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HomeMy WebLinkAbout39216-Z �4�osU�FQi�"cpG Town of Southold 11/3/2016 P.O.Box 1179 a o • 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38634 Date: 11/3/2016 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 810,Waterview Dr, Southold SCTM#: 473889 Sec/Block/Lot: 78.-7-29 Subdivision: Fled Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/15/2014 pursuant to which Building Permit No. 39216 dated 9/26/2014 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,FENCED TO CODE, AS APPLIED FOR The certificate is issued to Ericsson,Kurt&White,Christopher of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 39216 09-07-2016 PLUMBERS CERTIFICATION DATED (yho&d Signature '12 TOWN OF SOUTHOLD BUILDING DEPARTMENT C2 s ' TOWN CLERK'S OFFICE 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#: 39216 Date: 9/26/2014 Permission is hereby granted to: Ericsson, Kurt &White, Christopher 13 Ontario Rd Bellerose Village, NY 11001 To: Construction of an in-ground swimming pool as applied for. At premises located at: 810 Waterview Dr, Southold SCTM # 473889 Sec/Block/Lot# 78.-7-29 Pursuant to application dated 9/15/2014 and approved by the Building Inspector. To expire on 3/27/2016. Fees: IN-GROUND SWIMMING POOL $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 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. 9 /12 / New Construction: Old or Pre-existing Building: (check one) Location of Property: 8 l b W A-"oEt>_V LCA Q Sew-afOL-C> House No. Street Hamlet Owner or Owners of Property: C 4P_`M1QQ4�P. W tAlTe Q Suffolk County Tax Map No 1000, Section 7 O Block 7 Lot 1 Subdivision Filed Map. Lot: Permit No. 3 a ( Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ (50 Applicant Signature SOUry®l Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G �@ roger.richertO-town.southold.ny.us Southold,NY 11971-0959 ®lyc®UNTY,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: White/Ericsson Address: 810 Waterview Drive City: Southold St: New York Zip: 11971 Building Permit#: 39216 Section: 78 Block: 7 Lot: 29 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electrical Cont. 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 Ceding Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 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 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include; Bonding, 2- Pool Lights, Control Panel, 1-GFCI Circuit Breaker,Salt Generator,Pool Heat Pump. Notes: Inspector Signature: Date: September 7, 2016 OOElectrical 81 Compliance Form As /� I OF So�r�o o�ycoUNi`(,0c� TOWN OF SO.UTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ NAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: 02 • -- DATE O7 INSPECTOR t ?!�- Y SOUly�lo j l y"oufm � 1 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) REMARKS: Koo DATE INSPECTOR YC t ✓ 4�� O��OF SOUIyo! � o c0UN1`I,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] SOLATION [ ] FRAMING /STRAPPING ] FINAL 4-FlW-4t- [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: 4- Lp DOE &WN I� f n i DATE /e INSPECTOR FIELD INSPECTION R- tPoRT DATE COMMENTS t it FOUNDATION(IST) � ----------------------- -r r-----------rrrrrrr ' FOUNDATION(2ND) tt �rA y ROUGH FRAMING& y -s) PLUMBING C tai INSULATION PER N.Y. H STATE ENERGY CODE H • y V FINAL ,� G ADDITIOIVriL'CO1VIl12NT5�w O V e TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying9 TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 �B Survey SoutholdTown.NorthFork.net PERMIT NO. l Check Septic Form NYSDEC Trustees C 0 Application Flood Permit Examined 20 Single&Separate Storm-Water Assessment Form Contact: Approved —,20 Mail to• DLktA9,\^Ce AOC9L—�7 Disapproved a/c WwogoNelbl.t N N' Phone �p?j l 5�5• �p 1,tZ t Expiration 20 CBuilding Inspector LICATION FOR BUILDING PERMIT SEP 5 204 - Date 20 INSTRUCTIONS BLD DEPT a. �atiQli TST be comp etely filled m by typewriter or m ink and submitted to the Building Inspector with 4 [Lisewofp cc&ateplot-pl sea a ee 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 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,housiiyg code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. / (Signature of applicant or name,if a corporation) (Mailing address o applicant) State whether applicant is owner,lessee,agent,a chitect,engineer,general contractor,elec 'cian,plumber or builder Name of owner of premises C4 P- 1 D P4 F—P, w�A t T-I (As on the taV roll or latest deed) If applicant is a corporation,signature of duly authorized offs �<eNt,L6- -l.F 194PT-}wAf--) PP-C-S - �G (Name and title of corporate fficer) Builders License No. b!r X0 5- Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: gid VUAa:EP-yQR- SeuxWIr!�Ljp t\L-�(. 11971 House Number Street Hamlet —7 County Tax Map No. 1000 Section e 15 Block 7 Lot Z9 Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Q es I N—&a=. AZ L, b. Intended use and occupancy elc–�It)ew j L = 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work Y�9 L (Description) 4. Estimated Cost [ =0 Fee ZSO + 915 Geo (To be paid on filing this application) 5. If dwelling,number of dwelling units l Number of dwelling units on each floor If garage, number of cars 6 If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9. Size of lot:Front ( C)0 Rear t � Depth S-O 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_N04Will excess fill be removed from premises?YES NO_ 14 Names of Owner of�remisesCAfZlK'f-ORW k)f+tr ddress8(a ra1RW%)feW ILII P�ho}e No(�10(o So -36 St Name of Architect?A, N. K�5 fc t Address Is` lion-No L4'9• '7 1 1(o - Name of Contractor t7Ut�R.tE 662 -Address 3 to one No. :05'• 1 to I . 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO X� *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?*YES NO--)!(— *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS COUNTY OF 1,t FIFO (am OEmd 15AIP�M,{j being duly swom,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the C i O ontractor, gent,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 befgre me this (Z, day of OTH tate of New York Notary Pi6.01 B06092004.SUf101k L,0UPLY I Signature of Applicant Term Expires May 12,20 OF SO�jr�or Town Hall Annex 54375 Main Road Telephone(631)765-1802 ae P.O.Box 117 G � Q bo(631)765 Southold,NC 11971-0959 roaer.dchertftwn souggo nY us Iy�OUNCY,�� BUILDING DEPARTMENT - TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: j Id 1 Company Name: �� r ,-,, :� CBv�-1'►�c-Ec— - = - _ Name: la.