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HomeMy WebLinkAbout43648-Z ���0`��FF�t'fcG=, Town of Southold 8/13/2019 P.O.Box 1179 0 ?? 53095 Main Rd Southold,New York 11971 V CERTIFICATE OF OCCUPANCY No: 40616 Date: 8/13/2019 THIS CERTIFIES that the building GENERATOR Location of Property: 24975 Route 25, Cutchogue SCTM#: 473889 See/Block/Lot: 109.-1-21 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 4/10/2019 pursuant to which Building Permit No. 43648 dated 4/15/2019 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: ACCESSORY GENERATOR AS APPLIED FOR The certificate is issued to Bums,Patricia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43648 05-15-2019 PLUMBERS CERTIFICATION DATED Authorized Signature s�F oF� TOWN OF SOUTHOLD BUILDING DEPARTMENT N TOWN CLERK'S OFFICE o • SOUTHOLD, NY y,1j01 � a 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#: 43648 Date: 4/15/2019 Permission is hereby granted to: Burns, Patricia 20692 Route 25 Mattituck, NY 11952 To: install a generator as applied for. At premises located at: 24975 Route 25, Cutchogue SCTM # 473889 Sec/Block/Lot# 109.-1-21 Pursuant to application dated 4/10/2019 and approved by the Building Inspector. To expire on 10/14/2020. Fees: ACCESSORY $100.00 CO -ACCESSORY BUILDING $50.00 ELECTRIC $85.00 Total: $235.00 OBuil g Ispector 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. AoAd R 7 ozo 17 New Construction: Old or Pre-existing Building: X (check one) Location of Property: 941757 RAI:.I R0+J . C U+C k8s1LL F- New YWK //?/-3S House No. Street Hamlet Owner or Owners of Property: W illl Am A U RN S Suffolk County Tax Map No 1000, Section /D 17 Block / Lot 2-1 Subdivision Filed Map. nn Lot: ll Permit No. "65TDate,of Permit. Applicant: k.0 WE J'i • �SHN'riS Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: !/ (check one) Fee Submitted: $ �� 1 Applicant-Signature SO!/r�®l Town Hall Annex Telephone(631)765-1802 54375 Main Road cn Fax(631)765-9502 P.O.Box 1179 G Q Southold,NY 11971-0959 ® • yo roger.riche rtl-town.southoId.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Burns Address: 24975 Route 25 City: Cutchogue St: New York Zip: 11935 Budding Permit#: 43648 Section: 109 Block: 1 Lot: 21 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Shore Power Electrical License No: 42536-ME SITE DETAILS Office Use Only Residential X Indoor X Basement X Service Only Commerical Outdoor X 1st Floor Pool New Renovation 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 Wall Fixtures 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 Fixture Time Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other equipment. 22kw standby generator with 200a transfer switch Notes: Inspector Signature: = Date: May 15 2019 81-Cert Electrical Compliance Form.xls SOUIyo� # # TOWN OF SOUTHOLD 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) [ ] CODE VIOLATION ] CAULKING REMARKS: DATE / / INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(1ST) ...................................... 'FOUNDATION (2ND) Z r ROUGH FRAMING& PLUMBING �A y INSULATION PER N.Y: H STATE ENERGY CODE • y FINAL ADDITIONAL COMMENTS 95150 B 2 • 60 t �Z ' � a Z . ,H 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) 765-1502 Planning Board approval FAX: (631) 765-9502 Survey Southoldtownny.gov PERMIT NO. Check , Septfc norm N.Y.S.D.E.C. i Trustees C.O.Application Flood Permit Examined 20 Single&Separate r Truss Identification Form Il Storm-Water Assessment Form Contact: , Approved ,2d Mail to: S AdRE /owlsg Alm tk q Disapproved a/c '/a j4'z,4Aa/rl L,+w t / Phone: l 3/-395- '/OZ9 Exf-G Expiration ,20 D DWG/N oh�Q-u -L (� a � Building Inspector aam� /yA'Ql� RS 0 Hy/113 -P APR 1 0 2019 DAPPLICATION FOR BUILDING PERMIT Date AARi , 201? INSTRUCTIONS ' pliO ;f.TJ a. rffi ca on 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. 