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HomeMy WebLinkAbout38738-Z �o�Osi�coa Town of Southold 9/30/2015 P.O.Box 1179 co C* 53095 Main Rd �a40 Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 37805 Date: 9/30/2015 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 140 Oriole Dr, Southold SCTM#: 473889 Sec/Block/Lot: 55.-6-15.14 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/13/2014 pursuant to which Building Permit No. 38738 dated 3/26/2014 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 Henry,John&Henry,Laraine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38738 06-17-2014 PLUMBERS CERTIFICATION DATED Au ' ed ignat e TOWN OF SOUTHOLD BUILDING DEPARTMENT z TOWN CLERK'S OFFICE o� �ao� 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#: 38738 Date: 3/26/2014 Permission is hereby granted to: Henry, John & Henry, Laraine 140 Oriole Dr Southold, NY 11971 To: construct an In-Ground Swimming Pool, fenced to code At premises located at: 140 Oriole Dr, Southold SCTM # 473889 Sec/Block/Lot# 55.-6-15.14 Pursuant to application dated 3/13/2014 and approved by the Building Inspector. To expire on 9/25/2015. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 ELECTRIC $100.00 Total: $400.00 G- Building Inspector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines,streets, and unusual natural or topographic features. 2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building$50.00,Additions to accessory building$50.00, Businesses $50.00" 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential $15.00, Commercial$15.00 Date. New Construction: ✓ Old or Pre-existing Building: (check one) Location of Property: clwl-t �\L House No. Street Hamlet Owner or Owners of Property: neq Suffolk County Tax Map No 1000, Section Block fG Lot Subdivision Filed Map. Lot: Permit No._ Date of Permit. Applicant: Health Dept.,Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ w App cant Si9d9ture pF SOU�yolo Town Hall Annex Telephone(631)765-1802 54375 Main Road N 4W Fax(631)765-9502 P.O.Box 1179 G �� roger.richer D-town.southoId.ny.us Southold,NY 11971-0959 �® ,�C®UNTY,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: John Henry Address: 140 Oriole Dr City: Southold St: NY Zip: 11971 Budding Permit#: 38738 Section 55 Block 6 Lot: 1514 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Alan Hubbard Electrical License No: 4285-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 gas Duplec Recpt Ceding Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 3 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1-50 A/C Blower Range Recpt Fluorescent Fixture Pumps 2 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures 11 TVSS Other Equipment. in ground swimming pool to include, bonding, 2-pool lights, 1-GFI circuit breaker, 1-salt generator Notes: Inspector Signature: Date: June 17 2014 81-Cert Electrical Compliance Form.xls fit TOWN OF SOUTHOLD BUILDING-DEPT. 76S-1802 INSPECTION. I I/FOUNDATION IST ROUGH PLUMBING FOUNDATION 2ND INSULATION FRAMING [STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTMT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAJ!t REMARKS: ,17 DATE-"///C,4- INSP ECTOR OF SOUryolo . TOWN OF SOUTHOLD BUILDING"DEPT. 765-1802 INSPECTION, [ ] FOUNDATION 1 ST [ ] ROUGH PLUMBING [ ] 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 �? INSPECTOR 3 ` j SOF SO(/j�, o Co cour�m,N' TOWN OF SOUTHOLD BUILDING DEPT., 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] SOLATION [ ] FRAMING / STRAPPING [ -FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIO TION [ ] CAULKING REMARKS. / �3�c�f C --�' t DATE .INSPECTOR / OP SO(/ryolo . - 73 cOUNi`I TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION '[ ] FOUNDATION 1 ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] 1 LATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: c, DATE ( /� INSPECTOR rAf so 'cou TOWN OF SOUTHOLD BUILDING,DEPT. 765-1802 INSPECTION . - [ ] FOUNDATION IST ROUGH MOING Ro GH M' [ ] FOUNDATION 2ND IN L W FIN [ ] FRAMING / STRAPPING FIN I S FIREPLACE & CHIMNEY FIRE- _INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) ] CODE VIOLATION CAULKING REMARKS: DATE INSPECTOR FIELD INSPEg�ON REPORT DATE C NTS FOUNDATION(1ST) ------*------T------------ -- FOUNDATION(2ND) (( � ' I . I C C)cn ROUGH FRANT[NG& r y PLUMBING (� Cd INSULATION PER N.Y. H STATE ENERGY CODE C' FINAL ! ADDZT NAL Cb NTS Ac • j � m . 4 TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 3 sets of Building Plans TEL: 765-1802 Survey PERMIT NO. 3 alb Check Septic Form N.Y.S.D.E.C. Examined2 Trustees •✓ �i ,20� Contact:, Approved ,20_,/_ Mail to: Disapproved a/c Phone: -- --1 Building Inspector EC� � � �1 � i ! APPLICATION FOR BUILDING PERMIT (L� MAR 33 :201]40 Date � ,ZB , 20� BLDG DEPT INSTRUCTIONS jy TMNINI OF SOUTHOLD 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 partfor 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 demo ' ' n;herein described.The applicant agrees to comply with all applicable laws, ordinances,building code,housing code an relations, and to admit authorized inspectors on premises and in building for necessary inspections. OR [ R I yt,." -, ".I,t ,L-:.(Signa a applicant or na ,if a corporation) 1 90 n Pcaw 117�/ 15PI P J�t �3�,�" E L (Mailing address of applicant) ^ay` r ENCLOSE POOL TO CODE State w$etlier ,appiicantAis owner, lessee, agent, WReneral contractor, electrician,plumber or builder t)v✓,em- APPROVE AS NO"i'El) Name of owner of premises �/f DATE B P (as on the t roll orI:l est deed) By. NOTIFY BUILDING DEPARTIVIE- If applicant is a corporation, signature of duly authorized officer 765-1802 8 AM TO 4 PM FOR i FOLLOWING INSPECTIONS- (Name and title of corporate officer) 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE �) / z 2 ROUGH-FRAMING PLUI'^B:'•,G, Builders License No. �) — STRAPPING, ELECTRICAL'& CAI ; f 3 INSULATION Plumbers License No. 4 FINAL-CCNSTRUCTin�, :-I-EC` MUST BE CCMPLE t' - Electricians License No. ALL CONSTRUCTIONS- ai_ ". F REQUIREMENTS OF I- r Other Trade's License No. YORK STATE NOT P<< V DESIGN OR CO�ffhfA IS-104M,, VIIATER RUNOFF 1. Location of land on which proposed work will be done: ,{, S� PURSUANT TO CHAPTER 236 140 ��I�)� � c_!��`^� HE TOWN CODE.,, House Number Street Hamlet31,1(JIiX A 13F!AsOAr,,W1 :iaC)1�L!•yv`I �?l')w}�;,ilr� :�;iEji?r,' 1•''ai��:'� County Tax Map No. 1000 Section Block (9(0r Lot ',;�5��,�y Subdivision Filed Map No. „r Lotk:7 ,crib �' (Name) -- 2. State existing use and occupancy of premises nd intended use and occupancy of proposed construction: a. Existing use and occupancy KeSmp4Jee b. Intended use and occupancy -O 190• III�J?