Loading...
HomeMy WebLinkAbout48744-Z Ff01��� Town of Southold 4/28/2023 o y� ; P.O.Box 1179 W .� 53095 Main Rd oy o� fSouthold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44060 Date: 4/28/2023 THIS CERTIFIES that the building WINDOWS Location of Property: 665 Gillette Dr,East Marion SCTM#: 473889 Sec/Block/Lot: 38.4-3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/5/2022 pursuant to which Building Permit No. 48744 dated 1/18/2023 was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: replacement window"in-kind"as applied for. The certificate is issued to Webster,Kevin&Lynne of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Aut ize S nature F TOWN OF SOUTHOLD suFfoa,t ooy� BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE SOUTHOLD, NY dol � ,tads 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#: 48744 Date: 1/18/2023 Permission is hereby granted to: Webster, Kevin 665 Gillette Dr East Marion, NY 11939 To: Install replacement window,"in-kind" as applied for. At premises located at: 665 Gillette Dr, East Marion SCTM #473889 Sec/Block/Lot# 38.-4-3 Pursuant to application dated 12/5/2022 and approved by the Building Inspector. To expire on 7/19/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-RESIDENTIAL $50.00 Total: $250.00 Building Inspector S� oE SOU,yo� - -- # TOWN OF SOUTHOLD BUILDING DEPT. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL Of;&o [ ] .FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR = FIELD INSPECTION REPORT I DATE COMMENTS FOUNDATION (IST) .� -------------------------------------- C FOUNDATION (2ND) y � ROUGH FRAMING& � W P LUMBIN G r6 �r � r INSULATION PER N. Y. STATE ENERGY CODE S FINAL ADDITIONAL COMMENTS O z x - r� 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 hgps://,A-Aw.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT L For Office Use Only VIE L) L s PERMIT NO. V I Building Inspector: A61 DEC 5 2022 d fh................ M ..... if RUH -T -D= Jp� 0 th" whe,s-�' - - e- ,xu orria on=or%, e�comn ------ 0 F S'01:TH,f)L D Date: ....................................................... ........................................ ow .............................................. .. ,-n Name:, SCTM#1000- Project Address: S Phone#: 10�k g—i Email: s.vv%-am L 0 ale coq-VyMailing Address: U(jc,- o C\ Name: ,.,. M a ilin gAd d r es s Phone#: o c1t qu— �Cd�S Email: r VV,- L rYVI 14S Name: Mailing Address: Phone# 0 NMAM T Re Name:-- LA-U4• Mailing Address: Phone#: Email: \P"0—r VV% C� 'T E]NewStructure ElAddition OAlteration Repair ElDemolition Estimated Cost of Project: Elother V\) $ z)q Will the lot be re-graded? [:]YesHNo Will excess fill be removed from premises? E]Yes 0No )�vvvi,&V CC-,(� �ICLC41J r-J,,- Ck-p- DocuSign Envelope ID:BOD44FA8-C774-4098-957C-3F325D883987 a ; :-' yyg pp,}p{,�ulgnYy� Yyr.■�,y� �r �F•;-:;fit::,: '^'%N• 14�.'C+91•.3'"'f.' L:wP i Existing use of property: ^�" �` „ Intended,use of property: Zone or use district in which premises is situated:: Are there any covenants and restrictions with respect to this.property? E]Yes C No IF YES, PROVIDE A COPY. +\: v r f' .. " � �-''t!"d' -std` "1-11,1",,:',.:...... �.,p.. �M�`7Wx��.•n, r�ror�Idssd.�a % 31�I'tes 23S'aft,p�,,' tlWtf, e,.FAt?•.'iGAiTIC? $ )w l„ Q 'KKf 1 ltlltt ':: V 1 i28 . ,, t! tS d :.n.a .;. ;,•,; (� ,.. i., iii;a .�lE?`I5Sl1StXit (t ;`CT11Sd�Si3il .i!!'. '$titll �tN1L;" C1Fiiln nr�rsfth tnvun:r�f;5rei�;k�W s;Suiolk;Qpu ity;NeW,Yift ar ii`zitber f <bie;l is`:Qrdi»as ccs ai:�i fat#oris':fci :!#e-caasu a o b si`': "i<,:i'.�Y.,%..1;....,a-„�;n ::•.,� ..,ie,:nn!�..:.:�:` .(,:: '''-::it:-..•:i:, - .r,,;..,r��n..,.:.;..