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HomeMy WebLinkAbout51463-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#: 51463 Date: 12/11/2024 Permission is hereby granted to: Dmitry Goodman 90 N 5th St Apt 5B Brooklyn, NY 11249 To: install roof-mounted solar panels to existing single-family dwelling as applied for. Premises Located at: 415 McCann Ln, Greenport, NY 11944 SCTM# 33.-3-33 Pursuant to application dated 10/17/2024 and approved by the Building Inspector. To expire on 12/11/2026. Contractors: Required inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total $325.00 Iul in 'lnspector 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 h tr s:1/ww , oLitholdto nn . o Date Received APPLICATION FOR BUILDINGb , ��rr � ", For Office Use Only * � PERMIT NO, Building Inspector: , Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an t '.' Owner's Authorization form(Page 2)shall be completed. Date:October 4, 2024 OWNER(S)OF PROPERTY: Name:Dmitry Goodman scrM#1000-033.00-03.00-033.000 ProjectAddress:415 MCCANN LANE, GREENPORT, NY 11944 Phone#: 718-208-8817 1Email:dmitry212@gmail.com MailingAddress:415 MCCANN LANE, GREENPORT, NY 11944 CONTACT PERSON: Name:Terence Clement Mailing Address:999 Stewart Ave., Ste. 210 Bethpage, NY 11714 Phone#:516-578-2873 Email:permitting@empower-solar.com DESIGN PROFESSIONAL INFORMATION: Name:Gregory Sachs Mailing Address:999 Stewart Ave., Ste. 210 Bethpage, NY 11714 Phone#:516-578-2873 :Hll:p:ermitting@empower-solar.com CONTRACTOR INFORMATION: Name:EmPower CES LLC Mailing Address:999 Stewart Ave., Ste. 210 Bethpage, NY 11714 Phone#:516-578-2873 1Email:permitting@empower-solar.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: D Other Installation of(27)MXN 6 440w roof mounted solar, 11.88 kW system size $34,215.04 Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? ❑Yes WNo 1 PROPERTY INFORMATION Existinguse of property: Intended use of property:Residential 1 Family P P v Residential 1 Family Y Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes 10No 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 orfor 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):Terence Clement BAuthorized Agent ❑Owner Signature of Applicant: Date: 10/4/2024 STATE OF NEW YORK) SS: COUNTY OF Suffolk Terence Clement being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Agent (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. Sara E.McCaffrey Sworn before me this NOTARY PUBLIC,STATE OF NEW YORK Raualifled in Nassau on NO ;01MC6425412 County 4 day of October 2024 bar 22.2025 Quall PROPERTY TI RI TE (Where the applicant is not the owner) Dmitry Goodman 415 MCCANN LANE,'GREENPORT, NY 11944 I, residing at do hereby authorize Terence Clement to apply on my ehalfto the Town of Southold Building Department for approval as described herein. 6 s 10/4/2024 Owner`S Signature Date Dmitry Goodman Print Owner's Name 2 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 µA Telephone (631) 765-1802 - FAX (631) 765-9502 � iamesh southoldtownn . ov— seand southoldtownnygov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 10/4/2024 Company Name: EmPower CES LLC Electrician's Name: Timothy Crotty License No.: ME-65990 Elec. email:permitting@+empower-solar.com Elec. Phone No: 516-578-2873 211 request an email copy of Certificate of Compliance Elec. Address.: 999 Stewart Ave., Ste. 210 Bethpage, NY 11714 JOB SITE INFORMATION (All Information Required) Name: Dmitry Goodman Address: 415 MCCANN LANE, GREENPORT, NY 11944 Cross Street: Phone No.: 718-208-8817 Bldg.Permit#: 14707 email: dmitry212@gmail.com Tax Map District: 1000 Section:033.00 Block: 03.00 Lot:033.000 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Installation of (27) MXN 6 440w roof mounted solar panels, 11.88kW total system size Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES Li NO Issued On Temp Information: (All information required) Service SizeF-11 Ph[:]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information:. PAYMENT DUE WITH APPLICATION 10/4/24, 12:24 PM Goodman—Survey.png Of 1 1xUmQLUrw& SUTTON PLACE (so' WIDE) rAr le bf Im w'. S74-04'10-jr GRAPHIC SCALE ... ....J,,,, TO: LOT ARE11 IN Fm I Inch 30 M SURVEY OF PROPERTY �E SCALICE LOT 3 land surveying EASTERN SHORES ME DAM'04/27/1954 Su vt:,y.COM SrWM�NO 4021 ItmL r�3V 7... Lomw w unv No. GREENPORT,TOWN OF SOUTHOLD I OAW J�W N.Ml-u48 1 SUFFOLK COUNTY, NEW YORK t https://drive.google.com/drive/f`olders/1 Abn7s24IT9chEztAzfZpqyabmj50EJfM?ffhs=2 4T"EIW workers' CERTIFICATE OF INSURANCE COVERAGE ATE 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) 1 b.Business Telephone Number of Insured EMPOWER CES LLC DBA EMPOWER SOLAR 310-534-7994 999 STEWART AVENUE, SUITE 210 BETHPAGE, NY 11714 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 522407627 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 54375 ROUTE 25 3b.Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 DBL252634 3c.Policy effective period 05/10/2023 to 05/09/2025 4. Policy provides the following benefits: 21 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 c Her referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 4/5/2024 By 4440,-4t (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 413,4C or 513 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) IIIIIII'iiiiii1i2ii0iui1iiiiii1ii2iiii2ii1iiiilllllll Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box 1 a for disability and/or Paid Family Leave benefits under the 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. DB-120.1 (12-21) Reverse EMPOCES-01 _ TIRUN . CERTIFICATE OF LIABILITY INSURANCE [DAIE(MM/DDNYYY) www 5/1/2024 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 ri hts to the certificate holder in lieu of such endorsement'S PRODUCER _ Ana Bella License#0757776 Co ACr AdO E m HUB International Insurance Services Inc. PHONE Exe 10 568 5977 � FAAiX Np�n.n. 600 Corporate Pointe S.�n I conlmi } Suite 600 AIL ello�t qN internationalx . Culver City,CA 90230 .W_ INsURs-'R(9L&FFq6II11C±tl CovrRAGE ...... ,.. ..... ..... . ...�NAIF.:�..._.. ... _.� __.�... m__ ............�..... INSURER A,Southwest Marine&General Insurance(Company 12294 ..... INSURED IxsgR p_Certain Underwriters.-at LIoyds EmpowerCES LLC . ,.,Y Company _ 39993 INSURERC Colon Insurance,Co 999 Stewart Avenue,Suite 210 INSURER.,D,,,,,,,,, Bethpage,NY 11714 — INSURER E INSURER F COVERAGE CERTIFICATE Ill tl"OcR; _ 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 _FF CLAIMS. 2,000,000 INA COMMERCIALOGENERTIONS OF SUCH POLICIES.LIMITS S "POLICY EFF POLICY - LIMITS SHOWN MAY HAVE BEEN REDUCED BY INSURANCETR TYPE POLICY NUMBER LIMY EXP X AL LIABILITY EACH OCCURRENCE MITSLPM0Mn � CLAIMS-MADE OCCUR PK202400006109 5/4/2024 5/4/2025 DAMAGE IORENIED 500,000 �X... X FRFH1 ., CR .Uifd k XP(An ,one person,„ 0 000 ... .... .._.--------.�;. "..PERSONA..-....Y —�L � � , MED E -----��s ADV INJURY .,� 2,000,000 .. NPOLICY x �� LIMPITA� LO �� 4,000�000 A APPLIES PER: GENERAL AGGREGATE 4 00 GF GENERAL J�C� TS-COMP/OP AGG, $ PER PROJECT AGG �5,0011,.000 OTHER: AUTOMOBILE LIABILITY (EM- d iIh4CwLE LflMllll p ` �. . ANY AUTO BODI,,LY INJURY jPerperson.).,.._. _........,_ OWNED _. AUTOS ONLY AUTOSULED BODILY IN I,URY(Per acaden[)m, H I§•D NON- N,.L� G'cq er�cirtlY DAMAGE .-.,., AR SS ONLY . AUTOIQI A _( O. . _nt1...._, .. — $ X EXCESS LIAB X CLAIMS MADE ENVXSS425160 5/4/2024 5/4/2025 AGGREGATEURRENCE 300000 UMBRELLA LIAB OCCUR EACH OC $ 3,000,000 DED p RETENTION$ $ ww W WORKERS COMPENSATION PER T .m_ OTH AND EMPLOYERS'LIABILITY Y/N .w _5TATI/�F ER ....m ..