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HomeMy WebLinkAbout38564-Z giFat,++'>-, Town of Southold Annex 7/31/2014 P.O. Box 1179 54375 Main Road „ ,�, • x�`.;� Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 37052 Date: 7/31/2014 THIS CERTIFIES that the building RESIDENTIAL ALTERATION Location of Property: 1000 Ninth St, Greenport, SCTM #: 473889 Sec/Block/Lot: 46.-1-31.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 11/27/2013 pursuant to which Building Permit No. 38564 dated 12/12/2013 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: BATHROOM ALTERATION IN UNIT L87 AS APPLIED FOR The certificate is issued to Driftwood Cv Co Ownrs Inc (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 38564 07-28-2014 PLUMBERS CERTIFICATION DATED Aut ed Si/ature TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 0* ' 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 #: 38564 Date: 12/12/2013 Permission is hereby granted to: Driftwood Cv Co Ownrs Inc c/o John King PO BOX 1186 Westhampton Beach, NY 11978 To: construct a bathroom alteration at unit L87 as applied for At premises located at: 1000 Ninth St, Greenport SCTM # 473889 Sec/Block/Lot# 46.-1-31.1 Pursuant to application dated 11/27/2013 and approved by the Building Inspector. To expire on 6/13/2015. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 ELECTRIC $90.00 Total: $340.00 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: 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 frorn 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 - $?5 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.10 Date. V ` ( �t New Construction: Old or Pre-existing.Building: (check one) Location of Proper f ��(7 �1� f -,. l�-��2r�Vo k House No. Street Hamlet Owner or Owners of Prop Suffolk County Tax Map No 1000, Section Block Lot Subdivision Filed Map. Lot: Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: _ (check one) Fee Submitted: $ n) Applicant Signature *oF so�jyolo Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G roger.riche rtCa)-town.southoId.ny.us Southold,IVY 11971-0959 'Q �y�DUNTY,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Thomas F Quillin Address: 1000 9th St Apt L-87 Driftwood Cove City: Greenport St: NY Zip: 11944 Building Permit#: 38564 Section: 46 Block: 1 Lot: 31.1 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 Basement Service Only Commerical Outdoor 1st Floor X Pool New Renovation X 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures 1 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 2 Twist Lock El Exit Fixtures TVSS Other Equipment: 1-exhaust fan Notes: Inspector Signature: Date: July 28 2014 81-Cert Electrical Compliance Form.xls cou TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ] FOUNDATION I ST ROUGH PLUMBING FOUNDATION 2ND INSULATION FRAMING / STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE RESISTMT CONSTRUCTION FIRE RESISTMT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION CAULKING REMARKS: V DATE . -7 6/ - INSPECTOR SOUIy� UNrl,�c� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I LATION [ ] FRAMING /STRAPPING FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL" (FINAL) REMARKS: �/��= �1 i`� c '� G�—�✓� � � DATE / INSPECTOR �' FIELD INSPECTX0N REPORT DATE COMMENTS O'4 FOUNDATION(1ST) 6 FOUNDATION(2ND) ' � z d �O ROUGH FRAMING& y PLUMBING Cz1 INSUL•ATION PER N.Y. H STATE ENERGY CODE y C) AWC FINAL 17 00+ (� 00, 'ADDITIO COMMENT (� 0 0 o z �rn -c td ell W TOWN-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 Survey SoutholdTown.NorthFork.net PERMIT NO. 5 Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application 0J Flood Permit Examined t ` (�20 Single& Separate Storm-Water Assessment Form Contact: Approved i ,20 7 Mail to: Disapproved a/c Phone: Expiration 20 � - -- - l Building Inspector l! _ �M > PLICATION FOR BUILDING PERMIT "OV 21 2013 �l` ate � � �.� � , 20 INSTRUCTIONS Ufa. This app,l,ication,MUST be co etely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans;-accurat 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 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. ' V X 0 \ A (Signature of applicantnnor me, if a corpora on) C)0c) (Mailing address of applicant) 1Y.-Yy State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or buildeillt Naive of owner of premises:;I � , : V � (As o e tax roll or lat st deed) If applicant is a-corpoyatioia.,•signature of duly authorized officer (Name ar ,title oafgr tae officer) Builders License No. (p Plumbers License No. Electricians License No. �� ©O ^vc_ Other Trade's License No. d eW � 1. Location o�and on which��pUsed work w ill be done: House Number Street Hamlet County Tax Map No. 1000 Section �� Block , Lot ' Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy �y-�_ b. Intended use and occupancy 3. Nature of work heck which applicable): New Building Addition Alteration Repair V Removal Demolition Other Work 00 (Description) 4. Estimated Cost 1 QU C2 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. D'i ensions of existing structures, if any: Front Rear Depth Heig Number of Stories Dimension of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire ne onstruction: Front Rear Depth Height Number of Stories 9. Size of lot: Front 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 13. Will lot be re-graded? YES NO Will excess fill be removed from premises? YES NO 14. Names of Owner of pre Ad s Ph 14. Name of Architect A dress Phone o Name of Contractor 2 F�61(Md T Address 4,4 Popls 31,E Phone No. G 3 /-9,1 -33 r C«b'o 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. 1 vide survey, to scale, with accurate foundation plan and distances to property lines. �Ifevation 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.BUNCH Notary Pubk,State of New York (S)He is the (� n ��\ No in 81 01k C4 Utwlllied in Suffolk�txxtl�-� (Contractor, Agent, Corporate Officer, etc.) Cornn>feWm Expires April 14,2 of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me thi n day of n) I I J 7Vt� (. 20_1311 Notary Public Signature of Appl cast I O��Of SQ(/ryo ti to Town Hall Annex Telephone(631)765-1802 54375 Main Road N (631)765- 5 2 P.O.Box 1179 G Q rogerAchertAfown.soutfio�d nv us Southold,NY 11971-0959 �aUIYT'I,� i . BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: � ,�� , 1� , ti Date:--h Company Name: Name: License No.: Address: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: ` � k -, *Address: C) O 4 t� S Q Lee"Q u P, )\I. M k k( *Cross Street: e p({ �, , ,ti S �- r t-f- 0 0 M'e_ *Phone No.. ( �j 1 4��_ I Permit No.: Tax Map District: 1000 Section: � Block: Lot: i *BRIEF DESCRIPTION OF WORK(Please Print Clearly) i 4 (Please Circle All That Apply) *Is job ready for inspection: YES / NO Rough In Final j *Do you need a Temp Certificate: YES/ NO I Temp Information (if needed) i *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 i 82-Request for Inspection Form �: e G • a _ Page 1 of 1 0 C'C' Co n S�Tu ck 3 � II 1T Re-rvDJA, S p C CO��OCk J S��f, l �--12A G31 VV, (7 -7 9.s' https:Hwebtop.webmail.optimum.net/http/viewattachment?clientId=1405646209222&local... 7/17/2014 �� '. �. ,; „ ;, =�,y s��� . k�. y' �; ,ry '�., pill �': i „� Vi _�, XVII �w o ^�� �� �` ,�. `. •: ,. i.,. t M .o / � fr 76 J a's P /s f� s �� a3 4 \ -3' i k p. �•P z 4 g. E y.. fit 3 ` zr \, u L:: y' L � � Q �4 C ti B ♦ ♦ . -. •• �• .., arc� � ��-�� \ \ \ y Q� ♦yva �'rw �p ll 4 � Sy; q � D y�f r zi Ili c aw �N'nIpEdEI�I'� « k• W ��, p�`• ATF w.. a IB g , }, .: '' My2,y � •fid .r¢n... Y � V �WE,t a � .. '• \ � � 7�'F`\ z�'�\� y�,moi �b.�z , rJ � a. SO�ryol Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax (631)765-9502 P.O. Box 1179 G --INC Southold,NY 11971-0959 4UNT`I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD March 7, 2014 Thomas Quillin, Jr 1000 91h St, Apt L87 Greenport, NY 11944 TO WHOM IT MAY CONCERN: The Following Items(if Checked)Are Needed To Complete Your Certificate of Occupancy: "Note: As per inspection done on 2124/14, please have an architect or engineer certify all work done under this permit,including new floor framing, plumbing,and pressure test 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 4/1/84) Trustees Certificate of Compliance. (Town Trustees#769-1892) Final Planning Board Approval. (Planning#765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. Final inspection by Building Dept BUILDING PERMIT: BP - Residential Addition ACO-'->RCERTIFICATE OF LIABILITY INSURANCE DATE(MWODlY " 11122/2013 THIS CER IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ins)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Certain policies may require an endorsement. A statement on this certificate does not coofer rights to the certificate holder In lieu of such endorsement e, PRODUCER CONTACT NAME: Timothy 5 Purdy NE 631)821-2200 F 45 Route 25A suite D2 -PNE-MAIL A (631)821-2298 ADDRESS- Shoreham,NY 11786 INSURERS AFFORDING COVERAGE NAIC N INSURERA:Farm Fami Casualty Insurance Com an INSURED INSURER B Fenimore Hume Construction&Renovatlon Inc. INSRERc: 44 Park Blvd INSURER D: Ya hank INSURER E: p NY 11980-1002 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 SEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICYNUMBERFOLIC-IMMIDDlEPP P LlheTS A COMMERCIAL GENERAL IJAWL1TY 3152X2593 02/01/13 02/01/14 EACH OCCUW.MRRENCE S 1,000,000 CLAIMS-MADEI OCCURI;A100,000 x Contractors Advantage MED E%as Any one S 5,000 PERSONAL&ADV INJURY A 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY 1:1 T T 7]LOC PRODUCTS.cOMPrwAGG S 2,000,000 OTHER: i A AUTOMOBILE LIABILITY 3152C5183 02123113 02123/14 OMBBIINED SINGLE LIMIT derAl s 1,0W,000 ANYAUTO 6ODILYINJURY(Per pamon) $ WNED SCHEDULED AUTOS AUTOSBODILY INJURY(PeraWdanl) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAG AUTOS {PeecddeM = 3 A X UMBRELLA LIABOCCUR 3101 E1702 11/29112 11/29113 EACH OCCURRENCE S 1 000,000 EXCESSLIAB CLAIMS-MADE 11/29/13 11/29114 AGGREGATE S 1,000,000 DED I I RETENTION SS A WORKERSCOMPENSATION 3152W7128 02/26113 02/26/14X PER OTH- ANDEMPLOYERS'LIABILITY YIN ',U) ER ANY PROPRIETORIPARTNERIMKEGUTIVEN/A E.L.EACH ACCIDENT ! 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NMI 77 E.L.DISEASE•EA EMPLOYEE S 100,000 DESCRIPTION Of P AT ONS befcw El,DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Rem rks Schedule,m,iy be attached R mora space is mquired) Carpentry CERTIFICATE HOLDER CANCELLATION Town of Southold IF ANY OFELLED BEFORE 53095 Route 25 THEULD EXPIRATIIONHDATE EREOF ENO CEIEWILL C E�DELIVERED IN PQ Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE 1'4F.�...rt 19$9-2013 ACORD CORPORATION. All rights reserved. ACORD 2S(2013/04) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NY$DISABILITY BENEFITS LAW PART 1. To be coke leted bX Disability Benefits Carrier or Licensed Insurance A eget of that Csrricr IFI. Legal Name and Address of Insured(Use street address only) I lb.Business Telephone Number of Insured FENIMORE HOME CONSTRUCTION& RENOVATION 631-924-3309 INC lc.NYS Unemployment Insurance Employer Registration 44 PARK BLVD Number of Insured YAPHANK, NY 11980-9700 5557308 Id.Federal Employer Identification Number of Insured or Social Security Number 112984239 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) HARTFORD LIFE INSURANCE CO. Town of Southold 53095 Route 25 3b.Policy Number of entity listed in box"Ia": PO Box 1179 2P65170A5AA Southold, NY 11971 3e, Policy effective period: 01-01-2013 to 12-31-2013 4.Policy covers: a. All of the employer's employees eligible under the New York Disability Benefits Law b. Only the fallowing class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. 