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HomeMy WebLinkAbout49422-Z rr�OSUFF�t�coG Town of Southold 8/16/2023 yi ; P.O.Box 1179 C* _ 53095 Main Rd E,'j,j,�l �aoi� Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44453 Date: 8/16/2023 THIS CERTIFIES that the building ALTERATION Location of Property: 1400 Sound Rd, Greenport SCTM#: 473889 Sec/Block/Lot: 33.-4-83 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/23/2023 pursuant to which Building Permit No. 49422 dated 6/26/2023 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: "in kind"patio door replacement to existing singley dwelling as applied for. The certificate is issued to Berg,Mitchell&Jennifer of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Aut oriz d ignature ��SUFFQt TOWN OF SOUTHOLD BUILDING DEPARTMENT y x TOWN CLERK'S OFFICE oy • � ;�� SOUTHOLD, NY ,11 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#: 49422 Date: 6/26/2023 Permission is hereby granted to: Berg, Mitchell 333 E 30th St Apt 17M New York, NY 10016 To: Install a patio door "in kind" to an existing single family dwelling as applied for. At premises located at: 1400 Sound Rd, Greenport SCTM #473889 Sec/Block/Lot# 33.4-83 Pursuant to application dated 5/23/2023 and approved by the Building Inspector. To expire on 12/25/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector pF SOUTy�� * # TOWN OF SOUTHOLD BUILDING DEPT. `ycou�me�' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ NAL Pooe— �i���Ge,G(ri!' [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: ale- DATE 02 "�J INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) y -------------------------------------- FOUNDATION (2ND) O d �n O ROUGH FRAMING& ( �� PLUMBING V »y Jc INSULATION PER N.Y: STATE ENERGY CODE �- FINAL ADDITIONAL COMMENTS O Z m t� N �{ H x H x d b H F aUPFU;��ov,Yi TOWN OF SOUTHOLD—BUILDING DEPARTMENT t, Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 <� y Telephone 631 765-1802 Fax 631 765-9502 bttps://NvNAN",.soutbol.dtown.iiy.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only / PERMIT N0. Building Inspector: MAY 2 3 2023 Applications and,foi-ms riWst be filled out in,their entirety.Incomplete, app lications.will'not be accepted: 1Nhere the Applicant is:;not the owner;an � :Owner's Authoriiation form{Page,2}shall be completed`. Date: 5/17/2023 OWNERS)OF PROPERTY-',' ':,;, Name:Mitchell Berg, scTM# 1000- J •.Sound �- 3 .. . . . Project Address: and Rd. Greenport,_NY 11944 „ Phone#:646-258-8284 _ Email:mitchberg54@gmai_I.com Mailing Address:same CONTACT,PERSON: Name: Scott-Doughman / Go Permits LLC Mailing Address: 105 Buttonball Ln. Glastonbury, CT 06033, Phone#: 303-946-8685 Email: permits o ermits.or .. DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR,INFORMATiON: .: Name: Home Depot USA _.. Mailing Address: 2455 Paces Ferry Rd. Atlanta, GA 30339 Phone#: 303-946-8685...._ . ......_ .. .v...w_•...... . _ Email:..permits@gopermitsorg_ _..__. DESCRIPTION.OF PROPOSED CONSTRUCTION..•' ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther Window Replacement $ 4024 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes ®No vv�ov(_ a"..( r op L a-Lc 1 P q�4 t o cl crcl r- I S a►�,. s VVb ��•-��C.�- l.�r—ems �°�.cn.Y��L 1 DocuSign Envelope ID:FE10BD93-D2B2-4E75-8E93-3EE048COA850 IJ NSC.• ..^}i. ��\l, iV yA OO Existing use of property: Intended use of property: Zone or use district in xwhich premises',is situated: Are there any covenants and,restrictions with respect to this property? Yes CI No IF YES, P.ROVIbE A COPY, r: i ands a" i .` 1 f r3 a f eP:l C� 1 :`-T#ie'i�i / 33a LprJ+tsi'n ro#�sstt�ta#is i s � ie'ta #tura nage c�rniitd 6i saes",'prau'ida :by: ` C`7:I #54;i a�WERE�li•��4�DE;�t��i�i�;Bciildi)i�Dep�ttc�reiit fisrtt�e issuaaice of,"a$uiCding"Permitpw'susht"to,the.Baild€rid Zone t�ritir ric of ttiealisuurs esf Srsui ti 5uf ±untys:ril yr' t r t� d othar. pp ical�lg1aws,'t�rdinari�es q�„'egulatfi►ns#isrth tt�nscrurtioii:af.tiu#iilircgs; p. M . f rl ' d ' ' i a #a rees: 'z'' i .•%v th” 1`c"b€ i<.a.cis boli in ciiiie aoi9�tions;:a{test tt}ss orfar r rnq {zrr demo}ition� h6feit�des be,,rh Pp,k rt g tts s?rnrr y, i aN*tPp, a. is vs:did n.n . , d ., ,1464sipft a anti regu#at€onsarti .til tlmit;au' of d,'sltsps�ctnrs ran;pi i»Sesatid€n buiiiiira s}<�orx'02;"sesy inspectiar .' tse`statemer�ts made#�etein ei e. 1 able as V CIM A°�n�°ii#sd�rr�eaiior tir Era"t'a'Sei io'<>2111.45 of is Al ur.l orkState'Pena€=3 ii. . :_ , *' l� `,`. rsii V Application Submitted,Oy(print name):-Jen ife r Win' RAuthorized Agent ❑Owner Signature of Applicant:. ` Date.: �� a STATE OF K-W- K'}: SSc , COUNTY OF Guilford }' .. gig enol i er V ihke/ o Perm t being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named,, (, )he is the n (Contfactor;.Age.ht,Corporate Officer,etc.) of said owner or oitinees,and is duly authorized 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.arid belief, and that the,work will be performed in the manner set,forth in the application file therew Tyriq L Garrison NOTARY PUBLIC Sworn before me this Rockingham County,NC My mmission Expires March 29,2028 day of.. ,20 23 Notary Public , PROPERTY.OWNER AUTHORIZATION' (Where the applicant is not the owner) itohell Berg, ' ' 5 ours d. 1, residing•at Jennifer Wihke/ ©Permits do hereby authorize to apply on hg, gjkS the:7'bWn of Southold Building Department for approval as described herein.- 5/17/2023 erein. 5/17/2023 Owner's Signature Date . Mitch.ell Borg Print Owner's.Name 2 Go Permits, LLC 105 Butlonball Ln. Glastonbury, Ct 06033 "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! Jennifer Winke, Permit Expediter Go Permits, LLC Phone: 303-946-8685 Fax: 866-697-0768 jenniferwinke@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org Home Improvement Agreement: Page 1 Home Depot License#'s - For the most current listing visit www..Homedepot.com/LicenseNumbers Matthew Williams 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. ' 1 �.1. Service Provider'Contact Information .: ', .. . The Home Depot The Home Depot Service Provider Contact Name Service Provider Company Name (631)478-6101 customercancellationnortheast@homede Phone# Service Provider Email AddressService Provider License#(s) 2. Customer Informafiori _. _.. _...___. ...;_. ._ : ___ _........... berg mitchellLong Island F33388333 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# 54 Sound Road Greenport INY 111944 Customer Address City State Zip (646)258-8284 mitchberg54@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address 3:NOTICE'OYRIGHT TO: 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: 40 Oser Avenue I Hauppauge NY 11788 Address City State Zip BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: h6ll b4d04!19/2023 Customer's Signature Date 460 Standard Form HIA(21 Jul.2'Mitchell b e ra 4/19/202 ene t16%2o c, 62 /r-IVI 2'} `,•• fj, �� F 33,P v 0.1.12 (,TMx Home Improvement Agreement: Page 2 E 4. Ifescription ofVork to be Performed A detailed description of the work to be performed is included in the paragraph entitled Scope of Work,Specification, Customer Summary Sheet, Quote Form Estimate Invoice or Measure which is included in this Agreement. [5. Anticipated_Delivery Date/Installation"Schedule Approximate Start Date: Fl-o/-1-6—/2-0-23--1 Approximate Finish Date: 11/15/2023 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 any repair, if applicable. 6.Electronic Records Authorization - You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written 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. 1:7. Contract Price and;Payment Schedule Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 4024.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 0.00 . (If applicable, total amount of taxes included in Contract Price) *Maximum deposit ONLY applicable in MD,MA,ME(33%), NJ, WI(99%) Deposit% 25.0 Deposit Amount,$ 11006.0 Remaining Balance,$ _3018.0 S ,Finance Charges' _.... . _........_ .._._ . ......-_ _.._._ _ __. _ _ _....._....: w_-_ Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payments made payable to Home Depot. 9. Acceptance and Auth'orizahaa 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. era 4/19/23 Customer's Signature Date X I/s/The Home Depot 04/19/2023 The Home Depot Digital Signature Date For questions related to your installation, contact Service Provider at (631)478-6101 For any other concerns, contact The Home Depot at 1-800-466-3337 460 Standard FomiHIA(21Jul.21)(E)f C��e berg ,/�`�®��ene t.26.� g 3 .:.n .4M:54M13- V. v 0.1.12 Rocd APPROVED AS NOTED DATEI L-2-3 B.P.#� CpMPLY WITH ALL CODES OF FEa5�•�� BY NEW YORK STATE &TOWN CODES NOTIFY BUILDING DEPARTMENT AT ND CONDITIONS OF .REQU ASIRED A 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: S�UTHOLDTOWN ZBA 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE SOUTHOLD TOWN PLANNING gOARd ;c 2. ROUGH-FRAMING,PLUMBING, ". STRAPPING. ELECTRICAL&CAULKING SOUTHOLD TOWNTRUSmS 3. INSULATION _...• 4. FINAL-CONSTRUCTION &ELECTRICAL MUST BE COMPLETE FOR C.O. N.Y.S.DEC ALL CONSTRUCTION SHALL MEET THE I REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. lb • - - � • - • • � MIRM11 I-To • • • Datad: V301-9013 -:. -y W,y,�,-� ••may-,,.�.j�i'r�r- '^.;.'4::- r:r ,i, , �/Y• • With Grids - - �r .ii:s• R w� :Gla fn U r -:G ass P- a "e. 9<:-Y f r cfa �•� :,: F4 :::1, ,.SHGG.•• .,. S t ! p i �x. alC� �.7 rth rgoii � e F' - • fit.., u� Awning 6500 Base ProSolar Supercept 718" 0.26 0.23 0 0 -10.26 0.21 0 0 0 Casement 6500 Base ProSolar Supercept 718" 0.26 0.24 o a o 0 026 0.22 0 0 o a Transom 6500 Base ProSolar Supercept 1' 027 0.32 o 0 0.27 0.29 a o Double-Hung 6500 Base ProSolar Supercept 718" 0.29 0.26 0 0.29 ': 0"24 0 0 0 Picture Casement (NH) 6500 Base ProSolar Supercept 718" 0.26 0.28 alai 026 ! 0.25 o 0 Z. 0 Picture _ 6500 Base ProSolar Supercept 718" 0.27 0.29 o o 0.27 ; 0.26 o o 2 Panel Slider 6500 Base ProSolar Supercept 718" 029 0.26 0 0.29 023 o 0 0 3 Panel Sliders 6500 Base(s 21 Sgft) Pro Solar Supercept 718" 0.29 0.26 a0.28 : 0.23 0 0 0 • rr D• • - Gard 6500 Energy Star ProSolar SUN Super Spacer V 0.30 0.24 o a o 0 0"30 1 0.21 0 0 o a a io oor IN 6500.Base Pro Solar Super Spacer 1",, 0.26 1 0 1 01 1 10-31 023 1 o 0 1 0 0 • r 1 Homes located everywhere EXCEPT:Arizona,California,Idaho,Nevada,New Mexico,Oregon,Utah,and Washington" Awning(Inc Hopper} 6100 Base Pro Solar Intercept 718" 027 ' 0.24 o e o 0 0.28 0.21 o a o 0 Casement 6100 Base Pro Solar Intercept 718" 0.27 0.24 0 0 0 0 0.27 0.22 0 o 0 a Double-Hung 6100 Energy Star Pro Solar Supercept 314" 0.30 0.30 0 0.30 0.27 0 o a Picture_Casement(No Hinge) � 6100 Base Pro Solar Intercept 718" 027 0.28 0 0 0.27 0.25 0 0 0 0 Picture �u 6100 Base Pro Solar intercept 314" 0.27 0.31 0 0 0.27 028 o '0 2 Panel Slider 6100 Base Pro Solar Intercept 314" 0.30 0"28 0 0.30 0.27 0 3 Panel Slider 6100 Base Pro Solar Intercept 314" 0"30 0.29 0 0"30 ' 0.27 0 o A r p • Homes Jocated everywhere EXCEPT:Arizona,California,Idaho,Nevada,New Mexico,Oregon,Utah,and Washington. Patio Door IN_OVO _6100 Energy StarPro Solar Super Spacer 1" 0 0.28 0.26 1-1-FT0 28 0.23 0 0 0 Patio Door NARROW FRAME 6100(PD05)Base z Pro Solar � intercept 3/4j 0.28 0.30 0 0 0.28 0.26 0 0 • 0 Homes located only in following markets:Dallas,Denver,Detrol;Phila,Northern NJ,Long island,NY. Awning 6200 Base. Pro Solar SHADE Supercept 314" 0.27 0.25 0 0 0 0 0.26 023 o o o 0 Casement 6200 Base Pro Solar SHADE Supercept 314" 0"26 0.18 o 0 o 0 0.29 : 0.17 o 0 0 0 Picture Casement-NH 6200 Base Pro SolarSHADE Supercept 314" 0.25 0.21 0 0 0 0 0.25 0.19 0 0 0 0 Picture Window 6200 Base Pro Solar SHADE Supercept 314" 0.26 0.24 o o o o 0.26 0.22 0 0 0 0 Single Hung 6200 Base Pro Solar SHADE Supercept 314" 0.28 : 0.23 o a o o 0.28 0.21 0 0 0 Single Slider 6200 Base Pro Solar SHADE Supercept 3/4" 0.28 0.23 0 0 0 0.28 : 0.21 0 0 0 3 Panel Slider 6200 Base Pro Solar SHADE Supercept 314" 0.28 0.23 1 0 0 j 0.28 0.21 0 0 0 la • - ' r r Homes located in coastal areas. Awning SB+300VL Energy Star PS SUN/Lami Supercept 1" 026 023 o o 0 0 0.26 . 0.21c o 0 o Casement_ SB+300VL Base PS/Lami Super Spacer 1" 025 ` 0.23 o 0 0 o 0.25 0.21 0 o o 0 Double Hung SB+300VL Base PSiLami Super Spacer 1" 0.29 0.25 0 0 o o 0.29 0.23 o 0 0 o Slider SB+300VL Base PS 1 Lami_ Intercept 1" 0.29 0.25 0 0 o a 0.29 j 0.23 0 0 0 0 Patio Door SB+300VL ETC 366 PS Shade/Lami Super Spacer 1" 0.30 0.19 o a a o • o Garden_Door(CH) SB+300VL Base PS1L_ami _ Super Spacer 1" 0.30 028 0 © 0.30 025 21 oFla. •Dots Indicate Energy Star certified for that zone WINDOW SPECIFICATION SHEET - Spec.Sheet#: F33388333 Sheet: 1 of 1 Customer: mitchell berg Job#: F33388333 Consultant: Matthew Williams Date: 04/19/2023 - New Window Existing Window Hinge Locations r Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use 5 4 z r m O v ?c c Mull "S"=stationary o r °? o NO Style Wraps 0 :C "X" operating O O . O5 O O L' Room Floor Code (Y/N) Style Code Series Code w x Ui v d > > M STD,White,TMP:Full, WRAP,LSR 1 LIV list PDW- Y 65PDC2 6500 WH WH 72 80 152 GlassPack:Standard X S ALDER SPECIAL CONSIDERATIONS: 1:White Wrap Color Interior Casing Type Colonial Bay or Bow window: Seatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: Seatboard Material Yinyl only-White Pionite,Birch or Oak) "s Labor,Licensing&ConsumerAffairs HOME,IMPROVEMENT LICENSE Name RICHARD TOUSEY This cerUFles'that the Business-Name aearer.is duly licensed HOME DEPOT USA INC(14 SUPPS) 3y the County.of suffolk .License Number:H-53429 Rosalie tlrago Issued: 0511512014 Commissioner Expires: 11/0112024 *� This license is the property of Suffolk County k $Departiment.of Labor,Licensing&Consumer Affairs. ; Possession of this license:does•not guarantee its"validily: " Additional Business Name License Category H1-GC r t tion CERTIFICATE OF INSURANCE COVERAGE att DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD NW 678-231-8957 ATLANTA,GA 30339 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) 581853319 2.Name and Address of Entity Requesting Proof of 3a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) TOWN OF SOUTHOLD HARTFORD LIFE AND ACCIDENT 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"l a" SOUTHOLD, NY 11971 LNY713657 3c Policy effective period 01-01-2023 to 12-31-2023 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.Policeovers: L✓�A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date signed 11-17-2022 (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services 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 mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (Only if Box 4C or 5B of Part 1 has 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 with respect to all of his/her employees. Date Signed B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note;Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111111 DB7i,2 0.. 1H INEWRorkars' CERTIFICATE OF ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 770-433-8211 Home Depot USA,Inc. 2455 Paces Ferry Rd.,C-20 Atlanta,GA 30339 1c. NYS Unemployment Insurance Employer Registration Number of Insured 76011130 Work Location of Insured(Onlyrequired ifcoverage 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 58-1853319 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Company of North America 3b.Policy Number of Entity Listed in Box"1 all Town of Southold WLR C50668058 53095 Route 25 Southold,NY 11971 3c. Policy effective period 03/01/2023 to 03/012024 3d.The Proprietor,Partners or Executive Officers are 0 included. (Only check box if all partners/officers included) ❑X 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: Eric D.Tonn (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Sign . ) (Date) Title: Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: 678-795-4338 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 AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC R® ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance "'HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot U.S.A.,Inc.dba The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC H.D.W.Holding Company,Inc. Askuity,Inc. Home Depot Management Company,LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta ACO® ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Safety National Casualty Corporation Policy Number.LDS4068089(AL,AR,AZ,FL,ID,IA,IL,KS,KY,LA,MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA,WV,WY) Effective Date:03/01/2023 Expiration Date:03/0112024 (EL)Limit:$5,000,000 Carrier:Safety National Casualty Corporation Policy Number:SP4068090(QSI)(CA,OR,WA) Effective Date:03/0112023 Expiration Date:03/01/2024 (EL)Limit:$5,000,000 SIR:$1,000,000 Carrier:ACE American Insurance Company Policy Number:WCUC50668095(QSI)(GA,MI,NV,OH,UT) Effective Date:0310112023 Expiration Date:03101/2024 (EL)Limit:$4,000,000 SIR:$1,000,000 SIR(GA):$750,000 Carrier:Indemnity Insurance Company of North America Policy Number.WLRC50668058(AK,CO,CT,DC,DE,HI,IN,MA,MD,ME,MN,NH,NJ,NY,PA,RI,VT) Effective Date:03/01/2023 Expiration Date:03101/2024 (EL)Limit:$5,000,000 TX Employers XS Indemnity: Carder:Zurich American Insurance Company Policy Number:NSL1138319(TX) Effective Date:03/0112023 Expiration Date:0310112024 (EL)Limit:$6,000,000 SIR:$5,000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATE ACC)R 0® CERTIFICATE OF LIABILITY INSURANCE D0310312023 omvY) 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 MARSH USA,INC. NAME: FAX TWO ALLIANCE CENTER PHCNNo.Ext): No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC iF CN101642069-HomeD-GAW:22-25 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:Indemnity Ins Co Of North America 43575 HOME DEPOT U.S.A.,INC. INSURER C:ACE American Insurance Company 22667 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-06 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR I D D POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY MWZY316648 03/01/2022 03/01/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FE OCCUR DAMAGES(RENTED 1,000,000 PREMISES Ea occurcence $ X SIR:$1,000,000 MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 1:1 PRO ❑ LOC PRO- PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWTB316649 03/0112022 03101/2025 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB X OCCUR MWZX 316647 03/01/2022 0310112025 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ 1 $ B WORKERS COMPENSATION SCFC50668198(WI) 03/01/2023 03/01/2024 X PER I OTH- AND EMPLOYERS'LIABILITY STATUTE ER C YIN WLRC50668150(MT) 03101!2023 03/01/2024/ ECUTIVE 5,000,000 OFFICER/MEMBER EXCLUDED? � N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE'-EA EMPLOYEE $ 5,000,000 If yes,describe under Continued on Additional Page 5,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE iY�-'a�cdfi ?2.Srf 9rzc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD