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�orps� FF OTown of Southold 5/3/2019 y = P.O.Box 1179 W, 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40359 Date: 5/3/2019 THIS CERTIFIES that the building ALTERATION Location of Property: 935 Park Way, Southold SCTM#: 473889 Sec/Block/Lot: 70.-11-13 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/16/2019 pursuant to which Building Permit No. 43653 dated 4/16/2019 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: WINDOW REPLACEMENTS IN AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Patchell, Scott& Gayle of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 00 0 ' ed Signature o�SU �o TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 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#: 43653 Date: 4/16/2019 Permission is hereby granted to: Patchell, Scott 935 Park Way PO BOX 487 Southold, NY 11971 To: Alteration (window replacement) as applied for. Replaces BP# 39380 At premises located at: 935 Park Way, Southold SCTM #473889 Sec/Block/Lot# 70.-11-13 b Pursuant to application dated 4/16/2019 and approved by the Building Inspector. To expire on 10/15/2020. Fees: PERMIT RENEWAL $100.00 Total: $100.00 Building Inspector o�goFFot,r�oTOWN OF SOUTHOLD a� BUILDING DEPARTMENT y TOWN CLERK'S OFFICE �y • 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#: 39380 Date: 11/24/2014 Permission is hereby granted to: Patchell, Scott & Patchell, Gayle 935 Park Way PO BOX 487 Southold, NY 11971 To: Alteration (window replacement) as applied for. At premises located at: 935 Park Way, Southold SCTM #473889 Sec/Block/Lot# 70.-11-13 Pursuant to application dated 11/13/2014 and approved by the Building Inspector. To expire on 5/25/2016. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 To $250.00 Building nspector 11/12/2014 15:14 6108745030 PWS PAGE 01/07 Form Nn.G 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 buildin g or new use: 1. Final survey of property with accurate location of all buildings,property lines,streets, and unusual natural or topographic 1 eatures. 2. Final Appro,%al from Health Dept.of water supply and sewerage-disposal (S-9 form). 3. Approval of zlectrical 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 tines,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 Ceiti4icate of Occupancy- $50.00 5, Temporary Certificate of Occupancy-Residential$15.00,Commercial$15.00 Date. 11/12114 New Construction:. Old or Pre-existing Building: x (check one) Location of PrOperiy: 935 Parkway,Southold,NY 11979 House No. Street Hamlet Owner or Owners o-,Property: Gaye and Scott Patchall 935 Parkway,Southold,NY 11971 Suffolk County Tax Map No 1000,Section 910 Block Lot 3 Subdivision Filed Map, Lot: .Permit No.- Date of Permit, Applicant: Power Home Remodeling Group Health Dept. Approval, _ _Underwriters Approval: Planning Board Approval: Request for: Toraporary Certificate Final Certificate: (check one) Fee Submitted:$_ A scant Signature # TOWN OF SOUTHOLD BUILDING DEPT. coum, 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND WSULATION [ ] FRAMING /STRAPPING [ FINAL (,tWlAdUlvs [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: Com• Qi {�-✓ - DATE -Y 70 INSPECTOR FIELD IlVSPEON REPORT RATE w.. COMMENTS b 4 FOUNDATION(1ST) - -------- ----------- -- FOUNDATION(2ND) � ROUGH FR riH. F& y PLUMBING INSULATION PER N.Y. STATE ENEnoy CODE FINAL , .._ ADD�TbN" SCi�IVl141E1�TS�„•.w• ,.�x .. . 1 .. . '� �+ -716 &brID 1 TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying9 TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S RE C. Trustees C.0 Application Flood Permit Examined 20 Single&Separate it JM-- Storm-Water Assessment Form Contact: Approved 20 Mail to Disapproved a/c Phone. ��rExp—ratio `_ 1 �n -20 I lI�U�J <Znspec 2 NOV 12 2014 APPLICATION FOR BUILDING PERMIT BLDG DEPT Date 11/7 ,20 14 T01%P OF SOUTHOLD INSTRUCTIONS a This application MUST be completely filled in by typewriter or m 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 descnbed.