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HomeMy WebLinkAbout36285-Z8/12/2011 Town of Southold Annex 54375 Main Road Southold, New York ! 1971 CERTIFICATE OF OCCUPANCY No: 35138 Date: 8/12/2011 THIS CERTIFIES that the building RESIDENTIAL ADDITION Location of Property: 17192 Soundview Ave., Southold, NY, SCTM #: 473889 Sec/Block/Lot: 51.-2-5 Subdivision: Filed Map No. conforms substantially to the Application for Building Permit heretofore Lot No. filed in this officed dated 3/22/2011 pursuant to which Building Permit No. 36285 dated 4/1/2011 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: screened porch and deck addition to an existing one family dwelling as applied for. The certificate is issued to Ellis, Myriam & Mindus, Daniel (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36285 8/10/11 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 #: 36285 Date: 4/1/2011 Permission is hereby granted to: Ellis, Myrian & Mindus, Daniel 360 22nd St New York, NY 10011 To: Addition & Alteration to a Single Family Dwelling; Covered Porch & Deck with Steps, as applied for. At premises located at: 17192 Soundview Ave., Southold, NY SCTM # 473889 Sec/Block/Lot # 51.-2-5 Pursuant to application dated To expire on 9/30/2012. Fees: 312212011 and approved by the Building Inspector. CO - ADDITION TO DWELLING SINGLE FAMILY DWELLING - ADDITION OR ALTERATION Total: $50.00 $384.00 $434.00 Inspector Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF occUPANcy Tiffs application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey 0f property with accurate location of all buildings, property lines, streets, and unusual natural, or · topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical instalIation from Board 0fFire Underwriters. 4. Sworn statement from plumber certifying tha~ the solder used in system contains less than 2/10 of 1% teed. 5. Commeroial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6, Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and'unusufil natural or topographic features· 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, · Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.06. 2. Certificate of Occupancy on Pre-existing Building - $100.00 Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of Property: ~7 House No. Owner or owners of Property: ] 7 ] c~ ~ Old or Pre-existing Building: (check one) Street Hamlet Suffolk County Tax Map No 1000, Section Subdivision Permit No. 3¢ 'Z~,~ Date of Permit. Block Filed Map. Applicant: Lot Dept. Approval: t',a ./ Planning Board Approval: Request for: Temporary Certificate Foe Submitted: $ ~ · ~ Underwriters Approval: Final Certificate: (check one) Applicant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold. New York I 1971-0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 ro.qer, richert~town.southo d ny us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Mimi Ellis Address: 17192 Sound View Ave City: Southold St: NY Zip: 11971 Building Permit#: 36285 Section: 51 Block: 2 Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Platinum East Electric Inc License No: 34091-me SITE DETAILS Office Use Only Residential [~ Indoor ~ Basement ~ Service Only ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCl Recpt Main Panel A/C Condenser Single Recpt Sub Panel A/C Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: screen porch, 1 paddle fan Ceiling Fixtures Wall Fixtures Recessed Fixtures Fluorescent Fixture Emergency Fixtures~ Exit Fixtures L HID Fixtures Smoke Detectors CO Detectors Pumps Time Clocks TVSS Notes: Inspector Signature: Date: Aug 10 2011 81-Cert Electrical Compliance Form TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION XFOUNDATION 1ST [ ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ [ ] FIREPLACE & CHIMNEY [ [ ] RRE RESIST~T CONSTRUCTION [ REMARKS: DATE iNSPECTORJ~~, /~-~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION 1ST [ [ ]~UNDATION 2ND [ [ ~/] FRAMING / STRAPPING [ [ ] FIREPLACE & CHIMNEY [ ] REMARKS: ROUGH PLBG. INSULATION FINAL FIRE SAFETY INSPECTION FIRE RESISTANT FENETRATION TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENt.tA110N [~ ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE iNSPECTORX~-~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] ROUGH PLBG. [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] INS~,UL~ON [ ] FRAMING / STRAPPING [)/~/FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRiC/ALh(ROUGH) [ ] ELECTRICAL (FiNA_L) REMARK .S~-'-~' ~-q~ ~.~ -' ~/~ ~ ~''/~ c/' DATE INSPECTOR, TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] I~LATION FRAMING / STRAPPING [ ~/FINAL [ ] FIRE RESISTANT CONSTRUCTION [ [ ] ELECTRICAL (ROUGH) [ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION ] ELECTRICAL (FINAL) DATE INSPECTOR~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL iROUGH) ~ ] ELECTRICAL (FINAL) REMARKS: DATE iNSPECTOR-~__ ~~--~ L~zie.~X~,;*'%~N ~RT DATE COMMENTS STA~ E~R~ CODE TOWN OF SOUTH(5 BUILDING DEPAR1 TOWN HALL SOUTHOLD, NY 11 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown. Nort~ MAR 2 1 2011 ?ork.net 8I~PI~R~;MnlT NO. ;OWN OF gOUT!fOLD Expiration BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying'? Board of Health 4 sets of Building Plans Planning Board approval Survey Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Form Contact: Mail to: ,:o Phoae: 7 ~ 5--- 57)~''~° APPLICATION FOR BUILDING PERMIT Date ~,ckVc.-M }, 5 ,20 I \ INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and water~vays. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Pernfit to the applicant. Such a permit shall be kept on the premises available Ibr inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f~ Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the prope~y have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. ,APPLICATION IS HEREBY MADE to the Building Depamnent for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Sufi'olk County, New York, and other applicable Laws, Ordinances or Regulations, lbr the construction of buildings, additions, or alterations or tbr removal or demolition as herein described. Thc applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit attthorized inspectors on premises and in building for necessary , ,_.; ,. 1,~ ~0,, (Signature of applicant or name, ifa col~ratioo) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Nameofownerofpremises /-}O¼;~ccCO k_~ ~k.,q..~cktz, e.., F_ (As on the tax roll or latest deed) if applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed House Number Street Hamlet County Tax Map No. 1000 Section ~ I Block ~ Lot_ Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~,~o~\o ~b~,--,-~u ~,~,z,4?k_k,x~x.