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HomeMy WebLinkAbout46533-Z Town of Southold �o� ooy 2/2/2022 a P.O.Box 1179 0 co -V� 53095 Main Rd oy�,o� �Aao�fi Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42743 Date: 2/2/2022 THIS CERTIFIES that the building WINDOWS Location of Property: 9870 New Suffolk Ave., Cutchogue SCTM#: 473889 Sec/Block/Lot: 116.-5-1.3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/25/2021 pursuant to which Building Permit No. 46533 dated 7/1/2021 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: replacement windows, in kind and in like to existing single family dwelling as applied for. The certificate is issued to Sullivan,Jeffrey&Jill of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED A hori Signature �s�Ffot TOWN OF SOUTHOLD o`p c BUILDING DEPARTMENT Nx TOWN CLERK'S OFFICE Od • SOUTHOLD, NY r 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#: 46533 Date: 7/1/2021 Permission is hereby granted to: Sullivan, Jeffrey 9870 New Suffolk Ave PO BOX 230 Cutchogue, NY 11935 To: Replace existing windows, in like, in kind, at existing single family dwelling as applied for. At premises located at: 9870 New Suffolk Ave., Cutchogue SCTM #473889 Sec/Block/Lot# 116.-5-1.3 Pursuant to application dated 6/25/2021 and approved by the Building Inspector. To expire on 12/31/2022. 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 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 I%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. W I CQ s IoZOa l New Construction: Old or Pre-existing Building: (check one) Location of Property: 9$1-0 NEW 5QrFQUG AVE SDUiHO�� House No. Street Hamlet Owner or Owners of Property: J E PF IQEy S U W V AN Suffolk County Tax Map No 1000,Section Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: E(,I.31 E h 1F-7NJRO►J Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted:$ SU 0--> Applicant Signature ,x � �, J=��2cyw�.,swcU�✓�r�/ ��,aF,F�aE. ���� rack ;,.,,��°��.� ��� , _CO rcm DSL r YU&lpJ cus her4frj aF,ilson'r� `�cZ/�l�jla f t�i✓Cn� S t5 Apexto _ - v f Ag,.L,'Ql�Oltl$i31IA¢*�1Cj737�YY7�Yt �-.• m _ _ "�� � -,, t � 5 y , P06 ec jw q x t E� EvB )UKNgg �' r h07ARYPkS��iC Sfh?EOFYEW Y K �Wz � .' 'CosaauSs-#a�F_tSpire51�1R�'2 F +.�•- aw- =� fa•,..- rig' r SOF SOUTy — — �o� Olo # TOWN OF SOUTHOLD BUILDING- DEPT.- cou765-1802 INSPECTION ] FOUNDATION 1ST [ ] ROUGH PL13G. ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [Ir]''FINAL O 1rQ� pqktWW ' FIREPLACE & CHIMNEY [ ] FIRE SAFETYINSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: pdt, by .f\ 1 9L VY1 DATE INSPECTOR 44 6:5 laF SO(/Ty� —— --- ,`0 6 # TOWN OF SOUTHOLD BUILDING DEPT:. �`yrou►m 765-1802 INSPECTION [ _] FOUNDATION 1ST [ ] ROUGH PL13G. [ ] FOUNDATION 2ND [ ] NSULATION/CAULKING [ ] FRAMING/STRAPPING FINAL (Ajkm,< ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: _ 1 - VI DATE — .INSPECTOR --- # *. TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 _ INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ }. SULATIOWCAULKING [ ] FRAMING /STRAPPING [ FINAL CW(wA [ ] FIREPLACE & CHIMNEY [ ]- FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE INSPECTOR FIELD Y TOECTION REP'ORT' DA-E77 ` v FO . ATIQN(1ST) ...������������_ ���� w two.. ;• . •. ," •. FOUNDATION(SND) ' r.- rA ROU GEi �FRAIVIIN.G 8c . • � '�, P]�7 G AA ` • w INSLZkTION-MA N..Y. STATEI• NERCY CODED '' y < < V. Acts. qq -alh p �/ Z( yz fb rn 7. `' ; a. 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)765-9502Survey Southoldtownny.gov PERNHT NO. VhS--33 Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit Examined 20_.V Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: Approved 20 Mail to:SCOTT DOLA Cru MA� Disapproved a/c I OS 6plrbagRU, LtJ G1n4 -ONSUOT,Cr 060,33 Phone: U60) 952-X111 Z Expiration ,20 Building Inspector APPLICATION FOR BUILDING PERNHT Date ZZ 20 Z 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 permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) 10F 131.1TIb 60446 L/✓ (YLR$7�NBU6y G 06033 (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises . ISP F R e y 514 L U VAN (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. H S3 41? Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of and on which proposed work will be done: 89'0 NEtt/ AyIE, House Number Street �n Hamlet 2 County Tax Map No.1000 Section " Block Lot s REMOVE 4^r , t2P—pG,4GF_ U11%0, 0,),S90E 512'e—c' /✓o S%Qc(e%Gr,2As- CU,9WOf 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. 9ESrJE Ni 1,9'L - S�n/GU� Ff1 M1C-Y b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition Alteration Repair_ Removal Demolition Other Work 51WOat X21-PLACEMErj; (Description) 4. Estimated Cost 1 1-2 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 cd Sucrpua AVE y- 28y 14.Names of Owner of premises IEFFZEY SWO VAN Address 9840 N_ Phone No.49-31-�32 Name of Architect Address Phone No Name of Contractor 40nif aGPor 14SA Address—.?(f Z- -Wa �°-W Phone No. 60-°352 - U2 lFZ9N,',4,GR go33g 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 RF 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. ILLI 001 S STATE OF SRK) SS: COUNTY OF CW ) 1 23/Ei f} l")E 11 ')e'0d being duly swom,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, � OFFICIAL SEAL (S)He is the (Contractor,Agent,Corporate PUBLIC,STATE OF ILLINOIS MY COMMISSION EXPVES 08W032e'52ndof said owner or owners,and is duly authorized to perform or h ve erformed the said wor and 10le this application; that all statements contained in this application are true to the best o know g'!'eand�ie e; rk will be performed in the manner set forth in the application filed therewith. Sworn to before me this day f , ` 20ZI tary blic Signature of Applicant A`CORvim® CERTIFICATE OF LIABILITY INSURANCE °o r27=1l°"Yrr' 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 WANED,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 on PRODUCER dorse s. M MARSH USA,INC. ANE TWO ALLIANCE CENTERPHONE AA1XC No): 3560 LENOX ROAD,SUITE 2400 : ATLANTA,GA 30326 1 S AFFORDING COVERAGE NAIC i CN101642069+IomeD.GAW.-2122 INSURERA: Old Re pfficInwranceCo 24147 INSURED dNSURERB: nWM 19399 THE HOME DEPOT,INC. HOME DEPOTU.SA,INC. INsuREtC: HomeRisk Caom Insurance Compony WA 2455 PACES FERRY ROAD INSURER u r BUILDING C-20 ATLANTA,GA 30339 INSURER'E:: COVERAGES CERTIFICATE NUMBER: ATL-OD5072225-04 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. 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. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMBS A X commERCLALGENERALLJABRITY MWZY314574 03101/2019 '0310111022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS•MADEXI OCCUR PREMISES $ 1,000,000 X SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PEP, GENERALAGGREGATE $ 2,000,000 X POLICY 0 jECOT- F]LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ A AuroMoBILELIABILnrY MWTB314573 03/01/2019 03/01110'12 COMBINEDaccident) NGLELIMIT $ 1,000,000 X ANY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTYDAMAGE $ AUTOSONLY AUTOS ONLY (per accident) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CIAIMSMADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION WC 562402 (WI) 03/01/2021 03/01/2022 X B AD EMPLOYERS'LIABILITY STATUTE EOR ANYPROPRIETORIPARTNERIEXECUTTVE YIN N WLR 067818258(NC,VA) 03101/2021 02/01/2022 E.L.EACH ACCIDENT $ 5,000,000 OFFICERIMEMBEREXCLUDED7 � NIA andawyidescribe under CO�Wed on AddiUODal Pap EL DISEASE-EA EMPLOYEE $ 5,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 3 5,000.000 C Excess Auto 297110011002021 03/0112021 03/0112022 Limit 4,000,000 A Excess General Liability MW2X 314580 03/0112019 03/01/2022 Link 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached H more space is required) 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 G-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHOR®REPRESEPITATIVE of Marsh USA Int" Manashi Mukhoee ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ' AIC ® DATDDfYYYY) v CERTIFICATE OF LIABILITY INSURANCE o10/27/20/zo21 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 endorsemerrt(S). PRODUCER CONTACT MARSH USA,INC. NAME: PHONE FAX TWO ALLIANCE CENTER (A/C,No): 3560 LENOX ROAD,SUITE 2400 E-MAIL�: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC# CN101642069_HomeD-GAW.-21-22 INSURERA: Old Republic Insurance Co 24147 INSURED INSURER B: AIU Insurance Co 19399 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C: HomeRisk Caplhm Insuiance Company WA 2455 PACES FERRY ROAD INSURER D BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-OM7222504 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. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE ADOLS BR POLICY EFF POLtCYEXP LIMITS POLICY NUMBER IDD MIDD A X COMMERCIAL GENERAL LIABILITY MWZY314574 03/01/2019 03/01/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADEX❑OCCUR PREMISES Ea occurrence) $ 1,000,000 X SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PEP, GENERAL AGGREGATE $ 2,000,000 X JELOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY 1:1 OTHER: $ A AuroMoBILEIJABILmI MWTB314573 03/01/2019 03101/1022 COMBINED SINGLELIMIT ant) $(Ea 1,000,000 AINY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acutideM X UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC 56240269(WI) 03/01/2021 03/01/2022X PER OTH• B AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETORMARTNERIEXECUnVE Y/N WLR C67818258(NC,VA) 03101/2021 02101/2022 E.L.EACH ACCIDENT $ 5,000,000 OFFICERIMEMBEREXCLUDED? ❑N MIA (Mandatory in NH) Condi ued on Add'&&Page E.L.DISEASE-EA EMPLOYEE $ 5,000,000 H describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 5,000,000 C Excess Auto 297110011002021 03101/2021 0310112022 Limit: 4,000,000 A Excess General Uability MW2X314580 03/01/2019 03/01/2022 L'unit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is requhed) 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 AUTHOR®REPRESENTATiVE of Marsh USA Ina Manashi Mukhelee ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNI 01642069 LOC#: Atlanta ACO® ADDITIONAL REMARKS SCHEDULE Page 2 Of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING azo ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Cartier.Indemnity Insurance Company of North America Policy Number.WLR 067825287(AL,AR,FL,ID,IA,KS,KY,LA,MS MO,NE,NM,ND,OKSC,SD,TN,WV,WY) Effective Date:03101/2021 Expiration