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HomeMy WebLinkAbout50999-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE � ► �' SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLAINS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 50999 Date: 7/30/2024 Permission is hereby granted to: Yong, Trevena 101 Leonard St Apt PHA New York, NY 10013 To: Install roof mount solar to existing single family dwelling as applied for. Disconnects must be located on the exterior, labeled and readily accessible. At premises located at: 510 Slee Hollow Ln, Southold SCTM # 473889 Sec/Block/Lot# 78.-1-10.8 Pursuant to application dated 6/13/2024 and approved by the Building Inspector. To expire on 1/29/2026. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CO-RESIDENTIAL $100.00 Total: $325.00 Building Inspector 01 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 ll,tlpS://WWW.SOLitholdtownnv.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only , PERMIT NO. / Building Inspector,S�2AL- 1 2, 20 Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an uq riing Department Owner's Authorization form(Page 2)shall be completed. ,Town of Southold Date:06/11/2024 OWNER(S)OF PROPERTY: Name:Trevena Yong AECTM# 1000- 78.-1-10-.8 Physical Address: 510 Sleepy Hollow Lane Phone#: 917-655-2213 Email: trevena.yong@gmail.com Mailing Address: 510 Sleepy Hollow Lane Southold NY 11971 CONTACT PERSON: Name:Permit Dept./Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:Permits@GoPowerSolutions.com DESIGN PROFESSIONAL INFORMATION: Name:Michael E. Miele PE Mailing Address:33 Quaker Ave. PO BOX 530 Cornwall, NY 1218 Phone#: 845-629-9693 Email: Nypsengineer@gmail.com CONTRACTOR INFORMATION: Name:Michael Catizone/Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:mike@GoPowerSolutions.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition R'Alteration ❑Repair ❑Demolition Estimated Cost of Project: B Other Proposed( 21 )panel roof mounted array. ( 8.82 )kW System $ 29,988.00 Will the lot be re-graded? ❑yes I@No Will excess fill be removed from premises? ❑yes MNo 1 AMR/ ppsir,l,/" 1rr>Jrtl "HAKr f/' i fi%1 i i r Existing use of property:Single Family Dwelling Intended use of property:Single Family Dwelling 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. ,;�, r,// / t ,,� // ✓// r/ ✓ / ,f %/! 11/r ! �,/ /r /%/ r� � afY,9,c Al f,;r r/,,,i,o%ra,,,, r 1 ,, i, r rr f /J'tr i ➢ I I' r,1 r' ; �' l r l�r,, r(r', %/°pry,. r�- �I f�fr//i '� «1 f Yr',�/�//) /J r- /P 6 rf f r;/J/(irrrr R,('i �Iri/�" fiJiIft, l �r r �'�tCl� r✓«fir f'. Jy 1 I) i 1� � // / � rr� „-�✓ �a rvk rN�,rY>>' , �„�r s,e ir1Jr.oy I r 4 ri ,;�/e ti I'✓ y Ir J ar /?��,,r, r ( r. f ,di r aA r l �/ i�m / �'1I��ryry%I. s ,� „k Catizone Electrical/Long Island Power Solutions Application Submitted By(print name)I IgAuthorized Agent ❑Owner Signature of Applicant: Date: f I I �70 Lq , STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Michael Catizone being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the Contractor (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 day of 20, Notary Public DELCEMA 8t?RriN3 NOTMo���. . oJ!l;�E� ?��TF�oRB��T��3`m � �.e � (Where the applicant is not the owner) C Ex eattr!AlIn max 2027 I gat vLq "0 j do hereby authorize Michael Catizone/Long Island Power Solutions to apply on my behalf to the Town of Southold Building Department for approval as described herein. � - ✓ - -:))�� Cn �' Owner's Signature ate Print Owner's Name 2 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD tk Town Hall Annex- 54375 Main Road - PO Box 1179 a Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 � a ro err southoldtownn ov seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 06/11/2024 Company Name: Catizone ElectricaMong Island Power Solutions Name: Michael Catizone License No.: ME-53560 email: Permits@GoPowerSolutions.com Address: 2060 Ocean Avenue,Ronkonkoma,NY 11779 Phone No.: 631-348-0001 JOB SITE INFORMATION (AII Information Required) Name: Address: 510 Sleepy Hollow Lane Southold NY 11971 Cross Street: Grissom Lane Phone No.: 917-655-2213 yt Bldg.Permit#: o 2 11 email: treven.yong@gmail.com Tax Map District: 1000 Section: 78 Block: 1 Lot: 10.8 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Proposed( 21 )panel roof mounted array.. ( 8.82 )kW System 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 Reconnected- Underground -Overhead #Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: Inverters: 21 IQ8X-80-M-US Modules: 21 Rec 420AA PURE -R Su ort: Iron Ridge XR100 Lag Bolt PAYMENT DUE WITH APPLICATION Request for Inspection Form.As suffer County Dept of Labor.Lunging 6 Conaumer Af 's MASTER ELECTRICAL LICENSE Name MICHAEL CAT90NE Business Naffle ' LONG ISLAND POWER SOLUTIONS aoofts INC bramw b d0v koftsod oy mg Cam"tat suraIh Limm Number ME-635M Issued: 06f0612014 W09.4'T.Roserk Expired: 06101PIM Comnussio— ...,a Su County Demrt.of Labor.uco S C4rlsuaw Aftalre HOME IMPROVEMENT LICENSE Name MICHAEL J CATIZONE Business Fame LONE;ISLAND POWER SOLL111ONS C tlaet INC ru 1�awry by 4w Carty oI License Nwaber li-9 ksued: 0gIOGM14 Wagn&T.f AV4%, Expires: 06101f2M Cammnssioner Client#:83176 CATIELE _ -DATE(MWDD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 6/20/2023 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCERg2gj�CTCommercial Support Edgewood Partners Ins.Center P ONEAX N F,t;631-390-9700 No): 631-390-9790 40 Marcus Drive ADDRESS, NECertificates "ePIcbrokers.com ' 3rd Floor INSURER(S)AFFORDING COVERAGE NAIC# Melville,NY 11747-2647 INSURER A:Utica Mutual Insurance Company 25976 INSURED INSURER B: Catizone Electrical Inc INSURER C 2060 Ocean Avenue INSURER D: Ronkonkoma, NY 11779 INSURER E r 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 CONTRACTOR 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. N R ADOLSUBR p�LtCYEFF OLICYEXP T TYPE OF INSURANCE IN POLICY NUMBER P,D' YF MM/DD LIMITS A X,COMMERCIAL GENERAL LIABILITY CPP4784747 7/01/2023 07101/2024 EACH OCCURRENCE $1 000 000 CLAIMS-MADE : -emu OCCUR P tlS EaEcu sacs $100 OOO MED EXP(Any one person) $10 OOO w_ PERSONAL&ADV INJURY $1 000 000 1 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG s2,000,000 ECT OTHER: $ AUTOMOBILE LIABILITY MINED SINGLE LIMIT Ea ad�ixdant ANY AUTO BODILY INJURY(Per person) $ OWNED I SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS - �-- HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Pet a I n l $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION 4766763 7/01/2023 07/01/202 X .PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOdVPARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500,000 (MandatoryOFFICERMEMBEA n NH;) EXCLUDED? N/A E.L.DISEASE-E4 EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E L,DISEASE-POLICY LIMIT $500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold is included as additional insured for general liability coverage as required by written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S5673106/M5666984 KC001 YORx Workers'STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CATIZONE ELECTRICAL INC 477 MADISON AVE 6TH FLOOR#6975 646-383-3599 NEW YORK, NY 10022 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 45-5213112 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box I Southold, NY 11971 R97483-002 3c.Policy Effective Period 1/1/2020 to 10/1/2024 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: ❑X 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 des d above. Date Signed 10/3/2023 By �?44pt (Signature of insurance carrier's authoidedrepreseatitive or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 513 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(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) 'I IID�!'� "'i�w� �ui� iii 2 E Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured atizone Electrical Contracting Inc. 631348-0001 060 Ocean Avenue Ronkonkoma, NY 11779 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 1d.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) 202241963 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Utica Mutual Insurance Company Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 4766763 3c.Policy effective period 7/01/2023 to 07/01/2024 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all padners+o flcers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier) C-1- — ems' Approved by: 6 5/23 (Signature) (Date) Title: Authorized Re resentative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-390-9700 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 DATE(MM/DDIYYYY) ACIORDO CERTIFICATE OF LIABILITY INSURANCE 02/26/2024 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 endorsements„ PRODUCER CONTACT Christopher Curran Edwards and Company PHONE (631)472-8400 ��Na, (631)472-8486 140 Greene Avenue F-MAADDRESS, cents@edwardsandco.net INSURER(S)AFFORDING COVERAGE NAIC# Sayville NY 11782 INSURERA: James River Insurance Company 12203 INSURED INSURER B: Long Island Power Solutions,Inc dba New INSURER C: York Power Solutions;Michael Catizone INSURER D: 2060 Ocean Avenue INSURER E: Ronkonkoma NY 11779 INSURERF; COVERAGES CERTIFICATE NUMBER: 24/25 Master 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. POLICY LIMITS LTR TYPE OF INSURANCE N p POLICV NUMBER MMIDOIY FF X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE �OCCUR PREMf'S�.F,a rnas+si $ 50,000 " Contractual Liability MED EXP Any oneperson) $ Excluded A Y P0000000486 02/28/2024 02/28/2025 PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGG'REGATE,LIMITAPPLIESPER. GENERALAGGREGATE $ 4,000,000 POLICY[ �"I JRPcT ❑LOG 4000,000 PRODUCTS-COMP/OP AGG $ 07'HER�. $ AUTOMOBILE LIABILITY G0M'BINED SINGLE W $ Ea a..",ntL ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accidertl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER .ANY PROPRIETORIPARTNER,IEXECUTIVE ❑ NIA.. E.L.EACH ACCIDENT $ OFFICERNEMBER EXCLUDED? (Mandatary In KM E.L,DISEASE-EA EMPLOYEE $ If yes,describe under ,DESCRIPTION OF OPERATIONS below E,L,DISEASE-POLICY LIMIT $ Each Claim $2,000,000 Professional Liability A P0000000486 02/28I2024 EO2/28/2025 Aggregate $4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) As respects to General Liability if required by written contract the following are included as additional insured per the policy form FP5201„ 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. 