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Home My WebLink About46795-Z �oS�EF01�CpG Town of Southold 12/9/2021 0 y� P.O.Box 1179 0 C" 53095 Main Rd �'✓,�j0 �ao� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42590 Date: 12/9/2021 THIS CERTIFIES that the building WINDOWS Location of Property: 95 Donna Dr.,Mattituck SCTM#: 473889 Sec/Block/Lot: 115.-16-1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/30/2021 pursuant to which Building Permit No. 46795 dated 9/8/2021 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: one replacement window to existing.single family dwelling as applied for. The certificate is issued to Kirby D&D R Fmy Trt of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Oor ' e Signature �sufFo TOWN OF SOUTHOLD 00 ° 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#: 46795 Date: 9/8/2021 Permission is hereby granted to: Kirby D& D R Fmy Trt 75 Donna Dr Mattituck, NY 11952 To: Replace window at existing single family dwelling as applied for. At premises located at: 95 Donna Dr., Mattituck SCTM #473889 Sec/Block/Lot# 115.46-1 Pursuant to application dated 8/30/2021 and approved by the Building Inspector. To expire on 3/10/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector 131111ding Deparmiew Amilication �AUTITQRIZATJON (Wi;pre the App karat is--e-q dice C)vvqt-t) 1, --,-DQN,eoI residinz at WOR 1,M.AlLug Addt cs<j ,do here byauthorize., 9L2846—t—A4 X to Ipp!y on my bcWlsto the Southold BuildingDepax-tniont. (Ua'n^i sSignature) (Prim Owner's Name T I-F SOUTy� # # TOWN OF SOUTHOLD-BUILDING DEPT. co 765-1802 INSPECTION = [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ' ] pSULATIOWCAULKING = [ ] FRAMING /STRAPPING [ FINAL W IAJWWS [ '] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL-(ROUGH) : [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REM RKS: - n &� / - IA DATE �' Z B �21 INSPECTOR FIELD INSPiCTION REPORT 'DATE CO NQS FOUNDATION(1ST) .. . . . . • . • •' -'"'3 ............. ....�.�...... FOU ATION'(2NA) • • ' ROUG FRANING•& '. ni P IUMBIN.O, INSULATION.PER N.Y. STATE' NFRGY CODE FINAL ' -SCO v L INK t, v � '• •' 11�•' 'fir •• •' ',� 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 7 Survey Southoldtownny.gov PERMIT NO. 10 / �s Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application n Flood Permit Examined 20 ``� Single&Separate u Truss Identification Form StomrWater Assessment Form �-® AUG 3 0 2021 Contact: Approved �' 20 Mailto: SCO-IT I r 110 MAW Disapproved a/c �DEPT' 101; 6Q-1 TOr1B14 Uu LN &LtFSR0M3Ue V CT CGO-U Phone: $CO--ssz- 4112 Expiration 20 TOWN Building Inspector APPLICATION FOR BUILDING PERMIT Date 0e2 20-9/L 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. £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.ff 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. 17 (Signature of applicant or name,if a corporation) jos ISUiroW619U LN 01 06033 (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder A-6�_C n/i Name of owner of premises J n/ALS kJ Q,Q J (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 proposedork will be done: q5- �ON�� e M9T7 t7 UCr� A/r 1195Z House Number Street Hamlet County Tax Map No. 1000 Section 11 S Block (P Lot REMOVE AIV) ACPLAC6 4 utaDnu, 00n6 SrZE tJO Si�Pcrc,Z/i2�YL GHArt7�s 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 I12E5(.DE is rtA(, b. Intended use and occupancy, F_S( pr=n/i l RL' 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work Lg4.00,j eFPCACEmsiVJ (Description) 4. Estimated Cost , 0q9 Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage,number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions:Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13.Will lot be re-graded?YES NO Will excess fill be removed from premises?YES NO .9S .'