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HomeMy WebLinkAbout44120-Z Town of Southold 12/13/2019 P.O.Box 1179 53095 Main Rd ayA�w `� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40927 Date: 12/13/2019 THIS CERTIFIES that the building WINDOWS Location of Property: 10100 New Suffolk Ave, Cutchogue SCTM#: 473889 Sec/Block/Lot: 116.-6-1.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/20/2019 pursuant to which Building Permit No. 44120 dated 9/3/2019 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 IN AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Fragaszy,Richard&Wallace,Darby of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED th rize Si nature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 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#: 44120 Date: 9/3/2019 Permission is hereby granted to: Fragaszy, Richard &Wallace, Darby 3830 9th St N Apt 803E Arlington, VA 22203 To: replace windows as applied for. At premises located at: 10100 New Suffolk Ave, Cutchogue SCTM # 473889 Sec/Block/Lot# 116.-6-1.2 Pursuant to application dated 8/20/2019 and approved by the Building Inspector. To expire on 3/4/2021. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO - ERATI O DW $50.00 Total: $250.00 Building I spec 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 r 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. yl c /t New Construction: Old or Pre-existing Building:^ X (check one) Location of Property: W Gy "v Sod) kL House No. Street Hamlet Owner or Owners of Property: d r^o'-+ Suffolk County Tax Map No 1000,Section Block (F Lot Subdivision Filed Map. Lot: Permit No. �66 Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: - Request for: Temporary Certificate Final Certificate: x (check one) Fee Submitted: $ 10 cZ Ap&canf Signature AUT r'tfer�'ztte f�g�pt€ t smol,the 3Vdll r ` .. := ± r" aril ?ul i�cidzss} a - �- :�f,,:,< •';:� g .., ,:. � � ='fit',=•' e ^'"• -'- .,t- � xi3 ixt F� ' L'x^ 'L '„}sa :8� .R. ,, .�`fti` - „• .3 • .• .<'..";' ""yy!��}},fJ',���i{^.,,1(f�'1i.�J( ^ ,,4 jj �'.'•�f jJ'.t�,yjg <, if��'' '', � ",j�""�.i1�� ;. � �"' ,f .< '•r'z2� t.ce.� � i_.a',�t x i •�,-G;'« ,).ry;.b 4 11 I Yl �'s ,. .tis:` � 'a, ,. Yc `xt YY << tl•<< 'a., w .=.1: '. � a•���"� ti,.°A ';`,<P:^ .• ... . 1 ., -_ ,n < �J - ±'t'•� _ r^�':r.s;,fn,,.-.tJ� <•S,�a - - _ •2;,V , na' .s,t ,. ' ,., w ''�}. " <<.</. eta- - s,. vs�x5•-, �? , s "v`'<'t- ,..,. 'i" ' «. ' ,. � •r _ � '1<'� .. µ\Vi«H' , > « ?' ,,,. «. ro -f � . -aOF So0ly0 * # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm a 765-1802 -INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION'2ND- [ INSULATIOWCAULKING [ ] FRAMING /STRAPPING 11 ' FINAL OWU5 [ ] FIREPLACE & CHIMNEY [ ] FIRE.SAFETY-INSPECTION ' [ ] FIRE RESISTANT'CONSTRUCTION [ ] FIRE RESISTANT PENETRATION- [= ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: UU DATE INSPECTOR FIELD INSPECTION REPORT7 DATE COMMENTS FOUNDATION(IST) y -------=---------------------------- C FOUNDATION (2ND) CIO e H� ROUGH FRAMING& PLUMBING r INSULATION PER N.Y. H STATE ENERGY CODE IO O 1 qvio - A`fQ� FINAL ADDITIONAL COMMENTS O z rn � b o z x r x _ d TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SCe4=THOLD,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 cup � N.Y.S.DE.C. Trustees Gid-Application 1?lo ermit Examined 20 Single&Separate Storm-Water Assessment Form ♦3 p A V Contact: Approved 20 m Mail to: C—i 1 M���''a4 t✓t1rl r} Disapproved a/c 0S 1 vt f fc*n(pal/ �4t _ n ef=2 201�� I (�S(•(-v►l � C 7' Ca Building Inspec o U -' AUG 2 0 2019 APPL UILDING ) -tull,DTNG� ' a`o Date �l �( 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 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. •D N 'a (SigniAire of applicant or name,if a corporation) L", Ne S--'laK" C7 (Mailing address of applicant) FES _ „�la i=t'Ni IAFN1 AT State wh Ae�4 ' liets owner,le se ,e, tchitect,engineer,general contractor,electrician,plumber or builder 765-1� S A5 T O 4��/1 � " SPECTIONS: r . � lUh1DATI.OI� EG c OF Nameof of ,remises rr 1Pir cr--e-"� Z` Y WITH ALL CODES FORUurtit — (pRK S VVN CODES R A;Ir,;�= & PLU(�PiSl^iO As on the tax roll or l�e,�t FATE & If applica 0"9 rdti�On, ignafiire of duly authorized officer !V C 3 INSULATION A„r T AS REQUIRE (NWmLtitle@ �oipoati difi'cer�� Builders Lice e P1 F'"i1= _ � p Plumbers LicM( 'o11�-rr,�i,1 I irw SHA!l tilt- 5 ' SD Electrician,a �1Vot:; :, ru G r,nI�ES OF I t-MtV pWN TRUSTEES Other Trad' e 'ns�e�tiNcl."`' n r.C Dnr �IRf_E FOR SQ YORK S T AT t� `r' ERRORS. 1. Locatio dRvh(¢�i roti i�or�will be done: N•Y• (Q( o����e ot; Sw•[Fdl�j4yt` - House Number Street Hamlet County Tax Map No. 1000 Section % Block ce Lot /' �' Subdivision Filed Map No. Lot F, �C uv\.d�I Ct'� (\�'P��C O W•"'�C�G�"S ( S CA.w-c-- S Z--'L k%,0' k4, Cd. 2.c+State existing use and occupancy of premises and intenod use and occupancy of proposed construction: a. Existing use and occupancy -`'^'tl;i b. Intended use and occupancy S' l a"'t` r 2 3. Nature of work(check which applicable):New Building Addition Alteration Repair k Removal Demolition Other Work Q (Description) 4. Estimated Cost U S� Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units n�G'- 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 \" J P� 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 remises?YES_NO /GJoouC.W (LA) 33 Fs- 38 14.Names of Owner of premises �'" a _Address C�`E`�'"Sct`f <<9Phone No. 70 Name of Architect Address Phone No Name of contractor 2 tef 4-- Address hone No. % 4-- G 3 35 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO x *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 *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) (n '' w(� being duly swom,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (Contractor,Agent,Corporate Officer,etc.) MARITZA,.VIGII;;`;, of said owner or owners,and is duly authorized to perform or have performed the said grk' f OCT&W41 �@fi3"0 , that all statements contained in this application are true to the best of his knowledge �e1i v2d�iE66�A 445 performed in the manner set forth in the application filed therewith. MYommission Expires Dec 23, 2020 Sworn to before me this I'C L _day of l/l.�T 20A QkA Public Sign a of Applicant Go Permits, LLC 105 Buttonball Ln. AW Glastonbury, Ct 06033 Scoff Doughman Phone:860-952-4112 Fax:860-430-6719 scottdoughman@gopermits.org "WE UNDERSTAND THAT YOUR TIME IS MONEY" To Whom It May Concern: Enclosed you will .find a building permit application and check. If you have any questions regarding this application, feel free to call me at the number listed below. Please note the following: F`j L' , U�i L • Please mail original permit to the owner. -/ AUG 20 2019 - • Please fax or e-mail a copy of the permit and receipt to: BUT%,DYNG DFTT� Fax: 860-430-6719 (attn: Scott Doughman) Email: permits@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! Jennifer Winke, Permit Expediter Go Permits, LLC Phone: 303-946-8685 Fax: 866-697-0768 jenniferwinke@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org BILDATE C � nY,? . ' {►+1,l"il wym -: =CERTIFICATE OF' >i 7`Y<I SURANCE' 0210=19 •,ter'. ,1?- �,'n<t,r;.'t`:«�.. 6iiSN,h=+•4 'sa1K'=•,..,. 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' � . :Cf3 :S11 �1( �fS �' L1�1t891T: b:"�IIlL21tr'(" ` �' i WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-MIGHV3Z Sheet 1 of 2 Customer: Dorothy Fragaszy Job# 1-MIGHV3Z Consultant: Vance Comerford Date: 08/12/2019 New Window Hinge Locations Existing Window 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 i Screens For doors use v a o c o Mull "S"=stationary or ti H "X"=operating w Style Wraps `m li t7 a u m o u w o t Room Floor Code (Y/N) Style Code Series Code 5 3 x 5 r U., U W -9 > x -9 > x STD,White, WRAP,LSR 1 BED 1st DH N DH 6500 WH WH 32 46 78 GlassPack.Standard STD,White, LSR 2 BED 1st DH N DH 6500 WH WH 32 46 78 GlassPack-Standard STD,White, LSR 3 MEED 1st DH N DH 6500 WH WH 32 46 78 GlassPack Standard STD,White, LSR 4 MEED 1st DH N DH 6500 WH WH 32 46 78 GlassPack:Standard STD,White,TMP WRAP,LSR 5 BATH 1st DH Y DH 6500 WH WH 32 47 79 Bottom, GlassPack. Standard STD,White,TMP• WRAP,LSR 6 BATH 1st DH Y DH 6500 WH WH 32 47 79 Bottom, GlassPack: Standard STD,White, WRAP,LSR 7 LIV 1st DH Y DH 6500 WH WH 32 46 78 GlassPack:Standard STD,White, WRAP,LSR a LIV rt �DH Y DH 6500 WH WH 32 46 78 GlassPack Standard SPECIAL CONSIDERATIONS 5 White,6:White,7 White,8:White Wrap Color Interior Casing Type Bay or Bow window eatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,orCsmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I 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 PionRe,Birch or Oak) WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-MIGHV3Z Sheet: 2 of 2 Customer: Dorothy Fragaszy Job#. 1-MIGHV3Z Consultant Vance Comerford Date- 08/12/2019 New Window Hinge Locations Existing Window 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,RorS Glass Misc Items Hardware Code Screens For doors use c cMull "S"=stationary or % `o m m u N7a E H "X"=operating w Style Wraps d m '? B' U o m " m `o L Room Floor Code (Y/N) Style Code Series Code E ti 3 x i—ui U a 9 > x 9 > x STD,White, WRAP,LSR 9 LIV 1st DH Y DH 6500 WH WH 32 46 78 GlassPack Standard STD,White, LSR 10 LIV 1st CF N PW 6100 WH WH 60 48 108 GlassPack Standard IL SPECIAL CONSIDERATIONS. 