11-22-2013 � �``""�V(--- Date Signed By +� (Signatum of insumnee carrier's authorized repmentadve or NYS Licensed Insurance Agent of that insurance carrier) Telephone Numbcr 80 - 20Titfe Manager IMPORTANT' If box 14s"is checked,and this form Is aipned by the insuranceeor icr's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail It directly to the certifleate holder. rf box"4b"is checked,ibis coMfleate Is NOT COMPUTE for purposes of Section 220,Sobd.8 of the Disability Benefits Law.It most be resiled for completion to the Workers'Compensation Board,DA Puns Acceptance Unit,20 Park Street,Albany,New York 12207. PART 2. To be cam Ieted by N'Y$Workers'Compensation Board(OnIX if box"4b"of Part I has been checked State Of New York Workers' Compensation Board According to information maintained by tho NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability Benefttq Lave with!aspect to all of his/her employccs, Date Signed By (signature of NYS Workcrs'Compensation Board employee) Telephone Number Title Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorised to issue Porm DB-120.1. Insurance brokers are NOT authorked to issue this form. DB-120.1 (5-06) STATE OF NEW YORK WORKERS'COMPENSATION BOAR.I7 CERTWCATE OF NYS WORKERS, COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Fenimore Home Construction&Renovation Inc 631-924-3309 44 Park Blvd Yaphank, NY 11980-1002 le.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required}coverage isspecykally Id.Federal Employer Identification Number of Insured limited to certain locations in New York State, %e-, a Wrap-Up or Social Security Number Policy) 112984239 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Farm Family Casualty Insurance Company Town of Southold in box uta"3b.Policy Number of entity r! 53085 Route 25 �' h'liste PO Sox 1179 3152W7128 Southold,NY 11971 3c. Policy effective period 02126/13 to 02/26114 3d. The Proprietor,Partners or Executive Officers are included. (only check box Irsu pArtAM/brficery tncluded) all excluded or certain partnerstofficers 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 under 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&-the certificate holder in box"2". The Insurance Carrier will also not.y the above certificate holder within 10 days IF policy is canceled due to nonpayment o,f premiums or within 30 days IF rhere are reasons other than nonpayment ofpremiums that Cancel thepolicy or eliminate the insuredfrom the coverage indicated on this CertfBale. (These notices maybe sent by regular mail.) Otherwise,this Cerciteak is valld for oneyear after this farm Lv approved by the insurance carrier or 10 licensed agent,or amil the policy expiraden date listed in boor"3c",whichever is earlier, Please Note: Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Timothy Purdy (Print name of authorized repres�ennWive or licensed agent of insurance carrier) 7 Approved by: x,11 ..e LA d" (Signature) I (D-) Title: Representative/Agent Telephone Number of authorized repivsentative or licensed agent of insurance carrier: 631-821-2200 ,Please Note. Only insurance carriers and their licensed agents are authorized fo issue Form C-105,1. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.state.ny.us U ► �L i i� �X( �I N�- OA-r+4. 8 9" �N,111 _ zwr v 34" 24" i - N V/121 N� UJ TOILET 25" 0 DWi � �►�CTt�i G 5 4 APPROVED AS' DATE_!!04Z- U_B.P. FEE: d_ ' 114" a t,!', FY BUILDING CF ALL 7b5-1802 8 AM TO , ) FOLLOWING INSPECTICI.:_; ` 1. FOUNDATION-TWO ! + 1 . TE FOR POURED CONCR ,k PLUMBER CERTIFICATICN 2. ROUGH-FRAMING. PLU` IV L�,'`, ' 0QNTE1V. �FF00E STRAPPING, -I FC 7 �. ;Y 3. INSULATION 4. FINAL-C IS.,.,,. _ P�IUST E`l ALL CONSTRUCT, REQUIREMENI S All dimensions_size designations given areThis is an original design and must not be Designed: ]]/23/2013 YORK STATE. f<O i subject to verification on job site and released or copied unless applicable fee Printed: 11/23/2013 adjustment to fit job conditions. has been paid or job order placed. DESIGN OR CON'S:' �.. <.. . Design All Drawing#: 1