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HomeMy WebLinkAbout37514-Z ,,N~~~ { Town of Southold Annex 8/28/2013 c P.O. Box 1179 54375 Main Road i~q~ Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36473 Date: 8/28/2013 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2700 Fairway Dr, Cutchogue, SCTM 473889 Sec/Block/Lot: 109.-5-14.13 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Pernut heretofore filed in this officed dated 9/4/2012 pursuant to which Building Permit No. 37514 dated 9/13/2012 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 Around swimming pool with fence to code as applied for. The certificate is issued to Paulick, Walter (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 37514 11/13/12 PLUMBERS CERTIFICATION DATED AA ored Signature' ,,,~F~~ <<, TOWN OF SOUTHOLD ~y BUILDING DEPARTMENT o~ ~G`~ TOWN CLERK'S OFFICE :2 • SOUTHOLD, NY ,,.~i 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 37514 Date: 9/13/2012 Permission is hereby granted to: Paulick, Walter - 700 Fairway Dr_ - - - Cutcho ug e, NY 11935 To: construct an Inground Swimming Pool, fenced to code as applied for At premises located at: 2700 Fairway Dr, Cutchogue SCTM # 473889 Sec/Block/Lot # 109.-5-14.13 Pursuant to application dated 9/4/2012 and approved by the Building Inspector. To expire on 3/15/2014. Fees: 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 (IOAVA,/~_+~t/ BUILDING DEPARTMENT ~IJ 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 farm). 3. Approval of electrical installation from Boazd of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%Iead. 5. Commercial building,. industrial building, multiple residences and similaz buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6: Submit Planning Boazd Approval of completed site plan requirements. B. For existing buildings (prior to Apri14, 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, ftddifions [o accessory building $50.00, Businesses $50.00. 2. Certiftea[e of Occupancy on Fre-existing Building - $100.00 3. Copy of Certificate ofOccupancy - $.25 4. Updated Certificate ofOccupancy - $50.00 5. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 Date. ~I~IIZ New Construction: Orld or Pre-exnisting Building: (check one) Location of Property: 2~ -Y~Q{J/h(' UYCI t~Q, r t i7~t~j?e House N1oJ,.~ n,, Sheet Hamlet Owner or Owners of Property: ~Q~j Q/U~, I C IL rr Suffolk County Tax Map No I OOQ Section Block ~ Lot Iy ~ t!3 Subdivision Filed Map. Lot: PermitN4•. ~~5 .Date of Permit. `/3' / Applicant: -~~IdIQ,QI~~ Q~ Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: _ ~ (check one) Fee Submitted: $ J~~ , ~ ~i~ .L r~.a.luk Applicant Signature ~o~~pF SOpTyolo Town Hall Annex yy Telephone (6311 765-1802 54375 Main Road ~ T Fax (631) 765-9502 P.o. Box t t7v roper. richert(ciltown.southold.ny.us Sou hold, NY 11971-0959 ~ ~ ~1y00UN~'1,N~ BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Walter Paulick Address: 2700 Fairway Dr City: Cutchogue St: NY Zip: 11935 Building Permit#: 37514 Section: 109 Block: 5 Lot: 14.13 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Elec-T@C Inc License No: 4814-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 1 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 2 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS other Equipment: in ground swimming pool to include, bonding, 1-control panel, 2-GFCI circuit break 1-pool light, 1-heat pump Notes: Inspector Signature: ~~,L~J ~ Date: Nov 13 2012 81-Cert Electrical Compliance Form.xls T TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 1 NSPECTION ( FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING [ ]FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ] EL AL (FI ) REMARKS: G 6 ct DATE ~ y' INSPECTOR ~o~,~,OF SDUTyo6 ~~~1 '~~bUNl1 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING [ ]FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) ELECTRICAL (FINAL) REMARKS: DATE ~ ~ v INSPECTOR ~o~,~oF sour„~6 3 7sl ~ TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION iST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL) REMARKS: ~~r r ,tit.:-zy~. ~~w~ c.q DATE I ~ ~7 ~ l ~ INSPECTOR ~c- U / ( ~ ~o~~Of SOOTyo6 +IF ®'1<' TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]ROUGH G. [ ]FOUNDATION 2ND [ ] I CATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (~RO~UGQH) [ ]ELECTRICAL (FINAL) REMARKS ti-~-~-Q~ ~ c~ ~ ~ i DATE ~ ~ INSPECTOR / ~ C ho~.~,OF SOUTyo6 66 < 7"' ~ 'F ~CpUNf1,'~' TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTIO [ ]FOUNDATION 1ST [ ] ROU PLBG. [ ]FOUNDATION 2ND [ ] I ULATION [ ]FRAMING /STRAPPING ( FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL) REMARKS: DATE ~ INSPECTOR FIDSLD ~ N3tS.~I)AT DATE COMMENT3 ' ~ t'°a C ~l FOUNDATION (1ST) ae j ~ FOUNDATION (2ND) ~ ~ z 0 o . ROUGH FRAMING & ~ H PLUMBING W INSULATION PER N. Y. STATE ENERGY CODE l/' FINAL u' 'T, 0 .C J ADDTTIONAL COMMENTS -t C- 3 ~ . ~ $ - -I G/ 1 ~ ~~Lcz - d~ ~ z m z C~ o x ~ e - 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. :375/~ Check Septic Form N.Y.S.D,E.C. / Trustees Examined y// 20 ~Z ~ Contact: Approved~/~/3~, 20~~ ~ Mail to: Disapproved a/c ~ ~ Phone: . Building Inspector APPLICATION FOR BUILDING PERMIT Date , 20 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 azeas, 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 Pernut 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. asherein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, egulations, and to admit authorized inspectors on premises and in building for necessary inspections: a, (Signature of applican name, if a corporation) °'i11~ME~iATELY" ~ ~ ENCLOSE FOOL TO CODE UPON COi.1PLETION ~ii" ! ~~e~C 0(,,~Q BEFORE "WATER" _ : - (Mailing address of applicant) State whether applicant is owner, lessee,;a/gent, azchitect, engineer, general contractor, electrician, plumber or builder Name of owner of premises ~'RCIJ Qi1Ui,l ~fy ttikr~. i3 P 4+ 37s,~ (as on the tax roll or 1 tit deed - nt6i~FY i',.,I~G~N~~ ;;l ,ytRtMexStRT If applicant is a corporation, signature of duly authorized officer 7~ ta,;2 i# Ati1 ICa a ~~r ~U~LCIWING IN~HECfi~O~S (Name and title of corporate officer) i FOUNDATION • TYVO ta€ :U~t=,. J FOR POURED CONCRi=`i f Builders License No. ~y,, 2 ROUON • FRAMING, PLUM®IN STRAPPING. ELECTRICAt< 6 ~ d'- CK a.. INSULATION Plumbers License No. 1; FINAL • CONSTRUCTION d ELEifi~ lC MUST BE COMPLETE FOR C Q Electricians License No._~~ ALL CONSTRUCTION SNALL MEET Tlil REQUIREMENTS OF TWE CODES Ol N}~Ni Other Trade's License No. YORK STATE, NOT RESPONSIBLE F0~ OESION OR CONSTRUCTION ERRORS 1. Location of land on whi h proposednw-ork will be done: ,t~ House Number Sweet Hamlet„ County Tax Map No. 1000 Section Block ~ Lot Subdivision Filed Map No. `T6Y ' (Name) EL.~G~'~NC~L iR9~~~CT~t~~~.; ~1r i~(~~~~ 2. State existing use and occupancy of pre es and intended use and occupancy of proposed construction: a. Existing use and occupancy ~182n(~ b. Intended use and occupancy ~S ; ~,1iy19/ry1//t/$ P~,_ 3. Nature of work (check which applicable): New Building Addition_ Alter ion_ Repair Removal Demolition Other Work_ __I/I7 lid cXli. (Description) 4. Estimated Cost 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 Rear_ Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Q Number of Stories 8. Dimensions of entire new construction: Front ~6 t Rear ~ ~ Depth ~ ~z y ~ ~ Height Number of Stories 9. Size of lot: Front ~ Rear ~ ~ ~ Depth ZZS 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~~~//_ (~n Will excess fill be removed from premises: YE NO 14. Names of Owner of premisesf~N PAUUCk. Address P~ og?G~ ~ Phone No. Name of Architec~tyts 4 Qedly ~ _ Address!~~ /..J '~.trf><~ktwJ Phone No 7ZY-78$& Name of ContractorA~~i ~~~IJA,rras o 5p4 Address ~S1 P.~2s74 Phone No. ~7y~/-7~5 ygrlle,~ 15. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE R QUIRED - 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 YORK) SS: COUNTY OF being duly sworn, deposes and say:, that (s)he is the applicant (Name of individual signing contract) o/~ ~na Lm~~ed~,~~ , (S)He is the ~n l>11Kill.« (Contra, Agent, C.~inorate 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 set forth in the application filed therewith. Sworn to before me this day of tJs1- ' 20 /zT. 'Q 1~.r.