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HomeMy WebLinkAbout37604-ZTown of Southold Anuex P.O. Box 1179 54375 Main Road Southold, New York 11971 9/4/2013 CERTIFICATE OF OCCUPANCY No: 36487 Date: 9/4/2013 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 165 Sailors Needle Rd, Mattituck, SCTM #: 473889 Sec/Block/Lot: 144.-5-25.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this ofiiced dated 10/2/2012 pursuant to which Building Permit No. 37604 dated 10/31 /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 eround swimming_pool fenced to code as applied for. The certificate is issued to Klodnicki, Eric (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37604 6/11/13 t orize Si ature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD,NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 37604 Permission is hereby granted to: Klodnicki, Eric 2350 Deep Hole Dr Mattituck, NY 11952 Date: 10/31 /2012 To: construct an In Ground Swimming Pool fenced to code as applied for At premises located at 165 Sailors Needle Rd, Mattituck SCTM # 473889 Sec/Block/Lot # 144.-5-25.1 Pursuant to application dated 10/2/2012._ and approved by the Building Inspector. To expire on 5/2/2014. 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 n „ „~- ~ BUILDING DEPARTMENT '`-"~" TOW1V HALL $ °7Sr!oC~ 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 buildipg or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual nature} 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 finm plumber certifying that the solder used in system contains less than 2110 of 1 % lead. . S. 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. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 4, 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 spmpleted 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 [o the applicant. C. Fees 1. Certificate of Occupancy -New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool X50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00. 2. Certificate of Occupancy on Preexisting Building - $100.00 3. Copy of Certificate of.Occupancy - $:2S 4. Updated Certificate of Occupancy - $50.00 S. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 Si/ New Construction: Rb~- Old or Preexisting Building: Location of Progeny: House No. Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Date. ~~~~2- Hamlet Block O~ Lot 1~ / Subdivision Filed Map. Lot: Permit No. ~ 7 (o O ~ Date of Perout. /D ~ 3l - l o'~ Applicant: n /~-Q.cc~i~ / ,/vz9-~-0 Ilesith Dept. Approval: Planning Board Approval: Underwriters Approval: Request for: Temporary Certificate Fee Submitted: $ .~ ~ ~lVr-/ Final Certificate: 1/ (check one) Ap icant Signature (check one) ---~~ Town Hall Annex ~~ ~ Telephone (631) 765-1802 54375 Main Road ~ = Fax (631) 765-9502 P.O. Box 1179 O • Southold, NY 11971-0959 '~-1yo, „_ ,..>•or roger richertt7a town southold nv us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Eric Klodnicki Address: 165 Sailors Needle Rd City: Mattituck St: NY Zip: 11952 Building Permit #: 37604 Section: 144 Blak: 5 Lot: 25.