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HomeMy WebLinkAbout40214-Z Town of Southold 1/13/2016 4* ti P.O.Box 1179 � 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38042 Date: 1/13/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 580 Skunk Ln, Cutchogue SCTM#: 473889 Sec/Block/Lot: 97.-3-11.6 Subdivision: Filed Map No. - Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/26/2015 pursuant to which-Building Permit No. 40214 dated 10/26/2015 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 Haase, George of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 37482 11-14-2012 PLUMBERS CERTIFICATION DATED Arized Signature TOWN OF SOUTHOLD 0!014-,Ns: BUILDING DEPARTMENT TOWN CLERK'S OFFICE /# Baa 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 #: 40214 Date: 10/26/2015 Permission is hereby granted to: Haase, George 580 Skunk Ln Cutchogue, NY 11935 To: Construct an In-Ground Swimming Pool as'applied for Replaces expired bp #37482 At premises located at: - 580 Skunk Ln, Cutchogue SCTM # 473889 Sec/Block/Lot# 97.-3-11.6 Pursuant to application dated 10/26/2015 and approved by the Building Inspector. To expire on 4/26/2017. Fees: PERMIT RENEWAL $125.00 Total: $125.00 Buildi , a -ctor TOWN OF SOUTHOLD 4'49 * BUILDING DEPARTMENT Ze TOWN CLERK'S OFFICE SOUTHOLD, NY po * *„. 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 #: 37482 Date: 8/30/2012 Permission is hereby granted to: Haase, George PO BOX 765 Cutchogue, NY 11935 To: construct an In-Ground Swimming Pool as applied for At premises located at: 580 Skunk Ln, Cutchogue SCTM # 473889 Sec/Block/Lot# 97.-3-11.6 Pursuant to application dated 8/22/2012 and approved by the Building Inspector. To expire on 3/1/2014. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 • Total: $300.00 /I // 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: I. Accurate survey of property showing all property lines,streets,building andunusual 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. 92Cl2 , New Construction: ✓ O(ld or Pre-existing Building: (check one) Location of Property: 5g3 J{CONK f.ni • vzh.y�de House No. Street �l Hamlet . • Owner or Owners of Property: ( a. 1.4A- Suffolk County Tax Map No 1000, Section • Q 17 Block ,� Lot I (.QQa p Subdivision p- Filed Map. Lot: Permit NQ. 31 4 O pR .Date of Permit. e r 17-Applicant: kV 1,4,0f/2,)S F' 5 Health Dept.Approval: . Underwriters Approval: . Planning Board Approval: • . . Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 5a- P • • Applic nt ignat re 1,�� ��OF SO!/lyolo Town Hall Annex �� Telephone(631)765-1802 54375 Main Road 4 Fax(631)765-9502 P O.Box 1 179 roger.richerta(�town.southold.ny.us Southold,NY 11971-0959 L 43. 4. 1� cou Nu Aiio. BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To. G&L Haas Address: 580 Skunk La City. Cutchogue St: NY Zip. 11935 Building Permit#. 37482 Section: 97 Block: 3 Lot: 11 6 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric License No 2740-e 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 Wall Fixtures Smoke Detectors Main Panel NC Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1-308 NC Blower Range Recpt Fluorescent Fixture Pumps 2 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures TVSS Other Equipment: in ground swimming pool to include, bonding, 1-pool light, control panel, 1-heat pu 2-GFCI circuit breakers Notes: Inspector Signature: � Date: Nov 14 2012 81-Cert Electrical Compliance Form.xls 3 4of S00,06\v 0€1 *1 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 7INSPECTION : [ 1.1 OUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUG ) [ ] ELECT (FINAL) REMARKS: " & - - DATE 1/1 17/ INSPECTOR ' Y. ,--� 0fsorry c€ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ' [ ] FOUNDATION 1ST [ ] RO GH PLBG. [ ] FOUNDATION 2ND [ ] SULAT ON e/ [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: /Leg-7—CH /e` v37 Q, / — k6'C i,✓.r-1-i 14-hr& L , is 70. ofey,) DATE t INSPECTOR. I I .. , . ......, ,o, . TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 . INSPECTION: [ , FOUNDATION 1ST [ ] RO H PLUMBING [ ] FOUNDATION 2ND [ ] SULATION , [ ] FRAMING / STRAPPING [ FINAL ' [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION ' [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ I CAULKING REMARKS: Ze -' • CO DATE _(1 [-5 .' INSPECTOR A-7 • • . .,. ., 1 Lt. : FIELD INSPEC*ION REPDA ORT 1 Coi 'sg :' t.., . . , . , •. . ,, . .-,.. ' - ' 4 , • e' — 100 • . .1 ' . " -1 ir261< e-- —1-14-- (Pe - , Y.2- ;44 • • tTi : • ;,S1 POUNDOION(1ST) . 1 . . . . 1 • . . 1 Is 4' , , I g. • • FOUNDATION(2ND) . . • - . M • • • • • ROUGH FRA.MING& • • t=1 PLUMBING S"--- k . • . , • . _ • . .. . • . • .. . . . ... . . . . . • • • • 0:1 • . P$ • . INSULATION PER N.Y. • • • • : • c"._._'i STATE ENERGY CODE . . . . . • • U 1) •• . • . . . - - • • . • . . .• ' 1 ' i : . . : ' 9il14c-eopihsili Pthe— . • fri- 4- . ric, /4S_._ locoi,q-4 ,,ticiek_. .A2-0-? . .. • . 