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HomeMy WebLinkAbout48327-Z o�og11FF0[��,G Town of Southold 9/30/2023 y`^ P.O.Box 1179 o _ 53095 Main Rd X44%, �ao�,r f Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 48237 Date: 9/30/2023 THIS CERTIFIES that the building ALTERATION Location of Property: 730 Bayview Dr.,East Marion SCTM#: 473889 Sec/Block/Lot: 37.-5-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/8/2022 pursuant to which Building Permit No. 48327 dated 9/23/2022 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: plumbing repairs to existing single-family dwelling as applied for. The certificate is issued to Keller,Barbara&Robert of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 48327 12/29/2022 PLUMBERS CERTIFICATION DATED1�6 I LA ut ori a Signature TOWN OF SOUTHOLD BUILDING DEPARTMENT ' TOWN CLERK'S OFFICE • SOUTHOLD, NY r 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#: 48327 Date: 9/23/2022 Permission is hereby granted to: Gallagher, John 12 Winding Hills Dr Wallkill, NY 12589 To: construct plumbing repairs to existing single-family dwelling as applied for. At premises located at: 730 Bayview Dr., East Marion SCTM # 473889 Sec/Block/Lot# 37.-5-5 Pursuant to application dated 8/8/2022 and approved by the Building Inspector. To expire on 3/24/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Buil ing Inspector 1 SOUryol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 �e sean.devlint-town.southold.ny.us Southold,NY 11971-0959 Q�y'rDUNTY,�'c� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: John Gallagher Address: 730 Bayview Dr city:East Marion st: NY zip: 11939 Building Permit#: 48327 Section: 37 Block: 5 Lot: 5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Giella Electrical License No: 4411 ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt 6 Ceiling Fixtures Bath Exhaust Fan 1 Service 3 ph Hot Water GFCI Recpt 2 Wall Fixtures 2 Smoke Detectors Main Panel 100A A/C Condenser Single Recpt Recessed Fixtures 4 CO2 Detectors Sub Panel A/C Blower Range Recpt Gas Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4 4'LED Exit Fixtures 11 Sump Pump Other Equipment: Fridge, Oven, Micro / Hood, 100A Panel 30 Circuits /29 Used Notes: Kitchen, Bath and Panel Inspector Signature: Date: December 29, 2022 S.Devlin-Cert Electrical Compliance Form O'of SO�jTyQl � O Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 S Southold,NY 11971-0959 Q Y ly�OUNTV,�� E E E D BUILDING DEPARTMENT SEP 2 9 2023 TOWN OF SOUTHOLD Building Department ToWn of Southold CERTIFICATION Date: / ) L-13 Building Permit No. rl Owner:-- Vo (Please print) Plumber: C—u—rra-4,---) (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (Plumbers Signature) Sworn to before me this day of, , 20_,2,3 . Deborah A. Kaminski NOTARY PUBLIC, STATE OF NEW YORK Suffolk County License#01 KA4987268 Commission Expires: 7 Notary Public, County pF SOGTyO� - -- -1 TOWN OF SOUTHOLD BUILDING DEPT. co 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SULATION/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 REMA KS: � o DATE i7 INSPECTOR Iraf so * # TOWN OF SOUTHOLD BUILDING DEPT. 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: Z DATE INSPECTOR FIELD INSPECTION REPORT I DATE COMMENTS j FOUNDATION (1ST) J � ------------------------------------ -.z C FOUNDATION (2ND) z cn y ROUGH FRAMING& PLUMBING S � 1 vl r INSULATION PER N.Y. n STATE ENERGY CODE V 4A IIMn FINAL .� ADDITIONAL COMMENTS 0 '? 