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49079-Z
TOWN OF SOUTHOLD w. � BUILDING DEPARTMENT � w TOWN CLERK'S OFFICE 41 Y SOUTHOLD, NY wu: 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#: 49079 Date: 4/3/2023 Permission is hereby granted to: Meehan, William 625 Franklinville Rd Laurel NY 11948 To: legalize an "as built" conversion of an existing business building with dwelling unit to a single-family dwelling as applied for (and to construct new additions and alterations) as per SCHD approval. Additional certification will be required. At premises located at: 625 Franklinville Rd., Laurel SCTM # 473889 Sec/Block/Lot# 125.-2-1.25 Pursuant to application dated 8/22/2019 and approved by the Building Inspector. To expire on 10/2/2024. Fees: AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $2,601.60 SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $849.20 CO-NEW DWELLING $50.00 Total: $3,500.80 Building Inspector �1 Fl 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 � IIIa,,> � °.» u�Lh�l(a9uc� �mlotaw Date Received APPLICATION FOR BUILDING PERN111"' For Office Use Only w PERMIT NO. Building Inspector:................ MAR 3 '1 2023 Applications and forms must be filled out in their entirety. Incomplete app p pp applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S) OF PROPERTY: Name: ) �n'i'y� C SCTM#1000- 1,2 Project Address: ,- �� n ��1 %U4 Phone#: Email; Mailing Address: CONTACT PERSON: Mailing Address: '" Phone#:�Y - �� Em a il: ���ttjl ,n DESIGN PROFESSIONAL INFORMATION: Name: At- Mailing Address; ' Phone#: �� _ Email: CONTRACTOR INFORMATION,' Name: Mailing Address: "' z't Phone#: �� — �U� Email: DESCRIPTION OF PROPOSED CONSTRUCTION El New Structure ®a ddition ❑Alteration ❑Repair ❑Demolition Estimate Costtof_Project: ❑Other $ Q [� Will the lot be re-graded? ❑Yes eNo Will excess fill be removed from premises? ❑Yes No 1 PROPERTY INFORMATION Existing use of property:, Intended use of property: , j�� Zone or use district in which premises is situ 'ed. Are there any covenants an astrictions with r5p ct to this property? ❑Yes IF YES, PROVIDE A COPY, The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuantto Section 210.45 of the New York State Penal Law. Application Submitted By(print name):6o dg A06, uthorized Agent El Owner Signature of Applicant: Date: STATE OF NEW YORK) COUNTY OFf0A being duly sworn, deposes and says p t(s)he is the applicant (Name of individual signing contract) above named, (S)he is the 14 .� � (Contrac r Agen ;Corporate Officer, t .) of said owner or owners, and is duly authorized to perform or have performecltb wai work and to make ake an d file this application; rcthis true best oT his/her knowledge and belief;and that thewo k will be performedinhe annersetforth in the application file therewith. �--�-n-� Sworn before me this day of /b ,205 Notal iWi_Y ANN'tOPEZ Notary Public-State of New York No.01 L06290509 PROPERTY CMNERUTH ZA CIS�� � Qualified in Suffolk County __. --• My Corrlmission E;;pires 10107129 (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, W ffl ftg-�4 residing at (D:I ��� I l "��L, kA (Print property owner's name) (Mailing Address) -Defiftj 'awn� k�� w do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. (Owner's Signature)I/i a-Do 1�� at ) r (Print Owner's Name) Generated by REScheck-Web Software Compliance Certificate Project 625 Franklinville Energy Code: 2018 IECC Location: Laurel, New York Construction Type: Single-family Project Type: Addition Climate Zone: 4 (5331 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 625 Franklinville Rd Laurel, NY m m m ^ • - m Compliance: 5.4%Better Than Code Maximum UA: 92 Your UA: 87 Maximum SHGC: 0.40 Your SHGC: 0.34 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Slab-earn-graade tradeoffs are no po nger comsidered in the UA or performance cornpHaince path M IRI check. IE Each slab-on-grade rasas ei riNy lin the spa rifled rnll'uirrnaate zona*irrnust rruaet:the irn"nildiRlurn^u einergy code prnsrnallaatio n IR-value and depth iraagUirei rie nlMs, E 1i a Ceiling: Flat Ceiling or Scissor Truss 573 42.0 0.0 0.028 0.026 16 15 Wall:Wood Frame, 16" D.C. 576 21.0 0.0 0.057 0.060 31 33 Window:Vinyl Frame 34 0.320 0.320 11 11 SHGC: 0.34 Basement Wall: Solid Concrete or Masonry Wall height: 8.0' 512 15.0 0.0 0.052 0.059 26 30 Depth below grade: 8.0' Insulation depth: 7.5' Window:Vinyl Frame 10 0.320 0.320 3 3 SHGC: 0.34 Compliance Statement. The proposed building design described here is consistent with the building plans,specifications, and other calculations submitted with the permit application.The proposed building has been designed to meet the 2018 IECC requirements in REScheck Version : REScheck-Web and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name-Title Signature ^ t dye rr"Jr l :"n hq, µ 12 Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Pagel of 9 REScheck Software Version : REScheck-Web C�(J Inspection Checklist Energy Code: 2018 IECC Requirements: 15.0% 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 user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. .._# Pre-inspection/Plan Value ed Field aluefied mp Section an Review Plans Ver�fi _ Com li ...... .�. ._.m P ' ..ons & Req.ID q ��W�.._�., Comments/Assumptions 103.1, Construction drawings and ❑Complies 103.2 documentation demonstrate ❑Does Not [PR1]1 energy code compliance for the u„ building envelope.Thermal ❑Not Observable envelope represented on ❑Not Applicable construction documents. 103.1, Construction drawings and ElComplies Requirement will be met. 103.2, documentation demonstrate ❑Does Not 403.7 energy code compliance for [PR3]1 lighting and mechanical systems. []Not Observable Systems serving multiple ❑Not Applicable dwelling units must demonstrate compliance with the IECC Commercial Provisions, 403.7 sized per co Manual S based is Heating: Heating: ❑CDoo p�� � Requirement will be met. ACCA es Btu/hr Btu/hr ❑ [PR2]2 on loads calculated per ACCA Cooling: Cooling: Manual J or other methods ❑Not Observable approved by the code official. Btu/hr Btu/hr ❑Not Applicable Additional Comments/Assumptions: 1 High Impack(Tier 1) 2 Medium Impact(Tier 2 3 Low Impact(Tier 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 2 of 9 Section Plans fied FieIfied ValueV lue .._.... ,�,�,�_ ,,,��..,�..�.... . # Foundation Inspection Complies? Comments/Assumptions & Req.ID 402.1.1 Conditioned basement wall R- � R- � ❑Complies� � �See,ee the Ennvelvel...� ope Assemblies lies [FO4]1 insulation R-value.Where interior R_ R- ❑Does Not table for values. insulation is used,verification ''' may need to occur during [:]Not Observable Insulation Inspection. Not ❑Not Applicable required in warm-humid locations in Climate Zone 3. ....... . ..�,.... .. 303.2 Conditioned basement wall ❑Complies [FO5]1 insulation installed per ❑Does Not A� manufacturer's instructions. ❑Not Observable ❑Not Applicable 402.2.9 Conditioned basement wall....._...... ft. _ ...ft mm , Complies See the Envelope Assemblies [FO6]1 insulation depth of burial or ❑Does Not table for values. distance from top of wall. [--]Not Observable ❑Not Applicable 303.2.1 A protective covering is installed ❑Complies [FO1112 to protect exposed exterior ❑Does Not insulation and extends a minimum of 6 in. below grade. ❑Not Observable ❑Not Applicable �� 403.9 Snow-and ice-melting s...........�.�.._m__. �.... .._ ....... ���., ....................� ._._...m.. ............ ystem ❑Complies Requirement will be met. [FO12]2 controls installed. ❑Does Not ❑Not Observable []Not Applicable Additional Comments/Assumptions: ....... ............h I ct Tier 1 uLL .�._... .,._. _� i............................ . . ............................................................................................... .. �.���ww...wwww��_a�edium impact(Tier 2) 1 3 Low Impact(Tier 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 3 of 9 Section f Plans VerifieTdF ield Verified g / Rough-In Inspection a Comphes� Comments/Assumptwns & Re ID ��m-m ��.... ��Fram�n...m.,�... � .. m _.�.. w.._.��. .. Value .. , ,Valu __...m,_o_..._ �._._......... ------- 402.1.1, Glazing U-factor(area-weighted U- U- ❑Complies See the Envelope Assemblies 402.3.1, average). ❑Does Not table For values. 402.3.3, ',402.5 ❑Not Observable [FR2]1 ❑Not Applicable 303.1.3 U-factors of fenestrationroducts .. ew..�.. ._. _. �...... �� m.._. ._ .�.. . ..... _ m._.. ..— �..... _ n �mwn p ❑Complies [FR411 are determined in accordance ❑Does Not j , with the NFRC test procedure or taken from the default table. ❑Not Observable ❑Not Applicable 402.4.1.1 Air barrier and thermal barrier ❑'C'omplies [FR23]1 installed per manufacturer's ❑Does Not ,ko instructions. ❑Not Observable . .. .. ... _ w.. ...._.. ❑Not Applicable 402.4.3 Fenestration that is not site built ❑Complies [FR20]1 is listed and labeled as meeting []Does Not AAMA/WDMA/CSA 101/I.S.2/A440 or has infiltration rates per NFRC []Not Observable 400 that do not exceed code []Not Applicable limits. 402.4.5 IC-rated recessed lighting f _..�. .,.-..� , � � wu... .-.m�........... ... - ... � --nixtures ❑Complies [FR16]2 sealed at housing/interior finish ❑Does Not and labeled to indicate<_2.0 cfm leakage at 75 Pa. []Not Observable _ ❑Not Applicable 403. ......._. .Su.. ...I and return ducts i.... . .. ................. Supply n attics ❑C'omplies [FR12]1 insulated >= R-8 where duct is ❑Does Not >= 3 inches in diameter and >_ R-6 where < 3 inches. Supply and ❑Not Observable return ducts in other portions of ❑Not Applicable the building insulated >= R-6 for diameter>=3 inches and R-4.2 for< 3 inches in diameter. .. ... .. 6. „ ... �....�.�....._........._................ �_ � 403.3.2 Ducts, air handlers and filter ❑Complies [FR13]1 boxes are sealed with ❑Does Not joints/seams compliant with International Mechanical Code or ❑Not Observable International Residential Code, as ❑Not Applicable applicable. 403.3.5 . ,.....Building cavities are not used as ❑Complies I[FR15]3 ducts or plenums. ❑Does Not ❑Not Observable ❑Not Applicable .. 403.4m ........_ ......................._......_ .... eeeeeeee_. _.. . ,..........._._ .e ...._._. .... ............ ._. ............ _.............. ..... .. HVAC piping conveying fluids R R []Complies Requirement will be met. [FR17]2 above 105 QF or chilled fluids ❑Does Not to below 55 QF are insulated to?R- ❑ 3 Not Observable ❑Not Applicable 403.4.1 �Protection ofinsulation ............._.. �-.�p... on HVAC _ ❑Com lies Requirement will be _._�., �.. ��...... met. [FR24]1 piping. ❑Does Not [-]Not Observable ❑Not Applicable 403.5.3 " Hot water�i es are insulated to ...� _�. �.. _..� , ., .�...... .......... ��...� p p R R ❑Complies Requirement will be met. [FR18]2 >_R-3. ❑Does Not ` ❑Not Observable ❑Not Applicable .. P,e.. .m_ ..... ._..� .. ... ...... 403.6 Automatic or gravity dampers are ❑Complies [FR19]2 installed on all outdoor air ❑Does Not intakes and exhausts. ❑Not Observable ❑Not Applicable F-�.�_ act(Tier 2) 3 ,Low Impact 1 H g Impact(Tier 1) 2 Medium Imp 1 pac (Ti 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 4 of 9 Additional Comments/Assumptions: 1Hitt Imaacl (Tierml)mn^ Medium Impact(Tier 2)mm ^ Low Impact(Tier 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 5 of 9 11 Section Insulation Inspectiontion Pians Verified Field Verified Complies? Comments/Assumptions nts Assum P tions & Req..�� Value Value . 303.1 All installed insulation is labeled ❑C omplies [IN13)2 or the installed R-values []Does Not provided. ❑Not Observable ❑Not Applicable �n. _,.�m .-.......... _.,. ,.. .... .... _..�.�m.....�..._.......w__. _. _.�. 402.1.1 Wall insulation R-value. If this is a R R- ❑Complies See the Envelope Assemblies 402.2.5, mass wall with at least 1h of the ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.6 wall insulation on the wall ❑ Mass ❑ Mass []Not Observable [IN3)1 exterior,the exterior insulation requirement applies (FR10). ❑ Steel ❑ Steel ❑Not Applicable 303.2 Wall insulation is installed per .mm.�..00om...... .....m ..._._ .... ... .....m.AA ._m ��.�.�_... . .m.._ plies [IN4]1 manufacturer's instructions. ❑Does Not []Not Observable ❑Not Applicable Additional Comments/Assumptions: ........... _. 1 'Higha Impact(Tier l)mmm 2 Medium gmpact(�Ier 2) 3 LowImpact(Tier 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 6 of 9 -- ,, �._.._ �._...-..._.�.�....�.� ..._.. –mm W _.,.,......, Final Inspection Pro7 Plans Verified FieldVerified ornm ents Assumptions# isions Value Compies, & Req'ID 402.1.1, Ceiling insulation R-value. R- R- ❑Complies See the Envelope Assemblies 402.2.1, ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.2, ❑ Steel ❑ Steel ❑Not Observable (Fill'402,2,6 ❑Not APP licable FI1] _. __._.._. _ .._ m..M_. ..r... . 303.1.1.1, Ceiling insulation installed per ❑Complies 303.2 manufacturer's instructions. ❑Does Not [FI2]1 Blown insulation marked every 300 ft2. ❑Not Observable ❑Not Applicable 402.2.3.m,,.,,,�Vente...�. . .. . d attics with air permeable ❑ Complies [FI22]2 insulation include baffle adjacent ❑Does Not to soffit and eave vents that extends over insulation. []Not Observable ❑Not Applicable . 402.2.4 .Attic access hatch and doorR-,. . .... ��.� ._,,, w_. _... _ .. ,–a...w. _ �eee„.�......-�. .�_� ....a...... .. ..._... .�_ .._..._�wrw R- ClComplies [FI3]1 insulation aR-value of the ❑Does Not adjacent assembly. ❑Not Observable ❑Not Applicable 402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50 = ACH 50– ❑Complies [FI17]1 ach in Climate Zones 1-2, and ❑Does Not <=3 ach in Climate Zones 3-8. ❑Not Observable []Not Applicable ......._.......mmm... _........ _....._. ..�. ......_ ..m_ ..... .._. ..� .._� a... ._...w.,..�.,___...�__�.._._.�....._m__�.. �, ._....�....... 403.3.3 Ducts are pressure tested to cfm/100 cfm/100 ❑Complies (FI27]1 determine air leakage with ft2 ft2 ❑Does Not either: Rough-in test:Total leakage measured with a ❑Not Observable pressure differential of 0.1 inch ❑Not Applicable w.g. across the system including 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 handler enclosure. _ 403.3.4 Duct tightness test result of<=4 cfm/100 cfm/100 ❑Com mplies [FI4]1 cfm/100 ft2 across the system or ft2 ft2 ❑Does Not <=3 cfm/100 ft2 without air ❑Not Observable handler @ 25 Pa.For rough-in tests, verification may need to ❑Not Applicable _ occur during Framing Inspection. m._ ...—.–.... -... g _.._ _m. ,. .w .. w........_ _ .�........................__. _._......N_ ....... .. ....mm 403.3.2.1 Air handler leakage designated ❑Complies [FI24]1 by manufacturer at<=2%of ❑Does Not design air flow. ❑Not Observable ❑Not Applicable �........ ... _._��.w .�_ �.r. _ .–_.... 403.1.1 Programmable thermostats ❑Com!plies [FI 9]2 installed for control of primary ❑Does Not heating and cooling systems and initially set by manufacturer to [-]Not Observable code specifications. ❑Not Applicable ., .. . 6 W _............ .... ............. ..._....... 403.1,2. Heat umthermostat ._..... ...... --��m. -.– p p thermostat installed ❑Complies [FI 10]2 on heat pumps. ❑Does Not ❑Not Observable ❑Not Applicable 403.5Circulating service hot water Circulating s .,. ...., .�_ ..� ...� � ... .... ............... ❑Complies [FI 11]2 systems have automatic or ❑Does Not accessible manual controls. ❑Not Observable ❑Not Applicable 1 Hi h Im act (Tier 1) 2 Me p –..... ., 'jm mmm] (Tier 2) 3 'Low Impact(Tier 3) Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 7 of 9 se�.io_n_ .M ... wmw �... m„ .. ..,,. _... w e.. .. .. —........ w.......w ._,.__—- _._ Final Inspection Pro Plans Verified FieldVerified Complies' Comments/Assumptions I ions Value Value .... . 403.6.1 All mechanical ventilation system ❑Complies [FI25]2 fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits per Table []Not Observable R403.6.1. ❑Not Applicable 403.2 Hot water boilers supplying _ Com heat ... ❑ plies [FI26]2 through one-or two-pipe heating ❑Does Not systems have outdoor setback control to lower boiler water ❑Not Observable temperature based on outdoor ❑Not Applicable temperature. 403.5.1.1 Heated water circulation systems ❑Complies [FI28]2 have a circulation pump.The ❑Does Not system return pipe is a dedicated return pipe or a cold water supply ❑Not Observable pipe.Gravity and thermos- ❑Not Applicable syphon circulation systems are not present. Controls for circulating hot water system pumps start the pump with signal for hot water demand within the occupancy. Controls automatically turn off the pump when water is in circulation loop is at set-point temperature and no demand for hot water exists. _. .. ._�.�......._....m ...��- ........ . 403.5.1.2 Electric heat trace systems ❑Complies [F129]2 comply with IEEE 515.1 or UL ❑'Does Not 515.Controls automatically adjust the energy input to the ❑Not Observable heat tracing to maintain the ❑Not Applicable desired water temperature in the piping. _ . 403 5.2 Demand recirculation water .. ]CarrgfO) — ��_._. ......... ies [F130]2 systems have controls that ❑Does Not manage operation of the pump and limit the temperature of the ❑Not Observable water entering the cold water ❑Not Applicable piping to <= 1044F. ........... 403.5.4 Drain water heat recovery units ❑Complies [F131]2 tested in accordance with CSA ❑Does Not 1355.1.Potable water-side pressure loss of drain water heat ❑Not Observable recovery units < 3 psi for ❑Not Applicable individual units connected to one or two showers. Potable water- side pressure loss of drain water heat recovery units < 2 psi for individual units connected to three or more showers. 404..1 90%or more Wof....ermane.. ..... permanent ❑Complies [FI6]1 fixtures have high efficacy lamps. ❑Does Not ❑Not Observable ❑Not Applicable 404..._. 1.1Fuel gas w...lighw._tingsystems�e°Am...ee _ ..... .....- d w. __.. ._. .m.............................. have ❑Complies [FI23]3 no continuous pilot light. ❑Does Not ❑Not Observable _ ❑Not Applicable 401.3.,. Compliance certificate po ... ... ...m�..,, ............. ... p sted. ❑Complies [F17]2 ❑Does Not ❑Not Observable ❑Not Applicable High Impact(Tier 1) 2 Medium Impact (Tier 2) 3 Low Im aCt Tie Project Title: 625 Franklinville Report date: 12/20/22 Data filename: Page 8 of 9 la # Pl ns Verified Field Verified && R# Final Inspection Provisions Value Value Complies? Comments/Assumptions eaT 303.3 Manufacturer manuals for Elcomplies [1`11813 mechanical and water heating ElDoes Not systems have been provided. E]Not Observable 0Not Applicable AddUtionaUCommmments/Asmummmtions: Project Title: 82SFnanNinxU|e Report date: 12/30/22 Data filename: Page Qof 9 Effidency Certificate + NO Above-Grade Wall 21.00 Below-Grade Wall 15.00 Floor 0.00 Ceiling / Roof 42.00 Ductwork (unconditioned spaces): Window 0.32 0.34 Door jig Heating System: Cooling System: Water Heater: MM Name: Date: ` Comments f k P 4 v kl r lrriif �i kkM r r �� d ` q raw ' aw DATE(MM(DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE �. 02/14/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ,. .'E .. .... ... ... �.�... -NAME: Kirk Associates LTD PHONEFFit 631-727-7767 FAX 631-727-7941 E-MAIL enC kirk farm-fmul 18 First Street ADDREs . ywcom _... Riverhead, NY 11901 INSURERIS)AFFORDING COVERAGE ......... NAIC# ... mmmmmmmm uuumm www wwwwwwww _ INSURERA Farm FamllY Casualt Insurance. Com anY .... .1.m38..0..3 ..... ... .�...� NSURED INSURER B: SINCHI CARPENTRY CORP _.... __._. vrd.... .......... .... .w .........__ _.. INSURER C: INSURER D 12 Oak Street Suite 8 _ .......�_ ........._-._..........._.._.... .-.. _..._. .._. _. INSURER E: Westhampton NY 11978 INSURER........ ..............�.�...._ .__. ....--.�. F: OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. ............... .. _.... LIMITS NISR.TR ..-_ .. TYPE OF INSURANCE AIDL SUBI �.._.INS J POLICY NUMBER MMIDDY/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY X X 3101X8885 08/09/2022 08/09/2023 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE ��OCCUR PREMISES(Ea occurrence,) 100,000 MED EXP(Any one person $ 5,000 X CONTRACTUALLIABILITYPERSONAL&ADV INJURY $ 2,000,000m GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4 000 000 PRODUCTS COMP/OP AGG X POLICY JECT PRO 4,000,000 OTHER: LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person)_ $ OWNED SCHEDULED BODILY INJURY(Per accident) .._._ AUTOS ONLY AUTOS HIRED NON-OWNED I'RDF"LR'f t DAMAGE $ AUTOS ONLY AUTOS ONLY Prp �cia3enc _....- UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS'LIABILITY Y/N ,STATUTE ww ......J 9R ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ NIA A E,L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 (Mandatory ) _mm L.DISEASE-EA EMPLOYEE $ Mandato in NH Emmmmmmmmm If yes,describe!under E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below )ESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 'ERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED �E'RTIFI ATE HOLDER CANCELLATION Town Of Riverhead 992 East Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Riverhead, NY 11901 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE KIRK ASSOCIATES LTD ©1988-2015 ACORD CORPORATION. All rights reserved 4CORD 25(2016/031 The ACORD name and loao are reaistered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/01/2023 THIS CER"(IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). '.. PRODUCER CONTACT Stacia Lorenzo NAME _.......... ....._ E A Funk&Associates,Inc. K (631)467-5160 ° NN F (631)467-4747 (AM t 1919 Middle Country Road ADDRESS: slorenzo@eafunkinsurance.com Suite 300A INSURER(S)AFFORDING COVERAGE NAIC# ....... Centereach NY 11720 INSURERA: Merchants Mutual Insurance Company 23329 ...... INSURED INSURER B: Mongiori Electrical Corp INSURER C: 58 Joan Avenue INSURER D INSURER E Centereach NY 11720-4415 INSURER F: COVERAGES CERTIFICATE NUMBER: CL233105539 REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE LTR INSD WVD. POLICY EFF POLICY EXP LIMITS POLICY NUMBER MMIDD MMIDD '. _. _ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE---7, $ 1,000,000_ A 500000 CLAIMS-MADE Fx] OCCUR PREMISES(Ea occurrence $ , MED EXP(Any one person) $ 15,000 A BOP1098517 03/02/2023 03/02/2024 PERSONAL&ADV INJURY $ GEN ...._ - ........ _ 'L AGGREGATE LIMIT APPLIES PER:. GENERALA ......TEmm $ 2,000,000 PRO- 2,000,000 POLICY JECT LOC PRODUCTS-GOMP/OP AGG $ Empi Practices Liab Ins $ 100,000 .......OTHER. ._ ._.._ ..-.. . ..... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 300,000 (Ea accident) '.... ANYAUTO BODILY INJURY(Per person) $ ......_ .. ....... ......_� A OWNED SCHEDULED CAP1067486 09/22/2022 09/22/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAC`F.... $ AUTOS ONLY _ AUTOS ONLY 4Pu rtccident Underinsured motorist $ 100,000 UMBRELLA LIAB VV v ivy Vyv OCCUR 'EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ......... DED RETENTION $ $ .... ......... ........ .. ..._._. .._. WORKERS COMPENSATION PER ?RT EMPLOYERS'LIABILITY Y/N STATUTE. ER ANY PROPRIETOR/PARTNER/EXECUTIVE r— IN/A A E.L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? W_..._ (Mandatory in NH) """"""" E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 NY 25 AUTHORIZED REPRESENTATIVE a Southold NY 11971 P @ 1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD I� Workers' CERTIFICATE OF IOR --.w Yl�rATr Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (631)736-7188 Mongiori Electrical Corp. 58 Joan Avenue 1c.NYS Unemployment Insurance Employer Registration Number of Centereach,NY 11720 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 20-2659425 ..... .._ .............. 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Merchants Mutual Insurance Company Town of Southold 3b. Policy Number of Entity Listed in Box"I a" 54375 NY 25 WCA9101380 Southold,NY 11971 3c.Policy effective period 31212023 to 3/2/2024 3d.The Proprietor, Partners or Executive Officers are ❑ included.(only check box if all partners/officers included) ❑X all excluded or certain partners/officers excluded. ...... ......... ...... ........ This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Stacia Lorenzo Wvv (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �r Viµ, 3/1/2023 rgrratuures) �,_,, (Date) Title: Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier: (631)467-4747 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1, The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE CERTIFICATE OF LIABILITY INSURANCE DAT3/03/2023 Y, � 03/03/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(Ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C ONTACT _MICHAEL W MCCORD FAc AME: �• - • ONE 631-213-3331 ITm IANC N °631-213-3627 FARM FAMILY INSURANCE i&,DD SLRVICE.380 AMERICAN NA`fIONAL.COM 380 TOWNLINE RD SUITE 120 DR_ r,..._.- _. • HAUPPAUGE,NY 11788 FFo DING COVED LNIJRERIsi A' — INstIRERA: FARM FAMILY CASULTY INSURANCE COMPANY INSURED ImISURE6;. UNITED FARM FAMILY INSURANCE COMPANY GAS TEC PLUMBING&HEATING CORP INSURER C: SHELTERPOINT •••_ ........ P O BOX 233ttSURER D:_ INSURER E .�.... ......_. wr. WADING RIVER NY 11792 1 INSURER F: COVERAGES CERTIFICATE NUMBER, REVISION NUMBER! 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. w. ....�. .... . — lL'R.. .. 1111. L SUB 1111.. POLICY EFF POLICY •XP- LIMITS 1111. TYPE OF INSURANCE POLICY NUMBER MM1DDdYYY MMBDD A X COMMERCIAL GENERAL LIABILITY 3102X151.5 10/21/22 10/228123 EAC:HOCCURRENCE $ 1,000,000 54 N CLAIMS-MADE FROCCUR REh19SES IE ryrsu to ttl $ 100,0010 MED tX (AAr mne p es!au�) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,0[)0,1)00 PRO- P� .....�.... X POLICY❑)ECT � LOC _ROOUCTS-COMP/OP AGG $ 2,000„008' OTH'tuTt'; B AUTOMOBILE LIABILITY 310IC5824 "'I0/23/2a;.... 10/23/23 CCbIWtlBINFtSS9NGLELPMi"r $ 300„000 ...I��a zgldenl� „ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS •.• RTY DAMAGE XHIRED X NON-OWNED r PROPEqr 4�rfiEd n $ AUTOS ONLY ._.__, AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE. $ ........ EXCESS LIAR CLAIMS-MADE AGGRI:.GATE• $ 1111.. �.� DED RETEN710N' $ PER OTH- WORtCERS COMPENSATION TATIITE E; AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOMPARTNERIEXECUIIVE E.L.EACH ACCIDENT $ OFFICERITIEMBERE#'CLUDED'T LJ NIA (Mandatory In NH) E.L.DISEASE EA EMPLOYEE Idy�e ,de�pJbo under E.L.DISEASE-POLICY t.IMIT 1111$ DESCRIPTION OF OPERATIONS below C NYDBL D501500 2/28/17 Indefinite STATUTORY DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375A NY 25A THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southhold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �t t Workers' CERTIFICATE OF INSURANCE COVERAGE srArr Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed b NYS disability and Paid Family Leave benefits carrier or �... ....._ .... _.. y y y licensed insurance agent of that carrier _. _ .....................__ 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured GAS TEC PLUMBING&HEATING CORP 631-805-2088 PO BOX 233 WADING RIVER,NY 11792 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York Slate,i.e.,Wrap-Up Policy) 814258516 ......... - 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 Town Of Southhold 54375 NY 25A 3b.Policy Number of Entity Listed in Box"1 a" DBL501500 Southhold, NY 11971 3c.Policy effective period 02/28/2022 to 02127/2024 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. rl B.Disability benefits only. F1 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,t 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. I'Date Signed 9/15/2022 By (Signature of insurance carrier's authorized representative or NY5 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 513 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 I 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 sox 46,4C 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 08-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 11111111��iiiiiisiiinsiiiiiiiuiiri��r � iiIllII N'W Workers' YSTOa Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (use street address only) 1 b. Business Telephone Number of Insured GAS TEC PLUMBING & HEATING CORP (631)805-2088 1569 ROCKY POINT RD MIDDLE ISLAND NY 11953-1239 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1 d. Federal Employer Identification Number of Insured or limited to certain locations in New York State,i.e.a Wrap-Up Policy) Social Security Number 81-4258516 2. Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Accident and Indemnity Company Town of Southold 22357 54375 NEW YORK#25 A 3b.Policy Number of Entity Listed in Box"1 a": SOUTHOLD NY 11971 76 WEG AFOP1 D 3c. Policy effective period: 01/28/2023 to 01/28/2024 3d.The Proprietor, Partners or Executive Officers are ® Included.(Only check box if all partners/officers included) rX_1 all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box 1 a" for workers'compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2 The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage affordedby 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 Worker's 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: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: 03/06/2023 ��, ;���r,lr�� � �.�r�� � (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 866 467-8730 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) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 y 11K Workers' CERTIFICATE OF INSURANCE COVERAGE L4—NOFWATO Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 11 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) 1 b.Business Telephone Number of Insured DARWIN E VALEY (631)745-2542 21 POINT RD RIVERHEAD,NY 11901 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 947916192 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) TOWN OF SOUTHOLD 3b. 54375 MAIN RD Policy Number of Entity Listed in Box"1a" P.O.BOX 1179 DBL 7055 91-7 SOUTHOLD,NY 11971 3c.Policy effective period 04/18/2022 to 04/18/2023 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 employees 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 6/28/2022 By (Signature of insurance carrier's authorized representative or NY5 Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT: If Box 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, DB 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 58 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 BY (signature of Authorized NYS workers'Compensation Board f:mpioyee) 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 (10-17) Certificate Number 694356 Additional Instructions for Form 1313-120.1 By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Worker's 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 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 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. S (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 It M.4 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE sI * AA^A^A 364918857 LIGHTHOUSE AGENCY INC 960B MONTAUK HIGHWAY SHIRLEY NY 11967 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER VALEY CONSTRUCTION CORPORATION TOWN OF SOUTHOLD 21 POINT RD 54375 MAIN RD RIVERHEAD NY 11901 P.O.BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12442 651-2 48167 04/18/2022 TO 04/18/2023 6/28/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2442 651-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDERS REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/IWWW.NYSIF.COM/CERTICERTVALASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT DARWIN E VALEY VALEY CONSTRUCTION CORPORATION (ONE PERSON CORP) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SU CE FUND DIRECTOR„INSURANCE FUND UNDERWRITING VALIDATION NUMBER:237712466 0 DATE(MMIDDIYYYY) A��"' CERTIFICATE OF LIABILITY INSURANCE F 6/28/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must 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 ._.._Tanya R. ...�... ....� LIGHTHOUSE AGENCY INC PHONE Via* 631 399-0300 c,Nil: 631-399µµw0387 mmm 960B MONTAUK HWY E-MAIL SHIRLEY NY 11967 lDR,FSsu Tanya(WI aq nmtm COm ADmm -�........ .. .. INSURER,, ...(S)..AFFORDING COVERAGE NAIC# ...m... _.......-�_�-.... _.