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HomeMy WebLinkAbout41990-Z BUFF©(, �a Town of Southold 10/4/2017 P.O.Box 1179 a. 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39264 Date: 10/4/2017 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 230 Kimberly Ln, Southold SCTM#: 473889 Sec/Block/Lot: 70.43-20.19 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/26/2017 pursuant to which Building Permit No. 41990 dated 9/26/2017 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: ACCESSORY IN-GROUND SWIMMING POOL, FENCED TO CODE,AS APPLIED FOR The certificate is issued to Best Roger G Revoc Trust of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 39238 05-13-2015 PLUMBERS CERTIFICATION DATED \40 4 th0ed Signature g�yFFOtKTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o� • 04 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#: 41990 Date: 9/26/2017 Permission is hereby granted to: Best Roger G Revoc Trust 2913 Kitchums Pond Rd Williamsburg, VA 23185 To: Construction of an accessory in-ground swimming pool in the required rear yard as applied for. Replaces BP#39238 At premises located at: 230 Kimberly Ln, Southold SCTM # 473889 Sec/Block/Lot# 70.-13-20.19 Pursuant to application dated 9/26/2017 and approved by the Building Inspector. To expire on 3/28/2019. Fees: PERMIT RENEWAL $125.00 Total: $125.00 g Inspector TOWN OF SOUTHOLD o�sUFFot,r�oGy BUILDING DEPARTMENT TOWN CLERK'S OFFICE Cn x oy • SOUTHOLD, NY .Ifp1 ,� �ao4 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#: 39238 Date: 10/3/2014 Permission is hereby granted to: Best Roger G Revoc Trust 2913 Kitchums Pond Rd Williamsburg, VA 23185 To: Construction of an accessory in-ground swimming pool in the required rear yard as applied for. At premises located at: 230 Kimberly Ln, Southold SCTM # 473889 Sec/Block/Lot# 70.-13-20.19 Pursuant to application dated 9/23/2014 and approved by the Building Inspector. To expire on 4/3/2016. Fees: IN-GROUND SWIMMING POOL $250.00 CO - SWIMMING POOL $50.00 $300.00 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and "pre-existing"land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00, Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool $50.00,Accessory building$50.00, Additions to accessory building$50.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy- $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential $15.00, Commercial $15.00 Date. _7 :03 11al- New Construction: Old or Pre-existing Buil/ding: (check one) Location of Property: House No. Street Ham et Owner or Owners of Property: Suffolk County Tax Map No 1000, Section �c�. Block 15, C;V Lot Subdivision Ga/'G,�j!5� `j �/ / cr% �� Filed Map. Lot: / f 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: $ Applicant Signature ®F SO(/r�®lo Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G • �� roger.riche rt(d-)town.southold.ny.us Southold,NY 11971-0959 ®�yC4UNT`I,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Best Roger G. Revoc Trust Address: 230 Kimberly Lane City: Southold St: New York Zip: 11971 Building Permit#. A4 1 /(7() 8 Section: 70 Block: 13 Lot: 20.19 v/ WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: LC Electric License No: 38043-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 1 Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel AIC Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1 A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches r 11 1 Twist Lock 1 Exit Fixtures TVSS Other Equipment: In Ground Swimming Pool To Include - Bonding, 2- Pool Lights, 3- GFCI Circuit Breakers, 1-Salt Generator, 1-Gas Pool Heater, 1-Cover Motor Notes Inspector Signature: Date: May 13, 2015 Electrical 81 Compliance Form.xls rjf 30 TOWN OF SOUTHOLD BUILDING' DEPT. 765-1802 --..ANSPECTION ' [eleFOUNDATION 1ST A 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: -or� DATE I NSPECTOR 7,4 SOUT�olo / coutom,� , TOWN OF SOUTHOLD BUILDING DEPT- , �� ' 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ELECTRICAL (FINAL) REMARKS: DATE t'� INISPECTOR ' ( l1 0 OE SOUjy� coul r,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1502 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ VNSULAT!qN [ ] FRAMING / STRAPPING [ FINAL A& [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: Q 'l ,r DATE -A INSPECTOR Uk oa FIELD INSPE: T REPORT DATE COMMENTS FOUNDATION(187) FOUNDATION(2ND) z _ p rA ROUGH FRANDNG& y PLUMBING INSULATION PEA N.Y. STATE ENERGY CODE ' . Y 14 FINAL , _.. ADDITIONAL CnIVIIYIENT5 4 de- i . O.Oc� — "3 - b'. f� 0 X13Ll1 0 z 0 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 L�`�9-0 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO-944-3 Check Septic Form NYSDEC Trustees C O Application Flood Permit Examined 20 Single&Separate toStorm-Water Assessment Form 0� Contact: Approved —20 P,-Ie.-,, to ffa Disapproved a/c 5 /['7C�A /7,C�'L�v►9/!;//[ f�/y /�y�/ Phone K? IRK EE$Dii ati nn �1 Building Inspector SEP 232014 APPLICATION FOR BUILDING PERMIT g �j BLDG DEPT Date / ✓ � � 20,Y— TOV01 OF SOUTHOLO INSTRUCTIONS 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,housing e,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections (Si nature of applicant or name,if a corporation) i4f/-?//";,, Ile /rw 40) (Mailing address of applicant) State hetheerr applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber r builder Name of owner of premisesd" (As on the tax roll or latest deed). If ap ca t is/a,corporation,signature of dully auth�ized offtger (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. 3`170¢3 ^/vv Other Trade's License No. 1. Location of land on which proposed work will be done: Z'JrJ lS; // 4,of House Number Street / Hamlet n / County Tax Map No. 1000 Section (//� ✓n,aO Block /3i�� Lot O0 o(/ Subdivision ���/.�/ D !�/C' l ( Filed Map No. O Lot r 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy S%HTL 7�lrr�%/ r✓ /kik b. Intended use and occupancy 5r;,,75 le ,�Mme% �✓�►-elli�, 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work 20X4o /J ew, s �rt�°' /.a,�1 f bra//)er 4. Estimated Cos Z 52V 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 �,.3 / Rear y11t Depth ��• Height Number of Stories 2 Dimensions of same structure with alterations or additions Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front 21,2 Rear��/ / Depth 442 Height 3/ A2 -6' /Number of Stories 9. Size of lot:Front 6V /7Zt9V b Rear l✓Q. a� Depth , Pte' � /10.Date of Purchase 0Name of Former Owner lt76014 11.Zone or use district in which premises are situated 4 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO 13.Will lot be re-graded?YES NO ill excess fill be removed from premises?YES_ 0 14.Names of Owner of premises ef- Addresslr///iGt ,Ifiy i 04 14hone No. 757 20' Name of Architect,�hr l )`Z Address (_rifCGi �,/Z Phone No 63/ 7,5¢ Name of Contractor Ihe, Address Phone No.6_" 7 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO * IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY 13 RE IRED. b.Is this property within 300 feet of a tidal wetland?