HomeMy WebLinkAbout36523-Z ~
.x.... Town of Southold Annex 8/7/2013
4," ypfFOt,~ ~
P.O. Box 1179
a. 54375 Main Road
® 5
a Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 36435 Date: 8/7/2013
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 175 Clearview Ave, Southold,
SCTM 473889 SecBlock/Lot: 70.-8-40
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this officed dated
6/17/2011 pursuant to which Building Permit No. 36523 dated 6/29/2011
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 in ¢round swimmingpool with fence to code as applied for.
The Certifieate is issued to Worysz, Gerard &Worysz, Jean
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 36523 8/15/11
PLUMBERS CERTIFICATION DATED
- _ -
r' ~
A riz ignat e
~ Towu of Southold Annex 8/7/2013
q' sa?F~A'
P.O. Box 1179
v .;a
54375 Main Road
' '~.,+/yy,,, Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 36436 Date: 8/7/2013
THIS CERTIFIES that the building HOT TUB
Location of Property: 175 Clearview Ave, Southold,
SCTM 473889 SecBlock/Lot: 70.-8-40
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this officed dated
6/17/2011 pursuant to which Building Permit No. 36523 dated 6/29/2011
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 hot tub as applied for.
The certificate is issued to Worysz, Gerard &Worysz, Jean
(OWNER)
of [he aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 36523 6/18/13
PLUMBERS CERTIFICATION DATED
A t rite Signa ure
,~yiFFOi,~`-.~ TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
'a a
SOUTHOLD, NY
:,-fir
~
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 36523 Date: 6/29/2011
Permission is hereby granted to:
Worysz, Gerard 8~ Worysz, Jean
_ -
175 Clearview Ave
Southold, NY 11971
To: construct an in ground swimming pool fenced to code
At premises located at:
175 Clearview Ave
SCTM # 473889
Sec/Block/Lot # 70.-8-40
Pursuant to application dated 6/17/2011 and approved by the Building Inspector.
To expire on 12/28/2012.
Fees:
SWIMMING POOLS - lN-GROUND WITH FENCE ENCLOSURE $250.00
CO -SWIMMING POOL $50.00
Total: $300.00
Building Inspector
~ ~~~o~~
Form No. 6 D
TOWN OF SOUTHOLD - 5 2011
BUILDING DEPARTMENT
TOWN HALL
765-1802 atoc. or Pt.
TOWN OF SOUTHOLD
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 natura} or
topographic features.
2. Final Approval from Health Dept. of water supply and seweragedisposal (S-9 form).
3, Approval of electrical installation from Board of Fire Underwriters.
4. Swom statement from plumber certifying that the solder used in system contains less than 2110 of 1 % 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 building.
6: Subrrtit Planning Boazd Approval of completed site ptan 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
I. 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 ofOccupancy - $.25
4. Updated Certificate ofOccupancy - $50.00
5. Temporary Certificate ofOccupancy -Residential $15.00, Commercial $15.00 n
Date. 1- ~ "
New Construction: ~ Old or Pre-existing Building: (check one)
Location of Property: ~ ~,LeFl~VtCh1 Itv~ ~l..IV1~117(r~
House No. Stre~"et Hamlet
Owner or Owners of Property: ~f'.tQ~.~ C ~cQ11 Y y~~S2
Suffolk County Tax Map No 1000, Section ~ ~ Block ~ Lot ~ C'
Subdivision Filed Map. Lot:
Permit N4. 7j ~t~Ti ~--3 . Date of Permit. ~-~9~ ~ ~ Applicant:
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: ~ (check one)
Fee Submitted: $ 5~ ~~Xx
Applicant i re
FF~J jFFO(rrr~
Town Hall Annex `,vO~S~ ~c~G Telephone (631) 765-1802
~ y
54375 Main Road ~ ~ r Fax (631) 765-9502
P.O. Box 1179 G f
•
Southold, NY 11971-0959 ~>y~jp! ,~y~~;;l'' roger.richert(ciltown.southold.ny.us
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Jean & Gerry Worysz
