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HomeMy WebLinkAbout37173-Z6/3/2013 Town of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36278 Date: 6/3/2013 THIS CERTIFIES that the building Location of Property: SCTM #: 473889 Subdivision: IN GROUND POOL 1355 Cox Ln, Cutchogue, Sec/Block/Lot: 96.-3-8 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore 4/23/2012 pursuant to which Building Permit No. 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. filed in this ofllced dated 37173 dated 4/27/2012 The certificate is issued to Kaufinan, Aaron & Kaufinan, Susan (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37173 6/21/12 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 #: 37173 Date: 4/27/2012 Permission is hereby granted to: Kaufman, Aaron & Kaufman, Susan 1355 Cox Ln Cutchogue, NY 11935 To: construct an In-Ground Swimming Pool fenced to code At premises located at: 1355 Cox Ln, Cutchogue SCTM # 473889 Sec/Block/Lot # 96.-3-8 Pursuant to application dated To expire on 10/27/2013. Fees: 4/23/2012 and approved by the Building Inspector. SWIMMING POOLS - 1N-GROUND WITH FENCE ENCLOSURE CO - SWIMMING POOL Total: $250.00 $50.00 $300.00 Building Inspector Form No. 0 ~OWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to tile Building Department with the following: A. For new building or new use: Final survey of properly 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 Uuderwriters. 4. Sworn statemeut from plumber cet~tif~ing that the solder used in system contains less than 2/10 of I% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the buildiug. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildiugs (prior to Ap:'i! 9, 1957) non-conforming uses, or bnildings and "pre-existing" land uses: 1. Accurate survey of properly showing all properly lines, streets, building and unusual natural or topographic features. 2. A properly completed applicatiou and consent to inspect signed by the applicant. Ifa Certificate of Occupancy is denied, the Building Inspector shall state tile reasons therefor in writing to tile applicant. C. Fees t Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelliug $50.00, Swimming pool $5000, Accessory building $50.00, Additions to accessory building $50.00. Businesses $50.00 2. Certificate ofOccupancy on Pre existingBuildmg- $100.00 3. Copy of Certificale of Occupancy- $.25 4 UpdatedCerlificaleofOccupancy $5000 5. Temporary Certificate of'Occupancy - Residential $15.00, Commercial $15.00 Old or Pre-existing Bnilding: New Construction: Location of Prope~"ty: House No. Street (cbeck oue) Owner or Owners of Properly: __ /t~.¢,, Suffolk County Tax Map No 1000, Section SulSdivision Hamlet Permit No. ,~'~ I '73 Health Dept. Approval: 0~-i~O Block ~)3, ~) Lot Filed Map. Lot: Date of Permit.//- 27 - [ 2. Applicant: Planning Board Approval: Request for: Temporary Certificate Underwriters Approval: Final Certificate~/~ ~ Town Hall Annex 54375 Main Road P.O. Box 1179 Southold. NY 11971-0959 Telephone (631 ) 765- 1802 Fax (631) 765-9502 ro,qer.r chert~,town southold.ny, us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION ssued To: Aaron Kaufman ~,ddress: 1355 Cox Lane City: Cutchogue St: NY Zip: 1193~ 3uilding Permit #: 37173 Section: 96 Block: 3 Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE 3ontractor: DBA: KS&S License No: 4568-me 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 Service 3 ph Hot Water GFCl 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 [~[~ HID Fixtures Wall Fixtures ' I Smoke Detectors Recessed Fixtures CO Detectors Fluorescent Fixtun~ Pumps Emergency Fixture Time Clocks Exit Fixtures TVSS in ground swimming pool to include, bonding, 1-control panel, 1-GFCl circuit break Notes: Inspector Signature: Date: June 21 2012 81-Cert Electrical Compliance Form.xls TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 ... NSPECTION [,~..']"FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: ~'~ ~ ~ t~ ~..~ ~ rt.~ ~-~ DATE TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [/,/]'FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE INSPECTOR 765-1802 \% ~/~.20 T~OWN OF SOUTHOLD BUILDING DEPT. INSPECTION [ ] ROUGH PLBG. [ ] INSULATION [ ] FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION R~ECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) RKS: DATE ~ ~-~-- INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ~LECTRICAL (FINAL) REMARKS: DATE INSPECTOR~~'' ~ 765-1802 INSPECTION [ ] FOUNDATION I ST [ ] FOUNDATION 2ND [ ] FRAMING/STRAPPING [ ] FIREPLACE & CHIMNEY RO,~-PL BG. ]~I~[~ULATION FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION,,~. [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) INSPECTOR 37/73 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] I~~tl~ [ ] FRAMING/STRAPPING [~J FINAI.~ ~ ~) [ ] FIREPLACE & CHIMNEY [ ] FIRE S~I~'E'T~ INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMA~ / DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPARTME~NT TOWN HALL '~?~9 SOUTHOLD, NY 71 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined ~'~ .20 Approved Disapproved a/c q[>?.:o Ix Expirat IA] BLDG DEPT. PERMIT NO. BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health · ~,,~4 sets of Building Plans Planning Board approval Survey Check Septic Form N.Y.S.D.E.C. Trustees '~y C.O. Application Flood Permit Single & Separate Storm-Water Assessment Form Contact: ailto: ,370 / PLICATION FOR BUILDING PERMIT INSTRUCTIONS Date ,20 a. This application MUST be completely filled in by typewriter or iu ink and submitted to the Building Inspector with 4 sets of plahs, accurate plot plan to scale. Fee accordiug to schedule. b;Plot plan showing location of lot and of buildings ou premises, relatiouship 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. O. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall bo, kept on the premises available for inspection thronghout the work. e. No building shall be occupied or used in whole or iu part for any porpose what so ever until the Building Inspector issues a Certificate of Occopancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after tile date of issuance or has not been completed within 18 mouths from such date. If uo zoning amendments or other regulations affecting tile property have been enacted in the interim, tile Building Inspector may authorize, in writing, tile extension of the permit for an addition six months. Thereafter. a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Depamneut fbr the issuance ora Buildiag Permit pursuant to the Building Zone Ordinance of the Town of Soutllold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for tile construction of buildings, additions, or alterations or For removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, buildiug code, housing code, and regulations, and to admit authorized inspectors on premises and in bttilding for necessary inspections. "IMMEDIATELY" ENCLOSE POOL TO CODE UPON COMPLETION BEFORE "WATER" (Signatare of applicant or name, ifa corporation) (Mailing address of applicant) c> rNOT D State whether applicant is owner, lessee, agent, architect, engineer, general co ac~o~); ~etcmcia~, pTdmber or builder Name of owner of premises AO,,-o rl ~\ ~ tt-~rr}~rl -r~ m..