Date:03101/2022 (EL)Limit$5,000,000 Carrier.AIU Insurance Co. Policy Number.WC 023096003(AK,DC,DE,HI,IN,MD,MN,MT,NY,NJ NY,PJ VT) Effective Data:03101/2021 Expiration Date:03!01!2022 (EL)Limit:$5,000,000 Carrier.ACE American Insurance Company Policy Number.WCU C67805331(QSI)(CA,IL,OR,WA) Effective Date:0310112021 Expiration Date:03101/2022 (EL)Limit$5,000,000 SIR:$1,000,000 Cartier.National Union Fn:Insurance Company Policy Number.XWC 1647258(OSI)(CO,CT,GA ME MI,NV,OH,PA UT) Effective Date:0310112021 E)VnItIon Date:03/0112022 (EL)Limit$4,000,000 SIR:$1,000,000 Cartier.ACE American Insurance Company Policy Number.WLR C67818210(AZ) Effective Date:00112021 Expiration Date:0310111022 (EL)Limit$5,000,000 Cartier.National Union Fre Insurance Company Policy Number.XWC 1647259(QSQ(MA) EffLcWe Date:03/01/2021 Expiration Date:0310112022 (EL)Limit$4,500,000 SIR:$500,000 TX Employers XS Indemnity. Carderiitinios Union Insurance Company Policy Number.TNS C661949072(TX) Effective Date:03/0112021 Expiration Date:03/01/2022 (EL)Limit$10,000,000 SIR:$1,000,000 ACORD 101(2008101) 0 2008 ACORD CORPORATION. All rights reserved. The ACORD name 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: 10122/2020 Application: H-53429 Application Type: Home Improvement License Receipt No. 414174 Comments Payment Method Ref.Number Amount Paid Payment Date Cashier ID Renewal+ 14 Additional Check 0003181507 $1,800.00 10/2212020 GAB Locations Contact Info: R CHARD TOUSEA INC(14 SUPPS) PO BOX 105451 ATLANTA,GA 30348 Work Description: A Suffolk County Dept of j Labor,Licensing S Consumer Affairs j HOME IMPROVEMENT LICENSE ` Name RICHARD TOUSEY Business Name This cerlifies that Ow HOME DEPOT USA INC 04 SUPPS) hearer is duly licensed by the County of suffoli License Number:H-53429 Rosalie W890Issued: 05/1512014 CommissionerExpires: 11/01/2022 C Home Improvement Agreement: Page 1 Home Depot License#'s-For the most current listing visit www.Homedgpot.com/LicenseNumbers Vance Comerford 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. 1Service Provider Contact Information t The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101 Phone# Service Provider Email Address Service Provider License#(s) 2 ;Customer Information sullivan lieffrey I Long Island East 1-1W58W0TQ Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 9870 New Suffolk Avenue Cutchogue 111935 Customer Address City State Zip 71 (631) 734-2842 iillouteast@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address r3.,NOTICE-" 1 ]IRIGHT TO I CANCEL +YOU MAY CANCEL THIS AGREEMENT WITHOUTPENALTYOR OBLIGATION BY CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDERAT- icustomercancellationnortheast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 40 Oser Avenue Hauppauge NY 11788 Address City State Zip Y 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. YOUR 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 fTO YOU.OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. jTHE LAW REQUIRES THAT THE HOME POT GIVE YOU A NOTICE EXPLAINING YOUR ARIGHT TO CANCEL.PLEA IGN BEL TO ACK�NRCGE THAT YOU HAVE BEEN GIVEN f(ORAL AND WRITTEN NO IC OF YOU RIGHT TO Acknowledged by: os%�sn0i 1 C tomer' S Date 460 Standard Form HIA(02 Oct.20M Generated Date n 6/gR�7�71 d/PO# _ v 0.1.9 Home Improvement Agreement: Page 2 77777-7 4.Descriphoa of Work to be Performed A detailed description of the work to be performed is included mi the paragraph entitled Scope of Work, i Specification,Customer Summary Sheet,Quote Form,Estimate,Invoice or Measure which is included in this I y Agreement -77777 5 Anticipated DeLvery Date I Installation Schedule Approximate Start.Date: 08/13/2021 Approximate Finish Date: 09/10/2021 All dates are approximate and subject to change based on unforeseen events including inclement weather,permitting delays,and delays in confirming insurance coverage of Your claim for any repair,if applicable v ! _ 6 Electronic Record's Authorization You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy,your consent applies to this Agreement and all subsequent documents and written communications related to this Agreement. 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 email address above,you confirm that you have access to a computer that can receive and open emails and PDF I documents 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. eContract Price: $ 11127.00 Includes all applicable taxes.Excludes finance charges.* Sales Tax: $ 10.00 (If applicable,total amount of taxes included in Contract Price) Maximum deposit ONLY applicable in MD,MA,ME(33%),NJ, WI(99%) Deposit% 125.0 Deposit Amount$ 1281.75 Remaining Balance$ 1845.25 8 Finance Char es � ,, 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 funds 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 9 Acceptance and Authorization ' 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 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 Sup lement,if any; (ii)You are receiving a complete copy of this Agreement;(iii)all rights and interests under thi Agr ent are ely vested in the person listed as"Customer"above;and(iv)Electronic signatures will be j de med o inals r all purposes. X 06/18/2021 7777 is Si ature Date X I/s/ a Home Depot 06/18/2021 TEA Home Depot Digital Signature Date For questions related to your installation, contact Service Provider at (631) 478-6101 For any other concerns, contact The Home Depot at 1-800-466-3337 460 Standard Fonn HtA(02 Oct.20)(E) Generated Date Ofi/18/2021 Lead/PO4 I-1W58XU01Q. v 0.ts k n � DATE: a 3 C I 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. Scope of work: ! 61%OyE 141Jp CZE P09-CG :� �/i A00t,/ i S'ArIF SIZE NO STR4WC+UA04L- C."^IG-ES_ Location: `.3��J IV-b2 SU FFO Lt AVE E Authorized Agent Go Permits LLC istz&e_179 M E I W^j Service Agent Name Best Regards, Liceee Signature P 'nt Nage &License Number NO'T'E: PLEASE MAIL PERMIT TO: T4 E KOl7 E J.4 IoW JEFFRP(J, KUHR NOTARY PUBLIC,S;F:l E OF�;El•1�YOP,K THD AVHome Services,In.. Registration.igo`C+;i`-,U6004581 Qualified+n wi10an CouOy 40 Oser Avenue•Suite 17•Hauppauge,NY 1`17 gyres pllareh V ge Phone:631-478-6101•Fax:631-435-4837•Toll Free:877 issien f CCCUFANCY OR APPROVED AS NOT USE IS UNLAWFUL DATE: B.P.# D � BVI THOUT CERTIFICATE _ FEE: �F OCCUPANCY `4� ,)0• BY: �J NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. COMPLY WITH ALL CC!: 4 S OF OVW, ALL CONSTRUCTION SHALL MEET THE NEW YORK STATE & T � ;ODES REQUIREMENTS OF'fHECODES OFNEW AS REQUIRED ANDCONDITIGNS OF YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. SOUTHOLD TOWN ZBA SOUTHOLr TOWN PLANNING BOARC ::%l, TOWN TRUSTEES N.Y.S.DEC WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-1WSSWOTQ Sheet: 1 of 1 Customer:Jeffrey sualvan ,Job#.1-1W68WOTQ Consultant: Vence Comerford Date; 06118/2021 New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Openirig #of bars #of bars Csmnts,1 Pni, use L,R or S Glass Mlsc Items