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HomeMy WebLinkAbout44094-Z g4fFQt,� Town of Southold 10/25/2019 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40807 Date: 10/25/2019 THIS CERTIFIES that the building WINDOWS Location of Property: 895 Seawood Dr, Southold SCTM#: 473889 Sec/Block/Lot: 79.-7-64 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/13/2019 pursuant to which Building Permit No. 44094 dated 8/23/2019 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: REPLACEMENT WINDOWS (3)TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Napolitano,Blaise, i of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED uth d ignature TOWN OF SOUTHOLD FO(,t4 0" a BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY y�pl �aoe 01 r4id 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#: 44094 Date: 8/23/2019 Permission is hereby granted to: Napolitano, Blaise PO BOX 368 Greenport, NY 11944 To: install replacement windows to existing single-family dwelling as applied for. At premises located at: 895 Seawood Dr, Southold SCTM # 473889 Sec/Block/Lot# 79.-7-64 Pursuant to application dated 8/13/2019 and approved by the Building Inspector. To expire on 2/21/2021. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 Buildin ector Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings,property lines, streets,and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead. 5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957)non-conforming uses,or buildings and"pre-existing"land uses: 1. Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is denied,the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00, Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date. SL Iq New Construction: Old or Pre-existing Building: IZ (check one) Location of Property: $� <S � � O l ATl�✓P so jib GI House No. Street Hamlet Owner or Owners of Property: iS �10400r Suffolk County Tax Map No 1000, Section 7? Block 7 Lot Subdivision Filed Map. Lot: Permit No. 4�bDate of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) 00 Fee Submitted: $ tpp licant Signature Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) residing at W/ S ,�r'0'111 ,100 �,��'E (Print prope er's name) I (Mailing Address) do herelAle- by authorize � % � u . ( gent) � .n�� LL to apply on my behalf to the Southold Building Department. (Owner's Signature) J� (Print Owner's ame) Y�o r� SOF SOUrH # TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 Y INSPECTION [ ] FOUNDATION 1 ST _ [ ] ROUGH PL13G. [ ]- FOUNDATION 2ND [ ° ] SULATION/CAULKING [ ] FRAMING/STRAPPING [ FINAL ,110 06 /S [ ] FIREPLACE& CHIMNEY -[ ] FIRE SAFETY INSPECTION " [ ] FIRE RESISTANT CONSTRUCTION- [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) , [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: oy DATE 0 �C INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(1ST) ------------------------------------ � G FOUNDATION (2ND) IL li z � o � rA ROUGH FRAMING& l=i y PLUMBING O r INSULATION PER N.Y. H STATE ENERGY CODE V FINAL ADDITIONAL COMMENTS 7bvQ k, q)y&*A- :24-o almli ;aroO `m r �J 'b z d ro7 H APRO ED AS NOTE DATE: oZ3 B.P.#' d17 FEE-,-,9- d'® BY: 419 NOTIFY BULDING DEPARTMENT AT 765-18028 AM TO 4 PM FOR THE FOLLOWING'INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE "'2. ROUGH --'-,FRAMING & PLUMBING 3. INSULATIN 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL,CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SOtlTa M TO� NG..BOARD SOtiTi16�U ES OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE. OFOCCUPANCY WINDOW SPECIFICATION SHEET - Spec.Sheet#. 1-MFWOIPI Sheet. 