*YES NO * IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?* YES NO }�N * IF YES,PROVIDE A COPY. is 3 r�, STATE OF NEW YORK) C 1W> o Y OUN Y OF� 1 tU-00 @ aW being duly swom,deposes and says that(s)he is the applicant 0 u1 to (Xi ( ame of mdividu ignmg con ract)a ove amed, Z 0 1/ 'N (S)He is the (nZ a rac(Con or,Agen,Corporate Officer,etc) Y mm CY u of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application, Za that all statements contained in this application are true to the best of his knowl ge d belief, d that the work will be g performed in the manner set forth in the application filed therewith Swot¢�before me t day of 20 blic Signature of Applicant Scott A. Russell ��°� �� � STO] AWWATIEIR SUPURVISOR �M A1�A�G EAMUEN T SOT]�HOLD TO WN HALL-T1.0.Box 117'4 53095 Main Raad-50011-10L D,NEW YORK 11471'°�c Town o,f Southold CHAPTER 236 - STORAWATE+R 1V1ANAGEM ENT WORK, SHEET ( To BE COMPLETED BY THE APPLICANT ) ]DOES 1PII- YS PROJECT ERCT INVOlLV E ANY OF TI-12� FOLLOWING Yes 0 (C]iCCK ALL THAT APPLY) ❑ A. Clearing, grubbing, grading or stripping of land which affects more an 5,000 square 'feet of ground surface. ❑ & Excavation or filling involving more than 200 cubic yards of material ithin any parcel or any contiguous area. .-.S -tpa=,on o�� s Inhce d 1 x peg wl�ic e Q feet verti al rise 0 feet of horizontal distance. F-]E&15 Site preparation within 100 feet of wetlands, beach, bluff or coastal ton hazard area. ❑ . Site prepara't'ion within the one -hundrEd-year floodplain as depicted RM Map of any watercourse. [� Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management i Vontrol flan 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 witki your Name, Signature, Contact Worrnation, 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. APPt_ ]CANT: (Fr ny Ownar,Design Professional,Agnut,Contmctop,Qthed S'C•T.M, 1000 5aiC-: r)ISU'ICL NANIF, d Sectron Bloc& Lot liynuwA • ;{)ki LiIJIG,,,1711w'(� DEP t1']Ctl,;ly! [1 ( ONLY Contacr Ird'orrnatlon 6tydipn',�wuk i i Reviewed By: Pro eri Addre;3s/ Location of Constru/ction Work, — — — „ — _ — ]]ate` —� l{iA1 �� 5®�h0�® h/ Apuloved fol'processlug 8ulldityg Per IIL — !vl — — 5tor►Irwater Managumcnt C'ul•�trol Plct'I Not hrquired "�„��• ❑ Storrnwater Mariagrneem Control Plan IS Reyuirvd,� (Porww-d to Engineering Department tot'Review) 1=ORM " SMCP•' TOS MAY 2014 N/T0 39dd s3iasna TlOHinos Tb9999LTC9 09:60 t?TOZ/EZ/60 .......... j • 210 'MELECTRICA 6�T A EA _ST�,MORI n PAY TO THE ORDER OF � 7- DOLLARS -:­-71--W—TA—MPE-H—HES Z W L J .',s.-.. T ,.s M "Of V, lk�11 It;: cr— V ZE i. 0 Zt E100-, 'k4 1-1�,�-�:%Z--,--7\ REQUESTED BY. Date: Company Name: g I Name- License No.: Address: iPhone No.: . JOBSITE INFORMATION: (*Indicates required information) *Name: -3-C *Address: *Cross Street: *Phone No.: Permit No.: Ll I Tax-Map District: 1000 Section: Block: mo Lot: *BRIEF DESCRIPTION OF WORK(Please Print Clearly) (Please Circle All That Apply) *Is job ready for inspection: *Do.you need a Temp Certificate: "E / NO Rough In Final YES/ NO - Ternp Information(if needed) *Service Size: I Phase 3Phase ioo 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information- PAY ENT DUE WITH ALP_UCATION 824Request for Inspection Form TOWN OF SOUTHOLD PROPERTY RECORD CAR® /f ,17= OWNER STREET VILLAGE DIST. SUB. LOT t FORMER OWNE r N E ACR. ` MUO(h•r1,1G1 A,c'L Z-• Nl cAteomi S W TYPE OF BUILDING v RES -� o SEAS. VL.