~au _ No ary ublic S afore of A licant MARGARET A. KIDNEY Notary Public -State of New York No. 01 K 160211 11 Qualified in Suffolk County My'Canmission Expires March 8, 20~ ? Town of Southold -Chapter 236 - Stormwater Management ~ ~ *r~,f~~, SWPPP -Storm Water Pollution Prevention Plan Assessment Form GF.NF:y2Ai. INFORMATION: (All Requested Information is Required for a Complete Application) APPDCA/A W1ME: Owner-Agent-ConaulbM•Conbaebrv ONer (G(rcN One) Pro I. Per1Y OWNEiC jp Dpten:M Nan Apppcanq i z~ R A TaMtabonafi / - Fez fi T fi Fax fi ~ i E-Mafi 'T' - E-Map: ~ -7 r P'oPa'""°°°"` 2 /00 .FA~eN' ~E CJ~lt Oryv~ ~'afComsnrSon A~vit)'.Proposed sDUCdaatBMP., sal s.C.Tx fi Stabaliauoa BMPa, Project scopeand/or i 1000 ~ ~Si ~.I~ serNrnce ofCoashocOOa Atdvity . o4~ii a.ak. 1q rviwnaCMdUa.a P.yu as Nwae~ . w convector rxew troMactPamn Reapomibla rartmpkm.MeOOn aswPPP. ~~--pp.~~..yy~~~~ Ipr38 j~~~~~~ ~ ' WArcUS PJY n 5 f°"."F'°~"---"-'--~'-"-O_ IN~~.~p _ i q2a ~t 2~A I-lllltc cAt~ ---~-`-~~~--'t~/-J~~-i"~r~m~°~-rl/~-- --wl`Tlt__~(~_ r n.r ~ Faafi ~J.l__11~C~f_4~ _ ~tGL _-M';-_ -7 -Ol7V Name of P•nonsRespenaiM•lerhnWhpons MCMlenann olErosbn control Practlp: ~ Ille2__y4L__~?~ I ~ ll TekpMm fi Faa fi i , Trial Ar•aMM TolalArea or larM Ckadrg I~ Pmjerl Parceb: ~ arpxor GrgxM DISMpwwe: ~ . 13F.IAOa) IS.F.IApu) ' Project Duration: alga End eAnxdPalee) J7o :Date: (1 S Dale: l0) - WIIl this Project Disturbs five l5)or Mora Aeres at ! i f~'I ~ Any Ona Time During the Proposed Development? YL~ ~ Ir YES: Pleua Argwer tM Folbwinal r a. Does the Applicant have a Qualifred Inspeda On Q SFaB To Conduct the F3gquired Inspections ? rY"~es No b. Does the SWPPP Indicate How FrequentlyNe Site LJ O Llst Na NAMES or Oesviplion of all Potentially Impeded WaleNOdles ands Wvxands: Inspectrons wiN Occur and fa What period of Time ? Yes No c. Does~Ule SWPPP l Adequately ldenBfy Ad Temporary Q Q arailorPermalcentSoilSlabalfzationMeasured Yes No d. Does UIe SWPPP Adequately Mrrltifya Complete I .Project. Phasing Plan T O ~ sblua or Mpeo1•d Waf•rboay: ieg. TOOL. assla) Usted, xnpa4ed_.) . e. Does the SWPPP Indicate AddiOalal Site Spedfk PraCtjces ttW Wip be l10¢ed to ProteU Water Qualiy? YO 0 j - L Has the Applipnt Submitleda Completed DEC NOOce - Of Intent and SWPPP Aecepharxaa Form for Review Q O nTe °r Impacted Walaboay; (eg. bke, Creek Bay, Pond, Sound, FrahaaGr Wexand_.j by the Town ol3outhold ? Yes No I S'l A7'F. OF N6W YOItK, CO 'YOF ......................•bl-..............SS 1'haz I . L~.~~.K.,~..1.~,k,--.,, ~ l•/1~?[ nS,.•.. )Xing duly swum, deposes and says that he/she is the a Lcant for Penni I I ' IN?medt~ANdgl:gilnp`IiooilneM) ~ PP 4 Md thaz he•/she is the ._........_......1aXl.l.1f~"iS~ (OAn•r, t.aiYarlpr, Aged tgppala oace.,el'e) _ l Owner and/or represenptive of the Ownv of Owners, and is duly authorized to perform or have performed t}~e sard wprk and to I ~ make and file this application; that all statements contained in this appliation are true to the best of his Itnowledge and EelieF, and that the work will be pttformed in the manner set forth in the application filed herewith. Swom to-before me thu i~ . day onf 20.J2 , Notary Public ......~~.1~ aae ~ ) SWPPP Assessment FORM: D3-1? ~Y PIIbIIC _ f3~18 6f New Vbrk No. O t KI60211 11 Qualified in Suffolk-0ounty My Commission Expires March 8, 20~, T.O.S. "SWPPP" Preparation - Chapter 236 Feroepanm°"luaeonly: -7~1n A StOrM Water Pollwtion Prevention Plan 5.0.T.M.#: Property Adonaa; Z/yV rV}i (t /q,/ I{, ~ ~ Review Checklist Checklist # 1 10.00 ~ 1_4~~3 _ ~v-~ REQUIRED LAN INFO TION AND IMP MENTATION DETAILS; , ~ Does ttia SWPPP alai provide for and/or Indleatb ate Follow(ng: i YES , NO i NA ~ E%pWtation {or NO of _N~, Plan Sheet 1. Gra na e - _ ~ s t0 corltana moo nch in II n- de. - Locatlon (pg, 2. cona_trucgon Phtasl -Plan Indicatln 8e- mceoi ~ . ~---------g•_9o Proposed ConsWCUon Adlvlues. ~ ~ ~ i-----------------'----------------------._ 3 General Locatlon r~__ _ 'QI~I ~ 4 Drelallye Site Plan Drawn to Scale at 3IMx(80'),feat to the Inch or larger indlcanng Ne_F_ollowing i Q~©~ . . r- - e--4°94g4n~~93fNRgono{Prgpe1(y8oundades ..iC~i[~i r- - b Sltakcreay~L - ~ - f~~ ~ - - - c Ail _ - - : - - Exlstl~Nattasl and/or Man Made Features on and wkhm 50 of the Property Boundary -.;O~~i~`--SYILC. _ d Test Hole Data Indieatlng_SoU Cheraotartstics 8 D th b Seasonal _H~h Water Table a Q ~ , - e. Contcwre lndlcatfngproPerty_ElovatidrtejMln 2) - ..,Q'Qr r--------------------------.