Hardware Code Screens For doors use Mull •S"=stationary or E style wrap � .fig � �� "X"=operating TR. Fkr Code (YM) Style Code Series Code i > > STD,White, GlassPack: METAL, 1 LIV 1st SB-PW N PW 6100 WH WH 67 62 109 Standard LSR SPECIAL CONSIDERATIONS: Wrap Color nterior Casing Type Bay or Bow window: tboard material(vinyl only-Birch or Oak) ay Project Angie(30 or 46) y Flanker Type(DH,SH,or Csmnt) op of window to soffit(Inches) t tied to soffit,color of soffit materiel 1 have reviewed and agree with all the job specifications above and the nstruct Roof(Yes or No)• Special Terms and Conditions on the following page Garden Window: eatboerd Material(vinyl only-White Monte,Birch or Oak) The�Home Depot - Thermal Value of Products Manufactured by Simonton Dated: 513012018 WIR With Grids N MI-4 ;�MGC Mf-W MORINKII EN UZIM Awning 6500 Base ProSolar Supemeo 718' 026 0.23, a 0 0-.26, 2.21 Casement 6500 Base PrO.Solat. Supercept 7/8" 0.26 0.24 a o c o 0.26 1, 0.22 a 0 0 0 Transom' 8500 Base. ProSolar Supercept V 027 1 0.32 6 o 027 j 029 e e Double-Hung 6500 Base P roSo,I.ar Supercept 718" 0.29 1 026 0 029 1 024 Picture Casement (NII) 6500 Base ProSofar supevcept 7/8" 0.26 028 ® o 0.26 6.25 , Picture 6500 Base ProSolar Supercept 7/8- 627 1 6.29 0 ® 62711 0.26 a 2'PanelSfider. .6500-Base. ProSofar. SupemOpt 0-26 19 0-23 0. Q> 71ir .0.29 j 0 t ei' 850- -FO,28� 0.23 ip �Ejrt M P.Bqse,(:5,gj sqft) P.roSolar... Supercept 7/8 09 1 0 T P. Garden poor:C( 65bb Ene!qy Star ProSolar SUN. Super.Spacer 1" 1 0.74 1 1 1 A 030 021 0 0 01.6 YdtibGo INQVO.-._�,.. cz 031 j 0231 01 0 to 1.6 Pro'Sulae. Super 0.28.i :026 01, J.-.1 5pacer kcatwevei7mme MggpT Anzona;.caabmia,Idaho,Nevada:newmecep,omgmuoh,and .28 Q-2i a 4 Avviii -e.*146 '6400:Base ng n '..ppper-:,.. I=Mpt Wr 027 �.0.24 0 roG 022. �0. asdmen PSolas.. 71T -27 D.24 0.27. Q,_ . . zi pro g; >,O,w 1 0.30 03D f 0-27 Picture 7 100 Base Solar :MW :0.27, t p S cep jjj7� i.V.28 .. ;Picture, Oiv . .. ... d2t O�Z8 Q, :Q 0 Panel g 0( -Pros6w. in 3!4 0:30 Interow. $1 W4" .030 029 161 0.30 1 027 "Par 60 C�afifomfti*iio,)Vmo%,:NowMerico, regwU6han4 TNashington - 'M Pitio-00 Pro Solar 17 �.Q- 0.23 �O 10 Patio Door NIraROVlf-FRAME 6100;(PD05)Base Pio Solar .. ...... Irt�rr Pil. '.. . .3w�l...07�oi....O.30 .1.01:-I 1 IA-261 U& 1 o;1:-O.l • DW bffbwm*tqr�Mflas,Dower.De&W%#W/g,Northman MJ,"Long*iiitw yinf 0 0 0 M 0 3 e 28 2 7 0 8 e-NJ -Pro�W;kfSHADE Superp 0_26 1 pept. .. .025 : �-Jojoj 026. 0.23.. Casement. 620Q..Base Supercept 0� Pro..S arSH-ADE AW 0.�6 ]...016. 0201-0.17.. ;P�. 0 5 025; SHAW .61S .6 2. Picture tawfne�k: 6200 Base �Ph*Sofat. 0 ,6 4.26 �j .6.24. PI.O. Ristu,e 6266 4) 26 Oli.: : . 6200,sase .. --.-Pro Sdfar.SWDE.. -W.47' 028. 1 .23 0 028 0 0 0 O:n 1 0.21- . gin to Slides 6200:Base Pro Solar SHADE Supewept: 314*].0:28AI 0.23. 3.Partel'Sfider 6260:Base._ Ptb6oI6r8HADE..,....eu'percept 3/4"1-628.3.0:230.28�- PREMIUM MR1311M I , [t omen Ibcat6dftcoastal areas SW PS- M�-- + 'a 026 0 21 9 A; SB+300VL** w mi Sypercept V 026:, D23. 0� Casement '6E§t 3bbVL.Saoi� FS/Lami Sup&spii6i!i� v 6��s !�23 o' O:n 6 25 Double Hung E 021 `b8+1ML.Base. P 0.25 0.291 -84amill ....Super.Spader. V 0;29 1 0 29 b.i3 Slider: SB+ Base nam 0.20 6.25 a :e On. Pie -M�Y.Lairfli S - 8 �64. 1* 0-30 .0.19 9 -:SB*300VL ETC*61. _14 x+w pa -MEW 9• Garden:Door(CH) -SB+:300VL Base. PS1Lanii`. v. 0.30. .018 L. .0.30 0.25: •Dots hidicaie Energy Star certified for that zone -"winvolvin, he equirements of each(irder.