~ b. Intended use and occupancy _~-_~,~e'~J[e ~,-&-,c,-,,-&,k,~.4~ c~L.,_xo \k (~ 3. Nature of work (check which applicable): New Building Addition / Alteration Repair Removal Demolition Other Work 4. Estimated Cost I ~ ~ cD cz, c~ . c? c', 5. If dwelling, number of dwelling units If garage, number of cars ~ Fee (Description) (To be paid on filing this application) Number of dwelling units on each floor -- 7. Dimensions of existing structures, if any: Front [~ Height -- Number of Stories If business, commercial or mixed occupancy, specify nature and extent of each type of use. ~ Rear '~0 / Depth .2-(~) / Dimensions of same structure with alterations or additions: Front Depth ~_. cq~'t Height 8. Dimensions of entire new construction: Front /~ ~ Rear Height I[' Number of Stories 9. Size oflot: Front 2211,~~- Rear ~,~1 Rear Number of Stories Depth_ ~ ' Depth 10. Date ofPurchase3\~.4~ \ c~ % Name of Former Owner f,A,q_¥~'kc40 t~ --3 11. Zone or use district in which premises are situated ~.tc~ 12. Does proposed construction violate any zoning law, ordinance or regulation? YES 13. Will lot be re-graded? YES__ NO 'w"~Will excess fill be removed from premises? YES l~O 14. Names of Owner of premises 6.k,~ ,c,.t-c.. 5 (\~ Address ~ ?~ crt Do.~,cia~ o/a~hone No. Name of Architect We~mo% ~e ~ Address Phone No ~ Name of Contractor ~,,~ ~,~ ~,~rtts AddressSiq~ ~c~e M~ PhoneNo~-qqoo~ 15 a. Is this prope~y within 100 feet of a tidal wetland or a freshwater wetland? *YES ~NO / * 1F YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE~QUIRED. b. Is this prope~y within 300 feet ufa tidal wetland? * YES NO ~ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate tbundation plan and distances to property lines. ~ 7. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property'? * YES NO ~'/ · 1F YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY ].-I S,~ ~ - ~¢ ~. x^ \ t being duly sworn, deposes and says that (s)he is the applicant (Name Of individual signing contJact) above named, (S)He is the /~"NO kX & ~ ~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 knowledge and belief; and that the work will be pertbrmed in the manner set forth in the application filed therl~6~Et O. 'rO~FIr=$ NOtary Public, State of New Yo~ Sworn to, before me this ~ [ NO. 01TO6107193 f I ~'¥'~ day of ~,,,.f~C~'"~ 20 [ [ Ouelified.J~.qffolk County { - ~.,ommtssion B,xpires March 22, ~Oii \ ' ~ -' Notary Publi'c -- -- - Signature of Applicant L/ Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 119714)959 Telephone (631) 765-1802 ~'ax (631) 76~-,95q2, ro,qer, dchert(~,town.soutnolo.n¥.us BUILDING D EPARTItf~ENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Oompany Name: Name: License No.: Address: Phone No.: Date: JOBSITE INFORMATION: (*Indicates required information) *Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) .,200 (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Temp Certificate: Temp Information (If needed] *Service Size: I Phase *New Service: Re-connect Additional Information: YES/ ,) 3Phase 100 150 200 300 350 400 Underground Number of Meters Change of Service PAYMENT DUE WITH APPLICATION Final Other Overhead It e 82-Request for Inspection Form SUFFOLK COUNTY DEPARTMENT OF CONSUMER AFFAIRS This certifies that the bearer is duly licensed by the County of Suffolk Eric A Koop PROVEMENT CONTRACTOR KYLE J SCHADT NORTH FORK WOOD WORKS 45819-H 02/19/2009 L ~,~,n~.