HomeMy WebLinkAbout41472-Z �o�1c�uFFOt,�COG, Town of Southold 5/25/2018
y-{ P.O.Box 1179
e
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39666 Date: 5/25/2018
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 44190 Route 25, Peconic
SCTM#: 473889 Sec/Block/Lot: 75.-6-6.2
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
3/21/2017 pursuant to which Building Permit No. 41472 dated 3/29/2017
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 Found swimming pool with fence to code as applied for.
The certificate is issued to Richmond Creek LLC
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 41472 6/8/2017
PLUMBERS CERTIFICATION DATED
CI
O
Signature
��p�sy icy TOWN OF SOUTHOLD
a BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
o . SOUTHOLD, NY
�ap1-
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#: 41472 Date: 3/29/2017
Permission is hereby granted to:
Richmond Creek LLC
C/O Samuel Singer
515 E 72nd St Apt 8B
New York, NY 10021
To: construct an in-ground swimming pool as applied for.
At premises located at:
44190 Route 25, Peconic
SCTM # 473889
Sec/Block/Lot# 75.-6-6.2
Pursuant to application dated 3/21/2017 and approved by the Building Inspector.
To expire on 9/28/2018.
Fees:
IN-GROUND SWIMMING POOL $250.00
CO - SWIMMING POOL $50.00
Total: $300.00
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 1%lead.
5. Commercial building,industrial building,multiple residences and similar buildings and installations, a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9, 1957)non-conforming uses,or buildings and "pre-existing"land uses:
1. Accurate survey of property showing all property lines,streets, building and unusual natural or topographic
features.
2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is
denied,the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00.
2. Certificate of Occupancy on Pre-existing Building- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential $15.00,Commercial $15.00 l
Date.
New Construction: Old or Pre-existing Building: (check one)
Location of Property: �z3cn,G
House No. Street Hamlet
Owner or Owners of Property: V�J S�Y�CPl
Suffolk County Tax Map No 1000, Section Block Lot
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: $ ( '
ApplTea Signature
of so�r�®�
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: Richmond Creek LLC(Singer)
Address: 44190 Route 25 City: Peconic St: New York Zip: 11958
Building Permit#: 41472 Section: 75 Block: 6 Lot 6.2
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: Wildwood Electric License No: 4836-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 Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 1
Disconnect Switches Twist Lock Exit Fixtures TVSS
Other Equipment: In-ground Swimming Pool to Include; Bonding, Sub Panel, Control Panel,
2- GFCI Circuit Breakers, 4- Low Voltage Pool Lights, Gas Pool Heater.
Notes:
Inspector Signature: Date: June 8, 2017
0-Cert Electrical Compliance Form As
Of SOOT
vo,�0 y°<o
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I SULATION ,Q
[ ] FRAMING /STRAPPING [ FINAL Pot `0
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
oy)pm
C
DATE Z INSPECTOR
SOUlyolo
�c
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING / STRAPPING [ ] -FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE,RESISTANT CONSTRUCTION '[ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) `] ELECTRICAL (FINAL)
REMARKS:
DATE INSPECTOR SGC
`q TV OF SOUTyo
• ho
��'Y�OUMV,Nc�
TOWN OF SOUTHOLD BUILDING DEPT.
765-1602
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] SULATI N
[ ] t.
FRAMING / STRAPPING [ FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMAR lg Y
Vw L v i( Alr;L,/ A-iowwvx
DATE INSPECTOR
FIELD INSPECTION REPORT DATE COMMENTS
4-1
FOUNDATION(1ST) �H
--------------------------------------
FOUNDATION(2ND)
L::J-
C
ROUGH FRAMING&
PLUMBING
N
INSULATION PER N.Y.
STATE ENERGY CODE
of .Pi' lS
O
Vl( N✓�'rl
FINAL
ADDITIONAL COMMENTS
c,l of Pc Kj 600 3 t,,
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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)765-9502p Survey
SoutholdTown.NorthFork.net PERMIT NO. "1 I Check
Septic Form
N.Y.S.D.E.C.
