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HomeMy WebLinkAbout36968-Z Town of Southold Annex 12/11/2013 P.O. Box 1179 54375 Main Road } Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36654 Date: 12/11/2013 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1155 McCann Ln, Greenport, SCTM 473889 Sec/Block/Lot: 33.-3-27 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 1/30/2012 pursuant to which Building Permit No. 36968 dated 2/2/2012 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 ground swimming pool with fence to code as applied for. The certificate is issued to Goodman, Steven & Goodman, Susan (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 36968 4/13/12 PLUMBERS CERTIFICATION DATED th n ignate. •e TOWN OF SOUTHOLD BUILDING DEPARTMENT ® TOWN CLERK'S OFFICE SOUTHOLD,NY 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 36968 Date: 2/2/2012 Permission is hereby granted to: Goodman, Steven & Goodman, Susan 6 Piper Dr Searingtown, NY 11507 To: construct an accessory Inground Swimming Pool fenced to code as applied for At premises located at: 1155 McCann Ln, Greenport SCTM # 473889 Sec/Block/Lot # 31-3-27 Pursuant to application dated 1/30/2012 and approved by the Building Inspector. To expire on 8/3/2013. Fees: SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 1 Building Inspector ~-t e U -e (_Dooa rnet r) Form No. 6 TOWN OF SOUTHOLD RUILDINC DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OP 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 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 I % lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the 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 properly 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, 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 of Occupancy - Residential $15.00, Commercial $15.00 / Date. New Construction: V/ Old or Pre-existing Building: (check one) Location of Property: m c_ C-11N N G~ H N E^ Crle&r)0 k#Q T- House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section -2) J 3~ -1 . Block Lot Subdivision Filed Map. Lot. Permit No. 3 r2 l (o (1 Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ Applicant rgnature oa a ~L'-CiIL ~-u PO P~6 y l l 'd ~i Sl~~ t.~ t ? ti ")1 TO/10 39Vd S331SnNi Q-10Hinos T49999LT£9 £O:ZT £TOZ/60/ZT pF SOpTyolo Town Hall Annex Telephone (631) 765-1802 54375 Main Road 4 Fax (631) 765-9502 P.O. Box 1179 roger. richert(a)town.Southold. ny.us Southold, NY 11971-0959 o~yCOUlim,~ BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Steve Goodman Address: 1155 McCann Ln City: Greenport St: NY Zip: 11944 Building Permit#: 36968 Section: 33 Block: 3 Lot: 27 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric License No: 2740-me SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures TVSS Other Equipment: in ground swimming pool to include, bonding, 1 pool light, 1 control panel 2 GFCI circuit breakers, 1 pool heater Notes: Inspector Signature: Date: April 13 2012 81-Cert Electrical Compliance Form.xls ~+o~ sair~ 67 Q TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] 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: DATE 3 ~v INSPECTOR 3 / j ~ C/ o,~~,of SWltq¢o tO TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] IN LATION [ ] FRAMING / STRAPPING [1,1 FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH))) ~ Q[ ] ELECTRICAL (FINAL) 19 REMARKS: -T. y. DATED INSPECTOR 1-t -Y 3 G l g OF S0V TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ] 'DUG EIG. [ ] FOUNDATION 2ND [ ] I LATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICA (ROUGH) [ ] ELECTRICAL (F-IWJ_ REMARKS: DATE l / J INSPECTOR ~o~NOF SOUIyo TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROU PLEIG. [ ] FOUNDATION 2ND [ ] SULATION [ ] FRAMING/ STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE / INSPECTOR ~~o~ soar M,p TOWN OF SOUTHOLD BUILDING DEPT. 76s-1802 C U.~ INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION Q [ ] FRAMING/ STRAPPING [ ]FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTIO [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: - o cen~ DATE 3 ^ 7- INSPECTOR " Fffi.D N REPORT DATE COMMENTS ~ ro FOUNDATION (1ST) S at 0\ q FOUNDATION (ZND) Lf ti ROUGH FRAAMQ & PLUMBING W H INSULATION PER N. Y. STATE ENERGY CODE © 1 / O FINAL Z ?9 - 775 Ae c A ADDMON CO NTS O ;;E~ TZ 1 12" 41 rttd 4t-- i-l -DEG Ems- ' O wt b, m X W z d TOWN CIF 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. Check Septic Form N.Y.S.D.E.C. Trustee; Examined a , 20~_ ntact: p Approved, 20._L D Mail to, 7 t C - - ~~9 h- Disapproved a/c ~qN 3 0 2012 _g a ~3 Phone: Building Inspector APPLICATION FOR BUILDING PERMIT Date I - 25 - Z 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 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 a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of appli t or name, if a corporation) 2 NA lut Pc.1Ce (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises GoicuaN (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. 443c - 41 Plumbers License No. Electricians License No. a f?1L Other Trade's License No. 1. Location of land on which proposed work will be done: I IS5 I~rPnnn 11J Gt2~P a 7~qp~ tapir, House Number Street Harii1et r. , : att!,, Rw County Tax Map No. 1000 Section 63 Block 3 sI of ,2'~"' Subdivision Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and intended Ise and occupancy of proposed construction; a. Existing use and occupancy ! TDC t5192NCP b. Intended use and occupancy- kS1QNTAL ~ ImMil y(- JLX 3. Nature of work (check which applicable): New Building Addition _ Alteration Repair Removal Demolition Other Work J~gaJA0 6MMM/1V(~ 4. Estimated Cost_ 1`h M- _ Fee (Description) (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 ocpupftcy, specify nature and exte~ t of each type of use. 7. Dimensions of existing structures, if any: Front Rear ldf Depth c27 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 o2~ Rear_*J_____Depth 3'/z a $ Height Number of Stories _ 9. Size of lot: Front LO Rear Ito Depth 160 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: 1 `t o 13. Will lot be re-graded &AJ 24 QNt- Will excess fill be removed from premises: YES NO /~S~eenpaa 14. Names of Owner of premises L I - ~kueA CT~owtU Address 551UCCannLrn Phone No. 5)b- 40-3655 Name of Architect" b Qtj& D ei % ~c' Address 4t &g W L Phone No rIZJ • 7888 Name of Contractor Address Phone No. 15. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 16. Provide survey, to scale, with accurate foundation plan and distances to property- lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF ) !i r rte- J E&VAt05 being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the &tt'!'P` (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief, and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this -2~~ day of janJTT 201.2 ~ Q ~ of Public AWApplcant MARGARET A. KIDNEY Notary Public - State of Now York No. 01K16021 I I I Qualified in Suffolk County My Commission Exom March 8, 20~ 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: 0 APPLICATION FOR OUTDOOR POOL PERMIT EROSION SEDIMENTATION & WATER RUN ASSESSMENT FORM [ CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF LIABILITY INSURANCE SUFFOLK COUNTY LICENSE SUFFOLK COUNTY PLUMBER LICENSE SUFFOLK COUNTY ELECTRICIAN LICENSE [ ] 4 SETS OF PLANS - (3 STAMPED) [~Q 3 SURVEYS APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK APPLICATION FOR CERTIFICATE OF OCCUPANCY C.O. TAX BILL [ ] $300.00 CHECK FOR PERMIT FEE D JAN 3 0 2012 BLDG DEPT. TOWN OF SOUTHOLD AIGI 2013 ]rJ HO~o ! o t i 1 12 I.~ ~I V 1 i ~l 1 pF SO~lyOlo Town Hall Annex Telephone (631) 765-1802 54375 Main Road 4 Fax (631) 765-9502 P.O. Box 1179 Southold, NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD November 27, 2013 1 ok Steven & Susan Goodman S,' 6 Piper Dr Port Washington, NY 11050 TO WHOM IT MAY CONCERN: The Fol wing Items (if Checked) Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. (Contact your electrician) A fee of $50.