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HomeMy WebLinkAbout51468-Z �oy'�oF$oulyo� Town of Southold * # P.O. Box 1179 o� 53095 Main Rd Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 46040 Date: 03/14/2025 THIS CERTIFIES that the building HVAC Location of Property: 595 Kerwin Blvd Greenvort, NY 11944 Sec/Block/Lot: 53.-3-17.4 Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 10/18/2024 Pursuant to which Building Permit No. 51468 and dated: 12/11/2024 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: HVAC system as applied for. The certificate is issued to: William Clark Of the aforesaid building., SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 51468 3/11/2025 PLUMBERS CERTIFICATION: AuLrizU Signatur �o�aoFSQ�ryo`a 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#: 51468 Date: 12/11/2024 Permission is hereby granted to: William S Clark 595 Kerwin Blvd Greenport, NY 11944 To: Install HVAC system to an existing single-family dwelling as applied for per manufacturers specifications. Premises Located at: 595 Kerwin Blvd, Greenport, NY 11944 SCTM#53.-3-17.4 Pursuant to application dated 10/18/2024 and approved by the Building Inspector. To expire on 12/11/2026. Contractors: Required Inspections: ELECTRICAL-ROUGH, PLUMBING, ELECTRICAL-FINAL, FINAL, Fees: HVAC $250.00 CO-RESIDENTIAL $100.00 ELECTRIC -Residential $100.00 Total $450.00 4_"O�h Building Inspector pF SOUj��l Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 1197170959' 'O a OWN,0ct� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: William S Clark Address: 595 Kerwin Blvd City:Greenport St: NY Zip: 11944 Building Permit#: 51468 Section: 53 Block: 3 Lot: 17.4 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: AS BUILT License No: SITE DETAILS Office Use Only Indoor W Basement I✓ Service P7 Solar (— Outdoor 1st Floor rV71 Pool Spa 1- Renovation 1- 2nd Floor I— Hot Tub Generator (- Survey (✓ Attic Garage Battery Storage r INVENTORY Service 1 ph r, Heat Duplec Recpt 5 Ceiling Fixtures 4 Bath Exhaust Fan Service 3 ph r Hot Water GFCI Recpt 9 Wall Fixtures Smoke Detectors Main Panel 200A A/C Condenser I Single Recpt Recessed Fixtures 6 CO Detectors Sub Panel A/C Blower 1 Range Recpt 50A Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 6 4'LED Exit Fixtures Other Equipment: Fridge, Oven, DW, Micro, Mini Split, 200A Panel 40 Circuits / 26 Used, (5)120Combo (6)120ARC, (1)115ArC Fault Breakers Notes: �l AS BUILT NO VISUAL DEFECTS " HVAC & Most of House Rewire (Wires Dated 2006) Inspector Signature: Date: March 11, 2025 Sean Devlin Electrical Inspector sean.devlinCcr-town.southold.ny.us 595 Ke rwi n H VAC H o u s eAs B u i l t (�^� OF 50UTyO� ------_ -- TOWN OF SOUTHOLD-BUILDING DEPT. ro 631-765-1802 INSPECTION _- - -- [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [. FINAL W(1A_ie [ } -FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION- [..'] FIRE RESISTANT PENETRATION - [ ] ELECTRICAL(ROUGH) [. ] -ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O , [ ] RENTAL REMARKS: V� 40e, .O. l DATE INSPECTOR #�pF SOUIyO# 61 l b . 5 �� (Vvy TOWN SOUTHOL BUILDI G DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION-1ST/ REBAR [ ] ROUGH PLBG. [ -] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY- [ .] FIRE SAFETY.INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] . PRE C/O [ ]. RENTAL REMARKS: 6v "L(/J G -� auj tju �v►c DATE INSPECTOR I ,r � a ray �wr plow- law •R si�ln I�1�� L•-• i,.+�li/�.'.1J1�1i111rs1rrirl�--�- •, I�ye _..�-..�r.n�.rrlril._=�.�...ill..r1►r.� .... A&A rL--&La+ ira-.4 �1 S♦S •��� �Mr�ir .�..l�a JNI r ems• � w•�` `ry � `y f _ f ,•�,�y1 - �� is �! 'Yq r�ie _yL- ���'� ,•� �i• � '•' r✓.�. � ••' ••i� i r • �.n � • _.lr:r tee,��. 