-.~ tHLDING~.. -~DEP'~"q ............ r ME",!T AT (As on the tax roll or,_l~l~SPECftON$ If applicant is a corporation, signature of duly authorized officer Lr~'~ '-FOUNL)ATION - TW,i) RE(. 'IRED (Name and title of comorate officer) Builders License No. ~,~ Plumbers License No. I.I I~,TlllI~AL ' Electricians License No. Other Trade's License No. iNSPF. CTION ,,,-- ...... 1. Location of land on whic~ proposed work will be done: !33..5 House Number Street County Tax Map No. 1000 Section Block FOR POURED CONCg'ETE ROUGH - FRAMING PL., ,~DNG STRAPPING, ELECTRICAL & CAULKING INSULATION 4 FINAL- CONSTRUCTION & ELECTRICAL UU~T BE COMIIL/U'TE FOR C 0 ALL CON~TRUCTIOII SHALL MEET THE REOUIREMENT~ OF THE CODES OF NEW _YORK STATE. NOT RESPONSIBLE FOR DES TI R . H UANT %' ,HAPTER 236 OF ]'HE, TOWN ¢O E. -., _ Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended useandoccupancy_~"~,.~,~'~ ~',, [ 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work Estimated Cost Fee If dwelling, number of dwelling units If gara§e, number of cars (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height. Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Depth Height Number of Stories Rear 8. Dimensions of entire new construction: Front Height Number of Stories Rear .Depth 9. Size of lot: Front Rear .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? YES__ NO__ i3. Will lot be re-graded? YES__ NO __Will excess fill be removed front premises? YES NO 14. Names of Owner of premises Name of Architect Name of Contractor Address Phone No. Address Phone No Address Phone No. 15 a. Is this property within 100 feet cfa tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE R~-'U~RED. 9* b. Is this property within 300 feet cfa tidal xvetland. YES NO ~,~ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. ; .. · ,.,. ~;~g · ~ -'. .'- 5 ,'.,: .. 17. If elevation at any point on property is at 10 feet or below, must provide topographical dafa~}c. 18. Are there any covenants and restrictions with respect to this property? * YES NO v · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OP (Name of ir~ividual signing c~act) above named, (S)He is the n~:.., ent, Corporate Officer, etc. being duly sworn, deposes and says that (s)he is the applicant CONNIE D. BUNCH Notary Public, State of New York Qualified in Suffolk County Commission Expires April 14, of said owner or owners, and isidgl~ill~lo perform or have performed the said work and to make and file this application; that all statemenls,:ontained i~r~l~lil~rue to the best of his knowledge and belief; and that the work will be performed in ~)i~ }n,anner set ~h~ ~~ filed therewith. // S~orn to before m~;: '~''' 5. ;.' ';; . , // / ~ ~ Notary Public / Signature o~pplicant Town H~ At. ex P.O. Box 1179 ~uthoki, NY 1 Telephone (631) 765-1803 BUI! T~ING DEPARTMENT TOWN OF $OUTHOI.r) APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Company Name: Name: Address: ~- ~ 5 <.-',-),~, ~ C '7, No.: Date: ~-~,/~'/,~_ JOBSITE INFORMATION: (*Indicates required information) *Name: A/~ i~,~ 1,..) ~,.~ (.~_~ ~ *Address: /,3 ~-'~-- CO ~ ~__ C_¢¢~0~¢~ *Cross Street: *Phone No.: Permit No.: Tax-Map District: ,~'7/7.% 1000 Section: *BRIEp DESCRIPTION OF WORK (Please Pdnt Clearly) Block: "~ Lot: (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Temp Certificate: Temp Information (If needed] *Service Size: 1 Phase 3Phase *New Service: Re-connect Additienal Information: YES / NO Rough In Final YES / NO 100 150 200 300 350 400 Olher Underground Number of Meters Change of Service Overhead .PAYMENT DUE WITH APPLICATION B2-Request for Inspection Form ~ ~ ~ [~-) ) [-~ ~'~ Town of Southold. Chapter 236 - Stormwater Management ~ SWPPP - Storm Water Pollution Prevention Pain Assessment Forl~ GENERAL INFORMATION._L~A11 Requested Information is Required for a Complete Application) .",-,v-d, .