Loading...
HomeMy WebLinkAbout46775-Z oS�FF�t,f oyy, Town of Southold 7/13/2022 P.O.Box 1179 N 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43244 Date: 7/13/2022 THIS CERTIFIES that the building ALTERATION Location of Property: 2630 Gillette Dr,East Marion SCTM#: 473889 Sec/Block/Lot: 38.-2-27 Subdivision: Filed Map No. Lot No. conforms substantially to the Application.for Building Permit heretofore filed in this office dated 8/24/2021 pursuant to which Building Permit No. 46775 dated 9/2/2021 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: gas hot water heater as applied for. The certificate is issued to Terrell,Barbara of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46775 9/14/2021 PLUMBERS CERTIFICATION DATED K--�\ 0 A ize ature ao�su at�,co TOWN OF SOUTHOLD BUILDING DEPARTMENT y z 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#: 46775 Date: 9/2/2021 Permission is hereby granted to: Terrell, Barbara 132 N Jefferson Ave Lindenhurst, NY 11757 To: convert oil to gas hot water heater as applied for. At premises located at: 2630 Gillette Dr, East Marion SCTM #473889 Sec/Block/Lot# 38.-2-27 Pursuant to application dated 8/24/2021 and approved by the Building Inspector. To expire on 3/4/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building nspector o��pF SO�Tyol Town Hall Annex ~ Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Q sean.devlin(a)-town.southold.ny.us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Barbara Terrell Address: 2630 Gillette Dr city:East Marion st: NY zip: 11939 Building Permit#: 46775 Section: 38 Block: 2 Lot: 27 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Home Owner License No: SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor 1st Floor X Pool New Renovation X 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 3 Wall Fixtures 2 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures 2 CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 4'LED Exit Fixtures Pump Other Equipment: Floor Heat-1 Notes: Bathroom Renovation & Oil to Gas Conversion Inspector Signature: Date: September 14, 2021 S.Devlin-Cert Electrical Compliance Form �pF so) Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G . Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD ® E N1�1X17 E DEC 1 61021 BUILDIN13 DEPT. TOWN OF SOUTHOLD CERTIFICATION Date: Building Permit No. `I ( 19 Owner: � J/�` —T e ry o 1 (Please print) All (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (P umbers Signature) Sworn to before me this day of r-j-rf,-ry,kpr , 20 a-( V u--a-Au J-- Notary Public, 5 q:01A L County Vita Ross NOTARY PUBLIC,STATE OF NEW YORK Registration No.O1R04883.159 Qualified in Suffolk County Commission Expires February 9,20� i ,moo to # # =TOWN OF SOUTHOLD BUILDING DEPT. °`ycourm ''a 765-1802 1 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PL13G. [ ] -FOUNDATION'2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY,INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O REMARKS: . DATE L INSPECTOR Iftaf So # TOWN OF SOUTHOLD BUILDING DEPT. co 765-1802 INSPECTION.- FOUNDATION 1 ST [ ] ROUGH PL13G. [ = ] :FOUNDATION-21SID [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE:SAFETY INSPECTION " [ ] FIRE RESISTANT CONSTRUCTION f ] .FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O REMARKS: ` 1 Aj DATE 10- 1 INSPECTOR �� / v OE SOU # TOWN OF SOUTHOLD BUILDING DEPT. courm� 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ INSULATION/CAULKING [ ] FRAMING /STRAPPING ] FINAL p11 � GAS CoW410 [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE �� 70'Y� INSPECTOR Ing) FIELD;INSPECTION REPORT'. DATE ' FOUNDiATI,ON.(1ST) .... .r FO ATION(2NA):' .i :. 3a,P os ',RQUG��� FRAMINQ:'�8z . . ;" ,. '• . . y t Ph,U1YIBIN.�: p 77 INSULATION-.PER N.Y. . STATE"ENERGY CODE "i Vil FINAL' �--.-421*.