1 • '1 1 t r� r 1 � 4ELD INSPECTION REPORT DATE COMMENTS I � b FOUNDATION (1ST) - -- a --------------------------------- �C FOUNDATION (2ND) r z 0 ROUGH FRAMING& y t U PLUMBING v J r INSULATION PER N.Y. STATE ENERGY CODE - ok- 0 2 G.0. FINAL ADDITIONAL COMMENTS ed rn pe �x N 1�1 O z - x d b S�EFnc,r =off 000 TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 oy�01 �ao�� Telephone(631) 765-1802 Fax(631)765-9502 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT 0 For Office Use Only PERMIT NO. '5 I % Building Inspector: yA R OCT 1 8 2024 Applications ard'forms must be filled';out in their entirety.Incomplete .applications will not be accepted. Where the Applicant is not the owner,an Building Department Owner's Authorizatidn formr(Page 2)shall be completed Town of Southold Date: OWNER(S),OF PROPERTY Name: TSCTm # 1000- .3 , Project Address: J_ 2 i(1 . V v. -ISJ14 J 1 OL`I Y _ . Phone#: (03 1 , 83 (' Lorl Email: -oc )'n ood e _ ialS to m Mailing Address: CONTACT'PERSON Name: Loy ci r Mailing Address: -4'1 u. St) Phone#: c . . .(D..�V..�.�_c3.g_�-�. a_. 1... Email: DESIGN PROFESSIONAL INFORMATION . .' Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION .; Name: Mailing Address: Phone#� _ _3-1.._77___'_?A_..3_.______._____-__-_._ Emailry..___Pe.✓�i'Y_)1}'S°C� .as._.S__ C� __._ DESCRIPTION OF PROPOSED CONSTRUCTION - ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: Other �� f�C✓ lrl 3 (.P V l lP S o_10 $ 1( -7 4 Will the lot be re-graded? ❑Yeswo Will excess fill be removed from premises? ❑Yes�do 1 PROPERTY INFORMATION; Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to {Q ,� this property? ❑Yes [)4o IF YES, PROVIDE A COPY. ,enth After Rea/ding":�The owner/contra'ctor/designprofessional is responsible for all drainage and"storm water,issues asprovided'by Chapter 236 of the TowmCode.APPLICATION IS,HEREBY`MADE toahe'Building Department for the:issuance of a'BuildingPermit pursuant to the Building Zone 3"Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinancesor Regulations,forthe construction'of buildings, additions,,alterations or for removal or demolition ash eiei 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 toSection 210.4.5.o0he New York State Penal'Law. c Application Submitted By5ZIULLA& ame): Lo}/r{,,� � i�y r`fq. '�,r�jhorized Agent ❑Owner Signature of Applicant: Date: �l L ( STATE OF NEW YORK) SS: COUNTY OF&LL+ o t L ) l —o`-r0.-tY1Q,--Z)i T`"e.4k*a- being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Cv n}Y_6­1_�- r (Contractor)Agent,Corporate Officer,etc.) of said owner or owners,and is duly auth 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 �r day of A ��s� ,20� LOUIS J ROMEO Nota ublic Notary Public,State of New York No.01 R06314813 Qualified in Suffolk County PROPERTY OWNER AUTHORIZATION Commission Expires November 17,2 Where the applicant is not the owner) I, � " '--I— C l residing at 5 q 5 ke V-VP�) E I " � ! Y II i L1y do hereby authorize L—O"&4 .�>����'111j(U to apply on my behalf to the Town of Southold Building Department for approval as described herein. "S c_06--) CL4 L'�_ 21 svo L,�-q Owner's Signature Date LOUIS J ROMEO /' Notary Public,State of New York co -�-� I Gl.r1c No.01 R06314813 Qualified in Suffolk County Print Owner's Name Commission Expires November 17,201-,(* a02 111 2 �� 101,�cOGy BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o Town Hall Annex- 54375 Main Road - PO Box 1179 o • Southold, New York 11971-0959 y O� Telephone (631) 765-1802 - FAX (631) 765-9502 iamesh(D-southoldtownny.gov - sea nd cDsoutholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/26/24 Company Name: &lexyne nk- En l_I t, Electrician's Name:-j#.M1�R _,,- YY1.In Y' License No.: 5a Elec. email: �e i�� ��� S, C 0 0 Elec. Phone No: 01 request an email copy of Certifica of Compliance Elec. Address.