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HomeMy WebLinkAbout39281-ZO�Os�tf�l'�tpG , Town of Southold P.O. Box 1179 o® 53095 Main Rd Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 37690 Date: THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1080 Park View Ln, Orient SCTM #: 473889 Subdivision: See/Block/Lot: 15.-5-24.21 Filed Map No. 8/4/2015 8/4/2015 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. 39281 dated 10/17/2014 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 D'Agostino, Denise & D'Agostino, John of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 39281 05-19-2015 AutliRrized Signa ure " — TOWN OF SOUTHOLD �ogUFFO(�'co� BUILDING DEPARTMENT TOWN CLERK'S OFFICE Cn o �4. 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 #: 39281 Date: 10/17/2014 Permission is hereby granted to: D'Agostino, Denise & D'Agostino, John 90-14 69th Ave Forest Hills. NY 11375 To: Construction of an in -ground swimming pool as applied for. At premises located at: 1080 Park View Ln. Orient SCTM # 473889 Sec/Block/Lot # 15.-5-24.21 Pursuant to application dated 10/3/2014 and approved by the Building Inspector. To expire on 4/17/2016. Fees: IN -GROUND SWIMMING POOL $250.00 CO - SWIMMING POOL $50.00 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 IWlead. 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 r Date. _ oub New Construction: Old or Pre-existing Building: (check one) Location of Property: 06U L vleiv a House No. f Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Block Lotc-P q, 2 I Subdivision Filed Map. Lot: 171 Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ A icant Signature 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 rtg-town.southold. ny. us CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: D'Agostino Address: 1080 Park View Lane City: Orient St: New York Zip: 11957 Building Permit #- 39281 Section: 15 Block: 5 Lot: 24.21 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric License No: 2740 -ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt 3 Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1 A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 Twist Lock Exit Fixtures TVSS El Other Equipment: In Ground Swimming Pool To Include - Bonding, 1- Pool Light, 1- Salt Generator, 1- Salt Generator, 1- Pool Heater, 2- GFCI Circiut Breakers. Notes: Inspector Signature: Date: May 19, 2015 Electrical 81 Compliance Form.xls 1 a SOU i iQ UOUMY,�c� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ""141 �✓ /FOUNDATION 1 ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND �• [ ]INSULATION [ ] FRAMING/ STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATEINSPECTOR 1 � o TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ] FOUNDATION IST ] FOUNDATION 2ND ] FRAMING/ STRAPPING ] FIREPLACE & CHIMNEY ] FIRE RESISTANT CONSTRUCTION ] ELECTRICAL (ROUGH) ] CODE VIOLATIQN REMARKS: DATE [ ]ROUGH PLUMBING [ ]INS N [ INAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION [ ]ELECTRICAL (FINAL) [ ]CAULKING rll_l -�S eA = C c INSPECTOR 61 �1 TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION ] FOUNDATION 1ST ] FOUNDATION 2ND ] FRAMING / STRAPPING ] FIREPLACE A CHIMNEY ] FIRE RESISTANT CONSTRUCTION ] ELECTRICAL (ROUGH) ] CODE VIOLATI REMARKS: [ ] ROUGH PLUMBING [] 1 UL ATION [ FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (FINAL) [ ] CAULKING DATE D49 03 6/�-INSPECTOR�%'r`�]� FIELDINSPECT Cl ;BRM DATE COMMENTS FOUNDATION (IST) FOUNDATION (2ND) ROUGH FROONG & PLUMBING y C INSULATION PEA N. Y. STATE ENERGY COVE ' . Y FINAL , AD 614 CM1Y[ENTS , 0 e� �d TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying ? PERMIT NO� � �� Examined/,-7,20FD Approved , 20 Disapproved a/c Board of Health 3 sets of Building Plans Survey Check Septic Form FT- N.Y.S.D.E.C. Trustees Contact: ,(JMail to: -C" �j — b 'C LZS VyoL03 2014 Phone: (0 BLDG. DEPT. TOOF SOUTHOLD HOLD APPLICATION FOR BUILDING PERMIT Date 9 , 20J INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what -so -ever until a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and emulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or r(a iie, if a corporation) q2Oi �� .2-s�- %lil/ec- Pcau 117(oV (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ear&o&ok Name of owner of premises it b& a I /'V' O (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. 0-140 Plumbers License No. Electricians License No. 'q�� � Other Trade's License No. 1. Location of land on which pr9posed work will be done: I C 1Qn VAe-wet,/ LN House Number Street County Tax Map No. 1000 Section Subdivision (Name) Hamlet`, i,,ci� , Block Lot Filed Map No. Lot e71: 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy &3_ Dtr 211 b. Intended use and occupancy. 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work pit n g A 1A a YU me"M; i& L (Description) .19 Estimated Cost 0717— Fee (to be paid on filing this application) Number of dwelling units on each floor 5. If dwelling, number of dwelling units If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. VA Dimensions of existing structures, if any: Front`c� ' Rear 2- i Height Number of Stories S Dimensions of same structure with alterations or additions: Front Depth Height, Number of Stories Depth Rear ' 8. Dimensions of entire new construction: Front � Rear 45 —Depth 3 Height Number of Stories 0 Size of lot: Front .2-i0 Rear, 10. Date of Purchase ame of Former Owner 11. Zone or use district in which premises are situated Depth 2co 12. Does proposed construction violate any zoning law, ordinance or regulation: �yd 13. Will lot be re -graded co Will excess fill be removed from premises: e NO 14. Names of Owner of premisesAddress ©aie(\-�- Phone No. 323--0103 Name of Architect %;3rb& D &, I l 0c Address 4 &-zeJj j Phone No 72_LF-7E-FV Name of Contractor FDhJhxD1 Address 42_9 or 2sA Phone No. -7yq--7 "L 11 -el_ i9.Q c� 15. Is this property within 100 feet of a tidal wetland? 'AYES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF&q-0)L Z4 . L (:I being duly sworn, deposes and says that (s)he is the applicant (Name of individual 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 true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this �Jc J'"' day ofd//� 20 Qumx,�_ Q Notary Public MARGARET 4. MONEY ry 0Wic - State ®f New Fork No. 01 K16021 111 ®ual'ified in Suffolk County MY commission Evir®s march s, go. 1, Signature of Scott A. Russell SUPERVISOR SOUTHOLD TOWN HALL - P. O. Box 1179 53095 Main Road - SOUTHOLD, NEW YORK 11971 AWAAN AG]EAMI]ENT Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WQRK SHEET Yes I No C 107 ( TO BE COMPLETED BY THE APPLICANT) DOLES TICS PROJECT WVO1LVV1E ANY OF T)<IlE (CHECK ALL THAT APPLY) A. Clearing, grubbing, grading or stripping of land which affects more , than 5,000 square feet of ground surface. B. Excavation or filling involving more than 200 cubic yard. - within any parcel or any contiguous area. of material C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. D. Site preparation within 100 feet of wetlands, beach, bluff erosion hazard area. or coastal E. Site preparation within the one -hundred -year floodplain as depicted on FIRM Map of any watercourse. F. Installation of new or resurfaced impervious surfaces of feet or more, unless prior approval of a Stormwater Control Plan was received by the Town and the prof in-kind replacement of impervious surfaces. 