��J s^� �� i �'► /N 3. Nature of work(check which applicable): New Building Addition 'A/lteration Repair Removal Demolition Other Work #o I AqL U (Description) 4. Estimated Cost Fee (to be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front -70 ' Rear Depth 5V Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front *W 4Rear lee-4J- L Depth Height Number of Stories 9. Size of lot: Front )45 Rear !OS , Depth 203 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: 13. Will lot be re-graded Will excess fill be removed from premises. YES NO 14. Names of Owner of remise 1�� Address 140 QC015 bn Phone No. Name of Architect AP b GAV = Address 4&02& J-4 <,xji`1kil Phone No S4y-DYGO Name of Contractor ► os �,v Address 0,lac (C1- 2SA- Phone No. 7LP4- M1 1 I le,L- -c2 15. Is this property within 100 feet of a tidal wetland? *YES 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�L) ,4R-X, j being duly sworn, 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 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 thi day of 20 of ,Public, ignature of Ap 1' ant 'MARGARE'T A. KIDNEY Notary Public-State.of New York No. 01 K16021 111 Qualified in Suffolk County My Commission Expires March B,2N e r Scott A. Russell Russell James A. Richter, R.A. SUPERVISOR Michael M. Collins P.E. SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 Telephone#: (631)-765-1560 ' Fax#: (631)-765-9015 MICHAEL.COLLINS@TOWN.SOUTHOLD.NY.US � JAMIE.RICHTER@TOWN.SOUTHOLD.NY.US Office of the Engineer Town of Southold STORMWATER MANAGEMENT CONTROL PLAN REVIEW COVER SHEET ( TO BE COMPLETED BY THE APPLICANT ) PLEASE NOTE:All Contact &Project Information Requested by this FORM is Nessary for a Complete Application. ' APPLICANT. (Property Owner,Design Professional,Agent,Contractor,Other) PROPERTY OWNER (If Different from Applicant) NAME: NAME: ADDRESS: c ADDRESS: � A Telephone Number: Telephone Number: Completed Applications can be picked up at the Engineering Department after being notified by the Department, or; it can be Mailed to the Applicant with the submission of a Self Addressed 8.5"x 11"Envelope&Appropriate Postage. DATE: :5[yd 4 Property Address / Location of Construction Work: 14() 86(ole is . S C T M #: 1000 District Section Block Lot Required Documents for Stormwater Review: Copy of Complete Building Permit Application. Stormwater Management Control Plan. (2 Sets) Note: SMCP's are required whenever Grading or Excavations exceed 5,000 S.F,when New Impervious Surfaces are created,and/or when existing Roof Systems, Driveways, Patios or other Impervious Surfaces are Re-Surfaced. De Minimis Projects will NOT be Subject to the Submission of a SMCP During the Stormwater Review! Note: These Projects would be Limited to Interior Renovations, Replacement of exterior Doors&Windows,Deck Construction with Loose Fit Decking, Installation and/or Modification of Mechanical Systems or other similar Work. A Complete Description of the Scope of Work Proposed under the Building Permit Application, LIZ A Completed StprVwater Review Checklist. If No or NA are Indicated, Justification is Required. *** FOR I E RING DEPARTMENT USE ONLY Reviewed B . - Date 3 (v A prove oa`�J r 1i 111 �- Ad nal Information Required: / a t, +' e r CHAPTER 236 �a STORMWATER MANAGEMENT CONTROL PLAN CHECK LIST DATE: APPLICANT (Property Owner,Design Professional,Agent,Contractor.Other) # NAME: S C T M 1000 �eS I't21 �� to Is5"N District Section Block Lot Telephone Number: 76 — q)16 S M C P -Plan Requirements The applicant must provide a Complete Explanation and/or validation of all information Required by this Checklist if it has not been piovided, 1 A Site Plan drawn to scale Not Less that 60'to the inch MUSTY NO If You answered No or NA to any Item,Please Provide Justification Herel show all of the following items: NA If you need additional room for explanations, Please Provide additional Paper. a. Location & Description of Property Boundaries 0' b. Total Site Acreage r7=1= c. Existing-Natural & Man Made Features within 500 L.F. of the Site Boundary as required by§236-17(C)(2) loll d Test Hole Data indicating Soil Characteristics&Depth to Ground Water 0 0 AZO &7t-D /LL " /(i S Q /Z--7e . e. Limits of Clearing& Area of Proposed Land Disturbance. o-o e,-A IUb l \w f. Existing & Proposed Contours of the Site (Minimum 2'Intervals) X00 g. Location of all existing& proposed structures, roads, driveways, sidewalks, drainage improvements& utilities. h. Spot Grades & Finish Floor Elevations for all existing& proposed structures. 