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Home My WebLink About38342-Z ~_°yF9(r Town of Southold Annex 10/25/2013 (air P.O. Box 1179 54375 Main Road m Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 36579 Date: 10/25/2013 THIS CERTIFIES that the building ALTERATION Location of Property: 1125 Navy St, Orient, SCTM 473889 Sec/Block/Lot: 25.-3-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this of6ced dated 1/28/2011 pursuant to which Building Permit No. 38342 dated 9/19/2013 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: alterations to an existing one family dwelling as applied for. The certificate is issued to Havlik, Eric (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38342 10-10-2013 PLUMBERS CERTIFICATION DATED 10-22-2013 Edward H. King thorized Signature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY !t6! ,o 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 38342 Date: 9/19/2013 Permission is hereby granted to: ERIC K. HAVLIK 400 3rd STREET APT 4L BROOKLYN, NY 11215-2881 To: Alteration to a Single Family Dwelling; re-model kitchen, add a half Bath & re-locate Dining Room opening on 1st floor, and relocate toilet bowl on 2nd floor.Replaces expired B.P. 36180 At premises located at: 1125 NAVY STREET ORIENT SCTM #473889 Sec/Block/Lot # 25.-3-5 Pursuant to application dated 1/28/2011 and approved by the Building Inspector. To expire on 3/20/2015. Fees: PERMIT RENEWAL $112.80 Total: $112.80 Building Inspector TOWN OF SOUTHOLD BUILDING DEPARTMENT k4f 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 36180 Date: 2/15/2011 Permission is hereby granted to: Leung, Darian To: Alteration to a Single Family Dwelling; re-model kitchen, add a half Bath & re-locate Dining Room opening on 1st floor, and relocate toilet bowl on 2nd floor. At premises located at: 1125 Navy St., Orient, NY SCTM # 473889 Sec/Block/Lot # 25.-3-5 Pursuant to application dated 1/28/2011 and approved by the Building Inspector. To expire on 8116/2012. Fees: SINGLE FAMILY DWELLING - ADDITION OR ALTERATION $225.60 CO - ALTERATION TO DWELLING $50.00 Total: $275.60 - - - Building Inspector Form No. 6 TOWN OF SOUIHOLD 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: I . 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: I . 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 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 $50.00. 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. / ke )/j New Construction: Old or Pre-existing Building: (check one) Location of Property: ~ 11,2,5- A.Jay,J J)i 0t-1 ~f //9S7 House No. / Street Hamlet Owner or Owners of Property: ~)aK / M { U k (9 Suffolk County Tax Map No 1000, Section a Block 3 Lot S Subdivision _ Filed Map. Lot: Permit No. 3 & /'3 0 Date of Permit. C2 Applicant: od -tzm Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) c-`~ Pee Submitted: S 50- Xy Applicant tgnature pF SOpryolo Town Hall Annex yy yy Telephone (631) 765-1802 54375 Main Road T T Fax (631) 765-9502 P.O. Box 1179 c, • io roger. riche rt(a)town.soLitho Id.ny.us Southold, NY 11971-0959 ~1~00UNTy 0~ BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To Havlik Address: 1125 Navy St City: Orient St: NY Zip: 11957 Building Permit Section: Block: Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: as built