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HomeMy WebLinkAbout42350-Z ���StlFFUj��oG Town of Southold 4/20/2018 o - P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39611 Date: 4/20/2018 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 65 Ryder Farm Ln., Orient SCTM#: 473889 Sec/Block/Lot: 15.-8-1.4 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/7/2018 pursuant to which Building Permit No. 42350 dated 2/7/2018 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 Phillips,Robin of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 39650 05-12-2015 PLUMBERS CERTIFICATION DATED i A t ed Signature o�SOFFo��� TOWN OF SOUTHOLD o , 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#: 42350 Date: 2/7/2018 Permission is hereby granted to: Phillips, Robin 65 Ryder Farm Ln Orient, NY 11957 To: Construction of an inground swimming pool as applied for. Replaces BP# 39650 At premises located at: 65 Ryder Farm Ln., Orient SCTM # 473889 Sec/Block/Lot# 15.-8-1.4 Pursuant to application dated 2/7/2018 and approved by the Building Inspector. To expire on 8/9/2019. Fees: PERMIT RENEWAL $125.00 Total: $125.00 in I ector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 i •7 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. ollowing: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 Occu ancy-New dwelling$50.00,Additions to dwelling$50 00,Alterations to dwelling$50.00, wimming ool$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. Po Its New Construction. Old or Pre-existing Building (check one) �h Location of Property: 0_5V-\Cdr Fyja 1. Lane, , 0 r fn4 r W l� , t I Ts House No. Street Hamlet Owner or Owners of Property: YJ d C C Suffolk County Tax Map No 1000,Section Block 019 Lot r Subdivision Filed Map. Lot. Permit No Date of Permit. Applicant: Health Dept.Approval- Underwriters Approval: Planning Board Approval: Request for. Temporary Certificate Final Certificate: (check one) Fee Submitted: $ oum App scant Signature 6WamT�C_K�Q0lS (a-3L -�,2�1�' -c?,_ (�13 SOUryOlo Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 c ® roger.riche rt( -town.southoId.ny.us Southold,NY 11971-0959 ®�yCOUNT`I BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Robin Phillips Address: 65 Ryder Farm Lane City: Orient St: New York Zip: 11957 Budding Permit#: 39650 Section. 15 Block: 8 Lot- 1.4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Kel-Rob Electric License No: 37725-ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceding Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1 A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: In Ground Swimming Pool To Include - Bonding, 1- Pool Light, 1- Pool Pump, 1-GFCI Circuit Breaker,1-Pool Heater, 1-Salt Generator Notes: r 1 1 t 'i Inspector Signature: Date: May 12, 2015 Electrical 81 Compliance Form.xis i IJ ho��,OF SOplyOlo (� uP? • �o TOWN OF SOUTHOLD BUILDING DEPT. 76S-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] 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: If 26v� DATE `'� INSPECTORS SO(/l�,o� _ olycoUM`l,�`� TOWN OF SOUTHOLD BUILDING. DEPT. 765-1802 INSPECTIO [ ] FOUNDATION I ST [ ] ROU PLUMBING [ ] FOUNDATION 2ND [ ] I LATION [ ] FRAMING /STRAPPING [ FINAL- [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: �1 x r'r YC _ L40 CK- � � y DATE INSPECTOR, �o��pf SOUlyolo