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Home My WebLink About38154-Z®""a'40t� Town of Southold Annex 1/8/2015 P.O. Box 1179 = 54375 Main Road Southold, New York 11971 Z—* _ CERTIFICATE OF OCCUPANCY No: 37366 Date: 1/8/2015 THIS CERTIFIES that the building IN GROUND POOL Location of Property: SCTM #: 473889 770 Kenneys Rd, Southold, Sec/Block/Lot: 59.-3-17.5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/27/2013 pursuant to which Building Permit No. 38154 dated 7/3/2013 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 -GROUND SWIMMING POOL FENCED TO CODE AS APPLIED FOR The certificate is issued to Smith, Joshua & Smith, Wendy (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 38154 08-20-2013 u o ' ed Si 'nature Permit #: 38154 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) Permission is hereby granted to: Smith, Joshua & Smith, Wendy 770 Kenneys Rd Southold, NY 11971 To: construct an inground swimming pool, fenced to code At premises located at: 770 Kenneys Rd, Southold SCTM # 473889 Sec/Block/Lot # 59.-3-17.5 Date: 7/3/2013 Pursuant to application dated 6/27/2013 and approved by the Building Inspector. To expire on Fees: 112/2015. SWIMMING POOLS - IN -GROUND WITH FENCE ENCLOSURE $250.00 ELECTRIC $100.00 CO - SWIMMING POOL $50.00 Total: .$400.00 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 1% 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. New Construction: X Old or Pre-existing Building: (check/ Lo-n�e,), / Location of Property: 7 7 Q KenmS House No. Street Hamlet Owner or Owners of Property:, j UCCA 1t UV E I ki �Yrl l 9 Suffolk County Tax Map No 1000, Section 15q Block Subdivision Filed Map. Permit No. B 8 15 - Date of Permit. Applicant: Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ J5O ` co Underwriters Approval: Final Certificat Lot Lot: Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD Telephone (631) 765-1802 Fax (631) 765-9502 roger. richert@town.southold. ny.us CERTIFICATE OF ELECTRICIAL COMPLIANCE Issued To: Smith co + BUILDING DEPARTMENT TOWN OF SOUTHOLD Telephone (631) 765-1802 Fax (631) 765-9502 roger. richert@town.southold. ny.us CERTIFICATE OF ELECTRICIAL COMPLIANCE Issued To: Smith SITE LOCATION Address: 770 Kenneys Rd City: Southold St: NY Zip: 11971 Building Permit #. 38154 Section: 59 Block: 3 Lot: 17.5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: TRC Electric License No: 46689 -me SITE DETAILS Office Use Only Residential x Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool x New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches Twist Lock Exit Fixtures ri TVSS - Other Equipment: in ground swimming pool to include, bonding, 2 -pool lights, 1 -control panel, 1-GFCI circuit breaker Notes: Inspector Signature::Y::�,Date: Aug 20 2013 Electrical Certificate.xls OF SOUTy�Io �—A TOWN OF SOUTHOLD BUILDING DEPT. l V z� - 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) orfl E CTRICAL (FINAL) REMARKS: DATE �� INSPECTOR ' , pE SOUTy S� o�ycou a TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) r REMARKS: DATE �p l Z .3 INSPECTOR r22M,� TOWN.OlF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION' -- ]FOUNDATION IST ROUGH PLUMBING FOUNDATION 2ND IN TION FRAMING/ STRAPPING �FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTMT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAULKING 0Cl&fiA0W4Mm Irl DATE -INSPECTOR TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TCL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFo rk.n et Examined 20_0, Approved 2011 Disapproved a/c �D E C E, � W E N,,raura z �� D EPT. 