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. (Signa r of applicant or name,if a corporation) /d 8 FAd WFgW lad, 64,1i-4-2 CF v76 141V-cc, rte?' (Mailing address of applicant) /!93�4 State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder Name of owner of premises wdk4M CS aAms (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. Plumbers License No. Electricians License No. 1f-oZ S36 /` —F OtherTrade's License No. 1. Location of land on which proposed work will be done: House Number Street Hamlet County Tax Map No. 1000 Section /09 Block -1 Lot �- Subdivision /407 Filed Map No. / Lot Z/ 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 Repair Removal Demolition Other Woo-F S��iyd-by (Description) 4. Estimated Cost Fee 49Ehler?'OR (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 S. 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 14. Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 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: COUNTY OF l/ 1.6 UIS '4. De sf}H*/S being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the Z46 Gk -�' (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 dt ge d belief; and that the work will be performed in the manner set forth in the applicatio i RIN1E A-L7S- tote of Now York Registrption SOI WAS340064 Sworn to before me this} �upfifted In 80161k C06nty 0/,_day of (,� �'I 20 �Om�lo$jOh E�ipites April 11,2020 AMY 1114 WL6 to blit Sigt!�o of Appli an ��P,11E�r08I��� BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 -roger.richertgtown.southold.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: N 1,_�c] Date: o Company Name: Stix e POW&A VaCf.Q"Chl Name: Niahol4s License No.: '+�Z53& ME- email: ,c {o,eE owFa6�Ea c . aft Address: pg omtiv OAA -UW+-i Com+ gs NY / 3 Phone No.: 6 J- 3 yS- Yoa-9 x-o JOB SITE INFORNiATON: (All Information Required) Name: 1 % Il M uRNS Address: q 9 S' &4 o,+d CUL kQ51 CLE, N--1 Cross Street: ,LV #�y .44NE Phone No.. /0 3 - 7 3 9L- 7l0 7 Bldg.Permit#: email: L4ggS Fax Map District: 1 000 Section: f Block: Lot: Z/ BRIEF DESCRIPTION OF WORK(Please Print Clearly) ,�Ns�A/h&q o-P 9.2 Kw 19GNERA-hop. Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES Issued On Temp Information: (Ail information required) Service Size I Ph 3 Ph Size. A #Meters Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected - Underground -Overhead ## Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Paid Pec 82-Request for Inspection Form.As # ��� z V I ' • I 9 � S.C.T.M. NO. DISTRICT: 1000 SECTION: 109 BLOCK: I LOT(S):21 ,I MON A;. EL 42.5 , Alp- �1 VACANT LAND 150` S b59 n , Cm '; Eq 5) ; FRM. SHED MON. ` O TO BE REMOVED / EL 39.3 `; ti� EL I48 PROPOSED 3-4 BEDROOM _,• `� 1gi(4s o SANITARY SYSTEM • ) I low SAL. S.T. T (1) 8'X12'DEEP L.P. ELEV. 47.3 // OL DR BROWN 1.0' EL(42.o)..` \ may LOAM 0�0 tti v^ / BROWN '='� `,?" rs'� �i / / 9POO,c` 'L ML OAMY SAND 2_5' o ::..:.c•• o EL 50.0 �Oe EL 44.5 Cii:.�6.• / OQ P 9 SP PALE O -..; .o) ZS 4 \ BROWN rL0 4ao pl \49.5 s FINE SAND TYPICAL CLEAN OUT SAD TM9 13.5' R , DW LUNG /EUBLIC WATERSLATE OR SUITABLE COVER \ OR150 OPPER PLUG END �D� 1�V>O Ijs'•� i.TYJ \�G (Lu EL 49 FO \, ADS •..':: .C`'�`\��i:.::•': D IS! NO WATER 30 ELBOW 8'W - :t; f_ — 17' 60' WYE \ \ W 06-23-2017 \ ��ti �2� EL 50.2 N �•\ 1'O' 51. ! McDONALD GEOSCIENCE FLOW s9ti 2�,c oo ` eL a �a+.D3Gy�o<. cF z .•\.•\ � �G� ,pogo•\ \, / NON-CONFORMING LOT FRONT: 40' MIN \\ �F �s� SIDE: 15' MIN, 35' TOTAL \ DWEL NG I JELL REAR: 501v1JN d '� `�� ��ti ✓mssc,• �'� THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL \ LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS EXISTING sAN►T EL 50.5 < �• TO BE ABANDONED- \ AND OR DATA OBTAINED FROM OTHERS. AND BACKFILLED WITH CLEAN COARS AREA: 27,138.57 SQ•FT. or 0.62 ACRES ELEVA710N DATUM: ASSUMED SAND \ �5ari�.� \ EL 50,k�� UNAUTHORIZED AL7ERA71ON OR ADD17ION TO THIS SURVEY IS A VIOLATION OF SEC77ON 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID, 7RUE COPY. GUARANTEES INDICATED HEREON SHALL RUN G.V. i \ ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TIME COMPANY, GOVERNMENTAL AGENCY AND LENDING 1NST77U77ON , �.•� LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARAN7EES ARE NOT TRANSFERABLE a EL w1a ,p0 �• THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM 7HE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE old NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE 774E EREC77ON OF FENCES, ADD177ONAL STRUCTURES OR AND OTHER IMPROVEMEN7S EASEMENTS" WELL / ale AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY ' SURVEY OF: DESCRIBED PROPERTY WILLIAM BURNS; / au.P. CERTIFIED T0: /% � �•'• MAP OF: FILED: • �,.�' � GJRO SITUATED AT. CUTCHOGUE TOWN OF:SOUTHOLD =1 NEI TI7 M IYOYCHUK L4ND SURVEM0, PLLC SUFFOLK COUNTY, NEW YORK f Professional Land Surveying and Design ?, C P.O. Bos 153 Aquebogue, New York 11931 FILE # 17-127 SCALE: 1 n=40' DATE: SEPT. 3, 2017 {` PHONE (651)298-1586 FAX (831) 296-1686 N.Y.S. USC. NO. 050882 maintaining the records of Hobart J.Hemeny&Kenneth IL Boyehnfc ' SHORE-4 OP ID:KL CERTIFICATE OF LIABILITY INSURANCE D 08104/20/YY) Q8/04I2018 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(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condition of tho policy,certain policies may require an endorsements A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CO TACT PRODUCER NAME: Hometown insurance of Ll,incas°N o Ext,631-567-1011 Fac No):631-589-4207 Weber Agency EMAIL 5 Orville Drive,Suite 400 ADDRESS: Bohemia,NY 11716 James Small � INSURER(S)AFFORDING COVERAGE NAIC I! INSURER A:The Ohio Casualty Insurance Co INSURED Shore Power Electrical INSURERS:State Insurance Fund 36102 Contracting,Inc. INSURER C:Standard Security Life Ins.Co 69078 108 Frowein Road,#2 Center Moriches, NY 11934 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 D POLICY NUMBER —POLICY MIDDrYYYY MM1�D�Y LIMITS LTR A x COMMERCIAL,9ENERAL LMEILITY EACHOCOVRRENCE $ 1100DIDO DAMAGE TO RENTED CLAIMS-MADE I OCCUR BKO(19)57918685 07/17/2018 D711 712 01 9 PREMISES Ea oceurrencel S 300,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY®JECT 7 LDC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER- $ AUTOMOBILE LIASIUTY COMBINED SINGLE LIMIT S Ea accident ANY AUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED AUTOS BODILY INJURY(Per accident) S NON OWNED PROPERTY DAMAGE S HIREDAUTOS AUTOS (Per [dent) 5 UMBRELLA LIARHCLAIMS-MADE OCCUR EACH OCCURRENCE S EXCESS LIAR AGGREGATE $ OEO I I RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE ER OFFIPROPEMB�E CLUDED?�OTWE Y�NIA 11329705-6 07/20/2018 07/20/2019 E.L.EACH ACCIDENT S (Mandatory In NH) E L.DISEASE-EA EMPLOYEE S if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEA­-POLICY LIMIT S C DISABILITY BENEFIT 79516-00 01/0112018 08/03/2019 STATUTORY LAW DESCRIPTION OF OPERATIONS 1 LOCATIONS J VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Proof of insurance CERTIFICATE HOLDER CANCELLATION TOWN014 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hail Annex Southold,NY 11971 AUTHORIZED REPRESENTATIVE 4 9 .c ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD NEW Workers' YTOARK E Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured(use street address only) 1b. Business Telephone Number of Insured SHORE POWER ELECTRICAL CONTRACTING INC (631)399-4569 108 FROWEIN RD STE 2 CENTER MORICHES NY 11934 1 c, NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically 1d. Federal Employer Identification Number of insured or limited to certain locations in New York State,i.e. a Wrap-Up Policy) Social Security Number 20-4999885 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) The Hartford Casualty Insurance Company Town of Southold 29424 TOWN HALL ANX 3b. Policy Number of Entity Listed in Box"1a": SOUTHOLD NY 11971 12 WEC AB5PSI 3c. Policy effective period: 07/2012018 to 07/20/2019 3d.The Proprietor,Partners or Executive Officers are ❑ Included.