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HomeMy WebLinkAbout37870-Z Town of Southold Annex 3/18/2014 P.O. Box 1179 54375 Main Road $ Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36812 Date: 3/18/2014 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 285 Richmond Ln, Peconic, SCTM 473889 Sec/Block/Lot: 86.-1-4.3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 3/7/2013 pursuant to which Building Permit No. 37870 dated 3/15/2013 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: accessory in Around swimming pool with fence to code as applied for. The certificate is issued to Logan, Thomas & Logan, Jill (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 37870 8/28/13 PLUMBERS CERTIFICATION DATED Autt} r(z d Si atur TOWN OF SOUTHOLD a BUILDING DEPARTMENT TOWN CLERK'S OFFICE a 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 37870 Date: 3/15/2013 Permission is hereby granted to: Logan, Thomas & Logan, Jill 14 Hudson Rd Bellrose Village, NY 11001_ To: construct an accessory 20'X 40' In Ground Swimming Pool, fenced to code as applied for At premises located at: 285 Richmond Ln, Peconic SCTM # 473889 Sec/Block/Lot # 86.-1-4.3- Pursuant to application dated 3/7/2013 and approved by the Building Inspector. To expire on 9/14/2014. 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 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: 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 property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, 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. OJ New Construction: Old or Pre-existing Building: (check one) Location of Property: 1? C 11 e •1d- J_txr) t Pe &0 House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Block Lot_ Subdivision Filed Map. Lot: Permit No. ~-7 E ~7 D Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ )pplicant Sig ture ho~apF SO!/T141 Town Hall Annex Telephone (631) 765-1802 54375 Main Road Fax (631) 765-9502 P.O. Box 1179 Southold, NY 11971-0959 ~ ~O roger. richertCa)town.southold.nV.us ~1y00UNTV BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Tom Logan Address: 285 Richmond Ln City: Peconic St: NY Zip: 11958 Building Permit#: 37870 Section: 86 Block: 1 Lot: 4.3 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: RJ Corazzini Electric License No: 33419-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 gas 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 1 A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment in ground swimming pool to include-bonding, 1-pool light, 2-time clocks 2-GFCI circuit breakers, 1-chlorine generator Notes: Inspector Signature: Date: Aug 28 2013 81-Cert Electrical Compliance Form.xls ~j o~,~,OF SO(~l` TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ j ROUGH P [ ] FOUNDATION 2ND [ J INS [ ] FRAMING /STRAPPING INA [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: rzp ~j /r a lost DATE INSPECTOR 37~~ © sWi ~o TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSU ATI`0N [ ] FRAMING / STRAPPING [ INAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: L Ir / e DATE t'3 INSPECTOR OF SWl'yo6 TOWN OF SOUTHOLD BUILDING DEPT. (L~ 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) -jef-I ELECTRICAL (FINAL) REMARKS: 27 INSPECTOR DATE `2D / O ~o~~OF SOlITy~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. TION [ ] FOUNDATION 2ND =FINAL FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ] ELECTRICAL (FINAL) REMARKS: DATE ~10 INSPECTOR Lit FIELD IIV3PEC1~ N REPORT DATE COMMENTS FOUNDATION (1ST) Ox ~ C FOUNDATION (2ND) CJ, m z 0 y ROUGH FRAMING & PLUMBING l W INSULATION PER N. Y. STATE ENERGY CODE 1CL FINAL 3 ~o ADDITIONAL COMMENTS 6l-ec > R t - b 0 m y -r _ p ~z Z T' ~ TOWNaOF SOiVTHOLD, BUILDING PERMIT APPLICATION CHECKLIS' 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. 3 7 Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Examined , 20 Storm-Water Assessment Form 2 Contact: Approved iI~ /,S, 20 l3 Mail tt Disapproved a/c 471 Route 25A PhopMe?ky Point, NY 11778 Expiration 5 , 20 Building Inspector APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date , 200 a. This application 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 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 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 qI!W2!)1-name, if a corporation) .,tV~I 3 D In, rQ -e Al l con act , a ec plum er r ut der State whether ap licant is pwner, less tlb cect, engineer, ge~era Q ELECTRICAL FEE: BY N2TIEY ®IIILQIMn C+ ,FA,a i ~-nrt Name of owner of premises In -+-P -,U r kr ( n the tax roll or latest deed) If applicant is a corporation, signature of duly authorized of1c~~c to - qv,+w,I VI~I~~f'il~lJ~0AT0 CODE 5 IN`tl~a A a , ^AULKI (Name and title of corporate officer) UPON COMPLETION d FINAL ° < ' PC tai i~LECTRIC BEFORE "WATER" h ALLCONSTRUCi e:A-At '0 Builders License iaT',THE Plumbers License No. RERUIREMENN~ Cvt. ~MLEFON(,- VORKSTATE NCI RESPOn1Siill'FOR Electricians License No.v DESIGN OR CONS, ERRORS, Other Trade's License No. 1. Loco 0 o and on w c pro osed work will e d e: I l Q L1~. 0? !)J _K(~/4I STQM4 WA1ER RIIN(1! House Number Street Hamlet PURSUANT TO CHAPTER 236 I Got HVQVV~ODE County Tax Map No. 1000 Section Z~(0 Block ~ - a 2. State existing use and occupancy of premises grit ded used 0 CU c of roposed construction: a. Existing use and occupanc% U I ~(V 1Q b. Intended use and occupancye'LD (2 J le~a YL I (1 1 3. Nature of work (check which applicable): New Building_ _ Additio Alteratio Repair Removal Demolition Other Wor G/~ efy (Descript 6n) 4. Estimated Cost Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height 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 LWill excess fill be removed from premises? YES 14. Names of Owner of remises LL] dress f71U~SISY1 f :IPhone 7/o. 11. 3(1-to I Name of Architect W o Address Phone No Name of Contractor Address 4-? 1 J~= -2-SA- Phone No.'s t 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetl d? *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 topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO~ * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) (dv a ~ I 14 being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contr t) above amed, (S)He is the r W Ie* (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 ap is knowledge and belief; and that the work will be performed in the manner set forth in th , applicatOGrewith. N MYRUSNEOF1EWYOlK Sworn t efore me th COUNTY day of 20 r t 57 I 1124 1 -2,j No ry Public Signature of plicant ~o~~oF sairyolo Town Hall Annex if Telephone (631) 765-1802 54375 Main Road co (631) 76g~y5p~ P.O. Box 1179 G roger.richert t0NRl.solJlltOltl nV us Southold, NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: /?o /-)eX t o~,gzz. ~ . 7, Date: Company Name: o/? (-o r.A 0r- Name: License No.: Address: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: *Address: jf s G m' g r? *Cross Street: *Phone No.: Permit No.: Tax Map District: -1000 Section: Block: Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) rJM .2 1...e (Please Circle All That Apply) *Is job ready for inspection: ES NO Rough In F nal *Do you need a Temp Certificate: S I NO Temp Information (if needed) *Service Size: 1 Phase Whase 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 82-Request for Inspection Form STATE OF NEWYORK VIIORKER'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 la. Legal N ame and Address of Insured (Use street address only) 1b. Business Telephone N umber of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS & PATIOS 1c. NYS U nemploymentlnsurance Employer Registration 471 ROUTE 25A Number of Insured ROCKY POINT, NY 11778 td. Federal Employer Identification N umber of Insured or Sodd Security Number 113008276 2Nameand Addressof the Entity requesting Proof of Coverage 3a.Nameof InsuranceCarrier (Entity bdn g 11 sted as the C ertifi cate llolder) The First Rehabilitation Life Insurance Town of Southold Company of America 3b. Poll cy N um bar of E n ti ty Ii sted in box "la": 53095 Route 25 DBL37154 PO BOX 1179 3c. Policy effectiveperiod: Southold, NY 11971 02/01/2013 to 01/31/2014 A Policy covers: 2.?? All of the employer's employees eligible under theN ew York Disability Benefits Law b. F~ 0 my the following class or classes of the employer's employees: Under penalty of perjury, I certify that l am an authorized representative or licensed agent of th e i nsuran ce carrier referenced above and that the named insured has N YS D isability Ben efi is i nsurance coverage as described above. Date Signed 2111/2013 By ,(Yr~(~t/(li (Si granite of I nsurance card at's authorized representative or N YS Li censed I nwrance A gent of that insurance carder) TdephoneNumber 516-829-8100 Tide Chief Executive Officer I M PO R T A N T:1 f box "48" is checked, and this form Is signed by the inwrana arder's authorized representative or N YS Licensed Insurance Agent of thatarda, this cerdficatats CO M PLETE. Mail itdirecdy to the certieatehdder. If box "m"i s checked, this cerditate is NO T COMPLETE for the purposes of Section 224 Subd. Bar the Disability Benefits L aw. I tmustbe mailed for completion to the Worker's Compensation Board, 0B Plans Acceptance Unit, 20 Park Street, Albany, NY 122fI/. PART 2 To be completed by WS Worker's Compensation Board (Only if box "4T" of Part 1 has been checked) State of New York Mrker's Compensation Board According to information maintained by the N YS Worker's Compensation Board, the above-named employer has amplied with the N YS Disability Benefits Law with respect W all of hisher employees. D ate Signed By (Signature of N YS Worker's Compensation Board Employee) TelephoneNumber Title Please Note: Only insurance carriers licensed to write NYS Disability Benefits insurance policies and N YS Licensed Insurance Agents of those i n suran ce carriers are authorized to issue Form D B-120.1. Insurance brokers are NOT authorized to issue this form. D&12]1 (soq STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured Randy T Rodecker,Inc. 631-744-8100 Dba: Swim King Pools lc. NYS Unemployment Insurance Employer 471 Route 25A Registration Number of Insured Rocky Point NY 11778 Id. Federal Employer Identification Number of Insured Additional Named Insureds: or Social Security Number Fence King of Rocky Point, Inc. 113092960 Work Location of Insured (Only required ifcoverage is specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 3b. Policy Number of entity listed in box "Ia": 50395 Route 25 WWC3044104 PO Box 1179 Southold NY 11971 3c. Policy effective period: 9/1/2012 to 9/1/2013 3d. The Proprietor, Partners or Executive Officers are: ? included. (Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "T'. The Insurance Carrier will also notes the above certificate holder within 10 days IF apolicy is canceled due to nonpayment ofpremiums 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 Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or 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 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 depicted on this form. Approved by: Henry C. Sibley (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 4.~ B A6 9/7/2012 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 800-438-0160 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) STATE OF NEWYORK MRKER'S CONPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE WS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agentof that Carrier 1a. Legal Name and Address of Inwred(Use street address only) 1b. Business Telephone N umber of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS & PATIOS 1c N YS U nemploymentlnsuranceEmployer Registration 471 ROUTE 25A Number of Insured ROCKY POINT, NY 11778 1d. Federal Employer Identification Number of Insured or Social Security Number 113008276 ZN am a and Address of the Entity requesting Proof of Cov"age 3a.Name of In suranceCarrier (Entity being listed as the C ertifi ate H older) The First Rehabilitation Life Insurance Town of Southold Company of America 3b. Policy Number of Entity listed in box "ta": 53095 Route 25 DBL37154 PO Box 1179 3a Policy effective period: Southold, NY 11971 02/01/2013 to 01/31/2014 4 Policy avers: a. Z All of the employer's employees eligible under theNew York Disability . Benefits Law b.FJ Only the following dassordassesof the employer'semployees: Under penalty of perjury, I certify th at I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has N YS Disability Benefits insurance average as described abboove DateSigned 2/11/2013 By AW,O, (Signature of insurance am er's authorized representative or N YS Licensed I nsurana A gent of th atinsurana aM er) TelephoneNumber 516-829-8100 Title Chief Executive Officer I M PO R T A N T:I f box "4s" i s cha&ed, and this form is signed by the insurance carrier's authorized representative or N IS Licensed I nwrance A gent of thatarrier, this owtifiateisCOM PLETE. Mail it directly to the certificate holder. If box"4bhis checked, this artifiateis NOT COMPLETE for the purposes of Section M Subd. Bar the Disability Benefits]. aw. It most be mailed for completion to the Worker's Compensed on Board, D B PI ans A aeptana U nit 20Park Street, Albany, NY 122D7. PART 2 To be completed by WS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Mrker's Compensation Board A ceordi ng to Information maintained by the N YS Worker's Compensation Board, the eboveatamed employer has complied with the N YS Disability Benefits Law with respect to ail of h1 shier employees. D ate Signed By (Signature of N YS Worker's Compensation Board Employee) TelephoneNumber Title Please Note: Only insurance arrierslicensed to write N YS Disability Benefitsinsursnce policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form