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HomeMy WebLinkAbout48200-Z O�oSUF i,��o Town of Southold 10/15/2022 P.O.Box 1179 o • 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43503 Date: 10/15/2022 THIS CERTIFIES that the building WINDOWS Location of Property: 3 85 Center St,Mattituck Mattituck SCTM#: 473889 Sec/Block/Lot: 123.-2-10 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 7/11/2022 pursuant to which Building Permit No. 48200 dated 8/23/2022 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 England,Christopher&Christine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED "Y Aut ori ed Sign e �o�so�Fo k TOWN OF OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE cwn 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#: 48200 Date: 8/23/2022 . Permission is hereby granted to: England, Christopher 315 E.80th St#2K New York, NY 10075 To: install window replacements to existing single-family dwelling as applied for. At premises located at: 385 Center St SCTM #473889 Sec/Block/Lot# 123.-2-10 Pursuant to application dated 7/13/2022 -' and approved by the Building Inspector. To expire on 2/22/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00, CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building InG'spec or *10 50Ulyo� TOWN OF SOUTHOLD BUILDING DEPT. coum, 631-765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ /FINAL A)140 K�S [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 0k I2- DATE /0-/,)- - ?,P-- INSPECTOR FIELD INSPECTION REPORT I DATE COMMENTS FOUNDATION (1ST) -------------------------------------- FOUNDATION (2ND) z y ROUGH FRAMING& z. W PLUMBING o O t� INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS 0 m N O x x d b H 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://,,vN,,�v.soutboldtow.n.iiy.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only II 1�l/ PERMIT NO. Building Inspector: ED JUL 1 19119? `'Applications'antl forms`musfbbe.fillecl dut fn tfieif eritirety:`lneorriplete' BUILDING DEPT. applicatiori's,irrill riot.i�eaccepied. Whore.the Applieant is.nai tiie ow ger;an_: s TOWN OF SOUTHOLD Owner'S;Auth&.Izat'iaii (P to 2)shall'be corrjpleted Date:7/5/22 oWNIEa(s}OIF:PROPERTy: g : ,. SCTM#1000- Name: "Chris England ... _ Pr°jeGt Address:__385.Center St. Mattituck,_.NY 1..1952...... �. ._..____. _ .....____..._......._r_._ ... .. .. __. ..._ Phone#: Phal ._ . ._..............516-659-81..57Email:..�.....____�__...........�.�__ ._...._._�..._�chrstophermengland@gmailecc Mailing address: 385,MCenter".St.wwMattituck, NY 11952_ _.._._..._......_..... .. .. .. ..........w .._. ........ ._ . T IV�1 C' A T PER ASSON: �a Name:: Scott,Do.ughman"."7 Go Permits _..._.........___._._.._........_...__..._._w.._......_.. _... ..._....._.._...___... ........... Mailing Address:. 105 ButtOnball Ln. Glastonbury. CT 06033. ...._ _ ..r... _____...... .._........ ........ Phone#: .303-946-8685 ......._._..................... ._....._........... .. Email. pe.rrnts@g,opermits.org„ :;DESIGN;PROFE5S1ONAl INFORMATION:" a Name: Mailing Address: Phone#: Email: °:CONTRA O s CT R.IMFORMAT1011ti Name: .�_. . ._ Hor>1e._Depot,.USA Inc . ._ . _ _ . . . .. 11 Mailing Address:} 2.45.5 .Paces.Ferry_Rd, Atlanta,_GA 30339,,...........