1,000 square al includes If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT. (Property Owner, Design Professional, Agent, Contractor, Other) NAME: '�h)W1 Ib rin 1 ruaure) 22 pp^ Contact Information $31— 323-00 V (Telephone Number) — — — — — — — — — — — — — — — — Property Address / Location of Construction Work: t4 0M, VAavted LN nkient w i iR�r7 FORM * SMCP - TOS MAY 2014 S.C.T.M. #: 1000 District Section Block Lot **** FOR BUILDING DEP Reviewed By: Date. g1,-jo& NT USE ONLY **** Date: 46 -- -1 t4 rsg Approved foM`anagem`ent__2o_ntro­l Building Permit. Stormwater Plan Not Required. ®Stormwater Managementontrol Plan is Required. (Forward to Engineering apartment for Review.) ft�QF1E Tdwn HA Amex $4876Main Road P40I •A7M 1179 Southold' NY 119714969 `�lcphanc�(�FARbD765I8bE M mo-Dy—me BTJMDZNG DEPARTMENT d TOWN OF SOUTHOLD A L! R ATIO E�CTR� � ..� LcAL IN�I�I���oN• sTb B1!: Daae: duress: % // a sly° rat- �; ii°r P4 - j,,013SITE INFORMATION: (*i-'tldfratea required information) *"dtM% *Addmss: lt?gb. Vross Street: 'Phone No.: Rwmat No.: Tax hMp i7IStrlet: *f I F DESCRIPTION OF WORK (Please Print clef"4JJ'f�0)� � Tom. •information cif needed}, . *ServiCe ske: l Phasrv. 3Phase 100 15G 200 30Q. - 3BU 400 • Other *New Service: Reacunneot Undotground Number of Meters Change df Service Overheod Additional 11h1blmotion: PAYMENT DUI IT1-I PPLICA-T ON- OWNER VILLAGE DIST. SUB. LOT !;el7l FORMER OWNERC-D'(05 N E AC4 0 f " r"? I/i Pr, A b, -ID, C-1 S W TYPE OF BUILDING RES. SEAS. VL. j� FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARK Q Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowl,and DEPTH (&Ora 2e) House Plot BULKHEAD ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 FAX -744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: APPLICATION FOR OUTDOOR POOL PERMIT EROSION SEDIMENTATION & WATER RUN ASSESSMENT FORM [ CERTIFICATE OF WORKER'S COMPENSATION [1� CERTIFICATE OF LIABILITY INSURANCE j SUFFOLK COUNTY LICENSE �]® SUFFOLK COUNTY PLUMBER LICENSE ] SUFFOLK COUNTY ELECTRICIAN LICENSE //'"' 4 SETS OF PLANS - (3 STAMPED) 3 SURVEYS APPLICATION FOR ELECTRICAL INSPECTION WIH $100 CHECK [ APPLICATION FOR CERTIFICATE OF OCCUPANCY [ ] C.O. $ ` ] TAX BILL $300.00 CHECK FOR PERMIT FEE I Suffolk County Department of Labor Licensing & Consumer Affairs j VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 7/1/1978 No. 4436-H SUFFOLK COUNTY Home Improvement Contractor License This is to certify that ARTHUR J EDWARDS doing business as ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. NOT VALID WITHOUT DEPARTMENTAL SEAL AND A CURRENT CONSUMER AFF'AIRS ID CARD This certifies that the bearer is duly licensed by the County of Suffolk Additional Businesses ARTHUR J EDWARDS MASON, CONTRACTING CO INC DBA ARTHUR EDWARDS POOL & SPA ----e" CENTRE SUFFOLK COUNTY DEPT OF LABOR. License Category GC Pools & Spas / Certified Pools/Spas Commissioner Suffolk County Executive `g Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 No. 2740 -ISE SUFFOLK COUNTY 411111�� This is to certify that EDWARD S REIFF doing business as UNDERGROUND SPECIALTIES INC having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York. SUFFOLK COUNTY DEPT OF LABOR, 1 L-FMAIMn X ('nFJQI WACO APPA10C MASTER kasZOM013�4' This certifies that 'theT EDWARD S REIFF bearer is duly z licensed by the G NmW I" 0510 1/1980 County of Suffolk SUFFOLK COUNTY DEPT OF LABOR, 1 L-FMAIMn X ('nFJQI WACO APPA10C MASTER ELECTRICIAN EDWARD S REIFF BU3MEUNAM GENREADY. INC. DBA 2740—ME G NmW I" 0510 1/1980 '""s 05/01/2016 Additional Businesses ARTHU-1 OP ID: VM CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMBER: RFVISInN NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD DATE 011115/201 YY) 01/1512014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES -BELOW. THIS -CERTIFICATE OF INSURANCE -DOES MOT-CONSTfTUTE A -CONTRACT -BETWEEN THE -ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate -holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Bagatta Associates, Inc. 823 W Jericho Turnpike Ste 1A Smithtown, NY 11787 Bagatta Associates, Inc. CONTACT NAME: PHONE A1C No Ext): A1C No): E-MAIL ADDRESS: GENERAL LIABILITY INSURER(S) AFFORDING COVERAGE NAIC If INSURER A: Worcester Insurance Com pany 26182 INSURED Arthur J. Edwards Mason Contracting Co Inc. dba INSURER B : - - -- ------ ------ — Arthur J. Edwards Pool & INSURER C Spa Center 929 Route 25A INSURER D: INSURER E : Miller Place, NY 11764 INSURER F occurrence $ 100,00 COVERAGES CERTIFICATE NUMBER: RFVISInN NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUDL I SR SUB WVD POLICY NUMBER MMIDD EF MMIDD� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 9AAGESa A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR MPAOODD0038801 H 01/01/2014 01/01/2015 occurrence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,000 X BLANKET ADDITIONA GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG $ 2,000,000 POLICYJECT LOC I I $ AUTOMOBILE LIABILITY Ea eBIN EDInt)SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ PER ACCIDENT UMBRELLALIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED RETENTIOId $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNEREXECUTIVE OFFICER/MEMBER EXCLUDED? F] NIA I WC STATU- OTH- T02Y LIMITS R E L. EACH ACCIDENT $ — E L. DISEASE- EA EMPLOYEE $ (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) ""w 0000000 Town of Southold Town Hall P.O. Box 728 Southold, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK 111ORKER'S COMPENSATION BOARD CFRTIFIC'ATF, OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.-Legal -Name and address of Insured -(Use street address only) lb. Business Telephone Number of -Insured = Arthur •J Edwards Mason Contracting Company Inc. 516-250-7142 929 Rte 25A Miller Place, NY 11764 lc. NYS Unemployment Insurance Employer Registration Number of Insured DBA: Arthur J Edwards Pool & Spa Centre Id. Federal Employer Indentificatlon Number of Insured or Social Security Number 112377925 Work Location of Insured (Only required if coverage is specifically limited to certain location in New York State, i.e. a Wrap -Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Town of Southold PO Box 1179 3b. Policy Number or entity listed In box "la": Southold, NY 11971 RW C3319843 3c. Policy effective period: 3/1/2014 to 3/1/2015 3d. The Proprietor, Partners or Executive Officers are: Included (Only check box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "Ia" for workers' compensation under the New York State Workers' Compensation Law (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insuiance policy). The Insurance Carrier or its licensed agent will send this Certification of Insurance to the entity listed above as the certificate holder in box "T'. The Insurance Can•ier will also notify the above certificate holder within 10 days IF a policy is canceled dire to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c'; whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract -issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: Henry C. Sibley (Print name of authorized representative or licensed agent of insurance carrier) /,a;, nx� Approved By: Y 'tib 2/24/2014 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent ofinsurance cagier. CarrierPhone Please