1. Location of proposed Swimming Pool and discharge ring. X00' j. Location of proposed Soil Stockpile Area(s). �0 k Location of pioposed Construction Entrance/Staging Area(s) �D�I I. Location of proposed concrete washout area(s). 0�0 M. Location of all proposed erosion&sediment control measures. 00FZ- 2 Stormwater Mana;ement Control Plan must include Calculations showing that the stoi mwater improvements are sized to capture,stoie,and infiltrate on-site the run-off from all impervious surfaces generated by a two(2")inch rainfall/storm event 3. Details&Sectional Di awings for stoi mwater practices are required for approval. Items requiring details shall include but not be limited to- 'a Erosion &Sediment Controls. 0�0 b. Construction Entrance&Site Access. c. inlet Drainage Structures (e g.catch basins,trench drains,etc.) d. Leaching Structures (e.g infiltration basins,swales,etc) 0O� FORM # SWCP Check List-TOS JAN 2014 �O��OF SO�lyo`o Town Hall Annex Jf Telephone(631)765-1802 54375 Main Road H (631)765-95 P.O.sox 1179 G Q roger.richertown.souttlolcl.nV us i Southold,NY 11971-0959 BUILDING DEPARTMENT ' TOWN OF SOUTHOLD � APPLICATION FOR ELECTRICAL INSPECTION i REQUESTED BY: -AAJA/6&#� Date: Company Name: 11cb6Zd Name: License No.: Address: ��- Phone No.: 3 JOBSITE INFORMATION: (*Indicates required information) *Name: zy('hn 4en I *Address: Yl 64 *Cross Street: *Phone No.: Permit No.: '] Tax-Map District: 1000 Section: Block: Lot: , I *BRIEF DESCRIPTION OF WORK(Please Print Clearly) fit o7i-'0�o✓�cc aOC G✓y ` t jo U S tt-S2 PbaL - qh i C (Please Circle All That Apply) *Is job ready for inspection: YE / NO Rough in Fin *Do you need a Temp Certificate: YES NO Temp Information (if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service � Number of Meters Change of Service Overhead ' Additional Inf v PAYMENT DUE WITH APPLICATION w Ul n 82-Request f r fnspeclioqBLDG. DEPT b� FSDUTHDLD 1D �,\0 . 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: U APPLICATION FOR OUTDOOR POOL PERMIT [�Q EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM [� CERTIFICATE OF WORKER'S COMPENSATION [�]) CERTIFICATE OF LIABILITY INSURANCE SUFFOLK COUNTY LICENSE SUFFOLK COUNTY PLUMBER LICENSE [�] SUFFOLK COUNTY ELECTRICIAN LICENSE [ 4 SETS OF PLANS - (3 STAMPED) 3 SURVEYS [� APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK [� APPLICATION FOR CERTIFICATE OF OCCUPANCY �Q C.O. TAX BILL [ ] . $300.00 CHECK FOR PERMIT FEE 4 ,;,.y INV 01 N-11-1 'N. r ""N�nv "•a' M YM 2-K, A'N :AN -MW ........... Suffolk Counter Executive � Office of ConsumerATM-Irs VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEST YORK 11788 DATE ISSUED: 5/1/80 No. 2740-ME -SUFFOLK COUNTY .......... Master -E-71"ectrician License 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. PARTMENT SUFFOLK COUNPe DC OF CONSLUER AFFARS Additional Businesses MASTER ----------- EMN ARD S REIFF Thia t "Al 'Red the orf-Saftk [ DI-rec,or -ME L�2;411 ti /Arr­ STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER'THE NYS DiSASILOY BENEFITS LAW PART i.