-I q tj 0 601k 0-]V Ej N tq5 JOB SITE INFORMATION (All Information Required) Name: Scott Clark Address: 595 Kerwin Blvd, Greenport, NY 11944 Cross Street: Main Road Phone No.: 631-831-4177 Bldg.Permit#: 5 1 '41A email: Tax Map District: 1000 Section: 053.00 Block: 03.00 Lot: 017.004 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Install HVAC system Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES[RNO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES[R NO Issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service[]Fire Reconnect❑Flood Reconnect❑Service Reconnect[-]underground❑Overhead # Underground Laterals 1 2 H Frame 0 Pole Work done on Service? 0 Y N Additional Information: PAYMENT DUE WITH APPLICATION �gUEfOL,�e, BUILDING DEPARTMENT- Electrical Inspector OGyA TOWN OF SOUTHOLD y z Town Hall Annex - 54375 Main Road - PO Box 1179 ^+ Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 la mesh(aD-Southoldtownny.gov — sea nd(cD_southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/26/24 Company Name: Glejncn-�- CYtz L_ X-, Electrician's Name: Mk yY11' YYl,1 nyl lL License No.: .ra 15 Elec. email: 'Per Q e S Elec. Phone No: 01 q' Lqc13 0 I request an email copy of Certifica of Compliance Elec. Address.:"( qq 0 60Ltrj OLM. Mk i UkC NU - q6ki JOB SITE INFORMATION (All Information Required) Name: Scott Clark Address: 595 Kerwin Blvd, Greenport, NY 11944 Cross Street: Main Road Phone No.: 631-831-4177 Bldg.Permit#: 5 j q(eg email: Tax Map District: 1000 Section: 053.00 Block: 03.00 Lot: 017.004 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Install HVAC system �—�—J Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES LA NO [-]Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES ["NO Issued On Temp Information- (All information requir d) Service Size 1 h❑3 Ph Size:��A # Meters Old Meter# ew Service❑/ ire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION PERMIT# Address: Switches Outlets GFI' Surface �1A Sconces U"\ H H's i UC Lts Fridge HW POOL Panel Fans Mini Fr. W/D 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 I Blower AC AH I Hood Blower Service Amps Have �d Used Sub Amps Have l Used Comments ,�4,64 �-, �,p JZ I �C/ A�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/7/16/20 4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ROBERT S.FEDE INSURANCE AGENCY NAME: PHONE - FAX, 23 GREEN STREET,SUITE 102 AIC No Ext: A/CNo: E-MAIL HUNTINGTON,NY 11743 ADDRESS: ROBERTS.FEDE INSURANCE INSURERS AFFORDING COVERAGE NAIC# INSURERA:ADMIRAL INSURANCE COMPANY 24856 INSURED INSURER B:STATE INSURANCE FUND 523930 Element Energy LLC INSURERC:SHELTER POINT POINT _6f432F_ DBA ELEMENT ENERGY SYSTEMS INSURERD: 2 7470 SOUND AVENUE MATTITUCK, NY 11952 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE Min WVD POLICY NUMBER MM/DD/YYYY) (MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY CA00005380701 EACH OCCURRENCE $ 1,000,000 A X X 7/14/2024 7/14/2025 EACH RENT ED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 300,000 IMA389203C MED EXP(Any one person)- $ 5000 X 7/19/2024 7/19/2025 PERSONAL&ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY jE LOC PRODUCTS-COMP/OP AGG $ 1/2000000 ROTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED R ROPE PTYAMAGE D $ AUTOS ONLY AUTOS ONLY Per PER dent UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N 124494445 STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE 7/13/2024 7/13/2025 A B OFFICERIMEMBER EXCLUDED? � N/A E.L.EACH CCIDENT $ 11000,000 (Mandatory in NH)If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 non non NY State DBL DBL567527 1/01/2024 12/31/2025 Statutory DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED- CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Rcbes'tS. Fade, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATEYORK workers'Compensation CERTIFICATE OF INSURANCE COVERAGE 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 carrie 1 a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1c. 