(Only check box if all partners/officers included) ® all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box"1a"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 as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due-to nonpayment of premiums 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 may be sent by regular mail.) Otherwise, this Certificate 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"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon 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: Danielle Clausen {{ (print name of authorized representative or licensed agent of insurance carrier) Approved by: 07/19/2018 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 631-589-0100 CA 06.2(9-17) Form WC 88 31 21 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 YORK Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured SHORE POWER ELECTRICAL CONTRACTING, INC 10a FROWEIN RD-#2 6313954029 CENTER MORICHES, NY 11934 Work Location of insured(Only required if coverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations In New York State,he.,Wrap-up Policy) or Social Security Number 20-4999885 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (En�t�ity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York TOWN OF SOUTHOLD � Y P Y TOWN HALL A.NNEY, 3b.Policy Number of Entity Listed in Box"'la' SOUTHOLD, NY 11971 79516-00 3c.Policy effective period 1/1/2018 to 8/3/2019 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. Q B.Disability benefits only. Q C.Paid fatuity leave benefits oily. 5. Policy covers: Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. Q B.Only the following class or classes of employer's employees: Under penalty of perjury,1 certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability andlor Paid Family Leave Benefits insurance coverage as descpqad above Date Signed 8/4/2018 By (Signature of insurance carrier's authoriz d representative or NYS Licensed Insurance Agentof that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DEL/POLICY SERVICES IMPORTANT: If Boxes 4A and 5A are 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,4C or 513 fs checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B 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 and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'compensation Board Employee) Telephone Number Name and Title Please Note. Only Insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those Insurance carriers are authorized to issue Form DB-1213.1. Insurance brokers are NOT authorized to Issue this form. DB-'a°." (10.17) DIBI��12(0Iffl1lfl(I(�II�0II�f1l7illlfllll�Il OjECTMCAL VISM 014 REQUjRED APPROVED AS NOTED COMPLY WITH ALL TO CODES f e/ CODES DATE: B.P.# J /� NEAS W YORK ATE -C aMON&OF FE BY-c Nowm ( $A NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE $ FOLLOWING INSPECTIONS: gpU$TEES 1. FOUNDATION - TWO REQUIRED c FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. F!Nd L - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE I\�CY OCCUPA REQUIREMENTS OF THE CODES OF NEW OCCUPANCY YORKOR STATE. ORECONOSTRUCTONSI BLE FOR DERRORS. USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY GENERAC® GUARDIAN® SERIES - Residential Standby Generators Air-Cooled Gas Engine INCLUDES: Standby Power Rating • True Power'"" Electrical Technology Models G007036-0, G007037-0 (Aluminum - Bisque) - 16 kW 60 Hz • Two Line LCD Multilingual Digital Model G007035-0 (Aluminum -Bisque) - 16 kW 60 Hz Evolution" Controller (English/Spanish/ Models G007039-0, G007038-0 (Aluminum- Bisque) -20 kW 60 Hz French/Portuguese) Models G007043-0, G007042-0 (Aluminum - Bisque) -22 kW 60 Hz • Two Transfer Switch Options Available: _-.-- 100 Amp, 16 Circuit Switch or 200 Amp Service Rated Smart Switch. See Page 4 for Details. _ • Electronic Governor • System Status & Maintenance Interval LED Indicators • Sound Attenuated Enclosure GENERAC' ; • Flexible Fuel Line Connector • Direct-To-Dirt Composite Mounting Pad • Natural Gas or LP Gas Operation • 5 Year Limited Warranty C@us QVI ro • Capability to be installed within 18" (457 mm) LISTED of a building* Note.CUL certification only applies to unbundled units and units packaged with limited circuit switches Units packaged with the Smart Switch are UL certified in the USA only. *Only if located away from doors,windows and fresh air intakes,and unless other- wise directed by local codes FEATURES O INNOVATIVE DESIGN&PROTOTYPE TESTING are key components of O SOLID-STATE,FREQUENCY COMPENSATED VOLTAGE REGULATION. This state- GENERAC'S success in"IMPROVING POWER BY DESIGN"But it doesn't of-the-art power maximizing regulation system is standard on all Generac models.It stop there. Total commitment to component testing,reliability testing,'. provides optimized FAST RESPONSE to changing load conditions and MAXIMUM environmental testing,destruction and life testing,plus testing to applicable MOTOR STARTING CAPABILITY by electronically torque-matching the surge CSA,NEMA,EGSA,and other standards,allows you to choose GENERAC loads to the engine.Digital voltage regulation at±1% POWER SYSTEMS with the confidence that these systems will provide superior performance. O SINGLE SOURCE SERVICE RESPONSE from Generac's extensive dealer network provides parts and service know-how for the entire unit,from the engine to the O TRUE POWER'" ELECTRICAL TECHNOLOGY:Superior harmonics and sine wave ; . smallest electronic component. form produce less than 5%Total Harmonic Distorbon for utility quality power,This allows confident operation of sensitive electronic equipment and micro-chip based appliances, O GENERAC TRANSFER SWITCHES.Long life and reliability are synonymous such as variable speed HVAC systems. with GENERAC POWER SYSTEMS. One reason for this confidence is that the O TEST CRITERIA: GENERAC product line includes its own transfer systems and controls for total PROTOTYPE TESTED NEMA M61-22 EVALUATION system compatibility. SYSTEM TORSIONAL TESTED MOTOR STARTING ABILITY LU 161GE GENERAC SA MobilePROMISE Link • Buff in the USA using domestic and foreign parts GENERAC® ' ' _ 16/20/22 loll features and benefits Engine •Generac(OHVI)design Maximizes engine"breathing"for increased fuel efficiency Plateau honed cylinder walls and plasma moly rings helps the engine run cooler,reducing oil consumption resulting in longer engine life • Quiet Test"" Greatly reduces sound output and fuel consumption during bi-weekly exercise •"Spiny-lok"cast iron cylinder walls Rigid construction and added durability provide long engine life ' *Electronic ignition/spark advance These features combine to assure smooth,quick starting every time -Full pressure lubrication system Pressurized lubrication to all vital bearings means better performance, less maintenance and longer engine life Now featuring up to a 2 year/200 hour oil change interval. -Low oil pressure shutdown system Shutdown protection prevents catastrophic engine damage due to low oil. •High temperature shutdown Prevents damage due to overheating Generator •Revolving field Allows for a smaller,light weight unit that operates 25%more efficiently than a revolving armature generator. -Skewed stator Produces a smooth output waveform for compatibility with electronic equipment. -Displaced phase excitation Maximizes motor starting capability. -Automatic voltage regulation Regulates the output voltage to±1%prevents damaging voltage spikes. •UL 2200 listed For your safety Transfer Switch •Fully automatic Transfers your vital electrical loads to the energized source of power •Remote mounting Mounts near your existing distribution panel for simple,low-cost installation. -NEMA 3R Can be installed inside or outside for maximum flexibility Evolution"" Controls -Auto/Manual/Off illuminated buttons Selects the operating mode and provides easy,at-a-glance status indication in any condition •Two-line LCD multilingual display Provides homeowners easily visible logs of history,maintenance and events up to 50 occurrences -Sealed,raised buttons Smooth,weather-resistant user interface for programming and operations. •Utility voltage sensing Constantly monitors utility voltage,setpoints 65%dropout,80%pick-up,of