~ 02/01/2013 APR - 1 2011 BLDG DEPT. TOWN OF SOUTHOLD Town Hall Annex 54375 Main Road P.O. Box 1179 Southold~ New York 11971 0959 Telephone (631 ) 765-1802 Fax (631) 765-9502 BUILDING DEPARTMENT TOWN OF SOUTHOLD July 26, 2011 Myrian Ellis 360 22® St NewYork, NY 10011 Re: 17192 SoundviewAve, Southold TWO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: __ Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of 50.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) __ Final Planning Board Approval. __ Final Fire Inspection from Fire Marshall. __ Final Landmark Preservation approval. BUILDING PERMIT: 36285 - Covered Porch & Deck with Steps BUILDING PERMIT EXAMINER CHECKL1STr/~ *Date Submitted: applicant: ~ /~~ ~ Owner: ~_/.~'~- Oate Reviewed: .g-.3t --I [ SCTM# 1000-- ~-~'/__ oT- ~ Property Address: ! · No~t~. . Building Permits (Open/Expired). BP__ -Z / C/0 Z-__ Info: BP -Z / C/0 Z- , Info: BP __-Z / C/0 Z-__, Info: Single & Separate Search Required? Y or, Determination: City: ~z-~~ Estimated Cost: /0 ~ Subdivision: ---""-' Zone: t~ ~ Conforming? Pre COs? BP __-Z / C/0 Z- , Info: BP -Z / C/0 Z- , Info: REQ. Lot Size: ~'w/~ ACT. Lot Size: 7~e/).3 (o { 5V REQ. Lot Cov. ~ACT; ~t Coy. *~ ~Q. Front ~ ACT. Front 0~~ ~QSide /5~ ACT. Side ~ ~Q. Re~ ~Wo PROP. Re~ o~ ~Q. Height ~--/ ACT. Height 0 ~ ~. ~ Stb~5 ~.g~ ~ ~T o~ Waterfront? Y or~ If yes, water body: ~ Panel~ __ Flood Zone: ~ Bul~ead/BiuffDistanee: ~ ADDITIONAL APPROVALS REQUIRED Suffolk County Health: Y or~- If yes, *Bed#: *Date: / / *Permit#: - If no, certification required: Y or N Received: Y or N By: NYS DEC: e~-o~cga/Ts Y o(.JS~- Date: / / Permit ~: Southoid Trustees: Y o~ Date: / / Permit g: Southold ZBA: Y o~- Date: / /__ Permit g: Southold Planning: Y o~ Date: / / Permit ~: - Notes: Town Landmark C of A: Y o TE: / / *~S CODE Compliance (page 2)~ Town Septic: Y or~ or NJ Letter - Notes: or NJ Letter - Notes: - Notes: Fee Structure: Foundation: First Floor: Second Floor: Other: Total: Calculation: SF + Initial Fee: SF + Additional Fee ( _): SF SF X $ SF + Initial Fee: + Additional Fee ( ): ~ ~'o oo C_ 0) , TOTAL: $ NEW YORK STATE CODI~ COMPLIANCE CHECKLIST CLIMATIC/GEOGtLAPHIC DESIGN CRITERIA: Gro~!nd Snow Load: ~0 ~ Wind Speed: I10MPH w'~ Seismic Design Category/B Weathering: Severe__ .Frost Depth: 36" Termite: M-H Decay: Design Temp: 11 Ice Shield Underlay: YES Flood Hazards: USE/OCCUPANCY CLASSIFICATION: ] ~-'~/r/ · HEIGIZIT/FIRE AREA: ~/~ TYPE OF CONSTRUCTION: ,~-Vt~ DESIGN CRITERIA: ENGINEERED/P~ FULL FRAMING DESIGN ELEMENTS: ~/N aE,mERS: CEILING JO ISTS: ~/N FLO OR JO ISTS: ~/N LUB'IBER SPECIES AND GRADE'~/N GLRDERS: ~/N ROOF RAIWIVERS '~fN W12qDOW AND DOOR SCHEDULE: 0q~ .MISSLE TEST REJCUIREMENTS: Y~) EGRESS 5.7 S.F.: ~/N ~ LIGHT 8 % :.~/N VENT 4%: ~[N NAIL~G/CONSTRUCTION SCHEDULE: ~ ME~S OF EG~SS:~ PL~BmG mSER DIAG--: Y~ ~ ) LOCATION OF V~ PROTECTION EQUmMENT: Y~ a ~ TRUSS DESIGN: YI~ °h CERTIFICATION: Y/N 0/[ ENERGY CALCS: Y/~ o~ TOTAL COMPLIENCE?0/N (RETURN TO PAGE ONE) NORTFOR~7 DESR ACORD. CERTIFICATE OF LIABILITY INSURANCE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IAutomatic Data Processing Insurance ..= .