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HomeMy WebLinkAbout47439-Z ��oyOSUFfa1,��oG�� Town of Southold 7/17/2022 P.O.Box 1179 - _ � 53095 Main Rd o r 4 Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43271 Date: 7/17/2022 THIS CERTIFIES that the building WINDOWS Location of Property: 740 Brown St., Greenport SCTM#: 473889 Sec/Block/Lot: 48.-3-44 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/18/2022 pursuant to which Building Permit No. 47439 dated 2/9/2022 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: window replacements to existing single-family dwelling as applied for. The certificate is issued to O'Connell,Kevin&Ors. of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 0 Autri d S' ature suFFea TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE "oy • o�� SOUTHOLD, NY 4jp1 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#: 47439 Date: 2/9/2022 Permission is hereby granted to: O'Connell, Kevin 7844 Marywood Dr Newburgh, IN 47630 To: install window replacements to existing single-family dwelling as applied for. At premises located at: 740 Brown St., Greenport SCTM #473889 Sec/Block/Lot#48.-344 Pursuant to application dated 1/18/2022 and approved by the Building Inspector. To expire on 8/11/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Bu' ing Inspector /7 - - -- q so�lyo� . # # TOWN OF SOUTHOLD BUILDING DEPT. °ycoum, 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ �INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE ( INSPECTOR Fj: . " 'Rt - . ,v . : OyMIELD:V$i? T - G 8 . . . b . FOUNDATION:(1ST);, r• y . - .��'.... .� ::: cc. FOUNDATION'(2ND.)i. S �. .< ;: :G; . t� ;4,,,;., ;;.;.1;,:,,,.Q . :,:,.:... Z. ::e' ..., y ;r;z?..; Q ;. . :;t>; r :;::; ' Go H ci:i :.i7' - . , ': : "i:: .s,.".: a•.. :r'"i:`' ROUGH.F� O'& 1A1nIly .<;.;::.. :. H PLUM BIN,G' .. �,), . -ZZZZZ i a`, ' -i;tp`"r `t ri- .. W s;- _ +;, . 1.. 11 - 7.. - :?•SY` i.;c ?i°..... u�, . . ;i: . _ „�' . . . . .I. r INSULATION TIQ N.PI; 1Z:N: Y. :,: . . I STATE EN°ERGY'CODE I. . i. --b :,,; ;,,: .:r `;: s.' .. . A i:: _ . :.:.. . . 4- 1* A IT _ .. . .- . '.., - ..: 1. -... _, is .. , . .. ,. . :. . _ - 't'. _ .. ;ri,:. ,.),;,..�;jr:r;y:i tip`', :Ex R :.�5�..,.:: . . .. e� n V .:.'.. �. ` - _' :I .; ;:,,•-- . .. ;,. :r.;:;;.;..... {:`: w•',;., O . - . (� g C c.1 I` :' M ... �J i'' : ►V. . . 'I a ; Y:<;; . H i'y'' I. 11-t �' . . O :'}�j•' .. W . . ..'.: . .: ' .. ..... Ft .,.;J`,`. lJ ;;r..;. . H :,” ' - . . .: . :a:�. - . . H. . ,. i. ;. . a ... .. • , , .. . .... _ -- Y - . • , �•.", : � ., i4,,4 O��SUfFO1K�o TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 oy • 0� ;4� Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownw.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only E C E � � E JAN PERMIT NO. Building Inspector: R JAN 1 8 Zn7� BUILDING DEPT. Applications and forms must be filled out in their entirety.Incomplete TO\A!�,OF sOUTHOLD applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name:Michael Dinizio - n SCTM# 1000- ®3� Project Address:619 Brown Street, Greenport NY 11944 Phone#:(770) 855-1074 Email:michaeldinizio3@gmail.com Mailing Address:619 Brown Street, Greenport NY 11944 CONTACT PERSON: Name:Jessica Schiff Mailing Address:105 Buttonball Ln, Glastonbury CT 06033 Phone#:347-541-4613 Email:permits@gopermits.org DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Home Depot USA Mailing Address:2455 Paces Ferry Rd, Atlanta GA 30339 Phone#:347-541-4613 Email:perm its@gopermits.org DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ®Repair ❑Demolition Estimated Cost of Project: ❑Other $1922 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes 0 N 1 PROPERTY INFORMATION Existing use of property:Res Intended use of property:Res,. no_ change Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes []No 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 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-a0 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):Jessica Schiff ®Authorized Agent ❑Owner Signature of Applicant: (/V Date: �a 1;111 a\ STATE OF NEW YORK) SS: COUNTY OF TK/h UY ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the A IIAIA_� (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 jUaJ4 6L 20� Notary Public =Pubblic SAEVA ate of New York4977251PROPERTY OWNER AUTHORIZATIONnroe County ires Jan 28,2023 (Where the applicant is not the owner) I, �lr. residing at 1 ! &wh S1rcc 1 /J_ e 9 7 lT-re n do hereby authorize i S s'J [T_�/,�j ) to apply on my behalf to the Town of Southold Building Department for approval as described herein. k:A1ez_,�V _ '116/2Z Owner's Signature Date Print Owner's Name 2 Go Permits, LLC 105 Buttonball Ln. Glastonbury, CT 06033 permits@gopermits.org � e i. February 10, 2021 To: Town of Southold Re: 619 Brown St. Enclosed you will find check for the permit fee of $250. If you have any questions, feel free to call me at the number listed below. Please note the following: Please mail the permit to the homeowner. Please e-mail a copy of the permit and receipt to: Email: permits@gopermits.org Thank you! Jennifer Winke, Permit Expediter Go Permits, LLC Phone: 303-946-8685 Fax: 866-697-0768 jenniferwinke@gopermits.org Go Permits, LLC 105 Buttonball Ln, Glastonbury CT 06033 www.gopermits.org DATE(MM/DD/YYYY) A�V CERTIFICATE OF LIABILITY INSURANCE 09/07/2021 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(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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER PE Ent: (A No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069•HomeD-GAW:21-22 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:AIU Insurance Co 19399 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD INSURER D:N/A WA BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-01 REVISION NUMBER: 1 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. I TR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP D I wvo POLICY NUMBER MMIDDIYYYY MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 314574 03/01/2019 03101/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE M OCCUR DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ X SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWTB314573 03101/2019 03101/2022 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY er accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION WC 58240269(WI) 03/01/2 21 03/01/2022 X I PER OTH- B AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE WLR 067818258(NC,VA) 03/0112(121 03101/2022 5,000,000 OFFICERIMEMBEREXCLUDED? NIA E.LEACHACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 5,000,000 Dyes,describe under DContinued on Additional Pae E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 9 5,000,000 C Excess Auto 297110011002021 00112021 0310112022 Limit: 4,000,000 A Excess General Liability MWZX 314580 03/01/2019 03101/2022 Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS, SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: GN1U1642U69 Loc#• Atlanta ACO® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 k.,-- AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 CARRIER NAIC CODE ATLANTA,GA 30339 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: Carrier:Indemnity Insurance Company of North America Policy Number:WLR C67825287(AL,AR,FL,ID,IA,KS,KY,LA,MS,MO,NE,NKND,OK,SC,SD,TN,WV,WY) Effective Date:03/01/2021 Expiration Date:03/01/2022 (EL)Limit:$5,000,000 Carrier.AIU Insurance Co. Policy Number:WC 58240268 (AK,DC,DE,HI,IN,MD,MN,MT,NY,NJ,NY,RI,VT) Effective Date:0310112021 Expiration Date:03/01/2022 (EL)Umit:$5,000,000 Carrier:ACE American Insurance Company Policy Number.WCU C67805331(OSI)(CA,IL OR,WA) Effective Date:03/0112021 Expiration Date:03101/2022 (EL)Limit:$5,000,000 SIR:$1,000,000 Gamer:National Union Fre Insurance Company Policy Number:XWC 1647258(QSI)(CO,CT,GA,ME,MI,NV,OH,PA UT) Effective Date:03101/2021 Expiration Date:03/01/2022 (EL)Limit:$4,000,000 SIR:$1,000,000 SIR(CT):$350,000 