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HomeMy WebLinkAbout41594-Z cDGg Town of Southold 10/12/2017 0 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38286 Date: 10/12/2017 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 5825 Westphalia Rd.,Mattituck SCTM#: 473889 Sec/Block/Lot: 113.-12-2.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/26/2017 pursuant to which Building Permit No. 41594 dated 5/2/2017 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 McHale,James of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 41594 08-15-2017 PLUMBERS CERTIFICATION DATED I�\ n 4 Au ho ' d ignature TOWN OF SOUTHOLD BUILDING DEPARTMENT y 2 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#: 41594 Date: 5/2/2017 Permission is hereby granted to: Ryan, Carol Nolan 5825 Westphalia Rd Mattituck, NY 11952 To: construct an in-ground swimming g pool as aplied for. At premises located at: 5825 Westphalia Rd., Mattituck SCTM # 473889 Sec/Block/Lot# 113.-12-2.1 Pursuant to application dated 4/26/2017 and approved by the Building Inspector. To expire on 11/1/2018. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 Buildin Inspe a Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines,streets, and unusual natural or topographic features. 2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I%lead. 5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9,1957)non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees I. Certificate of Occupancy-New dwelling$50.00, dditions to dwellin $50.00 Iterations 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-exis 'ng Building: (check one) 4�k Location of Property: House No. Stre t / � Hamlet Owner or Owners of Property:� � �� O Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. 1 Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ 5� Applicant Signature SO!/l�®l® Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 ® �� roger.richert(aD-town.southoId.ny.us Southold,NY 11971-0959 mac' ®l�coulfN,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: McHale Address: 5825 Westphalia Road city,Mattituck st: New York zip: 11952 Building Permit t 41594 Section 113 Block: 12 Lot: 2.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: PSR Electric License No: 4802-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks 1 Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include; Bonding, 60A Pool Panel, 2- Pool Lights, Heat Pump, 2- GFCI Circuit Breakers, 1- Salt Generator. Notes. Inspector Signature: Date: August 15, 2017 0-Cert Electrical Compliance FormAs (' OF 50Uryolo Ooum N TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) REMARKS: <� DATE � INSPECTOR a0E SOUly how olo cout 1,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [/' AL ULAT NFRAMING / STRAPPING [ Aote- FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: IQ 0 u �- DATE /0 INSPECTOR A. FIELD IVS7PFMQl`T REVOR'r DATA COM�tv1Eggq FOUNDA tON(1ST) S r rIrrrww rw�w ww ww Mew w YwY ! FOTJNDATT4I`r (2N15) '� t� ROUGES FRANIlNG& PLUMBING -�— �D 4.