4.).c0e4444i-- 4iii) r. 6€ ;7-0 --4 0 4.i.-e(44-7 FINAL //‘ ..4. yy eee-c_. . • • /04;A:xl.'cA,(., ircal., , ADDITIONAL commtNT •_....6..,ei,,Lizeifet - . igP ,i,e/i2 ze -044e t-go'ci5' . . . • • : .<6-aa.91-/ . . . • `‘i 0 cpi< .1g-F-- ,. Q- A ' eil/ip,t,u-ec( 1,012 le I lc . V_e(',. . -LS-z-(.? 4121 2 S''w . 11) 914' 10-Z-is K'l 73 () ' . '1. • ciN . . . • ,. R\ • . . . . . i.c L • - , , • 7E12 . . . .. . . . . . . • - ' • • ':. • LI II . .: . , 1 1 • • CZ:11 • . . , . . . . . .. .. . . . .. -... 11 • . . I., • • M - 0 . , . •• • . . . .. . ,. . . . . . .,. , ... , . . . .. . . . .... . .. . . . .• • . • , _____ • TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDIN� 'DERTMENT 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 7(i r)- _ Check ' Septic Form N.Y.S.D.E.C. Trustees' Examined 30,20 7 Contact: Approved 20/,)_ Mail to: Disapproved a/c • • Lig®. „I/3V/ Phone: r"•. (‘txte -'11.0 0 C E- -V1 -E- ilding Inspector ' ' 012 ' ' ICATION FOR BUILDING PERMIT AUG 2. 2 2 —. Date E 120(i , 20 • iO'tBLDG.DEPT. _ ' INSTRUCTIONS TOWN OF OUT OLD .' ' 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 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 isissued-by theBuilding Inspector.'. APPLICATION IS HEREBY MADE to the.Building Department forthe•issiiante-of a.Building:Permit pursuant to the :Building Zone Ordinance of the Town of Southold, Suffolk County,New York, and other applicabl'e:°Laws,Ordinances or Ii-Regulations, for the_'.construction of buildings,;additions,or alterations'.or for,removal or-demoliton ase ein.,described. The :. : applicant<agr�ees=to comply with all applicable laws, ordinances,building code,housing code,.a -.'-.1., '.-,,.7:'.A,;a e:ations,and to admit autfiorized;inspectors on premises and in building for necessary.inspections: , . y . . ELI' gnature;of ap°�Oant.or'�•i�1-,if a corporation) (Si qA a 2A" _ _ int 1 ,,, Qct, (Mailing ad`d ess:of•applicant) ;..State whether applicant is owner, lessee, agent, architect, engineer, general contractor, elect-ici i pliirriber or builder - i:--..-: On-1cC1C. = 1 , --,-'i-Na f e:,of owner of premises 6, >:;1, (as on,the tax.roll or latest deed),- ; ' e;1 kapplicant is a corporation, signature of duly authorized officer. i `"(Narrie and.title of corporate officer) Bu�1d'e x6• '.: rniee_nse=No: P'lumliers cense No. - r- . 1 t'f: El'eetricians-License No. 0..141 • MC. _ - `r0therTrade's License No. = ;4_I;1T Locafion'of land on which proposed work will be done:- - ,`" - ,,,x sSK1AI LrJ /leap a.' AORAAA :' -- 'Hou .�f se Number Street Haml t +nr+�;34 1c eisE : itdat9 � . lI.l:t.0 !'i41..0...ol'l __:County Tax.Map No. 1000 Section n _- 3 ytnu ): i12 i i yip .t 7� Block � : „,(rJh�01 :Subdivision - - . NIa 'No. -lot�� = (Name) _ _ x�:. _ 2. State existing use and occupancy of premises,nd intended use and occupancy of proposed construction: a.' Existing use and occupancy 51, E ik. •. . -_, b. Intended use and occupancy (esu 31►(11M(,V9 Pa, 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work AI(40 umAto 51.4mryid9 (Description) 4. Estimated Cost AOa)- 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 57 ' Rear 1S7____ Depth 52 Height Number of Stories a Dimensions of same structure with alterations or additions: Front i, i. Rear IL..1 SE cc OUA Depth Height Number of Stories L.____ 8. Dimensions of entire new construction: Front oto Rear . 40 Depth. - -3- (o Height Number of Stories ' -` 9. Size of lot: Front 20 Rear 0290 Depth 41f3 10. Date of Purchase 7b31 I 2 Name of Former Owner u'C natecg, JiQnn 6 11. Zone or use district in which premises are situated 4D 12. Does proposed construction violate any zoning law, ordinance or regulation: WO 13. Will lot be re-graded 9001V- O Will excess fill be removed from premises: NO (?6-Itefee S$O at.r%c LN 14. Names of Owner f remises L s4- 14-Maddress CA0Ve. Phone No. 0261-01-925--4467 Name of Architect rta D- D lolly Q Address* B LJ swit'1l%(04,.JPhone No 72Y-7i _ Name of Contractor &Mos Address 0 et 2S71- Phone No. 7W-1/F1'- MitI .c. mu. Pe ii7.y 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)(ri.) ) . 7 ' .CAuc-j -6.01,44Z.45 // being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)He is the (, 4.-Ak_ . , (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 thafthe work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ,, ' ) ,• ' , ,23-7' day of usl- 20/2 , ,, 6-164-4i N ary Public ' : ature of A pplicaiir`' .. MARGARET A. KIDNEY ' Awry Public-State of New** No. 01 KI6021 I I I Qualified in Suffolk County ' My Commission.Expires March 8,20ir ' — ° Town of Southold - Chit apter 236 - Stormwater Management :. frbi ••: SWPP.P - Storm Water Pollution Prevention Plan Assessment Form • GENERAL O ATIoN: (All Requested Information is Required for a Complete Application) i• ' APCANT dreSs: NAME Owner-Agent-Consultant-Contractor orOther (Circle One) PropertyOWNEFC'(IfDifferentthan Appl'icant I I Atiit t r 1_11/41 CAAtiove Address: —"'.Q • i • T [Root 1 Fax 0 Telephone iF I Fax# • tI • E- _ •E-Mad ! tom i Property Address: KONt Led &)-iejioCjv2 Brief Description of Constmction Activity't op uc3 Structural BMPs,Soil S.C.T M tk 1000 Q7 3 'up(0 Stabaliation B14134 Project and/or Segtieive of Construction Activity section Medi tat (Provide Additional lonal Payes Neer'led) i.of Contractoi and/or Contact Person a for Implementation of SWPPP: - g2Qf ear 2iA, IU t tick as/cp 117ro� ; ilA)VOSen__,_g_20-.I.40_.