- g FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS t Som Oc)` --E V -7700 ��O � l� �{ 12/ �/,=�� -� �d 'f'� �- _ r �C� �' �/(r�(•t�^1yt�'-.�✓ � C5�`1���c��5 (90 I/7 300 cloy I- L Il%1 �' 144- d rrm6 +0lct-f�0o1 3e I ��fl 5 3 oD o Il l5 �3r S p crf7r) Cacti-a 00rc, Mafp-oni' I-en 4es-1-- �g Ss,7o o(. - 41 1 / 2 77S ✓ i 9 4d,416-7 - P* Saq 3S LOLAYO-6M Cvl �"�Yad�RoYa I LO ' 1a4 o P 3- ql'f Q di Huns t-0,,)b?/ a fio71 111V12-54 1y12,-1Z&-75 Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD i Meadowland OSZ 5d03 DEPTH House Plot l.�C:•� ACDO BULKHEAD Total 16-i/ 3 d \ riV - j N rl rdt'-" r, 3 N✓nFs t. v tYWl r rrW, 7� -s 'tt � • n t�t s'C �"+ }'3 rF 4wr _ .,,� � ?� �t ��aa J27 �4.,,1�,. r � u •�.n f� r},� x i S - - ..4e �. st�•� u y �. � it �ti b �: , �^ �^^--- � ,.. � •� 1r?S��/'. ■■■■■■■■■■■■■■■■ h`� t t ,� r N. 1,'-'�sus-`. „- n'`�,mt, `� .F , �4+,^ 'E`.w���`""y-' ■■■■■■■■■■■���■ � �� _�,� y 4 .� :.� - ,� �_ ■■■■■■■■m��■�■��■■a■■®■wee■o■� fir.+rn� __^ice"�:L...�_` .d:^i .'t.I-.. 1 .�iZl .'•' ' .»,+. _a �. .. :•` ���■■��■���■����© ■�■■ ■®■■■■■■��■�®■e■10m ■mo■■■■■■■ ■ ■■■ENO■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■MEN■■®■1■■■■■■■■■MEN ■ ■ WIM: r r GI CIO moo` t; ,� j .�► ALA F i ., i w: M '.t , V y i 4 � w'. a• r k r x " 4 9 4 a� • . �, cbI � � k .N• � a! j , 4 ar n Y �a 0 s t w s � y r v a a { t -k� 4, asp a a .I i - r 6 � , 2 yy raairtd3MM-a4M -40 s E - v F r r r It. • F r A t - ''"s�. rs+z-rte �.,-+•m-a : .: �' ." x# s �1 s .'. let -,. t wii ...+. 1. "' "•'lam "�, _ �-.'�. _' l" .•mow�rJ, f F r $� j, f mr s.• - T , JIMa r �1°�q0 .� �, �. �� ��� �_ ��1 � .� r.��� k� „ e ', hr.d �,� ��� �'�,��,._ r ..� �, +1'. � � y .`"�'f� �, m ��„ ' Y �. +. �� � t;•. .^�,,_ �-' 1 �.��,* . yt � +,. � x *���"... tj � f t; � � � ��� way•�. Y x W AA Southold Town Building Department o�SUFFnt,�coG P.O.Box 1179 Permit#: 39238 53095 Main Rd •coo; o � � Southold,New York 11971 Permit Date: 10/3/2014 y'yol �ao�' (631)765-1802 Expiration Date: 4/3/2016 Parcel ED: 70.-13-20.19 BUILDING PERMIT RENEWAL LETTER Dated: 8/31/2017 Applicant: Patrick Pools, Inc Location: 230 Kimberly Ln, Southold Work Description: IN GROUND POOL Construction of an accessory in-ground swimming pool in the required rear yard as applied for. A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Best Roger G Revoc Trust Address: 2913 Kitchums Pond Rd Williamsburg, VA 23185 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. 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Y' 3sfr�3$s ��'.•�%ia3.z:.'...`$-$ ��L$t�r � $ � ,�, t"_, '._.,..'�.�� .�,J, �"�;,��.':;Y "�"" r� �'3t'�'`". STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) IN Business Telephone Number of Insured PATRICK'S POOLS INC 631-831-0816 PO BOX 3024 lc.NYS Unemployment Insurance Employer EAST QUOGUE NY 11942 Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is or Social Security Number spec fcally limited to certain locations in New York State,de.,a 262929943 Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) WESCO INSURANCE CO Town of Southold Building Department 3b.Policy Number of entity listed in box"la" 53095 Route 25 WWC3060073 Southold NY 11971 3c. Policy effective period 5/13/2014 to 5/13/2015 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X all excluded or certainpartners/officers excluded. This certifies