-tur A. R I a� License No.: a$80 MF_ Address: 133 1 Lino-do Ave, 1 h>m� Niq 1 I7L4 ) Phone No.: C31--7 O JOBS ITE INFORMATION: (*Indicates requited information) - *Name: *Address: 5,10 ; `Waletwiew ter. *Cross Street: Main BA view R *Phone No.: 5 I LO- Lv So_ 3 $S2 Permit No.: 39 ZI Lo _ Tax-Map District: 1000 Section:��8 Block: 17 Lot: c>lR *BRIEF DESCRIPTION OF WORK (Please Print Clearly) �1�mw1► �i�1 wiri (Please Circle All That Apply) *Is job ready for inspection: YES ! NO Rough In final *Do.you need a Temp Certificate: YES _ _ Temp Information (if.needed) , kS®rviCe Size: 1`Phase 3Phase -100 -- 150 200 300 350 ;400 Other . 'New Service: Re-connect Underground Number of Meters Change of Service Overhead 4dditional In€ormation: PAYMENT DUE WITH APPLICATION Ito 11) 82-Request for inspection Form h�` fC Scott A. Russell , �°SU Ir 00, 5T01KAM1WATIE1Rt. SUPERVISOR MANAGEMENT SOUTHOLD TOWN HALL-P.O.Box 1179 u' 53095 Main Road-SOUTHOLD,NEW YORK 11971 ° Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES 'THIS PROJECT 1NVOLVE A-ITY OF THE :F0LILflWhiG: i Yes No (CHECK ALL THAT APPLY) i ❑❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. i ❑0 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 100 feet of horizontal distance. ❑® D. Site preparation within 100 feet of wetland, beach, bluff or coastal erosion hazard area. ❑[0 E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑� F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. %k 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. S.C.T.iVI. �': 1000 Date APPLICANT. (Propel ty Owner,Design Professional,Age ,Conti actor, ther) District (� NANIE- �T� PEON--� }} f •V 7 g ,Z14' N E Section Blcck Lot Q 1 FOR BUILDING DEPARTMENT USE ONLY Contact Information — — — — — — — — — — — — — — — — € Reviewed By: YAP e Date: Property Address/Location of Construction Work: — — — — — — — — — — — — — — — — 0 � l C E C1�V Appi owed for processing Building Permit. Stormwatei Management Control Plan Not Required. O LAX LA U L,0 N•\/• 11911 1 El 1 Stoi mwater Management Control Plan is Required. (Forward to Engineering Department for Review.) __ I FORM # SMCP-TOS MAY 2014 Y - TOWN OF SOUTHOLD PROPERTY RECORD CAR® 2--- 9- '.-OWNER STREET 1 VILLAGE DIST. SUB. LOT 0�2MER O NE_R- IIG �Ifl��- f� N ��c�r �� �� E ACR' • .-_ rC�»C.L� , L�?An 1,,�YfaalG ep S„ `W,' ` TYPE OF BUILDING d er x ate' rt `i1?`sit tr vtbs \✓ tom 4-f / V Y Q G 1s°ts+tom'W l� /e� .� / S 7 C1 s-g-�7 .RESw SEAS. VL. FARM COMM. CB. MICS. Mkt. Value ' ' r. LAND IMP. TOTAL - , DATE - REMARKS S'a� �y '✓ " , n ' " T- 116 - C c, ,6�6Z921 N4 wf-Z,—q S A 7 o t1 / U o ' 0 ? I�Sr 7 G jl�fi D �?d,.1 Ij rA)Q//141/Q 6 0 `76o zoo �f 4 C)o �(a /7 g$, ° 1 a��deck rtdd,'Abr) �ac-Aed access, Z/&-/, '15ds3cb tv_ iT _ a ry AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE FARM Acre Value Per Value Acre Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowland _sem` DEPTH House Plot BULKHEAD Total DOCK . J COLOR i,/ TRIM '� ..,i -,t" r ,'S i3•eta'i5'•{,_ 't "'k ;In — �: ,...'^,:"'. :.5, .".•.' '+... '-fid'' > .'` M1� "'� - �� '� a t}• _G.. �•� I ' � "'- :�*'�Y�� ��^�'$ .��-s��•.^`thy'; '."'•.:-:'�.'_v;,,,;_ :t�'..y„,.�e_ _':°a`, � � .%;..��+.._ ^':•: �.:- •�%%"';:�,f .jam �-�.. r,•E' ,., ' e„� � L.i�i�•� - _."r••'^�.Vv�1_r_ -4.�.�nt+•..M1 J�µ��-� t.�"�:�.�.j.,..Y.i•�.`. � _ w•=s`r<,��rr�y>'?�-_-moi-.ren•" ''�r`rr�,��.r-E. -.-3^.�...�i"a.'�_..., ;'�e;ii}-�' ,.•yam;�,', Te— i ��� �t: ..car:/�S'W��"Sr-r y��' -{ .-.-r_.... - _ •. _ _ '. y3 I-, I( D aI YJ 17-4 J M. Bldg. P71,30 ExtensionlS '�-ffZ© X � ¢.