HomeMy WebLinkAbout49324-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
sTOWN CLERK'S OFFICE
SOUTHOLD, NY
4
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#: 49324 Date: 5/31/2023
Permission is hereby granted to:
Doherty, Peter
PO BOX 644
New Suffolk, NY 11956
To: install replacement windows to existing single-family dwelling as applied for.
At premises located at:
4105 Deep Hole Dr, Mattituck
SCTM # 473889
Sec/Block/Lot# 115.-16-23
Pursuant to application dated 5/31/2023 and approved by the Building Inspector,
To expire on 11/29/2024.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00
CO-ALTERATION TO DWELLING $50.00
Total: $250.00
Building Inspector
DocuSign Envelope ID:BAE6A93B-22CC-4742-8AD5-3D6336C5394F
"gffa 4 TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
.' Telephone (631) 765-1802 Fax (631) 765-9502 $,t ;:,i� n� a tlwtl�� �c la wrtatYO�
Date Received
APPLICATION FOR BUILDING PER IT
For Office Use Only
a
d
PERMIT NO, �� Building Inspector: M AY0
Applications and forms must be filled out in their entirety. Incomplete
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorization form(Page,2)shall be completed.
Date: 5/25/23
OWNERS)OF,PROPERTY:
Name: Peter Doherty TSCTM"
#1000-
Project Address: 4105 Deep Hole Dr. Mattituck NY 11952
Phone#: 516-383-3263 Email:
Mailing Address: 4105 Deep Hole Dr. Mattituckk NY 11952
CONTACT PERSON:
Name: Scott Doughman - Go Permits
Mailing Address: 105 Buttonball Ln. Glastonbury, CT 06033
Phone#: 303-946-8685 Email: permits@gopermits.org
DESIGN PROFESSIONAL INFORMATION:
Name: n/a
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name: Home Depot USA
Mailing Address: 2455 Paces Ferry Rd. Atlanta, GA 30339
Phone#: 303-946-8685 Email permits@gopermits.org
DESCRIPTION OF PROPOSED CONSTRUCTION.
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
Fol Other Replacement of 15 windows, same size, no structural change. $ 22,564
Will the lot be re-graded? ❑Yes *No Will excess fill be removed from premises? ❑Yes ®No
1
DocuSign Envelope ID:BAE6A93B-22CC-4742-8AD5-3D6336C5394F
PROPERTY INFORMATION
Existing use of property:Single family Intended use of property:Single family
Zone or use district in which premises is situated:. Are there any covenants and restrictions with respect to
this property? ❑Yes RNo IF YES, PROVIDE A COPY.
99 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(print name): Jennifer Winke- Go Permits BAuthorized Agent ❑Owner
Signature of Applicant: `� „� y„������ '�� Date:
STATE OF ISR )
SS:
COUNTY OF Guilford
Jennifer Winke- Go Permits being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the Agent
(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 , , SAM'LO
Z��h � ww..w.•ww ✓ r►
t day of 20 7..� w** trcy w%%,w
w �
Notary *
` 0:Z 00. �
PROPERTY OWNER AUTHORIZATION '✓0w�"w« t� *�'
U,13
(Where the applicant is not the owner) 00 01-22 _ «%
wwww
1,41 M t�0
Peter Doherty residing at 4105 Deep Hole Dr.
do hereby authorize Jennifer Winke - Go Permits to apply on
pWL4d,gitt,Sq,the Tow_n of Southold Building Department for approval as described herein,
P" 5/25/2023
_. Owner's
s Signature Date
Peter Doherty
Print Owner's Name
2
(0F,%
ray �t Home Improvement Agreement: Page 1
rv��➢ ,ff.
Home Depot License#'s -For the most current Iistin x visit ww w.(l.o.nimed-co,ol cw�,�nill icer_ e'Nunibers
Adam Friedman
Friedman
Salesperson Name Registration# (Req.in CA,CT,ME,MD,M.I,NJ,DC)
Home Depot U.S.A.,Inc.("Home Depot") or Authorized Service Provider named below will furnish, install and/or
service the equipment listed below at the price, terns and conditions as outlined on this form.
