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HomeMy WebLinkAbout50698-Z ��o�S�fFOi Town of Southold 10/2/2024 190 a P.O.Box 1179 o _ :M. 53095 Main Rd y �aQr Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 45610 Date: 10/2/2024 THIS CERTIFIES that the building ALTERATION Location of Property: 2505 Wells Ave, Southold SCTM#: 473889 Sec/Block/Lot: 70.-4-18 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 9/21/2021 pursuant to which Building Permit No. 50698 dated 5/17/2024 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: oil to gas conversion in existing single-family dwelling as applied for. The certificate is issued to Geoffoy,Evan of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 50698 9/30/2024 PLUMBERS CERTIFICATION DATED 6/4/2024 Ross In . / IfIl" Auth rize S gnature �SOFEocXc , TOWN OF SOUTHOLD ��o may BUILDING DEPARTMENT y TOWN CLERK'S OFFICE "oy • o�� SOUTHOLD, NY a 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 #: 50698 Date: 5/17/2024 Permission is hereby granted to: Geoffroy, Evan 1 Arden St#314 New York, NY 10040 To: install oil to gas conversion in existing single-family dwelling as applied for. replaces bp#46917 At premises located at: 2505 Wells Ave, Southold SCTM # 473889 Sec/Block/Lot# 70.-4-18 Pursuant to application dated 9/21/2021 and approved by the Building Inspector. To expire on 11/16/2025. Fees: PERMIT RENEWAL $125.00 Total: $125.00 Buildin or �o�SUFFe` TOWN OF SOUTHOLD aye BUILDING DEPARTMENT TOWN CLERK'S OFFICE oy • o�� SOUTHOLD, NY col 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#: 46917 Date: 10/4/2021 Permission is hereby granted to: Geoffroy, Evan 1 Arden St#314 New York, NY 10040 To: install oil to gas conversion in existing single-family dwelling as applied for. At premises located at: 2605 Wells Ave, Southold SCTM #473889 Sec/Block/Lot# 70.4-18 Pursuant to application dated 9/21/2021 and approved by the Building Inspector. To expire on 415/2023. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00 CO-ALTERATION TO DWELLING $50.00 Total: $250.00 Building Inspector SOUryolo Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 11971-0959 '�c�l • ao Jamesh@southoldtownny.gov y�4UMy,�� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Evan Geoffroy Address: 2505 Wells Avenue city:Southold st: New York zip: 11971 Building Permit#: 50698 Section: 70 Block: 4 Lot: 18 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: NH Ross Electrician: Neal Ross License No: ME-4605 SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt 2 Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 1 tankless gas unit with 2 circulators Notes: AS BUILT HEATING Inspector Signature: Date: September 30, 2024 2505 wells ave ��SUF�o1x�o Town Hall Annex ,Q� Gy Telephone(631)765-1802 54375 Main RoadCD a .c P.O. Box 1179 N z Southold, NY 11971-0959 • BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: Building Permit No. " 6( P 450� K Owner: (Please print) '�)` n Plumber: 6L, (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. � (Plumbers Signature) Sworn to before me this 11 day of �(Q� 20 0 W-6c lq"lh- Notary Public, S 4 y- County Vita Ross NOTARY PUBLIC,STATE OF NEW YORE Registration No.01R04883559 Qualified in Suffolk County Commission Expires February 9,20� ,� aoe SouryO� S0l���# # TOWN OF SOUTHOLD BUILDING DEPT. �ycoormN�`` 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING / STRAPPING [ FINAL O/1 --aP 9t-S [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O ' [ ] RENTAL REMARKS: �l URiI 1�2� solj e— DATE S'ag'2 INSPECTOR iv:910y, OF SO(/Tho� r * TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ I;,,,N�ULATION/C AULKING FRAMING /STRAPPING [ FINAL CO Yj��( q6c,S [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: 9-�11u IMP S . e,-D[6(?r4- DATE INSPECTOR ;,. �- A /� iI" � ` • , ,., r" �- • �`. �' ..