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HomeMy WebLinkAbout49578-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE k 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 #: 49578 Date: 8/14/2023 Permission is hereby granted to: Kni fin , B an 1735 Clearview Ave Southold, NY 11971 To: construct additions and alterations to existing single-family dwelling as applied for. At premises located at: 100 Mailler Ct, Southold SCTM #473889 Sec/Block/Lot# 70.-9-52 Pursuant to application dated 6/30/2023 and approved by the Building Inspector. To expire on 2/12/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $442.40 CO-ADDITION TO DWELLING $50.00 Total: $492.40 Building Inspector rsci tot + a,, 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) 765-9502Hwww.south2ld_townpy ly o Date Received BUILDINGAPPLICATION FOR, For Office Use OnlyI �f PERMIT NO. - Building Inspector. q 3 0 2023 Applications and forms must be filled out in their entirety.Incomplete )ING DEPT applications will not be accepted. Where the Applicant is not the owner,an rm Owners Authorization form(Page 2)shall be completed. T0" Date:March 6th 2023 OWNER(S)OF PROPERTY: Name:Bryan & Kerri Knipfing SUM#1000-70.-9-52 Project Address:1735 Clearview Avenue Southold, NY 11971 Phone#:631-873-9386 Email:bryanknipfing@gmail.com Mailing Address: 1735 Clearview Avenue Southold, NY 11971 CONTACT PERSON: Name:Stromski Architecture, P.C. Mailing Address:P.O. Box 1254 Jamesport, NY 11947 Phone#:631-779-2832 Email:marisa@stromskiarchitecture.com DESIGN PROFESSIONAL INFORMATION: Name:Stromski Architecture, P.C. Mailing Address:P.O. Box 1254 Jamesport, NY 11947 Phone#:631-779-2832 Email:robert@stromskiarchitecture.com CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email:. DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure RAddition WAlteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $160,000 Will the lot be re-graded? ❑Yes R No Will excess fill be removed from premises? ❑Yes IRNo 1 PROPERTY INFORMATION Existing use of property:Single Family Residence Intended use of property:Single Family Residence Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R-40 this property? ❑Yes WNo IF YES, PROVIDE A COPY. J@ 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 me •R a tromskl 1@Authoriz d Agent ❑Owner Signature of Applicant: Date: "- " STATE OF NEW YORK) SS: COUNTY OF ) SMS being duly sworn,deposes and says that(s)he is the applicant (Name of individ al signing contract)above named, (S)he is the )14 (Cont, ctor,A ent,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 t with. Sworn before me this ,w day of U 'L 2C fir. C" No ry P9611c � JANE E STPOM * NOIARY P�UG LIG 01 PROPERTY OWNER AUTHORIZATION Q,UAUFIEnS6 - C'OdN'C"' W (Where the applicant is not the owner) TERM EXPIRES C)ECENISER t" I Bryan Knipfing Xe-, ,.,`&,• residing at 1735 Clearview Avenue Southold, NY 11971 do hereby authorize Robert Stromski to apply on my behalf to the Town of Southold Building Department for approval as described herein. y41� .Z-4A�Lal _ �3 L-3 Owners Signature Date Bryan Knipfing enrr. k " (ly Print Owner's Name 2 Generated by REScheck-Web Software Compliance Certificate Project Knipfing Residence Energy Code: 2018 IECC Location: Southold, New York Construction Type: Single-family Project Type: Addition Climate Zone: 4 (5572 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 1735 Clearview Avenue Bryan Knipfing Robert Stromski Southold, NY 11971 1735 Clearview Avenue Stromski Architecture P.C. Southold, NY 11971 P.O. Box 1254 631-873-9386 Jamesport, NY 11947 bryanknipfing@gmail.com 631-779-2832 robert@stromskiarchitecture.com • • a e Compliance: 0.7%Better Than Code Maximum UA: 279 Your UA: 277 Maximum SHGC: 0.40 Your SHGC: 0.31 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Slab-on-grade tradeoffs are no longer considered in the UA or performance compliance path in REScheck. Each slab-on-grade assembly in the specified climate zone must meet the minimum energy code insulation R-value and depth requirements. Env-elope Assemblies Prop.Gross Area Assembly or Cavity Cont. Req Prop. Perimeter R-Value 111-Value U-Factor U-Factor UA UA Ceiling: Flat Ceiling or Scissor Truss 1,775 38.0 0.0 0.030 0.026 53 46 Wall:Wood Frame, 16" o.c. 1,207 15.0 0.0 0.077 0.060 61 48 Door 1: Solid Door(under 50%glazing) 20 0.280 0.320 6 6 Door: Glass Door(over 50%glazing) 41 0.280 0.320 12 13 SHGC: 0.31 Window 2:Wood Frame 177 0.280 0.320 49 57 SHGC: 0.31 Window 2:Wood Frame 177 0.280 0.320 49 57 SHGC: 0.31 Wall 1:Wood Frame, 16" o.c. 471 22.0 0.0 0.056 0.060 21 23 Window 1:Wood Frame 91 0.280 0.320 26 29 SHGC: 0.31 Project Title: Knipfing Residence Report date: 03/10123 Data filename: Page 1 of10 N Compliance Statement: The proposed building design described h is consi-t t with the building plans,specifications, and other calculations submitted with the permit application.The proposed b A Eng ha be n designed to meet the 2018 IECC requirements in REScheck Version : REscheck-Web and to comply with the mandato y e listed ' t check Inspection Checklist. ,21,0z-,--.,��J �� Name-Title Sian t re Date Project Title: Knipfing ResidenceP Re ort date: 03/10123 Data filename: Page 2 of10 fZREScheck Software Version : REScheck-Web Inspection Checklist Energy Code: 2018 IECC Requirements: 0.0% were addressed directly in the REScheck software Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. Vedfied rt re nspect on/P wPIanffedSectn 'Ia Value Valu Complies? o mplie sd Comments/Assumptions omments/Assumptions 6Re ,Ip d 103.1, Construction drawings ❑Complies I103.2 documentation demonstrate ❑Does Not [PR111 energy code compliance for the building envelope.Thermal ❑Not Observable envelope represented on ❑Not Applicable construction documents. 103.1, ;Construction drawings and OComplies 103.2, documentation demonstrate ❑Does Not 403.7 ;energy code compliance for [PR311 ;lighting and mechanical systems. ❑Not Observable `Systems serving multiple ❑Not Applicable dwelling units must demonstrate ,compliance with the IECC Commercial Provisions. 302.1. Heating and cooling....._..............._.. M....._- __..._�.... m -- �._... .. _�.. _ ..e.._......w..m..... _.�... equipment is Heatingr Heating, ❑Complies 403.7 sized per ACCA Manual S based Btu/hr Btu/hr ❑Does Not [PR212 on loads calculated per ACCA Cooling: Cooling: Manual J or other methods Btu/hr Btu/hr ❑Not Observable approved by the code official. ❑Not Applicable Additional Comments/Assumptions: 1 _.a....._. �� „ Medium Impact(Tier 2)2 i3 1Low Impact(Tier 3) W ............._ Project Title: Knipfing Residence Report date: 03/10/23 Data filename: Page 3 of10 settlon Foundation Inspection Complies? Comments/Assumptions 303.2.1 A protective covering is installed to ❑Complies )FO1112 protect exposed exterior insulation ❑Does Not and extends a minimum of 6 in. below grade. ❑Not Observable ❑Not Applicable �... _. .......... ----------- ._. . 403,8 ;Snow-and ice-melting system controls ❑Complies 1.'01,2)2 installed. ,❑Does Not ❑Not Observable []Not Applicable Additional Comments/Assumptions: L1J High Impact(Tier 1) m2 ........ .... 2 ----- Medium Impact(Tie . ................ _iLo. Impct(Tier 3) __._ ...._ ........ Project Title: Knipfing Residence Report date: 03/10/23 Data filename: Page 4 of10 &ection Plans Verified Field Verified �.._ 5 # Framing/ Rough In InspectionValueValue Complies Comments/Assumptions ...,...Recd 402.1.1, Door U-factor, U- U- ❑Complies See the Envelope Assemblies 402.3.4 ❑Does Not table for values [FR1]1 ❑Not Observable �sE ❑Not Applicable 402.1.1, Glazing U-factor(area-weighted U- U- ❑Complies See the Envelope Assemblies 402.3.1, average). ❑Does Not table for values. 402.3.3, 402.5 ❑Not Observable [FR2]1 ❑Not Applicable 303.1.3 U-factors of fenestration products OComplies - [FR4]1 are determined in accordance ❑Does Not J; with the NFRC test procedure or taken from the default table. ❑Not Observable ❑Not Applicable ..oa ,. w.�,�www ,�g000.., ,.a.� _—_ ... ... ... 402.4.1.1 'Air barrier and thermal barrier ❑Complies [FR23]1 installed per manufacturer's ❑Does Not instructions. V, ❑Not Observable ❑Not Applicable 402.4.3 Fenestration that is not site b.... - - - � uilt ❑Complies [FR20]1 is listed and labeled as meeting ❑Does Not € AAMA/WDMA/CSA 101/I.S.2/A440 or has infiltration rates per NFRC ❑Not Observable `400 that do not exceed code ❑Not Applicable limits. 402.4.5 IC-rated recessed lighting fixtures ❑Complies [FR16]2 sealed at housing/interior finish ❑Does Not and labeled to indicate :52.0 cfm leakage at 75 Pa. ❑Not Observable ❑Not Applicable 4. _... .._................. m--.....-, ...,..-. ......... 3.3.1 Supply and return ducts in attics ❑Complies [FR12]1 insulated >= R-8 where duct is ❑Does Not V >= 3 inches in diameter and >_ R-6 where< 3 inches. Supply and ❑Not Observable return ducts in other portions of ❑Not Applicable the building insulated >= R-6 for diameter>= 3 inches and R-4.2 for< 3 inches in diameter. [FR13] boxes � plies 1403.3.2 Ducts, air handlers andd ifillter ❑Com 1 bare sealed with ❑Does Not ;joints/seams compliant with International Mechanical Code or ❑Not Observable International Residential Code, as ❑Not Applicable applicable. 403.3.5 Building cavities are not used as ❑Complies [FR15]3 ducts or plenums. ❑Does Not ❑Not Observable ❑Not Applicable I',,,,- -------------�----�-----__.._ -._.---___.--._-,� .,.. .._...... ...,.... ....... ,. .,., ..,,, N_— __ ....................__... - 403.3.6(1, Ducts partially or completely ❑Complies 2) buried in ceiling insulation have ❑Does Not [FR26]3 an insulation R-value not less Aj than R-8,the sum of the ceiling ❑Not Observable insulation R-value against and ❑Not Applicable above the top of the duct, and against and below the bottom of the duct, is>=than R-19, excluding the R-value of the duct insulation. ....................... 1 High Impact(Tier 1) ; 2 Medium Impact(Tier 2) J 3 Low Impact(Tier 3) Project Title: Knipfing Residence Report date: 03110123 Data filename: Page 5 of10 Se 0lon Framing Plans Verified Field Verified ,ing/ Rough In Inspection Value Value Complies Comments/Assumptions 403.3.7 Ducts declared to be within the ;❑Complies [FR28]3 conditioned space are either 1) ;❑Does Not completely within the continuous ❑Not Observable air barrier and within the building thermal envelope, 2) buried ❑Not Applicable within ceiling insulation in accordance with Section R403.3.6 and the air handler is located completely within the continuous air barrier and within the building thermal envelope and the duct leakage is <= 1.5 cfm/100 square feet of conditioned floor area served by the duct system, or 3)the ceiling insulation R-value installed against and above the insulated duct>=to the proposed ceiling insulation R-value, less the R- value of the insulation on the 403.4 ®HVAC piping conveying fluids R. _ -R.�... � � m .... _ _ .. _m. p'p' g y g - R- ❑Complies [FR17]2 above 105°F or chilled fluids ❑Does Not below 55°F are insulated to>_R- ❑Not Observable 3. ❑Not Applicable 403.4.1 'Protection of insulation on HVAC ❑Complies [FR24]1 piping„ ❑Does Not 5 []Not Observable ❑Not Applicable 403,53 Hot waterp'p i es are insulated to R- R- ❑Complies [FR1 ]2 >_R-3. ❑Does Not )a , ❑Not Observable ❑Not Applicable X4 93.6 Automatic or gravity dampers are -.. _ ......� e ,ElC om plies �. [FR 191! installed on all outdoor air ❑Does Not intakes and exhausts. ❑Not Observable []Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 y Medium pact(Tier 2) 3 Low Impact(Tier 3) Project Title: Knipfing Residence Report date: 03/10/23 Data filename: Page 6 of10 er insulation Inspection 7P— Value al Verified Nei trefied complies? � Comme �� ._ ... ,Section d .... ._.. .��m .�.e.. . .�...�ee�.ww..Aw .. . . .......a.�� ......�.� i._ .�. d, .mrts/A sum t1ons.... 30 .1 All installed insulation is labeled ❑Complies J'iN11312 or the installed R-values ❑Does Not provided. ❑Not Observable ❑Nat Applicable 402 1 1, :Wall insulation R-value.�If this is a R om#iiNes R- ESC see the env ,..... .,. ............._�_�,�m, _.. .. _. elope Assemblies 402 2.5„ mass wall with at least /2 of the 'VI'w°ood ❑ Wood ❑Does Not table for values. 4022,61 wall insulation on the wall [IN311 ;exterior,the exterior insulation Mass ❑ Mass ]Not Observable requirement applies(FR10). ❑ Steel E] Steel EINot Applicable ...... .. .._ .......�...... 303.2 Wall insulation is installed per 0 omplies [IN411 manufacturer's instructions. [...Does Not ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: ...... � 1 High Impact(Tierml) 2 Medium Impact(Tier 2) � Low Impact(Tier 3) mmm^mmmm� Project Title: Knipfing Residence Report date: 03/10/23 Data filename: Page 7 of10 Se Re on pection P complies? Comments/Assumptions ��I D &......�. .. ..-.m. Finalans........-.......��.m.rovisions Plans Verified Field Verified Value V lue � .. ....mm- .. .m.., ,.�. .-_._ . ... ....... 402.1.1, Ceiling insulation R-value, R- R- []Complies See the Envelope Assemblies 402.2.1, ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.2 E] Steel ❑ Steel ❑Not Observable [Fill' ❑Not Applicable _.................. ..... .�............................... _......._....... ...... _.,—- _... .. .., mm.... ...�...._ . .. .... 303.1.1.1, :Ceiling insulation installed per ❑Complies 303.2 manufacturer's instructions. ❑Does Not [F1211 Blown insulation marked every :300 ft2. ❑Not Observable ❑Not Applicable 402.2.3 Vented attics with air permeable ❑Complies [FI22]2 insulation include baffle adjacent ❑Does Not to soffit and eave vents that extends over insulation. ❑Not Observable ❑Not Applicable 402.2.4 Attic access hatch and door R- R- ❑Complies [F1311 insulation >_R-value of the ❑Does Not adjacent assembly. ❑Not Observable ❑Not Applicable 402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50 = ACH 50 = ❑Complies [FI17]1 ach in Climate Zones 1-2, and ❑Does Not <=3 ach in Climate Zones 3-8. ;❑Not Observable ❑Not Applicable �,4, _.... :.Wood-burning ..fireplaces have.. ,_�._..__e....._.._.....w_._.___._�___..__ _..........._...�,.._---.-.� w._rrr ,.... .... . .............- ❑Complies [FI81tight fitting flue dampers and ❑Does Not outdoor air for combustion. ❑Not Observable ❑Not Applicable 403.3.3 Ducts are pressure tested to � ft2 cf-mm .µ � m/100 cfm/100. ..�r❑.� __�..�...........� .._. .... ...........� Complies [F12711 determine air leakage with ft2 ft2 ❑Does Not either: Rough-in test:Total leakage measured with a ❑Not Observable ,pressure differential of 0.1 inch ❑Nat Applicable w.g. across the system including ;the manufacturer's air handler enclosure if installed at time of test. Postconstruction test:Total leakage measured with a pressure differential of 0.1 inch w.g. across the entire system including the manufacturer's air handler enclosure. -. 403.3.4 Duct tightness test result of<=4 cfm/100 _c -- fm/100 ❑Complies [F1411 cfm/100 ft2 across the system or ! ft2 ft2 ❑Does Not <=3 cfm/100 ft2 without air handler @ 25 Pa. For rough-in ❑Not Observable tests,verification may need to ❑Not Applicable occur during Framing Inspection. - 403.3.2.1 :Air handler leakage designated � ]JCplieso om lies [F12411 by manufacturer at<=2%of ❑Does Not design air flow. [-]Not Observable ❑Not Applicable 403.1.1 Programmable thermostats ❑Complies [Flg]2 installed for control of primary ❑Does Not heating and cooling systems and initially set by manufacturer to ❑Not Observable code specifications. ❑Not Applicable 4...................... ... ..._............................. ........ �e... �..�,n �m, ,,.,�. ._.._........_�...._���.:_ �........ _...._... 03.1.2 Heat pump thermostat installed ❑Complies [FI10]2 on heat pumps. ❑Does Not ❑Not Observable ❑Not Applicable 1 Hi h Impact(Tir 1) 2 Medium impact(Tier 2) g p p 3 j Low Irnpact(Tier 3) Project Title: Knipfing Residence Report date: 03/10/23 Data filename: Page 8 of10 +x;10 Plans Verified Field Verified Final Inspection Provisions Value Value Complies? Comments/Assumptions 403.5.1 Circulating service hot water ❑Complies [FI11]2 systems have automatic or ❑Does Not accessible manual controls. ❑Not Observable ❑Not Applicable 403.6.1 All mechanical ventilation system ❑Complies [F125]2 fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits per Table [:]Not Observable R403.6.1, ❑Not Applicable ....... ,...­ ­.. .. .-..........-. 