Address: 175 Clearview Ave City: Southold St: NY Zip: 11971
Building Permit 36523 Section: 70 Block: 8 Lot: 40
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
contractor: SBA: Jim Sage Elec License No:
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service Only
Commerical Outdoor X ist Floor Pool
New Renovation 2nd Floor Hot TUb X
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps
Transformer Appliances Dryer Recpt Emergency Fixtures Time Clacks
Disconnect Switches Twist Lock Exit Fixtures TVSS
other Equipment: self contained hot tub with GFCI protected disconnect
Noes:
~ -7~~~
Inspector Signature: ~'~i`"- `b~~ Date: June 18 2013
Electrical Certificate.xls
~O~~pF SOUTyolo
Town Hal I Annex Telephone (631) 765- I R02
54775 Main Road ~ ~ Fax (631) 765-9502
P.O. Box 1179 T Q
Southold, New York 1 197 1-0959 ~ ~ roger. richert(a~town.southold.nv.us
~~y00UNTY,~~
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: G&J Worysz
Address: 175 Clearview Ave City: Southold St: NY Zip: 11971
Building Permit#: 36523 Section: ]Q Block: 8 Lot: 40
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: U.S.I. Electric License No: 2]40-me
SITE DETAILS
Office Use Only
Residential X Indoor Basement Service Only
Commerical Outdoor X 1st Floor Pool X
New Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 2
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 1
Disconnect Switches 2 Twist Lock Exit Fixtures TVSS
Other Equipment: In ground SWInltnln pool to include bonding 2 GFCI circuit breakers 1-pool li ht
Notes:
Inspector Signature: ,,tom Date: Aug 15 2011
81-Cert Electrical Compliance Form
~I SZ3~ *
~oFSOUI~#
TOWN OF SOUTNOLD BUILDING DEPT.
765.1802
1 NSPECTION
[ ]FOUNDATION 1ST [ ] ROUG BG.
[ ]FOUNDATION 2ND [ ] 1 CATION
[ ]FRAMING /STRAPPING [ FINAL
[ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION
[ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION
[ ] ELECTR~AL )ROUGH) [ ]ELECTRICAL (FINAL)
~ REMARKS: ' ~ o ~
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DATE ~ Y INSPECTOR
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TOWN OF SOUTNOLD BUILDING DEPT.
765-1802
INSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INS ION
[ ]FRAMING /STRAPPING [ INAL
[ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION
( ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION
[ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL)
REMARKS:
F
DATE l~ INSPECTOR
~+D 1`iREPbIiT DATE CONIMENTS.
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FOIINDATION (1ST) ~ '
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FOUNDATION (2ND) ~ ~
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ROUG$ FRgN1ING & ~ ~
PLU~YlBING ~
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INSULATION PER N. I'. y
STATE ENERGY CODE
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FINAL v
ADDITIONAL COMMEN S 'r
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TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following, before applying ?
TOWN HALL Board of Health
SOUTHOLD, NY 11971 3 sets of Building Plans
TEL: 765-1802 Survey
PERMIT NO. S o~ 3 Check
Septic Form
N.Y.S.D.E.C.
Tmstees
Examined ~ ~.2~j , 20 Contact:
Approved 20 Mai] to:
Disapproved a/c
- r Z Phone:
D ~ ~ ~ ~ ~ Building Inspector
JUN 1 7 2011 LIGATION FOR BUILDING PERMIT /
6i DG. DEPT. ~ Date 6 I I i , 2011
TowN DE souTNOto 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.
o, 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 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, a regulations, and to admit
authorized inspectors on premises and in building for necessary inspections.
