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HomeMy WebLinkAbout47908-Z I .- Town of Southold 9/24/2022 P.O.Box 1179 o _ 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43431 Date: 9/24/2022 THIS CERTIFIES that the building ALTERATION Location of Property: 2145 Little Peconic Bay Ln, Southold SCTM#: 473889 Sec/Block/Lot: 90.-1-15 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/28/2022 pursuant to which Building Permit No. 47908 dated 6/3/2022 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: door replacement to existing single-family dwelling as applied for. The certificate is issued to Schein,Alvin&Lisa of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED CAth i ed Signature �o�svFF co oTOWN OF SOUTHOLD ay BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE o . 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#: 47908 Date: 6/3/2022 Permission is hereby granted to: Schein, Alvin 2145 Little Peconic Bay Ln Southold, NY 11971 To: install door replacement to existing single-family dwelling as applied for. At premises located at: 2145 Little Peconic Bay Ln, Southold SCTM #473889 Sec/Block/Lot# 90.-1-15 Pursuant to application dated 4/29/2022 and approved by the Building Inspector. To expire on 12/3/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Buildvg Inspector AOF SOUTyolo # * TOWN OF SOUTHOLD BUILDING DEPT. `ycourm, 631-765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] NSULATION/CeAULKING [ ] FRAMING /STRAPPING [ FINAL ��fv [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: %Z co DATEi2 INSPECTOR FIELD INSPECTION REPORT I DATE COMMENTS ►o FOUNDATION (1ST) -------------------------------------- FOUNDATION (2ND) � O y ROUGH FRAMING& 1 PLUMBINGy r INSULATION PER N.Y. E STATE ENERGY CODE r- CCU- FINAL C 1.FINAL ADDITIONAL COMMENTS Z� CO s s ' 0 z m r b O z �x �y x d b t TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://-%vww.southol.dtownny.gov Date Received APPLICATION I ! PERMIT For Office Use Only ® � (� r� r� �►7 PERMIT NO. �P', Building Inspector: l� I� II IIUI/ APR 2 8 2022 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: 4/21/22 qW. NER(S)OF PROPERTY: Name: Alvin Schein SCTM#1000- 1® . — 0 — AJC Project Address: 2145 Little Peconic Bay Ln, Southold,,,NY m11971 Phone#: 917727372064 Email: Mailing Address: 2145 Little Peconic Bay Ln, Southold,-NY 11971 CONTACT PERSON: Name: Scott Doughman - Go Permits Mailing Address: 105 Buttonball Ln Glastonbury Pt,06033 Phone#. 303-946-8685 Email: permits@gopermits.org DESIGN PROFESSIONAL INFORMA71ON:.., .. Name: Mailing Address: Phone#: TETail-, CONTRACTOR,'INFORMArlON: Name:Home Depot Mailing Address: 2455 Paces Ferry Rd, +Atlanta, G.A.30339 „ Phone#:303-946-8685 . Email: permits ermits or LDE CRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑AltelIration ®Repair ❑Demolition Estimated Cost of Project: ❑Other �Q a�1r�4PQ @ 1��...�= -� �d 'G'/`� se"11f S%z _ $14,944 a.c . . Will the lot be re-graded? ❑Yes ONo �� ,,� Will excess fill be removed from premises? ❑Yes WNo 1 -:YA„ -:ewA. 'x,�7"n ;2• mss; ;..s!: :Z::spa=g......�1 ..�;t •et.,' ,:.f:, °•aH .P: aw};,:;,t:;'. �;-:._ A p..<:,; r u•' ! -SS 5k. $o ro- ,7.... ,•..,b.oxx 4. >. .,. ...-..e. 3. ':'.ikk.i,�baa.: ".G),i. Existing use of property: residential,.. Intended use of property: residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? MYes R'No IF YES,PROVIDE A COPY. 'y' ,a ,rx<f> x.,"�„� '^iw kl” ... ...;:z.. ...:<+f'r ,.-r>. ;a., ,.,s.� r:a,:i .�•'"j'>:°;�>;;<�!::�;�.,• •'-t. ,;az...;<.:. •,r,; :-c .tar; a` t,�,'�:s ':F' ,.,"s}. - r.•d"`,"..�:'s:>s': ;s.`�;;;�-�;:.MA,=.....: >.R,,;.a'S;.� u - a7rEi'- t .M•'x P: i1. a' :t';. <l'.�r M1Eay� < '� '„ :•?5z -�YT?,5 ;W . 5. e*. '!T'V':i ,fey.I ...; .. .. ..,•:,:< •.. ._, .R7!.!S; .._. ,,z.. <•i y,....a.�"�':'ak�:. ''^.'4'.,.�'.C ,� ak."i Aa;>y, s „ >N Application Submitted By(print name): Jennifer Winke ®Authorized Agent ClOwner Signature of Applicant: bate: STATE OF Nf*-YaRK) S COUNTY OF Jennifer Winke being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contr rt above named, A (S)he is the An <<' (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 �Mv► ;20a� o otary Public SUZANNE S BENTON NOTARY PUBLIC PROPERTY OWNER AUTHHORIZATT�QN GULFORD COUNTY,NC My Commission Expires 2-21-2024 (Where the applicant is not the owner) ,, Alvin Schein residing at 2 @ 45 Little Peconic Bay Ln _do hereby authorize Jennifer ! e to apply on my behalf he"To of Southold Building Department for approval as deserib d herein. Ow er's Signature Date V Print Owner's Name 2 AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/24/2022 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 N o Ext): A/C No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW.22-25 INSURERA: Old Republic Insurance Co 24147 INSURED INSURER B: New Hampshire Ins CO THE HOME DEPOT,INC. 23841 HOME DEPOT U.S.A.,INC. INSURER C: ACE American Insurance Company 22667 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 j ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-02 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 POLICILS.-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR ISD WVD POLICY NUMBER MM/DD MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY316648 03/01/2022 03/01/2025. EACH OCCURRENCE $ 1,000,000' CLAIMS-MADE FxIOCCUR DAMAGE TO RENTEDPREMISES 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 PER: GENERAL AGGREGATE $ 2,000,000 X POLICY FIPRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWTB316649 03/01/2022 03101/2025 COMBINED SINGLE LIMIT $ Ea accident 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 PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ AUMBRELLALIAB X OCCUR MWZX316647 03/01/2022 03/01/2025 EACH OCCURRENCE $ '10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WC 065886029(WI) 03/0112022 03/01/2023 X PER OTH- C AND EMPLOYERS'LIABILITY STATUTE ER YIN N ANYPROPRIETOR/PARTNER/EXECUTIVE WLR C68916409(AZ,IL) 03/01/2022 03/01/2023 E.L.EACH ACCIDENT $ 5,000,000 OFFICER/MEMBEREXCLUDED? ❑N NIA ' (Mandatory in NH) Continued on Additional Page E.L.DISEASE-EA EMPLOYEE $ 5;000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 5,000,000 _F DESCRIPTION OF OPERATIONS/LOCATIONS/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 _ of Marsh USA Inc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta A�o® 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 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 C68916483(AOS) (AL,AR,FL,ID,IA,KS,KY,LA,MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA,WV,WY) Effective Date:03/01/2022 Expiration Date:03/01/2023 (EL)Limit:$5,000,000 Carrier.AIU Insurance Co. Policy Number:WC 065886028(AOS) (AK,CO,DC,DE,HI,IN,MA,MD,ME,MN,MT,NH,NJ,NY,PA,RI,VT) Effective Date:03/01/2022 Expiration Date:03/01/2023 (EL)Limit:$5,000,000 Carrier:ACE American Insurance Company Policy Number:WCU C68916446(QSI)(CA,OR,WA) Effective Date:03/0112022 Expiration Date:03/01/2023 (EL)Limit:$4,000,000 SIR:$1.000,000 Carrier:National Union Fire Insurance Company Policy Number:XWC 1647323(QSI) (CT,GA,MI,NV,OH,UT) Effective Date:03/01/2022 Expiration Date:03/01/2023 (EL)Limit:$4,000,000 SIR:$1,000,000 SIR(CT):$350,000 SIR(GA):$750,000 TX Employers XS Indemnity: Carder:lllinios Union Insurance Company Policy Number:TNSC68991006 (TX) Effective Date:03/01/2022 Expiration Date:03/01/2023 (EL)Limit:$6,000,000 SIR:$5,000,000 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 ACCW?"® 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 7NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot U.S.A.Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC H.D.W.Holding Company,Inc. Askuity,Inc. Home Depot Management Company,LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD brkef"e,' .Compensation CERTIFICATE OF NYS WORKERS COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Home Depot USA,Inc. 770-433-8.211 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 3b.Policy Number of Entity Listed in Box"1 all 53095 Route 25 Southold,NY 11971 WC 065886028 3c.Policy effective period 03/01/2022 to 03/01/2023 3d.The Proprietor,Partners or Executive Officers are Qincluded.(Only check box if all partners/officers 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,1 certify that 1 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) i. -r . - _ 02/07/2022 Approved by: (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 CERTIFICATE OF INSURANCE COVERAGE dco ':.•_ ... .. Si DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD NW 446-807-7093 ATLANTA,GA 30339 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 581853319 2.Name and Address of Entity Requesting Proof of a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD HARTFORD LIFE AND ACCIDENT 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"1a" SOUTHOLD, NY 11971 LNY713657 c Policy effective period 01-01-2022 to 12-31-2022 4.Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5.Polic covers: A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law._- B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 12-29-2021 7e_4M'Y (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY-13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form OB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) � ,1 ��„ `�� ��I�•��'�� IH Additional Instructions for Form 1313-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) 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 employment as defined in this article, and not withstanding 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 the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. 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 disability benefits to any such employee if so employed. (b) 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 employment as defined in this article and 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 the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article: DB-120.1(1017 Reverse R6, 1 Home Improvement Agreement: Page 1 Home Depot License#'s -For the most current listing visit www.Homedepot.com/LicenseNunibers Adam Friedman I F7 Salesperson Name Registration#(Req. in CA,CT,ME,MD,MI,NJ,DC) Home Depot U.S.A.,Inc.("Home Depot") or Authorized Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. 1 &rvice"Provider Contact,Information The Home Depot IThe Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101 customercancellationnortheast@hom Phone# _42: S? ceWvider Email Address Service Provider License#(s)ICustom�r,Ii�for>Enation ,-_.._.. v , ScheinAlvin Long Island 1-1YKVA736 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 2146 Little Peconic Bay Lane Southold NY 11971 Customer Address City State Zip (917) 273-2064 alschein@gmaii.com Home Phone# Work Phone# Cell Phone# Customer Email Address ___....__. _.,;...s...__.. __ ._ ....___. . .. _.; ._. _. .. .. .m..._ °RIGIIT TO 7777 .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 BYLAW 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 O YOU HT TO'CANCEL. Acknowledged by: 04/1 5/2022;': Customer's Signature Date 460 Standard Fonn IIIA(2I Jul.21)(E Gk neraled Date - L'-d'P()k v 0.1.12 Home Improvement Agreement: Page 2 4, Descri tion of-Woriz.to be Per£oi-nr�ed 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. Anticipated Deliv6rvMDate[Installation Scheduler Approximate Start Date: 10/12/2022 1 Approximate Finish Date: 11/11/2022 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. G. Electronic tiecocds_Aut_horization You are entitled to a paper copy of this Agreement if you Wchoose. 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 emailsµand PDF documents. . ,._,.. '7Contract Price and Pay anent 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: $ 14944.00_ Includes all applicable taxes. Excludes finance charges.' Sales Tax: $ 0.00 (If applicable, total amount of taxes included in Contract Price) '., axinium deposit 01VLYapplicable an 41D,1 A, J11E(33%),NJ, WI(99%) Deposit%,--125.0 Deposit Amount$ 3736.0 Remaining Balance $ _ 11208.770 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. _.._. _ pot. r. 9 Acceptance:and Authorization ., By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform any Services or (bb) 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 /s/The Home Depot 04/15/2022 The Home Depot Digital Signature Date For questions related to your installation, contact Service Provider at (631) 478-6101 For any otherconcerns, contact The Home Depot at 1-800-466-3337 460 Standard Fonn HIA(21 Jul.21)(E) GencratedDate 0.411519022 LeadN-1.1 1-1YK1lA736— ° 0.1.12 RECEIPT SUFFOLK COUNTY GOVERNMENT DEPARTMENT OF LABOR, LICENSING,AND CONSUMER AFFAIRS COMMISSIONER ROSALIE DRAGO. P.O. BOX 6100,HAUPPAUGE, NY 11788 (631)853-4600 Today Date: 10/22/2020 Application: H-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 $1,800.00 10122!2020 GAS Locations Contact Info: RO HARDEPOT USA D OUSEY INC(14 SUPPS) PO BOX 105451 ATLANTA,GA 30348 Work Description: i k Suffolk County Dept.of I; Labor,Licensing&consumer Affairs '7 - ' HOME IMPROVEMENT LICENSE Name RICHARD TOUSEY 8usin2ss Name This certifies that the s HOME DEPOT USA'INC(14 SUPPS) bearer is duly licensed by the county of suffoik I License Number:H-53429 Rosalie Drago Issued: 05/1512014 Y Commissioner Expires: 11/01/2022 t; U 1 1 ' I G APPROVED AS NOTED -1� W DATE: X B•P•# FEE: U •O NOTIFY BUILDiNG D::'FARTMENT AT 765=1802, 8-AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE. 2, ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR ".0. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE &OWN CODES AS REQUIRED AND CONDITIONS OF ��� ; tf;T6 S H- i l'JN Ptkf NG BOARD on LD OWN TRUSTEES JCCU PANCY OR USE,IS UNLAWFUL WITHOUT CERTIFICt OF OCCURANCY Andersen Wood SPEC SHEET SC: Adam Friedman Measure Tech: INSTALLER: Branch Name: Long Island Job#: 1-1YKVA736 Prepared By: ISM: Ship To Location: Customer Name: Alvin Schein Date: 0411512022 Page 1 Of 1 SPEC SPR SHEET# REF# NEW_WINDOW:UNIT.. ..ca'-sertsen" 9 :LOCK :Hardware ;aOPTIOW0 TION. i• �Sraaan ( o raditkJda n' =.t: 'sterid't WH <FCio1Stiino P9 >. ie oWriteOp r' tion - 'htcJuC �fULL ,DH,.Premie included �in BAS -, Hung_ "��mctuded - °.Existie YV{nddcu' "Amfarsen PRAIv1 INSHR'@ash .C31ass �h Hose' '.6 Lurlit, SASHUfT :'Fn BAS@ - .LABOR 9 TP Typo + Wlnildow TYPE` i 0olot1Pail8h`-_ .;:SC SIZE SOLID to TiP}'"';t+dF.ASUf2E TECH SIZE ONLV;ONLY OP(iMs .'CosBinerit}tandi�Ig Options' :'-OP .,tukeY' :r 6446 Options(PER SASH PRtCING}��':::.:f�J', :; OPT pricing)`OF116d$: 'tulit pr3ohlg) OPTtUN TOTALMT/ISM Interio TW SC UI Standard #Bars #Bars #Bars #Bars Pattern MISC Location Existin Serres Wlndo ExteriorFinish Jam Standar (WIDT Size Grid Exterior Interior Vert Horiz Vert Honz & Labor Windov Type Style Color Color Liner Size AW + CODE WALL SILL Sash HingE Temp Screen Type Grid Grid Pattern (per (per Locatio (Per (Per Location Obscure Finish Finis Finish Item Roo Floo Code CODE CODE CODE COD Cola Code Widt Height HEIGHT Width Height DEPT ANGLESplit Venting Handing Style CODE Options CODE Color Color CODE sash) sash) CODE Sash) Sash) CODE CODE CODE Type COD Type CODE CODES 1 LIV 1st IGD2- SPR- Outs White Whit 69.0 92.60 161 WRAP, CCH A- wing e 0 EXT C series door PVC .::. -,BAYfBOW tintuww: _ v-'!iC/InetaUarRihm>pnefiids m(eP.t:Caod f6pt Stac%CPtioat,CpostefPPrWIUCrti.UCrr t lt6rilJ teWPMlryv+mlowl4notl id,ANUFAC'lepERN07FS:([nldadP rnWSMP tPmHoiri, 'r'.'.. ....: .,..,.., -`'i::''' •:.�". reaaCnoMeC,ttsrkMAitotMnUtYpindolWOcH'. Prolectlon Angle:(Bay'30'1145') rop of Window to Somt(m,hes) SPR-(1)-Reason:Outswing Bay Window Flankers(DH/Casement width of Overhang(mches) construct Reol i(Yes/No) If red to Satin,color al sent malenal lTh..s no guarantee al news ng es will matt o st ng co r. - r..; - - WiNDUW&' DOOR fME=.i': ss Sorge Htn-e' `-MUtJ.tSTA _...-. Eri Smr: R dm ITEM ;;. y, -.Amii3rsen .. - .• MEASURE_ FUU. RA Gth1 •9, Or(. am, .. .. -•.� EAtstmg DoaT e, Dfor7VF'E :.>roWiJF,huait'. .-SG SIZE SOLD(Tip to TiB}. :,jEOH.SIZfi':, ,� ONLY, .Grillo Ojokni(PER SASH PRIC4 :bP110 Option Option "�;':,'Hingedanri U'ildhlg'Deor Options '' '.OPTlANS - ..MISC i.ABOti OPTIONS Options':,.,;-� Radios for Uott; PID Northern Assembl E TOTAL (200, Note: Location Smart.n Interio UI RO/ Inswing PD PD Gliding Hinged 400,& meets Existing Series Exterio Finish Standar (WIDTH TIP Ext Extensio Grid Exterio Interio #Bar #Bar Door Door A-Ser Lock Lock Options all other capitia Door Type Style Color Color Size AW + to Jamb Jamb Type Grid Grid Patter art( nz(P bscur Scree INor # Venting Venting gliding HRDW HRDW Keyed Mulled/ Special reogleosal Ne.,ry Roo Floo Code COD COD CODE CODE Code Width Haigh HEIGHT WidthHeigh TIP Size Location COD Color Color CODE Sash Sash CODE CODE OUT Parnek Handing Handing only) Type Finish Lock Stacked Notes MISC Labor Item CODES Yes or No Profile Width AW liu,IV-; Wieps.: #of boxes Color Approval Pdnt Nem.Alvin Schein Tlla Home Owner s 4� 3 i11c7 i "";?;'.w:rwr "-'ti v:5'-s� 3^{{�•.v,;�` .'r"yy �.-+w r„"ah.�:»}`k K ^sa.:•t::."'1-r.r "f4,�it .�� .y,,yr'.;•+;.?.fiv Z ±`bti.$.P.� ..`�.+.�:rt?.^'� r.� .rs�,.cx a :.r, s«��'Wl;,`a� �.s.,z.o-.r res'"-5"'�::+'"r'i'm ,?'' ..k•`t%":<ro'n�.:.:.....LR.., zywy� 3'to s�`: "F ..-vi�1+Tq.C�'1 .a1:d-C'+if119s.' 3li2tt17n-ak,,.r;_s,..:,tR:±r:m'S.�,"`. �.»:x;" :sa•,'..'�n�'.':'�:�:>':>*-,+•.,�.c-3e=>zb�,.,:_;S+tV:��..t4 t�' l No Grilles ANmwa0maiowo 0: 1,70 026 0.44 16 <0.2 11 11 - e Simulated Divided Lite or Installed Interior Removable AND-N-&00981-M02 0.30 1.70 023 0.38 14 - 3 g Fun Divided Lite ANo-Nt�op99a7-opool 0.32 tfiz 023 o.3E iz Finelight"(grilles-between-theglass) AND-N-600999-00001 0.30 1.70 023 0.38 14 <0.2 No Grilles AND-N-6-00982-00001 0.31 1.76 0.16 025 9 <0.2 - - - - W e Simulated Divided Lite or Installed Interior Removable AND-N80098-OOM 0.31 1.76 0.14 021 8 <0.2 k•0 - - - - - c Full Divided Lite AND-N0988-00001 0.32 1.82 0.14 021 7 <0.2 - - - Finelight"(grilles-between-the-glass) AND.N-6.O10UD-00001 0.31 1.76 0.14 021 8 <0.2 - - - - No Grilles AND44-6-00983-00001 0.30 1.70 0.18 0.40 12 <0.2 - - - tr Simulated Divided Lite or Installed Interior Removable AND-14800983.00002 0.30 1.70 0.15 0.34 10 <p2 ti eE Full Divided Lite AND-N-6*M9-00001 0.31 1.76 0.15 0.34 9 <0.2 - - - - W Finelight'v(grilles-between-theglass) AND-N-6.01001-011001 0.30 1.70 0.15 0.34 10 <0.2 - No Grilles AND-N-0-00980-00001 0.31 1.76 0A3 0A9 25 <0.2 - - - e ear ,� Simulated Divided Lite or Installed Interior Removable AND-N-6.00980-00002 0.31 1.76 0.37 OA2 21 <0.2 - - - - - - . m 3? •.o, N Full Divided Lite AND-14.6-00986-00001 0.32 1.82 0.37 0.42 20 <0.2 - - - - 6 Finelight'v(grilles-between-the-glass) AND.N-6.0099800001 0.31 1.76 0.37 0.42 21 <0.2 - - ! No Grilles AND-Nb01058-00001 027 1.53 026 0.43 20 <0.2 - - - Y Pe Simulated Divided Lite or Installed Interior Removable AND-N-"1058-00002 0.27 1,53 022 0.37 18 <0_2 - - R = Full Divided Lite AND-N801061-00001 0.29 1.65 022 0.37 15 <0.2 - - - 3 z FineligM"'(grillesbetwesn-meglass) AND-N-6-01067-00001 0.27 1.53 022 0.37 18 <02 x �7 No Grilles AND-14-6-01059-Mi 026 1.48 0.17 0.39 16 <0.2 3 W 5 o Simulated Divided Lite or Installed Interior Removable AND-14.6-01059-00002 026 7.48 0.15 0.33 15 <02 - C .. 400 Series _° E= Full Divided Lite AND-N-6-01062-00001 0.29 1.65 0.15 0.33 11 <0.2 - - Frenchwoode Gliding Patio Door w 3 Flnelight"(grill-between-the-glass) AND-N801068-00001 026 1.48 1 0.15 0.33 15 <0.2 - - - ! No Grilles AND.N801057-00001 027 1.53 1 0.39 0.48 27 <0.2 - e-" W h Simulated Divided Lite or Installed Interior Removable AND-N801057-00002 027 1.53 0.34 0.41 25 <0.2 - 3 N Full Divided Lite AND-14.6.07060-00001 0.30 1.70 0.34 0.41 21 <0.2 - - - - o_ S Finalight-(grilles.between-d glass) AND-N801066-00001 0.27 1.S3 0.34 0.41 25 <0.2 - - - .:f=<: OKI', �;L".=.i._._. ,,.esJ:,s:'.,,k...Y.0�;""%c•*• ;..,k,?,pis::`5;�•t:'...,.,...r:s�may.;,•>.'.... :..r.•tz.:�3`t��-0m •�.t`cy.=n:. ..,Y.a.. .;.,;,,,"<'� ..,d.•-. .-h;,,.,,�.i.f:er.:,:?`i:.>:-":i�.`�W'.rss a'�..,..';,'ii:�>- :::4.�:.tr:: ..aU>r�'3..t,,N,,..L.«. >2ei^1,t. "i Simulated Divided Lite or Installed Interior Removable AND-N-6-00961-00003 0.30 1.70 0.20 0.32 13 - - a 3 Full Divided Lite AND.N8-00993-00001 0.31 1.76 020 0.32 11 <0.2 - - 0 FlneligM"(grilles-between-theglass) AND-N-641005-00001 0.32 1.82 023 0.38 12 <0.2 - - - - - - Simulated Divided Lite or Installed Interior Removable AND-N-6410982-00003 031 1.76 0.13 0.18 7 <02 - - - - - - - 0 W Full Divided Lite AND-N800994-00001 0.32 1.82 0.13 0.18 6 <02 - - - - - 3 y 0 J Finelight'(grilies-between-theglasv) AND-N-"1006-00001 0.32 1.82 1 0.14 1 021 7 <0.2 - - - - - - J Simulated Divided Lite or Installed Interior Removable AND-148.00963-00003 0.30 7.70 Qib 029 9 <02 va 3 C Full Divided Lite AND-1480099500001 0.31 7.76 0.14 0.29 8 <0,2 - - H• FlneligM°1(grilles-between-die-glass) AND-N-6-07007-00007 0.31 1.76 0.15 0.34 9 <0.2 - - - - - - a c Simulated Divided Lite or Installed Interior Removable AND.N.& 980-00003 0.31 1.76 0.32 0.36 18 <0.2 - - - - - e W 3= Full Divided Lite AND-14800992.00001 0.32 1.82 0.32 036 17 c 0.2 - - - - - - - i Firelight-(grilles-between-theglass) AND-NS07004-00001 0.32 1.62 037 OA2 20 <0.2 - - - - - - �c Simulated Divided Lite or Installed Interior Removable AND-1801058-00003 0.27 1.53 020 0.32 16 <0.2 - - v u, Full Divided Lite AND-N801064-00001 029 1.65 020 0.32 14 <0.2 3 Finelight"(grilles-between-theglass) AND.N-6-01070-00001 028 1.59 022 0.37 16 <0.2 - - ! Simulated Divided Lite or Installed Interior Removable AND.N801059-00003 026 1,48 0.13 028 14 <0.2 - w d Full Divided Lite AND-N801065-00001 0.29 1.65 0.13 028 10 <0.2 E= s 3 FIrreIIgM"'(grilles-between-theglass) AND-N-6-07077-00007 1 0.28 1 1.59 0.15 0.33 12 <02 - - This information is for reference only. Performance varies b unit size and options selected. Page of 155 Deals­t as or Oa Pm a lSepage5.M14 ando moresubjimmation. y p 9 Seepage 1 Iw more inferma0an. For specific unit performance information,please contact your dealer or Andersen Sales Representative.