SIR(GA):$750,000 Carrier:ACE American Insurance Company Policy Number:WLR 067818210(AZ) Effective Date:0310112021 Expiration Date:03/01/2022 (EL)Limit:$5,000,000 Carrier.National Union Fre Insurance Company Policy Number:XWC 1647259(QSI)(MA) Effective Date:03/01/2021 Expiration Date:03/01/2022 (EL)Limit:$4,500,000 SIR:$500,000 TX Employers XS Indemnity: Camer:lllinios Union Insurance Company Policy Number.TNS 066949072 (TX) Effective Date:03101/2021 Expiration Date:03/01/2022 (EL)Limit:$10,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marcs of ACORD AGENCY CUSTOMER ID: CNI 01642069 LOC#: Atlanta AC4E>REP ADDITIONAL REMARKS SCHEDULE Page 3 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 C•20 ATLANTA,GA 30339 CARRIER MAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance SIR:$1,000,000 "`HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot USA,Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC Home Depot U.S.A.,Inc.dba The Home Depot Pro Interline Brands Barnett Hardware Express Leran Maintenance USA Renovations Plus Supplyworks US Lock Wilmar Tip Technologies H.D.V.I.Holding Company,Inc. Askuity,Inc. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YOR Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Home Depot USA,Inc. 770-433-8211 2455 Paces Ferry Rd.,C-20 Atlanta,GA 30339 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 58-1853319 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box 1 a" Southold,NY 11971 WC 058240268 3c.Policy effective period 03/01/2021 to 03/01/2022 3d.The Proprietor,Partners or Executive Officers are Q included.(Only check box if all partnerstofficers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Michael Price (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 02/27/2021 (Signature) (Date) Title: CEO North America Telephone Number of authorized representative or licensed agent of insurance carrier: 212-770-7000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17) REVERSE ® DATE(MMIDDIYYYY) AC40R V CERTIFICATE OF LIABILITY INSURANCE 09/07/2021 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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER A C Ext: NC No 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW:21-22 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B.AIU Insurance Co 19399 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Capfive Insurance Company 2455 PACES FERRY ROAD INSURER D:N/A N/A BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-01 REVISION NUMBER: 1 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR SD D POLICY NUMBER MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY MWZY314574 03101/2019 03101/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE E OCCUR DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ X SIR:$1,000,000 MED FRCP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 MOTHER: 'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY E a El LOC PRODUCTS-COMPIOP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY MVVTB314573 03/01/2019 03/01/2022 COMBINEDSINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ REXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ 1$ B WORKERS COMPENSATION WC 58240269(WI) 03/01/2021 03/01/2022 X I PER oTH- STATUTE 71 B AND EMPLOYERS'LIABILITY ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N WLR 667818258 INC,VA) 03/01!2021 03/0112022 5,000,000 OFFICERIMEMBEREXCLUDED? ® NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 5,000,000 If yes,describe under Continued on Additional Page 5,000 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Excess Auto 297110011002021 0310112021 03101/2022 Limit: 4,000,000 A Excess General Liability MWD(314580 03/01/2019 03/0112022 Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE �c2c- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#• Atlanta AC R® 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 C•20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFEC nV E 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: Carrier:Indemnity Insurance Company of North America Policy Number:WLR 067825287(ALAR,FL,ID,IA,KS,KY,LA,MS,MO,NE,NM,ND,OK,SC,SD,TN,WV,WY) Effective Date:03/0112021 Expiration Date:03101/2022 (EL)Limit:$5,000,000 Carrier:AIU Insurance Co. Policy Number:WC 56240268 (AK,DC,DE,HI,IN,MD,MN,MT,NY,NJ,NY,RI,VT) Effective Date:03101/2021 Expiration Date:03101/2022 (EL)Limit:$5,000,000 Carder:ACE American Insurance Company Policy Number.WCU 067805331(QSI)(CA,IL,OR,WA) Effective Date:03/01/2021 Expiration Date:03/01/2022 (EL)Limit:$5,000,000 SIR:$1,000,000 Carrier:National Union Fre Insurance Company Policy Number:XWC 1647258(QSI)(CO,CT,GA,ME,MI,NV,OH,PA UT) Effective Date:03/01/2021 Expiration Date:03/01/2022 (EL)Limit:$4,000,000 SIR:$1,000,000 SIR(CT):$350,000 SIR(GA):$750,000 Carrier:ACE American Insurance Company Policy Number:WLR 067818210(AZ) Effective Date:03/01/2021 Expiration Date:0310112022 (EL)Limit:$5,000,000 Carrier:National Union Fre Insurance Company Policy Number:XWC 1647259(QSI)(MA) Effective Date:03/01/2021 Expiration Date:03101/2022 (EL)Limit:$4,500,000 SIR:$500,000 TX Employers XS Indemnity: Carrier:lllinios Union Insurance Company Policy Number.TNS C66949072(TX) Effective Date:03/01/2021 Expiration Date:03/01/2022 (EL)Limit:$10,000,000 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 AC40RE)® ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME C. HOME DEPOT U SA.N NC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 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 SIR:$1,000,000 "'HOME DEPOT INSUREDS"' The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot USA,Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC Home Depot U.S.A.,Inc.dba The Home Depot Pro Interline Brands Barnett Hardware Express Leran Maintenance USA Renovations Plus Supplyworks US Lock Wilmar Zip Technologies H.D.W.Holding Company,Inc. Askuity,Inc. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Home Improvement Agreement: Page 1 Home Depot License#'s- For the most current listing visit www.Homedepot.com/LicenseNumbers Adam Friedman 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,terns and conditions as outlined on this fonn. The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101 customercancellationnortheast@horn Phone# tce vider Email Address Service Provider License#(s} 2.Customer Information------- . Dinizio IMichael Long Island 1-1X771K6V Customer Last Name Customer First Name Store#/Branch Name Customer Lead/POA 619 Brown Street Greenport NY 11944 Customer Address City State Zip (770) 855-1074 michaeldinizio3@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address 3.NOTICE OF RIGHT TO CANCEL YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: customercancellationnortheast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 40 Oser Avenue Hauppauge NY 11788 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. 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 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: Customers Signature Date .160StandvdForm 111A(21Jrd.21)(E) Genmtcd Date 1911419091_ L-,11P0= UIX7710V 0.1.12 Home Improvement Agreement: Page 2 A. Description of Work to be Performed A detailed description of the work to be performed is included in the paragraph entitled Scope of Work,Specification, Customer Summary Sheet, Quote Form, Estimate, Invoice or Measure which is included in this Agreement. 15."Anticipated Delivery mate/installation Schedule Approximate Start Date: 06/12/2022 Approximate Finish Date: 07/12/2022 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. 6.Electronic Records Auth®razation 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 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. Contract Price: $ 12908.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable, total amount of taxes included in Contract Price) Wa-rhquin depi sit ONLY applicable in AID, MA, ME(33%), NJ, 111(99%) Deposit%0 125.0 Deposit Amount$ 1727.0 Remaining Balance$ 12181.0. 1. 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 funds should be made payable to Service Provider; however, Service Provider may collect Customer's payments made payable to Home Depot_ 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 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 Customer's Signature Date X I/s/The Home Depot 12/14/2021 The Home Depot Digital Signature Date For questions related to your installation,contact Service Provider at (631) 478-6101 For any other concerns, contact The Bonne Depot at 1-800-466-3337 .160 Standard Foran 111A(21 Ad-21)(E) Generated Date 1211419021/2021 LCI&PO _ v 0.1.12 Koo AAPPRD AS NOTEDDATB.P.#FEE: BY: NOTIFY BUILDING DEPARTMENT AT 765-1802 8 A TO 4 P FOR THE FOLLOWING INSPECTIONS: I. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION S BALL MEET THE REQUIREMENTS OF-FHE 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 gni Burn n Trneini��d vv- vc � 0UttfN fNPJING BOARD B0UTP9LD4WRUSTEES DEG OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICV OF OCCUPANCY U.S. canada . o E41"Gv POOGY p W STM STAR Ad"I U • And4<Iew YOd NDOC CLAOfq r10d,am $ K Nradaal TYraa Gaal 72020. 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Mp:a4 n 04n O ur ant r el Jw-"2017 wd++wwn o N'+W 044 D+0+7 b nor.�nluw,40w, For specific unit performance information,please contact your dealer or Andersen Sales Representative. p EC EC I'dC �, JAN 18 2072 bj- BUILDING DEPT. TOW::OF SOUTHOLD Andersen Wood SPEC SHEET SC: Adam Friedman Measure Tech: INSTALLER: Branch Name Long Island JOyN; 1-IK77IK6Vn;,.au1-r� t rf' ISM: ShipTo Location 1A,c ;el D�n�:�o Uale PBge 1 O} 1 SPEC SPR Cu.±omer Name SHEET REFf NEW WINDOW UNIT tMKIg Ca..lmr.-: LOCK Haroware DIPTION OPTIONS Sween IST at T---.a! (SIr1Wr WH "0—j j Sumo Ie Mkided while Do- FULL OH Frame n �glFm BAS HIKp ntkKw MISC L.�mng WmtbP And~ FIAAAI INSER Sesh OMee in allies Glens urw SASH LVT mSASE LABOR TEN Type WkWow TVPB (.elelfFYY1f1 SC SIZE SOLO(Tin in TIP) ME ASURE TECH SIZE I ONLYI ONLY Caesnwe tHftbbnVdbvOpOorteOPTIOA pncei SameOptWm IPER SAS"P111CM1p) OPTI00i paoi OPTpN3 ural ) OPTION. TOTAL MT ISM h11 TW SC 111 Send— a Bets I Bars aBen aBarS Pattern MISC Serer E F IYIIDTI S,z,• GrW E*terror Inlenor Vert Hera Vert Honz 8 Labor Type Style Color Color Liner Sao CODE WALL SILL gash Temp Screen Type Gra GrW Pattern (per, Iyer Lova (Per (Per Catalan Obscur FZh Fm Faysn Item F COW CODE CODE CO CAW Height LEIGH Wmin Hv�{1nl DEPT ANGLE Split Van rH krq a^di^9 Style CODE Options COD Cdp Color CODE sash) aashl CODE sash) Sash) CODE CODE CODE Type COD Type CODE CODES 1 BED 1st Se CI 1,00 C10 JWH WH 31 48 Jg L STD none WH STD jW11 STD WH WRAP 2 SAT Hf SS-CI1OO CIO WN WH 23 37 60 L IF-11, none WH STD WH STD WH WRAP N STD bAyfomwwoOw met 6/Mwee We LeNF,MA NSOO/eee►AeaeM ealMertR Uw 4Me r b WMMY aAeeeareM aeaeeewlw.weeelelD uYeneYeey Rot�ign Angle i9+Y Y1 p.5 i Trp of Wnkrw to.Shc�l iwv rwai ft,W^bow FWksr.i C— kVrlN of (vclwl Cpl 1.1 nml1 iYns Not aebb..M$Ontrr . mtic arflvy cob ---_ NEW DOOR UNIT WINDOW h I i DOOR A"A."en MEASURE FULL FRAME Gine MYtpe MULL/STACK Enemy SM, 1 AW Trim IIIc e ExbW*Door Type N,or TYPE Color/Fmish SC SIZE SOLD{Tip 1.TIPI TECH SIZE ONLY Gnat Opaons IPER SASH PRICING; OPM Opeo.Opow wo aftsmaOdor Op61MD OPTIONS M16C LABOR OPTIONS 00" Ro*do 11 PD 4,— Anaemb ES' TOTAL (200, Nae L unun Lbtalan In!en UI ROI Inswing PO PD OIIdMp HugW 400.6 1, Ex stmF Sere E.Irw 1. Standar (WIDTH TIP Em E.tansa Ord Elder Inion z0ar,Agar pop Door A-Ser Lock Loch Optrona rl • poor Type SrNe Guar Co S�ie AW . to Jam Jamb Type CaM GrW Parser,ertl lel ler Sere IN or a VeMeq Vtxrttrlp gkdrg MRDW HROW Keyed Mulloo Spt�c,.lr�Or�BI yp h Floc Cafe COO COD- CODE JCODE Cade WWm HE WW1 Vbgn TIP Size Lbcaeon C Cruor Color CODE Sash Sasn CODE CODE OUT P-1 Handing only) Type Farsh Lock Slack(, No— MISC Labor Merit CODES V..N. ProMe � NO Wrdlh No AW CoN wRlp. ror oa.ee cap g00rMel ►Ife/Ns Micheal Chnizb TM Homs Owner -