'-~~'~~.'~ANCw' (7R '°IMME~IA~ELY'~
~ n 1{^
f`-} ; ; ENCLOSE °OOL TO CODE (Signature of applican name, if a corporation)
~ t r UPON C0MPl.ET10N ~e
, ~ T. BEFORE "WA7~R" Q.ZaI Qt ~'Sf} ~~2[
(Mailing address of applicant)
lJl" ~~:C~IPANCY
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
~ APPROVED AS NOTED
ATE 29 rl B.P. L > ~
Name of owner of premises ~e~to o ~qn 1 VQR ~ r
(as or_ the tax roll or 1~,jNG DEPART-
T
765-1802 8 AM TO 4 PM FOR THE
If applicant is a corporation, signature of duly authorized officer FOLLOWING INSPECTIONS:
t. FOUNDATION -TWO REQUIRED
(Name and title of corporate officer) FOR POURED CONCRETE
2. ROUGH -FRAMING, PLUMBING,
II STRAPPING, ELECTRICAL 8 CAULKING
Builders License No. ~'1~3~ - T 3. INSULATION
4. FINAL -CONSTRUCTION 8 ELECTRICAL
Plumbers License No. MUST BE COMPLETE FOR C.0.
ALL CONSTRUCTION SHALL MEET THE
Electricians License No. ~7~tQ- MC REQUIREMENTS OF THE CODES OF NEW
YORK STATE NOT RESPONSIF31_E FOR
Other Trade's License No. ELECTRICAL DESIGN OR CONS (RUCTION ERRORS.
.IV REQUIRED RETAIN STORM WATER RUNOFF
1. Location of land on which proposed work will be done: P RSUANT TO CHAPTER 236
~ ~ N CDDE.
House Number Street H
,~r~,.a lstoN
County Tax Map No. 1000 Section Block_ ~1:, Qj , ,i~r,OLot
Subdivision Filed-DQa}rI\lcn r no . a~Lot ~j
(Name)
2. State existing use and occupancy of prem' es and intended use and occupancy of proposed construction: ,
a. Existing use and occupancy ~SI pQ,~Qp n
b. Intended use and occupancy ~2Si0enRlit ~,rnM~n1e~ 1',p~
3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work~~¢.~~an ~rJimn4W;
II (Descnphon)
4. Estimated Cost 1~-t1Q~' Fee
(to be paid on filing this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor~
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. _
7. Dimensions of existing structures, if any: Front- ~5 Rear Depth 3J
Height Number of Stories_
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories__
8. Dimensions of entire new construction: Front o20 Rear a O Depth 4O
Height Number of Stories
9. Size of lot: Front ~ ~ Rear lOp' Depth 200
10. Date of Purchase Name of Former Owner
11. Zone or use district in which premises are situated
12. Does proposed construnnction violate any zoning law, ordinance or regulation:
13. Will lot be re-graded Fem. Q.G-~I Will excess fill be removed from premises: YES NO
_T
14. Names of Owner of~remise~fl/t2o e~Qn ~~SZAddress l~S- ~i,P,}¢V1P,? Phone No. 7bs ~I Ig
Name of Architect 1 h`~+~ ~ Re~ll Ot Addresses ~~c ,GJ S~r~m,~,.,Phone No ~IZ~I`7~~J
Name of Contractor vc~ontkeot ~-.e ~ln AddressgZa Rf zsl+ -Phone No. `7~f'(-7/Ff
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 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'SfORK) `
SS;
COUNTY OF )
~ (~~X OS being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named, ~ ~
(S)He is the f ,(~~~1'~ft%G UIL
.,;(contractor; Agent, Corporate 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 true to the best of his knowledge and belief; and that the work will be
performed in the manner sefforth in the application filed therewith.
Sworn t~before me this
day of C JUd~ 20~
of Public ~ Signat e f Applicant
IMAfiGARET A. Ki~r1Ev
MOWy Public - State of New York
No. O I KIG031 1 1 1
t]ualitied in Suffolk County.