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 411/84) Trustees Certificate of Compliance. (Town Trustees # 765-1892) Final Planning Board Approval. (Planning # 765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept BUILDING PERMIT: BP 36968 - Swimming Pool Town of Southold ® Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.c.T.M.s: THE FOLLOWINO ACTIONS MAY REQUIRE THE SUBMISSION OF A /s a a3on`03 d r7 k- CERTIF ED BYER DESIGN PROFDINAG ESS ONALrIN THE OSO STATE O/F NEW YORK. OL~ SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSMENT' Yes No a. What is the Total Area of the Project Parcels? (include Total Area of all Parcels located within (7 / _ /t Will this Project Retain All Stonn-Water Run-Off the Soope of Work for Proposed Construction) tW~ Generated by a Two (2") Inch Rainfall on Site? ? (S.F. / Ades) (This item will Include all run-off created by site b. What Is the Total Area of Land Clearing aQ ,f Gearing and/or construction activities as well as all JL and/or Ground Disturbance for the proposed 60 P !I` Improvements and the permanent creation of construction activity? Impervious surfaces.) (SF. / lam) Show PROVIDE BRIEF PRO]ECr DESCRIPTION Wm Adanmoaa 2 Does the Site Plan and/or Survey Location? l Proposed Pea" as Naa°itlj Drainage Structures Indicating Size e & & This Item shall Include all Proposed Grade Changes and ~L pmo05P,p aQ x q4 I A 4 2GJm3 Vlndt, Slopes Controlling Surface Water Flow. w mm IN9 0, _VL 3 Does the Site Plan and/or Survey describe the erosion and sediment control practices that will be used to control site erosion and storm water discharges. This 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 Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? fj Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? El v1 6 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 all Construction actMties Involving soft Beach? disturbances of one (1) or more scres; Including dist rbances of less than one aae that are pan of a largercemmon plan that will ultimately disturb one or more saes of land; 7 Will there be Site preparation on Existing Grade Slopes ? including Construction activities Imdving soil disturbances of lass than one (1) acre whore which Exceed Fifteen (15) feet of Vertical Rise to Ore DEC has determined that a SPDES Permit Is required for storm water discharges. One Hundred (100') of Horizontal Distance? ( SWPP.P'p Shall meet the Minimum Requirements of the SPOES General Permit 8 Will Driveways, Parking Areas or other impervious D for Storm Water Discharges from Construction activity -Permit No. GP-0+10-001.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shall be prepared prior to the submittal of the NCI. The Not shall be into and/or in the direction of a Town right-of way? submitted to tire Department prior to the commencement of constriction actlAty. 2. The SWPPP shall describe the srcelon and sediment contra practloas and where 9 Will this Project Require the Placement of Material, required, post- tructkn storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any constructed to reduce time pogdants In son water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions of this pent. In addition, the SWPPP shall El -4z/ Identify potential sources of pollution which may reasonably be expected to affect the Area? (This Ism wM NOT Include mhe 1--Wwbn madyawry Aprons) quality of storm Water discharges. NOTE: N Any Answer to Questions One through Nine Is Answered with a Check Mark 3. All SWPPPs that require the post-conatruction slorn water management prectioe in a Box and the construction site disturbance is between 5,000 S.F. b 1 Acts In area, component shag be prepared by a qualified Design Professional Licensed in New York a Slom-Water, grading, Drainage & Erosion Control Plan Is Required by the Town of that is knowledgeable in the principles and practices of Storm Water Management Southold and Must be Submitted for Review Pdorto Issatme OlAny So"" Permit (NO1E: ACheck Mark (4) "or Answer for eadr Question Is Regwred kr a complete Awkstim) STATE OF NEW YORK, COUNTY OF %~N.ERQ.L-K SS Thai i . .................