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HomeMy WebLinkAbout48739-Z Town of Southold 6/17/2023 $ P.O.Box 1179 0 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44199 Date: 6/8/2023 THIS CERTIFIES that the building ALTERATION Location of Property: 4550 Paradise Point Rd, Southold SCTM#: 473889 Sec/Block/Lot: 81.-3-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/2/2022 pursuant to which Building Permit No. 48739 dated 1/17/2023 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: interior alteration to existing single family dwelling as applied for. 6/17/2023 Corrected for Certificate of Occupancy number only. The certificate is issued to Horvath,Robert&Mary Ann of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 48739 5/3/2023 PLUMBERS CERTIFICATION DATED 6/6/2023 d Piecuc t z Signature S�fFO Town of Southold 6/8/2023 y P.O.Box 1179 0 53095 Main Rd oy o� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44149 Date: 6/8/2023 THIS CERTIFIES that the building ALTERATION Location of Property: 4550 Paradise Point Rd, Southold SCTM#: 473889 Sec/Block/Lot: 81.-3-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/2/2022 pursuant to which Building Permit No. 48739 dated 1/17/2023 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: interior alteration to existing single family dwelling as applied for. The certificate is issued to Horvath,Robert&Mary Ann of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 48739 5/3/2023 PLUMBERS CERTIFICATION DATED 6/6/2023 Piecuch th riz d ignature �o�SufFoc,��o. TOWN OF SOUTHOLD ay BUILDING DEPARTMENT C, x TOWN CLERK'S OFFICE "o • ,` 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 #: 48739 Date: 1/17/2023 Permission is hereby granted to: Horvath, Robert 111 Brompton Rd Garden City, NY 11530 To: Construct interior alteration to existing single family dwelling as applied for. At premises located at: 4550 Paradise Point Rd, Southold SCTM #473889 Sec/Block/Lot# 81.-3-5 Pursuant to application dated 12/2/2022 and approved by the Building Inspector. To expire on 7/18/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $294.40 CO-ALTERATION TO DWELLING $50.00 Total: $344.40 Building Inspector pE SO�jyol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.deviin(-town.southold.ny.us Southold,NY 1.1971-0959 QIyCOU�'�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Robert Horvath Address: 4550 Paradise Point Rd city:Southold st: NY zip: 11971 Building Permit#: 48739 Section: 81 Block: 3 Lot: 5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: RoSlak Electric License No: 3677ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor 1st Floor Pool New X Renovation X 2nd Floor X Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt 6 Ceiling Fixtures Bath Exhaust Fan 1 Service 3 ph Hot Water GFCI Recpt Wall Fixtures 1 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures 13 CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 6 4'LED Exit Fixtures Sump Pump Other Equipment: Notes: Second Floor Bath & Office Inspector Signature: Date: May 3, 2023 S.Devlin-Cert Electrical Compliance Form . . •.�o��OF SQU���f . Town Hall'Annex Telephone(631)76: 54375 Main Road Fax(631)765-9.