HomeMy WebLinkAbout41207-Z 11�..
Ff04ea Town of Southold 9/24/2018
P.O.Box 1179
a -
d' ? 53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39912 Date: 9/24/2018
THIS CERTIFIES that the building IN GROUND POOL
Location of Property: 12555 New Suffolk Ave., Cutchogue
SCTM#: 473889 Sec/Block/Lot: 116.-2-13
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
11/30/2016 pursuant to which Building Permit No. 41207 dated 12/7/2016
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 Fitzgerald, Shawn
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 41207 06-07-2017
PLUMBERS CERTIFICATION DATED
t o e Signature
Su�Fnt,r�� TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
oy,• �� 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#: 41207 Date: 12/7/2016
Permission is hereby granted to:
Fitzgerald, Shawn
12555 New Suffolk Ave
Cutchogue, NY 11935
To: Inground Swimming Pool as Applied for
At premises located at:
12555 New Suffolk Ave., Cutchogue
SCTM #473889
Sec/Block/Lot# 116.-2-13
Pursuant to application dated 11/30/2016 and approved by the Building Inspector.
To expire on 6/8/2018.
Fees:
SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00
CO - SWIMMING POOL $50.00
5a . $300.00
Building Ins ctor
Form Ne.6
TOWN OFSOUTHOLD
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 ne,.v building or nseiv-use:
1. Final survey of property with acct rate-location of all buildings,property lines,streets,and unusual natural or
topographic features_
2. Final Approval from Health DepL of water supply and sewerage-disposal(S-9 form).
3- Approval of electrical installation from Board of Fire Underwriters.
d. '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 Compliafice 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)6011-conforming uses,or buildings and"'pre--existing"land uses:
I. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic
features.
2_ A properly cpmpletecl 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. Certificaie 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. Cbrtifieate of Occupancy on Preexisting 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.
Slew Construction: Old or P XIS WE Building: ' (check one)
!A=60111of[property: 1 O� S� u
Housd No. Street
amle -
?®vner of Owners of Property: l ax"4)n - �
;uffolk County Tax Map No"1000,Section Block Lot
►ubdiivision filed Map. Lot:
'etmit No. 4(a 01 Date of Permit.
. Applicant:
kdth Dept.Approval: Underwriter's Approval:
'tanning Board Approval:
request for: Temporary Certificate Final Certificate: (check one)-
cc Submitted: $ Ju
Applicant Sienat re
pF SOU�yol
0
Town Hall Annex Telephone(631)765-1802
54375 Main Road cn Fax(631)765-9502
P.O.Box 1179 aQ roper.riche rt(a-town.southold.ny.us
Southold,NY 11971-0959 �QIyCOWN'��
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Fitzgerald
Address: 12555 New Suffolk Avenue City: Cutchogue St: New York Zip: 11935
Building Permit#: 41207 Section: 116 Block: 2 Lot: 13
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 Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors
Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks 1
Disconnect Switches 2 Twist Lock Exit Fixtures TVSS
Other Equipment: In-ground Swimming Pool to Include; Bonding, Control Panel, 1- Pool Light,
1- GFCI Circuit Breaker, Salt Generator.
Notes:
Inspector Signature: Date: June 7, 2017
0-Cert Electrical Compliance Form.xls
OF SOUlyo�
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
- INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING / STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL)
REMARKS:
DATE -7 // 7 INSPECTORTV
J
�o��OE SOUIyo�
# * TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PL13G.
[ ] FOUNDATION 2ND [ ] SULAT ON
FRAMING /STRAPPING FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] CAULKING
REMARKS:
40
DATEINSPECTOR VA4---1
FIELD INSPECTION REPORT DATE COMMENTS = `
FOUNDATION(1ST) O
--------------------------------------
FOUNDATION (2ND)
N O
ROUGH FRAMING& y
PLUMBING
INSULATION PER N.Y.