My Cammission F~irea March a 201 ~
d°~~~ Town of Southold
Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM
~1~ PROPERTY LOCATION: nS.C.7.M. 0: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A
\ 'Vl T ~ n /.f-t~ STORM•WATER GRADING DRAINAGE AND EROSION CONTROL PLgN
s e e on - oc CERTIFIED BY DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.
SCOPE OF WORK -PROPOSED CONSTRUCTION ITEM # / WORK ASSESSIVIENN'T Yes No
a. What is the Total Area of the Projed Parcels? ~ Will this Projec[ Retain All Stonn-Water Run-0f/
(Indude Total Area of all Parcels located within ~OIpOO yr Generated by a T\vo (2") Inch Rainfall on Site?
the Scope of Work for Proposed Comstrudion) ~ ?
b. What is the Total Area of Land Cleari (s.F. /A4ss) (ThIs Item wile Indude all runoff created by site
r5 Gearing and/or corutruction adn/itles as well as a0 -
and/or Ground Disturbance for the proposed . ~ Site Improvements andthe permanent creatlon of
constmdion aLNivily? ImpeMous surfaces.)
(S.F./Aria)
PROVIDE BRIEF PROJECT DFSCRIP'1TON (Pmvua AdtlltlwW 2 Does the Sile Plan and/or5urvey Snow All Proposed ?
Paa00pNee°etlI Drainage SWdures Indicating Size $ Locetlon? Thls
Item shall Indude all Proposed Grade Changes and -
,np,~~ ~,h JNgQv~ SlopesControllingSUrfaceWaterFlow.
~1"' M ~ n $ Does the Site Plan and/or Survey desalbe the erosion ? ?
V t ny~ SMIYIMI t4 Y~~ and sedknent control pradices inat will be used to
I- ~11 q contrd site erosion and storm water discharges. This
W~rT+ YQNQ~ N t, dQQ Item must be maintained throughout the EnBre
ConsWctlon Pedod.
Q Will this Projed Require any Land Filling, Grading or
6ecevatlon where there is a change to the Natural
Existing Grade Involving more than 200 Cubic Yards
of Material within any Parcel?
rj Will this Applicetlon Require Land Disturbing Adivitles
Encompassing an Area in 6ecess of Frve Thousand
(5,000 S.F.) Square Feet of Ground Surface?
6 Is there a NaWrel Water Course Running through the ?
Site? Is this Project within the Trustees jurisdictlon
cenerel DEC SWPPP Reaulraments: or within One Hundred (100') feet of a Wetland or
Submisskn d a SWPPP is required kx all ConsWUlon aUNiges Involving soil Beach?
disturbances of one (1) or more acres; includkg tlisNmerxxis of leas man one acre met 7 WIR there be Sile preparation on Existing Grade Slopes ? -
are van or a larger common plan mat wgl urematey disturb one or more acres o/ lantl; which Exceed Fifteen (15) feet of Vertlcal Rise t0
InUUding Consinxtkn actlvMea krvoNirg soil disWrbances of lass man one (1) acre where -
me DEC has determined mat a SPDES pemgt to required for storm water dbcharges. One Hundred (100') of HorizontaLDistance?
(SWPPP's Shag meat Na Mlnhnum Requiremanb or ma SPDES Genarel Permit $ Will Driveways, Parking Areas or other Impervious ?
for Storm Water Dlschargq from Conatrudion aegvlty -Permit No. GP-0.10-001.) Surfaces be Sloped to Dired Storm-Water Rurt-Off
t. The SWPPP shag be prepared pdor W the submittal of ttre NOI. The NOI shag be ' Into and/or Im the dlreCtlon Of a TOwn rightol-Wey7
submNletl tome Deparmred prbr m Ole commencement dcOnsWUbn ectlvity.
2. The SWPPP spell desrxme tlh eresbn rrndaediment conttol prectlces end where 9 WIII this Project Require the Placemerg of Material,
required, DwtconsWCtlon sbrm wales management preetlcee IhetwM ba used and/or Remdval of VegeteQon and/or the Constructltm of any
wnswr]ed m reduce th pdkdents h storm water dbdrarges and a eewre Item Within the Town Rightof--Way or Road Stwukter
compliance wNh me terms end conditlons d mis perm0. M etl0ilbn, me SWPPP shag Area? (fhb ibm wal NOT bduda tM IdaMarbn olDdrawayAprens.)
