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HomeMy WebLinkAbout41395-Z roG� Town of Southold 7/18/2018 P.O.Box 1179 a 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39772 Date: 7/18/2018 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 2060 The Long Way, East Marion SCTM#: 473889 Sec/Block/Lot: 30.-2-126 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/11/2014 pursuant to which Building Permit No. 41395 dated 3/3/2017 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 with fence to code as applied for. The certificate is issued to Wiseman,Barry&Rena of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 41395 3/28/2017 PLUMBERS CERTIFICATION DATED L110 ' d ignature o�S�FEnc��o TOWN OF SOUTHOLD �� oy BUILDING DEPARTMENT y: x TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 41395 Date: 3/3/2017 Permission is hereby granted to: Wiseman, Barry 7 Woodland Rd Mt Kisco, NY 10549 To: Construct an accessory Inground Pool, fenced to code. Replaces BP# 39207 At premises located at: 2060 The Long Way, East Marion SCTM # 473889'-- Sec/Block/Lot# 30.-2-126 Pursuant to application dated 3/3/2017 and approved by the Building Inspector. To expire on 9/2/2018. Fees: PERMIT RENEWAL $125.00 ELECTRIC $100.00 Total: $225.00 Buil 'ng Ins ector aFwt�r TOWN OF SOUTHOLD C�Gy BUILDING DEPARTMENT TOWN CLERK'S OFFICE CEO 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#: 39207 Date: 9/24/2014 Permission is hereby granted to: Wiseman, Barry &Wiseman, Rena 7 Woodland Rd Mt Kisco, NY 10549 / l/ To: construct an accessory Inground Pool, fenced to code At premises located at: 2060 The Long Way, East Marion SCTM # 473889 Sec/Block/Lot# 30.-2-126 Pursuant to application dated 9/11/2014 and approved by the Building Inspector. To expire on 3/25/2016. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $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 Tbis-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 2110 of I% lead. . 5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliahce'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)cion-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 complete cl 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, E 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 o€.Occupancy-$25 4_ Updated Certificate of Occupancy- $50.00 5_ Temporary Certificate of Occupancy-Residential $15.00,Commercial$15.00 Date- *Iew Construction: Old or Pre-existing Building_ (check one) lxw-ation of Property: 1­0T&�� Aiii AA/ IN *eQuoo --The- ous�No. Str t Haml Nmer or Owners of Property., latffolk County Tax Map No-I000,Section Block lit labdivision Filed Map. Jot: tamit No. J / Date of Permit. Applicant: health Dept.Approval: Underwrlters Approval: tanning Board Approval: :e,quest for: Temporary Certificate Final Certificate: (check one) ee Submitted: $ Applica t Signature *OF SO!/Ty0 Town Hall Annex Telephone(631)765-1802 54375 Main Road y Fax(631)765-9502 P.O.Box 1179 G aQ roper.richert(aD-town.southoId.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Wiseman Address: 2060 The Long Way City: East Marion St: New York Zip: 11939 Budding Permit#: 41395 Section: 30 Block: 2 Lot: 126 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Main Breaker Electric License No: 5150-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 1 Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches Ll Twist Lock 11 Exit Fixtures TVSS Other Equipment: Inground Swimming Pool to Include: Bonding, Pool Lights, 1- GFCI Circuit Breaker, 1- Heat Pump. Notes: Inspector Signature: Date: March 28, 2017 0-Cert Electrical Compliance Form.xls COD TOWN OF SOUTHOLD BUILDING, DEPT. 765-1802 INSPECTION I FOUNDATIONAST ROUGH PLUMBING FOUNDATION 2ND IN LATION FRAMING /STRAPPING [V;"F�INAL FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL) CODE VIOLATION CAULKING REMARKS: 0�2' i V'e'� DATE- INSPECTOR pF SOUjyolo �y00UNi'10c� vTHOLD BUILDING DEPT. TOWN OF SOU 765-1802 ANSPECTION [ ] 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 G d INSPECTOR '71i OF SOUIyo o�'�UOUNf'I,N� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 . INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] SOLATION [ ] FRAMING / STRAPPING [ ] FINAL Tw [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE 3 INSPECTOR ISOF SOUTy # # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] SULA N [ ] FRAMING /STRAPPING [ =FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: 62 S!A ViNt s,m mA SqA-p r,�ueod s � , .