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HomeMy WebLinkAbout50417-Z �p�g�yfFOl,fcO� Town of Southold 5/6/2024 G a y� P.O.Box 1179 0 H 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45168 Date: 5/6/2024 THIS CERTIFIES that the building ALTERATION Location of Property: 410 New Suffolk Rd, Cutchogue SCTM#: 473889 Sec/Block/Lot: 102.-6-4 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 2/6/2024 pursuant to which Building Permit No. 50417 dated 3/11/2024 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: alterations, including electric service and(2)entry door replacements,to existing single-family dwelling as applied for. The certificate is issued to Williamson Joyce Liv Trt of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50417 5/6/2024 PLUMBERS CERTIFICATION DATED th ze Si nature SueFot�c TOWN OF SOUTHOLD BUILDING DEPARTMENT H x TOWN CLERK'S OFFICE oy • 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#: 50417 Date: 3/11/2024 Permission.is hereby granted to: Williamson Joyce Liv Trt 410 New Suffolk Rd PO BOX 111 Cutchogue, NY 11935 To: install (2) entry door replacements to existing single-family dwelling as applied for. At premises located at: 410 New Suffolk Rd, Cutchogue SCTM #473889 Sec/Block/Lot# 102.-6-4 Pursuant to application dated 2/6/2024 and approved by the Building Inspector. To expire on 9/10/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00 CO-ALTERATION TO DWELLING $100.00 Total: $350.00 Building nspector oF so�ryol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 11971-0959 �� a0 sean.devlin(�-town.southold.ny.us �ycou ,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Williamson Joyce Liv Trt Address: 410 New Suffolk Rd city:Cutchogue st: NY zip: 11935 Building Permit#: 50417 Section: 102 Block: 6 Lot: 4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Homeowner License No: SITE DETAILS Office Use Only Residential X Indoor X Basement Service _X Commerical Outdoor X 1 st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 4 Wall Fixtures Smoke Detectors Main Panel 200A A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 200A Panel 40 Circuits /21 Used, (2)120Arc (2)120Combo Breakers Notes: New Service & Kitchen HR's Replaced Inspector Signature: e Date: May 6, 2024 S.Devlin-Cert Electrical Compliance Form pF SOUT,�O�o f # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUG PLBG. [ ] FOUNDATION 2ND [ ] I ULATION/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: fl Dtz DATE _� lD ?� I INSPECTOR OF SOGly�lo r� ( to AtwS G !V '* * I TOWN OF SOUTHOLD BUILDING DEPT. ll� � • ao `y10ou 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] 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: 4- k (7A /n I rL2 nDAA/ DATE 17J INSPECTOR J OE SOl¢yo� l f q ( C) Vl< � * TOWN. OF S UTHOLD BUILDING DEPT. °you m�i� 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] 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: 4- ��-�✓ _ DATE l INSPECTOR ° ZS }� to 0 3=old Y V JS, ,^' o. N X@e Spin till � W � M: p &off- G N - W IND CD CPo �B 8� N l7 a s � Z 0 0 i � as so 0 �yO?� c N N e r G 'Al j7nJ O N to IN FIELD INSPECTION REPORT DATE COMMENTS ` O r� FOUNDATION (1ST) S -------------------------------------- co'GC FOUNDATION (2ND) a � z 0 —�cn ROUGH FRAMING& y PLUMBING �1 6� INSULATION PER N.Y. 3 STATE ENERGY CODE FINAL ADDITIONAL COMMENTS �- 01 O t<e •� \ �� ew Secs y X _ ro z - x v b sutFocKc TOWN.OF SOUTHOLD—BUILDING DEPARTMENT o� oG y2 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telep4one,(631)765-1802 Fax(631) 765-9502 https:/%www.southoldtownny. ogo Date Received ' r APPLICATION FOR BUILDING PERMIT D EC E HE For Office Use Only F EB - 6 2024 PERMIT NO. -240- Building Inspector: Applications and forms must be filled out in their entirety.Incomplete Depa?Atxtent applications'will not.be accepted: Where the Applicant is not the owner,an. Town of Owner's Authorization,form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: k— L p SCTM#1000- Project Address: Phone#: Email: Mailing Address: CONTACT PERSON: ; Name: Mailing Address: _____.