- P.O. 65-9:P.O.Box 1179 Southold,NY 1197143959 O BUILDING DEPARTMENT TOWN OF SOUTHOLD j JUN - 7 2023 CERTIFICATION Date: 64/2-3 Building Perrnit No. 7 t�— Owner. �VAJk) 1011 (ple Plumber�`C"� (Please ice) I certify that the solder used in the water supply system contains less than 2110 of 1% lead. (PIum zs Signature) Swam to before me this day of�u 11 , 2t0 a3 SUSAN A.R1Z?© 1o�ary PON'C: e of 1J.e�+Yark t do•ql R16133459 -aq-,,gad ad in 8uifal°�county_-.. _ cotnrrissian E;;p=res lv3arch i7,2 , Notary Public, „ IL/. ' County laf so # # TOWN 01OUTHOLD BUILDING DEPT. 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 [ ] PREnC/O [ ] RENTAL REMARKS: �f-�I(� e 4-rl G 0 DATE /Z-3 INSPECTOR O��DE SOUTyO - - -- -- # # TOWN OF SOUTHOLD BUILDING DEPT. courm, 631.765-1802 INSPEC T ON [ ] /FONDATION 1ST [ ROUGH PLBG. NDATION 2ND [ NSULATION/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: r ' OF V � I IIl(v roti � DATE c3 V l INSPECTOR �E SOUIyo� Y V 3g H J 50 f * TOWN OF SOUTHOLD BUILDING DEPT. 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: d' 00e r DATE Z INSPECTOR 0f S0UTyO� Ll t-7 31--- -- 15 60 ��-- M -y- * TOWN OF SOUTHOLD BUILD N DE4T.J coum, 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: Ard DATE c.� INSPECTOR OF so(/TyOlo L4 SS 07AIe�VlSf- �T 7— TOWN TOWN OF SOUfH0LD BUILDING DEPT. co 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: IeIe 72Qmg;�, w 17moo- — �lp"Al 7- M A-PPL y --!F0 La= R DATE S 3 INSPECTOR OF SOGIy�� * # TOWN OF SOUTHOLD BUILDING DEPT. °y ouKr+N�'a� 631-765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ Ipil4l,ULATIOWCAULKING [ ] 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: LIZ ke 1 DATE INSPECTOR SOl/1,�°lo TOWN OF SOUTHOLD BUILDING DEPT. Courm, 631.765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] R UGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLTib ION [ ] PRE C/O [ ] RENTAL RrMR M RKS: l DATE INSPECTORKy 4 MELD INSPECTION REPORT DATE " COMMENTS FOUNDATION (1ST)---------------------------------- S —�—Do FOUNDATION (2ND) Y l ✓w4 I of _C. 00 G � ROUGH F11,AM]NG& W PLUMBING lI vl tit Q� 'b 4� O z INSULATION PER N. Y. STATE ENERGY CODE N FINAL ADDITIONAL COMMENTS 0 19 "ell�l �� A'►'n M1M � 00 x x FFQ Gy TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy ® Telephone(631)765-1802 Fax (631)765-9502 httpg-.,//www.goutholdtownny,Zoy Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only IIS ((,Jj I� 111�1I� PERMIT NO. Building Inspector: 2022 qq DECClr Q LOLL 'Applications"and"forms must be filled'out in their entirety. Incomplete ¢RIILDINC3 DEPT applications will not be accepted'. Where the Applicant is not the owner,an TOWN OFSOUT1 OLD Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: SCTM#1000- Project Address: C�,Sa, v�°1 c IJP �tl�'i � /� - .10k-fad i✓ Phone#: �- Email: ol�vA1P CAlfle-,CO^ Mailing Address: R �S'✓ i�,f�T�.✓ ` n�,J (�7� /l/i- /y'' v CONTACT PERSON: Name: j��7„�- Mailing Address: Phone'#: ,—/6 Kj—J- IYZJ— Email: Q e►�, G, 1PUf CP (1 14 IL , lOra, DESIGN PROFESSIONAL INFORMATION: " Name: J`j—A-UJVIAI Mailing Address: -70 OP4*1?. 1 weLr C tPa/ G!f /7/ l t�3o Phone#: �/� �g� 3.y�� Email: d�G UfrAVJ0-1U e,6'041&A1`1ZzT-J. Cv,z) CONTRACTOR INFORMATION: Name: Mailing Address: �0�( � i 4Y- Phone#: S��C 3;U- IS-3 7 Email: (A-�lLi t=C Jr" his l t,� � 'f�iv�tr✓L;i✓c`r DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition YAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $ sl pL)® Will the lot be re-graded? ❑Yes XNo Will excess fill be removed from premises? ❑Yes ❑No 1 PROPERTY INFORMATION 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? ❑Yes ❑No IF YES, PROVIDE A COPY. 