• ,� ,\,, r r r. �� � � � _► ;� ( � � ® ; �� ,� _�. ___. -- ..._ � � , 0 i w 1r� 4 ti �y i' 1� r C+ 1 i .�•z �ti a � _ . � 7` •� � ..�� .. . . ` • � Y, ♦. � �F.� � � �. '� at. ... ... - w � � . �• • � � i �► � r- 4 w t � y NNW 'LOUISV ILLS i r r { 1 z Vd&,+ � I J1 7 � 1 r , Y w�- 4 �'' • w, r f 0 xecft a 4 a r tl 1 t w: i i - F ✓. i t 1 't k r FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(IST) y ------------------------------------ -.C FOUNDATION(2ND) �� . z ROUGH FRAMING:& ` PLUMBING''. Cam- r INSULATION.PER N.'Y. H. STATE ENERGY CODE -.2�. CW k, Pox,C.a FINAL ADDITIONAL COMMENTS r (7` -��Nv w l `14;� b 3 `1 o • a� ©O rc;' c .1 O ?3 rn _P r z x . d jo�os°fFo���oG TOWN OF SOUTHOLD—BUILDING DEPARTMENT N Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 oy • o� Telephone(631) 765-1802 Fax(631) 765-9502 https://,Aww.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT No. 4b6l:LBuilding Inspector: SEP 2 1 2021 Applications and forms must be filled out in their entirety. Incomplete a applications will not be accepted. Where the Applicant is�not the owner,an .1>h TM e " Owner's Authorization form(Page 2)shall be completed. Date:,�! p�3 O.WNER(S)OF PROPERTY: " - Y Name: �I SCTM#1000 SeC, _—1p i3\IL� t Project Address:a ` �� }l Phone#: a_ �6 Email: e ar) Mailing Address: Q� CONTACT PERSON: Name: Y Cl ' YAC . Mailing Address: Phone# L Email: 06? r-&Ss . ,. 21 DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: - Mailing Address: 110 l � P*(&Jtjlandqc�7—'5 Phone# 5b Mq Email DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: [50ther pMa 9&rxqp E �t - $ X - - - Will excess fill be removed from premises? ❑Yes,4RI"JVo -- 1 i PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in,which remise s situated: Are there any covenants and restrictions with respect to Sec, is t this property? ❑Yes X No 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 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): 9AuthorizedAgent ❑Owner ('V lUr b-e Signature of Applicant: Date: STAT E OF NEW'rORK) - SS: COUNTY 0 �- ) being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)c,�ontract)above named, (S)he is the �`UV`V\v-4 X' (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 J i `� B ��( �� day of - ! � 20,5 V �-'1 IF o ary "Ross NOTARY PUBLIC,STATE OF NEW YORK Registration No.01RO4883MG) PROPERTY OWNER AUTHORIZA ION .Qualified in SuffoikCounty i ommissi,on Expires February 9,20_ (Where the applicant is not the owner.,...._...._...- I, eya l f ON,( —residing at)'Pj� W65 Ave U`WlcW kW o hereby authorize IVA RMI to apply on my behalf to a wn of old Building Department for approval as described herein. _ 9AOA Owner Signature Date �a cD Print Owner'slNameC 2 guFF01X, BUILDING DEPARTMENT-Electrical Inspector O� CAD TOWN OF SOUTHOLD c y� Town Hall Annex- 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 1 ' iameshOsoutholdtownnv.gov— seand0southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 06/06/2024 Company Name: NH Ross Electrician's Name: Neal Ross License No.: ME-4605 Elec. email: invoices@rosstotherescue.com Elec. Phone No: 631-924-0677 ❑1 request an email copy of Certificate of Compliance Elec. Address.: 120 Middle County Rd., Middle Island, NY 11953 JOB SITE INFORMATION (All Information Required) Name: Evan Geoffroy Address: 2505 Wells Ave Cross Street: Hill Road Phone No.: 646.872.8703 Bldg.Permit#: 4 50698 email: evan.geoffroy@gmail.com Tax Map District: 1000 Section:70 Block: 4 Lot: 18 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Plumbers did an oil to gas conversion and installed a new insta-hot to heat hot water and the radiators. Evan Geoffroy, homeowner, is requesting the electical inspection- plumbi ffSquare n I Footage: I 175o / Circle All That Apply: j5VO vi wtU WaKe- I v1s, . Is job ready for inspection?: YES❑NO Rough In Final Do you need a Temp Certificate?: YES[V—]NO Issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New ServiceOFire ReconnectOFlood Reconnect OService ReconnectQUnderground DOverhead #Underground Laterals 1 2 El H Frame Pole Work done on Service? n Y N Additional Information: tion PAYMENT DUE WITH APPLICATION g,I ,a'r '_4 X69 0d �G c4 /0 VOT3 Y 1 BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 Ca,A. - Southold, New York 11971-0959 ® ® ��®! Telephone (631) 765-1802 - FAX (631) 765-9502 jamesh@southoldtownnv.gov - seand(cDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 06/06/2024 Company Name: NH Ross Electrician's Name: Neal Ross License No.: ME-4605 Elec. email: invoices@rosstotherescue.com Elec. Phone No: 631-924-0677 ❑I request an email copy of Certificate of Compliance Elec. Address.: 120 Middle County Rd., Middle Island, NY 11953 JOB SITE INFORMATION (All information Required) Name: Evan Geoffroy Address: 2505 Wells Ave o Lei ka 11 IN71 Cross Street: Hill Road Phone No.: 646.872.8703 Bldg.Permit#: 4 50698 email: evan.geoffroy@gmail.com Tax Map District: 1000 Section:70 Block: 4 Lot: 18 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Plumbers did an oil to gas conversion and installed anew insta-hot to heat hot water and the radiators. Evan Geoffroy, homeowner, is requesting the electical inspection - plumbing in i n complete Square Footage: I 175o / Circle All That Apply: gsteLv>I X rLf—Q ry aK cIs job ready for inspection?: YES❑ NO ❑Rough In ❑✓ Final Do you need a Temp Certificate?: YES 0 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 n 1 2 H Frame F1 Pole Work done on Service? Y F1N Additional Information: tion PAYMENT DUE WITH APPLICATION ,a'( IPM.n X0900 �� e4- o a V0-7 � PERMIT# Address: Switches Outlets GFI's Surface Sconces H H's 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 6 c4gr e,r Southold Town Building Department P.O.Box 1179 Permit#: 46917 53095 Main Rd Southold,New York 11971 Permit Date: 10/4/2021 (631)765-1802 Expiration Date: 4/5/2023 Parcel ID: 70.4-18 i BUILDING PERMIT RENEWAL LETTER Dated: 5/9/2024 Applicant: Geoffroy,Evan Location: 2505 Wells Ave, Southold Work Description: ALTERATION install oil to gas conversion in existing single-family dwelling as applied for. A FEE OF $125 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: Geoffroy, Evan Address: 1 Arden St#314 New York,NY 10040 The permit listed above has expired. No work is permitted or authorized beyond the expiration date. Please submit the above fee made payable to the Town of Southold. Mail to the Town of Southold Building Department,P.O. Box 1179, Southold,New York 11971 THANK YOU, SOUTHOLD TOWN BUILDING DEPT. S.C.1M.NO. DISTRIPT., 1000 SECTION:70 BLOCK:4 LOT(S).:18 0 %p L40 WF OF _111— ALUSON NATHEL PST 1% \4 J. N. IN, LAND N/F OF RALPH vfvinmo 'o net 11:4 MY AMY BELLBELLSORMLS AND CEWM see acw ARr nmu nRD 0MVARM LwArva FEWA MAP136103C01,6611 AND CM SlArA vorAhm FROM onm AREA:27.707 IF. or 0.64 a&Ar=SAW NAVEISS Is WAUnOWEV ALWATKIV W AWNN W DO A*WVISA MARM OF SFVbW"N W PC MW MW SIAN—ICAM IAX ff%CrW",4,eh" MAP NQf MAIW ft I"SWWWW%SUPOM WA WU AM?St COMWO TO 8r A VA MC CkWr OMMMS NAV A%, SALr m rAv Fvmm rw omm nvz*m a AwAmm AAo ov ms mmar m Dc nnr AWXr AM;L0400 NSSIVWN r j,==f'WwAmm UPW POKIK AAC F0 PC ASWAf&GarVr4fCWW 4 9dWftffJP%4MWAftN AW Nor VOW, " �M r &juAu(d ac ovull cm bacman C" OW IV,::INWIU11113 AV MR A W8CW R^VSr AW UZ PCUr= AW Ao"'md"n'vmwx'ne m""I's a'w QW PC f=nW W MWL AWr9KU 2MCMINTS ON AW VVI APNOWNWIS, CAU%"15 OAKLAWN AVENUE AWAW AMWACC SMMIUM!