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HomeMy WebLinkAbout41997-Z �Q�c�UFFtII,��d . Town of Southold 11/28/2017 o; P.O.Box 1179 v' 2M53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39361 Date: 11/28/2017 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1785 Breakwater Rd., Mattituck SCTM#: 473889 Sec/Block/Lot: 106.-8-20.5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/15/2017 pursuant to which Building Permit No. 41997 dated 9/27/2017 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 Wilson, Thomas of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 41997 11-14-2017 PLUMBERS CERTIFICATION DATED 70d Signature SyFFOL,t TOWN OF SOUTHOLD Baa �p� BUILDING DEPARTMENT 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#: 41997 Date: 9/27/2017 Permission is hereby granted to: Wilson, Thomas 1785 Breakwater Rd Mattituck, NY 11952 To: Demolish & construct an accessory In-Ground Swimming Pool fenced to code. Replaces BP# 38625 At premises located at: 1785 Breakwater Rd., Mattituck SCTM #473889 Sec/Block/Lot# 106.-8-20.5 Pursuant to application dated 9/15/2017 and approved by the Building Inspector. To expire on 3/29/2019. Fees: ELECTRIC $100.00 PERMIT RENEWAL $125.00 Total: $225.00 B ector F TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERKS 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#: 38625 Date: 1/14/2014 Permission is hereby granted to: Wilson, Thomas &Wilson, Mary 1785 Breakwater Rd Mattituck, NY 11952 To: demolish & construct an accessory In-Ground Swimming Pool fenced to code At premises located at: 1785 Breakwater Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 106.-8-20.5 Pursuant to application dated 12/26/2013 and approved by the Building Inspector. To expire on 7/16/2015. Fees: DEMOLITION $100.00 SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250:00 CO - SWIMMING POOL $50.00 Total: $400.00 Building Inspector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets,and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I%lead. 5. Commercial building, industrial building,multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957)non-conforming uses,or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date. New Construction: ✓ Old or Pre-existing Building: o (check one) Location of Property: 7� [( G F4, House No. Street Hamlet l/" Owner or Owners of Property: 1 ` S t)—>, Suffolk County Tax Map No 1000, Section O Block Lot ® - Subdivision Filed Map. Lot: Permit No.Alqq) Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: �//(check one Fee Submitted: $ plicant Sig tore pF SO(�j�®� Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 roger.richert(D_town.Southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Wilson Address: 1785 Breakwater Road city,Mattituck st: New York zip: 11952 Building Permit#: 41997 Section: 106 Block. 8 Lot: 20.5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Hubbard Electric, LLC License No: 4709-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 2 Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches Twist Lock 2 Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include: Bonding, Control Panel, 2- GFCI Circuit Breaker 1- Filter Pump, 1- Pool Slide and Water Fall Pump, 2- Gas Pool Heaters. Notes: Inspector Signature: 2 Date: November 14, 2017 0-Cert Electrical Compliance Form.xls - OF SOpl�olo , cOUMY,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECT [ [ ] FOUNDATION 1 ST [ ] RO GW PLUMBING [ ] FOUNDATION 2ND [ ] SOLATION - [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS:0-4kCr-D G DATE INSPECTOMA:n=l ton �o��OF SOUTyOIo ��'YOOUNTV,ac� TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] NSULAT ON [ ] FRAMING / STRAPPING [ FINAL [ ] 70K�- FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FIN L) REMARKS. ALP], d)�/ G&-? M 0- se4 r� 6 1 V �� cool 4(fA DATE INSPECTOR OE SO(/lyolo �ycou N LIA l 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: lJ - ) /DATE i 1 � ) � - INSPECTORNS� FIELD IloiSPECTXON REPORT DATE COMMENTS FOUNDATION(IST) LA � - ............ .a............. �y FOUNDATION(2ND) � Cp ROUGH FRAMING& y � PLUMING INSULATION PER N.Y. H STATE ENERGY CODE 0A dflAU4 l FINAL p l0 I , Mv 0. ADDITIONAL COMMENTS - to s 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) 765-1802 Planning Board approval FAX: (631)765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. 6�1$�go2� Check Septic Form N.Y.S.D.E.C. I; �� /7 (� Trustees _1 y� L L/ L� Flood Permit Examined 1 -/" ,2lX J Storm-Water Assessment Form DEC 2 6 2013 Contact: Approved 20 mail tow Disapproved a/c B(DG DEPT T01Nl1 OF SOUMOLD Phone: 3 Expiration ,20 Building Inspector / Je 4 + 6 31 —I at APPLICATION FOR BUILDING PERMIT 4L(7-� - Date /((J, 20 V1 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, d regulations, and to admit authorized inspecfitors on premises and in building for necessary inspections. -za 1�� t; 1 3 t3 z °�Y."� i� 6P �"�� n ",. ._�,; �„1 �a � as `iti14°'"Iw,l I� 8� �; ��' (Signa re of applicant or name,if a corporation) � 'a �` x . ��; i�CLOSER -)-TOC a Ot;;FLE 1r �� i 'BEFORE,"WATER" / ailing�dlire ofa ' G State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electri ian lumber or builder ANPROV AS ROTED ELECTMAL r—L; 9 V V11"kV., ('4d Name of owner of premises , (As on the tax roll orAj����d�DiNG DEPARTMENT AT If applicant is a corporation, signature of duly authorized officer 765-1802 8 ANI TO 4 PM FOR THE FOLLOWING INSPECTIONS (Name and title of corporate officer) 1 FOUNDATION-TWO REQUIRED 11 FOR POURED CONCRETE Builders License No. 2 ROUGH-FRAMING,PLUMBING, STRAPPING, ELECTRICAL&CAULKING Plumbers License No. 3 INSULATION Electricians License No. I LW 4 FINAL-CONSTRUCTION &ELECTRICAL Other Trade's License No. MUST BE COMPLETE FOR C 0 ALL CONSTRUCTION SHALL MEET THE 1. Location of landwhich proposed work will be done: REQUIREMENTS OF THE CODES OF NEW , TATE OT RE P NSIBLE FOR PRnP,,4 M), - House Number S 'reet Hamlet County Tax Map No. 1000 Section 1 V Block V 9 Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and T* tended use and occupancy of ro osed construction: a. Existing use and occupancy 1'� 02 b. Intended use and occupancy3 ` Yl 191 it 3. Nature of work(chec;�h�h� licable)::New ding Addition 0teration Repair Removal Demolition—sj Other Work qu'Co I (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 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 construction: Front Rear Depth Height Number of Stories 9. Size of lot:Front ® Rear o:� �Dept' /®' a 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 NO- Will excess fill be removed from premises?YES NO 14.Names of Owner of premises LOglSC- Address Phone No. Name of Architect © Address Phone No —2i Q Name of Contractor -�GWdress Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO 4 * 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) a COUNTY OF50 S. Ma yk/ [ZW.