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HomeMy WebLinkAbout47569-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE . SOUTHOLD, NY w 0- w 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#: 47569 Date: 3/18/2022 Permission is hereby granted to: Mathew, Richard PO BOX 1240 Cutchogue, NY 11935 To: install generator as applied for. At premises located at: 6805 Alvahs Ln., Cutchogue SCTM # 473889 Sec/Block/Lot# 101.-1-16.5 Pursuant to application dated 2/17/2022 and approved by the Building Inspector. To expire on 9/17/2023. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 ,,Total: $235.00 l Buildih6 Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT _ Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 i :gyp; Date Received APPLICATION FOR BUILDING PERMIT ;l For Office Use Only PERMIT N0. 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:February 3, 2022 OWNER(S)OF PROPERTY: Name:Richard Mathew SCTM#1000-101-1-16.5 Project Address:6805 Alvah's Lane Cutchogue NY 11935 Phone#:631-204-1984 Email:rmmathewesq@aol.com Mailing Address:6805 Alvah's Lane Cutchogue NY 11935 CONTACT PERSON: Name:Sean ONeill MailingAddress:PQ Box 64 Jamesport Ny 11947 Phone#:631-722-3595 Email:oneilloutdoorpower@hotmail.com DESIGN PROFESSIONAL INFORMATION:` Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Universal Electrical Services Mailing Address:151 First Avenue Massapequa Park NY 11762 Phone#:516-242-9204 Email:gebhard73@gmail.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther generator $11,000 Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes No 1 ,.I PROPERTY INFORMATION Existing use of property:residential Intended use of property:resldentoal Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes *RNo IF YES, PROVIDE A COPY. ❑ Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town code.APPLICATION IS`HERE13Y 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,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(s)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name):Sean OneIII RAuthorized Agent El Owner Signature of Applicant: zei " Date: 2/3/2022 STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Sean III being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is theagent (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 �.� ', ��i1 , 20 IATEatorf, a Il Iuumb} rxyrAar New A s PUBW No.01OR62M2 MINIMPROPERTY cmm!it UT , cif . (Where the applicant is not the owner Richard t residing at 6805 Alvah's Lane Cutchogue Y I, Sean do hereby authorize III to apply on my behalf to the Town of Southold Building Department for approval as described herein. 2/3/2022 Owner's Signature Date Richard Print Owner's Name 2 g DING DEPARTMENT- Electrical Inspector }� _ TOWN OF SOUTHOLD gV 0 LTown Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(@southoldtownnv.gov — sea ndsoutholdtownyov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 2/3/2022 Company Name: Universal Electrical Services Electrician's Name: Dennis Gebhard License No.: ME-54018 Elec. email:gebhard73@gmail.com Elec. Phone No: 516-242-9204 ED I request an email copy of Certificate of Compliance Elec. Address.: PO Box 64 Jamesport NY 11947 JOB SITE INFORMATION (All Information Required) Name: Richard Mathew Address: 6805 Alvah's Lane Cutchogue NY 11935 Cross Street: Phone No.: 631-204-1984 Bldg.Permit#: email:rmmathewesq@aol.com Tax Map District: 1000 Section:101 Block: 1 Lot: 16.5 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 20kw generator installation Square Footage: Circle All That Apply: Is job ready for inspection?: El YES Z NO R Rough In ❑ Final Do you need a Temp Certificate?: F-1YES� NO Issued On Temp Information: (All information required) Service Size❑1 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead #Llnderground Laterals 1 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION W 1 f 7 Fil l HU11,I)NG DEPT SURVEY FOR TOW14 OF!301A)OLD t RIC1~E.