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HomeMy WebLinkAbout41445-Z 1 �`uEEQt Town of Southold 8/20/2018 P.O.Box 1179 is 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39851 Date: 8/20/2018 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 5765 Bergen Ave,Mattituck SCTM#: 473889 Sec/Block/Lot: 113.-2-14 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/16/2017 pursuant to which Building Permit No. 41445 dated 3/21/2017 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: ACCESSORY IN-GROUND SWIMMING POOL, FENCED TO CODE,AS APPLIED FOR The certificate is issued to Dylan Levy of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 41445 06-27-2017 PLUMBERS CERTIFICATION DATED th d ignature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE o� • 4� 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#: 41445 Date: 3/21/2017 Permission is hereby granted to: deMasi, Richard 5765 Bergen Ave Mattituck, NY 11952 To: construct accessory in-ground swimming pool, fenced to code, as applied for. At premises located at: 5765 Bergen Ave, Mattituck SCTM # 473889 Sec/Block/Lot# 113.-2-14 Pursuant to application dated 3/16/2017 and approved by the Building Inspector. To expire on 9/20/2018. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 i Buil pector Form No.6 i TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board,of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial building, industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9,1957)non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00, dditions to dwelling$50.00, Iterations 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: V Old or Pre-existing Building: (check one) Location of Property:,5 `� G House No. Street Hamlet ,Owner or Owners of Property: (� lr1 u ,Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: ,Permit No. 14 N(C S Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: ✓ (check one) ,Fee Submitted: $ . SO )ajo, bx� pplicant Signature pF SO�j�®l Town Hall Annex Telephone(631)765-1802 54375 Main Road e� Fax(631)765-9502 P.O.Box 1179 �� roger.richert@town.southold.nv.us Southold,NY 11971-0959 ��COUNTY,� BUELDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Levy Address: 5765 Bergen Avenue City: Mattituck St: New York Zip: 11952 Building Permit#: 41445 Section: 113 Block 2 Lot:_ 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electric License No: 40557-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 Ceding 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 FixtureTime Clocks 1 Disconnect Switches 2 Twist Lock Exit Fixtures TVSS Other Equipment: In-ground Swimming Pool to Include; Bonding, Control Panel, 1- GFCI Circuit Breaker, Salt Generator, 1- Pool Light, Gas Pool Heater. Notes: Inspector Signature: Date: June 27, 2017 0-Cert Electrical Compliance FormAs OF SOUryo� Il� UOUNi'I Nc� 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: - - - ISOF SOUIy �o� olo # TOWN OF SOUTHOLD BUILDING DEPT. courm,��' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLSG. [ ] FOUNDATION 2ND [ ] I SULAT O [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: M kin PAZ DATE INSPECTOR I ` �pF SOUIH # # TOWN OF SOUTHOLD BUILDING DEPT. °ycourm a�' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULAT O �Q [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING _ REMARKS: _= = -®ATE-= - - - __- -= _ - =INSPECTOR= 19u --- — -- - FIELD INSPECTION REPORT DATE COMMENTS b t� FOUNDATION(1ST) j ------------------------------------ �� C FOUNDATION (2ND) z - � o � c9� � a ROUGH FRAMING& PLUMBING INSULATION PER N.Y-. STATE ENERGY CODE Rot- AV $ Y toAU/A4 5 FINAL RK=r ADDITIONAL COMMENTS b I), --7 ;q g983 e z m X NM G � t y y� r d t�J rd TOWN OI4SO017HOLD BUILDING PERMIT APPLICATION CHECKLIS' BUIIi'DING DEPARTMENT Do you have or need the following,before applying' TOWN HAT 4, _ ; Dwrd o,f Health TOWN IV, SOUTHO1LD,NY 11971 4 sets of Building Plans TEL �`(631) 765-1802 Planning Board approval FAX:,!(631) 765-9502 Surve SoutholdTown.NorthForkxet PERMIT NO. Check- Septic, heckSeptic Form N.Y.S.D.E.C. Trustees Flood Permit Examined ' '2-04 Storm-Water Assessment Form Contact: /j Approved ,20� ail to: U� Disapproved a/c T�� Phone: Ex iration ,20 I �� p a; D V B g ctor v .SIS I M'Io.rL8. CC7'�-v-. D ?LICATION FOR ZUILIING PERMIT MAR -,S"2017 05 DateMar-c , 201 BUILDING DEPT. INSTRUCTIONS TTis N OF S® 'a. is application e 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 4,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 app canto name, a corporation) (Mailing address of app ican)t State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises a (As on thi tax roll or latest deed) If applicant is a corporation, signature of duly authorized offs er (Name and title of corporate officer) Builders License No. " Plumbers License No. Electricians License No. Other,Ti•ade's License No. 1. Loc6ti n.of _=d on ich roposed work will be one: House Number Street Hamlet 15Block Lot County Tax Map No. 1000 Section IV , 'l-.1 r X- T.T., T nt d 2. State existing us-, and occupancy of premises and intend d uge MT occupai c of p o oscd comiuctiou: 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 Work (Description) 4. Estimated Cost 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 r 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 NO 14.Names of Owner Wremisebs/)&V LP� Address Phone N �`�-o 4K,Name of Architec Address Phone NNamo of C�ntract ddress 4f? e 2 Phone Nob-E� 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland?iYES NO � * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY E 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____) being duly sworn, deposes and says that(s)he is the applicant P�m6o ,individual signing con act) above named, (S)He is the b Wrnu ,- (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 a EVE B MI�� NOTARY PUBLIC STATE Of NEW YORK Sworn to before me th' 0 SU�F0 COUNTY day of ` ,IC #01M 1 ` COMM.EXP. 2,o N tary Public ignature of Applicant ;;Scott A. Russell ST01 [ J SUPERVISOR l��l[A�I� (Gr]E1��1[]EIN D i SOUTHOLD TOWN HALL-P.O.Box 1179 BAR NO 0095 Main Road-SOUTHOLD,NEW YORK 11971' Town of Souu' To" ]DInn. soriTiloil) i CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT) DOES THIS PROJECT INVOLVE ANY OF THE ]FOLLOWING: Yes No (CHECK ALL THAT APPLY ❑ A. Clearing, grubbing, grading or stripping of land which, affects more than 5,000 square feet of ground surface., ❑ B. Excavation or filling involving more than 200 cubic yards of material [:]OIwithin any parcel or any contiguous area. C. Site preparation on slopes which