•------ - ) ..__Spot Grade 8 Flnbh Floor EI ___evatlpRfof Exlatlng end Proposed Structures __i~iQi g ~LOCa$ono7Wooaed7treas8lsolatedYreeswhhe~f~•llnlmumbimenstonottS•Dlammeter, ""iQi h. moll C-on"aervalfonDTa3TcFSolf$u - _ ,L'~, - 5 Back round In - - - - fl farmatlon about the3 Mthe Pro___~~don&Descd uon of the S,te ~ ;Q;~im,____________________________ Proposed Chan es to theSkeand Exlstl P , - ___D _ _____[t8, bevabpment do the site including the Following. 'Q~O~Q~ ~S~I' ' n~AA7 t(~ a_.AUJmPmvamnntsJnrlu9UfD7s~l.AmssilarW~lstut6ancel~Ts1e151te.&sa, '[~~~~p~-- ---~------vv-~1- ~cc_ SHnrnm,w9 ././~s~( b. al ExwwNon, FI . Uing, 3trlppfng 8 Greding Proposed and Identified as to daptH Volume ~ Q ~ Q iC~ 1 c., AlljvgasRq~W11ry CdgaMnAar!yor¢rubbingL_______ ~ ~ , , r_________ d, FUI Areas WhereT - - _'O,C1,I~J ba oad• opsoil is tO be Removed, Stockpiled and where Topsoil will ultimately I , ~ _ Q'Qi~, e All T~arlpore~B, Rtumanent Vegelafion to be Placed on SNe; _ _..;iQi[~r ~ - f All Tem raft'8 nt Stonri Wetar Runoff BMP Cc'nlrol M___ , r--'------- ensures Proposed; iQi~, _ ~ "rlteal a a Qate Ferrero of Surface DFalnaye Durln~Perlods of Peak RunoiF - , ~ r--------- - - h 7heLocatlonofail'F'Foaas,Odveway'a~Sldewaliia~Patfos.$trueWres;Ouliuei8a`ther ~Q~ i~i-_-------- - - P - - - - - lm rovemenfs,~~gl'imporary JCa'eas~toosEuctlon Smging_Areas- __.iO~L ~~7~---------°----------------------- _ t-7fieE>aa-dng'iGFinalZ'orifounanaa$- _ , 1 r----------------- ------------------po1-ETevadonsoft6eslte_-- - _ IQ,OI(~71 6 ASehWWe of fhs 3equsnos for the lnatalleaon of All Planned Sotl Erosion, Sedimentaaon ! ' r°-'----------------------------- BStarmwaterRunotTCOrdrolMea.mores, i~iQi~i 7 Desed gon of Ilutbn Preventlon Measures that wNl be lm lememed ~ _ iDiQ; -------p----~---------------- ----p A Description of the MlMmum Erosion & Sedimem Contol Practces to be Installed ancUor - ~ i i i Im IemeMsd for Each etlon that wlu result In Soil Disturbance. I Q' O' ' ~ _ _ _ , _ _ _t I I I 9. Descrl _ .PU3L~C90!tryxdaLa waste materiels Expectedbbe stored On-Sete. ~ r--------------------------- - - 10. Temporary & PermanAnt 3011 Stablgraflorl plan that meet }ha Current Version of the ' ~ ~ iQi i---'°------ - - - NewYork3faUStormWaterD- Manual T_e_r_hnl_ee_i_31a_n_da_r_d. ~Q~Q~ ~ 11. Generel Site Plan and consbudwn D forthe ecL I OrL~: 1 - - o - - _ 12. DlmensbrrsyMaterlalS~dGnuons&haWlsGOn DeWbfor At Erosion&SeAlment Control Practices. ;QiQ;~r~~_'-"-"-'---------------- _ _________________________________I 1 ' emporayPret3lcesthatwillbeConvenedt_oPermenerrtcantrolMeasure°.__________ -_~Q,Q,~__________________ 14. Impleman~ation 3cheAUls for Staging T°_ Erosion Control Prectlce or BMP. "~0f-°D'----- - IprO~~i----- - --------------i , , F-------------- 15. MalntenanoeSoAedulstoEnsureCOntirtuous&ERectlVeOperadonofErasion8 , , , , edlment Ctuarol Practloes. , Q i Q i 16. Named of Pottintlal Surface Waters ofthe State of New York andPor M54 that may be ; ' ' r~'-°-~'------- __-Im_r~gcte_d_ D_ iQiQ i~' _ C- ~ ..._J 1 I L y______-__ 17. Dellneafipn of3torm lf?ater Control Plan lm emeruauon Res ndbiliues for Eaeh art of the I , , , _ --°---'-~-°-------e0------------P--- ProjeMt:oaaauodpit"S~e. ----i0'O'L°~Jr-----------------------°------------- 18 All other ~:dstltry Data tltat Daserlbes Storm Water I~urwtf and/or Natural Dra_Inaga Swalea. _ ~Q'Q'Q'___I_~_.__ _ _ _ _ _ _ _ _ _ . _ 19'Idernlagtbn OfAiIATI Ca~trgcWr~s)!Su a , , , , ti0I1~_1'~1__ _ b•Corllfactar(j ResportslWeforlnstalifng,ConsWCtln , ~ ' ' Re alnn and Mro Erosion & Sediment Control Preedces. ~ Q i Q iQ i ~~UL ~ < /f _ _ _ _ Storm Water Ntaaagetneht Control Piaa Cheokltst # i : ~ 03.12 - JW aurrgt. DEC "SWPPP"~ Preparation - .Chapter 23619 ForDeparimentUe.ONy:' 5.0.T,M. Propeliy Addrosa: Storm Water Pollution prevention Plan Review Checklist Checklist # 2 tooo ~ 5 14.13 (Additional Items to be indudeti'with Checklist # 1 when Article III is trigered:) °iaBon ~ REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: , 1 1 I Plan Sheet Dow the SWPPP Ad ~ ats Provide fir md/or Indiate the Followin I YES , NO i N.A., Exptnatlon for NO or NA Must be Approved by 3M0 Location # (P8• ) 1. oas s n - _ or ow Oama at n