standard voltage •Generator voltage sensing Constantly monitors generator voltage to ensure the cleanest power delivered to the home •Utility interrupt delay Prevents nuisance start-ups of the engine,adjustable 2-1500 seconds from the factory default setting of 5 seconds by a qualified dealer. •Engine warm-up Ensures engine is ready to assume the load,setpoint approximately 5 seconds •Engine cool-down Allows engine to cool prior to shutdown,setpoint approximately 1 minute •Programmable exerciser Operates engine to prevent oil seal drying and damage between power outages by running the generator for 5 minutes every other week Also offers a selectable setting for weekly or monthly operation providing flexibility and potentially lower fuel costs to the owner -Smart battery charger Delivers charge to the battery only when needed at varying rates depending on outdoor air temperature Compatible with lead acid and AGM-style batteries •Electronic governor Maintains constant 60 Hz frequency Unit -SAE weather protective enclosure Sound attenuated enclosures ensure quiet operation and protection against mother nature,withstanding winds up to 150 mph Hinged key locking roof panel for security. Lift-out front for easy access to all routine maintenance items Electrostatically applied textured epoxy paint for added durability -Enclosed critical grade muffler Quiet,critical grade muffler is mounted inside the unit to prevent injuries -Small,compact,attractive Makes for an easy,eye appealing installation,as close as 18"away from a building. Installation System •1 ft(305 mm)flexible fuel line connector Absorbs any generator vibration when connected to rigid pipe •Direct-to-dirt composite mounting pad Complex lattice design prevents settling or sinking of the generator system. •Integral sediment trap Prevents particles and moisture from entering the fuel regulator and engine,prolonging engine life ` GENERAC® 16/20/22 kW specifications _ Generator Model G007035-0,G007038-0, G007038-0,G007039-0 G007042-0,G007043-0 G007037-0(16 kW) (20 kW) (22 kW) Rated Maximum Continuous Power Capacity(LP) 16,000 Watts* 20,000 Watts* 22,000 Watts* Rated Maximum Continuous Power Capacity(NG) 16,000 Watts* 18,000 Watts* 19,500 Watts* Rated Voltage 240 240 240 Rated Maximum Continuous Load Current—240 Volts(LP/NG) 66.6/666 83.3/75 91 6/81 3 Total Harmonic Distortion Less than 5% Less than 5% Less than 5% fr Main Line Circuit Breaker - 70 Amp 100 Amp 100 Amp Phase 1 1 1 Number of Rotor Poles 2 2 2 Rated AC Frequency_, 60 Hz 60 Hz 60 Hz Power Factor 10 1.0 1 0 Battery Requirement(not included)_ 12 Volts,Group 26R 540 CCA Minimum or Group 35AGM 650 CCA Minimum Unit Weight(Ib/kg) 409/186- 448/203 466/211 Dimensjons.(L x W x H),m/mm 48 x 25-x 29/1218 x 638 x 732 Sound output in dB(A)at 23 it(7 m)with generator operating at normal load** 66 66 67 Sound output in dB(A)at 23 ft(7 m)with generator in Quiet-Test'"'low-speed 58 58 58 exercise mode** Exercise duration 5 min 5 min 5 min E=ngine Type of Engine GENERAC OHVI V-TWI_N GENERAC OHVI V-TWIN_ GENERAC OHVI V-TWIN Number of Cylinders 2 2 2 Displacement 999 cc 999 cc 999 cc Cylinder Block Aluminum w/Cast Iron Sleeve Valve Arrangement Overhead Valve Overhead Valve- _" Overhead Valve Ignition System Solid-state w/Magneto Solid-state w/Magneto Solid-state w/Magneto Governor System Electronic Electronic Electronic Compression Ratio 951 95-1 95.1 Starter 12 Vdc 12 Vdc 12 Vdc Oil Capacity Including Filter Approx 19 qV1 8 L Approx.19 qV1 8 L Approx 19 gl/1 8 L Operating rpm 3,600° 3,600 3,600 Fuel Consumption Natural Gas ft3/hr(m3/hr) 1/2 Load 193(5 47) 205(5.8) 184(5 21) Full Load 312(8 83) 308(8 72) 281 (7 96) Liquid Propane 113/hr(gal/hr)[I/hr] 1/2 Load 69(1 9)[7 21 81 (2 23)[8 45] 78(2 16)18 16] Full Load 116(3 19)[12 071 14.0(3 85)[14.57] 134(3 68)[13 94] Note-Fuel pipe must be sized for full load. Required fuel pressure to generator fuel inlet at all load ranges-3 5-7"water column(7-13 mm mercury)for natural gas,10-12"water column(19-22 mm mercury)for LP gas..For.Btu content,multiply ft3/hr,x 2500(LP),or ft3/hr x 1000(NG) For Megajoule content,multiply m?