• '� � :. .. , • . . . moo. Lf'. ren Ov-6L. Vo. RIO } ri M t. ---1 =�ovOg�MIA,oGi TOWN OF SOUTHOLD—BUILDING DEPARTMENT N Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Way • o�� Telephone(631) 765-1802 Fax(631) 765-9502 https://-Aww.soutlioldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT r Office Use Only rk D 59iqDV[E D PERMIT NO. Building Inspector: AUG 2 4 2021 Applications and forms must be filled out in their entirety.Incomplete BUILDING DEPT. applications will not be accepted. Where the Applicant is not the owner,an TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed. Date:07/30/2021 OWNER(S)OF PROPERTY: Name:Dennis Terrell SCTM#1000-seC38 ,block2- lot27 Project Address:2630 Gillette Dr. East Marion N Y 11939 Phone#:631 252 4065 Email:dterre1146@verizon.net Mailing Address:2630 Gillette Dr. East Marion NY 11939 CONTACT PERSON: Name:Neal Ross and or Katelyn Herrera Mailing Address:120 Middle Country Rd. Middle Island NY 11953 Phone#:631 924 0677 Email:Katelyn@nhross.com DESIGN PROFESSIONAL INFORMATION: Name:NA Mailing Address: Phone#: Email: CONTRACTOR INFORMATION:, . Name:N.H. Ross, Inc. / Neal Ross (Plumber) Mailing Address:120 Middle Country Rd. Middle Island NY 11953 Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Z Otheroil to gas,Install Nortiz tankless natural gas HWH,total of 50ft of gas to range/hwh $7553.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? []Yes ®No 1 [-- - f PROPERTY INFORMATION Existing use of property:Residential Intended use of property:NO CHANGE Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to District 1000 this property? ❑Yes ®No IF YES, PROVIDE A COPY. 8 Check BoxAfter 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,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,'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):Neal Ross BAuthorized Agent [I Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF Suffolk Neal Ross �-- ( �. Ing duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)heisthe Plumber (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 L \ day of X�t�l , 20 —� ANT ar_y P is--Vtta Ross NOTARY PUBLIC,STATE OF NEW YC .i Registration No.01R04883559 �,�,,,,, ,�„ T, Qualified in Suffolk County Ria[�°r� 6$i�e OWN erg AUnv�Crt TION Expires February 9,20� (Where the applicant is not the owner) - -- I, Dennis Terrell residing at 2630 Gillette Drive -,......__ East Marion NY 11939 do hereby authorize Neal Ross to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date T 60-- Dennis JaDennis Terrell S'-� vf� ' -� 2-- Print Print Owner's Name ELIZABETH JOHNSON Notary Public,State of New York No.01 J05053133 2 QuAlified in Suffolk Cou Commission Expires DecemDer 11,20_ f' Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) 1, �i co-residing at (Print property owner's name) (Mailing Address) ��� � an 39 do hereby authorize ,10C (Agent) �0 � �(�JC_to apply on my behalf to the Southold Building Department. (Owner's Signature) (Date) -tom l il/1 ►y i S I Gam- i�"1�'e— (Print Owner's Name) su>rlat BUILDING DEPARTMENT- Electrical Inspector a@� ®G TOWN OF SOUTHOLD © Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(cb-southoldtownny.gov — seand(cD-southoldtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 09/08/2021 Company Name: NH Ross, Inc. Name: Dennis Terrell License.No.: 4605-ME email: Service@nhross.com Phone No: 631 252 4065 01 request an email copy of Certificate of Compliance Address::-2630 Gillette Dr. East Marion'NY 11939 JOB SITE INFORMATION (All Information Required) Name: Dennis Terrell . Address: 2630 Gillette Dr. East Marion NY 11939 Cross Street: Phone No.:.631 252-4065 . . Bldg.Permit#: 46775 email: Service@nhross.com Tax-Map District:. 