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48346-Z
�aotiOs�FF�t Town of Southold 2/12/2023 P.O.Box 1179 C2 53095 Main Rd WDy�01 �ao� Southold,New York 11971 . CERTIFICATE OF OCCUPANCY No: 43836 Date: 2/12/2023 THIS CERTIFIES that the building AS BUILT ALTERATION Location of Property: 1850 Rocky Point Rd.,East Marion SCTM#: 473889 Sec/Block/Lot: 31.-2-11 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/12/2022 pursuant to which Building Permit No. 48346 dated 9/29/2022 was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy fo'r which this certificate is issued is: "as built" interior alterations, including HVAC to a single family dwelling as applied for. The certificate is issued to 1850 Rocky Point LLC of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 48346 1/12/2023 PLUMBERS CERTIFICATION DATED 12/10/2022 NmiNrlowski o 'ze 7ature X TOWN OF SOUTHOLD �S�Ffot,t�o . o Gy BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy • SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 48346 Date: 9/29/2022 Permission is hereby granted to: Apidopoulos, George 1850 Rocky Point Rd PO BOX 195 East Marion, NY 11939 To: Legalize as built interior alterations to include HVAC to a single family dwelling as applied for . Additional certification may be required At premises located at: 1850 Rocky Point Rd., East Marion SCTM #473889 Sec/Block/Lot# 31.-2-11 Pursuant to application dated 8/12/2022 and approved by the Building Inspector. To expire on 3/30/2024. Fees: AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $400.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $450.00 JAY Building Inspector oF so�ryOlo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ sean.devlina-town.southold.ny.us Southold,NY 11971-0959 Q�yCOUm�,�a BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: 1850 Rocky Point LLC Address: 1850 Rocky Point Rd city:East Marion st: NY zip: 11939 Building Permit#: 48346 Section: 31 Block: 2 Lot: 11 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Bayman Electric License No: 4692ME SITE DETAILS Office Use Only Residential X Indoor X Basement X Service Commerical Outdoor X 1st Floor X Pool New Renovation X 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt 37 Ceiling Fixtures 10 Bath Exhaust Fan 2 Service 3 ph Hot Water Gas GFCI Recpt 5 Wall Fixtures Smoke Detectors 3 Main Panel A/C Condenser 1 Single Recpt Recessed Fixtures 12 CO2 Detectors Sub Panel A/C Blower 1 Range Recpt Gas Ceiling Fan Combo Smoke/CO 2 Transfer Switch UC Lights Dryer Recpt 30A Emergency Strobe Heat Detectors Disconnect Switches 2Q 4'LED Exit Fixtures 11 Sump Pump Other Equipment: Fridge, Oven, DW, Micro, W/D Notes: One Story Reno Inspector Signature: Date: January 12, 2023 S.Devlin-Cert Electrical Compliance Form Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959DT` '; UiUT!�;s. BUILDING DEPARTMENT TOWN OF SOUTHOLD C-E-R T L F.-I C A T I O.N. - Date: 1-2, (� 2 2 Building. No....Permit _ Owner: NS-0 9cxA1 J`4LLL. . Mic A'Aded P/19 14; lease rint ..,.: . .._.Plumber: �r►,es 0✓I�wjKl . . . _ . a ..., , .. � � -_ (Please print) I certify that the solder used in the water supply system contains Iess than 2/1 % lead. (P umbers Signature)— - " Sworn to before me this /a day of Dee,+em 20 22- JAIME RODRIGUEZ (Votary Public-State of New York adv No.01806332316 Qualified in Suffolk County My Commission Expires Nov.02,2023 Notary Public, oe souryOlo # f TOWN OF SOUTHOLD BUILDING DEPT. comm" 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ]. FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) ,[ `] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: b 6 <7 DATE � � INSPECTOR # TOWN OF SOU HOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [- ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIR ESISTANT CONSTRUCTION [ ] _FIRE RESISTANT PENETRATION [ ] ECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ CODE VIOLATION [ ] PRE C/O REMARKS: .0 VkAL4), v W,4T kf-e, r xcfif DATE INSPECTOR 1 SOUIyO� . U # TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPEC WN [ ] FOUNDATION 1ST WOUWP LBG. FOUNDATION 2ND ION/CAULKING FRAMING /STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL R ARKS: OJA Lum qA vre �-bJ DATE 010 '�/ INSPECTOR �O�aOE SOplyo� # TOWN OF SOUTHOLD BUILDING DE T. °`ycourmN�'' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [n ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 67 reA DATE C& IC //7,d.-,' INSPECTOR `\ SO(/lyo6 --- r TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN LATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 17DATE 1 ?00 INSPECTOR UF SOUTgOIo * # TOWN OF SOUTHOLD BUILDING EPT. °`ycourm��'i� 631-765-1802 % INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE 1 12, Z INSPECTOR ✓ � FIELD INSPECTION REPORT DATE COMMENTS ►o FOUNDATION (1ST) ------------------------------------ C FOUNDATION (2ND) z tim kt J o O H ROUGH FRAMING& O PLUMBING (�t � 1 S tt r t� INSULATION PER N.Y. 3 STATE ENERGY CODE 19 Y % n Q FINAL vw --P ADDITIONAL COMMENTS 02�'Z 0 10 3 oo � Z 0-o 1 Qi rn fN. 1►�0 O � y O yx H x d b y ate°ufipritr TOWN OF SOUTHOLD—BUILDING DEPARTMENT T Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 ��'� • �� Telephone (631) 765-1802 Fax (631) 765-9502 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT n For Office Use Only q qq PERMIT N0. 0 'J Building Inspector: AUG 12 LOLL BUILDING DEPT: Applications and forms must be filled out in their entirety..Ihcomplete TOWN OF SOUT!