2 S b H O x x v b H r o�g�FF01K G TOWN OF SOUTHOLD'—BUILDING DEPARTMENT y�C y x Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy��l �aop Telephone (631) 765-1802 Fax (631) 765-9502 lis://www.southoldtownnygov Date Received APPLICATION FOR BUILDING PE MIT L& For Office Use Only FD'j PERMIT NO. Building Inspector: AUG 0 0 GULL Applications and forms must be filled out in their entirety.Incomplete BUILDING DEPT. applications will not be accepted. Where the Applicant is not the owner,an TOINN OF SOUTH(--,LD Owner's Authorization form(Page 2)shall be completed. Date: 26 ?�- OWNER(S)OV PROPE TY: Name: SCTM#1000- o. � T L�i3A?/� - 37-D5--a5 ..._ Project Address: 60 Phone#: s ! a �. Email: K�'!1�/e �p/v�C k�/2.. I►/�Or2 . Mailing Address: CONTACT PERSON: Name: -f 7- 4266 Mailing Address: / .,,Ta . cel GUS- - i4 . . �.f_f6_ Phone#: Email �eR DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name_- ��..� /� �Q P S / i�1) Mailing Address/ Phone#: 9735— Email.: �/ CD/✓� (JG/ / N®� �L'' � DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Additibn ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ,KOther 1?6LVC /Z - Z 641ff ! D -- / I E $ 30.08&. d7� Will the lot be re-graded? ❑Yes �jV0 Will excess fill be removed from premises? ❑Yes ANO 1 PROPERTY INFORMATION Existing use of t o property: L Intended use of property: �� J1JNT _ ..._. . __ ?' 15 !'dW. 113%A Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to j� this property? ❑Yes ENO 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 By(print name): �6� ❑Authorized Agent Owner Signature of Applicant: Date: 7/2 /ZQ ZZ. STATE OF NEW YORK) SS: COUNTY OF 5 L•LFFO LPZ ) Rc b,.e.r-T 1�,, V_,-_LLER_ 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 aD —day of d , Notary Public Sarah I G ley Notary Public,State of New York Reglstratlon#01GR6037169 PROPERTY OWNER AUTHORIZATION l In Suffolk Coun My Commmismission Expires Feb.1 .202. (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 I� �Ln 13 2022 ILDING DEPARTMENT- Electrical Inspector �p DEC TOWN OF SOUTHOLD r o •'` BUILDING DEPS: . N own Hall Annex - 54375 Main Road - PO Box 1179 �. 1NMOFS.OUTHO� Southold, New York 11971-0959 cam �rry$ ,, O Telephone (631) 765-1802 - FAX (631) 765-98'02 " o °�a ro. (aD-southoldtownny.gov - seand(aD_southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: E l..L A �LC�T�fG► -L Cp Electrician's Name: 51, License No.: A4j5 5ry I Elec. email: slGrOc l Elec. Phone No:1C3)_ 3 g, j5 44 0 request an email cop of Certificate of Compliance Elec. Address.: 7-5/,-14 I46Ci►tLee- A0 C— 12p" 11a1-11.4-0 117� JOB SITE INFORMATION (All Information Required) Name: go/36A- 7- �L-:Lzf—Iz— Address: 7`36 /3 eE (nz b n- Cross Street: Phone No.: Bldg.Permit #: Z/gQ 3Z Z emai IvRKILL&kPA11ex< ASeAh 0/Q 0nP7 Tax Map District: 1000 . Sec(on: Block: Lot: BRIEF DDESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): �.. sG Square Footage: 6:e>t) Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑Rough In Final Do you need a Temp Certificate?: ❑ YES ❑ NO Issued On Temp Information: (All information required) Service Size E1 Ph❑3 Ph Size: ZD A # Meters Old Meter# ❑New Service[--1 Fire Reconnect❑Flood Reconnect❑Service Reconnect❑UndergroundAoverhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION jar— a� ro3� oti.���fg `DEC 1 2022 ILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD 1'BUIUDINGOE®down Hall Annex - 54375 Main Road - PO Box 1179 FS Southold, New York 11971-0959 0 ,�� �,�ti'r Telephone (631) 765-1802 - FAX (631) 765-9502 s ' rogerr(cDsoutholdtownny.gov - seand(a sou tholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ali Information Required) Date: Company Name: E LI,A Electrician's Name: STGv ,-zz-4-v4 License No.: UVJ,e Z/1Q/ Elec. email: s 14rtic f (01^4 ems-, coM Elec. Phone No:(�3J_ 3 g 1364 ❑1 request an email cop of Certificate of Compliance Elec. Address.: 7,5/-14 I-6aVtL4!�� ASC JOB SITE INFORMATION (Ail information Required) Name: goi--36d, 7- Address: 7 -3 D 86 Vi 1" W [� �- Cross Street: Phone No.: BIdg.Permit #: � Z 7 email Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE V,(.)TAG (Please Print Clearly): i Square Footage: Circle All That Apply: Is job ready for inspection?: YES ❑ NO ❑Rough In Final Do you need a Temp Certificate?: ❑ YES ❑ NO Issued On Temp Information: (All information required) Service SizeZ1 Ph❑3 Ph Size: dd A # Meters Old Meter# ❑New Service❑Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground2ioverhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION �� PERMIT # Address: Switches �` 1 Outlets GFI's II Surface l Sconces C` H H's I t l I UC Lts Fans Fridge HW Exhaust 1 Oven �vV WHO Smokes DW Mini Generator Micro r Carbon Combo Cooktop Transfer AC AH Hood Service Amps Have Used Special: �(t� �30 Comments Mejia, Evelin From: Mejia, Evelin Sent: Wednesday,August 30, 2023 11:38 AM To: 'rkeIler@nickersoncorp.com' Subject: Open Item on BP#48327 Attachments: ####48327tix_20230830113604.pdf Good Morning, A Plumbers Lead Solder Certificate is needed in order to close out Building Permit#48327 for the property at: 730 Bayview Dr, East Marion NY Attached is the Final Inspection Ticket. Thank you Evelin Mejia Town Of Southold Building Department Annex Building 54375 Main Road Southold, NY 11971 (631)765-1802 1 NYSIF New York State Insurance Fund PO Boz 66699;Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE A^A A^.A 113215565 •f RINGER CONSTRUCTION CORP. 776 MONTAUK HWY UNIT C ' BAYPORT NY 11705 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER RINGER CONSTRUCTION CORP. TOWN OF SOUTHOLD 776 MONTAUK HWY UNIT C 54375 MAIN ROAD BAYPORT NY 11705 PO BOX 1179 SOUTHOLD NY 11971-0959 POLICY NUMBER. CERTIFICATE NUMBER POLICY PERIOD DATE 11407.351-4 142862 12/07/2021 TO 12/07/2022 8/11/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEIN YORK STATE INSURANCE FUND UNDER POLICY NO, 1407351-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE .OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERTICERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OP FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT'COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT GEORGE RINGER RINGER CONSTRUCTION CORP.- A ONE PERSON CORPORATION(1 OF 1) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY'AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT S?NCE FUND / DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:684866331 U-26.3 RINGE-1 OP ID: DK CERTIFICATE OF LIABILITY INSURANCE DATE(MM108111!120222022Y) 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 631-589-5100 NAMEACT Jasmine Arettines FOLKS INSURANCE GROUP PHONE 631-589-5100 FAX 631-589-3335 33 MAIN STREET (A1C,N0,Ext): (A1C,No): WEST SAYVILLE,NY 11796 ADDRESS JAMES M.FOLKS JR INSURERS AFFORDING COVERAGE NAIC p INSURER A:Evanston Insurance Company 35378 I�ySURE Construction Corp INSURERS.Ohio Security Ins Co 24082 776 C Montauk Highway INSURER C:___ Bayport,NY 11705 -- INSURER 0: 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. /NSR _ TYPE OF INSURANCE ftNSD DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE a OCCUR 3FD5051 01116/2022 01116/2023 PREMISES ETORENTEO 100,000 R AGET R NTED nce MED EXP(Any oneperson) 5'000 _ PERSONAL&ADV INJURY _$ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: .GENERAL AGGREGATE 2,000,000 POLICY I X JE 0 u LOC PRODUCTS-_COMP/OP AGG $ 2,000,000 OTHER: S B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 {E�accident S X ANY AUTO BAS57636930 10131/2021 10/31/2022 BODILY INJURY Perperson) S OWNED SCHEDULED AUTEOS ONLY A ITOpS BODILY INJURY Per accident S AUTODS ONLY AUTOS ONLDY P a'd SAGE $ UMBRELLA LIAB FTcLcmLS-MADEj R EACH OCCURRENCE S EXCESS LIAB AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION LP SMU.CF ERH A AND EMPLOYERS'LIABILITY I""1 _ OrF10ER1MgMgrR EXCLUDED? �f IN NY PROPRIETORWARTNERJEXECUTIVE !A E.L.EACH ACCIDENT $ (Mandatory In NH) _E.L.DISEAS_E-EA EM_P_L_O_Y_E _$ If yes,descnbe under — '—' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If moia space Is required) CERTIFICATE HOLDER CANCELLATION TOWNSOH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road Southold,NY 11971-0959 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 la.Legal Name li,Address of Insured(use street address only) 1b.Business Telephone Number of Insured RINGER CONSTRUCTION CORP DBA R Q QUALITY INSULATION 631-589-8735 776 C MONTAUK HIGHWAY BAYPORT,NY 11705 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifrcally limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 113215565 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 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971-0959 DBL575832 3c.Policy effective period 01/01/2022 to 12/31/2023 4. Policy provides the following benefits: n A.Both disability and paid family leave benefits. E] B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] B.Only the following class or classes of employers 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 8/11/2022 B W440,mfY (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 413,4.0 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 Box 46,4C or ss 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. DB-120.1 (12-21) 111IIIIIIIIIIIIIoIIIIIIIIII`hu2ililillilil1111111 Suffolk County Dept. of Labor, Licensinq & Constimer Affairrs HMAF Name sow F OR.-� V R f. v N I' R. t[-1(--,1t V Ic' Icerlsed '-T � ON CORP 1(4-'VOI� S (-JLIIY h w. (',RoL Irl ty Of License NUmber .- H -22915 Rosalie Drago Issued : 04 !0 1 / 1 ,995 COMMISSIOrler E x pi res :, 04,'0112023 THIS INDENTURE,made the J day of August,two thousand and twenty-two BETWEEN John J. Gallagher and Joy E. Gallagher, as tenants in common,residing at 12 Winding Hills. Drive,Wallkill,NY 12589 party of the first part,and t� Barbara Keller`,residing at 11 Joyce's Way,Bayshore,NY 11706 CL^ (tr,,V� k- hvSh t°�t� r�y'Ll wks-C_ party of the second part, WITNESSETH,that the party of the first part, in consideration of ten dollars and other valuable consideration paid by the party of the second part, does hereby grant and release, unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, ALL that certain plot, piece or parcel of land with the buildings and improvements thereon erected, situate, lying and being in the SEE SCHEDULE A ATTACHED Being and intended to be a portion of the premises described in a deed from John J. Gallagher and Joy E. Gallagher, as tenants by the entirety to John J. Gallagher and Joy E. Gallagher, as tenants in common, dated August 11, 2005 and recorded January 31, 2006 in the Suffolk County Clerk's Office in Liber 12433 of Deeds at page 478. TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHER with the appurtenances and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party of the second part,the heirs or successors and assigns of the party of the second part forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever,except as aforesaid. AND the party of the first part, in compliance with Section 13 of the Lien Law,hereby covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word"party"shall be construed as if it read"parties"whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has duly,executed this deed the day and year first above written. IN PRESENCE OF: Joe o J. Gallagher Joy E Gall gher STATE OF NEW YORK,COUNTY OF ULSTER STATE OF ,COUNTY OF On the �AL-, day of August ,2022,before me,the On the day of , 2022, before me, the