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HomeMy WebLinkAbout39335-Z F04��G Town of Southold 10/17/2016 P.O.Box 1179 a - - °" 53095 Main Rd o�gy�` �o�� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38595 Date: 10/17/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 345 Clipper Dr, Southold SCTM#: 473889 Sec/Block/Lot: 79.-4-17.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 10/24/2014 pursuant to which Building Permit No. 39335 dated 10/31/2014 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: IN-GROUND SWIMMING POOL,FENCED TO CODE, AS APPLIED FOR The certificate is issued to Ghuneim,Mark of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 39335 05-06-2015 PLUMBERS CERTIFICATION DATED h ed Signature Enc TOWN OF SOUTHOLD K�QGy BUILDING DEPARTMENT TOWN CLERK'S OFFICE 2 _• 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#: 39335 Date: 10/31/2014 Permission is hereby granted to: Ghuneim, Mark 345 Clipper Dr Southold, NY 11971 To: Construction of an in-ground swimming pool as applied for. At premises located at: 345 Clipper Dr, Southold SCTM # 473669 Sec/Block/Lot# 79.-4-17.2 Pursuant to application dated 10/24/2014 and approved by the Building Inspector. To expire on 5/1/2016. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 to $300.00 Bui i Ins a r`f 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 15.00 jZ1,4f ,/Date. l New Construction: Old or Pre-existing Building: ( eck one) I (� Location of Property: ✓ 3 C �-''' 0(-kvQ- S O�T1\\ I /V- t - House No. l /Str et Hamlet Owner or Owners of Property: ✓ /y`c,,� U Yl e-,M Suffolk County Tax Map No 1000, Section Block o 4 -'Lot 1� Subdivision c� Filed Map. Lot: Permit No. —k-5 Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: ✓ (check one) Fee Submitted: $ 5_0 m 0 d Applicant Signat re pF SOUp�®� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 ® roger.riche rKED-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To- Mark Ghuneim Address: 345 Clipper Drive City: Southold St: New York Zip: 11971 Building Permit#. 39335 Section: 79 Block. 4 Lot 172 WAS EXAMINED AND FOUND TO BE.IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Doroski Electric Inc. License No: 2941-E SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1 A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches F3 Twist Lock 1 Exit Fixtures 11 TVSS Other Equipment: In Ground Swimming Pool To Include - Bonding, 2- Pool Lights, 1-GFI Circuit Breaker,1-Gas Pool Heater Notes: 1 Inspector Signature: Date: May 6, 2015 Electrical 81 Compliance Form.xls yUOUNi`1,� TOWN ,, SOUTHOLD' ILDI DEPT. 765-1802 1 N, FOUNDATION IST [ ] 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: DATE If -7 INSPECTOR q � ` ho��OF SOUTyolo coulm,��' . -TOWN OF "SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION '- 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 VIOLAI ON - [ ] CAULKING REMARKS: ,• • DATE INSPECTOR It / SOF SOUIy �o 0 TOWN OF SOUTHOLD BUILDING -DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULATION [ ] FRAMING / STRAPPING [ FINAL pobf [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: �/Y��Z, 4- �eA C kh/ -cl o "/ r_ L/ _64" ................... DATE to 1411 v INSPECTOR RQNAI_D.C. HANNA ARCHITECT - Suite 15 SEP 2 6 2016 761,CoatesAvenue Holbrook,New York 11741 UMM(G DEa". September 7,2016 TOWNOF 5U$J' "g®j,D Town,of Southold Town Niall Building Dept.