��'::_ .:.'ri`::%;.,:.::�. .: 'i. midi lani;al satior+s'r�r'. c rerriiival,or ifi i»ittlti to�s h r itt;ies�c 4`06,:ippGtP"greesto;r�mpE i(2ith^ali 'ptt b ;b +s;.ord naiices;;huitdua rrirle, housing"46r diacid ilt�uthorzje/nproi#14e4-�ntl i i I sy for hoos""s ,443 :triad 1rey�tn,a e ia3s.A rs►Isd 'ms arrt� 'r$p nk io;°" '£vis 210.45 Cof i" W Ys�rk' t ,. ✓ is Application Submitted By(plrint name):. v�r^�.t e W•"` PAuthorize+d Agent ❑Owner Signature of Applicant: 6 - Date: STATE OF NEGRK) SS: COUNTY OF �� ) being duty sworn,deposes,and says that(s)he.is the applicant (Name of individual sign ing'contract) above named; (S)he is the (1 ` (Contractor,Agent,Corporate Officer,etc,) of said owner or owners,and is duly authorized.to perforin or have performed the said work and to make and file this application;that all statements contained in.this applicatiorn.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 S day of. __G�/ s_t/l N> t+r .201 . SPENSER R BULMER NOTARY PUBLIC PROPERTY OWNER AUTHORIZATIM Guilford County,NC (Where the applicant is not the owner) My Commmian txpitft AUGUST 24;2027 (--residing at QvM t" A ur_- do,,hereby authorize t�;ria a�` G�)` kR `Qcr -rV1"', 4s to apply on m ARAW %the Town of Southold.BuildingDepartment'for approva#'as described herein.. 4r�-�Q 11/22/2022" Owners Signature {fate Prl t Owner's Name 2 DATE(MMIDWYYYY) ACOSPRV CERTIFICATE OF LIABILITY INSURANCE .. THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION (jNLY,ANb CONFERS 8 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)musVhaVe,ADDITIONAL,INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the,terms,and conditions of the,policy,certainpolicies may require an endorsement. Astatement 6n this certificate does not confer rights.to the certificate holder in lieu of such erid6irsernent(s). PRODUCER CONTACT MARSH USA,INC. NAME: ------- PHONE FAx TWO ALLIANCE CENTER' 3560 LENOX ROAD.SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: ............ INSURER 5 AFFORDI NO COVERAGE MAIC A CN101642U9-HomeD-GAW.-22-25 INSURER A: Old R NcJnuianceCo .............. INSURED INSURER 4: New I Hamushire jDa C . 23841 THE HOME-DEPOT,INC; HOME DEPOT U-S-A,,IK `'212667. 2455 PAGES FERRY ROAD INSURER 0: -BUILDING C-20 .......................................... -ATLANTA,GA30339 _INSURER 5: ............ INSURER F: COVERAGES CERTIFICATE NUMBER: ATLa5314714-02 REVISION NUMBER: i THIS'S 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 ORMAY PERTAIN, THE INSURANCE,AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.,LIMIT,S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. f0R7___ X66C&IJUR POLICY .............. ...... LTR; TYPE OF INSURANCE INSD wVD POLICY NUMBER I(AwAl (MM LIMITS A X comMERCIALGEN15RALUABILITY 'MWZY 316548 1 03/01/2022 0310112025 EACH OCCURRENCE _b;W�Gff'yO'Rff VEff, L !'CLAIMS-MADE' 09CUR PRFMIsESIEaocc'Urrbnce) $ X SIR!$`1,000,000 MED EXP one person) $ EXCLUDED ............... PERSON L&ADVINJURY ... ........................................... .......... r*GEN'L AGGREGATE LIMIT APPLIES,PER- GENERAL AGGREGATE PRO- PRODUCTS'CQM!�qPAGG POLICYE]JECT I.00 OTHER: A AUTOMOBILE LIABILITY MWT9316649 0310112022 0310M025. COMBINED SINGLE LIMIT ......1.003,000 ......... X i ANY AUTO SELFINSURED AUTO PHY DMG BODILY INJURY(Per parson) $ SCHEDULEDBODILY AUTOS ONLY AUTOS INJURY(Per accident) $ i HIRED, i NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY 1 AUTOS ONLY I 11 $ A i UM13RELLAUAS X OCCUR MV4ZX 316647 OwQwOk 03/0112025 . ',EACH OCCURRENCE 10.000,000 X EXCESS UAB CLDE $ AGGREGATE, 10,000,000 �IMS-MA I DE07=_RPENTION 51. 1 B !WORKERS COMPENSATION we 065886029 ;PER OTH 103101/2022 103161/2i]123 X 1 LtASILITY. STATUTE L AND EMPLOYERS' C IANYPROPRIETORIPARTNERJEXECUTIVE Y 1 N 1 WLR C68916409(AZ,IL) 1 03/0112022 03101/2023 E.L.EACH ACCIDENT $ 1OFFICEWMCIVISEREXCLUDED? 51 NIA ------ ...... .......... (Mandatory In !Continued on Additional Pa9e E.L;DISEASE-EA EMPLOYEEI$ 5.000,000 If s;describe under z 5,000,000 E.L DISEASE-POLICY LIMIT $ OACRIPTION OF OPERATIONS"below DESCRIPTION'OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be a6chad If more space Is required) CER itICATE HOLDER IS INCLUDED AS ADDITIONAL L INSURED IF REOUIRE0 BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPEC'I'TO LIABILITY ARISING OUT OF THE OPERATION'S OF THE NAMED INSURED. CERTIFICATE.HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE A13OVE DESCkIBED'P'0LICies BE CANCELLED 13EFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I PO BOX 1179 ACCORDANCE WITH tHIEVOLICYPRbVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE 11+ of Marsh USA Ivid. 0 198, 8;.2016,.ACORD,CORPORATION. All rights reserved. ACORD 25 J2016/03) The ACORN.name,and logo are registered marks of ACORD arkers ' CERTIFICATE-OF , ATE : 1 >s ioISYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name&Address of insured(use street address only) 1b.Business.Telephone Number of Insured Home Depot USA,Inc. 770-433-8211 l 245:5)Paces Ferry fed_,C-20 Atlanta,CA 30339 1c.NYS.Unempioyment Insurance Employer Registration Number-of 1 insured I 76011130 i work Location of insured(OpIy-required If coverage is specifically limited to ! 1d..Federal Empioy&Identification Number of Insured or Social Security r i contain locations in New York State,i.e..,a Wrap-Up Policy) 'Number 58-1863319. 2. Nance and Address of Ehtity.Requesting Proof of Coverage 3a.Name of Insurance:Carrier (Entity Being Listed as the C:ertlficate Holder) New Hampshire lnsurance Company Town of Southold 3b.Policy Number of Entity Listed in,Box"la' 53095 Route 25 Southold,.NY 11971 WC 065886028 130. Palicy effective period J D3/O1J2022 to 03101/2023 3d.-the Proprietor,Partners or Executive Officers are ®Included.(Only oheck boxif Al partners/officers included) I [:]'all excluded or.certain partners/officers excluded. L_. 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: (Touse 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.Insttrance 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,xeasons other,thari,rionpayment of premiumsthat.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 b' 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 luau. Under penalty of perjury,I certify that,l am ani authorized representative or licensed sgent.of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved,:by-. Michael Price ((Print narne of authorized representative or licensed agent of insurance carrier) Approved by: '02/07/2022 (Signature) (Date) Title: CEO North.Arnerica 212-770=7000 Telephone Number of authorized representative or licensed agent of insurance-carrier: Please (dote: Only insurance carriers and their licensed agents are authorized:to issue Form C-106:2. Insurance brolcors are NOT authorized to issue it., C-105.2 (9-17) www,wob.ny.gov AGENCY,CUSTOMER,10: CNI61642069 .'LOC#: Atlanta ADDITIONAL REMARKS SCHEDULE Page 2 Of 3 AGENCY MARRED INSURED' MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A„INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 -- ATLANTA,GA30339 CARRIERNAiC'CL1DE i0ECTiVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM 1S.A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier.Indemnity Insurance Company of North America Policy Numtier:WLR C68916483(AOS).