this ac et 2. Does the Plm Indkxte arM/or Show a Dosed on o<Eaeh Poet-ConsWCtldn Stormwater ' ' ~ - Meneyement Ptactlce 7 i D i~ i i_ . _ I , _ 3. ~DOw the Slt PIaNConseucdon Drawing(s) Indicate mdlor Show the Location & Size df fir- - - _ Each t-COndWd3on 3tarmtNaterM tPractlce9 iQil~i®i 4. Dees the Sde PtNConssuctlon Drawing(s) Indleat and/or Show Hydrologic 8 Hydraulic Analysis ; ; ~ , ~ - For Ad. StrucWrei Component Of the Stonnw2ter Menapemam System for Applicable Storms 7 i Q i Q ~ I _ _ 5. Does the SItB PtNConstrudlon Drawing(s) Irndcat and/or Provide a Comparison of ~osF , O i i Davetopme~d 9fonnmater Runoff Cont7dbns with Pre•Oevelopment Cbntlitlons 7 ~ ~ ~ ~ 6 DoestheSde Plan/ConsWetion brewing(s)Indlptandlor Show All Dimensions,Material ' ' ' r-------~LL- - - Spedtlcatlims & Instadatlon Detalt for Each Poat-ConsWCtlon Stormwatr Practice 1 - ~ p ~ Q~ 7. Does the Sit PtrdCOrtatructlonbrawinp(s) Indleat a Maintnance Schedule Provitled by I I , " - - - - the Constractor(s) to Ensure CorNnuous & ERectlve Operatlon of Each PosFConstructlon ; Q.l~; ~ I I ,I 1 Stormwatr Management Practce Z - _ _.-1 1 I 8. Does the Site PIarJConstruedon Drawing(s) Indkat mdlor Show Maintenance Easements to ~ ` ~ - Ensure Arcws to All S[ornlwater Management Prectlces et the Site for the Purpose of Inspection ~ O ~ O ~ L]CJ ~ end Re r7 I , , , _____.___y I , r___________._____________________..__.___.__- _ 9. Does the 81te PIaNConsitudlon Drawing(s) Indleat and/or Show Inspection and Maintenance i O i O i t~ ABreemeM(s)-that are SkMlhQnn Ad 3ultequent Lmdownere 7 _ _ ~ I , ~ _ 10. For Ad Adlvdlas mee the ThreahoWM23E18 ling (B)(1 the SWPPP shall be Prepared 8 Signed ' ' ~ - _ - " By a Profwalatal N the Prlndpts end Ptadkea of.Stormwater Management & Treatment Who i Q I Q 1® i Who Shad Ca tl+aa he Meet the Wremerrt of Cha tr23s. ' ' ' ' i. I , I ----t I , r-`--------------------------------------~- - 11. Dow the Plan Indicate and/or Idently All Potndai Sources of Pollution which may affed the , , , , ~ Quallt of Starrnerater D w 7 ; O, Q' ' 12. Dow the Plan Pfovide Dowmenttlon Supporting Me Determinatbm of Approval with Regard I Q ~ d I .I - - ~ ~ - - ___toHistoricPlaaeswArcheoloskalFtasourceaUtatlndudestheFodowlny;-------------., I , 1 a. Irtfomredon whether the atonnwater discharge or Intl development adivides would have I I I , an efted on a property that Is Ilated or ellgiblefor Itdng dr eligible fir listing on the ; O , , -----~~teor_~4rla~$gplscerotWl~9.Pi?casj-------------------`-----=---. , 1 _ _ _ b. Tha Results of Htbdc Resources 3creenin~DeterrMnatlons that hev_e been Conducted _ _ 10' ~ 1 m I c. Dwdlptbn of Meaauna Necessary to Avdd or Mlnirillae Adverse Impacts on Places Llstd, fO,OI (~1 or EII IWe for _ on the Site or Natlonel R ttr of Histodo Paces; and ' ' ' ' d. Whore Adverse Effects May Occur, Any Written Agreements In Place wdh the NY§ Office ~ ~ - ~ ~ - - - of Parks, Recreation and Httode Places (OPRHP) or other Governmental Agency to ~ Q ~ Q i ~ ~ - _ Mltl to ThOSa EIFBCfs. i ~ , r__________________________________________. 13. A Description Of the Sod(a) Present at the Site, Indudtng an Identlficadon of the - " " - H drsclb Sod Grou . iQiQi~ ----y----------p 14. Idendflcatlon of Arty Bements of the Design d,at ere not In Conformance vnth the ' ' ' ' ~ - " Design manual, Indudktg Reasons for Me Oevladon m Alternative Design and a Description i Q i Q i i of the ulwl wdh tleehnkal 3tertdards, 15. AHydrologlc and Hytlraudc Analyst for AllSWdurel Component of the ~ . , r________________________________________._ IOrQ, I . StormwaUrManayBmmtCat7olSystem. ' , ' ' 18. ADetalled 3umrrwry, wlt~ifJel-cu-latlons, of tiro Sixing Crdeda that was Used to Desi n ,Q, All POaFConatruCtlon emmtPwWcea. i i i i , r_____________________ I , I 17. An Operations end Maintemnea Fim that lndudw inspection and Maintenance _ SehedWw and Aetlon b Ensure Contlnuous and F_Redive Operetlon of Each ' Q' Q' , , 1 , PosUConetruetlon Storm Water Practce. I , , ' Storm Water Management Control Plan Checklist # 2 : 03-12 ~o~~~E SO(~ryo6 54375 Mam RaadRoad ~ ~ T (631) 7651802 P.O. Box 1179 toner.richartla~ov~ml~osud.rn.us s«~a, wsr umt-09s9 BUILDING DFBAR'IA~Nf TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: = ` Date: ~ , Company Name: Name: License No.: ~ ~ rn dress: '~eev-~~ I'1 _ . Phone No.: (o ~j JOBSITE INFORMATION: (*Indicates required information) *Name: l.