-_-- ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ . . �yyF_f^tlC.,.', MBER EXCLUDED? N/A (NEFIrtlddTary n NH) E LmDISmEASE-,EA EMPLOYEE $. If yes,describe under DESCRIPTION OF OPERATIONS below _ E L.DISEASE-POLL Y LIMIT C Excess(1 M x 3M) EX04287265 5/4/2024 5/4/2025 Aggregate/Occ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more Bpp�ace Is required) The certificate holder is listed as add insured per attached endorsements#G20100413&#'CG20370413 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PK202400006109 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OFF ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Any person or organization to the extent required of you All Covered Locations by a written contract executed; however, the written contract must be: 1. Currently in effect or becoming effective during the term of this policy; and 2. Executed by you before the "occurrence". Information re ulmd to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III— Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 10 0413 POLICY NUMBER: PK202400006109 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Location And Description Of Com lete QO erations (Any person or organization to the extent required of you by a written contract executed; however, the written contract must be: 1. Currently in effect or becoming effective during the term of this policy; and 2. Executed by you before the "occurrence"..) Information required to co m lets this Schedule, if not shown above„will be shown in the Declarations.. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and 1. Required by the contract or agreement; or included in the products-completed operations hazard". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. ,The insurance afforded to such additional whichever is less. insured only applies to,the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 A?--I NI�N NYSIF PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nySlf.Com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A 522407627 im AMWINS INSURANCE BROKERAGE LLC 200 ELWOOD DAVIS ROAD SUITE 200 Rol LIVERPOOL NY 13088 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER EMPOWER CES LLC TOWN OF SOUTHOLD 999 STEWART AVE, SUITE 210 54375 ROUTE 25 BETHPAGE NY 11714 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z 2546 624-4 706038 05/01/2024 TO 05/01/2025 04/19/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2546 624-4, 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://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 AFFORDS COVERAGE TO THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. DAVID SCHIEREN GREG SACHS EMPOWER CES LLC THIS CERTIFICATE DOES NOT APPLY TO THOSE JOB SITES WHICH ARE COVERED BY OTHER INSURANCE AND ARE SPECIFICALLY EXCLUDED BY ENDORSEMENT. 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 /, !/!/ DIRECTOR, I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 547880610 II1111000000000001122M67 8 M411 111111 Form WC-CERT-NOMNT Version 3(08/29/2019)[WC Policy-254662441 U-26.3 7(11 mnnnnnnnnnnna7aaccalrnnm-nnnmgdAA�6lr&d7irl AI7n-'i irrcrt N�P—T llmisnnoll Suffolk County Dept.of Labor,Licensing&Consumer Affairs a MASTER ELECTRICAL LICENSE Name TIMOTHY M GROTTY Business Name Empower CES LLC DBA This certlfies that the bearer is duly licensed License Number ME-65990 by the County of suffolk Issued: 11/12/2021 � Xa, Expires: 11/01/2025 Commissioner Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name GREGORY SACHS Business Name EMPOWER CES LLC DBA This certifies that the bearer is duty ricensed License Number H-50211 by the County of suffolk issued: 05/30/2012 t� K.&-r Rose Expires- 05l01l2026 Commissioner