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.B �• �-o o 'tT pp y(print na ❑Authorized Agent Pbwner Signature of Applicant: 7 Date: CONNIE D. BUNCH STATE OF NEW YORK) Notary Public,State of New York No. 01 BU6185050 SS: Qualified in Suffolk County COUNTY OF ) Commission Expires April 14,2_caq being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (Contractor,Agent,Corporate Officer,etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all 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 p �rtOt day of 20 A�3- Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 BUILDING DEPARTMENT - Electrical Inspector � Io TOWN OF SOUTHOLD 'gCC4 /a3 CD Town Hall Annex - 54375 Main Road - PO Box 1179 co - Southold, New York 11971-0959 4,, �p� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr a(�sot.itholdtownny.gov seand(a southoldtownny.gov' APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: ` Company Name: �- Name: o License No.. 3477 IYF— email: Address: p. Phone No.:«3/) --S O JOB SITE INFORMATION (All Information Required) Name: '7 Address: Cross Street: f Phone No.:16163 —SZ 71 Bldg.Permit#: // 97--32 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: Is job ready for inspection?-. (;,YES NO ough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Request for Inspection Form.xls gFfitK BUILDING DEPARTMENT - Electrical Inspector 10— �F COG TOWN OF SOUTHOLD ':grCn y� Town Hall Annex - 54375 Main Road - PO Box 1179 T - Southold, New York 11971-0959 y p� Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrAsot.ttholdtownny.gov -- seandpsoutholdtownn ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Au Information Required) Date: Zv 23 Company Name: -IOIC� Name: ' o LicenseNo.- 77 email: Address: j?, Phone No.:/ 31, '7-3 — S C' JOB SITE INFORMATION (All Information Required) Name: T Address: Cross Street: Phone No.: 7� Bldg.Permit #: Z,32 email Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: ' Is job ready for inspection?: AYES NO o�hl Final Do you need a Temp Certificate?: YES 1 NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: J, 9 — PAYMENT DUE WITH APPLICATION Request for Inspection Fonn.As PERMIT # Address: Switches Outlets i GFI's Surface Sconces I H H's I � UC Lts Fans Fridge HW Exhaust Oven WAD I Smokes DW Mini Carbon Micro Generator Combo Cooktop Transfer AC AH Hood Service Amps Have Used Special: Comments i Suffolk County Dept. of Labor, Licensing & Consumer Affairs i HOME IMPROVEMENT LICENSE Name ROBERT E GABRIELSEN Business Name This certifies that the bearer is duly licensed' GABRIELSEN BUILDERS LLC by the County of suffolk License Number: H-36517 Rosalie Drago Issued: 02/03/2005 Commissioner Expires: 02/01/2023 YORK Workers' CERTIFICATE OF SPATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE hoard 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Gabrielsen Builders LLC 631-722-5130 PO Box 317 Jamesport,NY 11947 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Farm Family Casualty Insurance Company Town of Southold Building 3b.Policy Number of Entity Listed