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HomeMy WebLinkAbout38256-Z Si: Town of Southold Annex 8/27/2013 ~ P.O. Box 1179 54375 Main Road tTtii Southold, New York 11971 "3: rae` 1 CERTIFICATE OF OCCUPANCY No: 36465 Date: 8/27/2013 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1250 White Eagle Drive, Laurel, SCTM 473889 SecBlock/Lot: 127.-9-18 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 5/5/2011 pursuant to which Building Permit No. 38256 dated 8/15/2013 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: accessoryground swimmine pool fenced to code as apnlied for. The certificate is issued to Thomas Short & Kay Lazidis (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38256 8/22/13 PLUMBERS CERTIFICATION DATED Au o ~ ed Si ature TOWN OF SOUTHOLD BUILDING DEPARTMENT ~ TOWN CLERK'S OFFICE SOUTHOLD, NY ,n , ~ ,F 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 38256 Date: 8/15/2013 Permission is hereby granted to: THOMAS SHORT ~ KAY LAZIDIS - 235 WEST 48TH STREET ~ ~ ~ ~~~T, j-f-,r.~_~ NEW YORK, N.Y. 10_035 To: construction of an in round swimmin g g pool, fenced to code as applied for. replaces expired b.p. # 36404 At premises located at: 1250 WHITE EAGLE DRIVE ,LAUREL N.Y. 11948 SCTM # 473889 Sec/Block/Lot # 127.-9-18 Pursuant to application dated 5/5/2011. and approved by the Building Inspector. To expire on 2/15/2015. Fees: PERMIT RENEWAL $125.00 Total $125.00 Building Inspector Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: I . Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similaz buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. 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 [he 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 [o dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate f Occupancy -Residential $15.00, Commercial $15.00 U Dat ~ / New Construction: Old ar Pre-existing Building: (check one) / Location of Propertyx /ZSO f-l~(~= ljfQl.~ ~+~/jTiLC(~ House No. L Street Hamlet Owner or Owners of Property: ~ ~b'1t'liL ~ s q- ~g y Z I ~ / ~ i Suffolk County Tax Map No 1000, Section / L ~ Block ~ Lot / Subdivision Filed Map. Lot: Permit No. _ ~ 0 Date of Permit. S 2CU - l / Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ ~ , Zti ~ C ` Applica Signature Y ~pF SOp Town Hall Anncx Telephone (631) 765-1A02 54375 Main Road ~ Fax (631) 765-9502 P.O. Box 1179 G ~ ~ ~oN roger. richert(ciltown.southold.nv.us Southold, NY 11971-0959 o~~00UNTV~ 6UILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Thomas Short Address: 1250 White Eagle Drive City: Laurel St: NY Zip: 11948 Building Permit 38256 Section: 127 Block: 9 Lot: 18 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Rocky Point Electric License No: 32644-me SITE DETAILS Offce 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 gas 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 1 A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches Twist Lock Exit Fixtures TVSS other Equipment: in ground swimmin pool to include, bondin 2-pool li hts 3-GFCI circuit breaker: Notes: Inspector Signature: ~ Date: Aug 22 2013 81-Cert Electrical Compliance Form.zls j ~ ~o~,~oF souryo6 C~ ~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ( ]FOUNDATION 1ST [ ]ROUGH P~BG. [ ]FOUNDATION 2ND [ ] IN ATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRIC OUGH) [ ]ELECTRICAL )FINAL) REMARKS: ~ ~ -~~r? r DATE ~ Z INSPECTOR l / _ , ~o~NOF SOUryp6 ~g®~ TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST ( ] ROUGH P [ ]FOUNDATION 2ND [ ] IN ATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) ( ]ELECTRICAL (FINAL) REMARKS: DATE I INSPECTOR ~o~,~oF souryo6 / l( ~ ~ ~ ~ 'P U TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 1 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: ~U ~ L~Zc~,c , G~. DATE 7i`V INSPECTOR FIELD ~ NItEF~DItT DATE COMMENTS. ;CJ) ~ FOUNDATION (1ST) s. ~ ~ i~ ~ FOUNDATI9N (2ND) ~ hY G y ROUGH FRAA2TNCF & S PLUIYIBING INSULATION PE1t N. Y. y STATE ENERGY CODE 7 1i_~ . ~ ~s ~ 1-~ ~v - FINAL ADDITIONAL COMMENTS ' ~ ti° ~ ? 3 DQ ~ eC c~6 ~ ~ o 1~ 2 R m a, u~ O z o 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 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. ~(Q Check Septic Form _ N.Y.S.D.EC. Trustees I Flood Permtt _ _ Examined - 20 I I Stornrwater Aasessmenl Form- _ Contact: -4PProved _ _ ~y~20~_ Mail to:~E~~~ y~p,.L~ Q Disapproved arc ~ 'l~"~'/'7/"'. ~~9~0 - -Phone: /6.369' /~'~C ~.~r Gxpiration---_ ~ . 20~~ ~ ~ ~~7' S~~ 0~ 2 ~ ~ ~ uilding Inspector IS 2011 A CATION FOR BUILDING PERMIT MAY Date S 3 . ~o aloe DEPT. INSTRUCTIONS TOW~J OF SOUiHOtD a. T ~ tea ton MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 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 sheets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Pern~il 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 the Building Inspector issues a Certificate of Occupancy. h. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not bean completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing. the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADti to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County. Ncw York and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or tin removal or demolition as herein described. 'The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. OCC~;'¢A6~~G`~' C)R "IMMEDIATELY" ~'eF IS UNLAWFUL ~6~f~r~~ p~ty~itS ' (Si nature of a licant or name, ifa cor oration) ENCLOSE POOL TO CODE a,,,_ i<?t/ ~ 6 uPONCOMPLEr10N ~~Vs-~H~.)U-~i~ CERTIFfCAT~ ~`t"'~'~~fi31 -T //s® E~FORE "WATER" (Mailing appddress of`~applicznt) State whether applicant is owner, lessee, agent, architect, engineer, general contracto~ePdt ,~1~~~~®uilder G~1/~ A FEE: By Name of owner of premises /N q~ L~1 Zr~lj /~/Qy~f ,~Q~OTIFY BUILDING DEPARTMENT AT 76~''OO~~T M FOR THE ( son the tax roll or latest d~1L0~NG INSPECTIONS: If applicant is a corporation, signature of duly authorized officer 1. FOUNDATION -TWO REQUIRED ~'Jfry~ y1tE,~~c~f FOR POURED CONCRETE (Name and title of corporate officer) 2. ROUGH • FRAMING, PLUMBING, STRAPPING' ELECTRICAL 8 CAULKING s?~k t~/~1o7 _ 3 INSULATION Builders License No. 7 /7 4. FINAL • CONSTRUCTION 8 ELECTRICAL Plumbers License No. ~LECTRiee~ MUST BECOMPLE7EFORC.O. Electricians License No. ~Ng'~EC"1`IAh1 DGA ALL CONSTRUCTION SHALL MEE77HE Other Trade's License No._ - ~ ~ . tJ~F~EC REQUIREMENTS OF THE CODES OF NFW ~ N YORK STATE. NOT RESPONSIBLE FAR DESIGN OR CONSTRUC''~~~. - ~-FOh I . Location of land on which proposed work will be done. RETAIN STORM WATER RUNOFF /z So W!/srF' [-9G~EGY+rntir ~9~FG k[ouse Number Street Hamlet OF THE TOWN COD~J Q County Tax Map No. 1000 Section ~L7 Block~_ Lot / _ Subdivision~~>y I~IC-~? N$dvh~S Filed Map No. 77'7 p Lot 2. State existing use and occupancy of premises and intende use and occupancy of proposed construction: a. Existing use and occupancy -~il~ ~1y/ lk~,>Lzta,~/G b. hltended use and occupancy_ -~1W(at.E /~ywgry ~tt~?4 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal_ Demolition Other Work,IW-~xyr?