�G 6 Extensionls '�� 4tt - Extension ZC> Z 11:7 p Foundation Bath Dinette Porch z U l Zu 1 Basement �t l Floors . K. Porch /!r/r� r,� Ext. Walls s Interior Finish LR. Breezeway Fire Place f Heat ( DR. Garage Type Roof Rooms lst Floor BR. Patio Recreation Room Rooms 2nd Floor FIN. B O. B. `vim y-o Dormer Driveway Total �7� �z 1' I STATE OF NEW YORK I WORKERS'COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW I PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier Ia. Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured Dunrite Manufacturing Corp 631-588-1300 � Dunrite Pools 3510 Veterans Memorial Highway lc.NYS Unemployment Insurance Employer Registration Bohemia,NY 11716 Number of Insured � 0592920-5 ld.Federal Employer Identification Number of Insured or Social Security Number 112245133 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) National Benefit Life Insurance Company 3b. Policy Number of entity listed in box"1 a": Town of Southold 8-910-0403697 Main Street Southold,NY 11971 3c. Policy effective period: 01/01/14 to-01/01/15- 4. o01/01/154.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: i 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 ,03/18/2014 By 6�' c l� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) I Telephone Number_845-783-2555 Title_President 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. I i 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) STATE OF NEW YORK WORKERS'COMPENSATION BOARD i CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured 631-588-1300 i Dunrite Manufacturing Corp Dunrite Pools lc.NYS Unemployment Insurance Employer 3510 Veterans Memorial Highway Registration Number of Insured Bohemia,NY 11716 0592920-5 Ill.Federal Employer Identification Number of Insured Work Location of Insured(Only required ifcoverage lsspeciJically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 112245133 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Town of Southold 3b.Policy Number of entity listed in box°`la" Main Street O 1 WECJX2028 Southold,NY 11971 3c. Policy effective period _03/27/14_to_03/27/15 3d. The Proprietor,Partners or Executive Officers are ❑ included. (Only check box if all partners/officers included) I X all excluded or certain partners/officers excluded. I This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "W' 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 I this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carr ler will also notify 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 i coverage indicated on this Certificate. (These notices maybe 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 thepolicy expiration date listed in box"3c",whichever is i 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: _Kevin McDonouEh (Print name of authorized representative or licensed agent of insurance carver) Approved by: �� 03/18/2014 (Signature) (Date) i Title: President of Walter Rose Agency,Inc Telephone Number of authorized representative or licensed agent of insurance carrier: 845-783-2555 Please Note. Only insurance carriers and their licensed agents are authorized to issue Form C-105 2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us DUNRI-1 OP ID: LC ACORL7" 703117114 (MMIDDIYYYY) CERTIFICATE ®F LIABILITY INSURANCE 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 