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: SBA: Rocky Point Electric License No: 32644-me SITE DE 1 AILS 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 Service 1 ph Heat gas Duplec Recpt Ceiling FiMUres HID Fixures Service 3 ph Hot W ater GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blawer Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Onfer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS other Equipment: in ground swimmin g po ol to include bo nding, 1-pool light, 1-salt generator 2-GFCI circuit breakers Niles: ,-~ Inspector Signature: y` ~~~-~'~-~--~ Date: June 11 2013 Electrical Ceridicale.xls a~~ o~ TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 -~ SPECTION ~~ [ OUNDATION 1ST [ ) ROUGH PLBG. J [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING/STRAPPING [ ]FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) ] ELECTRI REMARKS: ~ DATE ~ / f Y INSPECTOR 32~0`~~ ~~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ] IN TiON [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ] ELECTR ROUGH) ( ]ELECTRICAL (FINAL) d REMARKS: ~~~~ ~ // ~.% `9 ~ ~ ~~~ ~ ~~ ~~ T ~ ~ ~~ ~C?P ,A.~r-L„~-J ~ j `L'~ ~/Ze97D4.~- ~7 7 ~"~~ DATE G~~3 INSPECTOR ~~ f ko ~-y- ~-cc,Es1' ~~~.,~ ~~c~~ 3 7 ~p ~~ o~~'~SW'y°6 ~~~ ~~~~~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ] RO H PLBG. [ ]FOUNDATION 2ND [ ] SULATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL) DATE ut~a. ~' '~ ~Amror~ tl~ -r' ~ ~,~A~rxor~ ~yrm~ ~& .gpU6$ PL Il~~~$~GY COff~ ~p.T~ gQiAL ~~ ---_, b ~~ A ~ Q ! TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey PERMIT NO. 3760 f~ Check ~ Septic Form_ N.Y.S. D. E.C. Trustees I~ lip ~ ~ 1°J OCT - 2 ~nt~ BLDG. DiSdpnrOVe a/C TnViN nF Expiration ~j,~ , 20~ ~°T~ o,~~ Building Inspector C.O. Application_ Flood Permit Single & Separate Storm-Water Assessment Form Contact: ~L~~~ Mail to: /~~+1W ~5 Phone: 7/~e ~ 36/f ~ /~O~f C G~~ ICLp-r,~'~,- APPLICATION FOR BUILDING PERMIT Date l~ . 20 ~ Z INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building lnspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas. and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION I$ 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, and regulations, and to admit authorized inspectors on premises a~~i4~6tt€Iding for necess~~ inspections. ~ w ~ ~ "ED~AT O ~ `' ' ° ' ' ~~ S ~ ` • _ ' i ~'~ ~ , ~ - CODE ; t_ "`°" SE p~U i /L=-- ~ ~ UP6NGO1+I;PLETION it, .I,~., TE i ~ eCAT " i nature of a licant or me, if a cor oral o ) ~ g PP P ~ WA oEFOR~ ' s of ap licant) aBd s ~ ail 3~ p u DATE' State whether applicant is owner. lessee, gent architect, engineer . gener~}~ntr~t~i l eC or builder NOTIFY BUILDING DE ART 765-1802 8 AM TG 4 PM FOR THE FOLLOWING INSPECTIONS' Name of owner of premises Ei~SC ~~01.IN`lLs~r t FOUNDATION -TWO REQUIRED (As on the tax roll or2lat~~~q@ MING. PLUMBING, If p icant is a corporation, signature of duly authorized officer STRAPPING. ELECTRICAL d CAULKING ~7~Jjgy ~r~S,>ry~ I~'EPiPElydE~T 3. INSULATION (Name and t tle of corporate officer) 4. FINAL • CONSTRUCTION & ELECTRICAL Builders License No. y6 Ld7 -~ S//fOyL C!/ MUST BE COMPLETE FOR C O ALL CONSTRUCTION SHALL MEET THE Plumbers License No. REQUIREMENTS OF THE CODES OF NEW Electricians License No. YORK STATE. NOT RESPONSISIE FOR Other Trade's License No. DESIGN OR CONSTRUCTION ERRORS. l . Location of land on which proposed work will be done: House Number Street ~ rT" et "n!6•nr,r.Tl~1~,~ ~~~9.d4~~ PURSUANT 70 CHAPTER 238 ~ ~ f~6DF~ ~IE TOIpQ1 ~S QIF County Tax Map No. 1000 Section ! Block . L Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended t'ise and occupancy of oposed construction: a. Existing use and occupancy /~' ~ b. Intended use and occupancy --?A'-~~ /~~~~ 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work ,St~)sfil~.ali~ ~vL (Description) 4. Estimated Cost 73 FXt7 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: Fr. Height Number of Rear Depth 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 11. 