1. Service Provider Contact Information
The Home Depot The Hame Depot
Service Provider Contact Name Service Provider Company Name
(631) 478-6101 customercancellationnortheast@hom .- - -
Phone# MWOMvider Email Address Service Provider License 4(s)
2. Customer Information
erty peter � iLong Island F34146919
Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO#
4105 Deep Hole Drive Mattituck NY 11952
Customer Address City State Zip
1(516) 383-3263 quint105@optonline.net
Home Phone# Work Phone# Cell Phone# Customer Email Address
3.NOTICE OF RIGHT TO CANCEL
YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING
THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT:
customercancellationnortheast@homedepot.cgm
OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
40 Oser Avenue Hauppauge NY 11788
Address City State Zip
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF ' 'OV
It(" iwl,"1"O CANCEL
Acknowledged by: EP
05%09/2023
Customer's Signature Date
460 Smnd.,d Fou HTA(Y 1.10.21)(G) Gcnertatcd Data p- ,,. ��---._ 1..cad/po7 .F-34-UESLI-9— v 0'"'
t" qA' Home Improvement Agreement: Page 2
4. Description of Work to be Performed
A detailed description of the work to be performed is included in the paragraph entitled Scope of Work,Specification,
Customer Summary Sheet, Quote Form,Estimate, Invoice or Measure which is included in this Agreement.
5. Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 11/05/2023 Approximate Finish Date: 12/05/2023 All dates are approximate
and sub.ect to change based on unforeseen events including inclement weather, permitting delays, and delays in
confirming insurance coverage of Your claim for any repair, if applicable.
6. 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 cornmunications related to this Agreement. By
contacting your Service Provider,you may update your email address,withdraw your consent,or obtain a paper copy
of the Agreement or related documents at no charge. By providing your consent and verifying your email address
above,you confirm that you have access to a computer that can receive and open emails and PDF documents.
7. Contract Price and Payment Schedule
Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified
below or in a payment addendum.
Contract Price: $ 22564.95 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: $ 10.00 (If applicable, total amount of taxes included in Contract Price)
**Maximum deposit O.NLY applicable in ellA J114, ilff(33'16), AV, W1( 9 0)
Deposit% 100 0 De osit Amount$ 22564.95 Remaining Balance $ 0.0
P m._.._.._ .....� _.m_. . g � �
�8. Finance Charges
Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan
agreement, to which Home Depot is NOT a party, and will be in addition to Customer's payment under this
Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable.No
funds should be made payable to Service Provider; however, Service Provider may collect Customer's payments
made payable to Home Depot.
9. Acceptance and Authorization
By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform any Services or (b)
order and arrange for the delivery of special order merchandise, including special order merchandise that may be
custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's or permitting
information may need to be provided to You later.)By signing,you acknowledge that:(i)You have read,understand,
and accept this Agreement in its entirety, including the General Conditions and State Supplement, if any; (ii) You
are receiving a complete copy of this Agreement; (iii) all rights and interests under this Agreement are solely vested
in the person listed as "Customer"above; and (iv) Electronic signatures will be deemed originals for all purposes.
.. 23
.. ..--- -.w... . .. ��I-5/09/20m_.
Customer's Signature Date
X I/s/The Home Depot 05/09/2023
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 1-800-466-3337
460 5.,u-&ad Fom,F11A.(3t Jul,21 Generalm]Dnie - G.".� -¢�f2d�.2"� z..ead'To
................
CERTIFIC �IxAYC k"16'�3fi.1i2°`r""A"YN
`i6 llA C R7�FI AT IS ISSUE) AS A MATTER OF INFORMATION OmNLYmAND CONFERS NO RIGHTS UPON THE CERTIFICATE E
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND CTS 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.
irwFE T�NTa._if the certificate holder is an ADDITIONAL IN 1'.1i2 s)must have ADDITIONAL INSURED provisions or be ondaarsed,
It SLIB OGATICN 1,15 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 lien of such endorsoment(s),
%mCr9d1"dCLirY. GLBM"P"A 0.:r
tATn USA 1IY) YYAYiE
PHOW, IC"AX
�a fgt,,.V "hAk. 1'l rCiiF I +c,,Nn
.,n: Y2 inrh,mad p:
l'ae II '),RC,'77C1t0A0 5U E, 4C.NG4 E44Ann,
t°,`=i t fTP� GA 303216 9 raVtd:
P V dA,� iNnL4II" mD
V iuYi Ye,�)V°tl•
IN8JPRY:'er,N
u 0R1'D
rI E udC))It=I:7E}°Cal,NC. dYd.lieu,Mau�(e ,rr R r,a 1,� I � t�'uh•.i: a"r'°
)NI:£''MDI 'l.ry d4..WC, rnt,nlnYa_rve v,E,E vest ,w�veD rcC !2,tt'7
Yy q
APANTA,GA +'cro39 L �W
C IV if 1`3 ltd� C''GTlIR' tE IIIIC TE NUMBER:
VISION NUMBER ,
I9AT
THE V% I11 8, S OF ,NSLJIRYYdrE. USIr..C7 Villi I Clna�,° k afl L,e. "l� !' �id.:1 lr P}rli 1J ti1,3 Tm lwl tuLVF"I)fit�Ca��,l 0 RYI� 'ifi"aE f'O3 1GY ( L)
tSVf�d*^.,VywlCApt L:.D/y�M.(h�fwt�S^1F1117HS1��i!`�pptf�^llgG ANY Ff:=:(fN.J11llrp�E-14 it , '9"utn::�.8'1 G'�`4T"�{T�o"�)21.�0�(iC'JtN r,0..�F� A�P/�d1P C 0..)i�Y�a7�pfRtAw'I C��fJ� )f:fa�Ii��R i;�GECJv,�J1a1��1'i11 `Tp��"du"ry 9@w l^iE sri l:;'P� 1G� �`g0.'1nlun.,a:8 ull ll
d l..d'�.TNS`n'���Ya E". IY,Id"OF' i.. Iw�YSNdEI) �.R MAY i'"I...RI��`^eLN, Nit.- Mtllwti�"�UFu.490VC`E, .""44'F(',1,�RI,..d1...D Y'�'p 1 !E i'8411.4'rIEl J jar--.S�nY"kuigll:113 14f,"'EINAd 4S S1Jw9JY..0 f 4A' AL,i Il�tiLL.'
tl Xu,k"N.3,14::9ib 8 AND P;l;3NDI d II:NS&::7i=8LJC:ll�C7f.uC."l :>.d- I9 C,>;w ICDnJ vti'11? l"Td`avPl I G�1�l I ,il.i Y T f;b 'r 1i" d l r I1 l i,
.m. " i p� l iv a awTYPE OFINSURANC ra? , lts.CarRYG1 ll hirL
@P LI�_9Y.,artn✓Yu�r �rt
AY COMMERCIAL GEfiE �LIABILITY ald.Pt1 �c62j2 �ii746 t .
..,_ �..
'V
iDAd mC.
}t,dM-,G;.UP'k J PFYk.Py96alm�"�,'„sF`e tisr'ey,rnrray,a;m+) � ., e. �iy i IYd.I'
X 'zvt r 5 0:70.D(i0 .r a Ryard wu +v A0V 4,01
rC.'a♦°Oa"lCa itaa80^ BTdklDV1F P'Lw#"�' � �Gd"�llt6"t.d����n16C"Aw� � � 1�Y1',�y
..,,. _..
Y i7.al dC.' e <•' n..>
I" <" { PRODW,IS,CCTMAq DP C`4 n 2r,Vft:1 0
0.elBlp'Y,#
A�IPp'2,MYnl�'e�;la»€!�..8F4YSVs.9'V'"Y' 11497d�r��hwl"1v3�rR,� =,Y,l�lp"lMe�wJ'n.� 1 "rtd'!f.°Ihl°w� 'cd',DE.�&�dCwVNi9.'�'h�y1W^t.�I�`en..a��ll
lb,, Yuarla'eTry
Ui l' R P uk e'✓0.M t P"H
SELF °)R�..i ��}� rJY BODILY WJ JRY 0 er 005
'
- —
?
,M 7 ',°8I,x >a+a,t"i uDuY a)dhN4"( i IIr to�� ,arrxl,wtl ,n
. "t.�rrs 11 1 "V664 G aoYla2( I-', _ __
13"It>4€tevLl.A'�Idl3 ,SU`d, ;,1� tr�a,dMn,'liYd,1;4��G
_. .., .�"
X, E M4 E.SSx IL.fiAR dTn..R46':r�• (➢Y� I �6.:ni.n P�P.C3A'�'7h: �,'. I'. V'I 1�(•I
1AK6d
DnF r,n rE¢�l,!LOe�rMaYN YC4vEbsRqDl6'SR�'WLAkI t,4AaEln.rvI1Ln1LnIDTu
xtrO
NYAI
beyYytw tl11Nk� L.
Gs'1'J�.4+39MI1t(��"'tfl3✓,�1r _1 i C�'bk""tI�yy(WIPE —�n,,1 Pk
,_..._
i
a V C71Sre'4S4_ EAkl.CallaV+ YEEe 5" vr.�Cli),ft�0z
1 O'11kAul,df o,)d6�l�yl�l
IIMveGatn�9ti'�ntiu%F''�raFMrdl�n9tSw"�rN�uaJ .a l FM LWk"�rrk'�a Fyhll brkPnilw � �
I l
d @.00AT'MC71pS f (ACCD'YYD 10.,,Aei¢9N6 vnM IffRaamar'w'.r Schaedullev,may km,AtAcfiixl if retire space:iµrequredj
C;t i�;IFTl x0.:7' i#C7s,.lAi du.l Iba;a.Ud1h CY ou Afb%ll'N'1 yYYJatMw4)�UcG4:' I lr_4�1i 1„raY kluy it"Iv VY(;Y?NY"4 eaa .ii4�d"118.,evSXTA:C.,"'Yl."RAt I..ABIL1TY N)LI I,BUT:z NL,4'A`U'=1 RF.Cr.sl'.'C:" TO
AR1,l�uNG OUT OF H? ,C6'tnRATIC)W,i O 1 H:.i+JOtl(,ED flV4 JR&D.
CERTIFICATE HOLDERCANfuT:"wLI ATION
1 0,Viv 0 i t d 11Clz SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ROU I Y s..:25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
T10 BOX o1.�9 ACCORDANCE WITH THE POLICY PROVISION&
Wv,Lhl.l'M01,0,NY 1111?'1
AQ
2Ra t iAb K:.W6^tlCf �f fT'd"A."PnMFY,
ACCD CORPORATION. All rights reserved.�
ACOR D 25(2016103) The ACORD name and logo are registered marks of ACtt,RD
AGENCY USTO l : CNIO1642069
eta
A C C'>R FX ADDITIONAL REMARKS SCHEDULE Page 2 of 3
Fan',.9GnM'Y IWVv9&„":D04,4RV) .„ ....�....._
,00,8'H Id Ma Va yail P1F k" a.T 9u,
POLICY NUMBER � 24 ',i �4A CEES F04,WlafiaC'x
Aln Ad , ui,
M I' A
G ARRK,,CR NPPf GORE
Y hlfr P+",N'90Mn=f7�,a3..: j
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM'TITLE. �t iEI a fie;of Llabffl4y Insurance
r um'.'n
Viol:Vay MvTfl-xor :.l'40,,' 1'F,3
6 C.ai S TjQ,3123
r.rrt lDauc 0 3o011?62A
a4Vrrru i t eai9'flar+
'aln yud#„nV I `�,V'andd)ar�s;,1V1 ^P',441Y,A(JVtiodhrniq,�,
Vr a art i ut,1,n°IJ 1V'I�!:
�I
i l i"u,rtd�i r' u l'dfN�13'1
s n ,"t t�Nry i "u rn
Insuvmca C;a,vo3aanrt'a
u r,Vi_y V`M'iu rd,hlria°::{du".�,aulr.('ad'.aTad;d Vr��..�V�:d€a,Wa11,�,11C,G3uk,&.11";y I
d#drtr,,kiirda;
DaW4 WvG1°2021
Irornlaam sae .���GdCa.YICi>G
jA
torr ^y^,t,GUC�,C7CJ?i
G uiir pr.L Au^ep^0,,y 4r-s r,al,ua C1r,Ar°dlllaarVy urG)vdclh A r^ riiz
Pb.al'rgyNur hpr'VCR k VQIuCAC,53 o'3a G;'U`,3Y dbd:.,0°Vd,9h1 Ahd 49,,"H, d:.�IPdI C�4 P,x'„IYw G Irl i M ai,"1
�u Iv�Vuaiut�YaVr I arc�.a,Cti,d'9„�'.l➢�a;
t.'v 1.irreR a rf°�il+^r
�ov^aha ,u
XS�ud, r 4'1(
a7. V,nnL ,owmvaoi ansuirmmo of`IImiq
uV y INum d IL.1 u 19 ffXj1
II h n:P 6 Q i Y !M
r,n➢i..l,,,iydl
02008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER IDS 101642069
LOC# Xtl.arms
ADDITIONAL REMARKS SCHEDULE Page 3 of ....3
GrNcv � .._ .m._.._..._��...._.�W.. u�.,
NAMED aasSa3atEua _....
_............ HOMF DFP0 r k),S A,W(',
POLICYNOMBER 2458PACES f('.R,MYI RO,n D
BWIL f D9NG(,-21)
Cfa.a842IER I NAIC CODE.
I
FFFECTWt 7E;
ADDiTIONAL REMARKS
7111%ADDITIO AL REMARKS FORM iS A SCHEDULE TO ACORO FORM,
FORM NWASER, FORM TIT'S. 0lific^aW of t N�am�a8a@��P3�U�aY1u�
HV".;M 01:;O O f'N U w 4"i�"
v�o i-'tyiroY A�pvX�1,IiU'uti;
my^f1d .G V S Y'A., w oafs,, l h i a lilt IYv;gpnsn
�r ,in,'.II:oEpr,dG"`�wvg4u`al7llro n.V„'�a;„
4w7Tu „mio;,yi�a mYo k".q'i�oµuM1q�r��»➢re�.m.
HfaV➢.rW1,11 ijw:awj a w„kic
PadJAa '
9
i
d
ACORD 101 (2008103) ®r 2008 ACORD CORPORATION. AII1 rights reserved.
The ACORD namenarne and logo o are registered marks of ACORD
°° �� °° 1 �� w� CERTIFICATE° P
YORK,�aP " "
Boy°Board � NYS WORKERS' COMPENSATION INSURANCE COVERAGE
[1 a.Le
gaal Name&Address of insured(Use street address only, m ... � � m1h,Business Telephone Nurroer of Insured
Depot
i7G.i{ 3 f3'1
c.
Horneepcot IJSA ,r
24,55 Paces FerryRd-f,,...20
Atlanta,GA 30339 1c. NYS Unemployment Insurance Employer Registration Number of
Insured
76011130
,Nark Location ton o 4isur d(Only rt^quiled Jfcoverage is specifUr,offy jimifed to to F>,G c ed-p �A E� . ulB�errriticat6ssn Number&r6Insured rdsr�ae.� r `,:a e o-^sp��^M rsrit,r
rtdroa f.Y stan s 0)Vew York Staa�r �r,e,a Wrufu-tp Pofiry) k�,Iu1 d.Fn � �1.:
58-1 8S331 9
2. Name,and address of Entity Requesting Proof of Coverage 3<a.._... _ aN � � �m. �..�....�.....................__..��.____��.. _.....
fyllarrue of a9bcrorance Cars,cr
(Entity Being Listed as the Certificate Holder)
lndw;rt`inl ty Insurance CexlldparBta of North r`rod"Yk&''ym a
t,.Poli+�y Number of t ratity Ustited in Btax"a"'
Tc:n,t,n tl;w�tpq,:�Czull,iold rJrlt.R(.115yfsQ:801.8
53095rf�re.ite 15
oaYtra:ark, N1( ;,.,1171 3c. Policy effectiv(:,poirbd
03/0112023 _ _ to 03101 d2 24
3d-The Proprietor,Partners oi'Executive Officers are
3 included, i0niy check box if iii partnars1officers included)
oil 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.jTo use this form, New York(NY)must be listed under Nuri 3A.
