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HomeMy WebLinkAbout51289-Z hoy�aOf SO yo�o Town of Southold * * P.O. Box 1179 0 53095 Main Rd WIN Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45749 Date: 11/09/2024 THIS CERTIFIES that the building GENERATOR Location of Property: 770 Old Salt Rd Mattituck, NY 11952 Sec/Block/Lot: 144.-5-14 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 08/29/2024 Pursuant to which Building Permit No. 51289 and dated: 10/17/2024 Was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: "as built" accessory generator as applied for (maintain clearances to combustibles as required). The certificate is issued to: William King,Joan King Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 51289 11/04/2024 PLUMBERS CERTIFICATION: Auth ized Signa e Of SO yo�G TOWN OF SOUTHOLD BUILDING DEPARTMENT • e TOWN CLERK'S OFFICE * a vol.a �c 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#: 51289 Date: 10/17/2024 Permission is hereby granted to: William King 770 Old Salt Rd Mattituck, NY 11952 To: legalize "as built"generator as applied for. Premises Located at: 770 Old Salt Rd, Mattituck, NY 11952 SCTM# 144.-5-14 Pursuant to application dated 08/29/2024 and approved by the Building Inspector. To expire on 10/17/2026. Contractors: Required Inspections: Fees: As Built Generator $250.00 ELECTRIC -Residential $200.00 CO Accessory $100.00 Total $550.00 -- --- ---------------------- Building Inspector oF so�ryol Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 aQ Jamesh southoldtownny.gov Southold,NY 11971-0959 OIyCQU� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: William King Address: 770 Old Salt Road city:Mattituck st: New York zip: 11952 Building Permit#: 51289 Section: 144 Block: 5 Lot: 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Laurel Lighting LLC. Electrician: Frank Fenoy License No: 4718-ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel 200a A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch 200a UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 1 20kw generator with 100amp breaker, 1 200amp ats Notes: GENERATOR Inspector Signature: Date: November 4, 2024 770 old salt rd �o,*oFso Sl C2S1 7?0 Old 6�,Kb4o( # TOWN OF SOUTHOLD BUILDING DEPT.- co 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR ' [ ] ROUGH PLBG. [ ] .FOUNDATION-2ND [ ] INSULATION/CAULKING - FRAMING/STRAPPING [ ] FINAL [ ] 'FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION , [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) 14 ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE.C/O [ .] RENTAL REMARKS: G-e geyneah v v JK DATE «"�"� INSPECTOR so(/Th° # - TOWN. OF SOUTHOLD BUILDING DEPT. couNr+N�'' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL JA� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] -FIRE RESISTANT PENETRATION ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ .] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: r " DATE INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION (IST) H ------------------------------------- FOUNDATION (2ND) s z 0 J o H G_ _ ROUGH FRAMING& a PLUMBING .� t 1 a. t4 INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS � hu Q,UI Ce �71z�due 10�l� a eke �a s r,rn No � z x d b H i' 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.southoldtown.iiv.gov 'w:reutwsF. Date Received APPLICATION FOR BUILDING PERMIT .W._, d.:..... ..... . ....... For Office Use Only �� 1 , D PERMIT NO. a Building Inspector: AUG 2 9 2024 Applications and fauns rnasti 6iefilled out In their entirety.•lncamplete . ;applications Will'not be accepted: Where the Applicant is'not the owner,an. BI3D•D1N�i I}F+.1[ . Owner's Autharizat"rari form`(Page 2)shall be corn pleted." 'TOWN OF SOUT1101 Date:8/27/24 ovulvlE T11 �r� Name:William King 1SCTM #1000-144-5-14 Project Address:770 Old Salt Road Mattituck NY 11952 Phone#:860-798-7272 Email-wikingl7@gmail.com Mailing Address: CONTACT PERSON: t. Name:Sean O'Neill Mailing Address:PO Box 64 Jamesport NY 11947 Phone#:631-722-3595 Email:oneilloutdoorpower@hotmail.com DESIGNz PROFESSIONAL 1NIf,0RMATION: Name: Mailing Address: Phone#: Email: ,CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email: DESCRfPTION":0F PROPOSED CONSTRUCTION.�`.�a°W:�,,, y`�- ; d .... ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Oth e r Generator $10,000 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? DYes ®No 1 PROPERTY INFORMATION Existing use of property:e i'"` a Intended use of property:Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R2sidentia[ this property? ❑Yes ❑No IF YES, PROVIDE A COPY. - .,xw .�..- ® CItE!ck Box,AfteesReai'r g:�,The owaeeJcontractor�clesign professional is responaibie"#,ar all drainage and storm water issues"as,proOlded by; W<, Chapter 2xof the Cod Town e:,A0iLICATIQN IS HEREBY MADE to�the Building Department forthe issuance of a Building perinit'pursuant to.the Building.zane ©rdinance of the rnwn'of snuthold;$tiffoik,.County,New York and tither,applicable Laws,Ordinances or Reguiptians forthe.cor►struaiori of buildings; addltians;alterations or'for removal or demolition as herein descrltied.,Tlie applicant agrees to comply with`alI applicable taws,ordinances;building Coda;„ housing code and regulations and to admitauthorize'd inspectors on premises and In building(s)for necessary,inspec'66ns.False statements made herein are punishable as a Class A misdemeanorpursuant to Sectlon:21o:45 cif"the New York State Pena!taw. " Application Submitted B Sean O'Neill pp y(print name): ®Authorized Agent El Owner Signature of Applicant: Date: 8/27/24 ._..._.. ,......,........ ...,...._.......... ..CONNIE M-BUNCHm.-.,... Notary Public,State of New York STATE OF NEW YORK) No.01BU6185050 SS: Qualified in Suffolk County COUNTY OF Suffolk ) Commission Expires April 14,2 t�a� Sean O'Neill 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. Sworn before me this ��day of �J� 20� Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) William King residing at 770 Old Salt Road I, Mattituck NY do hereby authorize Sean O'Neill to apply on my behalf t e Town S uthold Building Department for approval as described herein. ner s atur Date William King Print Owner's Name 2 F01 BUILDING DEPARTMENT-Electrical Inspector ��O Gym► TOWN OF SOUTHOLD cox Town Hall Annex- 54375 Main Road - PO Box 1179 +- ^+ Southold, New York 11971-0959 G'yrJj�� �aO�Y� Telephone (631) 765-1802 - FAX (631) 765-9502 iamesh(a-southoldtownny.gov — seand(cb-southoldtownnv.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/28/2024 Company Name:, Laurel Lighting Inc Electrician's Name: Frank Fenoy License No.: 4718-ME Elec. email: kfcelectric@aol.com Elec. Phone No: 631-457-3363 ❑I request an email copy of Certificate of Compliance Elec. Address.: 1977 Main Road Laurel NY 11947 JOB SITE INFORMATION (All Information Required) Name: William King Address: 770 Old Salt Road Mattituck NY 11952 Cross Street: Phone No.: 860-798-7272 Bldg.Permit#: L- email: wfking17@gmail.com Tax Map District: 1000 Section: 144 Block: 05 Lot: 014 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 20kw generator installation Square Footage: 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 Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? F1 Y F1N Additional Information: PAYMENT DUE WITH APPLICATION !f.'✓rr�l��2 Fpt�� BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD -�` Town Hall Annex- 54375 Main Road - PO Box 1179 ` ® 'Z. Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 -' jamesh(cDsoutholdtownny.gov seand(c�southoldtownny.9ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/28/2024 Company Name: Laurel Lighting Inc Electrician's Name: Frank Fenoy License No.: 4718-ME Elec. email: kfcelectric@aol.com Elec. Phone No: 631-457-3363 ❑I request an email copy of Certificate of Compliance Elec. Address.: 1977 Main Road Laurel NY 11947 JOB SITE INFORMATION (All Information Required) Name: William King Address: 770 Old Salt Road Mattituck NY 11952 Cross Street: Phone No.: 860-798-7272 Bldg.Permit#: �S- email: wfking17@gmail.com Tax Map District: 1000 Section: 144 Block: 05 Lot: 014 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): 20kw,generator installation 10O,�04 P 6i-$&90r dQ9 4-fZD Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES ❑ NO ❑Rough In ❑ Final Do you need a Temp Certificate?: F I YES ❑ NO Issued On 1 Temp Information: (All information required) Service Size❑1 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 MN Additional Information: PAYMENT DUE WITH APPLICATION PERMIT# Address: Switches Outlets GFI's Surface Sconces H H's 4 UC Lts Fridge HW POOL Fans Mini.Fr. W/D Panel Pump Exhaust Oven Sump Heater Trnsfmr • Smokes DW Generator Salt Gen. Carbon Micro GrbDis Water Bond Lights Heat Pucks ERV HOT TUB/SPA Inst Hot DeHum Transfer Disc Combo Cooktop Minisplit Blower AC AH Hood Blower Service Amps Have Used Sub Amps Have Used Comments S.C.LM.NO. DISTRICT:1000 SECTION:144 BLOCk.5 LOT(S):14 SALT LAKE LANE U.P. OLD SALT ROAD W.V. N OOS'00"E 7S.00' "°3v uoN. EL 8 BEL�G LK. �• �'y 78rf W.M�T �. 4 BEDROOM SYSTEM I lez GAf.+e o LP. -a z EL 8.5 LIM LID tyn LP LP BLUE STONE I , APRON R•9.2 Lp LOT 3 IL :'i:•. .•. 21' 35• LOT 2 i : aviioss:;•: 29' 32' ::GF 9.3;; ;:• ar LOT 4 fe• JZVJi l 'gib :'{.'::''•:;.;WOOD DECK EL 9.34.8' :''}':�•'�;i•is�'•f•:r::��::°:::C��'+�::^'•':'::i�s" to ::'•:Z ST1C: :.•: ..f STY'F( .' .. ....DWELLING'•:::::;'r:ti:: e EL 9.4 BLUE STONE PATIO EL as b CNp FIREPLACE OO p CM/STONE WALL S�Q La Al o; ZONE ZONE VE(9-8) - STONE SPLASH AREA rCONC.SEA WALL S 79e0S00"W 100.00' �Y18TmmOCIC MHW AT BULKHEAD UPDATE 08-13-24 GREAT PECONIC BAY UPDATE 06-03-20 FINAL SURVEY 02-12-20. WE WATER MWLY, WUA ORMUS AND CESSPOOL FIRM MAP#36103CO482H LOCATIONS NOW ARE FROM FIELD OBSEOWAIMNS AND OR DATA O9fAWED FROM OWERS AREA:15,855.9 SO.FT. or 0.38 ACRES TO atmHEAO E1EVAIKW DAW NAVD88 UNAUAUORUZED ALIERAITON OR ADWlKW TO THIS SIAPWFY IS A YTOLAwm 0w'SEOTTON Ym OF 11Ri NEW TORK STALE EOUOARON LAw C?m OF O08 SURVEY MAP NOT BfARINO WE LAND SURIVIOW'S EA/B065ED SEAL SHALL NOT 8E CDIV90ERE0 10 fir A VALID NW COPY. GUARANIES#MCATED HL9 m SHALL RUN LWLY To THE PERSON FOR WOM DIE SURWr IS PREPARED AND ON MS BEHALF TO THE RILE OONPANY, GOVERNMENTAL AGENCY AND LEfUD/N6 RISRTURON LISTED HEREOIE AND TO 11fE ASSIGNEES GF INE LENOlN6 INSVIVITOL GUARANTEES ARE NOT TRANSFERABLE No INIENDEO TO Aft wm&r wE PPA TY U OR TO am WF ERE'CRON lON$SHOW HEREON FROM PC PROPERry LINES TO OF FEN;=AOWRW STRUCluRES07 ANDOwn ImmowmmEASEMENTS AND/OR SVBSURFAOE SMU@RIRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EWMF ON THE PR'L=AT WE 1TNE OF SURVEY suRver On LOT 3 46 OF INC CERTIFIED T0: ROY SALAME; MELISSA SALAME, MAP OF:SALT LAKE VILLAGE 1P tN u' IvoJ. ;p AMTRUST TITLE INSURANCE COMPANY• FILED:MAY 10, 1940 N0.1310 4�� �yc f SITUATED AT.MATTITUCK x � a TOM OF:SOUTHOLD o KENNBT$�TfOYC$UK LAND l3URVEYTNG, PLLC SUFFOLK COUNTY, NEW YORK O Y s4' profess lonal Land SuLveyllLg and Design F P.O. Box 163 Aquebogue, New York 11931 L PHONE(661)$06-1696 PAZ(eat)298.16M FILE/18-112 SCALE:1"=30' OATS: AUG. 28, 2018 N.Y.s:List NO. 05082 mduuwos IW a.wr4 of BoMM J.H&moV•Smoth W Vqv6ut NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.corn CERTIFICATE OF WORKERS' COMPENSATION INSURANCE [Nilv 0AAA^AA 202207186ROY H REEVE AGENCY INC 13400 