-........ _ INSURER A: Utica First Insurance Company 15326 ._................. INSURED INSURER B: Valey Construction Corporation INS ..�..�� ........... 21 Point Rd . Flanders, NY 11901 INSURER D -INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 0001 REVISION NUMBER- 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. _....___...- -w_w_------ A661 a ICY-� POLICY 'FF" POLtCYEKP (NSR TYPE OF INSURANCE POLICY NUMBER mMpDDdYYYY' MM1oV1YYYY LIMITS LTR. GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 9AnA5E_ UfktRrEd 500,000 ✓ COMMERCIAL GENERAL LIABILITY PREIy�.,(,SES-(,Ea orcun'ence) $ A CLAIMS-MADE ❑✓ OCCUR x ART5134833-01 09/26/21 09/26 MED EXP(Any oneperson) $ ..... ..IT 5,000 u PERSONAL&ADV INJURY $ mmm1,000,000 ........................._ .-.w.�.........m.mm._. ... GENERAL AGGREGATE $ _- .. 2,000,000 GEN'L ......... AGGREGATE LIMIT APPLIES'PER: PRODUCTS-COMP/OP AGG $ 2,000 000 . 1.71 POLICY PRO. ".00' $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident -$,..._.._ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) .......-, -.E..............._ NON-OWNED (PROPERTY DAMAGE $ HIRED AUTOS AUTOS ._.... ...........' $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ ... CLAIMS-MADE ..AGGREGATE $ ...._._.,.... EXCESS LIAB DED RETENT...........�-... ION$ $ WORKERS COMPENSATION WC S'rATU- I OTH- AND EMPLOYERS'LIABILITY YIN RX 1.1111 5 ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/Aww .. .. (Mandatory in NH) E,.L..DISEASE-EA EMPLOYEE $ If yes,describe under w,_._................. ..-------............... ......... DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) DESCRIPTION OF OPERATIONS:Carpentry Subject To Terms, Conditions and Exclusions of the Actual Policy at time of Issuance CERTIFICATE HOLDER LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE' ©1988-2010 ACORD COfMORATION. All rights reserved.. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD SITE DATA _ a0O o trander AYen"eY MY hood,Nen Y-k 119O1 N AREA=10136 ACRES tel 65L 9FI9roe l g<om SUBDIVISION-'HORSE HAVEW FIEDIN THEOFFICE OFTHEa.ERKOF �1tttg AA.M+yyA SUFFOLK COUNTY ON DEC.20,1908 AS FILE NO 9674. ;`e(Jl ej/ouugJ •VERTICAL DATUM=NAVD(1988) - S';-r—Lod 5—y- CONTOURS SHOWN HEREON,PREPARED UTILIZING FIVE TOWNS <f Fesebnal EnyMer '. cPebnl TOPOGRAPHICAL SURVEYS PREPARED FOR THE COUNTY OF SUFFOLK :# v __. •UTILIZING US65 LONG ISLAND DEPTH TO WATER VIEWER 2016.THE RabertO Tmt,Mehltect Robert 5tr—kl,Archltect _ HIGHEST EXPECTED GROUNDWATER ELEVATION WrW[N THE AREA OF THE _ PROPOSED SANITARY SYSTEM 15 ELEVATION 6.0. HEALTH DEPARTMENT USE S .\ t of i p 14 \ a� z } NOTES St � �� _"¢? •THERE ARE NO STORMWATER STRUCTURES :E I WITHIN THE SUB3ECIPROPERTY, THERE ARE NO UNDERGROUND R ES WITHIN THE SUBJECT PROPERTY UNLESS SHOWN HEREON •E7a5TING WOOD SHEDS AND 2 STORY FRAME 6ARA6EAREDRYBUILDINGS(NOWATEWSEWERI _. ENGINEER'S (RTI C1 TI l i° { ! \ —�.. 'IHEREBYCERTIFY THAT THE WATER SUPPLY(S)ANW'OR SEWA&E WSPC'ISAL IA r. . _ } \. \ S"-TEWS)FC*THIS #IBASEI PROJECT WERE DESIGNED STAKEOR STL MOONY R, E } 4 A 9 \ SIFE AM GROUNDWATER WMIITIONeS.ALL FAEIESMA.5fROPOSM ' T:s ' 41r=_ T - _ TO Tiff CWUNTV. O=HEASlT - �..t. CONSTWXrOM STANDA465 IN EFFECT AS O€THTaT€' - ¢�; I& Ny HOWARD W_YOUNG,N.Y 5 L5 NO.45093n _ u f `� \'f? THOMAS C,WOLPERT,RY S.RE NO,61483 } 4.Y DOU6LASE ADAMS,N.Y.S.PENO,8O897 SURVEYOR'S CERTIFICATION ,fit 4' •WE HEREBY CERTIFY TO WILLIAM MEEHAN&T9ONYA LLICKI g I! MSTING ° #z PRACTICCEE FOR LAND SURSVEYS ADDOOPTE 9v TE NEW YO SPATE \ SANITARY SYSTEMC' -^ ` Od ASSOCIATION OF 7AP- - - 3 (1Y50 B'E ST6 TT \\ N y 2-B'DIA x 8'ED IPS) RT\ PROPOSEADI STION No /EXISTING 's` Lff 4 WATER SERVICE ' sRY.gg ;� HOWARD W YOU :sem.T4 N6%tY� SNR # U `-� PROPOSED PORLYi a t aL rpx--g ONLY �� � {� �� � � SURVEY FOR gg - .� & 1. ss '0 3 Lott .-- WIU.IAM MEEHAN s; a SONYA LUCKI `APPrOV ~ Horse Haven t a a X . 9 Lot 1 Horse Haven q €Y A a `, \ y at Laurel,Town of Southold Ea - 0 Suffolk County,New York sBUMMING PERMxr SURVEY k [,! `` a`' Atw R„U =U 37 p', - ( tia ) _ t, cowtY re€ n=€1000 s. 125 eia� 02 L. 1.25 g 1-Ii€ 1s l €IT T U€T5 1- _011 �Sl FIELD SURVEY COMP.EIED SEPI.25.2020 -"'p '--{`'- oor€ { # - �S- �n /MP PREPARED SEPT.28.2020 s the `,.LTi at��,t€t. €3E e� � 3 LEGEND `_ s Record of Revisions DATE CMF =CONCRETE MONUMENT FOUND ) „( trvT j3—Zt1 $I'F 2Y.X21 CMS =CONCRETE MONUMENT SET Fq\ ' DEL 2921. OHW =OVERHEAD WIRES PVC F =PVC FENCE - G WDF =WOOD FENCE S WF =WIRE FENCE o WSF WOOD STAKE CWb7+ _..-- - r WSS -WOOD STAKE SEI s. 40. 0 220 40 A0 120 UTILITY POLE r 720.D�_0576i2020_0122_bp Scale:1”=40 JO122 DW1 OF 1