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HomeMy WebLinkAbout48347-Z zr- �o�OSu�fa�py Town of Southold 12/8/2022 P.O.Box 1179 y 53095 Main Rd O � r y o�rSouthold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43666 Date: 12/8/2022 THIS CERTIFIES that the building WINDOWS Location of Property: 1095 Seventh St., Greenport SCTM#: 473889 Sec/Block/Lot: 48.-2-42 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/15/2022 pursuant to which Building Permit No. 48347 dated 9/29/2022 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: replacement windows to existing single family dwelling as applied for. The certificate is issued to Willis,Charles of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED GAize ignature suFfot- TOWN OF SOUTHOLD ooh c��y BUILDING DEPARTMENT a TOWN CLERK'S OFFICE Cn • �fi 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 #: 48347 Date: 9/29/2022 Permission is hereby granted to: Willis, Charles 300 St James PI Brooklyn, NY 11238 To: Install replacement windows to an existing single family dwelling as applied for. At premises located at: 1095 Seventh St., Greenport SCTM #473889 Sec/Block/Lot# 48.-2-42 Pursuant to application dated 8/15/2022 and approved by the Building Inspector. To expire on 3/30/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector oE 50UlyO� -- TOWN .OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINALid/ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE 720 INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) ------------------------------------- FOUNDATION -----------------------------------FOUNDATION (2ND) r z � o C -S� ROUGH FRAMING& PLUMBING r INSULATION PER N.Y. STATE ENERGY CODE IZ ID�- Wtn�n�s FINAL ADDITIONAL COMMENTS ?)o �Y — �o z F�, M X C 1 r b rot O �x r� x v g�yFFO( =off K�oGy� TOWN OF SOUTHOLD-BUILDING DEPARTMENT H Town Hall Annex 54375 Main Road P. O.Box 1179 Southold,NY 11971-0959 oy o�g. Telephone(631)765-1802 Fax(631)765-9502 hgps://www.southoldtommo.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only *� `1G :15 2022 PERMIT NO.4 3 Building Inspector. Jea A� BUILDING�BpT [401-0 Applications and forms must be filled out.in their entirety.Incomplete .TOWN pF SO applications will-not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed.. Date: - pg I �Oo22 OWNERS)OF PROPERTY: Name: I SCTM#1000- _. - Cry A-I✓l,cs,_ , .. ....��1_s_.. .:. - Project Add_ 31eg1Si �RE �� — NY . �. _ - - - - - Phone#: g.l - �C37 Email: Cc�Ub� rnC�iL•Cc�i�'�. Mailing Address: -CONTACT PERSON: SCOT-� Jul((j ti H A rJ, �E�'M l'TS Name: Se0T _--_ _DOU&M M Pr 0- e a!i T - ,_,. ...... Mailing Address: 2C - Cr -MC 83. - -- -. Phone#: g113. �o _( -.,ko(Q Email:_ gM I. DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: HOME-..J_E Mailing Address: .A T Vt N+A_. CTA--_ _3C4,_99 Phone#: 941-- 64 I _ �6t� Email: ?Ee N►I'f5 r-opr— 1 r s., ceG DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition PZAlteration PRepair ❑Demolition Estimated Cost of Project: ❑Other WIN00ki7 Qf PLAGEhI N7' Will the lot be re-graded? ❑Yes)1No Will excess fill be removed from premises? ❑Yes P,No +.QJ 4Zf_e(,ACF 3 WIN_1D0L& $A••ME SIZE: ,,,o s1euC(4"G 1 C)IAN&C , DocuSign Envelope ID:E5414C7F-58AE-48E4-8957-8BAOD5185895 PROPERTY INFORMATION . Existing use of property: Si kGLZ FA r1(L� Intended use of property: St+JGI Flt Mi(,y Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes Mlo IF YES,PROVIDE A COPY. Check Box'After Reading: The owner/contractor/design professional Is responsible for all drainage and storm water Issues as provided by chapter 236 of the Town Code.APPLICATION IS HEREBY MADE to the Building Department for the Issuance of a Building Pernik pursuant to the Building Zone. Ordinance of the Town of Southold,Suffolk,County,New York and other applicable taws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and In lwilding(s)for necessary inspections.False statements made herein are punishable as a Gass A misdemeanor pursuant to Section 210AS of the New York State Penal low. Application Submitted By(print name): FLt5 iF r�lE►�/J�.on) Authorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF ) 6LZL I F_7A MF ND&DO being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the AGE N' (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 to u Sit` ,20 p Not =PUBLIC, AL EZ PROPERTY OWNER AUTHORIZATION E OF ILLINOIES 03/28/202(Where the applicant is not the owner) I, CHIA Q(.BS to I LL,iS residing at 3l0 4 6aesv J P02i i NY 119 bl do hereby authorize P_V_,Sk -0R MENJI?Qr' to apply on my behalf to the Town of Southold Building Department for approval as described herein. E ocuSigned by: WL 8/10/2022 aesAo .Signature Date Charles willis Print Owner's Name 2 - a Si.. , •.g o .. a' T. 4 . , _ ,. . ... .. . ..G,,�, • CCS�"!A ski - .., :.'. .. '• :.: :• . _ - �.�Nom} - J:r �.- •: - - ,ice,,1, c ... ,....... N : < • tt ti - 'TV :.,• E.C. a-• :[ C 4' d w• r. _ - w r� 11 {r, - -PrAD _. :c.: �i .of �recrr�o�'f •prwi�rj- °P •. ,..,->..„,�j. C u c• � >7� v 4 0` �.. _ A Gt/r/� I•r�['Y�1•?� O�`0/l7d y✓1-'�' :.,._,.. { •7C. a� 4`• _.Yti / •L,,d h� 3 .Y' Y r a ' C r' - iA 1 f Ar h ; ` f , .r r? i - f. f r _ Go Permits, LLC ® 105 Buttonball Lane Glastonbury, CT 06033 RAUGnn E u U 1 5 2022 DD BUILDING DEPT TOWN OF SOUTHOLD To Whom It May Concern, Please see the attached building permit application. If you have any questions or require any further information regarding this building permit application, feel free to call me at your convenience and I would be happy to assist you. Once the permit is ready: 1. Please mail the original permit to the owner 2. Also, Please email or fax a copy of the permit and receipt to: ➢ Email: permits@gopermits.org ➢ Fax: 860-430-6719 (Attention: Scott Doughman) ➢ If fax or email is not an option, please mail a copy of the permit and receipt to: Go Permits, LLC 105 Buttonball Lane Glastonbury, CT 06033 Thank you, Ella Mendron, Permit Expediter Go Permits, LLC Phone: 847-671-4606 Fax: 860-430-6719 elzbietamendront@gopermits.org Go Permits, LLC 105 Buttonball Lane Glastonbury, CT 06033 www.gopermits.org ® DATE(MM/DD/YYYY) �►�R® CERTIFICATE OF LIABILITY INSURANCE F0212412022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s). CONTACT PRODUCER NAME: MARSH USA,INC. ac°Na A TWO ALLIANCE CENTER FAic No 3560 LENOX ROAD,SUITE 2400 pRESS: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIC$ CN101642069-HomeD•GAW.-22-25 INSURER A: Old Republic Ins ranceCo 24147 INSURED INSURER B: New Hampshire Ins Co 23841 THE HOME DEPOT,INC. 22667 HOME DEPOT U.S.A.,INC. INSURER C: ACE niefican Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA,GA 30339 INSURERE: INSURERF: 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. ADDL SUBR POLICY EFF POLICY EXP ILT. TYPE OF INSURANCE POLICY NUMBER MIDDNYYYI,(MMIDDrCfM LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY316648 03/0112022 03/01/2025 EACH OCCURRENCE. $ 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADEX❑OCCUR PREMISES Ea occurrence $ MED ECP(Any one person) $ EXCLUDED X SIR:$1,000,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO-JEC __1�LOC PRODUCTS-COMP/OP AGO $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY MWTB316649 03/0112022 03101/2025 E08ma ntI INGLE LIMIT $ 1,000,000 X ANY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED Per accident $ AUTOS ONLY AUTOS ONLY A UMBRELLA UABX OCCUR MWZX 316647 03101/2022 03/0112025 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 10,000.00D DED I I RETENTION$ $ B WORKERS COMPENSATION WC 065886029(WI) 00112022 0310112023 X STATUTE ER AND EMPLOYERS'LIABILITY 03101/2022 03/01/2023 5,000,000 C ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N WLR 068916409(AZ,IL) E.L.EACH ACCIDENT $ OFFICER/MEMSEREXCLUEWE F NIA 5,000,000 (Mandatory In NH) Continued on Additional Page E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 5,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedulo,may bo attachod If Moro 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: M01642069 LOC#: Atlanta A`� ADDITIONAL