HomeMy WebLinkAbout41098-Z ®�SU�F04Cp�� Town of Southold 7/24/2017
9
a P.O.Box 1179
d' 53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39073 Date: 7/24/2017
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1925 Stars Rd, East Marion
SCTM#: 473889 Sec/Block/Lot: 22.4-9
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/14/2016 pursuant to which Building Permit No. 41098 dated 10/19/2016
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 Dalecki,Paul&Mary
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 41098 4/20/2017
PLUMBERS CERTIFICATION DATED
1"fl4z'6
ut o ed Signature
�SUFFncK TOWN OF SOUTHOLD
BUILDING DEPARTMENT
y TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 41098 Date: 10/19/2016
Permission is hereby granted to:
Dalecki, Paul
30 Davis Ln
Roslyn, NY 11576
To: construct an in-ground swimming pool as applied for.
At premises located at:
1925 Stars Rd, East Marion
SCTM # 473889
Sec/Block/Lot# 22.4-9
Pursuant to application dated 10/14/2016 and approved by the Building Inspector.
To expire on 4/20/2018.
Fees:
ELECTRIC $100.00
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - S G POOL $50.00
Total: $400.00
Builds g_jnspector
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or
topographic features.
2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead.
5. Commercial building, industrial building,multiple residences and similar buildings and installations,a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and"pre-existing"land uses:
1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic
features.
2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is
denied, the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Ftes
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. 1C 12/ o
New Construction: Old or Pre-existing Building: (check one)
Location of Property: I 25- ��1 5 KD Ivy lOn/
House No. pp Street Hamlet
Owner or Owners of Property: _ I"t '� QA LPe K;
Suffolk County Tax Map No 1000, Section Block Lot Q
Subdivision Filed Map. 30'V1 Lot: 13
Permit No. 41 Q Date of Permit. Applicant:
Health Dept. Approval: Underwriters Approval:
Planning Board Approval: /
Request for: Temporary Certificate Final Certificate: t" (check one)
Fee Submitted: $
Applicant Signature
SO!/jyolo
Town Hall Annex Telephone(631)765-1802
54375 Main Road N Fax(631)765-9502
P.O.Box 1179 ® aQ roger.rich ert(cD-town.southold.ny.us
Southold,NY 11971-0959
®lyC®UNTy,��
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Dalecki
Address: 1925 Stars Road City: East Marion St: New York Zip: 11939
Building Permit#- 41098 Section: 22 Block: 4 Lot: 9
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Leo's Electric License No: 2199-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 2
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 2
Disconnect Switches 2 Twist Lock Exit Fixtures �] TVSS
Other Equipment: Inground Swimming Pool To Include: Bonding, 2- Pool Lights, 20A Pool Cover
Circuit, Control Panel, Gas Pool Heater, 1- Salt Generator, 2- GFCI Circuit Breakers.
Notes:
Inspector Signature: Date: April 20, 2017
0-Cert Electrical Compliance Form.xls
qsSOUryo
o�y�OUNiV,��
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ FOUNDATION 1 S p [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND �4 [ ] INSULATION
..l
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS.9sh(5tcn -6p✓
S tfw,
DATE ► INSPECTOR
50Uryo
h� l0
TOWN OF SOUTHOLD BUILDING DEPT.
765-18®2
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ]XLATIONU
[ ] FRAMING /STRAPPING [ FINAL 7;f
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT-PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS: (9
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VV4 t-,( b,
DATE INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS
1lLA t \SIS im t, Ar' (.e—
FOUNDATION (1ST) 14<evshv r o%In
------------------------------------
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FOUNDATION (2ND)
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ROUGH FRAMING&
PLUMBING
INSULATION PER N.Y: "3
STATE ENERGY CODE
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FINAL ,Grj '4
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ADDITIONAL COMMENTS
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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 J R{� Survey
PERMIT No. V ( O Check
Septic Foran
N.Y.S.D.E.C.
Trustees
Examined ,20 Contact:
Approved ,20 Mail to:
Disapproved a/c
D
Buildi g Insp ctor OCT 1 -4 2016
IIlEPT.
