HomeMy WebLinkAbout40576-Z Fitt��oG. . Town of Southold 12/5/2016
P.O.Box 1179
53095 Main Rd
®r, p� Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 38692 Date: 12/5/2016
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 2885 Minnehaha Blvd., Southold
SCTM#: 473889 See/Block/Lot: 87.-3-32
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
3/24/2016 pursuant to which Building Permit No. 40576 dated 3/29/2016
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 Willgoos,Christine
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40575 08-09-2016
PLUMBERS CERTIFICATION DATED
Umlyd Signature
TOWN OF SOUTHOLD
�gUFfO(,�Co .
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
oy • 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#: 40576 Date: 3/29/2016
Permission is hereby granted to:
Willgoos, Christine
165 W 66th St Apt 7X
New York, NY 10023
To: construct accessoryround swimming in-g g pool as applied for.
At premises located at:
2885 Minnehaha Blvd., Southold
SCTM # 473889
Sec/Block/Lot# 87.-3-32
Pursuant to application dated 3/24/2016 and approved by the Building Inspector.
To expire on 9/28/2017.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
6MLector
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,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. Foes
1. Certificate of Occupancy-New dwelling$50.00, Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming pool $50.00, Accessory building$50.00,Additions to accessory building$50.00, Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Building- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00
Date. � ����
New Construction: Old or Pre-existing Building: (check one)
,QllaLocation of Property: �00 5 Nwdiaha Alm C.l)✓ k, 3
House No. ]]Street Hamlet
Owner or Owners of Property: NAOS�Vjt UlftIA DS
Suffolk County Tax Map No 1000, Section R r7 Block 3 Lot 3 2
Subdivision ' r Filed Map. Lot:
Permit No. -T�S� o Date of Permit. Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted: $
Applicant Signature
pF SOUTy®lo
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 G �Q roger.riche rt(aD_town.southoId.nV.us
Southold,NY 11971-0959
®l�C®UM,�c�
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Christine Willgoos
Address: 2885 Minnehaha Blvd. City: Southold St: New York Zip: 11971
Building Permit#: 40576 Section: 87 Block: 3 Lot: 32
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Standard Electric License No: 43098-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 FixturesTime Clocks 1
Disconnect Switches 1 Twist Lock Exit Fixtures TVSS
Other Equipment: Inground Swimming Pool to Include; Bonding, Control Panel, 1- GFCI Circuit
Breaker, 1-Salt Generator,1-Pool Light,1-Cover Motor,4-Land Scape Lights
Notes:
Inspector Signature: Date: August 9, 2016
OOElectrical 81 Compliance Form.xls
af Sol
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TOWN OFSOUTHOLD BUILDING DEPT.
765-1802
� INSPECTION
/]� FOUNDATION IST ROUGH PLUMBING-
FOUNDATION 2ND INSULATION
FRAMING /STRAPPING FINAL
FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION
FIRE RESISTMT CONSTRUCTION FIRE RESISTANT PENETRATION
ELECTRICAL (ROUGH) ELECTRICAL (FINAL)
] CODE VIOLATION ] CAULKING
REMARKS:
rc;�p )
A
4
DAT _ INSPECTOR,��
SOOlyOlo
�y00UM
V
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL)
REMARKS:
DATE INSPECTOR
BOE SOON,
�o� olo
o�'YOOUMV,��
TOWN OF SOUTHOLD BUILDING DEPT.
765-18®2
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] SULAT O
[ ] FRAMING / STRAPPING [ FINAL oo
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS: ® .
DATE Y '?�� INSPECTOR
r1 0 •. ^ � . Flim."71�
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STATE ENERGY cbm
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TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL Board of Health
SOUTHOLD,NY 11971 3 sets of Building Plans
TEL: 765-1802 Survey
PERMIT NO. Z--Check5 76
Septic Form
N.Y.S.D.E.C.
D
Trustees
Examined 3j� ,20J / Contact:
Approved ,20 /.O MAR 2 4 M rii4QL �IX?4?s
Disapproved a/c C
BUDDING DEQ Phone: 4131 7r/1/ Z�9,
`$'OWWT�T QF'S®UTSO
Buildi Inspect
APPLICATION FOR BUILDING PERMIT
Date �2� ( 20
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, and rpWations, and to admit
authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant or n ,if a corporation)
q��i 2t Z� - b4, IIS
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or&4vr, �t
Name of owner of premises i� ����Ne, N,I�16 a-13
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer))
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be -one:
���Il't��1 (f0
House Number Street Hamlet ,
County Tax Map No. 1000 Section Block 3 Lot J 2
2—
Subdivision
Subdivision Filed Map No. Lot
(Name)
2. State existing use and occupancy of premises and intended use and o upancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy Q� S W_'1_ Z l_"
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolitior�-- t-�^ Qth r,Woxlkk�. __ ru wn VigyL �.MMIY
,\ �� V n...)'e (Description)
4. Estimated Cost 1q,w J e
4'N�1�'eF,* (to be paid oh filing this application)
5. If dwelling, number of dwelling units Number od*veiling Os on each floor
If garage, number of cars ]
6. If business, commercial or mixed occupancy, specify nafu `and ekf6n'ty6f bea bitype of use.
7. Dimensions of existing structures, if any: Front -L11_ Rear T1 Depth
Height Number of Stories Q
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction: Front 19-K 3b Rear Depth 3'�Z
Height Number of Stories
9. Size of lot: Front "IJ Rear _75 Depth 172-
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: AID
13. Will lot be re-graded Pmoi. (1A � �Will excess fill be removed from premises: YES O
14. Names of Owner of premises lJ i l qQj S Address2W�_ P►Wlr &hA Phone No.
Name of Architect`R'6 , b &llu PC Address 4&zc,4.15,x;t�,''0Phone No (�,3�-7W 7�S&
Name of Contractor ,tl `Chi EOV4A'rflc its Address a2-7 9tl zr� Phone No. &3i-7w,(-7fflr
M,ILe_ (2,.ace
15. Is this property within 100 feet of a tidal wetland? *YES NO f
IF YES, SOUTHOLD TOWN TRUSTEES 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)
SS:
COUNTY OF( E
t,_ , OS being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing 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 J '
day of 20&
Now� lhE:r A. KIDNEY Signature o pplicant
Notary Public—State of New York
No. 01 K16021 1 1 1
Qualified in Suffolk County
My Commission Expires March 8,20A
Scott A. Russell 0AIr S`]F01KMWA_` F1E]K
SUPERVISOR
U, MANAGl]EAMI]ENT
SOUTHOLD TOWN HALL-P.O.Box 1179 �
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
O,f
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES TINS PROJECT INVOLVE ANY OF' THE FOI 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 surface.
❑
B. Excavation or filling involving more than 200 cubicY ards of material
within any parcel or any contiguous area.
❑QAC. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑[2/D. Site preparation within 100 feet of wetlands beach bluff or
P coastal
derosion hazard area.
E. Site preparation within the one-hundred-year floodplain 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.
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
NAME•
W, II 5 R �:J(
7 Disci 32 /�3123
"0 Section Block Lot
(Slgnelura) ****FOR BUILDING DEPARTMENT USE ONLY****
Contact Information. q l-7-U? -M2—
(Telephone Number)
Reviewed By: p
Property Address/Location of Construction Work• Date: 3
2 �� ��j �h� �l J Approved for processing Building Permit.
r I A Stormwater Management Control Plan Not Required.
A)y7t [7] Stormwater Management Control Plan is Required.
(Forward to Engineering Department for Review.)
FORM # SMCP-TOS MAY 2014
i
i
_ aF S�lyo
i
Town Hall Annex Telephone(631)78g65--1802
54375 Maio 15- l
x 1179 `� cC roller riche own sow O .m.us
r8outhoid, 11971-0959 ��
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATI6N FOR ELECTRICAL INSPECTION
REQUESTED BY. Date: i
Company Name:
Name: of o� '
License No.:
Address: (6 00 3c66,0
Phone No.:
JOBSITE INFORMATION: (*Indicates required information) i
*Nam: `s Ods
3
*Address:' ar6 ��
*Cross StreetXfo koms '
*Phone No.:
Permit No.:
Tax-Map District: 1000 Section:— Block: Lot:
*BRIEF DESCRIPTION OF WORK(Please Print Clearly) OU4Z6- r VOLA io�J R 2( VAP i
SEI � kl c L21MV Pb- 1( 1) Gf CA ko,:�- in., Rift C&4wr l
0-4 Vyir\CiE(\CR a`� ('P.R, . a 0v�t1 t nc3r �a' fU L(��1 ��
�Ij
(Please Circle All That Apply)
Is job ready for inspection: ` E I NO Rough i Final
*Do.you need a Temp Certificate: YES/ NO
Ternp Information Qf.needed) '
*Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead '
Additional Information: PAYMENT DUE WITH APPLICATION
l®C?
,82-Request for Inspection Form j�
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
[ f) CERTIFICATE OF WORKER'S COMPENSATION
( ]} CERTIFICATE OF DISABILITY INSURANCE
SUFFOLK COUNTY LICENSE
=-�]-- SUFFOLK COUNTY PLUMBER LICENSE
[V) SUFFOLK COUNTY ELECTRICIAN LICENSE
[ ] 4 SETS OF PLANS -(3 STAMPED)
3 SURVEYS
�] APPLICATION FOR ELECTRICAL INSPECTION WITH $100 CHECK
[ APPLICATION FOR CERTIFICATE OF OCCUPANCY
C.O.
[ ] TAX BILL
[ ] $300.00 CHECK FOR PERMIT FEE
� t�„- - ?�\ val ,cs., •s�if':. t�.i _ .ir�Z ti' ��%r.
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,�}.�'�;;":('r��.���.€^•�c',.•-.../rsc;:"l.�y v ,.n:, �J',�,'•�'.l' ��;' .w' �`�1� r �rk�.`: 'l•:�' ;i- .i ✓r%t, o-.c,ti �-� c' v r��`1* r,1�
1- •:-2i+.._•l7„'.:`-'--r.6:9c:`AS.��.Yi3...>.°s4LT3'.=-vrti..:-i::e:.:.dA�'9RY.T.,".d.'cZcv1�LL'^.."iSst:....T.:?.7.'a'.:"CxK.'�.^.24,:i 9'�aS�A7'&6Q^, rn��casnnx�.+--cna wacc•srs ;7 y��•.'.s'�ti S:AZ�S7GgA6'F4gd&"'�r'}F� ter'
"tori
Suffolk County Department of Labor Licensing &
Consumer Affairs
til K��1
VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 b
DATE ISSUED: 7/1/1978 No. 4436-H
SUFFOLK COUNTY
Horne Improvement Contractor License '
This is to certify that ARTHUR J EDWARDS r'
doing business as + '
"�, ARTHUR J EDWARDS MASON CONTRACTING CO INC DSA
having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules
1�+ _•r
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.
t I License Category
SUFFOLK COUNTY DEPT OF LABOR, ^" y!
s LICENSING&CONSUMERAFFAIRS Additional Businesses GC
HOME'IMPROVEMENT Pools&Spas/Certified
CONTRACTOR
r. II M,
I ARTHUR J EDWARDS MASON Pools/Spas
13 I CONTRACTING CO INC DBA
ARTHUR J EDWARDS ARTHUR EDWARDS POOL&SPA
Li f
CENTRE �G '
This certifies that the ensu+ NA"
ARTHUR J.EDWARDS MASON f
bearer is duly CONTRACTING CO INC DBA
licensed by the L—Numb.. 041.hmuw Commissioner My
County of Suffolk
4436-H 07/01/1978 r
0710112016
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��•�.1 ARTHU-1 OP ID:VM
AC�Ro� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
44�� 1 01/21/2016
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 Ileu of such endorsement(s).