&nencv, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 ADP Boulevard HOLDER. ~ ~ I iI:ICATE DOE~ HOT AMEND, EXTEND OR 'Roseland, NJ 07068 ALTER THE COVERAGE AFFORDED BY THE POLICfE$ BELOW. INSURERS AFFORDING COVERAGE NAIC INSURED NORTH FORK WOOD WORKS INC. INSURER ~ Travelem Casualty In~umnc~ Company ol 19046 5175 rt 48 INSU;~ s: Mattituck, NY 11952- COVERAGES THE POLICIES OF iNSURANCE LISTED BELOW HA~E B~EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTINITHSTAN DIN G ANY REQUIREMENT, TERM OR CONDITiON OF ANY CONTRACT OR OTHER DOCUMENT W~TH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY I=~ R~'N N, ~I~IE INSURANCE AFFORDED BY THE POLICIES DESCRIE~ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITiONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A EMPLOYERS' U~IUTY iSUB2562R83310 6/2/2010 6/2/2011 EL. E~CH ACC[DENT $ ~00,000 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001/08) ©ACORD CORPORATION 1988 COVERAGE INFORMATION: · Part One Workers Compensation Insurance: Statutory Requirements · Part One of the policy applies to the Workers Compensation Law of the states listed here: NY · Part Two Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Part One. The limits of our liability under Part Two are: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease Part Three $500,000 each accident $500,000 policy limit $500~000 each employee Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except AK, OH, ND, WA, WY POLICY PREMIUM: · Total Deposit Amount Due * $2,663 Notes Section: STATE PREMIUM SCHEDULE State NY TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA Premium Basis - Estimated Rates Per Class Total $100 of Location Code Description Remuneration Remuneration* CABINET WORK 001 5429 INSTALLATION $31,200 6.74 Empl. Liab. Increased Limits (9807) Estimated Premium $2,103 Total Estimated Standard Premium Expense Constant Terrorism CAT (other than Cert Acts of Termdsm) Total Estimated Premium Taxes & Surcharge Deposit Amount Due Estimated Premium $2,103 $200 $16 $3 $2,322 $341 $2,663 Terrorism Risk Insurance Act of 2002 Disclosure On December 26, 2007, the President of the United States signed into law amendments to the Terrorism Risk Insurance Act of 2002 (the "Act"), which, among other things, extend the Act and expand its scope. The Act establishes a program under which the Federal Government may partially reimburse "Insured Losses" (as defined in the Act) caused by "acts of terrorism". An "act of terrorism" is defined in Section 102(I) of the Act to mean any act that is certified by the Secretary of the Treasury - in concurrence with the Secretary of State and the Attorney General of the United States - to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States Mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. The federal government's share of compensation for Insured Losses is 85% of the amount of Insured Losses in excess of each Insurer's statutorily established deductible, subject to the "Program Trigger~', (as defined in the Act). In no event, however, will the federal government or any Insurer be required to pay any portion of the amount of aggregate Insured Losses occurring in any one year that exceeds $100,000,000,000, provided that such Insurer has met its deductible. If aggregate Insured Losses exceed $100,000,000,000 in any one year, your coverage may therefore be reduced. The charge for this exposure is an additional premium, which is reflected in the premium schedule and does not include any charge for the portion of losses covered by the federal government under the Act. Note - Terrorism premium charges are subject to change at any time based on Federal Law and state The Travelers Indemnity Company and its Affiliates Workers Compensation Insurance Proposal for: NORTH FORK WOOD WORKS INC. 5175 RT. 48 MAq-DITUCK, NY 11952 For Policy Effective: 06/02/2010 thru 06/02/2011 Proposal Number: UB-2562R83-3-10 Proposal Presented By: ADP 71 HANOVER RD FLORHAM PARK, NJ 07932 On Behalf of ADP and The Travelers Indemnity Company and its Affiliates, we appreciate the opportunity to provide NORTH FORK WOOD WORKS INC. with the following policy proposal. THE FOLLOWING OUTLINES THE COVERAGE FORMS, LIMITS OF INSURANCE, POLICY ENDORSEMENTS AND OTHER TERMS AND CONDITIONS PROVIDED IN THIS PROPOSAL/QUOTE. ANY POLICY COVERAGES, LIMITS OF INSURANCE, POLICY ENDORSEMENTS, COVERAGE SPECIFICATIONS, OR OTHER TERMS AND CONDITIONS THAT YOU HAVE REQUESTED THAT ARE NOT INCLUDED IN THIS PROPOSAL/QUOTE HAVE NOT BEEN AGREED TO BY TRAVELERS. PLEASE REVIEW THIS PROPOSAL/ QUOTE CAREFULLY AND IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR TRAVELERS REPRESENTATIVE. This proposal will expire thirty (30) days from the date of creation identified below and is not a binding contract for insurance. IMPORTANT NOTICE REGARDING COMPENSATION DISCLOSURE For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website: h..~_~p.://www.travelers.com/w3c/leqal/Producer Com.pensation Disclosure.html If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Enterprise Development, One Tower Square, Hartford, CT 06183. THIS PROPOSAL/QUOTE DOES NOT AMEND, OR OTHERWISE AFFECT, THE PROVISIONS OF COVERAGE OF ANY RESULTING INSURANCE POLICY ISSUED BY TRAVELERS. IT IS NOT A REPRESENTATION THAT COVERAGE DOES OR DOES NOT EXIST FOR ANY PARTICULAR CLAIM OR LOSS UNDER ANY SUCH POLICY. COVERAGE DEPENDS ON THE APPLICABLE PROVISIONS OF THE ACTUAL POLICY ISSUED, THE FACTS AND CIRCUMSTANCES INVOLVED IN THE CLAIM OR LOSS AND ANY APPLICABLE LAW. TOTAL DEPOSIT AMOUNT DUE*: $2,663 Underwritten By: The Travelers Indemnity Company and its Affiliates Acknowledged and Accepted By: X On (Signature of the Insured) (Date) The Travelers has been in the business for over 140 years and has established itself in the marketplace as a financially stable company that you can rely on. You can feel confident knowing that your business will be protected in the event of a loss. Our highly qualified team of professionals, including our sales force, underwriters, risk control consultants and claim professionals, know their business well and will provide you with the no-hassle service you expect from your insurance carrier. Our dedicated, knowledgeable claim professionals are committed to providing you with exceptional claim service 24 hours a day, 365 days a year. Simply call us directly using our toll- free claim reporting number, 800.238.6225, and your loss will be handled in a fast and efficient manner so you can get back to running your business. 