DBA: License No: SITE DETAILS Office Use Only Residential X Indoor X Basement Service Only Commerical Outdoor X 1st Floor X Pool New Renovation 2nd Floor X Hot Tub Addition Survey Atfic Garage X INVENTORY Service 1 ph Heat Duplec Recpt 6 Ceiling Fixtures 7 HID Fixtures Service 3 ph Hot Water GFCI Reept 5 Wall Fixtures 4 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors 1 Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances dw Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches 14 Twist Lock Exit Fixtures TVSS Other Equipment: alterations to house and electric to existing garage, 3-exhaust fans Notes: Inspector Signature: Date: Oct 10 2013 81-Cert Electrical Compliance Fonn.xls CERTIFICATION Date: l~ Building Permit No. Owner: S'lt I P K- I V hl (Please print) Plumber: vQLk-r C~1 ~ (Please print) I certify that the solder used in the water supply system contains less than 2/10 of I% lead. ,~z (Plumbers Sign re) Sworn to before ppm~~e this ~ G( day of ~ , 20 Notary Public, ~SQ 1 County CONNIE Q. BUNCH Notary Public, State of New York No. 01BU6185050 Qualified in Suffolk Count2 Commission Expires Apra ~o~y,OF 80UT~6 7OWN 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 PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE 3 l ' ( INSPECTOR -o TOWN OF SOUTHOLD BUILDING DEPT. 765.1602 INSPECTION [ ] FOUNDATION 1ST [f-ROUGH PLOG. [F NDATION 2ND [ ] INSULATION [ J FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] ANT PENETRATION REMARKS:-LL~ C DATE L ( INSPECTOR O ~ ~ V l/ ~ NSF SOU~~# TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPE:01 TI N [ ]FOUNDATION 1ST [ ROU PLBG. FOUNDATION 2ND I ULATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: G DATE INSPECTOR 7 TOWN OF SOUTHOLD BUILDING DEPT. 7654802 L~C« INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ELECTRICAL (FINAL) REMARKS: DATE to / 3 INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS 00 FOUNDATION (1ST) a FOUNDATION (2ND) z =W~ 9.> O y s~ ROUGH FRAMING & 1 y PLUMBING Vl 7D to C3 75 INSULATION PER N. Y. 5 STATE ENERGY CODE I'T /I FINAL ADDITIONAL COMMENTS r' ~o C tt<-sC,- 3 i~Z Q, O C/z :b m A~ Z f °z let e TONYN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following, before applying'? TOWN HALL Board of Health SOUTHOLD, NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 / S~ Survey SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Examined ' - , 20 Storm-Water Assessment Form Contact: Approved- o , 20 Mail to:: B4tl,proved3~c r:7P/K O~ n~ Phone: 6-1/- .2 7~ ' O Y 3 Expiration b , 200`- T9 - -7 V Lf3 Building Inspector l APPLICATION FOR BUILDING PERMIT Date ~o~?°^ r o2~ 20 / 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 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. 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 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 of a 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. (Signature of applicant or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises a-0 Z~e_ y''r~ (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. cf 394 ~7 f~ Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 11.2.