HomeMy WebLinkAbout40993-Z ��o�g11PFOt��oG� Town of Southold 8/3/2018
0
P.O.Box 1179
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39820 Date: 8/3/2018
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 1255 Kayleighs Ct., East Marion
SCTM#: 473889 Sec/Block/Lot: 22.-3-5.3
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
9/8/2016 pursuant to which Building Permit No. 40993 dated 9/14/2016
was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for
which this certificate is issued is:
ACCESSORY IN-GROUND SWIMMING POOL,FENCED TO CODE,AS APPLIED FOR
The certificate is issued to Grove Jr,Richard&Mady-Grove,Theresa
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40993 11/22/2016
PLUMBERS CERTIFICATION DATED
ho d Signature
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
o • SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 40993 Date: 9/14/2016
Permission is hereby granted to:
Chimney, Edward
1255 Kayleighs Ct
East Marion, NY 11939
To: construction of an in-ground swimming pool as applied for.
At premises located at:
1255 Kayleighs Ct., East Marion
SCTM # 473889
Sec/Block/Lot# 22.-3-5.3
Pursuant to application dated 9/8/2016 and approved by the Building Inspector.
To expire on 3/16/2018.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
To $300.00
uilding Inspecto
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
Date. ��°
New Construction: Old or Pre-existing Building: (check one)
Location of Property: 1f1F-24 m `�,�
Nouse No.
Stre t Hamlet
Owner or Owners of Property:
Suffolk County Tax Map No 1000, Section Block Lot
}
Subdivision Filed Map. JLot:
Permit No. ®�� Date of Permit. Applicant: 4--(,) cy,
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (ch ck one)
Fee Submitted: $ L 'A+
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Town Hall Annex Telephone(631)765-1802
54375 Main Road N trFax(631)765-9502
P.o.Box 1179 G �Q roger.riche rt(a)_town.southoId.ny.us
Southold,NY 11971-0959
BLTILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Chimney/Grove
Address: 1255 Kayleighs Court City: East Marion St: New York Zip: 11939
Building Permit#: 40993 Section: 22 Block. 3 Lot 5.3
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
Contractor: DBA: LC Electric License No: 38043-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 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 Fixtures Time Clocks 1
Disconnect Switches 2 Twist Lock 1 Exit Fixtures TVSS
Other Equipment: Inground Swimming Pool to Include; Bonding, Sub Panel, 3- GFCI Circuit
Breakers, Salt Generator, Gas Pool Heater, 1- Pool Cover Motor, 3- Pool Lights.
Notes:
Inspector Signature: Date: November 22, 2016
0-Cert Electrical Compliance Form.xls
D� OF so(/lyo
TOWN OF SOUTHOLD BUILDING DEPT®
765-1802
ANSPECTION
[ /FOUNDATION 1S1`�AAW) [ ] ROUGH PLRG.
[ ]
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ECTRICAL (FINAL)
REMARKS: kbw ole- 1
6>~ 4» � IV A&.tA
DATE A INSPECT®R
SOUjyolo
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t *outm,�
TOWN OF SOUTHOLD BUILDING-DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING /STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) ] ELECTRICAL (FINAL)
REMARKS:
DATE, ` � �� INSPECTOR `� -
SOUT,y�I
� o
TOWN OF SOUTHOLD BUILDING DEPT.
765-18®2
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLSG.
[ ] FOUNDATION 2ND [ ] SULATI N
[ ] FRAMING / STRAPPING [ FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS:
Fiv p4aisk
WAL Irw�vketA
DATE A W � INSPECTOR
SO(/jyo
H O
holy 0 M�,N
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] SULATII�ON
[ ] FRAMING / STRAPPING [ FINAL !w"
" /01"'-
[ ] FIREPLACE & CHIMNEY ' [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FIN L)
RE RKS: � czl & ,,.-,
f
DATE INSPECTOR Y
�o��oF soulyo`o
# TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I SULATI N
[ ] FRAMING /STRAPPING [ FINAL JPWt ---�
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
-[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
N �ov'P\ b&
6 '° ow ter.
DATE INSPECTOR
�o��oe soulyolo
# TOWN OF SOUTHOLD BUILDING DEPT.
cou765-1802
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]�FINALA;rA&-__�
LFRAMING /STRAPPING [
[ ] FIREPLACE & CHIMNEY [ } FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
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DATE INSPECTOR
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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 sets of Building Plans
TEL: (631) 765-1802 Planning Board approval
FAX: (631) 765-9502 �urvey
SoutholdTown.NorthFork.net PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
D Trustees
C.O.Application
Flood Permit
Examined '20 Single&Separate
-1
SEP ` 8 2016 �7 Storm-Water Assessment Form
r Contact:
Approved ' 120 BU"INGDEM Mail ti?i A q i
Disapproved a/c TOWNOFSQU$oi� �'� � P"L
Phone:
Expiration ,20� rJ? -
Building Inspector
APPLICATION FOR BUILDING PERMIT
Date , 20 16
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 regulations,and to admit
authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant or name,if a corporation)
Rck, I xv�t 1�, J.-I, I��q 9
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
V
Name of owner of premises �C11 &(I ov
(As on the tax roll or latest deed)
If ppli n is a or ation, signature of duly authorized officer
Pro'��
(Na e dd4itle offtDr r e'office�r)
Builders License No.
