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HomeMy WebLinkAbout41656-Z %,afFo4Town of Southold 7/12/2017 y P.O.Box 1179 0 • g 53095 Main Rd yI►�l �ao� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39049 Date: 7/12/2017 THIS CERTIFIES that the building DECK Location of Property: 1205 Route 25, Greenport SCTM#: 473889 See/Block/Lot: 35.4-25 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/11/2017 pursuant to which Building Permit No. 41656 dated 5/23/2017 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: DECK ADDITION TO AN EXISTING ONE FAMILY DWELLING (COTTAGE#49)AS APPLIED FOR The certificate is issued to Peconic Landing @Southold of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED th ed Signature `oSUFFD(,� TOWN OF SOUTHOLD BUILDING DEPARTMENT 9 TOWN CLERK'S OFFICE o . SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 41656 Date: 5/23/2017 Permission is hereby granted to: Peconic Landing @Southold 1500 Brecknock Rd Greenport, NY 11944 To: construct a deck addition to cottage #49 as applied for. At premises located at: 1205 Route 25, Greenport SCTM # 473889 Sec/Block/Lot# 35.-1-25 Pursuant to application dated 5/11/2017 and approved by the Building Inspector. To expire on 11/22/2018. Fees: SINGLE FAMILY DWELLING -ADD TERAT $2 .80 -ADDITION TO D LLING 0.00 Total: $326.80 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 propery 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., New Construction: Old or Pre-existing Building: (check one) `' Location of Property:/ chiz2 )i�6 L_ (-tq- F ��QO �.. 4:q_ use No.. Street Hamlet Owner or Owners of Property: C ec'avll C- Suffolk County Tax Map No 1000, Section Block / Lot Al LSubdivision // Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: V (check one) Fee Submitted: $ 1150 Appl icant'Signatur { �pF SOUTH 1 � O courm,��' TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ FOUNDATION 1ST [ ] ROUGH PLBG. [ ] UNDATION 2ND [ ] INSULATION [ FR. / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRIC (FINAL) REMARKS: f06,nN6o �(WAYui DATE low, INSPECTOR �� Of SObT N O i TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [FINAL pWL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS- DATE ANSPECTOR 1 � Y FIELI3 TI�S'T'�C"S�g1`7 T�.E�'OI�x CD ,�S '• � • S.to FOUND,.tON;(ISTD t� - • ........... , ----------- � cl I'OUND,,�J`zION'J(2NI5) • I � ROUGH FF 4Nn, NC PLUMM7 'G — t i I 1 INSULATION N.Y. STATE EI�EI. dY COSI; FJNAT� 1 . ►o NJ o"N z 1 , 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 Dets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 I Oryey SoutholdTown.NorthFork.net PERMIT NO. 1C Check Septic Form N.Y.S.D.E.C. �Tr�ustees .Application Flood Permit Examined / —,20 Single&Separate Storm-Water Assessment Form y � ontact: Approved ,20 l Mail to: Disapproved a/c 22 ^^ Phone-121—tal"x4 SD Expiration 1�201 kf' Q—�_u ��LS V L5 Bu nspecto MAY 1 1 2017 PPLICATION FOR BUILDING PERMIT Date �Q,,tj. , 20� BUILDING D)EPr. INSTRUCTIONS / TOWN OF SOUTTHOLD a.This application 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 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,h ing code,and regulations, and to admit authorized inspectors on premises and in building for necessary i ection / t, At I (Signature of applicant or name,if a corporation) ch RD/o)- j�"[Tl -t , (Mailing address of applicant) It qq` ` State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises Cc, (As n the tax roll or latest deed) If ajjplianys c�,ration, ature of du au t or' oDer ( am d title of corpor to officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which roposed work will be done: House Num er Street Hamlet County Tax Map No. 1000 Section Block ( Lot 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 N�AL n. 9 b. Intended use and occupancy �l► 6�L ��r(i i►�L L( V i P16 r, d- g�t4 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost Fee (To be paid on,filing this application) 5. If dwelling, number of dwelling units l Number of dwelling units on each floor_�Srn16LF EtfpQ 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 d _- Dimensions of same structure with alterations or additions: Front �l� Depth Height Number for Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories V ' 9. Size of lot: Front Rear Depth 1 . Date of Purchase � Name of Former Owner �c CA ► G 1'.. Zone or use district in which premises are situated 12. Does proposed construction violate any,zoning law, ordinance or regulation? YES NO ,I 1 . Will lot be re-graded? YES NO Will excess fill be removed from premises? YES NO 1 . Names of Owner of premises ,` Address /§r 8,6r �xx,K Phone No.�Jj-479 6?0'6 Name of Architect AIA IL 'ScAlw UAddressfC -o W _- Phone No, 3 i c _ [9f Name of Contractor 11>S CoKP• Address 69 0 LJoo R .Phone No. o �`rort`l �a2do/��lj,y .1I7�v ' 1 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 IF YES, D.E.C. PERMITS MAY BE REQUIRED.- 10. 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. 1 . Are there any covenants and restrictions with respect to this property? * YES NO 1/ * IF YES, PROVIDE A COPY. , S ATE OF NEW YORK) SS: COUNTY O 4) 4-,6 "1s k 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; th t all statements contained in this application are true to the best of his knowledge and belief, and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this day of 20 /7' LISA QUINN OTARY PUBLIC-STATE OF NEW 0 Notary Pu rc No. 019U622244 Si nature ofApplicant Qualifled in Suffolk county g Commission Expires May 24, 20Z YOB Workers' CERTIFICATE OF INSUPANCE COVERAGE I►rt Compensation UNDER THE NYS DISABILITY BENEFITS LAW Board PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured JDS BUILDING CORP 631-751-4698 1c.NYS Unemployment Insurance Employer Registration i Number of Insured 9 OLD WOOD ROAD 0599434 STONY BROOK, NY 11790 1d.Federal Employer Identification Number of Insured or Social Security Number 112735168 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) ShelterPoint Life Insurance Company Building DepartmentlTown of Southold 3b.Policy Number of Entity listed in box"1a": Town Hall Annex Building DBL150894 54375 Route 25- 3c.Policy effective period: P.O. Box 1179 08/02/2016 to 08/01/2018 Southold,,NY 11971 4.Policy covers: a. © All of the employer's employees eligible under the New York Disability Benefits Law b. ® Only the following class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described ab ove. Date Signed 5/10/2017 1 ifild(of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer IMPORTANT.if box"lie 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"41Y"Is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disabil Ity Benefits Law. It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit.328 State Street,Schenectady,NY 12305. PART 2.To be completed by NYS Worker's Compensation Board(Only if box"4b"of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by the NYS Worker's Compensation Board,the above-named employer has compiled with the NYS Disability Benefits Law with respect to all of hisiher employees. Date Signed By (Signature of NYS Worker's 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. D&120.1(9-15) ` ® DATE(9/20l A 17 �.� CERTIFICATE OF LIABILITY INSURANCE 5/9/2017 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CO TCT MSA Service Center NAME: AGENTS ADVANTAGE INC CL SC PHONE EtI, 866 676 3854 AIC No,.1866)332-4776 PO Box 2006 ADDRESS:servicecenter@msacjroup.com INSURER(S)AFFORDING COVERAGE NAIC 4 Keene NH 03431 INSURER A Main Street America Group 29939 INSURED INSURER B: JDS Building Corp INSURER C: 9 Old Wood Rd. INSURER D: INSURER E: Stony Brook NY 11790-1011 INSURERF: COVERAGES CERTIFICATENUMBER.-16-17 Master MP 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 POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE I SD POLICY NUMBER MMIDDIYYYY MMIODIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000 A CLAIMS-MADE FOOCCUR FREMISESIEaoccurrencel S 500,000 IIPZ5B68B 5/28/2016 5/28/2017 MED EXP(Any one person) S 10,000 PERSONAL RADV RIJURY S 1,000,000 GEN'LAGGREGATE LIGIITAPPLIES PER GENERAL AGGREGATE S 2,000,000 X POLICY❑MSOT F-1 LOC PRODUCTS-COMPIOPAGG 8 2,000,000 S OTHER AUTOMOBILE LIABILITY Ea acccidenyIIJGLE UM.11T tS GODLY INJURY(Per person) S A1JY AUTO ALL OWNED SCHEDULED BODLY INJURY(Pei accident) S AUTOS AUTOSIJED PROPERTY DAMAGENON-OWS HIRED AUTOS AUTOS Per accident S UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS UAB CIAIMS-MADE AGGREGATE S S DED RETENTIONS P WORKERS COMPENSATION STATUTER 'ER'" - AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNEIVEXECUTIVE EL EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? N I A EL DISEASE-EA EMPLOYEE S (Mandatoryin NH) If yes,describe under E L DISEASE-POLICY UI.IIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks SchedWe,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Tota Hall Annex Building AUTHORIZED REPRESENTATIVE 54375 Route 25 P.O. Box 1179 — Southold, NY 11971 Joel Heller/SPD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025120-.41 i v t ACA O' oATErIY+rn k..-- CERTIFICATE OF LIABILITY INSURANCE 5/9/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710H 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. TMS CERTIFICATE Of INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREF43),AUTNORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT-H the urtlEcatu rlolder O an-AbblYMNAL,INSUM6,the pD cy( )must Fe endorsed If WBROGAVON 18 AIVED,sublM to the termsand condlSons of#*policy.ceMn policies may require an endorsement A statement on this eemtleate does not confer tlghts to the cerolcob zdsr In Oeu of such W40750M4114 PROOVUR ;True . MSA service Center AM= ADVANTAGE INC CL SC A Evil.866 676 3850 A x 1Of61332-1T7s !O Boz 2006 $$A_ serviceeenterensagroup.can bl AFFOR05rI3 COVEEA6E a tKUG• Keene NH 03431 MSMRA Main Street America Gro 129939 Iros+suD "sum a. JDS Building Corp 0811RERC. I 9 Old stood Rd. z N80PERD FOURERE. Stony Brook NY 11790-1011 <ftWRMF COVERAGES CERTIRCA7E NUMBER_16-17 Master MP REVISION NUMBER: THIS I5 TO CE4TIFY THAT THE POLICiSS OF INSURANCE LISTED SELO'1Y HAVE BEEN ISSUED TO THE INSURED NAMED ARMS FOR THE PO-ICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREW04T.TERM OR CONDITION OF ANY CaWRACT OR OTHER DOCUMENT t%TTH RESP-ECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURMCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A_L THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LLVIfS SH(%%W MAY HAV€®FEN REDUCED BY PAID C:.AM ' TrFE Of eIStEIAMCE poucy F ia uum x Tc--,ft G317691M UAeitllr } 1 eACn c+��.ttEm (1 1.000,000 r— A ' �CLa1t�IIAL'E �jr,,aGfiLm ! j � kl.���4.1�T- �;,.y.�8 500,000 i j amz5B66t #5128!2016,5/28/4017 woEv-LAM% j # 6f?T�ft4t eArn rliA�tY s 2.000,000 'GE LAGGREC4:E UMT AFFLES PER I i i GRIEWL AGCRESATE is 2.000,000 X,P L.J•!�i•NY l4C I { } ffi.Ol4.T$•CC 3PA £ S 2.000,000 alnTt: s � I S AUTOICerLEUAStLh '- ttn_u.-t:ilG MI 's ASI`AUTO I t 6C;Clly l9Alti• 4 t .ALL_-ME. !SCICC LED i { i EJOIy'IislR•.Rr cx.x=S! S A.UT,� _ Atm-.S ItREE>nA3%F'-:t I �tiUrt c E 5 � . 1 {umBRELLA UAB •r4�rR ; i - ' - GV=l1 L'Cv_L♦±-'AETS _ S_, _..__,-- aEExC`ESSUA9 - filANz-tIME_}f (Si llsCtiEiJ.'E i� Y S T l4YWRIUMMIFEHMn011 !} i f tA%DEMALOYt wLtAISLITY •?Nk f 7 i�_.=.$.?S,i41TE.-: 4 f!P FReFMill;1, fit^-147A t1tNF IAA w*IP STRprLlSay la lei] - l E L MEASE•EA EUGtrYE 3 +.ysa pn:•W u�e9a• +El[i S£A.3E_PtuCY IIt!' S ` OESLC�11Cr�OPEWAAO�tItLR��91flYHfCE1 fAC0�10f,Al�MMQntYb2tl�e�6�.r►Nb�OMMMf6�te EfMY�iB ' CMRCAIE HOLDER CANCELLATION SMOYi.DAMY O*1Nt ADOME O�pll{W AOilglifE�l.LtD�0� D"M DOP=tmmt SIE laminal 0Y oAim lIstwi NONCE ILL W OELNGM M TOM of Southold ACCONQAmm"TME gouty a41IN a& i '!Tota Hill Ammo SUUALaq 59375 lUmte 35 wtwtwEo ae�u►n►t P.O. sox 1179 - r smtbad, my 11971 �tllt�pf9ACORDCORDORA71011.AN�ighesrestnid. ACORD251MAMI 7MACORD�miiad Wgoaw wge�arda�stksd ACORO IMS�IS.T-•a-� a State of New York WORKERS' COMPENSATION BOARD NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS EMPLOYEES UNDER THE NEW YORK STATE WORKERS'COMPENSATION LAW TO EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE TO: (Print Name and Address of Insurance Carrier Here) TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers' Compensation Law with respect to all the pglicies issued to the corporation by the insurance carrier named above. Name of Corporation 1.� Address of CorporationIF J ll Incorporated Under the Laws of the State of Type: froviOne-person corp. ElTwo-personcorp. (A two`pperson corporation may elect to exclude one or both executive officer , ded that between them they own all the stock in the corporation, and that each officer owns at least one share of stock.) ExecubveOfffcer(s) 1. Name ��J�—' J`� l Tile to be Excluded from Policy 2. Name Title CERTIFICATION SE FOR ONE-PERSON CORPORATION 1,, 1Z_ �RX W , certify that I am the sole executive officer of the above-named corporation;that I a have been since Y the sole owner of all issued and outstanding stock of the corporation and hold all the offices Date pursuant pt4 a graph (e) a 'on 715 the Business Corporation Law (A x corporate seal below,if you have one.) Signat of Officer Dat Telephone No. USE FOR TWO-PERSON CORPORATION We, and Name Title Name certify that we are the two executive officers of the