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�o�OS11FF0l�cp Town of Southold 2/18/2024 G. 0 P.O.Box 1179 o _ 53095 Main Rd yfj�l �ao�,r Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45001 Date: 2/18/2024 THIS CERTIFIES that the building GENERATOR Location of Property: 515 Gin Ln, Southold SCTM#: 473889 Sec/Block/Lot: 88.4-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/30/2023 pursuant to which Building Permit No. 50172 dated 1/2/2024 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: accessory generator as applied for. The certificate is issued to Farino,Anthony&Christine of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50172 1/31/2024 PLUMBERS CERTIFICATION DATED fi Au o iz ignature O�gpfFDi�� i TOWN OF SOUTHOLD BUILDING DEPARTMENT y _ TOWN CLERK'S OFFICE • 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#: 50172 Date: 1/2/2024 Permission is hereby granted to: Farino, Anthony 18 Ron Ct I Commack, NY 11725 To: install generator as applied for. Must maintain a minimum side yard setback of 5 feet. At premises located at: 515 Gin Ln, Southold SCTM #473889 Sec/Block/Lot# 88.4-5 Pursuant to application dated 11/30/2023 and approved by the Building Inspector. To'expire on 7/3/2025. - Fees: ACCESSORY $125.00 ELECTRIC $100.00 CERTIFICATE OF OCCUPANCY $100:00 Total: $325.00 Building Inspector pF SOUjyolo Town Hall Annex Telephone(631)765-1802 54375 Main Road CAP.O.Box 1179 Q -�► • �o sean.devlin(cD-town.southold.ny.us Southold,NY 1 1 97 1-0959 �y00WN,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE_OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Anthony Farino Address: 515 Gin Ln City:Southold St: NY zip: 11971 Building Permit#: 50172 Section: $$ Block: 4 Lot: 5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Universal Electric Services License No: 54018 SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Generator X INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch 200A UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 22kW Briggs & Stratton Generator w/ 200A Whole House Transfer Switch Notes: Generator �Inspector Signature: Date: January 31, 2024 S.Devlin-Cert Electrical Compliance Form 0FS0UTyolo l Z - # # TOWN OF SOUTHOLD BUILDING DEPT. °`ycauNn��' 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PL13G. [ ] 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: C/ N� DATE INSPECTOR pF SOUTyO� # * TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 ,rokl-�1 NSPECTION [ ] 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 REMARKS: uz INSPECTOR 'IELD INSPECTION REPORT DATE COMMENTS b FOUNDATION (1ST) ------------------------------------ - C FOUNDATION (2ND) z 0 - V1 ROUGH FRAMING& -- PLUMBING 1 s INSULATION PER N.Y. STATE ENERGY CODE r FINAL ADDITIONAL COMMENTS �leraln c O o�' o - z hn O z x d b a i �"g�EFDtXk�, TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 htlps://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector: ` NOV 3 0 2023 r Applications and forms must'be'tilled out in their en,.tirety."jncomplete -,applicatiioris,will not.be'accepted. Vl/here ttie Applicant`is not the owner;^an.:„ ' 1T5..1a �'.D1;'.k o 0 vner's A64 dzationfbrr6 Pa e 2 shall „be completed: ;�aa ' < 51'T° I ". Date:November 16, 2023 "OWNER(S).OF PROPERTY,, , Name:Anthony Farino_ SCTM#1000-88-4-5 Project Address: Gin Lane Southold NY 11971 Phone#:516-805-8092 _ Fanthonail: yjohn.farino@gmail.com Mailing Address:515 Gin Lane Southold NY 11971 SCONTACT PERSON: ' -'"__ y ^ Name:Sean ONeill Mailing Address:PO Box 64 Jamesport NY 11947 1phone#:63.17722-3595 .. Fmail:oneilloutdoor ower hotmall com E DESIGN••PROEESSIONAL INF..ORMATION:, Name: Mailing Address: Phone#: Email: -CONTRACTOR INFORMATION: ... ;•,_. Name: Mailing Address: Phone#: Email: DESCRIPTI)N OF PROPOSED CONSTRUCTION .,., ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOtherGenerator $12,000.