Identify potentlal sources of pogutkn whkh may reasonably be expeged m arteU me
quality d storm caster Olschargea. NOTE: gArry Anawar to Queatlons Ona mraagh Nirw Is Answarad wim a Cheek Nark
3. All SWPPPS that require ma postconsWdbn storm water management prectlce In a Bos and Ns csnatrucgon site dlsturbancs U betwearr 5,000 91.31 Aera In araa,
component shell be-prepared try a qualified Design Professbnal Lkensed In New York a Storm-Webs, Grading, Drainage $ Erosion Controj pbn b Raquked by tM Town of
That b knowledgeable in me prlnUplBS and preclkes of Storm Water Management Soumald and Must ba Submitted for Review Pdarb Issuance dArry Sugdkrg partNl
(NG7E: AChatlr Mark anNor Answer for eadi Osastlobb RequYed bra COmpbb App3albn)
STATE OF NEW YORK, ,~f~~'l
COUNTY O~F-.y....~.~.~.r~ SS
1'ha[ I . :.ilk ~ ~u~,~ing duly s»rom, deposes and sa s that h she is the a hcan[ for Penrut,
(Name d IMivldual signing Document] y PP
And that he/she is the ....................................:..............5.:.:'l.Y.:!.:11r~....
(Owner. ContraUOr, A Co
gen rporete Olgcer, etcJ
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 irate 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.
Swom to before me this,
......................1.1.`.:................ say of./~ zo.tt.
Notary Public :..............~~..(s.1.:.~'~!~..............'......... _
7 A. KIDNEY g^aarew ~ m)
FORM - 06/10 - too ew o
No. 01 K 16021 1 11
OuWMd Itq StAbMc Coulthr
M)r tJoenlN3ion ExpYa Mr~h & Z01~L
. ~0~~0~ S~r~~
Town Hall Annex ~ ~ Telephone (631) 765-1802
54375 Main Road N (631) 7
p_p• gox l lyg Q rogecrichert aC~.~ownsou~io9~d.nV.Us
- Southold, NY 11971.0959 _
°~un 1
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY: Date:
Company Name: U,S.T. E~~~-I-y/I~
Name: CP 1~C1~G
license Na.: 2 r]nn~ He
Address: YiJ~ASt~ Qo Kink Past.
Phone No.: (~31, 5~y_~y~p
JOBSITE INFORMATION: (*Indicates required information)
*Name: ~e~ a ~15n Z 1i•~02~SZ
*Address: I'~S ~I,QhtU1P~J l~Je J~,1.Tr11J1A
*Cross Street: ~A-2rn,Jet~ s ,~q,,u
*Phone No.: (a 31- 71oS• ~ 114
Permit No.:
Tax Map District: 1000 Section: -1~ Block: Lot:
*BRIEF DESCRIPTION OF WORK (Please Prlnt Clearly) PR~~'O ~xYO
~
n~aa~~ V~~.w ~i mwt tnlq P.ut_
(Please Circle AIF That Apply)
*is job ready for inspection: YES / NO Rough In Final
*Do yota need a Temp Certificate: YES / NO
Temp information (If needed}
*Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION U
i~g ~b~ .G~
C' ~
82-Request for Inspection Forth ~ \
~o~~OF SQ~jyo~
'1`oera Hai Annex l~r * Telephotx (631) 7651862
54375 Main Road ,..~x ((631 7~6~gq5pp~~
P.O. Box 1179 ~ f~7ef.flChert(rVWWr1.~0UrIlOItl.nV.US
Southold, NY 1(971-0959 - l~/y~~,,,~
"vU1t11,
BUILDING DFd'AR`I'MEN'I'
TOWPI OF SOiTFHOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY: Date:
Company Name:
Name:
License No.:
Address:
Phone No.:
JOBSITE INFORMATION: (*Indicates required information)
'Name: ~~1 ~ ~ r r`'y ~'`7\~~_SZ _
*Address: _ ) ~ S ~6
*Cmss Street: _ !