� Y DATE INSPECTOR r ` 221500* qso ti��� yO6 # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 - INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULA TI N [ ] FRAMING /STRAPPING [vieFINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE It INSPECTOR • r i • r 1 � —� i PLUAMINGty INSULATION i ENERGYSTATE • r PImRM � ��� t , �iAA , 11 .,� MOS • s. �► ,_�► • 11 r • I _ —Iffolipa mum, 11� a- • i tf 1 TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILD.,t'VG Dl'PARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 'V4sets of Building Plans TEL: (631) 765-1802 J Planning Board approval FAIL: (631) 765-9502 "Aurvey SoutholdTown.NorthFork.net PERMIT NO. fl 7 heck Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined �' 20i n Single&Separate ECG) u "./storm-Water Assessment Form 2014 Contact: Approved 20 ' SEp 1 1 Mil to: I A01& Disapproved a/c - BLDG DtPT TOV��I Or SOUTHOLD Phone: —�� Expiration ,20� . Building Inspector APPLICATION FOR BUILDING PERMIT Date 4--,20 1/47 INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize, in writing,the extension of the permit for an addition six months. Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and,other applicable Laws, Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws,ordinances,building code,housing code, and re ulations,and to admit authorized inspectors on premises and in building for necessary inspections. ld CLOSE POOL TO CODE ( ignature f applicant or name,if a corporation) ELIECTRMICAL IJ.PORI COMPLETION -7 "olard _0 EFORE`I INAT9��a-sv, A , Mailing� 1, t D State whether applicant is owner, lessee, agent, architect, engineer, general contractor, ffibewor ilc�Qr7 FEE — 13Y F111�--om rf,;;ZTIVIENT ! m 765-1802 8 AM TO 4 RM FOR Name of owner of premises FOLLOKING ItgSP r (As on t e tax roll or latest deJd) OUNDATION-TW,O REQUIRED If applicant is a corporation, signature of du } u htrized�o iceif .m -� 2 FOR POURED CONORE T jo L�l-'tai l ROUGH-FRAMING PLUMBING STRAPPING, ELECTRICAL & CAULKIIN,, (Name and title of corporate officer.) Sc- ANSE V) 3 INSULATION Builders License No. _ 4 FINAL-CONSTRUCTION&ELECTRICAL Plumbers License No. 2 1 Pi 1 I Q�,I �T I MUST BE COMPLETE FOR C 0 Electricians License No r ¢ 6 i , ALL CONSTRUCTION SHALL MEET THE Other Trade's License No. z, M REQUIREMENTS OF THE CODES OF NEW v YORK STATE NOT RESPONSIBLE FOR 1. Location of land on which proposed work wi 1 be done: DESIGN QR CONSTRUCTION ERRORS E4sf Man 6 Y\ House Number Street Hamlet County Tax Map No. 1000 Section 3C Block IIETINZTOR'"�-h' EIINOPF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and 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 WorkJXY-3 (Description) o 4. Estimated Cost 2 �� 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 O/w''ner. 11. Zone or use district in which premises are situatedy�— - U 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 13. Will lot be re-graded? YES NO C Will excess fill be removed from premises? YES NO l Wk-&yaqrss0b �'I�'o14.Names of Owner of premises Phone o.' — fD Name of Architect 1.0 7 b Addres� ,1 �ne No Name of Contractor Address 1 Phone No. P� � li12� 15 a. 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 MAYREQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO� * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF?--YIM TUOMO,44) being duly sworn,deposes and says that(s)he is the applicant (Name of indiv dual signing contrac)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 t ' ?L�-�J E8L1N�i day° P�TEOFNINYM SUFFOLK COUNTY / s`- Notary Public G '# 1 �, Sig ture of Applicant Scott A. Russell _,��°SUF��� ST�O�][Zl��l[\SVA\�C']E][� SUPERVISOR ,Cn MIA NA\G]EACENT SOUTHOLD TOWN'HALL-P.O.Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) �DOES THIS )PRIDJ EC T INVOLVE ANY OF THE )FO LL0WING. —� Yes No (CHECK ALL THAT APPLY) ❑MA. Clearing, grubbing, grading or stripping of land which affects more. than 5,000 square .feet of ground surface. ❑ B. Excavation or f illing 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. ❑[ 'i D. Site, preparation within 100 feet of wetlands, beach, bluff or coastal ff erosion hazard .area. ❑[X E. Site preparation within the one-hundred-year floodplain as depicted on FIRM Map of any watercourse. f ❑[L 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 Department with your Building Permit Application. APPLICANT (Pio ty O%tner.Deign Pr feutonal,Agen;tContractoi,,Othei) S.C.T,M. }: 1000 Date Distric NAME ISCAMJ4l vrmr q)414- Section Block Lot FOR. BUILDING DEPARTMENT USE ONLY ContacYlnformation Tr1epMM\umbrr) � Reviewed,By: G — — — — — — — — — — — — — Property Address / Location of Construction Work: I _ — _ _ _ — — — — — — — — — — i Approved for processing Building Permit. �' — — Stor mwater Management Control Plan Not Requrr ed. Stoi•mNvatei Management Control Plan is Required. I Wornvard to Engineer irig Department for Review) FORM # SMCP-TOS MAY 2014 4 r i 11 WAMR RUNOW I/ PURGUANT TO CHAPTER 236 y 6THE TOWN CODE.f� ' SUFFOLK ODUNTY HEALTH DEPARTMENT ` w�1��;4x�,sv Q X985 H. �, sro D. REF. # i 0 ' 5 The savage dis;aostil &,A WRt* SUPPly facilities for tt+i; 3.n ;1{:r• -ivv Veen inspected by OUS dGPCti+.:coat and Pound to bb satisPmBtory. Q•�^ V�.. j.�.' Chief AP G©ne al Engineering e f was r� Services 06 IL MrA�14W�OV40 9410 rod LO i ' : ` '��l ,� � h �. • is �'ar/?moo.A0 d 1+ • �/ ^"'/�?�'/rte �� .:.,��`/�'�f �� � •�„ ` !C 7J !, '•'N` �� IMS JJ vs :�i`:?i:...ta:'t' 3:drS�'4i:'hi4,, vt ib:tS.P�,• t.+.....7.r�'•^.::i ,•u,{2'. #1�•i� :$::•9br^rikilirPi7YA� .�'.{.i7Lr 3i'++�:t:aED1n..1P3:•+.Nt .d •r _ _ _. h , Client#:39819 RANDT ACORM CERTIFICATE OF LIABILITY INSURANCE9/04/2014 DATE(MMIDDNYYY) 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(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terns 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 NCONT AME: Cook Maran&Associates Southampton Commercial PHONE Ext):631 283-8000 AIC(FAXNe; 631 287-2207 Cook Maran 8 Associates E-MAIL cboumnaia@cookmaran.com Hampton Road ADDREss: oumna@cookmaran.com Southampton,NY 11968 INSURER(S)AFFORDING COVERAGE MAIC N INSURERA:Transportation Insurance Co. 20494 INSURED INSURER B:Rochdale Insurance Co. 12491 Fence King of Rocky Point,Inc. dba Swim King Pools&'Patios INSURER C:Continental Insurance Company 35289 471 Route 25A INSURER D: Rocky Point,NY 11778-8985 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN TYPE OF INSURANCE ADDLSUBRPOLICY EFF POLICY EXP INSR WVD POLICY NUMBER MMIDD/YYYY MM/DD LIMITS A GENERAL LIABILITY 2094735072 0910112014 09/0112015 pEAACCH��OECCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES t RENTED rrnce $100,000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $1:0001000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COM P/OPAGG $2,000000 POLICY X jRCT X LOC C AUTOMOBILE LIABILITY $ 2094735069 9/01/2014 09/01/201 Ea accld.n SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIARCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION RWC3342508 9/01/2014 09/01/201 X WCSTATU- OTH- AND EMPLOYERS'LIABILITYITORY LIMITS OFFICERMIEMBER EXCLUDED?ECUTIVE® N/A E.L EACH ACCIDENT $1,0()0,000 (Mandatory In NH)and E L DISEASE-EA EMPLOYEE $1,000,000 If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 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 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6254971M625431 'MH1 Certificate of NYS Workers' Compensation Insurance Coverage Page 1 of 2 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured Randy T Rodecker,Inc. 631-744-8100 471 Route 25A RockyPoint,NY 11778 lc.NYS Unemployment Insurance Employer DBA:Swim King Pools Registration Number of Insured Id.Federal Employer Indentiflcatlon Number of Insured or Social Security Number 113092960 Work Location of Insured(Only required if coverage isspecifically limited to certain location in New YorkStat4 i.e.a Wrap-Up Policy) 2.Name and Address or the Entity Requesting Proor of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Rochdale Insurance Company Town of Southold 50395 Route 25 3b.Poll Number orentity PO Box 1179 �7' tY listed In box"Ia": Southold,NY 11971 RWC3342508 3c.Policy effective period: 9/1/2014 to 9/1/2015 3d.The Proprietor,Partners or Executive Olflcers are: Included(Only check box if all partners/officers included) 3 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)roust 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"2". The Insurance Carrier will also not fy the above cert f sate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IA there are reasons other than nonpayment of premiums that cancel the policy or eliminate the ensured from the coverage indicated on this Certificate(These notices may be sent by regular mail.)Other vidse,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 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: Henry C.Sibley (Print name of authorized representative or licensed agent of insurance carrier) a eA 6, Approved By: 9/4/2014 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent ofinsumnce carrier.CarderPhone Please Atte: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) https://ao.amtrustgroup.com/anawc/PolicyNYCertificateOf WcIns.aspx?lndexId=87991&Iris... 9/4/2014 II v 1 40' 10., q CHECK VALVE J U NOTES FROM SKIMMER O PUMP CONCRETE WALLS / ALLE-20IOUCNONISTOBEINACC00.DANCEWITN7HEPEAUMALINCRDVFIWAMWR ` Co B 'PATE-2010ANDTNEANSI/NSPI-5-D35iANDAPDS FORREHDENTIAL INGPDVNDSWIMMINC O 1^i/ 0.x15 FO0.ATY➢E"POOL 2 SERVCTURE IS DE51GNED FOR USE BELOW GRADE AND ONLYIN AREAS WHERE TGROVND VFATERTABLE ISA MIN IMVM OF"'BELOW THE PROPOSED FIMSHEDGRADE 3. W/ FILL WITH CLEAN EARTH,FREE OF POO7S AND DEBRIS,W NOTALLOWIHE HEIGHTCF MCAR LL TO EXCEED THE HEIGHTOF THE WATER IN THE POOL BY MORE THAN B',ORTHEuj WATER TO EXCEED BACKFILL SYMORETHAN B' 7 4, PLACE CONCRETE ON SANDYTO LOAM SOIL REMOVEANYCIAYDEPOSITANDCOMPACT DRYW'0 v Z 5 WALKSTOBESMOOTH NON SKIDTYPE SLOPEDAWAY FROM POOL O Z CONC.FTG. v Q SEE DETAIL b WATER DISPOSAL SHALL BELIMITED TOOWNERS PPOPERry1NACCORDANCEVATHLOCAL DIVERTER DEEP WATER RETVRNS �. L O �'�� N 1 .( .F 7 ACCORDANCE BUILDING PPENDINTFENCONAG105 PEPMN VALVE O `� �,,, } 16' 11' I1' 2' ACCORDANCEWI BE COMPLETED NINETY DAYS MMENEM < ENCONsTR MUST BE WI7NIN NINETY OAVSAFIERTHE DATEOFCOMMENCGIEP 0 OFCONSTRVLTON �- % 1 9 THERE]NO MAIN DRAIN IN THIS POOL 5UCTIONFOXPOOLWATERORCVLATION IS PPONDED BYTPAOTEMMERS ONLY THIS MEETS REOVIREMENiSOFRG-SECTION PLiCM FD0. ENTRAPMENTPPOTEC710N FILTER 9 THIS POOL5HALL BE EOVIPPED RWITH AN APPIO EDPOOLALARM WHICH ISCLASSIFIED BY r /� O Q� 7 p N DIVE.BD. �- SPEOFICATONFOPoOLAALARMS,'ASADOPIEDINT2AON0 3' DAPDASTM220R ENfITLEDSTANDAI v N -2"H2O 8'H20 10 ATEMPOPARY ENCLOSVRE OR4 FT FENCE SHALL BEINPALLEDANDRFMAIN IN PLACE THROVCHOUTTHEPERIODOF CONSMVCTIONOFTHESWIMMIMG 4ORUNTILTHE COMPLEFIONOFA PERMANENTENCLOSVRE 11 POOLSHALL BEA0.0N VNOISNRBE05014 FREE OF PERT,MIKKOROTHE0.DF1ETElUOVS MATERIAL OFANY SIGNIFICANTAMOVNF VINYL COVERED A z THEPRESVMPTIVESOIL LOAD-BEARING PRPSSVREISA%VMEDTOAS24O0WVND5PE0. 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I Q Q ;; WATER LINE a GRADEo p 4 o Q O, a N= p O a cv C) mr a �/\ P L1.a N LU a �a ROLLED FOAM BETWEEN _ TOP OF WALL WATER LINE LINER AND CONCRETE a 1'-3" 3'-6" I— 2'-9" 1'-6" FORM TIES a � — — Z�Z Z a Ln 4 12 0 4 3500 PSI POURED CONC. a j/� Q in VINYL L1NERa 4 O U IM 2"TO4"SAND ��i\ DIVING BOARD — a o<-j DETAIL — —'bio SECTION_ B Scale: 1/8'=V-0" 9--3-2014 WALL SECTION - _ r