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HomeMy WebLinkAbout35516-Z ��� FFOd,�cOGy Town of Southold 4/15/2019 P.O.Box 1179 y. 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40319 Date: 4/15/2019 THIS CERTIFIES that the building RESIDENTIAL ALTERATION Location of Property: 76000 Route 25, Greenport SCTM#: 473889 Sec/Block/Lot: 48.4-14 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/26/2010 pursuant to which Building Permit No. 35516 dated 5/3/2010 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: KITCHEN ALTERATION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to David Zellerford of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 35516 04-12-2019 PLUMBERS CERTIFICATION DATED 04-09-2019 N B d Piecuc fi 0 ' ignature 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) PERMIT NO. 35516 Z Date MAY 3, 2010 Permission is hereby granted to: DAVID ZELLERFORD 483 PACIFIC ST, APT 2F BROOKLYN,NY 11217 for NEW ELECTRIC IN KITCHEN FOR AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR; AMENDED TO INCLUDE KITCHEN ALTERATION AS APPLIED FOR, 05/5/10 at premises located at 76000 MAIN RD GREENPORT County Tax Map No. 473889 Section 048 Block 0001 Lot No. 014 pursuant to application dated APRIL 26, 2010 and approved by the Building Inspector to expire on NOVEMBER 3 , 2011. Fee $ 290 . 00 � 9 D i .. L`Qa.,�L dpi' 1����s'6.1✓�VW.5 Authorized Signature ORIGINAL Rev. 5/8/02 forth No.6 TOWN OF SOUTIIOLD - ZUtf DING llIEPARTMENT 765=1802 APPLICATION FOR-CERTIFICATE OF OCCUPANCY This application must be filled in by,typewriter-o'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 buildingc,.praperty lines,streets,and unusual natural or topographic features.- 2. Final Approval from Health Dcpt.of watcr'supply.and sewerage-dispos.kl'(S-9'form). 3. Approval of electrical installation from Board of,Fire Underwriters.' d. Sworn statement from plumber certifying that,th.e,solder.used in system contains less than 2/10 of l%lead. 5'. -Commercial building,industrial building,multiple"residenccs'atid similar buildungs and'installations,,a certificate of Code Compliance from,architect orengmeer responsible for the building." 6. Submit Planning Board'Approval bfcompleted site,plan.requirements. B. For existing buildings(prior,to.April•9,1957)non-conforming uses,or buildings and"pre-existing"dand mses: 1. Accurate survey of property-showing.all property lines?streets,building and unusual natural-or topographic features: 2. A properly completed application and caonsent•to inspect signed by the applicant.if a Certificate of Occupancy is denied,the Building inspector shall state the reasons-dierei6r in writing io the applicant. C. Fees- 1. Certificate of Occupancy New dwelling$50:00.Additions to dwelling$51).0,0 -Atte ons to dwelling$50. Swimming pool S50.00,.Access6ry,'building$50.00;Additions to accessory building, s '50.00. 2. Certificate of Occupancy,on'1'cr.-existing Building-'.$100.00 3.. Copy of Certificate-of Occupancy 4. Updated Certificate of 0&60ancy= $50.00 5. "Temporary Certificate of Occupancy-Residential$15.00,Commercial$15.00 Date. New Construction: __ Old or Pre-existing Building: check one) ,4 _ Location of Propa ATL �' �"y s' I 140. Hamlet Owner.or Owners.of Property. C Pw� Suffolk County Tax Map Na 1000';Section ® Block' Lot Subdivision Filed Map:_ Gat: 1'crmitNo.!J� [)atc•of'Fermit. Q'. Applicant: Health Dept.Approval: UnderwritersApproval: Planning Board'Approval: + for: Temporary Certificate Final.Certificatte: C,,(check one) Request a „p rye Fee Submitted:.$_. J•�Q j _ - - • Applic i urc �_.__ rg so Town Hall Annex Telephone(631)765-1802 54375 Main Road Alc Fax(631)765-9502 P.O.Box 1179 >� roger.richert@town.southold.nV.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: David Zellerford Address: 76000 route 25 City: Greenport St: New York Zip: 11944 Building Permit#. 