•li"iLD applications will not be accepted. Where the Applicant is not the,owner,an Owner's Authorization form(Page 2)shall be completed.:..,. Date:8/9/2022 OWNER(S)OF PROPERTY: Name: CTM# 100 - 1.850 Rocky Point LLC __. .. . ._ . _.- J.1.-_. ProjectAddress:1850 Rocky Point Road ast Marion„NY„11939 Phone#:631-601-7459 Email:plattda@gmail.com Mailing Address:Dina Platti 29 E Bartlett Road Middle Island NY 11953 .CONTACT PERSON:. Name:Michael and Dina Platti Mailing Address:29 E Bartlett Road Middle Island NY 11953 Phone#:631-601-7459 Email:plattda@gmpiI.com DESIGN PROFESSIONAL,INFORMATION: r' Name:N/A Mailing Address: Phone#: Email: CONTRACT611 INFORMATION: Name: Michael Platti - Homeowner Mailing Address: 29 E Bartlett Road Middle Island NY 11953 Phone#:631-767-4474 ... Email:mwplatti@gmail.com .. .. .. .. ... DESCRIPTION,;OF PR0P6SED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration WRepair ❑Demolition Estimated Cost of Project: E1Other Permits are required for kitchen and bath renovations and new HVAC-replaced due to non-function $45,000 i Will the lot be re-graded? Yes ®No Will excess fill be removed)from premises? ❑Yes ❑No 1 PROPERTY INFORMATION Existing use of property:Sln,gle.fam.._home Intended use of property: S_Lflgle.fam._ho.me Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R-40 this property? ❑Yes No IF YES, PROVIDE A COPY. 8 Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building 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 pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(pri name): Dina Plat ❑Authorized Agent BOwner Signature of Applicant: Date: 8/9/2022 STATE OF NEW YORK) SS:` Sl)� ,� COUNTY OF UC ) �1RG bAk being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the rAVp\,ICCg-)+ =tuber (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this v` day of rAUak 20J-Z— O&�:, Notary Public JENNIFER A SWANSON SARNI Notary Public-State of New York N0.015w6249492 ROPERTY OWNER AUTHORIZATION Qualified in Suffolk County My Commission Expires 0ct 11,2023 (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 I BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD ()Sown Hall Annex - 54375 Main Road - PO Box 1179 CIO %A,-, ? �o�N�`�o Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr ,southoldtownny.gov - seand(pD-southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/9/2022 Company Name: Bayman Electric Electrician's Name: Mark Fricchione License No.: 4692-E Elec. email: baymanelectric@gmail.com Elec. Phone No: 631-445-7317 ✓❑I request an email copy of Certificate of Compliance Elec. Address.: 37 Winterberry Drive Middle Island NY 11953 JOB SITE INFORMATION (All Information Required) Name: 1850 Rocky Point LLC Address: 1850 Rocky Point Road East Marion NY 11939 Cross Street: Sound Avenue Phone No.: 631-601-7459 Bldg.Permit#: Z f�3 email: mwplatti@gmail.com Tax Map District: 1000 Section: 31 Block: 2 Lot: 11 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Some new wiring, new smokes, new HVAC Square Footage: 11o0 Circle All That Apply: Is job ready for inspection?: YES ❑ NO F,/]Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES ❑✓ NO issued On Temp Information: (All information required) Service Size[-11 Ph❑3 Ph Size: A # Meters Old Meter# F]New Service❑Fire Reconnect❑Flood Reconnect[-]Service Reconnect❑Underground❑Overhead # Underground Laterals 1 E12 0 H Frame Pole Work done on Service? Y N Additional Information: Please send all mail to: Michael and Dina Platti 29 E Bartlett Road Middle Island NY 11953 PAYMENT DUE WITH APPLICATION i ctricallnspector BUILDING DEPARTMENT- Ele TOWN OF SOUTHOLD Town Hall Annex -54375 Main Road- PO Box .1179 Southold,:New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(aD-southoldtownny.gov — seandCa)southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/9/2022 Company Name: Bayman Electric Electrician's Name: Mark Fricchione License No.: 4692-E Elec. email: baymanelectric@gmail.com Elec. Phone No: 631-445-7317 M I request an email copy of Certificate of Compliance Elec. Address.: 37 Winterberry Drive Middle Island NY 11953 JOB SITE INFORMATION (All Information Required). , .,.. Name: 1850 Rocky Point LLC Address: 1850 Rocky Point Road East Marion NY 11939 Cross Street: Sound Avenue Phone No.: 631-601-7459 Bldg. #: a email: mwplatti@gmail.com Tax Map District: 1000 Section: 31 Block: 2 Lot: 11 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Some new wiring, new smokes, new HVAC Square Footage: I 11oo Circle All That Apply: Is job ready for inspection?: YES ❑ NO 0✓ Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES NO Issued On Temp Information: (All information required) Service Size 1-11 Ph❑3 Ph ' Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground.Laterals 0 1 D2_D H Frame Pole Work done on Service? Y N Additional Information: Please send all mail to: Michael and Dina Platti 29 E Bartlett Road Middle Island NY 11953 PAYMENT DUE WITH APPLICATION l PERMIT tt Address: Switches 1 Outlets 4P I,. GFI's Surface �y f, Sconces H H's, " UC Lts Fans Fridge Exhaust f Oven CC� W/D Smokes' DW I Mini Carbon Micro Generator Combo I Cooktop Transfer ACAH Hood Service 111 I Amps Have Used Special: Comments SO!