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HomeMy WebLinkAbout38642-Z t``f �EFaI�'C Town of Southold 6/1/2016 P.O.Box 1179 lr i 53095 Main Rd 4,© cit- Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38213 Date: 6/1/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 4553 Wickham Ave, Mattituck SCTM#: 473889 Sec/Block/Lot: 107.-4-13 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/13/2014 pursuant to which Building Permit No. 38642 dated 1/27/2014 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 with fence to code as applied for. The certificate is issued to Kelly,Thomas&Linda of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38642 4/28/2015 PLUMBERS CERTIFICATION DATED Aut ►ied Signat e It, OF ��coG TOWN OF SOUTHOLD ,� yak BUILDING DEPARTMENT TOWN CLERK'S OFFICE 1 0� 0. ,'; SOUTHOLD, NY !ilt> 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 #: 38642 Date: 1/27/2014 Permission is hereby granted to: Kelly, Thomas 4553 Wickham Ave Mattituck, NY 11952 To: construct an In-Ground Swiming Pool, fenced to code & per Trustees & DEC approval At premises located at: 4553 Wickham Ave, Mattituck SCTM # 473889 Sec/Block/Lot# 107.-4-13 Pursuant to application dated 1/13/2014 and approved by the Building Inspector. To expire on 7/29/2015. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 , e- / - 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_Prre_-existing Building: (check one) Location of Property: 53 i (C [�hQa„i� . House No. Street Hamlet Owner or Owners of Property: 'l.a mss Suffolk County Tax Map No 1000,Section [ O'er Block 4' 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: (ch I.ne) Fee Submitted: $ Applicant gnature /.0, iii_..A siiislf Town Hall Annex �,'1 ; Telephone(631)765-1802 54375 Main Road ; % Fax(631)765-9502 P.O.Box 1179 , O �� �'11 roger.richert(a�town.southold.ny.us Southold,NY 11971-0959 ��rC®U�ly,� i '' —•... •i' BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Tom Kelly Address: 4553 Wickham Avenue City. Mattituck St: New York Zip: 11952 Building Permit#: 38642 Section: 107 Block: 4 Lot: 13 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electrical License No: 2880-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel NC Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel NC Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: In Ground Pool To Include - Bonding, 2- Pool Lights, 1- Control Panel, 1-GFCI Circuit Breaker, 1-Salt Generator, 1-Gas Pool Heater Notes: Inspector Signature: ' � t` Date: April 28, 2015 1 Electrical 81 Compliance Form.xls OF SOU - - - - - - - - - -- ��o�� Volo\`- ------- -- - ---- - -- - - - - ---- -- - )(I/ , 4 'ycOUIfIY,N °� TOWN OF SOUTHOLD BUILDING DEPT. - - ' 765-1802 INSPECTION - [ ] FOUNDATION 1ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ CAULKING REMARKS: � - -e Com. pow DATE 4 27 j INSPECTOR 34, (2_c0,-- _ pF SO(/r' - ---- * 0€ =1y00UHi`1 az.• ,��.' TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] IN ATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: /41-1-cif Hlite--e/120--AiArm cfr/Tif At..02.66 ,40 (6-22,eCe-IL e DATE ; ,/-5—' INSPECTOR '-47'/7* ,4 r-2,_,_ ��,,3 %SOF Sii4,-1\` TOWN OFSOUTHOLD BUILDING DEPT. - 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH LUMBING [ ] FOUNDATION 2ND [ ] 1 L;44401 [ ] FRAMING /STRAPPING [ FIN j [ ] FIREPLACE & CHIMNEY [ ] FIRE S ' ETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: CO .0)6. ___ ' I/ fir" - ..$) 4.c......_ 4 Ati DATE INSPECTOR FIELD INSPECTION ON REPORT DATE COMMENTS • i .. 6. 4 EOUNDA 'ION(1ST) . . _._.___, . . , , , . ... .".• • • FOUNDATION(ZND) I m • . • ROUGH FRAMING& EA PLUMBING t pa . H INSULATION PER N.Y. , STATE ENERGY CODE • • '• • (y/i/iir-. Z•47—qi Ili' Xgfrill,t/AC/114m..../eD &-& —4(497E1 - ttf dLAale>. J _ . ' .4 --e4-C_ - Co_„7,- c.. ---,-- s 7-,i —L-4 ' . _ / FINAL VI2--/lc.' T C e-& ., .. , • • • (9/..- ADDITIONAL COMMENTS ' C ' aeG c rervt IN axe,, • 11 jct i o csy-z8 -( cJ &`c Ca"- ice o �Z . ® m • k , p. • moo' • ()I 2 I2 . , \-"- E e TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL SOUTHOLD,NY 11971 Board of Health TEL:(631)765-1802 4 sets of Building Plans FAX:(631)765-9502 Planning Board approval SoutholdTown.NorthFork.net PERMIT NO. q uevey n�Li 9. CCheck C EU !% ��1 [E trines U i Examined //j,'' 20 //7,_ Flood PermitL 11111 / l Storm-Water Ass—.. ,, orm • J tac 3 2014 n Approved I /.)'7,20 I it. Mail to , Disapproved a/c Et sF z ,11 BLD Dr' ? '1 ..42,1* c w. ri - , i ,.. 45. Expiration 7/�7 ,20 S TOWN 0 sT ' ' v.:, ','i 4, ', fz *y =�a rlTTr r.t. l "- Building Inspector 47 25A° Roi«'ty point,Now 7�'.r;C 477 APPLICATION FOR BUILDING PERMIT` �/ j Date�"ail l 4 INSTRUCTIONS '20 a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant.Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until 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 appli,is e Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for remo •1 or demol i as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,ho ,g code, .I. egulations,and to admit authorized inspectors on premises and in building for necessary inspections. 