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a,Legal Name and Address of insured(Use sutat address only) 1b.8uslnass Toleplione Number of Insured UNDERGROUND SPECIALTIES INC 631.544-0400 In.NYS Unomployment Insurance Employer kegistration 128 PUL,ASKI ROAD Numberof lnsured KiNGS PARK, NY 11754 td,FedorAl Employer Idantifieatlon Numbarof Inwrisd or Social Security Number 112763133 2.Nanta and Addrens of the Entity requesting Proof of Coverage 3n.Name of 1 nsurarim Carrior (Entity being listed as the Gartificate Holder) The First Rehabilitation Life insurance Company of America 3b.Policy Number of Entity listed in box"1a": TOWN OF SMiTHTOWN 13BL285291 99 W. MAIN 81-BEET as Policy effective period: SMITHTOWN, NY 11787 01/01/2013 to 12/3112013- ' r Q.Policy covers: -— a. ® All of the employer's employees eligible under the New York Disability Benefits Lath b.[j Only the following Glass or classes or the employer's employees: Under petibity or pedury,I eettify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insurrd has NYS Disability Benefits Insurance coverage as described above. Date Sl npd 1/10/2013 - UJI 9t 9 �4 (Signatureefrnturnnceearrlor's4UshoN:edmpmttmtofiveorNVSLitmitbdlnsuranceAgarnnfthatInsuraneocarrief) Telephone Number_ 515-829�8100 Title_„ _ Chief Executive Officer IMPORTANT!If box 04e Is Chocked,and thIt farm is signed by tho lnsuran-n earaWsauthorized repmu+mauva or NV5 Llconsed Insurance Agent lit that carrier,this corsincMe Is COMPLETE.Mi it it dirWly to the eertificArn holder. IF box RUP If chocread,this mrtifieato Is NOT COMPLETE far tht purposes ref section 226.sdbd,ll ottlto QlspbUity Benotits Low. 11 must be tnnlied forcomplotion to Ihn Worke0scompon30119n Banrd,OB Plant Atxeplanee Unh.20 Park Street,Albsny.NY 12207. PARS'2.To be completed by NYS Worker's Compensation Board(Only if box 4b"of Para 7 has been checked) State of New York Worker's Compensation Board Acearding to informatlon maintained by she NUS warker's Compehsntion Bioard, complied with she IuYS pisoblllty Bamfiis Lawwlth respect to nil of hismoramployoos, Date Signed �. — By- - — •• (Signature,of NYS Vllntkaes Compamation Board Employao) Telephone Plumber_ . Title Please Note:Only Insurance carriors lle&nsed to write NYS omahnity Bnnoflts Inxuranc4 policies and NYS Licensed Insurance Agents of those insurance orders are authorized to Issue Form M120.1.insurance buskers aro NOT authbr d to Issue this for["- DD-120.1 Additional Instructions for Form DB-120.9 gy signing thtsform,the insurance carrier identified in Styx"3"ton this forrtt is certifying that itis insuring the business roferenced in Box"1a"for 6kebility benefits under the New York State Disability Benefits Lew,The inWrence carrier or Its licensed agent wl II send this Certificate of Insurance to the entity-listed as the certificate holdor in l3ox"2".This c6l'6608te is valid for<VWatUM of an®yber After this form is epprovad by the insurance carrier or its Iioonsed agent,or rho policy eupiration date listed in Sox"3c". Please Note:Upon[ho cancellation of the disability benefits potlty lndlrntpd on this farm,if the bushtass continues to I)e named on a permlt,aiconse or contract Issued by a cortifleatp holder,the business must provido that certificate holtlAr with a new Certificate of NYS tflsability Renefits doverego or other authorized proof that the businm 19 complying with tho mandatory coverage rpquiremonts or the New Ynrk State Disability Qenafin Low. DISABILITY BENEFITS MIN Section 220. Stolid. 81 (a)'Etre head of state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any'wdrk involving the employment of employees in employment as defined in this article,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 forst satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article, Nothing herein,however,shat I be construed as creating any liability on the part of such State or municipal department,board,commisslon 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 required by law to enter into any contract for or in connection with any work involving the emi7loyment 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 their,thatthe payment of disability benefits for all employees has been secured as provided by this article. 158.120.1 (s-os)Reverse New York State Insurmee Fund l�or1RB I Comapevasadon&Disabft Bearefds Specialises Since 8914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 Phone:(631)756,4300 CERTIFICATE OF WORKERV COMPENSATION INSURMCE AAAAAA 112763133 UNDERGROUND SPECIALTIES INC T/A U S I ELECTRIC 128 PULASKI ROAD KING PARK NY 11754 POLICYHOLDER CERTIFICATE HOLDER UNDERGROUND SPECIALTIES INCT/A TOWN OF SMITHTOWN U S I ELECTRIC 99 W MAIN STREET 128 PULASKI ROAD SMITHTOWN NY 11787 KING PARK NY 11754 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 11046681-1 990234 05/20/2011 TO 05/20/2013 4/16/2012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.1046 681-1 UNTIL 05/20/2013, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 05/20/2013 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. UNDERGROUND SPECIALTIES INC EDWARD S REIFF,PRES THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE ETD U DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web'site at https:/Avww.nysif.com/cerVeortval.asp or by calling(888)875-5790 VALIDATION NUMBER:36490570 U-26.3 PDF created with FinePrint DdfFactory trial version httD://www.finei)rint.com 't • Ik q0 DATE(MM/DDNWY) ACCO V CERTIFICATE OF LIABILITY INSURANCE 04/16/2012 THIS",CERYIFICATE 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 NOT CONSTITUTE 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(ies)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 ICONTACT NAME j PHONE - FAX - -FARM FAMILY CASUALTY (A/c,_No,Ext). _ _ __- _ __ -__ _ - W91 No� E-MAIC `- — 859 CONNETQUOT AVENUE I ADDRESS ISLIP TERRACE,NY 11752 I INSURER(S)AFFORDING COVERAGE NAIC# 631-277-7770 I INSURERA• FARM FAMILY CASUALTY INS.CO. ;13803 INSURED INSURERB STATE INSURANCE FUND UNDERGROUND SPECIALTIES INC. !INSURER C FIRST REHABILITATION LIFE INS CO 128 PULASKI ROAD INSURER D. KINGS PARK NY 11754 INSURER ---_-_-- INSURER F COVERAGES CERTIFICATE NUMBER: 106257 REVISION 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSRA-D L ISUBR — POLICY EFF POLICY EXP W - LTR /Y _ TYPE __ INSR WVD ___-- POLICY NUMBER LM/DDYYYJ_ LM/DD/YYYY) LIMITS ) GENERAL LIABILITYA 1,0_00,0_00 DAMAGE TO RENTED 52X1390 5/7/11 5/7/13 1 EACH OCCURRENCE $NTEDX NERA COMMERCIAL GEL LIABILITY I PREMISES(Ea occurrence) ?S 50,000 -- - - CLAIMS-MADE I X] OCCUR I MED_XP(Any one person) - $ - 5,000 _ PERSONAL&_ADV INJURY $ 1,000,000 - _ GENERALAG_GREGATE $ _2,000,000_ GEN'L AGGREGATE LIMIT APPLIES PER I I PRODUCTS-COMPR�P AGG $ - 1,0Q%000 000 ROI i -rX P—OL-ICY JECT --- -- _ - $ AUTOMOBILE LIABILITY ONBINEDSWGLEIMIT 000A _ 3152C4335 5/7/11 5/7/13 (Eeacadent) _-_-_ _ _ 00,___ _ ANYAUTO BODILY INJURY(Per person) - ALL OWNED1 SCHEDULED — - -- AUTOS X_l AUTOS BODILY INJURY(Per acadent) NON-OWNED PROPERTlDAMAGE `X HIRED AUTOS X I AUTOS (Per accident) - --_- _ ECU EACH OCCURRENCE — $ UM13RELLA UAB -! OCCUR EXCESS LIAB I CLAIMS MADE AGGREGATE S EDED RETENTION$ -- - ----- -------- — - --- ---------1 ------ -- -WORKERS COMPENSATION wC STATII �0� - B YIN CERTIFICATE ATTACHED I ( TOR�LI_NITSL�ER AND EMPLOYERS'LIABILITY ----------ANY PROPRIETOR/PARTNER/EXECUTIVE C! N/A i 1046681-1 i EL EACH ACCIDENT $ OFFICERWEMBEREXCLUDED? - --- --- ---- (Mandatory in NH) ! I EL DISEASE-EA EMPLOYEE S If yes,desabe under i --- --- - --_DESCRIPTION OF OPERATIONS below - _ E L DISEASE-POLICY LIMIT $ C NYSDBL DBL 265291 01/01/07 �INDEF-INI-T STATUTORY — ------ --------- -- —-- --- ------ — --- I - -E-- - ---- -- - - -- -- - -- DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF SMITHTOWN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 99 W MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. SMITHTOWN, NY 11787 AUTHORIZED REPRESENTATIVE SYNC�� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name-and logo are registered marks of ACORD PDF created with FinePrint DdfFactory trial version httD://www.finer)rint.com yol'urky ya-l'utg N fOO 0sirtiticler 4-ociatc, New Yo-rk / 190! �ijbdivi,3iorl "Mop c"j, A hh-f r if', ),I)f z It.$), I A' I.. j)(?-19,()4) floward ;J� hml,q, Land 4'1 o r PhorrItts C. Wo tpr 1, 111-ofi's".ma itfli -nee r E 4 at ' - D W `deep HEALTH DEPARTMENT USE N f3& 10 6) s t 'Is. f) e PROMe- F 0,&VLA ROL-5 to Pr0i tgaf- pf 13 j Acee T) < -ToW ZOAD 5 0- 0 3, rpt a) Cy C) a- T f CID 9. __j sa SURVEYOR'S CERTIFICATION vouNl) C) ,4: 2A WE HEREBY CERIIFY T`O JOHN HENRY HENRY THAI 11-11S SURVT-Y WAS PREPARE OD WITH THE CODI- OF PRACIIGE FOR LAND S 0 THE NEW YORK STA-IE ASSOCIATION OF P A O (31 -3420 SURVEYORS 82 0 X: 0 5. HOWARD W YoUNG, N.YB2 9. i-S. NO: v8S),3 .1; ------ --!�..... SIC) LAND jk SURVEY FOR -0 JOH HENRY & LARAINE HENRY LOT 1-1, "HIGHPOINT MEADOWS, -SECTION TWO" Mec.d At SOLIthold, .7 own of Southold ''-C�} �'' 1 Sic)st „�ttc3hte�t�onSUff0lk County, New York (j 44 S, 0 County !(3.x Mup l000 5," 06 15.14 �j11t)CjlVl`;IMC'�C��+N�i, p 1 sect 10(" F-C)t_) N D A TI C-)1�J L C)C, A TI C)N NOTE ARIFA 20,478 SO. FT, SUBDIVISION MAP 'Fjl"HPOINT MEADOWS, ';I'ClION IWO" F'OUNDA110N, -',)(,AlION JAN 10, 2003 MAP PRFPARr.D FILED IN 'THE orricE 6! 11-IF CILRK OF '.:-,UFFOI � (-�OUNTY ON JULY 31, 2002 MAR. 19, 1990 AS F11-131- NO, 8911 -- SCALE 1 50' e vF-7RriCAL DATUM N-G,V. DATUM (M.S.L. 10 9) JOB NO. 0371 FL I M"'N"DA rl i I fa ki"NiNfrl! r(,-R,`D "I"M "I A DWG 200',' 371 -foundation FM .1 �,)L — eM, SLutl-wl d xv X U" o AV �1 �9p � l �QV)5 I 24'-3' A—C 9'-3" B S S A B—C 19'-8" It A—D 19'-6" 6,_e, 4' 7� B—D 9'-2" L s' s' A—E 29'-7" t B' BEEP B—E 29'-4" D 6'-e• A—F 37'-5" B—F 25'-10" A—G 36'-11 " 24•-e• B—G 37'-11" zs'—s s/e" A—H 23'-11" B—H 34'-1" R 14' A—J 29'-6" 17'-10• B—J 24'-10"44._6. PDL A—K 48' s B—K 61'-4" J H A—M 50'-10" F 1 '-1/2" E B—M 44'-6" A—N 29'-10" 40• DEEP B—N 48'-5" A—P 44'-6" 19'-10• G z6-s• 19-10• B—P 50'-10" 9'-2 1/2" R M s . : : :12 ii K R AREA- 1262@4 ft. JOB NAME: NAEMEI PERIMETER= 162 � ICC SCALE— NOT TO SCALE YOS.CONC.- 1B nLENAME— NATURAL L MR,"= 248 POOL 8t SPA CE1�1'I'RE BRAWN BY: R.A�4ye A B 5bmme.4 RNume B E F B AM... Te ills Fh ills rile.k PYa„p To Now. /To RN,rrn (Dry Mee oNiiw) RoWd 1MN1 i Plan A Piping Arrangement wa sn6a, �F NEW 42" D C-2/a�� PS Section B—BC- ,. ssoo PSL Cannel. H—•-G `��� � Section A—A Typical Wall Section . --GiZ A.-B- C 0- E- F-C H---AREA:-CAP. FEET FT. FT. FT. FT. FT. FT. Fr. FT. SQ.Ff. CAL. �POOL SPA CENTRE 1602' 16' 32' 8' 14' 8' 4' 4' 8' 512 19,000 Add' PERMACRETE WALL SYSTEM 16'x36' 16' 36' 12' 14' 8' 4' 4' 8' 576 21,600 929 Route 25A Miller Place NY 11764 aty state 18'x36' 18' 36' 12' 14' 6' 4' 5' 8' 648 24,300 (631) 744-7185 FAX (631) 744-0174 ( ) Suffolk License #4436-HI Phone 2640' 20' 40' 14' 14' 8' 4' 6' 8' 800 30,000 Nassau License #HI74450000