gCAU'?:"' ,,L~.~ 3~ 3 INSUL/~'FION .~F' 4 FINAL-CONSTRUCTK ~gE.( MUST BE COMPL£'£ cb.' ALL CONSTRUCTION SHALI. f REQUIREMENTS OF THE cOD: o'Q-gq'O'-H~' YORK STATE NOT RESPONSIBLE DE$IGN OR CONSTRUCTION ERRORS ELECTRICAL RETAIN STORM WATER RUNOFF INSPECTIO~¥ RE'~ED PURSUANT T0 CHAPTER 236 Location of land on which proposed work will be done: ~. OF THE TOWN CODE. 76-0 d)J lOt .¢.,x: House Number Street Haffil~t"*~t* ! ' :' Builders License No. Plumbers License No. Electricians Licehse No. Other Trade's License No. County Tax Map No. 1000 Section Subdivision (Name) r~O Block q Lot ¢1 Filed Map No. Lot State existing use and occupancy of premises and intended use~nd occupancy of proposed construction: a. Existing use and occupancy ] ,.5'-~-t)~ ~'cvS~Oed¢-~2 b. Intended use and occupancy ~ca:'o}{~/d~/k_ ~'.~, R'I R11/tf~ ~O~0L Nature of work (check which applicable): New Building. Repair Removal Demolition Estimated Cost l~1000- Fee If dwelling, number of dwelling units If garage, number of cars Addition Alteration Other Work'._L~qgmt~o ~/im~,,,J4 (Descripti'on) (to be paid on filing this application) Nmnber 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 ¢20 Height Number of Stories 9. Size oflot: Front ilo Rear I[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 lot be re-graded ¢¢5- .~ 0~.~/ Will excess fill be removed from premises'~ NO 14. Nines of Owner of~remises ~ ~W~ Address ~0 Phone No. 9t?-Ol¢- qB2q NameofMchitect-l~ ~ ~,fl~ ~ Address~ ~ ~ ~t~ Phone No /a3P72q'7~g~ N~e of Contractor ~ ~¢~ ~ Address ~ ~ 2~g PhoneNo. 15. Is this prope~ within 100 feet of a tidal Wetl~d? *YES NO * W YES, SOUTHOLD TO~ TRUSTEES PE~ITS MAY BE REQUIRED .- 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any, l~o/,u.~:~a~.r ,glgqrty is at 10 feet or below, must provide topographical data on survey. '. STATE OF NEw YORK} SS: COUNTY OF /~'D'lv'c ,3 ~l)t¢tbt05 being duly sworn, deposes and says that (s)he is the applicant (Name of individual si~ng contract) aboye named, (S)He is the (Contractor, Agent, Co.orate Officer, etc.) of said 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 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_.,./ , ~V day of ~}/k/~4 20 · [ Ndtaryeubti~ MARGARET A. KIDNEY No~ry Public - State of New Yo~ No. 01KI6021111 Qualified in Suffolk County , ,sron Expires March 8, 20 TOwn of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF STOR'-WATER. G D'NO, D ,NAGEANDEROS,ONCONTRO. Distrfot Section Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW yoRK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSME~'T ~ Yes No a. Wfiat iS the Total Area of the Project Paroela7 (include Total Area of all Parcels located within c~3, ~ ~"(.) ~ '1 Will this Project Retain AI~ Storm-Water Run-Off the Scope of Work for Proposed Consb'uction) Generated by a Two (2") Inch Rainfall on Site? b. What is the Total Ama of Land Cleadng (S.F. / N:res) (This item will include all run-off ~eated by site clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed ~0 ~ Site Improvements and the permanent creation of construction achy/b/? impervious surfaces.) PROVI~)E BI~IEF ?ROJ'~CT D~CR[F~IOI/ m, oV,~,A~7~ P~. as N.d~: 2 DOCS the Site P)an and/or Survey Show All Proposed Drainage Stm(~ures Indicating Size & Location? This ,/r"'l Item shall incJude all Proposed Grade Changes and __v S'opeaCon o,,thgSurfaseWatar ,ow. d0L 3 Dces tho Site Plan and/or Survey deschbe the erosion and sediment control practices that wJti be used to / control site erosion and storm water discharges. This item must be maintained throughout the Entire Construction Period. 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 200 Cubic YardsI~1 __v of Matada) within any Parcel? 5 W/il this Application Require Land Disturbing ActiviUas Encompassing an Area in Excess of Five Thousend (5,000 S.F.) Square Feet of Ground Surface? 6 is there a Natural Water Course Rurming through the Site? Is this Project within the Trustees jurisdiction General DEC S',NPPp Requirements: or Within One Hundred (100') feet of a Wetland or Submission o[ a SWPPP is required lot all ConstmcUon activJUes invoMng soil Beach? disturbances of one (1) or mom acres; ~diudlng disturbances of less than one acre that 7Will there be Site preparation on Existing Grade Slopes are pan of a larger common plan that will uEimately disturb one or n~xe ac;es of land; which Exceed Fifteen (15} feet of Vertical Rise to including ConsmJct~n activities Involving soil disturbances of less than one (1) ac~e where One Hundred (100') of Horizontal Distance? i the DEC has determined that a SPDES permit is required for storm water discharges. ( 8WPPP's Shall rneel the Minimum Requirements of the 8PDES General Permit 8 Will Driveways, Parking Areas or other Impervious for Storm Water Discharges fi.om COnslruction activity - Permit No GP-O-t0-001.) Surfaces be Sloped to Direct Storm-Water Run-Off r~ 1. The swPPP shall be prepared prior tu the submiflal of the NOI. The NOI shall be into and/or in the direcUon of a Town right-of-way? submitted to ~e Department pdo~ to the commencement of c~rs~Jcdon actMty. 2. The SWPPP sha(I desc;'lbe the erosion and.sediment control practices and where 9 Will this Project Require the Placement of Material, required, past-consthJctfon sturm water management practices that will be used and/or Rem0val of Vegetation and/or the Coostruction of any [~ conslmcted to reduce the palluianis in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the tee'ms and conditions of this permit. I. addition, the SWPPP shall STATE OF NEW YORK, ,d, COUm EK). K. ........ ......... SS That 1 ~ '~ ~'~N'~qt~.~ being duly sworn, deposes and says that he/she is the applicant for Pcnmt, And that he/she is the ............................................ ~ .~..[/~~__~ ( r, ontmctor, Agent, Corper ai~)' ~1~:, ~'l~'.) ................................................................ 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 Wae to the bea 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; I) No. 01K1602 I Ill Qualified ~ Suffolk County ll/~ Exl31res March S, 20L~ Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 76.%1802 r0 . (6al) 76.5 .q er. nchert d(~n.sogg~o(~, ny.u s BUILDING DEPARTMENT TOWN OF $OITFHOLr{ APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Company Name: Name: Date: License No.: Phone No.: *Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: JOBSITE INFORMATION: (*Indicates required information) r'l~8- tm~t- q.~2q 1000 Section: . ~0 Block: ~ *BRIEF DESCRIPTION OF WORK (Please Print Cleady) lot: Gl (Please Circle All That Apply) *Is job ready for inspection: ~'Do you need a Temp Certificate: Temp .Information (If needed}· *Service size: 1 Phase *New Service: Re-connect Additional Information: YES Rough In Final 3Phase 100 150 200 300 350 400 Other Underground Number of Metf~rs Change of Service Overhead PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form Suffolk County Executive's Office of Co~sumer 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 EDWARD S RE1FF 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 certifies/hat the bearer is duly licensed by the County of Suffolk SUFFOLK COUNTy DEpAR1MENT OF ¢ONSLII~IER AF'FAIR:~ MA~TER ELECTRICIAN EDWARD S REIFF 2740-ME o5~1/198o ~"'~" ~ 0~01,~0~ 2 AddkionaI Busmesse:s UP ID: VM A ~_.~ O~1~ ~ [ DATE /M~IDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE , C""~FICA~ DOES NOT AFFIRMATIVELY O" NE~A~VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THmS CERTmFICATE OF mN~URANCE DOES NOT CON~TUTE A CONTRACT B~EEN THE IssUmNG INSURER(S), AUTHORmZED REPRESENTATIVE OR PRODUCER, AND THE CER~FICATE HOLDER, mMPORTANT: Ifthece~iflcateholderisan ADDmTmONAL mNSURED, the pomicy(ies) must be e~dorsed, tf SUBROGATION mSWAmVED, subjEct to th~(ermsandconditionsofthe policy, certain po)mcie~ may require an endorsement. A sta~ement on th)s certificate does not conf~r rights to the certificate holder in )leu of such endorsement(s). ~.;;ttUtCaE ,~.S S O e i at E S, '"~i 823 W Jericho TurnpikE ..gte lA Smithtown, NY 11787 Bagatta Associates, Inc. INSURED ArthurJ Edwards Mason Contracting Co Inc DBA Atlhur Edwards Pool & Spa Center 929 Route 25A Miller Place, NY 11764 631-864-1111 631-864-8274 CONTACT NAME PHONE ' FAX PRODUCER ARTHU 1 CUSTOMER ID #: rNEURER A: Worcester Insurance Co m pany NAIC # 126182 INSURER F: 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 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 CLArMS. ! X~ BLANKET ADDITIONA I iNA~L~ ~ POLICY HUM,ER V1PA00000038801H / ~ RETENTION $ WORKERS COMPENSATION ANY PROPRIBTOR/PART'qER/E,~ECUTIVE AND EM PLOY ERS' LIABILITY YIN ~ OFFICER/MEMBER EXCLUDED? ? j N I A I (Mandatory in NH) ~ D_SCRJPTION Or OPERATICNS below I POLICY EFF POLICY EXP I 01101112 01/01/13 Is $ DESCRIPTION Of 0 PEP. ATIO NE $ LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Ech eduJe, if more space is required) I E L EADH ACCIDENT DISEASE EA EMPLOYEE 1,000,00( 100,00C 5,00C 1,000,00C 2,000,00C 2,000,00C CERTIFICATE HOLDER CANCELLATION 0000000 Town of Southold Town Hall P.O. Box 728 Southold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF~ NO31CE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' CO?v~ENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la, Legal Name & Address of Insured (Use street address only) Arthur J. Edwards Mason Contractor, Inc. 929 Route 25 A Miller Place, NY 11764 Work Location of Insured (Only required If coverage Is specOqcally limited to certain locations In New ¥orl~ State, I.