Loading...
HomeMy WebLinkAbout41537-Z g'aEFOI'tCpGy Town of Southold 5/15/2018 0 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39644 Date: 5/15/2018 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 23765 Route 25, Orient SCTM#: 473889 Sec/Block/Lot: 18.-2-25 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/10/2017 pursuant to which Building Permit No. 41537 dated 4/14/2017 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 Medina,Angel&Donna of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 41587 09-13-2017 PLUMBERS CERTIFICATION DATED A riD;i gnature gUFFot�� TOWN OF SOUTHOLD ��o any v BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy • 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#: 41537 Date: 4/14/2017 Permission is hereby granted to: Medina, Angel & Donna 23765 Main Rd Orient, NY 11957 To: construct accessory in-ground swimming pool as applied for. At premises located at: 23765 Route 25, Orient SCTM # 473889 Sec/Block/Lot# 18.-2-25 Pursuant to application dated 4/10/2017 and approved by the Building Inspector. To expire on 10/14/2018. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 f Bui di 'tor 'i 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, dditions 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$15j00 Date. � 1 0 V _ New Construction: )) ,eO,lCCd.-�SJ or Pre-existing existing Bui�ding: (check one Location of Property: S 1 �/4,n House NoStr et Hamlet Owner or Owners of Property: - Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. 4 5�? Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) i Fee Submitted: $ , Appli Signature 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road N Fax(631)765-9502 P.O.sox 1179 • aQ roger.rich ert(cD-town.so utho Id.ny.us Southold,NY 11971-0959 Qlyc®UIV i�9�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Medina Address: 23765 Route 25 City:Orient st: New York zip: 11957 Building Permit#: 41537 section: 1$ Block: 2 Lot 25 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Grattan Electric License No: 43643-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 100A A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include: Bonding, 1- Pool Light, 1- GFCI Circuit Breaker. Notes: Inspector Signature: Date: September 13, 2017 0-Cert Electrical Compliance Form.xls SOUly�� lLj cOUMV 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) ff ELECTRICAL (FINAL) REMARKS: v 1 �/ - 61< DATE INSPECTO60� so �o�a0 blyolo TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [� MULATTO [ ] FRAMING /STRAPPING [ ]] FINAL P [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE LI INSPECTOR VA- f>1-4 0 l 4 FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION IST ------------------------------- FOUNDATION (2ND) . � O 9 ROUGH FRAMING& �— y PLUMBING Ll r � r INSULATION PER N.Y. y STATE ENERGY CODE t� FINAL ADDITIONAL COMMENTS �1 (airO Z m 1 t4 �z _ yy� t� � x d b H -.OLD BUILDING PERMIT APPLICATION CHECKLIST a,PARTMENT Do you have or need the following,before applying? tvLL Board of Health HOLD,NY 11971 4 sets of Building Plans EL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined 201_�_ Single&Separate Storm-Water Assessment Form Contact: Approved ,20A Mail to-�-. , " Disapproved a/c 1 Phone: Expiration 14 ,20 I �� 114DD FC is 0 V D IKMnenspector APR 1 0 2017 APPLICATION FOR BUILDING PERMIT � � , BUILDING DEQ• INSTRUCTIONS Date 201_)_ TOWN OF SOUTHOLD 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. ignature of applicant or name,if a corporation) 42 05 I a i►� (Mailing adress f ap VA State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder nkryvy— Name of owner of premises -(A on the tax roll or atest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of coqo, ate officer) Builders License No. ,4 Plumbers License No. Electricians License No. Other Trade's License No. 1. Locatio d n which jDroposed work will be done: o House Number Street Hamlet r County Tax Map No. 1000 Section Block Lot Filed Map No. Lot State existing use and occupancy of premises and intended use an4 occupancy of proposed construction: 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 Workup (Description) 4. Estimated Cost �� Fee T (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 Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated / 1 sip 12. Does proposed construction violate any zoning law, ordinance or regulation?YES NOVII;::�_ 13. Will lot be re-graded?YESNO Will excess fill be removed from premises?YES NO-)�, 14.Names of Owner o rerpise f V sc�31 � "V'l 1"h4 'e NW73 Name of Architec i'15 Address2M 440­01='",A'1'C_Phone N _X0— Name of Contractor Addres ')ltz jPhone No. rolyffl 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 BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO_X * 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) SS: COUNTY OF_Ana-t:�J Apd )) being duly sworn,deposes and says that(s)he is the applicant (Name of in 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 to before me thi day of MILLNER / NOTARY PUBLIC STATE OF NEW YORK01 �O he Notary Public LK COUNTY IV 11C.#01M 31 + Signature of Applicant COMM.D(P. f Scott A. Russell ,��° � 1:;IF 0>1R-A\11N VALIF E. K SUPERVISOR � � '� _ z l��l[A\1�.A\�GfIEA�I[]E�'7C' SOUTHOLD TOWN HALL-P.d.Udx,1179 . 53095 Miem Road-SOUTHOLD,NEW YORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SKEET ( TO BE COMPLETED.BY THE APPLICANT ) DOES THIS PROJECT INVOLVE Ali OF THE ]FOLLOWING: Yes 0 (CHECK ALL THAT APPLY) I ❑ A. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. l ❑ R. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑[ Cr Site preparation on slopes which exceed 10 feet vertical rise to- 100 o100 feet of horizontal distance. ❑ D: Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. ❑ E. Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse. F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was •received by the Town and the proposal includes ' in-kind replacement of impervious surfaces. J 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 TES 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 wit�your Building Permit Application. APPLICANT; (PrGperty O%kner.Desi Prof anal,Ag nt,Contractor,Other)1 ! S'C'T'/M•Qe: 1,000 Date I NAME: ff { U 6 Section Block Lot j 'n FOR BUILDING DEPARTMENT USE ONLY**** Contact Inrormatiom l\Q Rrlrphb,-bv. I� I Reviewed By. j — — — — — — — — — — — — — — — — !� �i Date: " -`� / -7 PropertyAd �dress/ Location of Construotto Work: — n/Approyed _ _ _ _ _ _ _ _for processing Building Permit. Stormwater Management Control Plan Not Required: ( � Stormwater Management Control Plan is Required. - - - - - - - - - - - - - -r (; (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 ` `[ ` _ .•-- _-�,' r f, � �� ` .,g r ' � r .. 1 -' _ *4 , - -- - „ rr+ ' .I�• - - `" . �• ,• _ AT ASSO 'N J• r r _ _ -r _ - ( -� ,� ,-,_• � )' : _ - �; _ .tn �• �� --_ _ _�--�.r' _ � r _ � yY ,- • - - '-r-'��:_ _ _�"r� �[, - • ' , - iJ'! _ !!� .///� IE PP 11 • _ ` � l_ + _`�`. , _ - - ` s - ` Y r ii _' T, `_- �4`k- '�' c� • C ",l 'J - � -- - - _ r r _ .c -- c • •� - ^ - - - k� - �_`I•'i;� _:!�'x�r - - TQ (f{J,t'J�r► I`it }3r.��V_, 'W_ - �� �R�.e � _. ./-. - _, • -jr-a-_ r _ - - Y _ pry. r '-ty u•r' _ "l� �_ J+ 'a-- - • '. i - �5� �•�'� - Y[Si - E.w.r: -[i,•. - `+^. �I _- � -•,•,:.� _ _ r' -. • a _ _ •s�if_ - - CoNi (CYr^ ( _ '. . . , �_,., �Y ,.a'_,�4�`�r _ _ tt _ �V'�,, .-, 'rr et-_�'•a• '_ ', -, f � .� ,;A� l' � Tltqr " yc .nF. - - . ^ '�.rY• _S. a.�+'• r. - C.', /y �}'' ) �p d f k }LY .. _ ,!M• ...,{ yL ' 1 i - F'".7 - `•c- t _ _ c3�'%'9 .• [ 1 � ,k,�•t �4 L t/jji�.f �,(�` s�!4'- .• _ - ''.tir? �:J :-►'"• _ 1-. :S-.c i L r _ _ - - , _ ,i �` _ ''sj(��`{�' ••`", �"f.i`�r�1+!�'�i.7 y;{ - - , '. 6� V•yr�[ .r'r--ryi'i_ c .. �� Mr`y ' iwr^+y `_ J- 1 - _ _ L_ ,/=_4� - , ,-` ,Y ` I c ' yr 1. �`_r! AU YiF - -,u -� [ - ��..,��•'+� YK r � • � y� -k� � •��`, - '�y'Jl/}r-`yT _ '4'� - -_=�'F, rN,l- t•!c zy' _- - [ CC�� c - !i J' '�• ��).7 -!'C NA , r ,� � � - ,_ - -.,�r _ �� w r. �� `��� :. [( c -Ro 'T'.a•' _ _ _ �'-' �c y - 1' - - - • r uA ^ � ! J F � --, .. ti - _`!- .•i-.R� .(syr [ � � - !' ��"Mdln=�"' � �+ _ - c - _ 'x ,•'ir>a fI urt [ � - . _- ��_ T '•k c! Ira�Jry�+��fy�7� f► • _- �' -.151 i �i�� F- _ .� `T _ - V.- _ -- � _ =_ 'C. •V?�I �+ _ r, - - _ •_?. .. _ _ r - ".+'i f� j�L ., •-R'��. , �' \J C,_ - � _ - - - .,`47 -�, _ _ _ - c ••L. [ y _ ry - __T r "F'- yiE • .� � 1 /11 //} LAND /yw-'� {/���y R[7�(� may[/ �/q/� � t- Y u}/:'•Y, S � 1 Y.�••Tn �Y 'R G r C - c \f , c r - - _ • r c - _•. ^F ,►"may fes, Lyw'J ♦N[}.� J. V/�p�{F I'.f�}E Y OFA r,' i� +r"� h ` nt `�.�.. `n r [ _[L i'- - a�..rr�.w�. ' �.L• 5' c n { .(- .'Y • • - :l - - M• /�Y IVY jj,� �L• •. - fl ., '- .. i �' „ �!� '...t ♦ "�-`-•,'�.".°•..i�;t•-+-'�.a ,��.ti ��„-g_ .�' .. -t.�.}. _ • +.•:f.-•.:.,.�.....s:��.1.,...,,•.R.y�..:r•.-"+n-..,++.�--"`�.- --, _jr p} - - - � `�-.'r,..xr�� �j' �`' f •ec- ,. ,�rr{?`� 71- y Ro r • y „ [ [ ~ �- �',�j�L-� C J� {' !- ”` - • c - �4 • r,�r.' c ` L `-` L•• �•�[ i IV•i•���tl�( '`r fit_ G ; , .- .L r. . ' c J [^. '� ,.- l -r SII-'r _.c IOU . �� � c f ,�r.� �� 8"��� C�� �, � - - �`�'••-f.- `'� r .. • ''�F •- , Cad+eR_ �ad'+o� pt _ �,.,-::r;, _ ==i ^�.; 2, � - c � ♦` , - •- ,-- �, r. r, '; - `�J�n �+�t��.+'�',R � .aT i.� - ' , - f 7d�tNera �_�_#•,�s-' �'- ., ?� : daa+lk" s 'yc:� *-•—��� � ,. � - L `: `�. '• - i _ � - -,4 _ . _ e r r "J+r.6 Flrsl!V'{�f �i+�Q�Ar [[ -� _ _ i . _`J. `y�j►j[ ����II11SSy�/�' r[/� ./�, �p4{ /� i - .1l , jI'Y _ AJi ik Yli7 _ _ .3* - - - - +R`M I• •�!v M a5i '.S �� nw j ^ .' r 'YTF�7�',L ttpj - - - .. � � -.- �- • .egtt[ir'r*sfYlr�-�Ya�,q',RIpfICq�i•'.T'+�1��'.1'_.[;�� :•,,�- rn-] - `, - ., r ''f,_ _ r _„ _ - _ u - ' ' -8'�s w'�►'Y'nst 4i'+o Fv �k+71t. - _"°-� := `�'-`a rj _ t - ,c -'r 'v'e. _ - � - 1 '� .�•� ati.i.rA-'AY°4YL��Y4'Q'Q10R f3h'f�if9�A�_ <f{ -tt-�t' ��{ r - _ _ _ c- ' - . .. '�._ - _ - - - _ °- 1'(_ .;N'u'R,l.�fu�yfls-•Ai ii�3�{IYN1L �i-^ :L`�� _;'.�:;1 YoeK Workers' CERTIFICATE OF INSURANCE COVERAGE sraTe Compensation UNDER THE NYS DISABILITY BENEFITS LAW Board 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. Only the following class or classes of the employer's employees: Under penalty of perjury,1 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 wid ht (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) vORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.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 ld.Federal Employer Identification Number of Insured specifically limited to certain locations in New York State, i.e., 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 3b.Policy Number of entity listed in box"la" Town of Southold 12WEOJ2677 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 9 Pa LLJ included. (Only check box if all partners/officers 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 "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"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) C�% -- Approved by: 8/29/16 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631 324-1440 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT SUFFOLK COUNTY DEPT OF LABOR, LICENSING 8 CONSUMER AFFAIRS HOMEIMPROVEMENT CONTRACTOR sum GENSE RANDYT RODECKER ThIS certifies that the •"""•",•� bearer Is duly FENCE KING OF ROCKY POINT INC DBA ricensed by the County of Suffolk 21412-H OM111992 �"`„` wo"A'no"O"m 06/01/2018 Workers! CERTIFICATE OF INSURANCE COVERAGE �► Compensation 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 8t 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.F] 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/ �f (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"416"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. D13-120.1 (9-15) voRKWorkers' ZATE Compensation CERTIFICATE OF 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 id.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 3b.Policy Number of entity listed in box"Ia" Town of Southold 12WEOJ2677 P.O.BRoute 25 3c. Policy effective period Southold,,NNY 11971 P.O.Box09/01/2016 to 09/01/2017 Y 3d. The Proprietor,Partners or Executive Officers are ?a9 included. (Only check box if all partners/officers 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 "l 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) Approved by: 8/29/16 (Signature) (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631 324-1440 Please Note. Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT SUFFOLK COUNTY DEPT OF LABOR, LICENSING&CONSUMER AFFAIRS HOMEIMPROVEMENT CONTRACTOR flue LlrgNaE RANDY T RODECKER This certifies that the bearer is duly FENCE KING OF ROCKY POINT INC DBA licensed by the County Of Suffolk "`��"'� 21412-H 0s0111992 `awdssi— °�""�'°"'� 06/01!201 S '2 N OTE5 I. NO SPOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION ATTHE SHALLOW END,OR6 FEET OF EXCAVATION ATTHE DEEP END O ELECTRICAL 0 2. THIS POOL MEETS THE REQUIREMENTS OFAN51/NSPI-5 AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUN1)SWIMMING e�l; a1ECTION REQUI '15EE POOLS"AND 1996 BOCA CODE-SECTION 421 DIVING EQUIPMENT 15NOTALLOWED 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SVRROUNDEDWITH ABARRIER CONSTRUCTED LAW REQUIREMENTS OF o�f SECTION R326.5,3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD On H2O H20 TOWNCODE. ACCESS GATES SHALL COMPLY WITH SECTION R326.5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BE SECURELY APP O IF AS NOT 7'•0' m 3'-6' LOCKED WHEN POOL IS NOT IN USEOR5UPERVISED ALL GATES ARE TO OPEN AWAY FROM THE POOLAREA 4 O DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY DATE: B.P.