9 White Wrap Color Interlor Casing Type Bay or Bow window eatboard 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 I 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 Pionne,Birch or Oak) The Home �aa))aate hermal ♦ " SProducts Manuf9gured t" �r•1s1,Sri .,$j.... t g .. ...� ., t+Yt#t Odds .f`tjl� OwPgckago= @ .it r. ; Sl/taC ' 9hA '` 4 amt 6500 Awril 650 Base PraSolar 3UPGrOW 708" 0.26.",0.28 0 .ffi m. •0.26 < 'i}.21 Gasemen# 45tifl Hese PresSc�lar Supercep4 7J8" 0.203 0x4 0 :� 0 0.26 = 0 2C; 0 0 � 0 Transom 65fl0 Base` PriiScttac �t, 9`. fl27 O.3 a 427 ;, 0.29 Double`Hun9 55t){3.Bay PsaSotar �t •708" 4.29.} 0,26 029. ' fl,24 PictureGasentent (N 6500 Base' _ PraSsltat SuPerce0i 708" 026"' 0.28 '020'. 0.25 Picture 6540 base ProSolar Siapercept 708 ti 27 ; 029 -027 ' fl.26 26Panel'Skfer -6500 Hasse ProSolar Supers apt :: 700+' 0.29 1,0216 0 6.29 ` 023 3 Panel Sliders 5540 Base(421 SqfO Pro Solas Supercept 718" fl29` 01:203 ' 0 2s ; .0.23.° OM WNRWN Carden Dear CHS 650D Enc Stec ProSolar SUN Su 0.30 024 q P. c , .0.30 421 . * ,b p Patio Boor 1{UOVO: $500 Base Pro Solar Super Spacer 1" 0.28 026'I's o 0.31.il 4.23 a, - 1 ! es�t ev+etyavliere�x Arizrr Cetdornf�,h�ha Nem 1+f�rv� ,Ctrl,ritah.'ard wasMagron., . Awning(Inc Hopper}: - 8104 Base Pro Solar hcept. Tt8"; 027 ; '4:24` .@ 028.' 021 0 Casement 6904 Base Pro Solar inter. JOV4 027 024 2" - 027 . .{#.22 e Double-Hu 8100 Star . Pm Solar S {?.30 ` 03.3011� 0.30 fl.27 Picture Casement ildo 0-t�gs3 .6104 Base PFo;Salat . 4.27,`° 428 0.27 i 0.25. ,picture 6100 Hose Pro Som intern 0}27 .0.31 0.27 0282 Pau�ei Slider. 61014 Base. Pro Solar # 430 ! :028Qat} ; 0273 Panel Slider 8140 Base. Pro Solar` in# apt•...... 0.30 ' 0.290.30 , 0.27 s 1 i !• s tc+aitdd everywh+erre•> CCEr :An==,CaffWr ,NOW,Nerreft'N ew Unko,+tin ea,Oftk aml WashLrgton Patio boos iNOVO 6140 Hrterillf-Slar lip Salm 0iuper Spacer Pada Door NARROW Ft MH610 0(PDOS)Base' Pro Solar- Intercept 304 ,p 28 i 030. 0 2$ 0.26 : i 1 F/ntrJ tosated o*ln fa tcw#ngmwkets.pastas,Denver,Detrok Phtk NorMerm N.4 IoW Wma NY. Awning 5200 Hale Psis SctlaF SFtAt3> Superespt, 3t" . 0?2? `l 425 +� � � � '426 `- t323 e. 0,10 m; Casement 6200 Base Pro Solar SHAflOM Supercx pt 314 0.26 i 0.18. Q Q 0.29 ? 0.17 Pieture.Oaserrtent-NH 62�ease Fra Soler SHADE' .s%spwc ept 31.0 4.25 g "(1.21: 0 � � P 03.25 3. 0.19 * *0 o �. `Picture Window 6200 Base Pro SotarSHADE rept_ 304^ 0?.26.$ 4.24 a Q 0 0 4.26- 0.22 a. m. m to Hun 620fl H&se Pr6 SalerSHADE 314". .428.` 023: ,Q ® .� 0:28 i 021 Single Slider 620101 t3as�a Pro;afar SHADE Wr 4.28 6 023 �? m 620 i .424 3.Panel Siler 624#3 Bele Pro Solar SHADE. .S�rr 3f4" :.0.28 :423 � � +�. 028.` 0.24 Flurries located In coastalwas Awrift SB+300VL-Ene_, Stag PSSUtaimi Supercep# 1- 0.261 023 n "a 14 1026 ! 0:21 ,a Casement SH+300VL Sere T'S urm Swer 4acer 1" '0,26 0.23 021. Double Hung SH+300VL Hasa PSIE.ar�ni Super Spacer 1°. '0.29., 03 25. "028 ! 0.23 0 ` Slider, SB+300VL.Base P$!Lami Intercept 1"° ,0 29 O25; e ffi 429 ? 0.23 Patio coot SB+SGOVL i:TC.30i5; PS Stlad61 LantO 'Super'paw 14' .a o Garden Door(CH) SB+300VL base PSA anti Super Spaw 1", 030 ; 0:28 @ as 0330 fl25 @ �? We irrdic8te Enemy Star cerklied fOFtl?at zone. . 