~, a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of Southold P.O. Box 728 Southold, NY 11971 I b. Business Telephone Number of Insured 631-744-7185 lc. NYS Unemployment Insurance Employer 24108715 Id. Federal Employer Identification Number of lnsured or Social Security Number 11 =2377925 3a. Name oflnsuranee Carrier Ullico Casualty Insurance Company 3b. Policy Number of entity listed in box "la" WCS-700093.00 Policy effective period 01/0j/2012 to 0t/0i/2013 Proprietor, Partners or Executive Officers are [ x ] included. (Only check box If nil partneratofllcerl included) [ ] all excluded or certain parthers/offlee~ ezelndt, d__ This certifies thru thc insurance cartier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to thc entity listed above as thc certificate holder in box "2". The Insurance Carrier will al~o notify the above certificate holder w/thin l O days IF apo/icy is canceled due to nonpayment of premluras or within 30 days IF there are reasons other than nonpayment of premiums that cancel the poltcy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mall..) Otherwise, thl~ Certificate Is valid for one year ~fter this form Is approved by the insurance carrier or its licensed agent, or until the pollcy expiration date II, ted in box "$c'; ~. Please Note: Upon the cancellation of the workers' compensation policy indicated on this lei'm, if thc 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 Workers' Compensation Coverage or other authorized prOOf that 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 or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as deplet~ on this for,re. ,,,,'~Pdnt flJ~t r nlc~'n'],.~4p(v..pt~;~vc Or licensed agent of hsurancc carrier) Title: of authorized representative or licensed agent of insurance carrier: Please Note: Only iv, suronce carriers and the/r l/ceded agents are a~lhorised lo isle Form ~-7 0§. 2. fr~nronce ~ro~rs are NOT authorized to issue it. ¢-~ 05.2 (9-07) www.web.statc.ny.us Workers' Compensation Law S~eflon 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a stere 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 thi~ chapter, and notwithstanding any general or special statute requiring or authorizing the issue of s~ch permits, shall not issue such permit unless proof duly subecribed by an insurance carrier is produced in a form sa~factnry to the chair, that compensation for all employees has been s~ur~d as provided by this chapter, Nothing her~in, however, shall be conslrued as creatin§ any liability on the part of such slate or municipal depar~'aent, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a slate or municipal deparlment, board, commission or office authorized or required by law to enter into any contract for or in oounootico with any work involving tho employment of employees in a hazardous employment der'mod by this chapter, notwithstanding any general or special statute requiring or authorizin§ any such cgntract, 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 ail employi~s has been secured as provided by this chapter. C-105,2 (9-07) Reverse 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 adaress only) Arthur 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 Southold Town Hall, PO Box 728 Southold, NY 11971 lb. Bu§iness 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: ~~" ,~a~*¢' Stuar[ 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 carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mall 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 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 Benefits Law with respect to all of his/her employees. Date Signed: By: (Signature of NYS Womers' 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 "1 a" 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, cor,lmission 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 requi/ing 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 cpnstrued 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 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-120.1 (5/06) Reverse 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 TAX BILL $300.00 CHECK FOR PERMIT FEE B C Plan Section B-B Section A-A Typical Wall Piping Arrangement Section SIZE A B C D E F G H AP~F~A CAP. FEET Fr. Pr. FT. FT. FT. FT. FT. FT. SQ.lq. C.~L. 16x32' 16' ~2' 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,~00 20'~44' 20' 44' 16' 14' 6' 4' 6' §' 800 24'x44' 24' 44' 18' 14' 8' 4' 6' 10' 798 ~,000 24'x48' 24' 48' 20' :16'8' 4' 6' 10' 900 30,00~ PERMACRETE WAI,I, SYSTEM 929 Route 25A Miller Place NY 11764 (6m) ?~-?~su ~x (6m) 744-m74 Suffolk License #4436-HI Nassau License #HI74450000