(AL,AR.FL,iD,IA,KS.KY,LA,MB,MO;NC,NE,NLI,ND,OK,S,G,SD,TN,VA,VV'V,WY) Effective Date:03/01/2022 Expiration Date:03f0i12023 (EL)Limit:$5,000,000 Carrier:AiU Insurance Co. Policy Number:WC 065886028(AOS) (AK,CO3DC,DE.HI,IN,MA,M0,ME,V�N,MT,NN,NJ,NY,PA,RI,VP) Effective Date:0310112022 Expiration Date:0310112023 i iEL)Limit,55,000.000 1 t Carrict:ACE American Insurance Con' any Policy Numher:WCU C68916446(OSI)(CA,OR,WA} i Effecove Date:OT0112022 f Expiration Date:03!0112023 (EL)limit.4.000,000 SIR:$1,000,000' . , Carrier:National Union Fire insurance Company Policy Number:XWC 1647323(QSI) (CT,CA,f 9l,NV,QH,UT) Effective Date:0310112022 Expiration Date:6310112023 (EL)Limb:$4,000,000 SIR:S1,000,000 SIR(CT)'.$350,000 SIR(GA):5750,000' TX Employers XS indemnity:, CarrierIllinios Union Insurance Company Policy Number:T NSC68%1006 (TX} ENei•five Date:0=12022 Expiration Date:0310112023 (EL)Limit:$6,000,000 SIR:55,009,000 i { ACORD 101 (2008101)" 0:2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are_registered marks of ACORD AGENCY CUSTOMER 10: CN101642069 LOC : Atlanta . ADDITIONAL REMARKS SCHEDULE Page 3 Of 3 AGENCY NAMiD IWSURED. MARSH USA,INC. THE HOME DEPOT;INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDINd C-20 CARRIERNAtC a;ODE ATLANTA,GA,1035q ; EFFECTtyE OATS: ADDITIONAL REMARKS ' THIS ADDITIONAL REMARKS FORM IS A SCHEDULE'TO AC.ORD FORM,, FORM NUMBER: _ 25 FORM TITLE: Certificate of Liability Insurance ,a HOME DEPOT iNSUREW" The Home Depot,Inc. Home Depot USA.,Ina Horne Depot U.S.A.Inc,d"aa The Horne Depot Home Depot o3 Puerto Rico,Inc. Homs;Depot Product Authority,I.I.C. Homo Dapo;Store Support,Inc. Red Beacon,LLC H.D.W,Holding Company,lrc; Askuity,Inc. Home Depot Management Company,LLC i ACORD 101 (2008101) 0 2008 ACORD CORPORATION`. All rights reserved. The ACORD-name and logo are registered,marks of ACORD CERTIFICATE OF INSURANCE-COVERAGE 1,a DISABILITY AND OAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid.Family Leave'Bertefits Carrier or Licensed.lnsurance Agent of that Carrier 1a.Legal Name&Address of insured(use street address only) I b.Business Tetephone`Nurnber of insured HOME DEPOT U.S.A.,INCy, . 446-$07-71193, . 2455 PACES FERRY ROAD NW ATLAM1 TA,GA 30339 1c.Federal Employer id.6htificatlon Number of Insured or Social Security umber Work Location of Insured(Only required if coverage is specirically limited to certain locations in ldew York State,i.e.,Wrap-Up Policy) 5$1$5331 , 2.Name and Address of Entity Requesting Proof of a Name of Insurance.Carrier Coverage(Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD HARTFORD LIFE AND ACCIDENT 1 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"1a" SOUTHOLD, NY 11971 LNY713657 i c Policy effective period '01W01-2022 to 12-31-2022' 4.Policy provides.the following ben®fits: ®A.Both disability and.pald family leave.benofits. ®.B.Disability benefits only. C.Paid family leave benefits only. 5.Poll overs* ❑� A.All of the employer's employees eligible under the NYS Disability and Paid Family_Leave Benefits Law. F]B.Only the following class,or classes ofempioyer's employees: Under penalty of perjury,I certify that.i.am an authorized representative,or licensed agent of the,insurance,carricr referenced above and.that the named Insured Disability and/or Paid Family Leave Benefits insurance.,coverage as.described.above. Date signed 2-29-2021 F& + 0 ?' j (signature or insurance carrioes.authorized representative or NYS Licensed insurance Agent of that insurance carrier) Telephone.Number,(212)553-6074 Name and Title:Elizabeth Telto-Assistant Director;Statutory Services IMPORTANT: if Boxes 4A'and SA are checked,and.'this form.is signed by the insurance carrier's authorized representative or.NYS Licensed insurance Agent.nf that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder, i If Bou 4B,4C'or.SB is checked,this certificate is NOT COMPLETE.for purposes of Section 220,Subd.,$of the NYS Disability,and'Paid Family Leave Benefits LaW.:lt must be_malled for aoiripletion to theWorkers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13$02-5200. PART 