exceed 10 feet vertical rise to ❑❑/ 100 feet of horizontal distance. D. Site preparation within 100 "feet of wetlands, beach, bluff or coastal erosion hazard area. ❑[ > 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. LZ If you answered NO to all of the questions above,"STOP!, Complete the Applicant section below with your Name, a Signature, Contact Information, Date & County Tag 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 1 and a completed Check List Form to,the Building Department wit7your Building Permit Application. M' T C. . . #: 1000 Datr. APPLICANT (Property Owner,Design Professional,Agent,Contractor,Oiher) S. District NAME —02 c5e tion Block Lot ****FOR BUILDING DEPART.MENT.U8E ONLY**** Contact Information.��' �� t j' ITd plm Number Reviewed By: — — — — — — — — — — — — — — — Date: - Pro ert Address/Location of Construction Work: — — — — — — — — — — — — — — — 1"57&5 Approved for processing Building Permit. Stormwater Management Control P1an:Not Required. ❑ Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 0f S0� Town Hall Annex Telephone(631)765-1802 54375 Main Road ,,aaxx(631)765-gg5Q2 P.O.Box 1179 � Q roger.rlchert LOWn.s0utt10 5 nv.us Southold,NY 11971-0959 �� BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION tEQUESTED BY: ,(`JVD po/,\ Nhr*c-j.o'C' Date: ',ompany Name: d C.®,n D IJP dame: icense No.: 7 N ►ddress: I�j - b A r Q 'il k,• 01 f w �w 'hone No.: (� IOBSITE INFORMATION: (*Indicates required information) Name: �- Address: 6- 22 zromv\ -v 11 Cross Street: Phone No.: -7 'ermit No.: 'ax-Map District: 1000 Section:�T� 2-) Block: Lot: Ll BRIEF DESCRIPTION OF WORK (Please Print Cle rly) G Please Circle All That Apply) Is job ready for inspection: nYESNO Rough in Final Do-you need a Temp Certificate: YES NO emp Information (if needed) Service Size: 1 Phase - 3Phase" 100 . 150 200 300 360 400 Other New,Service: 'Re-connscf Underground Number of Meters Change of Service Overhead ,dditional Information: PAYME T DUE WITH APPLICATION Sc Coll Die!" 0 11 1-1(t , w; R/\ on owe ASP AAAk cy / kA S-e, R\lt Omeo J v)� or- c e Cel n 82-Request for Inspection Form '"`e, C1 5-c? ✓/ 7 NEw "Workers' YORK CERTIFICATE �� STATE; 20darpd'" msati®n NYS WORKERS' COMPENSAT I DD COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Fence King of Rocky Point,Inc. - ���� ��� Dba Swim King Pools&Patios 631744-8100 • 471 Route 25A 'OWN of soumo )D i Rocky Point,NY 11778 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is Id.Federal Employer Identification Number of Insured o specifically limited to certain locations in New York State, i.e., a or Social Security Number Wrap-Up Policy) 113008276 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Twin City Fire Insurance Company 3b.Policy Number of entity listed in box"la" Town of Southold 12WEOJ2677 53095 Route 25 3c. Policy effective period P.O. Box 1179 09/01/2016 to 09/01/2017 Southold,NY 11971 3d. The Proprietor,Partners or Executive Officers are Pag LLJ included. (Only check box if all partners/officers included) Pag ? all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? YES NO This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect Please Note: Upon the cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. I' Approved by: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier) 1 - Approved by: 8/29/16 (Signature) (Date) Title: Authorized Representative ii, Telephone Number of authorized representative or licensed agent of insurance carrier: 631 324-1440 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT i 4&YIWorkers' CERTIFICATE OF INSURANCE COVERAGE I Compensation UNDER THE NYS DISABILITY BENEFITS LAW Board PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING POOLS&PATIOS 1c.NYS Unemployment Insurance Employer Registration Number of Insured 471 ROUTE 25A ROCKY POINT, NY 11778 1d.Federal Employer Identification Number of Insured or Social Security Number 113008276 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity listed in box"1a": 53095 Route 25; PO Box 1179 DBL37154 Southold NY 11971 3c.Policy effective period: 02/01/2017 to 01/31/2018 4.Policy covers: a. © All of the employer's employees eligible under the New York Disability Benefits Law b.F1 Only the following class or classes of the employer's employees: Under penalty of perjury,1 certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed 2/1/2017 B AW, hf Y (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer IMPORTANT:If box"4a"is checked,and this form is signed by the insurancecarrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305. PART 2.To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by the NYS Worker's Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By (Signature of NYS Worker's Compensation Board Employee) Telephone Number Title Please Note:Only insurance carriers licensed to write NYS Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (9-15) 47Y0RV_ Workers• CERTIFICATE OF INSURANCE COVERAGE E compensation, UNDER THE NYS DISABILITY BENEFITS LAW Boar 'PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured FENCE KING OF ROCKY POINT INC. DBA SWIM KING � POOLS&PATIOS 1c.NYS Unemployment Insurance Employer Registration Number of Insured 471 ROUTE 25A i, ROCKY POINT, NY 11778 1d.Federal Employer Identification Number of Insured or Social Security Number 113008276 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) ShelterPoint Life Insurance Company 'Town of Southold 3b.Policy Number of Entity listed in box"1a": 53095 Route 25; PO Box 1179 DBL37154 'Southold NY 11971 3c.Policy effective period: 02/01/2017 to 01/31/2018 4.Policy covers: a. © AII 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 2/1/2017 By Aho/ hf (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 I MPORTANT:If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305. PART 2.To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board According to information maintained by the NYS Worker's Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. 'Date Signed By (Signature of NYS Worker's Compensation Board Employee) 'Telephone Number Title Please Note:Only insurance carriers licensed to write NYS Disability Benefits insurance policies and NYS Licensed Insurance Agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (9-15) y SUFFOLK COUNTY DEPT OF LABOR, # t T LICENSING&CONSUMER AFFAIRS HOME IMPROVEMENT t° z CONTRACTOR � ! C E _, HAPM RANDY T RODECKER S _ This certifies that the �N" l FENCE KING OF ROCKY POINT INC DBA bearer is duly licensed by the County of Suffolk '.1412-H 06/01/1992 i commissb... Ex mnCNDUE 06/01/2018 