/T�,QI 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G • Q Southold,NY 11971-0959 �Q �yCOUN'fV,� BUILDING DEPARTMENT TOWN OF SOUTHOLD STOP WORK ORDER TO: George Apidoupoulos P.O. Box 195 East Marion, New York 11939 YOU ARE HEREBY NOTIFIED TO SUSPEND ALL WORK AT: 1850 Rocky Point Road, East Marion, New York TAX MAP NUMBER: 1000-31-2-11 Pursuant to Section 144-8 of the Town of Southold Code, you are hereby notified to immediately suspend all work until this order has been rescinded. BASIS OF STOP WORK ORDER: Construction without first obtaining a Building Permit CONDITIONS UNDER WHICH WORK MAY BE RESUMED: When a Building Permit has been issued. FAILURE TO REMEDY THE CONDITIONS AFORESAID AND TO COMPLY WITH THE APPLICABLE PROVISIONS OF LAW MAY CONSTITUTE AN OFFENSE PUNISHABLE BY FINE IMPRISONMENT OR 0TH. DATE: August 9, 2022 J hn Ja s S . uildi nsp ctor IT SHALL BE UNLAWFUL TO REMOV THI N TI I OUT WRITTEN CONSENT OF THE ISSUING AGENCY. Coln DATE IYYYY) ACo® Coln� CERTIFICATE OF LIABILITY INSURANCE 08//11 11/20/2022 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 I SURED 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 Ralph Melendez NAME: Percy Hoek Inc ANC% Ext: (631)589-4100 FAX No; (631)589-4182 180 West Main Street E-MAIL ralph@percyhoek.com ADDRESS: P.O.BOX 387 INSURER(S)AFFORDING COVERAGE NAIC 0 Sayville NY 11782-0387 INSORERA: Merchants Mutual 23329 INSURED INSURER B: Heatco Inc INSURER C: PO BOX 590 INSURER 0: INSURER E: Bayport NY 11705-0590 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2281111034 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 TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS. IL R TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYW POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE ©OCCUR' PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 15,000 A BOP9098721 09/21/2021 09/21/2022 PERSONAL BADVINJURY $ Included GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY1:1 PRO- FECT LOC PRODUCTS-COMP/OPAGG $ 2.000,000 OTHER: $ AUTOMOBILE LIABILITY MBINED S $INGLE LIMIT EaCOaccident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ It 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 is subject to the policy terms,conditions and exclusionis as per written contract. 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 Main Road AUT O IZE)DVRe)EPRE�SENT TIVE Southold NY 11971 / �� ©1988-2015 ACORD CORPORATION. All rights reserved. l ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD /Pk\ NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ;M1 A A A A A 112690866 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE HARRISON NY 10528 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER HEATCO INC TOWN OF SOUTHOLD 650-6 MONTAUK HIGHWAY 54375 MAIN ROAD P.O. BOX 590 SOUTHOLD NY 11971 BAYPORT NY 11705 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G1077 683-9 141205 05/01/2022 TO 05/01/2023 8/10/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1077 683-9, 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. _ IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.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. HEATCOINC DENNIS VALENTI MAUREEN VALENTI THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 SUR NCE FUND D[RECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 836219267 Col fYcr c�(r YORII Compensation workers' CERTIFICATE OF INSURANCE COVERAGE STATE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1 a.Legal Name 8 Address of Insured(use street address only) 1 b. Business Telephone Number of Insured H EATCO I NC 516-289-8282 650-6 MONTAUK HIGHWAY BAYPORT, NY 11705 1 c. 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) 112690866 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 Southold 54375 Main Road 3b. Policy Number of Entity Listed in Box"l a" Southold, NY 11972 DBL51934 3c.Policy effective period 10/01/2021 to 09/30/2023 4. Policy provides the following benefits: A. Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced bove and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 8/11/2022 By atW, hf (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (only if Box 46,4C or 513 have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DIB-1120.1 (12-21) I I I I111111111111111111111111111111111111111111111111 DB 120.1 (12-21) Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)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 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 NYS 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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 (12-21) Reverse sea'rch 3 1 ..........__.__..._.................. ........... .. ...._................................................................................... ........._•___...................... .............._................................. .........._........................ ......._..........._............................ .. ....__............_....._..................._ - _...._..� In Licen Last First Business Address Phone Email Catego Stat Date Date de se ID Name Nam Name and ry us Issue Expir x e Website d e 1 RE- Valenti : Den Heatco Inc Po Box 590, 63147 heatcoinc@ HVAC Acti 198 202 343 nis Bayport, NY 27464 optonline.n ve 4- 4- 2 11705 et 07- 07- 01 01 ................................................... ......................................._............................................................ .... .........._..........._........................ ... ................_.............................. ..................._............._................................. . _........_._.................. . l. ... ................................ . ........................ . .......................................... _ _.......................... l Index: 1 License ID: RE-3432 Name: Dennis Valenti Business Name: Heatco Inc Website: N_.. Address: Po Box 590, Bayport, NY 11705 Phone Number: 6314727464 Email: heatcoinc optonline.net Category: HVAC License Status:Active Date Issued: 1984-07-01 Date Expire: 2024-07-01 E �^ 5..