D B-1201.1 nsurance brokers are NOT authorized to issue this form. DB-1201 (56E) STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE I a. Legal Name and address of Insured (Use street address only) lb. Business Telephone Number of Insured Randy T Rodecker,Inc. 631-744-8100 Dba: Swim King Pools lc. NYS Unemployment Insurance Employer 471 Route 25A Registration Number of Insured Rocky Point NY 11778 Id. Federal Employer Identification Number of Insured Additional Named Insureds: or Social Security Number Fence King of Rocky Point, Inc. 113092960 Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State, Le. a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 3b. Policy Number of entity listed in box "Ia": 50395 Route 25 WWC3044104 PO Box 1179 Southold NY 11971 3c. Policy effective period: 9/1/2012 to 9/1/2013 3d. The Proprietor, Partners or Executive Officers are: ?X included. (Only check box if all partners/officers included) ? all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "I a" for workers' compensation under the New York State Workers' Compensation Law. (To use this forth, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured f •om the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year afer this form is approved by the insurance carrier or 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 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 depicted on this form. Approved by: Henry C. Sibley (Print time of authorized representative or licensed agent of insurance carrier) Approved by: 4 fr6 9/7/2012 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 800-438-0160 Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) LOT 3 mw OF RICHMOND SNORES AT PECONIC ME Na W" MW NOYOMER 20. 19" SrMATED AT zor~ PECONIC s i_l TOWN OF SOUTHOLD oiry i SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-86-01-43 nt/ 1~.f0' SCALE t'=40'^i MAY 24. 2OW ALY 246 2OW REeRM WXM SERVICE • _ • ' R=611.00' AREA s 23„577.56 q. Et. FWM AIEfXM JM.E VtWANCE COMPANY OF WkV YORK NSBC IIORIOM COBPOB im MOVEL SWAN" JOAN 3WAHM A G6 541• VYA ova o ~pr ~~x~ - avow "MOO %L ZAM &M N~/{'01R~{ ~ OF ~ ~W WA « A D 41'-8" 10" 11 3'~ 40' 10" CHECKVALVE FROM SKIMMER O Z PUMP Co B O F LL1 r o v } U LL1 Z Z~ z DRYWELLL V O N O VINYL COVERED STEPS / z W Y DIVERTE DEEP WATER RETURNS Z VALVE O O O 3'_4„ H2O r-6' H20 V) N O N N FILTE 4' 9' T 20' A CHECK VALVE TORETURNS PLAN CONC.WALLS PLUMBING SCHEMATI 20 z 40 Rectangle NOT TO SCALE Lt y f - NOTES WATER LINE 1. ALL CONSTRUCTION IS TO BE IN ACCORDANCE WITH THE RESIDENTIAL CODE OF NEW YORK STATE- 2010 AND THE ANSINSPI-5-03 STANDARDS FOR RESIDENTIAL INGROUND SWIMMING POOLS FOR A TYPE II POOL. 0 71 2. STRUCTURE IS DESIGNED FOR USE BELOW GRADE AND ONLY IN AREAS WHERE LL f` C (b COPING AND WALKWAY THE GROUNDWATER TABLE IS A MINIMUM OF 4'-8" BELOW THE PROPOSED _I (BY OTHERS) FINISHED GRADE. O 'v 10" 0 O } e WATER LINE 3. BACKFlLL WITH CLEAN EARTH, FREE OF ROOTS AND DEBRIS. W NOT ALLOW d O iC Z 2" to 4" SAND BOTTOM THE HEIGHT OF BACKFILL TO EXCEED THE HEIGHT OF THE WATER IN THE POOL C~j ,J s u GRADE BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" LLI~ FORMED CONCRETE STEPS a 4. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEPOSIT AND Q 0 COMPACT CLEAN BACKFILL. 2 O ry d SECTION A ROLLED FOAM BETWEEN O L LINER AND CONCRETE 5. WALKS TO BE SMOOTH, NON SKID TYPE, SLOPED AWAY FROM POOL. SCALE: 1/8"= V-0" . FORM TIES d 6. WATER DISPOSAL SHALL BE LIMITED TO OWNERS PROPERTY IN ACCORDANCE 3500 PSI POURED CONC. WITH LOCAL REGULATIONS. . ' \ TOP OF WALL WATER LINE 2" RETURN LINE 7. PROPERTY OWNER IS RESPONSIBLE TO INSTALL PERMANENT FENCE AROUND Q POOL IN ACCORDANCE WITH THE NYS BUILDING CODE, APPENDIX G, SECTION w } _ AG705. PERMANENT ENCLOSURE MUST BE COMPLETED WITHIN NINETY DAYS Z VINYL LINER Z 4' 12' 4' AFTER THE DATE OF COMMENCEMENT OF CONSTRUCTION. O W Z ~ 2" TO 4" SAND 8. THERE IS NO MAIN DRAIN IN THIS POOL. SUCTION FOR POOL WATER to LL7 Q O 4 CIRCULATION IS PROVIDED BY THE SKIMMERS ONLY. THIS MEETS Z m REQUIREMENTS OF RC- SECTION AG106 FOR ENTRAPMENT PROTECTK7N. O = u- In 9. THIS POOL SHALL BE EQUIPPED WITH AN APPROVED POOL ALARM WHICH IS CJ X'-1 w 11 1 az~ CLASSIFIED BY UNDERWITERS LABORATORY, INC TO REFERENCE STANDARD Q F- ASTM 2208 ENTITLED "STANDARD SPECIFICATION FOR POOL ALARMS," AS ---I in ce ADOPTEDIN 2008, O SECTION B WALL SECTION 10. ATEMPORARY ENCLOSURE, OR 4 FT FENCE SHALL BE INSTALLED AND SCALE: 1/8" = 1'-0" REMAIN IN PLACE THROUGHOUT THE PERIOD OF CONSTRUCTION OF THE 3-3-3013 SWIMMING POOL, OR UNTIL THE COMPLETION OF A PERMANENT ENCLOSURE.