403.2 Hot water boilers supplying heat ❑Complies [F126]2 through one-or two-pipe heating ❑Does Not systems have outdoor setback control to lower boiler water ❑Not Observable temperature based on outdoor ❑Not Applicable temperature. -...w__. .e. _. m.......... 403.5.1.1 Heated water circulation systems ❑Complies [F128]2 have a circulation pump.The ❑Does Not system return pipe is a dedicated return pipe or a cold water supply ❑Not Observable pipe. Gravity and thermos- []Not Applicable syphon circulation systems are not present. Controls for circulating hot water system pumps start the pump with signal for hot water demand within the occupancy. Controls automatically turn off the pump when water is in circulation loop is at set-point temperature and no demand for hot water exists. _.. �w __ ...................e.ww 403.5.1.2 Electric heat trace systems ❑Complies [F129]2 comply with IEEE 515.1 or UL ❑Does Not 515. Controls automatically adjust the energy input to the ❑Not Observable heat tracing to maintain the ❑Not Applicable desired water temperature in the piping. dem m d�de.. ._....... -------- ..........— ...._-_-- 4... 03.5.2 Demand recirculation water ❑Complies [F13012 systems have controls that ❑Does Not manage operation of the pump and limit the temperature of the ❑Not Observable water entering the cold water ❑Not Applicable piping to <= 1049F. 403.5.4 Drain water heat recovery units -� � � ElComp lies --..�. ....�,.___ [F131]2 =tested in accordance with CSA ❑Does Not B55.1. Potable water-side pressure loss of drain water heat ❑Not Observable recovery units < 3 psi for ❑Not Applicable individual units connected to one or two showers. Potable water- side pressure loss of drain water heat recovery units< 2 psi for individual units connected to three or more showers. m.,. ..._..._ - .. ........................--- 404.1 '90%or more of permanent ❑Complies [F1611 Ifixtures have high efficacy lamps. ❑Does Not ❑Not Observable ❑Nat Applicable e ... .._. .w,. .......,�.... ........ „_.... 6......_. .......... 404.1.1 Fuel gas lighting systems have ❑Complies [F12313 no continuous pilot light. ❑Does Not ❑Not Observable ❑Not Applicable r , imp 1 High Impact(Tier 1) 2 Medium Im act(Tier 2) 3 Low Impact(Tier 3) �, . i _.... Project Title: Knipfing Residence Report date: 03110123 Data filename: Page 9 of10 Verified Plans V rLdalu alue . .___-- ectlon ifiecl IFlelldl fk Final Inspection Provisions complies? cornrx eats s.seanptlons ..... ...�..... „w...................,,,.,.,� 401-3 Compliance certificate posted. ncomplies IF1712 nDloes Not nNot Observable ..... _ .o, ,e .,,... .....,, ,... ONot Applicable 303.3 Manufacturer manuals for ElComplies JF11.111`' mechanical and water heating ❑CYoes Not systems have been provided. ]Not Observable E]Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) . edium Impact(Tier 2) 1,�, tow Impact(Tear 3) ..�.._._..... Project Title: Knipfing Residence Report date: 03110123 Data filename: Page 10 of10 Effidency Certificate VA Above-Grade Wall 15.00 Below-Grade Wall 0.00 Floor 0.00 Ceiling / Roof 38.00 Ductwork (unconditioned spaces): Window 0.28 0.31 Door 0.28 0.31 Um. Mir . . Heating System: Cooling System• Water Heater:. Name: Date: Comments STROARC-01 LNG: ACORO° DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6121/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Neefus Stype Agency ° e Ext):(631)722-3500 IA/C No 722-3591 711 Union Ave. (Aa "N°` Aquebogue,NY 11931 in o: -sainsure.com INSURER S AFFO.DING.COYERA..E. NAIC# INSURER A:Utica National Ins Co of Ohio 13998 INSURED INSURER B:Utica Mutual Insurance Company 25976 Stromski Architecture PC INSURER C: PO Box 1254 INSURER D: Jamesport,NY 11947 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADDL SUBRI POLICY EFF POLICY EXP TYPE OF INSURANCE INSD WVD POLICY NUMBER 1NMMQD= IMM1120=1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 4O RENTED CLAIMS-MADE occuR 4519654 3/1212023 3112/2024 DAMAGE rs�enr,, $ M D EXP Any onion $ 1 O 000... PERSONAL✓3.ADV INJURY $ X. POL ICY ELIMITAPPLIESPER: GENERAL AGGREGATE $ 1,000,000 PRO- ❑LOC PRODUCTS-COMP/OP AGG $ GEN`L A GRE,�T1 JECT 07 HER,Il...._ $ AUTOMOBILE LIABILITY JM'SINEDSINGLE1.IMITaccIden $ ANY AUTO BODILY INJURY Per erson S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $•••• AUTOS ONLY AUUTOS ONLY PerG{ir�d JAMAGF ••••-I'$ $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X STATI fRH AND EMPLOYERS'LIABILITY Y 740865 500,0001 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ 4/212023 4/2/2024 EL EACH ACCIDENT $ OFFER/MEMBER EXCLUDED? N/A SOO,OOO ((Mandatory in NH) E,L DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E1 DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Town ACCORDANCE WITH THE POLICY PROVISIONS. Route Southold P.O.Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE In.Legal Name&Address of Insured(Use street address only) lb. Business Telephone Number of Insured Stromski Architecture PC (631) 779-2832 PO Box 1254 lc.NYS Unemployment Insurance Employer Registration Number of Insured Jamesport,NY 11947 Work Location of Insured(Only required ifcovera, eisspecifically Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, i.e., a Wrap-Up or Social Security Number Policy) 27-1728181 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Amtrust North America Town of Southold 3b.Policy Number of entity listed in box"1 a" 54375 Route 25 4740865 3c. Policy effective period P.O. Box 1179 04/02/2023 to 04/02/2024 Southold,NY 11971 3d. The Proprietor,Partners or Executive Officers are included. (only check box if all partners/officers included) Call excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notes the above certificate holder 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",whiilhever is earlier. Please Note: Upon the 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: SA Insurance Agency .Peter....S.a......at.......N........�.�� ww.. ____ ...__.. ..... ....... .... (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ye 07/14/2022 (Signature) (Date) Title: Sr. Partner Telephone Number of authorized representative or licensed agent of insurance carrier: 631-722-3500 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(9-07) www.wcb.state.ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein, however,shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2(9-07)Reverse TAT Compensation Workers' � CERTIFICATE OF INSURANCE COVERAGE '.. . sr�xr Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier ....... 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured STROMSKI ARCHITECTURE PC 516-380-3276 PO BOX 1254 JAMESPORT, NY 11947 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 271728181 ....... 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 54375 Route 25 3b.Policy Number of Entity Listed in Box"1 a" P.O. Box 1179 DBL442299 Southold, NY 11971 3c.Policy effective period 04/02/2023 to 04/01/2024 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑X 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. hJ � 6/21/2023 �� d° Date Signed By � � w �^° W .M.. wwww. (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if sox 46,4C or 513 have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. 06-120.1 (12.21) 111 DB-120.1 (12-21)�ININI Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1a for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c,whichever is earlier. This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. This Certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This Certificate may be used as evidence of a NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first,two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (12-21)Reverse 1 hJ 1t11 1 1 11 1 JJ 1JL 1 J. ! FILE No. 4770 FILED DECEMBER SITUATE SOUTHOLD TOWN OF SOUTH( SUFFOLK COUNTY, NE) S.C. TAX No. 1000-70- SCALE 1 "=20' OCTOBER 13, 2022 AREA = 21 ,899 sq. ft 0.503 ac. _ � o 14'x0„ Lop .r 2 44 / o a6W 1 94'06' 7. ev x o �y F ° GAR - cpc Ll&S x—-- r, —u _ s Cov c ., 12 as Y ° 126 W x� - N_ F / s ' LO 0v ?' z t 1 " I I C'0 ., \ >:- �p > O x 0 \ , vab 6 ° XI jk X— / U x 9.4 9 ^ UNAUTHORIZED Hyl TO THIS SURVE ° SECTION 7209 EDUCATION LAW ° COPIES OF THI: THE LAND SUM ®8� EMBOSSED SEAL TO BE A VAUD O CERTIFICATIONS OFR MON ONLY TO THE F - \ n IS PREPARED, A TITLE COMPANY, LENDING INSTfR TO THE ASSIGN[ °p TUTION. CERTIFN THE EXISTENC AND/OR EASE n ANY, NOT SHI