REMARKS SCHEDULE Page 2 Of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.SA,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 068916483(AOS)(AL AR FI ID,IA,KS,KY,LA MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA WV,WY) Effective Date:03101/2022 Expiration Date:0310112023 (EL)Limit$5,000,000 Carrier.Atli Insurance Co. Policy Number.WC 065886028(AOS) (AK,CO,DC,DE,HI,IN,MA MD,ME,MN,MT,NH,NJ,NY,PNRI,VT) Effective Date:0310112022 Expiration Date:03/01/2023 (EL)Limit$5,000,000 Carrier.ACE American Insurance Company Policy Number.WCU 068916446(QSQ(CA,OR,WA) Effective Date:0310112022 Expiration Date:03101/2023 (EL)Umit$4,000,000 SIR:$1,000,000 Cartier.National Union Fire Insurance Company Policy Number.XWC 1647323(QSQ (CT,GA MI,NV,OH,UT) Effective Date:03/0112022 Expiration Date:03101/2023 (EL)Limit$4,000,000 SIR:$1,D00,000 SIR(CT):$350,000 SIR(GA):$750,000 TX Employers XS Indemnity: Carriedflinios Union Insurance Company Policy Number.TNSC68991006 (TX) Effective Date:0310112022 Expiration Date:03101/2023 (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 A ® ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.SA,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 HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.SA,Inc. Home Depot U.SA 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.V.1.Holding Company,Inc.. Askuity,Inc. Home Depot Management Company,LLC ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD YotaK Workers' CERTIFICATE OF STATE COM pensatiort NYS WORKERS' COMPENSATI®N INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Home Depot USA,Inc. 770-433-8211 2455 Paces Ferry Rd.,C-20 Atlanta,GA 30339 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Only required if coverage is specifically limited to 1d.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"l a" 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 included.(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"1a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Michael Price (Print name of authorized representative or licensed agent of Insurance carrier) 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 'r/orkers' CERTIFICATE OF INSURANCE COVERAGE C-urnpensation Board 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. 446-807-7093 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 � . c.Federal Employer Identification Number of Insured or Social Security umber 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 Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT TOWN OF SOUTHOLD 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"Ia" 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. S.Poll c covers: CM A.Ail of the employee'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 12-29-2021 7_e " (Signature of insurance carnets 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 513 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'Componsatlon 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 Foran DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 -1� n1111m ® �0i0t®iill� IH RECEIPT SUFFOLK COUNTY GOVERNMENT NSING,AND CONSUMER DEPARTMENT OF LABOR, LICE AFFAIRS COMMISSIONER ROSALIE DRA P.O.BOX 6100,HAUPPAUGE.NY 11788 (631)853-4600 Today Date: 10122/2020 Application: H-53429 Application Type: Home Improvement License Receipt No. _ 414174 commentss Amount Paid Payment Date Cashier iD Renewal t 14 Additional Payment method Ref.Number $1,800.00 10!22!2020 GAB Locations Check 0003181507 Contact Info: HOME RDD T0k9S1EY INC{14 SUPPS) RICHA PO BOX 105451 t' ATLANTA,GA 30346 Work Description: ......... . . Suffolk County Dept.of Labor,Licensing&Consumer Affairs F!O[J{E IMPROVEMENT LICENSE li Fume RICHARD TOUSEY i Business Nam® This certifies that theHOME DEPOT USA INC(14 SUPPS) bearer is duly t'io by the County of License Number:H-53429 Rosalie Drago issued: 0511512014 c f 110)/2022 Commissioner Expires., r Road APPROVED AS NOTED DATEL2_q as B.P. # aF 3`f_7 COMPLY WITH ALL CODES OF FEE 5b• OO BY NEW YORK STATE & TOWN CODES NOTIFY BUILDING DEPARTMENT AT AS REQUIRED AND CONDITIONS OF 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: SOUTHOLD TOWN ZBA 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE SOUTHOLD TOWN PLANNING BOARD 2. ROUGH-FRAMING,PLUMBING, STRAPPING, ELECTRICAL&CAULKING SOUTHOLDTOWN TRUSTEES 3. INSULATION 4. FINAL-CONSTRUCTION &ELECTRICAL N.Y.S.DEC MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION.SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. Home Improvement Agreement: Page 1 Home Depot License#'s-For the most current listing visit www.Homedepot.com/LicenseNumbers Patrick Kenny Salesperson Name Registration#(Req.in CA,CT,ME,MD,MI,NJ,DC) Home Depot U.S.A.,Ine.("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. Service Provider Contact Information The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101 Icustornercancellationnortheast@hom Phone# r iceWovider Email Address Service Provider License#(s) 12. Customer Information_ _ willis Charles Long island 1-20NYMJ2K Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 310 7th Street Greenport INY 1 111944 Customer Address City State Zip (917) 673-7091 cdouble@gmail.com _Home Phone# Work Phon_e# Cell Phone# Customer Email Address j 3.NOTICE OF RIGHT _-_--_ _----_____-- 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 I Hauppauge NY 11788 Address City State zip BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCE Acknowledged by: � . ana /a /2o22 Customer's Signature Date 460 Standard Form 111A(21 Jul.21)(E) Generated Date r1R117/9099 Lead/PO# 1-90NYAA-19K v 0.1.12 Home Improvement Agreement: Page 2 4.Description of Work to be Performed A detailed description of the work to be performed is included in the paragraph entitled Scope of Work,Specification, Customer Summary Sheet, Quote Form,Estimate,Invoice or Measure which is included in this Agreement. 5.Anticipated Delivery Date/Installation Schedule Approximate Start Date: 02/03/2023 Approximate Finish Date: 03/05/2023 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; 16.Electronic 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 emails and PDF documents. 7. Contract Price and Payment Schedule Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 15236.03 Includes all applicable taxes.Excludes finance charges.* Sales Tax: $ 10.00 (If applicable, total amount of taxes included in Contract Price) *Maximum deposit ONLY applicable in MD,MA,ME(3301o),NJ, WI(9901o) Deposit% 30.01 _Deposit Amount$ 1570.9 Remaining Balance$ 13665.13 i8.Fi_nance Charges Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payments made payable to Home Depot_ !-9.Acceptance and Authorization = By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform any Services or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's or permitting information may need to be provided to You later.)By signing,you acknowledge that: (i)You have read,understand, and accept this Agreement in its entirety, including the General Conditions and State Supplement, if any; (ii) You are receiving a complete copy of this Agreement; (iii)all rights and interests under this Agreement are solely vested in the person listed as"Customer"above; and(iv)Electronic signatures will be deemed originals for all purposes. X Customer's Signature Date X I/s/The Home Depot 08/07/2022 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 Home Depot at 1-800-466-3337 460 Standard Form HIA(21 Jul.21)(E) Generated Date 08/07/2099 Lead'PO# 1 9nNYM17K v 0.1.12 WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-20NYMJ2K Sheet: 1 of 1 Customer: charles Willis Job#:1-20NYMJ2K Consultant: Patrick Kenny Date: 08/07/2022 New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,I Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use T Mull "S"=stationary or Style Wraps � m m "X"=operetmg Room Floor Code (Y/N) . StyleCode SeriesCode $ 5 ui L� a 7 PORCH 1st DHOFC Y DH 6500 C DW 30 58 88 FULL SCR, , DISPOSAL, STD,Dark Bronze,, J CHAN, GlassPack:Standard MULL R, WRAP,LSR 2 PORCH 1st DHOFC Y DH 6500 C DW 30 58 88 FULL SCR, , DISPOSAL, _ STD,Dark Bronze, J CHAN, GlassPack:Standard MULL R, WRAP,LSR FULL SCR,PT<120, DISPOSAL, 3 PORCH tat DHOFC Y DH 6500 C DW 30 58 88 STD,Dark Bronze, J CHAN, GlassPack:Standard MULL R, WRAP,LSR SPECIAL CONSIDERATIONS: 1:White,2:White,3:White Wrap Color nterior Casing Type Bay or Bow window: eatboard material(vinyl only-Birch or Oak) ay Project Angle(30 or 45) ay Flanker Type(DH,SH,or Csmnt) op of window to soffit(inches) f tied to soffit,cola of soffit material I have reviewed and agree with all the job ag j specifications above and the nstruct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: eatboard Material(vinyl only-White Plonite,Birch or Oak) The Rome Depot- Thermal Val_ueof ProftGtS ManUfactured by Simonton, c ;rr int�, m' 3�{ �YJ;��:� l.zi iii • WIM Grids Glazing U ( �fx1�i_s��� ,vI�' Style Glass Package Spacer IG (anwllirArgon) Fact SHGC,l �iij 1=s Fact;!SHGC il�l� e 1 L�! Awning 6500 Base ProSolar Supercept 7/8" 0.26 0.23 . o -1- 0.26 ; 0.21 0 0 0� Casement 6500 Base ProSolar Supercept 7/8" 0.26 0.24 0 0 0 0 0.26 ! 0.22 o o o o Transom 6500 Base ProSolar Supercept 1' 0. 7 T-0-ii- 0 0 0.27 f 0.29 o 0 Double-Hung 6500 Base ProSolar Supercept 7/6" 0.29 0.26 0 0.29 0.24 o a o Picture Casement (NH) 6500 Base ProSolar Supercept 7/8" 0.26 ; 0.28 o o 0.26 ; 0.25 0 0 o 0 Picture 6500 Base ProSolar Supercept 7/8" 0.27 0.29 10101 0.27 ', 0.26 0 0 2 Panel Slider 6500 Base ProSolar Supercept 7/8^ 0.29 0.260 029 ; 0.23 0 0. o 3 Panel Sliders 6500 Base(s 21 Sqft) Pro Solar Supercept 7/8" 0.29 ' 0.26 0 0.28 0.23 0 0 0 DR11111DOW Garden Door(CH) 6500 Energy Star ProSolar SUN Super Spacer 1" 0.30 ' 0.24 0 0 0 0 0.30 0.21 0 0 0 0 Patio Door INOVO 6500 Base Pro Solar Super Spacer 1" 0.28 j 0.26 1 0 I 0 0.31 0.23 1 0 10 0 0 1 1 Homes located everywhere EXCEPT:Arizona,California,Idaho,Nevada,New Mexico,Oregon,Utah,and Washington. Awning(Inc Hopper) 6100 Base Pro Solar Intercept 7/8" 0.27 0.24 0 0 0 0 0.28 ; 021ERF Casement 6100 Base Pro Solar Intercept 718" 0.27 0.24 0 0 0 0 0.27 0.22 Double-Hun 6100 Energy Star Pro Solar Supercept 314" 0.30 0.30 _ 0 0.30I 0.27 :-:E- Picture 0Picture Casement(No Hinge) 6100 Base Pro Solar Intercept 7/8" 0.27 0.28 o o 0.27 ; 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 F 0 0.30 0.27 0 MEMO 1 • • Homes/orated everywhere EXCEPT:Arizona,California,Idaho,Nevada,New Mexico,Oregon,Utah,and Washington. Patio Door INOVO 6100 Energy Star Pro Solar Super Spacer 1" 1 0.28 ' 0.26 0 01 1 1 0.28 ; 0.23 1-1-1- -Patio 0 0 0Patio Door NARROW FRAME. 6100(PD05)Base Pro Solar Intercept 314^1 0.28 ? 0.30 jolol 1 1 0.28 ! 0.26 jolol • 1 1 Homes located only in following markets.Dallas,Denver,Detroit,Phila,Northern NJ,Long Island,NY. Awning 6200 Base Pro Solar SHADE Supercept 314" 0.27 1 0.250 010 c 0.26 023 o o o o Casement 6200 Base Pro Solar SHADE Supercept ala^ 0.26 j 0.18 o 0 0 0 0.29 0.17 o o o 0 Picture Casement-NH 6200 Base Pro Solar SHADE Supercept 314" 0.25 0.21 0 0 0 0 0.25 ' 0.19 0 0 0 0 Picture Window 6200 Base Pro Solar SHADE Supercept 3/4" 0.26 i 0.24 lo 0 o o 0.26 i 0.22 o o o 0 Single Hung 6200 Base Pro Solar SHADE Supercept 314" 0.28 i 0.23 lo o o o 0.28 ; 0.21 0 0 0 Single Slider 6200 Base Pro Solar SHADE Supercept 314" 0281 0.23 oo 0 0.28 0.21 M.I . o 3 Panel Slider 6200 Base Pro Solar SHADE Supercept 3/a" 0.28 i 0.23 0 0 0 0.28 i 0.21 0 0 0 • : 1 1 Homes located In coastal areas. Awning SB+300VL Energy Star PS SUN/Lami Supercept 1" 0.26 0.23 0 0 o1ol 0.26 0.21 o 010101 Casement SB+300VL Base PS/Lami Super Spacer V 0.25 ( 0.23 o 0 o 0 0.25 i 0.21 o o 0 0 -- Double Hung SB+300VL Base PS/Lami Super Spacer 1" 0.29 0.25 0 0 0 0 0.29 0.23 o o 0 0 Slider SB+300VL Base PS/Lam! Intercept V 029 ' 0.25 0 0 0 0 0.29 i 0.23 o o o o Patio Door SB+300VL ETC 366 PS Shade/Lam! Super Spacer 1" 0.30 1 0.19 o o o o . . - -. Garden Door(CH) SB+300VL Base PS/Lami Super Spacer 1" 0.30 ? 0.28 0 0 0.30 0.25 0 0 0 0 •Dots indicate Energy Star certified for that zone