ii _ • SURVEY OF CERTIFIED T0:DYLAN LEVY. ' GLOBAL SERVE TITLE AGENCY L 0 T 3 CITIZENS BANK N.A. MAP OF JOB NO. 2004-230 - ROSEWOOD ESTATES MAP N0.:5240 .' FILED:JANUARY 24, 1969 SITUA TE A T REVISIONS: ;���'`;�'�J�• "��-•�, �� ADD ADJ. WELLS/SAN. 6/04/2004 MATTITUCK REV. PROP. DWELL LOC. 6/18/04Id TOWN OF SOUTHOLD FOUNDATION LOC, 7/30/04 SUFFOLK COUNTY, NEW YORK. FINAL 11/17/04 REV.CER TS 4/29/05 Y S.C.T.M. DIST. 1000 SEC. 113 BLK. 02 LOT 14 REV. TOWN 5/17/05 UPDATE 6/9/05 UPDATE SURVEY:2/13/17 )r iilE�� , 20 10 0 20 40 60 80 100 120 140 160 180 PLOT PROPOSED POOL:2/15/17 SCALE: 1"=40' DATE.APRIL 8, 2004 LICENSE NO.j 050363 LOT AREA:20,502 SQ.FT. =0.471 ACRE HANDS ON SURVEYING CURRENT ZONING:R-40, � - 26 SILVER BROOK DRIVE !i N SETBACKS AS PER SS 280-124 FLANDERS, NEW YORK A e ALLOWABLE LOT COVERAGE.4,100 SQ.FT. =20% 11901 EXISTING LOT COVERAGE:2,267 SQ.FT. = 11.1% TEL:(631)-369-8312-FAX.'(631)-36918313 MARTIN D. HAND L.S !11 PROPOSED ADDITIONAL LOT COVERAGE:576 SQ.FT. COPIES OF THIS SURVEY MAP,EITHER PAPER OR ELECTRONIC,NOT BEARING THE LAND SURVEYORS INKED SEAL OR EMBOSSED SEAL SHALL NOT BE TOTAL PROPOSED LOT COVERAGE.2,843 SQ.FT. = 13.9% CONSIDERED TO BEA VALID COPYAND SHALL NOT BE USED FOR ANY PURPOSE. ly •i I •I LOT 4 FN.0.3S L O • 0.4 GUYWIRE O it rl LOT 5 ° '20"E 189.04' POST&RAIL FENCE N 8509 1 CON ET i Z Z Q POSTE'IL FENCE _ ---- �'�I N. STOCKADE ENCE ROW 0 CEDARS � FN. # ', n, * g 30.6 CONC.MON. p 5'S ROW O�CEDAR 0.TS cp 8'X12' a SET 0 4'E .a _ FRAME rn I PROPOSED SHED °° g G C W tV POOL PROPANE S01�B � r m - - -- - Nj =PE000 CK 620' -a _- - --pE CEAlCrr Z�� &RAIL 0. UN > T2 STORYE �, ` • POS 60.61 -` N 6 8 G) UN FRAM m WEUJNG 22.1' 60.6' I14 �pp z I W OHIM a _ _ rn pRDR O) o 40 O , WATER LINE — ... • ' 9 0 EpUIP, A COVEREDWATER METER I 0 FN.0.8'NIRE N o 55,0' . �z ';s 0.3W p ND MON. CD p11 SET I Ci p''3�-'' HEDGE I" UTILE 29 0.3'N RGCKWALL(GFN POLE 0 I m HEpGEOT )IES OT pN.• N oCON,,pL W Op N 0.4' e W J D FN.0.81N G u 0.7'E N ' V � CONC.MON RGQ 3E 0 N�T�S li - I I - EASEMENTANMRSUSSURFACE STRUCTURESRECORDEDOR UNREDORDEDARENOT GUARANTEED UNLESSPHYSICALLYEVIDENTAT THE - nMEOFSURVEY THEOFFSET(OR DIMENSIONS)SHOWN HEEONFROM THESTAUCTURES TO THE - PROPERTYUNESAREFORASFEOFX PURPOSEAND USEAND THEWORE ANENOTINTENDED TO GUIDE THE ERECTION OF FENCES,RETAINING WALES,POOLS PATIOS.PLATING AREAS,ADDITIONS TOOUI DINGS - ANDANYOTHER CONSiRUCT10N UNAUTHORIZED AL TERAXIMORADDITION TOTHISSURVEYIS AWOLATIONOF i SEO➢OF THENEW VORIf STATE mVCATIOcanonuw CORES OF/HISSVRVEVMAPNOi OEVUNG E EIANOSURMSHALINNEDEEAL OR ' EAlWA VALIEAL SHALLN07ltEWNSIOERED roeEa vauD nnEeoRv +� CERTIFICATIONS INDICATEDHERONSHALL RUN I ONLY TO THE PERSON fORWHOM THEEVRVEY IS PREPARED ONHIS IU]IALf 70 THE nnECOMPANY GOVERNMENTAL AGENCYAND LENDING INSTITUTION LISTED HEREON,AND TO TNEASSIGNEES OF THE LENDING INSn TUnON CERRFICAnONSARENOTTRANSFERAELE - TOADDITIONA WSTITUTIONSORSUSSEDUENT OWNERS 3 A aAPIPRVED AS NOTED RETAIN STORM WATER RUNOFF DATEB.P.# S� PURSUANT TO CHAPTER 236 OF THE TOWN CODE. FEE: BY: NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: ELECTRICAL 1. FOUNDATION - TWO REQUIRED INSPECTION REQUIRED FCR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTR!)CTIC'N NIUST BE COMPLETE Frl't "'.*.0. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR IWIMEDIATELY, DESIGN OR CONSTRUCTION ERRORS. `ENCLOd 1 &SE OOL TO CODE °UP, OMPLETION '*ORE"WATER,. COMPLY WITH ALL CODES OF NEW YORK STATE TOJ fn'N CODES AS REOUIRED \NP OITIONS OF h(1 'TJ^ rruni�n SoUTh'"!r 7^�V l V'ry 5 N.Y.S OCCUPANCY OR USE IS UNLAW-FOL WITHOUT CERTIFICATE OF OCCUPANCY 36' NOTES O_ 1 NO SPOILSURCHARGE PERMITTED WITHIN 4 FEETOF EXCAVATION ATTHE SHALLOW END,OR 6 FEETOF EXCAVATION ATTHE DEEP E 2. THIS POOL MEETS THE REQUIREMENTS OFANSI/N5PI-5 'AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMIN D 320 V POOLS"AND 1996 BOCA CODE-SECTION 421. DIVING EQUIPMENT IS NOTALLOWED }� A 3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY SURROUNDED WITHABARRIERCONSTRUCTEDIAWREQUIREMENTSO 2017 s H20 - SECTION AND IN CONFORMITY WITH ALL SECTIONS OF THE TOWN CODE ACCE55 GATES SHALL COMPLY WITH SECTION R326.5.2 OF THE IRC AND BE SELF CLOSING,SELF LATCHING AND BESECVRELY LOCKED WHEN POOL IS NOT IN USEORSUPERVISED ALL GATES ARE TO OPEN AWAY FROM THE POOL AREA. O a } 4. DURING CONSTRUCTION THE CONTRACTOR SHALL ERECTA TEMPORARY BARRIERAROVND THE EXCAVATION LAW THE CODE OF THE TOWN OF SOUTHOLD. B ��T�Ef1 D 1 5, POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING CHILD ENTERING THE WATER AND SOUNDING TO N�o* H AN AUDIBLE ALARM WHEN DETECTED THAT IS AUDIBLE AT LOCATION ON THE PREMISES WHERE THE POOL A v'0 cONC WALLS IS LOCATED. THE ALARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTVRERS INSTRUCTIONS. d THE ALARM MUSTMEETA5TMF2208 'STAN PARD SPEOFICATIONFOP,POOL ALARMS. THE DEVICE MUSTOPERATE INDEPENDENT(NOT B ATTACHED TO ORDEPENDENTON)OFPERSONS V-1 oL 6. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO ASME/AN51 PLAN A11219.8M ORA MINIMUM 18"x 23"DRAIN GRATE ORA CHANNEL DRAIN SYSTEM POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH ATMOSPHERIC VACUUM RELIEF IN THE EVENTTHE GRATE COVERS LOCATED WITHIN THE POOL BECOME MISSING OR BROKEN SUCH VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME A112.19.17 OR BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD. POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE THE SUCTION FITTINGS SHALL BE SEPARATED BY MINIMUM OF 3'AND MUST BE PIPED SUCH THAT WATER IS DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE N a POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENTTOON THE SKIMMER/SKIMMERS ` } 2'fo 4'SAND BOTTOM 7. ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLY ARTICLE 680 AND THE IRC SECTIONSZ 4201 THROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BYA V u GROUNDFAULT CURRENT INTERRUPTER(GFCI) CURRENT CARRYI NG ELECTRICAL CONDUCTORS EXCEPT FOP,THOSE PROVI DING POWER TO POOL LIGHT]NGAND POOL EQUIPMENT SHALL MEET THE SEPARATIONREQUI REMENTS OF TABLE E4203 5.ALLMETALENCLOSURES, -� SECTION A FENCESOP RAI UNGS NEAR OR AWACENT TO THE SWIMMING POOL THAT MAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT v, WITHANELECTRICALCIRCUITSHALLBEEFFECTIVELY GROUNDED. p QJ TOP OF WALL WATER LINE 4' c/_ B. WATERSOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NYS PLUMBING CODE 608 0I 4' e' 4' 9. ALL PIPING 15 DIAGRAMMATIC UNLESS OTHERWISE STATED. Q) `v qj m S m 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE a 0 11 A MEANS OF EGRESS FOR DEEP AND SHALLOW ENDS MUST BE PROVIDED IAW ANSI/N5PI-5 SECTION 6. n. a ~ In 12. CONTRACTOR TO PLACE THE POOL