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HomeMy WebLinkAbout48884-Z suFFol� .O�p co Town of Southold 3/4/2023 y�43 P.O.Box 1179 H 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43876 Date: 3/4/2023 THIS CERTIFIES that the building WINDOWS Location of Property: 295 Mockingbird Ln, Southold SCTM#: 473889 See/Block/Lot: 55.-6-15.59 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 1/25/2023 pursuant to which Building Permit No. 48884 dated 2/8/2023 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: (1)window replacement to existing single-family dwelling as applied for. The certificate is issued to Imennov, Sergey&Alla of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Aut ri ed Si n ture TOWN OF SOUTHOLD o�SUFFo�,�� BUILDING DEPARTMENT C2 z TOWN CLERK'S OFFICE "oy�i• a�� � SOUTHOLD, NY ti lit 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#: 48884 Date: 2/8/2023 Permission is hereby granted to: Imennov, Sergey 295 Mockingbird Ln Southold, NY 11971 To: replace (1) window to existing single-family dwelling as applied for. At premises located at: 295 Mockingbird Ln, Southold SCTM # 473889 Sec/Block/Lot# 55.-6-15.59 Pursuant to application dated 1/25/2023 and approved by the Building Inspector. To expire on 8/9/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector �P SOUIyO� # # TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING/STRAPPING [ FINAL f j hllc Q / [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR FIELD INSPECTION REPORT I DATE COMMENTS m dC� FOUNDATION (1ST) y -------------------------------------- FOUNDATION (2ND) o z moo ' * LA �1 ROUGH FRAMING& PLUMBING H 1 S O INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS �S c � z w Xm k - b 0 z H x d b H TOWN OF SOUTHOLD-BUILDING DEPARTMENT F; Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 https://Nus ,,,.southoldtownnygoovv Date Received APPLICATION FOR BUILDING PERMIT For Office Use Onlyaq F e 2 n PERMIT NO. Building Inspector: D I[ II ;IQAI 2 5 9nn ..Applications'and.forms must be filled out in their entirety:Incompiete, BUILDINGDEPT. applications will not be'accepted. Whets the Appkant its not thi 'qwi heir,an TOWN OFSOURiOLD Owner's Authoriiati6nf4m.(Page'2)shall be'completed." Date: OWNER(S)'OF PROPERTY:. Name: S r- Z (me n n oV SCTM#1000- mss- (Q l S Sy Project Address: QO)S (�oC l��h ���� Cervi . SaU dj AJ y 11 "-/ Phone#: Email: SiVI'12Y1r1dV��'''`a•/• e � Mailing Address: Qq S o-c.4C-4'rL8�6,Y--t Lv.. Sd /Og-7 f CONTACT PERSON: Name: hn (`I-c (/l/�wk-e — o {fie r. LifS (.Lc- ._.._.__. __..M.. ....-..._..._._.._._ .__._.____ ...__._...... ._....__._._._.._.. ...__._ __...._.._._.._..........,.. _.-__.. __. Mailin Address: 10,S� �0 Phone#:..".. .. �or -9 Lt(r 00(a.. . ._......... _ ..... Email: �1�r•rYe r4-.% ,DESIGN PROFESSIONAL INFORMATION: /_ Name: Mailing Address: Phone#: Email: CONTRACfOR'INFORMAT'ION:- , Name: Mailing Address: Q y5";:- A,- 7-Grr ��, r' a'L-�'� CA X03 3 q/ Phone#: 3,f 3, -C}q(a -Apes- Email: errK t6110¢Crn `'fS ar- DESCRIPTIt?N Ot=.PROPOS ED CONSTRUC7lON.. ❑New Structure ❑Addition ❑Alteration XRepair ❑Demolition Estimated Cost of Project: ❑Other $ Will the lot be re-graded? ❑Yes tXNo Will excess fill be removed from premises? ❑Yes [No- 1 DocuSign Envelope ID:D7703B73-OCC5-407E-AAF8-25A6E6CA53E6 "r< PRE:7PEf1!T.IIVF &g37fi71 N i:? Existing use of property: .) r 1f Intended use of,property: Zone or use district in.which,premises is situated: Are there any.covenants and restrictions with respect to this.property?' OYes IVo IF YES, PROVIDE A COPY. t s, x�+��1=� �t�tt'tt�:;-'Che ovai�r'JracEiocjiestgc3`prsi#�*§slt�nalf is unsibii#rsralt dtper#9g 4»d sbrro w'atrr, s a5 Pray"by k,:lar 236 s .tlt .Taar►�vde;= t1GATtJ H113Y iU# lE totha ildtn l3aparLrnont•far thrs�ssuar�za, urldirsg-T?ermit prussh�nta tfiLi t7rdinance'hi tltr i Tcwrn of 5ouihol�i,S=zttilk;.Cour►ty;stew Yarh at�d.other appllrabte.LausF t)cdinaacs:r+C.R� rlaUarss;fru 4he_u�nstructiBn Ot bultdtngs, additlon5 alratIrsns4'fsrr,rm6vai ar itemrr tion as hers ri'descfieit.• Atte appttcaratP�s t0 cor»taiy with alt'�rppiica6k taws;tirxllri�iitres,bUEtdFYig cone, , trous'srsg'prt .arrd,regiil�a fcirss a»d to a mFf` u ri ezl;it s�er tors on pt' Ises ariii r b+uNdirr sj dor ereressary.lrisp cl3csris.Fal emanrs nxa l :tserutn are' plinl�h; l p Li ss r t if mr=}nes iuesuranx Steil Z1Il:A'S:ii#4 e r 4!iF r ps r t i w:;- Application Submitted By{print name): L '' ' authorized Agent ❑Owner Signature,of Applicant: Date: STATE OF MTTTM) SS: COUNTY OF t � being.duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (Contractor,Agent,Corporate Officer, etc.) of said owner or owners,and is duly authorized to perform or have performed.the said work and to make and.file this application;that all statementscontained 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 W U 1t ,20W Notary Public SPEMB R SULMER PROPERTY OWNER AUTHORIZATION NpTARYPUHLIc Where the a licant is not the owner GionExff&d h!sA ,NC { pla . . ) Myommission Expires AUGUST 24,2027 t'i �/" residingat c��1S � rr�.. do hereby authorize �t '�'41 1�0`1� "" °r ''r �.� to apply on m .beI�191fdtb9:the Town of Southold'$ullding Department for approval-as destdbed herein. S ✓�" 1/19/2023 22 owner's Signature. Date �c.t` � �tit C✓L d'to1i..: " Print O ner's Name 2 AC R® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/24/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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 MARSH USA,INC. NAME: PHONE FAX TWO ALLIANCE CENTER ac No Ext): (A/C, A/C No); 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW.22-25 INSURER A: Old Republic Insurance Co 24147 INSURED INSURER B: New Hampshire Ins Co 23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER c: ACE American Insurance Company 22667 2455 PACES FERRY ROAD INSURER D BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-02 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR I POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY MWZY 316648 03/01/2022 03/01/2025 EACH OCCURRENCE $ 1,000,000 X❑OCCUR DAMAGES(RENTED CLAIMS-MADE PREMISES Ea occurrence $ 1,000,000 X SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JE� F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWTB316649 03/01/2022 03/01/2025 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ A UMBRELLA LIAB X OCCUR MWZX 316647 03/01/2022 03/01/2025 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION WC 065886029(WI) 03/01/2022 03/01/2023 X STATUTE ET WLR C68916409AZ,ILH AND EMPLOYERS'LIABILITY C YIN 03/01/2022 03/01/2023 ANYPROPRIETOR/PARTNER/EXECUTIVE ( ) E.L.EACH ACCIDENT $ 5,000,000 OFFICERIMEMBEREXCLUDED? NIA (Mandatory in NH) Continued on Additional Page E.L.DISEASE-EA EMPLOYEE $ 5,000,000 If yes,describe under 5,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE of Marsh USA Inc, v�'AwZ11G,r /�j I�'4 f v(:-191-ir, ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta ACCM o® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.;INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number:WLR C68916483(AOS) (AL,AR,FL,ID,IA,KS,KY,LA,MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA,WV,WY) Effective Date:03/01/2022 Expiration Date:03/0112023 (EL)Limit:$5,000,000 Carrier:AIU Insurance Co. Policy Number:WC 065886028(AOS) (AK,CO,DC,DE,HI,IN,MA,MD,ME,MN,MT,NH,NJ,NY,PA,RI,VT) Effective Date:0310112022 Expiration Date:03101/2023 (EL)Limit:$5,000,000 Carrier:ACE American Insurance Company Policy Number:WCU C68916446(QSI)(CA,OR,WA) Effective Date:0310112022 Expiration Date:03/0112023 (EL)Limit:$4,000,000 SIR:$1,000,000 Carrier:National Union Fire Insurance Company Policy Number:XWC 1647323(QSI) (CT,GA,MI,NV,OH,UT) Effective Date:03/01/2022 Expiration Date:03/0112023 (EL)Limit:$4,000,000 SIR:$1,000,000 SIR(CT):$350,000 SIR(GA):$750,000 TX Employers XS Indemnity: Carderlllinios 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 g AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot U.S.A.Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC H.D.W.Holding Company,Inc. Askuity,Inc. Home Depot Management Company,LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v Workers' CERTIFICATE OF xSTATE Compensat bn NYS WORKERS' COMPENSATION INSURANCE COVERAGE Spo d` 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Home Depot USA,Inc. 770-433-8211 2455 Paces Ferry Rd.,C-20 Atlanta,GA 30339 1c.NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Only required if coverage is specifically limited to 1 d. Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 58-1853319 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Hampshire Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1a" 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) E] 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: Michael Price (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ` 02/07/2022 (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 tlo� CERTIFICATE OF INSURANCE COVERAGE DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured HOME DEPOT U.S.A.,INC. 678-231-8957 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 581853319 2.Name and Address of Entity Requesting Proof of a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD HARTFORD LIFE AND ACCIDENT 53095 ROUTE 25 b Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 LNY713657 c Policy effective period 01-01-2023 to 12-31-2023 4.Policy provides the following benefits: ❑A.Both disability and paid family leave benefits. F1 B.Disability benefits only. ❑C.Paid family leave benefits only. 5.Polic9overs: LI A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11-17-2022 7�P.ZZd- (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if sox 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) IH Additional Instructions for Form 1313-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices my be sent by regular mail.)Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand and twenty-one, the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1(IG-17)Reverse Go Permits, LLC 105 Buttonball Ln. Glastonbury, Ct 06033 "WE UNDERSTAND THAT YOUR TIME IS MONEY" To Whom It May Concern: Enclosed you will find a building permit application and check. If you have any questions regarding this application, feel free to call me at the number listed below. Please note the following: • Please mail original permit to the owner. • Please e-mail a copy of the permit and receipt to: Email: permits@gopermits.org Thank you! Jennifer Winke, Permit Expediter Go Permits, LLC Phone: 303-946-8685 Fax: 866-697-0768 jenniferwinke@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org Home Improvement Agreement: Page 1 Home Depot License#'s -For the most current listing visit www.Homedepot.com/LicenseNunibers Patrick Kenny Salesperson Name Registration#(Req.in CA,CT,ME,MD,MI,NJ,DC) Home Depot U.S.A.,Inc.("Hoene Depot") or Authorized Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. ;1'Service Provider Contact Information- The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631) icustomercancellationnortheast@hom Phone# S fM ce Provider Email Address Service Provider License#(s) . -77 i 2.Custvm&:Infarmition 'i Imennov e:rgey I Long Island I F31104745 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 295 Mockingbird Lane 7771 Southold —� NY 11971 Customer Address City State Zip (631) 765-9212 simennov@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address 3:NOTICE:OF;RIGHT TO CANCEL W YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: customercancellationnortheast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 40 Oser Avenue Hauppauge r 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 F YOUR RIG O CANCEL. Acknowledged by: 1 . 1 01/09/2023 ustomer's Signature Date 460 Standard Fonn HIA(21 Jul.2 1)(E) Generated Date /no/7n7 Lcad,T111 F-11104745 v 0.1.12 Home Improvement Agreement: Page 2 4.Description of V4'ork46'be Performed- A detailed description of the work to be performed is included in the paragraph entitled Scope of Work,Specification, CustomerSummarySheet, Quote Form,Estimate, Invoice or Measure which is included in this Agreement. _ ..._. 5.Anticipated,Delivery Date_/Installation Schedule Approximate Start Date: 07/08/2023 Approximate Finish Date: 08/07/2023 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in Pconfirming insurance coverage of Your claim for any repair, if applicable. - aS 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 Payirient 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: $ 11896.60 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable, total amount of taxes included in Contract Price) *Maximum deposit ONLYapplicable in :WD,MA, AAE(33%), 14'.1, W1(99%) De osit% 131.48 De osit Amount$ 1697.0 Remaining Balance $ 1299.6 :.8:Finance Charges W.-: w__ 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 01/09/2023; Cu om 's Signature Date X /s/The Home Depot 01/09/2023 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 I-800-466-3337 460 Standard Fonn HIA(21 Jul.21)(E) Generated Date 0110919028_ L-11P01 F 31104 a 5 v 0.1.12 APPROVED AS NOT . DATE: 3 B.P. FEE:, BY: NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING,INSPECTIONS: 1. FOUNDATION - TVvO REQUIRED FOR POURED C0NCRETE 2. ROUGH - FRAI-IING & PLUMBING 3. INSULATION 4. FINAL - GONS '!.JC' ^.•� MUST BE COMPLETE 1D. ALL CONSTRUC'i K:',, :,-iALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF SING BOARD SGJ I WIRUSTEES `OCCUPANCY OR JSE IS 'UNLA-WFUL NITHOUT CERTIFICA ')F OCCUPANCY WINDOW SPECIFICATION SHEET - Spec.Sheet#: F31104745 Sheet: 1 of 1 Customer: Sergey Imennov ,lob#: F31104745 Consultant: Patrick Kenny Date: 01/09/2023 New Window Hinge Locations Existing Window Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use o o m _ Mull "S"=stationary or .� r r d m o '� N o '� N ,.X„=operating Style Wraps d D rn a 0 c c W iU T O t0 O m O O y O H Room Floor Code (Y/N) Style Code Series Code S x 5 ai 0 CL > x 3 > x FULL SCR,STD,White, DISPOSAL, 1 LIV 1st WWTD Y TDH 6100 WH WH 70 50 120 F, WH,W C ALL 1 2 ALL 1 2 Glass Pack:Standard J CHAN, H-FF GBG H MULL R,F, WRAP,LSR SPECIAL CONSIDERATIONS: 1:White Line Level Notes: 1.MISC(1);New install Wrap Color Interior Casing Type Bay or Bow window: eatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: Seatboard Material(vinyl only-White Pionile,Birch or"ak) i a�The p• • • ofProducts • bySimonton " diTlth Grids 4 Fr{ G ziir" 1A�lr 1.. 'Glass Aa` •a�"`e°.. Is-go 17 SHGC. :rte,. rgori).- ,Facf` ;F' t� Awning 6500 Base ProSolar Supercept 718" 0.2fi 0.23 0 0 0 0.26 ' 0.21 0 0 0 Casement 6500 Base ProSolar Supercept 7/8" 0.26 : 0.240 0 0 0 0-26 f 0.22 0 o a'a Transom 6500 Base ProSolar Supercept 1' 027 0.32 0 0 0.27 0.29 0 0 Double-Hung 6500 Base ProSolar Supercept 718" 0.29 0.260 029 i 0.24 0 0 0 Picture Casement (NH) 6500 Base ProSolar Supercept 718" 0.26 0.28 0 0 0.26 1 0.25 m a o o Picture 6500 Base ProSolar Supercept 716" 0.27 0.29 0 0 0.27 ; 0.26 0 0 2 Panel Slider 6500 Base ProSolar Supercept 718^ 029 0.26 0 0.29 0.23 0 o a 3 Panel Sliders 6500 Base(s 21 sgnj Pro Solar Supercepi 718^ 0.29 I 0.26 0 0.28 j 0.23 e o 0 Garden Door(CH) 6500 Energy Star ProSolar SUN Super Spacer 1" 1 0.30 : 0.24 1 01 01olol 0.30 0.21 10 0 0 0 Patio Door INOVO 6500 Base Pro Solar Super Spacer 1^ 1 028 i 0.26 0 0 0.31 i 023 0 0 o a 1 / Homes located everywhere£XC£P7:Arizona,California,Idaho,Nevada,New Mexico,Oregon,Utah,and ➢Yashitrgton. Awning(Inc Hopper} 6100 Base Pro Solar Intercept 718" 0.27 ! 0.24 0 m © 0 0.28 ' 021H- Casement v a a 6100 Base Pro Solar Intercept 718" .027 0.241-10101- 0.27 0.220 0 0 Double-Hung 6100 Energy Star Pro Solar Supercept 314" .3 0,30 0 0.30 ! 0.27 0 0 0 Picture Casement(No Hinge) 6100 Base Pro Solar Intercept 718" 027 0.28 0 0 0.27 ± 025 0 0 0 o Picture 6100 Base Pro Solar Intercept 314" 0.27 0.31 0 0 0.27 028 0 0 2 Panel Slider 6100 Base Pro Solar Intercept 314" 0.30 ! 0.28 0 0.30 i 0.27 0 3 Panel Slider 6100 Base Pro Solar Intercept 314" 0.30 0.29 0 0.30 027 0 0 1 / • • Xomes located everywhere EXCEPT:Arizona,California,Who,Nevada,New Mexico,Oregon,Utah,and Washington. Patio Door(NOVO 6100.Energy Star Pro Solar Super Spacer 1" 1 0.28 0.26 1 0 1 0 0.28 ! 0.23 0 a o 0 Patio Door NARROW FRAME" 6100(PD05)Base Pro Solar Intercept 3/4!'l 028 ; 0.30 jolol 0.28 . 0.26 0 0 Xornes located only in fallowing markets:Dallas,Denver,Detroit,Phila,Northern NJ,tong!stand,NY. Awning 6200 Base Pro Solar SHADE Supercept 314" 0.27 : 025 0 01010 0.26 ' 0.23 o 0 o o Casement 6200 Base Pro Solar SHADE Supercept 314".k06.�26 0.18 a 0 0 o p2g 0,17 0 0 0 0 Picture Casement-NH 6200 Base Pio Solar SHADE Supercept 314" 0.21 0 0 2_1 0.25 0.19 0 0 0 0 Picture Window 6200 Base Pro Solar SHADE Supercept 314^ 0.24 o o 0 o 0,26 i 022 o oSingle Hung 6200 Base Pro Solar SHADE Supercept 314" 0.23 o o o o p2g + p,21 0 0 0 Single Slider 6200 Base Pro Solar SHADE Supercept 3fa' 0.28 j .0.23 0 a o 0,28 ? 021 1 1. 0_ 00 3 Panel Slider 6200 Base Pro Solar SHADE Supercept 314"1 028 1 0.23 a o 0.28 1 0.21 1 1., A o • C - - 1 1 Homes located in coastal areas. Awning SB+300VL Energy Star PS SUN/Lami Supercept 1' 026 1 02Moo .26 0.21 0 0 0 0 Casement SB+300VL Base PS/Lami Super Spacer 1' . 0.25 1 0.225 021 0 0 0 0Double Hung SB+300VL.Base PS/Lami Super Spacer V 0.29 .1 0.229 ' 0.23 o 0 0 0Slider SB+300VL Base PS/Lami Intercept V 0.29 0.229 i 0.23 0 0 o aPatio Door SB+300VL ETC 366• PS Shade/Lami Super Spacer 1" 0.30 s 0.1Garden Door(CH) SB+300VL Base PS/Lami Super Spacer 1" 0.30 0.230 : 025 0 0 0 �: •Dots Indicate Energy Star certified for that zone Please Note:.Simonton Windows • • given the req Wrements of each order.