~d~res,: / 3 55 CO~ IA ('~/'~- '~e l~,t~ Brief Description of Construction Activity, Proposed SIzucm~ BMPs, Soil Will [I; Project Olstu~e F~e (5) or More Acres at ~ ~ a. ~s ~e ~pli~nt have a Qualifi~ Ins~ ~ ~ ~ S~fl To Conducl ~e Requir~ Insp~ons ? Yes No ~oes ~e SWPPP I~i~e Add~o~l Si~ Spe~c ~ ~ s~ ~ :~ w~., ~: (~. ~ ~) u~ ~p~...) ~ Intent and 8WPPP Ac~p~nce Fo~ ~r Revi~ ~ ~ ~ ~e T~ of ~ld ? Yes No ~'ATEOFNEWYO~ ~ /,~ f COU~ OF .~----~ ............... SS ~unn~ u. auxin ~ota~ Publ~, ~to of Now No. O~ ~O618~50 ~d ~at h~she is ~e ~er ~([~pres[~m~ve o~e p~er or O~en: ~d. ts duly au~omed m peffo~r ~ve ~ffo~ed ~e s~d ~rk ~d to .me ~ me ~s appnm~on; ~t ~ s~emen~ con~ed m ~s appHmfion ~e ~e ~e best of his ~o~ed[e ~--~ ~ ' ~at ~ w~r~ mil be ~ffo~ed m ~e m~ner ~t fo~ ~ ~e apportion fded he~. ~. ~; No~y Public: ..~..~.....~...~ ............... . ............. SW~PP Assessment FORM: TOS "SWPPP" Preparation - Chapter 236 Article II - Storm Water Management Storm Water Pollution Prevention Plan Review Checklist Checklist # 1 REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: YES NO "N A; '-' lanation for NO or N A Plan Sheet (Does the SWPPP Adequately Provide for and/or Indicate tha Followln~l:} ~, I N.A~"xp -- ' ..... Location (pg. #) 1. Drainage Calculations & Stonnwatar BMPs Desianed to contain a Two Inch Rainfall On-Site , ~ ~[~ rTM 2. ConstructionPhasngPan nd cat ng Sequence of Proposed Construction ActMties I I b S te Acreage;_ ~ ~; r-'~ [--~T~ C~ ~AI~ E~isti~ ~qat;r-a- ~n-d/"~)-r~-a-n-M-a-d~-F~a.`t~ ~ ~n-d-~[hi~-~ ~e .P~ ~u~a~F -~ ~ ~ ~ ~ d. Test Hole Data Indicatigg Soil Characteristics & Depth to Seasonal High Water Table; .... e, Co n t0 u ~ Ind~c-a~i~ ~er~-E~e-v~ti-o-n~l~i~ -2~)= ~ r~l r~ll ~--~T~ f. Spot Grade & Finish Floor Elevations tor Existing and proposed Structures. n. Sod Conservation ulstHct Soi~urvey. 5. B a c kg r o u n d I n form ation a b~l{¥1~ '~'~l~e~0~f ~h~e-~t~j-e~t~'l~-0~ -&- ~ ~t~ ~ ~ ~ j~, ~, Proposed Chan~es to the Site and All Existing Development on the site nciud ng the Fo owing J I I II b. A I Excavation Filling Stripping & Grading Proposed and Identified as to depth, Volume ', !,--,--~ d. Ai~ Areas Where Topsoil is to be Removed, Stockpiled and where Topsoil will ultimately be placed; f. All Temporary & Permanent Storm Water Runoff BMP Control Measures Proposed hl~ Th e Lo~ii~ ~f'alq-R-o~] s-~ -D'fiSe-~,~,~'~S~e' w-a~k-s- ~a-t~ -S-tr~-~t-b-~e~O ti'-ii~$ ~ O~ er 6 A Schedule of the Sequence for the Installation of All Planned Sod Eromon Sed~mentatmn ~ ' I I;I 7. Description of Pollution Prevention Measures that will be I_mj~lemented 8. A Description of the Minimum Erosion & Sediment Control Practices to be Installed and/or II I~;I I.rn~pJemented for Each Construction Activi~that will result in Soil Disturbance. ; 10. Temporary & Permanent'§~§~§i~l'ti~TO~a~-tiTla'~n-e~-th-e-C~rlT~{'~r~i~-~f'~h~- r-'--q~--i'~-'~ New York State Storm Water Design Manual Technical Standard. ~ 14. Implementation Schedule for Staj~ing TemEo. rar2/Erceion Control Practice or BMP ff~l~ [~ II--'~-] ~ 15. Maintenance Schedule to Ensure Continuous & Effective Operation of Erosion & ,~ ,.._.~ ~/~ Sediment Control Practices. ~ impacted by Development. ~ f.