CON
PRODUCER NAME T Bagatta Associates, Inc.
Bagatta Associates,Inc. PHc ti 631-864-1111 Alc No: 631-864-8274
823 W Jericho Turnpike Ste 1A
Smithtown,NY 11787 ADDRESS:
Bagatta Associates,Inc.
INSURER(S)AFFORDING COVERAGE NAIC I
INSURER A:Worcester Insurance Company 26182
INSURED Arthur J 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 INSURER E
M filler 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.
I�TRR TYPE OF INSURANCE INSD WvO POLICY NUMBER MMIDD MM1DD yYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADEX1 OCCUR MPA00000038801 H 01/01/2016 01/01/2017 PREMISES Ea occurrence $ 100,00
MED EXP(Any one person) $ 5,000
X BLANKET ADDITIONA PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00
POLICY❑/ECT F—]LOC PRODUCTS-COMP/OPAGG $ 2,000,00
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
H RED 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 PER -
AND EMPLOYERS'LIABILITY STATUTE ER
TH
B ANY PROPRIETORIPARTNERIEXEE L.EACH ACCIDENT $CUTIVE YNIA RWC3363984 03/01/2015 03/01/2016 1,000,000
❑N
OFFICER/MEMBER EXCLUDED? 1,000000
(Mandatory In NH) E L DISEASE-EA EMPLOYEE $ r
If yes,describe under 1 000 000
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ i s
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If 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
Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS.
Town Hall AUTHORIZED REPRESENTATIVE
P.O. Box 728
Southold,NY 11971
OO 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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) 1 b. 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"l a":
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 employers 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: S � -:5• S V,0_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 Fonn DB-120.1. Insurance brokers are NOT
authorized to issue this form.
DB-120.1 (5/06)
1..G1L111L:dLG Ul 1N 1 J VVU1&G1J %—U1111JG11JQL1U11111JU1d11L:G I.0VC1dVG L1Zs•.>
STATE OF NEW YORK
WORKER'S COMPENSATION BOARD
CERTIFICATE OF NYS 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"Ia":
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"I a"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 notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums
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 9c';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 authorized representative or licensed agent of insurance carver)
Approved By- 3/2/2016
(Signature) (Date)
Title. Underwriting Manager
Telephone Number of authonzed representative or licensed agent of insurance carrier CarricrPhone
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/PolicyNYCertificateOf WcIns.aspx?Indexld=-1&Instanc... 3/2/2016
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Suffolk Coupitjlr Executive s Office of ConsumerAffairs
VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEWYORK 11788 Wer 0
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DATE ISSUED: 5/1/80
No. 2740
SUFFOLK COUNTY
Master Electrician License
This is to certify that EDWARD S REIFF
doing business as UNDERGROUND SPECIALTIES INC
having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in
st accordance with and
-subject to the provisions of applicable laws, rules and regulations of
the County of Suffolk, State of New York.