~ R»L hVs!>A'[.g)2[N/ (Description) 4. Estimated Cost 79~y~ Fee (To be paid on filing this application) 5. [f 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 miy: Front Rear Depth 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 Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner 1 1. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 13. Will lot be re-graded? YES NO ~ Will excess fill be removed from premises? YES NO 14. Names of Owner of premises~j~ ~sR~f Address ~~'je W/~EDcT E961F Phone No. 3YT 8~+0 • ZuD'r Name of Architect Address Phone No Name of Contractor A~rLJ Address(AM ~ ~1 Phone No. ~ 2 /.T aDjpy I S a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *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. 17. If elevation at any point on property is at 10 feet or below, must provide topobnaphical data on survey. l 8. Are there any!~o.;rdhati~fs and restrictions with respect to this property? *YES NO * IF YES, PROVIDE A COPY. STATE: OP NEW YORK) -"SS: COUNTY OF /~/•!•7~~ ~ being duly sworn, deposes and says that (s)he is the applicant (Name of i ividual signing contract) above named, (S)He is the (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 ~ue tq the best of 's 1~ww{ledge and belief; and that the work will be performed in the manner se[ forth in [he applicatidti j~ Swore o before me-this r day of ~ 20 I ~ ancE CACCAV Notary Public Notary Public-Steteof New York ignatureofApplicant No. 01CA8198619 ~ualfied in Suffolk County My Commission Expires December 29, 2012 A y. ~ ~ i bO~k Town of Southold Erosion, Sedimentation 8r Storm-Water Run-off ASSESSMENT FORM ~ veoPERTy LocanoN: s.cs.M. a: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A i ~4( ~ STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PWN Tirs chi 3-ectl n 'gkc r~ ~ CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK -PROPOSED CONSTRUCTION ITEM # /WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? (Indude Total Area of all Parcels bceted within ~ Will this Project Retain All Stoml-Water Run-Off the Scope of Work for Proposed Constmction) Generated by a Two (2') Inch Rainfall on Site? ? (S.F. /Aces) (This item will include all runoff created by site b. What is the Total Area of Land Clearing cleating andlor construction activities as well as all i and/or Ground Disturbance for the proposed ~ Site Improvements and the permanent creation of constmdion activity? impervious surfaces.) (5. IAaes) 2 Does the Site Plan andlor Survey Show All Proposed ? PROVIDE BRIEF PROJECT' DFSCRIPTiON 1Prmntle AEdltlonal Paea,uNaadM) Drainage SWdures lndicetlng Size&Location7 This Item shall include ail Proposed Grade Changes and Slopes Controlling Surface Water Flow. T ~l.~] / .~y, ~ ~ ~ wt 3 Does the Site Plan andlor Survey describe the erosion ~"7lin~n4w 0~'" 1-' vJ~a"~/~ and sediment control practices that will be used to ~ /~~G control site erosion and storm water discharges. This G `l~~s+.wr~ ~®L item must be maintained throughout the Entire ~ Construction Period, Q Will this Project Require any Land Filling, Grading or ? Excavation where there is a change to the Natural j Existing Grade Involving more than 200 Cubic Yards i of Matedal within any Parcel? , 5 Will this Application Require Land Disturbing Activities ? i Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? s Is there a Natural