can the INFORMATION PAGE of the workers'compensation insurance policy), The insurance Carrier or its hitensed agent will sena
this Cettificate of Insurance to the entity listed above as the certificate holder in box 2'.
ha insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
clue to nonpayment of premiums or Mthin 30 days IF there are reasons usher t' an nonpayment ol prerniums that cancel the policy cr
eiirrun,ate the insured from the coverage indicated can this Certificate. (These notices may be sent by regular maii.)Otherwise,this
Certificate is valid for one year after th is form is approved by the insurance carrier or its licensed agent, or distil the policy
expiration Mate listed in box"Sc",whichever is earlier.
This certificate is issued as a matter of information only and.1 confers no rights.upon th, e certificate holder.This certificate does not ar aend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained ill the
referenced policy,
This certificate may be used as evidence of a.Workers' Compensation contract t of insurance only while the underlying policy is in effect,
Please Mate. Upon cancellation of the workers'compensation policy indicated an 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 NetM York State:Workers'Compensation Law.
Under penalty of perjury, i certify that l am an authorized representative or tic iansed,agent of the insurance carrier referenced
above and that the named insured has;the coverage as depicted on this form.
Approvedby Eric D.Tonn
MrW nan^rp.asf a 6,P,r ort,,rcr rapresprita ive or uic-enso d agant of insurai ce mer)
Approved by;
f`itl8: Vice President:
V .1ealcne Numberof ?atharizrd representative tive c,r uur,ansr:rf agr;ni:of urj<.,i,aranue carrier a:a,"8-i"95..4. 3
Please Mute: Only insurance carriers and their licensed agents are authorized to issue Fortis C-105. . insurance brokers are el f_
authorized to issue it.
Workers' Compensation Law
Secion 67. Restriction on issue of permits and the entering into contracts unless compensation is so.Cured,
I The head of a state or municipal department, board, commission or office authorized or required bl law to issue any
perry"R for or in connection with any work lrivoMng the ernployment of employees in a hazardous employment defined
loy this chapter, and notwithstanding any general or special statute roquiring v authodzing the, iSSUe Of SUCh permits,
shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a forst satisfactory to
the chair, that cornpens ation for, ali employees has beeru secured Fis provided by fhls chapter. Nothing here.in,
however, shall be construed as creating am, / liability on the p. .rt of such state or municipal department, board,
commisslon or office to iny any compensation to any such ernployee if so employed.
2 The head of a state or rni-inicipal 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 ernployees in a hazardous ernployment
defined by tHs chapter, notwithstanding any general or special sl�atul:e requiring or,authorizing any such contrac.t, Shall
not enter into any SUch contract unless proof duly subscribed Ly an inSUranci',� carrier is prf)duced in a form safisfactUry
to the &ojr, that comipensation for,all employees has been secumd as provided by this chapter
C-105.2(0-17)REVERSE
CERTIFICATE SOF INSURANCECOVERAGE
,H1m"rl .k°, 1+�'YtmkuaVP�r�"rrr
DISABILITY AND PAID FAMILY LEAVE BENEF'I'TS LAW
PART 1,To be completed by Disability and paid Farmly Leave Benefits Carrier or Licensed Insurance agent of that Carrier
d.egai Name&Addrewta of insured(apse street address only) libeasiness Telephone Number of Insured
24,55 PACES FERRY ROAD N,,N 678-231...F��
i'm'l i_Fil`^J T A,GA 30 3'w9
tar,Federal Employer identification Number of Insured or Social Seem ity
Number
Work l ocat.;ioan of irs cared(I-)nly required fi coverage is,°p ecifica)(,l I
;mded to i"Orb,in locabt'air;a air RCew'York Spatc,iii,, 01nip-d.9p^)P'raisw.ayi �I 58185-3319
I
� of in�aavrarz�ge$�fIfisE3�i�sr#�isteedo��atiaerr�or#ifian�#arfihialeier
y ° 3aaamaer ur<arnte Carrier
N y � 3 3
530951 ROUTE 25
i :td'um Policy tinarratser of Entity Listed in boat"1 a"
1 SOUTHOLD, NY 11971
LNY713657
dfl'.la Poiiry affective period
01-01 20123 to 12-31 2023
4.Policy provides the following benefits.,
fl A.Both disability and paid family leave bevefits.