SUFFOIX OOUNTY DEPT OF UU30R,
Additional Businesses
LICENSING 8 CONSUMER AFFAIRS
MASTER
ELECTRICIAN
AA
EDWARDS
REIFF
This c&N66 ftathe GENRMY.No.ORA
bearer Is duty
licensed by the
County of Suffolk
U 2740-ME 0&0111980
...... 0510I/2016
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Yonf, _ _ Z T®W�N OF SOUTHOLD- PROPERTY RECORD, CARD
OWNER&,� i 1 STREET -(�/5/' VILLAGE DISTRICT SUB. LOT
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RES. SEAS. l� VL. _ FARM COMM. ( I IND. I CB. I MISC. I Est. Mkt. Value
LAND IMP. TOTAL DATE REMARKS
F0 000
CoQ / Utile
4n '-aiLe) i
10-n a5oc) 36c n--- SaoCA
1 c9-6--0 (0 500 1 7 3 0'0 13 i /o /oa-- L Nal 8 r n, ; 0�n
ba- d SSS
NEW NORMAL BELOW ABOVE FRONTAGE ON WATER
Farm Acre Value Per Acre Value FRONTAGE ON ROAD y�j� h _ /o-
Tillable 1 BULKHEAD
Tillable 2 DOCK
Tillable 3 (p ® ® PSa
- Cojo *,qc `6j7t'S aJYS• �.D
Woodland 1 'd41 1� ®,,ves> OV-'b 50,E
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House Plot
Total
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41
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87-3-32 9/02 I '
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Extension J 9 IJP Basement t" J Floors
Extension -- Ext. Walls -� Interior Finish
Extension —
2- x `� = Z"�� 7 1 Fire Place \ �c1 Heat
q x 112 = c� _7 �� Porch Roof Type
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Rooms 1st Floor
Breezeway Patio
J,� p Rooms 2nd Floor
vo
Garage i X � -`�f f ?,,Go Driveway Dormer i
SURVEY OF PROPERTY
AT
LAUGHINGDWATER
TOWN OF SOUTHOLD
®�A SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000-87-03-32
SCALE 1'=30'
FEBRUARY 27. 2001
lky f MARCH 9. 2001 REVISED2002 � MUSE LOCATION
MA" 29..2, I
i
AREA = 15.624.16 sq. ft.
0.359 cc.
St, '
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80N i ° CERTIFIED TO:
COMMONWEALTH LAND TITLE INSURANCE
COMPANY
01 TITLE No. RH 80014898
MICHAEL A. COJOHN
ARLENE M. COJOHN
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APPROVED AS NOTED ELECTRICAL
DATE: Lp.# , INSPECTION REQUIRED
FEE: Jib•��Y:
NOTIFY BUILDING DEPAR- AT
705-1802 8 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS: RETAIN STORM WATER RUNOFF
1. FOUNDATION - TWO REQUIRED PURSUANT TO CHAPTER 236
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING OF THE TOWN CODE.
3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET THE a� fl �,
REQUIREMENTS OF THE CODES OF NEW a- IVE K� 01 A T ELYo�
YORK STATE. NOT RESPONSIBLE FOR ENOLOSEsPOOLTO CODE
DESIGN OR CONSTRUCTION ERRORS. UPON COMPLETION
,BEFORE-.',WATER
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OFcICICUPA ICY
A
SWmmem Rotuma
i
/Aluminum
B E F B
To Filter From Fitts
Filter& Pump
To WRotuma
(Dry Well OpUnd)
Roiled Wig]F
Plan A Piping Arrangernef%t
Won seatien
=< 7 1
VIWA u �#4 Reb
42" SEW YORk
Section B—B 2.San 3500 P.S.L. Caumte o
I�LHJA
10" 1®.��"�o�v
Section A—A
Typical Wall Section
SIZE A B C D E F G H AREA CAP.
FEET FT. FT. FT. FT. FT. FT. FT. FT. SQ.FT. GAL. w l
16x32' 16' 32' 8' 14' 6' 4' 4' 8' 512 19,000 �$gJ� MI nAeh(A h o, 101V6
16'x36' 16' 36' 12' 14' 6' 4' 4' 8' 576 21,600L SPA CENTRE
PERMACRETE WAIL SYSTEM ���-� state !"q
18840 18 40 16 14 6 4 5 8 646 24,300 929 Route 2514 Miller Place IVY 11764 ( )
20'x40' 20' 40' 16' 14' 6' 4' 6' 8' 800 30,000 (631) 744-7185 FAX (631) 744-0174 phone code
IMI
24'x44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk License #4436—HI
24'x48' 24' 48' 20' 16' 8' 4' 6' 10' 900 30,000 Nassau License #1174450000