___Ipt.11/4/0 J VL wLrnMWi Tetephorrs p: ( 7 I_.--�L,'���� I Fax N:/ 3 I_� -- nom, �1 � __t:�'1.!'C-- IRS [�y (� 9b- 017 _+!-s1�Ai� !�-��6��1� i E-Mad: office AE Ols.own o/ �,Q�.� np �//��- -- Name of Persons Responsible for Installation b Mtlntenance of Erosion Control Practice: • �TLSr ,,/ --- '- l J _-l1GV 11 1 Address: --. � het---�o--S:44°C.- I ( t Telephone#: I Fax p: i r -Math F Total Area-of Alt Q.)0 0 1 Total Area of Land Clearing o n j6 •P��Pam: and/or M.P./A..4I and/or Ground Disturbance_ �J ' ., m ./A ' (SF/Aoes) Project Duration: 15tart End ._. •• .. (Antidpated) Date: q I I I Date: 1c4 1 . (Number eicalendar Daps) ---- __ • Will isxProject Disturbe five(5)or More Acres at : i this Any One Time During_the Proposed Development? Yes I I If YES:Please Answe,theFollowingl - • a. ;:Does the:Applicarit°have a Qualified Inspector On I I I I ! ' . •Staff To Conduct the uired Ins Yes No • • - - . �I peclions? .. I b.;:Does the SWPPP Indicate How Frequently-the Site •[) 1 List the NAMES or des ription of all:Potentially Impacted"Watertiodies and/or Wetlands: • -Inspecttonswill Occur-and for What Period of Time? Yes No c. ';Does.the.SWPPP;Adequately Identify Al,Temporary ! i r� I—1 I and/or.000.afieii�S irStabaraation Measures? Yes No i • d.';Doe's:t:SWPPFIAdequately Identify a Complete 1----11---1 • < Pro'�ect Phasiiuj'Rlan? Yes No 6 e..»-:.. Status of lin ed.Wa a Im - e::Does the`S,WPPP Indicate Additional Site Specific ! 1 1/:fes•:?MD�.3o d,'wskd hirP�uad-), ' Pradices•tha1 Witllbe'UU7ized to Protect Water Quality? Yes N 1 - t: ;Has tfj I c5�i Viii•rutted a:Completed DEC Notice - ?Of Inherit end PPF;' I---1 TYPe>of Impacted: ( a �. Acceptance Form for Review r Waterbody;., Lake,Creek;B e � _ k' y; o11d,`.;: :, F':,-.4 ater Welland_) Voipritthfitiry��i,Ai 6.2�g ? Yes - = i 1 i ! CO10h1A-It OS . OF •SS • 1 ;.:'.... ":: a. ag„y,s umeno mg duly sworn;deposes:and says that he/she is the appl�cant oc Permit, A 1,fhat heIsslie'js thie _ '•,:.,.,..,,,,,,,!V;5. ':::e _: a . ;:: - _. (ovKer.Contractor ..»... ... ..».»... .: a::::...., _ � - ..-7 ,:k ,F. AgmRCorpora2eONiri'r,,e ,: • .,.:...�;: 1 Qwntr:aadj!tJ;><e reseiitative:of Owrrtir: y `' ;w a . YP.. _ the. or Owners an i s. ..p , F.;)046-k.. 1 _ _::;-�;:�:f;, d'is duly aiit}io �ed'to o �• - �. �.�• ��malt�eani�ifilh` rF �.. �� •:� or lave:pei-f'ai3aels':f}ie sal' - .. e till's`application,that all statementca= 'tar + ,. t ef, to I ;'€ =�> e . ..,,?,. trrlen contained:in th s:.applleahon?ar ti ie;torth'e best of '"t" tit' a k will e':p ormed inmanner set forth in :, ':'linowled&eans ell' and i rSwoi to ftiir the the appli -"---4,,,,2:40- 4,4,-,2n C cri heieyvi, -. =-` , I x before.rn ` ratio -:::..f... • tri•: :`;>: ,"`''- -` d., of 1/Sr ,20 i ,1.- i SEs,.: / Offir .• Notary„Public_ /. 41 0. :=SYYPPP>'Assestsment FORM: t)3-1 ) :..,�.�.:,;. IAftCAR7 A. KIDNE wry Public-State of New York No. 01 K 16021 I I 1 Qualified in Suffolk-County MX Commission Expires March 8,20_ °"' " T.O.S. "SWPPP" Preparation - Chapter 236 For Department U,se Only: • Storm Water Pollutions.c.Ttw. Property _ Prevention Plan #: Address: NK Lk/ Review Checklist Checklist # 1000 arl 3 11.006 core 1 ve_ 8. • arm —al— REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: i i ii (Does the SWPPP Adequately Provide for and/or Indicate the Following:) ,YES, NO N A EXplartatfoh fat NO ori Plan Sheet 1. Dralna�e Calculations&Stormwater BMP(Designed to contain a Two Inch Rainfall On- .Phasing PlanJ�I I (pg.#) 3. General Location Map, $' 9 -. . ..----------- -_.___.-_ --'0'C ' r ._4, _Dralar�e:Slte Plan Drawn to Scale at 8 80 feet to the Inch or la er Indicating the Foliowin ' I >.,> - a. orotic ;ar)Sf_D crl of r9 ...... - i0;'' 'l:c: A.,;r_ _ b �. p e� ppono a Bo ries;--- -- - 'i ,, a,_-_. ,r.- ------- -_ _ Site_ik444 a -__-. _.J�rL .� _ 9• All_Ezl§ting NBtt)tahandlo[,Meni1N_a'de F_ea_ttires+on and withiProperty .r IL - "- C __-- • .- . n 50_of the d T.esttiHole Data In it tin Soil._C _ Boundary_ ' 7,':tis f� ___. _F ._9_ �;erlstlata Depth to Seasonal HI h Water Ta } -' � e. Contours fndtcatln ro ------- g ------ +CJI;'^•;" `�®, ----- - ------- t_ • � $�-..P_�''ElevaUonsSMlh:�2�� - ------------- -. _.. S_p_citztade 8i' Ifilst.FF bor=Eiei atlori§`for`iiiiiing and Proposed Structures; _]� - t„_„1. _... Loeaff,•oneo?oodea''lkreas. lsolateiTrees with ai�iTriimumbTmen"sfon oris^Diameter; r� - _h_6-oli C•onserva tont37slircf'tarServet'---- -- -- - - - 5 Background;fInformation about.the S . e of the pro --- -_.--i i= © (4� ------ _ cOp. Jett,Location&Description of the Site, ,0 __. Proposed_{Changes,toi_the,Site.and All:Existing Development On the site Including the Following. a.._Al1JQtD[s�ams. - ._ --_Following._ O C] - i ...._ -- .0 �;1►.lcl 0101 191016.a4i•Lends( anile Total$i1e. r.e ;__---__._.___a O L� O L L- _ UW)rXl _ • b. Aul,'Excavation~Filling,',.Stripping&Grading Proposed and identified-as to depth,Volume Lam, "- --- __._c._, AlllgreitaIt$etiONinearingand/or Grubb) i. -- --• - - -1= 0 ,..�C,- d. All Areas,WhereTopsoill Is to be Removed,Stockpiled and where Topsoil will ultimately 1 �' e. All Tem ra _Rsrmanent Ve station to be Placed ori Site; ___..__._. _.._f.-.All Tern'�o.. &Permanent Storm Water Runoff BItAP Centro)Measures Proposed: •'0 0 �r ---" -."" e -- _ �: The Arltici2ated.Patterrt of Surface Drainage DuringPeffods ofPeak Runoff --'- r r--- --- _- h. The Location'Ora711Coaas,3tiveways_Siaewalks.Patios,Structures;Otilities&other----- =_.3C= cz:IC_ _ ..-- 6nprovemenEs;fn afng 1 ernporary,Access i-ansfniclion&faging Areas; --- 0.O -1 T._Tfie F�clsffng S Pin>@�onfours ana or$p-o�1=fevatTons oftfie sife- ----- _ ------ • ----- 6. A Schedule of the Sequence for the Installation'of All Planned Soli Erosion,Sedimentation , StOrrnwa er RUnON Control Measures 10•0 ',--- & -- - - 7. DesccrlgtIon of Pollutign Prevention Measures that will be implemented. - .'�,0 0g.,__ . . • _ 8. A Descriptiom.of.the.Minimum Erosion&Sediment Control Practices to be installed and/or 10 E - • Im_plemented for Each Qgnstructlon Act1vitxthat will result•In Soil Disturbance.9. Descriptionof Construction&Waste materials Expected to be Stored On-Site. C-' _ _10. Temporary&Perrnanent Soll Stabilization Plan that meets the Current Version of the ; D1 _ New York;State:Storm Water Design Manual Technical Standard. ;0 0r • 11. General.Site Plan and Construction Drawlnys for the Pngg pct. 10 0 0 r 12. DlmensloniiMateilal•Seeclflcatlons&Installation Details for Al Erosion&Sediment Control Practices. ; 13. Temporary Practices.thst will be Converted to Permanent control Measures. O = ��r C • _ -. •__ 14. Implemettadon:Schedule.for Staging Temporary Erosion Control Practice or BMP. 0 0 L a' • 15. MaintertariCe.Schedule to EnsureContinuous&Effective Operation of Erosion& i 0 0 �i Sediment.Control Practices. --- - 16. Name§'of Potential Surface X0.0 �r- Waters of the State of New York and/or MS4 that may be Imeactedby;peveloelent. { ---- ---... __ t 17.�Delineation Of:Storm�Water Control Plan Implementation Responsibilities for Each part of the j O 0 �` Project t-OnstiuotrOrk Tte. ---- -- --- 18. All otherExlsting'Datati�at Oescrlbes Storm Water runoff and/or Natural Draln a Swale(_ • 19. Identification of:An.Coi,•,..•or(s)/Sub-ContracGo s Res '-- --�i' 0 C:3 r r( ) ponsible.forInstalling,Constructin , T-�rtC'ivz. ' Repairing,Replacing,`inspecting and Maintaining the Erosion&Sediment Control Practices. ,,0 0 0 i -� S ,��� n ,.fro Storm Water Management Control Plan Checklist#1 : 03-12 ` �r K� . .•a> .•..- DEC "SWPPP" Preparation : Chapter 23.6-19 For Department Use Only: / _� �-' `: Storm Water Pollution Prevention Plan S.C.T.M.#: Property Add s: ``1 °` ' (Additioo:nal I ems t be ieviencklist -luded d•with ChecklisChece Checklist Article is trrgered:) 10100 A� Inuit • District seouon Brock Lot REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: i i i i Plan Sheet (Does.the SWPPP Adequately Provide for and/or Indicate the Following:) ,YES, NO i N A r Explanation for NO or NA.Must be Approved by SMO Location(pg.#) rid( 1. Does Era Plan Indicate a or grow all Items 4%p - "Checklist #1"-In this Packet? (t) j ' • 2. Does the Plan indicate acrd/or Show a Description of Each Post-Construction Stormwater CSL—•) Mariapement Practice T ., , 3 Does:.tliie SlteiPlari/Construction Drawings)indicate and/or Show the Location&Size of r�y��" _Each=_Post-Con§.tructionStormwater.N1 ., m eent;Practice? 0 '•"•" 4 Does,the,;Site-Elan/ConatnrctionDrswing;(s)`Indlcate�and/o &r Show Hydrologic Hydraulic Analysis 0 , __`. - .. _ _ _For All Stiveturaimp Cobngr sof:the Sto"rtnwater Managern.ernt System for Applicable Storms? 1 _ 5. Doessthe$lte;Plan/Construction Drawing(s):Indicate and/or Provide a Comparison of Post Q Develo. tnent.'Stormwater.Runoff Conditions with Pre-Develo ment Conditions? _ ' _ 6. Does-the;Site:P-lara/C.onstructton Drawing�sJI-ndleateand/orShowAll Dimensions,Material - - -• - ._ Specliicatlo_ns&.installation Details for Each Post-Construction Storrnwater Practice? Q �L - F -i..- Does:t„..:- e P'lan/Constructlon�rawing(s)Indicate a Maintenance Schedule Provided by O '; -._. _. the Cortstractor(s)to Ensure Continuous&Effective Operation of Each Post-Construction , Stormwate Mena ement Practice? L • 8. Doeathe=She.!Plan/Construction Drawings)Indicate and/or Show Maintenance Easements to Ensure.Access to•All Stormwater Management Practices at the She for the Purpose of Inspection 0 0 0251 and kook? , 9. Does the Site Plan/Construction grawi - - n Maintenance—---1= r----------__'- rrg(s)Indicate and/or Show Inspection and Maintenance "_'"'--_-�-- -" -' Agreement(s) that are Binding on All Subsequent Landowners? 