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HomeMy WebLinkAbout37427-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 10~/2012 No: 35984 Date: 10/3/2012 THIS CERTIFIES that the building DECK Location of Property: SCTM #: 473889 Subdivision: 1165 Saltaire Way, Mattituck, Sec/Block/Lot: 100.-1-24 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretoibre filed in this officed dated 7/25/2012 pursuant to which Building Permit No. 37427 dated 8/7/2012 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: deck addition with outdoor cooking area to an existing one family dwelling as applied lbr per ZBA #6572, dated 7/19/12. The certificate is issued to Ziegler, Brian & Megan (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37427 9/25/12 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 #: 37427 Date: 8/7/2012 Permission is hereby granted to: Ziegler, Brian & Megan 150 W End Ave ;' ,,'; New York, NY 10023~ mo~ construction of a deck addition to an existing dwelling per ZBA decision #6572 as applied for At premises located at: 1165 Saltaire Way, Mattituck SCTM # 473889 Sec/Block/Lot # 100.-1-24 Pursuant to application dated To expire on 2/6/2014. Fees: 7/25/2012 and approved by the Building Inspector. SINGLE FAMILY DWELLING - ADDITION OR ALTERATION CO - ALTERATION TO DWELLING Total: $682.00 $5O.OO $732.00 Building Inspector Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This 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 of 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 installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial 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 unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. Ifa 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 $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date. New Construction: Location of Property: Old or Pre-existing Building: House No. Street (check one) Hamlet Lot Lot: Owner or Owners of Property: ~ ~x~ I -L~ F 61L~ ~. Suffolk County Tax Map No 1000, Section toO Block Subdivision '~¢-r' t~ t ~ ~ ~ ~ Filed Map. PermitNo. ~ ki '~ '~ DateofPermit.'~'-?}- I~_~ Applicant: Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ cf C ,t'"(7"W,-4 Underwriters Approval: Final Certificate: (check one) Applicant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971 0959 Telephone (631) 765 1802 Fax (631 ) 765-9502 ro.qer.dchert~town.southold, ny.us BUILDING DEPARTMENT TOWN OF ISOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION sued To: Brian Zieglar Address: 1165 Saltaire Way City: Mattituck St: NY Zip: 11952 Building Permit It: 37427 Section: 100 Block: 1 Lot: 24 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Grey Goose Electric Corp License No: 35471-me SITE DETAILS Office Use Only Residential [~ Indoor ~~1 Basement [~ Service Only ~1 Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI Recpt Main Panel A/C Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: outdoor cooking area (deck) Ceiling Fixtures ~l[~l HID Fixtures Wall Fixtures I I Smoke Detectors Recessed Fixtures CO Detectors Fluorescent Fixturt~ Pumps Emergency Fixture Time Clocks Exit Fixtures TVSS Notes: Inspector Signature: Date: Sept 25 2012 81-Cert Electrical Compliance Form.xls TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 PECTION 1ST [ ] )N 2ND FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: /~"~---,--~-¢! C~t~ ~ ROUGH PLBG. INSULATION FINAL FIRE SAFETY INSPECTION DATE TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST []//FOUNDATION 2ND [~/] FRAMING / STRAPPING [ ] ROUGH PLBG. [ ]INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (FINAL) FIREPLACE & CHIMNEY FIRE RESISTANT CONSTRUCTION ELECTRICAL (ROUGH) INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INS~.VJ.ATION [~]~NAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: ~/1 ~ INSPECTOR ~~ DATE ~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSU~ [ ] FRAMING/STRAPPING [/~FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: ~?? ~/~ DATE INSPECTOR TO Vy6 OVTUOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined Approved ~/q ,20 /' ~' Disapproved a/c eI i' Expiration ~ 7 ,20_ [ ¥( I PERMIT NO. 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: APPLICATION FOR BUILDING PERMIT Date ~-4_~ ,20 I~ INSTRUCTIONS a. This application ~US~T_be~,~mpletely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plan~7 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 waterways. 