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HomeMy WebLinkAbout50991-Z ho�"�oP s°uryo`o Town of Southold * * P.O. Box 1179 �04 53095 Main Rd °lq�oUK". Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45800 Date: 11/26/2024 THIS CERTIFIES that the building WINDOWS IN DWELLING Location of Property: 895 Jasmine Ln Southold, NY 11971 S ec/B to ck/L o t: 69.-3-24.1 Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 06/10/2024 Pursuant to which Building Permit No. 50991 and dated: 07/26/2024 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: window replacements in-kind to an existing single-family dwelling as applied for. The certificate is issued to: Nicoletta Stathakos Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: PLUMBERS CERTIFICATION: JA Aut riz d S nature r�s FQF TOWN OF SOUTHOLD BUILDING DEPARTMENT y �� TOWN CLERK'S OFFICE Wo' { 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#: 50991 Date: 7/26/2024 Permission is hereby granted to: Stathakos, Nicoletta 1023 79th St Brooklyn, NY 11228 To: Construct window replacements in-kind to an existing single-family,dwelling as applied for. At premises located at: 895 Jasmine Ln, Southold SCTM # 473889 Sec/Block/Lot# 69.-3-24.1 Pursuant to application dated 6/10/2024 and approved by the Building Inspector. To expire on 1/25/2026. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00 CERTIFICATE OF OCCUPANCY $100.00 Total: $350.00 Building Inspector OF SOGlyO6 -- # TOWN OF SOUTHOLD BUILDING DEPT. ou N 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] .FOUNDATION 2ND [ ] SULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL V)►lb^f> [ ] FIREPLACE-& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION . [ ` ] FIRE RESISTANT PENETRATION . [ ]' ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: Wlt�o� 4v/ ri MA64v fvqoit�& DATE fl INSPECTOR I I l I)D Zr�I FIELD INSPECTION REPORT 7ATE COMMENTS b FOUNDATION (IST) FOUNDATION (2ND) z — o cn ROUGH FRAMING& , - I PLUMBING r INSULATION PER N. Y. ---- y STATE ENERGY CODE — w FINAL ADDITIONAL COMMENTS A 0 " o z . IF 4r;kv wwouwtf A o �6T � �L x - d — - b H eLffft��w TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1.179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 httlis:"1ar%,Nx,.southoldtownnv.gov Date Received '8 APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. 0 Building Inspector: $ I :Apphcatfons and forn'rs must:be�iil�d octtrri thelx�niirety,Incomplete y J w applications wiliO3 5e accepted tHhler�the Appltcalnt rs natthe ofr<rrfer,an a ��tt►�e�t Ourner's Authonxafign farm(Paget)shall be camptQted* $U11d�ng SOU \ f : I Date: 6/3/24 n 04�iti�4E (S)OF Prt®PERN N.. Name:Nicolett: Stathakos bq - ' SCTM#1000- Project Address: 895 Jasmine Ln Phone#:631-371-1243 Email:'zaoutis50 ' .. .. .J .�a gmail.com Miailing Address.895 Jasmine Ln, Southold NY 11971 COr`VT.1C'r PERS01lt NEW I Name:Scott Doughman i � Mailing Address:105 Buttonball Ln, Glastonbury CT 06033 . . . I Phone# 303-946 8685 Email: permits.@9permits.org.. .. . Name:n/a Mailing Address: ; I Phone#: Email: U cow-rRACT .I Name: Home Depot USA Mail ing Address:2455 Paces Ferry. Rd. Atlanta GA 30339 Phone#: 303-946 8685 Email:p erml!ts@gopermits.org I � DE CReP ioN OF F OPOSECD GO�tSTR6JCTIQ� Yti q e 11evJ tructure OAddition CiAlte j I � S '' ration ❑Repair ❑Demolition Estimated Cost of Project. ,--.]Other Remove and replace 2 windows,same size,no structural change. $3665 � I vViil the lot be re-graded? Yes ONo Will excess fill be removed from premises? OYes -'-7fvo s , � 1 DocuSign Envelope ID:DB99U13AU-t59F-4DEO-9707-I Ut8rti79EE94 x , L.A.r �.M-, 1 E�rt'sn a�of dart/peCi S� � �1 tstteaarted:use car'nrocac�rty �.m oE" of`usja e'tllstrtc'a. n which premises issi ated [,Are ti�ere alay.cnvenant an restrtcFio vvtth.res ect:ts _, . n.- . ...... .. ... .. _ ty. `pr�.<er�:�Sa�p-Y:�es,rh1r�� Ei!YdesC Na kF.,aYE,%.1p��C 0l0 C Ca�VID�EF�j�1S'+4G P�Y� g�ts . a �+ � 11 el �f ^� Y t �AnkNw ,C a u c.a l Y1a t�t� !te Se Ers i fl�.aar iLev Ya r m r l� p # rim C rcitrranrrs zwSPAQ043, Pip.ki:4rE�x� s �.fadtsF�i�,Alt sca��z��z,�f r�.�a��Ir�s xI r�r�axt€�� ��t� eT���i�tr'fs �fire ��r§fia�asshr�cc6c6sa�aa�rs�rFt���l�a{�r�lr�t�vt�,�r��cxcfi�ran��, k'�osct�sge©t4ti"�z`Y. is li gati r 4€r Fta:g a 2 sL 3 rZ Eck stL�t 4�Yti�k! F Ur�zclw"MR! �t YS�T/; cemTsL a 3nc�ci �r3tl dill 9 RR r�4s�Ss�fS l a#a3s 4#'+��rl r :.y s �' a t' � z ✓ R - 3?' r<y 's.}r3 t3a raS SS??49a�r r� x Er'r�R 3Y�€a3RC5f'�ryl,Yi it r7£arr Ss�'.ti+7ri - '-DF FED'. ELL t}t`!f' n.t P Yt4(4..,,i^ i,x, S i Ii ataerrt ubr a6it e�� praitf�carrtQ gAuihorized Ageai 0l0,wrat�r J�L S,gca<xttsrta cfpplacat; t�a+re.�..�. .. . ( ...... ....<..w:... IA"F 1., tv K I� SS COUNT. OF. 0, v`r1 .�,-_- � .v.,lE.�` A»,,�:laeira�:r�iily:s�rrcirn,c#epcast.seni;��aYa.thatls�ht'is t�wpl��irat indivldu lsi ningcoYat€cCC}bOV :Eaarr?eG, }4 (;C�rrtra:ctr�r,:tn�,�a�iacrr��fe��3fi'lc�r,�#e :��`°��tit»°c��r�, �i�.c.d�a��l-s �z�d�s:c#u!�at?tihtsrrx�t!aq pirrfC«rt�a ur la�tve.p:r;�Fc�rtnr�d tlr�r sdicl r�vC�s 1 cirat�1t�:n^a�ftw��ciflfe tFrts prsllc,ail rr ;.that t kl�tatetnertts::c ernl inter ira ti is npla'i atloq,are tr(A!:ta the:b st cif hi. jeer krir�vaiedge t�ci:k ll rtti is`=f t:iae wr�rR rfi. f#be. erforaai !n h ir�arsner set fi nth ins ikie applicatio. file therewitf . Sworn.belf.are m;6-:tffl.s. da PENSS ,r � f 'ULM E R$ OT RY RBIC M UNc yC €mmaR .. N A THQ 10 27rres gyRST 24, fWht.re:.he appllcantis r o the t wn—ee): Jennifer Town Df Soutl'rrrld Su l.ding'pp.p vent:for appr Val as tiwribe'd'hLtein. C6{ SS 6/3/2024 ..V».,.Fr)78d87�'DAfl�B�JG.e'""".""" ..w-:»..�..,:;,.:.,....,...............�:;:,....�..:...: ._......._._..:....__.. ,.., .. :....,..�.., 9; ��wrlt:r.5�lrr��ttiie £1af�. Nicolette Stathakos r: .. DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 0211212024 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 endorsements. PRODUCER CONTACT MARSH USA,LLC. NAME: PHONE FAX TWO ALLIANCE CENTER Afc No 3560 LENOX ROAD,SUITE 2400 ddAJL ATLANTA,GA 30326 ADDRESS: _ INSURERS AFFORDINOCOVERAGE NAICi1 -_Z.__ _._.__-_—._—.- _ CN101642069-HomeD-GAW.-22-25 _ INSURER A;Old Republic Insurance Co 24147 INSURED --THE HOME DEPOT,INC. INSURER B;Indemnity Ins Co Of North Amedca 43575 HOME DEPOT U.S.A.,INC. INSURER C; 2455 PACES FERRY ROAD BUILDING C-20 INSURER D ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005314714-07 REVISION NUMBER: 2 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. INSRR TYPE OF INSURANCE INSD SUB POLICY NUMBER — MMIDID/YYYFY II MML�D YEYX_LTYY LIMITS A X COMMERCIAL GENERAL LIABILITY NIWZY 316548 03(01/2022 03/0112025 EACH OCCURRENCE $ 1,000.000 j--.�CLAIMS-MADE T OCCUR D'A AGE TOf2ENTED 1,000,000 i PREMISES(Ea occurrence $ _ _ X j SIR:$1,000,000 I EXCLUDED I MED EXP(Any one pe1,000,000 rsons PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I I GENERAL AGGREGATE $ 2,000,000 X POLICY E E O u LOG i I PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY MWT8318649 0310112022 03/0112025 COMBINED SINGLE LIMT Ea acciden $ 1,000,000 ts X7 ANY AUTO I BODILY INJURY(Per person) $ OWNED SCHEDULED ! SELF INSURED AUTO PHY DMG BODILY INJURY Por accident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED I PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY ; Per accident) $ $ UMBRELLA LUAB X OCCUR j tv1WZX 316647 03/01/2022 1 03/0112025 EACH OCCURRENCE $ 10,000,000 X ; EXCESS LIAR CLAIMS-MADE i j AGGREGATE $ 10,000,000 DED RETENTION$ ! 1{ $ B WORKERS COMPENSATION ' SCFC50670533(WI) 0310112024 �03/0112025 X PER OTH- AND EMPLOYERS'LIABILITY j STATUTE ER ANYPROPRIETORiPARTNERJE Y/NXEGUTIVE I E.L.EACH ACCIDENT $ 5,000.000 OFFICER/MEMBER EXCLUDED? NIA' I — (Mandatory In NH) ! E.L.DISEASE-EA EMPLOYEE $ 6,000,000 Ifyes,describe under -_-...-.....-.-..._...._.._..._...._._..............._....__..._.._.-..__._._____._.......-_.--..--.-.--..__ DESCRIPTION OF OPERATIONS below Continued on Additional Page E.L.DISEASE-POLICY LIMIT $ 5,000,000 i i i I i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED IF REQUIRED BY WRITTEN CONTRACT ON THE ABOVE GENERAL LIABILITY POLICY,BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 63095 ROUTE 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 _ LOC#: Atlanta ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMEDINSURED MARSH USA,LLC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance Workers Compensation Continued: Carrier.Safety National Casualty Corporation Policy Number:LDS4068089(AL,AR,AZ,FL,ID,IA,IL,KS,KY,LA,MS,MO,NC,NE,NM,ND,OK,SC,SD,TN,VA,WV,W1) Effective Date:03/01/2024 Expiration Date:63101/2D25 (EL)Limit:$5,000,000 Carrier.Safety National Casualty Corporation Policy Number.SP4068090(QSI)(CA,OR,WA) Effective Date:03/01/2024 Expiration Date:03101,12025 (EL)Limit:$5,000,000 SIR:$5,000,000 Carrier:ACE American Insurance Company Policy Number:WCUC50670375(QSI)(GA,MI,NV,OH,UT) Effective Date:03101/2024 Expiation Date:03/0112025 (EL)Limit:$5,000,000 SIR:$5,000,000 SIR(GA):S750,000 .(EL)(GA):$4,250,000 SIR(NV):$1,000,000 (EL)(NV):S4,000,000 Carrier.Indemnity Insurance Company of North America Policy Number:VVLRC50670284(AK,CO,CT,DC,DE,HI,IN.MA,MD,ME,MN.MT.NH.NJ,NY,PA.RI,VT) Effective Date:03,101/2024 Expiration Date:03101/2025 (EL)Limit:$5,000,000 TX Employers XS Indemnity: Carrier2urich American Insurance Company Policy Number;NSL1138319-01(TX) Effective Date:03/0112024 Expiration Date:03/01/2025 (EL)Limit:$8,000.000 SIR:$5,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN 101642069 _ LOC#: Atlanta ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURED MARSH USA,LLC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ATLANTA,GA 30339 CARRIER F777ODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance —HOME DEPOT INSUREDS— The Home Depot,Inc. Home Depot U.S.A.,Inc. Home Depot U.S.A.Inc.dha The Home Depot Home Depot of Puerto Rico,Inc. Home Depot Product Authority,LLC Home Depot Store Support,Inc. Red Beacon,LLC H.D.V.I.Ho16n0 Company,Inc. Askuily,Inc. Home Depot Management Company,LLC Home Depot Solutions,LLC ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD W Workers' CERTIFICATE OF ' � ;Cr�lla�p0ns�. tora gcaat-d NYS WORKERS'COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 770-433-8211 Home Depot USA, Inc. 2455 Paces Ferry Rd., C-20 1c.NYS Unemployment Insurance Employer Registration Numberof Atlanta, GA 30339 Insured 76011130 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) id.Federal Employer Identification Number of Insured or Social Security 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold Indemnity Insurance Company of North America 53095 Route 25 3b.Policy Number of Entity Listed in Box"Id' Southold,NY 11971 WLR C50670284 3c.Policy effective period 031DU2024 to 03f0112025 3d,The Proprietor,Partners or Executive Officers are included.(Only check box if all partnersfofficers included) Q 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 an 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: EricTonn (Print name of authorized representative or licensed agent of insurance carrier) .,` _ Approved by: �'�'"%''� 3/1/24 (Signatue) (Date) Title: Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: 678-795-4338 Please Note:Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT `�yaa ork rs' CERTIFICATE OF INSURANCE COVERAGE E. Lotn:(af�nsatlsrti r 2aa� " NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW l 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 HOME DEPOT U.S.A.,INC. 678-384-2193 2455 PACES FERRY ROAD NW ATLANTA,GA 30339 1c.Federal Employer Identification Number of Insured or Social Security Work Location of insured(Only required if coverage is specifically Number limited to certain locations in New York State,i.e.,Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD 53095 ROUTE 25 3b.Policy Number of Entity Listed in Box 1a PO BOX 1179 SOUTHOLD,NY 11971 LNY713657008 3c.Policy effective period 01-01-2024 to 12-31.2024 4.Policy provides the following benefits: Q 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 andlor Paid Family Leave benefits insurance coverage as described above. Date Signed 11-20-2023 By (Signature of Insurance carrier's authorized representative or NYS licensed Insurance agent of that Insurance carrier) Telephone Number 212 553.8074 Name and Title: ELIZABETH TELLO—ASSISTANT DIRECTOR STATUTORY SERVICES 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 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 Box 4B,4C or 58 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) ((1!r1r I®lelll®pi'vr5e®Ili//1��16�9o�t�yyli tr®�� 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 BENEFIT'S 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. DES-120.1 (12-21) Reverse Labor,Licensing'4'00nsurn6r'Affaits• ' 4 'HOME'IMPRQUENIENTLICEN3E - • Name ` RIGHARD TOUSEY This certillos that the 8usiness,Name. SCOW,is_dulyhcehsed'. HOME,DEPOTUSMNC(14SUPP5) :)y the County,of Suffolk License Plumber H-53429 Rosalie Drego ' issued 0511512014' Commissioner Expires:, 11.lQ112024; .This license is th®property of Suffolk County Department of Labor,Licensing 8,•Consumer Affairs".,t Possession of th s license doas;tot guarantee its validity Additiahal Business Name Licegse;Cotegbry H1-,GC' i i Z i. Workers' Compensation Lazo Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-I05.2(9-17)REVERSE Rome Improvement Agreement: Page I r"i M�- Rome Depot License#'s - For the most current listing visit wvv,-vi,.Homedei)ot.com/LicenseNutiibers Fdarn Friedman Salesperson Name Registration#(Req.in CA,CTMEMD,1Vf1,NJDC) Hom,;- Depot U.S.A.j-nc.("Home:Depot") or Authorized Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and.conditions as outlined on this form. .......... ------- 1. Service Provider Contact Information The Home Depot The Home Depot Sentice Provider Contact Name Service Provider Company Name -1 H631) 478-6101 Icustornercarwellationnort hea's.t@hom -- _YPPM& . . Phone 9 Ce,ROL vider Email Address Service Provider License#(s) 2. Customer Information Stathakos 1 Nicolette ILong isia d I 70 Customer Last Naine Customer.First Name Store# Branch Name Customer Lead/PO# —Lane I Southold N F F Customer Address City State ZIP z E-77-7_1 ) 371-1243 jzaoutis50@gmall.com 1 ac)u-ris-50@gmall.com Home Phone#• Work Phone# C611 Phoneg Customer Email Address 3. NOTICE OF RIGHT TO CANCEL YOU' RIAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION'BY CONTACTING THE SERVICE PROVIDER OR STORri, D.IRFCTIY;.F.NIAIII.NGSERVICF, PROVIDER AT: custarnercancellationnortlieast@homedepot.com OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT-: ram- 5 Hauppauge 140 oser Avenue NY 11788 L Address city State Zip BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER -SIGNING, UNLESS THE STATE S 111;P PLENN.IENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE :IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN: YOUR STATE. YOUR PAYNIENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR 'PICKUP BY HOME DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY' THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU TMAY CONTACT HGNIE DEPOT FOR INSTRUCTIONS REGARDING RE,TURN SIRIPMENT AT HOME DEPOT'S EXPENSE. T19E LAY-,I REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGPI-Ir TOND CACEL. ?LN01EASE SIGN 10EBELOUROW TO ACKN T OLEDGE THAT YOU' 11AVE ,BEEN GIVEN ORAL A WRNN 7 OF Y RIGHT O CANWCEL. Acknowledged bv: 1 F05128/2024 Customer's Signature Date 4t,11 Smadxd Fenn 111A(21 Jai.2 1)(13) Generated Date 0511281j2i)9A . LeadflOA F43357870 V 0.1,t2 �x f Visibis UV Block 10 4 Panay of U.Factor R.Valuo SHOO Transmit Center of J.insulated Glass Unit Pnckn o Low E Gas I S acer S tem Thick Gtaes Total Unit Tofit Untt Total Unit Total Unit Glass ,Ste ProSolar Argots Jintercept 314' 2 0.31 3.23 0.30 0.53 73% =nerg aver ! P oSotar on , 'S69ercepf 314' 3 2 0.20 3.45 a28 0.46 73% ENERGY STAR NoMern ProSolar Sun^� .Argon Sniper S3peer 314" ; 2� 0.30 3.33 OAS 0.60 71% EryEF.GY STAR,IocCl Cer)tral PraSolarA1gon .SuPsrp! 3f4T 2 0.30 3.33 O.3D 0.53 7395. ENERGY STAP.Sarah Cen;rai i PrnSCtar Shade I Argon ( Supercepi 314- 2 0.79 3AS 0.21 R49 92% ENERGY S'AR Southern j ProSolar Shade Argon Supercepl. 314- 1 Z 0.29 3.45 6.21 0.49 921/, With Grids _ t} Visible UV Black IG 4f Panas of U-Factor R•taiue SHGC Transmit Canty of Instrla led Glass.Unit PackaLee Low E T o Gas t spacer system Thick i Glass Total Unit Total Unit Total Unit Total Unit Glass Standard ! ProSdar Argon ( intercept 3(4- , 2 0S31: 3.23 0.27 0.47 73% cnergi5arar _ _ ProSolar .Argon i SUporcept' _ 314' r �2 fl:2_9_ _3.45 0.25_ 0.41 73% _ ENERGY STAR Northern ProSolar Sunw Argon Super Sparer 314"' _ 2 0:30-� 3.33 _ 0.44 �Oa3 71% ENERGY STAR Nora Cenral Pressler 'Argon Supercepi 3t4--T 2 0.30 1 3.33 0.27 0,47 1 7395 ENERGY STAR South Conrai i Frosoiar Shade Argon Supereept 3A- ; 2 0;29. 3.45 0.19 .0.44 9211. ENERGY STAR Southern # ProSolar Shade Argon Supercepl 314' i 2 0.29. 3.45 0.19 0.44 1 92% APPROVED AS NOTED DATE' -)LI f-B.p# COMPLY WITH ALL CODES OF NEW YORK STATE&TOWN CODES AS REQUIRED AND CONDITIONS OF NOTIFY BUILDING DEPARTMENT AT SOUMOIDTOWN ZBA 631a65-1802 eAM TO 4PM FOR THIE SoLITHOIDTOWN PLANNING BOAM FOLLOWING INSPECTIONS: SOUIHOIDMWNTRUSTEES FOUNDATION-TWO REQUIRED N.Y.S.DEC FOR POURED CONCRETE ROUGH-FRAMING&PLUMBING SOLOOLD HIV INSULAnON SCHD FINAL-CONSTRUCTION,MUST BE COMPLETE FOR.C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR:CONSTRUCnON'ERRORS