HomeMy WebLinkAbout51277-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 PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 51277 Date: 10/11/2024
Permission is hereby granted to:
Mary T Hoeltzel
213 Orchard Way
Wayne, PA 19087
To:
install hot tub as applied for,
Premises Located at:
6190 Great Peconic Bay Blvd, Laurel, NY 11948
SCTM# 128.-2-5
Pursuant to application dated 08/22/2024 and approved by the Building Inspector,
To expire on 10/11/2026.
Contractors:
Required Inspections:
FOOTING/REBAR, ELECTRICAL- ROUGH, ELECTRICAL-FINAL, DRAINAGE, FINAL,
Fees:
SWIMMING POOLS-ABOVE-GROUND WITH REQUIRED FENCING $300.00
CO Swimming Pool $100.00
Total 1400,00
i4ft6g Inspector
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 https://www.soutlioldtowiijiv, yov
Date Received
APPLICATION FOR BUILDING PERMIT
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For Office Use Only
PERMIT NO.. Building Ins ector: 0,
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Date:8/(22/2024
Name:Mary Hoeltzel SCTM # 1000-128-02-05
Project Address:6190 Peconic Bay Boulevard, Laurel 11948
Phone#:(610) 401-1177 Email:hmth1230@aol.com
Mailing Address:6190 Peconic Bay Boulevard, Laurel, NY 11948
c
Name: Daniel Zic
Mailing Address: P.O. Box 302, South Jamesport, NY 11970
Phone#:(917) 334-4111 Email:info@hallockbuilders.com
Name:
Mailing Address:
Phone#: Email:
tg
Name: Hallock Builders
Mailing Address: P.O. Box 302, South Jamesport, NY 11970
Phone#:(631) 722-3261 Email:info@hallockbuilders.com
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❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑■ Other Tub $ 12,000
Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes WIND
1 .
PRO RTYINFORMATION
Existing use of property:Single Family Dwelling Intended use of property:Single Family Dwe'lli lg
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes 0No IF YES, PROVIDE A COPY.
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Application Submitted By(print .),: Daniel Zic ®Authorized Agent ❑Owner
Signature of Applicant: Date: 8/22/2024
STATE OF NEW YORK)
SILIS
COUNTY OF
. being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
Noe is the
(Contractor, Agent,Corporate Officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application;that all statements contained in this application are true to the best of his/her knowledge and elief and
that the work will be performed in the manner set forth in the application file therewith.
IBARSH.TANl� �
Sworn before me this Notary Publio,State Of NaW**
No. OI TA 6086001
Oualified In Suffolk O � >a7
a� day of , 20� Commission Fxlr ��
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
Mary Hoeltzel residing at 6190 Peconic Bay Boulevard, Laurel, NY 11948
I,
do hereby authorize Daniel Zic to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Mary HoeltzelDaea'2oz 0 ;M16:29 o400' 8/22/2024
Owner's Signature Date
Mary Hoeltzel
Print Owner's Name
2
DATE(MMIDD/YYYY)
C " ,0 CERTIFICATE OF LIABILITY INSURANCE
08/22/2024
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 po icy(ies)must 6e enaorsed. if SUBROGATION AIVED,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 CON I AC I
NAME: Heywood Orensteln
The RUCK Insurance Agency,Inc. q C N I xR, 631 876 1231� c„Ngy,l: 631-546 5441
. ..
1549 Main Rd AmoREss: Wcady�rlaNlals ccBro
INSURER(S)AFFORDING COVERAGE_.... NAIC
Riverhead NY 11901 IN A: UTICA FIRST INS CO 15326
... .....�..... INSU
INSURED RER B a.
......_ ..............................
JNH Builders INSURER C s
PO Box 302 INSURER D
INSURER E:
South Jamesport NY 11970-0302 INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE _ INSO WVD POLICY NUMBER _ rSLC - ..._. -
rfJ'rt' AOD S
"- ...- MMIODI"1'"YYY (MMIDDIYYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
-RE
X I CLAIMS-MADE El OCCUR PREMISES(Ea oc urennce) $ 2,000,000
MED EXP(Any one person) $ 5000
A Y Y ART3000432570 08/23/2024 08/23/2025 - --....--_-..-........ �"PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
PRO- _ m..
X POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $
.-..........
OTHER: $
AUTOMOBILE LIABILITY (Ea aCC.i&1an1) $
.............
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED _---
HIRED AUTOS AUTOS (Per acrAde t),,,,,, $
X UMBRELLA LIAB X I OCCUR EACH OCCURRENCE $ 2,000,000
A EXCESS LIAB CLAIMS-MADE Y Y ULC1442438 08/23/2024 08/23/2025 AGGREGATE $ 2,000,000
DED RETENTION$ $
WORKERS COMPENSATION STATUTE ER
AND EMPLOYERS'LIABILITY0 14-
- -
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) YIN 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)
CARPENTRY AND CONSTRUCTION JG 'p " �024
BUILDING DEPT.
TOWN, S 0 ,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Southold
53095 Route 25 AUTHORIZED REPRESENTATIVE
PO Box 1179
Southold NY 11971 ®.heilu
1 19'883 2014 ACORD CORPORATION.. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
ACCWY CERTIFICATE OF LIABILITY INSURANCE [� E
DA0 'MM/°°"""'
08/22/2024
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.
IMPi5RTANT: 11 t e certificate Ro aer is an ADDITIONAL INSURED,the policy(ies)must have ADi5IT1ONAL INSURE5 provisions or a en orsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER NAME: Heywood Orenstein
PHONE 631 731-6000
CompassPoint Insurance Services Inc. (A/c.No.Ext). 631-731-6000Aac N°)w•.•_ ._.
1549 Main Road ADDRESS: office@cpinsured.com
_...... ............. ..... �....
INSURER(S)AFFORDING COVERAGE NAIC#
.� ...... _-.,..m. ...... .------. w_�.
Jamesport NY 11947 INSURERA: MERCHANTS INSURANCE GROUP 23329
�....,..,_ �_ �........_ ......�..._._ ....
INSURED INSURER B:
JNH Builders, Inc. INSURER C
PO BOX 302 INSURER D:
INSURER E¢.
SOUTH JAMESPORT NY 11970-0302 INSURERF.,
COVERAGES CERTIFICATE NUMBER: REVISION NUMBED:
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.
It
ILNTRR TYPE OF INSURANCE INOSD IM/D POLICY NUMBER MMIDD/YYYY) MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
" G
CLAIMS-MADE'OCCUR PREMISES Ea occurrence) $
MED EXP(Any one person) $
Y Y PERSONAL&ADV INJURY $
.. _� �. ................ ..
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1 $
.................... .......................
POLICY PRO El LOC PRODUCTS-COMP/OP... $
JECT
OTHER: $
AUTOMOBILE LIABILITY 'Ea arJdra¢ $ 500,000
ANY AUTO BODILY INJURY(Per person) $
A
OWNED SCHEDULED
CAPI064332 02/14/2024 02/14/2025 AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED $
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE'... AGGREGATE $
... ......... _.... ......�......... ..............
DED RETENTION$ $
WORKERS COMPENSATION
IEXCLUD IE ECUTIVE E.L.
L STATUTE ER
AND EMPLOYERS'LIABILITY Y/N ___--. ...•
ANY EACH ACCIDENT $
OFFICER/MEMBER
NIA _ ...
(Mandatory in NH) El E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CARPENTRY AND CONSTRUCTION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Southold
53095 Route 25 AUTHORIZED REPRESENTATIVE
PO Box 1179 l�
Southold NY 11971 6116
O a 1908-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
YO "okes
" " & CERTIFICATE OF INSURANCE COVERAGE
STATE Compensation
and 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
JNH BUILDERS INC (631)722-3261
P O BOX 302
S JAMESPORT,NY 11970 1c.Federal Employer Identification Number of Insured or Social Security
Work Location of Insured (Only required if coverage is specifically Number
limited to certain locations in New York State,i.e., Wrap-Up Policy) 205473113
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
Town of Riverhead
200 Howell Avenue
Riverhead,NY 11901 3b. Policy Number of Entity Listed in Box 1a
LNY334253
3c.Policy effective period
07/01/2023 to 06/30/2024
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:
❑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 described
+above.
E- ' r rtetZla-
Date Signed 01-12-2024 By
(Signature of insurance carders authodzed representative or NYS licensed insurance agent of that Insurance carrier)
Tble Irittnf�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 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 413,4C or 5B 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)
Y
P' 0 E0 AS 1 OTEO
FEE BY.
INO111 BUILDING DEPARTMENT AT
631-765-1802 8AM TO 4PM FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION-TkAfr)pEry itnrr)
FOR POURED CONCIR� '
2. ROUGH-FRAMING
3. INSULATION E L ECTRICAL
4. FINAL-CONSTRUCTION MUST E E III REQUIRED
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET TI E
REQUIREMENTS OF THE CODES OF NEVY
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTON ERRORS
compLy rm ALL CODES OF
NEW ORK STATE&TOWN CODES
S REQUIRED AND CONDITIONS F
S0 IW �" I
SOM '1' f" q I'�P 6�� BOARDS
SOUTH TOWN TRUSTEES
1
$ q PO
'b PA N C
USE IS UNLAWFUL
)!" O CUP Y
LIMELIGHT° COLLECTION
FreshWater"
Salt System Ready U L
u
Dual Action Filtration
SilentFlo Circulation
Salt
System '' �tiy✓� t
Ready IO 'fit
y F
freshwater �� �✓,,
�/��f��(��%/,�/ �%f�iY/i f.�I��l��f�d% to �ll Ui✓' ^,:. '
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FiberCor-9 �dp� "�
M+M1' ✓ � ix1L lr 1 K� � �J�'�/NP"�i���, i if � �t
High-Density Insulation t✓ r /� a✓�✓,r, % l�
s�ii i% a�r,✓i'"d ?/� N,' rti " ✓Mill� q i .. .. ✓�°ia�'`y'�,`;,'
e-
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h
M✓ ni ll✓lrt, r iW ��
Shown with Alpine White Shell
and Coastal Gray Cabinet
i
I
Color LCD Display
People Seating Jets Voltage
7 Seats Open 49 Jets 230 V
✓ a �
Size
715" x 7'5" x 38" 1 226 cm x 226 cm x 97 cm
Water Care
Freshwater' Salt System Ready
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,,✓;✓ �;,, �o #otSriiug`
/obi
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LIMELIGHT° COLLECTION HotSprrin `
every day mode better'
L E
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low
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L✓�1/ ra � Cscrftttl Jaf:>le Espresso
,
COVER COLORS
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LEGENDARY MASSAGE SIZE
49 Peirsounalized-Control Jets Dimensions 7'5"x 7'5"x 38"/ 226 cm x 226 cm x 97 cm
l XL Deal Rotary.i t CAPACITY
1XI. SintgleRrtaryiFt
2 Xi,Directional jets Seating Capacity 7 seats
daYanrJrarc:5ingle Rotor/ et;
2Standard 's Water Capacity 445 gallons/1,685liters
4 Rotary Precision jets Weight 1,015 lbs./460 kg dry;5,950 Ibs./2,700 kg filled"
:35 Directional reci;iv jetti
ADDITIONAL FEATURES
EASY WATER CARE Smart Spa Hot Spring Spas App,Powered by the Connected Spa Kit
Water Care System FreshWater®Salt System Ready Technology
Filtration System Dual action,100 sq.ft.,top loading Water Feature Vidro'a backlit ribbon waterfall
Cover Lifters CoverCradle"-',CoverCradle II,Lift'n Glide@,or UpRYtOl
LEADING ENERGY EFFICIENCY Steps Limelight Collection Step(Coastal Gray,
Jet Pump 1 Wavemaster®9200;Two-speed,2.5 HP Continuous Duty, Espresso,and Sable),Polymer Step(Ash)
5.2 HP Breakdown Torque Entertainment Bluetooth®Wireless Sound System(Optional)
Jet Pump 2 WavemasterO 9000;One-speed,2.5 HP Continuous Duty, Control System 10 20200 with LCD control panel
5.2 HP Breakdown Torque 230 V/50 amp,60 Hz
Circulation Pump SilentFlo 5000®for quiet,continuous filtration (Includes G.F.C.I.protected sub-panel)
Heater Titanium No-Fault®4,000 W/230 V Lighting System Raio0l multi-color interior points of light
Insulation FiberCor°Insulation;Certified to California Exterior multi-color lighting with timer
Energy Commission(CEC)and APSP 14 Cooling System CoolZone"(Optional)
energy efficiency standards for portable spas
Cover 3.5"to 2.5"tapered,2lb.density foam core
.,r..i,,,>i¢,r=.+tr'.9�m,:VA.cS.v rtP�s, rer gm�r,7tr0 »i:. udtfdn ?n r8� 0>,.Vdr�c,,.� 1b"v;Gti;r m i,=h��s.a•4tav'C
'I mdk ii',wain and uO..ift, nu i ie:r9r rx
DATE(MMIDDIYYYY)
A' C CERTIFICATE OF LIABILITY INSURANCE
09/13/2023
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.
ORTAN : If the certf flca,te Folder is an WD FHONAL INSURED,the po cy(ies)must have-AUDITIONAL INSURED pro islons 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).
enstein
PRODUCER P'HONE_ Heywood76r, _NAMF
000 .$ Nr�)
III�,IL
1549 Main Road ADDRESS: ofc __. 1 6000
Ext
63
6 m
Com assPoint Insurance ServicesInc. �Jc N ecpinsured co
#
INSURER(S)AFFORDING COVERAGE NAIC w
Jamesport NY 11947 INSURER
A UTICA F S INS CO.
INSURED INSURERB MERCHANTS INSURANCE NCE GROUP 233..