__..... ................_...._. ..__. .... . ?nene#: 303-946-8685..___._ _ _.._.. Eaill_Permits@goperrr� gD�sCRI ION cal:PRO'�Os o CO>iisriz`crlOiv=` ❑New Structure ❑Additio ❑Alteration ®Repair ❑Demolition Estimated Cost of Project: D Othe r Will the lot be re-graded? ❑Yes 9 N Will excess fill be removed from premises? ❑Yes ®No C°, 1 DocuSign Envelope ID:AEF32233-135E-46AA-B06B-7650BF82B260 AtiOl TY114 OERTYIN Existing use of property: n'tended use-of'prbperty: singlofamily.- ... ....... Zone or use district in which premises is.situated:, Are there any covenants and restrictions with respect to this property? OYes igNo IF YES,PROVIDE A COPY. Et h'4&,0ox,Aftet-,,ReAoln.�_i146vineqP6�6 d ToW4 ta M rY i�s C600S;t; se r r Application Submitted By(piln JenniTer link HAuthorized Agent FlOwner Signature of Applicant:cant: Date. STATE OF MtV17M) SS: COUNTYOF 6wArl being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above,named, (S)he is the (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 mannersetJorth in the application file therewith. Sworn before me this day of cJ l 20-.1 Notary-Public 5PE,-WER R SULMER PROPERTY OWNER AUTNOTARY PUBLICHORIZATION QUILFQRQ COUNTY,NC ' q '(Where the applicant is not the oMy 6om-n'p- towner) giKP! !os 8-24-2022 Chris England residing r at 335 Center St. Mattituck, NY 119512 Jennifer Winke ----do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described'her'ein. Docuftned by: of,A 1/, C;. AJAJI 7/5/2022 E7C61 ossig'nature Date Chris England Print Owners'Name 2 A00RO� CERTIFICATE OF LIABILITY INSURANCE sOATE1IYWY) � 02!242022?022 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: T`NO ALLIANCE CENTER PNcoNE ), 3560 LENOX ROAD,SUITE 22400 ARIL s ATLANTA,GA 30326 INSUFIER§1 AFFORDING COVERAGE MAIC# CN±0164206911amaC•GAW:22.25 --_.----__ __. INSURER A: bl i utslIl e�4 224147 INSURED THE HOME DEPOT.INC. INSURER R: Ne}��{�mpsljJLe�ns Ca -I 21 —--- -3&/._._-........ __.. HOME DEPOT U.S.A.,INC. INSURER c:_ACE Americ�p��J>arxGe_G9rs 22667 2455 PACES FERRY ROAD INSURER D BUILDING C-20 --—---- ATLANTA,GA 30339 INSURER E: i 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE DOL Su13R-- ---i POLICY EPF POLICY EXP LTR I POLICY NUMBER MIDDIYY MM1DD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 316548 03/0112022 0310112025 1 EACH OCCURRENCE 5 ',0^v0,000 I CLAIMS-AAAOE X {OCCUR I {DA�MAG T a��r _- -- —. PREMISESiE�occurreFce)_..._ _........_._--_ 1,000,000 X ' SIR:$1.000,100 EX {An _ i ...0 _...__.._. ... . ._ ME parson) �5 EXCLUDED -- -- ------.,...._.. ------_. ___•--- _ _ I ERSONAL&AD ATERY 15— —.. 1,000,000 ERSONAL 8 A IrEN L AGGREGATE.LIAJ7T APPLIES PER: 1 I ....-I PRO- r_ t ! —c'' ____...__._.-3-----.....-.- X ­.____..._..._`_�...'0___.. k. POLICY .J ECT L__--! LOC I �— PRODUCTS-COMP/OP AGG S 2,000,000 OTHL-R. l S A 'AUTOMOBILE LIABILITY .' ' MWT8316649103101/2(lZ2 03;0112025 {0 MBINED SINGLE LIMIT $ r" _ _a.-avc gent �___— 1,000,010 X Nv AUTO SELF INSURED AUTO PHY DMG + BODILY INJURY(Per Person) ,$ I OWNED SCHEDULED ---— --iAUTOS ONLY AUTOS j ;BODILY INJURY(Per accident) 5 HIRED ; NON-OWNED j I FPROPERTYDAMAGEAUTOS ONLY ;— AUTOS ONLY l a acc dent S L1______--__.__ —.— _ A r i UMBRELLA LIA9 " X WZOCCUR 03/0112022 0310112025 EACH OCCURRENCE S t0.000,OQ0 EXCESS LIAB ; CLAIA",S A9ADE ! I j AGGREGATE j g 10,000,000 s DED RETENTIONS 8 ;WORKERS COMPENSATION NIC 065886029 1471; 03/01/2022 PER ( 0310112023 j X _ C AND EMPLOYERS'LIABILITY _ STA 1 9 I E YIN I WLR C68916409(AZ.IL) j 03101/2022 0310102.1 I E L EA _ c ANYPROPRIETOR PARTNEFU�XECUTiVE (I ��1 ;NIAj E.L.EACH ACCIDENT OFFIC=R'MEMBEREXCLUDED? N " � _--._-- (Mandatory in NH) ' Continued on Additional Page �— x(!00,0/}0 i if yes.describe under E.L.DISEASE-EA EMPLOYEE?_8 �,..,-. .-,- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ;5 5.0001000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABODE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED, CERTIFICATE HOLDER CANCELLATION TOWN OFLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i 53095 ROOUTETE 25 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. D 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: GN101642069 _ LOC#: Atlanta ACC>R®0 ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. i THE HOME DEPOT,INC. -- HOME DEPOT U.S.A.,INC. PnLlcv NUMBER i 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Wmers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number.WLR 068916483(AOS) (AL,AR,FL,10:iA,KS,KY,LAlviS.rAC,NC,NE,NM,ND,OK,SC,SD,TN,VA,VN,4VY) Effective Date:03101?2022 Expiration Date:03101,023 (EL)L±mit:S5,000,000 Cartier.AIU Insurance Co. Policy Number:WC 065886028(AOS) (AK,CO,DC,DE,HI,IN,MA.MD.FAE.MN.M T,NH,NJ.NY,PA,Rt,VT) Effective Date:03.101,7022 Expirailen Date:03/0112023 (EL)Limit:$5,000,000 1 I Caner.ACE American insurance Company Policy Number:WCU 068916446(QSi)(CA,OR,I�1A) Effective Date:03a0112022 Expiration Date:03/01.72023 (EL)Limit:S4.000,000 SIR:51.000.000 Carrier:National Union Fire Insurance Company volley Number:XVVC 16:7323(QSI) (CT,GA,MI,NV,OH,UT) Effective Date:03101,2022 Expiration Date:03/0112023 (EL)Limit:$4,000,000 SIR11,000,000 SIR(CT):5350,000 SIR(GA):$750:000 TX Employers XS indemnity; Carr edifinios Union Insurance Company Policy Number:TNSC68991006 (TX) Effective Date:03r01?2022 Expiration Date:03@1,2023 (EL)Limit:$6,000,0+00 SIR:55,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER 1D: CN101642069 _ _ LOC#: Atlanta ADDITIONAL REMARKS SCHEDULE gage 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 I 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 Homo Depot,Inc. Home Depot:U.S A,Inc. Home Depot U.S.A.Inc.lba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Horne Depot Store Support,Inc. Ref Beaeon,LLC H.D.W.Holding Company,Inc. Ask(A,Inc. Home 09pot Manigemont Company,LLC I i i ACORD 101 (200$101) 42008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Workers' CERTIFICATE OF rE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Addrass of Insured(use street address only)_ 1 b.Business Telephone Number of Insured i Home Depot USA,Inc. 770-433-8211 24.55 Paces Ferre Rd:,C-20 Atlanta,GA 30339 1 c. NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Oniy required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-tip Policy) Number I 58-11853319 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) i i New Hampshire Insurance Company Town of Southold '3b. Policy Number of Entity Listed in Box",1a" 53095 Route 25 Southold,NY 11971 1 WC 065886028 's 3c. Policy effective period 03/01/2022 to 03101/2023 _ 3d.The Proprietor,Partners or Executive Officers are ®Included.