MAIN RDPO BOX 54 MATTITUCK NY 11952 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LAUREL LIGHTING INC TOWN OF SOUTHOLD 1977 MAIN ROAD 53095 RT.25 LAUREL NY 11948 PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11282 068-4 21960 09/21/2023 TO 09/21/2024 8/9/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1282 068-4, 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, 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://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. FRANK FENOY(PRES) OF ONE PERSON CORP LAUREL LIGHTING INC 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. 1 NEW YORK STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:531706178 U-26.3 ACO 0809® CERTIFICATE OF LIABILITY INSURANCE DATE/09// 0242024 Y) `,� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Pamela Moss NAME: Roy H Reeve Agency,Inc. H ON ,Ext: (631)298-4700 FAX(AINe: (631)298-3850 PO Box 54 E-MAIL ADDRESS: pmoss@royreeve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Merchants Preferred Ins Co 12901 INSURED INSURER B: Laurel Lighting Inc&Frank Fenoy INSURER C: 1977 Main Rd INSURER D: INSURER E: Laurel NY 11948 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2412620416 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. INSR AVULISUISR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PR EMISES Ea occurrence $ 100,000 MED ECP(Any one person) $ 5,000 A CTRIO10377 01/30/2024 01/30/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑JET LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) 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. 53095 Rt.25 PO BOX 1179 AUTHORIZED REPRESENTATIVE ,�? Southold NY 11971 _t.�- Ob4� @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NY I New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS'COMPENSATION INSURANCE A A A A A A 463076153 EASTERN.LI GAS SERVICES LLC 36 BROAD AVE. RIVERHEAD NY 11901 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER 770 OLD SALT RD. EASTERN LI GAS SERVICES LLC TOWN OF SOUTHOLD 36 BROAD AVE. 53095 MAIN ROAD RIVERHEAD NY 11901 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBERT POLICY PERIOD DATE 12344 620-6 60632 09/24/2023 TO 09/24/2024 8/27/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2344 620-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WESSITE AT HTTPS:/1WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN`fHE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 SU . NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:627450219 U-26.3 EASTLIG-01 SSCHMITT CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 8/27/2024 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 endorsement(s). PRODUCER NAMCONTA E:CT Neefus Stype Agency PHONE 631 722-3500 FAX 711 Union Ave. (A/C,No,E:t):( ) (A/c,No):(631)722-3591 Aquebogue,NY 11931 ADDRIESs•info@nsainsure.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:Northfield Insurance Co. 27987 INSURED INSURER B:National Specialty Insurance Company 22608 Eastern LI Gas Services LLC INSURER C: 36 Broad Ave INSURER D: Riverhead,NY 11901--5054 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 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LTR NSD WVD MM DD MM DD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR WHO19496 5/17/2024 5/17/2025 DAMAGE TO RENTED 100,000 PREM SE Ea occurrence $ MED EXP(Any oneperson) PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Ea aBINEDtSINGLE LIMIT $ 1,000,000 X ANY AUTO CAR31000024370 3/26/2024 3/26/2025 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ A�T OS ONLY AUUTO ONLY PeOr accident AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N T ATLITE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. 53095 Route 25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD