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42255-Z
Town of Southold 2/16/2018 P.O.Box 1179 e 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39516 Date: 2/16/2018 THIS CERTIFIES that the building RESIDENTIAL ALTERATION Location of Property: 1425 Kimberly Ln., Southold SCTM#: 473889 Sec/Block/Lot: 70.-13-20.9 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 12/21/2017 pursuant to which Building Permit No. 42255 dated 12/21/2017 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 Pashalis,Nicholas&Christina of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 42255 02-08-2018 PLUMBERS CERTIFICATION DATED 01-25-2018 jr Nicholas Votias ut ed Signature TOWN OF SOUTHOLD �ao� r BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY W. 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#: 42255 Date: 12/21/2017 Permission is hereby granted to: Pashalis, Nicholas 6 Westmoreland PI Douglaston, NY 11363 To: Alteration to an existing single family dwelling as applied for Replaces BP# 39510 At premises located at: 1425 Kimberly Ln., Southold SCTM # 473889 Sec/Block/Lot# 70.-13-20.9 Pursuant to application dated 12/21/2017 and approved by the Building Inspector. To expire on 6/22/2019. Fees: PERMIT RENEWAL $100.00 Total: $100.00 uilding Inspector 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 #: 39510 Date: 1/29/2015 Permission is hereby granted to: Pashalis, Nicholas & Pashalis, Christina 6 Westmoreland PI Douglaston, NY 11363 To: Alteration to an existing single family dwelling as applied for; Replaces BP# 37776 At premises located at: 1425 Kimberly Ln SCTM # 473889 Sec/Block/Lot# 70.-13-20.9 Pursuant to application dated 1/29/2015 and approved by the Building Inspector. To expire on 7/30/2016. Fees: PERMIT RENEWAL $100.00 Total: $100.00 Building Inspector TOWN OF SOUTHOLD BUILDING DEPARTMENT i TOWN CLERK'S OFFICE • a� 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#: 37776 Date: 1/28/2013 Permission is hereby granted to: Decarlo, Donald & Decarlo, Mary Ann 200 Manor Rd Douglaston, NY 11363 To: Alteration to an existing single family dwelling as applied for. At premises located at: 1425 Kimberly Ln, Southold SCTM # 473889 Sec/Block/Lot# 70.-13-20.9 Pursuant to application dated 1/22/2013 and approved by the Building Inspector. To expire on 7/30/2014. Fees: SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00 CO -ALTERATION TO DWELLING $50.00 Total: $250.00 ctordng 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. New Construction: Old or Pre-existing Building: (check one) Location of Property: 16" M ),,� House No. Stre&J Hamlet Owner or Owners of Property: �Ol �-�15 P Suffolk County Tax Map No 1000, Section 70 Block _ Lot Q0 3 Subdivision Filed Map. Lot: Permit No. a. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ Applicant Signature pF SO(/l�,ol Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 iQ roger.richert(a)-town.southold.ny.us Southold,NY 11971-0959 Q COU BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To Pashalis Address: 1425 Kimberly Lane City Southold st: New York zip: 11971 Building Permit#: 42255 Section: 70 Block: 13 Lot: 20,9 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA. MTM Electric License No. 3700-E SITE DETAILS Office Use Only Residential X Indoor X 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 3 HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures 5 CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches 3 Twist Lock Exit Fixtures TVSS Other Equipment: Kitchen, Bath, Foyer Renovation, Lighting Only. 2- GFCI Circuit Breakers. Notes: Inspector Signature: Date: February 8, 2018 0-Cert Electrical Compliance Form.xIs so�Tyo� Town Hall Annex Telephone(63-1).7654802 Fax(6'31).765-9502 54375 Main Road P.O. Box 1179 • Q Southold,New York 11971-0959 COUM BUILDING DEPARTMENT TOWN: OF SOUTHOLD J JAN 2 6 2018 TOWN OF SG'UMOLD CERTIFICATION Date: UQ� C Building Permit.No. y�-Z��✓ Owner: Nick Aprint) Plumber: �0 (Please.print) I certify that the solder used in the water supply system,contains less than 2/10 of 1%a lead. (Plumbers Signature) Sworn to before me this b�J day of flU0.r 20 MERRIE'C;JUSUF Notary Public, State of.New York Registration#01JU8339053 Qualified In Queens COMM Notary Public, County CdMM'8aion Expins MarcA 21 o��pG SO(/ry0 � <o 3-� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUND . TION 1 ST [ ] ROUGH PLBG. [ ] F DATION 2ND [ ] INSULATION [ FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] E ICAL (FINAL) REMARKS: .✓ DATE l d 3 INSPECTOR elf so yO<o TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 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: DATED INSPECTOR f SOUry� �y�vuHn� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTI [ ] FOUNDATION 1ST [ ] UGH PLEIG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELE TRICAL (FINAL) REMARKS: -(J oe f DATE INSPECTOR v OF SO(/lyo TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] F MING / STRAPPING [ ] FINAL [ FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: Hr / ` 7- 1-44 t DATE 3 / 3 INSPECTOR /�L .Z_ IV�1._ Of SO(lTyo ,`0 6 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 1 NSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] IN SULATION [ ] FRAMING / STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: " Yf(A04/ vzou�(1 1%, DON, Y' Cl000 — ,,, DATE INSPECTOR pF SOUTyo� 2 (/ ufm TOWN OF SO.UTHOLD 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 INSPECTOR A. 1 1 0 • ' � • 1 1. / •Lys�. �._�_ ` i ...r_ ROUGH FRAMING& w/ PLUMING IN$UL ATION PER N.Y. STATE ENERGY CODE 4 w r* : dam '. ris MME RI AMON"M �. 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. 6 Check Septic Form NYS.DE.0 Trustees ( C O Application Flood Permit. Examined 2O 20 (i Single& Separate C E H Storm-Water Assessment Form 2.� 3 ,�� Z 2 2013 Mail Approved , _0 � Mail to. Disapproved d/c BLDG. DEPT —1 TOWN OF SOUTHOLD' Phone. Expiration 7 36 20 l`f Building Inspector APPLICATION FOR BUILDING PERMIT Date ; 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 Ifno,zoiinig 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, a.nd 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 S (Signature of applicant or name, if a corporation) �3 3 0,4 Ik t w /'1--11v_, e), P7A (Mailing address of applicant) State whether applicant is owner, lessen, agent, architect, engineer, general contractor, electrician, plumber or builder Cr e,-, e✓ w I �o-1�z'-4.c ' 0 r- Name of owner of premises (As on the tax roll or latest deed) If applicant ' a c rpo- ion, stgna re of dul authorized officer ame a title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on whiclro osed work II � IMMAT p p t vYt� aildu9 ra)oN / n 14-112 L ,y AoffJiO.aOR ©v O C cSL i f House Number Street _ , ! A�tSM t�tix7 noizYmrrt�,1 Hamlet County Tax Map No. 1000 Section Block 113 Lot ad ,� 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 4---' Repair Removal Demolition Other Work (Description) 4. Estimated Cost , Qoo — 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 S S HAL If business, commercial or mixed occupancy, specify nature and extent of each type of use. L17 Di nensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions Front Rear Depth Height Number of Stories 8.� Dimensions of entire new construction: Front Rear Depth Height Number of Stories �9. Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner Lq/\ 11. Zone or use district in which premises are situated 2cs1 .