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HomeMy WebLinkAbout38690-Z {',ylpFpt�a Town of Southold Annex 7/7/2014 P.O. Box 1179 54375 Main Road Southold,New York 11971 i' 2 r,?':2YZT 'Z CERTIFICATE OF OCCUPANCY No: 37006 Date: 7/7/2014 THIS CERTIFIES that the building ALTERATION Location of Property: 515 Oak St, Cutchogue, SCTM#: 473889 Sec/Block/Lot: 136.-1-29 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 2/18/2014 pursuant to which Building Permit No. 38690 dated 2/28/2014 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: INTERIOR ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Russell, Scott (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38690 06-16-2014 PLUMBERS CERTIFICATION DATED A 1.14 0 riz Signat re ' TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE '$o 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#: 38690 Date: 2/28/2014 Permission is hereby granted to: Russell, Scott 515 Oak St _ PO BOX 547 Cutchogue, NY 11935 To: INTERIOR ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR At premises located at: 515 Oak St, Cutchogue SCTM #473889 Sec/Block/Lot# 136.-1-29 Pursuant to application dated 2/18/2014 and approved by the Building Inspector. To expire on 8/30/2015. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 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. 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. (my New Construction: Old or Pre-existing Building: (check one) Location of Property: House No. Street Hamlet Owner or Owners of Property: Sc% A ku*s50/ s Suffolk County Tax Map No 1000, Section ] Block l Lot CV Subdivision Filed Map. Lot: .� Permit No. Date of Permit. Applicant: "Mol Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ Applic t ig oF so�ryol 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 roger.riche rtCaD-town.southoId.ny.us Southold,NY 11971-0959 'Q BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Scott Russell Address: 515 Oak St City: Cutchogue St: NY Zip: 11935 Building Permit#: 38690 Section: 136 Block: 1 Lot: 29 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Goodale Electrical Cont. License No: 783-e SITE DETAILS Office Use Only Residential X Indoor X Basement Service Only Commerical Outdoor 1st Floor X Pool New Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage X INVENTORY Service 1 ph Heat Duplec Recpt 4 Ceiling Fixtures 1 HID Fixtures Service 3 ph Hot Water GFCI Recpt 7 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel 1-30 A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliancesdw Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 Twist Lock Exit Fixtures TVSS Other Equipment: assorted minor changes through out house and garage Notes: Inspector Signature: Date: June 16 2014 81-Cert Electrical Compliance Form.xls as cou TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST ROUGH PLUMBING [ ] FOUNDATION 2ND INSULATION FRAMING / STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTANT CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAULKING REMARKS: DATE - — INSPECTOR����� �� C�✓ SOF SO(/j�, �o� olo 3 coUNI`I, TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] IN ATION [ ] FRAMING /STRAPPING ( FINAL ( ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: �S Ae-1 A/,P,4.erc;F,�) DATE (o ( //X7 — INSPECTOR S CTOR FIELD IN WORT DATE COMIENTS FOUNDATION am ��Sl FOUNDATION(SND) o • Cri' LA02 , ROUGH QCT& PLUMING O INSULATION PEk N.Y. y STATE ENERGY CODE Y FINAL Fig ADDITIONAL COM 3NTS G !! o � z b BUILDING PERMIT APPLICATION CHECKLIST TOWN OF SOUTHOLD Do you have or need the following,before