1itlr�tic s ' i is .v. tlefF / IL Ahi..4 �NGLOS ;`(✓;�L ;(� Ct�DE Signature of..phcant or name,if a corporation) RETAIN STORM WAT UPON COMPLETION = .,1,.PF L. BEFORE "WATER" PURSUANT TO SHA'�ti -1; A,�� I. (Mailing address of apph .10 OF THE TOWN CODE. State whether applicant is owner,lessee,agent,architect,engineer,general contractor elec cian; u ber or builder Name of owner ofpremises DA --IL-1P:a P #....A/K6• q ami. - If applicant is a corporation,signature of d u h razed o,,e rollior lat c eek � ,_Byl l i iqq=' I 'AGE i'It.re-f 'r� NOTIFY ,U,I'I_ 'DING, DEPARTMENT (Name and title of corporate officer)" - u " ` ` ` 765-11802 $' A M TO 4 PM FOR I F ,f'� ^` ,��I =) L i e� FO MIN INSPECTIONS. Builders License No� 4 u ' @ `�< e' i t f,;- � L pA T!0 r- T�IVt?REQUIRED Plumbers License No. r'‘;', sip-L/�.i F ;;� ;i-;;;,= FOR POURED CRETE Electricians License No --=----- ' �r �'"'a?_ 1 ROUGH- lhd'C PLUMBING, Other Trade's License No. ST'RAWNG ELECTRICAL&CAULK!I' a 3` INSULATION 1. Location of land on which proposed work will be done: 4, -FINAL-C NSTRUCTION&ELECTRIC,'L A, _ �,�s .. !� di .� ec>ti: `E O °LETEFOR CO House u�e ire — jai I,.. 1I,, I' Ski 1' dt I ' County Tax Map No. 1000 Section '0 7 REQUIrRE TENT,(� I44E CQ17,i`S' CAL, Block YORK STA-Mt N411== . Subdivision Filed Map No. DESIGN OR CatIO6T RUCTION.ERRORS � �� a F0 f II 2. State existing use and occupancy of premises and intended use and occupancy of propos construction: a. Existing use and occupancy _t�l- Cyt f rr b. Intended use and occupancy • ie-c,t- F..:=.4:::::•( A 240 )< +10 I ZyC_t(e. L._./ -.1) 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work �- (Description) 4. Estimated Cost ! , 270 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 f? Number of Stories 9. Size of lot:Front 1"K .13---- Rear 247 .U.� Depth 2-�`� 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 -N./NOWill excess fill be removed from premises?YES \/1014.Names of Owner of premises 1 F t `I�'�"1e�, dress Phone No. Name of Architect A ess ' Phone No Name of Contractor Address ' Pho a No. 15 a.Is this roe * property rty within 100 feet of a tidal wetland or a fresh wetland? YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERM13'S MAYBE REQUIRED. - b.Is this property within 300 feet of a tidal wetland?*YES" NO_ *IF YES,D.E.C.PERMITS MAY BE REQUIRED. -r 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 NO k *IF YES,PROVIDE A COPY.STATE OF NEW YORK) SS: COUNTY OF ) . 1-711:717125 being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing� coontr_ ))aabove named, (S)He is the v�`"'/ `'C/ (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said wo d to make and file this application; that all statements contained in this application are true to the best of his knowledge and b lie •and that the work will be performed in the manner set forth in the application filed therewith. Luke Pranto p Sworn to before me this NOTARY PU6l1C,State of New Yolk �r j 5---a-day of /144.11144,117 20 /3 , No.01P.A6233029" -���-,,`. �p awed in Sur Cam Notary Public / Signatu • of Applicant pb/iMiSSi011 Expire$January 03,20/5 pono.41 mama. A /\N \. ,i.,,---A):,..t. ,,� \� i.! --iti•`' Y% .,. . 7 „4,,,,,,„,,,,,,rA,. /\ ' 1 t. li,;. BOARD OF SOUTHOLD TOWN TRUSTEES H ° [ I SOUTHOLD,NEW YORK PERMIT NO.8339 (Revised) DATE:JANUARY 22,2014 , ; r ISSUED TO: THOMAS& LINDA KELLY ��$ 4 PROPERTY ADDRESS: 4553 WICKHAM AVENUE,MATTITUCK(i SCTM# 107-4-13 r i , t 1 -:- y f,, AUTHORIZATION Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on January 22,2014,and 7 in consideration of application fee in the sum of$250.00 paid by Thomas&Linda Kelly and subject to the 7 Terms i ® the following:and ts Conditions as stated in the Resolution,the Southold Town Board of Trustees authorizes and perm \'(h i .",, Wetland Permit for construction of a 20'x40'with 12'i16' "L"extension in- �' -'.3 ground pool; construct a 1,700sq.ft. pool patio; install 4' high pool fencing; construct a ,., 10'x12' tool shed; construct a 700sq.ft. terrace seaward of existing covered porch; and A .. ' re-vegetate previously cleared areas;with the conditions of establishing a 50'wide Non ---. j[ - Disturbance Buffer landward of the edge of wetlands; that the pool fence to be located ,4 on the border of the Non-Disturbance Buffer; the Non-D'esturbance Buffer is to be re-sil[ "' vegetated using native vegetation; and a pool drywell to be installed; and as depicted on ; '` -7:' the project plan prepared by Thomas Kelly, received on November 12,2013,and ;-' T 11 (\ stamped approved on December 13,2013; and as also depicted on the site plan prepared by Kelly Brothers Landscaping,last dated November 8,2013 and'Stamp --li 1 ,, approved on December 13,2013. 1 r, IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, ; 1 '•' and these presents to be subscribed by a majority of the said Board as of this dates\ 4 „., ,,,,:,. , ,,..... .