(- Na~A/y S+- 01--p,,./4- ll9 F House Number Street Hamlet County Tax Map No. 1000 Section R,5r Block Lot 2:3- 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 b. Intended use and occupancy 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 e~9 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: Front Rear Depth 10. Date of'Purchase Name of Former Owner 11. Zone or use district in which premises are situated / 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO v 13. Will lot be re-graded? YES NO Will excess fill be removed from premises? YES_ NO 14. Names of Owner of premises Dam/ j. Z4- k Address l/aS'~t/o~Y Sr _Phone No. 9 ~a~ Y3S 3 Name of Architect Addresses Phone No Name of Contractor /yo+'K Address -'~YS" JrcA •.1~-J 9- Phone No. 671-a-7L -10'13 15 a. Is this property within 100 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. 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 * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) oT/! &ct t dj 0- being duly sworn, deposes and says that (s)he is the applicant (Name of individual ssrigning contract) above named, (S)He is the Coy ~raC CONNIE D. BUNCH Y06 (Contractor, Agent, Corporate Officer, etc.) Notary 118 14o. 01"185050 QuwW in guth* County of said owner or owners, and is duly authorized to perform or have performed 6&npediiktWl tW'aA af%r 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. Sworn to before me this day of NNNU!~N~ 20 Notary Public Signature Applicant oF so~ryQ~ Town Hall Annex Telephone (631) 765-1802 54375 Main Road (63l)7- • Q roger.richertta'~.fown.so65utPo~d nv.us P.O. Box 1179 CO* Southold, NY 11971-0959 °VUltl BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Fttnl,5T /Y1~h2M& A! _ Date: Company Name: &Ate Name: License No.: Address: pq d SS G oe W . Phone No.: J'Yl -7-7 0 p j JOBSITE INFORMATION: (*Indicates required information) *Name: a16 QA J < *Address: J12S /V/hzt ST b/Zf f !~!U !!°fs~ *Cross Street: b12(l *Phone No.: 91 -7 _ 3Z8 -~f35 3 Permit No.: 383gz Tax Map District: 1000 Section:- 2-57- Block: 3 Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) Re ! tV_a__ h b I-q (Please Circle All That Apply) *Is job ready for inspection: YES / NO Rough In Final *Do you need a Temp Certificate: YES / NO Temp Information (If needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Oth r / *New Service: Re-connect Underground Number of Meters Change of Service Overh d Additional Information: PAYMENT DUE WITH APPLICATION ~O( V'e G~ f p~ 82-Request for Inspection Form / C) B.P. # 3600 BUILDING PERMIT EXAMIr /FRR CHECKLIST *Date Submitted: Date Reviewed: a - II Applicant: ' l a4_ Owner: i~ Architect/Engineer: Estimated Cost: i SCTM# 1000- 0-5- -3 - S Subdivision: Zone: Conforming? {r 3 4'K3 Property Address: I 1 a S rye" , City:? Pre COs? Building Permits (Open/Expired): BP -Z / Go Z- Info: BP -Z / Go Z , Info: BP -Z / Go Z- Info: BP -Z / C/o Z- Info: BP -Z / C/o Z- Info: _ Single & Separate Search Required? Y o6Deternrination: In/? E)e 1 oK REQ. Lot Size: A'T eK+-V$/'~`ACT. Lot Size: REQ. Lot Cov. ACT. Lot Cov. I REQ. Front ACT. Front REQ Side ACT. Side REQ. Rear PROP. Rear REQ. Height ACT. Height KE:4z, Ba4L SIDES A CT Project Desc iption: -Z~1- c Waterfront? Y or If yes, water body: Panel# ' Flood Zone: Bulkhead/Bluff Distance: ADDITIONAL APPROVALS REQUIRED Suffolk County Health: Y ora- If yes, *Bed#: *Date: *Permit#: Town Septic: Y o6 - If Do, certification required: Y or N Received: Y or N