Is
'STATE ENERGY CODE
G
FINAL
ADDITIONAL COMMENTS
N
Ql-
rn
O
Z
C
H
TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALLBoard of Health
k
SOUTHOLD,NY 11971 4 sets of Building Plans
TEL:(631)765-1802 Planning Board approval
FAX:(631)765-9502 2p LZ Survey
SoutholdTown.NorthFork.net PERMIT NO. Check
Septic Form
`1 D N.Y.S D.E C.
D
Y Trustees
Flood Permit
Examined 20 Storm-Water Assessment Form( Z--h /�
/ NOV 3 0 2016 Contact: -S01 / /��LS
Approved 20� `� Mail to.
r r l F/��
Disapproved a/c
UMDING DEPT. Phone
Expiration 20G OF SOUTHOLD
K�L
Building Inspector
APPLICATION FOR BUILDING PERMIT j
Date V� �D 20
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 olitio a erein described.The
applicant agrees to comply with all applicable laws,ordinances,building code,housi c ations,and to admit
authorized inspectors on premises and in building for necessary inspections.
' (Si lure of ppl ant or name,if a corporation)
I�� P U
(Marling address of app scant)
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Name of owner of premises
(As on the tax roll or latest deed
If applicant is a corporation,signature of duly authorized officer
(Name and title of corporate officer)
Builders License Na M
Plumbers License No.
Electricians License No.
Other Trade's License No.. I I I,,
1. Lo� on r po d wo ill be 1 �j�— A,1� ck&,,�,rek W'—
House umber Street Hamlet
County Tax Map No. 1000 Section Block 1:;0-1 Lot
Subdivision Filed Map No. Lot
i
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 �-y'Removal Demolition Other Work
of
4. Estimated Cost y V Fee (Description)
(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 W
9. Size of lot:Front ��J Rear V U� Depth '7 V
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_NOXIv-
ill excess fill be removed from premises?YES_NO-
14.Names of Owner of a 'ses jf Co� r bA`" �- - Iione No
Name of Architect �: r horreNo 1
Name of Contractor Address Phone No.
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 If REQUIRED.
b.Is this property within 300 feet of a tidal wetland?*YES NO
O
*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
T, bg4duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract ab ve 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.
S om to before me this SON 'NER
�p day of :XATEW NEW YORK
SUFFOLK COUNTY
Notary I ublic uC,i9 ' Signature Jf Applicant
COMM.EXP. 1112 T
Scott A. Russell 0SuIFQ',r ST 01k1\\\A1WA\,T]E]k1.
SUPERVISOR
MAN A\G]EM]E"N'7C'
SOUTHOLD TOWN HALL-P.O.Box 1179 p
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
01 �
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
�— DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING:
Y No (CHECK ALL THAT APPLY)
❑ . Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
Il ❑ B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑ C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
RD. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
EIRE. Site preparation within the one-hundred-year f loodplain as depicted
i on FIRM Map of any watercourse.
EIM'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 witE—your Building Permit Application.
If I!I APPLICANT (Property Owner.Design
sign Prof »oal nt Contracto Other) S.C.T�.'M-.-+."J#: 1000
t Date-
(Properly
NAME: U
fl -30]
Sectiiorn
Block Lot
ii ***FOR BUILDING PARTMENT USE ONLY`
�I Contact i formation �'
�1 Number)
— — — — — — —
— — — — — — — — Reviewed By:
Date:
Property Address/Lckation of Construction Work: _ _ _ _ _ _ _ _ _
Approved for processing Building Permit.
— — Stormwater Management Control Plan Not Required.
— — — — — — — — — —
Stormwater Management Control Plan is Required_
(Forward to Engineering Department for Review.)
I
FORM # SMCP-TOS MAY 2014
oT-sa�ryo
Town Hall Annex 41 Telephone(631)765-1802
54375 Main Road ,ax(631)765-gg5Q2,
P.O.Box 1179 0 roger.richert(a{�o`wn.soutlloltl.ny.us
Southold,NY 11971-0959
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
APPLICATION FOR ELECTRICAL INSPECTION
tEQUESTED BY: W6f-At\0t/0 mArr-loc-,L Date:
',ompany Name: �� �,c ® ' � i� L_t
Jame: 1 �Nmc
.icense No.: 01 �'-1 -N NA t--'
►ddress: V"7"7 I— J n 6 o 1
'hone No.:
IOBSITE- INFORMATION: (*Indicates required information)
Name: FI TZG ETZ/11-L-t>
Address: N-ew y-e o
Cross Street: I.oN
Phone No.:
'ermit No.: -Z®
ax-Map District: 1000 Section: Block: Lot:
BRIEF DESCRIPTION OF WORK (Please Print Clearly)
<jWji^AAd �1,60f
Please Circle All That Apply)
Is job ready for inspection: YES NO Rough in Final
Do-you need a Temp Certificate: YES NQ:�
'emp Information (if needed)
Service Size: 1 Phase 3Phase 100 150 200 300 QX400=� =-,Oth2r,� ;
9St
New Service: Re-connect, Underground Number of Meters Chan 'eof Service Over ad
Aditional In€ormation: PAYMENT DUE WITH APPLICAfi
�� �r 0t- Oft( W& A^ AC"C+1 �F.,����. rx-71 Y6, l
82-Request for Inspection Form (&C,0 C) J�
544�
LOT AREA = 15,000 SQ. FT.
NOW OR FORMERLY POLECKI
S 76'58'20"E 100.00'
fonts FC FC4.3'E
0.9N chain Itnk fence 0.1?J
x\0 4TI metal fence FD
c� MON
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UI
FR ex O
GAR
0
m
26.2' Ex Lr)
LLQ IJ v fie
J 1 Cx P{t x
1 E I slate
patstio q
1 x
x
W , (6ts.o' o
44.7' 11.4' 9.3' x
31'E
1 1/2 STY
DO FR N
O3 N DWELL
W O
?� p 25.8' 13.9' 15.4—, d-
Z O I / r000vered O
stoop
l N (n
z L6
l �
1 N 76'58'20"W 100.00'
75� NEW SUFFOLK AVENUE
THE OFFSETS (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES To THE
PROPERTY UNES ARE FOR A SPECIFIC wRPOW AND USE AND THOOZORE AIS NOT JOB No. 16-182 FILE No. 747 F
INTENDED TO GUIDE THE ERECTION OF FEKOE:S, RETAINWG WALLS, POOLS, PATIOS,
PLANTING AREAS,ADDITION To BURDINGB OR ANY OTHER CONSTRUCTION. SURVEYED FOR SHAWN & NICOLE FlTZGERALD
UNAUTHORIZED ALTERATION;OR ADDITION TO 7M SURVEY IS A VIOLATION OF SECTION
7209 OF THE NEW YORK STATE EDUCATION LAW.
GUARANTEES INDICATED HEREON SHALL RUN ONLY To THE PERSON FOR WHOM THE
SURVEY IS PREPARED. AND ON HIS SEHAIF TO THE unE COMPANY, GOVERNMENTAL SITUATED AT CUTCHOGUE
AGENCY AND LOOM INSTITUTION USIED HEREON.AND TO THE ASSIGNEES OF THE
LENDING INSTITUTION. GUARANTEES ARE NOT tRANSIFEIRAM.E TO ADDITIONAL wsRnmONS TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y.
OR SUDSEQUENT OWNERS.
COPIES OF THIS SURVEY MAP NOT D SURVEYOR'S INKED SEAL OR SCALE 1" = 30' DATE 8-3-2016
EMS SEAL SHALL NOT AUD TRUE COPY. FILED MAP No. DATE
CERTIFIED 0 ®t.TRAdbp/0�'¢ TAX MAP No.(REF ONLY) 1000-116-2-13 DISK 2016
HAROLD F. TRANCHON JR. P.C.