54375 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD sNEW workers' CERTIFICATE OF INSURANCE COVERAGE nip Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured LONG ISLAND POWER SOLUTIONS INC 2060 OCEAN AVE 6313480001 RONKONKOMA,NY 11779 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 27-1175107 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Bein Listed as the Certificate Holder) Town of Southold Standard Security Life Insurance Company of New York 54375 Main Road 3b.Policy Number of Entity Listed in Box 1a Southold, NY 11971 R97411-000 3c.Policy Effective Period 1/1/2015 to 5/12/2025 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: ❑X 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 employers employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named ty y g above. Insured has NYS disability and/or Paid Family Leave benefits insurance coverage as desc� d Date Signed 5/13/2024 ByA*41* (Signature of insurance carrier's authorlW representative or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 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 56 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(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 toI issue this form. DB-120.1 (12-21) 111111, I Il1I1IIIIIII I I II I /7"WkN� NYi PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 271175107 m LOVELL SAFETY MGMT CO.,LLC 22 CORTLANDT STREET 33RD FLR NEW YORK NY 10007 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND POWER SOLUTIONS INC TOWN OF SOUTHOLD 2060 OCEAN AVENUE 53095 ROUTE 25 RONKONKOMA NY 11779 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z 2467 0-, 372393 04/01/2024 TO 04/01/2025 03/18/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2467 078-8, 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. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:I/WWW.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. PRESIDENT MICHAEL CATIZONE VICE PRESIDENT JOSEPH MILILLO TWO OF TWO OFFICERS LONG ISLAND POWER SOLUTIONS 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. NEW YORK STATE INSURANCE FUND 1111� 4 DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 97252850 1111 Milit monuNIA omMIMr 00000000001.25 4125I Form WCCERT-NOPRiNT Version 3(08/292019)[WC Policy-246707881 U-26.3 174 [00000000000125441258][0001-000024670788][ffZ][1634848][Cer NOPLIItT 1][01-00001] 4SY $WtK T workers' CERTIFICATE OF INSURANCE COVERAGE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured CATIZONE ELECTRICAL INC 477 MADISON AVE 6TH FLOOR#6975 646-383-3599 NEW YORK, NY 10022 Work Location of Insured(only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 45-5213112 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold Standard Security Life Insurance Company of New York 54375 Main Road 3b.Policy Number of Entity Listed in Box 1a Southold, NY 11971 R97483-002 3c.Policy Effective Period 1/1/2020 to 10/1/2024 4. Policy provides the following benefits: Q A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5. Policy covers: ❑X 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 descr > d above. Date Signed 10/3/2023 By (Signature of insurance carrier'sauahori represent Live or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 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 413,4C or 56 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(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. 1313-120.1 (12-21) 111111111u°°1°1°1°°1°111111111111111111111111111 NEWIt Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b,Business Telephone Number of Insured CATIZONE ELECTRICAL CONTRACTING, INC. (631)348-0001 2060 OCEAN AVE RONKONKOMA, NY 11779 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 202241963 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Graphic Arts Mutual Insurance Companv Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 4766763 3c.Policy effective period 07-01-2024 to 07-01-2025 3d.The Proprietor,Partners or Executive Officers are ® Included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box 1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate Is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,1 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: Shannon C. Peck (Print name of aauutthori d representative or licensed agent of insurance oarrter) Approved by: 06-28-2024 (Signature) (Date) Title: Director of Customer Retention and Experience Telephone Number of authorized representative or licensed agent of insurance carrier: (315)734-2000 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 Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured„ 1, 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