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HomeMy WebLinkAbout51460-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#: 51460 Date: 12/10/2024 Permission is hereby granted to: Jared Lettieri 170 Mill Rd Westhampton Beach, NY 11978 To: legalize "as built"alterations to existing single-family dwelling as applied for. Additional certification may be required. Premises Located at: 2285 Westview Dr, Mattituck, NY 11952 SCTM# 107.-7-1.1 Pursuant to application dated 10/11/2024 and approved by the Building Inspector. To expire on 12/10/2026. Contractors: Required Inspections: Fees: As Built Alteration $1,344.00 CO-RESIDENTIAL $100.00 Total $1,444.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 h Telephone (631) 765-1802 Fax (631) 765-9502 hi!ps://www.southoldtownpy.gov so Date Received APPLICATIONI For Office Use Only PERMIT NO. "D Building p Ins ector: Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. ' Date: October 1 II th 2024 OWNER(S)OF PROPERTY: Name:Jared lettieri SCTM#1000- 107.00-07.00-001 .001 Project Address: 2285 Westview Drive Mattituck NY 11952 Phone#:631 574-7450 Email:jared@lettiericonstruction.com Mailing Address: 170 Mill Road Westhampton Beach NY 11978 CONTACT PERSON: Name:Jared Lettieri Mailing Address: 170 Mill Road Westhampton Beach NY 11978 Phone#:631-574-7450 Email: jared@lettiericonstruction.com DESIGN PROFESSIONAL INFORMATION: Name:Raymond Renault Mailing Address:PO Box 284 Shelter Island NY11964 Phone#:631-721-3443 EKraymondrenaultarchitect@gmaii.com CONTRACTOR INFORMATION: Name:Lettieri Construction Inc. Mailing Address: 170 Mill Road Westhampton Beach NY 11978 Phone#: 631-288-4808 Email: tom@lettiericonstruction.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ®Repair ❑Demolition Estimated Cost of Project: DOther new roof, replace windows/doors,replace siding, new kitchen and bathroom finishes. $200,000. Will the lot be re-graded? Eyes R No Will excess fill be removed from premises? ❑Yes ®No 1 PROPERTY INFORMATION Existing use of property:single family residence Intended use of property:single family residence Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to residential this property? ❑Yes *No IF YES, PROVIDE A COPY. 8 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): Jared Lettieri El Authorized Agent BOwner Signature of Applicant: Date: 10/11-/2024 STATE OF NEW YORK) SS: COUNTY OF Suffolk ), Jared Lettieri being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Owner (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 October , 20 24 Nota Public Kathleen K.Hanna Ilabery public-State of New Yak NO.OIHA4899065 Oualilied in Suffolk Count/4 PROPERTY OWNER AUTHORIZATION OMMIsalm Eq*es Of3�29- (Where the applicant is not the owner) 1, 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 Client#: 2635 LETTCON '.. DATE(MMIDD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 10/11/2024 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Commercial Support Ed ewood Partners Ins.Center PHONEAX�ww_ 9 LOr N�, E 631 390-9700 JC Nag 631-390-9790 40 Marcus Drive E-MAIL awac, s� — @ P com NEcertificates a Icbrokers 3rd Floor INSURER(S)AFFORDING COV ERAGE NAIC# Melville, NY 11747 New York Marine And General Ins Co 16 ....... INSURER A: 6O8 .,.......... .... ......_.....-.....,.........._... ..�.,.,.,.,.,...�.. ._ ......... m,,,6� ............................. .... w._�..W.w INSURED INSURER B:Pennsylvania Manufacturers Indemnity/Co 41424 Lettlerl Construction,Inc. Merchants Mutual Insurance Company 2 INSURER C: p y 3329 POBox 1406 ................. _.....m......_ — .................................................................WW.... ..----- INSURER D Westhampton Beach,NY 11978 .n.��.�.. m_ ...................... .. INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LTRR R SSA..- ... ... POLICY EFF POLICY EXP ................... ...�.,_-.� TYPE OF INSURANCE POLICY NUMBER _(MMIDD/YYYY, �MMjp.q XY LIMITS COMMERCIAL GENERAL........ ....................... ...... ...... ..,-.,,,,, m................. �.. ....., A X LIABILITY GL2023LHBOO404 12/31/2023 12/31/2024 EACH OCCURRENCE $1 000 000 p h E 'N LNTED ---- ---.CLAIMS-MADE X�OCCUR „., o urrnf)c9;), $100p. ,,,,,,, X BIIPD Ded:5,000 MED EXP Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 ........... GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE .............. 