Water Course Running through the ? Site? Is this Project within the Trustees jurisdiction General DEC swPPP Requirements: or within One Hundred (100') feet of a Wetland Or Submission of a SWPPP is required for ell Conshudion activities invoving col Beach? disNmances of one (1) or more acres; inducting disturbances of less Than one acre that Will there be Site preparation On Existing Grade Slopes ? , are pan or a larger common plan that will ultimately dictum one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to inducting ConsW pion activities involving soil distumances of lass than one (7) acre where One Hundred (100') of Horizontal Distance? the DEC has determined that a SPDES permit a required for stone water dischayes. (SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit $ Will Ddveways, Parking Areas or other Impervious ? for Storm Water Diachargea from Conslructlon actlvily - Permtt No. GP-0-1g-0at.) SUrfaeeS be Sloped t0 Direct Storm-Water Run-Off 1. The SWPPP shall be prepared prior to the submittal of the NOT. The NOI shall be into and/Df In the direction Of a TOWm tight-of-Way? - submitted to the Dapedment prior [o the cemmencement of constmdion activity. 2. The SWPPP shall describe the erosion and sediment centrd practices and wham 9 Will this Project Require the Placement of Material, ? , required, poslconsbuctlon storm water management practices that wAl be used and/or Removal of Vegetation and/or the ConsWdion of any censtnu1e0 to reduce the polutants in storm water dischayes and to assure Item Within the Town Rightof-Way or Road Shoulder compliance Wlth the terms and COndltl0r13 of th6 permit In eddidon, the SWPPP shall - Area? rNS INm Mll NOT Ir~clutlv tM Inebllatbn a pdv.w.y gPmm.) Identify potential sources of poHWbn which may reasonably be expected to aged the quality of slortn rater dlseharges. NOTE: If My Mswer to Ouestlona One through Nina b Maweratl wah a Cheek Mark 3. All SWPPPS that require the posbcons(mdion storm water management practice in a Box end the corotruetlon ske disturbance is behveen s,aaa S.F. E 7 Ape N area, _ component shah be prepared by a qualified Design Professional Licensed In New Vode a Stertn-WaM, Greding, Drainage E Erosion Control Plan Is Required by me Town of that is knovAedgeabfe In Me pdndples end practices of Slone Water Management Southold and Must be Submitted for Raviaw Prior to hauance of My auilding Permit (NOTE: ACheck Mark N) anNn ui,etl fora COmpleb Apprimaon) o ary SPATE OF NEW YORK, No. Ot BU8185060 W o COUNTY OF SS QuailNed in Suffdk Counij- AA /~.~~yyuuL Commission E>gtlres April 14, 2- That I, ..........7•~.(~~/a./.~... being duly swom, deposes and says that he/she is the applicant for Pemut, QJama of individual sigMrg lbcument) ,~j~ And that he/she is the (Omer, Conbador, Agent, Corporate nitlcer, etc.j 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 we 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, lto hefore me this; y ~ Notary Public: ~ (Signature d AppFpnt) i FORM - 06/10 ho~~OF SO(/jhol ~I%.3// o~l Town Hall Annex Oyu ~ 54375 Main Road ~ ? Telephone (631) 765-1802 P.O. Boz 1179 ~ 0 rogecrichertCa~Ffowr%sou~tfioQd nv us ' Southold, NY 11971-0959 gava~ . ~otirm, BUILDING DEPAR'T'MENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name: ' Name: License No.. Address: ~ Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Address: ~U ~ *Cross Street: *Phone No.: _ q l Sc4 1 Permit No.: Tax Map District: 1000 Section: j Block: Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) ~~t'`t~,rc3wti.~ Pao ~ (Please Circle All Tfiat Apply) *Is job ready for inspection: YES / NO Rough In Final *Do you 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 i i 82-Request for Inspection Form Pelican Pools 509 County Road 39 Southampton, NY 11968 Attn: Gary Grismer Gary, Please take this document as confirmation that Thomas Short and I are co-owners of the property at 1250 White Eagle Drive, Laurel, NY 11948. We authorize Pelican Pools to construct an in-ground swimming pool on the property as outlined in the contract. Regards, Kay Lazidis A~ HeQiw Y. Brady Nntara Public • 8kak of Nee York No. OlHR49471108 Que!iGe~ in New York County e MM eaW eliAiion ¢aDiree Feb, 27, 20(}S ~~~~y ~ Town Hal I Annex ~ ~ O Telephone (631) 765- I A02 54375 Main Road ~ Fax (631) 765-9502 P.O. Box 1179 ~ Q Southold, NY 11971-0959 ~ i~ ~~~COUNT1,Ncc~ BUILDING DEPARTMENT TOWN OF SOUTHOLD August 23, 2013 Thomas Short Kay Lazidis 200 West 60`h St New York, NY 10023 Re: 1250 White Eagle Dr, Laurel TO WHOM IT MAY CONCERN: The Following Items (if Checked) Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) _[/~~~ectrical Underwriters Certificate. (contact your electrician) A fee of $50.00. Final Health Department Approval. PlUmberS SOlder CertlflCate. (All permits involving plumbing after 411/84) Trustees Certificate of Compliance. (Town trustees # ass-1ss2) Final Planning Board Approval. (Planning # 765-1638) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept BUILDING PERMIT: 38256 -Swimming Pool I NNNNrr 4gyrr r w W gru4y RNN Y - nuurl INmrunM1ryr Nrnrwuwuuuryyy NarMruuunyrgr dNrnuunuurnl rNrrNnnuanryy INUm uunuuxyl mu uum mw wuurryµµll ~ywwwl lyr ry 4Nrw NNNr ry N 11111 1111 plll 1111 11111 11g1~ 11111 1111 11111 1111 IN11 ~ ~ , Suffolk County Department of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/7/2009 No. 46207-H SUFFOLK COUNTY - = Home Improvement Contractor License This is to certify that ~ JAMES M OBRIEN _ doing business as PELICAN POOLS INC having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules ~ ~ and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk ~ License Category - NOT VALID WITHOUT Additional Businesses POOIs/Spas ` - ~ DEPARTMENTAL SEAL ' ~ AND A CURRF,N'f i CONSUMER AFFAIRS ~I ID CARD ~ ~ f ~ ~ ~ 1 C issioneF - ~ 1111 111) 11111 1111 tlNl ~tll/ tlIN tlll tl~ll tltf 1111/ ~ ~ a 1 N ylNrrrrrlrN INI N NN rlllrrrrrr Ilrl N r rrrrNlA rrrrrrrrr rrrrrrrrr rrrrrrrrrrrr rrrrrN NrNN rrrrrrrN rrrlN rrrrrrNrrNN MrrrrrrrrNrNµ rrrrrrrrr ~ r r rrrrrN N N;;~.. STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) Ib. Business Telephone Number of Insured (631)287-5135 Pelican Pools Inc. lc. NYS Unemployment Insurance Employer 509 County Rd 39 Registration Number of Insured Southampton, NY 11968 Work Location of Insured (Only required if coverage is ]d. Federal Employer Identification Number of Insured specifically limited to certain locations in New Yark State, i.e., a or Social Security Number wrap-up Policy) 112973725 2. Name and Address of the En[i[y Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) HARTFORD Insurance Group 36. Policy Number of entity listed in box "la" Town of Southold 12 W EQY2493 53095 Route 25 3c. Policy effective period PO Box 1179 11/01/2010-II/01/2011 Southold, NY 11971 3d. The Proprietor, Partners or Executive Officers are inClud¢d. (Only check box if all partners/officers included) - all excluded or certain partners/officers excluded. This certifies [hat 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 [he certificate holder in box " 2". The /nsurance Carrier wit/ also notify the above certificate holder within l0 days lF a policy is canceled due to nonpayment of premiums or within 30 days lF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this C'er[ificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid jor one year after this form is approved by the insurance currier ar its 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 certiRca[e holder, the business must provide that certificate holder with a new Certi£cate of Workers' Compensation Coverage or other authorized proof that [he business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, 1 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 depicted on this form. Approved by: Thomas P. Terry. CPCU ~ Print name of authonztd representative or I icensed agent of insurance tamer) Approved by: 04/12/2011 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier. (631) 283-8000 P/ease Nofe: Only insurance carriers and their licensed agents are authorized to issue h~orm C-10.1.2. !nsurance brokers are NOT authorised to issue it. C-105? (9-07) www.wcbstate.ny.us ,aco CERTIFICATE OF LIABILITY INSURANCE ogTE lMruoolYrrYl 4/12/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be entlorsetl. It SUBROGATION IS WAIVED, subject to the terms antl contlitions of the policy, certain policies may require an entlorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON ACT C thla BOllmnal8, AAI NAME: Yn Moran Corporate Risk Associates, Inc. juCD, NO,e%u: (631)283-8000 _ _ twc Noc tssll zBT-zzoT E4AAIL cboumnaia@mcrainsurance.com 300 Hampton Road A9RgSS:. _ - PRODUCER 00011880 4UBT~ID R: _ Southampton NY 11966 INSURERISI AFFORDING COVERAGE NAIC% - _ INSUREO INSURERA:H2rtPOrd Casualty Ins Co 29424 wsuREa e:HARTFORD Insurance Group * 00914 Pelican P0019 I3'lC. INSURER C: 509 County Rd 39 INSURER D: ' INSURER E Southampton NY 11968 INSURER F: COVERAGES CERTIFICATE NUMBER:GL Auto Umb 11-12 SVC 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 ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. INSR TypE OF INSURANCE ADOLj$UBR. POLICY NUMBER MM~OOY~ MMLOOYIYYYY LIMITS LTR GENERAL LIABILItt 'EACH OCCURRENCE_ $ 1,000,000 - - DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY _PREMISES lEa Oeeurtene9 __S 300,000 A CLAIMS-MADE X OCCUR 12WNQY29T9 4/11/2011 4/11/2012 MED EXP (Any one person) 5 10,000 PERSONALSADV INJURY 8 1,000,000 GENERAL AGGREGATE $ Z,000,OOO GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS ~COMPIOP AGG $ 2,000,000 X POLICY ~ PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1, OOO, OOO X ANV AUTO (Ea accitlent) - _ _ 12[nR4QY29T9 4/11/2011 4/11/2012 BODILY INJURY (Per person) $ A ALL OWNED AUTOS ~ - - (BODILY INJURY (Per accitlem) 4 SCHEDULED AUTOS _ PROPERTY DAMAGE $ _ HIRED AUTOS (Per accltlent) NON-OWNED AUTOS PIP-Basic $ Metlical payments $ X UMBRELLA LIAB OCCUR 'EACH OCCURRENCE S 1,000,000 - _ E%CESS LIgB CLAIMS-MADE AGGREGATE 5 1,000,000 _ _ _ DEDUCTIBLE $ A X RETENTION 8 10 000 1,12HBVQY2980 14/11/2011 4/11/2012 $ B WORKERS COMPENSATION X VJC STATU- OTH- ANDEMPLOYERS'LIABILItt .TORN LIMIT$.~B _ _ ANV PROPRIETOR/PARTNER/E%ECUTNE~ E. L. EACH ACCIDENT _$Q~~D00 OFFICER/MEMBER EXC WDED? NIA 12WEQY2492 11/1/2010 11/1/2011 (Mantlatory in NN) E.L DISEASE_EA.EMPLOYEFi$ SOD, DDD If yes tlescn~e untlar DESCRIPTION OF OPERATIONS Oelav EL DISEASE -POLICY LIMIT $ SOD OOO DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANacN ACORD 101, Atltlltlonal Remarks Sche4ule, if more space is requiretl) CERTIFICATE HOLDER CANCELLATION SHOULD ANV 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. 53095 Route 25 PO BOX 1179 AUTKORQEO REPRESENTATIVE Southold, NY 11971 T Terry, CPCU, AAI/SH ~r~ ACORD 25 (2009109) ©7988-2009 ACORD CORPORATION. All rights reserved. INS025 czoo9o91 The ACORD name and logo are registered marks of ACORD freye~ or fopnerly SURVEY OF LOT # 18 ranii aaase g `ko'ruf`anO SITUATE 37°02'Z2'E c°"crate Park LAUREL ~ ~°p~~ moundenr 8recreation area TOWN OF SOUTHOLD ~ ~ M zs. SUFFOLK COUNTY, NEW YORK N e• Pr°POSetlc^atnli°kfe SUBDIVISION MAP OF ao.o'--~ I ^ce 22p•93' GOLDEN VIEW ESTATES 'm+ y' °p_ °O"crate FILED AUGUST 30, 1984 = ~ manu"1ent O 40' AS MAP # 7770 "c = Q rovntl e.. c w; ~ F a m° ~ y ~ SCTM# 1000-127-9-18 ° N AREA = 41,723 sq ft a ° CERTIFIED TO : 5 ~ 0.96 acre zo.o• * KAY LA??nI5 u * THOMAS ANTHONY SHORT m r m m * FIDELITY NATIONAL TITLE ~ o, cellar INSURANCE COMPANY o > te~ entranee ti m ec m m 33.0' o °m w composite ¢ m a n tleck C m iiV w ° n 4, 0 m 31.6• c J/ m wootl 44s ~ ',>s. atePa house $ 9a a9e ~ as em Q pha/t drive n - 3t.e' 10.5' e, o u ^ n 2>.0~ t3.e' roof over W wootl °Pen porch ~ 4 at pa brick walk 3~0' a M ~0' ~~yy ~ ss.o• ~ ,t'~~',Q~N GAtC y~,y Y Cfi Hy°ti~ Z ~ ~ F~ may. evergreens w 132.46' _ t' west H P y ~ ~ concrete monument R-$70.00' ~ OSQ084 ~~0 found o h'hIITE Z=ZSS.47~ ~<qND Svc,. ~GLE r"f ~~tlenr JOHN CHER Djj j~ LAND SURVEYOR 59 FLORENCE DRIVE " REVISED : APRIL 20, 2011 (PROPOSED POOL, DECK & FENCE) MANORVILLE, N.Y. u949 °P"s~.-••~•• SURVEYED: OCTOBER 2, 2010 (63i) 8~4 - 0400 I POOL AMID PROPERTY TO OCHFORM TO N.Y. SPATE RESIDFIdfIAL OODE APPENDIX G 20fo EDITION i -POOL TU OGNPOltM 1f0 ANSI/NSPI SlAtalpR0.S AG103.1 ~+ItE IPT) A 0 C O E i O All CA CAV• ~ a. A L. ' t8 !1(ct _ . S.z~ ~ !,w?+\ r+ctamla , ~AVr M M.wPw) '(yam ~ .L~/fi~. ~+NUU.Vlt( 1x Da~lx uu~ M f V/.LVt /•xD cwL6~S-Dq L A A ant (~'roNwa -T•u6e \w GRnTEL ~8 B O ~ ~ ~ POOL P I- ~ N c p I I _ ~ OEoT1~oN L TN{OCSIGN K 3A3LD ON A ONAIN ACE SOIL rITN <4Y.. LIT. • . • ~ Gt%Cf 77ft ~IIVR (~'Q( 4{?lf A4SG11 Mf . CAQIMD rATCw LaAlt MOT CLST WR1tlN TxC VYRS OI TNC ~I+ w ~D , _ ~i~ L CiC1vATgN_ / GIDUTA rATCw C%1373 `nT1aN C'-O ?ClD'A' V,(,MC•,{Dwnp[k~ S W{{A u11G~ GRAD[ fICCLLL.-O[wAT L10NC IACUTK3 r'LLL K RCOU1wL0. :_T a~ }6. . ~ IY K~IfM rATCJl.~0cSt10 6L1YRC0 TO OM1CR~3 MOIp1TT. Ti ~r i W rJ/KriA11R ALIDwCD M1fN~-0~O! LUIIDr CNO < ~ i p(\.V(" ~ . AND ~~d OI OCV (MO. Y ..,.TM xY003T1\T(G, . x vA.wE Hite 3. M Isl(IWAMJTIIT At'I'L1CD IbNGRC TC (GVMfi CI 3+1wLt d' 'g~ : < co.,ICLTtR TvBf K A YIY M1Tx A NAZIYVY OC 3S .GwLIOKl or t ~ ~ H 6RAYpl t~'~<F rwTLRrinswa(orccYCNT. z ~N3&M15. --N~ia+~h~i hGHEt'1/CY~G t'l-O~"101NG~ilfSMN(nEI'1~N"r RLN/pwQMG STCCL INA LL wC IMTCwn CDIATL Gww DC ~ Mprs V,WN ~ILLCT STCCL TrRN A YIN IYVY LAI a 30 A4w- ~'~tr , I Av MO pF NFh, DuWCT[R3. 3. root rwTLw svrrlT sT orNL w'3 GAwD[M NOSL. ~ - _ _ 1 ! m,E( ~b~{0 ~Q~~ pT qOP TOOL TO K if lT lull OVwING iwCClING r(J1THC w.. V/4Y/s G 11/1 ~ - ysrtN <5- ) ~ (V~~ J9.P r~ IVY? WACJTT TO t( 3VI/IC1(NT TO [Y?TT TOOL I nlNl~ V-:. MMZ. ti/. )!'/•A * ~ r' w Movw:. ~ YPIGkL vlnT. 1l .c. Ai. _ , NhLL iS~G'~lorl n.~f ,ri.Aw+Mr.n nHp /urvti.rrt '6 `rF ~a~a~c I,azi. dis REVISED 5/iW H. ROY JAFFE, P.E. ~'D90F ~NP~` ]250 White Eagle Dr fSSlf,• w Laurel., [dY T~%-~i~ll