Loading...
HomeMy WebLinkAbout43840-Z �o�Oc,UFFOIy Town of Southold 1/15/2020 a P.O.Box 1179 o _ 53095 Main Rd y�o! �aorv� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40999 Date: 1/15/2020 I THIS CERTIFIES that the building WINDOWS Location of Property: 1175 Hiawathas Path, Southold SCTM#: 473889 Sec/Block/Lot: 78.-3-54 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/28/2019 pursuant to which Building Permit No. 43840 dated 6/10/2019 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 to an existing single-family dwelling as applied for. The certificate is issued to Boyles, Susan of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED th riz ignature TOWN OF SOUTHOLD �SOFFat,�co� moo y 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#: 43840 Date: 6/10/2019 Permission is hereby granted to: Boyles, Susan 1175 Hiawathas Path Southold, NY 11971 To: install window replacements on existing single-family dwelling as applied for. At premises located at: 1175 Hiawathas Path, Southold SCTM # 473889 Sec/Block/Lot# 78.-3-54 Pursuant to application dated 5/28/2019 and approved by the Building Inspector. To expire on 12/9/2020. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 Building In 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 G I Date. 5 '2_5 / New Construction: Old or Pre-existing Building: (check one) 4 a.{ Location of Property: ?� 'aA S Pa`, n so o-AD' ` House No. Street J Hamlet Owner or Owners of Property: `S u S ay) oy/e-S Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ F11) Applicant Signature SOUTyO - -- - --- ---- - - - # �# TOWN OF SOUTHOLD-BUILDING DEPT. couxn��' 765-1802 = 1 NSPECTION ' , [ ] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] SULATIOWCAULKING ' _ [ ] FRAMING /STRAPPING [ FINAL U)Jnja66 [` ] FIREPLACE & CHIMNEY --[ ] FIRE SAFETY INSPECTION [ ] ' FIRE-RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ]- ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: 02 DATE INSPECTOR10L* FIELD INSPECTION^REPORT DATE COMMENTS 4-7 FOUNDATION (1ST) o 'FOUNDATION (2ND) Z X01 ROUGH FRAMING& 4H 1 PLUMBING H INSULATION PER N.Y; STATE ENERGY CODE FINAL ADDITIONAL COMMENTS ` Z m z ,1 s TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 � V Survey South oldTown.NorthFork.net PERMIT NO. (J Check Septic Form N.Y.S D.E.C. Trustees C O Application /1hFlood Permit Examined 20 Single&Separate Storm-Water Assessment Form Contact: Approved U 20A Mail to Rob Schacht Disapproved a/c 999 S Oyster Bay Rd suite 409,Bethpage NY In 1Phone 888-736-6335 ext.2485 P Building Inspector M AY 2 6 2019 PPLICATION FOR BUILDING PERMIT Date May 22 120 19 INSTRUCTIONS ,29� i®��tuJompletely filled in by typewriter or in ink and submitted to the Building Inspector with 4 plaw,accurate pilot 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 Power HRG (Signature of applicant or name,if a corporation) 999 S Oyster Bay Rd Bethpage NY,11714 (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder general contractor Name of owner of premises William and Sue Boyles (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. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 1175 Hiawathas Path Southold House Number Street %� Hamlet County Tax Map No. 1000 Section . /1 Block ✓ Lot i 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 Primary res,owner occupied b. Intended use and occupancy Primary res,Owner Occupied 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work remove and replace 18 vinyl windows,u-factor 0 27 (Description) 4. Estimated Cost $16,666 Fee $20000 (To be paid on filing this application) 5. If dwelling,number of dwelling units 1 Number of dwelling units on each floor 1 If garage,number of cars 1 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions. Front Rear Depth Height Number of Stories 8 Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO x 13.Will lot be re-graded?YES_NO x Will excess fill be removed from premises?YES_NO 14.Names of Owner of premises V Barn and Sae Boylgs Addres9115 H awathas Path,SoNhald,NY 11971Phone No. (631)785-4319 Name of Architect Address Phone No Name of Contractor Power"RG Address 999 s oyster Bay b,Bethpage NY Phone No. 88B-7366335 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b Is this property within 300 feet of a tidal wetland?