35516 Section. 48 Block 1 Lot 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA' Stephen A Earl Electric License No: 5142-ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Only Commerical Outdoor 1st Floor X Pool New Renovation X 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt 4 Ceding Fixtures 3 HID Fixtures Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures 2 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures 5 CO Detectors Sub Panel A/C Blower Range Recpt 40a Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 9 Twist Lock Exit Fixtures 11 TVSS Other Equipment. "KITCHEN RENOVATION" Notes 2-kick heaters, 1-paddle fan, range hood,3-under cabinet lights Inspector Signature: 0"'� Date: April 12 2019 81-Cert Electrical Compliance Form As SO�T�® ~ it Town Hall Annex Telephone(531)•763-1$02•:-"''-` 54375 Main Road Fax(_631).765-95.01- P.0_Box 1179 = Southold,New York 11971-0959 BUnDINO IMPARTMENT z_ t TOS OF SOUTHOID APR - 9 2019 k -CERTIFICATION - TOWN OF SOUT""D ]Date: 12-D Building Permit No. � � Owner. �a�1 i ZP d ley-4I-d _ (Please print) Plumber. BfM ?l eCUC h (Please print) I certify that the solder used in the water supply system contains less.th_ an_ 2/10 of 10/6 - lead. a (Plumbers Signature) = Sworn to before me this day of ( l 20 1 CONNIE D.BUNCH ,y Notary Public,State of Nov, + Pio.01 BU616505t, Qualified in Suffolk 00) �Mgr Comminion Expirer-Qmi i q Via-(� _ Not ��—county '+ mY Public, t3' - 3sV�l� cOUNTI,�c� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FO ATION 2ND [ ] INSULATION [PTFRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: DATE INSPECTOR oF so�jyo� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ [ ] FOUNDATION 2ND [ N LATION [ ] FRAMING / STRAPPING [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: ✓� yy,L--, DATE �� INSPECTOR a � � OF SO(/jyo! � o cDUN1Y,�`� TOWN OF SOUTHOLD BUILDING DEPT. 765-16®2 INSPECTION [ ] FOUNDATION 1 ST [ ] RO PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING / STRAPPING [ ] FINAL L ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY( INISPECTION! L ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: DATE INSPECTOR �' Of SOcou UTyo� • ao TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN LATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRICTION [ ] FIRE RESISTANT PENETRATION REMARKS: Z-VAS DATE INSPECTOR OE SO(/Tyo cOUNiV,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] �INSATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: Q��-6 C-0 P a a DATE f INSPECTOR ho��OF SOUTyO� # # TOWN OF SOUTHOLD BUILDING DEPT. courm, 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) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE I N S P E C T OR FIELD INSPEeTI.ON REPORT DATE COMMENTS FOUNDATION(1ST) ----------------------------------- FOUNDATION(2ND) ROUGH FRABONG& H PLUMBING P `J INSULATION PER N.Y. H STATE ENERGY CODE r 4 f N O cd FINAL -w l ADDITIONAL COMMENTS S - t44i c, o del, a/C �rn d TOWN OF SOUTH CE �Il BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPAR 11 Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11 MAY 6 2010 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 _ Survey SoutholdTown.North ork.net TOWNS NO. Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Examined e ,201 O Storm-Water Assessment Form Contact: Approved S 20Mail to: Disapproved a/c Phone: Expiration 20" 1J Building Inspector APPLICATION FOR BUILDING PERMIT Date .z , 20 /c� 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. s 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 a, it authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) L-k��6o � �/�� ' _ Az_ � - (rUQ_ i � �— (Mailing address of applicant) 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 corporateofficer) Builders License No. Plumbers License No. 3 Electricians License No. Other Trade's License No. 1. Location of land on whic propos d work will be done: ! 3 ! ` &AQ� �xt House Number Street Hamlet County Tax Map No. 1000 Section Ll Is Block Lot Subdivision Filed IVIap,No.' Lot ;. ;,. 2. State existing use and occupancy of premises and itendediuse and ccupancy of proposed!construction: a. Existing use and occupancyS;(( Q Ar C JZ— b. Intended use and occupancy S ri �� # k 1 Y a'I y( 1y -Q C- 3. 3. Nature of work (check which applicable): New Building AdditioAlteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost ��� y(;G 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 0 Rear Depth Height rt a Number of Stories Dimensions of same structure with alterations or additions: Front �� Rear Depth Height ,=�, vl-- Number of Stories D1 8, Dimensions of entirenew construction: Front Rear Depth Height Number of Stories 9 9. Size of lot: Front Rear 0 ,' �l"c� 7 Depth r � 10. Date of Purchase ,�0 O Name of Former Owner CS M 0-/m E C-0 C ALA ,&/2Q_S'z-, 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zo ing 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 of premises Address Phone No.JS Name of Architect AddressPhone No Name of Contractor I i 3 e S&ALk Address 70,9 ( (264 12- Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? ES� NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BE UQkt1"RED. 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 ) c),Al L -S &A L& being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)He is the of tj Ile la e.-4 (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this &0L - DDEMA day of 20�Z t�,� W. MAZZAFERRO � .� ' `'` Mllir Stnte of New.York Notary Pub i No.01 A4667612 ' Signature of Applicant Qualified in Suffolk County Commission Expires August 31,20� ?a Oft sours 4 GT)b S� Town Hall Annex Telephone(631)765-1802 54375 Main Road y muxw31)765t95 P.O.Box 1179 roger.richertaon.souo nMms Southold,NY 11971-0959 CO Ul�i`t, BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: L Date: 6 /o Company Name: G Name: License No.: Address: Phone No.: 3I ©(D - 1277 JOBSITE INFORMATION: (*Indicates required information) *Name: � - �q" : le-cfW (6_5) ) 11? —v7.3 Ov *Address: -RP/1 *Cross Street: *Phone No.: Permit No.: Tax Map District: 1000 Section: _ Block:. Lot: *B;F DESCRIPTION OFF WORK (Please Print Clearly) k L4&y `�Ce Ir �9 Ci f fav (Please C role All That Apply) *Is job read for inspection:1 Y p YES Roug In Final *Do you need a Temp Certificate: YES 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 82-Request for Inspection Form hO��pF SO!/r�ol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road y Fax(631)765-9502 P.O.Box 1179 G �Q Southold,NY 11971-0959 'O couffm BUILDING DEPARTMENT TOWN OF SOUTHOLD September 21, 2010 David Zellerford 483 Pacific Street, Apt 2F Brooklyn, NY 11217 RE: 76000 Main Road, Greenport TO WHOM IT MAY CONCERN: The following items are needed to complete your Certificate of Occupancy: Application of Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of $25.00. Final Health Department approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) Trustees Certificate of Compliance. (Town Trustees#765-1892) Final Planning Board approval. Final Fire Inspection from Fire Marshal. Final Inspection from the Building Dept. Final Landmark Preservation approval. Building Permit: 35516-Z kitchen alteration OF SOU�yol Town Hall Annex O Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 56.l �Q yc4UN1`1,�1c� BUILDING DEPARTMENT TOWN OF SOUTHOLD December 19, 2011 David Zellerford 483 Pacific St., Apt 2F Brooklyn, NY 11217 Re: 76000 Main Rd., Greenport TO WHOM IT MAY CONCERN: The Following Items)Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) Z Electrical Underwriters Certificate. A fee of$25.