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HomeMy WebLinkAbout51549-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#: 51549 Date: 01/14/2025 Permission is hereby granted to: Jennifer McCarthy 740 Country Club Dr Cutchogue, NY 11935 To: install roof-mounted solar panels to existing single-family dwelling as applied for. Premises Located at: 740 Country Club Dr, Cutchogue, NY 11935 SCTM# 109.-3-2.10 Pursuant to application dated 11/13/2024 and approved by the Building Inspector. To expire on 01/14/2027. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total S325.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 b, �� Telephone (631) 765-1802 Fax (631) 765-9502 https.Hwww.southoldtownnY.gov Date Received APPLICATION FOR BUILDING II For Office Use Only ,y. PERMIT NO. Building Inspector: � ��° C.0 1 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: OWN ER(S)'OF'PROPERTY: Name: SUM# 1000- 10 4. 3- a. 10 Physical Address: 740 Country Club Dri e, Cutchogue NY 11935 Phone#: 646-345-1779 1 Email: jmccarthy218@gmail.com Mailing Address: 740 Country Club Drive, Cutchogue NY 11935 CONTACT PERSON: Name:Permit Dept./Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:Permits@GoPowerSolutions.com DESIGNiPROFESSIONAL INFORMATION: Name: Mailing Address: 33 Qu-leer- A\re- C.orn,✓a\ Phone#: gL(S_ (aq_ 9(o93 Email: NY PS CONTRACTOR;INFORMATION: Name:Michael Catizone/Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:mike@GoPowerSolutions.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition RAlteration ❑Repair ❑Demolition Estimated Cost of Project: 19 Other Proposed( 1 q )panel roof mounted array. ( r7.(oS0)kW System $ Q-( 00 Will the lot be re-graded? ❑Yes FA No Will excess fill be removed from premises? Dyes BNo 1 PROPERTY INFORMATION Existing use of property:Single Family Dwelling Intended use of property:Single Family Dwelling Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes RNo 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 inspectorson'premises and in buildings)for necessary inspections.False statementrmade hereinare punishable as a Class A misdemeanor pursuant to Section 210.45,of the New York`StatePenal Law. Catizone Electrical/Long Island Power Solutions Application Submitted By(print name): BAuthorized Agent ❑Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF Suffolk Michael Catizone being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the Contractor (Contractor, Agent, Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this i14)"'day of �pl�f'a(1��l° , 20 Notary Public ESCAYLIN CRISOL RIVERA RODRIGUEZ NOTARY PUBLIC-STAT E OF NEW YORK 51 No. 01 R1643403'1 PERTY OWNER AUTUORIZATION Qualified in Suffolk County (Where the applicant is not the owner) My COMI-nission Expires 05-31-2026 I, residing at 740 Country Club Drive, Cutchogue NY 11935 Michael Catizone/Long Island Power Solutions do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. i A O nets Signatur Date N ' 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 ." Telephone (631) 765-1802 - FAX (631) 765-9502 ro err@southoldtownny.gov - seand@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 1% 1 ,ld4tf Company Name: Catizone ElectricaVLong Island Power Solutions Name: Michael Catizone License No.: M c -535 66 email: Permits@GoPowerSolutions.com Address: 2060 Ocean Avenue,Ronkonkoma,NY 11779 Phone No.: 631-348-0001 JOB SITE INFORMATION (All Information Required) Name: �' ' aALw Address: 740 Country Club Drive, Cutchogue 11935 Cross Street: o o 4. Phone No.: 646-345-1779 Bldg.Permit#: 515LI 2 email: jmccarthy218@gmail.com Tax Map District: 1000 Section: t og Block: -3 Lot: Q. i o BRIEF DESCRIPTION OF WORK (Please Print Clearly) Proposed( 1 g )panel roof mounted array. (7 (,,So )kW System Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A #Meters Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected - Underground -Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: , +ever ors V E ,ram M C— - - (,fS PAYMENT DUE WITH APPLICATION Request for Inspection Forrn.)ds 7. u*.. ".„ y. n«. �•b«. q^ *�9r s.•, ..' %ly.« �" . ' '. r�K M �9���.« �,+ ,�" '"� ��k,r a Syr'��c"�r"�.'� tl• ..w�C"�'+ra w�� anv^ ,. ,�'�L"�,�.'��� '"�, " Y. . ^ •- . "�'• .. .. •ter+.. ..�.�.. _.� _ ,r .�w.r...'� "�y,n,:,l`w;:iM. w._r R+�„,b "':Kn'�«Et'.m� qM.,.�..." ",,.,�:«�.ywr. f sway ion Lot jo �+' D0MMICO MAUTARBLM & or JBLANTA XUCZYNSKA—MAUTARBLLI AIa do*!Z Jwuwnro Lot 26. - Clue Bitatai- CuteAeyw ^ r. Town of 8mattlola « ' 4420', """` •_,,, Suf W bounty.Now Yak law" A GIOM1�I' ". MGM cMy. qi 1.MGw r tqA UiL LF. .lo!24 d itMNYtlatl�it$ alc atilt IAaQww� rwsyp... 09 alt n,illl Al nC1aL as Lo! 20. 41"raft am wt I%=" all Ito aghlll aarmm m JIlAffu I�G-OWIrNmu LAND I= �,. "'"•,w lemoMa ae.vµv IIA"It I'm OLVA"Pow C'( �V JIM a a at+ll ra/*�wl N' Suffolk County Dept.of Labor,Licensing p&Consumer Affairs HOME IMPROVEMENT LICENSE Name MICHAEL J CATIZONE Business Name This rIs duly that the 3earartad LONG ISLAND POWER SOLUTIONS INC licensed n the County of suRolk License Number:H-53562 Roselle Drago Issued: 06/06/2014 Commissioner Expires: 06/01/2024 O f b�r�mrroo�o �' 8a n1�1 Couu ty Dept-of Labor,Licenslng&Consumer Affetrs MASTER ELECTRICAL LICENSE Name rr MICHAEL CATIZONE. Business Name ma'sCorona to We LONG ISLAND POWER SOLUTIONS INC srer le.duly GCwadd ®y we County of suffolk License Number:ME-53560 Rosalie Dra90 Issued: 0=61014 Commissioner Expires. 0810 1 12 0 24 sxTWorkers' CERTIFICATE OF INSURANCE COVERAGE T& ,Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LONG ISLAND POWER SOLUTIONS INC 2060 OCEAN AVE 6313480001 RONKONKOMA,NY 11779 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 27-1175107 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold y P Y 54375 Main Road 3b.Policy Number of Entity Listed in Box 1 a Southold, NY 11971 R97411-000 3c.Policy Effective Period 1/1/2015 to 5/12/2025 4. Policy provides the following benefits: ❑X A.Both disability and Paid Family Leave benefits. B.Disability benefits only. C.Paid Family Leave benefits only. 5. Policy covers: ❑)c 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 tie d above. Date Signed 5/13/2024 By 4APt (Signature of insurance Carrier'"s authori d representative or NYS licensed insurance agent of that insurance carrier) Telephone Number 212 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 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 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and Paid Family Leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. D13-120.1 (12-21) 111111, � �rN� u1111111111 1111 DATE(MMIDD/YYYY) ACIORV CERTIFICATE OF LIABILITY INSURANCE 02/26/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COMENTACT Christopher Curran Edwards and Company PHONED (631)472-8400 C No); (631)472-8486 140 Greene Avenue Au Bs, certs@edwardsandco.net INSURER.S)AFFORDING COVERAGE NAIC# Sayville NY 11782 INSURERA: James River Insurance Company 12203 INSURED INSURER B Long Island Power Solutions,Inc dba New INSURER C: York Power Solutions;Michael Catizone INSURER D: 2060 Ocean Avenue INSURER E: Ronkonkoma NY 11779 INSURERF. COVERAGES CERTIFICATE NUMBER: 24/25 Master REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RI!Rl ED S 50,000 CLAIMS-MADEX OCCUR PREMISES Ea occurrence $)X Contractual Liability MED EXP(Any one erson Excluded $ _ A Y P0000000486 02/28/2024 02/28/2025 PERSONAL&ADV INJURY s 2,000,000 GS:N"LAG R;EGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 4,000,000 ET LOC PRODUCTS- $POLICY P 4,000,000 OTHER; $ AUTOMOBILE LIABILITY COMBINED SINGLE t;1MIT $ Ea accOank ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS - HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acc�den $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB Id CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION TH AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 'OFFICER/MEMBER EXCLUDED? ,(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Claim $2,000,000 A Professional Liability POOO0000486 02/28/2024 02/28/2025 Aggregate $4,000,000 DESCRIPTION OF OPERA71ONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) As respects to General Liability if required by written contract the following are included as additional insured per the policy form FP5201, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD fio�"MRN—\ NY PO Box 66699,Albany,NY 12206 New York State Insurance Fund nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 271175107 LOVELL SAFETY MGMT CO.,LLC 22 CORTLANDT STREET 33RD FLR NEW YORK NY 10007 4mmil. SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND POWER SOLUTIONS INC TOWN OF SOUTHOLD 2060 OCEAN AVENUE 53095 ROUTE 25 RONKONKOMA NY 11779 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE Z 