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HomeMy WebLinkAbout38376-Z�itf�gtl�FQt,�C Town of Southold 5/19/2015 y� p P.O. Box 1179 53095 Main Rd Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 37569 Date: 5/19/2015 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2330 WELLS AVENUE SOUTHOLD SCTM #: 473889 Sec/Block/Lot: 70.-3-22.12 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/29/2011 pursuant to which Building Permit No. 38376 dated 10/1/2013 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 AS APPLIED FOR The certificate is issued to of the aforesaid building. J & MJ SMALL REVOCABLE TRUST SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36308 05-09-2011 9So�� TOWN OF SOUTHOLD coGy BUILDING DEPARTMENT z TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 38376 Date: 10/1/2013 Permission is hereby granted to: J & MJ SMALL REVOCABLE TRUST P.O. BOX 1627 SOUTHOLD. NY 11971-4053 To: TO CONSTRUCT AN ACCESSORY INGROUND SWIMMING POOL FENCED TO CODE. REPLACES EXPIRED B.P. # 36308 At premises located at: 2330 WELLS AVENUE SOUTHOLD SCTM # 473889 Sec/Block/Lot # 70.-3-22.12 Pursuant to application dated To expire on Fees: 4/8/2015. 3/29/2011 and approved by the Building Inspector. PERMIT RENEWAL $75.00 CO - SWIMMING POOL $50.00 Total: $125.00 Building Inspector sa�FVE� TOWN OF SOUTHOLD CIPA BUILDING DEPARTMENT TOWN CLERK'S OFFICE • SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 36308 Date: 4/8/2011 Permission is hereby granted to: 2004 J & MJ Small Revoc Trt 165 Deer Run Southold, NY 11971 To: to construct an accessory inground swimming pool, fenced to code At premises located at: 2330 Wells Ave SCTM # 473889 Sec/Block/Lot # 70.-3-22.12 Pursuant to application dated 3/29/2011 To expire on 10/7/2012. Fees: and approved by the Building Inspector. SWIMMING POOLS - IN -GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Building Inspector Form No. 6 TOWN OF SOUTIIOLD 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. 9 New Construction: Old or Pre-existing Building: (check one) Location of Property: (D House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. ,U C Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 51D D. � r74;�' _,Z4�Applicant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 pF SOUI�o� • �� COUNT`I,Nc� BUILDING DEPARTMENT TOWN OF SOUTHOLD Telephone (631) 765-1802 Fax (631) 765-9502 roger.richerta-town. Southold. ny.us CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Small Address: 2330 Wells Ave City: Southold St: NY Zip: 11971 Building Permit* 36308 Section: 70 Block: 3 Lot: 22.12 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Raymond Electrical Cont. License No: 5141 -me SITE DETAILS Office Use Only Residential X Indoor Basement Commerical Outdoor X 1st Floor New Renovation 2nd Floor Addition Survey Attic PkAl40k-toI31 Service Only Pool X Hot Tub Garage 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 1 Disconnect Switches 2 Twist Lock Exit Fixtures El TVSS Other Equipment: in ground pool, to include bonding, 1-GFCI circuit breaker, 2 -pool lights Notes: Inspector Signature: 4itv-Date: May 9 2011 81 -Cert Electrical Compliance Form ho��pF SOUTyOIo lig l � ' �IyCOUNMV,�� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING/ STRAPPING [ ] FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ LECTRICAL (FINAL) REMARKS: DATE -INSPECTOR"'- rtsf so TOWN OVSOUTHOLD BUILDING DEPT., 765-1802 INSPECTION.. ]FOUNDATION IST ROUGH PLBG. FOUNDATION 2ND INS LATION FRAMING I STRAPPING �FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) REMARKS: -, &,- - � t, - I DAT INSPECTOR I� 76Z o�00F SOUT,yOIo ��'YUOUMV,Nc� TOWN OF S'OUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] RO GH PLUMBING [ ] FOUNDATION 2ND [ ] SULATION [ ] FRAMING/ STRAPPING [ ] FINAL [ ]. FIREPLACE A CHIMNEY [ ] FIRE SAFETY -INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ } ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING ME -am AL wvw_ DATE � � � INSPECTOR � / MLD WSPECT dN SPORT DATE CoMA=NTS. FOUNDATION (1ST)ivv ' FOUNDATION' (2ND) rr ,A, V) � ROUGE[ FSG'& PLU11 ING � y INSULATION PER N. Y. STATE ENERGY CODE. . y FINAL O ° A e ADDITIONAL. COMMENTS —� ee c9A--f- Cos m ' m l,� M BUILDING PERMIT APPLICATION CHECKLIST Examined 20 If Approved , 20 t Disapproved a/c Expiration - C) 1 , 20—/d- D Building Inspector Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey - Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm -Water Assessment Form Contact: Sw i (Yi V, ✓1 � IS Mail to: Phone: -144 - 3),::,-2 E C E 11 V PPLICATION FOR BUILDING PERMIT D ✓ 1 W liilL 9E 20 MAR 2 9 2011 Date , INSTRUCTIONS _L a. iQWMUST be com letely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets o plans, accW . ee according to schedule. . o p an 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. + OCCIJPAI`1QCY OR IMMEDIATELY ti S � I �' V IN LAY V F I L (Signafuti of applic a"nf or name, if d corporation) ENCLOSE POOLTO,CQDE t `I Q f�UT CERTIFICATE �y Isye&�n©a UPON COMPlET10N (Mailing address of applicant) a Foa OF OCCUPANCY �n »�� i State whether applicant is owner, lessee, agent, architect, engineer, general contracARPXVFA i,� itnlWor builder 0bovte - Name of owner of premises DATE_ B.P. #_---- FEE: 'BY _-- NOTIFY BUILDING DEPARTMFN T I " (As on the tax roll or late?MdW 8 ANI TO 4 PM FOR I t, If applicant is a corporation, signature of duly authorized officer FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE (Name and title of corporate officer) 2. ROUGH - FRAMING, PLUMBING, STRAPPING, ELECTRICAL 8 CAULKING Builders License No. - 1-� 3. INSULATION 4. FINAL -CONSTRUCTION 8 ELECTRICAL Plumbers License No. ELECTAL MUST BE COMPLETE FOR C.O. ^^ ���' Electricians License No. a %� - _ 'TION OUIRED ALL CONSTRUCTION SHALL MEET THE Other Trade's License No. REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR 1. Location of land on which proposed work will b d e: DESIGN OR CONSTRUCTION ERRORS. _L, I--i1�on n ., - �i\) 1--knI Ir'fi RETAIN STORM WATER RUf3OFF umber Street - - 1=TamIet County Tax Map No. 1000 Section Subdivision 90 Block - Filed Map No 3 - OF THE T WN CODE. _Lot � a Lot TOWN OF SOUTHOLrf BUILDING DEPARTMENT TOWN HALL SOUTHOLD NY 11971'' TEL: (631) 765-1802 FAX: (631) 765-9502 ca SoutholdTown.NorthFork.net PERMI NO. -' BUILDING PERMIT APPLICATION CHECKLIST Examined 20 If Approved , 20 t Disapproved a/c Expiration - C) 1 , 20—/d- D Building Inspector Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey - Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm -Water Assessment Form Contact: Sw i (Yi V, ✓1 � IS Mail to: Phone: -144 - 3),::,-2 E C E 11 V PPLICATION FOR BUILDING PERMIT D ✓ 1 W liilL 9E 20 MAR 2 9 2011 Date , INSTRUCTIONS _L a. iQWMUST be com letely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets o plans, accW . ee according to schedule. . o p an 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. + OCCIJPAI`1QCY OR IMMEDIATELY ti S � I �' V IN LAY V F I L (Signafuti of applic a"nf or name, if d corporation) ENCLOSE POOLTO,CQDE t `I Q f�UT CERTIFICATE �y Isye&�n©a UPON COMPlET10N (Mailing address of applicant) a Foa OF OCCUPANCY �n »�� i State whether applicant is owner, lessee, agent, architect, engineer, general contracARPXVFA i,� itnlWor builder 0bovte - Name of owner of premises DATE_ B.P. #_---- FEE: 'BY _-- NOTIFY BUILDING DEPARTMFN T I " (As on the tax roll or late?MdW 8 ANI TO 4 PM FOR I t, If applicant is a corporation, signature of duly authorized officer FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE (Name and title of corporate officer) 2. ROUGH - FRAMING, PLUMBING, STRAPPING, ELECTRICAL 8 CAULKING Builders License No. - 1-� 3. INSULATION 4. FINAL -CONSTRUCTION 8 ELECTRICAL Plumbers License No. ELECTAL MUST BE COMPLETE FOR C.O. ^^ ���' Electricians License No. a %� - _ 'TION