�rv�g 'Pr- 14. PC14.Names of Owner of premises.DCHR'L() Kheg Y Address M g7iTU CE ,N Y Phone No. 100 Name of Architect Address Phone No Name of ContractorlaDnE 2W Poi USd} AddressJkst-PHCEs PeWYPhoneNo. 860-9,x2- y//2 ,4174w 74,Ga} 3033-9 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 *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?*YES NO *IF YES,PROVIDE A COPY. 1(,C/No(S STATE OF N AP.K-) p SS: C COUNTY OF W1- ) EL 23/E l74 Mfin(.QI20n) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the /4605N 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, 2a�►^ day of H 7207- OFFICIAL SEAL IZABETH SALGA t�CL oblic j0TWPUBLIC,STA IS Si tune of Applicant MY COMMISSION EXPIRES 12/01/2024 f F. Go Permits, LLC 105 Buttonball Ln. Glastonbury,Ct 06033 Scott Doughman Phone:860-952-4112 Fax:860-430-6719 scottdoughman@gopermits.org "WE UNDERSTAND THAT YOUR TIME IS MONEY" August 24, 2021 To: Town of Southold Building Department Subject: Permit Application for: DONALD KIRBY 95 DONNA DR MATTITUCK, NY 11952 The above listed homeowner has contracted with Sears Home Improvements to replace the windows in his home. The below listed documents are included with this letter. • Notarized permit application • CO Application • Check for$250 payable to Town of Southold • Contract with HD detailing scope of work • HD Suffolk County License • Certificate of Insurance • Letter of Authorization from HD allowing GoPermits to submit documents on their behalf • Authorization signed by the homeowner • Windows specification spec sheet Please note the following: • Please mail original permit to the owner. • Please fax or e-mail a copy of the permit and receipt to: Fax: 860--430-6719(attn:Scott Doughman) Email:scottdoughman@gopermits.org r • If fax or e-mail is not available, please mail a copy of the permit and receipt to: Go Permits, LLC 105 Buttonball Ln. Glastonbury,CT 06033 Thank you! Ella Mendron, Permit Expediter Go Permits, LLC Phone:847-671-4606 elzbietamendron@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org 1 N Home Improvement Agreement: Page 1 Home Depot License#'s-For the most current listing visit www.Homedepot.com/LicenseNumbers Salesperson Name Registration#(Req.in CA,CT,ME,MD,MI,NJ,DC) Home Depot U.S.A.,Inc.("Home Depot") or Authorized Service Provider named below will furnish, install and/or service the equipment listed below at the price,terms and conditions as outlined on this form. `1.Service Provider,Contact Informations The Home Depot Service Provider Contact Name Service Provider Company Name Phone# Service Provider Email Address Service Provider License#(s) .,., ..___. 7-1WBSGPX5 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 0 Customer Address City State Zip Home Phone# Work Phone# Cell Phone# Customer Email Address J.- E F_NOTICORIGHT TO CANCEL YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY f CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: i OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: E D D1 l Address City State Zip ,BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING,UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD.THE STATE SUPPLEMENT ,CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. IYOUR PAYMENT(S)WILL BE RETURNED WITHIN TEN(10)BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE.YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME }DEPOT OR SERVICE PROVIDER,AT YOUR SERVICE ADDRESS,AND IN SUBSTANTIALLY THE ;SAME CONDITION AS WHEN DELIVERED,ANY MERCHANDISE OR MATERIALS DELIVERED 'TO YOU.OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN ,SHIPMENT AT HOME DEPOT'S EXPENSE. ;THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR ,RIGHT TO CANCEL.PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ;ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: 1 7 107/22/2021 Customer'sSi-pattke Date 460 Standard Form 111A(02 Oct.20XE) Generated Date 07f29j702j Lead/P0# 1-1WggGpXri