1-111 10. For All Activities meeting the Threshold in 236,19(B)(1),the SWPPP shall be Prepare-d-&Signed � By a Professional in the Principles end Practices of.Stormwater Management&Treatment Who = 0 t:Ef Who Shall Cart,thatt he Desi-on Meets the Requirements of Chapter.236. 11. Does the Plan Indicate and/or Identify All Potential Sources of Pollution which may affect the , , _ -_' - Duality oT.Stormwater Dlscharpes? 0 0 1.174-r 12. Does the Plan Provide Documentation Supporting the Determination of Approval with Regard :0 0 11 - to Historic Places or Ar.+cheologlCal Resources that Includes the Following:, • __- - - a. Information whether the stormwater discharge or land development activities would have 1 1 _ an effect on a.property that Is listed or eligible for listing dr eligible fbr listing on the 1= 0 I5; - - §State Or Nptlorjal Registerof Hltkric,Places i • • b. The.Results of.Historic Resources Screening_Determinations that have been Conducted" . i 0I= L• c. Desc ilption of Measures Necessary to Avoid or Minimize Adverse Impacts on Places Listed,i 0 0 Et' or Eligible for Ustinguon the State or National Register of Historic Places;and J L d. Where Adverse Effects May Occur,Any Written Agreements In Place with the NYS Office - -- -` of Parks,Recreation and Historic Places(OPRHP)or other Governmental Agency to 0 0 1] • Mitigate Those Effects. •13. A DescrlptlOn of the Soll(s)Present at the Slte,Including an Identification of the i 0 0 r Hydraulic toll Group. , L -- - --------- •14 Identiflcatton of Any Elements of the Design that are not In Conformance with the Design manual,.Including Reasons for the Deviation or.Alternative D.esign and a Description 0 0 ctt of the Egulvaleney..with technical Standards. __ _ _ __ 15. A Hydrologic-and Hydraulic Analysis for All Structural Components of the --10 r= l�r Stormwater,,Manapement.Control System. ———— 16. A Detailed Summary;With'.Caiculatlons,of the Stang Criteria that was Used to Design it= 0 All Post-Construction StognwaterManagement Practices. • i r '17. An Operations and Maintenance Plantthat includes Inspection and Maintenance Schedulea.arid Action:to ErnsureContinuous and.EffeOWe Operation of Each 1= 0 I:2i . Post-Construction Stora"Water.management Practice.. . ! . Storm Water Management Corrttrol Plan Chee=kliat#2: 03-12 • • "ar"*Of S004; o 4 Town Hall Annex 1 l S�. Telephone(631)765-1802 54375 Main Road y ; m�ax(631 76 �9�2� P.O.Box1179 • G.� Q t� roger.rlChert(CU,IOWn. ou O nY.US - Southold,NY 11971-0959 4 COUNVIW'0.111�� ,rr BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION • REQUESTED BY: Date: Company Name: U,S .7. Elce-rn is Name: En kliT License NG.: 2910 .Ne Address: )22 List, PO 41A19S PAtt,. Phone No.: to3 - 5i4y--OyQO JOBSITE INFORMATION: (*Indicates required information) *Name: .nne CernNez *Address: 580 SKUNK )tervt euml4olue *Cross Street: MOWN QO *Phone No.: 103l--13,4- 2053 Permit No.: 3605,?‘7 Tax Map District: 1000 Section: Q`"I Block: .3 Lot: II.to *BRIEF DESCRIPTION OF WORK (Please Print Clearly) Pa lSka,,,n3 Ito 340 litylayon �,iW'. 5w rnM iNg (Please Circle All That Apply) *Isjob ready for inspection: YES / NO Rough In Final *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: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION I \ -§n_ C- 18000 S 1-o0 • 82-Request for Inspection Form 1 , C • '''''.% I..% '1 �+ OF SOUTHOLD PROPERTY RECORD CARD T \ 000 - 97 -3 - 11: 6 iit IVIG r.. i --73.OWNER1 STREET 5 �__ VILLAGE DIST. SUB. LOT ( l jf Ann L 6fnv'est_ . ! SIU 2 CA'4c,I.to,:. tit, ' 9 Nil ( I-1A i.. t:E i lij.i&'' FORMER OWNER. N E ACR. b SQ- '14' . L- LA - C. '" , i�A _ ....► • R . mss=_ 1 NI ceso Rea( W., S - W TYPE OF BUILDING (YI iY CAC. S I� isse1 \ P, i(E if-ec.g rt o. it +,lcarf 7'3 -zo.5:, '2./ Z .c 7 I -- :2,F r . RES. 2,4 Ij SEAS. _ VL. FARM COMM. CB. MICS. Mkt. Value / LAND IMP. TOTAL DATE REMARKS ' ' i ry-, .2.C7 0('_i Y�v �C:� GI 1 , i rr r: 3- 6. z _. %,3 _ Ch--,Yo�-e CA aZ yo o Z co.0 x/9 oo it11 ; '/i/o/ I eyf =,_.�,,,... .� 1 6 ::, r s 7.3 � - �-,.{S, ,-. i 1 -C..- ,,,c,- C�a Y"t-' C� c:• -.y.. 1-f� 0�40o v �„ 'oo_ d.s? 0 V Z 2�� `/3]e'4-Liao431p-7qoff -IJI..� -P.cf� GT ID 6eiows�G. i€ - '7,9-.1) l ". rJ - , S _16, a/*c o 4 _ .�, i ,4, ii+.; �/ z7/._ 07' /o OPO/ L;[ate p773- (--kno\VeSQ �' � D G /z 0 0e:nvvese- n/c- - Rev /0900 //3D//o (-4Q -I 04.34062-7 m rbunt Pao' gcOn q1I i It `� . Tillable _2 6, 3�?e? .-(9 FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowland DEPTH . House Plot ‘ etc . BULKHEAD Total -4#'Jr /.,/ ,�I;.t'tf fti+5r ar.r�. ttr''s ,•a k )ir 41@, !l a s' ski -'v �.h .... .a, l A n •`ylt { r 1. i l i'I_y._ �•\'N if t , n, ' !''iM,'° lF x :c1 '�i P.7.1:ry f. +i•.4 ti �i'•; 0 ?� jft't.jF pi, ttv r 1 its ysr jS. e I .� r•`\r.tl r 1i - \�'. ...:....% .. 1s,a A`� fir,:, r !� `s, nLSv .�. 6.0k lty \(„1 1 ,t' / l,( f yr,< 4 'y t C /11frf"i�' f L c 1r\5 fra t :+. ( ? 4,. �' r ✓`_.—`.'y r Irk I t +1' :-v t(I I E4 rt\ t!!a1 w, . ' , I '` f•• j/,•• }J� e.elf�t , r t !! t to ,,t{A!*,tie }+ +l! St / ,/,‘:•; -':- .J(''l5 s"'r k n y Lik a4 t jt. ly ttu�AAt Aj(1`'7n slti,\�tt .,,-;•;14,-,-v---',-:-,,,•;-.'••'' ' \ r J:". 1."•:, •••••%.::!•7;!. �.l >>� . ,, l ltNl,4' �1,/pl •1#! _n.[6Yf`4 et•".xl' `4 V.f4:.1:L••••••'4.:••t . j `' 1 A' 7D ,� 'rrAtt^Fpr�,::.i;,,;:, ::: —i,tfs.4.(/f�, ,Aft >`t•1 `,vl�•Al li:k.xio- _ ` • S I #.r 71'�ltAav` kl=. . .v'�\it `141.1!4'7�IJr- i\�' li';i''''W ,a? ..-' V. l� T s'. it/..t ! 1) �%r E ti t -..:...,...;_,,.:?1,:::;',,....:::a f t llf t u .S ,t r _ f 1 f 4 r."+ � t t t!It 1 'i+A l,:s t y 1 1 � !:.;.•,..,:;„ ,,. t ,..z'o ff' / < ,,\ \11 o1a . toy > s : "^r iiiIiflhiiiiaiiii r, I __ t,'r s t t ix,• tl\� t l i S r 4.k , .r u\%! • L_ V\� ,l�. st ` (( 44t{i ..\ / •r r 1 /. .1 5 Cill..f:...71.iil� 7iJ �( RR .- 11 !11)!11 t i 1 ?` 7 � R t •#! t•11YIt 111 • '0 21e • , 4N..,, �� M 3:f K,. rs ,+x n '� , RRRRRR ■RRRRR 11111rIn l 4 \ hf - 11 4 }.•.. _.:r.._c ", t -- n ...v6r:.:;Y, s... z, .r,Y-... . It+Z?'J,97-3-11.6 3/03 __adg. � _ -- •F-ound.atiol . . — v RS �.` Bath s�Z — Extension2 22 1 3� -7?q� Basement N Floors -WAi+ Extension Z �' F.xt. Walls / � a— ' , zit VIA>,1 Pict Q Interior Finish s 2 - Extension F ire.Place Heat ri-ki 9/10 P2-Y-ViQ �sn,-1- - ,_O 3.3 /V,G.. Porch .3 ?O �(0 1 - ,,513 24 ',1'2 Pool Attic - 1 Deck 1015 - r LS• - 2,7 Patio - . . Rooms 1st Floor 11 ? 1 Breezeway Driveway Rooms 2nd Floo `- �" r Garage 45(o %' 1- 570 - - 4AC- Q. B. z) —_ •••/..,<_ k32 l Z/2 Southold Town Building Department P.O.Box 1179 Permit#: 37482 54375 Main Road a Permit Date: 8/30/2012 Southold,New York 11971 • \-*4 } ao?;,' (631) 765-1802 Expiration Date: 3/1/2014 „ , Parcel ID: 97.-3-11.6 BUILDING PERMIT RENEWAL LETTER Dated: 11/6/2014 Applicant: Arthur Edwards Pool Location: 580 Skunk Ln, Cutchogue Work Description: IN GROUND POOL construct an In-Ground Swimming Pool as applied for replaces expired bp#36527 A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Own i r: Haase, George Address: PO BOX 765 Cutchogue,NY 11935 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold, New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. Southold Town Building Department % $1.? 4'co P.O.Box 1179 Permit#: 37482 53095 Main Rd Southold,New York 11971 Permit Date: 8/30/2012 \-44).4 �, (631) 765-1802 Expiration Date: 3/1/2014 ,,,, Parcel ID: 97.-3-11.6 • BUILDING PERMIT RENEWAL LETTER Dated: 4/20/2015 Applicant: Arthur Edwards Pool Location: 580 Skunk Ln, Cutchogue Work Description: IN GROUND POOL construct an In-Ground Swimming Pool as applied for replaces expired bp#36527 A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Haase, George Address: PO BOX 765 Cutchogue,NY 11935 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold, New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. gel sot,45,- I `O � Town Hall Annex :1 : Telephone(631)765-1802 54375 Main Road : 41 Fax(631)765-9502 PO.Box 1179 G Q Southold,NY 11971-0959 \0 1 CONK ; S November 9, 2015 BUILDING DEPARTMENT TOWN OF SOUTHOLD George Haase 580 Skunk Lane Cutchogue, NY 11935 TO WHOM IT MAY CONCERN: • The Following Items(if Checked)Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) / Electrical Underwriters Certificate. A fee of$50.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) Trustees Certificate of Compliance. (Town Trustees#765-1892) Final Planning Board Approval. (Planning#765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept. Final Storm Water Runoff Approval from Town Engineer BUILDING PERMIT - 40214— Swimming Pool BARGAIN AND SALE DEED WITH COVENANT AGAINST GRANTOR'S ACTS (INDIVIDUAL OR CORPORATION) STANDARD NYBTU FORM 8007 CAUTION:THIS AGREEMENT SHOULIj BE PREPARED BY AN ATTORNEY AND REVIEWED BY ATTORNEYS FOR SELLER AND PURCHASER BEFORE SIGNING. THIS INDENTURE, made the 7!-) day of �' 2012 between • JEANNE GENOVESE residing at 580 Skunk Lane,P. 0 Box 765, Cutchogue,NY 11935 party of the first part, and GEORGE HAASE and LISA HAASE, husband and wife, residing at 460 Ruch Lane, Southold,NY 11971 , party of the second part, , WITNESSETH, that the party of the first part, in consideration of Ten Dollars and other lawful consideration, lawful money of the United States,paid by the party of the second part, does hereby grant and release unto the party of the second part,the heirs or successors and assigns of the party of the second part forever, ALL that certain plot,piece or parcel of land, with the buildings and improvements thereon erected, situate, lying and being at Greenport,Town of Southold, County of Suffolk and State of New York. SEE SCHEDULE 'A' ATTACHED HERETO AND MADE A PART HEREOF Being and intended to be the same premises conveyed to the party of the first part by deed dated 5/3/2000,recorded 5/19/2000 in Liber 12043 page 742; and deed dated 10/20/2006,recorded 11/29/2006 in Liber 12480 page 773. TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof, TOGETHER with the appurtenances and all the estate and rights of the party of the first part in and to said premises, TO HAVE AND TO HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of the party of the second part forever. AND the party of the first part, covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever, except as aforesaid. • AND the party of the first part, in compliance with Section 13 of the Lien Law,covenants that the party of the first part will receive the consideration for this conveyance and will hold the right.to receive such- consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" shall be construed as if it read "parties" whenever the sense of this indenture so rPrniirrc IN WITNESS WHEREOF, the party of the first part has duly executed this deed the day and year first above written. JE , ► GENOVE NYSBA Residential?Real Estate Forms on HotDocs (9/00) Copyright Capsoftm Development I:.'•I.. � .._,......�'.4..�'.+.tirY.?�,:.'•rrl��.S..n...;' .;....�:I�.;�,r..i 1s'.i, .;.'J.��� -. ._ _ - • • STATE OF NEW YORK ) )ss : COUNTY OF SUFFOLK ) On the 7) day of , in the year 2012, before me, the undersigned personally appeared Jeanne Genovese,personally own to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her capacity,that by her signature on the instrument, the individual, or the-person upon behalf of which the individual acted,executed the instrument. • • NOTARY ' :LIC NOTARY PUBLIC-STATE OF NEW YORK NO.02 SI9011475 QUALIFIED IN NASSAU COUNTY MY COMMISSIr)N EXPIRES DEC.31,20141 DEED Title No. Section 097.00 Block 03.00 • JEANNE GENOVESE Lot 011.006 County or Town SUFFOLK To HAASE Return By Mail To: James J. Power, Esq. 6205 Fred III,Jr. Court' Pearl River, NY 10965 Reserve.This Space For Use Of Recording Office . STATE OF NEW YORK • • WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE • la.Legal Name&Address of Jnsured(Use street address only) lb. Business Telephone Number of Insured - 631-744-7185 Arthur J.Edwards Mason Contractor,Inc. 929 Route 25 A lc. NYS Unemployment Insurance Employer Miller Place,NY 11764 24108715 Id. Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is or Social Security Number specifically.limited to certain locations in New York State, i.e., a 11-2377925 Wrap-Up Policy) • 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Ullico Casualty Insurance Company Town of Southold 3b.Policy Number of entity listed in box "la" P.O. Box 728 WCS-700093 00 Southold,NY 11971 3c. Policy effective period 01/01/2012 to 01/01/2013 Proprietor,Partners or Executive Officers are- [x] included. (Only check box.ifall 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"la"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 insurance policy). The-Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also note the above certificate holder within 10 days IF a policy is canceled due to nonpayment of .premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel thePolicy;or eliminate the insured from.the coverage indicated.on this Certificate. (These notices may be sent by regular mail.) Otherwise,ti is-Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy:ex iration date listed in box "3c", whichever is earlier. Please;Note: Upon the cancellation of the workers' compensation policy indicated on this for.m.,:if#hebusiness continues to be nam'ed-`ona.permit,license or contract issued by a certificate holder,the pu"siness:must;provi-k(tiatkce_rtificate holder with a .new.Certificate.of Workers' Compensation Coverage or other authorized proof that the businessis*mplying with the man'datoryfcoverage requirements of the New York State Workers' Co`mpensation'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 depict d:on this form. Approved by: . .lidI /%'k..f . . Print n e ofaut..rize epr 5e ive-or1icense.d agent of nsurance carrier) Certified by: (Signature) (Dat Title: 01)1 4117//M. 4 41 R' Telephone Number of authorized representative or licensed agent of insurance carrier: .:£`_ -Please Note: Only insurance carriers and their licensed agents are authorised to issue Form C-105:2. Insurancebrokers are NOT { - authorized to issue it. - C-105.2(9-07) www.wcb.state.ny us Workers' Compensation Law • • • Section 57. Restriction on issue of permits and the entering into 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. • • • • a • i • • ' 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 1 c. NYS Unemployment Insurance Employer Registration • 929 ROUTE 25A Number.of Insured MILLER PLACE, NY 11764-2700 24 10871 1 d. 