2.To be,completed by the.NYS Workers' Compensation Board (Only if Box 4C or 513 of Part 1 has.been checked) State.of New York W rkers' Coimpensati+on Board Ac%cording to information maintained by the NYS Workers'Compensation Board,the above-named etiiplayer has complied with the NYS Disability and Paid Family Leave Senefits Law with respect to all of his/her employees. i pate Si ned By (Signature of Authorized NYS Workers'ComponsaN6h Board Employee)• Telephone Number Name and Title Picose Plots:Only Insurance carriers liaonsod to write/VY8 disability and paid family leave bonaflts hisuranca Policies and,NVS 11censed Insurance agents of those insurance carriers are authorized to-issue Form DB-920.1.Insurance brokers are NOT authorizer!to I}ssueQQ'jth]]is form. j� jj!! DB-120.1 (10-17). Additional linstirudians f'or' F&m DBA20.1 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 disab.1fity and/or paid family]eave 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 mustnotify the above certificate(folder and the Workers'Compensation Board Within 10 days IF a policy is cancelled,due to r7onpayment of premiums or within 30.days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate.the'insured from coverage indicated on.this Certificate.(These notices my be sent by regular mall.)©therwise,•this Certificate is valid.f6r 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.matterof information'only and confers no rights'upon thecertificate holder.This certificate does not amend, extend or after the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in-the referenced policy. This certificate may be.used,as evidence of a Disability and/or raid 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 coritract 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 uvith the.mandatorycoverage requirements of the New York State Disability.and.Paid Family Leave,Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFIT4 LAVIif' §220.'Sdbd. 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, tw,o.thousand eighteen,.the-payment of family leave benefits for all employees has been secured as provided by this article. DB420.1(10-17)Reverse c� RI�CEIPT . SUFFOLK.C.00NTY GOVERNMENT . DEPARTMENT OF LABOR; LICENSING,AND C©NSUNIER AFFAIRS COMMISSIONER ROSALIE DRAGO P.0,BOX.6100,HAUPPAUGE,NY 11788 {531)853-46x00 Today Date._ 10/2212020 Application. H-53429 H"ome;Improvement License Application Typo: Receipt No. , : 4141741'' Comments Arrrourtt Paid - Payment Date Cashier ID, RefRenewal 14 Atlditianai payment'Method- ;Number OAS: Check 0003181507 $1,,800,00 1,Ot2212020 Locations _ Contact Ingo: HOME DE MEDET US INC (14 SUPPS) RI I PG 130)(1'05451 ATLANTA;GA 30348 111Inrk Description: 22`" . Suffolk County Dept.of Labor,i.lcer sing&Consumer Affairs c: HOME IMPROVEMENT LlC> NSE Name. .. i WdHARD.TQ6,5EY Dttsiness Name, Thisckfius that the HOMO bFPaT,USA INC,(14 SUPPS) barer is duly licensed by ttte.county of suNolK. License Number.N-53429 Rosalie Drago Issued. 05/15/201 1 Cnmrriissioner. Expirds., 1110-112022 1 , f Go Permits, LLC ® 105 Buttonball Ln. Glastonbury, Ct 06033 j e e I "WE UNDERSTAND THAT YOUR TIME IS MONEY" To Whom It May Concern: Enclosed you will' find a building permit application and check. If you have any questions regarding this application, feel free to call me at the number listed below. Please note the following: • Please mail original permit to the owner. • Please e-mail a copy of the permit and receipt to: Email: permits@gopermits.org Thank you! ; ) LS UM , Jennifer Winke, Permit Expediter 3 DEC 5 2022 Go Permits, LLC Phone: 303-946-8685 Fax: 866-697-0768 7-74 1T, ,Tai.1E,T, . jenniferwinke@gopermits.org.. TC_'t7 Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org rt �� Home Improvement Agreement: Page 1 Home Depot License#'s-For the most current listing visit www.Homedepot.com/LicenseNumbers NY: Amherst HI-04712, Lockport 2395; Buffalo LT12-10023782, City Tonawanda 33257, East Hampton 4499, Long Beach 4917, N. Tonawanda 368.16, Nassau County H1171050000 - H1771053000, New York City 0900456-DCA, 900457-DCA, 0900458-DCA, 0910621-DCA, 0910622-DCA, 0920734-DCA, 0922474-DCA, 0968605-DCA, 1003822-DCA, 1003823-DCA, 1003825-DCA, 1003828-DCA, 1003830-DCA, 1003833-DCA, 1026224-DCA, 1075580-DCA, 1129555-DCA,1129556-DCA, 1129557-DCA, 1129562-DCA, 1129564-DCA, 1133444-DCA, Adam Friedman Salesperson Name Registration # (Req.in CA,CT,ME,MD,MI,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, terms and conditions as outlined on this form. iY.:.Service:Provider Contact,Iriformation - - _i The Home Depot I IThe Home Depot Service Provider Contact Name Service Provider Company Name (774)275-2175 customercancellationnortheast@homede I NY:Amherst HI-04712, Lockport 2395; Buffalo LT12-10023782, Phone# Service Provider Email Address Service Provider License#(s) 2:-Customer Infos"oration., ___ _. Webster lynne New England South F29485098 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 665 Gillette Drive East Marion NY 11939 Customer Address City State Zip (631)871-8347 j wwsmoml023@hotmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address 3:NOTICE OF RIGHT.TQ.CANCEL; " YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT: customercancellationnortheast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: ...., 11t S 11/15/2022. Customer's Signature Date 460 Standard Fornn H1A(21 Jul e21 E � ® D P,t' /� j` &Zed .je j��0�02z 7a:�. 4b`P�1 A .e #j v 0.1.12 �L '4L� i 1� Home Improvement Agreement: Page 2 of Wo 'to be Perf 4.Description r w o med.... : 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. 15 Anticipated Deliver "Date J TnstaIlatianSoli"educe - -: .� Approximate Start Date: 05/14/2023 Approximate Finish Date: os/13/2023 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for Vany repair, if applicable _w_.�• _W- W 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 communications related to this Agreement. By contacting your Service Provider,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that,you have access to a computer that can receive and open emails and PDF documents. 7.-Contract Price and Payment Schedule;.: Payment of the Contract Price is due upon signingunlessa different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 12495.11 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable, total amount of taxes included in Contract Price) *Maximum deposit ONLY applicable in MD,MA,ME (33%), NJ, WI(99%) Deposit% 25.0D99sit Amount$ 623.78 Remaining Balance $ 11871.33 _...... :$.Finance Char es 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.Acceplance`and A"uthori"zation 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. X11/16/22. Customer's Signature Date X /s/The Home Depot 11/15/2022 The Home Depot Digital Signature Date For questions related to your installation, contact Service Provider at (774)275-2175 For any other concerns, contact The Home Depot at 1-800-466-3337 460 Standard Form lllA(21Jul�l)(E �Q 'A.������ / �/ ted ate ��q 0Z � ,yLe # gqg � v 0.1.12 Road APPROVED AS NOTED r�t� DATE I-I� a3 B.P. #=1.