=ot Lrfflrn=Aw nor ammaw mW oWWmLrCW&r Av nC MMM Ar DC rW Or SOMY summy or.DESCRIBED PROPERTY CERTIFIED 10., M Of' "EL't, W. AP CGhfPANr,• rLt&. ONY MELLON: 11TUA70 AT: SOUTHOLD I owl or SOUTHOLD mp P= SUFFOLK COUNTY,NEW YORK mu=fff.9- mW a"pgasm P.O.Box 153 Aquabope.Now York 11931 [-1221-63 $Mbl-20' -1 MAPRIL 20. 2D21 w.r.S.L=ma omm PnXl 1631PI-IM FAS(M)nS-lMl$ <N(EW RK Workers' CERTIFICATE OF PARTICIPATION ATE Compensation Board Disability or Disability and Paid Family Leave Benefits Group Self-Insurance PART 1.To be completed by Disability or Disability and PFL Benefits Self-Insured Plan Administrator 14.Legal Name$Address of Insured(use street address only) 1b.Telephone Number of Insured N.H.Ross,Inc. (631)240-0100 120 Middle Country Rd. Middle Island,NY 11953 1 c.Federal Employer Identification Number of Insured (if no FEIN then use Social Security Number) i 2.iName and Address of Entity Requesting Proof of Coverage 3a.Name of Self-Insured Plan(Association,Union or Trust) (Entity Being Listed as the Certificate Holder) Cardinal Disability Trust Town of Southold 3b.Insurer Identification Number 54375 Route 25 S i uthold,NY 11971 B-305506 3c.Coverage effective period 01/01/2021 through 12/31/2021 4.I Group self-insurance provides: i �X A.Both disability and paid family leave benefits. B.Disability benefits only. 5.1 Group self-insurance covers: FXJ A.All of the employer's employees eligible under the New York State 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 I n dgistrator uthorized representative of the Self-Insured Plan referenced above and that the named insured has NYS Disability and/or Pa ave surance coverage as described above. I i Date Signed 08/12/2021 By (Slg a of Plan Administrator or authorized representative of the above named plan) Tel Number 518-724-3583 Name and Title Matthew;Mazzotta,Administrator I IMPORTANT: If Box 4A and 5A are checked,and this form is signed by the Plan Administrator or authorized representative of that plan,this certificate is complete.Mail it directly to the certificate holder.If Box 4B or 5B is checked,this certificate is incomplete for purposes of Section 220,Subd.8 of the Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13962-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4B or 5B of Part 1 has been checked) i 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 with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only Plan Administrators or their representatives are authorized to issue Form D13-120.2. DB-120.2(10-17) IIIIIII DB-1°1°1°111°1°(110-1°11)°IIIIIII i NYSIF New York State Insurance Fund 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ' � 0 A A^A 112233200 KEEVILY,SPERO-WHITELAW INC. 500 MAMARONECK AVENUE 0 HARRISON NY 10528 { SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER i N H ROSS INC TOWN OF SOUTHOLD 120 MIDDLE COUNTRY ROAD 54375 ROUTE 25 j MIDDLE ISLAND NY 11953 SOUTHOLD NY 11953 I 1 POLICY NUMBER : CERTIFICATE NUMBER POLICY PERIOD DATE G 824 595-3 763168 11/01/2020 TO 11/01/2021 8/12/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 824 595-3, 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. 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. i 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. i I i NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 1007969039 J-26.3 NHROSSI-01 CSOCCOA CERTIFICATE OF LIABILITY INSURANCE DAT/1212D/Y 812/2021 1 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(les)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 endorsements. PRODUCER C NT CT Kerri Illuminato UNFCU Financial Services,LLC dba Industrial Coverage acDNr o,Excl:(631)736-7500 145 FA aAX No 62 South Ocean Avenue E-MAI Patchogue,NY 11772 .killuminato@industrialcoverage.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Merchants Mutual Ins Co 23329 INSURED INSURER B: N H Ross,Inc. INSURER C: 120 Middle Country Road INSURERD: Middle Island,NY 11953-2519 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. INSR I TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR MMIDD -XL LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $, 1,000,000 CLAIMS-MADE F—X]OCCUR BOP1061411 10/1712020 10/17/2021 DAMAGE TO RENTED 500,000 MED EXP(Any oneperson) 16,000 PERSONAL BADV INJURY $ Included IGEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $. 2,000,000 POLICY❑jocoT LOC PRODUCTS-COMPIOPAGG 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO CAP9265309 1011712020 10/17/2021 BODILY INJURY Per arson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BO�DILY INJURY Per accident $ AUTOOS ONLY AUTOS ONLY PeOr acGRrlent AMAGE $ $ A I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAR CLAIMS-MADE CUP9139060 10/17/2020 10/17/2021 AGGREGATE 2,000,000 DED I X I RETENTION$ 10;000 WORKERS COMPENSATION PER OTH- �ANO EMPLOYERS.LIABILITY ANY PRRO/PMRIIETgOERR/PARTNER/IXECUTIVE YIN E.L.EACH ACCIDENT $. Mandatory in NH)EXCLUDED? N I A yy E.L.DISEASE-EA EMPLOYE DEas SCRIPTION OF OPERATIONS below describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached it more apace Is required) I ii i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Town Route ACCORDANCE WITH THE POLICY PROVISIONS. .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 66t APPR VED AS NOT D r e DATE: B.P.# FEE: BY: NOTIFY:BUILDING D--PARTMENT AT 765=1802'° .BAM TO PM FOR THE FOLLOWING]NSPECTIONS: I. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2 .:ROUGH: FRAMING & PLUMBING 3:"'INSUI:ATION: 4:;FINAL -,:CONSTRl1-T►ON MUST BE:COMPLETE FCP c,,0 ALL.;CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. COMPLY WITH'ALL CODES OF NEW YORK STATE & TOWN CODE` AS REQUIRED AND CONDITIONS OF TNN SBA SQ W '-n�ei�i �G BOAR' i USTEES OCCUPANCY OR USE IS. UNLAWFUL WITHOUT CERTIFICA . OF OCCUPANCY ELECTRICAL INSPECTION REQUIRED NORITZ Model NRCB199DV (GHQ-C3201 WX-FF US) and NRCB180DV (GHQ-C2801 WX-FF US) Residential Condensing Gas Combination Boiler •Standard Input-Gas consumption ranges: ?9 NRCB1 99:18,000 BTUh to 199,900 BTUh NRCB1 80:18,000 BTUh to 180,000 BTUh •Heating Mode Input-Gas consumption ranges: NRCB1 99:18,000 BTUh to 120,000 BTUh NRCB1 80:18,000 BTUh to 100,000 BTUh •Turndown Ratio-6.7(NRCB199)and 5.6(NRCB180) •Capacity Range-Flow rates of 0.4 GPM up to 11.1 GPM(NRCB199)and 9.8 GPM (NRCB180) s •Compact Design-ANSI Z21.13/CSA 4.9 certified design that can be wall-mounted indoors •Durable Steel Casing with Polyester Coating •Heat Exchanger-Manufactured with 316L stainless steel v •Venting Options-For indoor installation only.Convertible to Single Vent(-SV)with DVModel the use of conversion kit(#SV-CK-2) •Direct Electronic Ignition •AFUE-95% Model •Temperature Controls-Includes remote thermostat that can precisely adjust the NRC131DV(GHQ-C3201 WX-FF US) NRC61 80 DV(GHQ-C2801 WX-FF US) output temperature with the capability to display temperatures in°C,Domestic Mode:907 to 140°F,Heating Mode: 80°F to 180°F Accessories ❑ 2"&3"PVC Termination(#PVC-2C1)&(#PVC-3C7) •Outdoor Reset Control-Built-in customizable programming for Energy Savings and ❑ NRCB Manifold Kit(#MK-NRCB-7) Comfort with Outdoor Temperature Sensor(included) ❑ Quick Connect Cord(#QC-2) •Power Cord Installation Kit-6'power cord is included ❑ Neutralizer(#NC-1)(For 1 Water Heater) •Safety Devices-Flame Rod,High Limit Switch,Lightning Protection Device(ZNR), ❑ 3"Horizontal Hood Termination(#PVT-HL) Freezing Prevention Device,Fan Rotation Detector ❑ Isolation Valves(#IK-WV-200-1) •Internal Pump-Heating Mode:used for primary closed loop. Domestic Mode:used ❑ 2"&3'Bird Screen(#VT2-PVCS)&(#VT3-PVCS) for pre-heating of internal plate heat exchanger ❑ SVConversion Kit(#SV-CK-2)90 Elbow with Inlet Screen •10-Year*Limited Heat Exchanger Warranty for Residential Use ❑ Plastic Rain Cap(#PRC-1) •5-Year Limited Parts Warranty ❑ NRCB Service Kit(#SPK-NRCB 1) •1-Year Reasonable Labor Most Efficient LEao�'FREE H 2017 "Primary Heat Exchanger warranty is maintained at 10 years when used in a single family dwelling and 3 years when product is supplied with pre-heated or circulated water on the domestic waterside,in accordance with the Installation Manual. Refer to Noritz Limited Warranty for complete coverage details. —This product complies with California AB 1953 Low Lead Law and Section 1917(d)of the Safe Drinking WaterAct NORTZ AME RICA OORPORATION 11160 Grace Avenue,Fountain Valley,CA 92708 Tel.1-866-7NORTZ www.noritz.com Dimensions 18.5"(471mm 17.8" 451mm 17.7" 450mm 5.11, 130mm 10.1" 256mm 2.8" 71mm 02.4" 061 mm 02.4" 061 mm FLUE COLLAR AIR INLET Rol- E 0 WATER DRAIN VALVE PRESSURE RELIEF VALVE (WATER FILTER) WIRING THOROUGHWAY FOR HEATING(3/4a) E GAS INLET 3/4" WATER DRAIN VALVE _ WATER DRAIN VALVE C° HJEATING WATER OUTLET 1" (WATER FILTER) WIRING THOROUGHWAY DOMESTIC WATERINLET314° N (AC120V) HEATING WATER INLET 1" WATER DRAIN VALVE CONDENSATE DRAIN 1/2" It (WATER FILTER) DOMESTIC WATER OUTLET 314" AUTO FEEDER WATER INLET 1/2" WATER DRAIN VALVE Flow Rates Temperature Rise(°F) 30 40 45 50 60 70 80 90 100 Flow Rate NRCB799DV 11.1 9.5 8.4 7.6 6.3 5.4 4.7 4.2 3.8 (GPM) NRCB180DV 9.8 8.5 7.5 6.8 5.7 4.9 4.3 3.8 3.4 NRCB DHW Pressure Loss Curve NRCB Internal Pump Curve 90 18.0 80 16.0 70 14.0 ii 60 12.0 y Bypass Flow Control Valve Clan .-. J 50 n 10.0 2 40 N = 8.0 d30 Bypazs Flow Control Valve Open_ a 6.0 20 4.0 10 2.0 0 0.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 0 1 2 3 4 5 6 Flow Rate(GPM) Flow Rate(GPM) Specifications Model Name NRC8199DV NRCB180DV Weight 95(pounds) Operating Pressure 15-150 psi Gas Supply Pressure NG:3.5"-10.5" LP:8.0"-14.0" Water Holding Capacity Under 2 Gallons Water Inlet 3/4"NPT Hot Water Outlet 3/4"NPT Connection Gas Inlet 3/4"NPT Sizes Condensate Drain 1/2"Threaded NPT Auto Feeder Inlet 1/2"NPT Heating Supply 1" Heating Return 1" Power Supply 120VAC 60Hz Consumption NG:210W LP:210W Freeze Prevention 125W I NG:20OW LP:20OW Freeze Prevention 125W Freeze Protection 39°F(4°C) Domestic "F Mode 90-140°F(In 5°F intervals)(11 Options) emperature Hot Water °C Mode 32°C,35°C,37°C-48°C(In 1°C intervals),50°C,55°C,60°C(17 Options) Settings °F Mode 80•-180°F(In 1°F intervals)(81 Options) Heating °C Mode 27-82°C(In IT intervals)(43 Options) •Default temperature for heating setting is 11007.Refer to the installation manual in order to set it to 80"F. Noritz America reserves the right to discontinue,or change at any time,the designs and/or specifications of its products without notice. Rev. 09/17 �. to Q G.✓���'Q/VW""' \/U n Plumbing • Heating • Cooling • Electric Gas Conversion Specialist Drain Cleaning Home Generators Wtin isI% �(pr�i°� ;°a�•• ,�v,Q L f � 1' ti=D�;i:.���..'�.'-�;,� ..:Evi:..•;'r•:;.. .. ... .. ... ...'Jt�f.r `� �.•T; `c�Ft:�.•.. .. t. �;'4;.,:.•ir_•I 'p ,bv INR7Visit our Website for Money SavingCoupons � a . -866-980-2666 = '!•j't i�a .• •fSIMYsjlipl'46 www.NHRoss.com •' i-�� azsss, 'Cannot be combined with any other offer Licensed and Insured r rs �ton � ` o 1 ' q •� %1s ' Plumbing • Heating • Cooling • Electric Gas Conversion Specialist Drain Cleaning Home Generators 610 5'[2GV�- 'Ilk 1 � ti OVAu f / y a� i AR . i r Visit our Website for '! .A �:'•:.o:.'. '•y a a:.,iy'�e?;,r"e�='"it(•,•.. til Money Saving Coupons 1 -866,-980--2566 „ www.NHRoss.com "Cannot be combined with any other offer Licensed and Insured Z. Y. Plumbing • Heating • Cooling • Electric Gas Conversion Specialist Drain Cleaning Home Generators It kv wALL Ooe ap p�-�^�1+� «• a .;E;• ".>=.. � � _.:;-•-.:.:.t. .:i�'v': .._, r^-.e I C'a ()w �r Money Visit our Website for a ,.. �y:.' ::''4a17gi 5•a'` R .���Qi r� y Saving Coupons 1 --866,-980-2566 .. ... 't'i4�••a � o�i.rolwr'•• www.NHRoss.com 'Cannot be combined with any other offer Licensed and Insured " Plumbing • Heating • Cooling • Electric Gas Conversion Specialist Drain Cleaning Home Generators a — ' i � �E • r . Visit our Website for �:.::,;;• r�' ���- p) ��'I� • i-.�...••-A.. `..i1 ti:l�� f �pfi'!`�.'•,'Q.�'l�i-�{'I_"� Money y Coupons Saving - �.•��'� • ���� - �fr�(•,�,- : i.}!; rn�lt�cry �ii5 1 -866-980-2566 www.NHRoss.corn "Cannot be combined with any other offer , Licensed and Insured IRESG J UE! I I 120i:Middle Country Road-Middle Island, NY 11953 www.nhross.com - Fax: 631-924-2677 • Email: service@nhross.com Call Ross To The Rescue At. 631-924-0677 oil Submitted PROPOSAL CONTRACT TbOwner:_ JOB NAME INO. JOB LOCATION % ARCHITECT DATE OF PLANS I PHONE WORK COMPLETION DATE _2ZL —� APPROX.START DATE DATE THE CONTRACTOR AND OWNER HAVE DETERMINED THAT A DEFINITE Has Gas Service: - Q Yes No COMPLETION DATE: IS OF THE ESSENCE IS NOT OF THE ESSENCE WE HEREBY SUBMIT THE-FOLLOWING: Supply and Install as follows: 1 Remove old.boiler/furnace from premise. 11 Venal-G-124d 'M 2. - Install new Ross, Inc. supplied boiler/furnace: Brand Model # 11f,,,v 3. -N.-H-;-R-6ss-will-pay-Na.fiGne-l-GTid-$ _f or4­iew_bbj.I er./-fumace- 4. Equip boiler for ) zone heating with circulators„') flo valves,#--3L) expansion tank, feed valve, ;4 purge valves, I drain valves, relief valve, low water cut-off and all connecting pipe and fittings. 5. -InstalI _...gaUon-g-@LsLej-QQWc/ind,irect4ankless-loot-water-heater-with-man-u-fagt—uLeL!s----- year -warlran"-th-e-tank- 6. _Inst6II @p )ximately feet of qas.pi o boile nape, hptwater_h_eater,/rahb6). r yerj.,pooI-­----.7 .pr( qLl _6 lb�)_a�e a 6`e�_'h ' r,I and�� 7. instal (brand) programmable digital thermostat (s). 8.,. Stbrt-up'and'adjust system for proper.operation. 9. N.H. Ross, Inc. will pay for plumbing permit. Guarantee installation of N.H. Ross, Inc. supplied parts and labor for one/two full years�) Job Total: 174 Additional Related Services: Job Total: $ Remove oil tank from basement/house. Job Total: $ ------- Ins,tafl-Chimney J,aeras-per-eade—(-6ee-Below)- ENTIRE AGREEMENT:This Agreement constitutes the entire Agreement between the parties indicated relating to the materials, labor and services referenced herein, and it supersedes all prior representations or negotiations. A 2%per month service charge will be added to all past due accounts,effective annual rate 241/6. Purchaser agrees to pay attorney fees of 20%of unpaid balance when turned over for collection. WE PROPOSE hereby to furnish material and labor-complete in accordance with specifications below,for the sum of., ­7 dollars Payment Schedule: This contract is not considered to be binding without the authorized signature of an officer of NH Ross,Inc.All material is guaranteed to be as specified.All work to be performed In a workmanlike manner accord- ing to standard practices.Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.NH Ross,Inc.takes no responsibility for existing heating/cooling radiation,bleeders,heating/cooling distribution systems,other than directly at heating/cooling equipment connections.Poorly constructed or Interior obstructions in existing chimneys are not part of this contracL Existing heating/cooling deficiencies are addressed as a separate lnstallaflon cost an z NH Ross Is 7�:responslble.-for anviasbastos removal or remedlaflon..Maximum reasonable effort will be made to preserve the condition of floors,walls and landscaping,however NH Ross,Inc. rrer,,01V on. . ORES 120,,Middle Country Road-Middle Island, NY 11953 www.nhross.com 9 Fax: 631-924-2677 e Email: service@nhross.com Call Ross To The Rescue At. 631-924-0677 Submitted PROPOSAL CONTRACT To Owner: (2, JOB NAME/NO. JOB LOCATION ''2_sals 1,45"eiflic" /-A� ' ARCHITECT DATE OF PLANS A ICO I PHONE / DATE APPROX.START DATE WORK COMPLETION DATE K 7�2 THE CONTRACTORAND OWNER HAVE DETERMINED THAT A DEFINITE Has Gas Service: LJ Yes JR) No COMPLETION DATE: IS OF THE ESSENCE IS NOT OF THE ESSENCE WE HEREBY SUBMIT THE FOLLOWING: Supply and Install as follows: 1. Remove old boiler/furnace from premise. 2. . Install new-Ual'enal-GFMAN+� Ross, Inc. supplied boiler/furnace: T_ 1� I Brand 1Xk-.,7?_ Model # (4y, ' /A,-y -1F.1 3. -N.-H-R-6ss-will-pay-Natio,nal-Grkl-$-- for-new ler-/-f urn.ace.. 4. Equip boiler for zone heating with circulatorsQ_flo valves,# ) expansion tank, feed valve, purge valves, I drain valves, relief valve, low water cut-off and all connecting pipe and fittings. 5. .1netal6-------galongasLe-ec-r /indirect/tan Idess-hotwater-heater-w.Itb-maD—ua-c-We.Cs------year- warran"n-he-tarik- 6Install.@ppr3ximately feet of gas pi o boile _nape.,ho water-heater; dryer;,P001­­ heater, b k; q an p ace. be L 117 7. Install fie (brand) programmable digital thermostat (s). 8. . Start-up'and'adjust system for proper.operation. ..9. N.H. Ross, Inc. will pay for plumbing permit. Guarantee installation of N.H. Ross, Inc. supplied parts and labor for one/(iWo full yearsS). 617" up 1'9Z <_'&Y �4p Job Total: $ Job Total: $ Additional Related Services:AN-A-M-1191*2z 'm_ w_ Remove oil tank from basement/house. Job Total: $ ENTIRE AGREEMENT:This Agreement constitutes the entire Agreement between the parties indicated relating to the materials, labor and services referenced herein, and it supersedes all prior representations or negotiations. A 2%per month service charge will be added to all past due accounts,effective annual rate 241/6. Purchaser agrees to pay attorney fees of 20%of unpaid balance when turned over for collection. WE PROPOSE hereby to fumish material and labor.-complete in accordance with specification f .s below,for the sum o dollars Payment Schedule: This contract Is not considered to be binding without the authorized signature of an officer of NH Ross,Inc.All material is guaranteed to be as specified.All work to be performed in a workmanlike manner accord- ing to standard practices.Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the eiflmate.All agreements contingent upon strikes,accidents or delays beyond our control.NH Ross,Inc.takes no responsibility for existing heating/cooling radiation,bleeders,heating/cooling distribution systems,other than directly _.,a,heating/cooling equipment connections.Poorly constructed or interior obstructions In existing chimneys are not part of this contract,Existing heating/cooling deficiencies are addressed as a separate Installation cost on repairs NH,Ross,,lnc.,Is'not responsible-foranyasbastos removal or remediation.,Maximum reasonable effort will be made to preserve the condition of floors,walls and landscaping,however NH Ross,Inc. ,---=-'--swill=notb&,resoonsibld,for,restoratidn.1-