that the insurance carrier indicated above in box"T' 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 Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also note the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. ('These notices may be sent by regular mail.) Otherwise,this Cert fcate 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 OLAS ZULKOFSKE n e of authorized representative or licensed agent of insurance carrier) Approve by: 1 09/18/2014 ignature) (Date) Title: Authorized Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-9414113 Please Note. Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us DATE(MIirIDD/YYYIn CERTIFICATE OF LIABILITY INSURANCE 09/18!2014 THIS CERTIFICATE IS ISSUED AS A MATTEfi 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,subjectto the tarts 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 Brookhaven Agency,Inc. Brookhaven Agency,Inc. PHONE(AIC No 631 9414113 Fax 631 9414405 P.O.Box 850 E'ML . brookhaven.agencyCawerizon.not 150 Main Street PRODUCERin ,3941 East Setauket NY 11733 1NbURER(SI AFFORDING COVERAGE NAIC C INSURED INSURER A:Merchants Mutual Ins.Co. Patrick's Pools,Inc. INSURER B•Wesco Insurance Co. PO Box 3024 INSURER C: E.Quogue NY 11942 INSURER D: IN E• INSURER 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 CONTRACTOR 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 TYPE OF INSURANCE DL UB FOLIC NUMBER POIDDY EFF POLICY EXPIM LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 TO RENTED A X COMMERCIAL GENERAL LIABILITY X CMP8154061 2128/2014 2/28/2015 DAMAGE $100,000 CLAIMS MADE Fx-1 OCCUR MED EXP oneperson) $5,000 PERSONAL&ADV INJURY S 1 00O 000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LlAB CLAIMS-MADS AGGREGATE $ DEDUCTIBLE $ WORKERS COMPENSATION X I WC STATU• OTH- AND EMPLOYERS LIABILITY B ANY PRO RIETORfPAR NEPJELUDED?ECUTIV� N/A WWC3060073 5113114 5113115 E.LEACHACCIDENT $100000 (Mandatory In NH) u E.L.DISEASE-Fel EMPLOYEE $100,000 RIMS6 deaonbe under RIPTI!2N OF P NS Nlow E.L.DISEASE-POLICY LIMIT I S 500,000 T 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Certificate holder is also named as Additional Insured. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 53095 ROUTE 25 SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE <PAZ- ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured PATRICK'S POOLS INC 631-941-4113 1c.NYS Unemployment Insurance Employer Registration Number of Insured PO BOX 3024 EAST QUOGUE NY 11942 1d.Federal Employer Identification Number of Insured or Social Security Number 262929943 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 Town of Southold Building Department 3b.Policy Number of Entity listed in box"1a": 53095 Route 25 DBL318565 Southold NY 11971 3c.Policy effective period: 05/13/2014 to 05/12/2015 4.Policy covers: a. 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 a�f4q(li b�ov�e. s Date Signed 9/18/2014 By wid UI (Signature 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"4e is checked,and this form is signed by the Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability Benefits Low. It must be mailed for completion to the Worker's Compensation Board,DS Plans Acceptance Unit,20 Park Street,Albany,NY 12207. 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 Workers Compensation Board,the abovo-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her 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 DS-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1(5-06) t 1 _V PINE NECK ROA® FT ? . R' ( VACANT )i w P W LOT 20 0 ro c CP.ov into 315. 92 N o LO N. 6006 ' 50"E . ' /boy � lrlo� set 6 SSE e=. CLF. �� 0•S _�` EAS iM E N T a t- 27 ' ^I 10' EASEMENT FOR POSSIBLE WE��- (O4000 SITES AND WATER SERVICE LINES FOR LOTS ON EASTERLY SIDE OF CID® 0 r JY I ~` -f I KIMBERLY LANE WHERE AN INADEOATE o O �0.b 4 L) 4 i _J I ° 0 Ix=C f WATER SUPPLY IS ENCOUNTERED. w a i 2b.5' -�f rp I !�I i Ld Z o F o LOT 19 G�OldS{anG M ui -20 X 40 10, I U w a Z Z 6 - I v w C, Vey Ticil 40 Q L /i3 752' 00 v 2n, 0 -J!�" I II h •l v`y I I zai a e 40 Pool fel"vip w > O Z h a 0 z 0 IWELL �O v ;® ' lf� o Lf) II ° Z r_ ¢ Se f EA3I�f�NT ua 1 m n W >° S . 86° 0 6' 50" W. _ 30 9'. 69' set W >o J I J v i L r.T lid I \, 4 CAN ! AREA , v 47, 022 SQ. FT: ! SUR VEY®F LOT 19 TENNI or 1. 079;' ._acres i "MAP OF PARADISE BY THE EA Y" OF NEVI/�� aNY ALTERATION OR ADDITION r0 TkIS rt IRVEY 'S A V101-A ION FILED NOV '�, 197 FILE�� 64�'� LOT iv., '� . ' rF OF SECTION 7209 OF THE NEW YORK S-A rE �DuCA TION LAW. /q T SOUTHOLD ` . EXCEPT AS PER SECTION 7209 - S090/VIS/Old 2. ALL CERTIF/CATlt7NS To WN OF SOUTH®LD IfEREON ARE VALID FOR HIS MAP A y: -OPIES h1E1EREOF ONL Y /F CERTIFIED - i ,"- �` ! SAID MAP OR COPIES BEAR -IF RWFESS£O SEAL OF THE SURVEYOR ROGER G. BEST SUFFOLKC®U�T Y, N. Y WHOSE SIGNATURE APPEARS yEREOId ) ; = auREEN . BEST 1000 - 70- 13- 20.19 -IDDITIONALLY To COMPLY WI'y --A!:' _=N --7M ' AL TERED BY COMMONWEAL TH LANDY _ ���'"�'. Scale: 1"�: 30' `3 MUST BE USED i9Y ANY ANO s_� "r :.4"' J-ILIZ/NG A COPY COMPANY OF ANOTHER SUNVEYOR'P 44.4f. -fiat UC+► ' INSPECTED ' AND NORTH P'ORK BANK, NA June 30, 2004 $ ' BROUGHT - TO • DA rF- ' ARF v., -. 14 COMPL'ANCE WIT-! THE LAW. LAIC. N0. 49619 BLOOD ZONES FROM `-IRM 'i6,13,9166G V)b�ECONIC SURVE ORS, P.C. 514/1998 REVISIONS: P P71 DATE:JQ 3-!�"_ P.P. FEE:, � P_i-C E37��e NOTI Y BUILD!','G DEPARTMENT AT C0!,:''F f %�17 H j-'%LL CODES OF 76�5-1802 8 AM TO 4 PM FOR THE NEW YORK STATE & TOWN CODES FOLLOWING INSPECTIONS: AS REQUIRED A 1. FOUNDATION - TWO R=EOUIRED FOR POURED CONCRETE SSG ZEA 2. ROUGH - FRAIMIING & PLU1`,1,BINGT91'�'iP 1LY4Dnn RD 3. I'�?SIJLATION � =A 4. FINAL - CONSTRUCTION fv",UST „��� ,,�,l IrriUSTEES BE COMPLETE FOR C.Q. ALL CONSTRUCTION SHALL (MEET THEE iPpc c cQnFsQE W Y0�� S T ATE. NOf' RESPONSIBLE FOR DESIG OR CONSTRUCTION ERRORS. 2'BLUESTONE COPING 2'COPING 2'COPING GRADE GRADE - - - - 3'-6" STEPS - - - - - - - - - -- - - - - -- - - - - - - - - - - - - SKIMMER (TYPICAL) II $ I C�"CUPANCY OR ; Ii� I USE IS UNLAWFUL SIDE S WITHOUT CERTIFICATE OF OCCUPANCY Q U it I a 0 W DEEP END I SHALLOW END I I Un O I� 0 ❑ , w z I RETURN NEXUS LIGHT- (TYPICAL) I (TYPICAL) J",T COPING 2'COPING I - _,- - - - - - - _ _ _ _ GRADE GRADE ^ ,, STEPS ? ' oC,E i� 6�=F 40'-0" NE ST0RfvT WATER RUN10FF N rjRSUANT TO CHAPTER 236, OF THE TOWN CODE. � o END SECTION .� o M 8'DIA.X 4'DEEP c V OVERFLOW DRYWELL OFILTER AND PUMP rpc_000� NECT TO _ L HEATER COPING PAVERS LOCATE BEHIND GARAGE MORTAR (SEE SITE PLAN) 6"TILE BAND (WATER) C-4 CJ MARBLE DUST-► C I _ ==_=I .I_ �.... m 4 O #4 STEEL REBAR(VERTICAL) 10"OC(5-OC FOR DEPTHS EXCEEDING 5 FEET) 1.PROVIDE WATER SPIGOT AT POOL FOR AUTOMATIC WATER FILLS 13.(1)PENTAIR COMMERCIAL CLEAR WATER AUTOMATIC CHLORINATOR 18. DELIVER REQUIRED LOADS OF WATER TO FILL SWIMMING POOL.AND SPA. M OFF-LINE WITH (1) 1"PVC FEED AND RETURN FOR POOL WITH VALVES #4 STEEL REBAR ry