3 i CERTIFICATE OF LIABILITY INSURANCE DATE O2,T=190NYW1 { THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA'T'E 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an AD0111ONAL INSURED,the pollay(les)must have ADDITIONAL INSURED provisions or be endorsed. I If SUBROGATION IS WAIVED,subject to the terms and Conditions Of the'pollcy,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 MARSH USA,INC. IFAX TWO ALLIANCE CENTER PHONE 3560 LENOX ROAD,SUITE 2400 EAMRli ATLANTA,GA 30326 INSUR S AFFORDING COVERAGE NAICO I CN101542069-HrniteD-GAW-19.20 INSURER A:Ohl R 68c Ins€tranta Ga 24147 INSURED INSURER B.Now Ham hho Ins Co 23&Ii THE HOME DEPOT,INC. �_...,_.....W. .__...... ....._....._ HOME DEPOT U.S A„INC. INSURER C:HomeRisk Ca&O Insurance COMDanY 2455 PACES FERRY ROAD INSURER 0. _ ATLANTA,GA 30339 INSURER E jI INSURER F.- COVERAGES :COVERAGES CERTIFICATE NUMBER: ATL-004353439.28 REVISION NUMBER: 21 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD i 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. INSf2 µ w INC- 'y Lt BR LTR TYPE OF INSURANCE POCNURBER LtI Ts A X ;COMMERMALGENERALLIABILIrY ((NIWZY314674 !03t01t2019 03101!2022 EACMOCCURRENCE 1 3 f,OI ,fl00 ' DAMAGE TO RE CLAIMS-RADE ®OCCUR 1 I aRE Es ecr ,c�� I S 1,000,000 X SIR:$1,000,000 '' ' NED ExP'I�Phi $ EXCLUDED i?BRSONAL&ADVINJURY S 1100.000 GEN'LAGGREGATE LINITAPPLIES PER*� j € GENERAL AGGR�CAM__ S 1.O�t.OQ9 j X POLICY D JECT 0 LOG € PRODUCTS—COMPtOP AGG S 11000.000 OTHER, ' O # $ _ _. A AVTOIaBILE LtABtt i t`! j MWTB314573 03f0112019 0310172022 IEaaNSINED SINGLE LIMIT 5 1,01,000.0m acc3 € X ANY AUTO BODILY INJURY(Per person)M $ _ w I" OWNED SCHEDULED I SELF INSURED AUTO PHY DMG BODILY INJURY(Por eccklent) $ AUTOSONLY AUTO$ HIRED NON OWNBO ER DAMAGE j AUTOSONLY AUTOS ONLY I ! I UNBRE.LAUAS OCCUR ; EACH OCCURRENCE I$ EXCESS t lAB CLAIMS-MADE � I AGGREGATE_ $ DED ;RETENTION$ $ B WORKERS COMPENSATION WC 012717099( NH,NJ, 017019 0310142020 S( I'ER OTH- I AND EAIPLOYERV LIABILITYYIN STATUTE ER 8 ANYPROPMETORiPARTNEWEXECUTIVE Y t N WC 012717100 I 0310112019 fl3l0112020 5000,000 OFFICEftlMEMaERixxCLUDED? Q N f A �} EI.,EACH ACCIDENT W� i(Mandatory In NMI I E.L.DISEASE-F.A EMPLOYE 5 5,000,000 j If yes,describe under Confnued on Additional Page5,000.000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLlCY LIMIT 5 C Excess Auto ' 297110011002019 0310112019 0310112020 Limit: 4,000,000 A (Exoess Genesi UsWity MWZX 314580 03f01/2019 MIJ2022 Ldmtr 8,000,000 d DESCRIPTION OF OPERATIONS i LOCATIONS 7 VEHICLES(ACORD 101,Addifilobal Remarks Schedule,may be attached umcm spaca Is rapulmd) ' EVtDI NCE OF INSURANCE € s 3 i I s CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ! BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. i ATLANTA,GA 30339 AUTHORIZED REMSENTATNE of Adarsh USA Inc. J Manastti Mukher'jeE ! 19118-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD I. I- - At3ENCY CUSTOMER iia: ON401642069 LOC#: Atlanta � C4QR ADDITIONAL REMARKS SCHEDULE maga 2° of 3 AGENCYNAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC, HOME DEPOT US.A.,INC. POUCY NUMSBR 2455 PACES FERRY LOAD BUILDING C-20 I ATLANTA,GA 30339 CARRIER MAIC COBE EPPECTSYE DATE, ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A"SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE; Certificate of L€aWli Insurance 1 WMors Compensation Continued: CaterInderri*rn umnce Company of NoM Ameiica Polity Number WLR C65I3MO{AL,AR,FL,ID,IkK$,KY,LA,hi$,MO,NE,NM Nf#,OK6 SC,5D,TN,WV,WY) Effective Date'0AV2019 Explfatlon Data:0383112020 (EL)Limit:S5,0f#?,000 Carrier:Neva Hampsha'e Insurance Company Pokey t@umuar WC 012717096(DC,DIW,HI,IN,MD,MN,MT,NY,RI) 1 " j Effective Date:03MI 019 Ezpi:atitrt Date:0310112020 (EL)LjdL$5,000,000 Car6ar:ACE Amencari Insurance Company Policy Number WCU M890586(QSI)(AZ,CA,IL,NC,OR,VA,WA) Edfecbve Dae:0310112019 IExpdat an Date;0310112020 (EL)Uma;$4,DW,000 518;$1,00,000 SIR for the states of AZ,CkIL',Ntr,OR.VA,WA Confe,National Union Fire insurance Companq Policy Number XWC 5565596(OSI)(C0.CT,GA,ME.MI,NV,0H.PA,UT) Eflattive Date:0310V2019, lNoration Dale,03104/2020 I (EL)Urnit,$4,000,000 r i,000,WO$IR forthe states of CO,fw-fi W,MI,OH,PA,UT ' $750,000 SIR for the state of GA 5350,000 SIR for the state d GT Gamef:Nalonsf Union Fire hwrmm company Policy Number:XWC 5565597(081)(MA) £fYachve Data:0310112019 1 ajilretion Date.0310112020 (EL)Uat:$4,500,000 I SIR:S50t1,000 TX Employers XS Indemnity: i - cardarl6inios Union h'surence Company- ; Policy Numbar:TNS C66221019(TX) I 'Eif4d've Date.03101112019 Expire"Date:0310172020 (EL)Lama;$10.000,000 SIR:$1,060400 S ' ACORD 101(2008101) m 2008 ACORD CORPORATION.,Ail rights ressehied. j The ACOR6 name and largo are registered marks of ACORD ^ � R AGENCY CUSTOMER ID: Cid I O 1642069 LOC#: Atlanta ; ► ADDITIONAL REMARKS SCHEDULE Page 3 of 3 7,Rguey NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOMEDEPOTU.S.A..INC. wnUCY NUMSER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 3U330 CARMER NAlc ctaDlr EFFECMVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORAM IS A SCHEDULE TO ACORD FORM i FORM NUMBER, 25' FORM TITLE: Certificate of Liabili insurance - I i •:>HOME DEPOT INSUREDS" t i The Home Depot,Inc. The Home Depot USA,Inc. Home Depot USA,Inc.dbe The Home Depol Home Depot USA.Ino.dba Your Other Warehouse,LLC Home Depot of Puerta Rias,Inc, # Hama Depot Product Authority,LLC Home Depot Stare Support,Inc, I Red Beacon,LLC Hem Depot U$A,Ina,dba , i Intedine8rands i Bamatl ' I CapperTietd I Eagle Maintenance Supply i t Hard'arars Express Loran . Maintenance USA Ronovancuss Plus Supplywotka P US Look s. wpMar I' CteanSaurca - JanPak Seosauer i Ttayco Zip Tedsaolog es , - i - I 1 ACORD 101{2008!01} 0 2008 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD i I "" •" ... .. . .. .. .. .. .. 'Show Receipt Detail 'age t`cif 2 RECEIPT. j Suffolk CburyGovimMeiht tUFFOLKnGUN gLABOR,LICEMg ING4.0...011UMCy AFFAIRS , P.O.60X(3100 kAUPPAUGE,-NY-f1768 James N1;Andre f , �. A�rpttcattlm:'i-1-63�4�9' . AvocavonType; nsumerA#f irs/Licenses/HomA-fmprovemen 1 add�Is�: • ,. Owner Aisttrestt;, ftae,�Ipt No. 449086 § Puy(rlent Mothad R*f"umkw, A*ount paW ,Payment D* CaSh 1(D t7 Camnlet�b Check 3148046! $1,800,00 091A201,6 GLEMON RENEWAL l ' Work Deetrltitton; a t , < y ttUt t 9 t 6T tJC -- er httoss:l/ay.fax©d.cc unt .suftp6rtietslf elreceiPt" iev -d0?M0de==vi Ut-- 4j6e4&Wei— 9/21/2018 < ,