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~i~..~'LDA/zC.~ Address ~/0 ASS ~`~ Phone No. 9/7'P/~ - ~~73 Name of No Name of No. ~/~ -36 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES * 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. NO ,. :.~;,; 16. Provide survey, to scale, with accurate foundation plan and distances to property lines.' =~ -, ,. ..., 17. If elevation ~t„point on property,. is at 10 feet or below, must provide topographigal data on surve j>"' 18. Are there any._covenants and restrictions with respect to this property? *YES NO _ * IF YES, PROVIDE A COPY. ._ M.._.. „_- ~ ,+ STATE OF N.EW YO.~RyK) COUNTY O ~ U~1 ~-- ~~ ~~ 1'-1 S Y~ Q~'- being duly sworn, deposes and says that (s)he is the applicant (Name o 'ndivid'uaI signing contract) above named, (S)He is the ~ 1 (Contractpr; Agent, Co rate Officer, etc.) of said owner or owners, and is dulyauthorized to perform or have performed the said work and to make and file this application; that all statements contained in!thi~~8ppticatibmare 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 t9~efore me this ~ ~_ ~ C~~ . day of 'Q G-T ,~ 20~ VICKI ~'rH Notary PuWlc State of New v^: No. 01106190696 ~~ Qualified in Suffo1H fru~~- Notary Pudic ~ mm~ss~on Expire. ~~~+• Si ature of Applicant ~~~ Town of Southold -Chapter 236 - Stormwater Management ~~~Y SWPPP -Storm Water Pollution Prevention Plan Assessment Form GF.NF:RAT. INFORMATION: (All Requested In formation is Required For a Complete Application) APPI.ICA/A NAME. Owner-Agenl-Cwrs -eoesacmrorotner (circle Qxt l1r.~W ao I ProPertY OwNEJt ptnitxrentthaa AFPScsnq ~ /~10 o .P 9 S / ""~/6S~~Frtot~.tfr~zuE ,7z~/r~ ' e 369 / o -~`~`(oT t T / Sb 7 F~~ e-M.ik C,AR ~L.z7a9+t/f~7LJ2i/ . Coh E-r'~ERrCJ<[dow~rixs ~ ~9rL, ~' ^°""b'Adb°`/G.~ S9s1a~1./r~ s.GT.M.t. tpOp / 0 2S ~ n_iiiTeF' -ft"'' lldefnssrzigiooarcaoWSrlieoAmwb.prw~strfmrilBMPs,sd Shbarmtion BMPy Pcoktt3roye aadkr 3equmoe Dteonsln,ctim Ardmir Vpyilelddemll PequAMwNt ~L~' ttellle OFCOIW1bOf aMYW I:OIItaftPllSOq ttpp0lp~te tarlrrtplpnMlaNen bSNTPP; - r.~'~~J//~/]•~/ _____ E_Mart ___________________ Nwee et PersoeeRpponeiM brhtsppNerttMtlntenanea ol6eeNnl:aWW Pnefirs ------------------------Y------------------- __ ~ TeMplrorre /: Fa P. __ f'~!~_ ~ __d v ___SJ_ _ _~ }~W ~_ ~ ~ J ~ / ~ Y ~ _____ ____ ___ ~j~ 7(~~ - •• ~~-- ___ l 0 Te1al FVeaMM Pmjecl Panxh: r3F.,bvl Trial Area of land Creark5 anNa Glwnd Di5lwEarice: ISF.ibml __~/_ /,,('L___ _ _ ___~___~ _F---`a=_--J !! _!!!'!___ _ __ ____~D~_ .. .~ Proled Dwalion: wnuoPared) 7~ o: ~: /o is iy oa :: y i S ~ z _.__._________________ ____.__.__._____.__________ - --------------- -- - ~~=.,,.a,., - --------- Will this Project Disturbe five (5) or More Acres al - Any One Time During the Proposed Development 1 Yes No -------------------- dfYES:PMaseAwwerlMFOrkrwlrgr a. Does the ApprmaM have a Qualified Inspector On Q [~ i Y C F d I i N ________________________.-____._ ______________ 2gqu re ons ? es onduct the nspect o Stag To D. Does 1ha SWPPP Jndicate How Freyuenty the Sile Q ~ Inspections wll Occurand for Whorl Period dTime? Yes No c. Does-Ure SWPPP Adequately Mendfy AN Temporary [~ O andlor Permanent SoB StabaGzafion Measures? - Yes No A. Does Ibe SWPPP Adequately Iden6ry a Complete [_] ~ Plan? Yes No J'rojeM PhasM .lnr me »ASIES or desaiptlon aau Porenuaey Imwued wa<roodi<: anNO. WubrMS: ________________________________________________ ________________________________________________ _ -- _ --~-- ~ - -_ _ --- - g e. DDes the SWPPP Ifldkete Atiditlorlal Site Spedac Q o Practices That Wia be t111'¢ed to Prdect Water Wafily ? Yes No staNa of Mnwctsd WNweody: (eg.TMbl~ I73(d) DStea knPaged_) licant SubmitledaCom g A leted DEC Notice L H ----_-~'-'------'-'--'---'-"-~- p te pp as O(In[ent and SWPPP Aeeepfertce Eorm for Review C~I 0 Type W knwcud Waterkody: (eg. lake, u«k bay. Pons. sonrA, Frzshwatwwsaand_.) by the town of StwUaM ? Y SIP.-1'1: (Jrr Nb:W YVKK, COUN7Y OF ............._........- -l ---....._... SS That I, . .. ~~ ~`~ being duly swum, dcposu and says that he/she is the applicant for Pumi4 ~d' sgrLW~[ioaswWl........._ And that e/she is the ...._.._....» ................._...._._...» ...»__.~ __ pa~w'~tu~ ~ilBf++. t;a%nad: dea:"~_.,...._._...._....__. _____.........__.._...._ Owner and/or represetuative of the Owner or Owners, and is dtdy authoritcd to perform or have performed the said work and m make aril file this appligtion; that aB statunents contained in this appliation are true to the best of his knowledge and belief; and that the work will be ormed in the manner xt forth in the appliaUOn filed herewith. Sworn to before tree ' ; Notary Public: Assessment FORM: 03-1? a APPrr•+R) i i ~ I t ~ i r :I ' I' ,i 11 ~~! r j i l ~, !f I i i i i , i. 1_ i I '~ °® CERTIFICATE OF LIABILITY INSURANCE c~6~2oi2 Y) 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: M the ceRiOcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. H 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 certificate holder in Ileu of such endorsement(s). PRODUCER NAMEgGT Megan POglle, AAI Maran Corporate Risk Associates, Inc. PNONE (631)283-8000 X304 F^X .(531)28]-2207 300 Hampton Road eDOalESS. cboumnaia@mcrainsurance. com INSURED Pelican Pools Inc. 509 County Rd 39 NY 11968 f ~ Southampton P1SC 11968 ~ INSURER F: COVERAGES CERTIFICATE NUMBER:All Lines 12-13/WCSS-12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERTIFICATE MAV 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 HAVF RFFN RFnI ICFn RV PAIn CI AIMS ILTR TYPE OF INSURANCE POLICY NUMBER MM DDYIYYYY MIDDYIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000, 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence 300, 000 $ A CLAIM51.1ADE OCCUR 2UVNQY2979 /11/2012 /11/2013 MED EXP (An one person) $ 10,000 PERSONAL BADV INJURY E 1,000,000 GENERAL AGGREGATE E 2 , 000 , 000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG E 2,000,000 X POLICY PRO LOC $ AUT OMOBILE LIABILITY Ee erclOeM IN LE LIMIT 1 000 000 A X ANV AUTO BODILY INJURY (Per parson) $ ALL DNMED AUTOS SCHEDULED AUTOS 2UVNQY2979 /11/2012 /11/2013 BODILY INJURY (Per accitlenU $ HIRED AUTOS NON-ONMED AUTOS PROPERTY DAMAGE Pet eccitlent $ PIP-Basic $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1 , 000 , 000 A EXCESS LIAB CLAIMS~r1ADE AGGREGATE $ 1, 000, 000 DED X RETENTIONS 10,00 2BBUQY2980 /11/2012 /11/2013 $ $ WORKERS COMPENSATK]N X WC STATU- GTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCL DED? ^ N / A EL. EACH ACCIDENT $ 5DQ 000 U (Mandatory in NHl 2wEQY2492 1/1/2011 1/1/2012 E. L. DISEASE-EA EMPLOYE $ 500 000 If es, tlescrioe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ $00 000 ucs~.mr i vn yr Grercq Huns I LUI:q I IOHS /VEHICLES IANacR AGORD 101, AOOHlonal Ramaraa Sctletlule, It mom spice la roqulntl) CERTIFICATE Town of Southold 53095 Route 25 PO Box 1179 Southold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Terry, CPCU, AAI/ME ~~~ ~~ ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (zoloos~oi The ACORD name and logo are registered marks of ACORD T~~ ~~ ~ l79i~ Ny 1f71 ~~ y~g t Ii0 t' . I,~e: G ~ (_ -1 ---"'~ '- No- lW~~~~~ . ~ r..esrL.. •10sn~' ++~Ot16 ~= PeR~ ~4.: TeurMap D ~ Q~ BBD .;~.,: T~ ~ 1 P'1~ ~ `~`~ °rt' ,~~ ~~ ~~,,,,~~ff KII 13~ '~ ~o~ ~ ~ ~~ ~~~~~ ~ ~ . a ..... Wo~t~) '1s l~ ~ T~t?eN' P -..-----'~'..1 ~~~~~~~ tnn~OAFo+~ ,.,::,,: ~..,,,.. .,..hM,..~.r.~..,....~,...,~ ~ ......... _..._ S~f~Q~k Cvunty Dtepaartn~ent ~f ~o~as~r A~~rs VETERANS IVtEME2RIAL ~-IIGHWAY * HAUPPAUGE, NEW-YORK i I788 DATE ISSUED: 5/7/2009 No. 46207-I•I SiJ~FQLK COUNTY Ha~ne Improvement Contractor License This is to certify that JAIVIES 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. NOT VALID WITHOUT DEPARTMENTAL SEAL AND A CURREMf CONSUMER AFFAIRS ID CARD License Category Additional Businesses PoolslSpas C issionek SI)GTION G106 EN{I'RAPMEILP PRdPECPION REQUIRID POOL AND PROPERTY TO OD[gORM 'LC) N. Y. STATE RESIDENTIAL. S~a ION G107 ~E APPENDIX G ZOfo' EDITION ILL ALARM REQUIRID POOL 1U OCNFORM TlD ANSI/N;SPI STAISaARD6 AG103.1 eu E (F7) /~ D C o E F o AAN, [AV. a. is ~6 . .. _ . 3Z 7.. _.. _. t3 (__(~ C' FE I- A R't~uR~n F~~zER Pool P L.~N i 1 A „~, 7f1VL= A! M~Mw) GCx[RAL MOTCf~ - ~- S , ` nr L TNCOCSIGR tf lAXO OM A DRAINAGE SOIL xlTNtgx LlT.. , _ ~ b . i CROV NO xATCR fNALL NOT CXIST YfTWN TN[ WfTf Of TMC ~ ,(fTs 9 bY13 .~ C zCAwtT10N, I GI101R0 xATCR L%ISTS xTTMW a~-O KLAf .(~ LOIC/GIf) GRADC SfCGf{L-OCxATLINNG f/CRJT1[S mLL ~C REOUIRLO. ( ~'•,{•~~7~-~ R(n. TiGJ ;• ~ Tr4T[R. OCf IOS AL 6 UYRCO TO OxttRY M0101TT 7~ .~ ~ f ~~ . L YO >•.IIIgM71R ALA.OxCO MMfN i -0~ OF fNAL(px CNO - •~-- ARO a;-d of Kn cw. ~. 7_ M MIC1AtATIU4.lT AIIUCO CONCRCTC (wNrt [I s11ALt ~ '$ K A -, YIf: •TTTI A YAk1YUY Os S~•GAIIONi Of - . N 9 gyf5 xATLR IER idGK aF CCNCXT. ~ i . ~. ~- R[JNIT)RgYa fTCCI SNA LL DC INT[RY COIATC GMO( .. -i aatcT tTCU xrtN A YIN IYUY L1lI of 30 aAR. ' - y .. 4 ouYCrcllf. - ~'h'Q~~LTy{ 1 COOL xATCR fVIILT h'OxNCR~3 GAROCN NOS[- , ~~ M~~ IDOL TC1 K Kn Nll OVRING iRC CLU+G xUTNCR. ;~ YMlff (. p/~ - -UY- CA-AGTT TO •( SVffICICNT Tp [NITT fOOI nIN~~ - ~~,: -~~ i a z, Youlls. YPIGhL ~ LL ~SFG" tlOr7 Klodnicki 165 Sailors Needle Road Mattituck, NY 'S -- -t1ME fua+ ~ti 9 ~+ t ~ 1.. • -fftll '~ ~). T VLflj. 1 VdTT>• 1 ~GTOM G 4.T£L $?sO ~~~~ tr 7~aT1;oN ~ ~ f-isA PAY ixe 1Y1 r+va~ 1 t- tYV( ~u,r ~tfcgat ~' ~Lf .. __._.. -T 1~ ~ N ~LOOS7~T(c, vA.LVe ,.,+e cw-LCCi'tF. TvBf ~ ~µ 6RAY~8.44E Ltirt hGHEr'I,C7~Cr ~'WrIDINGI •rlftFNNGfEr16N-r µN1M~ ~+,Iw+w+rv +I IN oK1 MIO /.A /•h N!111Nf R4 REVISED ~y/4j H. ROY JAFFE, P. E_ ~ d - ~ 0 - f i