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 Permit to the applicant. Such a permit shall be kept on the premises available for 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. fi 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. ffno zoning amendments or other regulations affecting the property 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 Department for the issuance ora Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Sig-~ature ~'f applicant or name, if a corporation) I4 (Mailing address of ap, plicant) "' vaT I t'Tro State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, pluhqber or builder Name of owner of premises TD7 ~x~-I '7_} r2 Ck ~ F~;~2. (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 LicenseNo. }40 ~ ¢~'~ { 0000 Plumbers License No. Electricians License No. Other Trade s License No. 1. Location of land on which proposed work will be done: House Number Street Hamlet County Tax Map No. 1000 Section Subdivision ~ b~ OJ~_ ~ Block [ Lot 2. Mf. Filed Map No. ,4(.,.~,2.- Lot 2G, 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy [ b. Intended use and occupancy [ (-'x~ .~ 3. Nature of work (check which applicable): New Building Addition / Alteration Repair Removal Demolition Other Work 4. Estimated Cost P ~ ooo -'~'° Fee 5. If dwelling, number of dwelling units If garage, number of cars ~ (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front ~.7_ Rear 4'_0'Z. Depth Height va~,~ Number of Stories ! ~2. Dimensions of same structure with alterations or additions: Front .,ftc, .7__ Rear Depth .,(o .2. Height L] &a., ~?-~ Number of Stories 8. Dimensions of entire new construction: Front Rear 4e,-~ Depth Height ~4" Number of Stories I 9. Size of lot: Front ioo Rear I o~. ~ ~ Depth ~7~o4' q-- 3 10. Date of Purchase ~'[q iii Name of Former Owner .<~ I~.~'d~ ~. 11. Zone or use district in which premises are situated ~- %o 12. Does proposed construction violate any zoning law, ordinance or regulation? YES 13. Will lot be re-graded? YES NO NO V/Will excess fill be removed from premises? YES ~/'NO 14. Names of Owner of premises "~,~-* z~C~,c¢~L Address I~c~5 S,xt~t~3 ~a~'/PhoneNo. Name of Amhitect ~w~ ~ oV~ ¢~Z Address ~4 ~ ~.~,oce ~o Phone No ~ ~ ~ -~o~ Name of Contractor L~. ~ ~ o~ Address ~ ~ t t ~~ Phone No.~- ~4 -O~ o 15 a. Is this propeay within 100 feet of a tidal wetland or a freshwater wetland? *YES NO ~ * IF YES, SOUTHOLD TO~ TRUSTEES & D.E.C. PE~ITS MAY BE REQUIRED. b. Is this propeny within 300 feet of a tidal wetl~d? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. 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 OF~ ) ~'~N~ ~oc.t.-.,..~ being duly swom, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)Heisthe ~(3~o7'- (Contractor, Agent, Corporate Officer, etc.) of said owner or ownem, 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 performed in the manner set forth in the application filed therewith. Swom to before me this ~ ~:~t~ day of ~ 20 ~-. Signature of Applicant FORM NO. 3 NOTICE OF DISAPPROVAL DATE: May 3, 2012 Amended: June 18 2012 ro~ Eagle Design Enterprises for Brian Ziegler 924 Newbridge Road North Bellmore, NY 11710 Please take notice that your application dated April 30, 2012 For construction ora deck addition at Location of property 1165 Saltaire Way, Mattituck, NY County Tax Map No. 1000 Section 100 Block I Lot 24 ls returned herewith and disapproved on the following grounds: The deck addition on this non-conforming 20,274 sq.it, lot, is not permitted pursuant to Article XXIII Section 280-124 which states; "This section is intended to provide minimum standards for granting ora building permit for the principal buildings of lots which are recognized by the town under 280-9, are nonconforming & have not merged pursuant to 280-10.' On lots between 20,000 sq. It. and 39,999 sq. It., the required side yard setback is 15'. The site plan indicates a side yard setback of 10.5' & 33.7' combined.. (Authorized Signature Amended: to clarify setback requirements. ~D/' ' BOARD MEMBERS eslie Kanes Weisman, Chairperson James Dinizio, Jn Gerard lh Goehringer George Homing Ken Schneider Southold Town Hall 53095 Main Road · P.O. Box 1179 Southold, NY 