By: v NYS DEC: PRE-DEC 9/1175 Y or62 Date: Permit or NJ Letter - Notes: Southold Trustees: Y ore- Date: Permit or NJ Letter - Notes: Southold ZBA: Y or®- Date: Permit - Notes: Southold Planning: Y o Ig-- Date: Permit - Notes: Town Landmark C of A: Y o IoDTE: *NYS CODE Compliance (page 2)6or N Q CQ~ c Notes: -3 07 / . cp-, +m-vrwu-•-~ ~~`~t-~ 'Q~-. Fee Structure: Calculation: Foundation: SF 6 X $ (00 First Floor: Io SF + Initial Fee: $ oZ o o , 00 Second Floor: o SF + Additional Fee $ Other: SF SF X $ Total: 6 SF + Initial Fee: $ + Additional Fee ( $ TOTAL: $ a' a s, ( D NEW YORK STATE CODE COMPLIANCE CHECKLIST CLIMATIC/GEOGRAPHIC DESIGN CRITERIA: elF~ Ground Snow Load: 20_ Wind Speed:. 120MPH_ Seismic Design Category: B Weathering: Severe Frost Depth: 36" Termite: M-H Decay: S-M Design Temp: 11 Ice Shield Underlay: YES Flood Hazards: USE/OCCUPANCY CLASSIFICATION: HEIGHT/FIRE AREA: TYPE OF CONSTRUCTION: DESIGN CRITERIA: ENGINEERED/PRESCRIPTIVE FULL FRAMING DESIGN ELEMENTS: Y/N HEADERS: YIN WALL STUDS: Y/N GIRDERS; YIN CEILING JOISTS: Y/N FLOOR JOISTS: YIN ROOF RAFTERS: YIN LUMBER SPECIES AND GRADE: YIN WINDOW AND DOOR SCHEDULE: MISSLE TEST REQUIREMENTS: Y/N EGRESS 5.7 S.F.: Y/N LIGHT 8%: Y/N VENT 4%: Y/N NAILING/CONSTRUCTION SCHEDULE: Y/N MEANS OF EGRESS: Y/N PLUMBING RISER DIAGRAM: Y/N LOCATION OF FIRE PROTECTION EQUIPMENT: YIN TRUSS DESIGN. YIN CERTIFICATION Y/N ENERGY CALCS: Y/N TOTAL COMPLIENCE1Y N (RETURN TO PAGE ONE) - Southold Town Building Department d 4r~ I P.O. Box 1179 Permit 36180 54375 Main Road Southold, New York 11971 Permit Date: 2/15/2011 y+I (631) 765-1802 Expiration Date: 8/16/2012 Parcel ID: 25.-3-5 BUILDING PERMIT RENEWAL LETTER Dated: 6/18/2013 Applicant: ERIC K. HAVLIK Location: 1125 NAVY STREET ORIENT Work Description: SINGLE FAMILY DWELLING Alteration to a Single Family Dwelling; re-model kitchen, add a half Bath & re-locate Dining Room opening on 1 st floor, and relocate toilet bowl on 2nd floor. A FEE OF $112.80 IS REQUIRED TO RENEW THIS BUILDING PERMIT. Owner: ERIC K. HAVLIK Address: 400 3rd STREET APT 4L BROOKLYN, NY 11215-2881 The permit listed above has expired. Please contact our office as soon as possible to begin the renewal process. Ali work on the project must stop on the expiration date. No work is permitted or authorized beyond the expiration date. THANK YOU, SOUTHOLD TOWN BUILDING DEPT. SO Town Hall Annex Telephone (631) 765-1802 54375 Main Road T T Fax (631) 765-9502 P.O. Box 1 179 G Southold, NY 11971-0959 ~1~00UNTV BUILDING DEPARTMENT TOWN OF SOUTHOLD September 24, 2013 Eric Havlik 400 3`d St Apt 4L Brooklyn, NY 11215 RE: 1125 Navy St, Orient TO WHOM IT MAY CONCERN: The Following Items (if Checked) Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) -G~Electrical Underwriters Certificate. (Contact your electrician) A fee of $50.00. Final Health Department Approval. lumbers Solder Certificate. (All permits involving plumbing after 411/84) 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. Final inspection by Building Dept BUILDING PERMIT: 38342 - Alterations Jan 28 11 12:52p Brazier Insurance Agency 6312861406 p.1 PART 1. To be Completed b Dssbi Benefits Carrier or Licensed here re AcientollihatGarrier_ 1a. Legal Name and Address of Insured {Use street address only) 10. Business Telephorm Numbs of Insured 