pollcy(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 Phone:845-783-2555 NcAOMwEA:CT Lisa Cupertino Walter Rose Agency,Inc Fax:845-783-2425 PH E ,845-783-2555 Arc No. 845-783-2425 8 Stag Road Monroe,NY 10950 E-MAIL lisa@walterroseagency.com INSURER(S)AFFORDING COVERAGE NAIC 9 INISURERA-Valley Forge Ins.Co. 20508 INSURED Dunrite Manufacturing Corp INSURER B-Hartford 34690 Dunrite pools INSURERC.Central Insurance Companies 20230 3510 Veterans Memorial Highway Bohemia,NY 11716 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 CONDffION 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. LIY EXP INR TYPE OF INSURANCE Ma POLICY NUMBER MMIDD MLICY EFF MIDDIYYYY LIMITS GENERAL LLABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 5091412568 04/01/14 04!01115 EMGSES Ea occurrence $ 100,000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYX PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1000000 Ea a.,den[ $ , , C X ANY AUTO BAP 8880739 12/31/13 12/31/14 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUTIVE F— NIA 01WECJX2028 03127/14 03127/15 EL EACH ACCIDENT $ 100,000 OFRCERIMEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000 It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Swimming Pool Installation Service or Repair CERTIFICATE HOLDER CANCELLATION SOUTH-7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept Main Street AUTHORIZED REPRESENTATIVE Southold,NY 11971 moi ' O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD suWr.co. HKAL"4 DX T.APP VAL N.•. Nd. .bQ.l tL ok : - buff COU11TY KEAY,M DEI'AR'fMI JOHN 4 Mam G : E3-LaNCDC D R. D. RIF. # 606 73 W. 51 The sewage disposal and waLer supply NO, f3L*D_GEN ,N.J. 0.70 i facilitios for this local ' on have been (j-9N Z01- '3&A-W5:S) inspected by this d_e�p_a_r_�tzlZll 9t1 fo d AR5At I�,fi9Z 3 1.0 be aatisfaotory: � ;:4 V' Chief of General EA-igineoring nissdt�. i8 , D.A�Z ServiCe 1 QT�QVIEW�4 Ae AIS .���a►11t.- W I � b Aa r•t__ t O v < 10 .�Up m < 4 4'- ;ij ! m n 1 f r. koLrs w 0 m L-3 m / E{CALEB 'b._1,. lrelrl ��w � A•3' tV � - b D®mom O (-7URAVI"MIZIO ALTIVA-M00i OR ADDItIft 22 TO TWO SUNVEY 19 A VIOLA110N OF _ 320M r10F OF THE NEW TOK-STAW 1TIUCA11014 LAW. S;;7•�L 1,. L� COMES OF THIS SIFTVET OLA)NOT 1FAMd + / THE LkM SUFVETOE'S 14Z.0 SIAL Ot WOULD SEAL SMALL NGT R CONSI01"m TO IN A VALID frUT C.^,►v. U }� GOARAHTFES INOICATZO NCA_OV SMALL RtW • • / „� _ ONLY TO WE 0QSOA FO: IM. SUkvit vaC`J►'Ir - IS 1RIUAUD.Aub O,.113 tw:;ALI 10 IMS TITh COMPANY,&UY.Z. :.N.AI AGINCV AN& LEl1DITMp W110010m vSV:L• HJ%0.4. A—h TO THE ASSIGNiES OF Tit-at.xDINU M71• C.>rA'TIF. TUTION. GUARANTIES AU COT T11ANSFfRA1U TO ADDITIONAL*45TITUTIONS OR SUt1ROU[W 4w IOWNERS.vu - E1TAllEI/• Q *F PZOPE z-r,!( - to ++tie aF.,or�caF+ 7it1,t •RAt Ei. AT VbAyv v F—`V Irr*LwdneA CD.0 0 wrwArj Apr.I Z,l9TT TOWN OF SOUTt40LD , NY. "009 ACK VAM TUYL.•W. C: . V41...-e7- LIC.WkNO sUV1V1LY00M4 , Er.V. WU VW.CO.400MIr.CW N RALTH WWWWAW ErrATl dw Or IE 17weT Romart Builders 1" Frew A""OMAI. Or C0%*TWUC"0" ONLY A1111er P1ACC, Zj• X% AMA "M wATMyt tu"ILY AND G MlAGN ilk' DECK WILL GOND+" TO THK 7'h' 6 - 50 - 17Z K w. Mar. NO.: EUTAMOAR M CW Esurro" CD. *W.V. CW HWALTH, til�un►tc s. wE•iwovao: cst t1►' A E.'