1000 Section:.38 Block: 2. Lot: 27 ::BRIEF DESCRIPTION OFjWORK(Please Print Clearly) 11° �WWM°„M;M°WtoHMmd Me50a°9az�� m9° :.Install Nortiz brand tankless.HWH Model# EZ98 and run 50 ft of gas pipe to HWH acid"range Install Nortiz brand tankless HWH-Model# EZ98 and run 50 ft of gas pipe to HWH and range Check All.That Apply: Is job ready for inspection?: ❑YES ❑✓ NO _❑Rough In ❑Final Do you need a Temp Certificate?: ❑YES ❑NO Issued On 09/08/2021 Temp Information: (All information required) Service Size ❑l Ph ❑3 Ph Size: A #Meters Old Meter# ❑New Service ❑ Service Reconnect ❑ Underground ❑Overhead # Underground.Laterals ❑l ❑2 ❑H-Frame Opole Work done on Service?, [:]y, ❑N Additional Information: AA Does not pretain to the job AA ^^ Does not pretain to the job A^ "^ Does not pretain to the job ^^ PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx PERMIT# Address: Switches Outlets h GFI's i`I I Surface Sconces• H H's I UC Lts Fans Fridge HW Exhaust Oven W/D Smokes DW Mini. Carbon - :Micro Generator;_ Combo 'Cooktop Transfer AC AH Hood V Service Amps Have Used Special: co, 1— �,c'/ Comments: �o��SUFFO�,YcoG� BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex- 54375 Main Road - PO Box 1179 =o • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 ro err _southoldtownny.gov - seand(cb_southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 101\ Company Name: �A VAS Electrician's Name: ) License No.: Elec. email: Elec. Phone No:(� ct�t� ' }� ❑I request an email copy of Certificate of Compliance Elec. Address.: o JOB SITE INFORMATION (All Information Required) Address: Cross Street: Phone No.: WN Bldg.Permit#: email: �- Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): OA � �jC�-S C`�rnv2�St l ;�l�5��.1�2.�� \v �'�r -�1��5 a)tu y Z-0 .Y 5 bl CA �v\�.�.�s �- v a- A - c n< Won 6//L) <? V'2g O� a.n e-c Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO 0 Rough In Final Do you need a Temp Cert i 'tate?: ❑ YES []-NO Issued On Temp Informationdi (All information required) Service Size Ph❑3 Ph Size: -2,01J -A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame D Pole Work done on Service? Y N Additional Information: C (r' PAYMENT DUE WITH APPLICATION 4�" PJ 4A) DEC 292021 BUILDING DEPT. TOWN OF SOUTHOLD t vA.P Y/ m-o 0 F A Ld W IVA -MR IV E > z EA WN tu tn P. PI`tAVThQl(ILfD ALURA'HQM OR-ADDITION 10 THIS SURVEY 15 A VIOLATION Or AICTION 7209 OF 'HE NEW YORK STATE LU I MUCATION LAW. MON •EN, rXMES OF THIS SURVEY AW NOT/FARING P9 LAND lURVEY0'.0'S INICED RAL OR DOSSED SEAL SH kLL NOT N CONSIDUED12 8 4! 2 M , CO-TAX MAP ED Of A VALID At E COPY. t-, -FDATA 1� ,j rjUARANTEES INDIC kTEO HEREON SMALL RUN I PISLY TO THE PERSON FOR WHOM THE SWEY IS PREPARED, AND Jj N HIS BEHALF TO VHPI JITLE COMPANY,GOVERNMENTAL AGENCY AVS {ENDING IN61ITLIT16N LISTED HEMONI ' I, 1O THE ASSIGNEESIQF THE LENDING= fVTION.GUARANTEES ANI,:NOT T1 ADDITIONIAt • hQANI;'�r 4ro , t.J�4E'jy-rLp v A I U2 v- YED- 24! I-VTE MA U'C,LA-NP.,5URVE--','0Qs F t3; 'N YORK Workers' CERTIFICATE OF PARTICIPATION STATE Compensation Board Disability or Disability and Paid Family Leave Benefits Group Self-Insurance PART 1.To be completed by Disability or Disability and PFL Benefits Self-Insured Plan Administrator 1a.Legal Name&Address of Insured(use street address only) 1 b.Telephone Number of Insured N.H.Ross,Inc. (631)240-0100 120 Middle Country Rd. Middle Island,NY 11953 1c.Federal Employer Identification Number of Insured (if no FEIN then use Social Security Number) 11-2233200 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Self-Insured Plan(Association,Union or Trust) (Entity Being Listed as the Certificate Holder) Cardinal Disability Trust Town of Southold 3b.Insurer Identification Number 54375 Route 25 Southold,NY 11971 B-305506 3c.Coverage effective period 01/01/2021 through 12/31/2021 4. Group self-insurance provides: XD A.Both disability and paid family leave benefits. R B.Disability benefits only. 5. Group self-insurance covers: Q A.All of the employer's employees eligible under the New York State Disability and Paid Family Leave Benefits Law R B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorizedI n dmi ' trator o uthorized representative of the Self-Insured Plan referenced above and that the named insured has NYS Disability and/or Paaa ave surance coverage as described above. Date Signed 08/12/2021 By (SigWL e of Plan Administrator or authorized representative of the above named plan) Telephone Number 518-724-3583 Name and Title Matthew Mazzotta,Administrator IMPORTANT: If Box 4A and 5A are checked,and this form is signed by the Plan Administrator or authorized representative of that plan,this certificate is complete.Mail it directly to the certificate holder.If Box 4B or 513 is checked,this certificate is incomplete for purposes of Section 220,Subd.8 of the 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 4B 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. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only Plan Administrators or their representatives are authorized to issue Form DB-120.2. D13-1120.2(10-17) IIIIIIII1 DB-120.2 (10-17) IIII NHROSSI-01 CSOCCOA ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmmr)8/12/2021 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 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 Kerr!Illuminato UNFCU Financial Services,LLC dba Industrial Coverage PHONE, No,Ems);(631)736-7500 145 FAX No): 62 South Ocean Avenue E-MAIL Patchogue,NY 11772 ADDRE :killuminato@industrialcoverage.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Merchants Mutual Ins Co 23329 INSURED INSURER B: N H Ross,Inc. INSURER C: 120 Middle Country Road INSURERD: Middle Island,NY 11953-2519 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 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 OF INSURANCE ADSD SUBR WVDPOLICY NUMBER POLICY EFF POLICY LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F7X OCCUR BOP1061411 10/17/2020 10/17/2021 DAMAGE TO RENTED 500,000 P E IS a occurrence) $ MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2'000,000 POLICY❑JECT F] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Fa aBINdeD SINGLE LIMIT $ 1,000,000 X ANY AUTO CAP9265309 10/17/2020 10/17/2021 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS WN BODILY INJURY Per accident $ AUTOS ONLY AUOTOS ONLY PPe�acEcRdent AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAR CLAIMS-MADE CUP9139060 10/17/2020 10/17/2021 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTRH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA A E.L.EACH ACCIDENT $ (MandatoryMIn BE EXCLUDED? ) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Town Route h ACCORDANCE WITH THE POLICY PROVISIONS. 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 NYSIF New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE D D A^^^^^ 112233200 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER N H ROSS INC TOWN OF SOUTHOLD 120 MIDDLE COUNTRY ROAD 54375 ROUTE 25 MIDDLE ISLAND NY 11953 SOUTHOLD NY 11953 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 824 595-3 763168 11/01/2020 TO 11/01/2021 8/12/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 824 595-3, 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. 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. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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: 1007969039 U-26.3 ` Kod APR AS NO' DATE: . . xx B.P:# � FEE:-. , ��6 lU BY: NOTIFY BUILDING G=PARTMENT 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 - CONS r R! -.-ICN MUST BE COMPLETE F-2 -`.0. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS Or THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF �_��irk ini n Tn,Att,i 7�n SoaVqFJoWPMNG BOARD ���%ISTEES OPOY OR DISE rS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY ELECTPICAL INSPECTION REQUIRED NORITZ° EZ98DV (GQ-C2860WX-FF US) EZ111 DV (GQ-C3260WX-FF US) Residential Condensing Water Heater Specification Sheet -Standard Input-18,000-180,000 BTUh/0.5-9.8gpm(EZ98) 18,000-199,900 BTUh/0.5-11.1gpm(EZ111) . Uniform Energy Factor(UEF)- 0.97(NG)/0.97(LP) -Compact Design-ANSI Z21.10.3/CSA 4.3 certified design that can a be wall-mounted indoors or installed outdoors using the optional Vent Cap -Heat Exchanger-manufactured with high quality stainless steel -Venting Options-available in Direct Vent model that can use either 2° I or 3"Schedule 40 PVC/CPVC,flexible PP vent,or installed outdoors with Vent Cap. j .. -Wifi Capable ! -Direct Electronic Ignition i -Compatible with 1/2"gas pipe-see installation manual -Multi-System Capability-units can be linked together by using the optional 2-unit Quick Connect for twice the hot water capacity Accessories -Fully Modulating-BTU input range from 18,000 to 360,000/399,800 BTUh ❑Universal Concentric Vent Kit (with Quick Connect) with stable combustion provided by gas Venturi (#PVC-UCVK) and pre-mix burner.Each individual unit 10/11:1 Turndown Ratio ❑Low Profile Termination Kit -Temperature Controls-includes remote thermostat that can (#PVC-LP7) precisely adjust the output temperature from 100°F to 140°F ❑PVC Concentric Termination (#PVC-_C7) -Safety Devices-Flame Sensor,Overheat Prevention Device, ❑ 3"Horizontal Hood Termination Lightning Protection Device,Freeze Protection,Condensate Overfill (#PVT-HL) ❑ -25 Year*Limited Heat Exchanger Warranty for Residential Use SV Conversion(#SV-CK-2) ❑ Birdscreen(#VT-PVCS) - 5 Year Limited Parts Warranty&1 Year Reasonable Labor ❑Outdoor Vent Cap(#VC-6) -Approvals-CSA,UPC",NSF,Low NOx Approved By SCAQMD(Rule 1146.2) ❑PP Flex Vent Kit(#EZ2FVK-J ❑EZTR Conversion Kit(#EZ2-CK) ❑External Recirculation Pump Kit (#RPK-EX7) ❑Isolator Valves(#IK-WV-200) LOW-LEAD ❑Wireless Monitor(#NWC-ADAPTER) U PcF ' ❑Quick Connect Cord(#QC-2) ® ❑ *Refer to the Noritz Limited Warranty for complete coverage details,at Norimcom Neutralizerfor1-unit(#NC-1S) **This product complies with California AB 1953 Low Lead Law and section 1417(d)of the Safe Drinking WaterAct ❑Programmable Remote(#RC-9018) NORITZ AMERICA CORPORATION 11160 Grace Avenue,Fountain Valley,CA 92708 Tel.1-866-7NORITZ www.noritz.com r Dimensions WALL MOUTING BRACKET °IIITJI(gyRl> 7xW.2'ID6 (INCLUDED ACCE550RY) $a 16.0'14061 1].6'14131 lo.z'(z6Dl 8 __b (VIEW FROM SIDE) (VIEW FROM FRONT) 142'13621 "m 5.1'(1301 3x0.5'x1.W(12.401RECTANGLE HOLE HOT WATER OURETI3/4' n 7.2'11831 10.2.12601 18 5'147111 m 1.6'(401 0.3.181 14.1'[3591 17.8"[4511 5.1"11301 10.5"12661 wATFRDRAINVALVE 1.1"[27] WATER DNPW VPLVE (WATER HLTER) COLD WATER INLETI3/4') 3.5"1891 I,DID2.4"1(I)611 I,DO)2.4"[01611 AIR INLET FLUE COLLAR 171. (VIEW FROM BOTTOM) 0 0 WATER DRAIN VALVE WIRING THROUGHWAY CONDENSATE DflAIN(1/2') ®IOM IRINGTHROUGHWAY GAS INLET(3/4') C120V) iS 2.21561 HEIGHT OF EACH FITTING FROM CASE 3.9'11001 HOT WATER OUT TOP 1.9"(491 5.2"11321 COLD WATER INLET TOP 2.1"531 6.7'116911.7"1421 CONDENSATEDRAIN BOTTOM 1.7"1421 8.1'(2061 5,p(144j GAS INLET BOTTOM 2.2'56 m 4xQ11 11.2'12842x4x0.24'110.60BLONGHOLE 0.4-[101 415.'13 92 4x0.24'x0.6ri n HOLE 15.6"13971 Flow Rates Temperature Rise(°F) 30 40 45 50 60 70 80 90 100 110 120 130 140 EZ711DV (GPM) 11.1 9.7 8.7 7.8 6.5 5.5 4.8 4.3 3.9 3.5 3.2 3.0 2.8 EZ98DV (GPM) 9.8 8.6 7.6 6.9 5.7 4.9 4.4 3.8 3.4 3.1 2.9 2.6 2.4 Pressure Drop 35 80 t-por Flow C25-F V.I.CIA ee Set Bypass Flow CoPV°(Valve Open lamperaWre:126°For RigMr Set IempereNie:120°F w lower 30 70 : m d 25 60 L U) o °' 50 N 20 N y J 40 0 d 15 N 30 10 N d 20 a 5 10 0 L 0 0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 Flow Rate(GPM) Specifications Model Name EZ98DV/EZ711 DV GQ-C2860/3260WX-FF US Weight 70 pounds Operating Pressure 15-150 psi Gas Supply Pressure NG:3.5"-10.5" LP:8.0"-14.0" Water Holding Capacity 0.83 Gallon(3.1 Q Water Inlet 3/4"NPT Connection Hot Water outlet 3/4"NPT Sizes Gas Inlet 3/4"NPT Condensate Drain 1/2"NPT Power Supply 120VAC(601-1z),less than 4 amperes Consumption NG:75W(EZ98)96W(EZ111) LP:64W(EZ98)SOW(EZ111) Freeze Protection:114W Freeze Protection Outdoor:-4°F Indoor:-30°F Temperature Settings °F Mode 100-140°F(In 5°F intervals)(9 Options) °C Mode 37-48°C(In 1°C intervals),50-60°C(In 5°C intervals)(15 Options) Materials Front Cover Hot-dipped zinc-aluminum-magnesium-alloy-coated steel w/Polyester Coating Casing Zincified Steel Plate/Polyester Coating Noritz America reserves the right to discontinue,or change at any time,the designs and/or specifications of its products without notice. Rev.3/20 Plumbing • Heating • Cooling • Electric -Gas Conversion Specialist Drain Cleaning Home Generators a Ik I k L ESS Lf� W4 . �OL �FYDn v- Fl-o