*YES NO x *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey 18.Are there any covenants and restrictions with respect to this property?*YES NO_-,bNN`F D.$UNCH *IF YES,PROVIDE A COPY. NdWY iC,Std of �( STATE OF NEW YORK) T40,01BU61 SS: 0-off"" in Suf fOlfXPIMM lkiCO COUNTY OF Rob Schacht being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contra t)a ove named, n (S)He is the °" r (Contract�r,"A'gent,Corporate ffrcer,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 ot efore me thi day of ' 20/9 r i Notary Public Signature of Applicant (" ej tk) 'OL,VV\ I a vid 3-12�2 1��le s Civ ; Y-�d o LA) (Od CEJ ZIP 1`-'l0►�� �l i S l a w Of, Sa,� 11 � l Zqe5- i ;- i JUN 4 2019 T. 1 74/2/2019 E(MM/DDNYYY) ® CERTIFICATE OF LIABILITY INSURANCE 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 have ADDITIONAL INSURED provisions or 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 Insurance Agency PHONE FAX Lacher Insurance Group A/C No Ext):215-723-4378 A/C. /c No•215-723-5757 632 East Broad Street-- ADDRRESS: lather lacherinsurance com Souderton PA 18964- INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Pennsylvania Manufacturers 12262 INSURED POWERCL-01 INSURER B:Markel American Ins CO 28932 Power Home Remodeling Group, LLC 2501 Seaport Drive,4th Floor INSURER c:Endurance American Specialty 41718 Chester PA 19013 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:1255617737 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 INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YY A X COMMERCIAL GENERAL LIABILITY 301975-66-20-96-7 4/1/2019 4/1/2020 EACH OCCURRENCE $2,000,000 DAMAGE ToRENTED CLAIMS-MADE FX] OCCUR PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 POLICY1:1 PRO ❑ N LOC PRODUCTS-COMP/OPAGG $4,000,000 JECT OTHER $ A AUTOMOBILE LIABILITY 151800-66-20-96-7 10/1/2018 10/1/2019 COMBINED SINGLE LIMIT $1,000,000 Ea acc'dent X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident B UMBRELLA LIAB X OCCUR MKLM7EUL100123 4/1/2019 4/1/2020 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DED FX I RETENTION$() $ A WORKERS COMPENSATION 201875-66-20-96-7 10/1/2018 10/1/2019 X AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVEN/A E L EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? (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 C EXCESS LIABILITY ELD30000834201 4/1/2019 4/1/2020 EACH OCCURRENCE 5,000,000 OVER POLICY# AGGREGATE 5,000,000 MKLM7EUL100123 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 P.O. Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 USA �. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016)03) The ACORD name and logo are registered marks of ACORD "':5------------- 479,WIN h \k .. . .. .. ... Suffolk County Department of Labor, Licensing & . :. ; .Consumer Affairs VETERANS MEMORIAL HIGHWAY FUU-PPAUGE1 NEW YORK 11788 DATEISSUED: 4/77/2011 No. 48568-1i 'SUFFOLK COUNW- Hoine,Ilin rovemen-t-Contraetor License yl' This is to certify that KYLY-E BAPaUNG doing business as, POWER HONEEREMODELINGGROTR-;�L LG-, ds6�ji��t'i6 the provisions,ofiop1jeabI6.1dws;rules- I having fumished-th-etqwirL4nents-set�f6rth�irLaceoedaftce-,w 6f Suffolk,Siat�ofNdw.-,Yo,-rk-bhpreby licensed to cofia and regulationsof1hwC6uq-y Stiffb Oct,bdsiness-asa,,HOME DD INMROVEMEN-T,CONTRACTOR,in the Cotihty ofSuffolk. License Categqry NOT VALID NVITHOUT Additional Businesses GCis DEPARTMENTALSEAL AND A CURRENT 'CONSUMER AFFAIRS ID CARD Commissioner '3m�xr. . . ... . .. ryj ,,-7,✓'44��� y!4p�`Y'� f o0f+�. : �y(!��Pl�j,73 h - `l9 1V 0 1928 GOES 3461 L�hol IN U S A- Alt P,g4U Re-x--d N�1�T�L IGr,J� Steven Bellone Frank Nardelli �n Suffolk County Executive -rte Commissioner SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600 FAX(631) 853-4825 OCCUPATIONAL LICENSE RENEWAL APPLICATION Your check or money order must be payable to"Suffolk County Consumer Affairs" and returned/mailed to the address listed above. RENEWAL FEES: $400.00: Appliance Repair, Commercial Liquid Waste, Commercial Painting (unless you hold a valid HI license), Dry Cleaners(unless DEC exempt),Electrical Insp., Home Furnishings,Home Improvement,Master Electricians&Plumbers, Precious Metals,Tax Grievance,2"d Hand Dealers,Sign Hangers $200.00: Restricted Electricians &Plumbers,Expeditors Official Use Only $100.00: Backflow, Sales &Journeyman's ID Cards,Pools&Spas ADDITIONAL BUSINESS LOCATIONS: $100.00: Commercial Painters, Dry Cleaners,Home Furnishings, Home Improvement,Precious Metals; 2"d Hand Dealers Licensee Name: Kyle E. Barring License# 48568-H Business Name: Power Home Remodeling Email Address: shane.laird@powerhrg.com Business Address: 2501 Seaport Dr, First Floor, Chester, PA 19013 Each question must be answered by the licensee. The licensee must also sign and date this form. If the answer is"yes"to questions 1-9, please give details on a separate sheet. SINCE YOUR LAST LICENSE WAS ISSUED/RENEWED: YES /NO 1. Are you in arrears of any Child Support Judgment? ............................................ ❑ ✓ 2. Has your business name changed? .................................................................. ❑ �/ (If yes,you must contact this office before your license can be renewed) 3. Has the licensee gone out of business?(If yes, please return your ID card and certificate).. E] `/ 4. Have there been any changes in address or phone number of home or business? ............. ❑ ✓ 5. Have there been any changes in partners or corporate officers? ................................. ❑ V 6. Have you been convicted of any criminal charge? ................................................. ❑ ✓ 7. Are there any judgments filed against you or your business? .................................. ❑ ✓ 8. Have you or your business filed for bankruptcy? ................................................. ❑ ✓ 9. Do you apply fertilizers? .............................................................................. ❑ 1/ (If yes,you must attend a Nitrogen Turf Mgmt. Course&provide us with a certificate of completion) Provide a copy of your vehicle registration for each decal required No Occupational License will be renewed without a current certificate of insurance issued in your correct business name with S.C. 11 Department of Labor, Licensing Consumer Affairs as certificate holder. Precious Metals b Second Hand Dealers' renewals require a copy of your$5,000 License&Permit Bond Compliance Affirmation I understand that renewal of my license requires compliance with all laws applicable to my business. I understand that Title 8 USC 1324a makes the hiring of unauthorized aliens unlawful and imposes record keeping responsibilities if I am an employer. I am also obligated to pay taxes for employees'I may have. 'I affirm I am now and have been in compliance with Title 8 USC1324a and I have paid all required payroll tax payments for any employee including Social Security, Medicare and State and Federal unemployment taxes.. I affirm that the statements on this license renewal form are true. Licensee's Signature Date CA-L8 11/16 AC ® r ATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/20/2019 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 have ADDITIONAL INSURED provisions or 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 Insurance Agency PHONE FAX Lacher Insurance Group (AIC, A/C No Ext),215-723-4378 A/C NO).215-723-5757 632 