undersigned, personally appeared John J. Gallagher, undersigned,personally appeared , personally known to me or proved to me on the basis of personally known to me or proved to me on the basis satisfactory evidence to be the individual(s) whose of satisfactory evidence to be the individual(s)whose name(s) is (are) subsribed to the within instrument and names) is (are) subsribed to the within instrument acknowledged to me he/she/they executed the same in and acknowledged to me he/she/they executed the his/her/their capacity(ies), and that by his/her/their same in his/her/their capacity(ies), and that by signature(s) on the instrument, the individual(s), or the his/her/their signature(s) on the instrument, the person upon behalf of which the individual(s), acted, individual(s),or the person upon behalf of which the executed the instrument. individual(s),acted,executed the instrument. �I OTARY P LI' cad p H MORRISSEY,III NOTARY PUBLIC ubl(c,State 6f New Yo Quall edojn 1M0493fta k Comniisslon Exd ster County June z7,2® STATE OF NEW YORK,COUNTY OF ULSTER STATE OF ,COUNTY OF On the 9)k-, day of August, 2022, before me, the On the day of , 2022, before me, the undersigned, personally appeared Joy E. Gallagher, undersigned,personally appeared , personally known to me or proved to me on the basis of personally known to me or proved to me on the basis satisfactory evidence to be the individual(s) whose of satisfactory evidence to be the individual(s) whose name(s) is (are) subsribed to the within instrument and name(s) is (are) subsribed to the within instrument acknowledged to me he/she/they executed the same in and acknowledged to me he/she/they executed the his/her/their capacity(ies), and that by his/her/their same in his/her/their capacity(ies), and that by signature(s) on the instrument, the individual(s), or the his/her/their signature(s) on the instrument, the person upon behalf of which the individual(s), acted, individual(s),or the person upon behalf of which the executed the instrument. individual(s),acted,executed the instrument. N TARP P IY J-JOSEPH NOTARY PUBLIC aotary Public StatMOR -SSEY,Ill e9•No,p�tate of ryew York Quallfled In U site r�oun Comnilsslon Q,.June 27.28 z� Bargain and Sale Deed SECTION 1000-037.00 With Covenant Against Grantor's Acts BLOCK 05.00 LOTS 005.000 TITLE NO. COUNTY OR TOWN Suffolk GALLAGHER Recorded at Request of: To KELLER Return by Mail to: Thomas P.Zeph,Esq. 8 Ocean Way Bayshore,NY 11706 (631)563-0133 Si t 15'-611 oa 1st Floor XGUPANCY OR` USE IS-UNLAWFUL , IT CNV THOUT CERTIF�ICA . 16 -11 OCCUPANCY O _T e Fire Place Decki %10 pe_yL Ac Lj k' 11 PLUMBER CERTIFICATION' ONLEAD CONTENT BEFORE ny CERTIFICATE OF 66CUPAN,�1 - 15'-11 " SOLDER USED IN WATER AS NOTED v SUPPLY SYSTEM CANNC7 ® EXCEED 2/10 OF 1% LEAD. DATEJR40ED P:#FEE: 6 •��_ BY: NOTIFY BUILDING _'E:�:aRTMENT AT 765=1802 8 AM TO 4, PV1 FOR, THE - FOLLOWING INSPECT�C`n!S: LPA PLUtV1BINC: . - 1. FOUNDATION - TWO REQUIRED :ALL PLUMBING WASTE FOR POURED CONCRETE N .4, WA TER:LINES NEEDY.:.' 2. ROUGH - FRAMiNG & PLUMBING -COyERIfVQ. '. 3. INSULATION 91-811 4. FINAL - CONSTF!. -IrN MUST BE COMPLETE ALL CONSTRUCTir";ti' ALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. Ln 1 -1 FD 4 p p F11� �� AUG 0 8 2022 COMPLY WITH ALL CODES O ® O O NEW YORK STATE & TOWN COD E S e0 BUIL_!NG DEPT AS REQUIRED AND CONDITIONS OF { R'UTWI-D 3� 0 SGI rr' ^ 9W ?LAPddPiMIG B ARD O JEl I r'] SONG "�W�RUSTEES I N.Y_S-. — Residents: Robert and Barbara Keller ELECTRICAL �$,-9„ _ 730 Bayview Drive, 1INSPECTiON REQUIRED East Marion, New York 11939 f2 nd Floor Closet 31-411 ET Showe o ��f rel 71- T' Deck Closet — 15 1-1 OI► Residents: Robert and Barbara Keller 730 Bayview Drive, East Marion, New York 11939