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. ,3�� `/' Check I Septic Form N.Y.S.D.E.C. � Trustees Flood Permit Storm -Water Assessment Form Contact: Mail to: ,� I/�(� 0 L.'t I Building Inspector APPLICATION FOR BUILDING PERMIT Date 20 INSTRUCTIONS T0W1Rfq i"ETation MUST Pe completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 3MS-ofpla7s; dmmra tale. 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 demolinregu rein described. The applicant agrees to comply with all applicable laws, ordinances, building code oust g code, ado aauthorized inspectors on premises and in building for necessary inspections , —// ,;,,a / ®CUPAN0: 1 11 Of c vv�&t61�;�r�r}� if°��t �� G� j 9 `� J (j '� Signatureo `ptiaaume,ifacorporation) d6s5 �. ; li U63E iS' �UNlAV`!IFgJL 1 .1 0 ENCLOSE POOL TO CODE UPON COMPLEtf6k �ITHOU T III ' C��`tl ai► g o � t> -1 BEFORE°WATER _ 7 State whether applican � v e fiif 6 en tneeT general contract tri aN ��u bep( b ilde` Name of ownerot°premises qt WM4, NOTIFY BUILDING DEPART[ViENT (As on fhe tax roll or latest dee"; 0"" " " 11 1 TO 4 PM FOR Th If applicant is a corporation, signature of duly authorized officer I OWGSPECTIONS: 1. FOUNDATION - TWO REQUIRED (Name and title of corporate officer) FOR POURED CONCRETE 0 2. ROUGH - FRAMING, PLUMBING, Builders License No. 510 Il ' STRAPPING, ELECTRICAL & CAULKING Plumbers License No. "a tl ° �� 3. INSULATION Electricians License No. 4tf, 0T A1pr&4UP44' �'�� nl n 4. FINAL - CONSTRUCTION & ELECTRICAL Other Trade's License No. MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE 1. Locatio of land on which proposed r will be done: REQUIREM N ' F THE CODES .OF NEW 110 Vaingus- YORK STAT . ESPONSIBLE-FOR House umber I Str&f- Hamlet DESIGN OR CONST UCTIOWERRORS. County Tax Map No. 1000 S ction Block Subdivision Filed Map No. S I711iRETAIN STORM WATER RUMPF Lot MIMIT® CHAPTER 200 N CODE, . 2. State existing use and occupancy of prem', s an NAM- 5. „,epde use and occupancy of proposed construction: a. Existing use and occupancy �ri A i b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Addition Iteration Repair ggRemoval Demolition i Other Work (D scription) 4. Estimated Cost U� 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 .W i Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front y Rear Depth Height 1 Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height!! Number of Stories 9. Size of lot: Front l77. 5-0 Rear_ -V Depth 5 4 � - 4- / 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 �l 13. Will lot be re -graded? YES NO �J Will excess fill be removed from premises? YES NO � 14. Names of Owner of premise r I ddress 7=�1C 4/,ia Phone No. � Zi Name of Architect Address 7 Phone No —� Name of Contracto ”a ddress5� Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wet and? *YES NO y * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY J 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) S- I COUNTY j,OF2 `-� u� 17 S /M being duly swom, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)Fle is the (Contractor, Agent, 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. j Sworn to before me this :day of UjY4& 2023 ANCTCANGE / 0, PUBLIC, State of New Notary Public dirt upffolk-County (4No. of LA6124900 mission Expift Aptil 4, Q °°t Town of Southold - Chapter 236 - Stormwater Management W g SWPPP - Storm Water Pollution Prevention Plan Assessment Form GENERAL ORMATION: (All Requested Information is Required for a Complete Application) APPLiCA NAME: or Agant - Consultant -Contractor or Other (Circle One) Properly OWNER: (If Differentthan Applicant) Address: n nan Vy f f / ld Address: p s#: lC� Fax IP Telephone� fax # E - Mail:/92- E - Mail: Property Address: -�� ' Brief Description of Construction Activity, Proposed Strachtra) BMPs, Soil Staahalization BMPs, Pmjed Scope and/or Sequence of Construction Activity 1000 Drstrw Block Co" t—"' tProvW9 AddJianal P2ges a9 NCCdCd)NarmOe eaw* ponsr�' for Implementation of SWPPP: o E a dfor Can Persoft � - _45kddr Ttl/�.. n _ gip. -, kk'I,� -Q --I r ► �-_=_ ,r j�}]� I (`[n✓ �"' -�J^� _ _ - ___.._..___.._- �t /� Address. 3 !L{.1t16YC Vun Telephone # 699- &4100 1 Fax # E-Marl: NareeofPersons Responsible for stal(atkm& airt eeofErosionControlPractice: L o� '-T_____________________________------------ -------------------------------------------- --------------------------------------_-__-.--- -.•,_--___-_--_- ....._•..---------------------------_.•...._...-....-----_ Addr1 KiTelephonel� Fax E-Mai(: Total Area of All Total Area of Land Clearing ProjectParcels: andfor Ground Disturbance: I __________________________-__------_------_ -------------------------------------------- (SF.IA—) (SF. IA.—) . --------------------------------------------- - ProjectDuration: (Anticipated) �b start Date. / End Date (nnmicerarCawr o*l Will this Project Disturbe five (5) or More Acres at Any One Time During the'Proposed Development ? Yes No -------------------------,..__--_----_-_--___-- ----------------------------- ..•._-...__-------_- UYES: Please Answer the Fallowing[ a. Does the Applicant have a Qualified Inspector On Q Q Staff To Conduct the Required Inspections ? Yes No b. Does the SWPPP Indicate How Frequently the Site Q Q List the NAMES ordescription of all Potentially Impacted Waterbodies and/or Wellands: Inspections will Occur and for What Period of rime ? Yes No / c. Does the SWPPP Adequately Identify All Temporary Q Q and/or Permanent Soil Stabalization Measures ? Yes No d. Does the SWPPP Adequately Identify a Complete Q Q -_--•-•-•--.__......-•-•-•-.-•--.-.._._...__-_--_-_--------------- Project Phasing Pian ? Yes No e. Does the SWPPP Indicate Additional Site Specific Q = Status of Impacted Waterbody: (eq. TMDL, 303(d) t.tsted, Impaired-) Practices that Will be Utilized to Protect Water Quality? Yes No L Has the Applicant Submitted a Completed DEC Notice Of intent and SWPPP Acceptance Form for Review Q LQ Type of Impacted Waterbody: (eg. Lake, Creek, Day, Pond, Sound, Freshwater Wetland.„) by the Town of Southold ? Yes No STATE. OF NEW YORK, - r� COUNTY OF .... 1:k ............. SS That I, ... 11.:f:.IlA.I... � oA0.1.1 ....� ................ being duly sworn, deposes and says that lie/she is the applicant for Permit, (Nameof dMdualsigmng nn��.�. Andthat he/she is the ......../. .. .....l !! .... ................................................................... (Owne , .Agent, Corporate Officer, etc.) 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 true to the best of his knowledge and belief; and that the work will be performed in the martner set forth in the application filed here Sworn to before me this; . . .. .. ............. day o .J. . .......................... 206 p - NotaryPublic:.- .. ttLl�ICkAv".411........ .. ........... .................... �m TAPUBLIC, Stateof New ecu o SWPPP Assessment FORM: 03-1Z �auarN 01LAM24900u /� Commission ExpiresApril4,0p_ Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 REQUESTED BY: Company Name: Name: License No.: M Telephone (631) 765-1802 aithro er.rcheriwsouo9d.n .us BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION r JOBSITE INFORMATION. (*Indicates required information) *Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax -Map District: Date: *BRIEF DESCRIPTION_,OF WORK (Please Print Clearly) (Please Circle All That Apply) *Is job ready for inspection: YES/ NO Rough In Final *Do you need a Temp Certificate: YES N 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: JRAYMENT DUE WITH APPLICATION 82=Request for Inspection Form STATE OF NEW YORK WORKERS' 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 I a. Legal Frame and Address of Insured (Use street address only) 1 b. Business Telephone Number of Insured LONG ISLAND POOL & (631) 698 -4100 PATIO INC Ic. NYS Unemployment Insurance Employer Registration 543 MIDDLE COUNTRY ROAD Number of Insured CORAM, NY 11727 1 d. Federal Employer Identification Number of Insured or Social Security Number 112590890 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) NATIONAL BENEFIT LIFE INSURANCE COMPANY TOWN OF SOUTHOLD 3b. Policy Number of entity listed in box "1 a": 53095 ROUTE 25 SOUTHOLD, NY 11971 8-910-0222285 3c. Policy effective period: 03/05/2012 to 03/05/2014 4. Policy covers: a. FX All of the employer's employees eligible under the New York Disability Benefits Law b. F� 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 de—scribed above. eaass Date Signed 03/05/2012 By �t (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance tamer) Telephone Number 800-535-2711 Title Vice President V IMPORTANT: If box "4a" is checked, and this form is signed by the insurance carriers 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. 3 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 to Disability Law with respect to all of his/her employees. Date Signed By (Signature of NYS Workers' Compensation Board Employee) Telephone Number Title Please Note. Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorised to issue Form DB -120.1 _, Insurance brokers are NOT authorized to issue this form. DB -120.1 (5-06) New York State Insurance Fund Workers' Compensation & Disability Be; efits Specialists Since 1914 8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747-3129 Phone: (631) 756-4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^ ^AAAA 112590890 LONG ISLAND POOL & PATIO INC 543 MIDDLE COUNTRY ROAD CORAM NY 11727 -------- -- --- --- i POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND POOL & PATIO INC TOWN OF SOUTHOLD 543 MIDDLE COUNTRY ROAD 53095 ROUTE25 CORAM NY 11727 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 12067755-5 411920 02/26/2012 TO 02/26/2014 2/13/2013 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2067 755-5 UNTIL 02/26/2014, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 02/26/2014 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MICHAEL DOMINICI(PRES) OF A ONE PERSON CORP LONG ISLAND POOL & PATIO INC THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR, INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 631642754 1 iaa R New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747-3129 Phone: (631) 756-4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE '.A " ^ A ^ 112590890 LONG ISLAND POOL & PATIO INC 543 MIDDLE COUNTRY ROAD CORAM NY 11727 POLICYHOLDER LONG ISLAND POOL & PATIO INC 543 MIDDLE COUNTRY ROAD CORAM NY 11727 CERTIFICATE HOLDER TOWN OF SOUTHOLD 53095 ROUTE25 SOUTHOLD NY 11971 — POLICY NUMBER r CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 12067755-5 ! 411920 02/26/2012 TO 02/26/2014 2/13/2013 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.2067 755-5 UNTIL 02/26/2014, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 02/26/2014 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. MICHAEL DOMINICI(PRES) OF A ONE PERSON CORP LONG ISLAND POOL & PATIO INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 631642754 1iaa1; STATE OF NEW YORK WORKERS' 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 Ia. Legal Name and Address of Insured (Use street address only) lb. Business Telephone Number of Insured LONG ISLAND POOL & (631) 698 - 4100 PATIO INC lc. NYS Unemployment Insurance Employer Registration 543 MIDDLE COUNTRY ROAD Number of Insured CORAM, NY 11727 1 d. Federal Employer Identification Number of Insured or Social Security Number 112590890 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) NATIONAL BENEFIT LIFE INSURANCE COMPANY TOWN OF SOUTHOLD 3 b. Policy Number of entity listed in box "la": 53095 ROUTE 25 SOUTHOLD , NY 11971 8-910-0222285 3c. Policy effective period: 02/13/2013 to 02/13/2015 4. Policy covers: a. ❑X 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 02/13/2013 By (Signature of insurance carriees authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 800-535-2711 Title Vice President IMPORTANT: if box "4a" is checked, and this foram 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 (Signature of NYS Workers' Compensation Board Employee) Telephone Number Title Please Note: Only insurance carriers licensed to Wite NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorised to issue Form DB -120.1. Lzsurarnce brokers are NOT authorized to issue this form. DB -120.1 (5-06) C i •_ _ _a rte- T= . SUFFOLK COUNTY DEPT OFLAEOR, LICENSING & CONSUMERAFFAIRS _ '_ s HOME IMPROVEMEiV CONTRACTOR '_- 46 _ LICENSE MICHAEL J DOMIIVICI Th ►S CEr(lti2s tlt3t$tE SU=C-=r=m bEamrisduty LONG ISLAND POOL&PATIO INC ffcensed bythe Cour4 of Seriolk 45707--H- mml2aos f 011012as5 I nrtsik"maisthePmPmYottheSufdkCmmW aP�na+2oY carmarrerAffmrsf'oscssieoofthlspeatsedovsr=gm..t..tU S Additional Business Names J Town of Southold - Chapter 236 - Stormwater Management CONTRACTOR CERTIFICATION STATEMENT Prior to the commencement of construction activity, the owner or operator must identify ALL contractor(s) and sub-contractor(s) that will be responsible for Installing, constructing, repairing, replacing, inspecting and maintaining the erosion and sediment control practices included in the SWPPP; and the contractor(s) and Sub-contractor(s) that will be responsible for constructing the post -construction stormwater management practices included in the SWPPP. The owner and/or operator shall have each.of the contractors and/or sub -contractors identify at least one person from their company that will be responsible for implementation of the SWPPP. This person shall be known as the trained contractor. The owner and/or operator shall ensure that at least one trained contractor is on site on a daily basis when soil disturbance activities am being performed. The owner and/or operator shall have each of the contractors and subcontractors identified above sign a copy of the following certification statement below before they commence any construction activity: CERTIFICATION "I hereby certify that I understand and agree to comply with the terms and conditions