Note: Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form . Insurance brokers are NOT authorized to issue it. C-105.2 (9-07) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a. Legal Name and Address of Insured (use street address only) 1 b. Business Telephone Number of Insured ARTHUR J EDWARDS MASON 631-744-4455 CONTRACTING COMPANY INC 1c. NYS Unemployment Insurance Employer Registration 929 ROUTE 25A Number of Insured MILLER PLACE, NY 11764-2700 24-10871 1d. Federal Employer Identification Number of Insured or Social Security Number 11-2377925 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company of America TOWN OF SOUTHOLD 3b. Policy Number of entity listed in box "1a": . P.O. BOX 728 00984424-0000 SOUTHOLD, NY 11971 3c. Policy effective period: 07/01/2014 to 07/01/2015 4. Policy Covers: a. ® All of the employer's employees eligible under the New York Disability Benefits Law b. ❑ Only the following class or classes of the employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Akpw` Date Signed: 07/01/2014 By: ItX*AW Stuart J. Shawn, FSA, MAAA Telephone Number: 1-888-278-4542 Title: Vice President, Group Insurance IMPORTANT: If box "4a" is checked, and this form Is signed by the Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate Is COMPLETE. Mall 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 write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB -120.1. Insurance brokers are NOT authorized to issue this form. DB -120.1 (5/06) Additional Instructions for Form DB -120.1 By signing this form, the insurance carrier identified in box "3" on this form is certifying that it is insuring the business referenced in box 1 a" for disability benefits under the New York State Disability Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box "2". This Certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed'in box "3c': Please Note: Upon the cancellation of the disability benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW §220.Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a. form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article, and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB -120.1 (5/06) Reverse a I,OT � 78�5�.10'•I � ra�ll i t1 I 0 q3 G fij 736.25. w c�ti c; I 1T r i�r+rrrrc -- FV�: �^1 STM X usE n $ IL it —car. n-nt[ w.. "J ...�,.e•--- ^..�.^' - 04' '^7 u"ITY r m _lw. ;=;•,c: _. a d_ n _,� _ ..a n �-�• — -.En.0N or 87'09'40" ` W csre ',. vhrziacr+t Y � wt'tt 1,[1T 178) SURVEY OF LOT 1. "71 MAP OF ORIENT BY THE SEA SECTION THREE FILE No 6160 FILED OCTOBER 16, 1974 SITUATED A7' ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY, NEN/ YORK S.C. TAX No. 1000-15-05-24.21 SCALE 1 "=50' JULY 28, 2000 OCTOBER 3. 2000 REV#$ED PROP, WELL & SEPTIC SYarEM LOCATIONS MARCH 26 2002 RE�fl$ED PROPOSED HOUSE SEPTEMBER 2(S, 2602 UNOER CONSTRUCTION SURVEY JULY 23, 2003 FINAL SURVEY OCTOBER 21, 2003 UPDATE FINAL SURVEY SEPTEMBER 13, 2006 ADDED PROPOSED ADDMONS AREA = 42,802 sq. ft. 0.983 ac. DENISE D'AGOSTINO JOHN D'AGOSTINO FIDELITY NATIONAL INSURANCE COMPANY OF NEW YORK WASHINGTON MUTUAL F.A. vm- 1 S.C.D.H.S. REFERENCE No. RIO -00-0217 69-5-5 LOT 117:): i cgv pvl. t1 ,Wcg: TH Tw_ H0"w4 N StsT&YC AS ESTACU3WO At+Pm(m . ART) ld f,'PT m -w NEW YORIK S11kn LAND d S lJc�No 4908 --- r:f": tiTY tS t, tiID ATTJ:7 IN 0; THE NI -W YLRr,, Sih1E f#4 \ y 5§ l t,($ lf, f 4F e rO:;r.:I.TI:i: .klv {9 HH 6'ag E1 k$' -t,• -. ;rif5xt'ti:'r rlV' .'.JT t:FpRk#:. ,;i _AIL :iUn �'-tN�'S WTI) ticf�t OR F Waltlsu_ _.cp1. "'till Rol m COt.Si rm C E, F r�7ir a o e,,, A a a �'r i<n. r. �;i:v;Y� It.pY✓,IEU HERLON .sli&i hj, a(iti FOR W71 --y n1r' SU!7h'r r s�aFJ'.i4=L•. AHD ON }CS "Clwy Til i}ii ;r;fd^'4irr C.J1CRF r3+.T3.'7°°� A'.: try All!7i(,r Survey:: i:.Wh;;.^wm; Sett, rrcA•. (�^:asinrc•fion srlp:xi, 7TUTUZ (]>TC'1 HEREO,#, ANC 'ref \`.i:GN.CES 0 W URD(111�11 K_4n- nr: _, nc>;;AT10a1S ART_ Will 1J!IYiRr:a_# Pf;01, (631)727—Et)90 u3 (C,31)7,17 1711 CF R#GI;i Or WAYS°{•v'r,?t s.fi £k{E1#iS OF Rmm. iF 7':�ICF.' COwirff) ,AT 1,44faNO A1X',ATSS �'�Y .'C:T SkDV1 f; t -RL NOT GUAAaSNFit:t?, ill RUV40K,' At i.-jjL PO %_x 1931 ....r,.,-_, ��., ..�:�,....,r�.,.,�,. z.,.,....�.>._a.ti,-. a.....•..a.«�.-,....>r.a,..-.,.� ..--.�..�-„_..,.W...- ,,.--.w.....«.e��..:,..m...._.,...•.,a..�m..s.�....•..+e..n,:,a,. ....��,.�. i.tttiF;r.AC1, Fda<. Ypr i 1?S3L. .iC`Ol...gas"ir. l` SURVEY OF LOT 1. "71 MAP OF ORIENT BY THE SEA SECTION THREE FILE No 6160 FILED OCTOBER 16, 1974 SITUATED A7' ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY, NEN/ YORK S.C. TAX No. 1000-15-05-24.21 SCALE 1 "=50' JULY 28, 2000 OCTOBER 3. 2000 REV#$ED PROP, WELL & SEPTIC SYarEM LOCATIONS MARCH 26 2002 RE�fl$ED PROPOSED HOUSE SEPTEMBER 2(S, 2602 UNOER CONSTRUCTION SURVEY JULY 23, 2003 FINAL SURVEY OCTOBER 21, 2003 UPDATE FINAL SURVEY SEPTEMBER 13, 2006 ADDED PROPOSED ADDMONS AREA = 42,802 sq. ft. 0.983 ac. DENISE D'AGOSTINO JOHN D'AGOSTINO FIDELITY NATIONAL INSURANCE COMPANY OF NEW YORK WASHINGTON MUTUAL F.A. vm- 1 S.C.D.H.S. REFERENCE No. RIO -00-0217 69-5-5 LOT 117:): i cgv pvl. t1 ,Wcg: TH Tw_ H0"w4 N StsT&YC AS ESTACU3WO At+Pm(m . ART) ld f,'PT m -w NEW YORIK S11kn LAND d S lJc�No 4908 --- r:f": tiTY tS t, tiID ATTJ:7 IN 0; THE NI -W YLRr,, Sih1E f#4 \ y 5§ l t,($ lf, f 4F e rO:;r.:I.TI:i: .klv {9 HH 6'ag E1 k$' -t,• -. ;rif5xt'ti:'r rlV' .'.JT t:FpRk#:. ,;i _AIL :iUn �'-tN�'S WTI) ticf�t OR F Waltlsu_ _.cp1. "'till Rol m COt.Si rm C E, F r�7ir a o e,,, A a a �'r i<n. r. �;i:v;Y� It.pY✓,IEU HERLON .sli&i hj, a(iti FOR W71 --y n1r' SU!7h'r r s�aFJ'.i4=L•. AHD ON }CS "Clwy Til i}ii ;r;fd^'4irr C.J1CRF r3+.T3.'7°°� A'.: try All!7i(,r Survey:: i:.Wh;;.^wm; Sett, rrcA•. (�^:asinrc•fion srlp:xi, 7TUTUZ (]>TC'1 HEREO,#, ANC 'ref \`.i:GN.CES 0 W URD(111�11 K_4n- nr: _, nc>;;AT10a1S ART_ Will 1J!IYiRr:a_# Pf;01, (631)727—Et)90 u3 (C,31)7,17 1711 CF R#GI;i Or WAYS°{•v'r,?t s.fi £k{E1#iS OF Rmm. iF 7':�ICF.' COwirff) ,AT 1,44faNO A1X',ATSS �'�Y .'C:T SkDV1 f; t -RL NOT GUAAaSNFit:t?, ill RUV40K,' At i.-jjL PO %_x 1931 ....r,.,-_, ��., ..�:�,....,r�.,.,�,. z.,.,....�.>._a.ti,-. a.....•..a.«�.-,....>r.a,..-.,.� ..--.�..�-„_..,.W...- ,,.--.w.....«.e��..:,..m...._.,...•.,a..�m..s.�....•..+e..n,:,a,. ....��,.�. i.tttiF;r.AC1, Fda<. Ypr i 1?S3L. .iC`Ol...gas"ir. 014!p L'( ` V17 H- ' LL Lit V YOi'aK STAT & TOWN 1EQUIRED ANrr- Plan A i � wcji sacv" 42" i Section. B—B I Section A—A i SIZE A B C D C~' F G H AREA CAP FEET FT FT FT, FT FT. FT FT. FT. SQ FT GAL. E APPROVED AS NOTED .10/1 W/L/ B. P. 4 3 S� K IF BUILDING DEPT,RTMEI` 182 8 AM TO 4 PM FOR LOWING INSPECTIONS: O.UNDAT ION - TWO REQUIF OR POURED CONCRETE 4 GH - Fg'AMIKV& PLUM! FRW . '� DNSTRUC T 10i MUST Flftar & Pump MPI ETE FOR C Fmm CCNST UCTIO SHAM LL MEET; �;m;) T° R�«�a BEQUEF ITS 0 E CODES OF NEW YORK STAT . NOT R SPNSID:S �ng Arrangement DESIGN OR CONSTRU I N E 2" 49ny! j—§i Rotor 1011§1 11§1 S�p�M1 P �E�236 RE�P�N -gyp GN Qn Typical Wall Section 16 X 32 16 32 8 14 6 4 4 8 512 19000j 1 " POOL 4 SPA Cin 16X36' 16 36 12 14 6 4 4 8 576 21600 j%' PERMACRETE WALL SYSTEM 18X3618 12 14 E 4 5 8 648 24000 929 Route 25A Miller Place NY 11764 18X12SX42 ' 18 42 42 16 14 8 4 5 8 756 31000 (631) 744-7185 FAX (631) 744-0174 20X45' 20 45 20 14 7 4 6 ?3 900 36500 24X44' 24 44 18 14 8 4 6 10 798 30000 Suffolk License #4436—HI 22X48 22 48 22 14 8 4 5 12 1055 435001 Nassau License #H174450000 f� 4 t 'address" 1✓9'P� ;cat 0(11 eAt sate 16