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HomeMy WebLinkAbout40360-Z -XV41 FF04ir Town of Southold 5/26/2016 3 P.O.Box 1179 0 53095 Main Rd �ao01 Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38841 Date: 5/26/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2410 Bridge Ln, Cutchogue SCTM#: 473889 Sec/Block/Lot: 85.-2-24 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/14/2015 pursuant to which Building Permit No. 40360 dated 12/18/2015 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 Moscowitz,Marc&Carole of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 40360 4/13/2016 PLUMBERS CERTIFICATION DATED AutlkKed Signat re TOWN OF SOUTHOLD S�FFD(,gCo BUILDING DEPARTMENT job G�� y TOWN CLERK'S OFFICE o . 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#: 40360 Date: 12/18/2015 Permission is hereby granted to: Moscowitz, Marc PO BOX 778 Cutchogue, NY 11935 To: construct an in-ground swimming pool as applied for. At premises located at: 2410 Bridge Ln, Cutchogue SCTM # 473889 Sec/Block/Lot# 85.-2-24 Pursuant to application dated 12/14/2015 and approved by the Building Inspector. To expire on 6/18/2017. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING $50.00 Total: $300.00 Building Ins Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HAIL 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: yz Old or Pre-existing Building: (check one) Location of Property: 2,L--i t I'1� i i-1 u House No. I Street Hamlet Owner or Owners of Property: P o r C and Ca r-o if Suffolk County Tax Map No 1000, Section Block 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: $ 50 Applicant Signatur pF SOU��®�® Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G ® roger.riche rM-town.southold.ny.us Southold,NY 11971-0959 ®l�c®UNl°1,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: MOSCOWItZ Address: 2410 Bridge Lane City: Cutchogue St: New York Zip: 11935 Building Permit#. 40360 Section. 85 Block: 2 Lot- 24 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contracto DBA: Leo's Electric Corp. License No: 2199-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New X 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 A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches Twist Lock Exit Fixtures Ll TVSS Other Equipment: Inground Swimming Pool to Include Bonding, 1- Pump, 2- Switches, Pool Lights, 1-GFCI Recepticle, 1-Time Clock, 1-Salt Generator,2-GFCI Circuit Breakers Notes: Inspector Signature: Date: April 13, 2016 Electrical 81 Compliance Form As *_3 cou TOWN OF SOUTHOLD BUILDING DEPT., cor 1�6L 765-1802 INSPECTION - ' r1FOUFOUNDATION, 1ST ROUGH PLUMBING Ot NDATION 2ND INSULATION FRAMING / STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION - FIRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) I qODE VIOLATION CAULKING REMARKS- �it DATE — INSPECTOR aso cou TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION IST ROUGH PLUMBING FOUNDATION 2ND INSULATION FRAMING /STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION RRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAULKING REMARKS: DATE - INSPECTORA�x SOpT�olo 'yeOUNi`I,� 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: - J DATE 3 / INSPECTOR'E:I i Acq 3 Of SOpr�O louffo,� TOWN OF SOUTHOLD BUILDING- DEPT. 765-1802 INSPECTION , [ ] FOUNDATION 1 ST [ ] ROUG UMBING [ ] FOUNDATION 2ND [ ] IN LATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: Ccs- poi-� � �= � L DATE - INSPECTOR ` I DE SObr�ol cOUNiV,�c� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] UGH PLUMBING [ ] FOUNDATION 2ND [ NSUl. 0 [ ] FRAMING / STRAPPING [ ] F AL [ ] FIREPLACE & CHIMNEY [ ] TY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: C9 c",_ INO DATE v INSPECTOR fi 1 I i O� • � . � � • 1 1• r._ Mw ROUGH . . si • f: f �- STATE EnRoy • t m ME DWI I � A r 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 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. IWO Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined n 20 Single&Separate / `I--- Storm-Water Assessment Form 1 ✓ Contact: Approved20 Mail to Disapproved a/c Phone- Expiration 20 c C>> B APPLICA I I OR BUILDING PET DEC 14 2015 � RMI Date ,20 INSTRUCTIONS D,, DEPT a.T s application 1VIUS�bei c8mpI Lely filled in b typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, plschedule. 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 the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. o a�. (Signature of applicant or name,i corporation) y� -G Zorn 6f,J4(AA.,L[.,� V"), t� (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder 9 (ft,u('et,l C0(\A/',A_ Name of owner of premises f o r L C,r, c(X f-&(f !'Co W t4,� (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. 7,5 (I L( — tf Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on whi�h proposed work will be done: M �n Ci d i✓ House Number JrXreet H t County Tax Map No. 1000 Section Block Z Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work (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 Rear Depth 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 Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13.Will lot be re-graded?YES NO Will excess fill be removed from premises?YES NO 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY_BF�EQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO II// *IF YES,D.E.C.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. 18.Are there any covenants and restrictions with respect to this property?*YES NOy *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY being duly swom,deposes and says that(s)he is the applicant (Name of individual signing contluctj above named, CC CONNIE D.BUNCH (S)He is the 66c) -�-�`4 C- C Notary Public-_ pf H6uv York (Contractor,Agent,Corporate Officer,etc.) No.01 OU61 OW50 QuaNNed In Suffolk County of said owner or owners,and is duly authorized to perform or have performed the aftft I*ROa 00Wel*,iVa p Ti5atlor ' 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. S om to before me t _day of 20j—<— r Notary Public Signature of Applic Scott A. Russell 01- ST01RJ\\\4WA\' 1E1K SUPERVISOR 5 MAN SOUTHOLD TOWN HALL-P.O.Box 1179 6 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES T]H ffS PROJECT INVOLVE ANY OF THE FOLLOWING. Yes No (CHECK ALL THAT APPLY) ❑OA. 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 yards of material within any parcel or any contiguous area. ❑�. Site preparation on slopes which exceed 10 feet vertical rise to ❑E� 100 feet of horizontal distance. D. ite preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ E. Site preparation within the one-hundred-year f Ioodplain as depicted ❑ID/ on FIRM Map of any watercourse. F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. 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) S.C.T.M. 1000 Date ' ` t District�r�J t \` Gl� C,CiUV �� a Section Block of FO UILDING DEP A T USE ONLY**** Contact Information (0,31— Qrk m Num6rr! Reviewe — — — — — — — — — — — — — — — — Pro ert Address /Location of Construction Work: — — — — — — Date: -12 - 1�'r 16— Property 6 — roved for processing Building Permit. lJ 0 J{�t e l.• Stormwater Management Control Plan Not Required. Stormwater Management Control Plan is Required (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 J ' i S�ryo D x2 Telephone(631)7651802 SP.O.Box 1179a D G Q ro er.dchert Eo`J south�01& .us - �. Vuljl� BUILDING DEPT. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN OF SOUTHOLD - APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name: v Name: i License No.: Cl Address: q0 a 9 Phone No.: . o�9 1-7. C_ JOBSITE INFORMATION: (*Indicates required information) *Name; *Address: p f^c 3 S *Cross Street: to o *Phone No.: j1- a 274. as 0-0 Permit No.. pj(,�(' ---- Tax-Map District: 1000 Section: Block:_ Lot: *BRI DESCRIPTION OF WORK(Please Print Clearly) (Please Circle All That Apply) *Is job ready for inspection: Ina *Do-you need a Temp Certificate: YE NO Rough InYE Q S� 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 Addltio lnformat(ow, PAYMENT DUE WITH APPLICATION gt� t trL 82-Request for Inspecfton Form I /�� (� > G 1,0 nn- TOWN OF SOUTHOLD PROPERTYECORD CARD DWNER STREET VILLAGE Y�arc (e- S IST. SUB. LOT OL�-�n�(-)A---' 7') v FORMER OWNER N E a ACR n rpt rtec W TYPE OF BUILDING SEAS. VL.9 FARM Comm. CB. mics. Mkt. Value LAND IMP. TOTAL DATE REMARKS Z,t P A-r?Lj ps1<1 vur j v- lIvIr 7 fi -Z) q14-t 7 o L 1 9 D rp 7Z�6 G ra A� 11 3!�5 33 41 z"v SES I Go / d '4 al /Z-cc / I I I 1 0 1-L�5 Q (D 0 t36 412,bt>b To� 11able FRONTAGE ON WATER 3odlartd FRONTAGE ON ROAD ioclowkwW DEPTH 2e, use Plot BULKHEAD tai A ` 41 ■■'■■UM■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■M ' ■■■■■■■■■■■■■■■■ ■!■■■■■■■■■■■ ■r!■■■■1� !■■■■■■■■ ■� � ■■�■■■��r:■■■■M■■■■■■■■■■■ ■�■■■■r�. .. ��■■ ■■■■■■■■■■■■ ■■� ■■■■■■■■■■■■■ ■®!■■®■■!�■■■ ■■■■■■■■■■■■■■■ i■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ E■■■■■■■■■■®■ ` ■■■■■■■■■■■■■■■®��■■■■■■■■■Io ■■ ■■■■■■■■■■■■■■■1■■■■!i■iii■i■iii■®■ Foundation ..x Basement .2•..r:- - � W• is Interior Finish IFire Place Recreation Room Kooms 2nd Floor -S.C.T.M. NO, DISTRICT: 1000 SECTION: 85 BLOCK: 2 LOT(S):24 _ #RlO-07-0049 VACANT (FARM LAND) LAND N/F OF DAVIDS. -LAND N/F' OF DAVIDS S5501 7'!0"E' 133.009 MON FD \ 6' STOCKADE MON FD FE. 0.1'S AT CORN. 0.6'E 0.9'E uy L®T 7 0 ELi 58.5 EL 60.9 } 9 m LOT, 8 N • , � _�§� LOT 6 , stk. 2ND FLR. set DECK " - DRYWELL: - 2ND FLR: 18.5' WOOD DECK ( - 1 ECK , DRYWELL \�� EL 5/ 5.4•' COVERED ^N- 29.0' o -- PORCH vi I CELLAR 2 STY. FRAME 10.1', ENT. W/ BASEMENT ' n 2.8' #2410 x ; I FFL EL 61,5 I 36.3' of 10.4- C3 0.4'o GARAGE, GF 58.3 28.0' vi' EL 58.4 EL(58.0) 22.0' stk. 31.6' ROOF OVER set ' EL 57.8J BRICK CONC.STEPS2 ALK 5' W UJL 39 i BLUE STONE DRIVEWAY L P. U N EL 55.9 DWELLING I DWELLING EL'55.6 o. EL 54.7 FE. STORM DRAINAGE W p ROOF AND PORCH AREA_= 2325_S.F.-X 17 = 395 C.F. SUPPLY 2—'B' DIA 5' DEEP 10' V. X d2.14�.' d 2 I'3 EL 52.5 ' p _421 CF'STORAGE NOTE:-NO WELL WITHIN" 100'--T0, = S - / SCALE OF SEPTIC W i L In uj WELL O I m WELL STONE PILLARS ' . W/GATE EL,48.1 ADD REAR DECK 09-04-15 = EL 49.8 EL 50.6 MON FD MON. SET' I•' AT CORN. " :•, 'FINAL. SURVEY 11-15-07 111._03'- N65-09,20"wADD GRADING 'PLAN-7-2-07' N5�4�'40'�1Y• REVISED 6=7-07 ADD NOTE 22.53' -'BRIDGE, . . '(50,) LANE- CL 50.54. Cl.,"45.30 TOWN MAINTAINED -ROAD THE WATER SUPPLY, WELLS AND CESSPOOL ' _ _ _ LOCANONS SHOWN ARE FROM FIELD OBSERV477ONS - U.P. .EXISTING WATER MAIN= AND OR DATA OBTAINED FROM OTHERS. UPAJ19 , ---ASSUMED---------------- - ' AREA: 42,631.4 S': OR 0.98 ACRES ELEVArroa DAruM UNAUTHORIZED-ALTERATION'OR'ADDITION TD 'TH1S SURVEY IS•A :V10LATION OF'SECTION='7209,OF,•THE NEW YORK STATE EDUCATION LA,W. COPIES,OF (THIS SURVEY, ' MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED`SEAL SHALL NOT`BE CONSIDERED `TO. BE A VALID 'TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN, ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON.HIS BEHALF TO 'THE TITLE'COMPANY, GOVERNMENTAL,AGENCY AND-LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT-TRANSFERABLE. THE,OFFSETS-,OR DIMENSIONS_SHOWN HEREON FROM ,THE,PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE;-AND USE THEREFORE THEY'ARE. NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE' THE-ERECTION OF FENCES, ADD177ONAL STRUCTURES-OR AND OTHER IMPROVEMENTS."'-EASEMENTS ' AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE 'PREMISES AT THE TIME,OF SURVEY SURVEY'OF: LOT 7 CERTIFIED T0: MARC., A. MOSCOWITZ; MAP .OF: ISMAR ACRES CAROL. E. ,MOSCOWITZ; FILED: MARCH" 13, 1973 AS #5672• FIDELITY NATIONAL TITLE 'INSURANCE, 'COMPANY �;•'' i' z. 'OF NEW YORK , SITUATED AT: 'CUTCHOGUE " '_'� t'8°• S`r TOWN OF: SOUTHOLD 'KENNETH M. WOYCHUK" L.S. f SUFFOLK COUNTY, N,EW YORK . x- r, Land Surveying`and ;Design UPDATED OCT. 10, 2009 d P.O. Box 3, Mattituck, New York, 11'952 n , PHONE (631) '298-1588 FAX (631,) 298-1588 FILE-# 27-27 —SCALE:, 1 —30 DATE:-MAR. 10, 2007 N.,Y. S.'LIC4NO°,50227 . maintaining the records of, Robert J. Hennessy ' �1 PREST-2 OP ID:GS AcoR®- CERTIFICATE OF LIABILITY INSURANCE FDATE(fVI4/20 12/14/20 5 15 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 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 CONTACT John M Titolo,Inc NAME: John M Titolo,Inc 990 South 2nd Street,Suite 4 A/c No Ell:866-484-8656 ac Noy631-585-3171 Ronkonkoma,NY 11779 E-MAIL enc Gina tltoloa John M Titolo ADDRESS: g ycom INSURER(S)AFFORDING COVERAGE NAIC# INSURER Hartford Insurance 29459 INSURED Long Island Prestige Marble INSURER Dusting Inc 46-C Zorn Blvd. INSURER C. Yaphank, NY 11980 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL BR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ® OCCUR 22UENOJ2383 07/0912015 07/09/2016 PREM SES Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY jE F] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑NIA E L EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ B Disability D299764 07/09/2015 07/09/2016 Continued Until Cancelled DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNSH2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow TowTown Hall ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Main Road AUTHORIZED REPRESENTATIVE Southold, NY 11971 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0 New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 Phone.(631)756-4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A^A^A A 475064061 LONG ISLAND PRESTIGE MARBLE DUSTING INC 46-C ZORN BLVD YAPHANK NY 11980 POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND PRESTIGE MARBLE TOWN OF SOUTHOLD BLDG. DEPT DUSTING INC TOWN HALL 46-C ZORN BLVD MAIN ROAD YAPHANK NY 11980 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 12079414-5 153070 07/09/2015 TO 07/09/2016 12/14/2015 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.2079 414-5 UNTIL 07/09/2016, 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 07/09/2016 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. PRES WILLIAM MACAULAY LONG ISLAND PRESTIGE MARBLE DUSTING INC 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 FUND J, DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/cert/certval.asp or by calling(888)875-5790 VALIDATION NUMBER: 865475766 U-26.3 Yogic Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation UNDER THE NYS DISABILITY BENEFITS LAIN Board PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured LONG ISLAND PRESTIGE MARBLE DUSTING INC. 631-849-3642 1c.NYS Unemployment Insurance Employer Registration Number of Insured 46-C ZORN BOULEVARD YAPHANK NY 11980 1d.Federal Employer Identification Number of Insured or Social Security Number 475064061 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold Building Department 3b.Policy Number of Entity listed in box 1a": RE: Town Hall DBL299764 Main Road 3c.Policy effective period: Southold NY 11971 07/09/2015 to 07/08/2016 4.PoI!cy covers: a. ® All of the employer's employees eligible under the New York Disability Benefits Law b.F] 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 y 12/14/2015 B vial ht (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer MPORTANT:If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd 8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by the NYS Worker's Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees Date Signed By (Signature of NYS Worker's Compensation Board Employee) Telephone Number Title Please Note:Only insurance carriers licensed to write NYS Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form DB-1201 (9-15) • 3 e>-�" L. ID �'-4'' �1 Rtztvssap �"� C-ivnit tE FoX FAr�. /\c1To 'L'e�vl~TL. �' 0►1}'(ZAL'�o5 Ta coaV-naa -T€. %J/ . Aaru c� It l . 12J, 0_0 C4 ,. D006LE Mla,W p � o GaaTtnit.potlS TgarJT.? J � � ;0 0 F5NZS ALL Fv_ouaD ---�r -,y To QuMP > i STEPS Lan W Al.L1To rix (26LsckaL T 1 1 I_obl�RC� Z r;t.�t1a) �Afltus vA�t�s�c���t -Q` To -o� UrJntST�tp�,twr7 t I l= - E/z1?T�t .ate! Z, 1(t_pI1 P�luEraarlc� nLL�( =I I I� Itl�t 11'l i t=111 �apF'LIEr� Cr�nl�,?L.ETd✓ f3� ---�• 311 'D2NiJ Te t11^lil�ltl=(►t.tt(=1►t= ALATo C.ovF_c,_ NOTES: , 2 ._... n,j-._._ Tt I 1. Pool design is based on free draining granular soil with less than 10% silt. r Y _ 2. Pneumatically applied concrete shall be a mix of no more than 4 arts sand ;OM1````,-_„;�i'Ir•�Il�'•: t' II _ I II p !-t Y"1G 'p to 1 part cement with a maximum of 3.5 gallons of water per sack of rG achieve a minimum _ 1�r cement P ,,,;.ta 1= ;a. ;, ,m, x t'tt.1.. '�"�" Pneumatically applied concrete shall hiev 2. `=;,,.." i r', y- t*r�°� ,>r , ,Y , a�r ; compressive strength ,000psi 8 days. _ coni r en hof 4 @ 2 J 3. If groundwater is encountered during construction, a temporary dewatering 3. ..i'.i .rr`.'1151ii T l ..% e'• t •``Cs �{ i �t -HAL Cill.n r' ri',.� (irit; tv,,,,j-S1 J ' P �3 R J " -•'"' �w�•,. s p s"°r' '' "T' system shall be installed. The system shall have a minimum of two 11/2- 4. t�: - "CE: Ft,.i' C.f�. - -� _.-._,_.-__w. P4' � i � fi, : a ((`` -` .`1- inch diameter weep lines. Flow from the weep lines shall be discharges on iJ.l'11.PL J i ALL L j ��.� ri{,c:!_L fr T i'=._ _ _y . ...-. y �;`. Y.� ;'; : ?P ,� r-a o�e � -1�1 i Imo• `""�, COI F� "aTS C? THE CODES OF P' .F�' — i;�,^vS f j i T 1;- �t" CA E the premises in a tempor recharge g ary r ge basin. YORK �L` c � p 4. No spoil permitted within 4 feet of excavation. YORK STi;r '; �-.�:SPOi4:�I3:..E �CR _. „�.,_..�..,, OF O1.7i��1�i1 1 5. Finished grade shall slope away from the pool a minimum of 1/4-inch per ®ESi�i3 GR CC�,iSTRUCTIQN E MORS. r., �— foot. 6. All reinforcement shall be#4 bars, grade 40 minimum. All reinforcement s _ RET�t, ' STORM, WATER RUNIOFF splices shall be 30 bar diameter's minimum. `-�- PURSUANT TO CHAPTER 236 7. Double main drains with-vacuum relief system for entrapment protection ENIJCLOSE PPOOL OOL TO COODDE UPON COMPLETION OF THE TOWN CODE, shall be provided in accordance with Appendix G, Section G106 of the F• .>�t L� EE R5 VATER" Poo L Residential Code of New York State. ,p;,a.,.,,..., • t VE—RT. If 04. a.CA .. o� /\LL F_, ei1r&, s SLL C FLaQ :�"`.,�•. -`:�'� lie✓ #4 r Qr 'SCALE: �S w}�Al�p'� APPROVED BY: DRAWN BY JAMES K. MORROW JR., P.E. DATE: consulting Engineer F' PAT2ET� 'F'o-eZ e 24-lo Pz2.tr_){,`E, L-xan1E 2066.Bedford Ave. N. Bellmore, NY 11710 �� C•Flt°c�c►r t t1`f. .J1535 . .(516) 785-8.032 DRAWING NUMBER MoSGot.JtT�-