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 411184) Trustees Certificate of Compliance. (Town Trustees#765-1892) Final Planning Board Approval. Final Fire Inspection from Fire Marshall. — Bob Fisher Final Landmark Preservation approval. BUILDING PERMIT: 35516 — Kitchen Alteration 1 �®F souryolo Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 �l --INC co BUILDING BUILDING DEPARTMENT TOWN OF SOUTHOLD May 22, 2012 David Zellerford 483 Pacific St., Apt 2F Brooklyn, NY 11217 Re: 76000 Main Rd., Greenport TO WHOM IT MAY CONCERN: Thewing Items Are Needed To Complete Your Certificate of Occupancy: 7Application for Certificate of Occupancy. (Enclosed) //-Electrical Underwriters Certificate. (contact your electrician), /A fee of$259: - - Final Health Department Approval. -JR—Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) Trustees Certificate of Compliance. (Town Trustees#765-1892) Final Planning Board Approval. (Planning#765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. BUILDING PERMIT : 35516 — Kitchen Alteration 7 MAP i? 'PC� � C'7 ! - ' 'goal- �, f•- • .c�: .�•.-•_'� .P:a-�.>-.-. , ; _ .. • y_ :. "='I:ti:. ?1 �4 -DOMENI C0,-CAL yLy /�+�► -� y li3 t iq•�l k: - �' •�: . �h. ,� 9.�! ..33333—�--- �3`��'� - - - 'r'��' _�.'.'�� - - - ars . '�`•,"'i,-1 i :t ,_: .�. ��. • �,�'-":;�;;y k�: "'=�e�':'"-��',�``� " �. EJ.C>�JfB X3..0�=I", -4s -" ;;sem•: _ ��yy ,/, IX ;�,"�� ''k' `•� ~.`f:'�,• � 74.' !-:.,'if-1. 'riY 7`G+'��..y",�y.?^<� 't�., .�-__ r -, � t; .+' Ry-T� - r'+`'" .it - '�� +�:-'t.�•°,+•o-'E' •^{,' � a-''�,,.,�- r.,�� � �9r. ,.15y1a-�-�w�.�-�.�rii�irl,><vf't(€S:,'r;"�,�Z�i9dr�i�`f*f�_rP.� tsor�-�rs�l' `,• ?i: N ''Lq,� Ar. L'r; {7�":F:K ia_�7 •E ,N �,�' - Q./ N' wR..h• GV',�1�'� �� Q 't: , . ' �" �.�• J=. ` :a: s r'n Sit c°a:'tlr��s-� !�l5;d�.hfOMD. 353 ' -•.'ii•wr,Ayr :-. ........-�--- ' ' .� •„�; �Gudrart-f'E�B�.fa Sauf n1 �t `��� ,-t'. .. -,:- %. UEUUIHOP$ED ALTERAnOn oR l DT 1T(07E S.-$7�� �r 3s < tiv'ci �� fi".; GMtI.Ghicogo Tri�it�* lnsurdnc _TO THIS SURVEY IS A VIOLATION OF r i,,• •'Ss. v e SECTION 7109 OF THE HEW YORK STATE .s ur vd ye d ese�i 51 EDUCATION law: pep :'.• 147`x!. _ t . ,xv gip,••,' .Ye COPIES OF THIS S MAP 7 BFARINO ".i;ST.S, .LFA:i'' i., THE LAND URVEY NO .J _ - ����u `I j SURVFFOR'S IN,C AL OR a'" •' �"• _ l4Gd t'f �/j FMB A -c,,�• TO OSSED SEAL SNAIL NOT E.C,;NSIDEREO LD 's`R• :� .:�- ��•`K�•K's`0 �'•l!.g.,f�"�.-:• --+�: <_ /ri•. t/ �'..�, - ,BE A VA I Mu—,Copy, L - F. '•_j1..f,!'�t'r- ;'w ��r' {F Q�.�.: �I-� y. GUARANEECS. � :;E :'N SHALL RUN •. _ - •. -— Y _ L ONLY 70 THEtNDICA. ,�E'SON'OR V, ".1 THE SURVE 15 PREFARED,A\D OH NIS B:nAlF i0 fHE t( ilii£ GOV F L• <an• `T;[°. .'k..:`'.'r, aY<"_�:��' `ti ,. C�lc :Sar✓eQrs! -o iHeGAsnss o'ri1foN Li x.�EON,A� ••I- '" �ix;,;.,�c _ T IGIOFS OF TNE�LEL,pING IA571-,. y • ,.�.; _, - `•.4J;�,L: 1' %ain •- - G f'C�rlG/�I . �,l •- TUAO.W GUARANTEES ARE Nor TRANS FERA 1 70 ADDi7lOIUL I/E5TITU71ONS OR SUSSFQl7 Certificate of Attestation of Exemption From New Yak State Workers' Compensation and/or Disability Benefits Insurance Coverage **This form cannot be used to waive the workers'compensation rights or obligations of any party.** The applicant may use this Certificate of Attestation of Exemption ONLY to show a government entity that New York State specific workers' compensation and/or disability benefits insurance is not required. The applicant may NOT use this form to show another business or that business's insurance carrier that such insurance is not required. Please provide this form to the government entity from which you are requesting a permit,license or contract. This Certificate will not be accepted by government officials one year after the date printed on the form. In the Application of Business Applying For: (Legal Entity Name and Address): Home Improvement LUKE J.SLACK DBA:JUNK ARMY From:NASSAU COUNTY DEPT OF CONSUMER AFFAM 805 HARBOR LANE CUTCHOGUE,NY 11935 PHONE:631-252-5244 FEIN:XXXXX7924 Workers'Compensation Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE SPECIFIC WORKERS'COMPENSATION INSURANCE COVERAGE for the following reason: The business is owned by one individual and is not a corporation. Other than the owner,there are no employees,day labor,leased employees,borrowed employees,part-time employees,unpaid volunteers(including family members)or subcontractors. Disability Benefits Exemption Statement: The above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE STATUTORY DISABILITY BENEFITS INSURANCE COVERAGE for the following reason: The business MUST be either: 1) owned by one individual; OR 2) is a partnership(including LLC,LLP,PLLP,RLLP,or LP)under the laws of New York State and is not a corporation; OR 3) is a one or two person owned corporation,with those individuals owning all of the stock and holding all offices of the corporation(in a two person owned corporation each individual must be an officer and own at least one share of stock); OR 4) is a business with no NYS location. In addition,the business does not require disability benefits coverage at this time since it has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not considered to be employees under the Disability Benefits Law.) I,LUKE J.SLACK,am the Sole Proprietor with the above-named legal entity. I affirm that due to my position with the above-named business I have the knowledge,information and authority to make this Certificate of Attestation of Exemption. I hereby affirm that the statements made herein are true,that I have not made any materially false statements and I make this Certificate of Attestation of Exemption under the penalties of perjury. I further affirm that I understand that any false statement,representation or concealment will subject me to felony criminal prosecution,including jail and civil liability in accordance with the Workers'Compensation Law and all other New York State laws. By submitting this Certificate of Attestation of Exemption to the government entity listed above I also hereby affirm that if circumstances change so that workers'compensation insurance and/or disability benefits coverage is required,the above-named legal entity will immediately acquire appropriate New York State specific workers'compensation insurance and/or disability benefits coverage and also immediately furnish proof of that coverage on fors approved by the Chair of the Workers'Compensation Board to the government entity listed above. SIGN Signature: Date: HERE Exemptio>p& ate Number,-" ' 209 79,- y3 xd< k NYS Worke l nsatiolt-Board. CE-200 12/2008 ------- -AI-A�r N RTIFIC TION --- , , —- - - - - - - - -- -- - - - -- - -- -- —---- N LEAD CONTEN r F-;'G.;, CERTIFICATE OF OCC 0 FANCY Q OLDER USED Em NLAWFUL ;�.YsYSTEr✓ C"Af'`Y�,o 10 ote �Hn,� ,, ' CERTIFIC a . r; 4 � QD FANCY iZ 0 '0 � —- - u`�-�-� 1 � VASTf - &WATER LINES NEED 5 I` i twlNG BEFORE COVERING ALL COP1STt�U^;� 1 e�! LI MEET THE- r,EQt..t;1'. Q THE f ---_-- I CODES OF NEW TE p y:F AS, . 0 ED LI DAT E: Nr- !r'{ 1gluv_ G ui =tt' `ih1P?�r AT 1 - - cl-- _ �t - - 1 _ \i /C.�`.-�`1C ?J�,a,• T(_' k P?'vi 61•'OF: THE ;- FCu!'Jr+' �' REb 1tRED -_ FOR PO' �5� 2. ROUG': p1 3. II'-::�t_i' AL HE — r" U F. ,r �r.::D OF ' EW recti I n=:..• ie YO - '��j� °Oal g�(}t 'BLE FOR l 1 r 1` DE ION oo p I ORS. - DONALD G. FEILER ARCHITECT - 117 Maln Road • P.O.Box 1692 • M6MUIu k,erl -- - NDERINRITERS CERTIFICATE REQUIRED -- - --------------- 5 1.5-12D1 ------ - --- - --- ----- ----------- OF i FDk,j z , - o o - _ , . f t- NYS :1KV6GE)IC Zzf ��--=ter-�► �'-�-_ _ ���: _ • RCHITECT 11725 Maln Road • P.O.Box 1692 •.Mattituek, MY. 11952 - 5 ,20