‘. * • i , A‘ tpte.e......441.411... 1 i ' - ..?" \'L GO f 94-146.eg 42-- ter," II \it?! Nr 0 lir r r, �' dl�. • �. ;rel �d i, x 1 `.Zs-—/./��� \` ,w Y / .`,1�("`/: 1 .i....-- --,-.. i• 'V \� \ ---),5:..-V"^ ' 'i+ /ll��� iii.�,. • OF SOU John M.Bredemeyer III,President •�0/�� j�® Town Hall Annex Michael J. Domino,Vice-President ��� '1/46 4:::,�® ; 54375 Main Road P.O.Box 1179 James F.King,Trustee % 44 SIC Z Southold,New York 11971-0959 Dave Bergen,Trustee ' F; 4%--i�Telephone(631) 765-1892 Charles J.Sanders,Trustee e ,1 Fax(631) 765-6641 �C®UNU,, o i BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1192C Date: December 18, 2015 THIS CERTIFIES that the construction of a 20'x40' with 12'x16' "L" extension in- ground pool; construction of a 1,700 sq. ft. pool patio; install 4' high pool fencing; construct a 700 sq. ft. terrace seaward of existing covered porch; and re-vegetate previously cleared areas; with the conditions of establishing a 50' wide Non-Disturbance Buffer landward of the edge of wetlands; that the pool fence to be located on the border of the Non-Disturbance Buffer; the Non-Disturbance Buffer is to be re-vegetated using native vegetation; and a pool drywell to be installed At 4553 Wickham Avenue,Mattituck Suffolk County Tax Map #107-4-13 Conforms to the application for a Trustees Permit heretofore filed in this office Dated October 17, 2013 pursuant to which Trustees Wetland Permit#8339 Dated November 13, 2013 and revised on January 22, 2014,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the construction of a 20'x40' with 12'x16' "L" extension in-ground pool; construction of a 1,700 sq. ft. pool patio; install 4' high pool fencing; construct a 700 sq. ft. terrace seaward of existing covered porch; and re-vegetate previously cleared areas; with the conditions of establishing a 50' wide Non-Disturbance Buffer landward of the edge of wetlands; that the pool fence to be located on the border of the Non-Disturbance Buffer; the Non-Disturbance Buffer is to be re-vegetated using native vegetation; and a pool drywell to be installed. The certificate is issued to THOMAS & LINDA KELLY owners of the aforesaid property. dri.... ' aAm Authorized Signature NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATIONawe Facility DEC,ID 1-4738-03492 • PERMIT Under the Environmental Conservation Law (ECL) Per-mittee and Facility Information Permit Issued To: Facility: RICHARD BOSWORTH BOSWORTH PROPERTY 5035 PECONIC BAY BLVD 4553 WICKHAM AVE(RIGHT OF WAY-W SIDE&NW OF WICKHAM AVE&NE OF CONKLIN)ISCTM# 1000-107-4-13 LAUREL,NY 11948 MATTITUCK,NY 11952 • Facility Application Contact: (631) 878-1851 Facility Location: in SOUTHOLD in SUFFOLK COUNTY Facility Principal Reference Point: NYTM-E: 707.125 NYTM-N: 4541.691 Latitude: 41°00'00.4" Longitude: 73°32'14.3" Project Location: WATERCOURSE: LONG CREEK • Authorized Activity: Install a pool,hot tub,fence,patios and 4'wide access path, conduct clearing activities and instal turf/plantings, and'replace pervious drive with asphalt drive. All work must be done in accordance with the attached plans prepared by Ralph He,Metes and Bounds Surveying, last revised 10/10/09 and stamped NYSDEC approved on 11/13/09. Permit Authorizations Tidal Wetlands-Under Article 25 Permit ID 1-4738-03492/00003- New Permit Effective Date: 11/16/2009 Expiration Date: 11/16/2014 NYSDEC Approval By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations,-and all-conditions included as part of this permit. Permit Administrator:GEORGE W HAMMARTH, Deputy Regional Permit Administrator Address: i)4 NYSDEC REGION 1 HEADQUARTERS SUNY @ STONY BROOKI50 CIRCLE RD STONY BROOK,NY 11790-3409 Authorized Signature: Date// /If/ 97 Page 1 of 5 Ilk `'NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Nor • Facility DEC ID 1-4738-03492 Distribution List CARL GOVERNALE Marine Habitat Protection CLAIRE K WERNER 'Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS,APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: TIDAL WETLANDS 1. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work'herein authorized which may be caused by or result from future operations undertaken by the State for.the,conservation or improvement of navigation, or for other purposes, and no claim or right to`compensation shall accrue from any such damage. 2. Notice of Commencement.At least 48 hours prior,to commencement of the project, the permittee and'contractor shall sign and return the top portion of the enclosed'notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project,the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 3. Concrete Leachate -During construction,no wet or fresh concrete or leachate shall be allowed to escape into any,wetlands or waters,of New,York State,nor shall washings from ready-mixed concrete trucks,mixers, or other devices be allowed to enter any wetland or waters. Only watertight or waterproof forms shall be used. Wet concrete shall not be poured to displace water within the forms. 4. No Construction Debris in Wetland or Adjacent Area Any debris or excess material from construction of this project shall be completely removed from the adjacent area(upland) and removed to an approved upland area-for disposal. No debris is permitted in wetlands and/or protected buffer areas. 5. No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result,of thepermitted°activities. 6. Storage of Equipment,Materials The storage of construction equipment and materials shall be confined within the project work area and/or upland areas greater than 100 linear feet from the tidal wetland boundary. 7. No Unauthorized Fill No fill or backfill is authorized by this permit without further written approval from the department(permit,modification, amendment). Page 2 of 5 Aft NEW YK ORSTATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION i Facility DEC ID 1-4738-03492 8. Establish Vegetated Buffer To protect the values of the tidal wetlands, a permanent vegetated buffer zone shall be established. There shall be no disturbance to the natural vegetation or topography within an area extending 50 linear feet landward of the tidal wetland boundary. 9. Straw Bales or Other at Tidal Wetland A row of staked straw bales or approvable erosion control devices shall be placed at the landward edge of the buffer area or along the proposed clearing limits line as per the NYSDEC-approved plan,prior to commencement of any regulated activities and remain in place and in good, functional conditiomuntil the project is completed and all disturbed areas are • stabilized with vegetation. 10. Install,Maintain_Erosion Controls Necessary erosion control measures,i.e., straw bales, silt fencing, etc., are to be placed on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any disturbance of the ground occurs and is to be maintained in good and functional condition until thick vegetative cover is established. 11. No Drywells in or near Wetland Dry wells for pool filter backwash shall be located a minimum of 100 linear feet landward of the tidal wetland boundary. 12. No Pool Discharges to Wetland There shall be no draining of swimming pool water directly or indirectly into wetlands or protected buffer areas. 13. Direct Runoff Away from Tidal Wetland and Buffer Roads, driveways, and parking areas shall be graded to direct runoff awayifrom tidal wetlands and protected buffer areas. 14. Conformance WithPlans'All activities authorized by this permit must be in strict conformance with the approved plans submitted by the-applicant or applicant's agent as part of the permit application. Such approved plans were prepared by Ralph He Metes and Bounds Surveying, last revised 10/10/09 and stamped NYSDEC approved on 11/13/09. 15. State May Order Removal or Alteration of Work If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters_orflood flows or,lendanger the health, safety or welfare of the,people of the State, or cause loss or destruction of the natural resources of the State,the owner may be ordered by the Department to remove or alter the'structural work,obstructions, or'hazards caused thereby without expense to the State, and if,upon the expiration or revocation of this permit,the structure, fill,excavation, or other modification of the watercoursehereby authorized shall not be completed,the owners, shall, without expense to the State, and to sucli extent and in such time and manner as the Department of Environmental Conservation may require,remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. 16. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings,paints, concrete, leachate or any other environmentally deleterious materials associated with the project. 17. State May Require Site Restoration If upon'the expiration or revocation of this permit,the project hereby authorized has not been completed,the applicant shall;without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may Page 3 of 5 Aft NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Nor Facility DEC ID 1-4738-03492 require,remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. GENERAL CONDITIONS - Apply to ALL Authorized Permits: 1. Facility Inspection by The Department The permitted site or facility, including relevant records,is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation;(theYD)epartment)to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions,must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. 2. Relationship of this Permit toOther Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination: 3. Applications For Permit Renewals,Modifications or Transfers The permittee must submit a separate written application to the Department for permit renewal,modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal,modification or transfer granted by the Department must be in writing. Submission of applications for permit renewal,modification or transfer are to be submitted to: Regional Permit Administrator NYSDEC REGION 1 HEADQUARTERS SUNY @"STONY BROOIK150 CIRCLE RD STONY BROOK,sNY1-1790-3409 4. Submission,of Renewal Application The permittee must submit a renewal application at least 30 days before permit expiration for the following permit authorizations: Tidal Wetlands. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; b. failure by the permittee to comply with any teens or conditions of the permit; c. exceeding the scope of the project as described in the permit application; Page 4 of 5 NEW XOR STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION W , . Facility DEC ID 1-4738-03492 d. newly discovered material information or a material change in environmental conditions,relevant technology or applicable law or regulations since the issuance of the existing permit; e.' noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute,regulation or another permit condition. Applications for permit transfer should be submitted prior to actual transfer of ownership. NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York,its representatives, employees, and agents ("DEC")for all claims,suits, actions, and damages,to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with,or operation and maintenance of,the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions,Or to any claims, suits, or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit Thepermittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit,including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals,lands, easements and rights-of- way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Page 5 of 5 „r .. ofFO / SCOTT A. RUSSELL t5' �y ,� 1,•,l{--,,,acre 1 JAMES A.RICHTER, R.A. : 4 �., s r •.�,eir 4z MICHAEL M. COLLINS,E.E. SUPERVISOR )L�.r1 . 4— k 1 JJ Td ,��+4;jjS`, ''',• i, TOWN HALL - 53095 MAIN ROAD i1 uk• I iii,41 (�r,,,gl {fit TOWN Or SOUTIIOLD NEW YORK 11971 Tet. (631)-765-•1560 }1 7 o,� "� Ftvc. (631)-765-9015 I I y fit`} E �` � )rr 111_Ili_R1 :lii'IiR,irlOWN.SoinH01'r 1s.ly[6. „�4 . .., 65_4 OFFICE OF THE ENGINEER TOWN OF SOUTHOLD • STORMWATER MANAGEMENT CONTROL PLAN REVIEW COVER SHEET • ' (To be completed by the applicant) TO: . Engineering Department PLEASE A'77'ACH:' FROM: Buildin Department A•copy:ofth DATE: (�” • • •e•doirplet• ed:Appiicatipn•for" I 7 Building,' Permit ❑ A complete set of.Bulldf Pans APPLICANT: • • � � 0 A completed Chapter 236 Storm ter --�-� _ nn PERMIT#: Review ChecklistR 'E E 1J _1_ ,,.,t" $.C.T.M#: I �?��..,.: JAN 17 2014 BRIEF PROJECT DESCRIPTION: BLDG DEPT TOWN OF SOUTHOLD . , / * .- C> -K.24-'4=' I2. ((Q L— • MnIMINI :.. •F. 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N/ d.test hole data indicating soil characteristics and the depth to water e.proposed limits of clearing and the total area of proposed land F - disturbance a . NZ f.existing and proposed contours of the site(minimum 2' interval) 1 \Z" g. location of all existing and proposed structures,roads,driveways, J , sidewalks,drainage improvements and utilities \/ 1 h.spot i'aade and finished floor elevations for existing and proposed 1 / structures 1 ` / - i.location of the swimming pool discharge ring • I vVV co j.location of proposed soil stockpile area(s) ✓ Ico k.location of the proposed construction entrance/staging areas v I - 1. location of the proposed concrete washout area f m.location of all proposed erosion and sediment control measures 2.Plan includes calculations showing that the stormwater improvements PROilI06 17 RA i I,: : FoGZ l l ego - are sized to capture, store and infiltrate on-site the runoff from all I I -reQ.gAG a AR645. ' i impervious surfaces generated by a two-inch rainfall 3.Detail drawings(required for plan approval)provided for: - - ., a.erosion and sediment controls v /\ b.construction entrance / —, c.inlet structures(e.g.catch basins,trench drains,etc.) 1J t d.leaching structures(e.g.infiltration basins,swales,etc.) • ' `x , it REVISED 7/24/2013 ti 05/07/2014 22:29 FAX 6317506557 BETHEL ELECTRIC X1001 • • cif S004 • 1410" Town Hat!Annex � � 44ff Tet ( 1 102 E 54375 Main Road °V LLS P.O.Box 1179 : V. • c��' ro.er. ch� C► ,• ' .so-Nan .11s Southold,NY 11971.0959 `14 =_41111% MAY 8 2014 BUILDING oEFARTheNTDG DEPT TOWN OF SOUTHOLD TOWN OF SOUTHOLD APPLICATION LQR ELECTRICAL INSPECTION 4111.1•1411.1111.110, • REQUESTED BY: Date: company Name: � {"1riC�.� C cr . c Verne: • V'a- ULr 6-- ‘ p . _icense No.: . kddress: L.MCCAO -bvt Lij 'hone No.: • JOBSITE INFORMATION: (*Indicates required information) Name: TbCY\ `�-Q\\'`� � Address: • l.�SS \ �1nc�rcl ,'rte. Cross Street: \dd1.2 R.6 • . Y Phone No.: qv-A-a 5A0 c2$5— • )ermit No.: ax4Map District: 1000 Section: t 01 . Block: Lot: • BRIEF DESCRIPTION OF WORK(Please Print Clearly) • - \lriWCM 'VC& 111 Lr1u�-� _ . • Please Circle All That Apply) Is job ready for inspection: ( ! NO, Rough In 41250 Do.you need a Temp Certificate: YES I NO 'amp 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 vii,,/ ►dditional Information: PAYMENT DUE WITH APPLICATION V 4 I� I\ 13) di EMequest for Inspection Form - I�C Town Hall Annex � O : Telephone(631)765-1802 54375 Main Road C * Fax(631)765-9502 P.O.Box 1179 Q �l ,% Southold,NY 11971-0959 : ys/ ``i court* ,I.