+0.RD M.MATTHEW LOT 3 MAP O BAST COAST PROPETI:E' aas ;mro FILE Na. 0225 Masa¢MAY ax fez SJrTTJA TE l CUTCHOGUE Off TOWN OF NTMI N SUFFOLK COUNTY, NEW YORK $G TAX No. W00-101-01-16,5 m scus 1 543 � AucusT t4, 2017 awraa ;aaiias s a:r4. bamaaamwcaw % s oAREA Ir 9A,713 oqff, 2,174 m , r 1 ED RICHARD M, MATrNEW SUFFOLK COUNTY NATIONAL BANK, N,A. / aA ACM: won ��„"'" �,' ""w cw✓rArw A a~caffamrwq'�' L NOWN9l0iv .... aA rLVAMNO POOL .m.., A 14 � rxiurA T zo° sx,A Ma+. a w.................: A%MMti6N41+M5U 9 S 51gr,A�ppdp'dM Wq 9YdP tldn4tl'�MAi WWW?%W44 AYIAWPAG f�gN4� �I a1W w INJ)"ll, (Cl N n a f In Of o CHISTO LandVr6-tti-yor INEVEL Ao� �_.a�anrr�immw.r — a r+a�ue +dwm a,ro�,.w+a now(aAro raro x¢aA ray lraalror'a—agv n r' wra ru' A m"V LlrAl to Ar WPM ms's x Of�cAxrurw 'A¢x w "PSOSZ wu�m w. w aA ,t Wpr arw 'wAuw�uwpawn'aAur. Wman�Wa oAr«,taut 11047 rWk I BRIGGS&STRATTON r The Sm ,rT Ch � Introducing our dealer,exclusive lig 4 Available at your local Briggs& Stri %,, Dealer with these great featur ` t ULIM � . L New Upgraded Control System Charging System • New AVR optimizes generator performance with tighter voltage control Independent battery charger • LCD display that displays multi-line text and graphics Optimizes battery life with a 3-stage battery charger(bulk, • Default exercise cycle setting of 16 seconds absorption,and float stage) • Low speed exercise available to save.fuel and reduce noise Corrosion Resistant Enclosure& Base • Monitors cold temperatures to avoid moisture buildup in engine oil _. • Cleaner power with improved frequency regulation • Made with automotive grade galvanneal steel or aluminum to resist rust Designed for Easy Installation& Maintenance Powder-coated paint for years of protection against chips and abrasions • Approved for installation as close as 18"to a buildingz • Certified to withstand hurricane-force winds up to 175mph5 • Hinged lid with removable side panels for better service access to the eng.ne and-. I�.-o- - - - Briggs t - 11- a is a ra r i� -- • Controller,battery charger,and AVR can be replaced separately -- - • Cold weather kit included Shields the engine from low temperature sludge buildup and high temperature deposits • External on/off switch located on back of enclosure Reduces engine wear,scoring and abrasion Commercial Vanguard"Engine Compatible with Symphony®II Power • Easy conversion between natural gas(NG)and liquid propane vapor Management System (LPV)during installation • Advanced debris management keeping engine clean and cool for • Customizable to your home's needs enhanced durability and performance Automatically balances the power of your home's electrical load • Dynamically balanced crankshaft minimized engine noise and vibration including high wattage items like air conditioning units and electric ovens • Compatible transfer switches and modules sold separately MEN= Liquid Propane Vapor Natural Gas Limited Warranty' Model Enclosure Voltage Phase' Hz Circuit LPV kW' LPV Amps NG kW' NG Amps Parts,Labor,Travel Type Breaker Amps 040587 Steel 120/240 1 60 100 210= 83.3 18 75.5 6 Year 040589 Aluminum 120/240 1 60 100 = 83.3 18 75.5 6 Year 040609 Aluminum 120/240 1 60 100 20 83.3 18 F 10 Year " ^ce` _•�:i z2Cv;s°a:.c;�',e-,...g :e�;s ae�-sT �ee uti it -'S;a�ca•cs «cc-?. _ ..,..�;, z __._ rer_at - f - e mon— de s�eve„_ -� d� .