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HomeMy WebLinkAbout40898-Z Town of Southold 10/13/2016 G P.O.Box 1179 a v' ? 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38581 Date: 10/13/2016 THIS CERTIFIES that the building DECK Location of Property: 1455 Longview Ln, Southold SCTM#: 473889 Sec/Block/Lot: 88.-5-49 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 8/4/2016 pursuant to which Building Permit No. 40898 dated 8/10/2016 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: DECK ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Digregorio,Patricia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED ut ed Signature gu�ot� 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#: 40898 Date: 8/10/2016 Permission.is hereby granted to: Digregorio, Patricia 1455 Longview Ln Southold, NY 11971 To: construct deck addition to existing single-family dwelling as applied for. At premises located at: 1455 Longview Ln, Southold SCTM,# 473889 Sec/Block/Lot# 88.-5-49 Pursuant to application dated 8/4/2016 and approved by the Building Inspector. To expire on 2/9/2018. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $399.20 CO -ADDITION TO DWELLING $50.00 Total: $449.20 uildin spector Form No_6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERT IFICA T E 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. 7A& (� New Construction: Old or Pre-existing Building: (check one) �J �y Location of Property: 1,q5�5_ House No. St r et f Hamlet Owner or Owners of Property:` Suffolk County Tax Map No 1000, Section d 0 Block Lot 1<09 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: $ G � . f Applicant Signature 00V rjf s a 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 VIOL CAULKING REMARKS: DATE - INSPECTOR qo Olt) OF SOUIyo TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ INS LATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE a� �� �� INSPECTOR �aOF 30//lyo coumN TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I ULATION [ ] FRAMING /STRAPPING [ FINAL �i,�F�rV/a'✓ [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FI AL) REMARKS: S /h fly—a"Vit- cop– S 'v 144.1 y DATE to Iv I o INSPECTOR �VZ FIELD-INSPECTION REPORT DATE COMMENTS r FTV 0 C)n� FOUNDATION(IS y -------------------------------- FOUNDATION ------------------------------FOUNDATION(2ND) t� �o ROUGH FRAMING& y PLUMBING INSULATION PER N.Y. STATE ENERGY CODE W. ¢- J � F • P to !y 1 � S H/' r L10 /'P �Gv��/°✓ FINAL /c (7! �A'r✓f� I ! k G ADDITIONAL COMMENTS ` s l Z ih .Q d/ bi �� `��✓. cb w o z m ori O z H CC tC Lei b H TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT I Do you have or need the following,before applying? TOWN HALL . Board of Health SOUTHOLD, NY 11971 (4�ets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 1 �)rvey South oldTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D.E.C. stees C. .Application ood Permit Examined qjp 20 Single&Separate Storm-Water Assessment Form �( Contact: Approved U ,20 Mail to: Disapproved a/c 14 Phone:4/b'r _7®oZ — IAa. Expiration ,20 D �� B spector AJD JUL 2016 APPLICATION FOR BUILDING PERMIT Date �/��Ir� , 20 BUILDING D INSTRUCTIONS TOWN OF So LI! 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 prernises available for inspection throughout the work. e No building shall be occupied or used in whole or in part for anypurpose 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 rem or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, o ing code, and regulations, and to admit author' e ins ectors on remises and in building for necessary inspections. D (Signature of applicant or nly,if a corporation) QUG - 4 2016 BUILDING DEM (Mailing address of applicant) State wheT1?er a 10nrFC#9V7W, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premises (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. �W& _ - Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on whi h proposed work will be don r . 1q71 House Numb& Street Hamlef County Tax Map No. 1000 Section b t� Block 06. 