- ~D'~iin~ati~n o"-f-s-{ o-r~n- ~v~ t~' ~x~ n-t~-o~' ~1~ ~rTn ~l~n~n-t~tTo~-R-e~-n~i%i~it~e-s-f~r-E-a~ ~r~ ~l;~h-e~ -- ~ 19 Identi~r~ationofAIIContractor(s)/Sub-Contractor(s) Responsible for lnstalling, Constructing, ~l-~![----lir--i~ ' Repa' ing' Replacing, Inspecting and Maintaininc~I the ErosiOn & sediment ContrOl Practices- ' ~ ~'~ ~"~ b~ ~O~f ~'~ Storm Water Management Control Plan Checklist # t: 03-12 New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747~3129 Phone: (631) 75~4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 204439170 KEVIN C NORDEN INC PO BOX 348 EAST MORICHES NY 11940 POLICYHOLDER KEVIN C NORDENINC PO BOX 348 EAST MORICHES NY 11940 CERTIFICATE HOLDER TOWN OF SOUTHOLD SUFFOLK COUNTY PO BOX 1179 SOUTHHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER 1 2018 726-6 982471 PERIOD COVERED BY THIS CERTIFICATE DATE 04/01/2012 TO 04/01/2013 4/11/2012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2018 726-6 UNTIL 04/01/2013, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED. OR CHANGED PRIOR TO 04/01/2013 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY iN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. KEVIN NORDEN (OWNER) OF A ONE PERSON CORP KEVIN C NORDEN INC T/A FLAWLESS POOL SERVICE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U 26.3 NEW YORK STATE INSURANCE FUND DIRECTOR,iNSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:/Iwww.nysif.camlcertJcertval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 823811065 ~ FLAWPOO-01 KHANDLEY ACOI~D~ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MA'I-FER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIE$ BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEWVEEN THE ISSUING INSURER(B), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certlf'~te holder Is an ADDmONAL INSURED, the policy(ies) must be endorsed. IfSUBROGATIONISWAIVED, sub~sctto the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificats does not confer fights to the certificate holder in lieu of such endorsement(s). pco~uc~R License # BR-876726 CONT^CT NAME: Execu Ins Broker Fin Set Inc ~PA~cO~. NE,. ~,: (631) 563-8433 I ~A~ "ol: (631) 563-7706 915 Johnson Avenue Bohemia, NY 11716 AODRESS: __ INsur~J~ A =Atlantic Casualty Insurance Company INSURED INSURER B: Kevin C. Norden, Inc. INSURER C: DBA Flawless Pool Service; All Island Rebuild P.O. SOX 348 INSU;ER =: East MoHches, NY 11940 ~NSURER E: 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. NO~NITHSTANDING 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. LTR TYPE OF INSURANCE INSRI ~ POUCYNUMBER MM~Drt'~() {MM/OD/YY~ lIMITS I CLAIMS-UADE [] ~X~CUR MEOEXP{Anyoc, epefs~.~l) $ $ CERTIFICATE HOLDER CANCELLATION I Town of Southold Suffolk County PO Box 1179 Southold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POMCY PROVISIONS. AUTHORIZED REPRESENTAnVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Southampton Town License Review Board 116 HAMPTON ROAD NO. L001382 Home Improvement License SOUTHAMPTON, NY 11968 DATE ISSUED: May 12, 2010 This is to certify that Kevin C Norden doing business as Flawless Pool Service, D/B/A All Island Rebuild having furnished the requirements set forth in accordance with and subject to the provisions of the applicable laws, rules and regulations of the Town of Southampton, State of New York, is hereby licensed to conduct business under the provisions of the Home Improvement Contractors Law, Chapter 143. THIS LICENSE EXPIRES May 12, 2011 ANTHONY D'ITALIA, JR. Chairman License Review Board GENERAL NOTES TYPICAL WALL SECTION TYPICAL POOL SECTION 514 West End Avenue Suite 7B New York, NY 10024 P M G A r c h i t e c t s