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"1 a": P.O. BOX 728 009844240000 • SOUTHOLD, NY 11971 3c. Policy effective period: 07/01/201,2 to 07/01/2013 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. . Date Signed: 06/28/2012 By: S t —5 S kcu. Stuart J. Shaw, FSA, MMA 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.Mail it directly to the certificate holder. if.box"4b"is checked,this certificate Is NOT COMPLETE for.purposes of Section 220;.Subd 8 -of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,-D6?P.Iaris-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 • ' ...,:.4:;:je04.../A,; A.A4R(04.4;P,/kl‘i..,k),Wi401:41.'Ves4,“:,Ptt;iii0-4.0. ....0,0%,.w......4.*,..do.-4,4...A.$•„....w.cAtilitgvskiezktai,A.:A...0*0..,,,,14i.,...,•,-(40.4,,,,..(11m.,,...• :. -.;,.A.072z, k"..: 4,..‘,..,•,:e..? :i2v;iit:-.5:1%;.%.1 Suffolk Coiinty Executive's" Office of Consumer Affairs „,,,,,,„,,,,, VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 ,.....c.g.,....v.,,,,.., {,',...3,1:rx'-',7:1, This is to certify that EDWARD S REIFF tietAs-'<t. - ,,,--,-,:.--, -.. having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in' ,,,,,:x4,1*. . ..-,_,..-.,,c,:A.,:i., accordance with and subject to the provisions of applicable laws, rules and regulations of -pkvap . ...„.,... ...- the County of Suffolk, State of New.York. . 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N/F MIDGLEY –{ TI-1 C rn N 87°34'30"E 215 14' Nip•,oss N U1 a1° b S 75°Zp'�„E ' SHED IN (n ” DISREPARE • —I 0 �j N�S'20'Sp„ 1 0 165.5' (11 X S„poi z rn. wTf°e_ ir, oaNEwAY W (7 i D _ AND gSTORY RESID NC ° 13 BEORO MS.)AND B EAOAS T GOCWN ENT �, s 4.ska k H a .aa o Dm;.:2 � � mr • n� 14.9 o-' I.;r;iilP1 196) _ m C d" 199• / O m517 g 2 144.2 CONC Pl T Q' 14.7 _ t5 > I 8 II4 v W�D S o (n i 906 s PIT Rio $21'3p.,E 1 C , Cg et:ra • c 10.5 B S0.pp. Z fr Po��+ 0•.Or' N – — VYg1ER SER_yCE D i 37 WOOD Z 1V Ib' 4 f PO�rF ml � I CH0,4 .“,\.) - - � -_ - • �P I \N. -4------ � W o � EPTIC2L O ' O_ O 1 0 lP2 PROPOSED DRNEWA AND PARKIN° iii , i LPI -- —- ---- -- - - -- –- =R Q . 103.7 ►sus t3ASE I fJ , c7446,- w is ! Or, N v Clot 1 S 86°33'36"W 443.58' POST/RAIL FENCE GEN ALONG UNE LOT 2 SEPTIC LOCATIONS CORNER A CORNER B ' SEPTIC 1 67 47' SEPTIC 2 6T 53' LPI 74' 68.5' LP2 65' 66.5 .I • _ _ • Unauthorized alteration or addition to this document is a violation of Section 7209 i of the New York State Education Law. SURVEY OF: LOT 1 Cerittcations indicated hereon shall run only to the person for whom it is prepared and on his behalf to the Title Compeny,Govemrnental Agency and Lending Institutions listed hereon,end to the assignees of the Lending Institution or , MINOR SUBDIVISION FOR RONALD STRAIN OF NEW ! subsequent corers. �P*S� Yo9 ed Copies of this document not bearing the professionals inked seal or embossed . CUTCHOGUE, TOWN OF SOUTHOLD sear shall not be considera valid true copy 5 DESTIN G.GRAF f ! The offsets I a< 1shown t hereon from structures to the.pre the lines nre SUFFOLK COUNTY, NEW YORK for a specific purpose and use end therefore are not Intended to golds the erection d fences,retaining wails,pools,patieos,planting areas.addition to buildings,or any other P. construction. is O The(welter-lee of right of ways andtor easements of record.if any.not shown are i SURVEY.DATE: 4/19/01 not quarerda�ed. _SCALE 1"=60' mss:-�� .Ni , - - _ ._ - - -• - - - - - N� �'"= ' .g. CERTIFIED ONLY TO: .. E. ., k;. kJ '°q0 , 4O i JEANNE M.GENOVESE AND LOUIS J. GENOVESE I DESTIN G. GRAF • �P HSBC MORTGAGE CORP [USA] LAND SURVEYOR FIDELITY NATIONAL TITLE INSURANCE COMPANY I 73 Woodlawn Road Point,New York,11778 OF IVEihI YORK i pts-s21-34x2 By DEST1N G. GRAF N.Y'S LIC NO 50057 - - __ I ii .,turr,.. 411 A ' •, lir . O,sio . DmmerF . '' ,_ ''.;1 7 -• - „ , . , .n. C D : -B E P--L . 43. ' ' ' /'Alum • \ . --- \J--- o To Filter ocsatur a pump To Wastal.° Returns (Dry Well Optinal) From Filter Rolled Wall Foo Plan A Piping Arrangement Wall Section \ vin, U .. C j4 Rebar // . 411 • . os OF NE/4/), 42" --- es0 00.3 D. 0.4 / Section B—B 0 3500 P.S.I. Concrete 1 ' s: :; .4 * • Lu III" 4 Cr ‘ _#/ "''''' C)4.1 . 10" 1 p ,4),....: 04359 ,\•-\ (ji'ESS101`11\\" Section A—A . Typical Wall Section . . SIZE A B' C D E F G H AREA CAP. ' ' FEET FT. FT. Fr: FT. FT. FT. FT. FT. SQ.FT. GAL. Purchase 15x30' 15' 30' 8' 12' 6' 4' 4' 7' 450 16,000 , ' ARTHUR EDWARDS .,:. ; •. , POOL&SPACENTRE, Address ,,_• , 16'x36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600 ,- ' ,•• ' ' '- ' ,! - • • PEOMAORFTsF :WALL :SYSTEM 18'x36' 18' 36' 12' 14 6' 4' 5' 8648 24,300 929 Route ,26k Miller Plce 'NY 11764 City' sta. ,,... , ,- . 20x40 20 40' 16' 14' 6' 4' 6' 8' 800 30,000 (631)' '.iii-'71p5:,_'_ ,..4744,,;.(631.),:'74.1 .7p174 L ,i,a) zio code 24x44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 SuffolkLicense #44q6,.., .}0 ,; ,..„ ' . ';' ' ' ' ' ' , • : 24x48 24. 48. 20 16 8' 4' 6' 10 900 30,000 Nassau License '01174,4509:0j;' '' ''' ' • ' • , ; ,.,-, , ; , ' " - ; •• • ".• ; • , : . . .; . : , , . - , . •