� IMULATXON PBA N.Y. , y STATE ENERGY COS}E LZ FINAL rn z '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 _ 4 sets of Building Plans TEL:(631)7654802 Planning Board approval FAX:(631)765-9502415'n' qrvey SoutholdTown.NorthFork.net PERMIT NO. eck Septic Form D.E.C. Trustees Trustees Flood Permit Examined 20 Storni-Water Assessment Form Contact: Sw ivy, l.l.)Approved 20AP 201q7 Mail 1 Disapproved a/c �G Phon Expiration ,20 ® Buildin Ins e CAD APPLICATION FOR BUILDING PERMI Date 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 code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Si e t alp a t or na e,if corporation) ai ing address of a�p icant)State whether applicant is owner,lessee,agent,architect,engin eer,genera ontrac e ectncman,p er r builder Name of owner of premises (As on the tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate Builders License No. ,:::Q I Plumbers License No. Electricians License No. Other Trade's License No. I I 1. L a i whi h r t�+V+g: House Number Street Hamlet County Tax Map No. 1000 Section Block I�Lot Subdivision Filed Map No., Lot 2. State existing use and occupancy of" es and intend s and occp arc of proposed constriction: a. Existing use and occupancy b. Intended use and occupancy 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 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 strictures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new constriction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO 13.Will lot be re-graded?YES O_Will excess fill be removed from premises?YES_NO I 14.Names of Owner of pre - Address 'eUft I V ` lone No Name of Architect Address Mtjone No — I Name of Contractor i 4d Ahl ss �[ �_ Phone No. 102— 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wet lan ?*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. 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 *IF YES,PROVIDE A COPY. STATE OF NEW YORK) (�FSS: nV"" M'4WC--" being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (, y �J —� (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. S fore mAD ay I 0EVE MIILN�R Y PUBLIC STC,OF NEW YX. Lat., O K Notarybhc �a 7 Signature of Appli ant uc. C comm.D4P Scott A. Russell " 0��l .I�k INUVATER SUPERVISOR SOWHOLDTOWN Bf,•1 HALL-P.a 119 I��I•A\ AGIEMIE T 59095 Main Rbsd-5Q>�'I'HOLUNEW;. YOLK 11$71 � ^ - .�.�.: ,. TOWn OfSOuth0ld CH"TER 236 - STORMWATER.mANArrMEN`vT wnuw SKEET ( TO BE COMPLETED.BY THE APPLICANT ) Dols TMS PROJECT IWOLVE ;AW OF aim FOLLOWING: —_ Yes No CHECK ALL TMT APPLY) ❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5;000 square feet of ground .surface, [� B. Excavation or filling involving-more. than 200 cubic yards of materialwithin any parcel or any contiguous area. ❑� C. Site preparation on slopes. which exceed 10 feet vertical rise. to 100 feet of horizontal distance. ❑�D. Site preparation within 100 feet of wetlands, beach bluff b 1 or coastal ❑� erosion .hazard area. E Site preparation within the one-hundred-year floodplain on FIRM Map of any watercourse. y dplaln as depicted [] F. Installation of new or resurfaced impervious surfaces of' 1,000 square I 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 lY0 to all of the questions above,STOP! Cbtaplete the Applicant sectlon below ma your*Name, Signature, Contact hdormatlon,Date &�Connty Tau Map Number.! Chapter 236 does not apply to your protect. If you.answered ACES 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 wltCyour Building Permit Application. APPLICANT: —1BrtS.C<T.M. '� L000 DajW Pttiressbnal A ,Dont or,Other) XAME- (/! 5QQtfon Bion Lct Contact fnfonna do I 1 *** FOR BUILDING DEPAiiTMENT USE ONLY"'�* , ReH ys,^` Reviewed By: ji— Pro e t Address/ cation 'f Co strijet' n _ _ _ _ _Date_ �-a 7—/7 Approved for processing Building Permit. i Stormwater Management Control Plan Not Required. IStormwater Management Control P,lafr is Required l�--.y • __ ____ _ __ (Forward to Engineering Department for Review.) FORM : SMCP-TOS MAY 2014 ---- �uF sr�,r I Town Hall Annex 54375 Main Road Telephone(6311)�)78g65-1802 P.O.Box 1179 G roger,riGi7grt(C11t4W11 SO6VR6 Southold,NY 11971-0959 riVLtS�O� BUILDING DEPARTMENT TOWN OF SOUTHOLD i APPLICATION FOR ELECTRICAL INSPECTION F QUESTED BY: Date:pany Name:e: ft 2 - 1 License No.: v Address: � . ,/D , Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: "Address: Jh *Gross Street: /<�o *Phone No.: ,3�/E; �- �—� 7 fa/ Permit No.: U!5�0 /S— Tax•Map District: 1000 Section:_� Bioctc -_ Lot. , *BRIEF DESCRIPTION OF WORK(Please Print Clearly) Lt le (Please Circle All That Apply) - *Is job ready for inspection: I - YES Final *Do.you need a Temp Certificate: NO- Rough InYES Temp Information(lf.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 I i { BZ�xequest t'or inspection Form Ile oz-_'(D jr 1p- Oft i' . ♦ • • \ a � . 40 is AbC 4b .0 •• �....� ♦ s• ` J • f► •o • l , - � a •� i� _ �� f ♦ �. . .. r^. �;5. 1." � .. . . ,,K _. _ ,� ,._ L \si ,p , S �_ }c 'tea 7�["= .�.-:. '� _:ci �,-��It �- � t,,,���"� � alb ��� � all ` � �. e., �'i-.t �` T�: - � ,�.; ' � . �� rw .�, �� � ,, ,, � � � x� .�. .�_ �, �. � ., y +::.�- � � �.� .r , , r . � x� � - .. Y 4 � R� a _�^a' .. � � ��.. _ ' _> 1 �< x ,._ ��...._ :: �, �� , =i ,� air_:. �, _ s �"�' ���� N p'�~ �R���` '� �. �_ 9k l .. � �.i r c T}— �� _.. dT - i wK ,, �, i. .� ._ ,�.�, �� ., — ,� t e _ � �� r `'��+. }: .. .. \. .. � is ! Jyi'7 l+�'S�• 9�! t i,�(�,, � r 4 ;� �.,.� r � , w' ,� �T' � �-r4, �4' .y ..Z ~ � '.! �4•.iy� ' �-`v � � � -j �'>''a ,tea � `�h r, � .♦ 'Y�\ „� � t• � ,. .. g�rra.�� �'_ � � ►' � .;`� �, :�'� � � 'r�.,.Yr r .• 1 max; +�. �. \.�, F, '+ -S• � .icy` � S �4vYl 5F � � v, ri � .w•, , �T7 , e i 1 - 1 _ F+ R e( _ -_ "�'- rid' +� y�l 5q Li s SURVEY OF PROPERTY CERTIFIED To: SITUATE LANDS END ABSTRACT r� I�-�-I T�T�" TITLE No. LE-2541 MATTITUCK CITIBANK, N.A. JAMES T. McHALE TOWN 'OF 'SOUTHOLD ANN MARIE McHALE SUFFOLK COUNTY, NEW YORK S.C. TAX No-' 1000— 113- 12-2. 1 SCALE 1 "=20' JUNE 17, 2015 AREA = 19,952 sq. ft. � �� • �• - ' ; 0.458 ac. VIA .. �� ,� • '.• •P ' • WAS O%T •, q . . �Of.P� AS \ " e Oµ�5 .� - •• . q goo. e q ° ♦, ♦ ; 75.0 4 . 000G q °, a•• ° 1 o WEV" o` I :i e A tr AJ S.: 0 CR W 1 tH ;= wAtK":i '• .' CN N Sze 1 O.. 0 ':�oc•� • poa d 10 LOA �� X112 St�R� FRAME -4 n �d{� Slips- f dvER w, 7 q WALK 9 CO PORC�� �A.9 1 N C �, "'StatiE•1N SPND � fit,., Wpp9 `✓ � •ONS pA�Q: `_"'.i-��.i• '�dN N s � LA l"r Vl rnrn � m ` ry Z91 9It \ I PREPARED IN-ACCORDANCE WITH THE MINIMUM 1 ti 1 STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE LI.A LS. AND APPROVED D ADOPTED N004 l FOR SUCH USE BY THE MTE-J,ANO R� 1 TITLE ASSOCIATION, r OF)qe4" QC.µ0N. NNr r •r � •ti .Ow� to. No. 50467 SpLR RAIL� � F �µow • 1,00LOT O F ; 5 5 • u Vjsjolq, MAP coltA0 Nathan Taft Corwin III UNAUTHORIZED IS AItON OR ADDITION 13 GS�r+1�{ L�+'CaRK of�S o TO THIS SURVEY Is A VIOLATION OF Sl`� �3 SECTION 7209 OF THE NEW YORK STAIE a� Land Surveyor EDUCATION LAW. ,, COPIES OF THIS SURVEY MAP NOT BEARING �N ��MBER 18�g79 A5 THE LAND SURVEYOR'S INKED SEAL OR' FLEA kt� SEP EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. Successor To, Stanley J. lacksen, Jr. L.S. CERTIFICATIONS INDICATED HEREON SHALL RUN Joseph A. Ingegno L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY Title Surveys — Subdivisions, — Site Plans — Construction Layout IS PREPARED. AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND --- -------- LENDING INSTITUTION' -­I HEREON, AND YORIc Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Fence King of Rocky Point,Inc. _ Dba Swim King Pools&Patios 631744-8100 471 Route 25A Rocky Point,NY 11778 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is 1d.Federal Employer Identification Number of Insured specifically limited to certain locations in New York State, La, a or Social Security Number Wrap-Up Policy) 113008276 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Twin City Fire Insurance Company Town of Southold 3b.Policy Number of entity listed in box Gila" 12WE0J2677 53095 Route 25 3c. Policy effective period P.O.Box 1179 09/01/2016 to 09/01/2017 Southold,NY 11971 3d. The Proprietor,Partners or Executive Officers are fag included. (Only check box if all partnerstofficers included) Pag T 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 "1 a" for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above 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 NO 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 Workers'Compensation contract of insurance only while the underlying policy is in effect 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: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier) tri-�-- Approved by: 8/29/16 (Signature) (Date) Title: Authorized Re resentative Telephone Number of authorized representative or licensed agent of insurance carrier: 631 324-1440 Please Note: Only insurance carders and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT 4AE '� Workere CERTIFICATE OF INSURANCE COVERAGE , [ornpensation 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 and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS&PATIOS 1c.NYS Unemployment Insurance Employer Registration Number of Insured 471 ROUTE 25A ROCKY POINT, NY 11778 1d.Federal Employer Identification Number of Insured or Social Security Number 113008276 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 3b.Policy Number of Entity listed in box"1a": 53095 Route 25; PO Box 1179 DBL37154 Southold NY 11971 3c.Policy effective period: 02/01/2017 to 01/31/2018 4.Policy covers: a. ® All of the employer's employees eligible under the New York Disability Benefits Law b.FJ Only the following class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed 2/1/2017 By &W/4f (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"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box 4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability 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 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 DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (9-15) SUFFOLK COUNTY DEPT OF LABOR, LICENSING&CONSUMER AFFAIRS "4 HOME IMPROVEMENT CONTRACTOR LICENSF HAW RANDYT RODECKER This certifies that the SCE bearer is duly KING OF ROCKY POINT INC DBA licensed by the ry County of Suffolk p6101/1992 L1412-H 06/01/2018 10. 10,10, ;NOTES APPROVED AS NOTED DATE Islu Z• ® B.P.# 1 I. NO 5POIL5VRCHARGE PERMITTED WITHIN 4 FEETOF EXCAVATION ATTHE5HALLOW END,ORb FEETOF EXCAVATION ATTHE DEEP END. C 2, THIS POOL MEETS THE REQUIREMENTS OFAN5I/N5PI-5 "AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROVND SWIMMING FEE: BY: - POOLS"AND 1996 BOCA CODE-SECTION 421, DIVING EQUIPMENT 15 NOTALLOWED. NOTIILDING DEPARTMENTAT 3 SWIMMING POOL SHALL BECOMPLETELYANDCONTINUOUSLY SURROUNDEDWITH ABARRIER CONSTRUCTED IAWREQUIREMENTS OF CL 765-1 02 8A TO 4P FOR THE SECTION R326.5 3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD °�5 FOLL WING INSPECTIONS: TOWN CODE.ACCESS GATES SHALL COMPLY WITH SECTION R326 5 2 OFTHE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY Co LOCKED WHEN POOL 15 NOT IN USEORSVPERVI5ED. ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA I; 1. F NDATION - TWO REQUIRED 4. PUP ING CONSTRUCTION THE CONTRACTOR SHALL EKECTATEMPORARYBARRIERAROUNDTHE EXCAVATIONIAWTHE CODE OFTHE O F POURED CONCRETE ®` G TOWN OFSOUTHOLD. n- } 2. R UGH - FRAMING & PLUM ING eM410 y ®0�O\ON +5 POOL MUST BEEQVIPPEDWITHANAPPROVEDPOOLALARMCAPABLE0FDETECTINGACHILDENTERINGTHEWATERANDSOVNDING V 3. IN ULATION a� $�� CJF. �Qw\t'���, AN AUDIBLE ALARM WHEN DETECTED THAT 15 AUDIBLEAT POOLS]PE AND ATANOTH ER LOCATION ON THE PREMISES WHERETHE POOL Z <z 4. I AL - CONSTRUCTION MUT O'1'V�� ISLOCATED• THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS. vQo - F- I THEALAKM MUST MEETASTM F2208 "STANDARD SPECIFICATION FOR POOLALARMS THE DEVICEMVSTOPERATE INDEPENDENT(NOT w•0 B COMPLETE FOR C.O: P ATTACHED TO ORDEPENDENTON)OFPERSONS 3Q 9 0 ALL TONSTRUCTION SHALL M ET THE '6. POOL SUCTION FITTINGS(EXCEPTFOP,SURFACESKIMMERS)MUSTBEPROVIDEDWITHACOVERTHATCONFORMSTOASME/ANSI IREMENTS OFTHE.CODESOFNEW A112198MORA MINIMUM I8"x23'DRAIN GRATE ORA CHANNEL DRAIN SYSTEM POOLCIRCVLA710NSYSTEM MUST BEEQUIPPED WITH N h� CZ REQ REQSTATE. NOT RESPOND ATM05PHERIC VACUUM RELIEF IN THE EVENT THE GKATE COVERS LOCATED WITHIN THE POOL BECOME MI551NG OR BROKEN SUCH YOW VACUUM RELIEF SYSTEMS SHALL CON FORM WITH A5M E A112.1917 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. DESI NOR CONSTRUCTION ERRORS. �� �'` �� � POOL SHALL BE PROVIDED WITH A MIN IMVM OF 2 SUCTION FITTI NGS OF TH E ABOVE MENTION ED TYPE.TH E SUCTION FITTINGS SHALL BE SEPARATED BY A MINIMUM OF 3'AN D MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A �� ��{� � � "J ®3�� I VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE N POSITION,MINIMUM OF6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO _rn THE SKIMMER/SKIMMER5. `- C I7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF N FPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRC SECTIONS QJ Z c`n t-I-�� ��� ODES O r PLAN i 4201 THROUGH 4206. ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BYA U u I GROUND FAVLTCVRRENTINTERRVPTER(GFCI) CURRENT CARRYINGELECTRICAL CON DUCTORSEXCEPT FOR THOSE PROVIDING POWER c.T'�`' & TOWN CODES i TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E42055 ALLMETALENCL05URE5, PP,�� / T\ +3 ►vE�r� ,� �Jr' OF FENCES OR RAILINGS NEAR ORADJACENTTOTHESWIMMINGPOOLTHATMAYBECOME ELECTRICALLY CHARGED DVETOCONTACT � ,T r+r�c+, el'rlrl�l. AS p EQ I q ED A"'��� � t WITH AN ELECTRICAL CIRCUIT SHALL 8E EFFECTIVELY GROUNDED. v T1 `� 16'VINYL COVERED CONCRETE END5TEF5 { C�I ITI�(II }'�� �7�� 8. WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE IAW NYS PLUMBING CODE608. 4p N Im f�l(7 N PIAi� " ! 9. ALL PIPING 15 DIAGRAMMATIC VNLE55OTHERWISE STATED. V 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. „cry L Tr IL,a N iRUS l 11, A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/NSPI-5 SECTION 6. �- rC N ^ 2'to 4-SAND BOTTOM I Cl G �^•• 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTHOLD CODE SETBACKS 13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON 1 ESUBJECTPROPERTY. 4�,,,1 ��A p � p^°� SECTION A , 15 THE DESIGN I5 BASED ON A DRAINAGESOIL WITH<10%SILT, GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION, IFGROVND ri �b�4 �+' \9�g yRl-�-�l WATER EXISTS WITHIN 6'-O'FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. � S I S UNLAWFUL L 1 16. ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROVND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY "JICONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW AN51221.56 AND SHALL BE INSTALLED LAW WITHOUT �� � C� ����,p�A ALL WATERLINE GUARDSMANUFACTURERS SPECIFICATIONS STA OIL FIRED POOL HEATERS HOT SUHALL BERFACES TESTED LAW VL726• OL H ATERSHEATRS SHALL BE PROVIDEED OR, D WITH ����JJ"" 11 f GUARDED TO PROTECT AGAINSTACCIDENTAL CONTACT OF HOTSVRFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM.A BYPASS LINE SHALL ^^ q' va"a a BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE kip OF OCCUPANCY C PA C �� FOLLOWING ENERGY CONSERVATION MEASURES: 161 AT LEAST ONE THERMOSTAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM, Z 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE .� CHECKVALVE - OPERATIONOFTHEHEATERWITHOUTAD)USTINGTHETHERMOSTAT5ET1NGANDTOALLOWRESTARTINGWITHOUTRELIGHTINGTHE PILOT LIGHT, W j N�-N d PUMP FPOMSKIM1iMER 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THIS REQUIREMENTAREpUTDOOR POOLS W Q co oo < DERIVING 209OFTHEENERGY FOP,HEATING FROM RENEWABLESOVRCESASCOMPUTED OVERANOPERATING SEASON) y y rj 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET z Y a 2'-2° TO RUN THE MINIMUM TIME NECE55ARY TO MAINTAIN THE POOL WATER IN A CLEAN AND SANITARY CONDITION IAW APPLICABLE (' co co a 5V�5gt/ SECTION B SANITARY CODE OF NEW YORK STATE Z to Q;;9(9 TO DIF-.-- 10" .I ',1 M Y(p(p 1r Y DRYWELL / 17. THIS DRAWING IS FOR STRUCTURAL SHELL ONLY. ALL ACCESSORIES AND APPURTENANCES APE DEFINEDBYOTHERS. W.i n y COPING AND WALKWAY-,,,, N O DIVERTER O (SYorHERs) 18. BACKFILL WITH CLEAN EARTH,FREEOF ROOTSAND DEBRIS. DO NOTALLOW THE H EIGHT OF BACKFILL TO EXCEED THE HEIGHT OF THE ol•-I�a VALVE GRADE i WATER IN THE POOL BY MORE THAN 8, OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" W WATER LINEe� a T•. :''. 19. PLACE CONCRETEON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEP051TANDCOMPACT CLEAN BACKFILL U FILTER •'4 9 - vNDISTVRseD EARn " 21, THERE IS NO MAIN DRAIN IN THI5 POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY. THIS MEETS F E W �O 3500 PSI POURED CONC- •d; I REQUIREMENTS OF THE IRC-SECTION R326.6 FOR ENTRAPMENT PROTECTION. • N \ 3/8"REBAR 2)NP ' •.. .• • .� 22. THE POOL WAS DESIGNED LAW THE FOLLOWING. e VINYL LINER r� N \ _� �, ! 22,1. THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER42(2016) ( , f i°, a T rToa SAND 22,2, THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R/+03.10(2075) - Iy ` or T uj 2.3.3• THE INTERNATIONAL FUEL GAS CODE(2015) 1 I 1 I m LJLJ 22.4. THE NEW YORK5TATECODE 5VPPLEMENT-5ECTIONR326 (2016)TORETURNs 22,5. THE NEW YORK STATE SANITARY CODE. 0� CHECKVALVE J 226 ANSI/NSPI-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. `-' ax+ait•' 22.7. BOCA CODE-SECTION 421. 0 841 VERTICAL5/8'REBAR6A3'OC I 22.8 CODE OF THE TOWN OFSOVTHOLD. �Q� A [NOTSHOWN) I 23. ALL BACKWA5HTOBE5ELF-CONTAINED ON-SITESS��OF PLUMBING SCHEMATIC WALL 5ECTION E NTS NTS