APPLICATION FOR BUILDING PEV`&OF SOUTHOLD
Date �� Z - , 20_Uo
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 regulations, and to admit
authorized inspectors on premises and,in building for necessary inspections.
(Signature o applicant or e,if a,corporation)
Q2-q 9 - z�-.A- t-!,11-e,, �( g
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder
01 .c:t,3 r
Name of owner of premises f Qy L 12CK t
(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. C
Other Trade's License No.
1. Location of land on which proposed work will be done:
- 1g25' EA-�S�— 146,r10t
House Number Street Hamlet_
County Tax Map No. 1000 Section Block Lost,''
Subdivision Filed Ma No. t ` "''J} i +
(Name)
2. State existing use and occupancy of premises and intended use# occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy ies19 -ln N-1 mW/-1V
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work---T rj,,, V nyL - ,rnminJa �,a�c
(Description)
4. Estimated Cost Fee
(to be paid on filing this application)
5. If dwelling, number of dwelling 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 5'S' Rear 6-S Depth 3q '
Height Number of Stories 'a
Dimensions of same structure,with-alterations or additions: Front Rear
Depth Height Number of Stories
P63` x ,
8. Dimensions of entire new oenetra&tioR: Front Rear b-� Depth
Height Number of Stories
9. Size of lot: Front 11F , Rear. I(R Depth ?2-
10.
z10. 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:
13. Will lot be re-graded POOL kQ ayr'�q Will excess fill be removed from premises: ES NO
14. Names of Owner of premises Vt' Ut_pkv'eCK� Address 36 bAV1s LN kcs)yn/PhoneNo. 5?(0-r7N-7f7S-
Name of ''"' fl oats b QeaW Address'f &ze,kft✓ Sm-*6+j Phone Noli=,r7 41" Vyy-
Name of Contractor kms- 00'41'as P'0"s Addressg2-q 2r 2-!�-,4 Gil Q Phone No. 631-7qY-7/K
15. Is this property within 100 feet of a tidal wetland? *YES NO V'
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�J r-c -� )
:1 �-WjJ 'rlf being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,�
(S)He is the �``Afaciok
(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
day of 20J
Uauw� 0 IUX4�
Notary Public Signature of licant
o MARGARET A. KIDNEY
a Notary Public-State of New York
No. 01 K16021 1 1 1
Qualified in Suffolk County
My Commission Expires March 8,2014
_ x
FQ
Scott A. Russell d°S'U` /r� ST0>K1�\1WA\--,T1E1K
SUPERVISOR � AM[A\N A,G IEMIEINN F
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES THIS PROJECT INVOLVE ANY OF THE (FOLLOWING:
Yes No (CHECK ALL THAT APPLY)
❑[DA. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
❑[� B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑g C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑g D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
❑9 E. Site preparation within the one-hundred-year f loodplain as depicted
on FIRM Map of any watercourse.
❑[Zf 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:
A J
on District
NAME 1 L 4 r �AL�C►{k q /0-12--1
__EZ� (: Section Block Lot
n' Qj� **** FOR BUILDING DEPARTMENT USE ONLY****
Contact Information ko- 1 a ` - '7 q Tr
(Telephone Nomb,A
Reviewed By:
— — — — — — — — — — — — — — — —
- - - - - - - - Date
Property Address/Location of Construction Work: — — — — —
_ _ _
Approved for processing Building Permit.
_`Z p 1� Stormwater Management Control Plan Not Required.
i"u" t®� ❑ Stormwater Management Control Plan is Required.
(Forward to Engineering Department for Review.)
1.