in Box"1 a" Department 54375 Main Rd. 3152W8527 PO Box 1179 Southold,NY 11971 3c.Policy effective period 11/28/2022 to 11/28/2023 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: (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 35�_ 4L L (Signature)) (Date) Title: Telephone Number of authorized representative or licensed agent of insurance carrier: 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 YORK workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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 1 a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured GABRIELSEN BUILDERS LLC 631-722-5130 P.O.BOX 317 JAMESPORT,NY 11947 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) 203687759 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 -Building Department 54375 Main Road 3b.Policy Number of Entity Listed in Box 1 a" PO Box 1179 DBL244040 Southold, NY 11971 3c.Policy effective period 11/28/2022 to 11/27/2023 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 above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above.. 9 Date Signed 11/28/2022 By Wad/ 4f (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat 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 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 issu'eI this foam. DB-120.1 (12-21) DATE(MMIDDIYYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 11/28/2022 `�- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must 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: Katie Jackson Brian Micena PHONE (631)821-2200 1FAX AIIC No): (631)821-2296 O,Moo 45 Route 25A suite D2 a DRESS: Katie.Jackson@Amedean-National.com Shoreham, NY 11786 INSURER(S)AFFORDING COVERAGE MAIC INSURERA: Farm Family Casualty Insurance Company 13803 INSURED INSURER 0: Gabrielsen Builders LLC INSURER C: PO Box 317 INSURER D: INSURER E: Jamesport NY 11947-0317 INSURERF: 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 POLICY NUMBER MMIOD EFF POLICY EXP LIMITS LTR A COMMERCIAL GENERAL LIABILITY 3152X2148 11/03/22 11/03/23 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR PREMISES Ea occurrence $ 100,000 X Contractors Advantage MED EXP(Any one erson $ 5,000 PERSONAL$ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECTPRO F—]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITYED Ee accident 3152C7227 02/06/22 02/06/23 cOMBINa,,tl SINGLE $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIREDX NON-OWNED PROPER`I DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION 3152W8527 11/28/22 11/28/23 XPER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N NIA E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBEREXCLUDED7 ❑Y (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Mae describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remoft Schedule,may be attached H more space Is required) Residential Carpentry Jobsite: Jerry Loveno 1320 Little Peconic Bay Rd, Cutchogue, NY 11935 CERTIFICATE HOLDER CANCELLATION Town of Southold Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE / ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD e16Le� Gustayson/Dundes 1 COPYRIGHT © 2022 ALL RIGHTS RESERVED APPROVEO AS NO EO 1 EXIST z f� DATE' B,p v CONSULTANTS: IEXIST FEE03Y 6 BY: NOTIFY'BUILDING DEPARTMENTAT 1 P,4NTR'1' cn EXIST 631-765-1802 8AM TO 4PM FOR THE X 1.0 FOUNDATION ETWO REQUIRED FOR POURED CONCRETE 2. ROUGH-FRAMING&PLUMBING 3. INSULATION 4. FINAL-CONSTRUCTION MUST REVISIONS: BE COMPLETE FOR C.O. I � — — — ALL CONSTRUCTION SHALL MEET THE EXIST CL EXIST CL X REQUIREMENTS OF THE CODES OF NEW Ll 1 RAF w SYMBOLS LIST 11 DESIGN OR CONSTRUCTON ERRORSYORK STATE NOT RESPONSIBLE n! — FIXTURE DESCRIPTION OCCUPANCY O I EXIST a D I I I 04 1 _ O A RECESSED DN LIGHT DOWNLIGHT LOCATION USE IS UNLAWFUL tr EXIST i I _ QD SCONCE MTP.DECORATIVE WITHOUT CERTIFICATE I KITC�-IEN WALL SCONCE � f 1 I ; B,4TI-I W ��. ��rED OF OCCUPANCI� r� SINGLE POLE SWITCH LEVITON "5621-W � `I 125V - 15A-U GRCUND DUPLEX RECEPTACLE EXIST EQUAL TO LEVITON 016262-W I 11 — I LAUNDIRY CFI DUPLEX RECEPTACLE EQUAL125V - ITO LEVITON "6598-WTERRUPTER CATV® CABLE TV / INTERNET PLUMBER CERTIFICATION � VL, , ,%.�`� O` G `' uXi ON LEAD CONTENT BEFOR -vv VUR, TATE & TOWN CODES TOILET EXHAUST FAN ��� F•{E�UI EF CERTIFICATE OF OCCUPANCY ED AND CONDITIONS OF EXISTING HVAC GRILLE r WATER SOUTHOLD TO'�NNZBA FIE= SUPPLY SYSTEM CANNOT EXCEED 2/10 OF 1% LEAD. SOUTHOLD TOI'VN PL&VING BOARD f=AF,,TIAL FIR,5T FLOOR f L 4 N NO WORK SOUTHOLD TOWN TRUSTEES /� X102 C S ,4LE = 1/4" = 1'-011 NORTH DEC �A� W ��� TO HALL I 1 SIDE OF EXISTING DORMER / \ _ LIGHTS _ EXIST EXIST / 1 EXIST � / 1 54TH I b EXISTING LIGHT FIXTURES 5,4TH 1 a EXIST �4 SWITCHES - RELOCATE I �° FOR NEW LAYOUT AS i REQUIRED. PATCH PAINT 17 7 777777 N At REMOVALS TO MATCH � EXISTING X EXISTING 12 EXISTING w E, w GRILLES TO E' 12F HOUSE o PATCH d PAINT REMAIN AS REQ'D TO y i I MATCH E° _ — / \ EXISTING - / \ ,� TYPICAL NOTE: DN MODIFY OUTLETS E �� -1-� DN 5ADDLEll >' AND SWITCHES AS - (2) 2x1 HDR co REQUIRED FOR NEW BUILT-IN—� coEXIST CL LAYOUT I " EXIST CL SHELVING I — ° \ _ i ° REMOVE EXISTING LIGHT A F ' 7 NEW OFFICECATV 1 I I g�I 2 3® FIXTURES IN AREA OF NEW I I I 4 I I- NEW OFFICE 4 NEW POWDER NEW OFFICEI r I ,1 NEWr — -� ROOM. PATCH 4 PAINT AT I I ( I POUJDE1z REMOVALS TO MATCH N �/ I L J I I ROOM EXISTING IX A� � L J A° I ° ROOM ,�� I �- 41- TILE FL. (_ J NEW FIXTURES 4 , EF FITTINGS CATV EXIST EXIST EXISTING EXIST EXIST PROJECT NAME: GRILLES TO REMAIN INTERIOR ALTERATION ASTf 4L 5 SONE) fLOO FLAN HORVATH RESIDENCE K�t 2 � 3 �� � f �L � COND �LOO� ELECTRICAL PL,�N � � X� IO� ELEVATION ON �01 SCALE = 1/4" = 1'-0" SCALE = 1/4" = 1'-0" 02 C, ,41S4LE = 1/4" = 1'-011 LOOKING SOUTH 455 R 0 P,4 ,4DR ISE POINT D NORTH ,4102 NORTH SOUTHOLD, NY 11911 DRAWING TITLE: PARTIAL SECOND FLOOR PLAN WOOD BASE 4 ,—WOOD BASE 4 WOOD PARTIAL SECOND FLOOR ELECTRICAL BASE 8 WOOD BASE � PLAN CROWN CROWN GROWN r I CROWN POWDER ROOM ELEVATIONS OFFICE ELEVATION — PTD— — PTD — — PTD— — PTD — — PTD TO MATCH — EXISTING - gut? LD JO I agig 777. FH 070 oo . DOOR TO O POWDER RM - cc \ �EftED qR PROJECT NO: �pkimo C C,y'� 2 21 • - -- ---- Q' _�, __ �n SCALE: W , ELEVATION 2 ELEV,4TION 3 ELEV,4TION 4 ELEV,4TION 5 ° •; REVISION NO: LOOKING WEST LOOKING NORTH LOOKING E,45T LOOKING SOUTH BASE e CROWN to —TEMPERED GLASS DOOR 41 MATCH EXISTING9 °• 0149156 Qr 8 SIDELIGHTS F yp ISSUE DATE: DOORS TO SWING IBO. . :. DEGREES 8 PARK- SEAL: NOV. 28 2022 AGAINST SIDELIGHT�OUJD R �OOM EL VATIONS OF- ICLEELEVATION DRAWING FILE: A1025ECONDFL 4102 SC,4LE = 1/2" = 1'-0" ,4102 6C,4LE = 1/2" = 1'-0" LOOKING E,4ST DRAWING NO: