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Home My WebLink About45848-Z S11FF0(�-�, Town of Southold =off oy� 5/20/2021 P.O.Box 1179 0 o • 53095 Main Rd �ao�+ � Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42043 Date: 5/20/2021 THIS CERTIFIES that the building WINDOWS Location of Property: 1205 Bay Shore Rd, Greenport SCTM#: 473889 Sec/Block/Lot: 53.4-1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/16/2013 pursuant to which Building Permit No. 45848 dated 2/25/2021 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 kind and"as built"electric as applied for. The certificate is issued to Pomerantz,Paul of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45848 4/19/2021 PLUMBERS CERTIFICATION DATED 4 Au orie i ature g�FFotcP 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#: 45848 Date: 2/25/2021 Permission is hereby granted to: Pomerantz, Paul 1205 Bay Shore Rd Greenport, NY 11944 To: replace windows "in kind" as applied for. Replaces BP 38355. At premises located at: 1205 Bay Shore Rd, Greenport SCTM # 473889 Sec/Block/Lot# 53.-4-1 Pursuant to application dated 9/16/2013 and approved by the Building Inspector. To expire on 8/27/2022. Fees: PERMIT RENEWAL $125.00 Total: $125.00 Bui ing Inspector `og11fE0(� TOWN OF SOUTHOLD BUILDING DEPARTMENT y TOWN CLERK'S OFFICE SOUTHOLD, NY X01 � dao , 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#: 38355 Date: 9/25/2013 Permission is hereby granted to: Pomerantz, Paul 1205 Bay Shore Rd Greenport, NY 11944 To: Replace Windows "in kind" as applied for At premises located at: '1205 Bay Shore Rd, Greenport SCTM # 473889 Sec/Block/Lot# 53.-4-1 Pursuant to application dated 9/16/2013 and approved by the Building Inspector. To expire on 3/27/2015. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector Form No.6 \� TOWN OF SOUTHOLD 2Ce 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. September 10,2013 New Construction: Old or Pre-existing Building: X (check one) Location of Property: 1205 Bayshore Road Greenport House No. Street Hamlet Owner or Owners of Property: Paul Pomerantz Suffolk County Tax Map No 1000, Section 53 Block 4 Lot 1 Subdivision Filed Map. Lot: Permit No. Date of Permit./ -ZEo — (3Applicant: Rosalee Burgess-The Neher Group Health Dept. Approval: Underwriters Approval: Planning Board Approval. Request for: Temporary Certificate Final Certificate: X (check one) Fee Submitted: $ 5_Z) Applicant Signa e pF SOUr�®� Town Hall Annex ® Telephone(631)765-1802 54375 Main Road 01111110 Fax(631)765-9502 P.O.Box 1179 ® sean.devlinCa)-town.Southold.ny.us Southold,NY 11971-0959 COW N BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To. Paul Pomerantz Address: 1205 Bay Shore Rd city,Greenport st: NY zip: 11944 Budding Permit# 45848 Section. 53 Block: 4 Lot: 1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: AS BUILT License No- SITE DETAILS Office Use Only Residential X Indoor X Basement Service X Commerical Outdoor X 1 st Floor X Pool New Renovation 2nd Floor X Hot Tub Addition Survey X Attic Garage X INVENTORY Service 1 ph X Heat Duplec Recpt 3 Ceiling Fixtures 1 Bath Exhaust Fan Service 3 ph Hot Water Oil GFCI Recpt 3 Wall Fixtures 3 Smoke Detectors 4 Main Panel 100A. A/C Condenser Single Recpt Recessed Fixtures 1 CO2 Detectors Sub Panel A/C Blower Range Recpt Ceding Fan 1 Combo Smoke/CO 2 Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 5 4'LED Exit Fixtures Pump Other Equipment: DW, Micro, Oven, Fridge Notes: " AS BUILT NO VISUAL DEFECTS " Pre - CO Whole House Inspector Signature: Date: April 19, 2021 S Devlin-Cert Electrical Compliance Form.xls --- — --- - ------- oy�00F SOUIy� # # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECT-ION [ ] FOUNDATION IST [ ] RO GH PLBG. [ ] ,FOUNDATION 2ND KSULATIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL vt m [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE 3�I�o�'y0v1 INSPECTOR Vl--�Z4 50UlyO� # # OWN OF SOUTHOLD BUILDING DEPT. °�ycourme�' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION-2ND - j ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ]- FIREPLACE & CHIMNEY [ ] FIRE,SAFETY INSPECTION- [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) L 7(FI [ ] CODE VIOLATION ] PRE C/O REMARKS: Tgf,- OUT L115-- DATE r INSPECTOR ,lv-- # TOWN OF SOUTHOLD BUILDING DEPT. `ycourm '' 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND- [ ] INSULATIOWCAULKING, [ ] FRAMING/STRAPPING [ ] FINAL [° ] FIREPLACE-&-CHIMNEY j ] FIRE ZAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE-RESISTANT-PENETRATION [ ] ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: N126a DATE INSPECTOR �� r- i 1: I INOULATION M N.Y. / Y 1 1 . / 1 1. 1 r- - P TOWN-dF 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 Survey South oldTown.NorthFork.net PERMIT NO. ��C Check Septic Form N Y S.D.E.0 Trustees 5---20 �f]E L/ E Flood Permit Examined 20 Storm-Water Assessment Form Contact: Approved 20 SEP 16 2013 Marl to: The Neher Group Disapproved a/c 1239 Revere Drive, Chalfont, PA 18914 BLDG DEPT. Phone.—215-716-3539– i 215-716-353i&l Expiration ,20 1� OF SOUTHOLD Building Inspector APPLICATION FOR BUILDING PERMIT Date September 10 120 13 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 pen-nit 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. ` - Rosalee Burgess (Sib iature of ap icant or name,if a corporation) 1239 Rew�q PrJYP, CS 1Ug t,1 D5 14 (M i nl b a�[ttr�applicant) 3B P #-31b- State whether applicant is owner, lessee, agent, architect, engineer, general cont-aAjf:ir, c�ian,pluBY m o uilder AGENT FEE DEPARTMENT AT --765-1802 8 ANI TO 4 PM FOR Name of owner of premises Paul Pomerantz FOLLOWING INSPECTIONS (As on the tax roll or latest dted)DUNDATI0 - If a is n is a corpo ati,n, sig a�dlyorized officer FOR POURED CONCRETE �` ��j � 2 ROUGH FRAMING,PLUMBING, STRAPPING, ELECTRICAL&CAULKING (Name and title of corporate officer) 3 INSULATION 4 FINAL-CONSTRUCTION &ELECTRICAL Builders License No. 27587-H _ Pv UST BE COMPLETE FOR C 0 Plumbers License No. N/A __ ____ ALL CONSTRUCTION SHALL MEET THE Electricians License No. N/A _ _ _ REQUIREMENTS OF THE CODES OF NEW _ YORK STATE NOT RESPONSIBLE FOR Other Trade's License No. N/A -- DESIGN OR CONSTRUCTION ERRORS 1. Location of land on which proposed work will be done: 1205 Baychore RoadGreenpbrrrt( R -A Nl ry - House Number Street I gm g�0 p RR 53 ��VYF � ' County Tax Map No. 1000 Section Block 4 ) ! G�a M s6 __gg.,,��g r t Subdivision _ Filed Map No. -- y I I=ifd i _ y T E 10 y?L?U 4 B 9,E zl 4o ; i F� ' J Y 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Single Family Residence b. Intended use and occupancy Single Family Residence 3. Nature of work(check which applicable):New Building Addition Alteration Repair X Removal Demolition Other Work (Description) 4. Estimated Cost $14,378.00 Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units 1 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 Fortner 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 fiom premises?YES NO x 1205 Bayshore Road 14.Names of Owner of premises pain Pomerantz Address Greenport, Newyork Phone No. 631-477-1714 Name of Architect N/A Address Phone No Name of Contractor THn At-Hume SerVICeS Address 4n ngpc AypnP Ste 17Phone No. 877-RnR_nnrn Hauppauge, NY 11788 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 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 X * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OFgq�fee ) being duly sworn,deposes and says that(s)he is the applicant (Name of individuasi ning contract)above named, (S)He is the qe f (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief, and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this /O day of 0 20/3 Notary Public Signature of plicant AMUS D.STEVENS Notary Public,State of New York Qualified in Bronx county Reg.No.01ST6241005 my Commission Expires 05.09-2015 Tklvsf �'t O• OU1 LV111V LDJG6z1ART 1Yl E1VV`1- LICl.LIN ca I11l��Cl.LV1 � TOWN OF SOUTHOLD c =` Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(@-southoldtownny.gov - seand(c southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Name:Owner- Pre Exisitng C of O (Agent- Nick Mazzaferro, PE) l L ir_.PnSa IVn_: email- nickmazzaferro tav'�verizon.net Phone No: 516-457-5596 ❑✓ I request an email copy of Certificate of Compliance Address.: 1205 Bayshore Road, Greenporot NY 11944 JOB SITE INFORMATION (All Information Required) Name: Owner- Pre Exisitng C of O (Agent- Nick Mazzaferro, PE) Address: 129 Baysi fore Road, Gr eel por lit N Y 1 1944 Cross Street: none Phone No.: 516-457-5596 Bldg.Permit#: Pre-Exisitng �rj�, � email: nickmazzaferro @verizon.net Tax Map District: 1000 Section:53 Block: 04 Lot: 01 RRIEF DES RIPTinN OF WORK (Please Print (Nearly) Electrical Inspection required for Pre-Existing C of O Electrical Inspection required for Pre-Existing C of O Electrical Inspection required for Pre-Existing C of O Check All That Apply: Is job ready for inspection?: DYES ❑NO ❑Rough In [E]Final Do you need a Temp Certificate?: ❑YES ENO Issued On Temp Information: (All information required) Service Size ❑1 Ph ❑3.Ph Size:- A _ # Meters, Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead' # Underground Laterals ❑1 ❑2 ❑H Frame❑Pole Work done on Service? ❑Y ❑N Additional Information: PAYMENT DUE WITH APPLICATION riorrnrai in_vna_rrinn i:nrm ;4_t Wi ymv J� PERMIT# Address: \ I Switches`1 " outlets ------------------------------------------------------------------------ GFI's Surface - Sconces H H's r � UC Lts I i Fans � - Fridge HW 1 � � t , Exhaust ; Oven I Dryer Service yVlicro f- -. - - ,� - - �arpori -'--- -- _ • .. :, - ' �• � - - . . �G neratgr -� ; Gumbo Cooktop Transfer AC AH Mini Special: Comments: G Adv 49?9 ^ ke - 11 he eher ROUP1239 Revere Drive • Chalfont, PA 18914 • Phone: 215.716.3539 Fax: 215.716.3543 247 N. Main Street• Red Lion, PA 17356 • Phone: 717.417.6678 • Fax: 717.417.6320 Inc. FOR ALL YOUR PERMITTING NEEDS September 12, 2013 Building Department Town of Southold 53095 Route 25 Southold,NY 11971 RE: Windows permit for the property located @ 1205 Bayshore Road, Greenport,NY 11944 Dear Sir/Madam: I have enclosed a completed Building Permit Application Package, a self-addressed stamped envelope, and a check for two hundred fifty dollars ($250.00), the submission fee for the aforementioned property. Your assistance is greatly appreciated. If you have any questions please call Stephanie Neher at 215-716-3539. Suffolk County License#27587 THD At-Home Services, Inc. 40 Oser Avenue, Suite 17 Hauppauge,NY 11788 877.808.00500 C 1 75-2698460{Federal Id Number) L.�l Cordially, SEP :v„ i\�•k G -C�y BLDG DEPT. Rosalee urg s TOWN OF SOUTHOLD cc: Stephanie Neher A TT A if A 7r7 A U U T3 D 11 T) U a .� a a a a a .� 9 • •9 • l 9 81 Xzjz_j1 a1 �Jl�1 �!q 1 • a i• PO Box 57, Greenport,N.Y. 11944 Phone- 516-457-5596 Consulting Engineer February 24, 2021 Construction, Estimating, Labor Law Page 1 of 1 Town of Southold-Building Department 53095 Main Road PO Box 1179 Southold NY 11971 Re: 1205 Bayshore Road Sl_-_ _____ i TeT�7 'a 944 Greenport, N.Y. L-17 District-1000, Section-53 Block-04 Lot-01 Old Building Permit Number—38355 Dated 9-25-2013 Enclosed please find a check for $125.00. This application fee is for renewal of expired Building Permit- 38355. It is understood that the inspection for the work covered by this permit is scheduled for March 16, 2021 Thank You, Nicholas 1MTazzaferro Nicholas J. Mazzaferro, P.E. '' "A FEB 9 4 2021 STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) Ib.Business Telephone Number of Insured 770-433-8211 THD At-Home Services,Inc 2690 Cumberland Pkwy,Ste 300 lc.NYS Unemployment Insurance Employer _ Atlanta,GA 30339 Registration Number of Insured 45003895 Work Location of Insured(Only required ifcoverage is specifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York Stale, i.e., a Wrap-Up or Social Security Number Policy) 75-2698460 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company Town of Southold 3b.Policy Number of entity listed in box"la" 53095 Route 25 WC 033575314 Southold,NY 11971 3c. Policy effective period _03/01/2013 to 03/01/2014 3d. The Proprietor,Partners or Executive Officers are i X included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. i This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(M)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also not 6 the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) 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: John QlHstopher__ ()Lk-, name of authorized representative or licensed agent of msurance carrier) Y Approved by: 07/02/2013 (Signature) (Date) Title: Attorney-in-Fact Telephone Number of authorized representative or licensed agent of insurance carrier: 770-670-2000 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.ny.us 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) I b. Business Telephone Number of Insured (770)433-8211 THD AT-HOME SERVICES,INC. 1 c.NYS Unemployment Insurance Employer Registration DBA THE HOME DEPOT AT-HOME SERVICES Number of insured 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1 d.Federal Employer Identification Number of Insured or Social Security Number 75-2698460 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) AETNA LIFE INSURANCE COMPANY TOWN OF SOUTHOLD 3b.Policy Number of entity listed in box"la": 53095 ROUTE 25 GS-839226-311 SOUTHOLD,NY 11971 3c. Policy effective period: 01/01/2013 to 01/01/2014 4.Policy covers: a.® All of the employer's employees eligible under the New York Disability Benefits Law b.❑ 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_July 2,2013 By: (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number:(860)273-1237 Title:Compliance Consultant IMPORTANT If box "4a" 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"4b" is checked, this certificate is NOT COMPLETE for purposes of Section 220, Solid. S of the Disability Benefits Law. It must be mailed for completion to the Workers'Compensation Board DB Plans Acceptance Unit,20 Park Street Alban New York 12207. PART 2. To be completed by NYS Workers' Compensation Board(Only if box"011 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 ofNYS Workers'Compensation Board Employee) Telephone Number Title Please Note: Onlv 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-1201. Insurance brokers are NOT authorized to issue this form. DB-120.1 (5-06) i SUFFOLK COUNTY DEPARTMENT OF CONSUMER AFFAIRS MINVIRM HOME IMPROVEMENT a. CONTRACTOR " BOYD A UPHAM This certifies that the THD AT HOME SERVICES INC ATTN PEGGY bearer is duly PAYNE licensed by the Uesm.Numbs D...a w County of Suffolk 09/17/1999 Clifford Coleman 27587-H PRATM 09/01/2013 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 1 a. Legal Name and Address of Insured(Use street address only) 1 b Business Telephone Number of Insured (770)433-8211 THD AT-HOME SERVICES,INC. 1 c.NYS Unemployment Insurance Employer Registration DBA THE HOME DEPOT AT-HOME SERVICES Number of Insured 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1 d.Federal Employer Identification Number of Insured or Social Security Number 75-2698460 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) AETNA LIFE INSURANCE COMPANY TOWN OF SOUTHOLD 3b.Policy Number of entity listed in box"la„: 53095 ROUTE 25 GS-839226-311 SOUTHOLD,NY 11971 3c. Policy effective period: 01/01/2013 to 01/01/2014 4.Policy covers. a.® All of the employer's employees eligible under the New York Disability Benefits Law b.❑ Only the following class or classes of the employer's employees- Under penalty of peduly,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 July 2,2013 By q z� &ae-- (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number.(860)273-1237 Title:Compliance Consultant IMPORTANT If box "4a” is checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that earner,,this certificate is COMPLETE. Mad it directly to the certificate holder. If box"4b"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 (Sia aturc of NYS Workers'Compensation Board Employee) Telephone Number Title Please Note: 0n1v insurance corners 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) STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) Ib.Business Telephone Number of Insured 770-433-8211 THD At-Home Services,Inc 2690 Cumberland Pkwy,Ste 300 1c.NYS Unemployment Insurance Employer _ Atlanta,GA 30339 Registration Number of Insured 45003895 Work Location of Insured(Only required if coverage is specifically 1d.Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 75-2698460 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company Town of Southold 3b.Policy Number of entity listed in box"la" 53095 Route 25 WC 033575314 Southold,NY 11971 3c. Policy effective period 03/01/2013 to 03/01/2014 i 3d. The Proprietor,Partners or Executive Officers are X included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"1a" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremtums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) 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: Jolp Ckristopher rint name of authorized representative or licensed agent of insurance carver) Y Approved by: 07/02/2013 LT (Signature) (Date) Title: Attorney-in-Fact Telephone Number of authorized representative or licensed agent of insurance carrier: 770-670-2000 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.ny.us WINDDWSPECiFICATION MEET - Spec.Sheetk, 774 `t �1yA� Sheet of - _ Data. Customer:, _ - /obb:"��°=�� Consultant._ ___---_—// Naw Window - Labor HingeLucdt)ons Exlninq Window Measurements Grids ProductOPtlons Options From UtLeh to Mql,s t, ht CO Bays,Bows, QUrnnts,I Pnl, Location Color RoughOpemng Rofbars Aofbars use L,It or S 3 Glos; Mnt Item, Hardware Code Fordoors usa vi e; 9 Screens "S"=stationary or w a MUII "X°=o Pesating Style Wraps s71 S v° ti z :7 y xE N Rapm Hoar Code Y/N Sr Ie Cade SedeS Code 00 , fv` f� A�DD pf F �vrh �r Y p G(a ate-wrr41 All W 3-2 y401 wIAJ . - O - ASPECIAL CONSIDERATIONS, Wrupcolor minterlor[asingType --- - OayOeBdwwlndow: O 4q Sea,bearJM"terial cvinyltoByBlrchoroak) - — B.ayProjectlonAngle 00"orM") - -,'�-a Bay Flanker lype(UH,SH or ccmnt) - I op of window to snrat(inches) iTl6colorol soffit material I have rauhtWed and agcowrth all the Job spcaficannnsahtwe and the If ticd to so constructR t,cola df No) i Special Tor—and Candnlunsonthe back of theyellnw(Cusco—)copy Garden Window: 5eatbmrd Mate(latfvinyl only-White Piomte,Birch or Das) -- customer Signature Wall`flua - nchcs) - - --- Adddranal Shelf(Yes ar Nn) 1 Ihc•c om 9�+,n•�na,,.,.A,rgl.c+n'1 mat<haxi,my calor While-71W Home aeryro \4'Ino r<rslnn>cr MD-168 WINDOW SPECIFICATION SHEET - Spec•Sheem ��t�f� 7 7 7 sheet• of � Customer 4 4&e— t7 L.! ---- lob A:------ Consultant e4 Date• f New Window Existing Window Hinge I. itlans ti op Maawrementt Gilds ProductOptinns Diorons FroMmisldo, (� Left to Hight CLLocetron - says,Bows, Color RoughOpenrnq kofban Nofbar3 Unnnts,IPnl, useL RorS Glass Miseltems Hardware Code Fordoor3use i o, a @ Smells "5°=statlnnaryor Style Wraps Mull w r a r X-operating Room Ftoor Code tY/N St lelbde Series Cade W 3 00 l lahyt l �'l�- f 65'va wfi� 3�! �� 7 19 t 3 • a -- `° oar �a j q qg w* tw? ,s • 11 _— is 13 (n N - U Wrap color SPECIAL CUNSIDEBATIONS: WInteriortasing Type N E Bay or Bow window: 0 Seatboard Matedal(vrnylon(y-alrchoroah) L cu Bay RolecilorlAngle (309ar4S t) Bay rianxar Type(DH,SH or Csnv,l) �+ rep afw(ndow to sotht(Inehetl - - lr tied to soffit,color of soffit matp,lat _ I hava reviewed and agr¢ewith all the Job specifications above and the Construct nonf(Yes or No) 1 - 3(>ecWl T¢Imsand Conditions on the back of the yellow(Custgner)copy. Gorden Windnw: Seatbowd foalenel(vinyl ontyWhite Plooltc,Richer Oak) Wall Thickness,(Inches) Customrr Strrnatsne - Addldon+l shelf(Yes or No r.tasm n rovrxsm,r Jin nnr,h4,yrq xiImanrtu4h,J ral.r • Whve•Tho Hvnw Dvpol Yellow-L'uumm,, iHR rbo