N o 0 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] SULAT N FRAMING / STRAPPING FINAL [ ] [ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRI CAL (FINAL) REMARKS: 0 CAO& A "006/ D, ��'. w DATE YI Y�fwf INSPECTOR �1L�7 SOF SOUIyo comm,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 .INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] I ULATION [ ] FRAMING / STRAPPING [ FINAL Pz (xQ�) [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE INSPECTOR Is r r o • r ^ r t 1. , r 1 • r 1 � � • • It t ON rr 71� m in ,mv - MEIN ILI` olrarsX.M • 1 a • •� r �t t, � AW�.t T.®"I OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT „ . Dc you;have.or,need the,following;,before,applying? TO'WN`HALL „ : Board.af; Iealth �4 SOUTAOLD,NY 11971 4 sets of 13iiilding Plans ,,TEL: (631),765-1802 PlanningBoard approval '',,FAX:(631)`765=9502 Survey `x `www.northfork,netlSouthold/ PERNl[IT NO. ��� U Check .r;•s ,'j,r Septic Form, _ Trustees, ,Examined ,20_ - - Contact:4-i1`T.►I. I Q Cd(1YlD 75* Approved 20 t M�-PC t pp Mail to �^(X� S 'Disapproved a/c ��,, Phon �Q3�, IQQ O� 0qS "ltrll9q Expiration ® ,20 g" :ispec LE C LICATI(J1V-FOR°BUMDING`PERMIT'{ = LIAR 30 2015 . ;`. r t _ ... -th - Date1 QL'rc ,:20i5- 6LDC� DEPT INSTRUCTIONS,'J' TOWN is SDUTFIDLD a. s 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'adj oining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuanceof Building Permit. d.Upo4_gpproval,of this application;the Building Inspector-will'siss'at'aiiil2hrig.P-ermit'tdith&,,tpplicant�Such,,a`permit shall be kept on the premises available-for inspection througho A.the v�'ork , _ ' -- e,No-building-shalibe;occupied,or-used-in,whole,or in;pgirt for-any.-, t post,what,soteve�,untilsthe Buildit_ig:Inspector,^,-- issues a Certificate of 0c64ancv_ f.Every,building permivshall.expire.if work authori =has not coif menced itiun 12 inonthe:after..tha.tdate-of,: issuance or has iiot'been ooiiipleted within 18 months from such ate:If iio zoning,amen"druents"'�r'otherreg►uiztions-affecting the s� property have been enacted in the-interim,the Building Iuspector;may,authorize;in writing,the extension ,of the permit for an, addition-sbcinonth's:Tliereaftei,a'riew.permit'shall berequired: -APPLICATION=IS,-4k�BY."MADE to the Building Dep rfinent;forihe-issuance-of a-ruildingPermi"t"'pur"sdant`to the Building Zone,Ordinahce,of the Towii'of Southold,'Suffolk Cour1"�;New York;and other applicable-Laws,Ordi3iances or +'' Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described.The applicant agrees to comply w tfi,all applicable laws, ordinancesi''NIding Eode',,'liousing' de. and regulations;and,to admit'- authorized inspectors on premises.and-iil building for necessary?in'spections` ) (Signature o phcant or name,if a corporation) W YVIi"�ler laz' g tr PIGc� (Mailing.ad ess-,of applicant) LQ ' State whether applicant is owner,'les`see;agent, architect, engineer;general contractor, electri ian,,plumber,. r"builde Name of ownenof premises (As' ,n the taX'r6 of rat.,,-1,,ed) If ap cant is con7 'o , gnature of duly author' ed . "dicer s- ��� - , (Name and tit e o corporate'officer) -"CSS Ctrl al =t ` Builders 'License No: •. . —I_� Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: ' CQ�_ fnIQ - House Number 8treet, Hamlet County Tax Map No. 1000 Section Block OS :.r,' •,i:;,Lot' rf.;�; C�:.,.. ;, ' Subdivision Filed M�,qp�To. d' Lotr'> F a (Name) :::> 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occlt aficy b. Intended use and occupancy, n mO 3�ature of work(check which applicable): New Building - Addition' Alteration R air Removal. . . _Demolition Other Work (Description) Estimated Cost 1?ee (To.be paid on filing this application) 5., dwelling, number of dwelling units_ Number of dwelling units on each floor If garage, number of cars I 5. business, commercialor mixed occupancy, specify nature and extent of each type of use. 1. Dimensions of existing structures;if any: Front" Rear ! Depth Height Number of Stoddd `t'e,t=:d'P i Dimensions of same structure with alterat dns-or additions: Front Rear Depth Height f'`' Number of,Stories :nn, n r, na5a 3 Dimensions-of entire new construction: Front• Rear Depth Height Number of Stories - Size of lot: Front Rear Depth . Date of Purchase Name of Former Owner " i ./Zone or use district in which premises are situated ,12/'D' oes proposed construction violate any zoning law, e i dinance or regulation? YES NO ( Will lot be re-graded? YES__NO _Will''ex'eess fill be removed from premises? YES NO I ames of Owner of premises Address .Phone No. Address ame of Architect - ``Phone No Name of Contractor Address Phone No. 5 . Is this property within 100 feet of a tidal wetland,or a freshwater wetland? *YES NO X * IF YES, SOUTHOLD TOWN TRUSTEES &-D.E-C' PERMITS MAY BE-,0QUiR'ED. b. Is this property within 300 feet of a tidal wetland? * YES NO > ` * IFYES,D.E.C. PERMITS MAY BE REQUIR J).- rovide survey, to scale, with accurate foundation pla'n'.-.and distances to property lines✓ If elevation at;any point on property is at 10 feet or below,must provide topographical data on survey. ;TATE OF NEW YORK) SS: : Scott A. Russell ,��° '�� ST01R.-A IWAT]E1R. SUPERVISOR c MAk NA\cGl1EMIENT $pUrHOLD TOwx xAx.L-P.O.Box 1179 o Town of Southold Main Road-SOUTHOLD,NEW YORK 11971 CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET (TO BE COMPLETED BY THE APPLICANT ) DOES THIS' FROJWT INVOLVE .ANY OF TM FOLLOWING Yes NO CHECK ALL THAT APPLY) 3 ❑ A. Clearing, grubbing, grading or stripping of land which affects more 'l than 5,000 square feet of ground surface. 3 B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area, ! El C. Site preparation on slopes which exceed 10 feet vertical rise to << ?; 100 feet of horizontal distance. ❑b D. Site preparation within 100 feet of wetlands, beach, bluff or coastal ;3 I erosion hazard area. 11d- E. Site preparation within the one-hundred-year f loodplain as depicted ; j on FIRM Map of any watercourse. !" j ❑ F. Installation of new or resurfaced impervious surfaces of 1,000 square i feet or more, unless prior approval of a Stormwater Management a Control Plan was received by the Town and the proposal includes ; j in-kind replacement of impervious surfaces. If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information,Date & County Tax Map Number! Chapter 236 does not.apply to your project. If you answered YES to one or mote oftlib above;please submit Two copies of a Stormwater Management Control,Plan and a completed Check List Form to the Building Department with your Building Permit Application. APPLICANT: (Propert rer esign ProonaL Agent, ontractor,othee)I' S.C.T.M. #_ 