1 of 1 Customer: blaiss napolitano Job#:1-MFWOIPI Consultant: Vance Comerford Date: 07/30/2019 New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use o v E o o Mull "S"=stationary or W� Style Wraps m rn o o t "X"=operating C Room Floor Code (Y/N) Style Code Series Code 5 w = 5 I—' vi ci a > = -9 > x° STD,White, WRAP, 1 BED 2nd TDH Y TDH 6100 WH WH 66 46 112 Glass Pack:Standard RMW,LSR STD,White,TMP• WRAP,LSR 2 BATH 2nd DH Y DH 6100 WH WH 24 37 61 Bottom, GlassPack Standard STD,White, LSR 3 BED 2nd DH N DH 6100 WH WH 31 46 77 Glass Pack.Standard SPECIAL CONSIDERATIONS: 1.White,2•White Wrap Color Interior Casing Type Bay or Bow window: Seatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material 1 have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window eatboard Material(vinyl only-White Plonite,Birch or Oak) TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST Z BUILDING DEPARTMENT Do you have or need the following,before applying? S 'AiV' N HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802Planning Board approval FAX:(631)765-9502 01 Survey 4A61q SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D E.C. Trustees C.O.Application Flood Permit Examined a� 20 Single&Separate Storm-Water Assessment Form Contact: Approved a 20 Mail to: f' Disapproved a/c — - ,J-0 At1 yr Expiration fn,20OL BuilcY1ng"D5pector AUG 1 3 2019 1 APPLICATION FOR BUILDING PERMIT Date /- 20� X97 u 7�, (,ry �p r�➢ INSTRUCTIONS Lu.J.�_0.r17T�,1't 4 ➢t��ii.o r r a.,ThfS;Apjllfcaiion•RUST be completely filled m by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant.Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Si ature of applicant or name,if a7X. 6rj- a# q5150- tion) l (Mailing address of appli t) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises S e D/i (As fin 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. Plumbers License No. Electricians License No. Other Trade's License No. 1. Loco o��land on wNch ro osed ork ll be done: CDi WO f 1 Ve ��Q�U U House Number Street Hamlet County Tax Map No. 1000 Section q Block__7 Lot 4q ge-jto,Vf- &J rep�Ace, 2 w)Jw s, like r1,`f4 1j,ke', Ao s�Afaf OLI"s. Subdivision Filed Map No. Lot R i 2. State existing use and occupancy of premises anq inte ded se and occupancy of proposed construction: a. Existing use and occupancy I b. Intended use and occupancy P-e�t O�PLW 3. Nature of work(check which applicable):New Building Addition Alteration Repair _Remov/al Demolition Other Work 4. Estimated Cost 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 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 `s Address B9.S SCG 0,9#1 af. Phone No.631-0278Aa3l Name of Architect Address Phone No Name of Contractor Am P Oepo=SAAddress 2M f hone No. 940- I Aad�L S�- G 'V31 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 BF REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO -1-111— •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) ���•;��R I A( S'F,�''�� COUNTY OF 191 SS: n s Laurie Hemy Sbeing y X1 4 fat iSY g AM (Name individual signing contract)ab ve named, `v�' O� II�j����� x-24.2019 (S)He is the A_ (Conti ctor,Agent,Corporate Officer, Pb+)n+rn�►+``� 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. SwotUefore me this I day of $ I 201—L- r ww� teIAA410" Notary Public ignature of Applicant Go Permits, LLC 105 Buttonball Ln. Glastonbury, Ct 06033 o1° Scott Doughman J1JFJ, ; Phone:860-952-4112 MLL Fax:860-430-6719 scottdoughman@gopermits.org "WE UNDERSTAND THAT YOUR TIME IS MONEY" August 5, 2019 To: Town of Southold Building Department Subject: Permit Application for: Blaise Napolitano 895 Seawood Drive The above listed homeowner has contracted with The Home Depot to replace the windows in his home. The below listed documents are included with this letter. • Notarized permit application • CO Application • Check for$250 payable to Town of Southold • Contract with The Home Depot detailing scope of work • The Home Depot's Suffolk County License • Certificate of Insurance • Letter of Authorization from The Home Depot allowing GoPermits to submit documents on their behalf • Authorization signed by the homeowner • Windows specification spec sheet Please note the following: "Please-mail-original-permit t`o�he owner:` • Please-faxoor-e mail_a_copy-of the_permit_gnd_receipt to Fax: 860-430-6719(attn: Scott Doughman) Email: scottdoughman@gopermits.org • If fax or e-mail is not available, please mail a copy of the permit and receipt to: Go Permits, LLC 105 Buttonball Ln. Glastonbury, CT 06033 Thank you! Stephanie Bottomley, Permit Expediter Go Permits, LLC Phone: 513-293-2060 stephaniebottomley@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org Show Receipt Detail Page 1 of 2 RECEIPT Suffolk County Government SUFFOLK COUNTY LABOR, LICENSING&CONSUMER AFFAIRS P.O. BOX 6100 HAUPPAUGE, NY 11788 James M.Andrews Application:H-53429 Application Type:ConsumerAffairs/Licenses/Home Improvement/NA Address: Owner Name: Owner Address: Application Name: Receipt No. 149086 Payment Method Ref Number Amount Paid Payment Date Cashier ID Received Comments Check 3148046 $1,800.00 09/21/2018 CLEMON RENEWAL Work Description: Suffolk County Dept.of y b' a Vy Labor,Licensing&Consumer Affairs i HOME IMPROVEMENT LICENSE Name RICHARD TOUSEY Business Name HOME DEPOT U.S.A,INC. rl This certifies that the bearer is duly licensed License Number H-53429 by the County of Suffolk Issued: 05/15/2014 Commissioner i r;;one- Expires: 1110112020 Commissioner https://ay.prod.county.suf/portlets/fee/receiptView.do?mode=view&autoPrint=false&recei... 9/21/2018 ATE ,4k�oma® CERTIFICATE OF LIABILITY INSURANCE 002/1112019DrvYYY) 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(les)must have ADDITIONAL INSURED provisions or be endorsod, If SUBROGATION IS WAIVED,subject to the forms 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 MARSH USA,INC. NAME- TWO ALLIANCE CENTER PHONE aC No 3560 LENOX ROAD,SUITE 2400 Ep AIL ATLANTA,GA 30328 INSURER(S)AFFORDING COVERAGE NAIC S CN101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147 INSURED HOME DEPOT U.S.A.,INC. INSURER B:New Hampshire Ins CO 23841 DIBIA THE HOME DEPOT INSURER C:HomeRisk Captive Insurance Com art 2455 PACES FERRY ROAD INSURERD: BUILDING G20 ATLANTA,GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-004349185-17 REVISION NUMBER: 0 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. INSR LTR TYPEOFINSURANCE ADD 5 BR POLICY EFF POLICY EXP POLICYNUMBER MWDD M IOD LIMITS A X COMMERCIALGENERALUABILITY MWZY314574 03101/2019 03/01/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE a OCCUR O-AMAZE TO RENTED EM SES Ca occuire e1 1,000,000 X SIR:$1,000,000 MED EXP oneperson) S EXCLUDED PERSONAL&ADV INJURY S 1.000,000 GEMLAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE S 1,000,000 X POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: S A AUTOMOBILE LIABILITY MWT8314573 0310112019 03101/2022 COMBINED ISINGLE LIMIT $ 1,000,00() X ANY AUTO BODILY INJURY(Per parson) 5 OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident $ AUTOS ONLY AUTOS 1 HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per S UMBRELLALIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION S S B WORKERS COMPENSATION WC 012717099(AK,NH,NJ,VI) 2020 X SEA UTE ETH- B AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETORIPARTNERIEXECUTNE WC 012717100(WQ 0310112019 0310112020 E.L.EACH ACCIDENT S 5.000,000 OFFICERfMEMBEREXCLUDED7 FN NIA (Mandatory in NH) E.L.DISEASE-FLA EMPLOYEE S 5,000,000 If yes,descnbo under COnilnued on Addilbnal Page 5,000,000 DESCRIPTION OFOPERATIONS below E.L.DISEASE-POLICY LIMIT S C Excess Auto 297110011002019 031DUM119 03101/2020 Elmo: 4,000,000 A Excess General Llabllity MWZX 314560 03101/2019 0310112022 Unit: 8,000,000 J. LDESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If moro apace Is required) CERTIFICATE HOLDER CANCELLATION Town of Southold-Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hag Annex Building THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Route 25,P.O.Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE of March USA Inc. Manashi Mukherjee ..KMkA0,01" � ,+�ee�v�•�u. 61988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta A���® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. HOME DEPOT U.SA,INC. DIB1A THE HOME DEPOT POLICY NUMBER 2455 PACES FERRY ROAD BUILDING 020 ATLANTA,GA 30339 CARRIERNAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of L(ablllty Insurance Workers Compensation Continued. Carder.Indemnity Insurance Company of North Amerlca Polcy Number.WLR 065890549(AL AR,fL,ID,M KS,KY,LA,MS,MO,NE,NM,ND,OK SC,SO,TN,WV,WY) Effective Dale:031012019 Expbatbn Date:0310172020 (EL)Unit$5.11W,000 Carder.Now Hampshire Insurance Company Pokcy Number:WC 012717098(OC,DE HI,IN,MD,MN,MT,NY,RI) Effective Date:03/012019 Expiration Data:031012020 (EL)Limit$5,000,000 Carder:ACE American Insurance Company Policy Number.WCU C65890586(QSI)(AZ,CA,IL,NC,OR,VA WA) Effective Dale:031012019 Expiration Date:03/012020 (EL)Limit$4,000,W0 SIR:$1,000,000 SIR for Uro states of AZ,CA IL NC,OR,VA,WA Carder:National Union Fire Insurance Company Policy Number:XWC 5565598(QSI)(CO,CT,GA,ME M I,NV,OH,PA 11T) Effective Date:031012019 Expiration Date:0310112020 (EL)UmIL$4,000,000 $1,000,000 SIR for the stales of CO,ME,NV,MI,OH,PA,UT $750,000 SIR for the slate of GA $350,000 SIR for the stale of CT Carder.National Union Fire Insurance Company Policy Number.WC 6565597(QSI)(MA) Effective Dale:0310112019 Explraft Date:0310112020 (EL)Unit[:$4,500,000 SII:$500,000 TX Employers XS Indemnity. CarderiflInios Union Insurance Company Po icy Number.TNS C65221019(T)) Effective Data:03/012019 CxpiraU,on Date:03101/2020 (EL)Limit:Si0,00000 SIR.$1,000,000 ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ACCO v® ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMEDINSURED MARSH USA,INC. HOME DEPOT U.S.A.,INC. 0181A THE HOME DEPOT POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance "'HOME DEPOT INSUREDS"' The Homo Dapot,Inc. The Home Depot U.SA.,Inc. Home Depot USA,Inc.dba The Home Depot Home Depot USA,Inc.dba Your OlherWarehouse,LLC Home Depot of Puerto Rica,Inc. Home Depot Product Auttiodly,LLC Home Depot Stare SuppoA Inc. Red Beacon,LLC Home Depot U.S A,Inc.dba Interhe Brands Barnett Coppertield Eagle Maintenance Supply Hardware Express Loran Maintenance USA Renovations Pius Supplyworks US lock Wdmar. CleanSource JanPek AmSen Sexauer Trayco Zip Technologies ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Atm'w i-'f Z9 DATE: AT Town Building Inspector RE: PERMIT AUTHORIZATION LETTER To Whom It May Concern: In accordance with Public Act 91-95, this letter serves as written authorization and notification that Go Permits LLC, and its employees and agents have the authority to represent us in the procurement of permits and pertinent documentation on our behalf. This letter or a photocopy thereof may be regarded by any building official as its authority to recognize Go Permits LLC as our authorized Agent to sign on our behalf applications for permits and any other related documents that may be required by you, and we agree that, for all purposes,we and not Go Permits LLC or its employees and agents shall be deemed to be the signer of any such applications and related documents. Scope of work: PC IV )i&, fl StruejN'T •4 Location: 5P JA),j b riye- r Authorized Agent Go Permits LLC ervice Agent Name Best Regards, ZIUAI I —C'If Lice ee Signature P 'nt N e &License Number NOTE: PLEASE MAIL PERMIT TO: I i Klfl�EV'VjIORK JEFFRE'-NOTARY PU6LIC:,: c CSF idTHD At-Home Services,IniSud 40 Oser Avenue• Suite 17•Hauppauge,NY 117 Qual'siied in�����'^ Phone.631-478-6101 •Fax:631-435-4837•Toll Free:877 fission€x fres(dlereh� ZQ_ Home Improvement Agreement: Scope of Work Scope of Work Job#: Products: Spec. Install Product Total Sheet(s)#: Price: Price: Sales: 1-MFWOIPI Roofing Siding , Windows Insulation 1- 447.00 2158.00 Gutters/Covers Entry Door MFWOIPI Roofing Siding Windows Insulation Gutters/Covers Entry Door Roofing Siding Windows Insulation Gutters/Covers Entry Door Roofing Siding Windows Insulation Gutters/Covers Entry Door Roofing Siding Windows Insulation Gutters/Covers Entry Door Subtotal Sales Tax 0.00 Total Contract Amoun 1 2605.00 Notes: Warranty: The warranty on the work identified above is listed in the General Terms and Conditions, or if applicable, specified in the following documents: Warranty Name(s): The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800466-3337 460F1 HDE Customer Agreement(24 Jul.18) v 0.1.8