of the SWPPP and agree to implement any corrective actions identified by the qualified inspector during a site inspection. I also understand that the owner or operator must comply with the terms and conditions of the most current version of the New York State Pollutant Discharge Elimination System ("SPDES") general permit for stormwater discharges from construction activities and that It is unlawful for any person to cause or contribute to a violation of water quality standards. Furthermore, I understand that certifying false, incorrect or inaccurate information is a violation of the referenced permit and the laws of the State of New York and could subject me to criminal, civil and/or administrative proceedings. " RMW �: DaO� In addition to providing the certification statement above, this page must also identify the specific elements of the SWPPP that each contractor and/or sub- contractor will be responsible for. r �I Specific SWPPP Element: (Please Describe Here) .. ------------------------------------------------ NAME and TITLE of thQQLd ) responsible for SWPPP implemen ation; NAME, address and telephone number of the Contracting Firm; Property Address and Suffolk County Tax Map Number of the site; S.0 T.M. #: t 000 District Section Block Lot The owner and/or operator shall attach All certification statement(s) to the copy of the SWPPP that is maintained at the construction site. If new or additional contractors are hired to implement measures identified in the SWPPP after construction has commenced, they must also sign the certification statement and provide the Information listed above. For projects where the Department of Environmental Conservation requests a copy of the SWPPP or inspection reports, the owner and/or operator shall submit the documents in both electronic (PDF only) and paper format within five (5) business days, unless otherwise notified by the Department. SWPPP Certification Statement FORM: 03-12 bearer Is duly licensed by the County of Suffolk Clifford Coleman rn.da SUFFOLKCOUNTY DEPARTMENT �. nl .1 .A== AFFA117C MASTER ELECTRICIAN ram ROY D CHALMERS BUSUMHUM TRC ELECTRIC CORP as —ranft . 466MME muW-d o9�23/2009 09/01/2013 I JAN -23-2013 10:41 FROM: 631 648 7958 TOs6984111 P.2/5 Jul. 1?, tv11 I.jynm lou. 47U1 F. i I40w YOrk St8te InSUrRACC Fftnd IWorkon' Compensoibn & Dlspb1U&BenefZa SweialisO SMac-1914 ' 8 CORPORATE CENTER dR, SRO FLA MELVILLE. NEW Y(W 11747-3120 Phtmw. tesla 76a mo CERTIFICATE OF 1I ORKERS' COMPENSATION INSURANCE '.AAAAA 27091HOI TRC 1:4 2=10 CORP 16 VIVIAN LANE LAKE DROVE NY 11764 POLICYHOLDER TRC EI.EC1'= CORP 10 VIVIAN LANE LAKE CURVE NY 11755 POLICY NUMBER I C6RTIFI0A1E NUM9ER 12219 28W 1 119912 CERTIFICATE WOLQER LONG ISLAND POOL 8 PATIO 543 MIDDLE COUNTRY ROAD CORAM NY 11727 PE17100 COVEMO $Y THIS GERTJFICATE OATS 0710912012 TO 07100018 '1/1512012 THIS IS TO CEi;I'iFY THAT THE PbLICYHOLDeR NAMED ABOVE 18 IM$VA60 W17147Y,1E NEVI! YORK STATE INSURANCE FUND UNDER POLICY NO. 2219 263.7 UNTIL 0710912013, COVERING TMt; ENTIRE O13LIidAAYION OF TNI$ POLICYHOLDER POW WORKER& COMPI°NSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT Tb ALL OPERATIONS IN THE STATE OF NEW. YORK, EXCEPT AS INCIWF-0 BELOW, AND, WITH RFMOr TO OPMAT10NS OLfTSIDE QV NEW YORK, TO THE POLICYHOLDERS RE{1ULAR NEW YORK STATE EMPLOYEES ONLY. IF $A D POLICY 15 CANCELLED, OR 014ANSED PRIOR 'r0071091201S IN SUCH MANNER AS TO AFFI=GT THIS CERTiFicm. 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL OE GMN TO TIBC CERTIFICATE H=ER AROVE. NOTYORK6 ATE INS'UKANNCE FUNREGULAR MAIL o DOES NOT ASSUME ANY LLM 0 A00RE%9SE0 SHALL BE FICIENT ILITY N THE �COF FAILURE Ta GGINI: SUCH "NOTICE 'rKIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS No RiOFITS NOFt INSURANCE COVERAGE UPON THE CERTIFlCATE , HOLDER. THIS CERTIFICATE DOSS NOT AMBND, EXTEND OR ALTER THE COVERAGE AFFORMO OY THE POLICY. ,NEW YORK STATE INSURANCE FUND d'e.— L1IRECTOR,iN$URANCEFUND UNDERWRITING This carfifir- IH fAn hA v*1100401 nn M u, wok f .. l►.► Mii..^./A...... ..vr.recn a a.vrvrrr-MOM s lure tsVAKU 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 19, Legal Name and Address of insured (Use street address only) 1b. Business Talephone Number of insured T.A.C. ELECTRIC CORP 631-6484958 le. NVS Unemployment Insurance Employer Registration 46 ViVIAN LANE Number or insured LAKE GROVE, NY 11755 1d. Federal Entployar identification Number or insured or Social Security Number 270918601 2. Name and Address of the Entity roqum tg Proof orCoverage 3a. Name of Insurance Carrier (Entity being listed as the Certificate Holder) The First Rehabilitation Life Insurance TOWN OF SMITHTOWN Company of America 3b. Policy Number of Entity (toted in box "1e: 89 W MAIN STREET OBL342305 SMITHTOWN, NY 11787 3c. Policy erfectiva parlod: 07/09/2012 to 07/0812013 4. Polley covars: 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 pe duty, i eartlfy 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 7116/2012 B y (Signature of Inwmmct earner's autherized reptesentauve or NYS ('rcensad Insurance Agent oruut insurance rariler) Telephone Number 516-829-8100 Title Chief Executive Officer 1MP0RTAf#T:1t box *#e Is Checked, and this forth issignodby the i11SUJI rtCe e110isessuthorized ropmentetive arNVS Ummed insurance Agant of thaUsrder. this anifleete Is COMPLOE Malt It difee 1.1110 a C41011cate hoider. N box "4b" Is chocked. this ce iftcate Is NOT COMPLETE for the purpuras or Section zip. Saw. a of the disability Benefits Law. It must be mailed for completion to the worimes compensaum Board. DB pians Acceptance UnIL Ze Pane Street. Albany. NY 12207. PART 2. To be completed by NYS Worker's Compensation Board (Only if box 4b" of Part 1 has been checked) State of New York Worker`s Compensation Board ActArding to InfonnaHon malttlafttati byUw NYS Workers CompensaUon Saud. the above-mmed employer has complied wilb the NYS Olsability Benefits Law %Oh resprct to all olhisIher employees. Date Signed ` gy (Signatureof NYS Wwtter'aComponsetianBoard Emptopo Telephone Number Tltie Please Note: Only insurance carriers treensed,10 tt IM NYS Disability Benefits insurance policies and NYS Licensed insu angio Agants of those Insurance earners are authorized to Imull Form D114201. insurance brokers are NOTauthorized to fssue this form I 3 -- 4 -MAP:) E L ut zj.' ..... ..... ..... ..... .Y. 7 KEN'NE'- n.-.,O A V E . us� W SfAt 3su4t NIDI GE "-.16-PIE-Pi 56, !cry$ w4J, A44"Ou i.$;?V?mT lu waLti -LtYAT Aa" aysmu I rMkf.r. , llQ'--VTST NOT SUL 'LO T CERTIFIED To: "RIVAlos- PARAbOp-'j)'ljL*aS'-.,mm::a FIL , 77777=7! MAP.-_ W.. � SITUATED"'' T., 0.1-: SUWDL it p—p-:-A m int E R. A PATC-ffosur Ult VEY0,14 f-'4 t — Vol. DATE a 0 03* Fl N -A I - O"i-----! 4 0 0 A ut zj.' ..... ..... ..... ..... .Y. 7 KEN'NE'- n.-.,O A V E . us� W SfAt 3su4t NIDI GE "-.16-PIE-Pi 56, !cry$ w4J, A44"Ou i.$;?V?mT lu waLti -LtYAT Aa" aysmu I rMkf.r. , llQ'--VTST NOT SUL 'LO T CERTIFIED To: "RIVAlos- PARAbOp-'j)'ljL*aS'-.,mm::a FIL , 77777=7! MAP.