LAND SURVEYOR
Pio 4109$ P.O. BOX 616
�q. 0489 � 1866 WADING RIVER—MANOR RD. WADING RIVER,
LAND S%3 NEW YORK, 11792
HAROLD F. TRA NCH N.Y. LIC. No. 048992 631-929-4695
PENN. LIC. No. 2115—E
Y° Workers' CERTIFICATE OF INSURANCE COVERAGE
STATE Compensatleft
Board 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
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) ShelterPolrtt Life Insurance Company
3b.Policy Number of Entity listed in box"1a":
Town of Southold
P.O. Box 1179 DBL37154
53095 Route 25 3c.Policy effective period:
Southold, NY 11971
02/01/2016 to 01/31/2017
4.Policy covers:
a. ® All of the employer's employees eligible under the New York Disability Benefits Law
b.FJ Only the following class or classes of the employer's employees
Under penalty of perjury,I certify that 1 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 ab
ove.
MAODate Signed 2/4/2016 By
(Signature of Insurance carriers authorized representative or NYS Licensed Insurance Agent of that Insurance carrier)
Telephone Number 516-829-8100 Title Chief Executive Officer
rriers a
IMPORTANT:If box"4a'Is checked,and this form Is signed by the Insurance cauthorized representative or NYS Licensed Insurance Agent
of that carrier,this certificate Is COMPLETE.Mall It directly to the certificate holder.
If box"4b"Is chocked,this certificate Is NOT COMPLETE for the purposes of Seddon 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,W 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 Workers Compensation Board,the above-named employer has compiled with the NYS
Disability Benefits Law with respect to all of hlsiher 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.
1313-120.1 (9-15)
YORK '
Workers
ATE Compensation CERTIFICATE OF
Board NYS WORKERS' COMPENSATION INSURANCE
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
Rocky Point,NY 11778 lc.NYS Unemployment Insurance Employer
Registration Number of Insured
Work Location of Insured (Only required if coverage is ld.Federal Employer Identification Number of Insured
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
Town of Southold 3b.Policy Number of entity listed in box G°la',
12 W EOJ2677
53095 Route 25 NY 11971 3c. Policy effective period
Southold,NY
P.O.Box 1 09/01/2016 to 09/01/2017
3d. The Proprietor,Partners or Executive Officers are
Tag
included. (Only check box if all partners/officers included)
Pag
1 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 "l a" 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.
Approved by: Leonard Scioscia
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by:
(Signature) 8/29/16(Date)
Title: Authorized Representative
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
APPROVED AS NOTED
DATE:
FEE: n BY:
NUTIF BUILDING DEPA AT
765-1802 8 AM TO 4 PM FOR'THEA
FOLLOWING INSPECTIONS:,
!. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE � �
2. ROUGH - FRAMING &,PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION, MUST
BE COMPLETE FOR C.O. wA��RRVNOFF
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW *1 MIA S�0 J HpNvlYORK R 236
DESIGN ORECOOSTRUCT ON NT TERRORS. p�RBLE FOR HE1owN cot'-
0�j
COif';P I_"Y °s�`�1�� d-i r�L� CODES OF ;. N ose MpLE���N
NEW `FOR K ST�',-t �E TOWN CODES E ��ra c
U� ; W
AS REQUIRED A S.OF =3
SOLEHOLD TOWMA
50yp4a-B- t�BEARD
SOIL ! TRUSTEES
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
• ' 12
WATER LINE NOTES
38' it
tV
e
1 NO 5POILSVRCHARGE PERMITTED WITHIN 4 FEET OF EXCAVATION ATTHE SHALLOW END,OR 6 FEET OF EXCAVATION AT THE DEEP END to
0 2. THIS POOL MEETS THE REQUIREMENTS OFANSI/NSPI-5 "AMERICAN NATIONAL STANDARD FOR RESIDENTIAL INGROUND SWIMMING
MIN, DIM.5ECTION A POO LS'AND 1996 BOCA CODE-SECTION 421 DIVING EQVIPM ENT 15 NOTALLOWED. {-
3. SWIMMING POOL SHALL BE COMPLETELY AND CONTINUOUSLY 5URROUNDED WITH A BARRIER CONSTRUCTED LAW REQUIREMENTS OF Q_
A 15 SECTION R326 5.3 OF THE INTERNATIONAL RESIDENTIAL CODE(2016)AND IN CONFORMITY WITH ALL SECTIONS OF THE SOUTHOLD
WATERLINE TOWNCODE ACCE55GATE5SHALLCOMPLYWITHSECTIONR326.52OFTHEIRCANDBESELFCLOSING,SELFLATCH]NCANDBESECVRELY °�
LOCKED WH EN POOL 15 NOT IN USE OR SUPERVISED. ALL GATES ARE TO OPEN AWAY FROM TH E POOL AREA. (co
zo 3'-6` O g-200'
i a 4 DURING CONSTRUCTION TH E CONTRACTOR SHALL ERECTA TEMPORARY BARRIER AROVN D THE EXCAVATION LAW TH E CODE OF TH E O
TOWN OF SOUTHOLD O �c
d �O
5, POOL MUST BE EQUIPPED WITH AN APPROVED POOL ALARM CAPABLE OF DETECTING A CHILD ENTERING THE WATER AND SOUNDING V
ti IAN AUDIBLE ALARM WHEN DETECTED THAT I5 AUDIBLE AT POOLSIDEANDATANOTHER LOCATION ON THE PREMISES WHERE THE POOL
3,y,
IS LOCATED, THEAIARM MUST BE INSTALLED,MAINTAINED AND USED IN ACCORDANCE WITH THE MANUFACTURERS INSTRUCTIONS Q Z
6- " THE ALARM MUSTMEETASTMF2208 "STANDARD5PECIFICATION FORPOOLALARM5. THE DEVICEMVSTOPERATEINDEPENDENTCNOT N
�— ATTACHED TO OR DEPENDENTON)OF PERSONS •41 0
CONC WALLS MIN. DIM. SECTION 3°'
B B 6. POOL SUCTION FITTINGS(EXCEPT FOR SURFACE SKIMMERS)MUST BE PROVIDED WITH A COVER THAT CONFORMS TO A5ME/AN51 0�>'
A11219.81A ORA MINIMUM 18'•x 23"DRAIN GRATE OR A CHANNEL DRAIN SYSTEM. POOL CIRCULATION SYSTEM MUST BE EQUIPPED WITH
12• ATM05PHERIC VACUUM RELIEF IN THE EVENT THE GRATE COVERS LOCATED WITHIN THE POOL BECOMEM155ING OR BROKEN SUCH 'zt