v 0.19 Home Improvement Agreement: Page 2 �4 Description,of Work to be Performed- A detailed description of the work to be performed is included in the paragraph entitled Scope of Work, } �- r Specification,Customer Summary Sheet,Quote Form,Estimate,Invoice or Measure which is included in this Agreement. ) 5.Anticipated Delivery Dat_e%Installation Schedule Approximate Start Date: 01/78/2022 Approximate Finish Date: 02/17/2022 All dates are approximate a and subject to change based on unforeseen events including inclement weather,permitting delays,and delays mi confirming insurance coverage of Your claim for any repair,if applicable. 4 Electronic Records Authorization You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy,your consent f applies to this Agreement and all subsequent documents and written communications related to this Agreement. F By contacting your Service Provider,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your 3 email address above,you confirm that you have access to a computer that can receive and open emails and PDF documents._ _ 7.Contract Price and Payment Schedule Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. 3 9 Contract Price: $ 11049.00 Includes all applicable taxes.Excludes finance charges.* I Sales Tax: $ 0.00 (If applicable,total amount of taxes included in Contract Price) *Maximum deposit ONLY applicable in MD,MA,ME(33%),NJ, WI(99%) +, De osit% De osit Amount$ Remainin Balance$ f 8.Finance Charges ' Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement,to which Home Depot is NOT a party,and will be in addition to Customer's payment under this ;Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement,as applicable.No ,Agreement. should be made payable to Service Provider;however, Service Provider may collect Customer's payments made payable to Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. 1 (9:Aeceptanceand Authorizationr. . _ ._... _._...._,�, _ _ ._, By signing below,you authorize Home Depot to: (a)arrange for Service Provider to perform any Services or &(b)order and arrange for the delivery of special order merchandise,including special order merchandise that i may be custom made, as specified in this Agreement.Do not sign if blank or incomplete. (Service Provider's or permitting information may need to be provided to You later.)By signing,you acknowledge that: (i)You }have read,understand,and accept this Agreement in its entirety,including the General Conditions and State ":Supplement, if any; (ii)You are receiving a complete copy of this Agreement;(iii)all rights and interests under this Agreement are solely vested in the person listed as"Customer"above;and(iv)Electronic signatures will be !deemed originals for all purposes. X 07/22/2021 Customer's Signature Date X I/s/The Home Depot The Home Depot Digital Signature Date For questions related to your installation,contact Service Provider at (631) For any other concerns, contact The Home Depot at 1-800-466-3337 - 460 Standard Fenn IHA(02 Oct 20XE) Generated Date 07122/2021 Lead/PO# 1_1 W gSnpXrv 0 1 9 DATE: 09 lcz� lcw'�A ATTN: Town Building Inspector RE: PERMIT AUTHORIZATION LETTER To Whom It May Concern: In accordance with Public Act 91-95, this letter serves as written authorization and notification that Go Permits LLC, and its employees and agents have the authority to represent us in the procurement of permits and pertinent documentation on our behalf. This letter or a photocopy thereof may be regarded by'any building official as it's authority to recognize Go Permits LLC as our authorized Agent to sign on our behalf applications for permits and any other related documents that may be required by you, and we agree that, for all purposes,we and not Go Permits LLC or it's employees and agents shall be deemed to be the signer of any such applications and related documents. .ti Scope of work: NDO l� AMG S12-P7 No 8i"Q,uCij4e4U 'C*-►0rJC-yF-s, Location: 'qS (2>(0tjf\)A (L MRM 1 1TL4 C'V- ' tjyI ll 35Z OLO Authorized Agent Go Permits LLC 5L Z9 I F } M l;;rJ,t)p.,o J Service Agent Name Best Regards, � a Lice ee Signature t Ralqe &License Number NOTE: PLEASE MAIL PERMIT TO: JEFF RE"'i KUI-IR NOTARY PUBUG, .