�.);.)�d:l "I i. .. x.�i 22.., S' .�4 flk-��.ou n:."Z7£)ti�:6 w R. a'��..,�� •:2•�> ' Mme, ..aY � t' �N �aa��^; � .� � ��_�., License and Complaint Violation Look Up Use the form below to search for License and Complaint Violation information. Please note: Specific License Type search will only show license data, no complaint or violation data. If you need more information, please contact us. License Number: FREE-3432 First Name: __..... .. ...... ... ....... _. ..............._....... , Last Name: Business Name: LHeatco Inc Phone Number(10 digit numbers only): Address: ...................................... ................................. ....... ............. . .................................................. . ... _. .... _....................... . ... ............. ........ .. ... _........_ ...... ........... City: ........._ ....._.... . ....._. ........ .._ ... . Zip Code: r _.. . ...........__........ ................. Search for a Specific License Type/Complaint: <None> ...................... .... . ............... ..... Search for a Snecific Business Desianation_ oQp(�G� --� BAYMELE-01 JOSHAUGHNESSY ACORO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8111/2022 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 NAME: LPL Risk Mgt.Ltd631 FAX 148-2 Remington Blvd. (A/C,No,Ext):( )676-7020 A/C,No):(631)676-7030 Ronkonkoma,NY 11779 ADDRESS:info@lplrisk.com INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:Merchants Mutual Ins.Company 23329 INSURED INSURER B: Bayman Electric Inc. INSURER C.' 37 Winter Berry Dr INSURER D: _ Middle Island,NY 11953 INSURER E: _ 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. IN RI TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDDIYYYY PMIDD/YYYY A X i COMMERCIAL GENERAL LIABILITYI 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE ❑X OCCUR BOP1102658 2/21/2022 2/21/2023 DAMAGE TO RENTED 500,000 PREMI$ES_(Ea occurrence)_ $ _ MED EXP(Any one person) $ 15,000 PERSONAL 8 ADV INJURYIncluded $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 X POLICY JEo F-1LOC / PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea accc dent SINGLE LIMIT $ — ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION X STATUTE RRH AND EMPLOYERS'LIABILITY WCA1037082 2/21/2022 2/21/2023 100,000 OFFICERIMEMBER EXCLUDED?ECUTIVE YIN NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100'000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ' i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) As pertains to the insureds operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �tkC/)17 44'�— NEW Workers' S' s°RK rCompensation CERTIFICATE OF Board NYS WORKERS COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Bayman Electric Inc 631-445-7317 37 Winterberry Dr Middle Island,NY 11953 c.NYS Unemployment Insurance Employer Registration Number of Insured 1 d.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) 26-1438987 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 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 WCA1037082 3c.Policy effective period 2/21/22 to 2/21/23 3d.The Proprietor,Partners or Executive Officers are ❑Included.(only check box if all partners/officers included) �] all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box 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: Anthony Pomilla (Print name of authorized representative or licensed agent of insurance carrier) 8/9/22 Approved by: =' - r f,�rl ,� � (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 631-676-7020 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 YORK workers' CERTIFICATE OF INSURANCE COVERAGE TATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured BAYMAN ELECTRIC INC 631-445-7317 37 WINTERBERRY DRIVE MIDDLE ISLAND,NY 11953 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) 261438987 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 SOUTHOLD 54375 Main Road 3b.Policy Number of Entity Listed in Box"1a" Southold, NY 11971 DBL469282 3c.Policy effective period 06/30/2022 to 06/29/2023 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. FIB.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 8/11/2022 By i , W z,t (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if sox 4B,4C or 5B have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) II II P1°°°1°1°°°11°1°(11°!�°°°11)°111111 Additional Instructions for Form D13-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage(Certificate)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 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 NYS 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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 (12-21)Reverse Clear Foi fn Export Data ..ice, nfor i atio J resuft _.................__.........................................._............................................. I. . ...................... ..........................................1., ........................................................................ ...................................._..............._............. ...._...._................. .............1 In Licen Last First Business Address Phone Email Catego Stat Date Date de se ID Name Nam Name and ry us Issue Expir x e Website d e ;.. 1 h ME- Fricchi Mar Bayman 37 (631) bay manelec Act i 199 202 469 ' one k Electric Inc. Winterberry 924- tric gmail. ve 6- 2- 2 Drive, Middle 5698 cpm 11- 11- Island, NY 07 01 11953 i - . ..... .. ............ ...:............._..:... License Infno-nation Index: 1 License ID: ME-4692 Name: Mark Fricchione Business Name: Bayman Electric Inc. Website: Address: 37 Winterberry Drive, Middle Island, NY 11953 Phone Number: (631) 924-5698 Email: bay manelectric6barnail.com Category: License Status:Active Date Issued: 1996-11-07 Date Expire: 2022-11-01 .C.J�ilCB C.i li5 :"€'ot a Cizi�.en Access (�:i.t` ) �.3"�i�.1: '`'ortal Cot)j'Kiaht :_;' 202,'., Suffoolk L.o:1nty G€'?verni''ie:- Sup olok Count, Government Y. De ar nien : of C€. 11SLImer Affairs License and Complaint Violation Look Up Use the form below to search for License and Complaint Violation information. Please note: Specific License Type search will only show license data, no complaint or violation data. If you need more information, please contact us. License Number: First Name: .. ............... ........ . Last Name: Business Name: Bayman Phone Number(10 digit numbers only): _... .. .............. _...._....... .. ................................................ ..... ............................................. ...... ....... ... . Address: ...................................... .. .... .. ...................... _....................... ....... ........... ......... ._........ ..._................................................._.._......._......................... _....._ City: _. .........._......".............__........._.._...._......_..........................._........_ .......... _._ ..__..._.._ .... Zip Code: I Search for a Specific License Type/Complaint: <None> Search for a Specific Business Desianation_ Prum�v AC�� CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 08/10/2022 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 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 CONTANAME: Melissa Daley Melissa Daley AICNNo Ext: 631-542-0101 plc No: 631-532-4195 E-MAIL rnelissa.daley@american-national.com ssa. ae 85 Echo Ave Suite 2 ADDRESS: Y@american-national.com INSURER(S)AFFORDING COVERAGE NAIC tt Miller Place NY 11764 INSURERA: Farm Family Casualty Insurance Co. 13803 INSURED INSURER B: J&C Heating Air Conditioning&Plumbing LLC INSURER C: PO Box 1016 INSURER D: INSURER E: Remsenburg NY 11980 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDIYYYY POLICY EFF MMIDDN XP LTR lYY LIMITS A X COMMERCIAL GENERAL LIABILITY 31011-7720 09/10/21 09/10/22 EACH OCCURRENCE $ 1,000,000 09/10/22 09/10/23 DA MAG TD D CLAIMS-MADE X OCCUR PREMISES EaR ocN currence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 315206975 09/10/21 09/10/22 COMBINED SINGLE LIMIT $ 1,000,000 09/10/22 09/10/23 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS XHIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ F $ A WORKERS COMPENSATION 3101 W7538 10/10121 10/10/22 X STATUTE ETI PER H AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNET/EXECUTIVE Y/NN/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBEREXCLUC Y❑ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 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 54375 Main Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A00. apr ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NEW WorkersYORK ' STATE Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name &Address of Insured (use street address 1b. Business Telephone Number of Insured only) (631)926-8597 J &C Heating Air Conditioning& Plumbing LLC 1c. NYS Unemployment Insurance Employer Registration PO Box 1016 Number of Insured Remsenburg, NY 11960-1016 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is Social Security Number specifically limited to certain locations in New York State, 13-4337043 i.e., a Wrap-Up Policy) 2. Name and Address of Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage Farm Family Casualty Insurance Co. (Entity Being Listed as the Certificate Holder) 3b. Policy Number of Entity Listed in Box"1a" Town of Southold 3101W7538 54375 Main Rd Southold, NY 11971 3c. Policy effective period 10/10/2021 to 10/10/2022 3d. The Proprietor, Partners or Executive Officers are o included. (Only check box if all partners/officers included) o 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"la"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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? YES [X]NO 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: Melissa Daley (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ffel%,a a odw, August 10,2022 (Signature) (Date) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 631-542-0101 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(9-15) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 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. 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(9-15) REVERSE Suffolk Court-,, Gov,,erni-rion't" P1 WM De,oarUnent of Cons;ljmp� Affalvs r Nelp 4r License and Complaint Violation Look Up Use the form below to search for License and Complaint Violation information. Please note: Specific License Type search will only show license data, no complaint or violation data. If you need more information, please contact LIS. License Number: ............... . ............................ First Name: Last Name: ........... Business Name: Phone Number (10 digit numbers only): ................ ................ .......... ............................... ............. ................. -..-...................... ..... ................... ......... Address: LPO BOX 1016 City: IRemsenburg Zip Code: 1960 Search for a Specific License Type/Complaint: Master Plumbing License Search for a Snecific Business Designation: Clear Form Export Data co VG'S ovi-noio I " u'?,i: �! In Licen..........Last ................ First.... .... .... .Business ._.._..............Address...__...._._.._............ ...Phone...... Email.._.................... _. .......Catego.._.._-Stat..........Date... Date...._... de se ID Name Nam Name and ry us Issue Expir x e Website d e 1 MP- Orlows Jam J & C Po Box 1016, 63120 jcphambing g Acti 200 202 449 ki es Heating 4 Remsenburg, 81732 f 1969c gmai F ve 8- 4- 50 And Air s NY 11960 I,com 06- 06- ' a Conditionin € r 24 01 9 & Plumbing ; Uc :o iva-, 11,0 i,Ma, Ori _ Last: :S Years 12 r es-i. ............ . ...... ............. ......................................... Index Business Name Record ID Status Number of Number of by Status Open Status Closed Busine ss ..... ....... . 1 J & C Heating And Air CMP-21-141 Closed 0 1 Conditioning & Plumbing Ucs 2 J & C Heating And Air CMP-21-150 # Open 1 0 3 Conditioning & Plumbing Uc Total 1 1 .......................... ... License Ini"'Orma-ldon I result .......... .. ..... . .. Index: 1 License ID: MP-44950 Name:James Orlowski 1. 7 NEW YORK STATE DEPARTMENT OF STATE DIVISION OF CORPORATIONS, STATE RECORDS AND UNIFORM COMMERCIAL CODE FILING RECEIPT ENTITY NAME : 1850 ROCKY POINT LLC DOCUMENT TYPE : ARTICLES OF ORGANIZATION ENTITY TYPE : DOMESTIC LIMITED LIABILITY COMPANY of NE •. DOS ID : 6394629 :•�„ �•'•• FILE DATE : 02/03/2022 } '• FILE NUMBER: 220203002399 • TRANSACTION NUMBER: 202202030002594-592806 * • EXISTENCE DATE : 02/03/2022 ` `f W PERPETUAL DURATION/DISSOLUTION: : rd ``` • F=1cEisitiK �/ • COUNTY: SUFFOLK '.��� P c� •; '•. SENT ��•' SERVICE OF PROCESS ADDRESS : DINA PLATTI 29 E BARTLETT ROAD, MIDDLE ISLAND,NY, 11953,USA REGISTERED AGENT : DINA PLATTI 29 E BARTLETT ROAD, MIDDLE ISLAND,NY, 11953,USA FILER : CURTIS R.MORRISON,ESQ. 159 ROCKY POINT ROAD, MIDDLE ISLAND,NY, 11953,USA You may verfiy this document online at: http://ecorp.dos.ny.gov AUTHENTICATION NUMBER : 100001024536 TOTAL FEES: $210.00 TOTAL PAYMENTS RECEIVED: $210.00 FILING FEE: $200.00 CASH: $0.00 CERTIFICATE OF STATUS: $0.00 CHECK/MONEY ORDER: $0.00 CERTIFIED COPY: $10.00 CREDIT CARD: $210.00 COPY REQUEST: $0.00 DRAWDOWN ACCOUNT: $0.00 EXPEDITED HANDLING: $0.00 REFUND DUE: $0.00 DEPARTMENT OF TH TREAS 0 IRS INTERNAL REVENUEESERVVIICERY CINCINNATI OH 45999-0023 Date of this notice: 02-03-2022 Employer Identification Number: 87-4805881 Form: SS-4 Number of this notice: CP 575 B 1850 ROCKY POINT LLC DINA PLATTI MBR 29 E BARTLETT RD For assistance you may call us at: MIDDLE ISLAND, NY 11953 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 87-4805881. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. Taxpayers request an EIN for their business. Some taxpayers receive CP575 notices when another person has stolen their identity and are opening a business using their information. If you did not apply for this EIN, please contact us at the phone number or address listed on the top of this notice. When filing tax documents, making payments, or replying to any related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear-off stub and return it to us. Based on the information received from you or your representative, you must file the following forms by the dates shown. Form 1065 03/15/2023 If you have questions about the forms or the due dates shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year) , see Publication 538, Accounting Periods and Methods. We assigned you a tax classification (corporation, partnership, estate, trust, EPMF, etc.) based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2020-1, 2020-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. A limited liability company (LLC) may file Form 8832, Entity Classification Election, and elect to be classified as an association taxable as a corporation. If the LLC is eligible to be treated as a corporation that meets certain tests and it will be electing S corporation status, it must timely file Form 2553, Election by a Small Business Corporation. The LLC will be treated as a corporation as of the effective date of the S corporation election and does not need to file Form 8832. ti (IRS USE ONLY) 575B 02-03-2022 1850 B 9999999999 SS-4 IMPORTANT REMINDERS: * Keep a copy of this notice in your permanent records. This notice is issued only one time and the IRS will not be able to generate a duplicate copy for you. You may give a copy of this document to anyone asking for proof of your EIN. * Use this EIN and your name exactly as they appear at the top of this notice on all your federal tax forms. * Refer to this EIN on your tax-related correspondence and documents. * Provide future officers of your organization with a copy of this notice. Your name control associated with this EIN is 1850. 1 You will need to provide this information along with your EIN, if you file your returns electronically. Safeguard your EIN by referring to Publication 4557, Safeguarding Taxpayer Data: A Guide for Your Business. You can get any of the forms or publications mentioned in this letter by visiting our website at www.irs.gov/forms-pubs or by calling 800-TAX-FORM (800-829-3676) . If you have questions about your EIN, you can contact us at the phone number or address listed at the top of this notice. If you write, please tear off the stub at the bottom of this notice and include it with your letter. Thank you for your cooperation. Keep this part for your records. CP 575 B (Rev. 7-2007) ---------------------------------------------------------------------------------------------- Return this part with any correspondence so we may identify your account. Please CP 575 B correct any errors in your name or address. 