East Broad Street ADDRESS: lacher@lacherinsurance.com Souderton PA 18964 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Pennsylvania Manufacturers 12262 INSURED POWERCL-01 INSURER B: Power Home Remodeling Group, LLC 2501 Seaport Drive,4th Floor INSURER C Chester PA 19013 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1657346779 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 INSRPOLICY EXP LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DD/YYYOLICYF MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 6620967301975 4/1/2019 4/1/2020 EACH OCCURRENCE $2,000,000 CLAIMS-MADE � OCCUR DAMAGE T NTED PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 POLICY� PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $4,000,000 X OTHER $ A AUTOMOBILE LIABILITY 151800-66-20-96-7 10/1/2018 10/1/2019 COMBINED SINGLE LIMIT $1,000,000 (Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 201875-66-20-96-7 10/1/2018 10/1/2019 X OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E L EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDED7 (Mandatory In NH) E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suffolk County Dept of Consumer Affairs ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 6100 i Hauppauge NY 11788 AUTHORIZED REPRESENTATIVE USA 4�z_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WOX <ER$' QOWENSATIM BO./�IW CER'i IFXCATE OF NYS WORYCCR81 CONIPENSA.TXON JNjSANCIC COVERAGE Xa.Legal Name&A.ddress of Insured(Dge strcof nddres$roily) lU.Ilusiness Tolepiione Numbor of Insured Power Home Remodeing Group, LLC 610-874-5000 2601 Seaport Drive Suite B116 1c,NYS unemploytHent besurtince Fmpl6yer Chester PA 190.13 Registration NUDiber of Iusured WurLtTaocaklthtoflnsmed(Ortlyt'eqrilredtfcovp'age•isspeciflcally Id.Federal Employer ldentifiention Number of Insured tlntlted to VOMIT) lderrtiolts In NeJO YOYIC,Sla1e1 i.e., u Trap-TI,i or-Sociai Security_ Number Policy) 23-3030708 2.Nance olid Address of the Entity Acgulesting Proof of U, Ptame pf Insgranep Cartier Cdvorage(Bntlty$ebig I.rlstcd'm the Certificate Roldoi) -P*annsylvanla Manufoaturers'Assacletion Imunnnce Ccr pahy Suffolk County Dept of Consumer Affairs 3b.Policy Number of entity listed In box"1a" PO Box 6100 2Q1$75436-20-96-7 Hauppauge NY 11788 3e. Policy effective period 10-1-18 to 10-1-19 34, TheTroprietor,Partite"or El xeegtive Officers are E] included. (only checit hox if tilt parin0rsio(ncers Included) all excluded or certain excluded, Thifi ceifi6es that the insurance,calrier indidatcd abbve In box"3" ifisures th6 busine53 referenced above in box."la"for w,oi'kels' pomponsatfon under flio New York State Workers'Comprnsatioll Lavl,(Tp use thisform,Neiv York(NY)ntustbolisted tuiderAgmAA on the INFOI&ATION PAG1V of file workers'contpensati il,insul'atice policy).Tile Insurance•Carrier or its licensed agbntwillsend this Cbltificate of Instltance to ale entity listed above as the certificate holder-la box"211, .The Insurance Cd;-Her will also notify thc'alcove ce)'tylcate holdersvithin 10 ddys1F&po71cy is eaneeled duo to iionpaynlent ofpremlions or vithIn 30 days M thele arg reasons 000,1101)no)epbyrilent pfPrendums that cancellhe ppllcy o}-elilnip(to lire irlsta•edfr'our the c2verage indleated on'this C2r IJ&a1e, '(These notices lltay be sent by regularmail) dfherlvlse,1111 s Certlflertte is vttlld for one year offer tris form is djlprvped by the hisnpdwe carrlel'or ils llcetteRt algent,op mall the pollcy explratlan 9111th Ilsted in box 113c",ivide1rever is earlier. Plense Notei'Vpon the oaneellation of the workers'compensation policy indlentdd bn1his forint If the business continues to be named on a permit,license oi'cotttt'kct i§sued bye certificate holders the business must provide that eertifieate•holder with it new Cei•tiileAte of Workei-91 NihPettsatihn COVirage or other authprjea proof that the businoss is complying wl,tlt the mandatory coverage, quivenients of ttfe`New YOrkState`Workers'Coinpensati6rt craw. Under penally om f perjury,I certify fhatI aall auihorJzed reprMlitgtive or licensed pgent of the insurance canter referenced above and that the nnmed Iii itred has the'coverage as dopieted on this form. Approved by: Shirt Hedges (Print nonio ofna(boiized reprucWtivo or licensed tu$ent of 3n4uronco egricr) Approved by: s 9/26/18 ^_ (S}&lmlup) (Dat&,) Title: Undorwritor TelepbpneNpmber of hutlioxi7ad representative yr licensed ageni of insurnnee can•ier: 4.64^530.8392 .Please Note; Otily lnstrrprrce carrleiv and their licensed agents are autlforlzed to lssite;F''orip C-105.,2.Insin•ance brokers are NOT auillor'ized fo I.Twe It C-105.2(9-07) wwwmcb.statc.ny,us �sTOR I CERTIFICATE OF INSURANCE COVERAGE yEW I Workers' �__.. sznt'EjCotnpensation ` I Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAVH PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Power Home Remodeling Group LLC 290 Broadhollow Road Suite 220E 610-874-5000 Melville,NY 11747 Work Location of Insured(Only required if coverage Is specifically limited to 1 c Federal Employer Identification Number of Insured certain locations in New York State,i e,Wrap-Up Policy) or Social Security Number 233030708 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Arch Insurance Company Suffolk County Dept of Consumer Affairs 3b.Policy Number of Entity Listed in Box"l a" P.O. Box 6100 11 DBL9519600 Hauppauge, NY 11788 3c.Policy effective period 1/1/2019 to 12/31/2019 4 Policy provides the following benefits, ® A.Both disability and paid family leave benefits B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B Only the following class or classes of 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 and/or Paid Family Leave Benefits insurance coverage as described above Date Signed 12/10/2018 By (Signature of insurance��Prtrr's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 201-743-3937 Name and Title James lannlcelll, AVP Accident& Health IMPORTANT, If Boxes 4A and 5A are 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 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit, PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 58 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Conr ibnsation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note*Only insurance careers licensed to write NYS disability and pard family leave 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 (10.17) I DB-120.1 120.1 (10-17) c ' ?: NTY OERT OF MOR, -,L)CeNSit4d'&'CONSUMrzRAFFAIRS IMPROVEMENT ' COIVTRAGTOR _ This cerfifi, 'that the— ,al. ttef I$diil}r PdYJER �IiEMODElIR0,dR0UP LLC County of Suftoik 48588-H N/07/2011 c �""04t1 04/01)2019 National Headquarters William and Sue Boyles 2501 Seaport Drive,Chester, PA 19013 33-89224 888-736-6335 May 14, 2019 WWW.POWERHRG.COM 1440776-DCA �,- PRODUCT SPECIFICATIONS 48568-H RM00(tIM Buyer(s)'Information and Description of the Property: Project Number:33-89224 May 14,2019 William Boyles Date of Agreement y (631)765-4319(Home) Sue Boyles billsueb@optonline.net 1175 Hiawathas Path (516)316-7374(Sue's Cell) E-Mail Address 1 Southold, NY, 11971 County:Suffolk Township: Buyer(s) listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification ,sheets, in accordance with 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 for TBD. Windows-SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows only, welded corners, foam injected frames, Sashlite technology, Heatshield, Duraglass, exterior custom capping, installation, clean up and haul away of all job related debris. Doors-Dynasty Series Inclusions: Includes all new hardware, ball bearing hinges, foam core, reinforced wooden lock block, installation, clean up and haul away all job related debris. It is agreed and understood by and between the parties that the Product Specifications, along with the Custom Remodeling and Improvement Agreement, constitutes the entire understanding between the parties, and replace any and all prior negotiations, representations, or agreements, either written or oral. The Product Specifications may not be changed, modified, or varied In any way unless such changes are in writing and signed by both Buyer(s) and Contractor. Buyer(s) hereby acknowledge that Buyer(s) has read the Product Specifications. I have read and received each page of this 6 page agreement. P w r Home Remodeling Group .pyer(s) Buyer(s) /05/14/19 /05/14/19 J"-4� /05/14/19 Signature of Remodeling Consultant Signature Signature David Charon William Boyles Sue Boyles HS-60809 YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ,Y 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 RIGHT. May 14, 2019 10:42 n -1 -40 • I��FPi� 4,i� e „ r 4y°l Yly -/� •� wearrm T _ R R A c I 1 J + —1� Lr — _1• '4 z:o'_ _ _I .;_ _____ _.________._.,�_.� =i°__'.�----1'.-.y"-- a•s' _ —. a°'c _ ._ a So' -i\ st �'b ,.y-I � NO�K•r , r 'I I fir, I 1 MAS?E.p f O�•I r< `p_'r�:l r I w v,}fw^_ 11 ayl I ,BEDROOM '1 _ I e•95OROOM I 1. 4 y v I TI• Y` •. I °� �I '•. t i irsyr se 9 F���i _ Ir 21 n� I _� •13 r�F--1 se Y�'I 4�Lr 'll Cr _ i lI •rr-� 41�.",��i� ____ !�_@� r v_.t 11 I it 11 �____ I _ - �� ..: e` __ f"- �' ,•I _T °•�r,r'•�•6sd r�'q�a a __ '�L _ __I �I 1-_. 9 a ry O HALL K/;CREN 'd � I � ` ��_� _� �. � a•a�n erccairi,osar rvrtu I � I I_ + rrd.,rc o; - - `.1. fr9 i' - ay � ,a m# O' L 1 �• �'+_ - __ dee, __ "_-_ _i '�, �•i ' :I• '4� - ' ___ Bags Nl er1L �' '&A-X A'GE 01' i OI .B EDROOAI cO - Oe 6I9 BROOM �� .�, :I `� '�+ "^°' iw--.caace w e m ;i V !G 3•• n�_ ' 9'I'r !I• 6J l6'd,*' 9 HH L/V l.\'G RM ` i C LL —--� •. �,-d � a -----E,:'a~ r s:+' I tie C O N D F L O O R P L A N , 2-2:3oYJ scwce 'ss•l o „1 P L A N -Fijz-sr FCOOR LIVING ARGi a /G3B SO-Fr cG GOND . /qOG 44 Fr rcw c< 4••l v - TOTdC � a S Fr f' ZZ ('� Li rs�oc I ,.ry eur rrv,.e mw r,.< I I . I � I I II „ .L-------------------------------------------- ----------- ------------ `---------------- ��-------- -------- ---- —1ii R/ G H 7 S: U E E E V A 7/O Al PPP FRO /' T E LEVA710h1 ra>'a• ---- -- wr I ;1 ®I I �� _ r�.�E ew,Nrsw„w e_s,.wr,,,Nr �•.,:a• , .�•�- --- �o— in ann®rs Inc. ��176 4 APPROVED AS NOTED DATE: B.P.# FEE: BY: NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 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 SOUTHOLD SQUW04N4AANWQ BOARD S@E046L�-TISI�S OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY �y b;& National Headquarters William and Sue Boyles .z; S 2501 Seaport Drive,Chester, PA 19013 33-89224 888-736-6335 May 14, 2019 WWW.POWERHRG.COM w 1440776-DCA a�Haoa urs Project Specifications 48568-H Windows Kitchen 1 36 5"x49 0" WINDOWS. Models SL 2700 Styles Double Hung Types None Configs None OPTIONS. ColorWhite/White : Grid Pattern : Both Sashes: Colonial : Contour I Removal Wood I Additional Details None Windows. Bedrooms 2nd right 1 35 5"x45 0" WINDOWS. Models SL 2700 Styles Double Hung Types None Configs None t" OPTIONS Color White/White : Grid Pattern : Both Sashes: Colonial : Contour 1 Removal Wood I Additional Details None Windows Bedrooms left 1 35 5"x45 0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None " OPTIONS, Color White/White: Grid Pattern : Both Sashes: Colonial : Contour 1 Removal Wood I Additional Details None Windows Office 1 37 0"x45 0" WINDOWS. Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern : Both Sashes: Colonial : Contour 1 Removal Wood 1 Additional Details None Windows Bedrooms right 1 36.5"x45 0" WINDOWS Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White • Grid Pattern: Both Sashes: Colonial : Contour I Removal Wood I TFJ Additional Details None Windows Bathroom 1 35.5"x45 0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS Color White/White : Grid Pattern : Both Sashes: Colonial 'Contour I Removal Wood 1 Additional Details None May 14, 2019 10:42 ti National Headquarters William and Sue Boyles 2501 Seaport Drive,Chester, PA 19013 33-89224 888-736-6335 May 14, 2019 WWW.POWERHRG.COM a 1440776-DCA Project Specifications 48568-H Windows Garage 1 35 5"x45 0" WINDOWS- Models SL 2700 Styles Double Hung Types None Configs None `" OPTIONS Color White/White . Grid Pattern : Both Sashes: Colonial : Contour I Removal Wood I Additional Details None Windows. Dining room 1 36 5"x49.0" n.-i WINDOWS Models SL 2700 Styles Double Hung Types None Configs None OPTIONS. ColorWhite/White . Grid Pattern • Both Sashes " Colonial : Contour 1 Removal Wood 1 Additional Details Special Options(ie. Full Screen,Obscure Glass, etc)Full Screen No I Obscure Glass No I Specialty Color No I Different Color Capping No I Trim Options Yes New Inside Casing No I New Outside Brickmold No I New Sill No I New Stool Pine I New Apron No I Frame Options No I Remove and Reinstall No Windows living room 1 35 5"x49 0" WINDOWS- Models SL 2700 Styles Double Hung Types None Configs None b OPTIONS Color White/White : Grid Pattern : Both Sashes: Colonial : Contour I Removal Wood I Additional Details None Windows Kitchen 1 36.5"x49.0" ` WINDOWS Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White : Grid Pattern : Both Sashes: Colonial : Contour I Removal Wood I Additional Details None Windows Bedrooms 2nd right 1 35 5"x45.0" WINDOWS Models SL 2700 Styles Double Hung Types None Configs None 4m' OPTIONS: ColorWhite/White: Grid Pattern : Both Sashes: Colonial : Contour I Removal Wood I Additional Details None Windows. Bedrooms left 1 35 511x45.0" WINDOWS Models SL 2700 Styles Double Hung Types None Configs None OPTIONS. ColorWhite/White . Grid Pattern : Both Sashes: Colonial :'Contour 1 Removal Wood I Additional Details None May 14, 2019 10.42 . ti �.., National Headquarters William and Sue Boyles 2501 Seaport Drive,Chester, PA 19013 33-89224 888-736-6335 May 14, 2019 WWW.POWERHRG.COM 1440776-DCA Project Specifications 48568-H Windows Office 1 37.0"x45 0" WINDOWS. Models SL 2700 Styles Double Hung Types None Configs None OPTIONS. Color White I White: Grid Pattern : Both Sashes : Colonial : Contour I Removal Wood I Additional Details None EM Windows. Office 1 37.0"x45 0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White : Grid Pattern • Both Sashes: Colonial : Contour I Removal Wood I Additional Details Special Options(ie. Full Screen,Obscure Glass,etc)Full Screen No I Obscure Glass No I Specialty Color No I Different Color Capping No I Trim Options Yes New Inside Casing No I New Outside Brickmold No I New Sill No I New Stool Pine I New Apron No I Frame Options No I Remove and Reinstall No Windows- Bedrooms right 1 36.5"x45 0" WINDOWS- Models SL 2700 Styles Double Hung Types None Contigs None OPTIONS: Color White I White: Grid Pattern: Both Sashes: Colonial : Contour I Removal Wood I Additional Details Special Options(ie. Full Screen,Obscure Glass,etc) Full Screen No 1 Obscure Glass No I Specialty Color No I Different Color Capping No 1 Trim Options Yes New Inside Casing No I New Outside Brickmold No I New Sill No I New Stool Pine I New Apron No I Frame Options No I Remove and Reinstall No Windows. Garage 1 35 5"x45.0" WINDOWS. Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White I White: Grid Pattern • Both Sashes: Colonial : Contour 1 Removal Wood I I Additional Details None r.. I Windows Dining room 1 36.5"x49.0" WINDOWS Models SL 2700 Styles Double Hung Types None Configs None " OPTIONS- Color White/White : Grid Pattern : Both Sashes: Colonial : Contour 1 Removal Wood 1 Additional Details None Windows. living room 1 35 5"x49 0" WINDOWS- Models SL 2700 Styles Double Hung Types None Configs Nozne ' OPTIONS. Color White/White : Grid Pattern: Both Sashes: Colonial Contour I Removal Wood l Additional Details None May 14, 2019 10:42 I