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HomeMy WebLinkAbout50218-Z S�FFO[,�C Town of Southold 2/16/2024 o , P.O.Box 1179 o _ 53095 Main Rd d'170Ilb- rl` Southold,New York 11971 CERTIFICATE OF-OCCUPANCY No: 44992 Date: 2/16/2024 THIS CERTIFIES that the building WINDOWS Location of Property: 160 Sunset Ave,Mattituck SCTM#': 473889 Sec/Block/Lot: 115.-3-7 Subdivision: Filed Map No. Lot No. conforms substantially to the Application-for Building Permit heretofore filed in this office dated 12/12/2023 pursuant to which Building Permit No. 50218 dated 1/16/2024 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: (8)window replacements to existing single-family dwelling as applied for. The certificate is issued to Leon;Jose&Alvarez,Gilberto of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Autho ' e ignature �S�FFet�� TOWN OF SOUTHOLD moo. aye BUILDING DEPARTMENT TOWN CLERK'S OFFICE �y • SOUTHOLD, NY �Ol a 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#: 50218 Date: 1/16/2024 Permission is hereby granted to: Leon, Jose 162 Sterling Ave Greenport, NY 11944 To: install (8) window replacements`to existing single-family dwelling as applied for. At premises located at: 160 Sunset Ave, Mattituck SCTM #473889 . Sec/Block/Lot# 115.-3-7 Pursuant to application dated 12/12/2023 and approved by the Building Inspector. To expire on 7/17/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00 CO-ALTERATION TO DWELLING $100.00 Total: $350.00 Building Inspector pF SOUTyO� # # TOWN OF SOUTHOLD BUILDING DEPT. zo,; °�ycourm 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ �INAL A�IA, gmj.S [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOL ATIO [ ] PRE C/O [ ] RENTAL REMARKS: �- DATE INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (1ST) ------------------------------------ C FOUNDATION (2ND) z -- O 0 ROUGH FRAMING& y PLUMBING 'b � r INSULATION PER N.Y. �}."3 STATE ENERGY CODE ,1 •/ •a h�S G'o 4_ C 0 FINAL ADDITIONAL COMMENTS e, I ') Z 0 (}� z �b m (1 ro y O z x r� ro DocuSign Envelope ID:1782367E-7B38-440B-991E-5541E00785E4 MENT ' c�wn.Hall:Azii�ex�4375 IvIaiti load P. 0!. Box 1.1.79 Southc�lt,NY 11971-0959' F' . T 7ep icine{ 31)765-1"80 Fix(i3 ) 65- S02 lttt s:= r�xtiv: �rtizc�icltownn r, Date Received, 'For Office Use Only . PEfiMITN I :Sullaing Inspector D EC 1 2 2023 rltc tus 3#csrr +us :i_a6,filled ovie, h%e'6 i^i,U�:riri i ipl te:.., 64�ae �;� Sep tm cia : c keci..1# re'. ,, dhold }pi 1 s i#'riot € ,, tris itiPt is natr€ " Ts�w� �s= Dw .. gip. €vilira ' xttiaai�ri $>;slt die siispleez D6te: t - •. " g�{�y } ?: ;; io dame: SCTM#i0flt7- : 45- Project Address:, - Phone >...._.._rv_ w. , , .,...._-.. __...._... _...... _.-._.._. .,. Ma llin 'Adiress ' .�j` ',Sct - v�. fit ci �'i-ice t CCN ER ? m • M7ili6 Address:.. '. ;1 oL n a t ,T 6P v Phone#: �ti` ��s:��. Email: _,. _m....,......, ... ...... .._, Name: ; Mailing Address:, Phone,4: Email: Mailing AddresS.:: Phone#:, t� Email: . .. . : _._ . _. .._............... ova ,.. . hi i DNew,Stl•ucture,"ElAdditi""ri , Alteratirin Dlkepair, 1�,�]Demolition Estimated:Cost of Project: , b LP Wiil the lot be're-gracded�,,- Yes dNO' Will excess fill be removed from,premises? I.JYes C,No DocuSign Envelope ID: 1782367E-7B38-440B-991E-5541E00785E4 r., ;�- :•� :�'R'.PEFtTY`phlF�}l"t '�'ifl�a"' ,.:° , Existing use,of property ;t rti; t ; vr~s' ,a Intended use of property.- Zone or use:district in which premises is situated: Are'.there any covenants and restrictions with respect to this property? CJYes JN*o IF YE%PROVIDE A COPY. ......... ..w„ ii� � €� �A �Y!'i�i' d ::,:fie oivrter.coritractar sie'" rdf ;,f i5`'s;"s•:Ie`f` `r `` :a'. -=:� ;, .1� I, si��t.p�..e�s� Xe#?�6�t ib os'aJ1d atnagearisi�irvaaterissuai-as:pri�v3dn�S;by;; : 1i8 YFr' 6;Of the_ ,4l ,;:6-d 1Y n,h.:. r.<. p 3 >. eM. F l t +I}S, EREBY I+AtSE the;8yits'sEiga ilrtm4ntfa#--;the issuante-df,a,aU111ct `P�rm1#;pursuant talkie fold'ingZofie g Ordl ante of*e,Ts rr tt aulho d .c ot#4- a�an4y,i3ew Yortc anri other, piifiratrl w5;`t5i din ar s or"Re uiatEons;ftir rise constriictiori ref isitdiii&s;= ; ., „azidiliatfs,Ai£cretltsr ;iir,•f�r:rgmcva gr draiiisc»ashera�rt-tiessn"bes3:Tt%e apliiicai9ta{Ireies.Ct�`�srlpiy:i�+�th�l�applicalste laws,oiltiriazi�is;_bisitiiiii�.cvt3e Qi�° tYiBi(j5r15 [iL{ r'A it�ia�iio qds P '.•• ,•....� �..� Se ,._ ...,, ,.., - �`;."i�uus,rg c '�r ,;,� ri4 raze 7nslse`st�is.gri"pr�`,tr%ise�ae?tt ui�b�aiisliii�(sj'fc+r ni�rip tasp�ctivri�<,l`�t5'�'staiere�ei5ts rra�tie iici`ieir are:: p�iots3iatitc°�s��i7s"r" llils�A�s% �1��aitialri tip�cf�cq(en 2I€i,q�ai€�he:tile3r'Yi3t7t 5t�t�tie �11} 4•fi z .. 1, .. - .. Application Submitted By.(print neinie): ��.+�h��f- ���ir.l�t:t ;,, E@Authorized Agent 'CiOwner Signature'of Appiipant: Date: STATE OFF} N���rdl .. . CC}IJNTY C3 wi lr/\`.•} being duly'sworri,deposes.and says that(s)he is the applicant (Name.of odividuaI-signing%contract)above,named,, (S)he is the . (Contractor,.Agent,Corporate Officer,etc.) of said.owrier'or owners 'arid is d,uiy authorized to perform or have performed the.said work-and to make.and file this appiic�tion;That all-sfatements co. airied in this application are true to the best of his/her icnovviedge and belief;and that the work irviil;.be'performed in-the manner set forth in the application file therewith. Sworn beforo me this 44-5 rlay.of_ ,26. 2 _ Notary Pub b ii�riq L Garrison NOTARY PUBLIC :. PROPERTY,OWNER UT ORIZATIO Rddcingham County,NC My Comm1861011 Expires March 29,2028 (Wheee the applicant,is riot the owner)", Ave- residing 1, at ) ' do hereby acithoriae �t�. ni '- c'1, L; ' ¢ry\�-4-5 to apply on A@WL&�;,the Town of: outhold Building Department for approval.as described herein, 12/1/2M caner s 5ig6ature: :.. Date• Pri6t'bwner's Name 2 6� APPR VED AS NOTED Q DATE: B.P.# U FEE '6�BY: NOTIFY BUILDING DEPARTMENT AT 631-765-1802 8AM TO 4PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO REQ,.J!9FD FOR POURED CONCRETI 2. ROUGH-FRAMING&Pl-bi;r�r;�',:a 3. INSULATION 4. FINAL-CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTON ERRORS COMPLY WITH ALL CODES OF NEW YORK STATE &TOWN CODES AS REQUIRED AND CONDITIONS OF SOVDWNA SOANNING BOARD SOUSTEES N.YSO SO OCCUPANCY OR USE IS UNLAWFUL ',NITHOUT CERTIFICA- '�P OCCUPANCY WINDOW SPECIFICATION SHEET - Spec.Sheet#: F38905106 Sheet: 1 of 1 { Customer: Jose Leon Job#: F38905106 Consultant: Patrick Kenny Date: 11/29/2023 New Window Hinge Locations Existing Window 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,RorS Glass Misc Items Hardware Code Screens For doors use 2 Mull "S"=stationary or 3 g o o t to Z5 u N � N IV=operating Style Wraps .0 d a 0 a C7 ° >r o r u � W N T O N O N O p N O � Room Floor Code (Y/N) Style Code Series Code - of 3 3: ai c� a _1 > x J > x STD,White, GlassPack: DISPOSAL, 1 BED1 2nd 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,F, WRAP,LSR STD,White, GlassPack: DISPOSAL, 2 BED1 2nd 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 3 BED2 2nd 1 PNL Y 2,PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 4 BED2 2nd 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 5 BED3 1st 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 6 BED3 1st 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 7 BED4 1st 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X s BF,WRAP, LSR STD,White, GlassPack: DISPOSAL, 8 BED4 1st 1 PNL Y 2 PNL 6100 WH WH 61 36 97 Standard J CHAN, X S BF,WRAP, LSR SPECIAL CONSIDERATIONS: 1:White,2:White,3:White,4:White,5:White,6:White,7:White,8:White Line Level Notes: 1.MISC(1):(null) Wrap Color r Interior Casing Type 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: Seaboard Material(vinyl only-White Pionite,Birch or Oak) The • DepoWhermal Value of Products 'Wur' • by • • Dale 61-3-012018-- With Grids -n^,k,.:. grasrL-,��rYdS ..�M,:!u,'rKi"caj:'n n•-;? �,ymr <a'�w:':xf.r:: .x2y£'7Bvr,.. s�"'s-i": .a,., .: A�`iC,' ;ss ."w.k;.:;:??.^;:..tm ;i:3 .c'�.a .�t� r, a: n,.. r... S :ijx.. , ti.?I - w7 •.; s -r x:i 3' ;y k - Gia2'l "5ty�e.s;:rt<: ;- .il" - ._ GG; a Sf Gi .. ? � C ". .•:. ✓'^ •' x„- x' ,sk3'--.: `{.'r'4f. -,�{ � �fu..r.�%: .: ?•�r-.� i:• u;•?L.;r„A'.'s.$kt,a.a_i.arc.. :.:» & 1.,5..::i4:';a�.�€.::.3w•..u:<-..5._'.:,"...;.'1.%..+;Jx27� wa ?:L$::.<vs..'�ar s�:.�.-'v1'4i=,• >.,`r'(vz5,..:f�fiv:tiv n;" Y.J.�L, i.,,`.„.,5��. • li Awning 6500 Base ProSolar Supercept 7/9' 0.26 i 0.23 , Ole 0 0.26 0.21 0 C c Casement 6500 Base ProS.olar Supercept 718" 026 j 0.24 o 0 o o 026 i 6.22 0 o. o 0 Transom 6500.Base ProSotar Supercept 1' 0.27 1 0.32 0 0 0.27 ' 0:29 e a Double-Hung 6506 base ProSolar Supercept 71W 629 1, 026 0 029 }.0.24 0 0 0 Picture Casement (NH) 6500 Base ProSolar Supercept 7/8" •0.26 1 0,28 0 0 0.26 1 0.26 © 0 0 0 Picture 6500 Base, Pr6Solar Supercept 7la" 0.27 1 0.29 o o 027 ! 0.26 0 o. 2'Panel Sftder 6500 Base. ProSolar Supercept 7/9' -0.29 1 0.26 0 029 ; 0.23 o 0 o S 3 Panel Sliders 65D0)3a3e.(s 2i Sgft) Pro Solar Supercept 7t8." Q29 j .026 0 0:28 023 0 o a Garden Door(CH) 6500 Energy Star ProSolar SUN Super Spacer T' 1 0.30 ' 0.24 0 0 0 0 ,0.30 ; 021, w o 0. o Patio Door 1NOV0, 6500,Base Pro Solar Super Spacer. 1" 1 0.28 1 0:26 1-1© 0.31 i 0.23 0.1 01 0 1e • 1 Homes located everywhere EXCEPT:Arizona,California,Idaho,Nevada,New Mexico,.Oregon,Utah,and Washington. Awning(Inc Hopper) 6100 Base Pro Solar. Intercept 71a 027 0.24 0 0 0 0 0.28 1 0.21 0 0 0 a Casement 6100 Base Pro Solar Intercept 7/9" 0.27 0.24 0 0 0 0 0.27 0.22 0 0. o 0 Double-Hun 6100 Ener y Star Pro Solar Supercept' 3/4"V31 0 0.30 1 0.27 0 3 0 Picture Casement.(No t-rmge) 6100 Base Pro Solar Intercept 71W' 0 0 0.27 ! 025 0 010 0 I Picture 6100 Base Pro Solar Intercept 3/4" 0 o 0.27, 028 o 0 2 Panel Slider 6140 Base Pro Solar Intercept 3I4" 0 0.30 0.27 0 3 Panel Slider 6100 Base., Pro.Solar Intercept 3W . . 0 0.30 0.27 0 OEM, 1 1 • • Homes located everywhere EXCEPT:Arizona,California,Idaho,Nevada,New.Me)d Oregon,Ufah,'aaOF 1ashington. Patio Door INOVO 61.00 Ene*,,Star Pro Solar Super Spacer 1" 1 0.28 1 0.26 jol-I 1 1 0.28 0.23 Patio Door NARROW FRAME. 6100(PE),05);Base ProSolar Intercept 3/4" 0.28 ; 0.30 0 0 0.28 j 0.26, o 0 e 1 1 Homes located only in Wowing markets:Dallas,Denver,Detrok Phila,Northern NJ,Long Island,NY, Awning 6200.'Base' Pro Solar SHADE Supercept 314" 0.27 0.25 0 0 0 © 0.26 0.23 o a o 0 Casement 6206 ease Pro Solar SHADE Supercept 3/4" 026 OA8 e, 0 o o 0.29-; 0.17 0 0 0 0 Picture Casement NH 6200,Base Pro Solar SHADE Supercept 3/4 0.25 0.21 o 0 0 0 0.250.19 0 0 0 0 Picture Window ul0Q Base Pro Solar SHADE Supercept 3W 0.26 ; 0.24 e e a 0 0.26 ' 0.22 0 o o 0 Single Hung 6200 Base Pro Solar SHADE Supercept at4" 0.28 1 0.23 0 o c o 0:28 ? 0.21. 10010 Sin le slider. 6200.Base Pro.Solar SHADE Superwpt 3W 0.28 i 0.23 0 0 0 0.28 ';. 0.21 0 o c 3 Panel Slider 6200 Base Pro Solar SHADE Supercept 3kt" 0.28 ; 0.23, +� 0 0 0.28 0.21 0 0 0 • : - ' i 1 Energy)Sfar Homes located in coastal areas. Awning. 5B+300VL PS SUN/Lami Supercept 1" 0.26 ' 023 ® 0 0 © 026 i 0.2.1 0 0 0 e Casement -SB+300VL Base PS/Laini Super Spacer 1" 025 , 0.23- o © o 0 025 0.21 © ® o e Double Hung SB+300VL Base PS/Lami Super Spacer V 0.29 1..0.25 0 0 @ © 0.29 023 0 0 0 0 Slider SB+300VL Base. PS l Lami.. Intercept 1- :0.29 i 0.25 0 0 0 0 .0.29 1. 