9999999999 Your Telephone Number Best Time to Call DATE OF THIS NOTICE: 02-03-2022 ( ) - EMPLOYER IDENTIFICATION NUMBER: 87-4805881 FORM: SS-4 NOBOD INTERNAL REVENUE SERVICE 1850 ROCKY POINT LLC CINCINNATI OH 45999-0023 DINA PLATTI MBR 29 E BARTLETT RD MIDDLE ISLAND, NY 11953 I SYMBOL LEGEND 0 MONUMENT FND (0 MANHOLE TEST HOLE 0 I.P. /1.8. FND ® "A"-INLET TREE * I.P. /I.B. SET "B"-INLET SHRUB +,030 SPOT ELEVATIONS ® YARD INLET 0 BOLLARD COL) UTILITY POLE ® YARD INLET . WETLAND FLAG >— GUY WIRE © ELECTRIC METER CANT. CANTILEVER UTILITY POLE W/LIGHT © GAS METER FE.FENCE ( LIGHT POLE ® WATER METER MAS.MASONRY SIGN pd GAS VALVE PLAT.PLATFORM PVC,FENCE (PVC) WATER VALVE WW WINDOW WELL STOCKADE FENCE (STK) M B/W BAY WINDOW —X— CHAIN LINK FENCE (CLF)0/H OVERHANG C/E CELLAR ENTRANCE WIRE FENCE R/0 ROOF OVER Y FIRE HYDRANT D.C.DEPRESSED CURB A/C UNIT ® CROSS CUT G.O.L. GENERALLY ON LINE D STAKE 0/L ON LINE I BEARINGS SHOWN HEREON ARE BASED ON LIBER 12953 PAGE 0851 Ld� I TAX LOT 10.1 a I o MT° 112.20-(DEED) FND A WOQQ FEN. B. I w) PIN-Y Y N81"30 00"E WDF� WDF 112.12•(Q/is) PIN AR+ YYl'�.YY.Y"Y" YYYY-Y"Y'y" _ • 77 r � r —$ — —— —— — — —— —— —— — — —— — 1.1 t -4; ASPHALT O ASPHALT DRIVEWAY CONC. ��� ,GA GE _ I M O � -- -- -- - - -- --- - - - - - ' i ,27.0' '� O GAR WDF o0-4° �--fpH �< 3 TAX LOT 10.1 Q { ON ,1 EOC z a (Y I ON J o �_ WDF ^y I ( pH l ' V) o 0.1' 31.4' / i,38:3ej 'i w w I (r I 7 `t-. 'l_/ _ r a TAX LOT 11 ►� Q I EOC 4 STORY ,oD,i ,-FR -ME 1RESIDE�JC�! -o �t I lO ¢ l #1830 = i; ci STONE MAS. o I :t _B- 0 10.8, B- TAX LOT 10.2 o I C EOCY iiI %;/, c V +� i HD �' ( I �` - ,38:3` i' * I � Y rWCEL - C/E EC` �` FENL w 07 ^ N 00 DV PVC C O FEN M } ALL WALL Ox � )r } �0.5' 4, DILAP WOOD RET. WALL +0.6' f0.1' MTS AS87'a30 X00"W 6' PVC FEN. w FENT PIN �— lPVCFEN 120.05'(0/AS) " 0.6'1 12.8' 120.00'(DEED) a 0.2'f- TAX LOT 12 N Ia MAIN ROAD GRAPHIC SCALE 20 0 10 20 Q, Q GUARANTEED TO: 1850 ROCKY POINT LLC LOT AREA IN FEET ) PYRAMID TITLE AGENCY 11,608 S.F. VALLEY NATIONAL BANK, ISAOA/AVMA 0.27 AC. 1 inch = 20 ft. pF NEW SURVEY OF PROPERTY � P � I-EA4) y0 SCALICE CO O� �G' �� 1850 ROCKY POINT ROAD * and surveying SITUATE OEAST MARION, TOWN OF SOUTHOLD mjslandsurvey.com P:631 -957-2400 SUFFOLK COUNTY, NEW YORK 2� 050736 F� `q 73b DR.:MC CREW.:JT SCALE: 1" = 20' TAX MAP NO. NO DATE SURVEYED:05/10/2022 1 JOB No.S22-1405 1 1000-031.00-02.00-011.000 (1)UNAIfMOfUZED ALTERATION OR ADDITION TO THIS SUR"MAP BEARING A LICENSED LAND SURVEYOR'S SELL IS A NOTATION OF SECTION 7200,SUB-DNSION$OF NEW YORK STATE EDUCATION LAW.(Y)ONLY BOUNDARY SUNVEY AMPS WITH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND CORRECT CORES OF THE SURVEYOR'S ORIGINAL WORK AND OPINION. D CERTIFICATIONS ON THIS BOUNDARY SURVEY MAP SIGNIFY THAT THE IUP WAS PREPARED IN ACCORDANCE WITH THE CURRENT EXISTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSDCIA71ON OF PROFESSIONAL LAND SURVEYORS.INC.THE CERTIFICATION IS LIMITED TO PERSONS FOR WHOM THE BOUNDARY SURVEY WAP S PREPARED.TO THE TOLE COMPANY,TO THE GOVERNMENTAL AGENCY.AND TO THE LENDING INSTITUTION LISTED ON THIS BOUNDARY SURVEY WAP.(4)THE CERTIFICATIONS HEREIN ARE NOT TRASFERN (S)THE LOCATION OF UNDERGROUND IMPflOVEMENTS OR ENCROACHMENTS ARE NOT ALWAYS RN ONN AND OFTEN MUST BE ESTIMATED.IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS MW OR ARE SHORN.THE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THE SURVEY.(8)THE OFFSET(OR DOIENSIONS)SHOWN KEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FDR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT INTENDED TO GUIDE THE ERECTION OF FENCES.RETAKING WAY$POOLS.PATIOS PLANTING AREAS.ADDITIONS TO BUILDINGS.AND ANY GINER TYPE OF CONSTRUCIION.(»PROPERTY CORNER MONUMENTS WERE NOT SET AS PAR OF THIS SURVEY.(8)THIS SURVEY WAS PERFORMED WITH A SPECTRA FOCUS 30 ROBOTIC TOTAL STATION. (B)THE EOSTENCE OF TIGHTS OF WAY AND/OR EASEMENTS OF RECORD IF ANY.NOT SHOWN ARE NOT GUARANI®. (10)SURVEY S SUBJECT TO ANY STATE OF FACTS WELCH AN UP-TO-DATE TOLE EXAMINATION MAY DISCDSE. ®o c1 APPROVED AS NOTED �,� �,, DATE B•P.#L1�= FEE 50'oo BY NOTIFY BUILDING DEPARTMENT AT COMPLY WITH "... _ 100DIS OF 765-1802 8 AM TO 4 PM FOR THE NEW YORK STAFF- 1-OWN CODES FOLLOWING INSPECTIONS: 1. FOUNDATION -TWO REQUIRED AS REQUIRED AND 30NDITIONS OF FOR POURED CONCRETE 2. ROUGH FRAMING,PLUMBING, SOUTHOLD TOWN ZBA STRAPPING, ELECTRICAL&CAULKING 3. INSULATION SOUTHOLD TOWN PLANNING BOARD 4. FINAL-CONSTRUCTION &ELECTRICAL MUST BE COMPLETE FOR C.O. SOUTHOLD TOWN TRUSTEES ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW N.YS. DEC YORK STATE. NOT RESPONSIBLE FOR 7 DESIGN OR CONSTRUCTION ERRORS. ELECTRICAL INSPECTION REQUIRED PLUMBER CERTIFICATION ON LEAD CONTENT BEFORE CERTIFICATE OF OCCUPANCY SOLDER USED IN WATER SUPPLY SYSTEM CANNOT Additional EXCEED 2110 OF 1% LEAD. Certification May Be Required. PROPANE ;SAFETY CHECK yr AUG 2209 ; 47- FOR RESIDENTIAL CUSTOMERS` r BUILDING DEP TOWN OF SOUT "Account Numb Call Date SF r Date Requested Name j� C - i.�y±:.,.� C':•.�~c"t'... 4'i.a(•-, , ,R�'1r=�. Instructions: Address �1 J •r 707 Telephone: Office Home: EApnda Check Item: Central Heating 1 Space Heater 2 Water Heater 3 Range 4 Clothes Dryer 5 � ::Mrer , � Model No. ti ��, r7'r,t t ,L•p ,rt1;:' '`J''it;`r' ��rl\1. r� I�>>.� � Serial No. "c') Location 000 000 !I` 000 N/A N/A 000 000 BTU ' r Age Manual Shutoff emtalled,Ezistingl Venting f�-� TANK/CYLINDER Rebel Valve Fittings SIZE ;SERIAL NUMBER MFR. MFR.DATE Lest Test Date location Tank Cond, Paint Pigtail Fittings Gauge on et e Leek Test f"1`e t .��,{u1 r 7 t.: 1 % 4,i 1 % '7 (4_ i } f rr J '✓ ('r r �10Crw,_ }1}C rl/\ L_ff 'ilr 31��'i,.• ✓ / (� `;{ vI i PIPING/REGULATOR OPERATION/CONDITION REG.VEN' HOW FLOW PIPING REGULATOR REGULATOR MFR. MODEL POSITION PROTECTED PRESSURE .' SINGLE ;,MATERIAL ,SIZE DATE CODE CONDITION •, „r {T,(F/� it >,rl.X .�c'_.,!•t: / IN.WC STAGE r=t;; Ll Ar )Jri �.; PSIG 1ST TWO STAGE °� IN.we 2ND SYSTEM LEA TEST Comments: SINGLE Start Pressure End Pressure„ Time Held System OK J / llnchea W.C.1 (Inch.-W.C:) }'Y' f �` STAGE /1, ,ir'V` L J ' f �r IPSIGI IPSIGI ! F, fi7 /`,y- ', ! Pf'�% �`f C let t' r /, TWOl / STAGE 2nd Ilnches W.C.1 (Inches W.C.) ii 7 !r' 7 i �l�y ll.r f i1;1'f This inspection covers IpropenefLP-geabitems siid equipment visible and accessible to the earylea techMelen d a✓ _l�`I Reference Involt:e No Date end represents the conditions existing on the dote of impectlon.It does not ewer latent a'manufictwing defects, IMa DH Yr.l the internal working of sealed a.gtilpment,or structural components,and cannot be construed to cover future tij , • defects or unforseen happenings. J 1,i`j IPleeee Piint) t (Please Print( • �• Certify that I have completed the System Cheek a prescribed. ■Know how to turn off gas in case of emergency. , ■Hove smelled propene and ipn detect its odor. Performed Odor Test Q Yes Performed Pressure Test ❑Yes ■Have received the Con!9rrfer Safety Information. -" Left�Comeumer safety Info C1 Yell 1111 Had gas system dejlcrj}Gies end 1 a corrections.i1 any,clearly eap4lnad to me. ■Am satisfied witKtherservice work performed. µ4 „a•,i��....e�.:="�•+Pp _ ., •, ehvery Men I Technician Signoture ^— „✓- ,,r" Customer's Signature ,? i r n "IS E,9 FLk` l a ;� r - k—A7C 3{ � —CHOW FR DW lc/!FT— a � arrii� �cGl MqrioN NY 1IT31 -R E) 41nq Condc ions Air Model Number Identification a R92T Series Model Number Identification R 92 T IA — 040 1 3 17 M S A Rheem Series Motor- Design Series Input Stage-Single Airflow Cabinet, idth Configuration- S=Standard Revision- 92% Constant A sLDesipn BTU/HR 3, Unto 07. Multi-Position Marketing Efficient Torque B=2nd Design 040= 42,000[12.31 kW] 5-Up to 5 Tons 21 =21.0" (A-First Time C=3rd Design 060= 56 000 16.41 kW 24=24.5° Release) ,07 0,,000 2[ 0:5�,kW 085= 84,000[24.62 kW] 100= 98,000[28.72 kW] 115=112,000[32.82 kW] [ ]Designates Metric Conversions INTEGRATE D HOME COMFORT Air Physical Data&Specifications a R92T Series Physical Data and Specifications-Upflow Models U.S.and Canadian Models MODEL NUMBERS R92T(-) R92T(-) 92T= R92T(-) R92T(-) R92T(-) R92T(-) 0401317MSA 0601317MSA 97; _31 A 0701521MSA 0851521MSA 1001521MSA 1151524MSA HIGH FIRE INPUT BTU/HR[kW] i0 42,000[12.31] 56,000[16.41] 70,000[20.50] 70,000[20.50] 84,000[24.61] 98,000[28.72] 112,000[32.82] HEATING CAPACITY BTU/HR[kW] 38,600[11.31] 51,500[15.09] 64,400[18.87] 64,400[18.87] 77,200[22.62] 90,100[26.40] 103,000[30.18] HIGH ALTITUDE OUTPUT 34,700[10.16] 46,300[13.56] 57,900[16.96] 57,900[16.96] 69,500[20.36] 81,100[23.76] 92,700[27.16] 10%DEBATE[kW]0 BLOWER(DxW) 11x7 11x8 11x8 11x10 11x10 11x10 11x11 [mm] [279 x 178] [279 x 203] [279 x 203] [279 x 254] 1279 x 254] [279 x 254] 1279 x 2791 MOTOR H.P.[W]- 1/2[373]-5- 1/2[373]-5- 1/2[373]-5- 1 [746]-5- 1 [746]-5- 1 [746]-5- 1 [746]-5- TYPE Constant Constant Constant Constant Constant Constant Constant Torque ECM Torque ECM Torque ECM Torque ECM Torque ECM Torque ECM Torque ECM MIN.CIRCUIT AMPACITY 8.00 10.00 10.00 12.00 13.00 15.00 14.00 MIN.OVERLOAD 15.00 15.00 15.00 15.00 20.00 20.00 20.00 PROTECTION DEVICE MAX.OVERLOAD 15.00 15.00 15.00 20.00 20.00 20.00 20.00 PROTECTION DEVICE MOTOR FULL LOAD AMPS 4.0 6.8 6.8 10.6 8.3 8.3 8.3 HEATING SPEED MED-LOW MED-LOW MEDIUM MED-LOW MEDIUM MEDIUM MEDIUM COOLING SPEED HIGH HIGH HIGH HIGH HIGH HIGH HIGH MINIMUM EXT.STATIC PRESSURE .18[.045] .20[.050] .23[.057] .23[.057] .28[.070] .28[.070] .28[.070] (IN.W.C.)[kPa] MAXIMUM EXT.STATIC PRESSURE 9[0.224] .9[0.224] .9[0.224] .9[0.224] .9[0.224] .9[0.224] .9[0.224] (IN.W.C.)[kPa] HEATING CFM @.2"[.049 kPa] 982[463] 913[431] 1113[525] 1351 [638] 1574[743] 1651 [779] 1524[719] W.C.E.S.P.[Us] COOLING CFM @.5'[.124 kPa] 1239[585] 1227[579] 1198[565] 1750[826] 1833[865] 1975[932] 1748[825] W.C.E.S.P.[Us] TEMPERATURE RISE-HIGH FIRE 25-55 35-65 40-70 30-60 35-65 35-65 45-75 RANGE IN DEGREES°F[°C] [14-31] [19-361 (22-391 [17-33] [19-361 [19-36] [25-42] APPROX.SHIPPING WEIGHT 123.5[56] 128[58] 132[60] 1391631 147.5[67] 152[69] 165[75] (LBS.)[kg] AFUE OO 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% NOTES: All models are 115V,60HZ,1 phase Gas connection size for all models is 1/2"[13 mm]N.P.T. O Installation instructions for high altitude Berate. ©Canadian installations only. OO In accordance with D.O.E.test procedures. *S=Standard Models ' NOTE:Standard model complies with California low NOx requirements. This furnace does not meet air district requirements of 14 ng/J NOx emissions limit,and thus is subject to a mitigation fee of up to$450.This furnace is not eligible for the Clean Air Furnace Rebate Program:www.CleanAirFurnaceRebate.com. This furnace is to be installed for propane firing only in air districts requiring 14 ng/J NOx emission limits.Operating in natural gas mode is in violation of these Rules. [ ]Designates Metric Conversions