HomeMy WebLinkAbout38156-ZCERTIFICATE OF OCCUPANCY
8/27/2013
No: 36462 Date: 8/27/2013
THIS CERTIFIES that the building RESIDENTIAL ALTERATION
Location of Property: 3625 Delmar Dr, Laurel,
SCTM #: 473889 SecBlock/Lot: 125.-4-4
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this officed dated
7/5/2013 pursuant to which Building Permit No. 38156 dated 7/5/2013
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:
fire repairs to an existing sin¢le family dwelling as applied for.
The certificate is issued to Palmieri Jr, Frank
of the aforesaid building.
(OWNER)
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
Town of Southold Auuex
P.O. Box 1179
54375 Main Road
Southold, New York 11971
38156 8/13/13
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 #: 38156
Permission is hereby granted to:
Palmieri Jr, Frank 8~ Palmieri, Kathleen
3625 Delmar Dr
Date: 7I5I2013
Laurel, NY 11948
TO~ Fire repairs to an existing single family dwelling as applied for.
At premises located at:
3625 Delmar Dr, Laurel
SCTM-# 473889
SeclBlocklLot # 125.-4-4
Pursuant to application dated 7/5/2013 and approved by the Building Inspector.
To expire on 1/4/2015.
Fees:
ELECTRIC
AMENDMENT TO PERMIT
CO -ALTERATION TO DWELLING
Total:
Bui ding Inspector
$125.00
$356.00
$50.00
$531.00
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 #: 38156
Permission is hereby granted to:
Palmieri Jr, Frank 8 Palmieri, Kathleen
3625 Delmar Dr
Laurel, NY 11948
To: fire repair Qust electric so far -plans to come)
At premises located at:
3625 Delmar Dr, Laurel
SCTM # 473889
Sec/BlocklLot # 125.-4-4
Pursuant to application dated
To expire on 1/4/2015.
Fees:
Date: 7I5I2013
7/5/2013 and approved by the Building Inspector.
$125.00
00
ELECTRIC
~\
Fmm 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 ofelecttical installation from Board of Fire Underwriters.
4. Swom statement Crom 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 (priorto 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. If a Certificate of Occupancy is
denied, the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
I. 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 $50.00.
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. ~ `o(~ (
T'
New Constmction: Old or Pre-exist(i~ng Building: ~' (check one)
Location of Property: ~ V 1'`~ ~) Q\ m `^~ ~J c ~ ~ a,
House No. ` Sheet Hamlet
Owner or Owners of Property: ~ t ~, „ t~ ~ ~\ vn ~ Q L t \,
Suffolk County Tax Map No 1000, Section ~ d.~ Block `"\ Lot
Subdivision Filed Map. Loi:
Permit No. ~~~ ~}~ Date of Permit. -,7 ~ Applicant:-
Health Dept. Apprdval: Underwriters Approval
Planning Board'Approval:
Request for: Temporary Certificate Final Certificate: ~ (check one)
Fee Submitted: $ {`~ , ~ ~ C~
Appl~Sf~nai
Town Hall Annex
54375 Main Road
P.O. Box 1179
Southold, NY 11971-0959
~~
z
"O ~ i~',
~r f ~a~
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
Telephone (631) 765-1802
Fax (631)765-9502
rooer.richertCa~town.southold. ny. us
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To: Palmieri (Mustafa)
Address: 3625 Delmar Dr City: Laurel St: NY Zip: 11948
Building Permit #: 38156 Section: 125 Black: 4 Lot: 4
WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE
contractor: DaA: JpG Electric License No: 50629-me
Residential X Indoor
Commedcal Outdoor
New Renovation
Addkion Survey
SITE DETAILS
Office Use Only
X Basement Service Only
X 1st Floor X Pod
2nd Floor Hat Tub
Attic Garage
INVENTORY
Service 1 ph 200a Heat Duplec Recpt Ceiling Fixures HID Fixtures
Service 3 ph Hot W aler GFCI Recpt Wall Fixtures Smoke Detectors
Main Panel 200a A/C Condenser Single Recpt Recessed FiMUres CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent FiMure Pumps
Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks
Disconnect 200a Switches Twist Lock E>at Fixtures TVSS
Otner Equipment: FIRE REPAIR-remove and replace all fire damaged elec wire in residence includir
200a overhesd service
Niles:
Inspector Signature: ~,~~~~~~ Date: Aug 13 2013
Electrical Certrficate.xls
o~~,OF 80(/r~
~ ~ ®~
TOWN OF SOUTHOLD BUILDING DEPT.
~~ 765.1802
( 1 NSPECTION
[ ]FOUNDATION 1ST [
[ ]FOUNDATION 2ND [
[ ]FRAMING /STRAPPING [
[ ]FIREPLACE & CHIMNEY [
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
[ ]FIRE RESISTANT CONSTRUCTION [
[y,(J ELECTRICAL (ROUGH) [
RE`MARKS:
] FIRE RESISTANT PENETRATION
] ELECTRICAL (FINAL)
DATE ~ ZZ / INSPECTOR ~~
3~1~'~~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOU DATION 1ST [
[ ] F UNDATION 2ND [
[ FRAMING /STRAPPING [
[ ]FIREPLACE & CHIMNEY [
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
[ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION
[ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL)
,,
REMARKS:
~a~~~~
3~/S~~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
1 NSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
[ ]FOUNDATION 2ND [ ] I ATION
[ ]FRAMING /STRAPPING [ FINAL
[ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION
[ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION
[ ] ELECT(RI~AL (ROUGH) [ ]ELECTRICAL (FINAL)
REMARKiI: L~ _
INSPECTOR
~o~~,OF SO(/r~6
+~®~
~ ~ ,~,~.~
~~~ /~~~~`TOWN OF SOUTNOLD BUILDING DEPT.
~_~ }n 765.1802
~,~ 1 NSPECTION
[ ]FOUNDATION 1ST
[ ]FOUNDATION 2ND
[ ]FRAMING /STRAPPING
[ ]FIREPLACE & CHIMNEY
[ ]ROUGH PLBG.
[ ]INSULATION
[ ]FINAL
( ]FIRE SAFETY INSPECTION
[ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION
[ ]ELECTRICAL (ROUGH) ~] ELECTRICAL (FINAL)
REMARKS: -• 1
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DATE '~ 1 INSPECTOR ~
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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
SoutholdTown.NorthFork.net
Septic
N.Y.S
rz ,~
JP~~. ~~>4~~~ ~ ~~s~u~~~
(Signature of applicant or name, if a corporation)
~-v.QdX 3~31e /Cv~~~,~.s, ~-~-
(Mailing addwss of applicant)
Sta/te whether applicant is loIw//ner, lessee, agent, architect, engineer, gene/rat contractor, electrician, plumber or builder
Examined 7 ~ ~ , 20~
Approved .20~
Disapproved a/c
~ Expiration, 20 / ,
U~ ~ (N f II `il fs
~~~
X11 Jug -g ~~,~ ,~
BUILDING PERMIT APPLICATION C'HEC'KLIST
Do you have or need the following, before applying'!
Board of Health
4 sets of Building Plans _ _
Planning Board approval- _
PERMIT NO. /~~
Flood Permit
Storm-Water Assessment Fonn___
Contact:
Mail to:
Bm ding ffi'spec[or
Phonc.~~ I~3~= oa`a,~
FOR BUILDING PERMIT
INSTRUCTIONS
20
`- a. fRhis, applibation MUST be c mple[ely filled in by typewriter or in ink and submitted to the Building Inspector with 4
sets ofpuFatrgi pe80t9TIb'PjiGBt tan [o se .Fee acearding [o schedule.
-- o p an showing location of lot and of buildings on premises, relationship to adjoining premises or public streets ur
areas, and waterways.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of [his application, the Building Inspector will issue a Building Pemtit to the applicant Such a permit
shall be kept on the premises available for inspection throughout dre 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 dre
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an
addition siz months. Thereafter, a new permit shall be required.
APPLICATION IS HEREBY MADE to [he Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, SutY'olk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions, or alterations or Cor removal or demolition as herein described. "fhe
applicant agrees [o 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.
owner of premises
of duly authorized
t'~
the tax roll or latest deed)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No. ~ 9 S ~ -
1. Location of land on wchich woposed work
Street
Hamlet
c~.
County Tax Map No. 1000 Section ~ ~~ Block ] Lot
Subdivision Filed Map No. -Lot _ ______
r i~
2. Slate existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy ~ ~ ~ >` 6~-1 p ~^•
3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work__
(Description)
4. Estimated Cost
Fee
(To be paid on filing this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front Rear Depth
Height Number of Stories
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height Number of Stories
9. Size of lot:
10. Date of Purchase Name of Former Owner
1 I. Zone or use district in which premises are
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO
13. Will lo[ be re-graded? YES_ NOWill excess fill be removed from premises? YES_ NO
14. Names of Owner of premises Address Phone No.
Name of Architect Address Phone No
Name of Contractor Address Phone No.
15 a. Is this property within l00 feet of a tidal wetland or a freshwater wetland? *YES NO
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED.
b. Is this property within 300 feet of a tidal wetland? * 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. [f 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
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF )
being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named, CONNIE D. BUNCFI
(S)9e is the Public, State of f~av York
(Contractor, Agem, Corporate Officer, etc.) NO. 01 ~ ~ ~s
Qualified in Suffolk Cnu:^,ty2Ol
of said owner or owners, and is duly authorized to perform or have performed the said work ~Ip~~ond3Sl~if1~6 ~11iCati~rn, -
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 [he application filed therewith.
w [o before me [h~
day of 20 ~ 3
Notary Public
_-~
Signa ue of Applicant
Town hall Annex
54375 Main Goad
P.O. Box 1179
Southold, M'1 11471-0959
,~!';f OF StWlyo~
~ ~
Telephone (631) 765-1802
ro9er.richertCdS~towri lsout~io~d.nv.us
BUILDING DF1'AIYTMENT
TOWN OF SOUTHOT.D
APPLICATION FOR ELECTRICAL INSPECTfON
REQUESTED BY: ~~?qr1 y ~alcr~ c7 Date: ~ .
Company Name: (,~ r C
Name:
License No.: p (~ a- y - /~? E
Address: ~ v . /,3 v x 3 ~ G~ ,~ r~ rn~i /ti - - l~ ~
Phone No.: /- ~ ~ -
JOBSITE INFORMATION: (*Indicates required information)
*Name:
*Address:
*Cross Street:
*Phone No.:
Permit Nv.:
TaxMap District:
*BRIEF DESCRIPTION OF WORK (Please Print Clearly)
~~ ' >z r pd
(Please Circle Alf That Apply)
*Is job ready for inspection: YES / NO Rough In Final
*Do you need a Temp Certificate: ~ NO
Temp Information (If needed) '
*Service Size: 1 Phas 3Phase 100 150 ~ 300 350 400 Other
*New Service: nnect Underground Number of Meters Change of Service verhea
Add'Rional inform PAYMENT DUE WITH APPLICATION
~~
~~
,~
~g
'~,5,ta~
~~inL +~ 7-C c .I ~' C ~`
STATE OF NEW YORK
WORKER'S COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
~~, PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
'. 1a. Legal Name antl Address of Insured Nsa street address only) ! 1 b. lkssirsess Telephone Number of Insured
~, J.P.G. MAINTENANCE & CONSTRUCTION CORP. DBA 631-067-6744
'' J.P.G. ELECTRIC '~, 1a NYS UnempbymeM Insurance Employer Registration
P.O. BOX 386 I Number of lnwred
RONKONKOMA, NY 11779
2. Name and Address of tM Entity requestirsg ProoT of Coverage
' (Entity being listed es the CMiTicace Holder)
'I Town of Southold
I
~ 54375 Main Road
i, Southold, NY, 11971
'.. 9. Poliry rovers:
td Federal Employer Idemilleation Number of Insured
'~ or Sxial Severity Number
134236219
la. Name of Irswranw Carrier
TM Fkst Rehabilkation Life Inwrance
Company of Amerlu
~'~. lb. Poliry Numbs of Emity listed in box'ta':
DBL260059
'. 7c. Poliry eHeUive period:
09/01/2012 ~ 08/31/2014
a. ~ All of the emplryr'samployees eligible under tM Naw York Disability aercefks law
b.~ Only tM following slaw or classes oftM employ~r'semployen:
Under penalty of pe Jury, I cerury Wet I am an authorized represanra[ive or licensed agent of tM insurance nrtier referenced
alcove and Nat the named insured has NYS Disability Benefits irsssxarsce cevaraga as described above(!f.
Date signed __ 7/11/2013 ----By-- ft{{(~C~(.LJ1•!~
--- - - - -
($Igrratan of imuranw carriers wtlwrized rapraserdative w NVS Liwnsed Imunrsn Agent o(d1M inwranee wrtierl
TelepkoneNUmber___ 516-829-8100 rne_ ___ _Chief Executive Officer
IMPORTANT:I(bm'Ia" is chsekW, and Nis from la algrrtl by dse Imssrarrca enrlsrs asrtlsornetl npresvnbtlvs w NYS Liwnwd Irswnme Agent
of tlsx wrdey Nis cenmem is COMPLETE. Nnll k dinetly m tlr rani(kw holM.
1(bw Yb" fs chsdnd, Nis ewtifleata is NOT COMPLETE Ica Ilse purpoaw of Seniors 820. $ubd. a of Ne DbW 11iry BerseUn Lew.
It mun be mailed for completion w she Warker4 CanpenaUOn Bond, OB Plam Asxapwnw Unk, le Park $oeel Albarry, NY 122x1.
PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked)
_ -
State of New York
Worker's Compensation Board
AcwNirg to in(om,Nion msiMainad by she NVS Worker's CwnpemNiws eeerq Ne above-rumad smployw has wmpiNd wiN tM NYS
'. Disability BanaUn Law wiN rmpeq to ell of hisgsar employees.
Date Signsd_ __..
Telephone Number
BY ___ __ -..-__._... _ ___
(Signature o/ NYS Workers Corrpansalion Bwrd Empkryae)
Title
Please Nora: Only inwrance nniera licensed to verke NYS Disability BeneRn inwnnce policies and NYS Licensed Insurance Agenn of
tltose insurance wrier aro atrihwized to issw Form De-120.1. Isssurance brokers era NOT authorized m issue this form.
DB-120.1 (5-06)
STATE OF NEW YORK
WORKERS' COMPENSATION [30ARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
I n. Legal Name & Address of Insured (Use street address only) 1 b. Buainess Telephoue Number of Insured
(631)J67-6744
JPC Nlainlenance & Construction Corp.
t'O Box 386 lc. NYS Unemployment insurance Employer
Ronkonkoma, NV 11779 Registration Number of Ensured
1Vork Location of Insured (Only reyrrlred !j coverage Is Id. Federal Employer Identification Number of Insured
specificul/p limited to cerlnln focatimrs /n Nero York Siafe, l.e., rt or Social Security Number
134236219
2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage (Entity 13cing Listed as the CertiOcate Holder)
Hartford Insurance Cmnpany
Town of Southold 3b. Polky Number of entity listed in box "la"
54375 Main Rond
Southold, NY I197I 12WECLQ2696
3c. Policy effective period
9/3/2012 9/5/2013
3d. The Proprietor, Partners or Executiae Officers arc
^ included. (Only cheek 6oz It all partners/otdars Included)
X all excluded or certain partncrs/odicers excluded.
This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers'
compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed turder
item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed
agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2".
The huurran:e Currier will tdso uatify lire above cerf~cate bolder within /0 dr0>r IF a polic7~ is cmtce%d due to narpaynrerN ol~
premiums or within 30 da!> /F there are reasau alter rhmr »mywynrent of premiums 1hM camrl the policy or elieninme the insured
tram the coverage indicated orr this CerNTcaie. (These naices may be sem by regnlar marl) Ot/rerwlse, this CeN{/Tcofe !s nafld jar
rare-pent after t/rls jornt !s approved by the hurrmnce carder or !fs Ncensed agent, or an/!1 the po!!cp erplrafion dale /!sled lu box
tc", x'lrichn~er is earlkr.
Phase Note: Upon lire cnnccllation of the workers' compensation policy indicated on this form, if the brrsincss continues to be
rrattrred on a permit, license or contract issued by a certificate holder, the business moat provide That certificate kolder with a
rress• Certificate of Workers' Compensation Coverage or other authorized proof That the business is complying with tiro
mandatory rnveroge requirements of the New York State Workers' Compensation Law.
Under penalty of perjury, I certify that 1 am an authorized representative or licensed agent of the fusurarrce carrier referenced
abos•e and that [hc named insured has 16e coverage ns depicted oo Ihis form.
Approved by: William C. Cotgreave
(Print mme of audariud rcpresentalire or licensed ogenr of Maumee caa&r)
Approved by: /- 7/2!13
,/ ~'Si6nn ) (Date)
Title: President
Telephone Number of authm•ized representative or licensed agent of insurance carrier: 631-981-5400
Plruse rVafe: Only insurance cnrrlers mrd (heir !!tensed agents are authorized to issue Form C-/05.2. /nsnrmtce brokers are NOT
antlmrized to issue ir.
C-105.2 (9-07) www.wcbstate.ny.us
STATE OF NEW YORK
WORKER'S COMPEN5ATK)N BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Cartier
la. Legal Name and Address a InsurW itlsa street address only)
J.P.G. MAINTENANCE & CONSTRUCTION CORP. DBA
J.P.G. ELECTRIC
P.O. BOX 386
RONKONKOMA, NY 11779
lb. easiness Telephone Number of Insured
631-467-6744
lc NYS Unempbymwtt Insurance Employer RegistroBOn
Number of Insured
10. Fedsrel Empoyer Idemificrtion Number of Iltsure0
or Social Severity Number
134236219
L Name and Address of Uw Emily requa#hg Proof of Coverage
(Emily being listed astM CaniRerte Holds)
Town of Southold
k Name or IrsWance Grrier
The FFst Rehabiliatbn Lee Insurance
Company of Amena
3b Polity Number of Emily listed in box "la":
DBL260059
54375 Main Road
Southold, NY, 11971
3c Polity affective pwiod:
09/01/2012 ~ 08/31/2014
4. Policy coven:
a. ~ All of Us employer's employees eligible ands the New York Disability Benefay Law
b. ~ Only the following Blass or classes of the employer'semployees:
Untler penNty of perjury, I certify that i 8m an auatmizad replesenutive or iicarrsed agent of the insurance artier roferencetl
above and Nrt the named iruured has NYS Disability eanefits irtsunme cevsrage as slescrlbetl above.
' ` r d i ~ ~.
' '- ~..~ r
g §[9)a ~vJin~
Date Si netl 7/11/2013 By ~,~`_{.. r ,i ,. -
(SignaWn N inmsnnq anisYS auNOrizad repreaenaliw a NVS Liotmed Inwrann Agem N Itre(inswanea arriwl
Telephone Number 516-829-8100 ral.___. Chief F~cecutive Officer ,.
IMPORTANT:I/nNr `W' b shedsed, W mis Iarrrr b aieMtl eY the imurerke eerdaYa aurlrxrbW npnsenutiw a NYS LieenaW Inwrarw Aewn
M dW ewrier, misaninoN is COMPLETE Mail h tlxe#ry b tln extifkab hold#.
If bwr'aw Is elweked, mh ewtilMn b NOT CONWLETE for tM Isurpoaa of Se#bn 220, Sued. B oT the DlfaDlliry Benenu Law.