~A?1~3,,,,,,,,---, being duly sworn, deposes and says that he/she is the a (Name a kdHdua signing DocumenQ n pplicant for Permit, And that he/she is the ~51nz vu!n~ (Owner. Cgntrnaor, Agent, Corporate Officer, ek.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 tnle 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. Sworn to before me this; say of ...nyqx T..... ~ Notary Public:..... Q_ C ABET A. KIDNEY IIl01Ury.f ift.-aw of Now.Ytrrh.. !Signatur gppkam) FORM - 06/10 CueNUsd In Suffolk Courtly My Cwiffftalm Ex*u March 8,20i5_ OP ID: VM a~coiz° CERTIFICATE OF LIABILITY INSURANCE 0 DAT1/12/1YY" 01112/12 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 631-864-1111 NAME:C _ Bagatta Associates, Inc. 631-864-8274 PHONE FAX 823 W Jericho Turnpike Ste 1A AIC No Ex : AIC No: Smithtown, NY 11787 E-MAIL ADDRESS: Bagatta Associates, inc. C TPRODUC USTOM OlARTHU-1 INSURER(S) AFFORDING COVERAGE NAIC N INSURED ArthurJ Edwards Mason INSURER A: Worcester Insurance Company 26182 Contracting Co Inc DBA Arthur INSURER B: Edwards Pool & Spa Center 929 Route 25A NSURER c _ Miller Place, NY 11764 INSURER D: INSURER E'. INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER MMIDDfYYVV MMIDWVYYY LIMITS GENERAL LIABILITY I EACH OOCI. IRRENCE S 1,000,000 A X COMMERCIAL GENERAL LIABILITY IMPA00000038801H ! 01101/12 '1 01101/13 ~P~FS Ea occurrence $ 100,000 CLAIMS-MADE OCCUR DIME EXF'Any one person) $ 5,000 'FERSONAL&ADV INJURY $ 1,000,000 "X BLANKETADDITIONA GENERAL AGGREGATE $ 2,000,000 I GEN' L AGGREGATE LI MIT APPLIES PER. PRODUCTS. COMPIOP ASS $ 2,000,000 PRO POLICY JE C LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per eccldenq NON-OWNED ALICS $ ; UMBRELLA LIAB OCCUR IEACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION 'NCSTATU- OTH- ANO EMPLOYERS' LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERJEXECUTVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) L DISEASE-EA EMPLOYEE $ Met, describe under DESCRIPTION OF OPERATIONS below - DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Atltlldonal Remarks Schedule, If more space Is requhetl) 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 REPRESENTATIVE Southold, NY 11971 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK 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 631-7447185 Ar',bur J. Edwards Mason Contractor, Inc. 929 Route 25 A 1 a 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 specyleaUy lbnited to certain locations In New York State, 4a, 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) iTllco Casualty Insurance Company Town of Southold 3b. Policy Number of entity listed in box "1 a" P.O. Box 728 WCS-700093-00 Southold, NY 11971 3a Policy effective period 01/01/2012 to 01 120 Proprietor, Partners or Executive Officers are [ x j Included. (Only check box If all partnerstomcers included) ail excluded or certain rtners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 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 "T'. The Insurance Carrier will also noto the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Cerryficate. (These notices may be sent by regular mail.) Otherwise, 0als Certificate Is valldfor one year after thlr form Is approved by the insurance carrier or Its licensed agent, or until the polky expiradon date listed In box 3c , whichever Is eariter. 