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes ®No 1 . =PROPERTY INFORMATIION Existing use of property: Intended use of property: ......._.._, ..., ..._ denti•al ._.__.�._a_._.. _. ..�.._._._...... .__. �. ..__.._.....Resid.e,.ntia.l.�.......... . . _. Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ®No IF YES, PROVIDE A COPY. .'[],.Check Bbx After,R66din g:°pThe owner/contractorJdesign,profes§fonat is respdnstble for al[drainage and storm water Issues as provided =.Chapter M of the Town Code.,APPtICATIQN.15 HEREBY MADE;a the Building Oe{iartnient#or the issuance of a Building,Permit pursuantto the BuildingZvne'. 'Ordinance of the Town of Southold,Saffolk;.County,New York and other appiieable laws,Ordinances or'Regulations for.the construction of bgildings, ; aslditl' 'alterations or for,reimovator, demolition as herein described:The.appllcant,agrees to comply wlth all appllcabie laws,ordinances;building code,..:. housing code and regulationsand to admit autfiorized inspectors aipremises ond�in,tiuiiding(s)far necessary inspections.False statements madefierein are ;'punishable as;a,Class A i6isdemeadi r.'Oursuant toSection 21q',4'4 of,the.New:Ya�1i State Penariaw:' :y. Application Submitted By(print name):Sean O'Neill ®Authorized Agent El Owner Signature of Applicant: - �G/, ' Date: 11/16/2023 _......._._.. _r__._m........... _._,.. . . _. _ ..._......_ .. CONNIE-D.•BUNCH.....__..._....-.._...._...._._...__......._._. Notary Public,State of New York STATE OF NEW YORK) No.01 BU6185050 Qualified in Suffolk County COUNTY OF Suffolk SS: Commisslon Expires April 14,2�Lf ) Sean O'Neill being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Agent (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 � y of VV Uf-e� '�'^' Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) ,, Anthony Farino residing at 515 Gin Lane Southold NY do hereby authorize Sean O'Neill to apply on my behalf to the To;a, hold Building Department for approval as described herein. "/,/� 11/16/2023 Own e s Signature Date Anthony Farino Print Owner's Name 2 ,SUFFpj� BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex 54375 Main Road - PO Box 1179 o . Southold, New York 11971-0959 �'h0 apt, Telephone (631) 765-1802 - FAX (631) 765-9502 jamesh(cDsoutholdtownny.gov — seand(Dsoutholdtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: �-QL' CL� Z, Electrician's Name: License No.: Elec. email: „Q 1 Elec. Phone No:�i`- — �j S/ ®.I request an ail copy of Certificate f Compliance Elec. Address.: L S a,, ga/,,rQ-t JOB SITE INFORMATION (All Information Required) Name: Ah rj' p Address: cL/)2 �Sau4hv Ick I\J 6q I Cross Street: Phone No.: -5/( _ Q_ Bldg.Permit#: ,f!E�() /—7)-,\ email: Tax Map District: 1000 Section: Block: Lot: 5-- BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 26 gLj cnar i ram--�a- 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 Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[]Flood Reconnect❑Service Reconnect[]underground❑Overhead # Underground Laterals 1 R2 H Frame Pole Work done on Service? DY MN Additional Information: PAYMENT DUE WITH APPLICATION FRESHWATER POND FFL 14.2 COVER TO GRADE IF DROP "T" IS USED LOCKING CAST-IRON FINISHED GRADE ON INLET COVER TO GRADE ELEV 8.3 CLEANOUT DWELLINGS WITH PUBLIC WATER 20" MIN. CHIMNEY �-- 150' - 20" MIN. LOCATE DROP "T" UNDER ACCESS FOR MAINTENANCE IN LE ELEV 7.18 WATER MAIN HOUSE INVERT r E3 ® ®®Ao WM WM M WM WM WM M (7.64) OU INLET Im ® ®®s1) GINLANE ; ® ®®�� ��� nl PIPE ORDEQUALR 35, FLOW BAFFLE INV. 6.68 INV. 6.58 � • MIN. 4" DIA. SOR 35 EDGE OF PAVEMENT PITCHED 1/4" /FT. PIPE OR EQUAL LEACHING GALLEY(TYP.) PITCHED 1/8" PER FOOT 10' MIN. '': :.. ;� ° = 3' COLLAR BACK FILL 10' 8' MIN. "' I 8.5' LONG X 4.75' WIDE F MATERIAL TO BE U.P. N N.37054'10"E w.M. 125.0 450.00' BOTTOM OF ':' CLEAN AND GRAVEL SEPTIC TANKEL 3.18 z0 c° yod a ® ®00'- a ® ®e a o Z S } I '� I �1BOTTOM OF LEACHING GALLE ?:': : ' a ®74-0 CA a a CA 1 STY Zr" ¢o I n SINGLE I HIGHEST EXPECTED WATER EL 1.0 O FAMILY m I s' MIN. PENETRATION DWELLING I ►-� 5 BEDROOM SANITARY CROSS SECTION INTO A VIRGIN STRATA � S WOOD ELEV. 5.3 OF SAND &GRAVEL 2,478 SF DECK GARAGE DR BROWN N.T.S. OL 0.5' NOTES: FF 14.2 UNDER PROPOSED Crj ANDY LOAN1. AREA 15,625.00 SO. FT. OR 0.36 ACRES GF 5.6 25'x 35' z's* 2. FLOOD ZONE X 0.2% CHANCE ANNUAL FLOOD DWELLINGS WITH 88 ADDITION DWELLINGS WITH CL CLAYEY 1.3' PUBLIC WATER I a � I PUBLIC WATER 3. THE WATER SUPPLY,-WELLS, DRYWELLS AND 515 FFL 14.2 BROWN CESSPOOL LOCATIONS SHOWN ARE FROM FIELD I ��" � I 100' -150' O SAND OBSERVATIONS AND OR DATA-OBTAINED BY OTHERS. a VACANT 125' +� SP & 1.2 4. ELEVATION DATUM NAVD88 o �J GRAVEL _ J BROWN w", fi o C.O. 20,MIN. DRY 1 CL CLAYEY 1.3' HIGHEST EXPECTED TODR`�1�ELL WELL\ J SAND - GROUND WATER EL 1.0 � � z . tS MI"` '� LP LP 8'MIN 0 CL CLAY 1.0' ' �\ � WATER IN GROUND WATER EL 0.0 cadmmmm" � � � I4.0 oS� `EXISTING SANITARY CL CLAY 1.5 Iw»_� LOT 20 C-11LP LP LP TO BE ABANDONED O O SW MEDIUM 6 0'. MAP OF O -m �EXP�I-l�EXPxEX] PROPOSED 1,500 GAL. - SAND _ EXCgVATION INSPECTION REQUIRED BAY HAVEN z \20' SEPTIC TANK a FEB. 1, 2021 FOR SANITARY SYSTEM SITUATE _ _ _ _ _ _ W --_ K. WOYCHUK LS BY HEALTH DEPARTMENT SOUTHOLD s 37054'10" W 125.00' TOWN OF SOUTHOLD PROPOSED LEACHING GALLEYS(6) DWELLINGS WITH 8.6 LONG x 4.75'WIDE x TDEEP PUBLIC WATER SUFFOLK COUNTY, NEW YOftK -- 150' -- FILED: JAN. 22, 1959 MAP No: 2910 SCTM#. 1000-88-4-5 SITE PLAN SCALE: 1"=30' O F NEW SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES .�� yo PERMIT FOR APPROVAL OF CONSTRUCTION FORA D AN I E L R. F.ALA S C 0 Po E . P . C . �L SINGLE FAMILY RESIDENCE ONLY > > CONSULTING ENGINEER., DATE rlor2ozlH.S.MREF N�� o7zs o_ APPROVEDD •� 94 STEUBEN BLVD., NESCONSET, NY 11767 FOR MAXIMUM OF 5 BEDROOMS (516) 317-7209 056999 �=`v EXPIRES THREE YEARS FROM DATE OF APPROVAL DATE 03-10-21 SCALE DRAWING N0. R�FESSMitJP�, - - 05-14-21 �"=30' SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES i i . vo K Workers' CERTIFICATE OF INSURANCE COVERAGE STATE I Compensation Board 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured GEVINSKI INC (631)566-1464 84 VISTA COURT S JAMESPORT,NY 11970 1c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 853394006 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) TOWN of SouTHOLD 3b.Policy Number of Entity Listed in Box"1 a" 53095 MAIN RD Y Y SOUTHOLD,NY 11971 DBL 7453 06-2 3c.Policy effective period 02/18/2023 to 02/18/2024 4.Policy provides the following benefits: ® A.Both disability and paid family leave benefits B.Disability benefits only C.Paid family leave benefits only 5.Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 11/29/2023 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT: If Box 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 mailed for completion to the Workers'Compensation Board, DB 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 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 (10-17) Certificate Number 765359 Additional Instructions for Form 1313-120.1 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"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Worker's 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 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. 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 (10-17)Reverse t Yoat< workers°Compensati..dri CERTIFICATE OF INSURANCE COVERAGE sTAre . 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 carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured UNIVERSAL ELECTRICAL SERVICES LLC 516-850-7776 151 1ST AVENUE MASSAPEQUA PARK, NY 11762 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 471592478 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 Southold Building Department 54375 Main Road 3b.Policy Number of Entity Listed in Box"I a" Southold, NY 11971 DBL537882 3c.Policy effective period 07/09/2022 to 07/08/2024 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: © 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 6/29/2023 By (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 49,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit,PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if sox 4B,4C or 5113 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) 111°°��°�°�°°1°1°°1°°°11°111°III1111 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 1 a 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. 1313-120.1 (12-21)Reverse NYS1F New York State insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A 471592478 UNIVERSAL ELECTRICAL SERVICES,LLC 151 FIRST AVENUE MASSAPEQUA PARK NY 11762 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE,HOLDER UNIVERSAL ELECTRICAL SERVICES,LLC SOUTHOLD BUILDING DEPARTMENT 151 FIRST AVENUE 54375 MAIN ROAD MASSAPEQUA PARK NY 11762 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2449 563-2 895589 07/16/2023 TO 07/16/2024 11/19/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 563-2, 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:/IWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:532849254 U-26.3 UNIVELE-02 BEGEL7 ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE 11/27/2023Y) � 11/27/2023 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 Ellen Goldman(egoldman@butwin.com) Nathan Butwin Companyy,Inc. PHONE FAX 60 Cutter Mill Rd.Ste.414 (A/C,No,E:t):(516)466-4200 (A/c,No):(516)466-4213 Great Neck NY 11021 ADE-MDREAIL SS:info@butwin.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Utica First Insurance Co. 15326 INSURED INSURER B: Universal Electrical Services LLC INSURER C: 151 First Avenue INSURER D: Massapequa Park,NY 11762 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LT SD WVD MM DD MM DD LIMBS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F_X]OCCUR ART3000425430 8/20/2023 8/20/2024 DAEMA SETTO Ea NTED ce $ 50,000 MED EXP(Any oneperson) 1,000 PERSONAL BADVINJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY JE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY L AUTOS BODILY INJURY Per accident $ H RED NON-OWNED PROPERTY AMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ WORKERS COMPENSATION PER ITH- AND EMPLOYERS'LIABILITY Y/N TAT E ER ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ OFFICER/MgMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ _FF DESCRIPTION OF OPERATIONS/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 Southold Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South South Main Road ACCORDANCE WITH THE POLICY PROVISIONS. 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 ,Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/27/2023 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 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 NAME: Heywood Orensteln NE The RUOK Insurance Agency,Inc, AIC,No,E:f: 631-876-1231 (ac,No): 631-546-5441 PO Box 133 ADDRESS: woody@ruokins.com INSURER(S)AFFORDING COVERAGE NAIC# Manorville NY 11949 INSURER A: SECURITY MUT INS CO 15113 INSURED INSURER B Gevinski Inc DBA:Christopher C Gevinski INSURER C: PO Box 272 INSURER D: INSURER E: South Jamesport NY 11970 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDNYYY) (MMIDDNYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX]OCCUR PREMISES(Ea occurrence) $ INCLUDED MED EXP(Any one person) $ 1,000/25,000 A Y Y 0200000067 04/04/2024 04/04/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY $ AUTOS AUTOS RY(Per accident) HIRED AUTOS NON-OWNED $ AUTOS (Per accident) $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ElN/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If es,describe under 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 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Southold Town ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 AUTHORIZED REPRESENTATIVE Southold NY 11971-4642 611-e ,j" ;V @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 26 P0WERPR0TET_C DX'r, `° BRIGGS&STRATTON Standby_Generaf � R VED AS NOTED;kW �. DATE• a B.P.# S� ': YOU 'POWERED µ FEE r(/ BY: NOTIFY BUILDING DEPARTMENT AT „ . '93176&1802 8AM TO 4PM'F0R THE _ FOLLOWING INSPECTIONS:. 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE - R ES I D E NTIAL NS GLHH ION-FRAMING&PLUMBIC Standby Generators 4. FINAL=CONSTRUCTION MUS BE COMPLETE FOR C.O. ��. REQUIREMENTS OF THE CODES 0 YORK STATE. NOT RESPONSIBL. : DESIGN OR CONSTRUCTON ERROR SPECIFICATIONS OVERVIEW Briggs s&Stratton° y�;�;:-�:.�•�=.,���"�s. �f.r�.:�CQIi�IPLY..W.ITH..ALL._CODES_OF....._._.. ...._._......_.__..._.__.........__.._......... _ _..._.__.......__............_...._....._._.__.........._.____..................... s30�;eSNa.;,@ °'• NEUV^PORK STATE&TOWN CODES Power Protect"' _. _....................................................................._............._............................._..................__................._..........._................. .... 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Wariant3/1000 yp.Generatob'Illternationaih- '< :;(Parts'/,I abor/,Travel).:-Years/�tlou�s Wa`raoY Enetdssur"e;Suiface,Ruat"alld� r 1 iCorroslon(P.arts'/,iLahord,7Yavel) pYeais (k Warranty-Enclosure Rust'TIrroou9 `' (Paitsi%`I:ab'or/Travel)��Ye`a s b 3 Certifications 'UL Yes r},- Yes r' f ' No I'Massachusetts Plumbers and Gasfltters �r.p.-+. �stiri` r` Yes r t 2,6 .— POWERPR®TECT. `DX M EIRIGGS&STRATTON •Standby.Generators `; '��� s,•' " ' '4 V V RESIDE(VTIAL STANDBY GENERATORS SPECIFICflT10N5 Weights&Dimensions 'i."'ro..•,i ..f •i'-1'.- .,:.,"CS:i:.�:'ti.,. d•'A'-Mat:3'� ��N:'.:;:',rY'�� . ^Assembled Dimensions', ='' • ;;(L®ngtli"Ii,Wldih z Heigriej'(in=%mmj•t%�' 46.5 x 26.8 x 28.4/1181 x 681 x 721 __...................................................._..........................................._......._ .... ......................................................_.................... .......... .........._........._...._.................... a M•Assembled Wei'ht�Ibs'%�k p 540 245 H Peckaged;Dons:';: -"=F "�^'�-1. �:%- 48,8 x 305 x 50.5/1240 x 775 x 1283 Ceo th x Width z Hel lit (In;hmm 6251285 4a Y OutUneanil'PatlLayoat,Draviring''' °r"r _ 80104089 cam..:-�i-...=7"' �','az:, •..."_._•.,.::z:.°::::"�?_.-`T�'' ..,..__—.—__•_•._-_.__.-_..------------------'---------____—.___.._----------------------------._.___.._.-.-._..-._..._----.-.-..-------• I i -..:_,r:'_-....;:.r_,_:--'•• it � :' i III I 28.4 in (725 mm) I iili': Ii% i 0 ii Ci till O O 46.5 in(1181 mm) 26.8 in(681 mm) C UL US LISTED 'This generator is rated in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C22.2 No.100-14(motor and generators). 'Per ISO 3744.Sound level measurement at other locations around generator may differ depending on installation,based on lowest microphone at 7m. Normal operation based on average household usage, Fuel consumption rates are estimated based on normal operating conditions.Generator operation may be greatly affected by elevation and the cycling operation of multiple electrical appliances—fuel flow,rates may vary depending on these factors. 4 See operator's manual or BRIGGSaridSTRATTON.com for complete warranty details. Briggs&Stratton has a policy of continuous product improvement and reserves the right to modify BRIGGS 6 STRATTOM its specifications at any time and without prior notice. POST OFFICE BOX 702 This standby generator is not for Prime Power applications, MILWAUKEE,WI 53201 USA Published August 2021.Please visit BRIGGSandSTRATTON.com for the latest information. BS1332-8/21 Copyright©2021 Briggs&Stratton.All rights reserved.