2467 0-1 372393 04/01/2024 TO 04/01/2025 03/18/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2467 078-8, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS:/IWVVW.NYSIF.COM/CERT/ CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT MICHAEL CATIZONE VICE PRESIDENT JOSEPH MILILLO TWO OF TWO OFFICERS LONG ISLAND POWER SOLUTIONS INC THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND 111� 4 DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 97252850 Iiii r0000000Q0NM011205 811111 Form WCCERT-NOPRINT Version 3(09/29/2019)[WC PoUcy-24670788] U-263 174 [00000000000125441258][0001-000024670788][*#Z][36348-98][Cert-MP{FRT 1][01-00001] f"NEW YOR workers'Compensation CERTIFICATE OF INSURANCE COVERAGE STATE 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 CATIZONE ELECTRICAL CONTRACTING, INC. 2060 OCEAN AVE 631-348-0001 RONKONKOMA, NY 11779 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 45-5213112 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box 1a Southold, NY 11971 R97483-000 3c.Policy Effective Period 1/1/2015 to 9/5/2025 4. Policy provides the following benefits: ❑)c 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 de sc d above. Date Signed 9/6/2024 By ' 4��t_ (Signature of insurance carrier's author& d representative or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if sox 4B,4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers' Compensation Board, the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and Paid Family Leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 1ILIIhr� i0i1iuii1ri iOl� ADATE(MMIDD/YYYY) lii (w, V CERTIFICATE OF LIABILITY INSURANCE 06/24/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 ONT Dorene Wickes Edwards and Company PHONE (631)472-8400 PAX N+a• (631)472-8486 140 Greene Avenue E-MA Lss. certs@edwardsandco.net A-11INSURER(S)AFFORDING COVERAGE NAIC# Sayville NY 11782 INSURERA: James River Insurance Company 12203 INSURED INSURER B: Catizone Electrical Inc. INSURER C: 2060 Ocean Avenue INSURER D: INSURER E: Ronkonkoma NY 11779 INSURERiF. COVERAGES CERTIFICATE NUMBER* 24-25 Master REVISION NUMBM THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER MM MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 UA1309 TO MEN 1­95- CLAIMS-MADE �OCCUR PR MI occurrence $ 50,000 X Contractual Liability MED EXP(Any one person) $ Excluded A X Deduct: $10,000 Y P0000000486 02/28/2024 02/28/2025 PERSONAL&ADV INJURY $ 2,000,000 M'OTHER: LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 4,000,000 POLICY®PEQLOC PRODUCTS-COMP/OPAGG $ 4,000,000 $ AUTOMOBILE LIABILITY CE.�OI I NE'D. LE LIMIT $ n _ ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSONLY AUTOS HIRED NON-OWNED PROPERTY GE $ AUTOS ONLY AUTOS ONLY sEsE a den ',.. UMBRELLA LIAB OCCUR EACH.OCCURRENCE $ EXCESS LIAB Id CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION ' AND EMPLOYERS'LIABILITY YIN ST T TE RH ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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 I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) As respects to General Liability if required by written contract the following are included ad additional insured per the policy form FP5201. Town of Southold CERTIFICATE HOLDER CANCELLATION', SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r""�YNOMUK Workers' CERTIFICATE OF TAT Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CATIZONE ELECTRICAL CONTRACTING, INC. (631) 348-0001 2060 OCEAN AVE RONKONKOMA, NY 11779 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 202241963 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Graphic Arts Mutual Insurance Companv Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"1a" Southold, NY 11971 4766763 3c.Policy effective period 07-01-2024 to 07-01-2025 3d.The Proprietor,Partners or Executive Officers are ® included.(Only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box'3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box'2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Shannon C. Peck (Print name of aauutthori rre�epressentative or licensed agent of insurance carrier) IA Approved by: C ,"k, 06-28.2024 (Signature) (Date) Title: Director of Customer Retention and Experience Telephone Number of authorized representative or licensed agent of insurance carrier: (315)734-2000 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov