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Home My WebLink About41312-Z �o�SUPFOj,��oGy Town of Southold 7/31/2018 0 P.O.Box 1179 d' 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39810 Date: 7/31/2018 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 1655 Park Way, Southold SCTM#: 473889 Sec/Block/Lot: 70.-11-19 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/24/2017 pursuant to which Building Permit No. 41312 dated 1/24/2017 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 SWRVIMING POOL, FENCED TO CODE,AS APPLIED FOR The certificate is issued to Fujita,David&Suzanne of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 9091 10-09-2010 PLUMBERS CERTIFICATION DATED t ed Signature r SVFFOI�c TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE % SOUTHOLD, NY o4,o 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#: 41312 Date: 1/24/2017 Permission is hereby granted to: Fujita, David 1655 Parkway Southold, NY 11971 To: Construction of an inground swimming pool as applied for. This permit replaces 37932. At premises located at: 1655 Park Way, Southold SCTM # 473889 Sec/Block/Lot# 70.-11-19 Pursuant to application dated 1/24/2017 and approved by the Building Inspector. To expire on 7/26/2018. Fees: PERMIT RENEWAL $75.00 Total: $75.00 Building Inspector p�SOI2=- �oTOWN OF SOUTHOLD BUILDING DEPARTMENT a TOWN CLERK'S OFFICE o • SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 37932 Date: 4/11/2013 Permission is hereby granted to: Fujita, David & Fujita, Suzanne 1655 Parkway Southold, NY 11971 To: construction of an inground swimming pool as applied for. This permit replaces 35855. At premises located at: 1655 Park Way, Southold SCTM # 473889 Sec/Block/Lot# 70.-11-19 Pursuant to application dated 1/1/1900 and approved by the Building Inspector. To expire on 10/11/2014. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $75.00 CO -ACCESSORY BUILDING $50.00 Total: $125.00 BuildinbI e FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT, (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 3 A0- PERMIT NO. 855 Z Date SEPTEMBER 13 , 2010 Permission is hereby granted to: DAVID M FUJITA 1655 PARKWAY SOUTHOLD,NY 11971 for CONSTRUCTION OF AN INGROUND SWIMMING POOL AS APPLIED FOR at premises located at 1655 PARK WAY SOUTHOLD County Tax Map No. 473889 Section 070 Block 0011 Lot No. 019 pursuant to application dated AUGUST 26, 2010 and approved by the Building Inspector to expire on MARCH 13 , 2012 . Fee $ 250 . 00 Authorized Signature COPY Rev. 5/8/02 ecti Electrical Ins CC`' v D Nassau Suffolk p P.O. Box 549,Aquebogue,New York ♦ 11931 >� � Tel: 631-591-3097 Fax: 631-591-3098 AUG 2 3 2017 Application: 9091 Date: 10/9/10 - BUILDINGDEPT• Issued to: Fujita TOWN OFSOUTHOLD Address: 1655 Park Way Introduced By: Bethel Electric Cont. Village: Southold License#: 2880-ME Residential 0 Commercial The following was examined and approved up to the above date and found to be in compliance with the NEC: Switches Receptacle Fixtures G.F.I. Pool Panel Salt Generator —] 1 2 1 2 1 1 Fans Dishwasher Washer/Amps Dryer/Amps Oven Range/Amps Carbon Monoxide Furnace Oil Gas Heat Zones Whirlpool Exit Signs Limited Insp Final Insp Meter Amps Phase Motors 10/811 0: 10/9/10 1 In Ground Pool J ,r� Per mit#: Section: 70 Block: 11 Lot: 19 This certificate must not be altered in any manner Priv � of so� �� P 11 �yvvurm,��' TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: �-r L r 1 ?6AX, DATE 117 INSPECTOR / apF 50U1H hod o� # # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802- INSPECTION 65-18021NSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATI N [ ] FRAMING /STRAPPING [ FINAL Pot� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS:6) 6) 04g" A u�� r (' Rv m v vis r�� DATE lO 110 INSPECTOR 17APA • q souryO� # TOWN OF SOUTHOLD BUILDING DEPT. u765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] ISULAT N [ ] FRAMING /STRAPPING [ FINAL a', [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: 4CA41k Sato r v; opo & -I b - Vs mv�� c,�, , 0 A i!i - 6a+ CGI w - � SeAw- ) ogy, bOeb 4 �Acim J ,DATE AAIUN INSPECTOR q so # # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm��`' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] INSULAT N / [ ] FRAMING /STRAPPING �INAL G�S�/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE INSPECTOR pE 3001 coufol TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ VULATION S FRAMING /STRAPPING [ FINAL 1W [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ) ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARK (o4� AD DATE Y 7 INSPECTOR COMMENTS FOUNDATION(IST) 3a. ' • 11 •PLUMING INSULATION PEA N.Y. STATE ENERGY • 1 shm Al ADDiTibNAL COMMENTS r ,. . L_ TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD, NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. ;2 Check Septic Form R 131 N Y.S.D.E.C. Trustees Flood Permit Examined �,20 P Storm-Water Assessment Form lContact: Approved q/ �320 Mail to: Disapproved a/c Phone: Expiration ,20 1 -,)- 4l— - f1 APP ION 2 Building Inspector U ION FOR BUILDING PERMIT AUG 2 6 2010 Au(.UST I� 2010 - Date , BLDG DEPT, INSTRUCTIONS TOWN OF SOUTHOLD a. This application MUS e comp fled 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. OCCFANCY C� (Signature of applicant or name if a corporation) (JS i �N � E I,.`y,- �®OL-MA -1 Z"7 1 SM I�"(�1tOWPJ BLIJO N"ITHOUT iiCATE "IMMEDIATELY" t,.j es co C '' ` "' ENCI L®SE Pd °�*O E (Mailing a dress pplicant) ` UPON COVOLETON State G�--e 1 't is owner, lessee, ageAWQRff4N.kTWeer, general contractor, elect,APB,;VfAAS MTED � DATE•"�/7� (/ B.P. #—Z � FEE• �3 V BY n Name of owner of premises 1 ' Iv-t MVS DAV 10- 1 to NOTIFY BUILDINGn� z- (As--&n the takJroll or latest deed) 765-,.802 B VA T C 4 If applicant is a corporation, signature of duly authorized officer FOLLt-!r^v NG v��Er r, ._moi f-_D WRITERS CERTIFICATE -(-,),3Hc (Name and title of corporate officer) 2 REQUIRED etc; CA Builders License No. ��J 1-7 /-j`� ��d, 3. IN JL�,T;N' ° CAULKING-, Plumbers License No. e INAL GONSTRUCTi0p1 E.ECTRICAL'-'. %JST BE COMPLETE FOR C() Electricians License No. ALL CONSTRUCTION SHALL MEET THE Other Trade's License No. % HcP , Cc>- REQUIREMENTS OF THE CODES OF NEW' UV YORK STATE NOT RESPONSIBLE FOR 1. Location of land on which proposed work will be done: DESIGN OR CONSTRUCTION ERRORS F House Number Street Hamlet PURSUANCHAPTER 236 OF TH T CODE, County Tax Map No. 1000 Section -l® Block I C Lot Subdivision VI 1✓UJ 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 I 1FAM'I ULf RE'S t D eYM N L_ b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition- Other Work IV000una POOL- 4. Estimated Cost f? ®®o M VViDr1'P U Fee )8Y-36 1 n§h*A d#n)y'V%— (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 struc s, if any: Front r Depth Height Number of Stories -- - Dimensions of same struc e with alterations or additions: , nt, Rear Depth Height Number oaf Stories 8. Dimensions of entire new construction: Front Redr Depths Height Number of Stories i 9. Size of lot: Front Rear Depth 10. Date of Purchase 1`q6 Name of Former Owner L-ouI S Z i u_0 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 V Will excess fill be removed from premises? YES V'NO (031 al 14. Names of Owner of premises DAV I Q FUJ1T4 Address 6 S A-1 J Phone No. Name of Architect Address 1 Phone No Name of ContractorB I UR A V-0 S H I C — AddressE71 SMLjbkW hone No. 631 -73];W6 Wescm5e-fI I y 11-76 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 foundations plan and distances to property lines. 4 'Jng Tjl� I 17. If elevation at any point on property is at 10t! 0feet?tP� tb!!/�icif ,�intist provr'd'&tbpographical data on-survey. i° i-S �.��IS: mlc i 3 is q" f? fP•:, h� aS9v6 y S'=1" 18.'Are ther"d any covenants and restrictions with respect'to`tliis'propiL:er� �y? * YES NO � * IF YES, PROVIDE A_COPY. STATE OF NEW-YORK) SS: COUNTY OF c) _ [ch A V6 J�'111e Pgol M lAyt being.-duly sworn, deposes and says that(s)he is the applicant (Name of individual signing cont ct) above named; _ (S)He is the Coyyyf A�_'A'c (Contractor, Agent, Corporate Officer, etc.) of sa'd owner orr 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 per fo%ned'mAe manner.set;,forthdh the application filed therewith. Sworn to before°me.fhis /. ? 'day of; V'cGu 1 201® ;� AMY LATTAN 10 Notary Public, State of sw Public ,�1C'1eMrtificate sus In v{ Palk Cho3�j, 2 ature of Applicant 'llOrrBtM1d''h{.L.GIOn `...'\n/�i l'.�. �JV'PL yJq 20,E IDsuFFQ/r.� Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSP_$SMENT FORM PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE 5`UBMISSION OF A -`�(-� t( STORM-WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN D- sTtric� Section Block of CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK PROPOSED CONSTRUCTION ITEM# / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within 1?76 S Generated by a Two(2")Inch Rainfall on Site? (S.F../Acres) the Scope of Work for Proposed Construction) (This Item will include all run-off created by site b. What is the Tota(Area of Land Clearing clearing and/or construction activities as,well as all and/or Ground Disturbance for the proposed /2 SQ Site Improvements and the permanent cfeation of (S.F./Acres) construction activity? `C impervious surfaces.) - , 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed) Drainage Structures Indicating Size&Location?This Item shall include all Proposed Grade Changes and V36 Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion Q Ui�(� Vf n(,f e, JQpOI✓ and sediment control practices that will be used to control site erosion and storm water discharges. This V—U item must be maintained throughout the Entire Construction Period. 4 Will this Project Require any Land Filling,Grading or Excavation where there is a change to the Natural — Existing Grade Involving more than 200 Cubic Yards F� of Material within any Parcel? tj Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.)Square Peet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred(100')feet of a Wetland or F-1 Z Submission of a SWPPP is required for all Construction activities'involving soil Beach? disturbances of one(1)or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Exist(ng.Grade Slopes are part of a larger common plan that will ultimately disturb one or more acres of land; which Exceed Fifteen(15)feet of Vertical Rise to El including Construction activities involving soil disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance? the DEC has determined that a SPDES permit is required for storm water discharges. (SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways,Parking Areas or other Impervious for Storm Water Discharges from Construction activity-Permit No.GP-040-001.) Surfaces be Sloped to Direct Storm-Water Run-Off ve- 1.The SWPPP shall be prepared prior to the submittal of the NOI.The Not shall be into and/or in the direction of a Town right-of-way? submitted to the Department prior to the commencement of construction activity. 2.The SWPPP shall*describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material,' required,post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any ❑ — constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions of this permit.In addition,the SWPPP shall Area?(this item will NOT Include the Installation of Driveway Aprons.) Identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark 3.All SWPPPs that require the post-construction storm water management practice in a Box and the construction site disturbance is between 5,000 S.F.&1 Acre In area, component shall be prepared by a qualified Design Professional Licensed in New York a Storm-Water,Grading,Drainage&Erosion Control Plan is Required by the Town of that is knowledgeable in the principles and practices of Storm Water Management Southold and Must be Submitted for Review Prior to Issuance of Any Building Permit (NOTE. A Check Mark(,I) and/or Answer for each Question is Required for a Complete Application) STATE OF NEW YORK, COUNTY OF...........................................SS That I,... .I cyln!d....d h.K c.......................being duly sworn,deposes and says that he/she is the applicant for Permit, (Name of individual signing Document) �` And that he/she is the � �GI cwt ( ; Y! l• .�'.V t IrS �/• Flt 1 i# .................................... ........ ......' V : O er,Contractor,Agent,Corporate Officer,etc.) .. A Y L T ANZIO Owner and/or representative of the Owner or Owners and is duly authorized to perform ori }v��pP&SIecst�iNevor1od id to make and file this application;that all statements contained in this application are true to the est ofi`,htis(knortrledge'a`ir�i b kf,and that the work will be performed in the manner set forth in the application filed herewith. Certifloate fl(�_ ti. Z='; rcii< O�tT<y Sworn to before me this; Coir: ri L-.;�i, 6`'°` =`' _0. d if U 5� 20Z0 NotaryPubl' . . .. . ... .................................. (Signature of Applignt) FORM - 06/1 -�, Southold Town Building Department �c,UEfD��d P.O.Box 1179 Permit#: 35,855 54375 Main Road Permit Date: 9/13/2010 Southold,New York 11971 631 765-1802 °1 .a Expiration Date: 3/13/2012 Parcel W: 70.41-19 BUILDING PERMIT RENEWAL LETTER Dated: 12/3/2012 Applicant: DAVID& SUZANNE FUJITA Location: 1655 PARK WAY SOUTHOLD Work Description: IN GROUND POOL CONSTRUCTION OF AN INGROUND SWIMMING POOL AS APPLIED FOR _'0 C/' A FEE OF $175.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: DAVID& SUZANNE FUJITA Address: 1655 PARKWAY SOUTHOLD,NY 11971 The permit listed above has expired. Please contact our office as soon as possible to begin the renewal process. All work on the project must stop on the expiration date. No work is permitted or authorized beyond the expiration date. THANK YOU, SOUTHOLD TOWN BUILDING DEPT. Southold Town Building Department oO�gUFFQd,fcoG9 P.O.Box 1179 Permit#: 37932 53095 Main Rd xPermit Date: 4/11/2013 .f, Southold,New York 11971 �4A o� (631)765-1802 Expiration Date: 10/11/2014 Parcel ID: 70.41-19 BUILDING PERMIT RENEWAL LETTER Dated: 1/6/2017 Applicant: Fujita, David&Fujita, Suzanne Location: 1655 Park Way, Southold Work Description: IN GROUND POOL construction of an inground swimming pool as applied for. This permit replaces 35855. A FEE OF $75.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Fujita,David&Fujita, Suzanne Address: 1655 Parkway Southold,NY 11971 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold,New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. Southold Town Building Department ��FFaLI�c' P.O.Box 1179 Permit#: 37932 �.. 53095 Main Rd Southold,New York 11971 Permit Date: 4/11/2013 (631)765-1802 Expiration Date: 10/11/2014 Parcel ID: 70.41-19 BUILDING PERMIT RENEWAL LETTER Dated: 1/18/2017 Applicant: Fujita,David&Fujita, Suzanne Location: 1655 Park Way, Southold Work Description: IN GROUND POOL construction of an inground swimming pool as applied for. This permit replaces 35855. A FEE OF $75.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Fujita,David&Fujita, Suzanne Address: 1655 Parkway Southold,NY 11971 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department, P.O. Box 1179, Southold, New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. STATS OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of insured(Use street address only) lb.Business Telephone Number of Insured Swim Clean Pool Services Inc. 631-737-9600 271 Smithtown Blvd. Ic.NYSUnempleyment Insurance Employer Nesconset, NY 11767 Registration Number of Insured WorkLocation ofInsured(Only required tfcoverageisspecifically ld.Federal Employer Identification Number ofInsured limited to certain locations In New York State, i.e., a ffirap-Up or Social Security Number Policy) 112788598 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Insurance Company Town of Southold 3b.Policy Number of entity listed In box"la" Main Road 12WECLR4709 Southold, NY 11971 3c. Policy effective period 11/1/2nnA to 11111.1201 3d. The Proprietor,Partners or Executive Officers are ®included. (Only check box irall parinerstallicers included) ❑ all excluded or certain pnrtners/oflleers excluded. This certifies that the insurance carver indicated above in box"Y insures the business referenced above in box"la"for workers' compensation undertheNew York State Workers'CompensationLaw.(To use this form,New York(NY)must be listed underltem M on the INFORMATIONPAGE of the workers'compensation Insurance policy). The Insurance Carrier or its licensed agentwill send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Cmrter will also notify the obmv certificate holder within 10 days IFa policy Is canceled due to nonpayment ofpremirtma or within 30 days JF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otlteniise,this Cert feate is valtd jar one yearaf$er tltisforttt is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3e; 1,hichewr k 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 holderwith 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: A th presentativo or licensed agent of insurance carrier) Approved by; 40 --5 (signature (Date) Title: Area President Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note.Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-07) vtnnvwcb.state.ny.us k !CORPORATE AND SALES OFFICE .271 Smithtown Blvd. • Nesconset,NY 11767 r :RETAIL STORE '127-17 Smithtown Blvd. Nesconset,NY 11767 ri 'i { f� ! FU OwelIvi FFQMMT W e IM Ts l ! ! Thlc iift 3 �ivii ��€ �is2► �r� al�. PP} it i l� i I it STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured SWIM CLEAN POOL SERVICE, INC. D/B/A POOL 516-361-9080 MART 1c.NYS Unemployment Insurance Employer Registration 271 SMITHTOWN BOULEVARD Number of Insured NESCONSET, NY 11767 5954294 1d.Federal Employer Identification Number of Insured or Social Security Number 112788598 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) The First Rehabilitation Life Insurance Building Deptartment Company of America 3b.Policy Number of Entity listed in box"1a": Town Of Southold DBL70431 Main Road 36.Policy effective period: Southold NY 11971 02/22/2010 to 02/21/2011 4.Policy covers: a. F,(] All of the employer's employees eligible under the New York Disability Benefits Law b.F1 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 8/18/2010 By K (Signature of insurance carrier's authorized representative or r YS Liceed insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Title Sr. Vice President 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,20 Park Street,Albany,NY 12207. 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 (5-06) AC"RV CERTIFICATE OF LIABILITY INSURANCE DATE 08I 8120110 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LoVullo Associates,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6450 Transit Road HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Depew,NY 14043 INSURERS AFFORDING COVERAGE NAIC# INSURED Swim Clean Pool Service Inc INSURERA, COLONY INSURANCE COMPANY 39993 Richard Shire INSURERB: 271 Smithtown Blvd INSURER C: Nesconset,NY 11767 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS S D DTE MWDD DATE MM/DD GENERAL LIABILITY MP3171926 09/0212009 09/02/2010 EACH OCCURRENCE $ 1,000,000 A DAMAGETO RENTED 10O 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ + CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1+000+000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2+000+000 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Parperwn) $ HIREDAUTOS BODILY INJURY (Per accident) $ NON-OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMSMADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STALIMTU- OTH- OELt AND EMPLOYERS' A LLBILITY YIN ER • ANY PROPRIETORIPARTNER/EXECLMVE❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $ _ Ifyes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ OTHER Business Personal Property MP3171926 0910212009 09/0212010 $75,000 A Bll with Extra Expense $100,000 Deductible 1 $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPEC"PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MALL 10 DAYS WRITTEN TOWN OF SOUTHOLD NOTICETOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR MAIN ROAD-BUILDING DEPT REPRESENTATIVES. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE, I 04A ACORD 25(2009101) G 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD For more information contact: LPL Risk Mgt Ltd at 631-676-7020. C%a ItlCYY ,Vf%fx cwG WORKERS'COMPENSATION BOARD U022 CERTIFICATE"OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (Use street address only) 1 b. Business Telephone Number of Insured SWIM CLEAN POOL SERVICE, INC. P.M. 1c. NYS Unemployment Insurance Employer Registration 271 SMITHTOWN BLVD Number of Insured NESCONSET NY 11767 Work Location of Insured (Only required if coverage is 1 d.Federal Employer Identification Number of Insured or specifically limited to certain locations in New York State, i.e.a Social Security Number Wrap-up Policy) 112788598 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Sentinel Ins Co LTD The Town of Southold 3b.Policy Number of entity listed in box"1a": 12 WEC LR4709 Building Department 3c. Policy effective period: MAIN SOUTHOLD, NY 11971 11/01/2009 to 11/01/2010 3d. The Proprietor,Partners or Executive Officers are: Xincluded. (Only check box if all partners/officers included) all excluded or certain partnerstofficers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1a" 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". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certit"icate 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 eadier. 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: Kathi Golowski (Print name of authorized representative or licensed agent of insurance carrier) Approved by: f408-19-2010 ( ature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 866-467-8730 Please Note.Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it C-105.2 (9-07) " www.wcb.state.ny.us Form WC 88 3121 C Printed in U.S.A Pagel of 2 QF PROPE(2TY - . - • _` �S - •- . ' '. . .SUfLVEYEJ• ? ^- ..,ir.nr'-y. + - lVri.1;0.x..4-.�`.I.C:I'."+VL�!`a•7•.A •' - • - - �• '4 - J. +'r• •Y.=`:�y'n`-J`��r .•+,a-•`,,�y��,T � -+�$ti�.4`••'>i•:.i��•�-.i:w. _•1t«�"� a• �_ D _Y. . . �. S._ AIZEA :� _ '' .: _ ��`• is - ;i..: �' -_.ai ;•�i_::,=.� Y .• .•' .• a�°. ^i: ~:h•:•�it A+•i.':•�'�,"� '�:. ,,:�_,,.:•.�..i_i�':J'• r'• -. . -: 9�. .; i•s• ''' ti .GUARp NTEECf-"XQ EUiZODEA61'AMEl2f��Y,1 P.:Y,4. 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