-I OFi`RY YORK THD At-Home Services,In . Registratio;;rl� r;�isooa�st 40 Oser Avenue- Suite 17•Hauppauge,NY 117 Qualified in u:iui^ nur•{}199 Phone:631-478-6101•Fax:631-435-4837•Toll Free:677 fission€ ires Mareh 93• AC40 O® o1rnr1921 CERTIFICATE OF LIABILITY INSURANCE °A'27021 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cerdflcate does not courer rights to the ate holder in lieu of such endo s PRODUCER GOWAUF MARSH USA,INC. NAu£ TWO ALLIANCE CENTER PHDNE I FAX M1. 3560 LENOX ROAD,VME2400 E sg: ATLANTA,GA 30326 HISII wNacovEruse NAICs CN101642069+brneD-GAW:21-22 INSURER A: OU Be MfthMIa=CQ 24147 INSURED INSURE 8: AIU lr&wjm Ca 19399 THE HOME DEPOT,WC. HOME DEPOT U.SA,INC. INSURER C:HpW&RISk QpM kISUMM CbMpM IVA 2455 PACES FERRY ROAD INSURER D.- BUILDING ,BUILDING C-20 ATLANTA,GA 30339 BSE: IDISURERF: COVERAGES CERTIFICATE NUMBER: AT601)5072225-04 REVISION NUMBER: 2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING 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 POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSSR TWEOFINSURANCE Pim sum POLICYNUMBERTR POIICYEW POLICYEW UNITS A X commElcrAt eENERALuAeu TY MWZYM4574 03101/2019 0310112022 EACNoCcURRENcE $ 1,000.090 CLAIMSMADE X❑OCCUR PORE14SEg $ 1,000,000 X SIR:$I,000,ODD ME)Exp(Arryone ) S EXCLUDED PERSONAL&ADVOWRY S 1,000,000 GEM AGGREGATELRUTAPPLIESPER GMERALAGGREGANE $ 2,000,000 X POLICY❑JPRO-ECT El LOC PRODUCTS-COMPIOPAGG 5 2,099000 OTHER: S A AvroxIOWLEUABeaY MWFB314573 0310171019 MMMC°jr I��I a Ism S 1,000.000 X ANY AUTO SELF INSURED AUTO PHY DMG BOMLY VuURr(P8rPwwn) S OWNED SCHEDULED AUTOS ONLY AUT BODILY INJURY(Per eoddeM) S HIRED NON-OWNED PROPER_TY°AIIIAGE $ AUTOS ONLY AUTOS ONLY S U!/BRELLAUAe HOCCLIR EACHOCCURRENCE $ EXCESSLLAS CLAIM54AADE AGGREGATE S DEO I I RETEMION S B I ND f IERSCOMPE lA TION WC 582402E(Wl) 03/012021 031017!022 X $A a B ANVPR TCSRIPARTNHiIEXECUriVE YIN M/w WLRC67818258(NC,VA) 03/0171021 o2►M7t021 E.L.EACHACcmEJT S 5.090.000 (Mandatory in NIR Conlirwed a1 Asim Page E.L.DISEASE-EA EMPLOYEE S 5.0001090 Mier DESCRi OFOPE RTIONStelow EL DISEASE-POLICYLISUr S 5.00D.WD C ExaewAift 297110011002021 034012021 0310171!122 Urnt: 4.000.000 A Excess General Uabf'dy MWD(314560 03/012019 00171022 Unit 8,00,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101.AddMoretReourbSNedutq.nsaYbeaf achedUmoro space Isrequired) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORED REPRESIrATIVE of Marsh USA hm Manashi Mukhedee ®1988 2016 ACORD CORPORATION. All rights reserved ACORD 25(2016(03) The ACORD name and logo are registered merits of ACORD AGENCY CUSTOMER ID: CNI 01642069 LOC 0: Atlanta ACO ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGETICY NAMED WSURED MARSH USA,INC 7HE HOME DEPOT,OJC. HOME DEPOT tLM M. POLICY NUMeIM 2455 PACES FERRY ROAD BUR DING C-20 ATLANTA,GA3= CARRIER UMCME EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL.REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMSER: 25 FORM TITLE: Certificate of Liability Insurance Wo(kw C01I nCW&VlW- Carrier.MdeaxMy transoms Company 0f NaOnAnxrea Policy Number WLR 067825287(AL ARR�,1ANS KY�I S I�O.tB.tom ND.OKX.SDJN.WV.Wf) Elective Date:03012021 ExpfrationDalacM IrMn (EL)Un t$5,000.000 Canier.AIU horaw Co. Policy Number:WC 023096003(AK DCAE.FB,IN.MD.IB W.NYJ'U.WAVT) Effective Date 03101/2021 E)#mt m Dale:03I012ir22 (EL)Unit$5,000000 CamecAMAwavankmancoCOMPany Policy Number.WCU C878 WI(QSQ(Ck IL OR WA) Elective Date:03f UMI Ewmilon Dees:aii012022 (EL)Limit$5,00D.Wo SIR$1,000.000 Center National Union Re triswww Company Policy Number.XWC 1647258(Ckq(CO.CT.GA,MW.NV QH.PA.M Effective Date:03101/2021 Expi don Da1er:03011i2022 (E)Umx 34AWA00 SIR$IA0.000 Caner.ACEAmaican Inaoarece CLOWN Policy Number WLR 087818210(AZ) EBeg Dale:0310112021 ExpW=Date:03012022 (EL)U mit$5A00,00D Carrier:NaWd then Foe limmm COMPMy Pormy Number:XWC 1647269(OSq(MA) Ettective Date:OMMI E*radm Date:031012022 (EL)Limit$455.000 M.