~ ~ sec' PG c) ~ t C1~ -Address: ~~"a2~:c, uxx~. Cy'~c1-~i to 6~ *Cross Street: 'Phone No.: Permit No.: Tax Map District: 1000 Sectiom .tay , Block: Lot: , ' 1 *BRIEF DESCRIPTION OF WORK (Please Print Clearly) ~~~k~~ ~ ~,a61 (Please Clr+cle All That Apply) *Is-job ready for inspection: NO Rough In Fina *Do you need a Temp Certificate: YE~ Temp lnfonnation (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 Overh~d Additional Information: PAYMENT DUE WITH APPLICATION ~ ta~o, R-e ~J-~o3 az-Request ror UspecUon Form t ~ - ~ ~~j " l a Town Hall Telephone (631) 765.180E 54375 Main. Road (631 7GS:A502 r.o. eox u79 rogecrichert(c~own. oUtnOltl nv us . Southold, NY 11971.0959 . ~ BUILDING DEPAR'I'11~NT TOVYI~i .OF SOU'i'IHOIi.D APPLICATION FOR ELECTRICAL INSPECTION REQUESTED 6Y: Date: Company Name: U,S.T. E~~lr`l7tIC Name: ~P ~CI~ icense Na.: 2~ Ne Address: YiJU15t~ Ro ~uJ s Qom( ` Phone No.: 131- ~4-QyQp JOBSITE INFORMATION: (*Indicates required information) 'Name:. ~QQ/~ p~LICI(, `Address: ,"Z~ ~ ~~,-yl„~ `Cross Street: 1~0 ~ `Phone No.: Z Permit=No.: S! Tax Map bistrict: 1000 Section: Block: _ Lot: ry.,t. *BRdEF DESCRIPTION OF WORK (Please Print Clearly) ~I ~ INSQa1nm ~nyc 5nli/{i/p~n/~ (PleaBti Clcele Alt That Apply) *Is~ jt>b ready for inspection: YE / NO Rough In Final *Do you need a Temp Certincate: YES / NO T~emp~lrfformation (If needed} *Servi~e Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *NeW Service: Re-connect. Underground Number of I(71t3ters Change of"i~lbe Overhead Additional Information: PAYMENT DL?E WITH' APPI~I - ~N 82-Request far Inspection Forrn r. ~ . .may , TOWN OF SOUTHOLD PROPERTY CORD CARD /'r OWNER STREET~',p VILLAGE DIST. SUB. LOT F~zMER OWNER E ACR. ~l~~a C)'~i'r 1 ~ lt~prire/ ~ S W TYPE OF BUILDING RES. y~ SEAS. VL. FARM COMM. CB. MICS. Mkt. Value jO ~ /i"1 ~ LAND IMP. TOTAL DATE REMARKS ,Q C>o f ~ /3f 7~'' 7 /2 i""; SOLQ 3i ?o? ~ ~ a . o 1, co ~ i -l~°r #w ~ u11 ' - ~`i~35noa <<'oo LoD /3 zoo 3 ~ 05' 0 -L 4 - ~ 4 I' ~rv~- a7 J (D D CV ~ 'G ~ CbZ a D~- S 1' ' 'n l0~0''11 ~LLi d -L12 Z l - a ~ -L rl (k l R ~gu ~ lC.~ ~2 L?ls ~ t~°d Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD ECiJ i dvleodowlamd DEPTH 2 Z S House Plot BULKHEAD Totol - pLOR TRIM D 3 < 7 s nE 4 S~ '1 7 ~ 3 ~ - - - ' 109-5-14.13 2/04 ~ ~ tt M. Bldg. 7/ f 3 j = 2393- ~1 Fx4enaian 9f /7= IS3 q ,r = a!o 799 ySo /Z 59L Extension ~/f 3 ° 3 3 Extension 20~~' C V Foundation c Bath 3 Dinette 7 IVG Qof~~o.,. yK ~y= 7(D .ro 38 Basement ~ Floors K. cr f~7 /3/0 /,oo /36 arc Ext. Walls Interior Finish LR. Breezeway Fire Place Yes Heat G. DR. hsGar~e /yf y~ 3~y ~ 6Z$ ~0 9 y,Z Type Roof Rooms 1st Floor BR. die ~ o~r~ Patio ra gA23 = 2a ~ Recreation Room Rooms grid Floor FIN. B p, B, Dormer ~ Driveway 5,n1ti„ Qmp,,..~ Total ~,3 7/Z is ? ~/2uNhu 7s"' 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 [~J CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF LIABILITY INSURANCE SUFFOLK COUNTY LICENSE ~J'- SUFFOLK COUNTY PLUMBER LICENSE [~Q SUFFOLK COUNTY ELECTRICIAN LICENSE 4 SETS OF PLANS - (3 STAMPED) 3SURVEYS APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK j~ APPLICATION FOR CERTIFICATE OF OCCUPANCY [ ] C.O. [ ] TAX BILL $300.00 CHECK FOR PERMIT FEE 1 Suffolk County Executive s Office of Consumer Affairs ~7ETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 7/1/7$ No. 4436-H . - SUFFOLK COUNTY _T~on~~~ T~~ro~ve~nent Contractor Llcerrse This is to certify that ARTHUR J EDWARDS doing, business as ARTHUR EDWARDS MASON CONTRACTING INC lavin~* 1'tnar~l7eu Prie Per,~~iremPY>i5 sei fuitii it accordance with and subject to the provisions of applicable laws, rrirs and iegrlatious c`the Cotxn:;~ of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. SUFFOLK COUNTY DEPARTMENT AQd1C10R3I BllS1I1CSSBS aF CONSUMER AFFAIRS i HOMEIMPROVEMENT 1 CONTRACTOR j ARTHUR J EDWARDS 1 This certifNS that the B1°""° barer is dui ARTHUR EDWARDS MASON ~ ~ J n Y CONTRACTING INC DBA lY/A"R?.i'VKnNn ^ licensed by the J` County of Suffolk 4436-H mrovts7s Duector - R...GSR. l71 c...w.+... I °'"""°"wre 07/07/2014 OP ID: VM '`~t~C...