29
„
JNH Builders,Inc. INSURER c
PO BOX 302 INSURER D:
INSURER E R _
SOUTH JAMESPORT NY 11970-0302 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED FAMED 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.
GENERAL LIABILITY ""AOOL StI'BFr """ �""'""".—....... -........Pm�LT�j 1MfRmfOOYIYYVY EACH OCCURRENCE�F, ,.....
LTR TYPE OF INSURANCE INN yyVO POLICY NUMBER IMM/00 � �A �� LIMITS
X $ 1 000 000
COMMERCIAL GE .... „._ ...:
s uMI $ 50,000
CLAIMS-MADE �. ._,� OCCUR I REMISES(Ea aro.� !er rl.......,.:.._._.—--.. .__.-_......
MED EXP(Any one person) $ 10,000
q Y Y ART3000432570 08/23/2023 08/23/2024 PERSONAL a ADv INJURY $ 1000000 m y
GEN'L AGGREGATE LIMIT APPLIES m --...— - -•PER: ...... $ 2,000,000
GENERAL AGGREGATE _. ,,. ,„..„.___.._._...._....
POLICY PRO- LOG COMP/OP AGG $ 2,000,000
PRO PRODUCTS COMP .,.. .
X � $
AU OTHER:
IT AUTOMOBILE LIABILITY (Ea acclden) ' $ 500 000
BODILY.. person) .. $...,�...._ m_
INJURY Per e
ANY AUTO ( p
rDI� .� _
B AAUTOS ONLY AUTOSULED CAPI064332 02/1412023 02/14/2024 BODILY INJURY(Per accident) $
" HIRED " — NON-OWNED TYC5AI4ARI $
AUTOS ONLY AUTOS ONLY 4Perre�damt) •m• "
$
UMBRELLA LIAB h. OCCUR ,EACH OCCURRENCE $ S,,000 000
------------
A EXCESS LIAB CLAIMS-MADE Y ULC1442438 08/23/2023 08/23/2024 aG�GR„EGATE $
_ CEO AT
RETENTION$ p� $
WORKERS COMPENSATION V LITIE I R
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E L EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?(Mand E.L.DISEASE
EASE EA EMPLOYEE $
atory in NH) E ..�,.,, .. .., .._......,. ...
If yes,describe under E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CARPENTRY AND CONSTRUCTION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Southold
53095 Route 25 AUTHORIZED REPRESENTATIVE
PO Box 1179
Southold NY 11971 �{r.°, ISG, , � ���7�G�
1g8B-201 ACORD�CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
N Y S' I F
New York.State insurance Fund PO Box 66699,Albany,NY 12206
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CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED)
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COMPASSPOINT INSURANCE
SERVICES INC "
PO BOX 1350
JAMESPORT NY 11947 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
JNH BUILDERS INC. TOWN OF SOUTHOLD
PO BOX 302 53095 ROUTE 25
SOUTH JAMESPORT NY 11970 PO BOX 1179
SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD :am]
12303 349-1 995666 02/14/2024 TO 02/14/2025
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK-STATE INSURANCE
FUND UNDER POLICY NO. 2303 349-1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS INS' 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:INVWW.NYSIF.COM/CERTICERTVAL.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
JEFF HALLOCK
JNH BUILDERS INC
(A ONE PERSON CORP)
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 SUi NE FUND
4 �/
DIRECTOR,1NSUR,ANCE FUND UNDERWRITING
VALIDATION NUMBER_ 259460194
INE DEPARTMENT-Electrical Inspector
TOWN OF SOUTHOLD
own Hall Annex- 54375 Main Road - PO Box 1179
DINGDE Southoid!New York 1 1 971-0959
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ephone (631)765-1802 - FAX (831)765-9502
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ELECTRICIAN IN N (wi information Required) Date.
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Company Name:
Electrician's Name:
License No.: - 0_jL_.-.. ..Elec. M
email: a J��✓ �. VA, d�
Elec. Phone No: 631. -21gy . Q54 request fin email copy ifinds of Compliance
Elem Address.:
JOB SITE INFORMATION (All Information Required)
Name: L=t.
Address: 1 c-C a c 9!
Cross Street:
Phone No.: 31- 9 UL S
BIdg.Permit#:
email:
Tax MaE District: 1000 Section: Block:
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Circle All That Apply:
Is lob ready for inspection?: YES10 Rough In Final
Do you need a Temp Certificate?: 0 YES CKNO Issued On
"e pY Information: (All Information required)
Service Size71 Ph 03 Ph Size: A #Motors Old Meter#
❑New SerAce0 Fire Reconnect[]Fiood Reconnect[Service Reconnect[_
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Additional Information:
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