��LjlLVA being duly sworn,deposes and says that(s)he is the applicant (Name of ind f idual signing contract)above named, (S)He is the (Contractor,Agent, Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; 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 t before me this l day of 2013 � a MELMIE V.MW mw�U4 Notary Public .4 of Signature of Applicant ` in SuVolk ,mon E Od.I ' C Scott A. Russell °s� `� James A. Richter,, R.A. SUPERVISOR � Michael M. Collins P.E. 501 BOLD TOWN W I.I.-P.O.Box 1179 $3095 Main Road-SOUTHOLD,NEW YORK 1197E Telephone#e (631)-765-ISM Fax#: (631)-765-9015 AIC�IIAIEI»COLLINS@TQwN.SQ Qi,D.NY.US '�> Je#MII RICI1'YIsMOWN.SOII'YHOT.ri.N MS Office of the Engineer Town of Southold STORMWAT'ER MANAGEMENT CONTROL PLAN REVIEW COVER SHEET (TO BE COMPLETED BY THE APPLICANT) TO: ENGINEERING DEPARTMENT PLEASE ATTACK T15 l+i7.LLOlM Poamw'or m271d!lAPtag..• FROM BUIL ING DEPARTMENT Copy of completed Application for Building Permit - DATE: �L 2J 1 -_7 4 - © Stormwater Management Control Plan r APPLICANT= �� lsc Q Completed Chapter 236 Stormwater s.C.T.M. o(a Review Checklist PROPERTY ADDRESS- L7 6 � ' BRIEr�ECT DESCRIPTION: t ; i { j - i I I 'k***FOR ENGINEERING DEPARTMENT USE ONLY* * i Reviewed Br. Date: f E] Approved Additional Information Required: 1 Z /� # ?6ZBbtiL �µ LZ 9l ��-ZO-Z6 . N �+G'fi6fF�tR• - 5b w - CHAPTER 236 � APPLIC AM. StOrmwater Review Checklist S.C.TM, PHYSICAL ADDRESS: Stormvvater I1'Ia4agemeat CpntroI Plan Regiureimn Yes Na SIA If i\To or NA,Please Provide Additional Information ]. Pian drawn to scale of nqt Ieas thea 64 Feet•to the inch showing: ` a, location and description ofpmperE3'•boundaries b.total site acreage 01 c. existing and natural man-made on and �Safl fees Of the site baun 8s se'aired in 23 la C 2 . d.test hole data indicating soil chid the e. Proposed limits Of clearing ��to water disturbance and the#ataI area of pro lead f f. existing and proposed contours of the sitem ( au�nuiri 2'interval) - g. location dao drain n Affig and Proposed s ctnres, roads,driveways, sidewalks drain ends and ties h. spot grade andishecltloor elevations for structures and Proposed m i. location oftlse �g pool discharge ^' ling N j. location of proposed soil stacltpite area(s) k, loca-ion of the pmposW tonMuction ea1raaceJstaging areas f, location oftiie proposed;conercte t ashout area m. location of all proposed erosioa td sedi hent control measures 2, Plan includes calc�zlatfons showing brat the stormwater improvements ` are sized to captUre,store and infftate on-site the ranofrfrom all inn eryious surfaces generated bly atwo:iaeh raiai'alp 3. Detail drawings{rec�ui d for elan a�roM"'I provided a• erosion and sediment controls : b.construction entrance c. inlet streFct (e.g,catch y trench drams,etc.) d. leaching structures(e.g.titration basins swat es,ete.) 1� ' N N REVISED 7124/2013 0'F SO/jlyol Town Hall Annex JR Telephone(631)765-1802 54375 Main Road N ,,��::ax(631)765- 50o22 1 �Q roper_richert(a�town.sout�olU nV us D SEP 1 5 2017 �= BUILDING DEPARTMENT TOWN OF SOUTHOLD 13 *DCDF- P;PLICATION FOR ELECTRICAL INSPECTION TOWN OF SOUTH f REQUESTED BY- Date: Company Name: . Name: License No.: Address: Phone No.: ( i- i- JOBSITE INFORMATION: (*Indicates required i formation) *Name: ! *Address: *Cross Street: *Phone No.: I Permit No.: DOC Tax-Map District: 1000 Section: Co Block: Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) - I (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 I . *New Service: Re-connect. Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form 1� 01 .� I Southold Town Building Department gti�FOl,t� P.O.Box 1179 a . Permit#: 38625 53095 Main Rd • Southold,New York 11971 Permit Date: 1/14/2014 yAl �a� (631)765-1802 Expiration Date: 7/16/2015 Parcel ID: 106.-8-20.5 BUILDING PERMIT RENEWAL LETTER Dated: 8/17/2017 Applicant: Wilson, Thomas&Wilson, Mary Location: 1785 Breakwater Rd,Mattituck Work Description: IN GROUND POOL demolish&construct an accessory In-Ground Swimming Pool fenced to code A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. S", Owner: Wilson, Thomas&Wilson,Mary Address: 1785 Breakwater Rd Mattituck,NY 11952 The permit listed above has-expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold,New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. STATE-OF NEW YORK WORKERS'COMPENSATION BOARD CIERTIFI<CAT,E,O F XYS:W0RFER8'•C-_I TION IX,,SURANCE C0V- ER.GIE la.Legal'Nairie and Addtess-of Insured-(Use Street Address Only) lb.Business Tet'ephoM Number o£Insured 631-744-8100 Fence King of Rocky Point, Inc. DBS: Swim King Pools & Patios lc.NyS>Tnempl`ay►rieiit Insurance Employer 471 Route 25A Registration Number ofInsured. Rocky Point, NY 11788- 1 d.Federal Employer Identificatibn Number of Insured. of-Social Security Number Work Location;of insured(Qnly required t1;cotxr'ageJs speeificallY 113008276 limiter}to cer.Cain.locatiorrs-in-New Y•okk,State,i.e;a Trap F07icy), A.ddre"ss.of the Eud*'ReVes,pg'aof�of Coverage 3a.Nahie of Insurance Cartier (1✓ntity`JBeing'Listed as tlxe Certitie�te IYoliler) / (:Oallial7 dmf� y .. 3.b. Policy Number•of entityliste-d'iim box"la": a WWC3t76816:3 Town.&$outho(d 5309-$ Rouse,25 .3c. 1Policy;effeetive:petiod: PO �99 1*1 Z9 ,9%1/,2.013-to 9/1/.2014 sgmu hold, MY 1,1971 3d: The Proprietor,•1'ai`Mtr5 at EXecuEive-Officers arc: .' included.(gnly>checic<lioxifAllpaittietsfof6ocisinc]uded} all exelud-ed or.ceYtaiin-partners/ofrivorsvxcluded-. This csrtiftes:tliat-tlzo.ix►suranc�carries`indicated`in box"T'insures the tit?siness.re`ferenced above ih,bb-k 5`].p'-'fovworkers'competisatiibn ntider,'tlieNew .work State Workers'C'ompen'sation L•avy (ra iise this foim,;New', ork(N�mA*be;liste under Item 3A ora t e INF'ORIvIATI02`1PAGE-of.the wbrke s'compensakion insurance policy} �he,Insurance,Carrler-:ot its licensed agent will'send this Certscate;of Insurance to flee entity listed above as the certificate'liolder iri to '2''': The In'su"ra7zc�e C'arrierwill'a7so notify t3�e above-cert tate ho'Ider.'ir ih 10'dayslF a-ppl_icy s,ccit�cele l due to nbt:ptly�rtent,ofpretniurirs or within 30 days 1F them are re softs other than-nonpayment;afprenz ums that-cancel=the policyor`eLiiruriq�e the.irzfiured°from_,`tlte coverage indicated on tjz`is Certificate, (T heseri61ices'.*gy be sent•'by regit)dr mail:).-,OtheMse,'this Cert�cate is ital�ds fog ai�e year after?his,,fdrnz i� appioyed'hy-the insurance carrieri prJis.licensed agent,or-untzl•,the blicy expiratioa•�lute listed in lion`F3�r' wTiichever is earlier. 'lease;N'o#e:7Upon the caareellation of the VF+orkers�.cornpe�isatiort g4licy;incDieated on'ttiis:fdfm,?f>he business,continues to bi,named ou a:pernait,license or'coritract,issued.byra cerftleate hQlder,'tb�e liasiiiess AMA provide that,d.ortificate liolder-witb;a-new Certificate of Workers? Gompensataon Coverage or•otlier au#horized jprgoitlia't ttie bUsimess-is:complying,vPith the mandatory coverage recjd*emegts'.of the``New YQrk State Workers'Compensation LapV: i7mder penalty of`perjury,I certify that Y ani an-authorized representative or licensed.agent 4f�the W ur:ince-cnrrier:refe�reneed atiove- ' apil that'the named'iitsured-lias'the coivei age as depicted ori this 0kV; Approved by:. •Leaxitie,-Flue (1';'iiitria ie:o£auiliorizedrepresenfatiVe;bi:licepsetl'agexnt_Ofinsu_r�an-ceca`rcier); Certified'by: �l_6/2Q13: (Signature)_ (bath) Title: ;vifiori7md- e .te entatXve - TeXeplaone,Number of authorized ie�iresentatit!e.ar licensed.ag�q.of insurance carrier:877.=528-7.$7$; •Please Note:'OnIX insurance eainiers•and their'licensed•agenls arA_-attili6rixed to issue-.fhe,-C 1_Q,S.2;td AA. 7nsicrance_brokers are;NOT autligrizetl fo.issuefl, - STATE OF NEWYORK IACIRKER'S COIVPENSATION 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 Add ress•ofInsured (Use street address only) 1b.Business Tel ephone Number ofInsured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS& PATIOS 1a NYS Unemployment lnsuran ceEmployer Registration 471 ROUTE 25A Number of Insured ROCKY POINT, NY 11778 1d.Federal Employer Identification Numberof Insured or Soda] Security Number 113008276 2 N ame and Address of the Entity requesting Proof of Coverage 3a.N am of InsuranceCarrier (Entity b ei n g I i sted as the Certificate Holder) The First Rehabilitation Life Insurance Town of Southold Company of America 3b.Policy N umber of Entity listed in box"1a": 53095 Route 25 DBL37154 PO Box 1179 ~ 3c.Policy effective period: Southold, NY 11971 02/01/2013 to 01/31/2014 4 Policy covers: a. Z All of the employer's employees eligible under the N ew Y ork D i sability Benefits L aw b.F] 0 my the following dass or dasses of the employer's employees: U rider penalty of perjury,I certify that I am an authorized representative orlicensed agent of the insurance carrier referenced above and that the nam ed i n su red has N YS D i sabi 1 i ty Benefits insurance coverage as described above. Date Signed 2/11/2013 By (�W/ hf (Signature of in su ran cecarrier's au thori zed representative or NY S Licensed Insurance Agent of that!nsu ran cecarrier) Telephone N umber 516-829-8100 Title Chief Executive Officer M PO R T A N T:I f box"4a"i s checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of th at carrier,this certifi cate i s C 0 M PL E T E.M ai I it directly to the certificate holder. If box"4b"is checked,this certificateis NOT COMPLETE for the purposes of Section 220,Subd.Bof the Disability Benefits Law. 1 t m u st b e m ai 1 ed for com pl etion to the Worker's Compensation Board,D B PI ans A ccep tan ceU ni t,20 Park S veer,A I b any,N Y 12207. PART 2 To be completed by NYS Mrker'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 N YS Worker's Compensation Board,the above-named employer has complied with the N YS Disability Benefits Law with resp ect to all of hi skier employees. D ate Signed By (Signature of N YS Worker's Compensation Board Employee) Telephone Number Title PI ease N ote:0 nl y insurance carriers licensed to w ri to N Y S Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carri els are authorized to i ssu a Form D B-1201.Insurance brokers are N OT authorized to issue this form. DB-12:)l (5 3E) Client#:39819 RANDT AC®RDTM CERTIFICATE OF LIABILITY DATE(MMIDDIYYYY)INSURANCE 8/29/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Southampton Commercial A/cN o Ext;631324-1440 FAX No Cook Maran&Associates E-MAIL 300 Hampton