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 54375 MAIN STREET 3b.Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01/01/2024 to 12/31/2025 4_ Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/10/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston Welsh,Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 48,4C 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 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) 111111111°°�!°�l!1°11°1°11m1°°°°111 III IIII AFMN-�N NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD DBA ELEMENT ENERGY SYSTEMS 54375 MAIN ROAD 7470 SOUND AVENUE SOUTHOLD NY 11971 MATTITUCK NY 11952 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449 444-5 962287 07/13/2024 TO 07/13/2025 7/11/2024 THIS IS TO CERTIFY THAT THE,POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 444-5, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/MIWW.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 THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 SU NCE FUND DI RECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799006 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com I CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED), I w � AAAAAA 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 ff HUNTINGTON NY 11743 1 SCAN TO VALIDATE AND SUBSCRIBE I POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD DBA ELEMENT ENERGY SYSTEMS 54375 MAIN ROAD 7470 SOUND AVENUE I SOUTHOLD NY 11971 MATTITUCK NY 11952 i POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449 444-5 ! 962287 07/13/2024 TO 07/13/2025 '7/11/2024 THIS IS TO CERTIFY THAT THE!POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 444-5, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://VWI/W.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 THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 INSUREDITHAT 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. i I I I i I NEW YORK STATE SU 13 A NCE FUND i I DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799i006 �® CERTIFICATE OF LIABILITY INSURANCE DATE(MM7,16 0�4 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 thel certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ROBERTS.FEDE INSURANCE AGENCY PHONE - - FAX - - 23 GREEN STREET,SUITE 102E-MAIL o.Ext: A1C No HUNTINGTON,NY 11743 i ADDRESS: ROBERTS.FEDE INSURANCE INSURERS AFFORDING COVERAGE NAIC# INSURER A:ADMIRAL INSURANCE COMPANY 24856 INSURED INSURERB:STATE INSURANCE FUND 523930 Element Energy LLC INSURER C:SHELTER POINT POINT 81434 DBA ELEMENT ENERGY SYSTEMS INSURERD:GENERAL STAR MANAGEMENT 37362 7470 SOUND AVENUE INSURERE: MATTITUCK, NY 11952 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDO/YYYY MMIDD/YYYY COMMERCIAL GENERAL LIABILITY CA00005380701 EACH OCCURRENCE $ 1,000,000 A X X 7/14/2024 7/14/2025 CLAIMS-MADE �OCCUR DAMAGE T R NT � PREMISES Ea occurrence $ 300,000 IMA389203C MED EXP(Any one person) $ 5000 X 7/19/2024 7/19/2025 PERSONAL 8 ADV INJURY $ 1000000 i GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEC LOC 1/2000000 PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODI LY I NJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) '$ HIRED NON-OWNED I PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ $ WORKERS COMPENSATION 124494445 X IPER OTH- AND EMPLOYERS'LIABILITY Y/N 7/13/2024 7/13/2025 STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 B OFFICERIMEMBER EXCLUDED? Ix I N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i non QM NY State DBL DBL567527 1/01/2024 12/31/2025 Statutory i I I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED- CERTIFICATE HOLDER CANCELLATION i Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED �REPRESENTATIVE /�.Vl7Y..1'L.S. Fed& ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD YT0ATE Compensation workers' CERTIFICATE OF INSURANCE COVERAGE STAT 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 carrie 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) i 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carder (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 54375 MAIN STREET 3b. Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 DBL567527 I 3c.Policy effective period 01/01/2024 to 12/31/2025 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: I Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carder referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/10/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston Welsh,Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 48,4C 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 413,4C or 5113 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. i 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. I DB-120.1 (12-21) III jIIP111°°1°°°°11° (1°11�°�!°!°!°IIIIII I I APPROVED AS!NOTED COMPLY WITH ALL CODES OF cJ g NEW YORK STATE&TOWN CODES DgTE' a_I a+B.P#i AS REQUIRED AND CONDITIONS OF FEE3 S b CZ BY: $OUtHOIDTOWNZBA NOTIFY BUILDING DEPARTMENT AT 34Ui WTWN P0MNG BOARD 631-765-1802 8AM TO 4.PM FOR THE mAmm1flum FOLLOWING INSPECTIONS: RYIDEC FOUNDATION-TWO REQUIRED FOR POURED CONCRETESo ROUGH-FRAMING&PLUMBING INSULATION FINAL-CONSTRUCTION MUST BE COMPLETE FOR C.O. Additional ALL CONSTRUCTION iSHALL E NEW Certification REQUIREMENTS OF THE COD S YORK STATE. NOT RESPONSIBLE FOR May Be Required. DESIGN OR CONSTRUCTION ERRORS i ELECTRICAL INSPECTION f EQUIRED II I i i I i I i I i I i I i I i I Page No. 3 of 7 Pages ��o�aaar 11500 Old Sound Avenue,PO Box 106 colbMattituck,New York 11952 P 631-298-5527 1 F 631-298-5534 HEATING + COOLING www•kolbmechanical.com PROPOSAL SUBMRTED TO PHONE DATE Scott Clark 631) 831-4177 February 27, 2024 STREET J013NAME 595 Kerwin Boulevard 595 Kerwin Boulevard CITY,STATE AND ZIP ' J LOCATION Greenport, NY 111944 �,reenport, NY 11944 .Er oD- Mpinewoodperennials.com We hereby submit spedficatlons and esVmales for, Please initial beside any accepted option/s: i - Option #1 - Mitsubishi Ducted Heating &Air Conditioning: Provide and install) a new Mitsubishi M-Series ducted Variable Refrigerant Flow high efficiency heat pump heating and air conditioning system to consist of the fallowing: Scope of Work: • Provide all engineering for the design and installation of the HVAC system. • Equlpment and ductwork shall reside within the semi-conditioned building envelope. • Provide and install sheet metal ductwork, insulated as per New York State Energy Conservation Construction Code. • Provide and Install flexible connectors at the supply and return connections. • All sheet metal return ductwork to be internally lined with sound attenuating acoustical liner. Liner to be fastened by means of glue and mechanical weld pin fasteners. ■ All duct seams to be sealed with UL181 metal foil tape. • All branch ducts to be UL class 1 air duct, meeting NFPA 90A and 906 and/or insulated rigid sheet metal duct. • Provide and install balancing dampers for all supply branch ducts. • All visible distribution plenum boxes to be painted with flat black paint. • Provide and install one(1) Mitsubishi M-Series, model #SVZ-KP24NA, 24,000 BTU, ducted multi-position high efficiency fully modulating fan coil unit to be installed in the residence attic,suspended from roof rafters by means of threaded rod and kindorf with a secondary drain pan and moisture sensor. • Provide and install one(1) Mitsubishi M-Series, model #SUZ-KP24NA, 24,000 BTU, Variable Refrigerant Flow high efficiency outdoor heat pump condensing unit to be installed at the residence exterior, exact location to be determined. Unit shall be set on a pre-cast slab. I l *Upon acceptance,please date,sign by the AV and return yellow copy wdh your deposit. KOLB MECHANICAL HEATING&AIR CONDITIONING In the event this account is�forwarded to counsef for collection the purchaser shall be gable for all reasonable fees of Kolb Mechanical Corp., It is the responsibility of the Homeowner to have qualified Service Mechanics maintain heating and air conditioning equipment as required by Man- ufacturer in order to preserve warranties. All equipment shall remainproperty of Kolb Mechanical Corp.,until fully paid All past due accourlts shalf be charged interest of 1.5%per month. All payments Due Upon Receipt. =t-`rt0PM hereby'to furnish material and isbar—complete in accordance with above spedrgatiom for the Stan of. Base Total options Total Grand Total Payment to be made as foibws: i AS mife'J a gumateed to be as rlfed%d.All.MR b be caryoted in a MV.—amn vmrm aanni+g to w dad praftm Aril guam or deviation ton mow weditfem tm my adn, Authorized ccstsw3beermondafjupwmftrortar<a7dvvi bamnleMairadrarge ov5rmdebeeire Signature e&nab. Owrsrb tarty Poe,tornado and Ober nay hsi w_t Our Aa ers as kaj wed by Yiahnank Note:This project may be tanpers£an Instrarrrn. withdrawn by rrs if nut accepted wittin 16 CCwam Of JorgV004f The above prices,specifications and ��-G f, I candq=s are satisfactory and are hereby accepted. You are authorized to do the wark as spedfied.Payment will be made as cut4rted above. Print m Date of Acceptance "' Z signature ._ I ' � I .r1 • Page No. 4 of 7 Pages 0;100of 11500 Old Sound Avenue,PO Box 106 Hkl'olbP 631-uck,New York -29 631-298-5527 F 631-Z96-5534 H EATING + COOLING www.kolbmechanical.com PROPOSAL SUBMITTED TO j PHONE DATE Scott Clark 631 831-4177 February 27, 2024 'STFIEUT JOB NAIVE 595 Kerwin Boulevard 595 Kerwin Boulevard CITY,STATE AND ZIP i JOB LOCATION Greenport, NY 1.1944 Greenport, NY 11944 EhtAILADO ES$, rc� f�JQ(J� ScottCa pInewoodverennials.com et We hereby submit specifl hors and estimates for. Scope of Work!(Continued): • Provide and install one(1)AprilAire, model #2213,S"thick MERV-13 HEPA media type wholle home air purifier. • Provide an'd install vibration isolators for all motor bearing equipment. • Provide and install Armorflex cleaned and capped lnsulated type V nitrogenized refrigeration piping. • Charge refrigerant circuits with new R-410A Puron non-ozone depleting environmentally compliant refrigerant. • Provide and install all condensate schedule 40 PVC piping for the HVAC system. • Provide and install Hart&Cooley grilles and registers throughout, • Provide and install one (1) Mitsubishi digital thermostats. • Provide and install all low voltage HVAC control wiring. • Coordinate power wiring load requirements and power wiring schematics with the electrician. • Perform all testing and balancing of HVAC system upon start-up. • System to include a one(1) year parts and labor service contract. I i i *Upon acceptance,please date,sign by die W and return yellow copy with your deposit. KOLB MECHANICAL HEATING&AIR CONDITIONING In the evem this aewunt is forwarded to wtutsei for coaection the purchaser shalt be gable for all reasonable tees of Kolb Mechanical Corp., It is the responsibiLty of the Homeowner to have qualified Service Mechanics maintain heating and air conditioning equipment as required by man- ufacturer in order to preserve warranties. AD equipment shad remain property of Kolb Mechanical Corp.,until fully paid M past due accounts stall be charged interest of 1.5%.per month. All payments Due Uponi Receipt USTIMMe hereby to furnish material and tabor—wAroete in accordance with above specifications,for the sum of: Base Total Options Total Grand Total Payment to be made as follows: I , i AI rtlar�l's gumrxsf to betas ill tiradr b be oompfsed m a notars&e rranoar amodag105 Fzd priCbMIAyaI Authefized o=w3beeao4edardyufmvo#moduSard bsmraaaro7attwgemerardabrne:tie Signature ssbmwe.ACsgree.T&Z cendgent upon Cbs,rmrkrt'sardP�sttrpdart mneeL L1a�erb carry fie,Imiado aM ether—Illy&u nve Ott wwk=am t*cmv?d by hatenads Note:This project may be Canyetsa`'an biaaance. I withdrawn by Liss it not accepted within 76 I =rtZpfa= of TaWonT The above priors,specifications and cofdaiors are satisfactory arahereby ate. You are authorized to do the work as specified. t will be made as otdfined above. Print Name Date of Acceptance 1—1 X Signature I I I I Page No. 5 of 7 Pages 11500 Old Sound Avenue,PO Box 106 - ,New York 11952 XkoIb P 631298-5527 1 F 631-29 8-5534 HEATING + COOLING www.kolbmechanical.com i PROPOSAL SUBMITTED TO PHONE DATE Scott Clark 631 831-4177 Februa 27 2024 STRET JOB NAME 59E5 Kerwin Boulevard 59 Kerwin Boulevard CITY,STATE AND ZIP JOB LOCATION Greenport, NY 11944 Greenport, NY 11944 EMAILADDREss i CELL HON ScotttDlpinmoodaerennials.com JZ/GS?et IWe hereby submit spec?cations and estimates for.Excludes: I • Line voltage power wiring, by Electrician. • Cutting, patching, painting, and/or framing of sheetrock, and carpentry for HVAC, if required. • Specialty g lilles/registers and materials/finishes. • Sound attenuation for mechanical equipment. • HERS rating;testing and certifications. Warranty: • All work to be done in a professional manner by trained installers and service personnel. • One-year parts &labor service during normal business hours on above system. • Exclusive Mitsubishi Elite Diamond Dealer Twelve-year parts and compressor warranty. • All factory warranties honored. i Additional Investment: $ 16,745.00 i I I *Upon acceptance,please date,sign by the W and return yellow copy vdth your deposit I KOLB MECHANICAL HEATING&AIR CONDITIONING In the event[his account is forwarded to counsel for collection the purchaser shall be liable for all reasonable fees of Kolo Mechanical Corp:, It Is the responsibility of the Homeowner to have qualified Service Mechanics mahUn heating and air conditioning equipment as required by marl ulacturer in order to preserve warranties. All equipment shall remain prgperty of Kolb Mechanical Corp.,until fully paid All past due accounts shall beicharged interest of 1S%per month. Al payments Due Upon ReceipL ;TE!TLOp00t hereby to furnish material and labor—complete In accordance with above specifications,for the sum of: Base Total options Total i Grand Total Payment to be made as follows: Al mdffel's gurmrted m be as speaffi ed All work ID be mnpkM�n a wakrerOs mama aau9 gfoluidxdpraaor�cry r'�rr ordev, at Son�me spe nrlsiauWgeraa Authorized caar wifx eremtM any uponu�dartl iv8 tremrre en aCadssye avartl abt+e die Signature estio>ars.AS agrenneras aolifyertl upon 5taw�s�denkor de+ays baymd arc wNrd.Dwr»tto Goy fire,bmado and oft—moessrry fn worn Our'Awkers are%4 ccae:ed by VVdWaWs Note:This project may be Cartpfflmton inures. withdrawn by us it not accepted tvitnin 16 'Umptam of`Ftoponr The above-prices.specifications and SC con&iars are saUsfactory ard are hereby accepted. You are auf fined to do the work as specified Payment will be made as outlined above. Print Na e Date of AcceptanceSignature I ' I