# c�3 TOWN OF SOUTHOLD V 3 FEE: BY: 5 POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OFDETECTINGACHILD ENTERING THE WATER AND SOUNDING z ¢Z AN AUDI BLE ALARM WH EN DETECTED THAT 15 AUDI BLE AT POOL51 PE AN D AT ANOTH Elk LOCATION ON TH E PREMISES WH ERE THE POOL Ln NOTIF BUILDING DEPART I A IS LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS. rt C 765-1 2 8Ai~il TO 4PM FOR THE CONCWALLS _k THE ALARM MUST MEETA5TMF2208 "STANDARDSPEC]FICATIONFOP,POOLALARMS THE DEVICE MUST OPERATE IN DEPEND ENT -a% 0 A ATTACHED TO OR DEPENDENTON)OF PERSONS O>. FOLLC WING INSPECTIONS: B `z 1. FO INDATION - TWO REQUIRED RETAIN STORM WATER RUNOFF 6. POOL SUCTION FITTINGS(EXCEPT FOP,SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THATCONFOPMS TO ASME/ANSI 0 A11219.8M ORA MINIMUM 18"x23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH FrO) POURED CONCRETE PLAN PURSUANT TO CHAPTER 235 ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN. SUCH VACUUM RELI EF SYSTEMS SHALL CONFORM WITH A5ME A112.19.17 OR BE A GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD, 2. RO IGH - FRAMING & PLUMBINGPOOL SHALL BE PROVIDED WITH AMINIMUM OF2SUCTION FITTINGS OFTHE ABOVE MENTIONED•TYPE. THE SUCTION FITTINGS SHALL BE 3• INS LATION OF THE TOWN CODE. SEPARATED BY A MINIMUM OF 3'AND MUST BE PIPED SUCH THATWATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE 4. FIN L - CONSTRUCTION I POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTO THE SKIMMER/SKIMMERS BE COMPLETE FOR C.O.a ;i M Ln ALL ALL NSIRUCTiON SNAP I 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE RE0UIREMENT5OFNFPA70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRCSECTIONS V a m 4201THROUGH4206. ALL ELECTRICAL DEVICES MUST BEAPPROVEDBYUNDERWRITERS LABORATORIES AND BEPROTECTED BYA REOLREMENTS OF THE CODES OF NEW fit= I 3'foa'SANDBOTTOM OCCUPANCY ®R GROUNDFAULTCURRENTINTERRVPTER(GFCUCURRENTCARRYINGELECTRICALCONDUCTOR5EXCEPTFOP,THOSEPROVIDINGPOWER ,.q.Z YORK STATE. NOT RESPONSIBLE FOR TO POOL LIGHTING AND POOL EQVIPMENTSHALLMEET THE SEPARATIONREQVIREMENTSOFTABLE E4203.5. ALL METAL ENCLOSURES, FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOLTHATMAYBECOME ELECTRICALLYCHARGEDDUETOCONTACTv c DESICN OR CONSTRUCTION ERRORS. SECTION A WITH AN ELECTRICALCIRCVIT5HALLBEEFFECTIVELYGROUNDED p/ - USEIS UNLAWFUL LAV�IFU L 8 WATER SOURCE FILLINGTHE POOL 5HALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NY5 PLUMBI NGCCD E608. w TOD OF WALL WATER LINEWIT HOUT CERTIFICATE 9. ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED. 8 .� 00 r COMPLY WITH ALL CODES O 4' 4' •C� 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. C N w YORK STATE & TOWN OF OCCUPANCY �, A REQUIRED AND CONDITIONS OF 11. AMEANSOFEGRESSFORDEEPAN1)SHALL.OWENDSMUSTBEPROVIDEDIAWANSI/NSPI-5 SECTION 6. p 4 s . ri n f * •,� i e 12. CONTRACTOR TO PLACE THE POOL IAW TOWN OF SOUTH OLE)CODE SETBACKS /`7IIUT1lQ �f4_ N C u1 i U$E k+'i�-L T 6w E�ICLOSEPUCLTOCODE 13 ALL DRAINAGE FROM THE POOL SHALL BEMAINTAINED ONTHE SUBJECT PROPERTY, $Cl fihf6 E -�;" 4I gpQRp SECTION B UPON COMPLETION 15. THE DESIGN 15 BASED ONADRAINAGE SOIL WITH<10%SILT. GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IFGROUND b 1 ITI I�f T��{AI TSI I�� EIEFORE"WATER" WATER EXISTS WITHIN 6'-O"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. N Ln 16 ALL GAS AND OIL HEATERS(IF INSTALLED)FOR THE INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY � CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW ANSI 22156 AND SHALL BE INSTALLED IAW MANUFACTURERS SPECIFICATIONS OIL FIRED POOL HEATERS SHALL BE TESTED IAW UL726. POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCI 1)ENTAL CONTACT OF HOT SURFACES BY PERSONS. POOL HEATERS SHALL BE PROVIDED WITH V TEMPERATURE AND PRES5VRE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM. A BYPASS LINE SHALL CHECK VALVE 2,_z" BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE (� FROM SKIMMER COPING AND WALKWAY FOLLOWING ENERGY CONSERVATION MEASURES. 0p PUMP (BYOTHER5) 10" V/ GRADE 16.1 AT LEAST ONE TH ERMOSTAT SHALL BE PROVIDED FOP EACH HEATING SYSTEM.WATER LINE 16 2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFFSWITCH MOUNTED FOR EA5YACCE5S TO ALLOW SHUTTING OFF THE e OPERATION OF THE HEATER WITHOUTAD)USTINGTHE THERMO5TATSETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE PILOT LIGHT. W >ti a a ro vI\ - UNDISTURBED EARTH » 16 3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM TH15 REQUIREMENTARE OUTDOOR POOLS W Q b C. co DRYWELL 3500 P51 POURED CONC •d DERIVING20%OFTHE ENERGY FOR HEATING FROM RENEWABLESOVRCESASCOMPUTEDOVERAN OPERATING SEASON) C} / w 164 TIME CLOCKS SHALL BE INSTALLED SO THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET e.a Y J/ 3/8'REBAR z)TYP. .;� ; TO RUN THE MINIMUM TIME NECE55ARYT0 MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION IAW APPLICABLE 3 o co co F, VALVE R O VINYLLINER� •,: . SANITARY CODE OF NEW YORK STATE = o co z roa SAND \ ; 17. THIS DRAWING I5 FOR STRVCTURAL5HELLONLY. ALLACCESSORIESANDAPPURTENANCESAREDEFINEDBYOTHERS. w N o X Y 41 FILTER r 16 BACKFILL WITH CLEAN EARTH,FREE OF ROO75 AND DEBRIS. DO NOTALLOW THE HEIGHTOF BACKFILL TO EXCEED THE HEIGHTOF THE W 0~LL WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" w a .-•--�Im :Z�dNA 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAND COMPACT CLEAN BACKFILL UofNE ` VERTISHOW°REBAR®3'OC , IT (NOT SHOWN) 21. THERE 15 NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATERCIRCVLATION 15 PROVIDED BYTHE SKIMMERS ONLY, THIS MEETS F P,s REQUIREMENTS OF THE IRC-SECTION R326.6 FOR ENTRAPMENT PROTECTION ��G� ^✓( 9S WALL SECTION 22. THE POOL WAS DESIGNED IAW THE FOLLOWING. / TO RETURNS NTS 22.1 THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER 42(2016) LLJ CHECK VALVE J 22 2. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2015) r 'O �� LuZ 22.3. THE INTERNATIONAL FUEL GAS COPE(2015) 22.4 THE NEW YORK STATE CODE SUPPLEMENT-SECTIONR326 (2016) „`� _ ;<F" 22.5. TH E N EW YORK STATE SAN ITA RY COPE. f 22.6 ANSI/NSPI-5 STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS. ��08841 PLUMBING SCHEMATIC 22.7. BODE CODE-SECTOF F �RoFESS o�P` 22.8 CODE OF THE TOWNOFSOUTHOLD 23 ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. N T.S.