~?1
'Phone No.: _ ~ _ c1 I (et
Permit No.:
Tax Map District: 1000 Section: 0 Block: Lot: ~
*BRIEF DESCRIPTION OF WORK (Please Print Clearly)
(Please Circle Alt That Apply)
*Is job ready for inspection: NO Rough In Final
*Do you need a Temp Certificate: YES / NO
Temp Information (If needed)
"Service Size: 9 Phase 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION ¢kg-p'-~,~/~I]
- - ~e____r
cC "/V~OVjU
82-Request for Inspection Form G ~ ~ J
Gerard and Jean Worysz
175 Clearview Ave
Southold, NY 11971
631-765-9119
Dec 12, 2012
Town on Southold Building Department
Town Hall Annex Building
54375 Route 25
PO Box 1179
Southold, NY 11971
To whom it may concern,
Please extend our current building permit (#36523) for our in-ground pool. We will comply with
all requirements within the next 6 months. If you need any additional information, please call us at 631-
765-9119. Thank you in this matter.
Sincerely,
Gerard and Jean Worysz
~ f_~~r~~~n~1C
D~2,~ D
BLDG.DFPT.
TO!N~ p. ~OG1HOtD
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 o(Buainess Participating In Group ]d. Business TelepMne Number of Busiaess Referenced is "la".
Self-Insurance (Use Street Address Only)
(631)744-7185
Arthur J. Edwards Mason Contractor, Inc.
DBA: Arthur Edwards Pool & Spa Centre
929 Route 25 A le. NYS Unemployment Insurance Employer Registretlon Number of Business
Miller Place, NY 11764 ~ Registered in Box "la".
16. EBective Dete of Membership io the Group 4/24/2002 24108715
Issue Date 7/27/2010
Expiration Date 7/26/2011
lf. Federal Employer Identscadon Number of Business Referenced in Boz
lc. The Proprietor, Partners, or Executive Otlicers are la ' .
® Included. (Only check if as partners / oRcers inluded. 111277925
All excluded or certain partners / otiicera excluded.
2. Name sod Address of the Entity Requesdog Proof of Coverage 3. Name and Address of Group Self Insurer.
(Entlty Being Listed as Certificate Holder).
Town of Southold ~ Special Trades, Contracting And Construction Trust
Town Hall 6250 South Bay Road
PO Box 728 Syracuse, NY 13039
Southold, New York 11971 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 instill 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.) Otherwise, this Certificate is valid for
a maximum of one yeaz from the date certified by the group self-insurer.'.
If 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 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: David F ancey
(Print name of authorized representative of the Group Self-insurer)
Certified By: 7/27/2010
(SignaNre) (Date)
Title: TrustAdmi rator
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
carrier 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 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:T~s 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 Croup 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
STATE OF NEW YORK
WORKER'S COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABIIRY BENEFITS LAW
PART 1. To be com ietad b Dfaability Benefits CaMsr or Licensed Insurance Agent of thst Carrier
1 a. Legal Name antl Address of Insured lure aVeer eeerme sMrl 1 b. Business Telephone Number of Insured
631-744-4455
Arthur J Edwards Mason Contracting Company Inc. te. NYS Unemployment Insurance Employer Registration
929 Route 25A Number of Insured
Miller Place, NY 11764
24-10871
1tl. Federal Employer Identification Number of Insured or
Social Security Number
11-2377925
2. Name and Address of the Entlty Requesting Proof of 3a. Name o1 Insurance Carrier
r.OVBlage (EMity Being Listed aB the Certilkffia Holoer) Guardian Life Insurance Company of America
Town of Southold 3b. Policy Number of entity listed in box "ta":
53095 Main Road 984424-0000
PO Box 1179 3c. Policy effective period:
Southold, NY 11971
07/01/1986 to 06/30/2011
4. Policy Covers:
a. ® All 01 the employer's employees eligible under the New York Disability Benefits Law
b. ? Only the following class or Gasses 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 Disabill ur a coverage as described above.