�' June 4, 2015 •I "" BUILDING DEPARTMENT TOWN OF SOUTHOLD Thomas Kelly 4553 Wickham Ave Mattituck NY 11952 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 — 38642 —Swimming Pool LOT AREA =• 78,823 SO. FT . 1 81 acres 1 , l� 1 flagging ' A - G g?5 -M2 , �.�`� N P I >kQ`L3p h , , a4, .4400( ,flogging .. LJ' ' O( ^'\ on ..4ggtng , ; - D 1 6 c ^D9- , 4-) ff+ o 0_ �C:iI ..,. flagging ,, • . D FLAGGING LABELED A that i t� TIDAL WrERANDS AS RAGGED BY flagging THOMAS W. CRAMER, ASIA ON OCT 4 2013 , . 4 flagging. Ca / flagging e. ,C _//T 0 flagging note. connect I TO 8, tidal and frnchwatcr I wetland's mixCS3 , flogging \nagging FUNGGING ' LABELED I that 8 . 8 FRESHWATER WETLANDS AS FLAGGED BY mows tv CRAMER, ASIA ON OCT 4 2013 U CA flogging . - V , ' z .�.p..- \ p \ nagg/ ing N 72'25'20"E 115 00' �o\ Ln - -11 ,. MON MON CNi-I�\ O _�_ 6 73 (nagging L—I conc retaining wall �) IJI \ - K (t5 �{~ .` raised wd platform N 03'S with AC units 73 l r-7 e ' 4x20'. 2 2'S - P Cit. ` - r— ICy r.ti.�t v._ -A G /fagging r FD —716=` • PIPE 1 - mac I 32.O' -4 , to ,ill �%_ ,. _� _,t 1- ti, Ln 1 13 0' • ' ' - fagging cov ahd 14.0 S 1{ #3 Oa co � w covered O 4 a V .. �,,� ,!` J/+;p�1Ip.,?. v2 STY FR N. porch O e. �, GCI` ......./flagging DWELL CD naggingz j` .-._ F'8' cs1 \o y121.0' - \3, U a 0...1 12 7' GAR a Sig I I 29.3' J l ` . ;t GAR T-3 wit 1godrng __ - AA 'S' -' _ .1 and st:pc' -�� - \ - - - - t \ I ',4.3 =.5'x5 4' %,5 44,- iJ 1 ')i-b ' ''.9 \ \ A I r' 4.Oi. \U1 ��—.--..__.. - -P .,,.__. t ° (CI COLO - _ ?PLD.°� o\ .-1 o PFD FD � I MON 1 . -' S 7725'20"W 342.64' / . NOW OR FORMERLY NOW OR FORMERLY o CONLON STEVENSON -) - 70 - ` - .-) 0 r 'ICI£.HAM AVENUE V. (ELLSWORTH TUTHILL ROAD) , • 111E OFFSETS (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE ' PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT I INTENDED TO GUIDE THE ERECTION OF FENCES, RETAINING WALLS, POOLS, PATIOS, JOB No 1'3-255 FILE No 952 F PLANTING AREAS, ADDITION TO BUILDINGS OR ANY OTHER CONSTRUCTION SURVEYED FOR THOMAS KELLY - UNAUINORI7_ED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW GUARANTEES INDICATED HERON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED. AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL SITUATED AT MATTITUCK AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION GUARPN1F.t5 ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS TOWN OF SO 'THOLD, SUFFOLK COUNTY, N.Y. OR SUBSEQUENT OWNERS COPIES OF MIS SURVEY MAP NOT B + ,`(;+TIE "bi' t VEYOR'S INKED SEAL OR ' SCALE 1" = 50' DATE I0-7-2013 EMBOSSED SEAL SHALL NOT BE c ERET7' TO BE' 4'AV. >9 UE COPY • FILED MAP No DATE CERTIFIED ONI. Tf ie � �� _.. ' �` TAX MAP No (REF ONLY) 1000-107-1-13 DISK 2013 . i Li. ��,I 1 , L HAROLD F TRANCHON JR. P.0v :j- aL LAND SURVEYOR . e,,-,' 4t, C� •.�, , , P 0, BOX 616 4,,;e_,4,, (;1• a,zLr ' - .;,et:" .'=K�';"hgl,,:: 1866 WADING RIVER-MANOR RD. WADING RIVER, • -�,; L ;f° 1„, 7�,1,, NEW YORK, 11792 . ""°'.,.."„' N.Y. LIC No. 048992 . 631-929-4-695 HAROLD F TRANCHON JR PENN. LIC No 2,115--E ' . LOT AREA -= 78,823 SO ,FT - 1 81 acres • • Gj r,Q) , �p '`` ffaggmry . 4:9 '><I`2 bQ FD 4Q MON - ,,i r. �pgof flogging - t O'‘,\ + ,i-MP0 . ,cop 1,,,,,, 0c edging , oR q flagging ll' .- - D FLAGGING LABELED A thru I �T 71OAL WETLANDS AS (LAGGED ay -13 nOgging' THOMAS W. CRAMER, ASIA ON OCT 4 2013 a _ 1 C 417' nagging --/. . Ragging w I s--- _z_ G flogging note connect I TO 8, t,dol and Iractnrater 1 wetlands mr m •I �� ..ryoggmg \flo9I di ng ,FLAGGING LABELED I thru-8 a N FRESHWATER WETLANDS AS FLAGGED BY J THOMAS'Y! CRAMER, ASIA ON OCT 4 2013 l 0 0 y`` eep I504 (�e 1 u x o 0o W1 ►� NRac� o z �naggeng �E,AGN1 �,� 72'25'20"E 115.00' Ln1 \ . �/ ' e 1 MT N\MON N ,71 70 {noggin) �: cont retaining wall ', 3 o \' K ! �'S w raised wd platform N 0 3'S G) CO Frl / with AC units V, - 77 \'‘ ,-....6.- ,, ! /rfe-yV2:-,'S c u_ 4'x20', 2 2'5 CD�0 ' . Z /fogging / Yc�---�'�716� M FPE Irl � ,sj',n 1 32.0' v 13.0.7 nag3ng I ,,, c po h,..4 O R. is ,, CO Jl �w covered O_ 1 . '",-1 \ g \.,q_. / 'I,S;sfy'"r.-'CF m 2 2 STY FR n). Porch O 1 ' i DWELL O 91 9I OVII06 PR�}I N� s __ — 21.0' \3 ,FoR A-` New 1 impe9 V1OUS t3 Iz 7' CAR l \ \ ' ' '',''Lerma 6R6A5 _ -. `I w,,d to Sd,Oa .6/ , !'`24,3. ' 4• °Euh `N%f J ` '� _ ' 9 Fog Stag 5' �lr \ \ I SI"4l'W I /7 I - °�r a/ �°-`'c4�''s \to , -T--- �;_ _� J R / / N ( I io \o • aaU s �,_ O\ J „ ON. __ .... _... ...,_. ._ -- _... _. _ -\,O - PIPE sD MON ,....iC1'‘' S 72'25'20"W 342 64' v AGI NOW_OR FORMERLY NOW OR FORMERLY o_ CONLON STEVENSON N a 0 O v . WICI<RAM AVENUE , (ELLSWORTH TUTHILL -ROAD) THE OFFSETS (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE . PROPERTY ONES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT JOB No 13-255 FILE No 952 F INTENDED TO GUIDE THE ERECTION OF FENCES, RETNHING WALLS, POOLS. PATIOS. PLANTING AREAS, ADDITION'TO BUILDINGS OR ANY OTHER CONSTRUCTION SURVEYED ,FOR THOMAS KELLY -UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION .7209 OF THE NEW YORK STATE EDUCATION LAW GUARANTEES INDICATED HERON SHALL RUN ONLY TO THE PERSON FOR WHOM THE ' SURVEY IS PREPARED. AND ON HIS BEHALF TO,THE TITLE COMPANY, GOVERNMENTAL SITUATED AT MATTITUCK ' AGENCY AND LENDING INSTITUTION LISTED HEREON. AND TO THE ASSIGNEES OF DIE LENDING INSTITUTION- GUARANTEES ARE NO1 TRANSFERABLE TO ADDmONAL INsmu110NS TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y OR SUBSEQUENT OWNERS COPIES OF TIES SURVEY MAP NOT B,y."