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) 2501 Seaport or Chester,Pa 19013 (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Contractor Name of owner of premises Gayle and Scott Patchell (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 No. 48568-H Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 935 Parkway,Southold,NY 11971 House Number Street Hamlet County Tax Map No. 1000 Section- -7o Block I Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Residential b. Intended use and occupancy Residential 3. Nature of work(check which applicable):New Building Addition Alteration x Repair Removal Demolition Other Work (Description) 4. Estimated Cost $11,566 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 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 of premises Gayle and Scott Patchell Address 935 Parkway,Southold,NY 1 PKbne No. (516)446-2754 Name of Architect Address Phone No Name of Contractor Power Home Remodeling Group Address 2501 Seaport Dr.Chester,PFhone No.666-736-6335 x2391 19013 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 ¢ o * IF YES,PROVIDE A COPY. o y Z U r STATE OF NEW YORK) z —+y cc W SS. a WY=3 y COUNTY OF o —'a a ¢W 7'W x (� J cc Z A O C L- being duly sworn,deposes and says that(s)he is the applicant o uj a z o (Name of individual signing contract)above named, z W y w E (S)He is the C (Contractor,Agent,Corporate Officer,etc.) _> U� 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 ll 1 ` day of ¢�'`J� 20LIL Cary Public Signature of Applicant Southold Town Building Department ofF04IPIPG P.O.Box 1179 _ Permit#: 39380 53095 Main Rd Cm M, Southold,New York 11971 Permit Date: 11/24/2014 (631) 765-1802 Expiration Date: 5/25/2016 Parcel ID: 70.41-13 BUILDING PERMIT RENEWAL LETTER Dated: 11/16/2018 Applicant: Patchell, Scott&Patchell, Gayle Location: 935 Park Way, Southold Work Description: ALTERATION Alteration(window replacement)as applied for. A FEE OF $100.00 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Patchell, Scott&Patchell, Gayle Address: 935 Park Way PO BOX 487 Southold,NY 11971 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building ,Department, P.O. Box 1179, Southold,New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. 11/12/2014 15:14 6108745030 PWS PAGE 02/07 Scott A. Russell SUMRIWOR MANAGEMENT SOU MOLIU TOWN fr.4LL-P.O.Box 11" 53095 Main Road-SOUTYTown 11M .+[ own of Southold 1 CHAPTER 236 - STORMWATER MANAGEMENT WORE; SHEEN' ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PRO=T INVOLVE, ANY OF THE FOU-OWING: _ , I IC14ECK ALL THAT APPLY) I Yeti No ❑ A. Clef-Rring, 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 II within any parcel or any contiguous area. [� C, Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. II ❑ D, SitF preparation within 100 feet of wetlands, beach, bluff or coastal ; l; l� erosion hazard area. i ❑ J E. 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 !? fee- or more, unless prior approval of a Storrnwater Management l: I. Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces, if you answered N4 to all of the questions abtn+c, STOP'- Complete the Applicant section below with your Name, Signature,Ctntaret information,Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YF5 to one or more of the above,please submit Two copies of a Stormwater Management Control Plan and a compitexcl Check List Form to the Building Department'wit Yyour Buildhg Pennit Application- -_ S,C.T.M. 1000 Dote. APPLICAN_T• Mrq)erty(mmer,DcsiQn Profe%slonal,Arent.Controctar,Other) District i NAME g�ct)pn BIoCk Lnt FOR BUILDING DFPARTME.NT USE ONLY"* 1 j '�gr'1�tF—tr33S X ��'„nract inPormstton eviewed By. — — — T — &31(1,N-A-r R — J- j Datr: Property Addrese I Location of CorL3truction Work: — — — — — — — — — — — -' ! Approved rot,processing FRnitding Permit. f tormwater Management Control Plan Nal Required. ; )Pk - - - — — - - ;I ,0-1 5tormwatcr Menagctnent Control Plan is RcgidrCd. I j i (Forward to Enginccnng Department for Review.) FORM--i-§M--CP-'T OS MAY 2014 T - MOMH.B.NO. 9-1—jou H. D. RTP. q€WrIlp dioDosal'and rater supply Piiitiel dor this location have been iij g000ted bl• tbia department and found . ARS: ,7� .¢x! �'. f', t1i-bb eatiaftota , Mot or Nikulo bums ,kms. - - ,o. '' ,y �b bier"� � � ,•• -- � V 147. - S),e. �...a4 CALM A z '—''' `� ` � 5 .ti •� u w�rAVLNo�ALTZTrATiON oR,Annt,soK �� cli TO UM&KT i5 A VIOLATION CW L flu �1: SECTION 710!OF 71116 MW-Y=STATI t--oma'—` r t PIJGT(ONLAW. COPI6 OF 111W StiZVE!MAP NOT WRING j`j .•i` - � TM LAND SURYFTc3S'S itlKfC SAL OR WMW SO SEAL SPALL NOT i._ CONStD M 10 1E A VALID!.p_COPi. =412 NIUS IMIGTSD SHALL RUN OKV To TNb P[-S-al4 FOR V- ;JA Till MAY11 IS PWAR[O,AIILI ON W.5 L-.-ojk to THE ` Tau COAIPOW,G04tMtA0,,AL AGR:CY AND IEN�N6 C'S7•iIJ?!?H L-SUL IkFiONr AND ASS.WUS OF TNI ovDM WTI. TUTIOFL 4UAMA1-lnS A:'s NOT TRANSR&ME '] 4POP-041 1s'�8 to U.-A 4 t C VC &P.-TIOPW iNSTUUTIONS.OR SUI$ F'A I .. ,> �wf�'�.♦�i �4f 7+ tai ' �r�+�' ,� •MINFkSr - •� SUMP SISO 0?"1-0-4.p. AMUCK VAN 1M. V. c. A CW Yo uc.urns aurev R"Nft r-H. _ � ,tY_Ii, r�J, �.� A/,..z J""fb.i 5�.�,,i�:�...�f"l!�1. f/lnrti- +C,.....s.�tbA ell.._J. r r /- L in . .-. - •- - POWER-1 OP ID:EL ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/11/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Lacher&Associates Ins Agency PHONE 215-723-4378 FAX c No):215-723-8604 Lacher Insurance Group we Ne Ext 632 E Broad St P O Box 64398 E-MAIL Souderton,PA 18964 ADDRESS: Chad Lacher INSURERS AFFORDING COVERAGE NAIC# INSURER A:Harleysville Preferred Ins.Co 35696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Co 26182 LLC INSURER C:Nationwide Mutual Ins Company 23787 2501 Seaport Drive,Suite 8110 Chester,PA 19013 INSURER D:Pennsylvania Manufacturers 12262 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R TYPE OF INSURANCE ADD B POLICY NUMBER MMIDDY� MM/DDIYYYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ® MPAOOOOOO89793N 10/01/2014 10/01/2015 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 000 Ea accident) + , B X ANY AUTO BA 00000089796N 10/01/2014 10/01/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000+000 G X EXCESS LIAB CLAIMS-MADE CMB00000089794N 10/01/2014 10/01/2015 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'LIABILITY STATUTE ER D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 2014006620967 10/01/2014 10/01/2015 E L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDEI Y� N I A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000 B Mass Auto BA 00000018227P 10/01/2014 10101/2015 Auto Liab 1,000,000 B NY Auto BA 00000074849R 10/01/2014 10/01/2015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SOUTNY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Route 25 P.O.Box 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD STATS OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Power Home Remodeling Group, LLC 610-874-5000 2501 Seaport Drive Suite 8110 lc.NYS Unemployment Insurance Employer Chester PA 19013 Registration Number of Insured Work Location of Insured(Only required if coverage Is specifically 1d.Federal Employer Identification Number of Insured liinited to certain locations In New York State, Ie., a Wrap-Up or Social Security Number Policy) 23-3030708 e 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Pennsylvanla Manufacturers'Association Insurance Company Town of Southold 3b.Policy Number of entity listed in box i110 53095 Route 25 P.O. Box 1179 201400 6620967 Southold NY 11971 3c. Policy effective period 10/1/14 to 10/1/15 i 3d. The Proprietor,Partners or Executive Officers are F1 included. (Only checkboxif allpartners/oiiTcers Included) all excluded or certain partners/officers excluded. This-certifies that the insurance carrier indicated above in box"Y insures the business referenced above in box"la"for workers' compensationunder theNcwYork State Workers'CompensationLaw.(To use this form,NewYork(NY)mustbe listed underI em 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The hrsurance Carrier orits licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"21'. The lnsurance Carrier will also note the above certificate holder within 10 days IF apolicy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremtums that cancel thepolicy or eliminate the insuredfrom the coverage indicated on this Certificate. (These notices maybe sent by regularmatl) Otherwise,this Certificate is valid for one year after this form Is approved by the insurance carrier or its licensed agent;or until the policy expiration date listed In box"3c';whichever Is earlier. Please Note:Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate 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: ��42 rC UJ 0 (—(71,6-C(� (Print name of authorized representative or licensed agent of insurance cam ) Approved by C fJL 042, (Signature) (Da c) Title: UP 0 C2 VI-9//—ne � Telephone Number of authorized representative or licensed agent of insurance carrier: 616 Please Note.Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue It. C-105.2(9-07) www.wcb.state.nyus STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier Ia.Legal Name and Address of Insured(Use street address only) Ib.Business Telephone Number of Insured 610-874-5000 Power Home Remodeling Group LLC 290 Broadhollow Road lc.NYS Unemployment Insurance Employer Registration Suite 220E Number of Insured Melville, NY 11747 ld.Federal Employer Identification Number of Insured or Social Security Number 233030708 2. Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Arch Insurance Company Town of Southold 3b.Policy Number of entity listed in box"Ia": 53095 Route 25 11 DBL9519600 P.O. Box 1179 Southold NY 11971 3c.Policy effective period: 1/1/2014 to 12/31/2014 4.Policy covers: a. O All of the employer's employees eligible under the New York Disability Benefits Law b.n 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 12/17/2013 By (Signature of insurance came s au orized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 646-563-5824 Title AVP Accident& Health IMPORTANT.If box Na"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",lb"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd 8 of the Disability Benefits Law It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,20 Park Street,Albany,New York 12207. PART 2.To be completed by NYS Workers'Compensation Board (Only if box"4b"of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers'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 Workers'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 (5-06) ME HE & N", 9k, HWAV v 'Sm"Yealk Cbuidy Ao'partmeh,t of sf - onsuMerAffw C *' .--U_RPAUGE-,N ' VETERANS . ...... MEMORIAL M EW YORK 11788 DATE -H A 4/7'i 11 No.; 48568 'Y' Otw T T_ Tomel'",rdve me Olt C,&httged,o: :xL:ievns�e. 4 14, This-i§to,c6ftifythat KYL E'E BAI WNG, doing business as- E HO G.�,GRQUYLLC furnished the,fe�uirenfdnts "d We , rules- hay-ingfUrnis set f6iih-:ig 6`6- th i0jedtlb laws Ks ARF� . I ` :2 "1 ", ' - -1. Vabusiness'.as a�HOME ions of the-County Suff6lk,'Sidf6 of Mwf- "I and regulat York s4ierdby' ice 0 - I ' , � , '-, -, - " 4 1 ."� 1 1, 1 _T�ff' ' "i `;' 6 County' 'i)f SUMIL" �CONTRACT R,-InIM -ens,&.t#egqry ,Lk ,qg 4 'i,�u§inesses GC NOT VALID WITHOUT kddi�iona DEPARTMENTAL SEAL DEPARTMENTAL ' ' I : � I" I I I . k4bA'IbURRE&T.'.' CONSVMERAif "8 ID CARD "',C6inmissioner, '2 .IRIS & MOM ¢CcaooD .: g,-- (1a 1 16. wit g'. /Z. WV4,IN, wx'p'� Z1. I T��k g _�v _'4 K RIM., �.'Wr5 Q lklza 651093 GOES D4II31 LITHO.IN U SA M-R,gh!s Ras ed 11/12/2014 15:14 6108745030 PWS PAGE 03/07 NATtoNAL Hl:ADUUARTERS Gayle and Scott Patchell 2591 Seaport[love,Chester,PA 19013 70WER 31-28671 _ October 21,2014 =888-REMO.0114= ®• 1440776 PRODUCT SPECIFICATIONS 48560-H suyer(s)'Information and description of the Property: Project Number:31-28671 October 21,8014 Data ofAomemeni Gayle Patchell (596)448-2T54(Scott's Cell) Scott Patchell 935 Parkway Southold,NY,11971 County:Sufralk - Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification shoats,in accordance wit-i the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this°Agreement")• Pre Installation Inspection Date-Your pre installation inspection Is tentatively scheduled far Thu 10/30 between 1:10p and 2:10p. Windows -SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety looks on double hung windows only,welded corners,foam injected frames, Sashlite technology, Heatshleld,Duraglass,exterior custom capping, installation, clean up and haul away of all jab related debris. O^Cp q PANCY OR �E aS UNLAWFUL APPROV7 A NOTED � ���TfflGATE ATE: 2 B.P.# �(� ��'TH®vT ��S ®F OF ��C�����C� FEE: BY: �`'� i�'1eF� TO 4C®®s F NOTIF BUILDING DEPART ENT AT COIR K S� � 765-1802 8 AM TO 4 PM FOR THE 14ENEQv�R�� P. TSN FOLLOWING INSPECTIONS: 1. FO.UNDATION - TWO REQUIRED �� S4 PSD FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING SDS 3. INSULATION �� r 4. FINAL - CONSTRUCTION MUST It is a B CMP ETE FOR C.O. is g�thpMrties that the Product specifioptions;along with the Custom Remodeling and Imp r Z ' �Ajr erstanding between the parties,and replace any and all prior negotiations, repro§ n61wwa IN ire% Mgken al, The Product Specifications may not be changed,modified,or varied in any way unless such s p ¢r, 7�wt 8�aR�€i�; of § r(s)and Contractor. Buyer(s)hereby acknowledge that Buyers)has read the Product Speci %Rft OR CONSTRUCTION ERRORS. I have read and received each page of this 4 page agreement, Power Home Rernodoling Croup Buyer(s) Buyer(s) /10121114 110/21114 110121/14 Signature of Remodeling Consultant Signature Signature Geoffrey Batt Gayle Patchell Scott Patchell YOU,THE BUYER($),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION,SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS DIGHT. October 21,2014 20:29 I I Page 1 of 4 11/12/2014 15:14 6108745030 PWS PAGE 04107 i Gayle and Scott Patchell NATIONAL HEADOUARTERS OW 31-28671 2501 seaport Drive,Che-Ter PA 19013 Qctob6r 21,2414 888-REMO EL it■ 1 1440776 project Specifications ansae-H Windows' Dining Room 1 1 33.0"x45.0" WINDOWS: Models SL 27CO.Styles Double Hung Types None Corlfirgs None OPTIONS, Gefor Whlte 1 W Tito: Grid Pattern: Top Sash Only: Colonial: Coniour I Removal Wood I Additional Details None Windows: Dining Room 2 t 33.0"x45.0" WINDOWS: Models SL 2704 Styles Doug Hung Types None Conrrgs None OPTIONS: Color White t White: Grid Pattern; Top Sash Only. Colonial: Contour{Removal Wood I Additional Details None 0 Windows Dining Room 3 1 33.0"x45.0" WINDOWS' Models 5L 2770 Styles Double Hung Types None Ccnftgs None OPTIONS: Color White 1 White. Grid Pattern: Top Sash Only: Colonial: Contour I Removal Wood{ Additions!Detaus None Windows: Living Room 1 35.0"x61.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Conffgs None OPTIONS: Color White f While: Grid Pattern: Top Sash Only: Colonial, Contour{Removal Wood I Additional DaWls None W Windows: Living Room 2 7 35.0"x61.0° WINDOWS: Models SL V00 Styles Double Hung Types None Confrgs None OPTIONS. Color White l Whita: Grid Pattern: Top Sash Only: colonial: Contour{Removal Wood I Additional Datafls None Windows: Eat In 1 32.0"x45.0" WINDOWS: Models SL 2 700 Styles Double Hung Types None Configs None OPTIONS: Corer White!'lYhite: Grid Pattern: Top Sash Only; Colonial; Contour I Removal Wood I Additional Details None October 21,2014 20:29 Il111111111l1111�111f1(111�11111�11((I11Illl Ill Page 2 of 4 11/12/2014 15:14 6108745030 PWS PAGE 05/07 NATIONAL HEADOVARTERSGayle and Scott Patchell 7501 Seaport Drive,Chester,PA 19813 POWER : 31-28671 _ r„",�� October 21.2014 INK 7M IDEL 1440776 ,. Project Specifit;ationS 485e9-H Windows: Eat in 1 32.0"x45 0" WINDOWS: Models SL 27110 Styles Double Hung Types Nona Configs None OPTIONS ColorWhita 1 White: Grid Pattern: Top Sash Only: Colonial: Contour(Removal Wood Additional Details None Windows: Robbie's Room 1 36.0"x61.0" WINDOWS: Modals SL 2770 Styles Double Hung Types None Contigs None OPTIONS: Color White/white: Grld Pattani: Top Swh Only: colonial: Contour I Removal Wood( +•i Additlonal Detar7s None r7 Windows: Katie's Room 1 36.0"x45.0" W1NDOWS: Models SL 2700 Styles Double Hung Types None ConRgs None OPTIONS: Color WK l Vlhito: Grid Pattern: Top Sash Only: Colonial, Centaur I Removal Wood I Additional Details None Windows: Katie's Room t 35.0"x61.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Conflgo Nona OPTIONS: Calor White 1 White: Grid Pattern; Top Sash Only: Colonial: Contour I Removal Wood I Additional Details None Windows: Master Bed 1 36.0"x45.0" r� WINDOWS: Models SL 2700 Styles Double Hung Typos None Contigs Nano OPTIONS: Color White 1ltilhite. Grid Pattem. Top Sash Only: Colonial; Centaur I Removal Woad I Additional Details Special Options(ie.Full Sbraen.Obscure Glass,etc)Full Semen No I Obsoum Glass No I speoialty Color No I Different Color Capping No I Trim Options Yes Now Inside Casing No I New Outside 13di*mo1d No I New Sill Na I New Stool Pine I New Apron No I Upgrade Head,Seel and Jambs No I Frame at Opllons No I Remove and Ror'nstall No Windows: Master bed 1 3e.0"x45.0" WINDOWS: Models SL 2 700 Was Double Hung Types Nona Conllgs None OPTIONS: Color White VNhits: Grid Pattern., Tap Sash Only: Colonial: Contour Removat wood I Additiortai Details None October 21,2014 70::?9 I�IIII I��1��111I�II�II��I1�lI�lUII��IIIlIl�1� 1 Page 3 of 4 11/12/2014 15:14 6106745030 PWS PAGE 06/07 Gayle and Scott Patchell NATIONAL HEADQUARTERS 31-28671 2501 Seaport Drive,Oester,PA 19,013 '� October 21,2014 [$8$-REM01 .. Vefesa . 1440775 project Specifications 45668-H Windows: Master Bed 1 36.0"x45.0" WINDOWS- Models SL 2700 Styles Double Hung TYPOS Nona Conags None OPTIONS: Color White 1 White: Grid Pattern: Top Saah Only, Colonial: Contour I Removal Wood Additional Refarls None Windows: Master Bathroom 24 0"x38.0" WINDOWS' Models SL 2700 Styles Double Hung Types None Configls None OPTIONS: CoforWhite/White, Grid Pattern: Top Sash Only: Colonial- Contour I Removal Weed I Additional Details None Windows: Hall Bathroom 1 24,0"06.0" WINDOWS: Modals SL 27)0 Stylas Double Hung Typos None Conrrgs Nana OPTIONS: Color White 1 White: Grid Pattern: Top Sash Only., Colonial: Contour I Removal Wood I LI JA Additional Details None i.} Windows: Garage 1 35.0"x17.5' WINDOWS: Models SL 2700 Styles Awning Types None Conrrgs None OPTIONS: Color White/White. Grid Pattern: Colonial, Contour I Removal Wood I Additional Details None Windows: Garage 2 1 35.0"x17.5' WINDOWS: Models SL 2''00 Styles Awning 7jtpes Nana Configs None OPTIONS: Color White I White: Grid Pattern: Colonial: Contour I Removal Wood I Additional Details None October 21,2014 20:29 1� ISI��1� 11 I 1 Ii I Page 4 of 4 fltCH ILS=. �.;r - ti 97;lFIglj;. IN 00= actor.{i1:S'1�=P;,_ Sb(�r,Hat;Gain:Co2fFi�i.2rit i:�lisible Ttahsm,ttanab =Colt��n"s�ton:,R25istance="u 1^' _ _ _..�•h... " , Z Hr 1 J f'-r ; •Tl'r .r4��... ...5_.t..,.tx.,�•1. •_F.,_:..- i e1 - i5'i,1 4. t�r,snE7 �;•;=f1= r_.4�i`'�p Y`-���;�j�lGc llj�f1�I ri1'Sr `�„1° j tl 1 ,•,,.t�, �E ,ix )p!<=�'1 rTyrl •la "D�isti`J�1'!E. � r! LS'.• " m„-' n+ x . liK�`i;::- �'� �ix J. , L it,.� Pr r^l�4.�T••if l(2A[.� J`I���r. ,Nxfj�•'J7�-.r, r..rr •� r -1,�'1�� 1 �„ 1! ,J ; `. ! 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