Date Signed: September 29, 2010 By -
Telephone Number: (212) 964-2150 Title: President
IMPOgTAM: a hox "ee" 4 eMeked, aM thla form Is afanw M the Inaunnes eerHer'a authortaad npreaentexve or NTS Lkenaed
hreurarrp Apwd of that earner, lhla wrlMate b COMPLETE. AMx It dlncdy b Uro certllkete holder.
N hoe "4b" u checked, thle eertllketa Ia NOT COMPLETE for purpoeee of Ssetlon 240, Suh0. a W Me gwblllry
aenellle Lasr. II mwt foe mellsd for eomplNlon to the Workare' Companstllon Boerd, DB Aens Aceaptenn Unk,
4o P.rk sr.«L uh.nv, N.w rark t 44m.
PART 2. To be can leted by NYS Workers' Co satbn Board (Only If box "4b" of Part 1 has been checked)
State Of New York
Workers' Compensetlon 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 or hislher employees.
Date Signed: By:
Telephone Number, Title:
Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed
insurance agents of those insurance carriers are authorized to issue Form DB-120. f. Insurance brokers are NOT
authorized to Issue this form.
DB-120.1 (7109)
Additional Instructions for Form DB-120.1
By signing this form, the insurance carrier identlfied 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 ac the certificate holder in box "2". This
Certificate is valid for fhe earlier o/one year alter this /orm is approved by the insurance carder 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.B
(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 anywork 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 farm 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 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 contrail unless proof duly subscribed by an insurance carrier is produced in a form
satisfactory to the chair, [hat the payment of disability benefits for all employees has bean secured as provided by
Yhis article.
DB-120.1 (7/09) Reverse
~~""1 OP ID: VM
°,RO~ CERTIFICATE OF LIABILITY INSURANCE oarE(MM/oonvvvl
01/11/11
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 cert'rficete holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS 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
certfcate holder in lieu of such endorsements .
PRODUCER 631-864-1111 NAMEACT
Regatta Associates, Inc. 631-864-8274 PHONE Fax
823 W Jericho Turnpike Ste 1A A/C No Ext: AK, No):
$mlthtOWrl, NY 11787 EMAIL
ADDRESS: _
Regatta Associates, Ina PRODUCER ARTHU-1
' CUSTOMER ID#. _
INSURER(sI PFFORDING COVERAGE NAIC#
INSURED Arthur) Edwards Mason INSURERA:Wercester Insurance Com pany 126182
Contracting Co Inc DBA Arthur INSURER a: '
Edwards Poo 18 Spa Center wsuRER c
929 Route 25A
Miller Place, NY 11764 INSURER O:
INSURER 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. NOTYYITH STAN DING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH 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. LIMTS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS.
