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HomeMy WebLinkAbout42624-Z Town of Southold 5/3/2018 P.O.Box 1179 gy' 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 39626 Date: 5/3/2018 THIS CERTIFIES that the building WINDOWS Location of Property: 25705 CR 48, Cutchogue SCTM#: 473889 Sec/Block/Lot: 84.-2-2.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/30/2018 pursuant to which Building Permit No. 42624 dated 4/30/2018 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: REPLACEMENT WINDOWS IN AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Richert,Kenneth&Callahan,Danielle of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED t o ' e Signature SVFFot,r, . TOWN OF SOUTHOLD cPa BUILDING DEPARTMENT 4 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#: 42624 Date: 4/30/2018 Permission is hereby granted to: Richert, Kenneth 25705 CR 48 Cutchogue, NY 11935 To: Install replacement windows (19) as applied for Replaces BP# 39423 At premises located at: 25705 CR 48, Cutchogue SCTM # 473889 Sec/Block/Lot# 84.-2-2.2 Pursuant to application dated 4/30/2018 and approved by the Building Inspector. To expire on 10/30/2019. Fees: PERMIT RENEWAL $100.00 Total: $100.00 (k, Building Thspector TOWN OF SOUTHOLD BUILDING DEPARTMENT a ' TOWN CLERK'S OFFICE Py . 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#: 39423 Date: 12/16/2014 Permission is hereby granted to: Richert, Kenneth & Callahan, Danielle 25705 CR 48 Cutchogue, NY 11935 To: install replacement windows (19) as applied for At premises located at: 25705 CR 48, Cutchogue SCTM # 473889 Sec/Block/Lot# 84.-2-2.2 Pursuant to application dated 12/9/2014 and approved by the Building Inspector. To expire on 6/16/2016. 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 I%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: � �j� �/0'/2. y1 :&e � G House No. Street Hamlet Owner or Owners of Property: 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: $ Applicant Signature f� V OE SOUI�o s �o �yc0UNT1,� TOWN OF SOUTHOLD BUILDING DEPT. 765-16®2 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] ULATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE INSPECTOR FIELD INSPECT =PORT DATE ColyMENTS � t4 FOUNDATION(1ST) FOUNDATION(2ND) ROUGH FRAMITTG& H PLUMBING INSULATION PER,N.Y. y STATE ENERGY CODE • • V FINAL , • AJ1TixT�Oi��G"C�I�1YiEi�TS'K"'S 39 Li Ll . rn . o • z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying9 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. 39��3 Check Septic Form N.YSDEC. Trustees C.0 Application Flood Permit Examined Single&Separate Storm-Water Assessment Form Contact: Power Home Remodeling Group Approved 20 Mail to- 2501 Seaport or Disapproved a/c Chester,PA 19013 Phone. 888-736-6335 x3440 Expiration _ Building Inspector DEC 014 APPLICATION FOR BUILDING PERMIT _ Date 11/26 ,20 14 INSTRUCTIONS BLDG DEPT y TOIiii,,i lhisdp�ili'6dtibnMUST b_e_ompletely filled in by typewriter or in ink and submitted to the Building Inspector with 4 --sets-of-plans,accurate plot plan to scale Fee according to schedule. b Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant Such a permit shall be kept on the premises available for inspection throughout the work e No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter,a new permit shall be required APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as herein described The --ap hcan grees to-complywith-all-a =jaws,ordinances,building code,housing code,and regulations,and to admit auoriinVect�rs IWpre 4�iise , building"for'necessary,"inspectons r a s T Power Home Remodeling Group I I i i DEC - 9 2014 ,,; Ll ignature Qf6a gl'ipa icor Mair ei(��ci gralio' .t g i1^ �P.`_ `N'It:� f' tea. { u l E t C •A 501 Seap Dl 'hesJer� 1 lilili %r 4• a.y^ c 5 i 3 aim d pica I BI DG DEPT ,a ����,,,,�� State whether applicdti0 is owner,le see,agent,architect,engineer,general ccfnfractoi lL�otrisian,pit ffi'b - - -- — NOTIFY BUILDING DEPARTMENT AT Agent 765-1802 8 AM TO E PM FOR THE FOLLOWING INSPECTIONS' Name of owner of premises Kenny and Danielle Richert 1 FOUNDATION-TUVnkF(ii-iiR=E1 (As on the tax roll or latest deed) POURED CONCRETE If applicant is a corporation,signature of duly authorized officer 2 ROUGH-FRAMING PLUMS NG, STRAPPING, ELECTRICAL & CAULK!NG (Name and title of corporate officer) 3 INSULATION Builders License No. 4 FINAL-CONSTRUCTION &ELECTRICAL Plumbers License No. MUST BE COMPLETE FOR C 0 Electricians License No. ALL CONST RUCTION SHALL MEET THE Other Trade's License No. REQUIREMENTS OF THE CODES OF NEW 1. Location of land on which proposed work will be done: YORK STATE `NOT RESPONSIBLF FOR 25705 CR-48 W,Peconic,NY 11958 DESIGN OR CONSTRUCTION ERRORS House Number Street Hamlet l County Tax Map No. 1000 Section Block,�C 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 single family dwelling b. Intended use and occupancy 19 vtv.yl v-cp�a�cw+,,� 3. Nature of work(check which applicable):New Building Addition Alteration x Repair Removal Demolition Other Work (Description) 4. Estimated Cost 13,004 Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Rear Depth Height Number of Stories 9. Size of lot:Front Rear Depth 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13.Will lot be re-graded?YES_NO Will excess fill be removed from premises?YES_NO 25705 CR-48 W,Peconic,NY 11958 14.Names of Owner of premises Kenny and Danielle Richert Address Phone No. (631)734-8235 Name of Architect Address Phone No Name of Contractor Power Home Remodeling Group Address 2501 Seaport or Chester Phone No. 888-736-6335 x3440 PA,19013 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NO *IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 18.Are there any covenants and restrictions with respect to this property?*YES NO * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS = c OUNTY OF A mN C Steve Likoff being duly sworn,deposes and says that(s)he is the applicant y70 rn z (Name of individual signing contract)above named, ca o D�y w z y )He is the Agent T m'4 m n o v n C (Contractor,Agent,Corporate Officer,etc) > .n y Cr v C_y" N,A— f said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application, o mo at all statements contained in this application are true to the best of his knowledge and belief;and that the work will be z rfonned in the manner set forth in the application filed therewith N Z Sworn to before me this ) day of -o`�T�F 20 N Signature of Applicant Scott A. Russell ``J� r��,r�� STORMWA SUPERVISOR �`�', (�`� �� �vJtA\NA\GJEI�v]C1EN`]C' l � - SOUTHOLD TOWN HALL-P.O_Box 1179 V!__ Z0 53095 Main Road-SOUTHOLD,NEW YORK 11971 `own of Southold CHAPTER 236 - STo121VWATER MANAGEMENT WORK SHEET (TO BE COMPLETED BY THE APPLICANT ) IDES THIS PROJEC r INVOLVE ANY OF THE F'oI.LOWIN&. YeS KRECK ALL THAT APPLY)IN r ❑ . Clearing, grubbing, grading or stripping of land which affects more r than 5,000 square feet of ground surface. ❑ B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. e_pxprti�n an s e hi �Yc�el fee vertical rise to 100 feet of horizontal distance. ❑ D. Site preparation within 100 feet of wetlands, beach, bluff or coastal ; erosion hazard area. y E ❑ E. Site preparation within the one-hundred-year f loodplain as depicted on FIRM Map of any watercourse. ❑ 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 Cbeck List Form to the Building Department with your Building Permit Application. APPLICANT: (Property Owner,Design Professional,Agent,Contractor,01 her) S-C.T'R9. 1000 Date: NAME. - 5ecUon Black Lct - - t.FOP1_t�(Li .X L)1_f :7L,';wiF IV'E I);, . 01 1127 J Contan Informal lam x S4 4 L :.cv.c,uetj l.y. Da!e- rPfoperty Addjess / Location of Construction work: - - - - -- — - - - - Fiff t�...�%I` "l v_w—_ - ---- — r;nurr�•ed icr prclre,�r:;13.ontr l i-Tin �/_ -- -/� 51orn;��.atc°r ;��lat.,:get71°:n: Control :'lar;�.,, i:cc.;tred. 1 ecolki G V�+� ��'"1 �� - - - ❑ �101fiiJrJlCr it'j,In""')Cilr:`J1; -Cr:l1O( :'(�fi 15 Re(:wrefl' - --- �;-J .'r.7s�l0�tlJ.r:rCf',ti;int r•f;"tCil .O:i'�C.les•'; STATE OF NEW YORK WORKERS'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 1 a.Legal Name and Address of Insured(Use street address only) 1 b.Business Telephone Number of Insured 610-874-5000 Power Home Remodeling Group LLC Ic.NYS Unemployment Insurance Employer Registration 290 Broadhollow Road Suite 220E Number of Insured Melville, NY 11747 1 d.Federal Employer Identification Number of Insured or Social Security Number 233030708 2. Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Arch Insurance Company Town of Southold 3b.Policy Number of entity listed in box"Ia": 53095 Route 25 11DBL9519600 P.O. Box 1179 Southold NY 11971 3c.Policy effective period: 1/1/2014 to 12/31/2014 4.Policy covers: a. 0 All of the employer's employees eligible under the New York Disability Benefits Law b. F1 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 12/17/2013 By (Signature of insurance carrier s au orized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 646-563-5824 Title AVP Accident&Health 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 carver, this certificate is COMPLETE Mail it directly to the certificate holder If box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd 8 of the Disability Benefits Law It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,20 Park Street,Albany,New York 12207 PART 2.To be completed by NYS Workers' Compensation Board (Only if box"4b" of Part 1 has been checked) State Of New York Workers' Compensation Board According to information maintained by the NYS Workers'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) POWER-1 OP ID: EL �coRO° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/11/2014 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 endorsement(s). PRODUCER CONTACT NAME: Lacher&Associates Ins Agency PHONE 215-723-4378 FAXIC'No):215-723-8604 Lacher Insurance Group 'V No Ext 632 E Broad St P 0 Box 64398 E-MAIL ADDRESS: Souderton,PA 18964 Chad Lacher INSURERS AFFORDING COVERAGE NAIC# INSURER A:Harleysville Preferred Ins.Co 35696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Co 26182 LLC INSURER C:Nationwide Mutual Ins Company 23787 2501 Seaport Drive,Suite 8110 Chester,PA 19013 INSURER D:Pennsylvania Manufacturers 12262 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 XO MPA00000089793N 10/01/2014 10/01/2015 DAMAGETORE ED 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY DO JET 7 LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY EO a.identSiNGLE LIMIT $ 1,000,000 B X ANY AUTO BA 00000089796N 10/01/2014 10101/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOSAUTOS Per accident UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C X EXCESS LIAB CLAIMS-MADE CMB00000089794N 10/01/2014 10/01/2015 AGGREGATE $ 10,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER YIN D ANY PROPRIETOR/PARTNER/EXECUTIVE 2014006620967 10/01/2014 10/01/2015 E.L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,descnbe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ B Mass Auto BA OO000018227P 10/01/2014 10/01/2015 Auto Liab 1,000,000 B NY Auto BA 00000074849R 10/01/2014 10/01/2015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached,f more space Is required) CERTIFICATE HOLDER CANCELLATION SOUTNY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Route 25 P.O.Box 1179 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS'COMPENSATION INSURANCE COVERAGE In.Legal Name&Address of Insured(Use street address only) 1b.Business Telephone Number of Insured Power Home Remodeling Group, LLC 610-874-5000 2501 Seaport Drive Suite 13110 lc.NYS Unemployment Insurance Employer Chester PA 19013 Registration Number of Insured Work Location of Insured(Only required if coverage is spec kally Id.Federal Employer Identification Number of Insured limited to certain locallons in New York State, Le., a Wrap-Up or Social Security Number Policy) 23-3030708 i 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Pennsylvania Manufacturers'Association Insurance Company 3b.Policy Number of entity listed in box"In" Town of Southold 201400 6620967 53095 Route 25 P.O. Box 1179 Southold NY 11971 3c. Policy effective period f 1011/14 to 10/1/15 3d. The Proprietor,Partners or Executive Officers are E] included. (Only check box Kan partners/oficeralndaded) all excluded or certain partners/officers excluded. Thin certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"la" for workers' compensationundertheNewYorkStateWorkers'CompensationLaw.(To use this form,Newyork(NY)mustbellstedunderItem 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier orits licensed agentwill send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notify the above cert;ficate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otherwise,this Certs,f icate is valid for one year after this form Is approved by the Insurance carrier or its licensed agent,or until the policy expiration date listed in box 1*114 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: Y ' �2 IL (JJ o�—C-/,I-C(-�- (Print name of authorized representative or licensed agent of insurance cam ) Approved by: C 4 q Z /L( (Signature) (Da e) Title: (, p oC— (,tX l/—ne Telephone Number of authorized representative or licensed agent of insurance carrier: 610 30 DSII Please Note.Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to Issue it. C-105.2(9-07) www.wcb.state.ny.us Zln 01�I • ANSI mgo., 'AN a omdb ,�I, a A-A') ti a" ZA R, Nyll MILE ISt of L abor, Licensing & U 'o,1k County A artmen -a Consumer Ap. if,� VETERANS.MEMORIAL HIGHWAY *' HAUPPAUGF,,,NEW YORK 11718 8 -vY E -,417i2011 48568-H 4q., _ DATRISSUD. -StW" ',_0,LK,Q0UNTT I --t -C-o n trap t License I1 r am m.110-I - . Hin ARRING This is-to certify that XYLE1 B doing businessas , ,t6'WER.,HOME,-IRE-MbliELIN6,6RO.UP-LLC 6 require'm' 'ents.set B T jn havin' umished'th x�h o.t iep•rovisi6fis of aTplicable I rules 9 aws and regulation'softhe,Couny'of Suffolk,StaI6 ofNiw-Yrik Is her6bylkensed t6,c� et businesg,aa H01ffi . IMPROVEMENT'CONTRACTOR, in the, 'oi6t .of Suffolk. License Category 90 NOT VALID WITHOUT AdditionalRusinesses GC DEPARTMENTAL SEAL Z21 AND A CURRENT CONSUMER AFFAIRS ID CARD &XIV 16L Rp IRS— I y I yfffff. 34am v q "t'y -a;v �;W _22si�, 010 N"O" g:Eve �@A Of,!0 -1,�w ��"±'gin nJ` � �� `-�7<-��\ INN f's '6�/,1,16 '10"um _0 %N W, V ORR D 4( IN "qp CIMGOFS3461 UTHO IN U SA MP,qhtsReserved NATIONAL HEADQUARTERS -�,. Kenny Richert and Danielle Ichert 2501 Seaport Drive,Chester,PA 19013 _ v, _ ;/OWER 31-31013 November 09,2014 .;�;; >>. Home Rertaticl Gtou 888-REMODEL e 0" 7-7777Z. _ 1440776 PRODUCT SPECIFICATIONS 48568-H Buyer(s)'Information and Description of the Property: Project Number: 31-31013„ November 09,2014 Kenny Richert (631)872-4679(Danielle's Cell) Date of Agreement Danielle Ichert seegersb2@optonline.net 25705 CR-48 W (631)734-8235(Kenny's Cell) E-Mad Address 1 Peconic,NY,11958 County:Suffolk Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date:Your pre installation inspection is tentatively scheduled for Thu 11/20 between 10:00a and 11:00a. Windows -SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows only,welded corners,foam injected frames, Sashlite technology, Heatshield, Duraglass, exterior custom capping, installation, clean up and haul away of all job related debris. It is agreed and understood by and between the parties that the Product Specifications,along with the Custom Remodeling and Improvement Agreement,constitutes the entire understanding between the parties,and replace any and all prior negotiations, representations,or agreements,either written or oral. The Product Specifications may not be changed, modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 3 page agreement. Power Home Remodeling Group Buyer(s) Buyer(s) /11/09/14 /11/09/14 /11/09/14 Signature of Remodeling Consultant Signature Signature Timothy Spadaro Kenny Richert Danielle Ichert 1462179 YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. November 09, 2014 14:24 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIII Page 1 of 3 NATIONAL HEADQUARTERS Kenny Richert and Daniellelchert 2501 Seaport Drive,Chester,PA 19013 . „ <a EWER . 31-31013 _- w, �_.;--•.W '^a..H- � Gm�P-: Rp, ll,9 . , November 09,2014 .. 1888-REMODEL .�,�.w � � .� - 1440776 Project Specifications 48568-H Windows- kitchen 1 47.0'x39.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Gnd Pattern: None I Removal Wood I Additional Details None t=3 Windows: downastairs bathroom(left side of house) 1 24.0'x37.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None I-,DO Windows: office 1 32.0'x37 0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None U OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: living room 3 40.0'x49 0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None k�? Windows: riley room 2 32.0'x37.5' WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White. Grid Pattern: None I Removal Wood I Additional Details None Windows: master bedroom 2 32.0'x37.5' " WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS Color White/White: Grid Pattern: None I Removal Wood I Additional Details None t November 09, 2014 14:24 IIIIIII IIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIII�I Page 2 of 3 NATIONAL HEADQUARTERS Kenny Richert and Danielle lchert 2501 Seaport Drive,Chester,PA .9013 31-31013 R-MM"G November 09,2014 888-REMODEL 1440776 Project Specifications 48568-H Windows: master bedroom bath 1 32.0"x37.5" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None 71 -J0 , Windows: brody room 3 32.0"x37.5", WINDOWS: Models SL 2700 Styles Double Hung Types None Conligs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: garage 2 32.5"x37.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: shutters 3 1.0"X1.9, WINDOWS: Models SL 2700 Styles Shutters Types No Hinge Configs Panel OPTIONS: ColorWhite I Additional Details None IMAGE NOT AVAILABLE November 09, 2014 14:24 VIII VIII IIII IIIIII IIIII IIIII VIII VIII IIII IIII II Page 3 of 3