0.23 0 .o c .0 Patio Door _ SB+300VL ETC'366 PS Shade I Lauri. Super Spacer 1' 0-30 0.19 0 0 0 0 • GardenDoor_(CH) SB+300VL Base PS/Larni per Spacer 1" Q.30. i 02$ @ ® 0.30 1 025 ® a a o •Dots Indicate Energy Star certified forthatzone w~ Please • -: Simonton Windowswindows 1 Home Improvement Agreement: Page 1 Home.Depot License#'s-For the most current listing visit www.Homedepot.com/LicenseNumbers Patrick Kenny 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. • a, .{'�....- .�,.,.r--...t, -..:: .�::.:,.:�::::;.•; .""'r�.�_,..."'.^�,:—�..,'"�.�"T�p`�;C?'�,. .�w����.hr,�' "a,�li:-:>� 1s::,'t..�;E;��4`:,;' •t 1 .,1!., 4 ��xi+:•vJ fe..'(!'`�.•i"`�'�� ,•,'�;. '`�.:. Ma 'f; .�.e.� C,..ri'p Lt,..,.�t.,...F, .. -�:. .� ,.2v;r.sr`;hxv;�:,s fit?.`r::t�- ,,;� �..s"^ �a�{?�s,5 rY'..,.a-.T:r.; •M.�v-`•'"- .1 _Ser•.�ice��Provideic,.Contact,InformationF •:�;�,��,,. ,� o,:,z,,.;:.;�x,:r:J,r.�.rz,�.� ..,,«'��,�'r>�r.�� . ...4v_.,.,..��'_- •,<,...�.�>r - ., The Home Depot T The Home Depot Service Provider Contact Name Service Provider Company Name (631) 478-6101 customercancellationnortheast@hom Phone# �c Prrovider Email Address Service Provider License#(s) (-".y.. .,�,,...::�., ::.�+:i",''' :'�+: ,",.vS. "Y:is ..t.`Sa`._ �iW::- :'7:�- ..,t.,...., ^�%�•^ijyi;'•-.:'.".� , Y;r �`.y��^.y^�.: v.i .':7+:.. ..�':�fy.:.:.. +.��'..•+.L :Fq,!'.4'.. i-Y.- .J>: ..uc•¢^�• n'-1 s^r t. ..5:. .�.<5`- .,S c :.13 y":r„ •f'�.,\dit..-.r, u:-}._ 12 ,;Custv.%ner.Iriformahonr:.>.. �:� ���s� �., x�:'� -' � �; •. :. •,'�- ,, t. .k z:,s,.�.�.,�a-'� ..,,:vl e�.?.1_,.tt.,•.;�;a...+.:-.'.'r-:a::�::::':<..::s :F::»x.,>z:,.._..,..s,�:;:•:a_.�:.�.�s�:':;:>';.=at",5:.:...:._a�<�::•,l.�:SM`',;. Leon ~� .„ X� Jose � Long Island � F38905106 Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO# F Sunset Avenue atttuck -� 11952M Customer,Address City State Zip (917) 792-1105 oosealeonm14@gmail.com Hoene Phone# Work Phone# Cell Phone# Customer Email Address _ ^ac•+-rxn--e_.^.^><^�;•'+rc�'.^r."^,m.•' _ - w'�Tx�_ �.� .- ....may'.. _ -'+_ ;:raH:p'-_-`'.',«'^�..yY_Y,^.-.-....3�: - >^.,r.- ^-�z'sr--�--�r•-.;�r.-,3:- E „t•,.'s"..- "•r"si"§-%.emr%' .::;i'F r's.'�r,^ �:5: 'T:.��t•'�fi"y';;C:'�i`;,'� 's,i'z?' 'w"'#'',i'��...:., >•�- .k..._ *c,:ca%rtJ.f ':{'"' �r,, s��.,�r;�;.r...g'."FJ'.:-��.€,x,. ;,,r..,�, _r .r.�,.;c��,r<:�,,.,..,, �r�.:=:dY••r, - .�,' ..,,(", 1.+,y.�:.(":�:f..f',:..r:'✓�,.t -:•y.i..d:;;• �h:y�y.: j�~r-r'.:�xt-, h:-' 4 i'b.`^,%� -fe. ':3 =NUT CEKO•E.RTGHT'TO�CANCET:;�.. ,.,, %�::�.:� .,,� rr:�::�� u'-� +�r.�.� -...->,r � ���� '� r«,�. '``' I,.,:Z.+.y_:..+z.�..:zr..:ua..-�::.-,..:w.n+.x:...>..x.:.:...iwc.:cxc�'sz._.r,.11.w.�.s:.....:.....:vr.:'r"......wx_^�.r.'aS:rswu.,wdu.5'.-:..,.-.:?::��'�:F.:w�:..:`,�.+.x�.w w:.:...�;'?-,. ,.:.P:.x-3>,.zf�-�,•-'.`:.':Y.,�iu..s3,:..:.u,�u". �ii7.;-;-•' YOU MAY CANCEL THIS AGREEMENT W.ITHOtTT.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 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 O OUR RIGJIT TO CANCEL. J29J2023 Acknowledged by: Cu o is Signature _ Date 460 St-dad Form HIA(21 Jul.21)(E) Generated Date 11./„7_9.I?n 9 3 LeadTO# F g A 9()5106 v 0.1.1_ Home Improvement Agreement: Page 2 ,r��- «r., �.-r;,- --,..,..s,.....,. ,'x:".T,.:'....,. ,.,..e.:.xiY.",•'." ..'�t"'h,„�"*r'T,`n:S';^;'C^v^:�;;:"" ";y'.'?"""_^v41+',::�.�x.:•.^•:C:i"'ye;;. ."r,: ;Vt.,-..-axt� .t.,�� �:t^ :»' --i�,.,,=.'�'^', t:i �>�`..,_,.srs-: •W' .�,�i:i M;Y,:i:;^.;'„`�.,v aly.<7- ,w, '+.: .t,-�r ,Ei� :, ? mot,..;,r',7.,,z., `-�':,,.w:-r,.,,�,� re. .� ^f��� 3',�,.`i. 'XY':rn�` 5.�:�Ms;y.:,;'?::"``,•:. �,,,:,,... y ,µt•t ? •-t.,'1':)� .h„s,4,w+ - ���v"T,�`?"`W;"l ,.�. .E:.+1< g4'"114 (i' ���:`:i"_�:fi~� , .:x,r�..>:.w.,:,..r,�..u»u,.;,....r,suer._...a.,:_:.z:..:_.�..�.a+:.c,..,.,.�,.s.,,x._.,u-...,...`?.,........,3'.r..'L'.:�i:rx.::::;�'�:'�r�•i....,.:..,_r.<Ys•:':s)r>.a.�+.�'�£:.•.. n.,1"ir-_,�,._... .•i....'"" „`_-�:. t•�.-:.:.�'„_ 'fit�^:. 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. - QT„'-�.,.:,-.p„v,...,,.,.,,:,.7•;- Y.•rr-::�•r ,.:..""^'_??xr.:,r^^-r«rr.*',.:r^S ::,:r., .✓,• '�.a::i�,"r •- ,•✓,';--•�'i�,;;�F r..x.,-T";a:^"c^,<:a �;i�x 'g; �,. .f�» .,,a. ,.✓r� �+ 1. '`"``<-",.;x;�';`Js�, 't,u :�,ri'�Kris;l.:.�;. ��_F< ;:.'i,. „�• _ .."s. „x„h''j,•,._; _ 1' �� .+,Y1,t✓-�"':w,. :h�Y .4", p ';�'i''rjl�F";'^'rJ• %yFT..,,"r i;�, , Approximate Start Date: 05/27/2024 Approximate Finish Date: 06/26/2024 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 aRplicable. � `=w•":t 77i' ?�.,•Y:• - ,'.��a:w .a. ,T, .CkS i� .•i:. �.;c...:�nr: .;y ra<:;;v u:h�a,..�l s:. `'ti+:-h'' :a.t i.;.X: !`�':� r;t;_' ��r,4�;'^:.,^:s ''.i2:7.,,:*,syz'y�.{;✓,4 s...� ,u,�s,"j,a'a;;,"V y"�','. .3 i, '.{ 6e�1✓1 ctrrairii+_Records=Author�za_tivii: r k. .,.�. t�=..1.. .��„ ,,.tr k. - xr�.:.��s��>:.�:>.::�_sr,.:., .,�,, -�,x�.t ;�..;'z;_�:.,. �. , � ., - ....xwy,,.,:.:a�.,.,,. ., v �....i'�k:5..;.,.-:7�6�i;�J.�¢.r�,:.:`,ir��.��.1.,.1» ".v`5fn`..;».»:ntc�:a.o....ay.,..v..:,-...S...rh.��n-:G:..::M.:...i•.•"_'i ... 1J),'�:i:'�:...?:.". .r,:"�,".r;. 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. ;s�'�C w +'.G',"r?„*"•' r�""�s`';:???,.�,�.ra..-""•},^,.*.� vx. ,x�y.,,r- r',,'r'r,?:T.�;r.�.4:="��r.o»i�..�-7r-m4 .:j.. '�"-..p.......,-�'1',•- """`C.. T•t�`�?rt `*� a - .;`�� t:.,; :f,-:�,•.s4f.,,'_:7' d e,,t..a'?a,.�v :f:r:�f;'.,tig�z.,va„ �'„a ��, 7��Ci�itr''act�:Pr:�ce�and':Pa":uierit'Sc .�:h:� .�_f;.. :�:� :�, -�� �1;,;:.�,v.• A, <..,v,.. �,rv� :,f:,.n,,....vrh..:� _,.,.„_,_K„�...��;.�`>,`spa';�•w.n,*s��{e<5_,.�•:.._r::,� a.%a ,`,>,,`i5.'�ar,:<::.x.-.<:.. :'�''v...t:;rc�-,�sr.'„ ,.i, to-:�-''fiµ<i__.-.,_".s�i:., r� , 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: $ 6656.60� Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 0.00 (If applicable, total amount of taxes included pin Contract Price) *Maximum deposit ONLY applicable in AM, NIA,ME(33%),NJ, R (99 Deposit% 100.0 Deposit Amount$ 6656.E � Remaining Balance$ o.o .^ „xt 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. r{r: S.:Y.tj '�A", ':tvs ,'�.M �:TM`,$'.+F'.�.':',"`�r :ftt:: Y`� S'•-rr,'%:' S, G' 'h'orizatton"��` 5s ". .s,•.�..: .�,..ki',:.`.v'-T,,.z,.:.*..-i�.� .:f...tv Ys�' '�':'. r ,�. r_-. .9. Aece�itar%e�ad.Ault �„ �; N �"...r.<� ,:rr,-.. .,.., :-���:�__���,.>±..r.xr:<:w�`°:<<w.T.,:t�v ..s.k_T:�.�, .��•::,;, By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform any Services or (b) order and arrange far 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. X Cu o er's Signature ` Date X /s/The Home Depot 11/29/2023 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 1-800466-3337 460 Standard Form HIA(21 A.I.21)(E) Generated Date 11/99/2023 Lead,PO4 F.12905106 v 0.1.12 G P m' s, LLC I15 Et�n II Ln. ldstonbury, t 6033 WE UNDERSTAND THAT YOUR TIMFI ��i1fl'+C7N Z3 To Whom It May Concern: Enclosed you will, find a 'building permit application and check. If you have any questions regarding#his 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: 303446-8685 Fax: 866-697-0768 jenniferwinke@gopermits.org Go Permits LLC, 105 Buttonball Ln. Glastonbury CT 06033, scottdoughman@gopermits.org. 1 DATE(MM/DD/YYYY) ,�ocoRv CERTIFICATE OF LIABILITY INSURANCE 03103/2023 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). CONTACT PRODUCER NAME: ' MARSH USA,INC. FAX PHONE TWO ALLIANCE CENTER C No Ext: AIC No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ADDRESS: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIC# 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 1 ADDL FSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE I POLICY NUMBER MM/DD MMIDD A X COMMERCIAL GENERAL LIABILITY MWZY316648 03/0112022 03/01/2025 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE M OCCUR PREMISES Ea occurrence $ EXCLUDED X SIR:$1,000,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,000 JECT OTHER: MBINED A AUTOMOBILE LIABILITY MWTB316649 03/0112022 0310112025 Ea a cid.",SINGLE LIMIT $ 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 UMBRELLALIAB X OCCUR MWZX 316647 03/01/2022 03/01/2025 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ _ $ B WORKERS COMPENSATION SCFC50668198(WI) 03 01 2023 0310112024 X STATUTE ER IPER H AND EMPLOYERS'LIABILITY LIAB C Y/N WLRC50668150(MT) 0310112023 0310112024 E.L.EACH ACCIDENT $ 5,000,000 ANYP ROPRI ETOR/PARTN ER/EXECUTIV E OFFICER/MEMBEREXCLUE M N/A 5,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD z AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta 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:03/0112023 Expiration Date:03/0112024 (EL)Limit:$5,000,000 Carrier:Safety National Casualty Corporation Policy Number:SP4068090(QSI)(CA,OR,WA) Effective Date:03/01/2023 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:03/01/2023 Expiration Date:03/01/2024 (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 Dale:03/01/2023 Expiration Date:03/01/2024 (EL)Limit:$5,000,000 TX Employers XS Indemnity: Carrier:Zudch American Insurance Company Policy Number:NSL1138319(TX) Effective Date:03101/2023 Expiration Date:03/01/2024 (EL)Limit:$6,000,000 SIR:$5,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD o ` AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC D® 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 7AIC 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 i r ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and.logo are registered marks of ACORD I i voIW Workers' CERTIFICATE OF sTA: Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.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 1c. NYS Unemployment Insurance Employer Registration Number of Atlanta,GA 30339 Insured 76011130 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 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 a" 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 ❑ 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"la"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"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 t (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 2/081202.3 (Sign e) (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 Workers' Compensation Lawn Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a'form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. c-105.2(9-17) REVERSE e L Ir CERTIFICATE OF INSURANCE COVERAGE ^STA CcntjaenSatit)n 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 S 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"la" SOUTHOLD, NY 11971 LNY713657 3c Policy effective period 01-01-2023 to 12-31-2023 4.Policy provides the following benefits: 0 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. e 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 1 TP�LLO (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 t (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) a i 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 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 my 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(1047)Reverse Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name RICHARD TOUSEY Business-Name This certifies that the nearer is duly licensed HOME DEPOT USA INC(14 SUPPS) 3y the County of suffolk License Number:H-53429 Rosalie Drago Issued: 05/15/2014 Commissioner Expires: 11101/2024 4M This license is the property of Suffolk County Department of Labor,Licensing&Consumer Affairs. Possession of this license does not guarantee its validity. Additional Business Name License Categbry HI-GC t ' 1