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HomeMy WebLinkAbout40541-Z ���OgtlFFO1,fCOG Town of Southold 9/12/2016 o - P.O.Box 1179 53095 Main Rd og,�jD� �ao� Southold,New York 11971 CERTIFICATE OF OCCUPANCY r No: 38508 Date: 9/12/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 580 Gus Dr., East Marion, East Marion SCTM#: 473889 Sec/Block/Lot: 38.-7-10.15 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/11/2016 pursuant to which Building Permit No. 40541 dated 3/18/2016 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, FENCED TO CODE, AS APPLIED FOR The certificate is issued to Barnes II,Tyrone of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 40541 07/13/2016 PLUMBERS CERTIFICATION DATED , Autho ' ed Signatu Fa4e, TOWN OF SOUTHOLD BUILDING DEPARTMENT y a 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#: 40541 Date: 3/18/2016 Permission is hereby granted to: Wiederman, Patricia 580 Gus Dr East Marion, NY 11939 To: construct accessory in-ground swimming pool as applied for. At premises located at: 580 Gus Dr., East Marion SCTM # 473889 Sec/Block/Lot# 38.-7-10.15 Pursuant to application dated 3/11/2016 and approved by the Building Inspector. To expire on 9/17/2017. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 it in ector 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 I%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,buildingand*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. 5lq-/f New Construction: Old or Pre-existing Building: (check one) Location of Property: 5W by-ll/, M,,�ht C)�j House No. Street Hamlet Owner or Owners of Property: LWo\oA &RNeS Suffolk County Tax Map No 1000, Section Block r] Lot Subdivision Filed Map. Lot: oar/ Permit No. w q j Date of Permit. Applicant: Health Dept.,Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) � Fee Submitted: $ .2L— tApplicant Signature soUry®� Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 ® roger.riche rtRtown.southoId.ny.us Southold,NY 11971-0959 ,onuffN,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To Wiederman Address: 580 Gus Drive City: East Marion St: New York Zip: 11939 Building Permit#. 40541 Section: 38 Block- 7 Lot. 10.15 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: USI Electric License No: 2240-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 1 Ceding 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 2 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures TVSS Ll Other Equipment: Inground Swimming Pool to Include; Bonding, 1- Control Panel, 2-GFCI Circuit Breakers,1-Salt Generator, 1-Pool Heater,1-Pool Light. Notes Inspector Signature: Date: July 13, 2016 z Electrical 81 Compliance Form.xls rjf s 0 cou 40 TOWN OFSOUTHOLD BUILDINGDEPT. 765-1802 INSPECTION I FOUNDATION 1 ST ROUGH PLUMBING FOUNDATION 2ND INSULATION FRAMING /STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAULKING REMARKS: 7 DATE INSPECTOR *OF SOUIyo l# 40 TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLDG. [ ] FOUNDATION 2ND [ ] INS LATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: dV ` aeop Lool or DATE INSPECTOR s q r �O���E SOpTyolo i� cOUNi`I,N TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [vj--�FINAL(Xe-) [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: Q� C. © - o a G� - DATE / � INSPECTOR Thomas D. Reilly P.E. Consulting Engineer 'For every house is built by sarraxxte,but the budder of an#*W is God" Hebrews 3.4 4 Bezel Lane Smithtown,N.Y.11787 Tel:(631)724-7888 Fax:(631)7145740 ENGINEERING DEPARTMENT TOWN OF SOUTOLD 53095 MAIN ROAD D P.O. BOX 1179 SOUTOLD, NY 11971 V SEP 1 0 2016 August 2, 2016 BUMDING DEff. TOWN OF sOUTHOLD PERMIT#40541 To Whom It May Concern: Re: Alexandria &Tyrone Barnes 580 Gus Drive East Marion, NY 11939 This is to certify that the installation of the subject swimming pool was built in compliance with New York State code & to the manufacture's standards. The poured concrete walls are 10" thick and have 3 rows of # 4 rods, of rebar. Very Truly Yours, /4 0 N E L11LU THOMAS D. REILLY, P.E. ti`' s¢` 043595 QA�'t1FESS����� r: r t • : O •� ,, r • 1 r. u 1 STATE ENERGY • r WMA Mon r - n TOWN OF SOUTROLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 3 sets of Building Plans TEL: 765-1502Z- Surve O: Q I y PERMIT N 4&5 Check Septic Form N.Y.S.D.E.C. Trustees Examined ,20 Contact: pp Approved e 20 MAR I 1 816 Disapproved a/c l� l ^ 2 4-7 P 9 r- V.DMG DEM Phone: TOWN OF sovffl i Buildin s or APPLICATION FOR BUILDING PERMIT Date 15b , 20 r INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas, and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupancy is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County,New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances,building code,housing code,an gulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature o plicant or e,if a corporation) q2q 01-- (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder W tC K_ Name of owner of premises (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer). -/ -T-- Builders License No. 174- Plumbers License No. ao— nn Electricians License No. 7 V Other Trade's License No. 1. Location of land on which roposed work will be done: 5-M Xji0S t c -e_, House Number Street Hain et" County Tax Map No. 1000 Section J0 Block / Lot „ /01 S Subdivision Filed Map No'. Lot �? (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ^18eAf6-2-1 b. Intended use and occupancy 4610QAIAU �h IMmlNJ POO(- 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work-3i jgr,3jmo VinyL Sw,mn,„✓g AQ � w (Description) 4. Estimated Cost �`'!�VV�J` f s 7111 (to, aid on filing this application) 5. If dwelling, number of dwelling units IWON o�d��tw��.1 urii'ts on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify 4466k.i�and*&ienf-of ach 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. 'Omensions of entire new construction: Front I(a ' X 32' Rear f_ —' Depth Height Number of Stories 9. Size of lot: Front 17S' Rear l�3 Depth Z� 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: �U 13. Will lot be re-graded Q�?< LOA- Will excess fill be removed from premises: YES NO 14. Names of Owner of premises flAkKakoz(A- 6A-,f-&1Z& Address �(�s p2 E, � Phone No. qO$-241 Mt -SZ�'78 Name of A `PX3)- � Re-k Q4� Address 4 &zeL- LJ S 4-,kV.hone Nc631-7z4-�7$e¢ Name of ContractorFoos Pax Address R2cr & 2T/A- H111-ILP. Phone No. 6 1-7414--118V 15. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE QUIRED 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 : S COUNTY OF 6A�CU C &�� duly sworn, deposes and says that(s)he is the applicant (Name of individual sigAing contract) above named, (S)He is the (:� �- (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief, and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this day of —201(o 0- of Public Signature of Appli t MARGARE r A. KIDNEY Notary Public-State of New York No. 01 K16021 1 11 Qualified in Suffolk County My Commission Expires March 8,20A Scott A. Russell °S� '�1b, S`]F0]KMWA,` F1E1R. SUPERVISOR AMIAN � r �T Z A\G]El��l[1E1�T SOUTHOLD TOWN HALL-P.O.Boz 1179 0 53095 Main Road-SOUTHOLD,NEWYORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) I , DOES TIES IPROUIECr INVOLVE ANS' OF TM FO)<LOWIN&. Yes No (CHECK ALL THAT APPLY) A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surf ace. ❑ B. Excavation or f illing involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑Ef c. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. ❑ ffD. Site preparation within 100 feet'of wetlands, beach, bluff or coastal erosion hazard area. Elff E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑[.7f 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 District NAME: Ay aNlpe oN w 5 3M)(o Section Block Lot mgmmrd ****FOR BUILDING DEPARTMENT USE ONLY Contact Information _ '7VL2%_5D% (Telephone Numbed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Reviewed By: j4 01 A Y:� Property Address/Location of Construction Work: Date: lI0 Date: , V us ��UP Approved for processing Building Permit. Stormwater Management Control Plan Not Required. E. Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 pf SO�r�Q! . � o Town Hall Annex Telephone(631)765-1802 54375 Main Road N (631)765- 5 P.O.Box 1179 • yQ roger.rlchertrC:eown.soutg'oilA.ny.us Southold,NY 11971-0959 Q I�cOUNi`I,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name: Name: License No.: Address: pi lAS16 Ro �Inl S Pte:. Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: A Leitrut"+ es *Address: 6 U &Ve- Phe .rtl *Cross Street: LN *Phone No.: TO Permit No.: Tax Map District: 1000 Section: Block: Lot: 10Jr *BRIEF DESCRIPTION OF WORK(Please Print Clearly) ' gyp.-�P�� 3Z P /1 (Please Circle All That Apply) *Is job 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 *i`.e'vii Service. Re-cot nec1 Under gr oui d Number of Meters Change of Service Overhead 4 j Additional Information: PAYMENT DUE WITH APPLICATION 2 7A 7101 82-Request for Inspection Fomi �I 1111111t11'TI(�Ilf iflI?II�IIIIItIRIIT11111E+IIi11Hll�ll,!Ilio"I�1''" '-'�'" "„�'0' r t ,' rI , rye ' ^� , ,. Y � N* • - n 1 fw Again I, 2 �1Alm W w i - .. _ • -jai_ 3 Y Alt ♦ Iwo I` J „y J '+1 Y Ilk 3 lw 5 7 ..... ICY F _ '4 f t i Y ! V4 + t� s i appreciate your help, Ty Ty Barnes 908.296.5078 ARTHUR EDWARDS POOL & SPA CENTRE 929 ROUTE 25A MILLER PLACE, NY 11764 516-744-7185 - FAX-744-0174 APPLICATION FOR A SWIMMING POOL PERMIT: SOUTHOLD TOWN OF SOUTHOLD MAIN ROAD (P.O. BOX 1179) SOUTHOLD, NY 11971 (631) 765-1802 PAPERS ENCLOSED: APPLICATION FOR OUTDOOR POOL PERMIT EROSION SEDIMENTATION &WATER RUN ASSESSMENT FORM [� CERTIFICATE OF WORKER'S COMPENSATION CERTIFICATE OF DISABILITY INSURANCE [� SUFFOLK COUNTY LICENSE SUFFOLK COUNTY PLUMBER LICENSE [� SUFFOLK COUNTY ELECTRICIAN LICENSE 4 SETS OF PLANS - (3 STAMPED) [ j 3 SURVEYS APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK APPLICATION FOR CERTIFICATE OF OCCUPANCY [ ] C.O. [ ] TAX BILL $300.00 CHECK FOR PERMIT FEE Pontino, Susan From: Ty Barnes H <tybarnes99@gmail.com> Sent: Monday,July 11, 2016 3:20 PM To: Pontino, Susan; Dria de Botton Barnes;Ty Barnes II Subject: 580 Gus Drive E Marion Pool Electric Inspection Hi Susan, Thank you for your help earlier when you answered my questions about our pool inspection this Wed 7/13. Attached please find the pictures of the electric work that was completed by our licensed electrician last week for our pool. I had to modify my work schedule and will not be able to get back on the island for the inspection on Wednesday, but provide permission for the inspector to enter and validate the work performed. Our electric panel is in the basement of the house and I will leave the front door open. i %-X1U11L ILC U1 1V 1 J VV U1RC1J k.V111Pr,11bdL1V11111JU1d11L:C k.VVC1agv STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF NO'S WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Arthur J Edwards Mason Contracting Company Inc 631-744-7185 929 Route 25A Miller Place,NY 11764 lc.NYS Unemployment Insurance Employer Registration Number of Insured DBA:Arthur Edwards Pool&Spa Centre Id.Federal Employer Indentification Number of Insured or Social Security Number 112377925 Work Location of Insured(Only required if coverage is specifically limited to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Town of Southold Town Hall 3b.Policy Number of entity listed in box"la": P O.Box 728 RWC3405186 Southold,NY 11971 3c.Policy effective period: 3/1/2016 to 3/1/2017 3d.The Proprietor,Partners or Executive Officers are: ❑included(Only check box if all partners/officers included) ®all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"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 Certification of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also not fy the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c';whichever is earlier. Please Note:Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By Henry C.Sibley (Print name of authonzed representative or licensed agent of insurance carver) ,�� '). Approved By . titl 3/2/2016 (Signature) (Date) Title. Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance cameo CamerPhone Please Note Only insurance carriers and their licensed agents are authorized to issue the C-105 2 form Insurance brokers are NOT authorized to issue it C-105.2(9-07) https://ao.amtrustgroup.com/anawc/PolicyNYCertificateOfWcIns.aspx?IndexId=-1&Instanc... 3/2/2016 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 la. Legal Name and Address of Insured (use street address only) 1b. Business Telephone Number of Insured ARTHUR J EDWARDS MASON CONTRACTING MILLER PLACE COMPANY INC 1c. NYS Unemployment Insurance Employer Registration 929 ROUTE 25A Number of Insured MILLER PLACE NY 11764-2700 2410871 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"1a": P.O. BOX 728 00984424-0000 SOUTHOLD, NY 11971 3c. Policy effective period:, 07/01/2015 to 07/01/2016 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: 07/07/2015 By: Lko."t 4 w Stuart J. Shaw, FSA, MAAA Telephone Number: 1-888-278-4542 Title: Vice President, Group Insurance IMPORTANT: If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.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,DB Plans Acceptance Unit, 20 Park Street,Albany,New York 12207. PART 2. To be completed by NYS Workers' Compensation Board(Only if box"4b"of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed: By: (Signature of NYS Workers'Compensation Board Employee) Telephone Number: Title: Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5/06) „✓'.f^”. �„`,�.,_., ..�;.?;t`:u,,,, "';:`;�°,,. �'` ,�N. ;.find ,1' 's5� M ..,Y' s �•X . '1i /! .' r D'; ;. y�'3?i:, r i'3:ic �'`:St�� 'r�,5ti�.•'.r°..4.$�•����•t-'.t-.. wa -t r ° 'vG '.. �'ty..w:.. �Y. >'d.`i'•ss�"..._1'`-'�'�-..;/�+�..e�Y�;.`1.r.�.;,,,.J.i`' C'�ir.�Lv, 'v�L�•"��1�s" f�R •.�iy�c �'�l ..ba_ �� f +t..p i,, a r-`ti-. z •':- V s>'.S.�S�sL::u:'b?'<�'�),{;:{S�>•a'�'.itd'isG{`.^,i :5.:.�^.+.,S.r"�n�s»X^�2£_>".,+.6i2tYr,_' ��.hiX6kd&i`v'�'rS5i1::°✓�.�8'�•J•.'+Ts'P.3.. S3.t�;td-�. 4ffiT.S."XL. «sfi�oQL4�'�£l Al6t: k4'�...�.�D3"R. sr :,5,' Suffolk County De"artment of Labor, Licensing & J a a Gyk ' Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE NEW YORK 11788 DATE ISSUED: 7/1/1978 No. 4436-H r r-r SUFFOLK COUNTY Horne Improvement Contractor License ' t y \at, �s a•.r This is to certify that ARTHUR J EDWARDS r � doing business as ; >� ARTHUR J EDWARDS MASON CONTRACTING CO INC DBA having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules ,� •' and regulations of the County of Suffolk, State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. i El s ` SUFFOLK COUNTY DEPT OF LABOR, License Category i Z B` Cw: LICENSING B.CONSUMER AFFAIRS }~ GCwv a- , HOME IMPROVEMENT Additional Businesses CONTRACTOR Pools&Spas/Certified J €, LICENSEARTHUR J EDWARDS MASON, Pools/Spas Y WVaE ARTHUR J EDWARDS CONTRACTING CO INC DBA ' ~.=,:'- ARTHUR EDWARDS POOL&SPA y This certifies that the, 111155"E"NAGE CENTRE ; 1 ARTHUR J EDWARDS MASON bearer Is duly CONTRACTING CO INC DBA licensed by the COunCommissioner OtSUff01k u�«,.rxmn.. oK.u.�.a iy tYs = 4436-H 07/01/1978 co,�n..ro..r I E%PIMTON DATE 07/01/2016 ...ri* Swam` ...�'•� ..,;>�r?-.�u�r's",.. Q�'�',P C�q�+�-,S�'��,.,ar.. �r.� .:C:.-"r' A 4 i�N^ t�,•w. '� � �� la'=,�1, - ��� a�r���r .3 '.�%'7 '+ �. a jai (•��a•- L„-=:y-.,."-,'�,r�;�t'ts� �d .�'S4-fie , �r 4` ;M� •i'4 , C -~/ �:c ti 5;�•:�^3''r� ��...��xh.:'��''a'- 'K•,� ��„�t,'�'...:i7S Vii,., - A r, ate, i �k�a�,�}�tJi^,� ....�.1`•a�i,,�jt' ,/'� =r�ilr= �:sci� - .:a, `t,-a ARTHU-1 OP ID:VM ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) t� 01121/2016 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CON PRODUCER NAME Bagatta Associates,Inc. Ba atta Associates,Inc. PHONE 631-864-1111 W.No): 631-864-8274 823 W Jericho Turnpike Ste 1A C No E Smithtown, NY 11787 ADDRESS: Bagatta Associates,Inc. INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Worcester Insurance Company 26182 INSURED Arthur Edwards Mason INSURER B:Rochdale Insurance Company 12491 Contracting,Company Inc.DBA Arthur Edwards Pool& INSURER C: Spa Centre INSURER D: Arthur J.Edwards 929 Route 25A INSURERE: Miller Place NY 11764 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. iLTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMlDD1WYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEIT_ CLAIMS-MADE N OCCUR MPA00000038801 H 01/01/2016 01/01/2017 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 X BLANKET ADDITIONA PERSONAL&ADV INJURY $ 1,000,00 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY ❑JECT LOC OTHER $ AUTOMOBILE LIABILITY Ea acccldentED SINGLE LIMIT $ 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 LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY AND ER B ANY PROPRIETORIPARTNERE)EECUTIVE YIN RWC3363984 03101/2015 0310112016 E L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? F� NIA 1,000,000 (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached I more space Is required) CERTIFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold Town Hall AUTHORIZED REPRESENTATIVE P.O. Box 728 Southold, NY 11971 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD S.C.T•M. NO. DISTRICT: 1000 SECTION: 38 BLOCK: 07 LOT(S): 10.15 - 1 1 \ � 5 SEs SeCS\ON 23.0'N \\ OT >> OF SUMM\S E SP gPs\N zo.o'Ns" rC�F \\\ o.s'w op'? HPROE 20.O'N NcF \0.7'N 1 C\2 O X � U k 2 (Q 20.6'N 1 p + lit Y ❑ lv�oo 1 V' L o S �. 0.3'E SHED•w 1 3' 7.7' 00 3 VI qYL PICKET Co ❑ ci d� LOT 27 o.7'w LOT 26 W U w Ib' PQo���o FemeQ LOT 28 I� PRS Cam 2s o , STONE DRIVEWAY L_ STORAGE WOOD BELG. BLK. CURB STEPS �s' BRICK WALK WOOD STEPS . 50.0 - - - 63.9' O.TW - 0.1'E ❑ ,, 6' VINYL FENCE ❑ 6' VINYL FENCE c ❑ -k2 STY FRM.: c p � e'2 CAR GARAGE DWELLING , W o� #580 5.5' CO 415 �� 21.2' N_ • 17.4' 44.4' LO JQ0 JJ••7.5 CgVEREiD 37.8' 4 0 G PORCH O BRICK WALK CrJ LO 0 _ o \\3r MON. R=860.00 "P111,0" �•8 L--95.00' S �\��0. 0o'MDN. W.M. R=860.00' GUS DRIVE THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. AREA: 30,466.3 S.F. OR 0.70 ACRES ELEVATION DATUM: _________________________ UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. 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, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE STRUEfURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY SURVEY OF: LOT 27 CERTIFIED TO: TYRONE BARNES; MAP OF: SUMMIT ESTATES SECTION 3 FIDELITY NATIONAL TITLE INS. SERVICES, LLC; FLED: MAY 21, 2002 AS #10769 WELLS FARGO HOME MORTGAGE; SITUATED AT: EAST MARION TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK F Professional Land Surveying and Design P.O. Box 153 Aquebogue, New York 11931 FILE # 1 6 f SCALE: 1 "=30' DATE: FEB. 16 2016 PHONE (831)298-1588 FAX (631) 298 18 N.Y.S. Ll';;,. .VO. 050882 maintaining the records of Robert J. Hennessy & Ken"'—. M. Woychuk APPROVED AS NOTED DATE: 8.P.# 5 L ELECTRICAL FEE: b. , BY: INSPECTION REQUIRED NOTIFY BUILDING DEPART AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING Eo' 7'ELY" 3. INSULATION ENCLOSE,POOL TO CODE 4. FINAL - CONSTRUCTION MUST UPON COMPLETION BE COMPLETE F09 C.O. 'REf:ORE "WATER" ALL CONSTRUCTION SHALL. MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF mumotDiewlag 1mDFewv%%E_& OCCUPANCY OR USE -IS UNLAWFUL V ITHOUT CERTIFICATE OF OCCUPANCY A >Swmmww Retume B E F B /Aluminum To FRtw From J[���yJ(FWtar�Pump To Wastes —To P-ft— okY Wan SMI) Rollod WallF Plan Piping Arrangement WWI Section Vlryi Li Rebar 42" -jOF NEU!Y Section B—B 2.so asoo P.Sl oceerete ro��' 7/ �® w a ;" w ®. Section A—A Typical Wall Section ®FESs�° SIZE AB C D E F G H AREA CAP. �� � &A16FEET FP. FT. FT. FT. FP. FT. FT. FT. SQ.FT. GAL. w 16232' 16' 32' 8' 14' 6' 4' 4' 8' 512 19,000 � �� Ais 1� 16'X36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600 POOL C»E PERMACRETE WALL SYSTEM EAS' W :tat 18'X36' 18' 36' 12' 14' 6' 4' S' 8' 648 24,300 929 Route 25A Miller Place NY 11764 c'tv 20'X40' 20' 40' 16' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (631) 744-0174 00 00 2q6- �� 24'X44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk License #4436—ISI 24'X48' 24' 48' 20' 16' 8' 4' 6' 10' 900 30,000 Nassau License #H17445OOOO