°iRO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 01/12/12 THIS CERTIPICATE 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 INSURERjS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcyjles) 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 certlflcate does not confer rights to the certlflcate holder In Ilea of such endorsements . PRODUCER 631-864-1111 NAME: BagattaAssoclates,lnc. 631-864.8274 PHOr>F FAX 823 W Jericho Tumplke Ste 1A C No Es : AIC No: Smithtown, NY 17787 E-MAIL Bagatta Associates, Ino, ADDRESS: CUSTOMER ID ARTH t1'1 INSURERS AFFORDING COVERAGE NAIC / INSURED Arthur) Edwards Mason INSURERA:WorcesterlnsuranceCompany 26162 Contracting Co Inc DBA Arthur INSURER B: Edwards Pool 8 Spa Center 929 Route 25A INSURER C: Miller Place, NY 11764 INSURER D: 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDRION 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. LIMrr3 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER MMIDDM'VV MMIDDIYYYY LIMnS GENERAL LIABILITY EACH OCCURRENCE $ t,000,OO A X COMMERCIAL GENERALLIABILITV MPA00000038601H 01/07/12 01/01N3 PREMISES Eeoccurrence $ 100,00 CLAIMSMADE OCCUR MEDEXP(Anyoneperson) $ 5,000 ~ PERSONALBADV INJURY $ 1,000,00 X BLANKETADDITIONA cENERALACCRECnTE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS~COMP/OP AGG $ 2,000,00 POLICY PRO LOC ~ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accitlenq ANY AUTO BODILY INJURY (Par person) $ ALL OWNED AUTOS BODILY INJURY (Per accitlent) $ SCHECULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accitlent) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE 8 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STAT U- OTH- ANDEMPLOYERS'LIABILITV YIN TORY IMITS ER ANY PRGPRIETOR/PARTNER/EKFrCUTIVE E.L. EACH ACCIDENT T OFFICERMIEMBER EXCLUDED ~ N 1 A (Mantlatory In NH) E.L. DISEASE ~ EA EMPLOYEE $ It es Describe antler DESCRIPTION OF OPERATIONS belvrv E.L. DISEASE- POLICY LIMIT S DESCRIPTION OF OPERATIONS! LOCATIONS! VEHCLES (Attach ACORD 701, Atltlltlonal Remarks SChstlule, Irmore space is requlretl) CERTIFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall P.O. BOX 728 AUTHORIZED REPRESENTATNE Southold, NY 11971 _ 7 OO 1966.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) lb. Business Telephone Number of Insured 631-74.4-7185 Arthur J. Edwards Mason Contractor, Inc. 929 Route 25 A lc. NYS Unemployment Insurance Employer Miller Place, NY 11764 24108715 Id. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is or Social Security Number spec~cally limited to certain locations in New York State, i.e., a 11-2377925 Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Ullico Casualty Insurance Company Town of Southold 3b. Policy Number of entity listed in box "la" P.O. Box 728 WCS-700093-00 _ Southold, NY 11971 3c. Policy effective period 01/01/2012 to 01/Cl/2013 Proprietor, Partners or Executive Officers are [ x ]included. (Only check box if all partners/o(ficers included) all excluded or certain artners/officers excluded. This certifies that the insurance carrier 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 the entity listed above as the certificate holder in box " 2". The Insurance Carrier will also notes the above certificate holder within /0 days iF a policy is canceled due to nonpayment of premiums or within 30 days !F there are reasons other than nonpayment afpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, lhts Cert~cate is valid for one year after this jorm is approved by the Insurance carrier or tts licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier Please Note:.Upon the cancellation of the workers' compensation 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 tli(Yt?ci:rtifirate holder with a new Certificate of Workers' Compensation Coverage or other anthorized prooYthat thebusiness is ciYtifplying 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 depict d on this form. Approved by: r / ~L~ s tint n me of au[ rize ep se~~~rve or licensed agent of nsurance carricr) Certified by: / /9 / (Sign/a~ture) (Dat Title: OM /YI~G7~/C~ /UICt//t 6t' i Telephone Number of authorized representative or licensed agent of insurance carrier: °t OpZ ~ ~ ~lf ` ' 79~ Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C 