.A}1T J . POOL SIZE L`"CTRId AL C POOL SIZE WITH STEP A B C D E F G H K L M N GALLONS Ian' ° �E. _1 r q�1 12X24 12X28 12'-0" 24'-0" 3'-4" 6'-0" 6'-0" 8'-0" 6'-3" 4'-0" 4'-0" 4'-3" 4'-0" 6'-3-1/8" 91050 16X24 16X28 16'-0".24'-0" 3'-6" 7'-0" 6'-0" 8'-0" 6'-3" 4'-0" 4'-0" 8'-3" 4';0" 6'-3-1/8" 13,750 16x32 16X36 16'-0"132'-0":3'-4" 8'-0" 8'-6" 13'-6" 6'-3" T-0" 4'-0" 8'-3" 4'-0" TA" 19,500 ` //- 18X36 '-'18X40- 18'-0" 36'-0" 3'-4" 8'-0" 10'-6" 13'-6" 8'-3" 4'-0" 4'-0" 10'-3" 4'-0" 7'-0" 25,500 \ /// M 20X40 20X44 20'-0" 40'-0" 3'-4" 8'-0" 12'-6" 13'-6" 10'-3" 4'-0" 4'-0" 12'-3'• 4'-0" 7'4" 32,000 16X34 16X38 16'-0" 34'-0" 3'-4" 8'-0" 10'-6" 13'-6" 6'-3" 4'-0" 4'-0" 8'-3" 4'-0" TA" 20,900 """ SU=N 25X50 25X54 25'-0" 50'-0" 3'-4" 8-6" 20'-6" 13'-6" 12'-3" 4'-0" 4'-0" 17'-3" 4'-0" T-7-5/16" 58,750 30X60 30X64 30'-0" 60'-0" 3'-4" 8-6" 20'-0" 15'-0"120'-3" 4'-6" 4'-6" 21'-3" 4'-6" 8'-2-3/8" 79,550 v �� 14X28 14X32 141-0" 281-011 T-4" 6'-0" 8'-0" 12'-0"14'-3" 4'-0" 4'-0"tin -3" 4' " 6'-3-1116" 12,100 \\ // o e1 ��ATELY 13 X26 12X30 13 26 3'-4" 6'-0" 81-0" 10'-0" 4'-3" 4'-0" 4'-0" -3" 4'-0" 6'-3-1116" 11,600 DNINGEOAEO i< ENCLOSE POOL TO C_O AL 16X38 16X42- 16 38 3'-4" 81-0" 14'-0" 141-0" 6'-0" 4-0" 4'-0" '-3" 4'-0" 7'4" 22,000 / \�\ UPON COMPLETION .„,.,;BEFORE ,-WATER” la9D(eIe•9E1P DRLLLING 9CREWD - - �••••••• //// \\\\ ePACD •O.O o CONCRETE'OR WOOD DECK IJP TO - - �•••••• I 9LOP1D dWAT FROM POOL PANEL ALJJHINICI COPING - � _ LON6 5T ANGIP / � d TTTP ALOI'IiRPT COATWG vuMv // .�• `\`\ _ _ �I p ell MYI LN�R ENTRAPMENT PROTECTION IN a RETURN N K COMPLIANCE WITH SECTION AG 106 .�G rRAnE IB.LSP�. O Brm WALL PAI�l DTEM AN� !/e•-fear B0.r Nli fU wAENERD - p _ BTAKE B naNDWT . PR VED AS NOSED POOL PLAN BTm ° Y n+luc vvanlcuLrtE TE nD - " - - DATE: L__�, ANGLE wuzn Bonon ZC� B.P.# O - wW DIA.CARRIAGE WLTD 0" 7,111, 11=III=11I-III=III=111=III=1=11=1III 1 T1=1�1=11=111' W IW.sHER I vaJT - _ =lll�ll=i I�I��L=r1_I�ISIII��L=111 ILIII�II-111=1�t00411 _ FEE: B 1=III=III II-111=111=III-III-II-III-1=II-III-111=I1t=11L TOP CORNER C AT 11911=1 1 1.. .. ig _ ¶=1- IB'LONG BTEF3.RI]NFORGMG ROD I VERTICAL�. „ , m TMI'ICI mmO�z�we TM- �" NOTI UILDING DEPARTMENT 'l1=III fgI=III IIII=III= "DEEB M BOTTOn 6 PA hV . - - p p p p 7illll ' I�'lI1JI��UI I��ll 1l '= 2 8 AM TO 4 PM FOR THE ING INSPECTIONS: nl_IJill-,IIIrII11.Slllln lllIllirlu=llil IIIc , To e � vT u m " MIN 2'THICK VERMICULITE 4 1 F0. NDATION - TWO REQUIRED TYPICAL WALL SECTION AT "A" FRAME DAMV"rSoL� AGGREGATE TAMPERED FO.11 POURED CONCRETE 2. RO GH : FRAMING & PLUMBING ULATION H - F E 4. FI AL - CONSTRUCTION MUST BE COMPLETE FOR C.O. rLD� ON CORNER CONNECTION DETAIL L CONSTRUCTION SHALL MEET THE D�Euix6G.P.�- tr -� - POOL SECTION RETAIN STORM WATER Rv��h DED TOP I— -- - - - EOUIR TS OF THE CODES OF NEW � i ®ES PURGUANT TO CHAPTER 23G YORK s TE. OT RESPONSIBLE FOR e4s REQUIRE n RUBBER FULCRUM nr THE TOWN CODE. DESIGN CM ERRORS. PAD 'M -r,1 Py0 ® I UTI TOWN ZBA 310'REINFORCING ROD ( 1 )et rc)pt�(* W�^����^ Urmli� OCr UTH _ PLAN BOARD ,�� S�U WikTekCft�dU OP, �d Dunrite Pools, Inc r a *� 1THOLDTOWN . ES .�> 5oto�Q� f�-y. J�� UNLAWFUL _ g 2 p� A ®p�A 510 Lu Veterans Memorial Hi hwaY DIVING BOARD Lt 9�� WITHOUT CETIFIC T ; .S.DEC N.T.S. Bohemia New York 11718 FOA P� P016C TYPE: RECTANGLE REV. SCALE: NTS Pool Complies With ANSI 514,2010 RCNYS, it JAMES DEERKOSKI, P.E. DATE: TYPICAL PANEL STIFFNER Appendix G,Design in Acceptable for ALL 260 DEER DRIVE COMMON SOIL CONDITIONS MATTITUK, NEW YORK 11952 DRAWING NUMBER 1 OF 1 1 1