11971-0959 Office Location: Town Annex/First Floor, Capital One Bank 54375 Main Road (at Youngs Avenue) Southold, NY 11971 http://southoldtown.north fork.net ZONING BOARD OF APPEALS TOWN OF SOUTHOLD Tel. (631) 765-1509 · Fax (631) 765-9064 _~,0t0 i~Jl)iNGS, DELIBERATIONS AND DETERMINATION MEETING OF JULY 19, 2012 ZBA FILE: 6572 NAME OF APPLICANT: Brian Ziegler PROPERTY LOCATION: 1165 Saltaire Way, Mattituck, NY SCTM#1000-100-1-24 SEQRA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type II category of the State's List of Actions, without further steps under SEQRA. LWRP DETERMINATION.' The relief, permit, or interpretation requested in this application is listed under the Minor Actions exempt list and is not subject to review under Chapter 268. PROPERTY FACTS/DESCRIPTION.' Subject property is a non-conforming 20,273.9 sq. fi. lot located in a R-40 zone. It is improved with a one story dwelling, attached deck and accessory shed. It has 100.00 feet of frontage on Saltaire Way, 204.23 feet along the southern property line, 100.05 feet along the western property and 201.25 feet along the northern property line as shown on the survey prepared by Island Wide Surveyors dated May 17, 2012. BASIS OF APPLICATION: Request for Variance from Article XXIII Section 280-124 and the Building Inspector's May 3, 2012 Notice of Disapproval based on an application for building permit for a deck addition to existing single family dwelling at: 1 ) less than the code required minimum side yard setback of 15 feet; 2) less than the total combined side yards of 35 feet. RELIEF REQUESTED: The applicant requests variances to construct a proposed deck addition having a side yard setback of 10.5 feet, where the code requires 15 feet and a combined side yard setback of 33.7', where the code requires 35 feet. ADDITIONAL INFORMATION: The applicant has an existing rear deck which is to be completely removed and a new larger deck is being proposed. AMENDED APPLICATION: During the hearing, the applicant was asked to bring the plan into more conformity with the code. The applicant on July 13, 2012 submitted a plan increasing the side yard setback to 12 feet which eliminated the need for a combined side yard setback variance and brought the plan into more conformity with the codes. FINDINGS OF FACT/REASONS FOR BOARD ACTION: The Zoning Board of Appeals held a public hearing on this application on July 5, 2012, at which time written and oral evidence were presented. Based upon all testimony, documentation, personal inspection of the property and Page 2 of 3 - July 19, 2012 ZBA File#6572 R Ziegler surrounding neighborhood, and other evidence, the Zoning Board finds the following facts to be true and relevant and makes the following findings: 1. Town Law §267-b(3){b)(1). Grant of alternative relief will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. Deck additions are characteristic of residential neighborhoods and the proposed amended location will not be visible from neighboring properties due to dense vegetation at the adjoining property lines. 2. Town Law §267-b(3)(b)(2). The benefit sought by the applicant can be achieved by some method, feasible for the applicant to pursue, other than an area variance. The applicant could construct a deck addition without the need of a variance. 3. Town Law §267-b(3)(b)(3). The variance granted herein, of alternative relief for a 12.foot side yard setback, is mathematically substantial, representing 19% relief from the code. However, the substantiality is mitigated when considering the alternative relief has eliminated the need to request a combined side yard setback variance. 4. Town Law §267-b(3)(b){4) No evidence has been submitted to suggest that a variance in this residential community wilI have an adverse impact on the physical or environmental conditions in the neighborhood. The applicant will comply with Chapter 236 of the Town Code's storm water management requirements and the Town's drainage code. 5. Town Law §267-b(3)(b)(5). The difficulty has been self-created. The applicant's desire to construct a deck addition in a nonconforming location has created the difficulty. 6. Town Law §267-b. Grant of alternative relief for a 12 foot side yard setback is the minimum action necessary and adequate to enable the applicant to enjoy the benefit of a deck addition, while preserving and protecting the character of the neighborhood and the health, safety and welfare of the community. RESOLUTION OF THE BOARD: In considering all of the above factors and applying the balancing test under New York Town Law 267-B, motion was offered by Member Schneider, seconded by Member Goehringer, and duly carried, to DENY as applied for, and GRANT ALTERNATIVE RELIEF as follows: minimum side yard shall be 12 feet, as shown on the revised survey dated July 10, 2012 and architectural plans prepared by Dennis T. Oliver, Architect dated 7/10/12 drawing # 120406 three pages. CONDITIONS: 1. The Deck addition shall remain open to the sky That the above conditions be written into the Building Inspector's Certificate of Occupancy, when issued. Any deviation from the survey, site plan and/or architectural drawings cited in this decision will result in delays and/or a possible denial by the Building Department ora building permit, and may require a new application and public hearing before the Zoning Board of Appeals. Any deviation from the variance(~9 granted herein as shown on the architectural drawings, site plan and/or survey cited above, such as alterations, extensions, or demolitions, are not authorized under this application when involving nonco~fi>rmities under the zoning code This action does not authorize or condone any current or future use, setback or other feature of the subject property that may v~olate the Zoning Code, other than such uses, setbacks and other features as are expressly addressed in this action. Page3of3 July 19,2012 ZBA File#6572 - Ziegler CTM: 1000-100q-24 The Board reserves the right to substitute a similar design that is de mmimis In nature for an alteration that does not increase the degree of noncor~)rmt~. Vote of the Board. Ayes: Members Weisman (Chairperson), Goehrlnger, Dinizio, Schneider, Homing. Ibis Resolution was duly adopted (5-0). .3~-25-12;!~:08 , 171~812266 , # J/ ~ Tow~ ~ ,54875 M~n P.O. Ik, x 1179 $oudmId, N%' 11971-0959 REQUESTED BY: Company Name: Name: License No.: Address: =hone No.: BUE..DI~ DF..PARTMF~T TOW~ OF APPLICATION FOR ELECTRICAL INSPECTION Date: *BRIEF DESCPJPTION OF WORK (Please Print Cleady) _ For am outdoor '5~5~ JOBSITE INFORMATION: (*Indicates required information) 'Name: ~r;om ~/eq ar *Cms~ Street: ~ou~ V, eW Avenv~ ~ *~oneNo.: ~17 6ffl 161~ PermE No,: H ~ ~ ~ ~ Tax Map District: 1000 Sec~on: lOC Block: I ~rovra~ Lot: (Please Cimle All That Apply) *is job ready for inspection: *Do you need a Tamp Certificate: Tamp Information (If needed1 *Service Size: I Phase *New Service: Re-connect Additional Information; YES/(~ 3Phase 100 150 200 300 350 400 Other Underground Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION EAGLE DESIGN ASSOCIATES 924 NEWBRIDGE RD. NORTH BELLMORE NEW 11710 Phone 516-731-5506 Fax 516-826-6368 YORK Town of Southold 53095 Main Road Southold, N Y 11971 Attention: Building Department JUL 2 4 2012 BLDG DEP1. TO~,'~F,J OF ,q~IUTHOLD July 23, 2012 Re: 1165 Saltaire Way Mattituck, N Y 11952 To whom it may concern, Attached are plans and new surveys which reflect the Board of Appeals decision for the above property. The Board of Appeals has not issued the decision yet but I am submitting these plans in the hopes of getting this application in the lineup so that when the BZA issues its decision there will be a minimum delay in obtaining the approval for the plans. Please advise this office if you require any additional information. Dennis Oliver Town Hall Anncx 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631 ) 765-9502 BUILDING DEPARTMENT TOWN OF SOUTHOLD September 17, 2012 f' 150 West End Ave, Apt 7A New York, NY 10023 Re: 1165 Saltaire Way, Mattituck TO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: __ Application for Certificate of Occupancy. (Enclosed) -//Electrical Underwriters Certificate. (contact your electrician) A fee of $50.00. __ Final Health Department Approval. __ Plumbers Solder Certificate. (All permits involving plumbing after 4/t/84) __ Trustees Certificate of Compliance. (Town Trustees # 765-1892) __ Final Planning Board Approval. (Planning # 765-1938) __ Final Fire Inspection from Fire Marshall. __ Final Landmark Preservation approval. BUILDING PERMIT: 37427 - Deck Addition CONSENT TO INSPECTION Owner(s) Name(s) the undersigned, do(es) hereby state: That the undersigned (is) (are) the owner(s) of the premises in the Town of Southold, located at which is shown and designated on the Suffolk County Tax Map as District 1000, Section , Block , Lot That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: That the undersigned do(es) hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon, to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances, rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances, rules or regulations of the Town of Southold. Dated: (Print Name) (Signature) (Print Name) RPR-12-2012 00:2? From: To:98266~68 Paee:~ZS STATE OF hTE~ YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF I~SURANCE COVERAGE UHDER THE NYS DISABILITY BENEFITS LAW' PART 1. TO be completed bY Disability Benefits Came[ or Licensed Insurance Agent ofthat Canlet la. L~al Name and Addr~s~ Of las~Leed (Use slreel address otdy) LONG ISLAND DECKING INC 3311 ROYAL AVENUE OCEAN,SIDE, NY 11572 2. Name -'md Address o f t be F,,~ity Requesllng Proof o f Coverase (E,fib' Beln$ Liat.-d ~ the Ceai6~ate Bolder) Megan &amp; Brian Z. iegler 1165 Saltaire Way Mattit~:k, NY 11952 Id_ Federal ~ploye[ Idemitka6~.] Nmube~ of lasu~ed or Social Sec~i~v Nt,mbe~ 113-47-2548 Name of I~a'~¢¢ Cani~ NEW YORK SLATE INSURANCE FUND Policy l~mxbe~ of entity lisled i~ box "la": DeL 5638 06 - 0 [~l~cy effec~ve peliod: 07/15/2011 to 07/15/2012 a. ~] All of ~he employe~s employees eligible m~ler de New Ye,,-k Disability Beef,s Law b. [] Only the foJlowlo$ class m classes of ~be employers employees: Umtel' pm~ai~ of P~my, I ~enlf ~ s~ ,0411012012 Tel~m~r, (866) 697-4~2 Titb D~ec~r of ~sa~li~ ~ Iflsuran~ ~TA~: PA~ 2. To ~ ~:;:;: ~ NYS W~m' CG~,,~;~ ~ (~ ~ ~ -~- ~ Pa~ 1 has k~n ch~kaa] 5~te ~ New York Work. s' Co~en~tJon Date S~ Tel~e Numar Tide Please Nole: (inly k,-,uau~e c~,;u~ licensed Io w~ite NYS ~li~ ~fia m~ polici. ~ ~S I~ ~t~ ~ems of f~ ~s~ ~e~ ~ a~ 10 ~ Fo~ DB-I~. 1. [n~rance ~m a~ NOT ~thodz~ on.]~.] (s~) ~if~e Nu~r APR-12-2012 00:2? From: To:9~266368 Pa~e:2,'5 New York State Insurance Fund Workers' Com~BeneJ'tts Speci~ists Since 1914 B CORPORATE CENTER DR, 2ND FLR, MELVILLE, NEW YORK 11747-3166 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 113472548 LONG ISLAND DECKING INC 3311 ROYAL AVENUE OCEANSIDE NY 1 '~572 POLICYHOLDER LONG ISLAND DECKINGIINC :3311 ROYAL AVENUE OCEANSIDE NY 1 !51'2 CERTIFICATE HOLDER MEGAN & BRIAN ZIEGLER 1165 S.ALTAIRE WAY MA3'rlTUCK NY 11952 POUGYNUM~ER / CERTIFICATE NUMBER / PERIOD COVERED BYTHIS CERTIFICATE DATE H 1412 335~0{ 975006 J 12/06/2011 TO 12/06/20'12 4/5/~012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1412335-0 UNTIL 12/06/2012, COVERING THE ENTIRE OBLIGATION OF THIS POLICYFK)LDteR FOR WORKERS' COMPENSATION UNDER THE NEW' YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THESTATP OF NEW' YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOL~ER'$ REGULAR NEIN YORK STATE EMPLOYEES ONLY. IF SAIO POLICY IS CANCELLED. OR CHANGED PRIOR TO 12J06/2012 IN SUCH MANNER AS TO AFFECT THI~ CERTIFICATE. 10 DAYS WRITTEN NOT!CE OF SUCH CANCELLATION WiLL SE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANy LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MAI'I'ER OF INFOI~4AT{ONONLYANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE [CERTIFICATE HOLDER. THIS CERTfFICATE DOES NOT AMIEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE F~IND UNDERWRITES This certflicat~ can be validated on our w~b site at https://www.nysif.cam/cer~cerb/al.asp or by callln9 (888) VALIDATION NUMBER; 740830042 APR-i~-~Oi~ 00:~8 From: To:98~66368 Page:4/5 · ~.,._u,,~u CERTIFICATE OF LIABILITY INSURANCE ~oe~ 4~1 ~ ~V~, ~ ~0~ H~ ~]$ ~Fi~ ~ NOT FL~H~ ~ I1~5 ~ ~E ~E~G~D ~Y ~E.,~ THE I~E ~FO~D BY THE ~IES DE~b~ HERBH ;S S~JECT TO A~ T~ T~ ~US~S ~D CON~ ~ ~CH - ; NIA APR-i~-~Oi~ 00:~8 Fpom: To:98~66568 THE COUNTY OF NASSAU OFFICE OF CONSUMER AFFAIRS 200 COUNTY SEAT DRIVE, MINEOLA N.Y. Telephone 571-3871 LICENSE FOR LICENSE NO. CA~PENTE~. CUNT%~C T~.S OXl'l~ OF ~SSUE ]D~ R. OYA~ AVE L H0625~10000 O~/O1/2Otl 03/31/2013 TIllS LICENSF MUST BE CONSPICUOUSLY DISPLAYED DOES NOT CONSTITUTE A PLUMBING OR ELECTRICAL LICENSE it 5URVP(NO, 1£-1174g IDIST: I000 1SECTION: I00 IDLOCK: ~ ITAXLOT: 24 MAP OF PROPERTY ~,~L~.O. 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