�L RiE,ei,f' I; -YOR'S INKED SEAL OR SCALE 1” = 50' DATE 10-7-2013 EMBOSSED SEAL SHALL NOT 8E . D1TO T li VfirUI's'tiCRUE COPY. ' ' r'''s t$d14 e 1,f- t. f-• . FILED MAP No DATE CERTIFIED 0Nf' T.J<)'1 ao �`' TAX MAP No (REF 'ONLY) 1000-107-4-13 , DISK 2013 �f a •C '• # 1 HAROLD-F. TRANCHON JR. P,C r:31:d"1`-' j u,-Le 41 LAND SURVEYOR ? A" � ` S- / P-0 BOX 616 a -d�� '''- * 1866 WADING RIVER-MANOR RD. WADING RIVER, '' �r "'}` ''* NEW YORK, 11792 HAROLD F TRANCHON JR .^.I-nPE N.Y. LICCNo.0218159 E . 631-7929-4695 . . .. • . __, , — • ,.,:-..f...;•,t,i:,.•-.__,-. : -_ .. -2-- -,-, : ..".;:'4.0.',2--: .-, ...:-...- ---2,- ,,,..-,,:,--_;•• , :. • „- - ,-.- , _. - - -_-•,..,, ;. ---..-_,: :::-.H, . .. _ STATE OF NEW YORK WORKERS' COMPENSATION BOARD , CERTWICATE OF NYS WORKERS'-COMPENSATION INSURANCE COVERAGE la.LegalName.and Address'of Insure4Use Street Address Only) lb.Business Telephone Number_ofInsiired 6311-744-8100 Fence King of Rocky Point, Inc. DBA; StVim King Pools & Patio$ 1p.NYST:Inipl,byt.6ntIfturancelnaployer 471 'Route 25A ne Registration Number of Insured . Rocky Point, NY 14788 14.Federal EmployerldentifibatienNurnber of Insured. or.Social Security Number Work Location-of Insured:(Qnly_r*uir'ed 17.cov8r4gels-spee,ifipiiily 11.3008276. iimitect to qertafn,16:c-alibYlkinNdw YokState,i.e;a-;Wrap-Up Polley). . , • 2.-Name and AdclreS§,of the Entity Reques'dkik-prbrif-of Coverage SU-..Naltie-pf Insurance Carrier , '(FAiti4.BeinigtiSted as-the-CeritifieUte quitler) ---.•kb, ,,,,,,,Ardgitifjs.,1-161,:ti4, , , :„,,• ..,—,..,..„...,....„.....,,,,,,a-i,,,t,,,,,,,s4,,t,:•„•.,,ix,. -1.13.i• kifdiey Nil mberof_entifilistedlii box;"la": Toviin:of 8outhold WW0068161 ' 53095 Route 25 ' 3c. P'oliey-.effediyeperiat PO eigx 1179 f9//12dfaio•-9/1/k14 ' SouthOld, NY 11971 ; 3.4,-The Proprietor,.Ea:titer§or pzeeutive•Offiters are: , ,included (Only chec104,if-all pa-in ersioifims-iiic,104 11 excluded or-certain partners/officers'exelnde& . . • ThiS,ceilitiesihnt-the insurance carrier indicated in "3'insfires tAe•busiuess:,riferenced above-ire'bo5"`la"for workers'compensation 1 • - tinder the New York State Workers'Compensation Law. (To use this l'orn.li,New'York(NY)ranstibe,-.1tste4 under Item SA on the ' INF',ORIC4A,TIONTAGE-oftheiWorkers compensation insurance p'plie,y)- Theinsurance,Carrkr-Or its licensed ogent,wiltseod this ' 'Certificateof Insurancoto the:entity_li,sted above-.as--the certific ate,'holder in h:ox'4-2' I The Insurance Carrier will also natify'the-above•certipcath hO14rWithin 10days1F-asollex Is can'o1444e•to-nonpayntent,ofpreiniiitith,or within 30 days IF,thel.e-are-reapns-atiler than•nonpayment-ofpreiniants'ihotzatzeetihe poliex-or<eliminate the,. insuredfrom,,the cOPerage, indicated on-this Certificate. (These,nolices,may be-sentlyregillizr ntail) -Otherwise, this:Cell:We*iS,:ktiidfof one year after'111 is form is approvedby_th e•insurance carriear-itsqleensed agent, or-ungthe'iptilf0 expiratioirdatelisted in-b*l'jci"-; Whtc-hever-is-rearber. ' Please,Note11powthe cancellation 61'.theiVorker '..conopensation pnlicyindicated on thislOrin,.if the bttginess continues to he named • on a-perniit„Alcense or contract issiled,hy•a certificate holder,th _bifginOs Must provide that crtiflcateliolder•With:a new Certificate of Workers' Compensation CO:VerateOr other authorized proof that p*ilicsittegg_is,comPlYlitg-with-0e-'inandakory-coverage requiiremettivoitheNew YorkState Workers'Compensation Lc. Under pennity' of perjury,reertiffthiat lain-an-authorized representative or licensed agent of-the inturaitce-carrierreferenced,aboVe and that the named insured,hakthe coverage as depicted off,this-loran.. Appro-vedlay:.. Leanne 1,-hie _ . :(P Iiit,nanle:of authorizectrepresenlatiiie-Oilieetfsedagent of insurance:barrier): .Certified'by 916/2013 (Signature) " (Date)- Title:- Audlorized RepreSPIltatiV-0 _ ., „ ._ . . . .. _ Telephohe-Number of authoridarepresentative-or licenSedegeinkotinstrance carrier:8,77-5-28-78•78 Pleg.:e Natef6nlyinsurane0 carriers and their lieensecl-agentsAre]-an10 thorizedt6 issue the,C- 5:2!Orin. i snsitranee'brokers are NOT ' outlibriled to issue:it. C-105%2'047) STATE OF NEWYORK 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 la.Legal N am e and Address of Insured (U se street address only) lb.Business T elephone N umber of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS & PATIOS 1c.NYS U nemployment I nsurance Employer Registration 471 ROUTE 25A N umber of Insured ROCKY POINT, NY 