Loading...
HomeMy WebLinkAbout40515-Z r �o�05�FFot,�ioGy Town of Southold 5/16/2017 0 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38950 Date: 5/16/2017 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 840 Bridle Ln, Cutchogue SCTM#: 473889 See/Block/Lot: 102.-8-16 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/1/2016 pursuant to which Building Permit No. 40515 dated 3/9/2016 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 Jacobson,Roni&David of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 40515 05/31/2016 PLUMBERS CERTIFICATION DATED AA, 'kin 4n�� t ed Signature sofFnt TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy • o� SOUTHOLD, NY • ?Jpl� .�a 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#: 40515 Date: 3/9/2016 Permission is hereby granted to: Jacobson, Ron! & David 175 W 73rd St#2J New York, NY 10023 To: construct an in-ground swimming pool as applied for. At premises located at: 840 Bridle Ln, Cutchogue SCTM # 473889 Sec/Block/Lot# 102.-8-16 Pursuant to application dated 3/1/2016 and approved by the Building Inspector. To expire on 9/8/2017. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 L: -$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 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. 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. l� New Construction: Old or Pre-existing Building: (check one) >, Location of Property: RLO /__ 4- House No. Street Hamlet Owner or Owners of Property: P-o tool E � AGoo 5 Suffolk County Tax Map No 1000, Section d — Block Lot Subdivision Filed Map. Lot: Permit No. 40 5 S Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 5 Applicant ig t e OF SOU�y®l Town Hall Annex ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G roger.riche rt(a-)town.southoId.ny.us Southold,NY 11971-0959 ®lyc®UNIr-4 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Jacobson Address: 840 Bridle Lane City: Cutchogue St: New York Zip: 11935 Budding Permit#, 40515 Section. 102 Block. 8 Lot- 16 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Sweet Hollow II License No: 4300-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 2 Ceding Fixtures HID Fixtures Service 3 ph Hot Water - GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixturesTime Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include; Bonding, 1-Control Panel, 3- GFCI Circuit Breakers, 1-Gas Pool Heater,Bonding for Future Cover Motor Notes- Inspector Signature: �QJjt.��� Date: May 31, 2016 z Electrical 81 Compliance Form(2).xls Own TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION I- 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: V A16 t &sdav� 4 /jy C- fjj CX,,e- -z ka,-6� 4 A,-& f Y, DATE - INSPECTOR "OF 30/1 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTI-ON - [ ] FOUNDATION- I ST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] INS ATION [ ] FRAMING / STRAPPING [ INAL [• ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLA ON [ ] CAULKING REMARKS: DATE 07 �5 INSPECTOR l 0 o��pE SOUryo! � o �o 0 MV,N�Q - TOWN.-OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION' [ ] -FOUNDATION 1 ST [ ] ROUGH PLRG. [ ] FOUNDATION 2ND [ ] SULATIION [ ] FRAMING / STRAPPING FINAL PW [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECT ICAL (FINAL) REMARKS: iia - ok bo4t� OV-1 DATE INSPECTOR L,�l"Vii/ �,�`� �_- t`'' •� �� � - .� �' ..� fir' ;.� LI!! r • r � w ..� .fry. .i .;tt L �.��:. - �� � , I/F111i ,_WI,? 1 • STATE ENBROY Y r r G /PM MUCK. Wd, /� .r / /� �• �I� r r . MAXY? . AN e � a it r R► r . Rilm .