Trustees
C.O.Application
Flood Permit
Examined 20 Single&Separate
Storm-Water Assessment Form
Contact:
Approved —,20 Mail to
Disapproved a/c
Phone: 1-
Expiration —20
Buildin Spector —7 5--
D APPLICATION FOR BUILDING PERMIT
MAR 2 1 2017 Date ,20�
INSTRUCTIONS
BUM1V1NGMUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
T0VWf@RS@UJH9Mn 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 desc bed.The
applicant agrees to comply with all applicable laws,ordinances,building code,housing code d re tions d to admit
authorized inspectors on premises and in building for necessary inspections. ZZ
(Signature of a icant or name,if a corporation)
515 &t 9?d- St- V FQ- /W/V/003/
(Mailing address of ap licant)
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
So
Name of owner of premises V \Y-%W 1 yLG
(As on the tax roll or latest deed)
If applicant is a corporation,signature of duly authorized officer
(Name and title of corporate officer)
Builders License No. 1543
Plumbers License No.
Electricians License No. `
Other Trade's License No.
1. Location of land on which prop�ed work will be done: n
House Number Street Hamlet
/
County Tax Map No. 1000 Section �f Block W Lot �. 0�'
Subdivision Filed Map No. Lot
2. State existing use and occupancy of prem es and intended use and occupancy of proposed construction:
a. Existing use and occupancy_ S��p
b. Intended use and occupancy_� ae � `�;,i
3. Nature of work(check which applicable):New Building Addition Alteration
Repair Removal Demolition Other Work�-9,02,Ink qW1 m wnC (?8vl
(Description)
4. Estimated Cost � �'p pip. CO 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 Depth
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated
12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO
13.Will lot be re-graded?YES �^ NO/ Will excess fill be removed from premises?YES V NO_
14.Names of Owner of zemises�F l �I n�el Address 4A D gto a Phone No. bq0'330'
Name of Architect IVUO 66fe, Address 6& I rrcPhone No (,3�- � 1'��a'
Name of Contractor �ou'�.(� i:,.b s Address i Sr, hone No. �!51-Jam-2YCD
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
*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 v�
*IF YES,PROVIDE A COPY.
STATE OF NEW YORK)
COUNTY F
Ct ()4Qln(e being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing con ct)above named,
(S)He is the 0W-Je4Z--
(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 wor be
performed in the manner set forth in the application filed therewith.
Sw to before me thiqn
f ESCALERA
o n 6111598
Notary
York
Notary Public Qualified in Suffolk County Signature of Applicant
Commission Expires June 14,
�.�-°s�,Ir� ST�O R IM[WAT]E)E,
Scott A. Russell �
SUPERVISOR z IWANA(G IEMUENT
SOTnRoad- WN HALL-P. Box 1179
MTown of,Southold
53095 Main Road-SOUTHOLD,NEW YORK 11971 'L
CHTA PTER 236 - STORMWATER MANAGEMENT WORK SHEET
(TO BE COMPLETED BY THE APPLICANT)
- ------- -I.3®�-THIS---PROJECT—II VOLV �Y)I 0�TIl� -—--—= --- ----
Yes No (CHECK ALL THAT APPLY
® A. Clearing, grubbing, grading or stripping of land which affects'more
l
than 5,000 square feet of ground surface.
0® B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑( C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑E6. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area. t
❑[0/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.
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 more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building DcpartmenLmdtbyouur Building Permit Application.
APPLICAN Property Owner,Design ro1essional, o 51-Cont actor,Other) - S.C.T.M. 1000 Date.
District
NAME r Aa— 1
Section Block Lot
'°`-� r �• :`
FOR BCit NG DEt N ?T. !EENT -Sr- 0_NL1`
Contact Information:
Reviewed By:
Date:
Property Address / Location of Construct ion Work: — — — — — — — — — — — — — — — —
❑ Approved for processing Building Pernw.
I� Stormwater Management Control Plan Not Required.
r_' Stormwater Management Control P!an i�.P,cqu.red.
Lj (Forward to Engineering Department for Resew)
FORM SMCP- TOS MAY 2014
Town Hall Annex Telephone(631)765-1842
54375 Main Road Zax g QQgg
P.O.Box 1179 Q roger.richeri:A n u holtl.ny.us
Southold,NSC 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY:
. �i�LP�► P�rsst�r.�:,� `Tcz Date:
CompanyName:
W%LvJ0o i=I,,EG'irz_%C_ aj,�C
Name:
License No.: y
Address- 6z�x 906, W- J G �Z\v 4 11-7 q7-
Phone No.: Z3 6- ZZ(J
JOBSITE INFORMATION: (*Indicates required information)
*Name:
*Address: _ y i°�� Z`I ZSA Ti=C.o-M i C,
*Cross Street: VJ E LLS DAA
i
*Phone No.: (31 -
Permit No.: 1 q-72-
Tax
ZTax Map District: 1000 Section:-75 Block: Lot: ,
*BRIEF DESCRIPTION OF WORK(Please Print Clearly)
5ALT -mss CM y - 12Vc l+ _•pco l.- L i !knS
1- CAMS %AuNn-M
(Please Circle All That Apply)
*Is job ready for inspection: YE_ / NO Rough In, final
*Do you need a Temp Certificate: YES NO
Temp Information (if needed)
*Service Size: 1 Phase 3Phase 100 150 200 300 360 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION
- too
,82-Request for Inspection Form ��'�
i
SURVEY OF PROPERTY
SITUATE
PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
v� pGFO�eP��� S.C. TAX No. 1000-75-06- 6 .2
C?,o° per`\t' E SJ�o�
P10% GGJ� �l SCALE 1 "= 100'
� G � o�
�G Qt°f FEBRUARY 1 , 2015
Aly
` Ln
JPO a�6 A JJ O
p' eol , ° cP TOTAL AREA = 80,003 sq. ft.
1 .837 ac.
P
O 16a t51•�y Y
43 5 o 1 CER TIFIED TO:
G °o � 9? o � � RICHMOND CREEK LLC
GOLDMAN SACHS BANK USA
66�° `>o. °°s �kp° z -s STEWART TITLE INSURANCE COMPANY
1s, o 0' ADVOCATES ABSTRACT, Inc.
OO PNS p '44%0'
,tea J fRPME FR JO�pR� � � c7
GPRPG� U0
•t9
42.2 a, (�
13 sPF
�� R PtNs Ea O O
FRPM�SN 122 O PREPARED I STANDARDS FOR TITLE SURVEYS NCE WITH THE MINIMUM
J SURVEYS B ESTABLISHED
BY THE L USE�,BtF—TF�E.NEW�D K STATEAND DPTED
LAND
�p„- `
J AF T F a,
c
16•� r ,i l
f S Lic No 50467
UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF THE NEW YORK STATE
EDUCATION LAW Natha orn III
COPIES OF THIS SURVEY MAP NOT BEARING E'� —__ V l9l�i i
THE LAND SURVEYOR'S INKED SEAL Land Surveyor
EMBOSSED SEAL SHALL NOT BE CONSIDERED
TO BE A VALID TRUE COPY
CERTIFICATIONS INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED.AND ON HIS BEHALF TO THE Successor To Stanley J Isoksen, Jr L S
TITLE COMPANY, GOVERNMENTAL AGENCY AND Joseph A Ingegno L.S
LENDING INSTITUTION LISTED HEREON,AND
TO THE ASSIGNEES OF THE LENDING INSTI— Title Surveys — Subdivisions — Site Plans — Construction Layout
TUITION CERTIFICATIONS ARE NOT TRANSFERABLE
THE EXISTENCE OF RIGHT OF WAYS PHONE (631)727-2090 Fax (631)7DDRESS 7
AND/OR EASEMENTS OF RECORD, IF OFFICES LOCATED AT MAILING ADDRESS
ANY, NOT SHOWN ARE NOT GUARANTEED. 1586 Main Road P 0 Box 16
Jamesport, New York 11947 Jomesport, New York 11947
SOUTHPO-01 MMARR
CERTIFICATE OF LIABILITY INSURANCE DA03!00771!22017017 Y)
�- 03
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 pollcy(Iss)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIM), subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer ri hta to the Certificate holder In lieu of such ondorsement s.
PRooucER Lic Liao p BR-878726 ACr
EXecu Ins Broker Fin Ser Inc PHONE FAX
515 Johnson Avenue (A1C,No,Ext): 631 663-8433 A1C,N01031)583.7706
Bohemia,NY 11718 .r:ertiflcates t;lf:l online.com
INSURERS AFFORDAFFORI)INO 0,091EIRAGE NAIC r♦
A.-0 11
INSURED IN$U E :NPM Insurance Company
South Share Pools Inc. INSURER c:
76 East Main Street
EaSt Islip,NY 11730 INSURER r,:
INSURER F:
CVgRAGES CERIIFIOATE NUMBER ION 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THF POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
ILTA NSR1
YPE OF INSURANCE ADDL gUBR P U EFF POLICY 2XP
POLICY NUMBER LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE8 1,000,000
CLAIMS•MADE a ODOUR 5084808888 03104!2017 03108/2018 °Ah1 E ESD 100,000
MED EXP dna ersa 61000
PERSONAL&ADV INJURY 1,000,000
N'L AGGREGATE UMITAPPLIES PGR- OENERALAGGREGATE 2,000,000
X POLICY❑jt& 0 LOC P -COMPIOPAGG S 21000,000
OTHER:
B AUTOMOBILE LIABILITY 8 1,000,000
C4M81N 'SLIMIT
c
ANY AUTO $gpp}}{{�� 81091130 03109/2017 03108/2018 BODILY JURY Per mon
AU��T08DONLY X INp�pS�ULED §001Y INJURY eraaddo S
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AUTODS ONLY X ADTOS ONCY Oa ER AMAGE 5
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UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS[JAB CLAIMS-MADE AGG
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RETEM90NS;
WORKERS COMPENSATION EE DTH•
AND EMPLOYERS'WABILRY YIN T T
ANY FROPRIETORIPARTNERIEXECUTIVE E L EA !DENT
OFFnaE�R.,VJMBEREXCLUDEP7 NIA
rIf yes,tlas�rl6e untler -EL DISEASE-EA OYE S
OESCRI OF OPERATION pW DISEASE•POLICY LIMIT 5
A Commercial Property 6064909888 0310912017 0310912015 Scheduled equip 66,662
Commercial Auto RIUB1130 03/08/2017 03!0812018 Collision deductible 1,000
CRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Add8lodal Rawrlts SchsUuls,may be atbahad it more tpaoa Is squired)
f of Insurance
CERTIFICATE HQJDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER D IN
64376 Main Road NY-29 ACCORDANCE WITH THE POLICY PROVISIONS.
Southold,NY 11971
AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) ®19$$-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
J-Wtorker�1� 'i;trtioiu CERT)FICATE,OF INSURANCE COVERAGE. ns
Board'' Uh1jER THE NYY8 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) 1 b,Business Telephone Number of Insured
SOUTH SHORE POOLS, INC. 516 472-4791
1c.NYS Unemployment Insurance Employer Registration
Number of Insured
75 EAST MAIN STREET
EAST ISLIP, NY 11730 td.Federal Employer Identification Number of Insured
or Social security Number
030421899
2.Name and Address of the Entity requesting Proof of coverage 8a.Name of Insurance Carrier
(Ehtity being listed as the Certificate Holder) SheiterPolnt Life Insurance Company
3b Policy Number of Entity listed in box"1a":
Town of Southold DBL66865
54375 Main Road 3c.Policy effective period-,
Southold, NY 11971 01/01/2017 to 12/31/2017
4.Polley covers:
a. All of the employer's employees eligible under the Now York Disability Benefits Law
b. Only the following class or classes of the employer's employees:
Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the Insurance carrier referenced
above and that the Named Insured has NYS Disability Beneflis Insurance coverage as described above.
Date signed 3/712017 BY hf
(Signature of Insurance carrier's authorized represehiative or NYS Licensed Insurance Agent of that Insurance carrier)
Telephone Number 516-829-8100 Title Chief Executive officer
IMPORTANT:If box 1,4a"Is checked,and this form Is signed by the Insurance Carrier's authorized representative or NYS Licensed Insurance Agent
of that Carrier,this Ceftiflcete Is COMPLETE Mail it directly to the certificate holder.