-_ W.. � SITUATED"'' T., 0.1-: SUWDL it p—p-:-A m int E R. A PATC-ffosur Ult VEY0,14 f-'4 t — Vol. DATE a 0 03* Fl N -A I - O"i-----! 4 0 0 COMPOSME WALL POOLSYSTEM . 201 x 28' x 40' TRUE -L 2'R DWG #: CM -4239 DATE: 6/20/2013' 'REV: A ' PAGE 2 OF 2 • . :AREA (SgFt):.425, PERIMETER: 131' EST. VOLUME: 'US GAL: 40'-0" C -360 C -720L C 720 C -Z20 C -770 C, 720 C -360 CU -24 oorA Cu-2a�cR 3t_4n 4'-0" C1 C 720 C -360 C -720L 20170„ C .-720 28'-0" • .: C -360 c 7?0 4'-0° . c 7�a ' � c •240. c azo � c -no u U cu,; zgooca CU 240008 CU-2400CR' C COMPOSITE BRACE C �z40 M§6045BW . ' cftx sur . 16'-0" . ' ptars nlLTrcou .. .. .. 3t 3^ aVaPORT wou asaa• 5tsral .. • . gt_prt east .. 14!-0 --'_ ..'-moi+^ 6.0 4 -0 OIVINR MAY �. Tnurtmr Mlp.Ix mems auv inose mil esenraUnns w ml are Silted In lts vdd?n wamnN. Any ottar nirm antatlmn. st9txmmtt, or an6aCt made G/ the deddrimal dw In the w:l°mu lnynduy sny minpolmts woduoattn RESULT IN SERIOUS, Trrc2cmr wg.lx aro attrlAu!aile totx Ewer/convector alN• TAedealer or con tracts uT* calls of l 5ypufpod if an lntStp01dar1ttrntraCm arO lsndt'anowt s C?Iplwx of ftlhmdw Milt, ilia the caminrcuctl l�akts INJURY 0R DEATH. L Iwtrate0 Aem are 5uppesDons m a epptj omy.to nermy Go int eonpa an Ttr a mny t c oad:t mrJ precauuoni s Wor meaads orconttiuuwn. ne msromminN is m• wnt xt c. •� merry nrg wml In q s is to w pamwnenrry 'l dukhed Y;0 -lo Ilse'sha9ow sloe of OrJ Pdnt. al Ant slope A1a11t1e• •t>:tATent f edlods A•Id vdwtidnns mair6s dictated W "sins gru na mndtWa Ire, isto bud?terminad trl,,�d Is ttb mp-10dty ur dq runtish« W KI r, fqt nn rac Si na emust be ermanantl attached a0tl tof lfi°mau Iter Ol thecmnponunt pa t5.•Url �pm is to Pn da wimxcadanoo wph atl rederL state andl�l4uJd rgeoda,'dtw•A MANS.I•MJ.p,l. wQq cedstrndYdS.•BOTTOM WELTF[CAI1.IC5 MUS HI£TOR 9 . 9P Y OCE OA.N.S.L1tL5.PJfAP.S.P.iI[GOMNENDEDSTN10ARpS 1tU11Y1M1K7aignnpemustbepvmsc BYMtadrdtptlemd�pvmeteroTl�:pod.° 2ln[twYwiW%;Q>vd,•LTI9acccaIEHDwI?NOT IRISTALL t around. the'' Perimeter Of,the PORI. MING BOARDSSARD/OR SLIDING EQUIPMENTON RESIDENTTAI,"cLs. if dlving boor&olid/or siMing equIpinent is lnitalmd.by tDecunituctor, wch dlvinDfl°etdiand alWltgpqulpment MUST CE INSTALLIM , f PQnI'61116 WITHIN TILE 6ViOEUNES ESTABLISHED BY ANSI11417fASPA RECOMME11*0 STANDTAROS; AND IN ACCORDArICE WITII ALL APPLICAOLE?TATE AND LOCAL CODES ANO IfEGULATIONS. ALL IVIANUFACTURED,ITEMS AND CONSTRUCTION SHALL COMPLY WITH THE RESIDENTIAL BUILDING CODE OF NEW YORK STATE 2010, INCLUDING THE SPECIFICATIONS IN APPENDIX G: . ILTERED WATER RETURN. NUMBER FI T R ORNOZZLES VARIES PER POOL SIZE. li l KIMMER __rPOOLSs UAL MAIN 37-0! MIN. DRAINw/ 3'- O. .SPACI G . •STRAINE 4d mi ..IRGINIA GRAEME BAKER SA ACT APPROVED DRAINS ' NOTE:' .. I , , , . . . . . - DRAWING CONFORMS TO ANSI /APSP.7 SUCTION ENTRAPMENT AVOIDANCE CODES. MAIN, DRAIN, PIPING SCHEMATIC (NOT TO SCALE) W z J `� N cnz p zona = I-- NOTE: co . a & ALL WATER EITHER OVERFLOWING'OR FROM SHALL 1.2 H EMPTYING THE POOL BE DISPOSED OF ON THE OWNERS LAND. z CE s 0 0.to . JOB Ne ' NIA f0 C0 C3 d � Cc 8 € a F2 o r 0 g= • AS NOTED ' m M o m s U_ ?I!q a C) U) to°�l O. ads�� n f ccoo E S v O I6aa Lo �! i R! a . ' � O < CG d Q • N r Of r z n Q}(V �- Z 0�} SECTION G103 -SWIMMING POOLS; SECTION G105 -BARRIER REQUIREMENTS; SECTION G106'- ENTRAPMENT PROTECTION FOR SWIMMING POOL $ SPA SUCTION OUTLETS; SECTION G107 -SWIMMING POOL & SPA ALARMS 1 OF 1 W z J . OZ cnz p zona = I-- Tn 2: C7 O T� G7 z O JOB Ne ' NIA orwwn av CTC rcrtl:oer SGH JUNE 24, 2013' • AS NOTED ' 1 OF 1