OUIRED ALL CONSTRUCTION SHALL MEET THE Other Trade's License No. REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR 1. Location of land on which proposed work will b d e: DESIGN OR CONSTRUCTION ERRORS. _L, I--i1�on n ., - �i\) 1--knI Ir'fi RETAIN STORM WATER RUf3OFF umber Street - - 1=TamIet County Tax Map No. 1000 Section Subdivision 90 Block - Filed Map No 3 - OF THE T WN CODE. _Lot � a Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy i`2 IryA U 1-7,-,t zd jt f r a A22Lf z b. Intended use and occupancy 1, 3. Nature of work check which applicable): New BuildingAddit 6 ` '_',�teration J . Repair Removal -:Demolition Other. Work.,;7,m, O J/i ar: CO %bFCIC .:'.,(Zscription) 114 CC0H cF 4. Estimated Cost Fee F - 6^C:.i.:0V'U C i'!r F (To b.,d p,laid, `,o.n filing this application) � ll� t'I', 5. If dwelling, number of dwelling units Number of dwelling units,. -o oor: ;"i If garage, number of cars ,earl%, ,oMCL;�=c.Vr_1_L' 6. If business, commercial or mixed occupancy, specify nature and extent of eacli�type'of isr:.i;O�t�. _.... - i t'! i�.:l irr LAs it.! ? r;'uij f '. 7. Dimensions of existing structures, if any: Front Rear i'io'.i''`k mirc)i'te-I?ptiit_�.`-' Height Number of Stories L Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of:Storie'sf't": 8. Dinehszoris ;o `)re new construction: Front Rear Depth _Height -,� Number.ofStories ' 9: Shd o'flot:-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_X,_Will excess fill be removed from premises? YES NO 14. Names of Owner of remises 1vla& a'1e5" 4dress J0� �X RLJ4 Phone No. Name of Architect WW J-(�D I'1 nsa✓) Address_ 115 U►e-Fm A-Vc— Phone No SSI - 2t —5 Name of Contractor .6,/- Address IPI Rte o -l" Phone No. i-�U4- 8 1,,02- 15 �Z15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO� * IF YES, D.E.C. PERMITS.MAY BE REQUIRED. 16. Provide survey, to scale; -with accurate foundation plan and distances to property lines. point on property is at 10 feet or below, must provide topographical data on survey. 17. If elevatiori'af any 18. Are there any covenants and restrictions with respect to this property? * YES NO * IF YES; PROVIDE ACOPY. STATE OF NEW YORK) SS: COUNTY OFn r� v�e_ ) being duly sworn, deposes and says that (s)he is the applicant (Name of m-divic1hal signing contract) above named, (S)He is the 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 of his knowledge and belief; and that the work will be performed in the manner set forth in the applicatio i led th wi . Sworn to before me this 9 F-j'a day of 20 1 \ 43 4; Notary Public a Applicant Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 roaer.richertd-ME (r�i s) u to S.nv.us BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name:' - _ mrnwd ec_—c- .�� C-0 6-wa- ch 11 a (-_0 y- iName: 1 License No.: 514 1 M E Address: &1-42- N Co Vln i-r Phone No.: i i (o ' �' �] 3 7q JOBSITE INFORMATION: (*Indicates. required information) *Name: _ an G(Yl d � cxa) 4C' _ od *Address: 7 - y�1'�l - - *Cross Street: YVYA ,( *Phone No.: ,,' 5 i 6 cn Permit No.: 62 ? 0 Tax Map District: -1000 Section: _�A Block: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) - I n n axxy -1 sv i t NVY)k n a bay I >n (Please Circle All That Apply) *Isjob ready for inspection: *Do you need a Temp Certificate: YES NO Rough In YES &0 Lot: fi/a P Final Temp -Information (If needed) - *Service Size: 1 Phase 3Phase 100 150. 200 300 350 400 Other *New Service: - Re -connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION /0 �� C/ ,DSIIIFQ/r Town of Southold W Erosion, Sedimentation & Storm -Water Run-off ASSESSMENT FORM a 0 PROPERTY LOCATION: s.c.r.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A .L ry01 JL '% �/ 7, ,� I STORM -WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN Drsfrict Section oc Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? �i-� I �5 Total Area of all Parcels located within (J Will this Project Retain All Storm -Water Run -Off (Include / the Scope of Work for Proposed Construction) Generated by a Two (2") Inch Rainfall on Site? (This item will include all run-off created by site ✓❑ (S.F. /Acres) b. What is the Total Area of Land Clearing Q1 and/or Ground Disturbance for the propose I clearing and/or construction activities as well as all Site Improvements and the permanent creation of construction activity? (S.F. /Acres) impervious surfaces.) / 2 Does the Site Plan and/or Survey Show All Proposed _�// PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed) Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and -M Slopes Controlling Surface Water Flow. and sediment control practices that will be used to 3 Does the Site Plan and/or Survey describe the erosion /' El control site erosion and storm water discharges. This item must be maintained throughout the Entire Construction Period. 4 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? 5 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the ❑ — Site? Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or General DEC SWPPP Requirements: Submission of a SWPPP is required for all Construction activities involving soil disturbances of one (1) or more acres; including disturbances of less than one acre that Beach? 7 Will there be Site preparation on Existing Grade Slopes are part of a larger common plan that will ultimately disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to ❑ including Construction activities involving soil disturbances of less than one (1) acre where One Hundred (100') of Horizontal Distance? the DEC has determined that a SPDES permit is required for storm water discharges. (SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious for Storm Water Discharges from Construction activity - Permit No. GP -0-10.001.) Surfaces be Sloped to Direct Storm -Water Run -Off F 1. The SWPPP shall be prepared prior to the submittal of the NOI. The NOI shall be into and/or in the direction of a Town right-of-way? submitted to the Department prior to the commencement of construction activity. 2. The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material, required, post -construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any El— constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right -of -Way or Road Shoulder compliance with the terms and conditions of this permit. In addition, the SWPPP shall Area? (This item will NOT Include the installation of Driveway Aprons.) identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark 3. All SWPPPs that require the post -construction storm water management practice component shall be prepared by a qualified Design Professional Licensed in New York in a Box and the construction site disturbance is between 5,000 S.F. & 1 Acre in area, a Storm -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 Prior to Issuance of Any Building Permit (NOTE: A Check Mark (.(r ) and/or Answer for each Question is Required for a Complete Application) STATE OF NEW YORK, COUNTY OF..........................................�SS That I, ......'�J �•`°•• `�x:r'......... Tvin... l.. being duly sworn, deposes and says that he/she is die applicant for Permit, Document) (Name of individ alg C� And that he/she is the...................................................................... ..................................................................................... (Owner, Contractor, 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 manner set forth in the application filed her Sworn to before me this; P-11�1" r ................�1................... day of ...... ....�q.. .................. , 20.� l NotaryPublic:..�! ..... Y .............................................................................. . (Si nature of pplicant) ?. FORM - 06/10 KifA vOM0"We"t RoY No.0leoNll.o I aiwiWInsiA *-ft-oft corrimiseion Expired Sept. 28.10 Southold Town Building Department gUFFO`'�r P.O. Box 1179 34�A oG�� Permit #: 36308 54375 Main Road T Southold, New York 11971 Permit Date: 4/8/2011 (631) 765-1802 Expiration Date: 10/7/2012 Parcel ID: 70.-3-22.12 BUILDING PERMIT RENEWAL LETTER Dated: 9/23/2013 Applicant: J & MJ SMALL REVOCABLE TRUST Location: 2330 WELLS AVENUE SOUTHOLD Work Description: IN GROUND POOL TO CONSTRUCT AN ACCESSORY INGROUND SWIMMING POOL FENCED TO CODE. A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: J & MJ SMALL REVOCABLE TRUST Address: 165 DEER RUN SOUTHOLD, NY 11971-4053 The permit listed above has expired. Please contact our office as soon as possible to begin the renewal process. All work on the project must stop on the expiration date. No work is permitted or authorized beyond the expiration date. THANK YOU, SOUTHOLD TOWN BUILDING DEPT. 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)744-8100 Randy T. Rodecker, Inc. la NYS Unemployment Insurance Employer DBA: Swim King Pools Registration Number of Insured DBA: Fence King of Rbcky Point 471 Route 25A Rocky Point, NY 11778-8985 Id. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only. required if coverage is 11-3092960 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 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) Valley Forge Insurance Co. Town of Southold i 3b. Policy Number of entity listed in box "la" 2094735086 53095 Route 25 3c. Policy effective period PO Box 1179 09/01/2010 — 09/01/2011 Southold NY 11971 3d. The Proprietor, Partners or Executive Officers are • ® included. (Only check box if all partnerstofficers 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 "W' for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York QM 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 note 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 of premiums 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: Thomas P. Terry. CPCU (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 08/25/2010 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: (631) 283-8000 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.wcb.state.ny.us 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 1a. Legal Name and Address of Insured (Use street address only) 1b. Business Telephone Number of Insured RANDY T. RODECKER, INC. DBA SWIM KING POOLS 1c. NYS Unemployment Insurance Employer Registration 471 ROUTE 25A Number of Insured ROCKY POINT, NY 11778 8561753 1d. Federal Employer Identification Number of Insured or Social Security Number 113092960 2. Name and Address of the Entity requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity being I isted as the Certificate Holder) The First Rehabilitation Life Insurance Town of Southold Company of America 3b. Policy Number of Entity listed in box "1a": 53095 Route 25 DBL37154 PO Box 1179 3c. Policy effective period: Southold NY 11971 02/01/2011 to 01/31/2012 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 pedury, 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. A. 2/7/2011 .B d 01 Date Signed (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer 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 the purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board, DB Plans Acceptance Unit, 20 Park 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 According to information maintained by the NYS Worker's 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 Worker's 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 authorized to issue Form DB -120.1. Insurance brokers are NOT authorized to issue this form. DB -120.1 (5-06) LOT AREA- 57,598 sq. ft. _4V n t00 In FA WELLS ROAD p0.p0,1 FD R=189.38' L= MON R SET s STK Covered o n :? bC blk.drive ` 1.7'N � b 2 4 wood o b X blk.drive /FC 1.0'N W u q � 1 \ S Oro n 41' ' ! VX1 } 45' 40.3 00 GAR i i� 2 STY FR 12.4' -- J DWELL c1, — 54.1 ' r`i ._ _Ce i- 17.9' 2nd STY wood deck 12'x8' N vol FC 0.8'N 0.2'EFD 50.18' MON -MONN 30114'300)W N 36'53'40"W LOT NUMBER 2 1 LOT NUMBER 3 NOTE: CESSPOOL. SEPTIC TANK & WATER SERVICE LOCATIONS BY OTHERS. THE OFFSETS (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES, RETAINING WALLS, POOLS. PATIOS, PLANTING AREAS, ADDITION TO BUILDINGS OR ANY OTHER CONSTRUCTION. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. OUARANTEEs.INDICATED HERON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSMUnCN LISTED HEREON, AND TD THE ASSIGNEES OF THE LENDING INSMUTIOW GUARANTEES ARE NOT TRANSFERABLE TO ADDMONAL. INSITTLMONS OR SUBSEQUENT OWNERS. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS INKED SEAL. OR E34BOSSFD SEAL. SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. CERTIFIED ONLY TO: NAIIC. No. 048992 HAROLD F. TRANCHON JR. PENN. LIC. No. 2115—E N I,- to rto p SET STK 0 in 110 SET `- STK (n d 7-31-2010 LOCATED and FLAG PROPERT CORNC€25 and &ET STAKES ON LiN£ FQ MON LOT NUMBER 7 166.56' � Lor NUMBER 4 8-28-2006 REVISE WA R SERV. LOCATION 6-26-2006 FINAL SURVEY 5-27-2005 FOUNDATION LOCATION JOB No. 01-617 FILE No. PECONIC DEVEL. CORP. SURVEYED FOR LOT NUMBER 12 MAP OF PECONIC DEVELOPMENT CORP. AT SOUTHOLD SITUATED AT SOUTHOLD TOWN OF SOUTHOLD — 'SUFFOLK COUNTY N.Y. SCALE 1" = 50' DATE 12-20-2001 FILED MAP No. DATE TAY AAAP No. (REF ONLY) 1000-70-3-22.12 DISK 500 HAROLD F. TRANCHON JR. P.C. LAND SURVEYOR 1666 ),JADING RIVER—MANOR RD. WADING RIVER, NEW YORK, 11792 631-929-4695 i i 8 0 PLAN 24 x 44 Rolling Lake W ATER LINE FORMED CONC. STEPS M m N 2"to 4" SAND BOTTOM TOP0�'"'"" SECTION A Scale: 1/8" =1'-0" SECTION B Sca le: 1/8" =1'-0" WATER LINE 10° CHECK VALVE PUMP TO Do DRYWE DIVERT VALVE FI LTER CHECK VALVE PLUMBING SCHEMATIC NOT TO SCALE NOTES -► v Q? O N- t- (� . L e— V } V Z Z " �= o z '� NO Z o0 � rz ON mQZ 0 Cil 0 cr v M Id � O N 0 O O ss.. a. �} Z OLLn v�zo e - Z f_.., Q � N =-�W�- O_ u- rrY czLLJ w� o oQ� � J L cL r' a 13-26-2011 1 1. 1. ALL CONSTRUCTION 15 TO BE IN ACCORDANCE WITH THE RESIDENTIAL CODE OF NEW YORK STATE- 2010 AND THEAN5I/N5P1-5-03 STANDARDS FOR RESIDENTIAL INGROUND SWIMMING POOLS FORA TYPE II POOL. COPING AND WALKWAY (BY OTHERS) 2. STRUCTURE 15 DESIGNED FOR USE BELOW GRADE AND ONLY IN AREAS WHERE THE GROUND WATER TABLE 15 A MINIMUM OF4'-8" BELOW THE PROPOSED FINISHED GRADE, WATER LINE GRADE 3. BACKFILL WITH CLEAN EARTH, FREE OF ROOTS AND DEBRIS. DO NOTALLOW THE HEIGHT co OF BACKFILL TO EXCEED THE HEIGHT OF THE WATER IN THE POOL BY MORE THAN 8", OR TH E WATER TO EXCEED BACKFILL BY MORE THAN 8". / j $� 4. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVEANY CLAY DEPOSIT ROLLED FOAM BETWEEN AND COMPACT CLEAN BACKFILL. LINER AND CONCRETE a. / 5. WALK5 TO BE SMOOTH, NONSKID TYPE, SLOPED AWAY FROM POOL FORM TIES 6• WATER DISPOSAL SHALL BE LIMITED TO OWNERS PROPERTY IN ACCORDANCE WITH d a ...., . j (o LOCAL REGULATIONS 3500 PSI POURED CONC. a :, �� 7. NO DIVING BOARD. VINYL LINER 8. PROPERTYOWNER 15 RESPONSIBLE TO INSTALL PERMANENT FENCE AROUND POOL IN ACCORDANCE j�� WITH THE NYS BUILDING CODE, APPENDIX G, SECTION AG105. PERMANENT ENCLOSURE MUST BE COMPLETED WITHIN NINETY DAYSAFTER THE DATE OF COMMENCEMENT OF CONSTRUCTION. 2"TO4"SAND 9. THERE 15 NO MAIN DRAIN IN THIS POOL. SUCTION FOR POOL WATER CIRCULATION / IS PROVIDED BY THE SKIMMERS ONLY. THIS MEETS REQUIREMENTS OF RC- SECTION AG106 FOR ENTRAPMENT PROTECTION. 10. THI5 POOL SHALL BE EQUIPPED WITH AN APPROVED POOLALARM WHICH 15 CLASSIFIED BY UNDERWITERS LABORATORY, INC TO REFERENCE 5TANDARDASTM 2208ENTITLED "STANDARD SPECIFICATION FOR POOL ALARMS,"A5ADOPTEDIN2008. WALL SECTION 11 THROUTEMPORARY IN PLACE G OUTTHEPE IOD OF CONSTRUCTION OFTHESWIMMIN POOL, UNTI L TH E COMPLETION OFA PERMAN ENT ENCLOSURE. -► v Q? O N- t- (� . L e— V } V Z Z " �= o z '� NO Z o0 � rz ON mQZ 0 Cil 0 cr v M Id � O N 0 O O ss.. a. �} Z OLLn v�zo e - Z f_.., Q � N =-�W�- O_ u- rrY czLLJ w� o oQ� � J L cL r' a 13-26-2011 1