00 Lot ®�� 1 Subdivision Filed Map No. '- Lot 2. State existing use and occupancy of premi s and intendq use and occupancy of proposed construction: a. Existing use and occupancy /moi b. Intended use and occupancy &/7a/C 441f/1Ur Ahs P&5_ We L- 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 l If garage, number of cars 2 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. — /7 A 7. Dimensions of existing structures, if any: Frontcg Rear �5 (o Depth Height I,s Number of Stories / Dimensions Q same structure with alterations o��CC''additions: Front Depth Height ,/�"�'� Number ofto�i! „,x f 8. Dimensions of entire new construction: Front Rear — -w� �Dtepth-, Height Number of Stories 9. Size of lot: Front 43 Rear / Depth �p(jt {nJgr4141 4l "16£'u[t G,4'la-�'i i..�n..w✓i r,y/. f �'yii 10. Date of Purchase 1.3 Name of Former Owner LA 6t-ej 0 11. Zone or use district in which premises are situated �R qh 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 premises4/J7 r YL° rddress/ 14 60 k Phone No. 601-7(a s'/1C1 Name of Architect Address Phone No Name of Contractoc1q& Address 5f/r9 ( �� Phone No. AiV/17® 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 grope"y Ti �' 17. If elevation at any point on property is at 10 feet or below, must provide topogr cal,data on-survey,. -' 18. Are there any covenants and restrictions with respect to this property? * YES NO IF YES, PROVIDE A COPY. �g VT4L�.'3.: ) 4W5 STATE OF NEW YORK) COUNTY OF P614-�'IaA_ld being duly sworn, deposes and says that(s)fie is the applicant (Name of individual signing contract) above named, oy (S)He is the /7 t,-9�< (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 application; that all statements contained in this application are true to the best of his kno}�' ed e and belief; and that the work will be performed in the manner set forth in the application filed therewith.' j Sworn to before me this 6 day of 20 l�ra RICHARD W.VANDENBURG 4 L i Notary public,state of New York Notary Publi No.2 9-Suffolk conn Signature of Appl ant commission Expires May 16, Scott A. Russella` SUPERVISOR . SOUTHOLD TOWN HALL-P.O-Box 1179 53095 Main Road-SOUTHOLD,NEW YORK 11971 /�y� �—/ ,cam` Town of Southold CHAPTER 236 STORMVVATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) --- - - -- - - -- - - - DOES HIS PROJECT INVOLVE ANY OB~ THE FOLLOWING:` (CHECK ALL THAT APPLY) YesNo ® A_ Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. (Z' B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. ❑�. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance- F1[�- Site t 100 feet of wetlands, beach, bluff or coastal i preparation Paration within ' erosion hazard area. El[J`E. Site preparation within the one floodplain as depicted - -__Zen:,_Zen==FIRA-4-Map-=of-any—w--ate— ❑[/F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind replacement of impervious surfaces- . ..... . ..... .-.. . ---- - -- -- - -- ---- If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name, Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project. If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. S.C.T.M. �`: 1000 Date APPLICANT: Property Owner,Design Professional.Agent.Contractor.Other) D,;trict NAME Section Block Lot �7 FOR BUILDIINIG DEPARTNIENT USE OCL."' Contact Informatiorc 101P Reviewed By: — — — — — — — — — — — — — — — — — — Date: Property Address / Location of Construction Work: — - - — — — — — — — — — — — ! — — Approved for processing Building Permit. — — — /- .` (� Stormwater Management Control Plan Not Required. Llj elni It Stormwater Management Control Plan is Required. (Forward to Engineering Department for Review.) FORM , SMCP -TOS MAY 2014 f l MAP OF PRr .UN �y Dk' czo 1 �F J irk1✓x-r°r _k _•ti� uR�t�stns or (2A1 IFF,JCE ° ' f` _ �. I T , Sermon 7N�!isa c(an}�na �, 2�gre N �y of jdsu n�i �YRdI embc s sink-ds be ng,, to by a valid notbs tY f �^ rel ere , ri �J fa .7 nJc �' per hereonstr�prun ,,. ! t ?t e Bred r tai ihi yhorh the sUIV j. +.,. tenclmgm s ,'1 °ler+ii jsrregj t tolhe taU►eion�o,' dh�reoe ` hitt �'$5>✓J a ar>d • :r ' t� o� yet :rses 9l ndu`tji vrie�tionallrstitu knot transf � �F•:: •+ _ :.: '� � �• ;,,tom � , . _� � - \ � •, _ ' � • Cr? t +- l., igta { LS OF NF ,`Q'OFg1CK Nq LS�e OQ I 1 SAND SURD f 1 - t GUARANTE9i'' TC _ i�1 �{rJi�f�tfEALT'H L.NQ T{TE_�, f:�,i-`,.-I:RA�'.�:CE ' I - :�2TFG;E� V��1J►YAC"; ....... _.._�..- ,.,.. ,_... _ - N, jtZV'cYEC) -- - .1u �3 , 993 VAN TUYL ,RC. T�?E $111 , Ce7.CLE2Y,'_ Grcrr - Al MSP Y�:G.2;`�' !�� �r'fQs.-q.. .� . -3_ s; New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 Phone.(631)766-4300 CERTIFICATE OF WORKERS' COMPE<19SA` ION MURAMCE ^^^^^^ 262315970 MARCOR CONSTRUCTION INC. 419 K GREAT EAST NECK ROAD a WEST BABYLON NY 11704 Scan to Validate POLICYHOLDER CERTIFICATE HOLDER MARCOR CONSTRUCTION INC. TOWN OF SOUTHOLD 419 K GREAT EAST NECK ROAD BUILDING DEPT TOWN HALL WEST BABYLON NY 11704 53095 RT 25 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE 12330058-5 556730 01/01/2016 TO 01/01/2017 7/2D5 206 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO.2330 058-5 UNTIL 01/01/2017, 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 01/01/2017 IN SUCH MANNER AS TO AFFECT PHIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLAI ION WILL BE GIVEN TO THE CERTIFICATE HOLDER` ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SI IAL(. BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. I-HE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE '1 HE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST" THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLGYEE OF OUR INSURED A THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT. THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED 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 IRECTOR,INSURANCE FUND This certificate can be validated on our web site at haps-//www.nysif.com/cerYcertval.asp or by calling(888)875-5790 UNDERWRITING VALIDATION NUMBER:146266636 U-26.3 CIent#:36552 MARCOCONST DATE(M_MIDD Y)Y )! ORDA. CR} RCATE O UAJ TQ y URnNCE / 20725116 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIFERS NO RIGHTS UPON THE CE FtTIFICATF }(OLDER,THISCERTIFICATE 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(6s)must kse endorsed.If SUBROGATION IS WA- VED,sUj't to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not co certificate holder in lieu of such endorsement(s). confer rights to the PRODUCER CONTACT Cool Insuring Agency Inc NAME: PHONE 784 Troy Schenectady Road E-MAILn.Ext 516 783^2665 — (Ax,No). 5187838754 E-Pd - Latham, NY 12110 ADDRESS. _ 518 783-2665 I_ _ INSURERS)AFFORDING COVERAGE_ 1-NAIC# - INSURER A.AdmiPaO Insurance Company ;2 5856 INSURED -- '— -.-- — Marcor Construction Inc. INSURER B: — — 419 A Great East Bleck Rd I INSURER C -- -- -- - — - - -tnrsuRER D -- West Babylon,NY 11704 -- - — IINSURERE: - I INSURER F: -- - — -- -- -- �" ---- -- COVERAGES CERTIFICATE NUMBER: n REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM2D ABOVE FOR TFIE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. INSR ADDLSUBR LTR YPE OF INSURANCE _ INSR WVD POLICY NUMBER POLICY EFF POLICY EXP — - - — —- --- ---_ -- — _- -_- MM/DD/YYYY).1 MMIDD/YYYY LIMITS A �( COMMERCIAL GENERAL LIABILITY CA00002407401 – 4/1512016104/15/201 EACH OCCURRENCE CLAIMS-MADE ®OCCUR i DgqbbCAGE(0 RENTED $1,000'000 X1/PD DI I�f�f M13E5(Ea accr.cr�ru I450,000 ; 03ed:$5,000 _ MED XP(Anvoneperson) $5,000 - _X� Pr®ject Age Cap:$51lfl--- � GEN'L AGGREGATE LIMIT APPLIES PER PERSONAL 8 ADV_INJURY _ $1,000,00() QFNERALAGGREGATE 1 X POLICY®PRO JECT LOC I I I —'-- `_J��rQ00'OQ0 B OTHER: l PRODUCTS-t;aSAPOr'AGG $2,000,000 - -- -- --- $ AUTOMOBILE LIABILITY TO BE 0$$01=® I LEn accidunt) g _-- --- _ I ANY AUTO SEPARATELYBODILY INJURY(Per person) , ALL OWNED SCHEDULED _ AUTOS AUTOS BODILY INJURY(Per accdent - � L�HIRED AUTOS AUTOS4YNEL ) - - AUTOS ('ROPER 1'Y DA 147AC=F— " f.(P013CCId@Ill) - - - UMBRELLA LtAB - — __ OGf'UREACH CN_CUlIR&.-;.F EXCESS LIAB - L_ L;LAI?,I1 reIAI)E. --- -- - — - ---- - — �,-- _ �DED =RETENTIUi�; AGGREGAr[ - ---- .—_ %OORKERS COMPENSATION AND EMPLOYERS'LIABILITY TO BE ISSUED PER }r --'STAI47E____I :R FTH -- - I ANY PROPRIETOR/PARTNER/EXECUTIVE J_f OFFICERIMEMBER EXCLUDED? N/A f ELY Ic...EaC;•t ACCp)FN7 e, (Mandatory In NH) I I SEPARATELY If yes,describe under �E.L D;SE,ASE-FA EMPI OYEF DESCRIPTION OF OPERATIONSba.-, EL.DISEASE-POLICY LI M_R 1 — --• --- - -' -- 9: ------- I DESCRIPTION OF OPERATIONS/LOCATfONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may bo attached If more space Is raqulrod) With respect to the Commercial General Liability coverage evidenced herein,Town Of Southold is named as an additional insured but only With respect to operations performed by the insured or on the insured's 1 behalf with respects to permits issued by the state or political subdivision. CERTIFICATE HOLDER - CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Ball THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Rt 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENrATIVE - r' ©11)88-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S8015751M770108 DAH - Ya iK l Aforkers' CERTIFICATE OF MURANCE COVERAGE � raTE i t3oardCompo1� iG�a UNDER THE MYS DISABILITY RENEWS LA PART 1_To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier— 3a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured MARCOR CONSTRUCTION INC lc.NYS Unemployment Insurance Employer Registration Number of Onsured 419B GREAT EAST NECK ROA® Federal Employer identification Number of Insured WEST BABYLON, NY 11704 Z of or Social Security Number i — I 262315970 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Bolder) I ShelterPoint Life Insurance Company I Town of Southold 3b.Policy Number of Entity listed in box"1a": Town Hall, 53095 Rt 25 I DBL470561 ( Southold, NY 11971 3c.Policy effective period: 07/22/2016 to-- _- 07/2112017 4.Policy covers: - -- -- - —- -- - — — - a. ® All of the employer's employees eligible under the New York Disability Benefits Law b.® Only the following class or classes of the employer's employees: Under penalty of pe jury,l 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. J' (;y- a�'; 1. '' Date Signed_ 7/25/2016 - - $Y_ _ ( ss`('(.� �i!/J _ (Signature of insurance carrier's authorized representative or NYS Licensed ce A Insurangent of that insurance ca,rio�)I Telephone Number _ 516-829-8100 Title— _ Chief Executive Officer II i IMPORTANT:If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Subd.8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,MY 12305. PANT 2.To be completed by NYS Worker's Compensation Board(Only if boat nob"of Part`V-has been checked)—I State of New York --- — - Worker's Compensation Board According to information maintained by the NYS Worker's Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed_ - — By_ _-- - (Signature of NYS Worker's 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 authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1(9-15) .'u zip,1) Vie/ .. .... 40' /v 0 01�1,1511M_Q "- 0", "M .... ....... yr gp ..71 q 0-WM" Suff(O 1k County Department of Consumer Affa N irs VETERANS 114EMORLA_L MGHWAY HAUPPAUGE, NEW YORK 1178 8 M. H; DATE ISSUED: 4/21/2008 44604-ffff R � ..E\ "S am nN SUF1POLK COUNTY Home Improvement Contractor L This is to certifv that -A GARYRAIARZANo El doing business as MARCOR CONSTR having furnished the requAremenis set forth in accordance with and subject to tile provisioas ofap rales �Qwltg and regulations of the County of Suff'olk, State of Ncw -j.,-ork is he plicable ja-vxrs. rebv jjcellseo� It c oi2dUCt 1)USjjjeSq as a 14() 141 MPROVEMENT C0NTRA(70PZ_ jjj of Suffou<. �Z&N '01 .t� NOT VALID WITHOUT M Ad&tional Businesses 11C)OWS and Siding DEPARTMENTAL SEAL �'BMW Roofing AND A CURRENT MARCOR CONSTRUcTioN iNc(i CONSUMER AFFAIRS SUPP) 17 A IDCARD gg ap,"I gg g IS PC :J' Its Director 'A g, J, EK. AP ROVED AS NOTED DATE: 6.P.# FEE: o BY: COMPLY WITH ALL CODES OF NOTIFY BUILDING DEPARTURT AT NEW YORK STATE & TOWN CODESRUNOFF 765-1802 8 AM TO 4 PM FOR THE AS REQUIRED AND CONDITIONS OF PURSUANT TO CHAPTER 23 FOLLOWING INSPECTIONS: 6 1. FOUNDATION - TWO REQUIRED OF THE TOWN CODE.. 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