above-named corporation, having been -rtle duly appointed by corporate resolution;that we have been since the sole owners of all issued and outstanding Date stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to paragraph (e)of Section 715 of the Business Corporation Law. (Affix corporate seal below,if you have one.) Signature of Officer Date Telephone No. Signature of Officer Date Telephone No. THIS ELECTION IS FINAL AND BINDING UPON THE OFFICER(S) NAMED UNTIL CORPORATE REVOKED BY THE CORPORATION. SEAL` See reverse side for relevant portions of Sec.54,subd.6(WCL) *If the corporation does not and Sec.715,Par.(e)of the Business Corporation Law. have a seal,check here C-105.51 (1-04) www.wcb.ny.gov wodmv CERTIFICATE OF INSURANCE COVERAGE UNDER THE MY$DISABILITY BENEFITS LAW PART 7 To be completed by Di oOfty Benefits Carrier or I lnsttrance ABsnt of that Carrier 1a.LsgdNsfnewWAddmssafheud(LhesU+estaW 1R8tainessTeiephoneNun6erarimreed JDS BUILDING CORP 631751-1698 1e NYS Lbmmplwymed lnsr rmm 6nptayorRegiswadm Number of brad 9 OLD WOOD ROAD 0599434 STONY BROOK, NY 11790 1a F.aaral Employer ldn0ficoMm Murrberaf lrrnrad arSoeial Searity Number 112735168 ZNww ndAddna$ortheEhvtyrswms ngPi arlensane cwter (Er tt bring lisfed astheCerti%=w Holdw) shenwr at ub hugra as company Binding DepamnentlTown of Soot d 3b.Pdiey NuriberorEntity tistd inboa"tai Town Hall Annex Buiflding DBL150894 54375 Route 25 3cPaUcyiO1t P.O.Box 1179 081022016 to 08101/2018 Southold,NY 11971 4.gray novas a.® Ali cram emptoyeesemplayasenquewlertleeMwYatDftdd t 8wditsLaw b. Only the fdmwbvdmsardmnofttnenplayeeseamployas Urr wpmuftcfpwju%lartftdmlamannahwiudnpresetatioarlianudsjmoftbeinsuartmm.i rnerwaad abmewddmdwrraroeIinsuredhasNnDtsabilkyBerefimhum=savmapasdeswibedabove: 51102017 , ��� {min►ofMaa,raamnidsa�asr�Aee�pr .ar ellrs tieenea temrr�aAgmrofe�aR iraasanuetrrter) Telephons N516-829-8100 Tide Chief Executive Of er lLW0 TAW.frons,artse mkw&mwtM ram,tsstgbydatmeaea im'sumimiaar .orUt3uameabnsaamagm artlrrenrrbrdttsarr<iflab isf50[NPtErERudi ttdaahrmo,.arnnat.aate.. irtmoarbd■rkmteismwimaabnrorcaWWMroruwpnpo atSoomnLSeasarw.Dtmb§ny ta.c rtnrnte.mtlbaroreom{U.tlaumnrwarlorPsCaeq�taoaeerd,cisPlasAeerpWims uaR��e� .N1r11!3o6. PART 2.To be compleed by NYS Workees Compettsatiott Board(Only N box'4b"of Part 1 has been d ck9M State of Now York Workers Compensation Board Aaeadtngm IrMsrmrt�nrr�rtrrrdtsyrir Mrsvrartrr�s Voo�p.�srnrntior4nnabo�r.arara eeriproyaraasasbnprtadrraastra Mrs Dir errMm caw vsam rnspret b aN a<airlarr.sipw�s DatoS%pud (Stgoasrar<d MYS Mtaka's Coa�r�rian Hard Tdeplrwre Number Title Pleae Note:OWy hwmww cordes licensed b who NYS Disability Benefits brats==polides and fM Lkwwed Inus we Agents of those insurance carriers are audwind to issue Farm DB-1211.Irawrsa w brokas aro NOT mutlro n d to iwuo tus farm. DS-12o.1(9-]5) 294 294 2erl 1;If ol OP pr -1: 16 OP �r do S�% 1% .......... Vk% 2 cN 27 27 EetEdB ® , Nip, NO © b�•v. f6 sivc"� � b, lominrr�nseaa� 77 e SEE SMIS]&4 FOR NUNCANE MRAPPINO CETNL I- *-LAWLLQrA1= f.ln _ n . 'law• M y�y�.nt Nau 11�A0mo-amrfl Mi .—ti, loa=`_�7iR�.r'.7Cr." �..-ial.�■�•• r..n u t•R�• � N`.wu■. s s Ft I. D u s iO _(D—_ mp law -m ` Qd e �p 1/r eOP ' • N '° °�,� "" '�•°"" .