Plumbers License No.
Electricians License No. �,) 1-$
Other Trade's License-No.
1. Locationtof,land-on wh icti,pro oseq work will be done:
C40 C
``Hou;S' INurnber' "' St' et Hamlet
County Tax Map No. 1000 Section )La Block ®� Lot��=j
Subdivision Filed Map No. Lot
2. State existing use and occupancy of premises and 'ntendedand occupan,T of proposed construction'
a. Existing use and occupancy 5 `l �Cti � ov
b. Intended use and occupancyi
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work _ Ly%4AA "
(p scr ption)
4. Estimated Cost �j 00 i •` : e `q tr:' + °
(To b,[[paid on filing this application)
5. f dwelling, number of dwelling units �umb,er,,of dwellinngaunitslotileach floor
" : c' _ s
I arage, number of cars
If business, commercial or mixed occupancy, specify nature1118yMift o'Teach type of use.
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
Dimensions of entire new construction: Front Rear Depth
Height Number of Stories
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 remises? YES 7NO '
b � p
lzy� �'_71e'6 Cour' -- 5-t,6 8I6 toog
14. Names of Owner of premises dress .n4-A,,-, - Phone No.
Name of Architect 5 Address EAZjUvX C,J-Phone No 4 3 S��
Name of Contractor + `5 Address S 2s Phone No. h�,f X03 G
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
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF&F1-L�'
1�1 6 being duly sworn, deposes and says that(s)he is the applicant
(Name of individual igning contract) above named,
(S)He is the
(Contracto(,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. TRACEY L. DWYER
NOTARY PUBLIC,STATE OF NEW YORK
Sworn to before me this NO.01 DW6306900
day of -C 20 ( _ QUALIFIED IN SUFFOLK COUNTY
X COMMISSION EXPIRES JUNE 30,20t6
"Amw r�Notary Public S7,gn)tM of Applicant
4,
Scott A. Russell
�0°SuFFQ.k � `]F01K1\\ WA\`]F]E1K
SUPERVISOR co AMIANA\(Gl]ENIENT
SOUTHOLD TOWN HALL-P.O.Box 1179 a
53095 Main Road-SOUTHOLD,NEW YORK 11971 �O Town of So u th o l d
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOLES THIS PROJECT INVOLVE ANY OF THE FOLLOWING:
❑Yes No (CHECK ALL THAT APPLY)
Clearing, grubbing, gradingor stripping of land which affects more
❑� than 5,000 square feet of ground surface.
. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑Lraz"�"'. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑2K D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
❑0"'EE., 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 Department with your Building Permit Application.
APPLICANT (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T.M. #: 1000 Date
District �j�
NAME ��" VDt At \lV G��f 5a 3 1 —0 ,W
w, Section Block Lot
FOR BUILDING DEPAF{TN41=:NT [,SE ONL E
Contact Information 63( 5 —+G 6 V
Reviewed By:
- - — — — — — — — — — — — —
Date
Property Address / Location of Construction Work- — — — — — — — — — —
Approved for procesbing Building Permit.
Stormwater Management Control Plan Not Required
- - - - - - - - - - - - - - - - -
' \ y �1 ❑ Stormwater Management Control Plan is Required
(Forward to Engineering Department for Review)
FORM * SMCP-TOS MAY 2014
- Of SO�IyD
Town Hall Annex 4Telephone(631)765-1802
54375 Main Road N (631)765.A51
P.O.Box 1179 G roaer.richertCa�#own.souod nv us ;
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY' Date: i
Company Name: G,
Name: 'V 1
License No.: fl
Address: (/J I j
Phone No.: V _DST •e ))q f
!
JOBSITE INFORMATION: (*Indicates required information)
*Name:
*Address:
*Cross Street:
*Phone No.:
Permit No.:
Tax-Map District: 1000 Section: aa�. "Block:, Lot: 5'
f
*BRIEF DESCRIPTION OF WORK(Please Print Clearly)
I
(Please Circle All That Apply)
*Is job ready for inspection:
OYESNO Rough In Final
*Do you need a Temp Certificate: YES/d�P '
I
Temp Information(if needed)
*Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other"
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION
f -
82-Request for Inspection Form �� U
j
S(f�jl�O! -
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Town Hall Annex 41 Telephone(631)765-1802
54375 Main Road Q2
P.O.Box 1179 G Q roer.richert {63 5763 Dltl.n .us 1
Southold,NY 11971-0959 ! �(�/7�
o�co �� D V
D
BUILDING DEPARTMENT JAN 2 0 2017 !
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION tTILDING DEPT.
TOWN OF
SotMOLD
REQUESTED BY.
_ Date: j
Company Name: L C �I«� �W
Name: L l ;_
License No.: 3 713 ,
Address: A r �ICI L
Phone No.:
JOBSITE INFORMATION: (*Indicates required information) f
*Name:
*Address: 12 S� k i�,�., I e,; �,. s - ��<-!- ��� ►�.�,r;
*Cross Street:
*Phone No.:
Permit No.: t
Tax Map District: 4 000 Section: Block: Lot:
*BRIEF DESCRIPTION OF WORK(Please Print Clearly)
P-z-(31
(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: 4 Phase 3Phase 100 150 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WITH APPLICATION
82-Request for Inspection Form \ nV
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f
ADDITION(1)UNAUTHORIZED ALTERATION OR TO THIS SURVEY IS A VIOLATION OF�SECTION 72D9 OF THE NEW YORK STATE EDUCATION LAW (2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE NOT TO BE USED TO ESTABLISH PROPERTY LINES OR FOR ERECTION OF FENCES(3)COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY.(4)CERTIFICATION
INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY 15 PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY.GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON.AND TO THE ASSIGNEES OF THE LENDING INSTITUTION CERTIFICATIDNS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS DR SUBSEQUENT OWNERS (5)THE LOCATION OF WELLS(W)•SEPTIC TANKS(ST)&CESSPOOLS(CP)SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS.
1 1
1 1 400 Ostrander Avenue,Riverhead,New York 11401
1 1 tel.631651.121.0144
admin@youngenginearlms.com
Howard IN.Young,Land Surveyor
1 1 Thomas G,Wolpert,Professional mEngineer
#- E�FE—E Douglas E.Adas,Professional Engineer
Robert G.Tost,Architect
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„fit hp0 SITE DATA
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1 eox e►5
i; , 3 AREA = 45,5161 SQ. FT.
2�✓1'6Q ji� EUBDIV15ION- "HIGWOINT WOODS"FILED IN THE OFFICE OF THE
1 QOq'4011� 1N CLERK OF SUFFOLK COUNTY ON JULY 25,IdicM AS FILE NO.10035.
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THERESA MADY-GROVE, COMMONWEALTH LAND
` U) TITLE INSURANCE COMPANY & EMINENT
ABSTRACT,
INC. TFIAT THIS SURVEY PREPARM IN
131,4' . 2�5?�(1 m 5� L^� AGORDANGEWITH THE c,=F-O PRACTICE P
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1 Suffolk County, New York
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TITLE SURVEY
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1 NO County Tax Map District 1000 S..tlo.22 Block 05 Lot 5.5
5 FIELD SURVEY COMPLETED JJLY 12,2016
- MAP PREPARED JULY Is,2016
1 Record of.Revisions
` RECORD OF REVI510N5 DATE
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'
o� Workers' CERTIFICATE OF INSl1 NCE COVERAGE
aTE Compensation V UNDER THE NYS DISABILITY BENEFITS LA
Board
PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
1a.Legal Name and Address of Insured(Use street address only) 16:Business Telephone Number of Insured
PATRICK'S POOLS INC 631-941-4113
1c.NYS Unemployment Insurance Employer Registration
Number of Insured
PO BOX 3024
EAST QUOGUE NY 11942 1d.Federal Employer Identification Number of insured
or Social Security Number
262929943
2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of insurance Carrier
(Entity being listed as the Certificate holder) ShelterPoint Life Insurance Company
Town of Southold
3b.Policy Number of Entity listed in box"1a":
54375 Main Rd PO Box 1179 DBL318565
Southold NY 11971 3c.Policy effective period:
05/13/2016 to 05/12/2017
4.Policy covers:
a. Me All of the employer's employees eligible under the New York Disability Benefits Law
b.® Only the following class or classes of the employer's employees:
Under penalty of perjury,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 8/9/2016 By UJI,fft
(Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier)
Telephone Number 516-829-8100 Title Chief Executive Officer
IMPORTANT:lf boa"49"Is checked,and this forst 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.a of the Disability Benefits Law.
It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305.
PART 2.To be completed by NYS Worker's Compensation Board(Only if box "4b"of Part 1 has been checked)
State of Nein York
Worker's Compensation Board
According to information maintained by the NYS Worker's Compensation Board,the above-named employer has compiled with the NYS
Disability Benefits Law with respect to all of hislhar 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.
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