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Home My WebLink About46857-Z � alTOWN 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 #: 46857 Date: 9/21/2021 Permission is hereby granted to: Weinberg RM 2016 Rv Trt 10 W 66th St New York, NY 10023 To: Construct addition and alterations to existing single family dwelling as applied for. At premises located at: 2420 Indian Neck Ln., Peconic SCTM # 473889 Sec/Block/Lot# 86.4-6.6 Pursuant to application dated 6/8/2021 and approved by the Building Inspector. To expire on 3/23/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $636.00 CO-ADDITION TO DWELLING $50.00 Total: $686.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 lbs Date Received APPLICATION OR BU11ILDIING �� T For Office Use Only � E PERMIT NO. Building Inspector Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:06/03/2021 OWNER(S)OF PROPERTY: Name:Richard M Weinberg 2016 Revocable Trust&Elaine M Reich Revocable Trust SCTM# 1000-86-04-6.6 Project Address:2420 INDIAN NECK LN, PECONIC, NY 11958 Phone#:631 734-8894 Email:ereich@graubard.com Mailing Address:2420 Indian Neck Lane, Peconic, NY 11958 CONTACT PERSON: Name:JORGE A RIOS Mailing Address:42 MONTAUK AVE, EAST HAMPTON, NY 11937 Phone#:631 377-2077 Email:jariosdwg@gmail.com DESIGN PROFESSIONAL INFORMATION: Name:JORGE A RIOS Mailing Address:42 MONTAUK AVE, EAST HAMPTON, NY 11937 Phone#:631 377-2077 TTmall�jariosdwg@gmail.com CONTRACTOR INFORMATION: Name: PHIL PAPE - Pape Construction Co., Inc. Mailing Address:P.O. BOX 2088, BRIDGEHAMPTON, NY 11932 Phone#:631 204-5044 Email:Phil@papeconstruction.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure > Addition ❑Alteration ❑Repair *Demolition Estimated Cost of Project: ❑Other d c)0 t) a Will the lot be re-graded? Dyes *mNo Will excess fill be removed from premises? Yes []No 1 ..� ..�._:� �\\ Ex istin use of props Single IIResidenceIntends use o property:Single i i Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to I AC_.a - PY _ this props Yes o IF YES,PROVIDE MT 3 Application Submitted (print ne): —` RAuthonzed Agent ner Signature f Applicant- 3 = Dates STATE OF NEW ) SS: COUNTY OF SUFFOLK ) 0 being duly sworn,deposes and says that(s)he is the applicant (Nave of individual signing contract)above named, 3 (S)he is the (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/her knowledge and belief,and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of Mo � / N StateV-69 VNotary Public Commission PROPERTY OWNER AUTHORIZATION (Where the applicant is not theowner) I, EVa It, residing at 2420 Indian Neck Lane 9 YM- do hereby authorize to apply on my a f to thewr; Southold uii in Department for approval as described herein- I , WS 1 Owner's Signature Date PrintOwner's Name 2 Generated by REScheck-Web Software Compliance Certificate Project 2420 Indian Neck lane Q 01i Energy Code: 2018 IIIECC Location; Peconic, New York Construction Type: Single-family sp- Project Type: Addition Climate Zone: 4 (5572 HDD) Permit Date, Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 2420 Indian Neck Lane Elaine& Richard Weinberg Jorge Rios Peconlc, NY 11958 631-377-2077 J ariosdwg@g mail,corn Compliance: 2.4%Better Than Code Maximum UA: 328 Your UA: 320 Maximum SHGC: 0.40 Your SHGC: 0.30 The%Better or worse Than Code index reflects how close to compliance the house Is based on code tracle-off rules, It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Envelope AS_S!Q_MWieS Ceiling: Cathedral Ceiling 1,425 40.0 0.0 0.026 0.026 37 37 Wall: Wood Frame, 1611 o.c. 1,590 21.0 0,0 0.057 0,060 69 72 Door: Glass Door(over 50%glazing) SHGC:0.30 72 0.300 0,320 22 23 Window: Vinyl Frame SHGC: 0.30 311 0,300 0,320 93 100 Floor: All-Wood joist/Truss 395 1910 0.0 0.047 0,047 19 19 Floor 1: Slab-Cm-Grade (Unheated) Insulation depth: 0,01 110 0.0 0,730 0.700 80 77 Compliance Statement., The proposed building design described here is consistent with the building plans,specifications, and other calculations submitted with the permit application,The proposed building has been designed to meet the 2018 IECC requirements in RE_Sche�t Version- RES eck-Web incl to corn !,,h the mandatory require- nts listed in the REScheck Inspectionfhe list. -" I if I Name -Title 5�nature Dat# Project Title: 2420 Indian Neck lane Report date: 07/19/21 Data filename: Page 1 of 9 i i REScheck Software Version ; REScheck-Web Inspection Checklist Energy Code: 2018 IECC Requirements: 100.0% were addressed directly in the REScheck software T ext in the "Comments/Assumptions" columns provided its the user in the REScheck Requirements screen. For each requirement, the user certifies that a code reauirernent will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is prodded, Section Plans Verified Field Verified # Pre-Inspection/Plan Review Complies? Comments/Assumptions tions l& Re .ID Value i Value 1 p 103.1, 1 Construction drawings and g :I3Cornplies ;Requirement will be meta 103.2 !documentation demonstrate —lDoes Not [PR111 ;energy code compliance for the l ; l ;building envelope.Thermal ; Not Observable ;envelope represented on jNotApplicable ;construction documents, 103.1 ;Construction drawings and ; ornplies ;Requirement will h, met. 103,2, ;documentation demonstrate ,]Does Not 1403,7 ;energy code compliance for [PR3]1 l llght no ano mechanical systems llok Observable 'Systems serving multiple EINot Applicable !dwelling units must demonstrate l :compliance with the IECC ;Commercial Provisions, 302.1, !Heating and cooling equipment is; Heating: Heating: ; Complies ,Requirement will be met. 403.7 :sized per ACCA Manual S based Btu/hr Btu/hr E]Does Not [PR212 on icads calculated per ACCA } Manual J or other methods Btujhrg: CoolinBtuu/hrg iL7Not Observable :approved by the code official. UNot Applicable , F � f Additional Comments/Assumptions: I 1_High Impact(Tier l) 2 Medium Impact (Tier 2) ; 3 [Law Impact(Tier 3) Project Title: 2420 Report date: 07/19/21 Data filename: Page 2 of 9 Section ! Plans Verified Field Verified # Foundation Inspection Value Value Complies? Comments/Assumptnsio &Req.ID 402.1.2 £Slab edge Insulation R-value, R- R- ;Dcomplles ;see the EnvelopeAssemblles (FO1]1 ❑ Unheated El Unheated .❑Does Not ;table for values. I ❑ Pleated ❑ Heated ![:]Not Observable 1 :EINot Applicable ` 402,1.2 ;Slab edge insulation ft i ft '❑complies 'See the Envelope Assemblles (F03]1 I depth/length, ;❑Does Not ;table for values. ;❑Not Observable ;❑Not Applicable 303.2.1 A prate the covefing is ins.a#led ,❑complies :Requirement will be met. [FO11]2 3to protest exposea exterior f i ODoes Not insulat on and..emends a }minimum of 6 in,below grade, []Not Observable ❑Not AoPl cable 403.9 ;Snow-and ice-melting system '❑comolies ;Re uirement will be met. (FO12]2 Pcontrols installed. q I i ❑Does Not ',::]No,Observable [ i T❑Not Aophcable f Additional Comments/Assumptions: i I 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 l Low Impact(Tier 3) Project Title: 2420 Report date: 07/1.9/21 Data filename: Page 3 of 9 Section Plans Verified j Field Verified # Framing/Rough-In Inspection; Complies? Comments/Assumptions & R Value Value 402.1.1, ;Glazing U-factor (area-weighted U- U- ;❑iCorttpliese the EnVeloce Assemblies 402.3.1, :average). :table ferva, 5 F 402.3.3, L.Does Not ➢ 402.5 1,F—]Not Observable [FR2]1 E]Not Applicable I �303.1.3 :U-factors of fenestration products' a ❑Compiles !Requirement will be met. [FR411 ;are determined in accordance #with the NERC test procedure or Does Not taken from the default table, L` Not Observable ; ❑Noa Applicable 402,4.1,1 ;Air barrier and thermal barrier 'LlComplies "Requirement will be met, I[FR23]1 installed per manufacturer's i Instructions, Goes Not ',[]Not Observable ❑Not Applicable 402,4.3 ;Fenestration that is not site built ,❑Complies 'Requirement will be met. 1 [FR20]1 `is listed and labeled as meeting i �❑Does Not ' s HAMA/WDMA/CSA 101/I.S.2/A4401 or has infiltration rates per NFRC [ L'ONot Observable ;400 that do not exceed code ;❑Not Applicable ¢limits. 402.4.5 IC-rated recessed lighting fixtures; ;❑Complies 'Requirement will be met, (FR16]2 )sealed at hour ng,lnterlor finish ;❑ Does Not land labeiec. to Ind°tate s2.0 cfm iealcage at 75 a ) I'❑Not Observable I I❑Not Applicable z 403.3.1 ,Supply and return ducts in attics ;�lCornplles Requlrement will be met. [FR12] ;insulated >= R-8 where duct is _ ❑[1s Not I >= 3 inches in diameter and >_ R-6 where < 3 inches. Supply and= ❑Not Observable , !return ducts in other portions of COW,Applicable ;the building insulated >= R-6 for ; ;diameter>= 3 inches and R-4.2 E )for< 3 inches In diameter, I 1 403,3.2 ;Ducts, air handlers and filter ❑Complies ;Requirement will be met. [FR13) boxes are sealed with ' =❑Does Not ;joints/seams compliant with i ❑Not Observable International Mechanical Code or ; International Residential Code, ash ❑Not Applicable applicable. - I 403.3.5 ;Building cavities are not used as 1. .❑Complies ;Requirement will be met, [FR15] Iducts or plenums. 'Does Not i ❑Not Observable I °-:l❑Not Applicable I 1403.4 'HVAC piping conveying fluids R- i R- '❑Corn €les ;Requirement will be met, (FR17]2 ;above 105 F o_r chilled fluids ❑Does Not !below 55 V are insulated to }R i !3, ❑Not Observable TDNot Applicable 403.4.1 ;Protection of insulation on HVAC ! - 10cornpl es ;Requirement will be met, �(FR24]1 :piping. _,=❑Does Not '❑Not Observable € ❑Not Applicable 1403.5.3 ;Hot water pipes are insulated to ; R- R IL Cornolies ;Requirement will be met, (FRI8]2 !?R-3. ❑Does Not ! ) ;❑Not Observable ❑No`Applicable 403.6 Automatic or gravity dampers are; Co pf,es =Requirement will be mat. (FR19]2 installed on all outdoor air ;❑Does Not intakes and exhausts. i ❑Not Observable i irlNot Applicable 1 High Impact {Tier 1) j 2 Medium Impact{Tier 2) 3 Law impact(Tier 3) Project Title: 2420 Report date, 07/19/21 Data filename: Page 4 of 9 i Additional Comments/Assumptions: i 1 i High Impact(Tier 1) 2 Medium Impact(Tier 2) =3 Low Impact(Tier 3) I Project Title: 2420 Report date: 07/19/21 Data filename: Page 5 of 9 on 1 Plans Verified 1 Field Verified # Insulation Inspection Value [ Value Complies? Comments/Assumptions &Req.11) 303.1 ;All installed insulation is labeled :i omplles Requirement will be met. [IN13]1 or the installed R-values Does Not ;provided. , ; Not Observable 1 ON t Applicable f 402.1.1, Floor insulation R-value. i R- R- :JCompiles ;see the Envelope Assemblies 402,2.6 ❑ Woad E] Wood ODo Piot ;table for values. [IN1]1 }❑ Steel '❑ Steel ,❑Not Observable 4-b 1 ; Nat Appficable a # X303.2, ;Floor insulation installed per i LJ ^mplies Requirement well be met, 402.2,8 ;manufacturer's Instructions and IL—Does Not [IN2]1 !in substantial contact with the Not Observable ;underside of the subfloor, or floor; framing cavity insulation is in ; tL�Not Applicable ,contact with the top side of ;sheathing, or continuous s ;insulation Is installed on the I ;underside of floor framing and extends from the bottom to the l ;top of all perimeter floor framing !members. 402.1.1; ;Wali Insulation R-value. If this is a R- R- omphes Seethe Envelope Assemblies 402.2.5, !mass wall with at least 1/2 of the 3❑ Wood ❑ Wood `Does Not El Mass E] Mass ; A 'table for values, 1402.2.6 ;wall Insulation on the wall ,DNot Obsv =able ; [IN3]1 -exterior,the exterior insulation = 1 ' �) 'requirement applies (FRISteel Steel Not Aoplcable ; I 303,2 ;Wall Insulation is installed per omplles ;Requirement will be met. [1N4] #manufacturer's instructions, sO'Loes Not ;❑Not Observable Not Appicable } Additional Comments/Assumptions: 1'high Impact(Tier 1) 2 Medium Impact(Tier 2) ] 3 Low Impact (Tier 3) Project Title: 2420 Report date: 07/19/21 Data filename: Page 6 of 9 l Section € Plans Verified Field Verlfied # Final inspection Provisions ; Complies? Comments/Assumptions tions & Re .ID Value Value P P 402.1.1, ;Ceiling insulation R-value. R- ' R- 1❑CompJles S_e the ErvelopeAssemblles 402.2.1, Wood 1 le fore es. 402.2.2, ;❑ d ,❑Does Not 402.2.6 ❑ Steel l Steel :, ]Not Observable (FI1]15 !❑Not Applicable f l 1 1 l f 303.1 1,1,sCelling insulation Installed perCornplles ' ;Requirement will be met. 303,2 'manufacturers instructions, =❑Does Not [FI2]1 4 Blown Insulation marked every 300 ft2, 17Not Observable >❑Not Apolicable ' 402.2.3 "Vented.attics with air permeable ;❑Complies ;Requirement will be met, [FI2211 €insulaton include baffle adjacent 1 ❑ ,Yes Not 1 to scffit a o cave encs that ;extends over insulatlof-1, ('LlNot Observable j 1❑Not Applicable 402,2.4 ;Attic access hatch and door , R- R- ,❑Como;[es 'Requirement will be met. [F13] 'insulation ?R-value of the 3❑Does Not :adjacent assembly, k I i flN Not Observable ' ofApplicable 402,4.1.2 ;Blower door test @ 50 Pa. <=5 ACH 50 ACH 50 = Chorr;plies :Requirement will be met, [FI1711 =ach in Climate Zones 1-2, and 1 'Does Not <=3 ach in Climate Zones 3-8. ❑Not Observable i 'ONot Applicable E 403.3.3 !Ducts are pressure tested to cfm/100 cfm/100 omolies Requirement will be met. I IF12711 determine air leakage with tet= ft' #Does Not 'either: Rough-in test:Total ' ;leakage measured with a ;❑Not Observable pressure differential of 0,1 inch li�lNot Applicable w.g. across the system including :the manufacturer's air handier (enclosure if installed at time of 'test.Postconstruction test;Total .leakage measured with a ;pressure differential of 0,1 inch l 1 w.g. across the entire system 1 i I Including the manufacturer's air 1 :handier enclosure. 403.3.4 ;Duct tightness test result of<=4 ; cfm/100 cfm/100 ;❑CoEmplies ;Requirement will be met, [F14] ;cfm/100 ft2 across the system or ; ft2 ftz 1❑Does Not l<=3 cfm/100 ft2 without air 3 handler @ 25 Pa. For rough-in ❑Not Observable ;tests, verification may need to ❑Not Applicable ;occur during Framing Inspection. f l 403,3.2.1 ;Air handler leakage denigrated ,❑Complies ;Requirement will be met, [F124]1 'by manufacturer at<=2 of ❑Does Not I :design airflow. l I ❑Not Observable l 10Not Applicable 403.2 1 Programmable thermostats ( ;❑:Complies ;Requirement will be met. IR !installed for control of primary j❑poen Not I heating and cooling systems and l z 'Initially set by manufacturer to '❑Not Observable �� :J❑Not Applicable code specifications. ) = � _ - 403.1.2 .Heat pump thermostat installed T]Complies Requirement will be met. [FI10]2 on heat pumps. e � - '''❑Does Not ❑Not Observable ❑Not Applicable 403.5.1 !Circulating service hot water _ ❑Complies 3Requirement will be met. [Fill] .systems have automatic or _ ❑I?oes Not 'accessible manual controls. i j n❑Not Observable :❑Not, pplicable 3 1 High Impact(Tier 1) i 2 Medium Impact(Tier 2) : 3 Low Impact(Tier 3) Project Title: 2420 Report date: 07/19/21 Hata filename: Page 7 of 9 Section Plans Verified Field Verified ' # Final Inspection Provisions Value : Complies? Comments/Assum tions & Re .ID Value I P 403.61 All mechanical ventilaton system lllCornphes 'Requirement wlJl be met, [FI25]2 lfans not part of tested and listed , Does Not HVAC equipment meet efficacy l i and air flow limits per Table UNot Observable j R4016.1, iUNot Applicable 1403.2 ',Piot watt "Eters supplying heat 'E]Com lies iReoujrement will be met, z + P [F126] ti r gh o ,e=ort o-p:p heating I i QDoes Not � ysterns have outdoor lea Ch } ; ;control to lower boiler water IDNot Observable [temperature based on outdoor l--!Not Applicable jtemperature. 3 403.5.1.1 '_,Heated water circulation systems , Complies ;Exception: Requirement is [FI281z E have a circulation pump.The ?Does Not :not applicable. s stem return ! Y n pipe is a dedicated I =return pipe or a cold water supplyjNot Observable pipe. Gravity and thermos- *E]Not Applicable i isyphon circulation systems are not present. Controls for ;circulating hot water system 1 zpumps start the pump with signal l ;for hot water demand within the 1 ;occupancy, Controls automatically turn off the pump { }w"e -water is in circulation Iooci i is at set-point temperature and no demand for hot water exists. 403.5.1.2 ;Electric heat trace systems JOComplies 'Exception: Requirement is [FI29]2 £comply with IEEE 515.1 or UL Does Not ;not applicable. 515. Controls automatically I !adjust the energy input to the i E]Not Observable heat tracing to maintaln the Not Applicable desired water temperature in the 1 ;piping, 1403.5.2 ;demand recirculation water Complies ,Exception: Requirement is — [F13012 =systems have controls that [ Does Not not applicable. Imarage operation of rhe pump [and limit the temperature of the 'ONot Observable ;water entering the cold waken11J—Nct Applicable piping to<= 1042F. 403.5.4 'Drain water heat recovery units - Compljes °Exception; Requirement is [F131]2 Itested in accordance with CSA ) Goes Not not applicable, B55.1. Potable water-side f pressure loss of drain water heat I _ ONot Observable E recovery units < 3 psi for FINot Appilcable individual units connected to one or two showers. Potable water- side pressure loss of drain water 1 !heat recovery units < 2 psi for =individual units connected to i ;three or more showers. 404.1 90%or more of permanent I ; Complies ;Requirement w111 be met. [F1611 ,fixtures have high efficacy lamps.: _ jE]Does Not 1 s #._ ?[]Not Observable U—Not Applicable 404.1.1 1 Fuel gas lighting systems have :�Cotnpl e Requirement will be met, [F123] no continuous pilot light, ?. Does Not 0Not Observable t 1171N3t Applicable 401.3 $Compliance certificate posted. € ,111 Complies Requirement will be met, z [F17] i1Does Not ONot Observable E i V7f of Applicable 1 High Impact{Tier 1} 2 Medium Impact{Tier 2j 3 Low Impact{Tier 3) Project Title: 2420 Reportdate: 07/19/21 Data filename: Page 8 of 9 Section Plans Verified Field Verified &Re ID Final Inspection Provisions Value Value Complies? 1 Comments/Assumptions 3033 ;Manufacturer manuals for '€ l omplies ;Requirement will be met, F11813 mechanical and water heating ; Does Not systems have been provided, , Not Observable 1 l]Not Apnl`.able Additional Comments/Assumptions: 1 ENigh Impact(Tier 1) 2 'Medium Impact(Tier 2) 1 3 ILow impact{Tier 3) Project Title; 2420 Report date: 07/19/21 Data filename: Page 9 of 9 r LX Lnergy Efficiency Certificate Above-Grade Wall 21,00 Below-Grade Wall 0.00 Floor 19.00 Ceiling J Roof 40.00 Ductwork (unconditioned spaces): Window 0.30 0.30 Door 0.30 0.30 Heating System: Cooling System; Water Heater• Name: Date_: Comments STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia. Legal Name&Address of Insured(Use street address only) lb. Business Telephone Number of Insured Pape Construction Co., Inc. (631) 807-3560 P.O. Box 2088 1c. NYS Unemployment Insurance Employer Registration Number of Insured Bridgehampton,NY 11932 Work Location of Insured(Only required ifcoverage is specifically Id. Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 14-1903499 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) New York State Insurance Fund Town of Southold 3b. Policy Number of entity listed in box"la" 54375 Main Rd 23353758 PO Box 1179 3c. Policy effective period Southold, NY 11971 05/24/2021 to 05/24/2022 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) 0611 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 notes 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 maybe sent by regular mail.) Otherwise,this Certificate is valid for oneyear 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: Peter Sabat -NSA Insurance Agency (Print name of authorized representative or licensed agent of insurance carrier) Approved by: _ 06/04/2021 (Signature) (Date) Title: Sr. Partner Telephone Number of authorized representative or licensed agent of insurance carrier: 631-722-3500 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 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-07)Reverse PAPECON-01 COASILVA DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITYINSURANCE 61021 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 l this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME_ iNeefus Stype Agency PHONE - - -- 1711 Union Ave. f=i No,Ext):(631)722-3500 � (kx-N.)_(r31)7.2_2-3591 'Aquebogue, NY 11931 R info@nsainsure.com 4 INS(1RER(S)AFFOADING COVERAPF riAfC# _ INSURER A:Evanston Insurance Co. _ _ INSURED s INSURER B: Pape Construction Co.,Inc. INSURER C: P.0 BOX 2088 INSURER D Bridgehampton, NY 11932 - - - - - - INSURER E: I INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ll 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 -- - -- -- — ADDL SUBR: POLICY EFF POLICY EXP E €ILT R TYPE OF INSURANCE POLICY NUMBER °LTR'' !N WVD MM/O_ - MM/D[tlYYVY LIMITS t A X 1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ::X]l OCCUR X 3AA451986 2/2/2021 2/2/2022 ur °R� 0 RENTED $ 100;000 MED EXP{Any ona P.m5,0001..) -- PERSONAL&ADV INJURY $ 1,000,000 GE N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 , PRO JECT- LOC = 1,000,000 PRODUCTS-COMP/OP AGG =$ _ OTHER. AUTOMOBILE LIABILITY COr1BI ED SINGLE LIMIT $ _ ANY AUTO - BODILY INJURY(Parperson) OWNED SCHEDULED BODILY INJURY{per accident),: S _ AUTOS ONLY AUTOS HIRED NOP IED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY ,reit S - . ---- UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE, (_AGGREGATE DED RETENTION$ $ i WORKERS COMPENSATION PER OTH- a AND EMPLOYERS'LIABILITY Y/N RTAT�IJTE FR ANY PROPRIETOR/PARTNER/EXECUTIVEt "°-E�e =MEMBER EXCLUDED? N/A' E1.EACH ACCIDENT 4$ (11. arory in NH) E L DISEASE EA Et 1PLOYEE$ i If yes,describe under -�` - �-— -; DESCRIPTION OF OPERATIONS below ( _ E .DISEASE-POLICY LIMIT i DESCRIPTION OF OPERAT10NS1 LOCATIONS)VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached iftnorespace is required) Certificate Holder is included as additional insured with respect to General Liability as required by written contract. i { CERTIFICATE HOLDER CANCELLATION _ I l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ; 54375 Main Rd ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE i i I ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ®CD 3 0{] Emsƒ . k { �\` . ! { 0 XE E f k ; $ ; f ; $ ° ° r-/ k 2 0 _e e § \ E a § 7 _ _ , _ T £2 § / \ ƒ % y § to o m go } \ \ z -0 k M 01< \ o m j ? / ` 7 §7 < { �« / 5 � I