11000 Date fess 3! i J53 18 I yr YAMS 1 l Section Block Lot FOR BUILDING DEPARTMENT USE ONLY 3 , Contact information j ! Reviewed BY: "' Date: Propertv Address/Location of Construction Work: — — — — — — — — — — — — u!s V\',�^ ev Farm �n n n Approved for processing Building Permit. V lJ` i�l CI Stormwater Management Control Plan Not Required. i Stormwater Ivianagement Control Plan Is Required. !f (Forward to Engineering Department for Review.) j I FORM "' SMCP-TOS MAY 2014 SQ(flyo� Town Hall Annex � � Tel �vy-- 54375 Main Road 6 a r� � V/ - P.O.Box 1179 G ro end he 1)a65- 5 l Southold,NY 11971-0959 �OQ APR 2 4 2015 u MaDING DEPARTMENT rrrr r TOWN OF SOUTHOLD roar ,o�sou r o�c -APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: ,(3 o-b b i (-Cq 0 r J o Date: Lla► 17 Company Name: Name: —8a6 i r-F-q ro r r o License No.: 3-1-7 S - NI e - Address: a 1 S S- J 0 n J Uj 1 L Tun� /!74 Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: S ci l t rn �ch h �ob 1,0 ph"ll "/g 'Address: 'Cross Street: a 'Phone No.: 03 a 3 - $ �Iermlt No.: 3 9(os O tax-Map District: 4000 . Section:--LLBlock: 09- Lot: 1 . 1 `BRIEF DESCRIPTION OF WORK(Please Print Clearly) sal rylmin coo/ Gt.11 rte Please Circle All That Apply) Is job ready for inspection: VISS O Rough In in Do-you need a Temp Certificate: NO 'ernp Information(if needed) Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other New Service: Re-connect Underground Number of Meters Change of Service Overhead ►dditional Information: PAYMENT DUE WITH APPLICATION c�p� .82=Request for inspection Form Southold Town Building Department P.O.Box 1179 Permit#: 39650 53095 Main Rd o Southold,New York 11971 Permit Date: 4/6/2015 (631)765-1802 Expiration Date: 10/5/2016 Parcel ID: 15.-8-1.4 BUILDING PERMIT RENEWAL LETTER Dated: 1/29/2018 Applicant: Phillips, Robin Location: 65 Ryder Farm Ln, Orient Work Description: IN GROUND POOL Construction of an inground swimming pool as applied for. A FEE OF $125.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Phillips,Robin Address: 65 Ryder Farm Ln Orient,NY 11957 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. •�k �''msw�s�: "<' ••<',• .. •�, "'CCC"" • e +ty •Y•. J n• 't .....•• ,•4�^^—i"+ .. i.I.F. :. •n fs .•Y:.• .. f4.J'• ••}' ::},�:�--Y4 Y.t:.. •rC i .� ,.�''�. �., �����..y AW , _ •,.�.�,:»�- :Vii` #w` �.��' '�:����i" { •+fit:: '. :'►" *. �.;�,}. ' jam^: `.�: '• • .. . .'::.'?'• �''•'":i�`` ";• .fir ..r�.�� .} �.„�'>�'. 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CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 1/30/2015 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 PHONE 631 324-1440 AX AIC No Ext: A/C No): Cook Maran&Associates E-MAIL 300 Hampton Road ADDRESS: Southampton,NY 11968 INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:National Fire Ins.of Hartford 20478 INSURED Swimtech Pool Services,Inc. INSURER B:Merchants Mutual Ins.Co. - 23329 467 Miller Place Rd INSURER C: Miller Place,NY 11764 INSURER D 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 SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP INSR WVD POLICY NUMBER MWDD MWDD/YYYY) LIMITS A GENERAL LIABILITY 5099324804 2/01/2015 02101/2016 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES Ea occurrence $100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) s5,000 X Contractual Llab. PERSONAL&ADV INJURY . $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'LAGGREGRTELIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLJCY SECT PRO- LOC $ B AUTOMOBILE LIABILITY CAP1060260 3/10/2014 03/10/201ECOMBINED SINGLE LIMIT Ea accident $1,000,000 X ANY AUTO _ BODILY INJURY(Per person) $ ALL OWNED SCHEDULED id P BODILY INJURY(Per accent AUTOS AUTOS ( ) $ X' HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per ac.dent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY - - ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N - E L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED7 N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If es,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S687865/M687640 KL3 Certificate ofNTYS Workers' Compensation Insurance Coverage Page 2 of 3 STATE OF NEW YORK WORKER'S COMPENSATION]BOARD CERTIFICATE OF NX WORKERS' COMPENSATION INSURANCE COVERAGE Is.Legal A'atne and address of Insured(Use street address only) 1b.Business Telephone Number of Insured Swim Tech Pool services,Inc. 631 473-7b65 467 Miller Place Road Miller Place,NY 11764 le.NYS Unemployment Insurance Employer Registration number of Insured Id.Federal Employer Indentification Number of Insured Work Location of Insured(Only required ircoverage isspecifrcally limited or Social Security Number to certain location in Nety York State,i.e.a Wrap-Up Policy) 112855800 2.Name and Address.of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Lisied as'the Certificate holder) Town of Southold Rochdale;Instirance Company 53095 Route 95 P.O.Box 1179 3b.Policy Number of entity listed in box"la": Southold,NY 11971 RWC3354805 3c.Policy effective period: 12/192014 to 12/192015 3d.The Proprietor,Partners Or Executive Officers are: included(Only check box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"'la"for workers' compensation under the New York State Workers'Compensation Law.(To use.this form,New York(NY)musi be listed under Item 3A-on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certification of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notify 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 ofpremiurns that cancel the policy or eliminate the insured from the coverage indicated on this Certificate(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed In box"3c';whichever is earlier. Please Note:Upon the cancellation of the worker's'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 certifieate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: Henry C Sibley (Print name of authorized representative or licensed agent of insurance A canter) Approved By: I � 3242015 (Signature) (fie) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance tamer.Carnerphone Please Note;Only insurance carriers and their licensed agents are authorized to issue the C-105 2 form.insurance brokers are NOT authorized to issue it. C-105.2(9-07) l s" https://ao.amtrustgroup.coin/anaWc/PolicyNYCertificateOMIns.aspx?Indexld=-1&Instar... 3/24/2015 CUPAN Y O „� .� CO it!"E�'LY V,!!'_'; I i A i,.L CODES OF 4�)35_0 E 6 UNLAWFUL NEW YOr K STAB All L__ & TOWN CODES APPI OVER AS NOTED OTOUT CERTHCATE As REQUIRED Kin G1 IT s OF v DATE: B.P. OCCUPANCY SOUTT�F 4(.8�9� BA� FEE:OF A BY:f -BOARD NOTIUILDING DEPARTMENT AT �n n-r,�nr �FFS 765-1802 8 AM TO 4 PM FOR THE -- ---- - �OLLOIPJINU INSPEGI Oi 5: -. _,__.