(only check box i'all partner%lofficers included) u all excluded or certain partnerslofficers excluded. This certifies that the insurance carrier indicated above in box`'3"insures the business referenced above in box"l a"for workers' ���•���JJI 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 certifiicate 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 dohs 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. Tease 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 argent of insurance carrier) "'4`/tf `-- Approved by: ,^` 0210712022 (Sltgnaiure) (Date) Title: CEO North America Telephone Number of authorized representative or licensed argent 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 worlters' CERTIFICATE OF INSURANCE COVERAGE rrnri ����ettsatian snarl DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier � 1 a.Legal Name 1£Address of Insured{use street address only} I b.Business Telephone Number of Insured I NOME DEPOT U.S.A.,INC. 4h6-807-7093 2455 PACES FERRY ROAD NW 1 ATLANTA,GA 30339 1c.Federal Employer identification Number of Insured or Social Security Number Work Location of insured(Only required if coverage is specificaily limited to certain locations in Now 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"1 a" SOUTHOLD, NY 11971 i 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. l B.Disability benefits only. i r-1 C.Paid family leave benefits only. l t 5.Polic covers: i 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: rU,d,, enalty of perjury,I certify that i am an authorized representative or licensed agent of the insurance carrier referenced above and that the named Insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 12-29-2021 F � 7e-&z7- (Signature or insurance carriers authorized represontative or NYS Licensed Insurance Agent of that insurance carrier) I Telephone Number (212)563-8074 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. i I 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 i 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. 1 i Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) I Telephone Number Name and Title Pleases Nota;Only insurance carriers licensed to write NYS disability and paid family leave benel<ts insurance policies and NYS licensed Insurance agrnts of those Insurance carriers are authorized to issue Form DS-120.9.Insurance brokers are NOT authorized to issue this form. DB-120.1(10-17) J Additional Instructions for Form D13-120.1 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(10-17)Reverse k' E', Home Improvement Agreement: Page 1 'Home Depot License#'s - For the most current listing visit www.Homedepot.com/LicenseNumbers e Adam Friedman Salesperson Name Registration.#(Req.in CA,CT,ME,MD,NH 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. , vice:Provider�Contact Infarinataon The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101customercancellationnortheast@hom Phone# t8?provider Email Address Service Provider License#(s) .�,•a. , .2 Cu tomer,Inrma fotion .: England Chris Long Island 1-202J7YU7 F Customer Last Name Customer'First Name Store#/Branch Name Customer Lead/PO# 385 Center Street Mattituck NY 11952 Customer Address' City State Zip (516) 659-8157 christophermengland@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address 3::NOTICE OI+''RIGHT TO CA CEL _ y._. N YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING TIME SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: customercancellationnortheast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 40 Oser Avenue rHI NY 7111788 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 ISISPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WELL BE,"IkETURNED 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 YO R RI T %CAN/1V XEL. Acknowledged by: 0 /0 /2022" Customer's Signature Date 460 Standard FonnHlA(21Jul.21)(E) Generated Date 07./01.,12022' LeadT0# 1-2012 )7YU7 v 0.1.12 E1 Nome Improvement Agreement: Page 2 x_11 ..................... `4.Description of Fork to be.Performe,d' 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. 5. Anticipated Delivery.Date/Installation Schedule: Approximate Start Date: Approximate Finish Date: 01/27/2023 All dates are approxnnate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage;of Yourclaim for any repair, if applicable. 6: l aic Records Authorization You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this Agreement. By contacting your Service Provider,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emaiis and PDF documents. ' nattract Price and Pay engt 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: $ 5699.11 _� Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable,total amount of taxes included in Contract Price) *Maxim um deposit ONL Y applicable in MD,IWA, 11E(33%), INU, W1(9.9%) Deposit°io 25.0 Deposit osit Amount$ 1424.78 Remaining Balance $ 4274.33 P _ _.._. `:8. Finance Changes 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 gillbe 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. lcceptann a 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. ,17 07101/202L CJdSt<6'&eS Signature Date X /s/The Home Depot 07/01/2022 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 Mose Depot at I-800-466-3337 460 Standard FonnH1A(21Jul.21)(E) Genzcratecl.Date o7/o1J2o22 L=11POI 1-20217YI17 v 0.1.12 a i R".ECEIPT ♦ r SUFFOLK COUNTY GOVERNMENT DEPARTMENT OF LABOR, LICENSING, AND CONSUMER AFFAIRS COMMISSIONER ROSAdE URAGO p,O,t3OX 6100,HAUPPAUGE, NY i1788 X631}8�3-46bb , Today Date; 16122/2020 APplicatiOn: H-53420 Application Type: Home Improvement License Receipt No, 414174 Comments payment Method Ref. Number Amount Paid Payment Date Cashier ib Renewal+14 Additional r 1,8bb,bCl ib12202C GAB. Check oob3181507 $ Locations contact info, HOME DEPOT USA INC (14 SUPPS) RICHARD-TOUSEY Po BOX 105461 ATLANTA,GA.30348 Work Description: f ",.r• SufCptk County Dept,ref: r. La6ot,Licensing a Consumer Aftirs i HOME ImpRovEMENT t.ICENStr . Piame RICHARD TOUSCY Business Mame 'i THIS certifies that the HOME DEPOT USA INC(14 SUPPS) bearer is duly licensed by the County Of 5100k License Number:N-53428 Rosalie Drago issued: 05/151201.4 Commissl6ner ' tzpires: i 110112022 d ' '4 �i AAP� ROVED AS NOTED DATEB.P.# FEE: NOTIFY BUILDIPWG "-',RTMENT AT 765-1802, SAM "i 4 'Ptj FOR THE FOLLOWING INSPEC"i IONS: I. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL CONSTRUCTION MUST BE COMPLETE = -,.0. ALL CONSTRUCTION -ALL 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 & TOWN CODES AS REQUIRED AND CONDITIONS OF a•`, G BOARD -- � USTEES ' c OCCUPANCY OR USE IS UNLAWFUL -WITHOUT CERTIFICA i' DF OCCUPANCY WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-202J7YU7 Sheet: 1 of 1 Customer: Chris England Job#: 1-202J7YU7 Consultant: Adam Friedman Date: 07/0112022 New Window Hinge Locations Existing Window Measurements Grids Product Options Labor Options From outside, Left to Right - --- _ Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use c = c m Mull "S"=stationary or a o o L t LL Co s N s N "X"=operating 'C N pNitl LJ Style Wraps x a •� a C7 o m o d o o Room Floor Code (YIN) Style Code Series Code w 3 = u v IL > x > s FULL SCR,STD,White, METAL, 1 LIV 1st SH-A Y DH 6100 WH WH 39 54 93 GlassPack:Standard WRAP,LSR FULL SCR,STD,White, METAL, 2 LIV 1st SH-A Y DH 6100 WH WH 39 54 93 GlassPack:Standard WRAP,LSR FULL SCR,STD,White, METAL, 3 DINE 1st SH-A Y DH 6100 WH WH 39 54 93 GlassPack:Standard WRAP,LSR FULL SCR,STD,White, METAL, 4 KITCH 1st SH-A Y DH 6100 WH WH 28 33 61 GlassPack:Standard WRAP,LSR FULL SCR,STD,White, METAL, 5 BED1 1st SH-A Y DH 6100 WH WH 39 54 93 GlassPack:Standard WRAP,LSR FULL SCR,STD,White, METAL, 6 BED2 1st SH-A Y DH 6100 WH WH 39 54 93 GlassPack:Standard WRAP,LSR SPECIAL CONSIDERATIONS: 1:White,2:White,3:White,4:White,5:White,6:White Wrap Color C Interior Casing Type Bay or Bow window: Seatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: Seatboard Material(vinyl only-White Pionite,Birch or Oak) The Home Depot - Thermal Vailue of Pr'oducts Manufactured by Simonton Dated: 5620/2018 .111N." t ,, a a" o-...a..:..�..:FF:�•?old With Grids - t,. s ►/ -f 9 >; :,,. a, n S v.GiassiPack e'a -.- .� r h k >�;:. r`�r �:_Srttff��:cess....;sl�., n��e�,f •=SHGC, •tel':' - ':':i r:u � .i Y i':? .r`'�al!iakti';A on ;S x^' � ' :+t S`: f. r9 .�^. �'lkc. .i�;•3:. EFaCts.iL _:,%F•' t.;, � 3 'vY4� �.:.t;.:. .•5• - `:t,Y�' '-�":: yf- - .`-,-..Sc. ti-W�+;, .,�t! �-• �i:�1.A.. _ :...�- a+.:�u,L'! .,#,-..Jn `i'fi::.t!',i..-: :;7j+�:= ,.:r'<;r',rj• :.,- a.})^..4t:^;x&.+.�tir.>ft �tz�'^w-. �-s� 6500 Awning 6500 Base ProSolar Supercept 719" 6.26 '0.23 o o 0 0.26 1 0.21 0 0 0 Casement 6500 Base ProSolar, Supercept 7!8" 0.26 i 0.24 o a o 0 0,26, 0.22 0 0. o 0 Transom 6500 Base ProSolar Supercept 1' 027 0.32 0 o 0.27 i 0.29 ® c Double-Hung 6500 Base ProSolar Supercept 718" 0.29 0.26 a 0.29 0.24 o a 0 Picture Casement (NH) 6500 Base ProSolar Supercept 7i8" 0.26 0.28 a ® 026 0.25 0 0 0 0 Picture 6500 Base ProSolar Supercept 718" 0.27 ' 0.29 a .0 027 ; 026 0 0 2'Panel Slider 6500 Base ProSolar Supercept 718" 0.29 0.26 0 029 ' 0.23 0 0 0 3 Panel Sliders 6500 Base(s 21 Sgtt) - Pro Solar Supercept 718" 0.29 026 a 0.28 '1 023 o a 0 Garden Door(CH) 6500 Energy Star ProSolar SUN Super Spacer 1" 1 0.30 1 024 0 0 0. 0 0.30 0.21 1,3 1 ® a Patio Door(NOVO 6500 Base Pro Solar Super Spacer 1" 1 028 ; 0.26 1 a 1 a 1 1 11 0.31 0.23 1 0 1 0.1 v 1 o • Homes located everywhere EXCEPT:Arizona,California,Who,Nevada,New Mexico,Oregon,Utah,and Washington. Awning(Inc Hopper) 6100 Base Pro Solar intercept 713" 0.27 ( .024 o 0 o 00.28 i 0.21 0 ® o 0 Casement 6100 Base Pro Solar Intercept 7/8" 0.27 0.24 a 0 0 0 10.27 0.22 0 0 o 0 �Dauble-Hu 6100 Ener Star Pro Solar Supercept 3/4". 0.30 0.30 © 0.30 . 0.27 0 0 0 Picture Casement(No Hinge) 6100 Base Pro Solar Intercept 718". U7j 0.28 a m 0.27 i 0.25 0 0 0 0 'Picture 6100 Base Pro Solar ,intercept 314" 0.27 0.31 o 0 0.27 0-28 0 0 2 Panel Slider 6100 Base Pro Solar Intercept 314" 0.30 : 0.28 0 0.30 . 0.27 0 3 Panel Slider 6100 Base Pro Solar Intercept .3/4" 0,30 0.29 0 0.30 ; 0.27 0 0 1 / • • Homes located everywhere EXCEPT:Arizona,Califomia,.Idaho,Nevada,New Mexico,Oregon,Utah,and Washington. Patio Door I_NOVb 6100 Energy Star' Pro Solar Super Spacer i" Q.28 0.26 0 0 0.28 , 0.23 c o 0 3 Patio Door NARROW FRAME 6100(PD05)Base Pro Solar Intercept 3AJ 0.28 : 0.30 o a1 1 10.28 . 0.26 0 1 Homes located onlyin following markets:Dallas,Denver,Detroit;Ph/la,Northem NJ,Long island,NY. Awning 6200 Base. Pro Solar SHADE Supercept 3/4" 0.27 i 0.25 0 0 o o 0.26 0.23 o o o It, Casement > 6200 Base Pro Solar SHADE Supercept 3/4" 0.26 1 0.18 0 o e o 0.29 ; 0,17 0 0 0 0 Picture Casement-NH 6200 Base Pro Solar SHADE Supercept 3/4" 0.26 i 021 o a o 0 0.25 i 0.19 o o o o Picture Window-,' 6200 Base Pro Solar SHADE Supercept 314" 0.26 ; 0.24 o a 0 0 0.26 0.22 0 0 0 0 Single Hung 6200 Base 'Pro Solar SHADE Supercept 3/4" 0.28 i 0.23 0 o a 0.28 ; 0.21 0 0 0 Since gle Slider 6200 Base Pro Solar SHADE Supercept 314" 0.28 1 0.23 0 0 0 0,28 Q.21 o a o 3 Panel Slider 6200 Base Pro Solar SHADE Supercept 3/4" 028 1 0.23 0 01 0 0.28 0.21 w 0 a • ; - MINOR=M11 Pmes located in coastal areas. Awning SB+300VL Energy Star PS SUN/Lami Supercept 1" 026 1 023 0 ® o '0 0,26 p21 a 0 o a Casement SB+300VL Base PS/Lami Super Spacer 1" 0.25 0.23 0 0 0 6 0.251' 0.21 o 0 0 Double Hung. SB+300VL Base PS/Lami Super Spacer 1" 0.29 i 0.25 o 0 0 o 0.29 0-23 o o 0 o Slider - SB+300VL Base PS./Lam! __ Intercept 1° 0.29 0.25 0 >m o a 0.29 : 0.23 0 0 0 0 Patio Door SB+300VL ETC 366 PS Shade/Lami Super Spacer '1° 0.30 ; 0.19 0 0 0 0 • Garden Door(CH) SB+300VL Base PSILami Super Spacer 1" D.30 ? 0.28 a e 0.30 0.25 a. o o a •Dots indicate Energy Star certified for that zone _ Y ___ V61-- Horne Services Exteriors Change Order - EXHIBIT "A" (Amend Scope of Work) ' AV idarlw s and Patio Doors Color O Sizelg Grids Hinges/Handings ,� Window o M 'j• v � � oo $ Increase / o o -c 1,54 oo o E a &Glass Series o ;5 Z Z 5 0 DecreaseSt le m '� : 'E W MCU CZ Ed Options ' ca W , 0 0 N C Living 1 Dh 6100 Wh Wh S,GBG Wh Wh C All 2 1 All 2 1 $ 93.00 C Living 2 Dh 6100 Wh Wh S.GBG Wh Wh C All 2 1 All 2 1 $ 93.00 C Bed 1 5 Dh 6100 Wh Wh S,GBG Wh Wh C All 2 1 All 2 1 $ 93.00 C Bed 2 6 Dh 6100 Wh Wh S,GBG Wh Wh C All 2 1 All 2 1 $ 93.00 $ $ 1Vliscewne6u's diinges` "Reason°for'Chauges' ` Adding sculpted GBG grills to line 1,2, 5, 6. All grills V2-1-11 if retry Doors DESCRIPTION OF CHANGE REASON FOR CHANGE $Increase/ Decrease Original Contract Amount: $ 5,699.11 Change to Scope of Work Amount:$ 372.00 Change to Promo: $ Sales Tax (if applicable)::�. .��__, New Contract Amoun : $ 6,071.11 Less Original Deposit: $ 1,424.78 Customer Initia ' Balance Due Upon Completion: $ 4,646.33 11(i Hnn1e Services F_xterior Change Oi er( .21) Generated Date Lead/PO# V 0.1.19 .s