WATER LINE VACUUM RELIEF SYSTEMS SHALL CONFORM WITH ASME A11219.17 OR BEA GRAVITY SYSTEM APPROVED BY THE TOWN OF SOUTHOLD
PLAN POOL SHALL BE PROVIDED WITH A MINIMUM OF 2 SUCTION FITTINGS OF THE ABOVE MENTIONED TYPE THE5UCTIONFITTING5SHALL BE
SEPARATED BY MINIMUM OF3'AND MUST BE PIPED SUCH THAT WATER 15 DRAWN THROUGH THEM SIMULTANEOUSLY THROUGH A
VACUUM RELIEF-PROTECTED LINE TO THE PUMP(OR PUMPS) VACUUM/PRESSURE CLEANING FITTINGS SHALL BE IN AN ACCESSIBLE
POSITION,MINIMUM OF 6"AND NO GREATER THAN 12"BELOW THE MINIMUM OPERATIONAL WATER LEVEL OR BEAN ATTACHMENT TO b
THE 5KIMMER/SKIMMER5. °J
M MIN, DIM.SECTION /`\ 7, ALL ELECTRICAL WORK SHALL COMPLY WITH THE REQUIREMENTS OF NFPA 70(NEC)PRINCIPALLYARTICLE680AND THE IRC SECTIONS Z
4201 TH ROUGH 4206 ALL ELECTRICAL DEVICES MUST BE APPROVED BY UNDERWRITERS LABORATORIES AND BE PROTECTED BY A
GROUND FAULTCURRENT INTERRUPTER(GFCU CURRENT CARRYING ELECTRICAL CON DVCTOR5 EXCEPT FOR THOSE PROVIDING POWER V
2'to 4'SANDBOTTOM v 2_2• TO POOL LIGHTING AND POOL EQUIPMENT SHALL MEETTH E SEPARATION REQUIREMENTS OF TABLE E4203.5 ALL METAL ENCLOSURES, ��
FENCES OR RAILINGS N FAR OR ADJACENT TO THE SWIMMING POOL THATMAY BECOME ELECTRICALLY CHARGED DUE TO CONTACT
COPINGAND WALKWAY --tT ,-
(BY
(BY OTH ERS) 10° WITH AN ELECTRICAL CIRCVITSHALL BE EFFECTIVELYGROUNDED N
V
SECTION A WATERLINE GRADE 8 WATER SOURCE FILLING THE POOL SHALL BE EQUIPPED WITH A BACKFLOW PROTECTION DEVICE LAW NYS PLUMBING CODE 608
a
TOP OF WALL WATERLINE '-•• •
uNDI_RBED EARTH ` 9, ALL PIPING IS DIAGRAMMATIC UNLESS OTHERWISE STATED
i O
3500 P51 POURED CONC d' - 10. WALKS IF PROVIDED SHALL BE NONSLIP AND SLOPE AWAY FROM POOL EDGE. p j
fy 4' 10' 4' • iv O
w 3!8'REBAR 2)NP w 11. A MEANS OF EGRESS FOR DEED AND SHALLOW ENDS MUST BE PROVIDED LAW AN51/NSPI-5 SECTION 6, a' -N
4 �o
i VINYL LINER
a 12. CONTRACTOR TO PLACE THE POOL LAW TOWN OF SOUTHOLD CODE SETBACKS Ln
2'TO4'SAND� a _
13, ALL DRAINAGE FROM THE POOL SHALL BE MAINTAINED ON THE SUBJECT PROPERTY. a d - r
15. THE DESIGN 15 BASED ON A DRAINAGE 5011.WITH(105 SILT, GROUND WATER SHALL NOT EXIST WITHIN THE EXCAVATION. IF GROUND o
SECTION B WATER EXISTS WITHIN 6'-0"FROM GRADE,DEWATERING FACILITIES WILL BE REQUIRED, S
VERTICA1.3/6'REBARO)YOC. 16. ALL GAS AND OIL H EATERS(IF INSTALLED)FORTH E INGROUND SWIMMING POOL SHALL BE NATIONAL APPLIANCE ENERGY
(NOTSHOWN) CONSERVATION ACT(NAECA)COMPLIANT. POOL HEATERS SHALL BE TESTED IAW AN51221.56 AND SHALL BE INSTALLED LAW
MANUFACTURERS SPECIFICATIONS OIL FIRED POOL HEATERS SHALL BE TESTED IAW VL726. POOL HEATERS SHALL BE LOCATED OR
GUARDED TO PROTECTAGAINSTACCIDENTAL CONTACT OF HOT SURFACES BY PERSONS POOL HEATERS SHALL BE PROVIDED WITH
WALL SECTION TEMPERATVREAND PRE55URE-RELIEF VALVES. FOR HEATERS NOT PROVIDED WITH AN INTEGRAL BYPA555YSTEM A BYPA55 LINE SHALL
BE INSTALLED FROM INLETTO OUTLETTOADIVST WATER FLOW THROUGH THE HEATER, POOL HEATERS SHALL BE PROVIDED WITH THE U
CHECK VALVE MT,S FOLLOWING ENERGY CONSERVATION MEASURES: Fl.l
PvMP FROM SKIMMER 16,1 AT LEAST ONE THERM05TAT5HALLBEPROVIDED FOP,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 (7
OPERATION OF THE H EATER WITHOVTAPJUSTING THE TH ERMO5TAT5ETTING AND TO ALLOW RESTARTING WITHOUT RELIGHTING THE z
PILOT LIGHT. �+
16.3 HEATED SWIMMING POOLS SHALL BE EQUIPPED WITH A POOL COVER(EXEMPTED FROM THI5 REQVIREMENTAREOUTDOOR POOLS �+
DERIVING 20%OF TH E ENERGY FOP,H EATING FROM REN EWABLE SOURCES AS COMPUTED OVEP AN OPERATING SEASON) W >I� d
ro DI 16.4 TIME CLOCKS SHALL BE INSTALLED 50 THE PUMP CAN BE SET TO RUN DURING OFF-PEAK ELECTRICAL DEMAND PERIODS AND CAN BE SET !d I Q co a
DRY, L TO RUN THE MINIMUM TIME NECE55ARYTO MAINTAIN THE POOL WATER INA CLEAN AND SAN ITARY CON DITION IAW APPLICABLE
e'
SAN ITARY COPE OF NEW YORK STATE Z Y CD CID
C73Rimmo
VALVE R O •� 20'WHITERUBBER 17 THIS DRAWING IS FOR STRUCTURAL ALLACCFSSORIESANDAPPVRTENANCESAREDEFINEDBYOTHERS Z 2 0�`" d
FULCRUM PAD W ^ C om...v g
5TNSTLTUBE 18 BACKFILL WITH CLEAN EARTH,FREE OF ROOTS AND DEBRIS DO NOTALLOW THE HEIGHTOF BACKFILL TO EXCEED THE HEIGHTOFTHE N o_ R G
FILTER ROpSrypNF W/MIRROR FlNISH COPING@PATIO WATER IN THE POOL BY MORE THAN 8", OR THE WATER TO EXCEED BACKFILL BY MORE THAN 8" F Iy
CONC SLAB DONE BY OTHERS I w a
(awiDEMIN> 19. PLACE CONCRETE ON SANDY TO LOAM SOIL. REMOVE ANY CLAY DEP051TANDCOMPACT CLEAN BACKFILL.
o a ti' • �, u
21 THERE 15 NO MAIN DRAIN IN THIS POOL SUCTION FOR POOL WATER CIRCULATION 15 PROVIDED BY THE SKIMMERS ONLY THIS MEETS
�'•' REQUIREMENTS OF THE IRC-SECTION R326 6 FOR ENTRAPMENT PROTECTION
11
V-3' ,,_e. OF NEW Y
`,•�� 22. THE POOL WAS DESIGNED IAW THE FOLLOWING
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FI
In-
22.1. THE INTERNATIONAL RESIDENTIAL CODE(IRC)-CHAPTER 42(2016)
/ 222. THE INTERNATIONAL ENERGY CONSERVATION CONSTRUCTION CODE-SECTION R40310(2015) Q N TO RETURNS DIVING BOARD 223• TH E I NTERNATIONAL FUEL GAS CODE(2015) +
CHECK VALVE) 2_-4, THE NEW YORK STATE CODE SUPPLEMENT-SECTION 8326 (2016) _ _ � y
DETAIL �' 225. THE NEW YORK STATE SANITARY CODE. ,per ' m clf
w
t'` ? 226, AN51/NSPI-5 STANDARD FOR RESIDENTIAL LN-GROUND SWIMMING POOLS. _ _ :,y y L` m W
LA
22.7. BOCACODE-SECTION 421.
228, CODE OF TH E TOWN OF SOUTHOLD.
PLUM, B I N G SC H EMATI C 25 ALL BACKWASH TO BE SELF-CONTAINED ON-SITE. (CQ 08841`'
N Ts. AROFESS�O�P