Y' 8.Disability benefits only,
p C.Paid family leave beraeftts only.
5.Policy overs:
CID A.All of the employer's employees eligible under the NYS Disability avid Paid Family Leave Benefits Law,
S.Only the following Mass or classes of employer's ernployemi
7- ..... . .. ..r... » - ... .._.
gander penalty of perjury,1 certify that I arra ars 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 Srtfrwedi 11-17-2022
.W.Y.. _.. ... ...,. ,.., ...,,...,_ ,..»..,. ..>.....,,.,,,.,.e.,,.�,^,...., ......m...,�,- r,� —. ..,.� ............... ..,.. ,.. .�e� __ .,.m..
isleJr.w94mmcr+a�ri"iiancaw Auwo rr�h a wr8lae,wwu#o°W refirr. ufftfive aai 1J a 1l Ucaru m,al Imuranto Ileo w of Mai dunwoii44tlw t a,,*rnori
Telephone Number (21 2)553-8074 Name arsi;.l'r tle„FiiL,Rbeth Tedio ArpisiAnt T orerizus,fetch ulrrr',y"Services
IMPORTANT,, If Boxes 4and SA are checked,and this foram 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 maid Family Leave Benefits Law.It must be mailed for completion to the WarkersCompensation
Board,Plans Acceptance Unit,PO Box 5200,Binghamton,ICY 13002-5200.
f l� IiT 2,io be completed by the NYS Workers' Compensation Board(only if Boy 4C or 5B of part.!has been checked)
...
State of New York
Workers' Compensation Board
According to information maintained by the NYS Workers'Coaaz`pensation Board,the above-named employer has complied with
j the NYS Disability and Paid Fancily Leave Benefits Law with respect to all of his/her employees.
l
lfantaa° igraed S ....w.,....
e ,. m w�...... . ..�_m.......... � r., ....__...........
(awugn aturmm eaf AwiwfRriaoi:A NY:F'�(ca��ca�rru"»;ermemra&r�r��&fcuav Cloard Ernpp oyraew
relefaiaoot,Number t4arne and Title
Please Nofu:Only insurance carriers licensed to write NYS disability and paid h2mityk�ays b,®n flfs insurance policies and NYS lice..,.artsead .ur .�,...� .._.,t,
Irr��neasrca,��arafs
of those insurance carriers are authorized to issue Forma 1)2-120 J.Insurance brokers are NOT authorised to issue this form..
DS-121101(10-17)
Additional Instructions for Form DB-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"I a"for disability andlor 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 an 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 arnend, extend or alter the coverage afforded by the policy listed, nor does it center 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 Beriefits contract of Insurance only while
the underlying policy is in effect,
Please Note: Upon the cancellation of the disability andlor 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 m produced in a form satisfactory to the chair, that the
payment of disability benefits and after Januanj first two thousand and twenty-one, the payment of family leave benefits
;ear 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 ernployee if so employed.
(b) The head of a state or municipal department, board, cornmission 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,
DS-120.1(10-17)Reverse
r,
WAME U'll ;:A ;u T 9 9 1.3x,
ll��3^;zi�qq Yg,pp��W� m Mn S Y
9'dj 8ta
Wy Hcallvgd I IME DEPOT LMA INC�adv SUPrI,)
agar County 0 quAlYi olk
LlIc m^nsts W„un bsn 33•.5342
arra �1a� 33dG33d2024
This UrAwnst W the Ixoperty of if ` 33;County
fUnpanment of Labor,UcetmIng&4d nswmn,wi A3Wrk.
a."4 [dutw""ca 4jotk s not gtmv16Yw'0'L.
Ucenve Categbn
II-GC