applying? BUILDING DEPARTMENT Board of Health TOWN HALL SOUTHOLD,NY 11971 4 sets of Building Plans Planning Board approval — TEL: (631) 765-1802 FAX: (631)765-9502 Surrey 910 l�� Check SoutholdTown.NorthFork.net PERMIT NO- Septic Form N.Y.S.D.E.C. Trustees Flood Permit 20--& Storm-Water Assessment Form Examined Contact: Approved �'20LIL Mail to: Disapproved a/c Phone: Expiration 20�_ 1 Building Inspector APPLICATION FOR BUILDING PERMIT FFA �nt4 E }} i Date 1 , 20 - � INSTRUCTIONS _s a.This application MUS'T-Ge 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 Pen nit 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 it the work authorized has not coInmeAced within 12 IIIonths atter 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 authorise, 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.1� ' � (Signature of pplicant or n e,If a corporation) tsar (Mailing address of applicant) en architect, engineer,general conjk (° i"fer or builder State whether applicant is owner, lessee, ag to g DATEW44=B.P. 0Ss� FEE:.. ._. _.�BY Name of owner of premises �� - , ,c (As on the tax roll or ej ;ce ANI TO 4 PM FOR TF' If applicant is ora nae orized officer FGLLr ii G `INSPECTIONS tu' fdu� ! F0�Jh',DATUq -TWO RECD FOR �,Ui,ED C(�nirF,r (Name and titl er) 2 ROU01—i FR'AUING STi R A Builders License No. 3. IN,c'1j! f i0'' Plumbers License No. 4, FINAL-CCI'' Electricians License No. NIUS f E; Other Trade's License No. ALL CONSr t.;'..,! REQUiRENIEN" " Gr- -1 YORK STATE NI-Rf- ; 1. Location of land on which roposed ork will be do Le'� V SIC 0 0tJ y i fe House Number Street 0 amlet County Tax Map No. 1000 Section ( �Lv Block I Lot 19 Subdivision Filed Map No. Lot a. 2. State existing use and occupancy of pre ses and ' ended use an a. Existing use and occupancy J'n 1 d-m4upancy of proposed construction: b. Intended use and occupancy S, n(: 3. Nature of work(check which applicable): New Building Addition Repair RemovalDemolition Alteration_ _ Other Work 4. Estimated Cost nco Fee (Description) 5. If dwelling,number of dwellingunits (To be paid on filing this application) If garage, number of cars Number of dwelling units on each floor � 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. Win 7. Dimensions of existing structures,if any: Front-710 I ' pth De HeightRear _ Number of Stories 15 Dimensions Of same structure with alterations or additions: Front 9C),- � � Depth 5 Height Rear Number of Stories 8. Dimensions of entire new construction: Front —.Rear Rear Height Depth Number of Stories 9. Size of lot: Front �� 1 Rear�(� � Depth 10. Date of Purchase i l Q_S_ Name of Former Owner Al�flc �� 50 11. Zone or use district in which premises are situated P—Vo 12. Does proposed construction violate any zoning law, ordinance or regulation?YES NO� 13. Will lot be re-graded? YES NO__X_Will excess fill be removed,frompre ises?YES NOX 14. Names of Owner of premisestr Name of Architect i Address a NNJ Phone No. Name of Contractor Address Phone No Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C.PERMITS MAY BE REQUIRED NO 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 N * IF YES,PROVIDE A COPY. O STATE OF NEW YORK) � ` S: COUNTY OF ul\©I Q� I V1p being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above nam d, (S)He is the (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 that all statements contained in this application are true to the best of his knowledge and belief,and that the work will application; e performed in the manner set forth in the application filed therewith. Sworn to before me this __ate Cday of — , ��.. 1 20�y Notary Pu is Ruth Love Signa a pplicant Notary Public State of New York No. 01L06054063 Qualified in Suffolk County Commission Expires March 5, 20 S FQ Scott A. Russell °SrIr James A. Richter, R.A. SUPERVISOR Michael M. Collins, P.E. SOUTHOLD TOWN HALL-P.O.Box 1179 � 53095 Main Road-SOUTHOLD,NEW YORK 11971 Telephone#: (631)-765-1560 'G Fax#: (631)-765-9015 MICHAEL.COLLINS@TOWN.SOUTHOLD.NY.US ©t JAMIE.RICHTER@TOWN.SOUTHOLD.NY.US Office of the Engineer Town of Southold STORMWATER MANAGEMENT CONTROL PLAN REVIEW COVER SHEET ( TO BE COMPLETED BY THE APPLICANT ) PLEASE NOTE: All Contact & Project Information Requested by this FORM is Nessary for a Complete Application. APPLICANT: (Property �O�wneer,Design Professiiopna�l,Agent,Contract r,Other) PROPERTY OWNER: (If Different from Applicant) NAME: _� � NAME: J L,Dtroetygge11 ADDRESS: (� ADDRESS: S S 6 S 1 7T Telephone Number: 5' j Telephone Number: Completed Applications can be picked up at the Engineering Department after being notified by the Department, or; it can be Mailed to the Applicant with the submission of a Self Addressed 8.5'x 1 I" Envelope&Appropriate Postage. DATE: p'1—(�-{l� Property Address / Location of Construction Work: SCTM *: 1000 ( ( � 515 U� ay District Section Block Lot Required Documents for Stormwater Review: Copy of Complete Building Permit Application. Stormwater Management Control Plan. (2 Sets) Note: SMCP's are required whenever Grading or Excavations exceed 5,000 ST,when New Impervious Surfaces are created, and/or when existing Roof Systems, Driveways,Patios or other Impervious Surfaces are Re-Surfaced. De Minimis Projects will NOT be Subject to the Submission of a SMCP During the Stormwater Review! Note: These Projects would be Limited to Interior Renovations, Replacement of exterior Doors&Windows, Deck Construction with Loose Fit Decking, Installation and/or Modification of Mechanical Systems or other similar Work. A Complete Description of the Scope of Work Proposed under the Building Permit Application. A Completed Stormwa eview Chech4ist. If No or NA are Indicated, Justification is Required. * ** F R ENG E EPARTMENT USE ONLY Reviewed By: Z, Date: Appy ved: ❑��-� .Add do Information Required: � U �, CHAPTER 236 STORMWATER MANAGEMENT CONTROL PLAN CHECK LIST APPLICANT: (Property Owner,D gn Profj,ssional,Agent,Contractor,Other) DATE: � fl( � - `' LL ii NAME: �,etL� � � S C T M *: 1000 l Telephone Number: District P�cion Block Lot S M C P -Plan Requirements: The applicant must provide a Complete Explanation and/or validation of all Information Required by this Checklist if it has not been provided! 1. A Site Plan drawn to scale Not Less that 60'to the inch MUST ) If You answered No or NA to any Item,Please Provide Justification Here., show all of the following items: YE NNA If you need additional room for explanations, Please Provide additional Paper. a. Location & Description of Property Boundaries b. Total Site Acreage. O0 c. Existing - Natural & Man Made Features within 500 L.F. of the Site Boundary as required by§236-17(C)(2). d. Test Hole Data Indicating Soil Characteristics&Depth to Ground Water. �O e. Limits of Clearing& Area of Proposed Land Disturbance. 0 g. Location of all existing & proposed structures, roads, f. Existing & Proposed Contours of the Site (Minimum 2'Intervals) driveways, sidewalks,drainage improvements& utilities. h. Spot Grades& Finish Floor Elevations for all existing& proposed structures. I. Location of proposed Swimming Pool and discharge ring. j. Location of proposed Soil Stockpile Area(s). k. Location of proposed Construction Entrance/Staging Area(s). I. Location of proposed concrete washout area(s). 00 M. Location of all proposed erosion&sediment control measures. 2. Stormwater Management Control Plan must include Calculations showing that the stormwater improvements are sized to capture,store,and infiltrate O� on-site the run-off from all impervious surfaces generated by a two(21 inch rainfall/storm event. 3. Details&Sectional Drawings for stormwater practices are required for approval. Items requiring details shall include but not be limited to: a. Erosion & Sediment Controls. b. Construction Entrance&Site Access. c. Inlet Drainage Structures (e.g.catch basins,trench drains,etc.) d. Leaching Structures (e.g.infiltration basins,swales,etc.) FORM # SWCP Check List-TOS JAN 2014 i ��OF SO{/jy Town Hall Annex ~ !O TC E9 54375 Main Road 1)765g5JJ5 P.O.Box 1179 G Q r0 er.richertSO h .us1 1 Southold,NY 1197I-0959Ql �� 014 iL BLDG. DF°T. BUILDING DEPARTMENT ro� ri r? our��o!-u TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: ( �Oc>� ice' Date: — I Company Name: Name: License No.: is I . Address: d der' Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: *Address: ,rte C1110 *Cross Street: *Phone No.: Permit No.: --- s Tax-Map District: 1000 Section: Block: _5�_IL Lot: *BRIEF DESCRIPTION OF WORK(Please Print Clearly) '� hi T50 A4w `• {Please rrcle All That Apply) *Is job ready for inspection: Y / NO Rough In *Do you need a Temp Certificate: ES•1 Temp Information(if needed) G 3 *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82=Request for inspection Form �� G TOWN OF SOUTHOLD RECORD C4 OVI111=R ST'REE{ 511Vi L.AG� D I STR1 CT SU LOT1. 5 r/E ''7 f/ t°•��2.rT��f, s �� -( }2 ERt�} VN N ACREAGE " S W TYPE OF BUILDING SEAS. VL. FARM comm. I IND. 1 CB. 11JlISC. � Est. Mkt. Value \-<LAND IMP. TOTAL DATE REMARKS _V 0 CD4 r 3z 2 - - _ C L 4 Y I C�- z lCrD 6 /,YO �'� fi ` Z s t = 1G r Qui 2m ,Jai I — -� o� lrra ; G 6Oct B I l ' `- co 1)04� EIN i�14R1�1AL )ELL?, a / V FRONTAGE ON WATER Farm Acre Vatiue Per Acre Value FRONTAGE ON ROAD - _ v Tillable 1 BULKHEAD Tillable 2 DOCK Tillable. 3 Woodland Swampland 'Brushiand House_Plot Total r1.�`+ i'�; Yl f4 47 -17 NEON INN i t '.SM Er ` i• f• MEN r WMWWT 7 r R.• Qe a McCarthy Management, Inc. February 28, 2014 Town of Southold Building Dept. RE: Russell Residence P.O. Box 1179 350 Oak Street Southold,NY 11971 Cutchogue,NY 11935 To Whom It May Concern: Per your request, below you will find a list of improvements for a supplement to our building permit application dated February 14, 2014. IMPROVEMENTS Renovate kitchen consisting of: Removal of old cabinets ■ Installation of new cabinets ■ Relocation of gas stove ■ Installation of new microwave ■ Additional circuits to backsplash ■ Sink remains in the same location ■ Addition of dishwasher ■ Replacing one window with smaller unit in existing opening o Other work: installing new sheetrock over existing wallboard in areas o Replace interior doors o Install new flooring o Relocate one window from kitchen opening- no structural changes o Replace one window in Living Room- no structural changes o New flooring in bathroom o Install bedroom closet o Miscellaneous painting and maintenance It is my understanding that a building permit is not required for all of the above mentioned work, only portions thereof. ZRLove FEB 2 8 2014 Office Manager 46520 Route 48 Tel. 631.765.5815 Southold, NY 11971 Fax.631.765.5816 New York State Insurance Fund Workers'Compensation&Disability Benefits Specia/ists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 Phone:(631)756-4300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 113125165 MCCARTHY MANAGEMENT INC 46520 ROUTE 48 SOUTHOLD NY 11971 POLICYHOLDER CERTIFICATE HOLDER MCCARTHY MANAGEMENT INC TOWN OF SOUTHOLD,BLDING DEPT. 46520 ROUTE 48 P.O. BOX 1179 SOUTHOLD NY 11971 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE 11143348-9 992040 03/30/2013 TO 03/3012015 i 2/14/2014 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.1143 348-9 UNTIL 03/30/2015, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 03/30/2015 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 NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. THOMAS J MCCARTHY THIS CERTIFICATE IS ISSUED ASA 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 DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:/twww.nysif.com/cert/certval.asp or by calling(888)875-5790 VALIDATION NUMBER:569642030 U-26.3 PRODUCER CODE PRODUCER ppp�a QuakerSpecial Risk AUDIT FREt7VENCV PREVIOUS FOI.ICV ND. Annual GI-20121-H600329 COMMON POLICY DECLARATIONS POLICY NUMBER: GL2013LRB00329 COVERAGE IS PROVIDED BY SOUTHWEST MARINE AND GENERAL INSURANCE COMPANY 2999 North 44th Street,Suite 250 Phoenix.AZ 85018 Named Insured: McCarthy Management Inc&/or Equity Opportunity Fund, LLC Mailing Address: 46b20 Route 48 Southold,NY 11971 Policy Period: From: 08/19/2013 To- 08/19/2014 In return for the payment of premium end subject to all the terms of this policy,we agree with y«,to provide the insurance as stated in this policy. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS. FOR WHICH PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial General Liability Coverage Part $ b.b00.00 Terrorism Risk insurance Act-Certified Acts Coverage Coverage Pan $ THE INSURER(S)NAMED HEREIN IS(ARE)NOT LICENSED Total Policy Premium $ 5.500.00 BY THE STATE OF NEW YORK,NOT SUBJECT TO ITS Tax $ 198.00 SUPERVISION,AND IN THE EVENT OF THE INSOLVENCY OF THE INSURER(S),NOT PROTECTED BY Stamping Fee $ 11.00 THE NEW YORK STATE SECURITY FUNDS.THE POLICY 200.00 MAY NOT BE SUBJECT TO ALL OF THE REGULATIONS Broker Fee OF THE DEPARTMENT OF FINANCIAL SERVICES Inspection Fee 100.00 PERTAINING TO POLICY FORMS. TOTAL POLICY CHARGES $ 6,009.00 Foran of Business: X Corporation Individual Partnership Joint Venture Other Business Description: Remodeling General Contractor Forms and Endorsements(other than applicable Forms and Endorsements shown elsewhere in the policy) Refer to GL 0070 1010 THESE POLICY DECLARATIONS AND THE COMMERCIAL GENERAL LIABILITY DECLARATIONS—TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S), AND FORMS AND ENDORSEMENTS ISSUED TO FORM A PART THEREOF—COMPLETE THE ABOVE-NUMBERED POLICY This policy is made and accepted subject to the foregoing provisions and stipulations and those hereinafter stated.which are hereby made a part of this policy. together with such other provisions,stipulafons,and agreements as may be added hereto.as provided in this policy. COUNTERSIGNED AT: Eatontown,NJ 07724 BY: ' UTHORIZED REPRESENTATIVE DATE: 08,11 b/13 PB t # ProSiglr GL 0066 1010 Page 1 of 1yy ,: ,,i;,"'W This is to certify that Excess Line Association of New York received and reviewed the 08/30/2013 attached insurance document in accordance with Article 21 of the New York State Insurance Law 6_'�IVAV THE INSURER(S)NAMED HEREIN IS(ARE)NOT LICENSED BY THE STATE OF NEW YORK, EXCESS LwF Assoc'1AT/ON NOT SUBJECT TO ITS SUPERVISION,AND IN THE EVENT OF THE INSOLVENCY OF THE Of,NEW YORK INSURER(S),NOT PROTECTED BY THE NEW YORK STATE SECURITY FUNDS.THE POLICY MAY NOT BE SUBJECT TO ALL OF THE REGULATIONS OF THE DEPARTMENT OF FINANCIAL SERVICES PERTAINING TO POLICY FORMS.