INSR rypE OF INSURANCE POLICY EFF PpLICY E%P
LTR POLICY NUMBER MM/DD/YVYY MMADM'YY LIMITS
OENERAL LIABILITY EACH OCCURRENCE 6 1,000,000
A X COMMERCIAL GENERAL LIPBILITY MPA00000036601H 01101/11 01/01112 PeEMISES Ea ocwrre~w s 100,000
uAiMSMAOE ~X occuR ~ IMED Ex~lAny one person) $ 5,000
I PEasoNALaADV IN,uRV $ 1,000,000
tIt X BLANKET ADOITIONA I GENERAL AGGRECnrE $ 2,000,000
~'L AGGREC--ATE LIMIT PPPLIEG RER ~ PRODUCTS-COMP/OP AGG $ 2,000,000
I POLICY PRO- LCC I $
AIJYOMOBILE LIABILITY CON.EINED SINGLE LIMIT c
'ANYAUTO ~I ~ lEZ acr oenll
I ~ ~ BCCaLY e:,YJ RY IPer parsanl I F
ALLOWNED AUt05 ~ I I
' ! EODiti iN..URV IPer eccidenp', %
SCHEDULED AUTOS ~ p,R
EFTT'DAMAGE i $
HIRED AUTOS ~ I ~ ~ IPSrewldenn
NON-OWNED AUTOS ~ I b
UMBRELLA LIAa OCCUR j EACH OCCURRENCE $
~ EXCE39 LIAB OLAIMJ'JNADE ( '
(AGGREGATE $
I
I DEDUCTIBLE I~_ $
' RETENTION $
WOAKER3 COMPENSATION WC STATU- OTH-
ANDEMPLOYERS'LIABILITY y/N ~ .TORY LIMITS ER
qNY PftOPRIErORIPARTNER/EXECUTIVE ~ ~ E_ EACH A;;CIDENT $
OFFI~RIMEMEER E%CLUDEDD N I A
(Mandatory In NH) E.L DISEAp'E-EA EMPLO VEE $
Ir W s. aescrma under
DESCRIPTION OF OPERATIONS DeIOw E.L. DISEASE-POLICY LIMB $
j
OE9CRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (AaacF ACORD 101, Atlditlonal Rema Ma Schetlule, If mon space Is requi,ndl
CERTIFICATE HOLDER CANCELLATION
0000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E%PIRATION DATE THEREOF, NOTCE WILL BE DELIVERED IN
Town of Southold ACCORDANCE WITH TH `OLICY PROVISIONS.
Town Hall
P,O. Box 728 AUTHORIZED REPRESENTATNE
Southold, NY 19971
~
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
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
j~ EROSION SEDIMENTATION & WATER RUN ASSESSMENT FORM
[~(J CERTIFICATE OF WORKER'S COMPENSATION
[~I 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
[~Q C.O.
TAX BILL
$300.00 CHECK FOR PERMIT FEE
PLEASE CALL OUR OFFICE IF THERE ARE ANY QUESTIONS REGARDING
THIS APPLICATION.
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s~ VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788
y~;~ DATE ISSUED: 5/1/80 No. 2740-ME
_ - _
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SUFFOLK COUNTY ~ b
Wn _
Master Electrician License
=2-,
.
This is to certify that EDWARD S REIFF
doing business as UNDERGROUND SPECIALTIES INC ~
having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in
3
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x4`~ ~i ~~r5; ~
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SUFFOLK COUNTY OE!'ARTMENi Additional Businesses
OF CONSUIu1FR AF'FA1R:i y~
ELECTRICIAN
~ii I EDWARD S REIFF
w.wa»we.q
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~ bier is duly licensed ~0"'~~'!'~ f-""c"``-t~~'%~-
L6'vMA~BY OleiaW
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Section A-A Typical Wall Section J
SIZE A B C D E F G H AREA CAP.
FESf FT. FT. FT. FT. FT. FT. FT. FT. SQ.FT. GAL rim..
IBz92' 16' 32' 8' 14' 8' 4' 4' 8' 512 19,000 ~tt/~iit~'dafc~tds_
16'f~6' 18' 3B' 12' 14' 6' 4' 4' 8' 576 21,800 POOL & SPA CENTRE
PERMACRETE WALL SYSTEM
18'fd8' 18' 3B' 12' 14' 6' 4' 5' 8' 848 24,300 929 Route 25A Miller Place NY 11764
20'z40' 20' 40' 18' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (831) 744-0174
24'z44' 24' 44' 18' 14' 8' 4' 8' 10' 798 30,000 Suffolk License #4436-HI
24'z48' 24' 48' 20' 1B' 8' 4' 6' 10' 900 30000 Nassau License #HI7445OOOO