11778 ld.Federal Employer Identification N umber of Insured orSodal Security Number 113008276 2.N am e and Address of the Entity requesting Proof of Coverage 3a.N ame of Insurance Carrier (Entity being listed as the Certificate H older) The First Rehabilitation Life Insurance Town of Southold Company of America 3b.Policy N umber of Entity listed in box"la": 53095 Route 25 DBL37154 PO Box 1179 3c.Policy effective period: Southold, NY 11971 02/01/2013 to 01/31/2014 4 Policy covers: a. Z All of the employer's employees eligible under the N ew York Disability Benefits L aw b.J Only the following dans or dasses of the employer's employees: Under penalty of perjury,I certify that) 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. DateSigned 2/11/2013 By /4a i (Signature of insurance carrier's authorized representative or N YS Licensed Insurance A gent of that i nsurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer I M PO RT A N T:I f box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or N YS Licensed Insurance A gent of that carrier,this certificate isCOMPLETE.Mail it directly to the certificate holder. If box"4b"i s checked,this certifi cate is N 0 T COMPLETE for the purposes of Section 220,Subd.8 of the D i sabi li ty Benefits Law. I t must be mailed for completion to the Worker's Compensation Board,D B Plans A cceptance Unit,20 Park Street,Albany,N Y 12207. PART 2 To be completed by NYS Vllbrker's Compensation Board (Only if box "43" of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by the N YS Worker's Compensation Board,the above-named employer has complied with the N YS Disability Benefits Law with respect to all of hi sih er employees. D ate Signed By (Signature of N YS Worker's Compensation Board Employee) TelephoneNumber Title Please N ote:Only insurance carriers licensed to w ri to N Y S Disability Benefits insurance policies and NYS L i cen sed Insurance A gents of those insurance carriers are authorized to issue Form D B-1207.I n su ran ce brokers are N 0 T authorized to issue this form. DB-12:M(50) 10" 41'-8" 3'-6" / 40' / / CHECK VALVE c.11 / // ' .— O // 10' O FROM SKIMMER 0 PUMP iROO-© .� CO 0 I� \TDO RYWELLSAV • U /1 ����--7777 'oJ \ DIVERTERJ O Z O Z VALVE 16' / 12' / 8' ;IIIIlI ;;:\\ 4 L¢n 0 DEEP WATER RETURNS 0 CO FILTER N Q. b hi N r N N O 1-- , z00 /' 3'-4"H2O 7'-6"H2O L/1cc eL )'IP Q ME d / TO RETURNS \ \ -S ), , ., .1 'OHECK VALVE.-..-..----•-•-•'.......'---........' // ,...ig Q. CAST-IN-PLACE 10- 0 �� s,,,,,.` r CONC. STEPS r PLAN li E PLUMBING SCHEMATIC ° e 20 X 40 REC 12X16 RE L SCALE:1/8"=1-0" in NW Ayr ' ✓ Y '1' '�.�ll�Sr.H �I;'l �� ���9'V7 1I 16' P.01„r?',,,:..., 1 111: .-`,.lis i1;;t1 17'-s" NOTES47,4 s��� �„ �� tia o O COPING AND WALKWAY 1 ALL CONSTRUCTION IS TO BE IN ACCORDANCE WITH THE RESIDENTIAL CODE.OF EW j YORK STATE-2010 AND THE ANSIMSPI-5-03 STANDARDS FOR RESIDENTIAL INGROUND O SWIMMING POOLS FOR A TYPE II POOL J \Q (BY OTHERS) / 10„ / 0 8 2 STRUCTURE IS DESIGNED FOR USE BELOW GRADE AND ONLY IN AREAS WHERE THE WATER LINE — GROUND WATER TABLE IS A MINIMUM OF 4'-8"BELOW THE PROPOSED FINISHED GRADE. 0 Q) 3. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS DO NOT ALLOW THE HEIGHT U -_ WALLS AND STEPS O GRAD OF BACKFILL TO EXCEED THE HEIGHT OF THE WATER IN THE POOL BY MORE THAN 8", OR TH w r. k;it 8 L/ ^,/\ WATER TO EXCEED BACKFILL BY MORE THAN 8" �, ,4„., �y ` �1��/ ROLLED FOAM BETWEEN �t ' ,���� 4. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEPOSIT AND COMPACT• O M ��\\\�� M `� LINER AND CONCRETE i� ° �\ CLEAN BACKFILL 0 �� • .�, x, ,,„� ' FORM TIES �� 5. WALKS TO BE SMOOTH,NON SKID TYPE,SLOPED AWAY FROM POOL a /\\ ` n. ' 3500 PSI POURED CONC. ” ° � k' 6. WATER DISPOSAL SHALL BE LIMITED TO OWNERS PROPERTY IN ACCORDANCE WITH 2"to 4"SAND BOTTOM \---NC21-' // En LOCAL REGULATIONS. 2"RETURN LINE /\/ �\ 7. PROPERTY OWNER IS RESPONSIBLE TO INSTALL PERMANENT FENCE AROUND POOL IN w VINYL LINER ACCORDANCE WITH THE NYS BUILDING CODE,APPENDIX G,SECTION AG105. PERMANENT SECTION A � Z TOP OF WALL 4 /" ENCLOSURE CONSTRUCTION.USTE COMPLETED WITHIN NINETY DAYS AFTER THE DATE OF COMMENCEME Z K1 Z s. WATER LINE \ 2"TO 4"SAND aQ \//� 0 U w Z in o \ �` > 8. THERE IS NO MAIN DRAIN IN THIS POOL. SUCTION FOR POOL WATER CIRCULATION IS W Q 0 N PROVIDED BY THE SKIMMERS ONLY THIS MEETS REQUIREMENTS OF RC-SECTION AG106 Z F-- eL I nu. 4' VARIES 4' Ir��ie= io //,\,,y�` �• \\:>/ �. w _IL� ! ✓ ✓ s IwI � � �/ ��������/�/ , FOR ENTRAPMENT PROTECTION. I_ M • ip .it, • � \ � � � � � � � �/ 9. THIS POOL SHALL BE EQUIPPED WITH AN APPROVED POOL ALARM WHICH IS CLASSIFIED O U W W �-' ��` ��` ��`/��`��' �� �� �� �� �� �� BY UNDERWITERS LABORATORY,INC TO REFERENCE STANDARD ASTM 2208 ENTITLED Qca .Mp "STANDARD SPECIFICATION FOR POOL ALARMS,"AS ADOPTEDIN 2008. Q /'. . 10. A TEMPORARY ENCLOSURE,OR 4 FT FENCE SHALL BE INSTALLED AND REMAIN IN PLACE t"--a. \ \ THROUGHOUT THE PERIOD OF CONSTRUCTION OF THE SWIMMING POOL, OR UNTIL THE COMPLETION OF A PERMANENT ENCLOSURE SECTION B WALL SECTION 11-20-2013