2,000,000 POLICY .. .. ,. ...... S COMP/OPAGG s2,000,000 OTHER PRO- PRODUCT X, JECT LOC C 2/31.... AUTOMOBILE LIABILITY CAP9253222 1 COMS1NEt3�uiNGB.L LIMIT /202312131/202 E�a��id�nD__----------- 0,000,000 X ANY AUTO BODILY INJURY(Per person) $ _ OWNED SCHEDULED BODILY INJURY(Perm accident)ac ..... $ AUTOS ONLY AUTOS ONLY ,AUTOS ONLY HIRED NON-OWNED Pk2'OPERTY $ X.... X Auros Par ..DAMA�. A UMBRELLA LIABX OCCUR $5 000,000 EX2023LHB00109 12131/2023 12/31/202 EACH OCCURRENCE X CLAIMS MADE PER---- —.OTH- $mm��.._000 WORKER O. RETENTION$ --- ............... .... ....... ------- ......_-------- .......... ........,a....... EXCESS LIAB AGGREGATE $ DED ...m .. ._._ ... COMPENSATION JI" pI AND EMPLOYERS'LIABILITY .5.T TVTE•--�-�`--"ER' '............. ANY PROPRIETGRJP'ACITNER/EXECUTIVE —N E.L EACH ACCIDENT $ OFFICE.RIMEMSER EXCLUDED? ❑ N/A �....,m.___ . (Mn:ndatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under ......................__ -. . _ DESCRIPTION OF OPERATIONS below -------------____ E.L.DISEASE-POLICY LIMIT $ B Excess Liability m._....m --- 6023019210584 12/31/2023 121 - - _....__ y 31/202 $5,000,000 OcculAgg DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Southold -Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Rd ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 11971-0959 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 #S6963930/M6110295 SON01 Client#:2635 LETTCON DATE(MM/DD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 10/10/2024 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. ^-IM VOA TANT:If the certificate holder is an ADDITIONAL INSURED,the olic y('les-mmmm WWWWWWWWWW µmm -p s)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). PRODUCER CONTACT Commercial Support Ed ewood Partners Ins.Center PHONE Est —11 www� ..... - 9 631-390-9700 631 390 9790 40 Marcus Drive E-MAIL _ s NEcertificates@epicbrokers.com R 3rd Floor WSURER� INSURE S)A FFORDING COVERAGE .. _ _NAIC# Melville,NY 11747 A.New York Marine And General Ins Co ....... 16608 INSURED INSURER B:Pennsylvania Manufacturers Indemnity nity Co 41424 Lettieri Construction, Inc. Merchants Mutual Insurance Company a����� INSURER C: p ny 23329 POBox 1406 .... —................................................�W�W�........�..W�W........r._ INSURER D WesthamptonBeach, NY 11978 INs.....m_____—.......... ................................................................m..__ .........,... ...................................W......... URER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LTR ....._. ,. SR WVD ,., POLICY NUMBER MMIDD/YYYY�m AAAI DDIYXYY - --TYPE OF INSURANCE LIMITS �- gNSR ---..I...... m AODL SUBR POLICY'EFF POLICY EXP 1 .....m OCCUR pRF�b9 µ(�a_a�rc�or�el�� $100p0000 A '+ COMMERCIAL GENERAL LIABILITY GL2023LHBOO404 12/31/2023..12131/202 EACH OCCURRENCE $1 000 OO CLAIMS-MADE X� AM O ENrEU .......... BI/PD Ded:5,000 PERSONAL r000 - &ADV INJURY OOO 0 on)- ED EXP Any one pers RY s 1 OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,,000 }}PRO 1 0 POLICY�„XI.........JECT � .,J LOC 'COip,JB:.I,pED'SIhIGMELnP�IdTGG $2,1000100„ . OTHER C AUTOMOBILE LIABILITY CAP9253222 12/31/2023 12/31/202 E�COMBINED 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ..�,..,.,,,...( ... .. . ............... OWNED -.......... SCHEDULED .... ...... AUTOS ONLY AUTOS X AUTOS ONLY X A NON-OWNED ONLY BODILY INJURY DAMAGE Per accident) $$B DAMAGE . ... . ....._ .... cu A UMBRELLA L IAB X OCCUR EX2023LHBOO109 1 2131/202312131/202 EACHoc RRENCE .......mm $5 OOO OOO X..EXCESS LIAB CLAIMS-MADE AGGREGATE s5,000,000 DED .�RETENTION$ _ ...... ........_,. ................,......__ _.—.I ,. n...__.. ... ... .. .,,. .....................r ......_.......... ,......,.. .......... ......,..,.,.. ___ ......... ... WORKERS COMPENSATION - PER IOTH- AND EMPLOYERS'LIABILITY YIN ------. ......... ............. ""' E.L.DISEASE A EMPLOYEE - (Mandatory in NH) ,E $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EA H _ OFFICER/MEMBER EXCLUDED? N/A ...,.�••° mmmmmmmmmmmmmm Y If yes,describe under DESCRIPTION OF OPERATIONS below _ ...__. ...----------- .. -POLICY E.L.DISEASE B Excess Liability 60230 19210584 � ������2/3112023 12/31/202...'��$5,000,000 Oc��������� ggJ I ������� ��������� � �-culA I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Jared 8r Leah Lettieri SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2285 WestvieW Dr. ACCORDANCE WITH THE POLICY PROVISIONS. Mattituck, NY 11952 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 #S69633331M6110295 RHA07 IE Workers' CERTIFICATE OF 1rAlrl Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (631)288-4808 Lettieri Construction Inc, PO Box 1406 1 c.NYS Unemployment Insurance Employer Registration Number of Westhampton Beach,NY 11978 Insured Work Location of Insured(Only required if coverage is specifically limited 1d.Federal Employer Identification Number of Insured or Social Security to certain locations in New York State,i.e.,a Wrap-Up Policy) Number 11-3412703 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Company Town of Southold—Building Dept 3b.Policy Number of Entity Listed in Box"la" -455519.01-01 54375 Main Road PO Box 1179 3c. Policy effective period Southold NY 11975 04/01/2024 to 04/01/2025 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"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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? ❑x YES []NO 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: Patrick Scanlon (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 10/9/2024 (Signature) (Date) Title: Managing Partner Telephone Number of authorized representative or licensed agent of insurance carrier: 212-947-4298 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 NEW Workers' CERTIFICATE OF S"rJ1T1>w Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (631)288-4808 Lettieri Construction Inc, PO Box 1406 1c.NYS Unemployment Insurance Employer Registration Number of Westhampton Beach,NY 11978 Insured Work Location of Insured(Only required if coverage is specifically limited 1 d.Federal Employer Identification Number of Insured or Social Security to certain locations in New York State,i.e., a Wrap-Up Policy) Number 1 1-34 1 270 3 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Continental Indemnity Company Jared&Leah Lettieri 3b. Policy Number of Entity Listed in Box"'I a"37.4i5519-01-01 2285 Westview Dr Mattituck 11952 3c.Policy effective period 04/01/2024 to 04/01/2025 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"3"insures the business referenced above in box"1a"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". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? ❑x YES E]NO 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: Patrick Scanlon (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 10/9/2024 (Signature) (Date) Title: Managing Partner Telephone Number of authorized representative or licensed agent of insurance carrier: 212-947-4298 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-106.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov YORK workers'ri" Compensation CERTIFICATE OF INSURANCE COVERAGE Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW a 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 LETTIERI CONSTRUCTION INC 631-288-4808 P O BOX 1406 WESTHAMPTON BEACH, NY 11978 1 c.Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 113412703 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 - Building Dept. 54375 Main Rd 3b.Policy Number of Entity Listed in Box"1 a" PO Box 1179 DBL111803 Southold, NY 11971-0959 3c.Policy effective period 02/01/2024 to 01/31/2026 4, Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 10/11/2024_ By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston Welsh 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 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) III 1 1°I I°I°°11°1°°1°1I III III DB 120.1 (12-21) Irkw Workers's TrAarr 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 1 a.Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured LETTIERI CONSTRUCTION INC 631-288-4808 P O BOX 1406 WESTHAMPTON BEACH, NY 11978 1c.Federal Employer Identification Number of Insured Work Location of Insured (Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 113412703 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 Jared & Leah Lettieri 2285 Westview Dr 3b.Policy Number of Entity Listed in Box"1 a" Mattituck, NY 11952 DBL111803 3c.Policy effective period 02/01/2024 to 01/31/2026 4. Policy provides the following benefits: © A. Both disability and paid family leave benefits. B. Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: © A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 10/11/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston Welsh 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 413,4C or 56 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) 11111111111111111111111111 DB-120.1 (12-21) Suffolk County Dept of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name THOMAS P LETTIERI Business Name LETTIERI CONSTRUCTION INC This certifies that the bearer is duly licensed License Number H-49441 by the County of suNolk Issued; 11115/2011 Ulu,C r"-'-' Expires: 11/0112025 Commissioner 5() / s ilk qTj v G .CPI 1019 Aa �' a 44, ICPr Cep LO