� a_- TO 12:"Does proposed construction violate any zoning law, ordinance or regulation? YES NO C/ �• .� 1�_. + n crr�C _ wr.'l._LI-i, __/ �.J f I .1 i Y. �:ses—? V'E_S. .,_ NO `13. Will 1l) be re= faded 1 i;J tvv v _VV 14. ill'c��CeSS-iCl� JC-'`i�.n1C'v'e f'Jrii iii:-. (,": -;�:�. I-v L.�►'- 14. Names of Owner of premises ►G �_PR:6Address 3, S . Phone No. Name of Architect Address Phone No Name of Contractor `��.� 2� " -5�- -�� Address Phone No. 15 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. c1 :- 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. 8. re there any covenants and restrictions with respect to this property? * YES NO IF YES, PROVIDELA 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, 1 (S)He is the CON Lo (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 knowledge and belief; and that the work will be performed in the manner set forth in the application fled therewith. TAkW S.WATt M1 Sworn to before me this Nftv PuMk �eof Now 1 � day of 20 3 � SuffolkC113%. 1 of Notary Public 0 Sig ature of Applicant SO!/lyol o Town Hall Annex Telephone(631)765-1802 54375 Main Road cn (631)765-9502 P.O.Box 1179 G Q roger.riche rti-fown.southold.ny.us Southold,NY 11971-0959 � • �� ���C4UNT`I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: _:!�- 7 /3 Company Name: AITIVELe �i✓'G Name: �,,� o �q_ License No.: 3 49a e— Address: �Q �D A Phone No.: '/lr JOBSITE INFORMATION: (*Indicates required information) *Name: /y�C�/to�G� .� AS�G� ,lS *Address: *Cross Street: R � *Phone No.: Permit No.: _ 3 a 5 Tax Map District: 1000 Section: -70 Block: I Lot: 1 *BRIEF DESCRIPTION OF WORK Please Print Clearly) >� // 4 (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 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 1 82-Request for Inspection Form '9 "� John Zotos Inc. P.O. Box 989 Southold N.Y. 11971 (p)631.793.2077(f) 631.228.4899 D E C E � V nn E July 11, 2014 JUL 18 2014 BLDGDEPT Re: Building Permit Extension Request TOWN Of SOUTHOLD Owner Name: Decarlo/ Pashalis Property Address: 1425 Kimberly Lane, Southold NY 11971 Permit#37776 Expires: 7/31/14 Reason for Request: Do to the harsh winter we had work is running behind schedule. I would like to request a 6 month extension, which I understand is at no charge. John Zotos 1 � -kuJ / '{a5 �� imbnly lane, Q 419 - 1093 -030� January 25, 2018 Ms. Sue JAN 262018 Town Hall Annex 54375 Main Road "TF TOWN OF SOiTTHOLD P.O. Box 1179 Southold,New York 11971-0959 Dear Ms. Sue, I am sending you the certification of the plumber, enclosed. I will contact you soon regarding the electrical inspection. Smcerely, Nick Pashalis LOT AREA 47,769 SO. FT (TO TIE UNE 9-27-2012) i e o wvr or Maw.or an Am m TME Oillm 100 0 ml� )owwM watEW FAw rwE mlu m m ME or wmow,r mo.wor wow AK NOr mpAAwI®. PRWOM tM AQ FOR A tFOOM PUWM NO UU AND INGROM Awr nor JOB No. 12-241 FILE No. PARADISE BY THE BAY 1.097 acres .m m w wai M t m or frmm ft nwo twu.POWs,Pow. PLANW mca..cones W MAIM W Awr cu[n rolefl{I 110H. SURVEYED FOR uwamal@Eo VMsWx OR AW11014 lo no fOwY[Y e A wLArgw of escrow y1W y MEE�W�t E mteArM LAr. LOT NUMBER 9 , P~w NwAm"am w w w oar m ac mmk ww wtow MAP OF PARADISE BY THE SAY wwYn a rlar.wm,Awa W we SOW m ME w"CO~.mmmom. .SITUATED AT SOUTHOLD Acorn'w0 LOCOM IN7MAW LWO HUMOw.AND t0 ME ASS"m,OF ME LDOr10 Falb..MWOMfin ARE war TIM"UMetc 10 AWITOVI oemvlwws TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y OR weEauart WNan. , corws or Me amAt1'w ww ft l n ME VOD wRMWS"a sm ON SCALE 1' = 40' DATE 9-27-2012 WMM EGL aarwi Not wE CONSOl7lm M K A WUO rMlF mW. ��� NE ROAD CERTIFIED ONLY TO- FILED MAP No. 6463 GATE 11-4=1978 ROXAN AD of NEW TAX MAP No.(REF ONLY) 1000-70-13-20.9 DISK 2012 R=25.00' b�O f.IRANCy L=3854' o HAROLD F. TRANCHON JR. RC ? LAND SURVEYOR Q, ^6, P.0 BOX 616 f yz 1866 WADING RNER-MANOR RD.WADING RNER, 1 NEW YORK, 11792 uae`� No.048992 631-929-4695 HAROLD F TRA N, QNv IC.No.2115-E LOT NUMBER 8 293.53' p1 84.22'20"E Fp ry HO IN ONUNE �� r 283.10' o n cn chaln link fence FC N 00 0.1's FC N O . R=60-00' 0.0's v V wootl cp, N L=55.22' _ Geck Z N Ulf, b 3 oro t*i0{ ..,ggtt F 1s/O� t96 2nd 0 rd 6 >Pool x Op e g s °ga ry o:xW KOJ$'dio. p Z 9'dio. rood"I to Hoch .7 i K 0wy Cl) Ll O 3 stop. 4>1 OJ. flw�e J O f*1 xnd Ely ' K NOTE AS PER FILED MAP DATED 11-4-1976 ? °h outdoor M mer 5 0917 4' 10' EASEMENT BETWEEN LOTS 11&12 0 ' °0 under oR 234 69' 17 74 ARE FOR POSSIBLE WELL SITES AND WAFER SERVICE p FC --'`r .-- I _ LINES FOR LOTS ON THE EASTERLY SIDE OF KIMBERLY UL_ u. FC 0.5'N B rote ler'ce po LANE WHERE AN INADEQUATir WATER SUPPLY IS ENCOUNTERED ,pP o.e N sOu�N N O N chain link FMCe ON UNE 306.94' �fOeAa S 84'22'20 W LOT NUMBER t0 i New York State Insurance Fund o Workers'Compensation&Disability Benefits Specialists Since 1914 199 CHURCH STREET,NEW YORK,N.Y.10007-1100 Phone:(888)997-3863 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 271200717 JOHN ZOTOS INC. 133 OAKLAND AVENUE MILLER PLACE NY 11764 POLICYHOLDER CERTIFICATE HOLDER JOHN ZOTOS INC. TOWN OF SOUTHOLD 133 OAKLAND AVENUE 53095 MAIN ROAD MILLER PLACE NY 11764 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE Z 2245 288-2 378839 11/17/2012 TO 11/01/2013 1/22/2013 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO 2245 288-2 UNTIL 11/01/2013, 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. IF SAID POLICY IS CANCELLED,OR CHANGED PRIOR TO 11/01/2013 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. JOHN ZOTOS-PRESIDENT OF JOHN ZOTOS INC 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 f NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can,be validated on our web site at https://www.nysif com/cert/certval.asp or by calling(888)875-5790 VALIDATION NUMBER: 385408260 U-26.3 t � JOHNZ-1 OP ID:JJ ,4`oRo° CERTIFICATE OF LIABILITY INSURANCE DA011221D20 i 13 THIS CERTIFICATE 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(ies) 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 confer rights to the certificate holder In lieu of such endorsemen s. PRODUCER Phone:866-484-8656 NNAAME:c John M Titolo,Inc Fax: 631�85�171 PHONE 990 South 2nd Street Suite 4 c o ac No Ronkonkoma,NY 117179 E-MAIL John M Titolo ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC tt INSURER A.Burlington Insurance Company INSURED John Zotos Inc INSURERS: 133 Oakland Ave Miller Place,NY 11764 INSURER c INSURER D: INSURER E. 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 BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER MP�O/LDIC EFF MM/DD EXP LTR LIMITS LT GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A COMMERCIAL GENERAL LIABILITY HGL0032162 09/06/2012 09/06/2013 DAMAGE TO RENTEIF- PREMISES a occurrence $ 50,00 CLAIMS4iADE E OCCUR MED EXP(Any one person) $ EXclud PERSONAL d ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PECTRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OVWED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS ar accklent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC YS TATU- OTH- AND EMPLOYERS'LIABILITY Y/NUMI IER ANY PROPRIETOR/PARTNER/EXECUTrVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ii yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,K more space Is required) CERTIFICATE HOLDER CANCELLATION TOWNSH2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town TownMain Road ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name and Address of Insured(Use street address only) 1b.Business Telephone Number of Insured JOHN ZOTOS INC 631-228-4899 1c.NYS Unemployment Insurance Employer Registration 133 OAKLAND AVENUE Number of Insured MILLER PLACE, NY 11764 1d.Federal Employer Identification Number of Insured or Social Security Number 271200717 2.Name and Address of the Entity requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity being listed as the Certificate Holder) The First Rehabilitation Life Insurance TOWN OF SOUTHOLD Company of America 3b.Policy Number of Entity listed in box"1a": 53095 MAIN ROAD DBL343689 SOUTHOLD , NY 11971 3c.Policy effective period: 07/16/2012 to 07/15/2014 4.Policy covers: a. Q 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 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. Date Signed 1/25/2013 By (Wvt (Signature of insurance carriers authorized representative or NYS Licensed Insurance Agent of that Insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer 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,20 Park Street,Albany,NY 12207. PART 2. To be completed by NYS Worker's Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board 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 Workers 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 (5-06) Additional Instructions for Form 1313-120.1 By signing this form,the insurance carrier identified in Box"3"on this form is certifying that it is insuring the business referenced in Box"1a"for disability benefits under the New York State Disability Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box"2".This certificate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent,or the policy expiration date listed in Box"3c". Please Note:Upon the cancellation of the disability benefits 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 NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW Section 220. Subd. 8 (a)The head of state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board,commission or office to pay any disability benefits to any such employee if so employed. (b)The head of state or municipal department, board,commission,or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article,and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits for all employees has been secured as provided by this article. DB-120.1 (5-06) Reverse 11 a ass- PROPOSAL ssPROPOSAL By JOHN ZOTOS INC 133 Oakland Ave Miller Place NY, 11764 Phone/Fax 631-228-4899 Permit# - 37776 �ec��o Relocate plumbing as follows. Master bath—relocate master shower,bide and toilet. Shared bathroom—relocated shower body only. Powder room—relocate toilet and sink' Kitchen—relocate kitchen sink and add 1 additional sink to island. FCEC MAY - 6 2413 BLDG.DEPT. TOWN OF SOUTHOLD 1425 Kimberly Lane Southold,NY 11971 Additional work to be performed: 1) Remove glass block in stair well, replace upper with new windows and close in lower opening's (no-glass) with framing and siding to match existing. 2) Remove existing sliding glass door in kitchen and install new C13-3 Anderson- window. 3) Remove existing window's over kitchen sink and install new PS6—Anderson— sliding glass door. 4) Remove existing 12 foot sliding glass door in family room'and replace with new NLGD120611- Anderson sliding glass door to match existing.opening. 5) Remove existing 6 foot sliding glass door in rear foyer and replace with new PS6180—Anderson sliding glass door to match existing opening. J t I ` i10�1�� r;t�l►i� ■limit �1�'!I �1 •1�-'°�.""�..-. _..�e:a-� :.®— --- �I� oil ! 111 itim 1!1 r of!1 Al .. It! sh, ®8►Yrs p'i ,ll t`t !- { - iii II, to of !ii rl�l!r + III Iif +Illfa �BIIIIIIi, � I --- 111 It til A 1!!Idl'li� ilk��lfl: x611 — uo 1 Ise�Ii,� i>t��;t+, iuiotiiolil�s� N 111,111: ;limy!®r� la�sl�l.�l�I - 1� - ' 111 LFl�lRi IM • III - ��1� Iii � Ci� su) • I ► i i- Oki MIN I t fit ■i►��f� � �i14ppu ; � ` dd — � Bolts 16" „ %"0 2x12 ACQ 2 „ z 2 2„ (2) 0.625”FP 33 „ I I Flitch Beam Details Scale: 1" = 1'-0" 24" I I I 2 „ Z 210-- 33�a” I I 2 x 10 ACQ Ledger Hot Dipped Sistered (4) 2 x 12 Beam Details Galv. Lag Bolt to Wall with 8"O Lag Bolts 16"OC Staggered Scale: 1" = 1'-0" New (3) 2 x 8 4 �QG � �1ro+ F�� 0 Ni / e�L f�9 N �}- rJ m `\ _ New 3 2"x 11 8"APB TZExisting2x8FJ -t• N '��2x CQ FJ ` W16" CwU — — — cx = � Existing ) 2 x 12 e/w (2)0.75"FP Exi ing (3) 2 x 12 3 � a� New (3) 2 x 6 I Simpson HUC412 Pack 79 Out on Both Sides of Beam'p+ IIS TOCC�X")J� Co N ICU- � N N N I I o �\ s � � CD + N I I 0 C '6* W w ( W I w i N Kitchen ti+�L �ti�� !2 I I N_ s IIM Cli JI (4) 2 x 4 New Existing (3) 2 x 12 /j, z 9 2 Column Existing 2 x12 FJ _ + +7 Walls to Be Removed Sim n HUC412 Pack \ sf on Both Sides of Beam Existing x 1 (2)0.5"FP 2nd Floor Framing Drawing prepared based on plans prepared by Tast+ Clemancy Architects dated 5/5/1990. = Plans are prepared by Condon Engineering,P.C. It is a violation of the New York State Education Scale: 1/4" 1'-0' Condon Engineering, P.C. Law,Article 145,Section 7209,for any person unless acting under the direction ofa licensed Professional Engineer,Architect, Land Surveyor,to alter arty item in anyway.If an item bearing Drawn b : JJC 1755 Sigsbee Road 1425 Kimberly Lane the seal of an Engineer,Architectt,, y or Land Surveyor is altered,the altering Engineer,Architect,or Land Surveyor shall affix to the item his/her seal and the notation"Altered by"followed by his/her Mattituck, New York 11952 signature and the date of such alterations,and a specific description of the alteration. Date : 4-10-2013 (631) 298-1986 Southold New York %"0 Bolts 2x12 ACQ I I I —221 2'If 2 (2) 0.625"FP 33/4„ I I Flitch Beam Details Scale: 1" = 1'-0" Ft. ado NA, / s�. x -1- w Existing 2 x I FJ — — �� Existing ) 2 x 12 e/w (2)0.75"FP Exi ing (3) 2 x 12 III I im s n S u p o HUC412 Pack 9 Out on Both Sides of Beam`'.+- ILL ? II N_ pip N_ I I U- LO X X XC-4 C14 ILO I I N c CF, ' II C � I C4 Ln Mn N w w w i t Kitchen lafd1" N!i^`¢t4D s X I I IIT DATE. N I II - i C" JI v NOTIFI' E UI'_Dir. 705-1802 8!"." .j 0 („fENT AT ' ''.” FOR THE X Existing (3) 2 x 12 /i, z FOI_LO1,vI;qG I. FOU .')AT!0;J ;WO REi�::J17'[D Existing 2x12 FJ FOR I JU?Ela — — 2. Fi0U0 t FR/IP.!i;1,,, c= `';_�1!_ f,'!i, 3. INSULATION 4. FINAL - C&;�".,-;UC T ION P1'L'S T Walls to Be Removed" Si n HUC412 Pack 1Z BE CORPFLETr op C 0 on Both Sides of Beam ALL CONSTRUCTION !;,r;_L M,-7GT THE REQUIREh,1rNTS 0''THE CODES OF NEW YORK STATE. NOTF�LSC0N'S!DLE FOR Existing x 1 (2)0.5"IF /� DESIG,J OR COPJSTRUCTION ERRORS, C 2nd Floor Framing Drawing prepared based on plans prepared by Tast+ Clemancy Architects dated 5/5/1990. A SS14�P Scale: 1/4" = T-0' Condon Engineering P.C. Plans are prepared by Condon Engineering,P.C. It is a violation of the New York State Education 9 Law,Article 145,Section 7209,for any person unless acting under the direction of a licensed Prothe seal of n EnEnggineer, Architect,or L d Surveyor,tis altered, any them in anyway.Engineer,A m bearing or Drawn b : JJC 1755 Sigsbee Road 142 5 Kimberly Lane � the seal of an Engineer,Architect,or Land Surveyor is altered,the altering Engineer,Architect,or y Land Surveyor shall affix to the item his/her seal and the notation'Altered by'followed by his/her Mattituck, New York 11952 signature and the date of such alterations,and a specific description of the alteration. (631 298-1986 Southold New York Date : 1-18-2013 E - Ij1q.' 4 W�r�.c� �c�s. Pt r'� (��� t • �j!�'.N?� ---N4�a >�d-l.- �%�il�•:� T'(PIC.At. 'JINYL Gdh�I r�G� �''N i,�H GLL4tL h/P - Coy tjR,, :5j VIT ^L-1 !'' 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