If box"415"is checked,this cartifinte is NOT COMPLETE for the purposes or Section 220,SUbd,8 of the DI33bl lity Benefits Law.
It must be mailed farcomplotion 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 Lew With respect to all of his/her employees,
Date Signed By
(Signature of NYS Worker's Compansatlon Board Employee)
Telephone Number Title
Please Note:chly 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 NOY authorized to issue this form,
DB-120,1(9-15)
STATE OF NEW YORK CERT TCATE OF
WORKERS' COMPENSATION BOARD NYS WORKERS'COMPENSATION INSURANCE COVERAGE
11 Legal Nome&Address of Insured(use street address only) 1 b.Business Telephone Number of insured
South Shore Pools,Inc. (631)277-9800
dba South Shore Pools,Inc.
75$Main St 1 c.NYS Unemployment Insurance Employer Registration
East Islip,NY 11730-2.102 Number of insured
Work Location of lmured(Only required({coverage is specifically Id.Federal Employer Identification Number of Insured or
limited to certain locations in Ncw York State,1 e,a Wrap.Up Policy) Social Security Number
030421899
2.Name and Address of Entity requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier
Being Listed as the Certificate Bolder)
Continental Indemnity Co.
The Town of Southold 3b.Policy Number of Entity Listed in Box"la"
54375 Main Road
NY-25 4"32744-02-06
Southold,NY 11971 3c.Policy effective period
Ater.Project Manager
01/16/17 to 01/16/18
3d,The Proprietor,Partners or Executive officers are
❑ included,(Only check box If alt partoern/offican�included)
®all excluded or certain patmers/otheers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"Ia"for workers'
compensation under the New York State Workers'Compensation Law, (To ase this forth,Newyork(NY)must be listed under
3A on the INI'ORMATION PAGE of the workers'eompeusatloniusuranee 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 elinnioated 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 nights 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 cancellation ofthe workers'eompeusatian policyindieated on this form,If the business continues to be named
an a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with anew Certifi-
cate of Workers'Cotnpensatiort 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 arts an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depleted on this form
Approved by: Todd Brown
(Print name of 39ftn&ed representative or licenced agent of insurance carrier)
Approved by:
03/07/2017
(Signature) (bate)
Title: Authorized Re r�eserltative
Telephone Number of authorized representative or licensed agent of insurance carrier: (877)234.4424
Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-185.2. Insurance brokers are
DM authorized to issue it.
C-105.2(9-15)
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I. NO SPOIL SURCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION AT THE SHALLOW END, OR 6 FEET OF EXCAVATION AT THE DEEP END. FBF
2. THIS POOL MEETS THE REQUIREMENTS OF THE 2016 UNIFORM GODS SUPPLEMENT, WHICH INCORPORATES THE 2015 INTERNATIONAL RESIDENTIAL GODS AND IS DESIGNED r^
AND CONSTRUCTED IN CONFORMANCE WITH AN51/N5PI-5. :`; Yo^
5. ALL ELEGTRIGAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70 (BASED ON 2014 NEG), PRINCIPALLY ARTICLE 680 AND THE 2015 INTERNATIONAL RESIDENTIAL '"
CODE SECTION 4202 THROUGH 4206. z m m
ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A GROUND FAULT CURRENT INTERRUPTER (6FGI). CURRENT GARRYING 0:u:.2ELECTRICAL CONDUCTORS EXCEPT FOR THOSE PROVIDING POWER TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEET THE SEPARATION REQUIREMENTS OF TABLE E4203.5.
ALL METAL ENCLOSURES, FENCES OR RAILINGS NEAR OR ADJACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY GHARGED DUE TO CONTACT WITH AN ELECTRICAL
CIRCUIT SHALL BE EFFECTIVELY GROUNDED. m , .
4. SWIMMING POOL AND POOL EQUIPMENT SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITH A BARRIER CONSTRUCTED IN ACCORDANCE WITH THE 2016 UNIFORM rF= O
CODE SUPPLEMENT, WHIGH INCORPORATES THE 2015 INTERNATIONAL RESIDENTIAL CODE AND IN CONFORMITY WITH ALL SECTIONS OF THE BUILDING ZONE ORDINANCE OF THE TOWN. mJj 4 `'
ACCESS GATES SHALL COMPLY WITH SECTION 326.5 OF THE 2016 UNIFORM GODS SUPPLEMENT, WHIGH INCORPORATES THE 2015 INTERNATIONAL RESIDENTIAL CODE AND BE SELF
G OSIN6 AND SELF LATGHIN6 AND OPEN AWAY FROM THE POOL AREA. SECTIONS OF THE ENCLOSURE THAT ARE COMPRISED OF A FENCE SHALL BE AT LEAST WAND NONCLIMBABLE. "`rt
FINISHED SIDE OF FENCES SHALL BE LOCATED ON THE OUTSIDE OF THE REQUIRED FENCE. THE RESULTING CONSTRUCTION SHALL COMPLY WITH CODE SECTION 526 OF THE 2016
UNIFORM GODS SUPPLEMENT, WHIGH INCORPORATES THE 2015 INTERNATIONAL RESIDENTIAL CODE. O O
5. POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM, AS PER THE 2016 UNIFORM GODS SUPPLEMENT, WHIGH INCORPORATES THE 2015 INTERNATIONAL
RESIDENTIAL CODE, SECTION 526.7. THE POOL ALARM MUST BE CAPABLE OF DETECTING A CHILD ENTERING THE WATER AND SOUNDING AN AUDIBLE ALARM WHEN DETECTED THAT
IS AUDIBLE AT POOLSIDE AND AT ANOTHER LOCATION ON THE PREMISES WHERE THE POOL 15 LOCATED. THE ALARM MUST BE INSTALLED, MAINTAINED AND USED IN ACCORDANCE
WITH THE MANUFACTURERS INSTRUCTIONS. THE ALARM MUST MEET ASTM F22O8 "STANDARD SPECIFICATION FOR POOL ALARMS". THE DEVICE MUST OPERATE INDEPENDENT (NOT
ATTACHED TO OR DEPENDENT ON) OF PERSONS.
6. POOL SUCTION FITTINGS (EXCEPT FOR SURFACE SKIMMERS) MUST BE BE PROVIDED WITH A COVER THAT CONFORMS TO A5ME/AN51 A112.Iq.&M OR A MINIMUM 12"XI2"
DRAIN GRATE OR A CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH ATMOSPHERIC VACUUM RELIEF IN THE EVENT THAT GRATE °
COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN. SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME A112.I9.17 OR BE A GoRAVITY SYSTEM o l-
APPROVED BY THE TOWN. POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTIN65 OF THE ABOVE MENTIONED TYPE THE SUCTION FITTIN65 w }§
ix=�!a.
ALL BE SEPARATED BY A MINIMUM OR 3' AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELEIF-PROTEGTED =1a4
LINE TO THE PUMP (OR PUMPS). VACUUM/PRE55URE GLEANING FITTINGS SHALL BE IN AN AGGE5515LE POSITION, MINIMUM OF 6" AND NO 6REATER THEN 12" BELOW THE m�dn
MINIMUM OPERATIONAL WATER LEVEL OR BE AN ATTACHMENT TO THE SKIMMER/SKIMMERS.
7. WATER SOURCE FILLING POOL SHALL BE EQUIPPED WITH A BAGKFLOW PROTECTION DEVICE AS PER THE 2016 N.Y.S. CODE. zIDS
8. A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED AS PER AN51/N5PI-5 SECTION 6. I
Q. GONTRAGTOR SHALL PLACE THE POOL AND POOL EQUIPMENT ON THE LOT AS PER TOWN CODE. POOL AND POOL EQUIPMENT SHALL NOT BE CLOSER THAN 4 FEET FROM REAR
AND SIDE PROPERTY LINES. POOLS SHALL NOT OCCUPY MORE THAN 40% OF THE REAR YARD (OTHER ACCESSORY STRUCTURES ARE NOT FIGURED INTO TH15 CALCULATION). U �
10. THE CONTRACTOR SHALL ERECT A TEMPORARY BARRIER DURING CONSTRUCTION.
11. ALL PIPING 15 DIA6RAMMATIG UNLE55 OTHERWISE STATED. ALL PIPING TO BE POLYETHYLENE. ow�
12 WALKS, IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. p<_
13. ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY.
— N
. POOL AREA 720 SQ. FT., PERIMETER I I6'-O" W���z
15. THE DESIGN IS BASED ON A DRAINAGE 501L WITH <I0% SILT AND A55UMED BEARING CAPACITY OF 2,000 PSF. GROUND WATER SHALL NOT EX15T WITHIN THE o m
EXCAVATION. IF GROUND WATER EXISTS WITHIN 6'-0" FROM GRADE, SPECIAL DEWATERING FACILITIES WILL BE REQUIRED. € Zz
16. ALL GAS AND OIL WATER HEATERS (IF INSTALLED) FOR THE IN-GROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY CONSERVATION ACT (NAECA) e N g
COMPLIANT. POOL HEATERS SHALL BE TESTED IN ACCORDANCE WITH AN51 221.56 AND SHALL BE INSTALLED AS PER MANUFAGTURERS' SPEGIFIGATIONS. OIL FIRED POOL HEATERS o m
SHALL BE TESTED IN ACCORDANCE WITH UL726. POOL HEATERS SHALL BE LOCATED OR GUARDED TO PROTECT AGAINST ACCIDENTAL CONTACT OF HOT 5URFAGE5 BY PERSONS. °m RovftlmIlaw
POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRE55URE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BY PA55 SYSTEM, mawrmp*
A BYPASS LINE SHALL BE INSTALLED FROM INLET TO OUTLET TO ADJUST WATER FLOW THROUGH THE HEATER. POOL HEATERS SHALL BE PROVIDED WITH THE N�
FOLLOWING ENERGY CONSERVATION MEASURES: °„msr 4
16.1. ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITGH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE OPERATION OF THE HEATER
Lrl
WITHOUT ADJUSTING THE THERMOSTAT SETTING AND TO ALLOW RESTARTING. Prgedo
16.2. HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER (EXEMPTED FROM THIS REQUIREMENT ARE OUTDOOR POOLS DERIVING 20% OF THE g
ENERGY FOR HEATIN6-FROM RENEWABLE SOURCES, AS COMPUTED OVER AN OPERATING SEASON) acme AS
16.5. TIME GLOGKS SHALL BE INSTALLED 50 THE PUMP GAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS, AND GAN BE SET TO RUN THE MINIMUM ��
TIME NECESSARY TO MAINTAIN THE POOL WATER IN A GLEAN AND SANITARY CONDITION AS PER THE APPLIGABLE SANITARY CODE OF NEW YORK STATE.
17. THIS DRAWING IS FOR STRUCTURAL SHELL ONLY. ALL AGGE55ORIE5 AND APPURTENANCES ARE DEFINED BY OTHERS.
0. G.G. TO INSPECT EXI5TIN6 SOIL CONDITIONS PRIOR TO COMMENCEMENT OF WORK; PROVIDE 10" WIDE" X 8" DP. PRECAST FTG. RINGS m ALL DRYWELLS IF POOR SOIL CONDITIONS EXIST. A=2
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GONG. SLAB 1'-0" MIN. - to�d 2
FINISHED GRADE _ Q I��
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INLET 6"oP PV�:DAT
SDR 35, PITC3'-0" MIN. DRYWELL VOLUME1/4" PER 1' MI _ U
COLLAR 4'x4' PRECAST RING= 0 W o o
PIxRxRxH=
WOXBACKFILL UNDER AND 3.14x2x2x4=50 GU FT. PER RING to Z r
PRE A DEEP AROUND DRAINAGE RING 7.48 GALLONS PER GU. FT. Mfd
W= n
PRECAST DRYWELL
RING5 MEDIUM TO COARSE 50x7.48= 315 6ALLON5 z `m
(4000 P51 GONG) GRAVEL W
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4'-0" DIA. a
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SEE GENERAL NOTES FOR 2' MIN. ABDYE o �'
ADDITIONAL INFORMATION GROUNDWATER
Dds R�rltbnllpw LI
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