/hr x_9315(LP)or m3/hr x 37 26(NG) Controls 2-Line Plain Text Multilingual LCD Display _ Simple user interface for ease of operation. Mode Buttons Auto Automatic Start on Utility failure 7 day exerciser Manual ' Start with starter control,unit stays on If utility fads,transfer to load takes place Off Stops unit Power is removed Control and charger still operate Ready to Run/Maintenance Messages Standard Engine Run Hours Indication Standard Programmable start delay between 2-1500 seconds Standard(programmable by dealer only) Utility Voltage Loss/Return to Utility Adjustable(Brownout Setting) From 140-171 V/190-216 V Future Set Capable Exerciser/Exercise-Set Error Warning Standard Run/Alarm/Maintenance Logs 50 Events Each Engine Start Sequence. Cyclic cranking 16 sec on,7 rest(90 sec maximum duration) Starter Lock-out Starter cannot re-engage until 5 sec after engine has stopped _Smart Battery Charger Standard Charger Fault/Missing AC Warning Standard Low Battery/BatteryProblem,Protection and Battery Condition Indication __ Standard Automatic Voltage Regulation with Over and Under Voltage Protection Standard Under-Frequency/Overload/Stepper Overcurrent Protection Standard Safety Fused/Fuse Problem Protection Standard Automatic Low Oil Pressure/High Oil Temperature Shutdown _ _ Standard Overcrank/Overspeed(@ 72 Hz)/rpm Sense Loss Shutdown _ Standard High Engine Temperature Shutdown Standard Internal FaulVlncorrect Wiring Protection Standard Common External Fault Capability Standard Field Upgradable Firmware Standard "Sound levels are taken from the hunt of the generator Sound levels taken from other sides of the generator may be higher depending on installation parameters Rating definitions-Standby Applicable for supplying emergency power for the duration of the utility power outage No overload capability is available for this rating (All ratings in accordance with BS5514,IS03046 and DIN6271) 'Maximum wattage and current are subject to and limited by such factors as fuel Btu/megajoule content, ambient temperature,altitude,engine power and condition,etc Maiamum power decreases about 3 5 percent for each 1,000 feet(304 8 meters)above sea level,and also will decrease about 1 percent for each 6`C(10°F)above 16°C(60'n 16/20/22 kW switch options Limited Circuit Switch Model G007036-0(16 kW) • 16 Circuits No of Pales 2 Current Rating(Amps) 100 • Electrically operated,mechanically-held contacts for fast,positive connections Voltage Rating(VAC) 120/240,10 • Rated for all classes of load,100%equipment rated, both Inductive and resistive Utility Voltage Monitor(Fixed)* -Pick-up 80% • 2 pole,250 VAC contactors -Dropout 65% • 30 millisecond transfer time. Return to Utility* approx 15 sec Exercise bi-weekly for 12 minutes* Standard • Dual coil design. UL Listed Standard Total of Pre-wired Circuits 16 • Rated for both copper and aluminum conductors. No 15 A 120 V 5 • Main contacts are silver plated or silver alloy to resist welding and sticking No 20 A 120 V 5 No 20 A 240 V 1 • NEMA 3R aluminum outdoor enclosure allows for Indoor or outdoor mounting No.30 A 240 V - flexibility. No 40A240V 1 No 50 A 240V 1 • Multi listed for use with 1"standard,tandem,GFCI and AFCI breakers from Tandem Breaker Capability 8 spaces Siemens, Murray, Eaton and Square D for the most flexible and cost effective Install Circuit Breaker Protected Available RMS Symmetrical Fault Current Q 250 Volts 10,000 *Function of Evolution Controller Exercise can be set to weekly or monthly w Dimensions 200 Amps 120/240,10 Open Transition Service Rated Height Width Depth H1 H2 W1 W2 in 2724 1 30.0 114 135 7.09 HS H, mm 692 0 762.4 289 0 3430 1 1800 Wire Ranges Conductor Lug Neutral Lug Ground Lug 2/0-#14 2/0-#14 2/0-#14 Service Rated Smart Switch Features G007037-0(16 kW)/GO07039-0(20 kW)/ • Includes Digital Power Management Technology standard(DPM). