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HomeMy WebLinkAbout48577-Z fl TOWN OF SOUTHOLD d ' r BUILDING DEPARTMENT TOWN CLERK'S OFFICE � SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 48577 Date: 12/9/2022 Permission is hereby granted to.- 150 o:150 Deer Run LLC 337WWWMerrick Rd___..., _. ...... Ly brook, 1563 . ...... .. ... ... . 6 To: Construct a single family dwelling as applied for per SCHD and Planning Board approvals. Lot clearing shall be limited to one acre. At premises located at: 15.0 Deer Run, Southold.. ... ...... _. ........ ._.m..... SCTM # 473889 .... Sec/Block/Lot# 79.-4-17.19 Pursuant to application dated 10/6/2022 and approved by the Building Inspector, To expire on ITITIT 6/9/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $3,802.00 CO-NEW DWELLING $50.00 Tot�1. 01) orn nn u.. ...._------gid ........�..............______� ........................�......... ........ Building Inspector 11 riVi TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1 � . Telephone (631) 765-1802 Fax (631) 765-9502 j X79:Southold, NY 11971 -0959 OL Itholdtowill,APPLICATION FOR BUILDING PERMIT . o Date Received For Office Use Onlyj PERMIT NO. �� J Building Inspector: � ': °----,2 Ii ry WON Applications and forms must be filled out in their entirety„ Incomplete applications will not be accepted. Where the Applicant is not the owner,an �� /�I�� ���r I �I Owner's Authorization form(Page 2)shall be completed. Date:7/19/22 OWNERS)OF PROPERTY: Name: 150 DEER RUN LLC Project Address: SCTM#1000-079.00-04.00-017.019 150 DEER RUN SOUTHOLD, NY 11971 Phone#: 631-830-0200 � Mailing Address: c/o DAVEY LAW pC 22 Email; rda daveylaw.us PC, 0 MAIN STREET CENTER MORICHES, NY 11934 CONTACT PERSON: Name:RACHAEL C, DAVEY Mailing Address:220 MAIN STREET CENTER MORIC P #: HES, NY 11934 Phone 631-830-0200 DESIGN PROFESSIONAL INFORMATION: Email: rd@daveylaw.us Name:N&P ENGINEERING, ARCHITECTURE & LAN Mailing Address:70 MAXESS ROAD MELVILLE, NY 11747 SURVEYING, PLLC Phone#: TA7 631-427-5665 CONTRACTOR INFORMATION: Email:rmcgrathQa nelsonpope.com Name: KAISER GROUP INC DBA KAISER BUILT Mailing Address: Phone#: 276 CEDAR AVENUE PATCHOGUE, NY 11772 631-831-3801 DESCRIPTION OF PROPOSED CONSTRUCTION Email: garrettlaPkaserbuilt.com *New Structure OAddition ❑Alteration Opm -,,. rte— ❑vther -- -P-1 "Demolition Estlm ' ated Cost of Project: Will the lot be re-graded? []Yes *No $ 1 5 000.00 Will excess fill be removed from premises? ❑Yes *No 1 r PROPERTY INFORMATION Existing use of property:Vacant Lot Intended use of pro ert ; Zone or use district in which premises is situated: P y SIn9�e Family Residence AC Are there any covenants and restrictions with respect to this property? iiiYes ❑No IF YES, PROVIDE A COPY, Check Boz After Reading: The owner/+contractor/design Professional is responsible for all drainage Chapter 236 of the Town Code. APPLICATIo�N IS HEREBY MADE to the Building Department for the issoaano a of a�uiiding Permit pursuant ana�,ge and storm grater issues as protrided by C9rdinance of the Tawe of Southold,SufFolk,t otrratY,New York and other applicable Laws,ordinances or Regulations,Builfor the i mdditions,ahCeratioots or for reavroval or denoolitlon as herein descrEt�ed,The applicant L agrees to comply with all a construction of the buildiBuildings, zone housln5 aide and regulations and toadnait authorized inspectors ern premises and in building(sto for necessary ihafaelicabl,Fal nstou�tion df lauildings Punishable as a Glass A isdaerneanor pursuant to Sectloa tRd.45 0;the Neuro York State C;iw„ applicable laws,ordinances,building code, PenalFalse statements Heade herein are Application Submitted By(pri name):MI HAEL SCIARA Signature of Applicant: RAuthorized Agent ❑Owner STATE OF NEW YORK) Date: �6/4� SS: COUNTY OF SUFFOLK ) MICHAEL SCIARA being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the ARCHITECT (ContractorAgent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform oand to application;that all statements contained in this application are true t the best of his/here saido rk knowled a an and file this that the work will be performed in the manner set forth in the application file therewith. g d belief; and Sworn before me this -dayJULY of 20 22 , otary Public Ashley L Marciazyn . ) ) Notary Public, Mate of New York (Where the applicant is not the owner No. 01M,A 310007 (qualified in Suffolk County Term ExpireAugust 1 i3,24„ I, Rache'I C• Dave . as authorized si natcrr , doing business� o Dave Law PC Main S . beet. Center Moriches, NY 11934 do hereby authorize Nelson�, Po a,and M'iGhael Sciara to apply on my behalf to the Town of Southold Building Department for approval as described harain Owner's Si ure July 20, 2022 Date Rachael C. Dave =AAH tel- Sl nator fear 110 Deer Run I,C.0 lt I-loldin s Print Owner's Name 2 Generated by EScheck-Web Software Compliance Certificate Project 150 Deer Run Energy Code: 2018 IECC Location: Southold, New York Construction Type: Single-family Project Type: New Construction Orientation: Bldg. faces 270 deg. from North Conditioned Floor Area; 4,657 ft2 Glazing Area 12% Climate Zone: 4 (5572 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 150 Deer Run Southold, NY 11971 Compliance: 4.1%Better Than Code Slab-on-grade tradeoffs are no longer considered in the UA or performance compliance path in REScheck. Each s0ab.on.grade assembUy in the specified climate zone must meet the rnilnimum energy code insulation R-value and depth requirements. Envelope A e—m ie Gross Area Cavity Cont. Prop. Req. Prop.; Req. Perimeter I Flat Ceiling: Flat Ceiling or Scissor Truss 813 50.0 0.0 0.026 0.026 21 21 Cathedral Ceiling: Cathedral Ceiling 1,445 50.0 0.0 0.021 0.026 30 38 North Wall: Wood Frame, 16" o.c. 1,077 21.0 0.0 0.057 0.060 55 58 Orientation: Left side Door: Glass Door(over 50% glazing) SHGC: 0.21 63 0.270 0.320 17 20 Orientation: Left side Window: Wood Frame SHGC: 0.27 55 0.270 0.320 15 18 Orientation: Left side East Wall: Wood Frame, 16" o.c. 1,863 21.0 0.0 0.057 0.060 87 92 Orientation: Back Solid Door: Solid Door(under 50% glazing) 21 0,210 0.320 4 7 Orientation: Back Door: Glass Door(over 50% glazing) SHGC: 0.21 141 0.270 0.320 38 45 Orientation: Back Window: Wood Frame SHGC: 0.27 169 0.270 0.320 46 54 Orientation: Back South Wall: Wood Frame, 16" o.c. 1,213 21.0 0.0 0,057 0.060 65 68 Orientation: Right side Project Title: 150 Deer Run Report date: 07/27/22 Data filename: Page 1 of 8 Gross Area Cavity Cont. Prop. Prop. Perimeter Solid Door: Solid Door(under 50%glazing) 21 0.210 0.320 4 7 Orientation: Right side Window: Wood Frame SHGC: 0.27 60 0.270 0.320 16 19 Orientation: Right side West Wall: Wood Frame, 16" o.c. 1,833 21.0 0.0 0.057 0.060 90 95 Orientation: Front Door: Glass Door(over 50% glazing) SHGC: 0.21 49 0.270 0.320 13 16 Orientation: Front Window: Wood Frame SHGC: 0.27 207 0.270 0.320 56 66 Orientation: Front 1st Floor: All-Wood Joist/Truss 2,516 30.0 0.0 0.033 0.047 83 118 Bonus Room Floor:All-Wood Joist/Truss 513 30.0 0.0 0.033 0.047 17 24 Mechanical Equipment Description Fueltype Efficiency Boiler 80 AFUE Air Conditioner 16 SEER Compliance Statement. The proposed building design described h re is consistent with the building plans, specifications, and other calculations submitted with the permit application.The proposed' Ming has been designed to meet the 2018 IECC requirements in REScheck Version : REScheck-Web and to comply with the man dry requirem nts listed in the REScheck Inspection Checklist. SGS - .. ,.. � ... Name-Title i na re Date Project Title: 150 Deer Run Report date: 07/27/22 Data filename: Page 2 of 8 REScheck Software Version : REScheck-Web Inspection Checklist Energy Code: 2018 IECC Requirements: 61.0% were addressed directly in the REScheck software Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each requirement, the usercertifies that a code requirement will be met and how that is documented, or that an exception is being claimed. ' there compliance is itemized in a separate table, a reference to that table is provided. F# Pre-inspection/Plan n Review Plans Verified Field VerifiedValue Value Complies? Comments/Assumptions umentation wings nnstruction drawin sand "" "'---�� �•---- ate ❑Complies rgy code compliance for the DDoes Not 0 building envelope. Thermal ❑Not Observable envelope represented on ❑Not Applicable construction documents. 103.1, Construction drawings and 103.2, documentation demonstrate ❑Complies Re uirementwill be meta 403.7 energy code compliance for ❑Does Not [PR311 lighting and mechanical systems. ❑Not Observable Location on plans/spec: M- Systems serving multiple ❑Not Applicable 801 dwelling units must demonstrate compliance with the IECC Commercial Provisions. 302.1, Heating and cooling equipment is Heating: Heating: 403.7 sized per ACCA Manual S based Btu/hr g' ❑com lies Requirement will be—met. [PR2]2 on loads calculated per ACCA Btu/hr ODoes Not AManual J or other methods Cooling: Cooling: Btu/hr ❑Not Observable approved by the code official. Btu/hr ❑Not Applicable Additional Comments/Assumptions: .. . l _ i h Im act Tier 1 2 Medium Im act Tier 2 3ITIT' H 9 p ( ) p (ww._....�. Project Title: 150 Deer Run ) Low Impact(Tier 3) Data filename: Report date: 07/27/22 Page 3 of 8 S ection Lsypectiontion InspectionComplies. Comments/Assumptions d Bring is i stalledi n mplie �... � _.. . o �Oompiies _.m Ela:es[`Vatminimum of 6 in. below ❑Not Observable eltin s � � Not AP licable PP ""— g ystem controls C t om lies Exception: Requirement is not Does Not applicable. �� ..�.. ._ ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 1 Hi h Im , µ 9� pact(Tier 1) 2 Medium I'mpact Ti � �'Lo� ...._. .�._._.�.m_._...� m..�.._ �_�P.ct(Tier 3 Project Title: 150 Deer Run (Tier 2) 3 w Im a5 Data filename: Report date: 07/27/22 Page 4 of 8 Section 9 pection[Plans Verified Field Verified .. Value Value Complies? 402.1.1, Doo Comments/Assumptions Framing/Rough-in Ins & Re 13 Door U-factor. "w .. U__ ... Envelope Assemblies 4 RI]1 U- _... �._._ DDompNes _.. table for nvelo. ..�.. 2.3.4 es values values [F 6; _ ❑Not Observable 402.1-1, Glazing 402.3.1, average). .._or(area-weighted hted. ,._U .. _. Ct�rt�ppeSicable .See the.,w .. _ .. ctor are _ g ) U_ 402.3.3, Envelope Assemblies 402.5 DDoes Not table for values. [FR2]1 ❑Not Observable ❑Not Applicable 303.1.3 are determined of stra lion products r ucts td-fact p FICo ;m with the NFRC test procedure or FIDom Pies Not taken from the default table. ❑Not Observable 402.4.1.1 Air barrier and thermal barrierDNot Applicable � � ❑Complies [F R23]1 installed per manufacturer's DDoesNot .. instructions. ❑Not Observable �.._ PP FR20 is listed a Not Applicable 02.43 Fenestration that is not site [ and labeled as meeting DCarr liesicabl _ . 4V AAMA/WDMA/CSA 101/1-S.2/A440 DDoes Not or has infiltration rates per NFRC 400 that do not exceed code ❑Not Observable limits„ DNot Applicable 402.4.5 IC-rated recessed lighting erifinish[FR16 2fixtures �a-----.—.� ._. ] seabed at housing/interior mplies .. and labeled to Indicate s2.0 cfm ElDoes Not leakage at 75 Pa. DNot Observable 405.2All ou ducts i the building unconditioned need spaces — DNot Applicable [FR25]1 or R- DComplies Requirement will be met. are insulated to >R-6. Pe DDoes Not DNot Observable �LOocation on plans/spec: M- Buil[FR15 5 ducding cavitits or es are not usseded as ---• DComplies Requirement will be met. DDoes Not DNot Observable `DNotApplicable 03.4lVAC Piping conveying s Requiremen_t willl b"e mt.[FR17 2 above 0For�hille� fluid 559F are Insulated to > _ Does Not 3, .. DNot Observable Location on plans/spec: M- ❑Not Obse 801 403.411 Protection � cable of insulation on HVAC • DComplies Requirement will be met. [(W DDoes Not DNot Observable 403.6]2 Autamatic lled oncall alvity outdoor i�r er. _� DNot Applicable insq Y dampers are '��."°"" DCamplies Intakes and exhausts. []Does Not DNot Observable Additional Comments/Assumptions: ❑Not Applicable Project Title: 150 Dee Runigh Impact(Ties 1) T 2 Medium lm act Tier 2 .. 3 . ..... ... ( ) Low Impact(Tier 3) Data filename: Report date: 07/27/22 Page 5 of 8 Section # Insulation Inspection Verified & Ite .ID ie Field Verified M __ Value 303.1 _-. Value Complies? Comments/Assumptions All installed insulation is labeled N13]2 or the installed R-values provided. ❑Complies .__. Does Not . Floo—rInsu—. .--- � E]Not Observable40ation R-value. ❑Not Applicable402.2.6 R_ [IN1]i . ❑ WAV ood ❑ Wood ❑Compldes dee thenvelape Assemblies ❑ Steel Does Not table for values.. ❑ Steel ❑Not Observable X03 2 ❑Not Applicable ,. p . 02.2.8 manufacturer's instructions and insulati in sub [IN2]i Floor,stantialocon stalled e and tact with the goes Not �00 underside of the subfloor, or floor framing cavity insulation is In :[:]Not Observable contact with the top side of ❑Not A sheathing, or continuous Applicable insulation is Installed on the underside of floor framing and extends from the bottom to the top of all perimeter floor framing members, _ 40..� .. _ 402 1.1, Wall insulation - R-value. If this is a 402.2.5, R- ..._.. n mass wall with at least 1/z of the 8- 2.2.6 ❑Com ices ._ �� _ wale insulation on the wall ❑ Wood P see tlleEnvelope Assembliies [IN3]i exterior, the exterior insulation St ❑ Wood ❑Does Not table for values I requirement a ❑ Mass applies (FR10), eel E] Steel ❑Not Observable ❑Not Applicable 303.2 Wall insulation is installed' �'— [IN4]1 p r .-- manufacturer' s instructions. ❑Com I P ie1 ODcres Not �...�..�.�-...,�..� ❑Not Observable Additional Comments/Assumptions: ❑Not Applicable �1�Hdh Impact(Tier 1--�.- "`�""' �2 edwm� P ct _- �, ,.__ Im a (Tier 2) 3' ... Project Title; 150 Deer Run "" Low Impact(Tier 3) p Data filename: l_ _ ITW _.�.Wd Report date: 07/27/22 Page 6 of 8 Section # Final Ins Plans Verified & Re .ID Field Verified ....... �.. ..,...__.. ,� Value 4021.1, Ceilin Value Complies? Comments/Assn Inspection Provisions g insulation R-value, . . _ 402.2.1, _ ITp mptions R .�Doea._.... ,... 402.2.2, ❑ Wood OComplies See the Fnvelo e Assemblie . 402.2.6 El s Not table for values. s [FI1]1 El Steel � Steel ❑Not Observable ❑Not Applicable 303 1,1.1, Ceiling insulation installed per m_... 303.2 ,_ . manufacturer's instructions. ..... .m_....� .. _ .. [FI2]1 Blown Insulation marked every CCornplles __ .. . 300 ft2, C]Does Not µ ❑Not Observable [F122] 3 Vented attics with air permeable ONot A [FI22 z �_""'_""' -. Applicable ] insulation include baffle adjacent . e to soffit and eave vents that Ccam lies extends over insulation. ODoes Not ❑Not Observable 402.4.1.2 ach Blown Climate Zdne5 1 2„ an [FI17 1 @ 50 Pa <5 - -- ❑Not Applicable ACH50 = ACH 50 = PP ­3 ach In Climate Zones 3-8, OComl"'es ODoes Not `w ❑Not Observable 403 3.3 `_ ..�M._.._.�.�__ ..�.._._.u.._..�,.�_ 1 with z cfm _ Applicable [FI27 either; Rough-in test,, ted td ftz... /100 -ONot _�_ acts are pressure tested ] determine air leakage cfm/100 Total ft OCom lies Requirement will be met. leakage measured with a ODoes Not Pressure differential of 0,1 inch ❑Not Observable w.g. across the system Including ❑Not Applicable the manufacturer's air handler enclosure if installed at time of test, Postconstruction test.Total leakage measured with a pressure differential of 0.1 inch w'•g,across the entire system including the manufacturer's air handier enclosure. �...�_ .. s ] c. 403.3.4 Duct tightness test resin _ [FI4 1 g It of�=4 ft W .w fm/100 ft2 across the cfm/100 cfm/100 """""'IT" =3 cfm/100 ft2 without stem or ftz z OCpmplies Requirement will be met. handler air ODoes Not @ 25 Pa, For rough-in tests, verification may need to []Not Observable occur during Framing Inspection, _9.edit ❑Not Applicable 403.3.2.1 Ahanmanufacturerler lea at d=2% of [FI24]1 byr g _ .. M design air Flaw, [3Does Not mm. gment wi Re uire i I be met. . ❑Not Observable 403;1.1 in W� m z ble thermostats [FI9 �" � � ONot Applicable stalled for control of primary heating and cooling systems and OComptlies "" initially set by manufacturer to E]Does Not Requirement will be met. code specifications. ❑Not Observable 403.1.2 Heft pump thermostat installed w [FI10]2 on heat pumps. • ONot Applicable OComplies Exception: Requirement ❑Does Not is not applicable. 403.5.1 - _ []Not Observable Circulating service hot water [FI11]z systems have automatic orm-' ONot Applicable accessible manual controls. OComplies Requirement uirement will be met ❑Does Not 40.�.j.l fa not .�. ,.�..�..��._ __ uwuL uoservable 8�1a"on on plans/spec: P- [F125]2 apical ventilation system ❑Not Applicable Pa of tested and listed � � _ HVAC equipment meet efficacy CoODoes Nomplies Requirement will be met. and air flow limits per Table t R403.6.1• []Not Observable g m act 1) 2 . ❑Not Applicable P .. (Tieredium . .. . . Project Title: 150 Impact(Tier 2) 3 _- Low Im act Tier 3�....�_... Deer Run �. .. P Data filename: - Report date: 07/27/22 Page 7 of 8 lection & »ID Final Inspection Provisions Plans Verified 03 Value Field Verified 403.2 blot water boilers suppl in � e Complies? F12'612 through one or Lwow g heat _m„w Comments/Assumptions Ripe heating a - ..