__-------•�a--- 9 -- .--.Lw� � __._--_�/.- .___._-/ 3s=-_-------- _---------- --------------------- Phone#: Email: DESIGN PROFESSIONAL'INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR-1 N FORMATION.:. Name: ---- Mailing Address: --...._.._._---------- Phone#: Email: DESCRIPTION-OF PROPOSED CONSTRUCTION ❑New Struc re ❑Addition ❑Alterati n Tfepair ❑Demolition Estimated Cost of Project: ❑Other T ` $ 4,000.0.0 Will the lot be re-graded? ❑Yes ®1<o Will excess fill be removed from premises? ❑Yes R< 1 PROPERTY INFORMATION ' Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ONO 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): S1 D,J T RrAuthorized Agent El owner Signature of Applicant: ` Date: STATE OF NEW YORK) SS: COUNTY OF SLAP-F-OA, ) aC V,eq -0 3-1' being duly sworn,deposes and says that(s)he is the applicant (Name of irldividual siiggninglcontract)'above named, (S)he is the l -(N (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,lad i''` day of Februar 20_Q`� b o ry Public EVE L.GATZ-SCHWAMBORN NOTARY PUBLIC.STATE OF NEW YORK PROPERTY OWNER AUTHORIZATION Registration No.OIGA6274028 (Where the applicant is not the owner Qualified in Suffolk County , ,1 pp ) Commission Expires Dec.24,20�I 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 4,< •,.i. SUfFp�,l: 31 BUIL TNG DEPARTMENT- Electrical Inspector �O� CMG >1PR 1 2 2024. TOWN OF SOUTHOLD -�` Town Hall Annex - 54375 Main Road - PO Box 1179 ;u:�1m,DMTC,ryF,Vr Southold New York 11971-0959 Ferephone (631) 765-1802 - FAX (631) 765-9502 jamesh(asoutholdtownny.gov - seand( -southoldtownny.Qov APPLICATION FOR ELECTRICAL INSPECTION ' ELECTRICIAN INFORMATION (Ail Information Required) Date: q 12-IZ-f Company Name: k Electrician's Name: License No.: Elec. email: Elec. Phone No:. Ell request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: Address: , J �vFz Cross Street: ?5 - 9 Phone No.: 931- 7,V - y Bldg.Permit #: 6oyj7. email:W IckM5®n � Com Tax Map District: 1000 Section: \�VJ Block: 4%. Lot:op -6 2- BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): apzAcgd �'Leu�,e,e,�.Q &'V cc r Square Footage: Circle All That Apply: Is job ready for inspection?: aYES [] NO []Rough In Final Do you need a Temp Certificate?: ❑ YES R'NO Issued On Temp Information: (All information req fired) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground[�verhead # Underground Laterals 1 2 M H Frame Pole Work done on Service? Y , N Additional Information: PAYMENT DUE WITH APPLICATION 01 J- b� PERMIT# Address: Switches Outlets GFI's ) M Surface Sconces H H's UC Lts Fridge HW POOL Fans Mini Fr. W/D Panel Pump Exhaust Oven Sump Heater Trnsfmr Smokes DW Generator Salt Gen. Carbon Micro GrbDis Water Bond Lights Heat Pucks ERV HOT TUB/SPA Inst Hot DeHum Transfer Disc Combo Cooktop Minisplit Blower AC AH Hood Blower Service Amps Have �� Used i Sub Amps Have Used Comments Building Department Avi lication AUTHORIZATION (Where the Applicant is not the Owner) 1I gMG9 ding at 1 N!?Ad su (Print property owner's name) (Mailing Address) do hereby authorize S 1� 2P�Q n (Agent) Q os' RU 1 e,(N6' to apply on my behalf to the Southold Building Department. v (Owner's Signature) (Date) WI ),CR ma 0 1 (Print Owner's Name) Y t ��Yti �AR � g 2024 r;. � a>'. NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) � 0 AAAAAA 112994098 HAMOND SAFETY MANAGEMENT LLC 6800 JERICHO TURNPIKE QI f SUITE 105W SYOSSET NY 11791 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SID BEEBE&SONS BUILDERS INC TOWN OF SOUTHOLD P O BOX 979 PO BOX 1179 CUTCHOGUE NY 11935 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G2096 932-5 1 35675 01/01/2024 TO 01/01/2025 12/7/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2096 932-5, 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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. SIDNEY D BEEBE PRESIDENT THOMAS E BEEBE VICE PRESIDENT SID BEEBE&SONS BUILDERS INC THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 30 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK STATE SUR NCE FUND T �V DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 145326815 U-26.3 AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1 210 7/2 0 2 3 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 Debra Simicich NAME: Roy H Reeve Agency,Inc. PHONE Ext: (631)298-4700 ac No: (631)298-3850 PO Box 54 E-MAIL dsimicich@royreeve.com - ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Evanston Ins Co INSURED INSURER B: Merchants Preferred Ins CO 12901 Sid Beebe&Sons Builders Inc INSURER C: PO BOX 979 INSURER D: INSURER E Cutchogue NY 11935 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2332718852 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM1DDIYW MM/DDY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE TO RENTF-17- CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 A MKLVlPBC003295 04/03/2023 04/03/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEC ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED CAPI068395 04/03/2023 04/03/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Underinsured motorist $ 1,000,000 UMBRELLA LIAB ��,,,�,,,��WREN` OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town of Southold is included as an additional insured for permit as per the terms and conditions of form CG2012 Additional Insured-State of GOvernmental Agency or Subdivision Political Subdivision-Permits or Authorizations as required by written contract CERTIFICATE HOLDER CANCELLATION 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. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ti ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD F NvoA,c Workers' am Compen CERTIFICATE OF INSURANCE COVERAGE Tsation 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 SID BEEBE AND SONS BUILDERS INC MAIN ROAD CUTCHOGUE, NY 11935 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Onlyrequired ifcoverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 112994098 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 PO BOX 1179 3b.Policy Number of Entity Listed in Box"l a" Southold NY 11971 DBL242568 3c.Policy effective period 01/01/2024 to 12/31/2024 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: FXJ 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.. Signed Date Si 2/1/2024 B C� � U'i GGMfI� 9 Y (Signature of Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers' Compensation Board (only if Box 4B,4C or 58 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) DB 120.1 (12-21) b 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 I 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 T APPRQVED AS NOTED DA - B.P.# �d ' NOTIFY BUILDING DEPARTMENT-AT 631 765-1802 8AM TO 4PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO REQUIRED FOR POURED CONCRETE 2. ROUGH-FRAMING A PLUMBING 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 RESPONS18LE FOR DESIGN OR CONSTRUCTON€ERROR$ COMPLY WITH ALL CODES OF NEW YORK STATE &TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTH0:TO ZBA SOUTHOLD T N PLANNING BOARD SOUTHOLD OWN TRUSTEES N.Y.S.D SO LD HPC SCH OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICA OF OCCUPANCY Quote Form ��_ ,�.,,..Fa AMAGANSETT BUILDING MATTITUCK K 12585 SOUND AVE MATTITUCK NY 11935 631-996-4800 SUiLDING MATERIALS a n�AG SETT BUILDING MATERIALS Project Information (ID#7789292 Revision #11629159) Ripe Project Name:Sid Beebe Quote Date: 12/28/2023 Customer: Submitted Date: Contact Name: PO#: Phone(Main): Phone (Cell): Sales Rep Name:Tom Goodwin Customer Type: Salesperson: Terms: Delivery Information Hine Shipping Contact: Comments: Shipping Address: City: State: Zip: Unit Detail Wide All Confieuraiion OEtions Item:0002:Ext 30"x 80"S132-RTLE LHI 4 9/16"FraineSaver Location:4� Quantity:I ® Smooth Star 30"x80" Single Door 1,045.40 (Left Hand j Configuration Options MijP Inswing i j ! • Product Category: Exterior Doors j • Manufacturer: Reeb-Smooth Star Product Material:Smooth Star Fiberglass • Material Type:Smooth Star Product Type: Entry • Brand:Therma-Tru • Configuration (Units viewed from Exterior):Single Door • Reeb Finish: No • Slab Width: 30" • Slab Height:80" • Product Style: 1/2 Lite • Glass Type: Clear • Glass Style: Blinds • Glazing Type: Insert • Insulation: Low E • Grille Type: None • Model:S132-RTLE • Frame Material: FrameSaver • Handing: Left Hand Inswing • Casing/Brickmould Pattern:Standard Brickmould • Casing/Brickmould Type: FrameSaver • Ship Casing/Brickmould Loose: No • Hinge Type: Radius x Square (Self Aligning) • Hinge Brand:Therma-Tru • Hinge Finish: Oil Rubbed Bronze • Jamb Depth:4 9/16" • Sill: Composite Adjustable • Sill Finish: Mill Finish w Light Cap • Lock Option: None • Bore:Single Lock Bore 2-3/8" Backset • Weatherstrip Type: Compression • Weatherstrip Color:White • Custom Height Option: No • Mail Slot: None • Sill Cover: No • Sill Pan: No • Rough Opening Width: 321/2" • Rough Opening Height:821/2" • Total Unit Width(Includes Exterior Casing): 34 1/4" • Total Unit Height(Includes Exterior Casing): 83 3/8" Item Total:$ 1,045.40 Item Quantity Total:$ 1,045.40 Item:0003:Ext 36"x 80"RS132RT GBGCWLE LHI 4 9/16"FrameSaver Location: Quantity:I ���� Smooth Star 36"x80" Single Door 1,090.85 ` I l�-;Left Hand Configuration Options Piide ' Inswing 1 I • Product Category: Exterior Doors • Manufacturer: Reeb-Smooth Star �' j • Product Material:Smooth Star Fiberglass • Material Type:Smooth Star --- -- -------{ • Product Type: Entry • Brand:Therma-Tru • Configuration (Units viewed from Exterior):Single Door • Reeb Finish: No • Slab Width: 36" • Slab Height:80" • Product Style: 1/2 Lite • Glass Type: Clear • Glass Style: Blinds • Glazing Type: Insert • Insulation: Low E • Grille Type: White Contour Bar • Model: RS132RT GBGCWLE • Frame Material: FrameSaver • Handing: Left Hand Inswing • Casing/Brickmould Pattern:Standard Brickmould • Casing/Brickmould Type: FrameSaver • Ship Casing/Brickmould Loose: No • Hinge Type: Radius x Square (Self Aligning) • Hinge Brand:Therma-Tru • Hinge Finish: Oil Rubbed Bronze • Jamb Depth:4 9/16" • Sill: Composite Adjustable • Sill Finish: Mill Finish w Light Cap • Lock Option: None • Bore:Single Lock Bore 2-3/8" Backset • Weatherstrip Type: Compression • Weatherstrip Color:White • Custom Height Option: No • Kick Plate: None • Sill Cover: No • Sill Pan: No • Rough Opening Width: 381/2" • Rough Opening Height: 821/2" • Total Unit Width(Includes Exterior Casing):40 1/4" • Total Unit Height(Includes Exterior Casing): 83 3/8" Item Total:$ 1,090.85 Item Quantity Total:$ 1,090.85 Unit Summary Z. Item Description Quantity Unit Price Total Price uJ� Ext 30" x 80" S132=11TLE LHI 4 9/16" FrameSaver 1 $ 1,045.40$ 1,045.40 2, _ Ext 36"x 80" RS132RT GBGCWLE LHI 4 9/16�� FrameSaver 1 $ 1,090.85$ 1,090.85 SUBMITTED BY: SUBTOTAL: $ 2,136.25 ACCEPTED BY: TAXES (8.625 %): $ 184.25 DATE: GRAND TOTAL: $ 2,320.50 Warranty Information: .si}_W�cai'ra.niies ■ OM ■ r ■ ■ 21 Additional Information: I understand that this order will be placed according to these specifications and is non- refundable. All products are unfinished unless otherwise specified and should be finished as per the instructions provided by the manufacturer. Images on this quote should be considered a representation of the product and may vary with respect to color, actual finish options and decorative glass privacy ratings. Please verify with sales associate before purchasing. Unless otherwise noted, prices are subject to change without notice, and orders accepted subject to prices in effect at time of shipment. Prices in this catalog apply only to sizes and descriptions listed; any other specifications will be considered special and invoiced as such.