�s TOWN OF SOUTHOLD-i BUILDING PERMIT APPLICATION'CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,,NY 11971>> �t; :, +,4'sets,of Building Plan's i i: TEL:,(631)765-1802 Planning'Boazd'approyal'.,, - FAX: (631)765-9502j�— Survey SoutholdTown.NorthForLnet PERMIT NO. . r6� Check „ Li- Septic „ r-.•1,,a F - -- -. - - - --- - - - --- - - - - - Septic Form N,Y.S.D:E.C. Trustees - - - - - - - -C.O.Application - - Flood Permit Examined 20Y _ Single&Se pazate Stone-Water Assessment Form -_ — i Yi.i ,>rS .,, , . r"��..; ,S —l7i ' +• ._.—. t el i -, :,. '.' r_' ±,F,, Contact: Approved ,20 Mail to: Disapproved a/c ,F Sf:.3: ;.,`i;• k,, Phone: Expiration_. ... 20 .. / ✓ - R " .' '!` .IES., l44 ^Y`�, •{- ,r`ii,�}i 1 TV% - - :t'''ee' mg'In ctor,, Q 1' 2Q1 - APPLICATION FOR BUIIDING PERMIT '20_ 131=ING DEPT. INSTRUCTIONS WN QF - ,. a. lis applicationSOUTSOLD MUST be-completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets_of plans,_accurate plot plan to scale.Fee accordingto 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,theBuildingInspector;will issue a,Building Pernut to;the,applicant. Sueh,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. � L Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has-not'been complet4within-18 months-from such`date:'If no.zoning.amendments or'otherregulations affecting'the property have been enacted•in'the'interim,the Building Inspector'may'authorize,,in writing,the extension of the permit fofan” addition six months.Thereafteni a&v 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.onalterations or for;removal or demolition as herein described. The ; applicant agrees to comply with all applicable laws,ordinances;•buildingrcode,,housing code,and regulations,,and to admit, authorized inspectors on premises and in building for necessary inspections: Y - .._ : (Sign&44 of applicant or name'-if,'a'coiporaticn)+, o (Mailing address of applicant), M State whether applicant is owner, lessee,agent,architect,engineer, general contractor, electrician 'plumber or builder Ott)A)a-- Name of owner of premises p ,n 1 -- - - - - ,; (As,omthe,,tax,roll or latest deed),., If applicant is a corporation, signature of duly authorized officer _(Name and titlofficer)_ of corporate ocer) ; Builders License No. Plumbers License No. Electricians License`-No: �,I_ , ; ,.; _, . - . ' '�..-9: . - ,, - ;� � ,. ' ,- ,-. ,�: -„�.� :,; , -_. ,f . s „ � �•, ; • Other Trade's'License No: 1. Location of land on whit roposed work will be done: House Number; Street Hamlet +1fi,3'AT ai�Wl County Tax MapNa.1000; Section„[ a �:V � ;131 bra•ear -Lot :> •gt,•�ts'y apatl'tt��b=lFis6Uf� ,. , .......•..--,G�,�1L`A:;{:fIR�T+�{9Ql42f1tifl`tfi+� _Subdivision' x " Filed Map No. 2. State existing use and'occupancy,of premises and intended use and occupancy of proposed`constructioi:. a. Existing use-and,occupancy b� ntended use and occupan 3. Nature of-work(check which applicable):New Building Addition A Itiation Repair - Removal'" ` Demolition Other'Work ° - (Description) 4. Esti mated_Co_st r ;r Fee { (To be paid on filing this application) 5. If dwelling,numberofdwelling units Number of dwelling units on-each floor. If garage, number of cars {' 6. If business, commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear __ ,Depth Height Number of Stories /P,.—tj I nT "art Dimensions of same structure with alterations'or'additions: Front f V IRear�-?�,`� f� 'Depth Height Number of` brtes V7, drh, w g ' r SU dimensions of entire new construction:Front Rear lie' ,h ern Height *Z,b`-4t> Number of Stories 9. Size of lot:Front Rear Depth an'r r 6 r yff ,Q • l 1. _ ,i _i:l. ! i {,s , - ii 5 ,i ,. 'i i , .i'f i .7`rl •«1 .ar ' + _.k 5 _ .. . rr+�.i '-V -.1+ � ' 10.Date of Purchase Name of FormerOwner tK: 11.Zone or use district in'which premises are situated ' _ `.r, r`. ..,rr'= r` _, ,�fS.r. _{+ ,C: . ;d , ,+,: :+; ;, _.,,, -• .t'a, '',, moi[ , 12.'136es proposed construction'violate"any'zoning law_ r,'ordinane orcregulation?YES NO d .S _ `y,., ,. :1'1,r -vil ,11 i15fn„ 13.Will lo_t be're-graded?YES ISO Will'exces'slfillFbelremoved fronitpremi'ses? 14,Names of O,,weer of,pre_mises; Address_ Phone No. Name of Architect• ,Address ;', ' Phone•No Name of Contractor Address _ t =Phone No. +, ��{ 't' v' ,i{ .. i' .. ,> ;,' �;G{. _ r? '_`;rr-,,..,,{ ,., r' , ',.�jw ....,y, -: ` e' s: A+! :•` "•-: r _'"C-. "' ,� - r 15a.Is this property within,100'feet of•a-tidal weth nd-or a rfreshwater'wetl'and?*YES-,,, „,­NO F YES;-SOUTHOLD`TOWN TRUSTEES&-D:E.C.'PERMITS MAY BE-REQUH EDD',' b.Is'this property'withifi 360,`feet of a"tidal'wv`tland?'*'YES'-''"'• ''''NO +IFNES,�D.E C.PERMITS MAY BE REQUIRED:` 46 -Provi4e,survey,_to scale,with accurate foundation plan and distances to property lines. -47.If'elevation At. point on property is at 10 feet or below,must provide topographical data on survey. I8 �A,re,there any covenants and restrictions with respect to this property? * YES NO *-I�„yES,PROVIDEA;COP.-Y. ,, -�' t: ' . ,.-,,; . ",_c,-,._,f, , ,, ',,, ;•: ..: _ .” , w, • . r; . r. ;l ,- .'�, . .,+1�� 4,_^.� STATE OF NEW YORK) COUNTY OFIYY �S: - - -"' - •__- -_ -- ._ ,_ ._ _-_. _ _ __ .. . _. - _.- - �G N e;o( �d bA.t , 'q` "=being°duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)Heisthe (Contractor,Agent,Corporate Officer,etc.) 1 . 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 lis knowledge and belief;and that the work-will.be-j, . u performed in the manner set forth in the application filed therewith. V Sworn to before me this to +ti° _. day of -f_ebr%jacy- 20 NOTAR ROSE TATALeoN ._ NotaryPublic' Y NO.of iFa ST'Apolicant 14, C*WdN ate Fkd bi New Yak Coun itNo Cuad In KingsC=ft ty Canmts m Expires Aug.5, jrQ? c`�c � Scott A. Russell `s ��` a ST(0 R IMMAT]ER SUPERVISOR a IMLANA(G IEIMUEN T SOUTHOLD TOWN HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of,So u th o l d CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT) - DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING: 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!r& 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 t _.,� 100 feet of horizontal distance. [:1E D_ Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑[EfE. Site preparation within the one-hundred-year floodplain as depicted �, / on-F-IR-M-l�il-ap- of any watercourse. ®Ej r 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. S APPLICANT (Property Owner,Design Professional,Agent Contractor,Other) .C.T-M. 1��� Date Dutnct NAME: �•�(� Section Block Lot _,p. F'0R BU1UANG D EP:\K'r. H T LSLE t),^'LY Contact Information Reviewed By Date. 02 Property Address / Location of Construction Work — — — — — — — — — — — �� f� Approved for procea�tng Building Permit (� ���/� (�N Stormwater Management Control Plan Not Required CQ I �-'1T �� _ F] (Forward Management Control Plan a Required (Forward to Engineering or Re Department fview) FORM " SMCP-TOS MAY 2014 Town Hall Annex ] Telephone(631)765-1802 54375 Main Road �ax P.O.Box 1179 c� rogenrichert e (631)76 Southold,NY 11971-0959 �� BUM DING DUARTN[,NT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: 5+�LR`-t . <3a-r�f-A Date: Company Name: s ;Ac- Name- License AcName:License No.: 3 oa — � Address: � 17 841 Phone No.: -3 JOBSITE INFORMATION: (*Indicates required information) *Name: *Address:*Cross Street:Street: ,� A La,,-Pl d P *Phone No.: 3 Permit No.: Tax-Map District: 1000 Section: 1 oZ . Block: Lot ) � *BRIEF DESCRIPTION OF WORK(Please Print Clearly) t M ��J� \(,,�Lbs (Please Circle All That Apply) *Is job ready for inspection: N ough I Final *Do.you need a Temp Certificate: YES . Temp Information(if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form (� Will 4 • i M + + 7 r �� • � Y; M IF milli It fit Alk 41 s r ... nom:•_.-.. �'' �,,,✓ n * 7'i r T :e. � w I C M � L V ` � � I /v � j � • i X110 .inos &TMO; = a ONI Immag b Cl _ Q kr .1 a S, r , IL � i r Ld L11 TOWN OF SUUTHOLD PROPERTY RECORD CARD '� OWNER STREET -"------ - n r ! DIST .SUB. LOT C. madft I �� n1- l4 )izncf ACR. REMARKS � WrfJ J"r � L�ai��n 11 � �Y� TYPE OF BLD. ------ . 6117/03 w ` PROP. CLASS N lD ! 0 - L r ! d in . LAND 1MP, TOTAL DATE r �` j t ! OSific-e - - I_C _ 07,olo �oope LD m Lo m Ln m ' u� m FRONTAGE ON WATER TILLABLE Lo FRONTAGE ON ROAD WOODLAND -- DEPTH MEADOWLAND 00 - -_ BULKHEAD HOUSE/LOT TOTAL TOWN OF SOUTHOLD PROPERTY JkKORD CARD OWNER STREET VILLAGE DIST. SUS. LOT !J ,�'. 73 P+ b L t-- J R N i cf 1 1'�(� t> r gr f z !ri.� f4 A! S f S FORMER INNER �iiYGGr �r n V AR E ACI . . . rr w Pr w • W TYPE OF BUILDING p RES. W/USEAS. VL, g FARM COMM. CB. MICS. Mkt. Value m o LAND IMP. TOTAL DATE REMARKS wIn (' 00 C� / / / i J 191 to c�� f 1.46 c) � -� z �� + �I.p -�4c� �" -r-r L:`i~5 i a � o n cf) r._ yc �� -5'/�d �9 �- 8[)'*J s z- eon . O-Ae n, A kae I Z��' :0700 -�� SDO a o o + 026 �` J - - Q,,L 4- 4 1 a- Ll 653 1- rt r°� -{o r tr+t �wr �kl Y 5VS K -4o Car)5(n.� r:4I t�' a 4� m LO — Lo n - m- U0 �Tillabie FRONTAGE ON WATER mWoodland FRONTAGE ON ROAD ^/ r U0 -Meadowland DEPTH V N i ° °House Plot BULKHEAD m m Total 4 M-5 ■■ ■■ ■■■■■■■■■■■!■■■■■SEEM ■■ ■■■■■■■■■■■■■■■■■■■■■■ ■NONE F, _� .. ■■■■■■■■■■■■■■■■>■■■! ■■■■■ ` ` 1 ■ ■■■■■■■■■■■!■■ ■■■■■■■■■■MEMEMONLONEMONEN Nomoom No n■ MENIMELININEmfmmm ■■■■■■■■■■■■■■ ■ ■i.,■■■�■■■■■em■■■■■■■■■■■■■■ ��1�■■i■■■lr��.i■■■■■■■ ■■■E Foundation Basement Interior.Fjnjs� Wm� ' . '- .. •.. . c;lc;lr r MIAn SIAIE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSAIION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb„Business Ielephone Number of Insured Triple A Pools&Spas,Inc. 631-363-0510 50 A Purick Street lc..NYS Unemployment Insurance Employer Blue Point,NY 11725 Registration Number of Insured WorkLocation of Insured(Only required if coverage is specifically Id.Federal Employer Identification Number of Insured limited to certain: locations in New York State, Le.,, a Wrap-Up or Social Security Number Policy) 113551370 2„Name and Address of the Entity Requesting Proof'of 3a„ Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Commerce and Industry Ins.Co. Town of Southold 3b„Policy Number of entity listed in box"la" 54375 Main Road WC 082312 14 Southold,NY 11971 _ 3c. Policy effective period 5/2/15 to 5/2/16 3d„ The Proprietor,Partners or Executive Officers are B included.. (Only check box if all partnerslofficus included) ❑ all excluded or certain partners/officers excluded„ This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy),. The Insurance Cau ier or its licensed agent will send this Certificate 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 dare 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 maybe sent by regular mail) Otherrvfse,this Certificate is valid for oneyear after this form is approved by the insurance carrier or its licensed agent,or until thepolicy 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 car tier referenced above and that the named insured has the coverage as depicted on this form ApproN,ed by: Eugene A.Bartow Eugene A.Bartow Insurance Agency,Inc. (Print name of authorized representative or licensed agent of insurance cagier) Approved by: 4W. 0 X4W. 1217115 IV (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-242-4745 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-1052 Insurance brokers are NOT authorized to issue it C-105.2(9-07) www wcb state ny us �--� TRIPL-5 OP ID: PM A�ofRo CERTIFICATE OF LIABILITY INSURANCE DATEIMWDD/YYYY) 12/07/2015 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(ies) 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 Walter Rose Agency,Inc NAME: Walter Rose Agency — 8 Stage Road PHONE.Extl:645-783-2555 'FAX ^— Monroe,NY 1095Q EMAIL ;{Alc,Hol• 845-78.3-2425_ ADDRESS' INSURERS)AFFORDING COVERAGE NAIC k _ INSURER A:National Fire Ins.Co. _ 2047$ INSURED Triple A Pools Sr Spas,Inc. INSURER B: -� 50 Purick St Blue Point,NY 11715 INSURER C. - 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 A60L UB I POLICY EFF POLICY E7(PT -- LTR TYPE OF INSURANCE POLICY NUMBER MMfppIYYyY� MMIDD/YYYY LIMITS A , X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE X OCCUR 6016676892 10710112015 07101/2016 Fp^" EEaENT sS nE $ 300,00 — `MED EXP(Any one person) S 5,00 I PERSONAL 8 ADV INJURY 'S 1,000,00 GEML AGGREGATE LIMIT APPLIES PER ( I GENERAL AGGREGATE S 2,000,00 PRO- F PLOCOLICY JECT I_ ; I I PRODUCTS-COMP/OP AGG S 2,000,00 OTHER- — AUTOMOBILE LIABILITY ' COMBINED SINGLE LIMIT $ ' i � (Ea acadentl ANY AUTO BODILY INJURY(Per parser) $ ALL OWNED SCHEDULED - AUTOS AUTOS I BODILY INJURY(Per accident) $ ' HIRED AUTOS AUTOS YNED 1 i PROPERTY DAMAGE AUTOS $ 1 Peracadent _ --_ i$ UMBRELLA LIAS OCCUR I �— i EACH OCCURRENCE EXCESS LIAB CLAIMS MADE AGGREGATE _ $ DED RETENTION WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N } i STATUTE ER H ANY PROPRIETOR/PARTNER/EXECUTIVE i E L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED N 1 A (Mandatory In under --- If I E L DISEASE-EA EMPLOYEE $ yes,describe w --- DESCRIPTION OF OPERATIONS below I F l DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 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 53095 Main Rd. AUTHORIZED REPRESENTATIVE P O Box 1179 Southold,NY 11971 C ,Q, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD A � ��ED AS N� TED DATE: B.P.# ® - COlArPL Y glTH ALL CODES OF FEL Oro B`f: NE1�4' `'t'� '{ STATE i E TOWN CODES NOT Y BUILDING DEPARTMENT AT AS REQUIRED A"`--GGNQ 4QNS-OF 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: �� T 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE Shu`7vi- �',' EES 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.G. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW ELECTRIGA YORK STATE. NOT RESPONSIBLE FOR ,� DESIGN OR CONSTRUCTION ERRORS. �mspEr ' pixj "IMMEDIATELrw 4 RETAIN STORM WATER RUNOFF ENCLOSE POOL TO CODE, PURSUANT TO CHAPTER 236 UPON COMPLETION OF THE TOWN CODE. BEFORE"WATEH 2UPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY SIZEAFT) A I ID I Cj D I E I F I G I AREA CAP. . y FT. GAL 20X40 201.40 10 10 20 3 7 800 32000 DIVING BOARD _ LADDER .. - INLET [ INLET-.FITTING • J 'fir I/ AUTOMATIC SKIMMER _ �• UNDERWATER O LIGHT o TIONAL)' O !I G 1 r MAIN DRAIN 12" PLAN c Q 0 GENERAL NOTES- ''�='�' .+ GXe y1 SECTION A—A •� TILE FACING WATER ' 1.THE DESIGN IS BASED ON A DRAINAGE SOIL WITH<10%SILT •''�• •• LINE _ GROUND WATER SHALL NOT'EXIST WITHIN THE LIMITS OF THE '-I•?;•:• -; 1 2 WASTE FILTER EXCAVATION.IF GROUND WATER EXISTS WITHIN W-O'BELOW •t•� PUMP HAIR B LINT ' GRADE SPECIAL D,E}WATERING FACILITIES WILL BE REWIRED, r• "a= o f CATCHER SKIMMER WATER.yNSPOSALISLIMITED TOOWNER'S PROPERTY •i•'•�t `i - L ' 2_NO SUIICHiRGE ALLOWED WITHIN 4'-0"OF SHALLOW END °•� `r�: p --WATER LINE -- AND 6�-O"OF DEEP END. 3*3 BARS "•--�. '. ':� ►• • rl� RETURN TO CONT BOND BEAM w °A 2 3.THE PNEUMATICALLY APPLIED CONCRETE IGUNIT E)SHALL ' rr�� > INLET i ALL AROUND (� MARBLE BE A Y4 MIX WITH A MAXIMUM OF 3/2 GALLONS OF _•:; •fit} DUST a 1 WATER PER SACK OF CEMENT. TIES YL"OC f_t :•-. FINISH = MAIN DRAIN 4. REINFORCING STEEL SHALL BE INTERMEDIATE GRADE BILLET STEEL WITH A•MINIMUM LAP OF 30 BAR DIAMETERS. =,+ -..j• S POOL WATER SUPPLY BY OWNER'S GARDEN HOSE. POOL TO DE KEPT FULL DURING FREEZING WEATHER. >I'r( ;.•` RADIUS VARIES _ SCHEMATIC PIPING ARRANGMENT PUMP CAPACITY TO BE SUFFICIENT -TO EMPTY POOL •'f' 6'1.24"SHALLOW END `'IN 24 HOURS - 25"UP ON DEEP END '�•;. 03 STEEL REINFORCED ^II W`4 CONTRACTORn �'• j DEPTH <5'-O" • �" �- WALL SECTION _ HORIZ. 12 0 B' oc � -q B_ B ��'•`;� VERT Iz".o o... G"uc � i? T' � ;5^y 1 .C? ah`� ty •OWNEFI i '��I ^�9 f 0F'1 iia�,'OV f �"d SURVEY OF LOT 19 MAP OF �r �� HIGHLAND ESTATES 0� FILE No.6537 FILED APRIL 26, 1977 SITUATE CUTCHOGUE TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000- 102-08- 16 SCALE 1 "=30' ��000 JANUARY 27, 2016 t � AREA = 41 ,271 sq. ff. 0.947 ac. _1k . e S NOTES: 1. ELEVATIONS ARE REFERENCED TO AN ASSUMED DATUM ` EXISTING ELEVATIONS ARE SHOWN THUS:.�_(X_x ` ���• FFL. - FIRST FLOOR 'X Fti S 41 GJ v2 S i \ fit^ °C,f• \ <1\ \ � ° a � PB . 4 o J a of tiY �F9 0 f o �G x �0 61 1 4IG��1 n 9AP° / '10 n \ 6O+c° Co �v� �Gp \/ 46. 9 \ °��� a s .8 x Q� GOO O J6b G�\\��Fy x .�O e �Q 1 6 47. \ x oho o `��GPR F P{o°� \�. 0�\� 48.5 92 \ 48.4 20 O s i. x a8 1 \ \ 48.. I � o� 487 ^j 0 OQ'OGJ�O R SQ . �J^ 48.0 \Pss.s Q so.z 5 0, x \ 0 1, \ 57.`a _ - 50.7 T0° 49.2 ^'��.,3 \ Q 9 7 /61.6pA �Fn m F x _� �Pz� °J`�°' 29. y cF o 'p<°_ g8 s sr° x 40'4 x 60.z A. �`��F�9`\ P OL �S.G° , yFo x x O \ ��F c 055.3 SpfZ ��P�E O ` x'91- x�7{Jycc� O x �.l'�Y�� �• PREPARED IN ACCORDANCE WITH THE MINIMUM q- � STANDARDS FOR TITLE SURVEYS AS ESTABLISHED Q ('_ BY THE L.I.A.L.S. AND APPROVED AND ADOPTED �\ 59 3p q> x 52 9 Q �P 51. TORE SA SOCIA I UCH E BY THE.TR7£W`70MF-SZATE LAND All x�ti 62.5 N.<TIS or co Y<< Zl►:Ft Grb� I 4,y"1 C'�d 588 SJ. CP A p 99 C�� x 25 57.1 O01�1 �ci"erg ra N.Y.S. Lic. No. 50467 nth,�- O 64.0 .�\ V UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SO �/ SECTION 72OF THE NEW YORK STATE C G�T� EDUCATION LANathan T a f t Corwin i i i � 0 �� �<v M!^�~P LAW.COPIES OF THIS SURVEY MAP NOT BEARING o o F 1 THESURVEYOR'S INKED SEAL OR Land Surveyor ��o o•( EMBOSSEDLLT BE CONSIDERED 62TO BE AVALID TRUECOPY .8 _J CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Successor To: StanleyJ. Isaksen, Jr. L.S. TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND Joseph A. Ingegno L.S. TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE, Title Surveys — Subdivisions — Site Plans — Construction Layout PHONE (631)727-2090 Fax (631)727-1727 THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILING ADDRESS AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16 ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947 36-008