__. .... systems have outdoor setback Complies control to lower boiler water Does NReulrem'ot q ent will be met.. temperature based on Outdoor ❑Not Observable 403521; Heat��°.-_- — ❑Not Applicable 1 I lasted water circulation systems [FI28] have a circulation _ .. Pump,The .P--� system return pipe is a dedicated oDoes Not Requirement will be met. return P!Pe or a cold water supply Oboes Not Pipe.Gravity and thermos. Location on plans/spec: P- syphon circulation systerrls are ❑Not Observable not present. Controls for ❑Not Applicable 701 circulating hot water system Pumps start the pump with signal for hot water demand within the occupant automatically turn off the pump when water is in circulation loop is at set-point temperature and no demand for hot water exists. 403.5.1.2 1.2 Electric heat trace systerns comply with IEEE 515.1 or UL 515, Controls automatically �complies adjust the ever Exception Requirement is energy input to the 0Does Not not applicable, heat tracing to maintain the er ❑Not Observable desired water temperature p store in the ❑Not Applicable 403.5.2 Demand recirculation water [F130]2 systems have controls that Com li manage operation of the pumpp eS rceo -R-e semen and limit the temperature of te ❑Does Not p . Requirement'is water entering the cold water not applicable. piping to <= 1049F, ❑Not Observable 403.5.4 [FI31]2 Drain water heat recovery units ❑Not Applicable to 1 sted In accordance water-side ceside accordance with CSA. 0omPlies Excep'tion.• Requirementis Pressure lass of drain water heat Does Not not applicable. recovery units< 3 Psi for individual units connected to one Not Observable ❑ or two showers. heat recovery uPotable water, Not Applicable side pressure loss of drain water nits <2 psi for individual units connected to three or more showers,_ 404.1 90%or more of pW [F16]1 ermanent fixtures have high efficacy lamps, m Complies . .- ._.�� .. _ Requirement will be met. W- EDoes Not _� ❑Not Observable .404.j.l no continuous [F123 3 9hting systems have "w° �NotApplicable pilot light. . M. .. 9Cornplies ___ caption: RequiremW ODoes Not not applicable, ent is ❑Not Observable [F17]2 Compliance certificate posted„ ""`"`- -—.— --0Not A pplicable Complies Does Not 303.3 Manfa Mechanical and water Not Observable nufacturer manuals _FI1213 fpr m- n� tApOcable _._.. heating � —�•�..�:. systems have been provided. DomPlies Requirement will be met. EIDoes Not ❑Not Observable Additional Comments/Assumptions: ❑Not Applicable 1Hjig h l'mPact(Tier lj. 150 Deer R �- �? Medium Impaci t(Ties 2 ( 3 Project Title: _•• � ) 3 p r Run l,ow Im act l Data filename: Report date: 07/27/22 Page 8 of 8 2018 IECC Energy n I I I C-N,j/. I icate AbOv°e-Grade Wall Below-Grade Wall 21.00 Floor 0.00 Ceiling / Roof 30.00 Ductwork (uncondiS0.00 tioned spaces): Window Door 0.27 0.27 0.27 0.21 Boiler Air Conditioner 80 AFUE Water Heater: 16 SEER Name: ate: Comments D A NEW -",sTATr Compensation workers' eCERTIFICATE OF INSURANCE COVERAGE -",,STATE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured KAISER GROUP INC DBA KAISER BUILT 631-831-3801 ATTN:GARRETT KAISER 276 CEDAR AVENUE PATCHOGUE,NY 11772 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 611731582 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company 150 Deer Run LLC DBA AH Realty Holdings 3b. Policy Number of Entity Listed in Box"1 a" 150 Deer Run DBL449109 Southold, NY 11971 3c.Policy effective period 07/21/2021 to 07/20/2023 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. Policy 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 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 7/19/2022 By Via (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer 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 emailed to PAU@wcb.ny.gov or it can 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 413,4C or 5B have 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(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (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 DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 1111111 ° III DB 120.1 (12-21) /7--q\4N11ll NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE nAAAAA 611731582 " ' ■ NICHOLAS DEVITO AGENCY =' 449 ROUTE 24A MT SINAI NY 11766 SCAN TO VALIDATE POLICYHOLDER AND SUBSCRIBE KAISER GROUP INC DBA KAISER BUILT CERTIFICATE HOLDER 276 CEDAR AVENUE 150 DEER RUN LLC PATCHOGUE NY 11772 DBA AH REALTY HOLDINGS 150 DEER RUN SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER 12416430-3 96070 POLICY PERIOD 05/06/2022 TO 05/06/2023 DATE THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK 7/NSUR 2 FUND UNDER POLICY NO. 2416 430-3, COVERING THE ENTIRE OBLIGATION OF THIS POLI WORKERS" COMPENSATION UNDER THE NEW YORK WORKERS" COMPENSATION LAW WITHKRESPECTINSURANCE OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND WITH RESPECT" ER FOR OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES OILY, TO ALL TO OPERATIONS IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTIsS,;/ .NYSIF.COIIIIICERTICE'RTVAL ,THE NEV4► Y'O'RK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS .ASP THIS POLICY DOES NOT COVER CLAIMS OR BUNTS THAT ARISE FROM BODILY INJURY SUFFERED BY TH'EOFFI INSURED CORPORATION, PRESIDENT CERS OF THE GARRETT KAISER OF A ONE PERSON CORPORATION THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR COVER"A"GE` UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND THE COVERAGE AFFORDED BY THE POLICY. INSURANCE OR ALTER NEW YORK STAT SU NCE FUND 4 �V VALIDATION NUMBER: 6051198 DIRECTOR,INSU'Rq,NCE'FUND UNDERWRITING CERTIFICATE OF LIABILITY INSURANCE THISE r CERTI R IrED A E ATE DOES NOT AFFIRMATIVELYOR NEGATIVELYAMEN: E DATE(MMIDDnryYY) BELOWE CERTIFICATE CERTIFICATE OF INSURANCE DOES NO TEND OR ALTER RIGH" S Uf+d t!7HE CERTIFrCq E H 17/19'A2022 REPRESENTATIt/E OR PRODUCER,AND'THE C ONLY AND CONFERS NO T TE HOLDER, OL ER, A CONT AFFORDED B'� AUTH THIS THE COVERAGE OLDER. IMPORTANT: If the certificate holder is an ADCIITIOribAL OD�the UrNG INSURERIS rT HE P RI2ED CT BETWEEN THE ISS If SUBROGATION IS WAIVED subject to the terms and conditions of the y this certificate does not confer ri hts to the certificate holder in lieu of such endorse policy must have ADDrTrONA(,rNSURED provislon•s or be endorsed. 'PRODUCER poke certain policies may require an endorsement. A statement on Nicholas 17e1Vlto Agency, Inc, ment CONTACT 449 Route 25IwF; Jennifer Heiser Mountnal, NY 11766 EµAIAIL . Sinai, A D ennrfer devatoa FANn; 631 509-0099 enc .com INSURED ��..�.. _, ,INSURR S AIF�"ORCIING COVERA4yE �. Kaiser Group Inc, _.. � ; �R�►Ian t r .._.. C16 I�CaIs er Built rNuIaERB Pr .�eS �aBJu �7 276 Cedar Ave, INSCIRER c Patchogue, INsuRER D .. og r NY' - COVERAGES THIS IS TO CIeRTIFY CEI TrFrCl�tTENUMBER. 00033718-269762ERF" INDICATED, THAT 71"IE POLICIES OF INSIJRANCE LISTED P�ELOW HAVE SEEN ISSUED TO THE —�..�.���..� NOTWITHS�"ANDINC AIIY REOLIIREI TENT,TERM OR CDNDNTION OF ANY'CONTRACTOR OTHER o REVISION NUMBER, 14 CERTIFICATE MAYBE(S,SyJED OR MAY PERTAIN THE INSLyRANCE AFFORDED BY TI IE POLICIES DE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BE aNsR "�" .----.��—_�.. INSURED HEREIN IS SAMED 60VE FOR THE'POLICY PERIOD __ CCJMENT WITH RESPECT TO WHICH THIS T TYPE OF INSURANCE _ _ SCRIBE A X BEEN REDUCED SY PAID CLAIMS„ UO/ECT TO ALL THE TERMS, COMMERCIAL GENERAL LIABILITY ADDL SU � �- POLIYNUMBER POL PLOICYEXP M ..._. .".,.. PAC 72299,53 . LIMITS CLAIMS-MADE .m.--_•--.••w,.w._�. ' OX occuR 04/16/2022 04/16/2023 �CACH OCCURRENCE F4G-o u� r�eJ 1 000a 000 PRtI T JL I r ALOC ga LAOGRI:iaA' � Y,ane 1��r,�nnp PRr APPI,ILSP R. PERS 5 UIQ X POLICY dNACDv Ir�aRY_.. 000 0 . hDC OTHER: ENERAL,AGGREGATErt_� sC}• _.�._._ B AuroMoeaEuaBlurY RrIDucTs.cDMP/cP��c i_ ANY AUTO 02034523.2 � OWNED 04/16/2022 04/16/2023 COMBINED SINGLE LIMIT AUTOS ONLY SCI IEDULEDcn� S AU"rD r 300 000 HY TO N()N- BODILY INJURY(Per person) $WW ------ AUTOS AUTOS ONLY OAINLY ONLY � --.�_`...__.._.`. _ BODILY INJURY(Per accade'nt) UMBRELLA LIAB 9PgkOR,k_f,_0_A_ Al G EXCESS LIAB OCCURer 5c�pxl AOE WORKERS CLAIMS',-M EACH O — -�- COMPENSATION AGGREGATE' . .. . AN"EMPLOYERS'LIABILITY - , ANY PR 4'JPRIETOR,'PARTNFR„IE ECUTjVE YIN OFPICER1MOMER E„XCLUDED7 PER Y rylnNH) N/A T�,TU E H IMandatoEl If es,desrrtlbe vender _� W,_,_ DESc RII3TI E,1..EACMACCNI7Edk'r KwYI^WOOF+wP'E�RAT"ff:%hk'S.dMatlour .�....-... ".".�..._. - E,L.,DISEASE.,ELF MPLOYE 5. . E"I..DBSEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 707, Additional Remarks Schedule,may be attached if more space is required) ^CERTIFICATE F90r-DER CANCELt,ATdt~rN 150 deer Run I-.I..0 Hlatal.I�ANY aF TIrE AB�rvE Ia�8cRI8EIa� 136A AI I Realty Floldln THE EXPIRATION DATE THEREOF, IrITICE WILL BE DELIVERED L 150 Feer Run ACCORDANCE WITH THE POLICY, BE BE BE CANCELLED BEFORE Southold, NY 11971 AUTHORIZED REPRESENTATIVE CORD 25(2016/03) The ACORD name and lo_ 0 4 ©1988-2015 ACORD CORPO d`It q are re_ Istered marks of ACORD RATION- All rights reserved, Printed by J-H on 07/19/2022 at 04:31PM OWNI""" ia ot",� F11 " P011CY No.: OP-22-NY1135-12779353 File No.: 21-AS-58123 This Policy does not insure against loss or damage (and the Company Will not pay costs, attorney's fees or expenses) which arise by reason of. y 1- Survey made by Kenneth M. Woychuk Land Surveying, PLLC dated August 26, 2014 and updated October 1,2021 discloses the following:fence along part of easterly record line, 2. Natural and Undisturbed Vegetation Retention Buffer as set forth on Filed Map Number 11166. 3. Notes as set forth on Filed Map Number 1.1166. 4. Building Envelope as set forth on Filed Map Number 1.1166. 5. Declaration Of Covenants and Restrictions recorded in Liber 12314 Page 392. 6. Declaration Of Covenants and Restrictions recorded in Liber 12329 Page 39. 7. Utility Easement recorded in Liber 12396 Page 381. 8. Declaration Of Protective Covenants and Building Restrictions recorded in Liber 12524 Page 63, as amended by Liber 125,130 Page 54. 9. Declaration Of Covenants and Restrictions recorded in Liber 12612 Page 453. ALTA OWNER'S POLICY Schedule B Parr co I� � C0 7 q C � t W E � y � p p _ � y N N CY . . 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