It nw#M mailed MaomplNion to UnWar*w'a Canpensedon tkw4 DB PWa Aeapbna Unk,m Park yawlAlb#y, NY 122W.
PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked)
State of New York
Worker's Compensation Board
"' Aaoraing to inlormNion mairwirrd by Uw NYS Worker's Compemelion Bmrq Use abovsnamad enployer has complied with ors NYS
~~ DisWillry Barwfita ism wiin ropa#lo N7NhldhN ampbyew.
I
Dab Signed . _ gY- ----
~~ -- _ (5ignetun of NYS WarksYS Cornpsnsarbn Bwrtl Employee)
Telephone Numhef
Plesse Note: Only inslsmce cerriers licensed to write NYS Disability Benefits insurance policies and NYS Lkensed Insurance Agents of
those insurance carriers aro authorized to issue Form DB-1M7. Imurar#a brokers era NOr wthorizad ao issue this form.
DB-120.1 (5-65}
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1 a. Legal Name & Address of Insural (Use street address only) 1 b. Business Telephone Number of Insured
(b31)d67-67dd
JPG Mairrtcnance s4i Construction Corp.
I'O Box 386 lc. NYS Unemployment Insurance Employer
Ronkonkoma, NY 11779 Registration Number of Insured
Work Location of insured (Only regrrlred {j coverage Is ld. Federal Employer Identification Number of lusured
specifrca/(r /lnriled to cer-nln locutions !n New Ywk State, le., n or Social Security Number
11'rnp-Up Pogn)
134236219
2. Nantc and Address of the Entity Requesting Proof of 3s. Name of Insurance Carrkr
Covcrogc (Entity Being Listed os the CertlBcate Hokkr)
Hartford lesuronce Company
Tosvn of Southold 3b. Polky Number of entity listed is box "laa
54375 Miain Road
Southold, NY 11971 12WECLQ2696
3c. Policy effective period
9/5/2012 9/2013
3d. The Proprietor, Partners or Executive Officers arc
^ included. (Only rbeek box hall partners/olllcen inrlutlrd)
X all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers'
compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must 6e listed tntder
item 3A on the INFORMATION PAGE of tha workers' compensation insuraucc policy} The Insurance Cattier or its licensed
went ~viil send this Certificate of Insurance to the entity listed above as the certificate holder in box'7".
The hrsurarrce Crnrier• mill also xofify dre above cert(/Icnre holder mhh/n !0 drr3>: IF a policy is crurceled dxe to nmtpapmetu of
prrnrirxns or within 30 da/'s lF there are reasmu other fha» rrmywymenf of premixms tha! cnrtce! the policy or elimimrte die fttswed
front the coverage indicmed ar this Certificate. (7Yrese m>lices may be sent by regxlrv mail.) Olhnwlsr, Ihls CeN>ncote !s wrl/d jar
rmr,Penr nJter Ihls fond Is upprored by I/ie htsarance carder or Hs licensed ngurl, or and! !!re policy erp/radox dale /!sled !n bov
"ic", x'ltic/ier'er is torNer.
Please Note: Upon the cancellation of the workers' compensation policy indicated on [his form, if the business continues to be
maned on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a
new Certiffcnte of Workers' Compensation Coverage or other authorized proof that the business fs complying with the
mandatory coverage requirements of the New York State Workers' Compensation Law.
Under penalty of perjury, I certify that 1 am an authorized representative or licensed agent of the iasurance carrier referenced
above and that the named insured bas the coverage as depicted on t61s form.
Approved by: William C. Cotgreave
(Print none of aWhmiud reprezentelire or licemed agent of insuraucc wrier)
Approved by:
Title: President
Telephone Number of authorized representative or licensed agent of insurance carrier: b31-981-5400
Please rYole: OnlP insurance carriers tard (heir licensed agents are axlhorized to issue Fonrr C-105.2. hrsxrmrce brokers are NOT
oxdrari<ed to issue il.
C-105.2 (9-07) www.wcbstate.ny.us