Road ADDRESS: Southampton,NY 11968 Valley AFFORDING COVERAGE NAIC Vae f/ INSURER A: y Forge Insurance Company 20508 INSURED Fence King of Rocky Point,Inc INSURER B:Wesco Insurance Company 25011 DSA:Swim King Pools&Patios INSURER C 471 Route 25A INSURER D: Rocky Point,NY 11778-8985 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: -` THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 SdCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR D POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY 2094735072 09/01/2013 09/01/2014 EACH OCCURRENCE $11`000P000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100 000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 JECT LOC $ 7X POLICY A AUTOMOBILE LIABILITY 2094735069 09/01/2013 09/01/201 EDaccidentSINGLELIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOSJ{ NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION MMC3044104 0910112013 09/0112014 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE-1Y I N E L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 01`1 The ACORD name and logo are registered marks of ACORD 59'4" LA \ 1�1 /s 58' \\/ - 10' 9' Cf1 O ? NO b. O � BEEP END LLI r 10" CONC.WALL ROE URNS � U V Z LLQ Z o �= 10' 4' 16' 18' 6' < O 10" N T-6"H2O ' Z O O 8"H2O 3'-4"H2O t/1 Cn Z CO Cr C0 co M Q 28' CHECK VALV16 PUMP 10" CONC.WALL---' PLANo CHECK VALVE PLUMBING SCHEMATIC ° Scale;1/8"=V-0" c 3 FILTER 30 X 32 Rec 16 x 28 L O¢ DIVERTER CAST-IN-PLACE VALVE CONC. STEPS �����® A �°C�aa`, ru WATER LINE � v — N NOTES 07 7 �L 2"to 4"SAND BOTTOM a 1 1. ALL CONSTRUCTION IS TO BE IN ACCORDANCE WITH THE RESIDENTIAL CODE OF NEW S' CAST-IN-PLACE CONC.STEPS YORK STATE-2010 AND THE ANSI/NSPI-5-03 STANDARDS FOR RESIDENTIAL INGROUND < Y� SWIMMING POOLS FOR A TYPE II POOL. C - I 2. STRUCTURE IS DESIGNED FOR USE BELOW GRADE AND ONLY IN AREAS WHERE THE (BY OTHERS) 101, SECTION A + GROUND WATER TABLE IS A MINIMUM OF 4'-8"BELOW THE PROPOSED FINISHED GRADE. 3. BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS DO NOT ALLOW THE HEIGHTOF BACKFILL TO EXCEED THE W } WATER LINE WATER TO EXCEED BACKFILL BY THAN 8"OF THE WATER IN THE POOL BY MORE THAN 8", OR THE N z Z - Ln GRADE 4. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSIT AND COMPACT CLEAN BACKFILL O U w Z O N W� O Q ROLLED FOAM BETWEEN � 5. WALKS TO BE SMOOTH,NON SKID TYPE,SLOPED AWAY FROM POOL =_?-- W LINER AND CONCRETE o 6. WATER DISPOSAL SHALL BE LIMITED TO OWNERS PROPERTY IN ACCORDANCE WITH Q U W LL. FORM TIES LOCAL REGULATIONS. -1�/m 7. PROPERTY OWNER IS RESPONSIBLE TO INSTALL PERMANENT FENCE AROUND POOL IN Q Ln 3500 PSI POURED CONC. ° \� O ACCORDANCE WITH THE NYS BUILDING CODE,APPENDIX G,SECTION AG105 PERMANENT r O ENCLOSURE MUST BE COMPLETED WITHIN NINETY DAYS AFTER THE DATE OF COMMENCEMEN r p 2"RETURN LINE OF CONSTRUCTION. O VINYL LINER 8. THERE IS NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATER CIRCULATION IS 4 �\ PROVIDED BY THE SKIMMERS ONLY. THIS MEETS REQUIREMENTS OF RC-SECTION AG106 2"TO 4"SANDa /\ FOR ENTRAPMENT PROTECTION. 9 THIS POOL SHALL BE EQUIPPED WITH AN APPROVED POOL ALARM WHICH IS CLASSIFIED BY UNDERWITERS LABORATORY,INC TO REFERENCE STANDARD ASTM 2208 ENTITLED "STANDARD SPECIFICATION FOR POOL ALARMS,"AS ADOPTEDIN 2008 �11-28-2013 10. ATEMPORARY ENCLOSURE,OR 4 FT FENCE SHALL BE INSTALLED AND REMAIN IN PLACE THROUGHOUT THE PERIOD OF CONSTRUCTION OF THE SWIMMING POOL, OR UNTIL THE COMPLETION OF A PERMANENT ENCLOSURE. WALL SECTION z- E