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 that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business Is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depict on this form. Approved by: ov~ / &a-rlt t n of s 'zc vve or licensed agent of insurance terrier) Certified by: ~aaJ (Signature) (Dal Title:-. , Telephone Number of authorized representative or licensed agent of insurance carrier: °t Op't ' 9d 7~7 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C 105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) www.webstate.ny.us Workers' Compensation. Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of it state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work Involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in it form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in it hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an Insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse 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 1 a. Legal Name and Address of Insured (use streetaddress only) 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 td. 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 Coverage (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 "l a": Town Hall, PO Box 728 00984424 - 0000 Southold, NY 11971 3c. Policy effective period: 07/01/1986 to 06/30/2012 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: 07/07/2011 By: Itill a Ate. Stuart J. Shaw, FSA, MAAA Telephone Number: 1-888-278-4542 Title: Vice President, Group Insurance IMPORTANT: If box "4a" Is checked, and this form Is signed by the Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate Is COMPLETE. Mail It directly to the certificate holder. If box "4b" Is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Compensation Board, DB 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: By: BIgnature of NYS Workers' Compensation Board Employea) 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 (5/06) Additional Instructions for Form DB-120.1 By signing this form, the insurance carrier identified in box "T' on this form is certifying that it is insuring the business referenced in box "la" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box "2". This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in box "3c". Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220.Subd.8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5/06) Reverse Suffolk County Executive s Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 7/1/78 No. 4436-H 'SUFFOLK COUNTY -fforl?R Improvement Contractor License This is to certify that ARTHUR J EDWARDS doing business as ARTHUR EDWARDS MASON CONTRACTING INC having funi b.t d l rid reci firemet t , sec forth in accordance with and subject to the provisions of applicable laws, rules and r;:g-ziatioos of the Coun of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. SUFFOLK COUNTYD€PARTMENT Additional Businesses OF CONSWI IRAFFAIRS HOME -'-T CONTRACTOR - HCFtNW ARTHUR J.EDWARDS ARTHUR EUN ABS MASON TAis the1HQE C-f. litl°dGLC~C/VyQ/L YMS2f is Slubf GONTAA&"RNp RIS fMM hoom Aby the Cowiftmf.Sutfdk mow` ""YU0 07#14/1978 Director Derria McEiligott 44WH - AM~ ,nab, g y i`•'°' ~,w a"n \'*u %"~i Y 'er"+ ":fyx Y~d'~ ~'t 'R` 'd O "S s s `1 h` k s - ,~w rr~ ,.r ~.yt.L%_A~iu l~l. ._._d:.:1, 7 £~'n. f• tti t v' f'A u$ i~yYx f:.. w' ] A`may- S #t4 ~ 5~~~{1. 41~ 4 Suffolk County Executives Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 No. 2740-ME SUFFOLK COUNTY Master Electrician License This is to certify that EDWARD S REIFF doing business as UNDERGROUND SPECIALTIES INC ys 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. H - SUFFOLK COUNTY DEPARTMENT Additional Businesses x - OF CONSUMER AFFAIRS? i sue ELECTRICIAN y EDWARD S REIFF UNDERGROUND SPECIALTIES Pie 6 `e bmFef is duly fiowwd by the coUAFy of SUHeIk . °OMI- 2740-ME/1 vector i ~A. S~ndas mwaoxwn O5N1l2072 N SURVEY OF PROPERTY A T GREENPORT TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. \ 1000-33-03-27 - SCALE 1'=300 LOT 0 160 ~XN£ 10, 2008 p 3,E Q~ OCNOV. 179 2009 T. 28, 013 (POOL FINAL) 'g Cl ao- N Nj4,04,10MC std \ ASPHALT Z O,6'H to = J a CERTIFIED TO, r~ m STEVEN GOODMAN SUSAN GOODMAN - CHICAGO TITLE INSURANCE COMPANY ~ . L-0 9 a SKYLINE TITLE LLC WATo CT` j( S'TO Sk1CK 39-W _ O 17-1 n ~sM GATE u L 7- 60- ~j Q cK G st d GRA o Te Sl4'04~~0~W 8 LOT LOT NUMBERS REFER TO "MAP OF EASTERN SHORES AT o~ GREENPORT" FILED IN THE SUFFOLK COUNTY CLERK'S u,; - Py~,cE OFFICE ON APRI 1964 AS FILE NO. 4021. I~ hw ..8 r,£l N s > r EMC, C~ CFPi. f~~1 C ~ t fi.~ %a o No 7- 6 O Y.S. LIC. NO. 49618 S ANY ALTERA77ON OR ADDIDON TO THIS SURVEY IS A WOLADON C G'io S NIC S ORS, P. C. OF SECDON 72090E 1HE NEW YORK STATE EDUCADON LAW. , tygU 1 765-5020 FAX 631 765-1797 EXCEPT AS PER SECDON 7209-SUBDIVISION 2. ALL CER77FICA77ONS HEREON ARE VALID FOR 7HIS M ,4P AND COPIES THEREOF ONLY IF P.O. BOX 909 AREA=17,600 SO. FT. ¦=MONUMENT SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET • =PIPE NOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971 FOB-151 I i N SURVEY OF PROPERTY AT GREENPORT TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. 1000-33-03-27 SCALE` r--30' JUNE f0, 2008 LOT 10 160.00 g NOV. 17, 2009 as'E • Fi Y woo° 0 N1+0041 E uT a f PVD05~ Z POOL d o~ - o CERTIFIED TO, ALI U)` t+i t" STEVEN GOODMAN 20 m m o SUSAN GOODMAN { > 14 CHICAGO TITLE INSURANCE COMPANY cn x ' c, A i SKYLINE TITLE LLC cT a a ~ i o > m wA o ~L LOT - O m M ° O- c' f Z s r ~ 160.0°. O 0O pMVEWAY o SAVrL ~A O O wW - o ~ ~ s~4°410 LOt $ o LOT NUMBERS REFER TO MAP OF EASTERN SHORES AT w ~ GREENPORT" FILED IN THE SUFFOLK COUNTY CLERK'S o N~ \ N P CE OFFICE ON APRIL 27, 1964 AS FILE NO~ GOF SW z WTTO z 7~ N o C~~<h ~_s,, .tom x to C A` a o 1 49618 ANY ALTERA77ON OR ADDI770N TO THIS SURVEY IS A VIOLATION OF SEC77ON 72090E THE NEW YORK STATE EDUCA71ON LAW. CONic s EXCEPT AS PER •SECAON 7209-SUBDIVISION 2. ALL CER77F7CA77ONS (631) 765-5024 k 765-1797 HEREON ARE VAUD FOR THIS MAP AND COPIES THEREOF ONLY IF P.O. BOX 909 AREA=17,6W 80. FT. ¦=MONUMENT SAIr~ ~COOPPI~e~s SEE IMPP/RESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET -VGNA RE • =P/PE SOUTHOLD, N. Y° 11971 08-151 N. _ SURVEY OF PROPERTY AT GREENPORT TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. \ 1000-33-03-27 - SCALE P=30' JUNE 10, 2" LD'f ~0 160 p0 NOV. 17, 2009 E OCT. 28, 2013 (POOL FNAL) GUFS N74004'looc sTocg",x o wood 0.6'1 CURB CERTIFIED TO, STEVEN GOODMAN w SUSAN GOODMAN - j > CHICAGO TITLE INSURANCE COMPANY LOT 9 A( j SKYLINE TITLE LLC ° " ST BawK\ aF 2. wm- ° ° O eR~K x1000/ 7C POwE CMS COVEW'AY ` 10 LOt 8 + ~ LOT NUMBERS REFER TO "MAP OF EASTERN SHORES AT ^ GREENPORT" FILED IN THE SUFFOLK COUNTY CLERK'S \ N PLO OFFICE ON APRI 1964 AS FILE NO. 4021. OFNE6yrO C rF"yes':ga Y .S. LLC. NO. 49618 ANY ALTERA71ON OR ADDIT70N TO THIS SURVEY IS A VIOLATION f~o.496~s NIC S ORS, P. C. • OF SECTION 7209OF THE NEW YORK STATE EDUCAT70N LAW. 1 765-5020 FAX 631 765-1797 EXCEPT AS PER SEC77ON 7209-SUBDIVISION 2. ALL CER77FICA77ONS ) 65-1797 HEREON ARE VALID FOR THIS M P AND COPIES 7HEREOF ONLY IF P. 0. BOX 909 AREA-17,600 SQ. 1 R. ¦=MONUMENT SAID MAP OR COPIES BEAR 774E IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET 0 =PIPE WHOSE SIGNATURE APPEARS HEREON: SOUTHOLD, N. Y. 11971 Fo8-151 A srJmmer. ke4,nr / Ak. . B F B Fmm To FBler Fih.: Pury T. To Rehem (Dry WN OPO-0 . RoleE Wd F . Plan A Piping Arrangement Wdl S.Cl h y X14 Ra 42" Section B-B H Section A-A Typical Wall Section SIZE A B C D E F G H AREA CAP. FEET FT. Ff. FT. FT. FT. Ff. FT. FT. SQ.FT. GAL Praob. 16x32' 16' 32' 8' 14' 6' 4' 4' 8' 512 19,000 ~iI~G44~Q,L(~dat- 16'x36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600 POOL SPA CENTRE AddrOes - 18'x36' 18' 36' 12' 14' s' 4' 5' 8' 646 24,300 PERMACRETE WALL SYSTEM 929 Route 25A Miller Place NY 11764 ci state 20'x44' 20' 44' 16' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (631) 744-0174 ( ) Phone zi, cod, 2444' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk License #4436-HI 2448' 24' 48' 20' 16' 8' 4' 6' 10' 900 30,000 Nassau License #H174450000