(LL i COMPLY WITH ALL CODES OF x50.06 BNEW YORK STATE & TOWN CODES NOTIFY BUILDING DEPARTMENT AT AS REQUIRED AND CONDITIONS OF 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: ^, SOUTHOLD TOWN ZBA 1. FOUNDATION-TWO REQUIRED $' FOR POURED CONCRETE SOUTHOLD TOWN PLANNING BOARD 2. ROUGH-FRAMING,PLUMBING, " STRAPPING, ELECTRICAL&CAULKING SOUTHOLD TOWN TRUSTEES 3. INSULATION 4. FINAL-CONSTRUCTION &ELECTRICAL N.Y.S.DEC MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE ' REQUIREMENTS OF THE CODES OF NEW ' YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. Andersen Wood SPEC SHEET SC-. Adam Friedman Measure Tech: INSTALLER: Branch Name: New England South Job#: F29485098 Prepared By: ISM: Ship To Location: Customer Name: lynne will Date: 11/15/2022 Page 1 of 1 SPEC SPR SHEET# REF# hw,%MD bW ium .71 7-1, qCK Op1mistIq v I lot (Tro;Ii, WH olrffi 09 J" 0, FULL whis pece dude 4 um� SAs14 LIFT BASe 0 P11 Ns oft dd n ME' WMI VSW1:sl Gas- J�elilsift.Window. z AndersenBase TSM x1l 'A'k4lit-WTV 'idkripl.11P) M cam"aiiiiii'l Mill ociv PE SIM EASUMTECH Vn;ONLY.ONLY400il O*P 0*196 OpsUnd(PER SASH PfIl OP4 OPTIC TOTAL MT/ISM Location Existir� Series UI Standard Q.rs #8— Pattern MISC TW So 1 11..'s " I Finish Labor Stenciler, (WID Grid Exterior Interior Hod. H.dz Wild,, Type Liner Size AW CODE WALL SILL Sash Hill Tell Type Grid Grid' Pattern (per (per call Vert (Per Location Obsc'uni h Vert F'oe Code CODE Well Exton "erij Color Code ...an Lo or(Per Finish Finis am Fills Roo style Col. C-10 Color HEIGHT Width Height DEPT ANGLE Split Venting Handing Style CODE Options CODE Color Color CODE sash) sash) CODE Sash) Sash) CODE CODE CODE CODE 00 Widtj Heigh CODE Type CODE Type CODE.C01= 1 KIT 1st SB- 400 AWN-WH JAH 1 35 35 70 x E5-N none WH 11. WH STD WH S700L, CH AWN O-FF H H i..... WRAP let PojectbnAogIe:(l1ay.30-or45-j Top of window to I(hore Bay Wildaw Flank—(DH/casement) Width of Overhang(inches) C-Mot.Fool I(Y./No) If bad to sore.calor of Soffit material I Thera bno g—Me the.—.rg-wi maro.-Ulg i'- WINDOW "SURE x Aricallal" kit W E,:,Icolor a Hinged!arA Gliding W1, SA SASH PR CiW). OPTIO!, PD Northam Asserltil ES? TOTAL (200, Note: Location UI Rol Gliding Hinged 4l ...Is Intel., Inswing PD PD soled.o F�cisting Series Exterior Finish Standarc (WIDTHTIP Extensior Exterio Interioi #Bar-"B" Door Door A-Ser Lock Optional anomer Door Type Style Color Color Size AW to Jamb Jamb Grid Grid Patter lert(PI Scree r IN or # Venting d Venting, gliding HRDWF HFDWF Keyed Mulled I Special regional `-P`*y Roo Floo Code CODE CODE CODE CODE Code Width He] TIP Sin Location Color Color CODE Sash)on( panel, Type tube? Profile Grid Saz+..DE CODE OUT Handing Handing only) ..k Type Heigh HEIGHT Width Heigh' 1 -1 C..j Finish Lock Stacked Notes MISC Labor Item CODES No Yes Width boxes color 44 Approval Piril lynx, webster Tire Home Owner m vStR fir' t3Y� t�q Glass z Prr •a� n C) U t y-�iiFa ' - .:>.'f!?'•,:ri,. �It9:'S..-yi•:t•t"ia'tP�•.r�� .;CSX°�"J'c'Gs>:C=:;:y`^s;:=t•" _`,rte:. �T. 'cv':rY-u1"?'.:::P=e..;:a:��.,.__..,.. .. ti L tr:.F'r mfr`t,>.','.`, • t'C;c'. 2:2%1nDeaFedlGiass�-; o'M' a• �,�, -*;,:•,',3.,r, �,. a:c,'.�•.,; Ies�andisn�tes.Gessilhan;t� p-�,•�,.F.r, ,,�r�r +,'++ •^ "_�f:.x7--� No Grilles AND-N-2-01430.00001 0.28 1.59 0.31 0.53 23 <p-2 Y w Simulated Divided Lite or Installed Interior Removable AND-N-2-0143040002 0.28 1.59 0.28 0.48 21 -0.2 - - - Full Di fired Lite AND-N-2-07448-00001 0.29 1.65 0.28 0.48 20 <0.2 Ffnelight"(grilles-between-the-glass) AND-N-2-01436-00001 0.28 1.59 0.28 0.48 21 <0.2 No Grilles AND•N-2-07431-00001 0.28 1.59 0.19 0.29 16 <0.2 - - - ,za.. w e Simulated Divided Lite or Installed Interior Removable AND-N-2-01431.00002 0.28 1.59 0.18 0.27 15 <0.2 - 3 ' ~+ Full Divided Lite AND•N-2-01449-00001 0.29 1.65 0.18 0.27 14 <0.2 NG - 4 Finelight^'(grilles-between-the-glass) ANbN-2-07437-00001 0.28 1.59 0.18 0.27 15 10.2 - NG ,a- No Grilles AND-N-2-07432-00001 0.27 1.53 0.21 0.48 78 40.2 NC - �ci ne euai Simulated Divided Lite or Installed Interior Removable AND-N-2-01432-00002 0.27 1.53 0.19 OA3 17 <0.2ME .q I 3 3 E;; Full Divided Lite AND-N-2-01450-00001 0.28 1.59 0.19 0.43 16 <0.2 - NG 31 - - '�9 Finelight"'(grilles-between-the-glass) AND•N-2-01438-00001 0.27 1.53 0.19 0.43 77 40.2 N,G•� �t No Grilles AND-N-2-01429-00001 0.29 1.65 0.51 0.59 33 <0.2 - - - euvt 3 Simulated Divided Lite or Installed Interior Removable AND-N-2-01429-00002 0.29 1.65 0.47 0.53 31 <0.2 - w 3 3. Full Divided Lite AND-N-2-01447-00001 0.79 1.65 0.47 0.53 31 <0.2 - - - - i FinelightT (grilles-between-the-glass) AND-N-2-01435-00001 0.29 1.65 0.47 0.53 31 <0.2 - s No Grilles AND-N-2-01531-00001 0.25 1.42 0.31 0.52 27 <0.2 IC' - t.< w Simulated Divided Lite or Installed Interior Removable AND-N-2-01631-00002 0.25 1.42 0.28 0.47 25 <0.2 - 3 = Full Divided Lite AND-N-2-01560-00001 0.26 1.48 1 0.28 0.47 24 <0.2 - 3 Finelight"(grilles-between-the-glass) AND-N-2-01534-00001 0.25 1.42 0.28 0.47 25 <0.2 No Grilles AND•N-2-01532-00001 0.24 1.36 0.20 0.47 22 <0.2 NC E x - w c � Simulated Divided Lite or Installed Interior Removable AN0.N-2-01532-00002 0.24 1.36 0.19 0.42 21 -0.2 rn= Full Divided Lite AND-N-2-01541-00001 0.25 1.42 0.19 0.42 20 <0.2 NG 400 Series Awning 3 t Firelight-(grilles-between-the-glass) AND-N-2-01535-00001 0.24 1.36 0.19 0.42 21 <0.2 No Grilles AND-N-2-01530-00001 0.25 1.42 0.47 0.57 36 <0.2 'L c Y u+ as w � o Simulated Divided Lite or Installed Interior Removable AN0.N-2-01530-00002 0.25 1.42 0.43 0.52 34 <02 - - - 3 2 d o x Full Divided Lite AND-N-2-01539-00001 0.26 1.48 OA3 0.52 32 <0.2 - - o. 8 Finelight-(grilles-between-the-glass) AND-N•2-01533-00001 0.25 1.42 0.43 0.52 3d <0.2 - - - ;f��,.0.t'I. a.f.a _ q.tw)-.:�+h,:kwl•: r.{.., %.p,:; ..Jyt7t:+�1�Y;::';iai rtr,:: rMir2<: ;;:ry.�.. .,ir,: -- ' .:h 2:2.Aniieitei7�C�2ss��:wl:6ii9es^I Oti'Greatei r 'c; _ '.ia�"a. '..'�;�;,'.•;?n:::' , r.r Simulated Divided Lite or Installed Interior Removable AND-N-2-0143040003 0.28 1.59 026 0.43 20 c 0.2 w 1 3 Full Divided Lite AND-N-2-01454-00001 0,28 1.59 0.26 0.44 20 <0.2 � - - o Finelight"(grilles-between4heyiass) AND-N-2-01442-00001 0.29 1.65 0.28 0.48 20 <0.2 - NC - Simulated Divided Lite or Installed Interior Removable AND-N-2-07431-00003 0.28 1.59 0.16 0.24 14 -0.2 - fiC, - - w 3 N Full Divided Lite AND-N-24145500001 0.29 7.65 0.16 0.24 73 <0.2 - NC - - av Firelight"'(grilles-between-the lass) AND-N-2-0144300007 0.30 1.70 0.18 02713 j!C - t - ® c Simulated Divided Lite or Installed Interior Removable AND-N-2-01432.00003 0.27 1.53 0.17 0.39 16 <C I, - - w G,•. Full Divided Lite AND-N-2-0145640001 0.28 1.59 0.17 0.39 15 <0.2 - o FinelightTM(grilles-between-the-glass) AND-N-2-0i444-00001 0.29 1.65 0.19 0.43 15 <0.2 Nd - - Simulated Divided Lite or Installed Interior Removable AND-N-2-07429-00003 0.29 1.65 0.43 0.48 29 <0.2Zr - e 3 i Full Divided Lite AND-N-2-01453-00001 0.29 1.65 0.43 0.48 29 10.2 J o. Finelight" (grilles-between-the-glass) AND-N-2-01441-001701 0.30 1.70 1 0.47 0.53 30 <0.2 - t s Simulated Divided Lite or Installed Interior Removable AND-N-2-01531-00003 0.25 1.42 0.26 0.43 24 <0.2 3 = Full Divided Lite AND-N-2-01543.00001 0.26 1.48 0.26 0.43 22 <0.2 3 Finelight"(grilles-between•th"lass) AND-N•2-01537-00001 025 1.42 0.28 0.47 25 <0-2 A - - a s Simulated Divided Lite or Installed Interior Removable AND-N-2-01532-00003 0.24 1.36 0.17 0.38 20 <0.2 - ea 3 r u Full Divided Lit. AND-N-2-0154400007 0.25 1.42 0.17 0.38 19 <0.2 NC - D = 3 Finelfght^(grilles-between-the-glass) AND-N-2-01538-00001 0.25 1.42 0.19 0.42 20 <0.2 This information is for reference only. Performance varies b unit size and options selected. page8 of 155 Data cu mt as of Deceunbc S5.apa entl iss f-ati- y pSee page 1 fo.....nformation. For specific unit performance information,please contact your dealer or Andersen Sales Representative. P