FORM * SMCP-TOS MAY 2014
SOUryO
Town Hall Annex Telephone(631)765-1802
54375 Main Road (631)765- 5
P.O.sox 1179 G' ro_ger.richeril'a own.soutf9ioAny.us
Southold,NY 11971-0959 ern
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION '
REQUESTED BY: Date: 10-12—/�,
Company Name: ,5`�"'. I-em 10
Name: EP Ik
License No.: 2 1`740
Address: )22 Puas►c, ego 4dis P*L
Phone No.. 01- 51400
JOBSITE INFORMATION: (*Indicates required information)
(� �_ -
*Name: PAJL �- Mary IJ/SL�CK l o
*Address: IQ2-5- 6..+-�QS 6
*Cross Street:
*Phone No.: 57to-r794_riq,75-
Permit No.: Lf f�
Tax Map District: " 1000 Section: 99 Block: 4 _ Lot:
*BRIEF DESCRIPTION OF WORK(Please Print Clearly) �1_
IVAr0i0Cs V►n�c. �N►mmtNC� C.
(Please Circle All That Apply)
*is.job ready for inspection: YES / NO Rough In Final
*Do you need a Temp Certificate: YES / NO
Temp Information (If needed} -
*Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION
0 CO
82-Request for Inspection Form ) I `
t
r
pf S
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.O.Box 1179 G
Southold,NY 11971-0959 '®
�`�COUiVTy,��
July 14, 2017
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Paul Dalecki
30 Davis Lane
Roslyn NY 11576
Re: 1925 Stars Rd, East Marion
TO WHOM IT MAY CONCERN:
The Following Items(if Checked)Are Needed To Complete Your Certificate of Occupancy:
Before the C of O is issued for the pool,you need to apply for a permit for the hot tub. We need a
building permit application, C of O application,copy of survey with location of hot tub drawn on, an
electric application and the hot tub specs. And the fee unfortunately will be dou led since a permit
was not issued for the hot tub before it was installed. It would be$500 for the per it,$50 for the C
of O and$100 for the electric permit.
Application for Certificate of Occupancy. (Enclosed)
Electrical Underwriters Certificate.
A fee of$50.00. e7
Final Health Department Approval.
Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84)
Trustees Certificate of Compliance. (Town Trustees#765-1892)
Final Planning Board Approval. (Planning#765-1938)
Final Fire Inspection from Fire Marshall.
Final Landmark Preservation approval.
Final inspection by Building Dept.
Final Storm Water Runoff Approval from Town Engineer
BUILDING PERMIT — 41098 — Swimming Pool
LOT AREA 20,390 S4. FT. aKO01A�IlYOjT 15-211
MPF>Dq/ TjpUCT� 1� 16-120
I �► ► �> loan n ,
be aloft" ldtQYfls t�
=14tH�oFy FOR A MAXMI
Walter J.Hilt�rtr ,�
Office of WssteWeter Managem nj
LOT NUMBER 14
FD NON '
5.7'N N 79'42'40"E
173.50'
Z roof �rywelt well MON
_. drywell N
p 11 bur4red
Ul O �-p tank 74.5'
00 encl g 1
W t 39,0' to
50.5 ►��
J ro walk v
JFDo N Lo roof over p cn2 STY FR 26.0 45.9'DWELL GAR�h 3", 12 2s.o' roof drywell34 5' 15' 0- blueetone driveway ON pole i
/113
blgm bl curbing o
S 79'42'40"W 172.09' FD MON
LOT NUMBER 12 (ted)
NJ
- -_ _ -- - - -- - - - w
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C
WILLOW- DRIVE
NOTE: CESSPOOL, SEPTIC TANK & WATER
SERVICE LOCATIONS BY OTHERS.
REE" � µ _
UFF.CO.V ,.
FFICE OF Ilk �as. 6-22-2016 FINAL SURVEY
10-7-2015 LOCATED FOUNDATION
TIL£OffxTS (eR oftmems) prom ►moron "m 1NE S1IRICTNR�g 10 TIIE
PROPEMY tNES ARE FOR A SPtE M P"OSE AND USE AIA 11tE>ggtERE
ANOT
"°nNDED TO OWE THE 010C M'aF Fenn. RETAMNo%%.L% POOtB. PATIOS. JOB No 15-61 FILE No STARS MANOR
PLMIM AWS,ARTOITTON To RNA*cs OR ANY Oetoa ColaTp#.WrM
UK*jR'oRaW ALiTr7NgIWN Olt ABOF To Wa SUR IS A VIOL M OF SECTION SURVEYED FOR
OF THE NWS TORI( STAT¢ MUCATM UW LOT NUMBER 13
HOWDN SWAL MM OWY TO TW PvtgM FOR■AY rmE MAP OF STARS MANOR
SAY IS Pf*PN60. AIA ON "IS ®Ew1tF TO DIE TRU Dor WV. 0WA7NIADM%. SITUATED AT EAST MARION
AootcY ANO ISA DOMURM US= HWXOK AND 10 THE A3904M OF THE
OR �OWIM ANE NOT TO AooTTIONAL ursnT�>oNs TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y.
COPES OF T1*`' PAWY MAP NOT WfWW THE LAND VAheyOR-S NO) SEAL OR
BAOSSEO SOL SHALL NOT BE SCALE I" — 40' DATE 5-6-2015
TRUE COPY.
FILED MAP No. 3864 DATE 10-19-1963
CERTIFIED ONLY T '�
�oO 'T RA n eyZ��' TAX MAP No (REF ONLY) 1000-22_4-9 DISK 2015
Q �t HAROLD F. TRANCHON JR. P.C.
LAND SURVEYOR
P.0 BOX 616
':�66 WADING RIVER-MANOR RD. WADING RIVER,
LA IC. No. 048992 NEW YORK, 11792
HAROLD F. TRANCHON NN LIC. No 2115-E 631-929-4695
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
CERTIFICATE OF WORKER'S COMPENSATION
[ CERTIFICATE OF LIABILITY INSURANCE
SUFFOLK COUNTY LICENSE
SUFFOLK COUNTY PLUMBER LICENSE
[ 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
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VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEW YORK 11788
DATE ISSUED: 5/1/80
No. 2740-1�ffi
SUFFOLK COUNTY
Master Electrician License
This is to certify that EDWARD S REIFF
doing business as UNDERGROUND SPECLALTIES INC
having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN infi
W-
accordance with and-subject to the provisions of applicable laws, rules and regulations of
the County of Suffolk, State of New York.
SUFFOLK COUNTY DmPT OF LABOR,
Additional Businesses
LICENSING&CONSUMER AFFAIRS
MASTER
ELECTRICIAN
t
NAW
EDWARD 8 REIFF
t
This c' hat the
11 I'M
GENREWY, No.ODA
b rar Is duly 1-M
11rensed
by the
T County
of Fufr
olk
2740-ME
05/01/1980 ct
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4;� '-"'RJ!
NEW Workers'
S Compensation CERTIFICATE OF INSURANCE COVERAGE
Board UNDER THE NYS DISABILITY BENEFITS LAW
PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Arthur J Edwards Mason Contracting Company Inc (631)744-4455
929 Route 25A 1c.NYS Unemployment Insurance Employer Registration Number of
Miller Place,NY 11764 Insured
24-10871 - -
Work
4-10871 -Work Location of Insured(Only required If coverage is specifically,limited to 1d.Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,he.,a Wrap-Up Policy) Number
11-2377925
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) The Guardian Life Insurance Company Inc
P.O. Box 728
Town Southold 3b.Policy Number of Entity Listed in Box"1 a"
Southold,NY 11971 984424-0000
3c.Policy effective period
07/01/2016 to 07/01/2017
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 employers employees. -
Under penalty of perjury,I certify that I am an authorized representative or II gent of the insurance carrier referenced above and that the named
Insured has NYS Disability Benefits insurance coverage as described ab e
If JLA
Date Signed July 13,2016 By OA
(Signature of insurance carrier s authoriud representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number (212)964-2150 Title President
IMPORTANT: If Box"4a"is checked,and this form is signed by the insurance carriers 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,328 State Street,Schenectady,NY 12305
PART 2.To be completed by the 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 Form DB-120.9. Insurance brokers are NOT authorized to Issue this form.
DS-120.1 (9-15)
Additional Instructions for Form D13-120.1
By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business
referenced in box"1a"for disability benefits under the New York State Disability Benefits Law.The Insurance Carrier or its
licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2".
Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if
cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the
policy effective period? YES [RNO
This certificate Is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,
extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Disability Benefits contract of insurance only while the underlying policy is in effect. .
Please Note:Upon the cancellation of the disability benefits 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 NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory
coverage requirements of the New York State Disability Benefits Law.
DISABILITY BENEFITS LAW
§220. Subd. 8
(a) The head of a state or municipal department, board,commission or office authorized or required by law to issue any
permit for or in connection with any work involving the employment of employees in employment as defined in this article,and
not withstanding any general or special statute requiring or'authorizing the issue of such permits,shall not issue such permit
unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of
disability benefits for all employees has been secured as provided by this article. Nothing herein,however,shall be construed
as creating any liability on the part of such state or municipal department,board,commission or office to pay any disability
benefits to any such employee if so employed.
(b)The head of a state or municipal department, board,commission or office authorized or required by law to enter into any
contract for or in connection with any work involving the employment of employees in employment as defined in this article
and notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such
contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment
of disability benefits for all employees has been secured as provided by this article.
DB-120.1 (9-15)Reverse
ARTHU-1 OP ID:VM
ACORO" orrvyv)
E(mmro
CERTIFICATE OF LIABILITY INSURANCE F0DATE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CNAM
E; Bagatta Associates,Inc.
BagW Jericho Turnpike Ste 1A atta Associates,Inc. PHONE
823 631-864-1111 we N,; 631-M-8274
Smithtown,NY 11787 ADDRESS:
Bagatta Associates,Inc.
INSURER(3)AFFORDING COVERAGE NAIC A
INSURER A:Worcester Insurance Com pany 26182
INSURED Arthur Edwards Mason INSURER B:Rochdale Insurance Company 12491
Contracting,Company Inc.DBA
Arthur Edwards Pool 8, INSURER C:
Spa Centre INSURER D:
Arthur J.Edwards
929 Route 25A ENSURER E
Miller Place NY 11764 INSURERF:
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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
I�TRRTYPE OF INSURANCE lRa3mPOLICY NUMBER MMIDD MMIDDIYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTE17-
CLAIMS-MADE ®OCCUR MPA00000038801 H 01/01/2016 01/0112017 PREMISES Ea occurrence $ 100,000
MED EXP(Any one person) $ 5,000
X BLANKET ADDITIONA PERSONAL&ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
POLICY F-1 PRO F—]LOC PRODUCTS-COMPIOP AGG $ 2,000,000
JE
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOSNON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
UMBRELLA LIAB HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY STATUTE ER
IN
B ANY PROPRIETORIPARTNERF�
ICUTIVE Y❑ NIA RWC3363984 03/0112015 03/01/2016 E L EACH ACCIDENT $ 1,000,000
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below I I I I I I E L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached B 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 GP
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
t-ertulcate or iN 16 w orxers t-ompensanon insurance t,overage rage o oT 1 /
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
DBA:Arthur Edwards Pool&Spa Centre Registration Number of Insured
1d.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"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 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"3c" 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 authorized representative or licensed agent of insurance carver CarrierPhone
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.aintrustgroup.com/anawc/PolicyNYCertificateOf WcIns.aspx?Indexld=-1&Instant... 3/2/2016
--
Workers' Compensation Lava
Section 57.Restriction on issue of permits and the entering contracts unless compensation is secured.
1.The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit
for or in connection with any work involving the employment of employees in a hazardous employment defined by this
chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue
such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that
compensation for all employees has been secured as provided by this chapter.Nothing herein,however,shall be construed as
creating any liability on the part of such state or municipal department,board,commission or office to pay any compensation
to any such employee if so employed.
2.The head of a state or municipal department,board,commission or office authorized or required by law to enter into any
contract for or in connection with any work involving the employment of employees in a hazardous employment defined by
this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any
such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that
compensation for all employees has been secured as provided by this chapter.
C-105.2(9-07)Reverse
https://ao.amtrustgroup.com/anawc/PolicyNYCertificateOfWclns.aspx?Indexld=-1&Instanc... 3/2/2016
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•t �1�''Ya',��-�+f�, r=.,�_ �l i �, s �.G-t ... i=-Sn,'t. � .�i"�3 •a; /f,.� -? '"'"x. ��,.'� _ ,r \ t' it �� �`�' ?rr•-�.Zl ..+ - .T� ^r.
J�
E Suffolk County Department of Labor, Licensing & _
Consumer A airs ` -E
, 5.,. VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788
DATE ISSUED: 7/1/1978 No. 4436-H
tN SUFFOLK COUNTY
,,�`_ • o s F`e
Home Improvement Contractor License '
a"5 This is to certify that I
fY ARTHUR J EDWARDS
doing business as
ARTHUR J EDWARDS MASON CONTRACTING CO INC DDA
J having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules
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.
- License Category
SUFFOLK COUNTY DEPT OF LABOR, 1
LICENSING&CONSUMER AFFAIRS GC
�..'� Additional Businesses
HOME IMPROVEMENT Pools&Spas/Certified
' CONTRACTOR
ARTHUR J EDWARDS MASON Pools/SpasLICENSE
- 14M* CONTRACTING CO INC DBA I -
Id ARTHUR J EDWARDS ARTHUR EDWARDS POOL&SPA }
x :•
r•� -'
This certifies that the BUSNESS CENTRE ARTHUR J EDWARDS MASON
barer Is duty CONTRACTING CO-INC DBA(I SUPP)
licensed by the U.—N—bw Deb I--- Commissioner
County of Suffolk 07/01/1978 t
4436-H
eo�.ti.adn. "PRAnON QAnd
07/01/2018 �
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.z`sr��i��:�F ."k`S-.;•r;�_;� ��`'_.r�S �j.�.�.;�� ���' �`• _�;:s�.^ ��� ,.:;.��.+ �:.:%f i��:f - � i ���� �, `'>~�-��.�lj f
� �a,�-• ,` _ .'sa .a°°' a e,� 6 _ `
4_:_
APR VEDAS NOTED
DATE:( B.P.# X
FEE:
Fr� , ALLODS OF NOTIFY SUiLD1`,a ,�_ Ar,i MENT AT
$ -r- &-fOWN CODES 765-1802 8 ASA TO 4 PM Fl-)R THE
NEW YORK S ►A I� � 'T' '' FOLLOWING INSPECTIONS:
AS FkEQujF P �� 1. FOUNDATION - TWO REQUIRED
SCUT
1 ��' FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
SG ':• '-r' 4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.,
. .d• ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
`.G .
ENCLOSE POOL TOCbDE
UPC
BEFOREMWA EION
R'l R
CCCUPANCY
USE IS UNLA FUL
WITHOUT CERTIFICATE
OF OCCUPANCY
mo
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E F
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To W a Returns
(Dry Well OpUnoQ
Rolled Niall Foa
Plan A Piping Arrangemefit
Wall Sermon
Vinyl U f4
42"
- SEW YO
Section B—B 2"Son 3500 P.S L Concrete 0�ro® I
10" iv
Section A—A Typical Nall Section ��SF�sS ���®��
SIZE A B C D E F G H AREA CAP. AnL
FEET FT. FT. FT.FT.FT.FT.FT.FT.SQ.FT. GAL. Purchw
12 X 20 12 20 8 9 0 3 3 6 240 8,000 �'�� ®aavw
16 X 36 16 36 12 14 6 4 4 8 576 21,600 P®sDL�SPA CIEINM
18 X 40 18 40 16 14 6 4 4 8 720 28,500 PERMACRETE WAIL SYSTEM � W,gor l its
929 Rotate 25A Miller Place NY 11764
15'X 55 15 55 25 17 10 3 3 9 825 25,000 (631) 744-7185 FAX (631) 744-0174 �(i� � - / zt aaae X939
24 X 44 24 44 18 14 8 4 6 10 796 30,000 Suffolk License #4436-HI
24 X 48 24 48 20 16 8 4 6 10 900 31,000 . Nassau License #HI74450000