$W0.0w TX Employers XS Indemnity Carderilli dos Union Irvaeance Company Pdicy Number:TNS 066949072(Dg Effective We.031012021 Expiratim Date:031012022 (EL)Lunt$10,000,000 SIR$1,000,000 ACORD 101(2008!01) ®2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ACo® ADDITIONAL REMARKS SCHEDULE Page g °f g AGENCY NAMED INSURED MARSH USA INC. THE HOME DEPOT,INC. HOMEDEPOTU.S.A,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUBDiIRG F20 ATLANTAAA30339 CARRIER Nate CODE EFFECTIVEDATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabiffity Insurance HOME DEPOT INSUREDS— The Horrre Depot,bm Hoare Depot U.SA,Ire. Now Depot USA,Inm dba The Horne Depot Home Depot otPeeds ISco,Inc. Hone Depot ProdudArdlrentf,LLC Home Depot Store Support,Inc. Red BOOM,LLC Hone Depot U.SA,Inc-dba The Horne DepotPro Interhae Brands Bamed Hardware Express Lem MandeMM USA Renovations Plus Supp)waft IIS Lack Wmar Zp Tedmolaaws HD V.I.Holding Company,Ire:. Ask ft Inc. i ACORD 101(2008101) 0 2008 ACORD CORPORATION. All rights reserved. The ACORD(tame and logo are registered marks of ACORD RECEIPT SUFFOLK COUNTY GOVERNMENT DEPARTMENT OF LABOR,LICENSING,AND CONSUMER AFFAIRS COMMISSIONER ROSALIE DRAGO P.O.BOX 6100,HAUPPAUGE,NY'11788 (631)853-4600 Today Date: 10/22/2020 Application: H-53428 Application Type: Home Improvement Ucense Receipt No. 414174 Comments Payment Method Ref.Number Amount Paid Payment Date Cashier ID Renewal+14 Additional Check - 0003181507 $1,800.00 10122!2020 GABRenewal - Contact Info: RICHARD OUSEYOME DEPOT A INC(14 SUPPS) p0 BOX 105451 ATLANTA,GA 30348 Work Description: Suffolk County Dept of ` Labor,Licensing a Consumer Affairs HOME IMPRUvEMENT LICENSE Name RICHARD TOUSEY i Business Name [Thisoardfies thatiheHOME DEPOT USA INC(14 SUPPS) beareris duly 1W"d by the county of sulfola i License Number.H-53429 Rosalie Otago Issued: 05/1512014 commisslorw Expires: 1110112022 OCCUPANCY OR USE IS UNLAWFUL APPROVED AS NOTED WITHOUT CERTIFICATE DATE: 9. , B.P. OF OCCUPANCY FEE: Y: 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 COMPLY WITH ALL CODES OF 4. FINAL - CONSTRUCTION',MUST NEW YORK STATE & TOWN CODES BE COMPLETE FOR C.O. AS REQUIRED � ND CONDITIONS OF ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW SOUTHOLD TOWN ZBA YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. SOUTHOLD TOWN PLANNING BOARD SOUTHOLD TOWN TRUSTEES N.Y.S.DEC WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-1WBSOPX5 Sheet: 1 of 1 Customer:donald kirby Job#:1-1WBSGPXB Corlsuftant: Frank Marra Date: 07122/2021 1� New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outslde, Lek to Right ' Bays,Sows Location Color Rough Opening #of bars #of bars Camms,1 Pnl, use L,R or S Glass Mlec Items Hardware Code Screens For doors use 8r Mull "S"-stationery or We Wrap Room Floor Cade (YM) I Style Code Serles Code FS a "X"=operating STD,White, WRAP 1 LIV 1st SB-PW Y PW 8100 WH WH so 48 108 F. WH,W C ALL 3 3 ALL 3 3 GlassPack:Standard 08o H SPECIAL CONSIDERATIONS: 1:White eP Color nterlor Casing Type Say or Sow window: atboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) ay Flanker Type(DH,SH,or Csmm) op of window to soffit(inches) t tied to soffitcolor of soffit materiel I have reviewed and agree with all the job specifications above and the I efruct Roof(Yes or No)• Special Terms and Conditions on the folkwring page Garden Window: atboard Material(vinyl only-Whtte Plonite,Birch or Oak)