1111611110 KAFFAGAELIMNATOR (831)276-7613 TERMITE •PEST OOMMOL 505 ORCHAM 1c. NYS Unemployment Inwranm Employer Registration Number of ORIENT, NY 11667 Insured 1d. Federal Employer Ideni ftailon Number of insured or Social Security Number 1055886/8 2. Nome and Address of the Ert%RTusetkp Proof of Coverage (Entity Sa. Name of Insurance, Comer Being Listed as the Certifipre Holda TOWN OF SOUSHAM11TON NATIONAL BENEFIT LFE INSURANCE COMPANY BUILOM DEPARTMENT TOM NALL 3b_ Policy Number of entity listed in bou'llart. SOUTFIAAPTOfI, NY 11671 "104MEM2 i W. Poicy eaerdve period: 03100Nmo 10 0112811013 4. Policy covers: a. 4 Ai of the employer's employees eilgibk under am New York Disati Benefits Law. b. Only the following class or dasses of the orrpluyer's employees: Under penalty of perjury I certify that I am an authonzed representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefit insurance coverage as downed alm". Q Date Signed: O'IMMi 1 By dMlarem ofIn~. srmhes audwoed representative or NYS UcarsN Insurance Agent Telephone Number: 800888,2711 Title:Vloe PlealdWd IMPORTANT: If bm'4a' is checked. and this form Is aal1ipnrteed by the insurance ®miers wMorbod rapraeenletive or NYS Llceneea Inwranm Agent dtMt cards, this ceNficale is COMPLETE. Mail it directly to Me rzrifcMe hot Irler. If box "4b' is checked. this mnifrafa Is NOT COMPLETE for purposes of Section 220, Suited. 8 of the Disability Benefits Law. It must be mailed for completion to the Workers' Cwrgersedon Dowd, DB Plana Acoeptanm Unit, 2D Park Street, Alberry, New York 12107. WIR T 2. To be ebed 111'8 VIa11alY Calivaladen Dowd (OWN basil "A r of Part I I= been chisdaM According to inlonrlatlon maintained by the NYE Workers` Compensation Board. the abovanamed employer has complied will, the NYS Disability Bansfes Lew with respect to all of hiepter employees. Dale Signed : By (Signature of NYS Worker' Compensation Board Employes) Telephone Number : Tdla : Please Note: Only Insurance carder licensed to write NYS dimbllNy benefit insurance policies and NYS licensed Insurance agents of Nose Insurance carders ma authorized lic ssue Form OB-12D.1. tneu cenm broker are NOT suthorized to Issue this Torrm. D0-120.1 (&W Jan 28 11 12:52p Brazier Insurance Agency 6312861406 p.2 By sigring this form N insurance carrier identifmd in box -X on this iorrn is cer0'yirg that it is insuring the business referenced in box ie for disability banelis under the New Yak State D'eab4dy Bernaeb Lax. The Insurance Carrier or its licensed agent will send this Certificate of Insuraram b the eMny rated as N certificate holder in box 7. This Lbpf eft Is valid krN eaRarypne yeafalbrUse hm ygppowdbyNo xarlxwaafaerfeyonbdcwladagwKbrMrpoky atpiaYUrrdalsgeledlinhow W. P1 I Ndw Upon the cenceMSlbn of N diabBly berra11 pow bndcedd only form. ¦N bwinws co nUraata b be and on ¦ gmmk, karate aoott- - Issix d fry a eatgf?ale holder,11th Wei eve iswl prwtla the orlMrralsholdrvaM a max CaNcelled NY8 DMONV BwrsI araNr sNmodaed prdfiatN bWnaso bearp~IrpMpm N mrNessy misrape reryliememda of N NwyYak Slale ONabNly Ster.m sad. a (a) The heed of a stale or muni pal dgmarirnerV, board, commission or offcs aulhor®d w required by raw to issue any pmmit for or in connection with are, work nhmkvg the amploynsnt of eermrppbbyeas In emytoymere as defogd in this article, and rot withstanding aygeneral w spatial statute requiring or aahorrzirp the issue of such Farina. shall not issue such parnk Walls proof duty subscribed try an Murance carver is produced in a form satisfactory to the chair, that the psyrnara of disability tense for all empl yeas has been secured as povided by this article, slo ib heroin, hoe xxor. shall be corstmod as create" any liability on she pan of won sister w municipal department. board, mmnlaion or office to pay any dlaaWey benefda to any such employee if so arnpnyed. (b) T he head at a slate or municipal departmaht hoard, commisson or office authorized a required by taw to enter into my contract for or in connection with any work in oWfrg the anplaymadd anploywh s it arnploymant as dented in this ari la, and nolargnslanding any general or special suave mgwnng or auNrtzirg any such contract, shall not enter Into any such oamtac unless proof duty subscribed by an Insurance sth produced In a form satisfactory to the chair. that the paynaml of dLwbisy bwaffs for all errydcyses has been secured asproyided by the centere. arti D&120.1 (5-06) Remorse 01/28/2011 FRI 11:45 FAX 0001/001 OP ID: BL CERTIFICATE O Y INSURANCE 0 DAT1128)DIYYYY) 01 r26n 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR S NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS NEGATI BELOW. C THIS C@1F1C IFUF IRMATIVELYURANCE DOES NV TTBETWEENER THE ~HAF~B UTHORZIED 6 6 REPRESENTATIVrRtlR, AND THE CERTIFICA ye 11 IMPORTANT: If t e QQAt is an ADDITIONAL I t be endorsed. If SUBROGATION IS WAIVED, subject to the terms ane~2'l~i8{t{ dp'~a y, certain policies may A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER 914-395.3131 Select Insurance Agency, Inc. 914-395 0200 PHONE 95 Main Street - *A"JCNo , _ )nrc, NO 95 Main St 10707-2911 BUILDING PVT - - TOWN OF1~ _ _ . ENSURE S AFFORDING COVERAGE NAIC W INSURED Eliminator Termite & Pest Cont INSURER A: American Safety RRG 25448 DBA Mark V. Kaffaga INSURERS: CP-631-278-7043 585 Orchard Street NSURER C Orient, NY 11957 -INSURER D:... NSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER: 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. - DD SUB -_061CICV EFF -PODC iEltis LTR TYPE OF INSURANCEPOLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS 111.1 I GENERAL LIABILITY EACH OCCURRENCE $ 1,000,9 A X COMMERCIAL GENERAL LIABILITY X PG-701306-05 04111110 04111!11 PREMISES (Ea occunoncel S 190, CLAIMS-MADE ~Xl OCCUR - MED E%P (Arty one Percon) $ 5,000 PERSONAL&AOV INJURY $ 1,090,9 GENERAL AGGREGATE S 2,900,99 GENT AGGREGATEPRO -IMIT.APPLIES PER PRODUCTS-COMPIOPAGG f 2,000,011 - X POLICY LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Eaaccident) ANY AUTO BODILY NJURY (Per person) S ALI OWNED AU 'f0a DOOILVINJURY(POracc,0era) S SCHEDULED . AUTOS , - - - PROPEF(TY td DAMAGE $ _ HIRED AUTO$ (Per (Per ar acWo nt) NONOWNED AUTOS $ f UMBRELLALMB OCCUR EACH000URRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ OFDUCfIBLE f RETENTION $ I S WORKERS COMPENSATION WC STATU- OTH. AND EMPLOYERS'LIABILITY YIN 1_QRY LIMITS. ER....- ANY ANY PROPRIFTORIPARINERIEXECU'I IVF: LI EACN ACCIDENT $ OFFICERIMEMDER EXCLUDE D'r J N/Al (Mandatory in NH) E .L. DISEASE FA EMPLOYEE $ OESCRIPTIOrv OF O 11 yv;desctlUe uMerPERATIONS below E. I.. DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more apace Is required) Re:Carpentry & Pest Control Services Certificate holdrt as additional Insured CERTIFICATE HOLDER CANCELLATION TOWNOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Towel Hall Southold, NY 11971 AUTHORIZED REPRESENTATIVE //7 V~Ij6r~ ®1888-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Jan 28 11 12:53p Brazier Insurance Agency 6312861406 p.3 New York State Insurance Fund Wonters' Compensation A Dtwbi&fy Rmeffs SpedaHVC Sm" 1914 8 CORPORATE CENTER OR 3RD FLR MELVLLLE, NEW YORK 11767-3129 Phme: (631) 75 6 4 3 0 0 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 105565645 MARK V KAFFAGA DJ6/A ELIMINATOR TERMITE & PEST CONTROL 585 ORCHARD STREET ORIENT NY 11957 POLICYHOLDER CERTIFICATE HOLDER MARK V .KAFFAGA D/B/A ELIMINATOR TOWN OF SOUTHAMPTON TERMITE & PEST CONTROL BUILDING DEPARTMENT SBS ORCHARD STREET TOWN HALL ORIENT NY 11957 SOUTHAMPTON NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 12095343-6 403453 03109/2010 TO 0310912011 1/28/2011 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.20953436 UNTIL 03/09/2011, 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 TOOPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR 700310912011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE 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 NOTASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS ANWOR MEMBERS OF A LIMITED LIABILITY COMPANY- 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 INSURANCE FUND DIRECTORNISURANCE FUND UNDERWRITING This certificate can be validated on ourvmb site at https9iwww.nysif.oom/cerUmrtval.asp or by calling (888) 8755790 VALIDATION NUMBER: 766501581 U, 26.3 SURVEY OF PROPERTY SITUATE CEN77.F= TO : ORIENT ORC"Ap-D STREET TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK 122.06 ,06 1 2 s s AREA q ft ft Row ORFORVERy 1 A AREA 9 PETER OOOOY 1 0.28 acre L Sol'SO•SO' "TE%EMPT 4iE1yE TRUST &fn 1 N N22°0 30'E a 13.25'- r. 1..• 162.60' pJ 587.46'20'!; , I9• ,es' - - r 0 20• b ~4at26.00 - - N ~ , ux - „ph.R a w P :r' hams t _ - 17.5 •sOi ox y. ~ 0 9 OO .uw,oM lwe.d ~ y. ,v w.w ~~179' L• 404 Ixw s°np.b ~ q w o O a° ty ~ ~ I I i a4 h~ a.r w 2 sro7 /rams ~ e ti y hWSe ,P s. 1.9' T N83°13.20-W xr. NOW M FOP~fty 222.SS• R P'. RWLEY ' ~pF Mac y~~,'o car y0 1t I ' r F~~Aosm"5v~J~ap ao - . - SURVEYED: SEPTEMBER 26, 2010 LAND SURVEYOR 59Y 11ENCEDR)VE (6 t ORVDl.E, N.Y.11949 9,)874-u4oo i I a30 vJ~ ELECTRICAL APF AM E) INSPECTION REQUIRED DA B.P., 36 f 8`d 3 u FEE: r~OBY ii +Vi TWNOTtFY IA02 • D4 PNRR THEE FOLL t. FO - TWO REQUIRED FOR CONCRETE 2. ROUGH , PLUMS, KIM I OERT~~ SSA ELECTRICAL & CAtAxmG CEm*cAn, o=^ c 4. FINAL • tBECT1UClIL S( .t l 'IN WATER fib MUST FONC.O. / ~i NEYII EXCEED 2110 OF 1 % LEAD. YORK 1 R a OESM n 0111 COMPLY W H ALL CODES OF NEW YORK S T & TOWN CODES AS REQUIRED CONDITIONS OF D TOWN ZBA ' ~p\ D TOWN PLANNING BOARD U' D TO'NN TRUSTEES PLUMBING /FJIVrIH Y.S. DEC, rESr sE NEW } eGE1~ IVice-s 3 fp c ~ o''~ . t o pZ r ~T J,`h r ~s I r c^ ~ .s AN `Z1 LIVING ROOM RUOM ~ r TOIL. i M PL D EC D FEB 2 2 2011 F I R5T FLOOR i=L!~N BLDG. DEPT. 5CAALE /4M s 1•-0" TOWN OF SOUTHOLD rn I I iv r-I ,l °0 BEDROOM BEDROOM I 4'- 5 I Lr, F i BEDROOM B TH Lr, ~d HO TUB I 'I :D En. ILl FEB 3LDG.DEPT. iOVJIV Of SOL'iHOLD / ~ ~V