LAW TOWN OF SOUTHOLD CODE SETBACKS. SECTION B 13 ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. b N 15. THE DESIGN IS BASED ON A DRAINAGE SOIL WITH<101,SILT. GROUND WATER SHALL NOT EX15T WITHIN THE EXCAVATION. IFGROVND WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED. M '16. ALL GAS AND OIL HEATERS(IF INSTALLED)FORTH E INGROUND SWIMMING POOL SHALL BE NA71ONAL APPLIANCE EN ERGY CONSERVATION ACT(NAECA)COMPLIANT POOL HEATERS SHALL BE TESTED IAW ANSI 22156 AND SHALL BE INSTALLED LAW MANUFACTURERS SPECIFICATIONS OIL FIRED POOL HEATERS SHALL BE TESTED LAW UL726. POOL HEATERS SHALL BE LOCATED OR U CHECK VALVE 2,2, GVARDED TO PROTECT AGA I NST ACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS, POOL HEATERS SHALL BE PROVIDED WITH TEMPERATURE AND PRESSURE-RELIEF VALVES, FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPASS SYSTEM A BYPA55 LINE SHALL PUMP FROMSKIMMER COPING AND WALKWAY 10" BE INSTALLED FROM INLET TO OUTLET TO ADIUST WATER FLOW THROUGH THE HEATER POOL HEATERS SHALL BE PROVIDED WITH THE (BY OTHERS) FOLLOWING ENERGY CONSERVATION MEASURES, y WATER LINE GRADE z a e 16.1 AT LEAST ONE THERMOSTAT SHALL BE PROVIDED FOR EACH HEATING SYSTEM. 16.2 ALL POOL HEATERS SHALL BE EQUIPPED WITH AN ON-OFF SWITCH MOUNTED FOR EASY ACCESS TO ALLOW SHUTTING OFF THE iO DISPOSAL/ VNDISNRBEDEARTH ,.4 OPERATION OF THE HEATER WITHOUTADJLISTING THE THERMOSTATSETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE � Q�mm DRYWELL • PILOTLIGHT, aQ 3500 PSI POVRED CONC .4; 16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THI5 REQUI REM ENT A RE OUTDOOR POOLS 3/8'REBAP 2)TYP a DERIVING 20%OFTHE ENERGY FOR HEATING FROM RENEWABLE SOURCESAS COMPUTED OVERAN OPERATINGSEASON) Z n h $ DIVERTER ''• " 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SETTO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BESET A E c VALVE O VINYLLINER� •,• TO RUN THE MINIMUM TIME NECESSARY TO MAINTAIN THE POOL WATER INA CLEAN AND SANITARY CONDITION LAWAPPLICABLE z = C m m Ca) 2'TO 4'SAND SANITARYCODEOF NEWYORKSTATE. W co oCD co w y y N x u FILTER �' �•'`` 17, THIS DRAWING IS FOR STRUCTURAL SHELL ONLY, ALL ACCESSORIES AND APPURTENANCES ARE DEFINEDBYOTHERS. r'" 0E-ti / W a 18 BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS DO NOTALLOW THE HEIGHTOF BACKFILL TO EXCEED THE HEIGHTOF THE (� WATER IN THE POOL BY MORE THAN 8, OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" OF N EDW 1 VERTICAL 'REBAR®3'0C SHOW (NOT SHOWN) 19. PLACE CONCRETE ON SANDY TO LOAM SOIL REMOVE ANY CLAY DEPOSITAND COMPACT CLEAN BACKFILL F 21. THERE 15 NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY. THI5 MEETS REQUIREMENTS OF THE IRC-SECTION R326.6 FOR ENTRAPMENT PROTECTION. WALL SECTION w TO RETURNS 22, THE POOL WAS DESIGNED LAW THE FOLLOWING a1 g W NTS CHECK VALVE 22.1 THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER 42(2016) 22.2. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R403.10(2015) 223 THE INTERNATIONAL FUEL GAS CODE(2015) O aq�5 22,4. THE NEW YORK STATE CODE SUPPLEMENT-SECTION R326 (2016) e 22.5. THE N EW YORK STATE SANITARY CODE, 22.6, ANSI/NSPI-S STANDARD FOR RESIDENTIAL IN-GROUND SWIMMING POOLS ��pROFESS\O- PLUMBING SCHEMATIC 22.7. BOCA CODE-SECTION 421. 228. CODE OF THE TOWN OFSOUTHOLD. N T5 23, ALL BACKWASH TO BE SELF-CONTAINED ON-51TE.