105.2 /iisu'rltnce brokers are NOT authorized to issue it C-105.2 (9-07) www.wcbstate.ny.us 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 ta. Legal Name and Address of Insured (use streetaadresson~y) 1b. Business Telephone Number of Insured ARTHUR J EDWARDS MASON 631-744-4455 CONTRACTING COMPANY INC 1c. NYS Unemployment Insurance Employer Registration 929 ROUTE 25A Number of Insured MILLER PLACE, NY 11764-2700 24 10871 1 d. Federal Employer Identification Number of Insured or Social Security Number 11 2377925 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier COV@rage (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America TOWN OF SOUTHOLD 3b. Policy Number of entity listed in box "18": P.O. BOX 728 009844240000 SOUTHOLD, NY 11971 3c. Policy effective period: 07/01 /2012 to 07/01 /2013 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: 06/28/2012 ey: s ~u~,~ S ~a,w Stuan J. Shaw, FSA, MAAA Telephone Number: 1-888-278-4542 Title: Vice President, Group Insurance IMPORTANT: If box "49" Is checked, end this form is signed by the Insurence cartier's authorized representative or NYS Licensed Insurance Agent of that carrier, this cerilfleate is COMPLETE:MaII It directly to the certiticateholder. If box "4b" Is checked, this certificate Is NOT COMPLETE for purposes of Section 220, Subtl.8 of the Disability aenefRS Law. It must be mailed for completion to the Workers' COmpensetlon Board, l)B Plans Acceptance Unit, 20 Park Street, Albany, New York 12207. PART 2. To be completed by NYS Workers' Compensation Board (Only if box "4b" of.Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed: gy; (Spnature of NYS Workers' Compensation Board Employee) 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-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5/O6) F £ a , ~ \ A ~ a .YY Y Y~ Y 'y f ~ \ /(5 u~a~ ~ i ~~H 9, i~, w 4+. ~ 3F vF:x~" nom' c, ~ x a , ~V .t 1. :~".iMY' \ p,M S, V' ~ I k w o x I ex xV+Na `Y~y+ \fq ~ ~ ' X,: dry . ~'T "f"qv' ~ a....'~i ~ a~ "16' ~ 1 5"~~'~i/'~ \ ~ ~ + ~ q ~ 8 'Yh ~',g~ x\}~ f~ \ N ~ 3 T ~r_IA eR'~43v aid! .i_5~1~~ 1~# .;..1~.4 ~~.1~..~i~;.~f .n ~r~~a. wi i'av ~5.,. y pxs~ 1.~a ' i I ~ x.y. • m n 7 vv ~ l ~ ' Suffolk County Executive s Office of Consumer Affairs 4 VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 No. 2740-ME I _ _ _ '.y ~ SUFFOLK COUNTY f Master Electrician License - This is to certify that EDWARD S REIFF doing business as UNDERGROUND SPECIALTIES INC 4 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. SUfi'4XJS OaJflTY pEPAR'1fi0ENT of ~ kFFNRB Additional Businesses ~ ELECSRlC!!aN . i ,3 } , I £171/M1tRp ~ REIfF ~ ~ ~ iTit G68 tl~t ~s 1 L f ~ S"141Pi I~Y® {:VMYfYW~ 1~~./1'K.~~ `!:'~"i-1~. A. /I, !S.' L.-.. 2740-ME {~uOttlg6p ~ s i r~ ' ep .~ww.v ~ ~ sx I, an..a~ ~ m+nro.ns 05X11lZDT< _ _ ~ r " H, I _ - 7 h "VS~ w 4 4 J' h i. I n~ A\ ~ ~ ~ ~ '~\Ff.v% / np FAbi t#~' £ °n '4 ~ ~ 0. 14 4 [N, vk Ac z L b'+ f v P ~Y krd a.a Rb,~..a v .W V Ark ~ ro ~r as '\t xm ~v. IAr~. tit'^k„ ~1 w.sY ~1?v ~E y'f` may, ~',~.py: ~ ',`~?ay" ~ ~~sv.~ ~ ti./ - - H AREA-607sq.ft. PERIMETER- 110' YDS.CONC.- 12 ~ REBAR- 17 FORM TIES- 156 c H E Rs ~a D z A R6'-l0' 0 R6' S A-C 43'-7" _i ~ Rs' B-D 43'-7" I 2 5 A-E 29'-2" ~ B-E 36'-9" c 5 F G Rs'-z~' A-F 19•_8" 8-F 23'-11" A-G 1T-10" R6'-a~' B-G 22'-$" ao'-1o• a-H 10,_2•, N 14 s ° 1e'-s B-H 26'-11" l3'-a• o A-J 14,_10,• o / M K B-J 13' RB' ~ p A-K 20' B-K 1$'-1" `r S A-L 32'_9° A-M 34'-10" B-M 33'-3" ~ R6'-10' S A-N 33'-10" C 2 20 B B-N 32'-9" L 38'-3' B A A ia.,,.,. iw.". B F B / n.,+..e . rw n.m ie w1r~ "T• xwn~ (on rr gulag ,eu.e uw c Plan " Piping. Arrangement wM M ur 42" ! Section B-B 10" Section A-A Typical Wall Section SfLE A B C D E F G H AREA CAP. FE61' Ff. FT. FT. Ff. FT. FT. Ff. FT. 9Q.FT. GA4 18x92' 18' 32' 8' 14' 8' 4' 4' B' 512 19,000 GnQJ(-l-~-6_ IB'z90' 18' 30' 12' f4' 8' 4' 4' 8' 578 21,800 & $PA CENMt6~_ '°tr~ PERMACRETE WALL SYSTEM IB'z9B` IB' 98' 14' 14' 8' 4' 5' 8' 848 24,900 929 Route 25A Miller Place NY 1Y764 °1t ZO'z90' ZO' 90' IB' 14' 8' 4' B' 8' 800 90,000 (831) 744-7185 FAX (831) 744-Q8.'74 w 24'z44' 24' 44' 18' 14' 8' 4' 8' 10' 798 90,000 Suffolk License (/4438-HI 24'x98' 24' 48' 20' 18' 8' 4' 8' 10' 900 90000 Nassau License #HI74450000