■_■uYeA. RECEIVED rr Nam SEP - S 2t A N .11/t ... ..e. y a ■ THIS WNGTAS . D Y..Y. ® 3 s FROM APPROVED PLANS D OR E - mom � APPROVED SY5fEMS DRA NG$. - 0 '4 .....w .r REEEABlW FOp Z ... u.. ■ n+muerna Released for --- o nom A%ax ro •Ir ac.' Production re N �•�• 00-m sl ® © DATE:Sl: aQQQ, awI1„w m MA- rtsas 1./I■.I■FI. Aao. } NOTM'' FAQs uue.l eTF ele Cwsm 1'" . L wo w Ce. -TyyF!( WRAP *rww WmUL.L...e *.j na Cem IG41r_ ro '�• ALNOOHEA�S N BE 7•T' r •Aly#11[fIfEWOyR�pW�ApLLS TO NAVE DBµpL1{TOP PUTES w �-�—�M* > : AO�SS „D i NSiALIEO DN.SNE BY ouga I 67090 P7aF�im REVISIONS �� KOM UWOWO CUSTOMER: COTTAGE#49 GENERAL NOTES sWLOAD-20-P.M �°oa 1. .P W Nae W M1oae FlOR 6uloellF oRrol wHT a •ALL Tm■smamS U)VALLA.omm ]/r•Ir PLvw D emma wmm SWN 3r AFF FOR vium Hmack'" CiUD o nm PIAS 1 .Ai Omli FSU.OE Rn•S4.1/INRaJON 4"•low WW.=nun,F�Ft NAu M f EY TAn O.P.e•Air -aAB 6M9 w a y�Q7nJg1 MI alcr w nn ra etoR m RUn RA,N FAN�viF m se elDl of if0.5E la tistyrol roR eulwon rutueE GBINET IIaIR ++. c A r w1191 as. a w.r sp• Aws 1 rrmW.IID sues 1 s rrE 11 ,,, oA>t .IOIq 1 •R VAW1Y GeNciS/JO o00 1Ot1It 3/4' R AU 1�/T MIDBO Im101roFeeR9O1//0REa* I4 m rL 10391N,Bi8, REVISIONS i Oo° ® 1 i LEDGER BOARD TO BE FASTENDED 1 TO BUILDING WITH TIMBERLOK® SELF-COUNTERSINKING SCREWS O BY OLYMPIC MANUFACTURING , (2 SCREWS @ 32"O.C.) ' , , o (5)2X_6 ACQ — (5)2X6 ACQ_ � O TIMBERTECH DECKING N N U r\ H V 1 go, 1 O i 12"dia.CONC.PIERv e Z 00 /• a 3'BELOW GRADE C) o y (TYPICAL) 1 ` V e^1 _ 3)2X6 ACQ .3j 2X6 ACQ. . . . - ----------------- ------------------- c 8'-0" 8'-011 ~ 16'-0" t 16'-0" FLOOR PLAN SCALE: 1/4" - 1' FOUNDATION PLAN SCALE: 1/4" = V z Ix w o0 U W Q 0.i ri C,0UC'� W 1!�- FOR EXISTING 5 2X6 AC (3) 2X6 ACQ �. Fii.I`',! 2X ACQ LEDGER O Q GIRDER GIRDER N 6` CC��'°.'i,.-i E F'.""I C:,"). w/ FLASHING - , o- E,t_� ce��,s�rr,u,;�;��,; ;�°-�,-� I, _�. TH:� � p!t (��—,�Fg'/t 5/4" DECKING QU-77:,,,E;TC OF I;: L �� c� c _ : ' 2X6 AC 16"OC 2X6 AC 16"OC GRADE YORK G. E. k�,O� IF`J;F '" � ; ��� � L �..{ STATE. � :-, �.���tcS L� �5 __ T , T!'011 EFF ; t a ,� 1,.. ' 44 1 — ���� per. 11 III '--� I��-11 •�' ����— i��� i — , J _ —IIII;-1IIlIi �1: — .c tl ����� IIILIIIihiIII1= •�d —III A ter. r1 • a .�� �..,_ ,gt,, '�/ O III---Iiiillll=. t— 12 dia. o • i . • t � Z CONC. v Baa .e v .� ao PIER e - 1 'AiEn CFF o •a v q Q p rTn tr.) (Tt'^�' l� F! z �ti�,SU,",�j ►0 CFIRPTEn 236 z Ch TLhE TQ�'`�i� Con" H a C� ACROSS SECTION t X SCALE. 3/8 - 1 DRAWN: MH MS SCALE: 1/4"=1'-0" JOB#: ., May 02,2017 -4 . 1233 t` �+ SHEET NUMBER: OF Ns-e Arl REVISIONS \X/IND LOAD -PATH CONNECTION AND CONSTRUCTION DETAIL DRAWINGS USE THE FOLLOWING OR APPROVED USP METAL CONNECTORS FOR PROPER WIND RESISTANT CONSTRUCTION. FOLLOW MANUFACTURE'S RECOMMENDED INSTALLATION INSTRUCTIONS TO ACHIEVE MAXIMUM UPLIFT LOAD CAPACITY. 4"MAX. 4"MAX. 4"DIA.MAXIMUM 4"DIA.MAXIMUM POST GIRDER/HEADER 0 � n o p OOO OO 10 M � • POST/COLUMN 0 Z 12"x12"xl2" CONCRETE FOOTING + . •+�• ° m DECK POST FTG.CONNECTION DECK/PORCH RAILING LOCATION I USP NUMBER I DESCRIPTION APPLICATION 4X4 POST I PAU44 OR WE44 1POST/BEAM ANCHOR APPLY TO EACH FOOTING STAIR RAILING POST-TO-GIRDER/HEADER CONNECTION USE MIN.(2)1/2"DIA.GALV.BOLTS WITH WASHERS AND NUTS 6X6 POST IPAU66 OR WE66 IPOST/BEAM ANCHOR JAPPLY TO EACH FOOTING N ti 1-1/2"SPACE () a m M MINIMUM HANDRAILS GIRDER U w 00 Z POST U GIRDER/HEADER a x r\ 5. U er RIM/DECK JOIST POST/COLUMN ••i ��� BALUSTERS o CONCRETE PIER o •�' cr OPEN BALUSTER ATTACHED TO WALL HANDRAIL CONNECTION ALL HANDRAILS SHALL BE CONTINUOUS THE FULL LENGTH POST-TO-DECK CONNECTION OF THE STAIRS. HANDGRIP PORTION OF ALL HANDRAILS HEADER/GIRDER-TO-POST CONNECTION SHALL NOT BE LESS THAN 1-1/4"NOR MORE THAN 2"IN LOCATION USP NUMBER DESCRIPTION APPLICATION CROSS SECTIONAL DIMENSION,OR THE SHAPE SHALL USE MIN.(2)1/2"DIA.GALV.BOLTS WITH WASHERS AND NUTS (2)BEAMS PAU44 OR WE44 POST/BEAM ANCHOR JAPPLY TO EACH PIER PROVIDE AN EQUIVALENT GRIPPING SURFACE GIRDER/HEADER TO POST/COLUMN CONNECTION (3)BEAMS IPAU66 OR WE66 IPOST/BEAM ANCHOR JAPPLYTO EACH PIER FLASHING TUCKED UNDER TOP PIECE OF SIDING AND LAPPED OVER FIRST CONTIN. C/] GIRDER/HEADER PIECE OF SIDING BELOW U� 2-1/2"DIA.LAG BOLTS W/WASHERS r�l CONNECTED TO BLDG.p32"OC UNDISTURBED SOIL WW LAY ON STAIR TREAD C c UNDISTUR ED SOIC BASEILLIRECTLY(ORGA ICS REMOVED) ^ Q POST/COLUMN u G LEVEL BASE 1--� z RIM BOARD FIT CONSTRUCTION TUBE AND PLUMB rrl 00 STRINGER FLOOR FRAMING BRACE TUBE 2x JOISTS �''I'1` FILL AS PER MANUFACTURES'INSTRUCTIONS O U BLOCKING FOR 111=III=11 B — _III=�11° JOIST HANGER POST-TO-GIRDER/HEADER CONNECTION LAG BOLTS p e -III ��� LOCATION USP NUMBER DESCRIPTION APPLICATION RIM JOIST/BD. C a n ' O 4x4 SOLID COLUMN PBS44/PBSE44/KC44 POST CAP ANCHOR APPLY TO EACH COLUMN • F+� STRINGER TO DECKIPORCH CONNECTION 6x6 SOLID COLUMN PBS66/PBSE66/KC66 POST CAP ANCHOR JAPPLY TO EACH COLUMN U HOLLOW COLUMN SIMPSON STRRI/2 H.C. ANCHOR JAPPLY TO EACH COLUMN DECK/PORCH LEDGER CONNECTION DISTURBED/POOR SOIL LAY 4-6"LAYER OF CRUSHED STONE OR GRAVEL LEVEL AND COMPACT BY HAND LAY PLASTIC BASE ON COMPACTED GRAVEL LEVEL BASE FIT CONSTRUCTION TUBE AND PLUMB BRACE TUBE FILL AS PER MANUFACTURES'INSTRUCTIONS STRINGERI=11-_- 1=11= =!=1 Q16" c =111 111-111 111 111 111-111 111=111-11 (2)THRU- WOOD JOIST JOIST h. BOLTS s PB44 POST 4 i ANCHOR "d1a GIRDER/HEADER CONC,PIER FOOTING c PIER 16"TREAD BIGFOOT SYSTEMS FOOTING FORM WOOD JOIST I • G GIRDER/HEADER IN ACCORDANCE WITH SECTION 104.11 OF N.Y.S.RESIDENTIAL CODE THIS DESIGN nCOMPLIES WITH THE INTENT OF THE CODE AND THE MATERIAL OFFERED IS 0 GRADE CONC.SLAB AT LEAST THE EQUIVALENT IN DURABILITY AND EFFECTIVENESS OF THAT Z (AS REQ.) ;:a A PRESCRIBED IN THE CODE. �n FLUSH JOISTS WITH HEADER/GIRDER THE DIVISION OF CODE ENFORCEMENT AND ADMINISTRATIONS FINDS THIS PRODUCT _ 1^ a b B"dia. °"b a DECK PIER ALL JOISTS CONNECTED TO A FLUSH HEADER TO BE SUPPORTED WITH ACCEPTABLE FOR USE IN N.Y.S.BASED UPON ICBO EVALUATION SERVICE REPORT Z Z 3,A„ G CONC. •�'•' PER PLAN SPLICED JOISTS OVER HEADER/GIRDER ER-5495 AND SUBJECT TO THE CONDITIONS THEREIN. J PIER THE PROPER STEEL CONNECTOR. -•4e p,r4e IF ABLE,SET FIR JOISTS APROX.1/4"HIGHER THAN LVL HEADERS LOCATION USP NUMBER DESCRIPTION APPLICATION M 4 e�°• TO ALLOW FOR SHRINKAGE. JOIST TO GIRDER/HEADER RTIO TYDOWN ANCHOR CONNECT TO EACH JOIST ^ V O 4 e• •e 4 q •,q• O a .°•v ea ,o° Z CLIMATIC&GEOGRAPHIC DESIGN CRITERIA d HANDRAIL NOTES: DECK& PORCH NOTES: C' GROUNE WIND SEISMIC FROST WINTER ICESHIELD FLOOD NAILING SCHEDULE All required handrails shall be of one of the following types 1).Unless otherwise noted,all framing material to be#1 ACQ pressure treated lumber. SNOW SPEED DESIGN WEATHERINC LINE TERMITE DECAY DESIGN UNDERLAYME or provided equivalent ras abili All fasteners,hangers and anchors to be alvinized or stainless steel. LOAD HAZARDS JOINT DESCRIPTION NAIL NAIL NOTES p q g p ty. g g (MPH) CATEGORY DEPTH TEMP. REQUIREDr. QTY. SPACING 1).Type I.Handrails with circular cross section shall have an ).Girders for deck joists to be bolted or anchored to each post or pier with washers and nuts 20 PSF 130 6 SEVERE 3 FT. MODERATE SLIGHT TO JOIST TO: PER TOE = 11 NONE 4-Sd COMMON outside diameter of at least 1-1/4 inches and not greater P proper TO HEAVY MODERATE SILL,TOP PLATE OR GIRDER JOIST NAIL Girders on concrete piers shall be anchored with ro er steel connectors anchored than 2 inches.If the handrail is not circular it shall have a into concrete with a minimum 1/2"dia x 7"long anchor bolt with washers and nuts. BRIDGING 2-Ed COMMON EACH TOE TO JOIST END NAIL + �• 1° m perimeter dimension of at least 4 inches and not greater f t. 3).Posts supporting girders shall be anchored to a 12"x12N12"thick concrete footing. BLOCKING EACH TOE IN S than 6.1/4 inches with a maximum cross section of Use a minimum 1/2"dia x 7"Ion anchor bolt with washers and nuts.Footings Shall CODE: 20�$ IRI., 2016 NYS UNIFORM FORM SUPPLEMENT 2-8d COMMONGj" �. ,• �•I j/ }' g g TO JOIST END NAIL C` /; �. Ch DRAWN: MH/MS dimension of 2-1/4 inches, be 4 ft.below grade. BLOCKING TO: EACH TOE V` '� SOIL COMPACTION: 3.16dCOMMO ;� 0 �. � 2).Type II.Handrails with a perimeter greater than 6-1/4 SILL OR TOP PLATE BLOCK NAIL �e /� SCALE: 1/4"=V-0" 4).Deck joists to have blocking at 8'0 o.c.. ft,(; Inches shall provide graspable finger recess area on both I ti "�' ' P g P g LEDGER STRIP EACH FACE 1^ i..,p. 1).CONTRACTOR TO PROVIDE SOIL TEST TO VERIFY EXISTING CONDITIONS.MINIMUM 3000N 3-16d COMMo w ', JOB#: sides of the profile.The finger recess shalt begin with a 5).A minimum of 10 inch flashing shall be installed between the building and ledger. TO BEAM JOIST NAIL � �' s� ' 1�' �^ distance of 3/4 inch measured vertically from the tallest Ledger to be fastened to building with 1/2"dia.bolts with washers and nuts CAPACITY. JOIST ON LEDGER PER TOE 1 Y rvrw i May 02,2017 portion of the profile and achieve a depth of at least 5/16 at 16"o.c. 3-Bd COMMON s.. >j TO BEAM JOIST NAIL SHEET NUMBER: inch within 7/8 inch below the widest portion of the 2).NEW FILL TO BE CLEAN OF ORGANIC MATERIAL.CONTRACTOR TO VERIFY EXISTING SOIL BAND JOIST PER END ;��► �. c• profile.The required depth shall continue for at least 3/8 6).Concrete piers shall be a minimum 6"above grade. -3 16d COMMO i inch to a level that is not less than 1-3/4 inches below the CONDITIONS PRIOR TO FILL.REMOVE AND ADD ADDITIONAL FILL AS NEEDED. TO JOIST !01ST NAIL 0'1- 2 p Q p •e tallest portion of the profile.The minimum width of the 7).All joists to be supported with hangers and anchors.Each Joist shall also be anchored BAND JOIST TO: PER ,_�� "1. 23 girder(s). 2-16d COMMO TOE NAIL handrail above the recess shall be 1-1/4 inches to a to g' ()• 3).COMPACTION OF NEW FILL SHALL BE AT LEAST 95%PROCTOR DENSITY(PER ASTM D 698 SILL OR TOP PLATE FOOT -•„ ,Cy p Nc�� maximum of 2.3/4 inches.Edges shall have a minimum 8)•Use Simpson hangers and anchors with Z-MAX tripple protective coating or equal AND ASTM D 1557). COMPACT THE SOIL AT 12"LIFTS(TYPICAL).CONTRACTOR TO HAVE radius of 0.01 inches. for any contact with ACQ. FILL TESTED BY A PROFFESSIONAL AGENCY FOR COMPACTION. A-2