- - P.O.Box 728 Southoldi NY 11971 Re:Ghuneim Residence 345 Clipper Drive Southold,NY Gentlemen: This-is to certify that t inspected the steel reinforcing for-the'swimming pool constructed at the, subject residence,and tb the best of my knowledge and professional opinion it met the requirements of the'appraved permit drawling. Ve truly yours, �� ttED a Ronald C. Hanna j t fi? "T"i" .1 Architect x oyer aei3�� 1; r t • r L. • r r. 1IMUL,ATION STATE ENERGY • r , � d OMNI . rr , • 1 t 1 4� r .Y TGVMGF SOUTHOLD BUILDING-PERMIT APPLICATION CHECKLIST BUIELDING 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 www. northfork,net/Southold/ PERMIT NO3FI`) Check Septic Form, N.Y.S.D.E.C. Trustees /1~xamined _ Contact--- ( `t Approved 20 Mail to: Disapproved a/c �' o . Expiration ;260CT 24 2014 g In a or �. vi OF SOUTHOLD APP-LICATION—FOR-BUILDINGP-ERWT-- Date., C� Z L 20 U INSTRUCT-IONS 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. chedule:b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways.- c. aterways: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 Buildirig`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 d6de.housing code,and re' tions, to admit - authorized inspectors on premises-and in building for necessary inspeciio (Signature of ap licant or name,if a corporation) Mailin address of applicant) State whether applicant is owner, lessee, agent,architect,engineer, general contractor, electrician,plumber.or builder Name of owner of premises' Ak� 0.f'oL °•-z"U h 1✓ m (As on the tax roll or latest deed) If apllicant is a corpora}on, signature o dPly authoriz office (Name and title of corporate officer) Builders T,icence•No— - r Plumbers License No. Electricians License No. ` Other Trade's License No. 1. Location of land on which proposed rk will be done:— -3, H e 0 AD6- 1 , sook\-�,A -i '/ House Number 0,Atreet Hamlet County Tax Map No. 1000 Section Block' 4 Lot 2 Subdivision filed-Ma6NI o.- Lot (Name) I 2. __Mate-existing_useand_occupanay-ofpremis,es d-intended-use occ ncy-pfproposed_construction: a. Existinguse-andoccupancy ,nCl S cJIP C� �' ; b. Intended use and occupancy RQS► 2�� a 1 S w l�r�L I^3 P�d 3. Nature of work(check which applicable):New Building Addition Alte ation Repair Removal Demolition Other Work S4- Mm inti D a f (Description) 4. Estimated Cost 66 a Fee (To be paid on filing'this app ication) 5. If dwelling;-number-of-dwelling-units- Number-af dwelling-units-on-each-floor-- Ifgarage, 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 earDeDimensions of same structure with alterations,or,additions: Front Rear- Depth pth Height Number of Stories K, 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_ ro osed—co ��tion_violate_ zonin wrordinance or regulation?-YES-_ - NO. P p ani' g1a 13.Will lot be re-graded?YES NO x 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 freshwaterwetlarid? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C.PERMITS,MAY BEREQUIRED. . b.Is this-property within 3ff0 def of-a' tidarwetland?