01/'2~2flll 16:49 (F^×)631 765 §398 ?.ous/uu~ UTICA FIRST INSURANCE COMPANY CONSTITUTED IN OHIO AS UTICA FIRST INSURANCE COMPANY (MUTUAL) Home Office - 5981 Airport Road, Oriskany NY 13424 Mail Address - P.O. Box 85% Utica, NY 13503-0851 FORMS INVENTORY PAGE Policy Number: ART 5004367 O0 Named Insured: NORTH FORK WOODWORKS INC. Agent: NATHAN BLITWlN CO, INC 3128000 AP 0231NY GL890LA AP-100 CP-382 AP 0233 AP 5454 AP 0230 AP 0365 AP 0700 CL 0605 PRIV0401 FORMS INVENTORY (10/08) Exclusion - Water Damage AP-22~ (1.00) ASBEST XSP1 {12/96) (1.00} Contractors Special Policy CP-380 (12/86) (10/87) N.Y. Amend (Anti-Arson End't) GL-219 (01/87) (09/91) Roofing Exclusion Endorsement AP 0643 (12/99) (01/08} Exclusion - War & Military Act AP 0235 {02/08) (01/99} Loss of Income 72WaitingPeriod XClgTR (1.00) (09/08) NY Amendatory Endorsement AP 0690 (06/02) (11/05) Silica Exclusion CL 0310 (10/06) (02/07) Virus or Bacterial Excl DN 0365 (10/06) (01/08) Certified Terrorism Loss CL 1045 101/08) (01/08) Certified Terrorism Prem Discl DN 0700T (01/08) (04/01) Privacy Statement GL-242 (1.00) (1.10) Blanket Additional Insured Property Damage Liability Ded. ~xcl-Commercial Spray Painting New York Amendments Exclusion Explosion Collapse Known Injury or Damage Amend. Can-Spam Exclusion Excl of Injury to Emp,Contract EIFS Exclusion Disclosure Notice Silica Virus and Bacteria Disc Not Notice of Terrorism Coverage TRIPRA Discl Notice Care, Custody or Control Excep Issued Date: 05/27/10 FORMINV 0609 INSURED COPY /FA×lb31 7bb CONTRACTORS SPECIAL POLICY DECLARATIONS PAGE New Business Declaration UTICA FIRST INSURANCE COMPANY CONSTITUTED IN OHIO AS UTICA FIRST INSURANCE COMPANY (MUTUAL) Direct Billed - Insured Home Office - 5981 Airpod Road. Ofiskany NY 13424 Mail Address - PO Box 851. Utica, NY 13503-0851 Policy Number: ART 5004367 00 Renewal of Number: NAMED INSURED AND MAILING ADDRESS NORTH FORK WOODWORKS INC. 5175 ROUTE 48 ~L~TTITUCK NY 11952-9999 Agent 3128000 NATHAN BUTWIN CO, INC * 60 CUTTER MILL RD STE 414 GREAT NECK, NY 11021-3104 POLICY PERIOD: 12:01 A.M. S~ndard Time at the Lo~tion of Designated Premiss. 05/21/~0 05/21/xl From I O -- Item Prof. Rate Description and Location Number Class Group Cons't _of Property Covered 1 pP 02 F Description: CARPENTRY Location: 5175 ROUTE 48 MATTITUCK, NY 11952-9999 County: SUFFOLK AGREEMENT In return for your payment of the required premium, we provide the insurance described in this policy. LIABILITY INSURANCE COVERAGE LIMITS ANNUAL PREMIUM Each Occurrence Limit $ 1, ooo, ooo /per occurrence Medical Payment Limit $ 5, ooo Iper person General Aggregate Limit (other than Products/Completed Work) $ 2,000,000 Aggregate Limit $ 2,000,000 (Products/Completed Work) $ 50,000 /per occurrence Fire Legal Liability /per occurrence Personal and Advertising Injury $ ~ , ooo, oo0 Property Damage Deductible $ 500 Included PROPERTY INSURANCE COVERAGE DEDUCTIBLEI LIMIT AUTOMATIC REPLACEMENT ACV ' PROTECTIVE ANNUAL INCREASE '~ COST DEVICES PREMIUM Building Business Personal Property 250 5000 N X Included Loss of Income 5000 lq X Included Business Personal Property- Off Premises FORMS AND ENDORSEMENTS SEE FORMS INVENTORY PAGE ANNUAL FORM NUMBER DESCRIPTION PREMIUM BAI-1 Blanket Additional Insured (Contractors) Included $150 Minimum Retained Premium ANNUAL SUB TOTAL $2,148.00 Name and Address NYS Fire Fee $ 1.2 7 of Mortgagee: POLICY TOTAL $2,14 9.2 7 Countersignature Date 0 5 / 2 7 / 1 0 INSURED COPY 02/0~/2011 13:12 IFAX)631 765 fi~98 P. O01/O01 AC_ORD. CERTIFICATE OF LIABILITY INSURANCE PRO=UC~R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Christopher Manfredi ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Nathan Bulwin Co. Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Po Box 1345 ALTER THE COVERAGE AFFORDED BY THE POMCIES BELOW· Sotdho~d. NY 11971 INSURERS AFFORDING COVERAGE COVERAGES ITHE POLICI~G OF INSURANCE LISTED BE*LOW HAVE BEEN ISSUEDTOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NO~ITHSTANDING , SO CEA-'O DEDB ~t[~ICIESDE.CRIBEDHERE(NIS,gU~ECrTOALL~ETERMS ~XCLUS~ONSAND~ONDITIONSD; CJCH ' ~ 05/12/10 05/12/11 ARTS004367 O0 $ $ CANCELLATION Suffolk County Department of Consumer Affairs Po Box 6100 Hauppauge, NY 11788 ACORD 25-S (7/97) S?: SURVEY OF PROPERTY A T SOUTHOLD TOIFN OF SOUTHOLD SUFFOLK COUNTY, N.Y. 1000--51--02-05 $CAL~: JULY 21, 2DI0 ELE;"A TIONS REFERENCED TO N. C. ~,< O AREA=2',-'.!,;~81 ~",Q, F F. =MONUMENT =PIPE ~S. LIC NO. 49615 ( ~0 FAX (631) 765-~797 P.O. BOX 909 1230 [F.~,EiFR STR£ET[ qD__q~ SOUTHO¢,3, ,,.K 11971 [zc/ . ~ ReTAiN COLU/V~N ~ ROOF List of Drawings ~_A-I~ Den~olition Plan A2 First Floor Plan A3 Roof Plan A4 ~s A5 Sections A6 A7 A8 ELECTRICAL INSPECTION REQUI~ED ..~,~PPROVED~OTED .¥-1-4/.p Details NOTIFY BUILDING DEPAR1MENT AT Details~j 765-1a02 8 ,old TO 4 PM FOR THE R¢fl~cected Ceiling Plan FOLLOWING INSPECTIONS: 1. FOUNDATION ~ TWO I~EQUIRED Framing Plans FOR POURED COI~RETE 2 ROUGH - FPAMING~LUMBiNG' STRAPPING, ELECTRICAL & CAULKING 3. INSUlaTION 4. FIN^~.~(~UN~TRUCTION & ELECTRICAL ~.U$T BE COUPLETE FOR C.O. ~t[ co~s:mucmo~ sl~J..~gr TV~ /.' .... ~?-~-~RE~/~REU~TS pVTHE COD~S OF NE -' / / / / / " YO'RKSTAI~. NOTRESPONSIBLEFOR DESIGN OR CONS'ffiUOTION ERRORS, RETAIN STORM WATEI PUBSU)/,'T ¥0 CHAP~R 236 COb'PLY WITH ALL CODES OF 4'-7 1/2' 4'-7 I/ 4'-7 #2" 51 DESIGN CRITERIA GROUND SNOW LOAD - 20 PSF WIND LOAD - 120 MPH - EXPOSURE C L1VE LOAD - DECK 40 PSK DECK FRAMING DRJLLED I PiNE #1,#2 IMPSON STRONG TIE. ZMAX HOT DIPPED OR GALVANITI~Fi - HILTI - KWIK BOLT 3 ROOM TRIM, RAFTERS, CEILING AND RALLYING TO BE FBXlISHED V~TH OPAQUE WI-lITE STAIN Ellis Residence, Southold, Ellis Residence, Southold, NY Roof Plan & Details 1/4" = 1'-0" March 2011 A3 NEW ROOff Pfl'~H THROUOI (~ South Elevation 1/4"= 1'-0" (~ North Elevation 1/4"= 1'-0" East Elevation 1/4" = 1'-0" B/8',~ OAL¥. ~ W/NUT ~ WAeHeR. (~ Section through Porch 1/4"= 1'-0" (~ Section 1/4''= 1'-0" Section 1/4"= 1'-0" March 2~11 ~ (~) WALL SECTION 3" = 1LO" 2 X 6 RAPTER T~ W/$ (~) DECK 3" = ~".." - H', ,,/'%,, ~;-_.- ..-~'.*.~;~',e.~..~r ~ ~/ ~ .'(. / / .-'~/ -/ . ,, . . - / z . / / / x /' / / ' ./x..- , I ,,.- /~,' '~r"~'.// / ,' / X / ",' < / - -',- ~ J ' .... x" - " ' .... . .4 ,,,. % x / .< ",.~ W -ff}f ~ '-, '-/ .: :' % ~ , x ~ , % ~ ~ . I'~, ~ ~ ~-, ~ ~ X , '.. x x. ~ .... x ~, x ',/ ,~,. ,~ ,,~J ' x / ', ' ,. .. ', ~ / .- x ~ ~/ / ,,.- ,,.. ,, ./ ./ / .. .. - -, / .x / .- . . ~ / / ,,/',', / -~/ - / / / %/ ' /' ' ,, _, / ,' /% ~.. / I,.q[ A",.~5.~ ..... ~ / / ,';. ,'"x N '.'x ." ~',~, '%,A 2(]~, ~, ~ x. ..". ~ . '~ ~ ~,,/.,,'. ,, 4/ ... ~.- . '. '.. /... x ~ . / /x x. X > ~, :., J~ I 'x : ,. - -. .. ~ . / / / > .x/ n' -' '/". '// /'. . '. ' , --/ / / ./ /'. / ./ , /7 .~. 2' ~/ / / >. / - .~ . / - - ~. / / . J ./ '~1' . .... ~. .. .-- /.~ ',, ~ / /.' .~ '~ ./ * ./ /: '/ Y ~ /' / ',~ Scale as eqoted March 2011 A7 /tx Ellis Residence, Southold, NY March 2011 A8 DESIGN LOADS GROUND SNOW LOAD - 20 PSF v~rIND LOAD - 120 MPH - EXPOSURE C LIVE LOAD - DECK 40 PSF CONCRETE - 3000 PSI REINFORCING - ASTM A615 ROOF FRA2qI1NG LUMBER - DOUGLAS FIR #1