The URL can be used to link to this page

Home My WebLink About39274-ZTown of Southold 6/1/2015 P.O. Box 1179 w P 53095 Main Rd ,1 W Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 37583 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 4020 The Long Way, East Marion SCTM #: 473889 Subdivision: Sec/Block/Lot: 30.-2-98 Filed Map No. Date: 6/1/2015 Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/3/2014 pursuant to which Building Permit No. 39274 dated 10/16/2014 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 Cinelli, Antonio & Cinelli, Gina of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 39274 05-12-2015 Aut ed ignatu Permit #: 39274 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: Cinelli, Antonio & Cinelli, Gina 1714 Park Ave New Hvde Park. NY 11040 To: install an accessory inground swimming pool, fenced to code At premises located at: 4020 The Long Way, East Marion SCTM # 473889 Sec/Block/Lot # 30.-2-98 Pursuant to application dated To expire on Fees: 4/16/2016. 10/3/2014 Date: 10/16/2014 and approved by the Building Inspector. SWIMMING POOLS - IN -GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Ir (2d 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. Ce a e offl-fOFO ancy g denied, the Building Inspector shall state the reasons therefor in writing to the app t I1; C. Fees � 1. Certificate of Occupancy -New dwelling $50.00, Additions to dwelling $50.00, Al # t4WellQ,$5W$, 'Swimming pool $50.00, Accessory building $50:00, Additions to accessory buil $5 00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy.of Certificate of Occupancy - $.25 Bi_DG CEP C 4. Updated Certificate of Occupancy - $50.00 ------ 5. Temporary Certificate of Occupancy - Residential $15.00, ,Commercial $15.00 Date. 5' a 9 a o i J New Construction: Old or Pre-existing Building: (check one) `S Location of Property: House No. )—Or16- W A q - - Oq s, / Street Owner or Owners of Property: �J�%71/J ('0 +- hAM 0_)�VE �- 1 Suffolk County Tax Map No 1000, Section O 3 0, Do Block Do? - O 9 Lot � Do n Subdivision PEi 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. riche rt(aD-town.southoId. ny.us CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Gina Cinelli Address: 4020 The Long Way City: East Marion St: New York Zip: 11939 Building Permit #: 39274 Section: 30 Block: 2 Lot: 98 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electrical License No: 38043 -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 100A A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixturesTime Clocks 1 Disconnect F-1 Switches 3 Twist Lock 1 Exit Fixtures TVSS Other Equipment: In Ground Swimming Pool To Include, Bonding, 1- Control Panel, 1- Gas Pool Heatl 1- Salt Generator, 3- GFCI Circuit Breakers, 2- Pool Lights, 1- Pool Cover Motor Notes: Inspector Signature: Date: May 12, 2015 Electrical 81 Compliance Form.xls SO(/jyol TOWN OF .SOUTHOLD BUILDING DEPT. - 765-1802 INSPECTION. [FOUNDATION IST [ ] ROUGH PLUMBING Y:kl FOUNDATION 2ND [ ] INSULATION. ] FRAMING/ STRAPPING [ ] FINAL [ ] FIREPLACE A CHIMNEY [ ]FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE `` l� INSPECTOR pF SOUTyo TOWN :OF SOUTHOLD. BUILDING' DEPT. 765-1802 INSPECTION } FOUNDATION 4ST ] FOUNDATION 2ND ] FRAMING/ STRAPPING ] FIREPLACE A CHIMNEY ] FIRE RESISTANT CONSTRUCTION ] ELECTRICAL (ROUGH) ] CODE VIOLATION 1/®, . , r [ ]ROUGH PLUMBING I l�N N FINAL [ L [ ] FlRE SAFETY INSPECTION I lFIRE RESISTANT PENETRATION I 1 ELECTRICAL (FINAL) [ ] CAULKINGAtaD K" 4cc-41,p r -v 4,6�, - t 7?/ - INSPECTOR hO��OF SOUryolo I�YCm.M e1� TOWN OF 'SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION—,. [ j FOUNDATION 15T [ ]ROUGH PLUMBING [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING [ ]FINAL I- ] FIREPLACE 8 CHIMNEY [ ]FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTAIIT PENETRATION [ ]ELECTRICAL (ROUGH) [�j '] ELECTRICAL (FINAL) [ ]CODE VIOLATION [V�] CAULKING REMARKS: ,row DATE '� Z �� INSPECTO � o��OF SO(/r�ol couHr+,��' TOWN=OF SOUTHOLD .BUILDING DEPT. 765-1802 I=NSPECTION [ ] FOUNDATION 1 ST- [ ] R GH PLUMBING [ ] FOUNDATION -2ND [ ] SUI U N [ ] FRAMING /STRAPPING [ FINA [ ] FIREPLACE & CHIMNEY [ ] FIRE $ INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL,(FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE � �' _7 r[S INSPECTOR • • WAN .. INSULATIONPLUAMING r 0 0►'�• r �tl� VIA 0 do TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined 20 BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval PERMIT NO. 3 Approved /t'P 20—/Y Disapproved a/c Expiration i 20 Septic Form N.Y.S.D.E.C. Trustees C.O. Application_ Flood Permit_ Single & Separate Contact: Storm m -Water Assessment ForAWA ��Ohy Mail to: �7 '-�/ A" � A /i-.41-7V�r ,'i1 e /t// /(!j-f2 Phone)y Building Inspector 1TION FOR BUILDING PERMIT /� (/ 111 20 4 1�...�' Date le � , 20 OCT - 3 INSTRUCTIONS a. ThisBR lUn MUST be comp etely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plarlQk46fat IUn to scale. F according to schedule. --''--5. P of pwing 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 Soutfiold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for rempavyl or demolition as herein described. The applicant agrees tocomply with all applicable laws, ordinances,`building code sin ode, and regulations, and to admit authorized inspectors on premises and in 6buildmg fog n cess i, inspections. r C O M�� ,. U p � � L AFUL (Signature of applican�� ame if corporation) 1~14COSE POOL TO CODE , �d6 6—+ UPON COMPLETION wrn (Mmihnga rapplicant)BY �BEFORE:y"'WATER A 17 N IF, . E U111.( 'I Vv E . IST VIENT AT State whether applicant is �d9ne> o ri ra hl tt�engineer, general contractor.,ele�tdr�c�an,Upyumbe i`buI.- OR THE FiJLLOVNIP.G !NSPEC;(-"NS Name of owner of premises /•6 /1`�l/) If of c& is a corporation, signature .1"1111k7,M-1 k1� •;Z-° (Name aid -title of corpofate officer) Builders License No. Plumbers License No. Electricians License No. Al Other Trade's License No. of land on whieb proposed work will be done: Number Street County Tax Map No. 1000 Section 50 ,q D1 A - t v ,r, r r_QUIRED PC)UhED CONCf,ETE ff%YJiA�csr uucuT - - .. .... ,.. STRAPPING, ELECTRICAL & CAULKING GUM INSULATION 4. FINAL - CONSTRUCTION & ELECTRICAL MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT -RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. Block 02 Hamlet LUTAIN� RM -WATER RUNOFF PURSUANT TO CHAPTER 236 ' OF THE TOWN CODE.,, Subdivision (�- &e "6 /K-' Filed Map No. 62C-1� Lot 6t5 2. State existing use and occupancy of premises and inten d use ajp�d occu ancy of proposed construction: a. Existing use and occupancy �%7rr/r� 7/-i /�/ L�/ el/, :c r r b. Intended use and occupancy 1%1�-7Gj le T�� i 6� �1 �S 6: /'" 3. Nature of work (check which applicable): New Building Addition Alteration �jlp�1 Repair Removal Demolition Other Work ►'►r ' m2l ;-7SA//4f,�v, 4. Estimated Cost_; ' ��, �� Fee (Description) (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front—A61,171 / ?1e.Depth Height Number of Stories 7— Dimensions Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front �� / Reer' 4g / Depth Height Number of Stories ! 