-*YES- NO- * 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. STATE OF NEW-YORK). f S: COUNTY OFSval yll�>.. - o � ` � 6�—�``d` being-duly-sworriT deposes-arid says•that,-(s)he_is the applicant , (Name-of individual si ' g-eontract}pbove=named, (S)He is the Ca r-\ (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will,be performed in the manner set forth in the application filed therewith. Sworn to before me thi day of 20� C Notary Public Signa of Applicant- { ; LAURIE KA-HORN j NOTARY PUBLIC,STATE OF NEW,YORK „ Registration No.01KA6205483 Qualified in SUFFOLK COUNTY Commission Expires MAY 11,2017 I /a Scott A. Russell ,��°s� �� STOKA�1 WA\T]EIR� SUPERVISOR U MANAGEMENT SOUTHOLD TOWN HALL-P.O.Box 1179 %)-- 53095 Main Road-SOUTHOLD,NEW YORK ll971 Town of Southold' CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TQ BE COMPLETED BY THE APPLICANT ) DOLES THIS PROJECT INVOLVE ANY OF THE, FO]LI OWING. Yes No (CHECK ALL THAT APPLY) ❑ A. 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. ❑ C. Site preparation on slopes which exceed 10 feet vertical rise to 00 feet of horizontal distance. ❑ , D. Si preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ rF. Installation preparation within the one-hundred-year floodplain as depicted IRM Map of any watercourse. ❑ 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 Otivner, ign Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date y, n District r l 'r AA NAME: A oQAf ��� o Z Section Block Lot (6j" ****FOR BUILDING DEPARTMENT USE ONLY**** Contact Information. o 17�� G&pbon.N—bc) Reviewed By. Date: Property Address/Location of Constzuction Work: 6.-;Ap — —r k V� proved for processing Building Permit. e / Stormwater Management Control Plan Not Required. SO Y-o T 1 ® Stormwater Management Control Plan is Required (Forward to Engineering Department for Review.) FORM 4 SMCP-TOS MAY 2014 'Town Hall Annex a Telephone(631)765.1801 54375 Main Road F (631)76. 30 P.O.Box 1179 rocrer.r�chert{a7 awn.aouthotd.nyus Southold.NY 11971-0959 BUILDING DEIPARTMEYr TOWN OF SOUTHCOI D APP ]CATION FOR ELECTRICAL. INSPECTION �+ w [REQUESTED BY: �o �, a Date:ompany Name: c�os�C� e.�-��: d-D c Name: oV + - License No.: 2 9 !J 1 —4—: - Address, p G, R ,OX -Z S k " KII Phone No.: -71 c4 -7_C_Z3, JOBSITE INFORMATION: (*indicates required information) *Name: ��1 o.,rk G, U�I e-'%" _ *Address: 3 GENA rc'V, *Cross Street: _ *Phone No.: _ Permit No.. Tax Map District: 1000 Section:_ S90ek: Lot: _ *BRIEF DESCRIPTION OF WORK (Please Print Clearly) �1)elj o (Please Circle All That A 3ply) *Is job ready for inspection: YES / NO Rough Irk Final *Do you need a Temp Certificate: YES NO Temp information (if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of N1I Change of Service Overhead Additional Information: - 'TNT DiJE WITH APPLICATION 1 �'1 -� J LuIf - 82-Request for Inspection Form ` l BLDG DEPTen , TOWN Of SOUTHOLD �v� TOWN OF SOUTHOLD iPROPERTY RECORD CARD OWNER STREET:-� I VILLAGE DIST. SUB. LOT it VY-\ H eaYL,�ny FORMER OWNER N EACR. ''y pitVtvf AvmNh1reA-11U1�1f O.S�4-r 1 4 UJ-F S W TYPE OF BUILDING RES. �z to SEAS. VL. FARM comm. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS can- Or 14 770-6 '12") dkk/11,0671 d new A 6 -, -� a, lWassi' �Ps, ) 00 --7-1 06 Oq�5<A,lh/vvlv�� fh) U r"lle,�m Tillable FRONTAGE ON WATER Woodland' FRONTAGE ON ROAD Meadowland DEPTH House Plot BULKHEAD Total « SAM ,,. +�,, �a �,+�- .. �� c J4d��7 ,� . ,: t '. ■■■■■■■■■■■■■■■■ 1010 1010 i • Y • M 1010■■■■■ 1010■ MUMEM MEN ' 1010■ ®■■�■�■©��!■�■■®®®■l. 1010 1010■■■®1010■■■f■■■■�■■■■ 1010■■■,®■■■■■�■®®©®�■■■■ ■■■■■�_■_■_■_■ ����� 1010■ MEN■■■■■o■■0 NEW ONE . :MMEMM 1010■■■■■ ■MM■■ ■■■■■■■■■■■■ 1010■■■■ _ 10010■■■■■■■■MEMO■■■■. * ` ► ' . • Rooms 1st Floor SURVEY OF LOT '78 MAP OF HARBOR LIGHTS ESTATES SECTION FOUR FILE No. 7703 FILED MARCH 1, 1984 SITUATE C� BAYVIEW TOWN OF SOUTHOLD IV SUFFOLK COUNTY, NEW YORK c V� S.C. TAX No. 1000-79-04-17.2 SCALE 1"=20' MAY 20, 2014 AREA = 43,000 sq. ft. A� 0.987 CO. �? 3 ' 41 ° 3 8� .ham CERTIFIED TO v MARK GHUNEIM • ti`y ' S R 6 AND 4.OS f ° 00 i p"G 10„ �i ?S P�oY O' £ "f 6 0',Rs'p X9'0 .• ° N - IFS 4g(fR ES''• • • A'j(F pA.S�i C • J WME FENCE 517 `Fsz K Cpu"Y 4 0,°xF l' • / FCM16C c� 00, sk �� tie • •. ° • \ / / °jNC z1S \ 29♦ •°' y ca dh y V J�4 • ° OO z°^ CoQ•aY o za al • h .°� ry s Rye 4 �'� `��Q•U Q N?W� �' • �� B, � v Jti�����No r°' tip o • _,�$ �� 2Po N � J00 V oo. �} /° : • S sA� \\ `,^SAO IC \ \ N 4 64.OS1 p q •. IV \ I l • i DoTwi 4V.4, PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR 7171E SURVEYS AS ESTABLISHED HY THE LIALSAND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW YORK STATE LAND TITLE ASSOCIATION 6�� truer c `q� Nh �sS• - s1 x �' 215 `CryC�, o 00, s �4LCIF UT`' S Llc No. 50457 Nathan Taft Corwin III To SE TIO SURVEY 15 AA VIOLATION OF ON �A F l�T EDU C AT IO N�fAWTHE NEW YORK STATE sAa LandSurveyor COPIES OF THIS SURVEY MAP NOT BEARING F1((,p'2OV SG AC4 THE LAND SURVEYOR'S INKED SEAL OR r� EMBOSSED ASEAL UD TRUE SHALL NOT BE CONSIDERED PY 0"111 p9V fiS Successor To Stanley J Isoksen,Jr L S CERTIFICATIONS INDICATED HEREON SHALL RUN ppT BfCf pO 1'��,bq Joseph A Ingegno L S ONLY TO THE PERSON FOR WHOM THE SURVEY O R p1 Hf 9CrI p OF IS PREPARED,AND ON HIS BEHALF TO THE TRI,Surveys—Subd,V srorls — Slle Pions — C°nsfruch-Layout TITL COMPANY COVERHMENTAL AGENCY AND Opo C((.q NG LENDING INSTITUTION LISTED HEREON,AND PHONE(631)727-2090 Fox (631)727-1727 TUTIONTO E AS TARE NOT RE ITRANSNG FERABLE 4S 1y(fFS rORA OFFICES LOCATED AT MAILING ADDRESS THE EXISTENCE OF RIGHT OF WAYS "o !!p66 1586 Moln Rood P 0.Box 16 AND/OR EASEMENTS OF RECORD, IF 166 COU"TY Jomesporl,New York 11947 Jomesport,New York 11947 ANY, NOT SHOWN ARE NOT GUARANTEED. MATRI-1 OP ID:VM ACORN" 70TI E(MMIDDNYYY) �.� CERTIFICATE OF LIABILITY INSURANCE /1512014 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). PRODUCER CONTACT NAME: Bagatta Associates,Inc. PHONE FAX 823 W Jericho Turnpike Ste 1A A/C No Ext A/c No. Smithtown, NY 11787 E-MADDRESS: Bagatta Associates,Inc. INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:Worcester Insurance Company 26182 INSURED Matrix Development Corp INSURERB:Tower Group Companies 44300 P.O. Box 1033 INSURER C Hampton Bays, NY 11946 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 P FF POLICY EXP LIMITS LTR INS POLICY NUMBER MMIDD MMIDDffYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPA00000065795H 02/01/2014 02101/2015A AGE O R 100 000 PREMISES Ea occurrence $ , CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 X Contractual Liab. PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY J CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000 000 Ea accident $ , B ANY AUTO CAC700397702 02/0112014 02/01/2015 BODILY INJURY(Per person) $ ALL OWNEDLX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN IMITER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N!A EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Town Hall AUTHORIZED REPRESENTATIVE Southold, NY 11971 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD New York State Insurance Fund n Workers'Compensation&Disabilitt,Beiiefrts Specialists Since 1914 199 CHURCH STREET,NEW YORK,NY.10007-1100 Phone (888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112399668 MATRIX DEVELOPMENT CORP 11 WOODED LANE P 0 BOX 1033 HAMPTON BAYS NY 11946 POLICYHOLDER CERTIFICATE HOLDER i MATRIX DEVELOPMENT CORP TOWN'OF SOUTHOLD 11 WOODED LANE I BUILDING DEPARTMENT I P 0 BOX 1033 TOWN HALL HAMPTON BAYS NY 11946 i SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE—I DATE Z 639 161-9 751589 02/28/2011 TO 02/28/2015 1/25/2013 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 639161-9 UNTIL 02/28/2015, 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 02/28/2015 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. JANET BONAWANDT SECRETARY/TREASURER OF MATRIX DEVELOPMENT CORP 1 OF 2 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 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: 1002734706 U-26 3 499/CD47088-20/501 i i v ' 1 O lR.`�'•+V E j' f,,c, G•tic!Thr' --—- -- — •--• —--- = Ii � CeM eu,uA. S xt)�. _ -1 cc CA gie-v./.;N f i • -���t.lalt: ti- 4 fia c�L., c�•p�.��ry f .P,bL,YF-"yLt%Aj= >pJV/WEJ.. f;*.• ENTRAPMENT PROTECTION FOR SWIMMINGLY POOL AND SPA DUCTION OUTLETS POOL ALARM G106.1 General. Suction uutluts shall ba designed to ptu- duce circulation throughout the pool or spa.Singh;-outlet+yr• IMMEDIATELY' THIS POOL SHALL BE EQUIPPED %TM AN ALARM! SYS MM tcmr, such as automatic vacuum uluunrr systentr+,or multiple ���� r, /ta'r, s� ,,���. AS FOLLOWS: ruction outlets, whethet isolatud by valva+,or utherwiw.•hull ;; t'�:. �: . :'. � 1 C i t#D ENCLOSE POOL TO CODE M:protected agalnht user entlapmem. �2 q UPON COMPLETION 1S CAPABLE OF DECTLI.'MG A Cl11LD L7':'ERLVG I Nl: WA1'F.R � DATM: 1O1—'1 ���., Es.P•�;3-1 � BEFUR'="WATER" C1t16.1,1 (.ompllunce utterawtive. Suctiu,t ouilcta airy AND GIVING A-! Al AMB E At.AP-%i Will-..%4 i r DECrECi S A CHILD he designed and installed in accordance with ANSI/A('SP• �� 1:NTERL�iG WATER F— ENTERING - _ ..._.-. IS AUDIBLE POOLSIDE AND ATANomER LOCATION ONTHE PJOT �Y D-UILL,,!N i :;'. .F�Tt��td T AT PREMISES. V IU6.2 Suction Qttln{ts. Poul and spa ruction uuticla ,It.11 p t - have:a cover that conforms to AIv'SUASME Al 12.19.8.4v au 7� 1802 F; ,`J9 TO <i ; �1i THc '° �'ING �``� FOLL0'%N!NO IP.1Si'r=..:i IJC'.`',: IS INSTALLED, USED AND MAINrA11`if_D IN ACCORDANCE 111 inch x 2.1 inch(457mm by 594 nun)drain grutc or huger, -I. FO'JtiDATION - TVVO Ri QUi QED UNLAlNFUL WITH MANUFACTURERS INSTRUCTIONS. ur,u,sppruved channel drain system. FOR POUi'EC CC'NC-'-i7E � P �-ICUT CERTIFICATE IS CLASSIFIED BY UNDERWRFIF-RS LABORA 17011Y, INC. Exceptlont Surfucc Ai,runers 2. ROUGH - Fr^.1'1:'40 LUG'^1.'< a _ ` F 0P' (UR OTHER APPRO%'L•ll INDEPL�DE-'�tT TE.ti I7NU LAB.)TO G1(M.3 AtmrnphNric vacuum retlet'systent req3. INSULATION required. P.x,t �•a EFERE qCE STANDARD ASTI4 1`220S.ENTITLED-STANDARD mid r,pu single-or multiplc-outlet circulation systems Shull be 4. FiNAL - COI; 'i iIUCT;ON PnUST � �CUPCY f SPECCFICA11ONS FOR POOL AL.VLWS"'.AS AI)UP11rU (N _'17t)2 cY ui pJ with utmoy hc6c vacuum relief►huuld grutc Cover,; _ BE CO`v'PLETE FOR C.O. located the,cin becou c miaaing or broLcm rhis vacutun relief ALL CONSTRUCTION SHALL t r ET THE AND EDITORIALLY CORRECTED IN JUNI:2W5. PUL;LIS(IIID BY REG�UIREPv i_NTS OFT CODEC OF U[�J "+ ay,;tcm ►hull incttxie at Icuat or►e approval or cnginccrrtl RETAIN STORM WATER RU+.OFF AST'Ni M7 F-RNATT NAL, 100 BARR HARBOR DRIVE , methud of the lypu specified hcroiu,us follows; YORK STATE. NOT RESF'Ot4SIBLE FOR CONSIIOIIOCILL-N.PA. 19429. DESIGN OR CONSTRUCTION ErriORS. PURSUANT TO CRAFTER 236 1. S:dcty vacuum toleaae system confunning to ASML OF THE TOWN CODE. IS NOT AN ALARM DEVICE WIIICII IS LOCATED ON PERSONS A112,19.17;of OR WHICH IS DEPI:NDEW ON DEVICES ON PF1tSOtiS FOR rrs 2. An upproveJ gravity drainage ay►twn. PROPER OPERATION. (;106.4 Dual drain separmlon.Single or multiple pump sir rO :r- I `;r `%`117-1 iiLl- CODES OF T}IE POOL ALARM NIUST BE CAPABLE OF DEL.'TECTING ENI RY culatiun systems have a mininrunt or two suction outlets of NE-W YO;=iK S[.A, 'L & TOWN CODES INTO ITIS WATER AI'ANY POINTON THE SURFACE OF THE POOL. the uppi-mcd tyle.A minimum horizontal or vertical distance AS REQUIRED A IF NECESSARY TO PROVIDE DETECTION Al*EVERY POINT. .MORE of .1 feet (9 14 mm) ,hull separate: the outlets. These Suction outlets shall he piped sty that water k drawn through client 4� THAN ONE ALARM SHALL DE INSTALLED. `� 7'` rtutr;ltancuuyly through u vaeuunt•retief•prutcetcd line to the pun►p or pump►. " .;;_ , rn,F: v, N) ,RD POOL ALARM SHALL BE P00L GUARD SIODL•L PGRM OR EQUAL (;I(M.5 Poul cleuner tlttings. Whe,e provided, vacuum or ^" AND COMPLIES WITH N.Y.S. BUILDING CODE TI CLE 19 SL:CTION pre,r►ure eacandr tittln (s g f shall be 1m;uted in un aecesciblo 1221.3 N EEnNG AsTm F22Cd. pusinows) at leuat 6 inches 052 mm) and not more than 12 lochea(.IUs mm)below the minhnunt uperutlunal water level or as an atlachmcat to the slimmcr(s). SIZE A C D 1— F C AA EA C• JO. • �'�tr 16x 44- 18 4.4' 8 2.4 M V 8 'j 92 vj4-= �e�:�.•ter t.r tn,.vc.•u�nco vr~.L, u►xce�Cw7�ttL'� 3• �-Mt»v e.teHr ' G cc?n C-A-u tm) G I �- Cc(" / / 5 c G Lo t-1 cv-j-r 4.A L, L)oTr C> ' .! � � a� I. �1i✓ 0'1✓s'JGI.J 1q t���A GJ A t:k',/�1��..E�. ��t, �j� MAri-2 i4k;4°l• ?o PA 9'm j.4, tJltN � loy�7/f.T'. ci�s�c-�O vJJ.t�R. �F�l t� 11^r co z*Ar z vc>� t r-c� - —a--,��.,.t,r,c � c�M J.11t-�1T" Exe?f' ri/Jt3P:+tJ Titt u,ctl TLS Cr- >✓.c..r..•.y.c71e-#.1 • t a-et tr V"Ant` 'iC. A:yj mJ-) Gt•d e,rue, C• - IKti►yrt Aut14.. Cly , !' 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