-�_� t.S. 1. FOUNDATION - TWO REQUIRED 40' FOR POURED CONCRETE A—FRAME DETAIL D SSW ❑ T �ldEi_ PLUMBING 6' 34' 3. INrO5 M A-FRAME 4. - RUCTION MUS 2' BRACE E3 OMPLE FOR C.O. 6' ALL C TRUC ONAt��ME ME"T THE _T PANEL REQUI .E NT F I HE CODES F NEW IS 11 YORK STAT I T RESPONSIB E FOR 9' DFLE G R STRUCTION E ROBS. L STAKE 2' HORIZONTAL BRACE a® de �q�����°B MANDATORY ROPE it FLOAT 12 NON-DIVING POOL @�66 INCHES FROM SLOPE CHANGE -TJ NCLOSE POOL T®C®®� �s _ED UPON COfVIPLE�I®N � � ° 1) DEPTH AND SHAPE OF POOL MEET MINIMUM STANDARDS BEFORE"WATER' OF THE INTERNATIONAL RESIDENTIAL CODE 2009 AG103.1 -- (ANSI/APSP-5) FOR RESIDENTIAL USE. 2)A MEANS OF EGRESS FOR BOTH THE DEEP END AND THE PANEL T- FINISHED _r SHALLOW END OF THE POOL MUST BE PROVIDED AS HEIGHT 3-6 3'-4' DEPTH 5, FINISHED REQUIRED BY ANSI/NSPI-5 SECTION-6. �- DEPTH 3) BUILDER TO PROVIDE A MEANS OF EQUIPOTENTIAL BONDING IN ACCORDANCE WITH NEC SECTION 680. 4)ALL A-FRAME BRACES WILL BE MOUNDED WITH A MINIMUM OF (1) CUBIC FOOT OF CONCRETE, OR A 6- 16' 11' 11' 2' POURED CONTINUOUS CONCRETE PERIMETER COLLAR. 2 INCHES SAND 5) 'NO DIVING' LABELS TO BE INSTALLED AROUND PERIMETER OR VERMICULITE ❑F THE POOL. 6)ENTRAPMENT AVOIDANCE MUST BE INSTALLLED IN ACCORDANCE WITH ANSI/APSP-7. INTERNATIONAL SWIMMING POOLS NOTES SWIMMING POOLS ARE DANGEROUS WHEN USED IMPROPERLY. POOL PERIMETER: 110' I N T E R P ❑ ❑ L NEVER DIVE IN THE SHALLOW END OF ANY POOL. CONSULT WITH THE DIVING BOARD AND SLIDE MANUFACTURERS) AND THE ASSOCIATION OF POOL AND SPA PROFESSIONALS 12111 EISENHOWER AVENUE POOL AREA: 600 SgFt ALEXTHISAPOOLATOVENSURE,THEOPOOLBMEETS)THEOR TO EDUIPMENTALLING DIVING MANUFACTUURERSBOARDS AND/OR SLIDES MIN114UM STANDARDS FOR VOLUME: 18,700 APPROX. GAL. 15' X 40' RECTANGLE ALLOWABLE INSTALLATION OF THEIR PRODUCT(S) ON THIS POOL. INTERNATIONAL SWIMMING POOLS IS WITH 6' X 6' STEEL STEP NOT RESPONSIBLE FOR THE POOL'S INTERIOR DETAIL, RATHER THE LINER MANUFACTURER MUST ENSURE THE INTERIOR MEETS A.P.S.P. AND A N.S. 1. STANDARDS. IT IS THE RESPONSIBILITY OF POOL BUILDERS, TOWN OFFICIALS AND POOL OWNERS TO F13LLOW ALL SAFETY GUIDELINES OF THE A.P.S.P., LOCAL DATE: 03/24/15 SCALE-NONE ORDINANCES. AND EGUIP14ENT MANUFACTURERS. DRAWN BY: P.T. ACADREF:SDRT1540 6' X 6' STEEL STEP SYSTEM 90' VF 2' 8' 8' 8l 8' PANEL BILL OF MATERIALS QTY DESCRIPTION 6'-6' 1 1' STRAIGHT PANEL 2 2' STRAIGHT PANEL 42'-Sa- 2• 2 6'-6' STRAIGHT PANEL 8, 10 8' STRAIGHT PANEL 6'-6' 3 90 DEGREE VERTICAL FILLER 1• 1 6' X 6' STEEL STEP SYSTEM (REFER TO 6TNSSCP.DWG.) 8' 88' 81 90' VF 90' VF INTERP ❑ ❑ L 15' X 40' RECTANGLE WITH 6' X 6' STEEL STEP DATE:03/24/15 SCALE:NONE DRAWN BY: P.T. ACADREF:SDRT1540 R BILL OF MATERIALS J � 61 QTY. DESCRIPTION PART # R6" ❑PTI❑NAL 1 90 DEG TOP CORNER A I + STEP G 1 GREC. STEP MID. LEFT B 1 GREC. STEP MID. RIGHT C .olb '9 S 6' 1 GREC. STEP BOTTOM D LEFT 1 GREC. STEP BOTTOM E RIGHT �9 1 STEP SUPPORT F F y 1 STEP SIDE PANEL G LEFT 1 STEP SIDE PANEL H STEEL STEPS RIGHT SIDE VIEW PROFILE 1 SET(3) STAIR RODS 29991 1 SET(12) STAIR CLIPS 29990 1 90 DEG ANGLE IR❑N I 1 6° RAD TOP FILLER J 1'-2 1'-2 1'-6• e° °FINISHE D 3'-4 101' DEPTH ANEL 3'-6'H 10�' EGHT INTERP ❑❑L FINISHED TRUE 90 DEGREE CORNER STEP RISER 10�°RISER HEIGHT 1 -0 DEPTH DATE: 05/04/04 scALE: NONE DRAWN BY: T.F CADREF: 6TNSSCP