9. Size of lot: Front �/. I / Rear 14 ! Depth 10. ate of Purchase Name of Former Owner 11 Zone or use district in which premises are situated 12. Does proposed construction violate any zonin ordinance or regulation? YES_ NO 13. Will lot be re -graded? YES_ NOWill excess fill be removed from premises? YES NO 14. Names of Owner of premises Address Phone No. Name of Architect r? V Address f-a&0"e Phone No Name of Contractor ILA -illi /,' $nc Addressz-f;4G0G2' Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO_ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. Z,-;-<�6.Pro ' survey, to scale, with accurate foundation plan and distances to property lines.:, ..J" . If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.:,,. CONNIE Gy` 18. Are there any covenants and restrictions with respect to this property? * YES Notes , State'' o$ New York ' * IF YES, PROVIDE A COPY. o. 1 5116165050 Qualified in Suffolk County /I STATE OF NEW YORK) Commission Expires April 14, 2 �b SS: COUNTY OF ) being duly swom, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work an to make and file this application; that all statements contained in this application are true to the best of his knowledged that the work will be andref; performed in the manner set forth in the application filed therewith. /� i Sworn to before me thi fs ' day of �Q�/ _ 20 Notary Public V Signatu of Applicant a AGE ;K. `. a _. •_41 a =. r r i,gg § 04-0 cml3 + s< all r .': - y. a � ,� �°. � �� p °� r (..r� ix��`� is < --c ielc��lhuraidi, g ap ZY a- .. ic . a=?1: Tnt or ' u : "mss, ..; d t .,$ p ,. ie `. %; xl z a s „ ,,_ .ate---� e. � .Nil "C..' ttis Y -1 10a: >##s3;., 5"# {. A $ 111.11W 111T) 3 X33 -ip 'a r , pou'r nc ME ra w Nta , TVMP w �C ti ef lhc Obot Ami =-. ga ma 17, m - Company Name: No.. cf Lf /I JOBSITE tNFORMATION: (*Indicates required information) *Name: N G_I *Address: *Cross Street *Phone No.: Permit No.: 3 L A7 V Tax -Map District. '!0{10 Section: Stock: Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) (Please Circle All That Apply) Is Job ready for inspection: 0'_YESNO. Rough In Final *Do- you need a Temp Certificate: YES t NO Temp Information (11: needed) *Service Size: 1 Phase 3Phase 100 150 200 300- 350 400 Other *Mew Service: Re -connect- Underground Number of Meters Change of Service Overhead Additional Information:PAYMENT DUE WITH APPLICATION MRf,quest for inspection Form b` September 22, 2014 Town of Southold Building Department 54375 Route 25 Southold, NY 11971 To Whom It May Concern: I, Gina A. Cinelli, owner of property located at 4020 The Long Way, East Marion, NY 11939, Authorize, Patrick Kenney of Patrick's Pools, Inc., to be my agent, and act on my behalf, in applying for All Building Permits needed for construction of an IN ground pool at above mentioned property. Gina A. Cinelli Ai4 /I iv;i it ju A ;`�J 2? 4020 The Long Way East Marion, NY 11939 1000-030-00-02-00-098.000 LISAMARIE MORE -LU Notary Public, State of New York No. 01 fv1O6122056 Qualified m Nassau Feb. Commission Exp 0 000"Pat 0• 4 14. V, 0 iAk Suffolk- County Deparbnent of Labor, Licensing & Consumer Affairs VETFIRAMS MEMMAL 1-3IGHWAY HAUPPAUGE. NEW YORK 11 7:9$ N,o. 51699-1-1 'Dj-A, ISSUED: 5,/16/2013 - SUFFOLK COUN"ry "n 11-10 T t Cantractor License Ir I **F This as to certifi, that PATRICK 0 KENNEY doing busmessa-s PATRICKS POOLS INC hat iner furnished tile requireTpelits setfoah in accordance with and subject to tile, provisions, of applicable laws, rudes, and reguiLmons of the County of SuIT01k. State orNevx- York is here -by licensed to conduct business .35 a 110NAE V,1 .NjL,'\",j'C0NT1;UNCT0R, in the County OUSWTOIL Licensc CategOTY NOT VAUD Nif ITHOUT P Additional BUSjUCA�tS- ooWSpas DEPARTMENTAL SFAL ANDA CURRENT CO,NSUNIER AFFAIRS I D CARD CammiSsinaer s" WJ - .40 10/02/2014 22:27 6312456513 PATRICKS POOLS INC PAGE 01/01 I � OL4 THIS CERTIFICATE 13 JIMU19D ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON E CERTIFICATE MOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAG AFFORDED SYE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSU NG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. Lm1 LA U�)r�,'i� .. . PRODIJC9i IBrookhaven Brookhaven Agency, Inc. P.O. Box 850 150 Main street East Sebuket NY 11733 CERTIFICATEvpaF LIABILITY INSURANC INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DoCUMEi T WITH RESPECT70 WHICH THIS CERTIFICATE MAY BE 16SUF_D OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIF IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 0911;9!2074 THIS CERTIFICATE 13 JIMU19D ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON E CERTIFICATE MOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAG AFFORDED SYE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSU NG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. (MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policytles) must be andamed. 1 SUBR the tsmis and cendHi* of the policy. certain policies may require an endorsemunw A Statement on this cardfKate cardiftate holder in Ileo of such endomen 4s . GATION IS WAIVED, subject to does not confler rights to the PRODIJC9i IBrookhaven Brookhaven Agency, Inc. P.O. Box 850 150 Main street East Sebuket NY 11733 Aaemy, Inc, PHONE 831 941-4113 FAX Nal -L64 1 1 941-4405 L brookhaven.a enc eriz n.net rUODacERID , 3941 1 AP ROING COW Mrd MAC a imum Patriws Pools, Ine. PO Box 3024 E. Quogue NY 11942 - Merchants Mutual Ins. Co. • Wesco Insurance Co. s 1� O 0 000 C: x CMIERM GENEILIiY X IN E - 2128/2014 1N REN7sD s 700 000 ,one 00VERAGES I CERTIFICATE NUMBER: REVISION NUMBER: THIS iS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DoCUMEi T WITH RESPECT70 WHICH THIS CERTIFICATE MAY BE 16SUF_D OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIF IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNBli 7YPEOFINBURANGBRIM AWL B NUMC9tlk POLICY EFF POLICY EXP 6nAITS c"ERAL LIABILITY s 1� O 0 000 A x CMIERM GENEILIiY X CMP9154061 2128/2014 212812015 REN7sD s 700 000 ,one C,LAIM$•MAP9 IX OCCUR MED nwn S OOO PERS d INJURY 31 ODO QOn GENERAL 7E e2 000 000 C04L AWREGATE LrelrT iwP PER; P c7 $1 ,000,000 POLICY X OC 5 I AUTOMOBILE N.IABNLI(Y ANYAUTO AL OWNED AUTOS COMBINE4 SINGLE LWIT i (a 40d0l) BODILY IN URY (Per pennon) 6 BODILY IN URY (Per eoddano S SCHEDULED AUTOS HIRED AUT09 PROr GE $ � NONOWNED AUTQ4 UMBROJ A LIAa OCCUR H DOC URRENCE AGGR re EXMSUAe I MS-0RADE DEDUCTIBLE = i F3 WORKEWCOMPENBATION AIID 9MPL0YEW UwL"jv VI ANY PROARIETORfp=ERIF�( CUTNt (4�I Flaida ) FJICLUDEOT i I N A WWC3060073 5113114 5113115 X VMe a7U. OTH- EA H CIDENT S108000� E - EA EnaPLD 100 000 E.L. MS -POLICY LIMIT son n00 D66CABh' mO W oPgm7W NB / LOCA=ms t VEmeLo (AMM ACORD 101, Addidoymt h lam yAmme, If MOM RpAce I* Lequm) Certificate holier is slso named as Additional Insured. I TOWN OF SOUTI BUILDING DEEPAwill M C 19 SHOULD ANY OF THE ABOVE DESCRIGE4 POLICIES BE CANCELLED BEFORE THE EXPIRAMON DATE THEREOF, t4MCE WILL BE DELIVERED IN ACCORDANCE VUM THE POLICY PROVISI & 10/02/2014 22:28 6312456513 PATRICKS POOLS INC STATE OF NEW YORK WORKERS' COMPENSATION BOARD 4-hM rl MCATE OF NYS WORIK ERS' COP"ENSAT ION 1NSURAN, i 1a. Legal Name & Address of Insured (Use street address only) 1b. Business Telephone Nut PATRICK'S POiDIS INC 631-831-0816 PO BOX 3024 le. NYS Unemployment Ins EAST QUOGUE NY 11942 itegistratiou Number of Work Location Specifically iimb, Wrap-up Policy) 2. Name and At Coverage(Et 'own of South( $3095 Route 25 Southold NY I l Insured (Only required {f coverage is to certain location in New York Stale, Le., a US of the Entity Requesting Proof of . Y Being Listed as t5e Certificate Holder) Building I)epartment 1d. Federal Employer or Social Security 262929943 30. Name of Insurance Car WESCO INSURANCE CO 31). Policy Number of entity WWC3060073 3c. Policy effective period U/ /2014 to PAGE 02105 of Insured cc Employer red ion Number o$Insured In box "ala" 3d. The Proprietor, Partners oaf Executive included. (Only check box it all battaersiame X all excluded or certain are This certifies that the insurance carrier indicated above in box 9" insures the business referenced above in box "lie' or workers' compensation under the New York State Workers, Compensation Law. (To use this form, New York on the 21FORMATiON PAGE of the workers'Compensation insurance olio The.Xnsurance Carr:�'er rrti be seed agunder wilI se Item d this Certificate of Ins! p P y)" �P ance to the entity listed above as the certificate holder in box "2 The Insurance Carrier will also nolo the above certipate holder within 10 days IF a policy is canceled du to nonpayment o premiums or within 30 days lF there are reasons other than nonpayment of premiums that cancel the policy or eli lnate the insur�d from the coverage indicated on this Cert trate. (These notices may be senr by regular mail.) Otherwise, this Certi}i e Is valid for oneyear after lids form IF approve i by the tnsgrance carrier or In llcamed agent, or until the policy expiration date lis! in box "3c' ; w�ilc/rever,ts eaNier. Please Note: Upon the can"llatfon of the workers' compensation policy indicated on this form, if t business coat named on a permit, license or contract issued by a certificate holder, the business roust provide Haat ce 'ticate holder CertWwate of Workers' Compensation Coverage or other authorized proof that the business is cOMI lying with the coverage requirements of the New'York State Workers' Compensation Law. Under penalty of p $bove and that the Approved Telephone Number of Please Note: only in authorized to issue it. C-105.2 (9-07) I certify that I am an authorized representative or lfeensed agent of the insured bas the coverage as depicted on this form. reprrsentetivc or licensed agent of insurance carrier) (Date) :ed representative or licensed agent of insurance carrier: 631-9414113 carriers and their licensed agents vre cndhorized to issue Form C-105 Z carrier brokers ;tobe a new NOT .res 10/02/2014 22:28 6312456513 PATRICKS POOLS INC Workers' Compensation Law S"60n 57. Restrictiou on issue of permits and the entering into contracts unless compensation is I. The head Of a state or municipal department, board, commission or off ice authorized or required by la v to issue any p connection with any work involving the employment of employees in a hazardous employment defined by th s chapter, and ni any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit ess proof duly an insurance carrieriis produced in a form3atisfactolry to the chair, that compensation for all employees has b xn secured as pj chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or nuaicipal deem commission or office to pay any compensation to any such employee if so employed. 2. The head of a st in connection with, any general or spec by an insurance car, this chapter. C-105.2 (9-07) or municipal department, board, commission or office authorized or required by lav r work involving the employment ofemployees in a hazardous employment defined statute requiring or authorizing any such contract, shall not enter into any such conte Is produced in a form satisfactory to the chair, that compensation for all employees enter into any this chapter, ni t unless proof d s been secured PAGE 03/05 ]it for or in rithstanding ascribed by ided by this ant; board, itract for or ithstanding subscribed 10/02/2014 22:28 6312456513 PATRICKS POOLS INC i I - STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENZ PART 1.To be completed by Disability Benefits Cartier or 1.1mused Insurance Agent of 1a. Legal Nanta and Address of Insured (Use street address only) lb. Busittttss Telephone Number of h PATRICK S POOLS INC 831-941-4113 le. IUYS Unemptvymant Insurance rm Numberof Insured PO BOX 3024 PAST QUOGUE, NY 11942 4 Name mW Address of the Entity requesting prwf of Coverage (Enuh► being rinsed its the Certificate Holder) Town of Southold Building Department 53095 Route; 25 Southold NYi 11971 4. Policy covafs: a. 4. 1d. I'Mieral Employer Identification Or Social Security Number 262929943 30. Name of Insurance carrier ShelteflRornt Life tnatrrance 3b. Policy Number of Entity listed in DBL318565 3c. Polley effective period: 05/13/2014 to All Of the employer'$ employee= eligible under the NeW York Disability agnefin Law Only fire following class or classes of the employer's employees; S LAW Carrier I rr Registration ror Insured 05/12/2016 Under penally of podury, I earthy that I am an authorized mprosentetivc or Ilcen w agent or the Insurance carrier ral warm above and that the named insured has NYS Disability Senofits inyufwm coverage as dti dbed above. i Date signed I 9/18/2014 By W, -#t (Sigmum of insunmeew Ws authorh1d rePresemariw or NYS Lkah od r Ago „t Telephone Numl 1MPORTANT:Ir of If It 1 PART 2. To bI At o"loinrorm D"Illty Benefits I Dma signed_` Tefephone Numb Please Note On time insurance D11-120.7 (54q r 518-829-8100 Title_ Chief Executive Officer ue '48F is checked, and Oils form is signed by the "Wrens earner's aeuhoered MP/pFapye Or NYS LlamMd In warice Agent Mt carrier, this codfimta 4 COMPLETE, !Nail it direedy to the oertlficam holder - 5z fib" b Cl -ked, 41116 wdffeate is NOT COMPLETE for ties purposes of section 9A Subdt a of the orsWilty a nentS Low. ust be melted for eaaeplsoon to the Worker's Cempematlon heard, DB Plans Aeoep== Unit, 20 Park $trlM Aft my, NY 12207. completed by NYS Worker's CoMPQnsadon Board (Only if box "4b" of part 1 has been State of NeW York Worker's Compensation Board Gorr metnWnw try the NYS worker's Comp --don lie M the shove Homed employer has complied with rho N W with respeetto oll othIMMOneployees. By Title V 'rata$$* carriers (iovnsed tp write NYS Disablllty Benefits Insurance policies and NYS Cleansed Insurance Ageft o arrlers are authorized to tssao Fenny 08.120.1. Inaruance brokers are NOT authorized to issue this firm. PAGE 04/05 10/02/2014 22:28 6312456513 PATRICKS POOLS INC PAGE 05/05 Additional Instrttstlons for Form t78.120.1 BY sign ng this farm, the insurance carrier identified in Box "3" on this form is certifyintt it g hat i1s business referenced in box "1a" for disability benefits under the New York state Disability Benefits insurantDe carrier or its licensed agent will send this Certificate of Insurance to the entity listed as th holder in Box "21. This certificate is valid f�f one year after this fbrM is approved hI carriu Or its licensed ager}% or the policy expiration date listed in Box °3c". Please Note. Upon the cancellation of the disability benefits Indicated on this flarm. if the on a perrhit- lk*me or contract issueO by a certificate holder, the business out prOv"rde that reniifiisrate }told k Cerflage it of NYS i)isebitily Benefits Coverage or otttar authorized prod that the business Is eompiying with th ooveregelrequirenlnnts orthe New York State Disability 8enerits LAW. DISABILITY BENIEFITS LAW 5ectiott 220. Subd. 8 (a) The Mead of state or municipal department, board, commission or office authorized or law to issue any permit for or in connection with any work involving the employment of etttployrnent as defined in this article, and notwithstanding any general or special statute i authorizing the issue of such permits, shall not issue such permit unless proof duly stasubtute insurance carrier is produced in a form satisfactory to the chair, that the payment of disabi for all employees has been secured as provided by this article. Nothing herein, however, sl construed as treating any liability on the part of such state or municipal department, boars or office�to pay any disability benefits to any such employee if so employed, . (b) The head of state or municipal department, board, commission, or office authorized or law to eritter into any contract for or in connection with any work involving the employmet in employment as defined in this article, and notwithstanding any general or special StatUt authorizing any such contract, shall not enter into any such contract untess proof duly sub! Insurance' carrier is produced in a form satisfactory to the chair, that the payment of disabil all employees has been secureq as provided by this article. M120.1 (5-06) Revarse wring the 5W. The certificate ho insurance ft to be named th a new , mandatary quired by iptoyses in quiring or ed by an ty benefits III be commission squired by I of employees requiring or :ribed by an N benefits for THE LONG WAY 7� N 76`2$,30 0 o HE°GE .'�.. z CO NC :. MER ApR°N. '---WPjER :n • o' Oa•p5FtV4S. �•pNEWFY' Do I65® J-89.3— -- -- — � OO�ER-1E! O O O z L a 0» W 1, o GAS VALVE -76o 2 L S c w z of Qaek Pyov, T+ � 'L O z SURVEY OF LOT 63 MAP OF PEBBLE BEACH FARMS FILE No. 6266 FILED JUNE 11, 1975 SITUATED AT EAST MARION TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-30-02-98 SCALE 1 "=30' MAY 10, 2007 AREA = 31 ,009.57 sq. ft. 0.712 ac. LOT g a~_ coPaD 01 p -0 5 SO q' Lo :5 Wiz•.- -.. L� _R L,.. .��_' 9 oma o�soAs ` �s00 T 32 5 i a'p P� %1y 0N0 To $� LOT 62 LOT 6 UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. 37 9 52, -5(34.90 11 94 90' PREPAREC# IN ACCORDANCE WITH THE MINIMUM STANDAR FOR TITLE SURVEYS AS ESTABLISHED BY THE - I.A.L.S. AND APPROVED AND ADOPTED FOR SUCUSE BY THE NEW YORK STATE LAND TITEE- _ TION. ca IIlrr `',arc.. rr 4`,vF"?�1j 1 �kfso N.Y.S. Lic. No. 49668 Joseph A. Ingegno Land Surveyor Title Surveys - Subdivisions - Site Plans - Construction Layout PHONE (631)727-2090 Fax (631)727-1727 OFFICES LOCATED AT MAILING ADDRESS 322 ROANOKE AVENUE P.O. Box 1931 RIVERHEAD, New York 11901 Riverhead, New York 11901-0965 L -e 6 ell, t77A . ,,/,.4 & Is 4- ti rl 51; r4 rl --Oo� HT hE EIREDj Y 0 789A OF N Id a N