�.. „e..."� ^s;'�e`..�.�'R. [ �i-,_,> ��.e�cl�;�.°e .:.-�c�.. _ie l�F..e c.,�.t�,_ e:,�'e.:;��' - _-,. -and eb ... gc 3t v.€P--f- e-• s,.... sre[dr'S R GCS..-d5 i RATTo Nxo�.. �ter cc P10. Fent-de-;oh C : a.ed- a - 3^Le tr '� i;1�Ss17 � 20kW' Fortress"Standby Generator VV �. \�� yo Engine Brand Vanguard Oil Capacity(L/qt) 2.3/2,46 Engine Speed(RPM) 3600 Low Pressure Switch Included Engine Fuel Liquid Pro_.ar-,Vapor(LPV)or Lubrication System Full Pressure Natural Gas.NG1 Engine Cylinder Configuration OHV Oil Briggs&Stratton 5W30 Full Synthetic Number of Cylinders 2 Low Oil Pressure Sensor Yes Displacement(L/Ci) 0,993/60,60 Compression Ratio 9;7:1 Manufacturer Briggs&Stratton Governor Type Electronic Type Self-Excited,4-Lead Frequency Regulation +/-0.3 Hz(0.5%) Voltage Regulator Automatic Valves OHV with Hardened Seats Insulation Class F Ignition System Fixed Timing Magnetron' Peak Motor Starting kVA 41 Starter Motor Rating Voltage 12 Volt 12 Volt,Group BCI 26 or 51, Battery Required 540 CCA Minimum Generator Sensing Single phase voltage monitoring High Temperature Switch Included LCD Display Displays multi-line text and graphics Dura-Bore Cast Iron Included Fault Display Provides up to 39 detailed fault codes Cylinder Sleeve Exercise Cycle Six exercise length options Default;Start and run for 16 seconds; Abort exercise below 40'F(internal temperature) Full Load 1/2 Load No Load Low Idle Mode 64 dBA° BTU/hr NG-260,000 NG-187,000 NG-99,000 No Load 67 dBA° LPV-337,500 LPV-207,500 LPV-100,000 ft'/hr NG-260 NG-187 NG-99 LPV-135 LPV-83 LPV-40 m'/hr NG-7.36 NG-5.30 NG-2.80 LPV-3.82 LPV-2.35 LPV-1.13 g/fir LPV-3.65 LPV-2.2_` _PV-1.108 Parts•Labor•Travel Unlike some other standby generator manufacturers, our warranty covers parts, Limited labor AND travel for the full length of the warranty with no start-up costs! Warranty' s rc,- 0 3744,SOUrd_'46-Meas -" �.;�-�>,ru ..,�.,,.ens.... �.,z .�_,� z..�..e ._:h--.r..�,'u„a -3 - .e­i_ ..a;b _� 6:.de-r. olfigvati a__-_ L 20M' Fortress"Standby Generator Engine Warm Up(sec) 20 seconds after all settable delays CARB Compliant* Engine Cool Down(min) 5 FCC Part 15 Class B/CAN ICES-003(B) Response Time(sec) Immediate after engine warm up NFPA 37 Compliant cUL Listed to CSA 22.2 No.100-14 Assembled Weight(lbs i kg) Steel-489/222 UL2200 Listed Aluminum-440/200 Overall Dimensions(in/mm) 50.5 x 33.8 x 30.6/1283 x 859 x 777 EPA Certifled Fuel System Packaged Weight(Ibs/kg) Steel-634/288 Complies with NFPA 374.1.4.1.2 Aluminum-580/263 Packaged Dimensions(in/mm) 68.1 x 41 x 39.9/1730 x 1041 x 1013 Galvanneal Steel or Aluminum Maintenance Kit 6036 Enclosure Material with Corrosion Resistant Paint E-Stop Kit 6491 Power Management 71052,71053 071100 l00 Amp Low Voltage Modulo Power Management 71051 071150 150 Amp High Voltage Module Generator Status LED Kit 6535 071200 200 Amp - BatteryWarmer 6578 071071 Symphony 11 100 Amp - InfoHub Universal 6574 071070 Symphony 11 150 Amp 071068 Symphony 11 200 Amp 071057 Symphony II Dual 200 Amp 50.5 in(1283 mm) 33.a in(859 mm) fli _ a E 30.8 in (777 mm) e x 3 48.1 in(1222 mm) 29.81n(752 mm) CTRs e.ae.apt ger—W--s du'Futting less than So-HP.t,„ay the GRA sta'nda-d=acp'.,. 'This ganerawr i$ce-Vi ed m acco,da,,ceMth mt.wn�g.,.,:e.s Lrbo!ato6esi 2200 tstati C2.s No-100-14 uta e and c reratc 3 IRI 1 � a 2OkW' Fortress—Standby Generator This generate,is cerz fled is accoma-ce-�i:`.^:UL"Underwtiie€s Laboratonesi 2200-stab a v engi-e aer;ere'0r a<a2tlb ieci z..^:j CSA(6ansdi�n SSaidam� Associa'.an)sle .wu b22.2 Na; -i+(mot sr" ar,d gSf eY9 JTZ, BRIGGS S STRATTON CORPORATION 13'.gcs& nn has s p..cy gf C—t nicjs nv m::pry: .enr a..c reg&-,es the-ip' c 4 diff} POST OFFICE BOX 702 SRIGG --- t t'm' _ +u 3_ ;; MILWAUKEE,WI 53201 USA f ss=l 5-9.19 I`-o'Pyr ghs @2010,All r ghts reserves, YOU.POWEREO. _DATE(MM/DD/YYYY) -.... CERTIFICATEI II INSURANCE 11/09/2021 THIS CERTIFICATE IS ISSUED ASA 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 ADDITION INSURE ,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 aMT CT Carol LosQuadr9 Roy H Reeve Agency,Inc. PHONE (631)298-4700 FAx (631)298-3850 3 t No E'rc: I to .Nos; PO Box 54 closquadro@royreeve.com ADDRESS: 13400 Main Road INSURERS)AFFORDING COVERAGE j NAIC# Mattituck NY 11952 INSURER A: Maxum Ind Co 1 26743 INSURED INSURE I.B i Eastern LI Gas Services LLC ! INSURERC: PO Box 1134 1 INSURER D: INSURER E: _ MattituckNY 11952 ;INSURER F: _ COVERAGES CERTIFICATE NUMBER. CL219115163 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. WEIR _ ' OLICYEFE ! POLiCYEXP LTR I TYPE OF INSURANCE (NSD WVD, POLICY NUMBER I MMIDD/YYYYI l(MMIOD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 .DAMAGE 1-0 RENTED FX OCCUR 50,000CLAIMS•MADE o currance� is I I MED EXP(Anv one person) s 5,000 A j BDG0082594-08 09/1812021 09/18/2022 i PERSONAL&ADV INJURY s 1.000,000 GEN'L AGGREGATE LIMITAPPLIES PER: ' I GENERAL AGGREGATE i$ 2,000,000 _ POLICY F PRO- F LOC € I PRODUCTS-COMP/OPAGG s 1,000,000 OTHER. $ AUTOMOBILE LIABILITYr CUTA NED SINGLE UkfiT 1 s [ANY AUTO )BODILY INJURY(Per person) j$ [OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS F I ! HIRED NON-OWNED € ( CA€A OE I$ `AUTOS ONLY AUTOS ONLY - ;tlaer `2 s I i i !$ UMBRELLA LIAB OCCUR F r I E EACH OCCURRENCE is I EXCESS UAB CLAIMS-MADE r AGGREGATE i 17� YOM ;workers'Cotion CERTIFICATE OF INSURANCE COVERAGE tpensa Boartf DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured EASTERN LI GAS SERVICES LLC 631-603-5687 1622 MAIN RD JAMESPORT,NY 11947 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 463076153 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southhold 53095 Main Road 3b.Policy Number of Entity Listed in Box"l a" P.O.Box 1179 DBL615307 Southhold,NY 11971 3c.Policy effective period 04/19/2021 to 04/18/2023 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. 11/15/2021 Date Signed By {`(" (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer I IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS 3 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 56 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 and Paid Family Leave Benefits Law with respect to all of his/her employees. i Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) 1 E Telephone Number Name and Title i Please Note:Only insurance carriers licensed to write NYS disability and paid 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) DB 120.1 (10-1 =) Suffolk County Dept.of Labor,Licensing&Consumer Affairs MASTER ELECTRICAL LICENSE Name ANTHONY J SEMONELLA Business Name "l141s 0sriafw s that l%4e UNIVERSAL ELECTRICAL SERVICES LLC bearer is duty Viaelised by the Counly 04Uf((WM1K License Number.ME-54018 Rosalie Drego issued: 08/2812014 Commissioner Expires: 08101/2022 � a UNIVELE-02 EEGEL1 DATE(MMIDD/YYYY) ' 46.� CERTIFICATE OF LIABILITY1 812012021 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 Ellen Goldman(egoldman a@butwin.com) 'Nathan Butwin Company,Inc. PHONE FAX 60 Cutter Mill Rd.Ste.41 (AIC,No,Ext):(516)466-4200 (A/C,No):(516)466-4213 Great Neck,NY 11021 A RES_$: butwin.com INSURERISI AFFORDING COVERAGE MAIC INSURER A:Utica First Insurance Co. 115326 INSURED INSURER B: j Universal Electrical Services LLC INSURER C 151 First Avenue INSURER D Massapequa Park,NY 11762 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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 I 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 IADDL SUBRI POLICY EFF j POLICY EXP ; LTR! TYPEOFINSURANCE J NSDI WAD= POLICY NUMBER r WDD(YYYY)I fMMrmD = LIMITS A X COMMERCIAL GENERAL LIABILITY i 1,000,000' _ EACH OCCURRENCE -� CLAIMS-MADE FOCCUR DAMAGE TO RENTED 50,000 �❑ X ART505787807 8/20/2021 8/20/2022 PRFMI�Es r,a pry renCe) $ MED EXP(Anv one person) 1$ 1,000 i [PERSONAL&ADV INJURY �$ 1,000,000; GEN A ..gEGATE LIMIT APPLIES PER GENERAL AGGREGATE �Q 2,000,000_ POLICY❑JECT ❑Loc 210001000 PROOLICTS-COMPIOP AGG $ i dFIT O I c:Ti-IE[i a j AUTOMOBILE LIABILITY I`"semRIN SINGLE 3 g 1 ❑ANY AUTO - BODILY INJURY(Psr g9r54n1 OWNED SCHEDULED _$ AUTOS ONLY AUTOS - i BonII Y INJURY(Per accident)i$ f HIRED I NON-AWNED i iOR GAGE AUTOS ONLY AUTOS ONLY ! j =F - ='t ! I ! E UMBRELLA LIAB ❑OCCUR _ 1 EACH OCCURRENCE $ - ` �yj EXCESS LIAB CLAIMS-MADE= -AGG.RECATE $ i DED RETENTION$ j is WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY ! TE. sTc FR Y# ANY PROPREIETOR/PARTNER/EXECUTIVE _ =E.L EACH ACCIDENT :S ((; datory in NH)EXCLUDED? ❑,N/A I - If yes describe under I i E L-DISEASE-EA EMPLOYE 'DESCRIPTION OF OPERATIONS Li_ela_w i E L DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 1 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southold BuildingDepartment THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p : ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road Southold,NY 11971 — AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ew YORK - ' CERTIFICATE OF INSURANCE COVERAGE o nsat E Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured UNIVERSAL ELECTRICAL SERVICES LLC 516-850-7776 151 1 ST AVENUE MASSAPEQUA PARK,NY 11762 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,wrap-Up Policy) 471592478 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Southold Building Department 54375 Main Road 13b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL537882 i 3c.Policy effective period 07/09/2021 to 07/08/2022 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. B.Disability benefits only. 3 C.Paid family leave benefits only. 15. 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: I i 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. 7/9/2021 '`f' Date Signed By U (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) i Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer '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 sox 4C or 5B 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 and Paid Family Leave Benefits Law with respect to all of his/her employees. i Date Signed By (Signature of Authorized NYS workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid 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. D13-120.1 (10-17) III 1111111111111111111111111111111111111111111111Il DB-120.1 (10-17) 4 NYSIF New York S'tateinsurance Fund 8 CORPORATE CENTER DR,2ND FLR,MELVILLE,NEW YORK 11747-3166 1 nysif.com CERTIFICATE S' COMPENSATION INSURANCE RE FRI A^^AAA 471592478 UNIVERSAL ELECTRICAL SERVICES,LLC 151 FIRST AVENUE mom, MASSAPEQUA PARK NY 11762 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER UNIVERSAL ELECTRICAL SERVICES, LLC SOUTHOLD BUILDING DEPARTMENT 151 FIRST AVENUE 54375 MAIN ROAD MASSAPEQUA PARK NY 11762 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2449 563-2 792334 07/16/2021 TO 07/16/2022 8/20/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 563-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY_ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:656275677 U-26.3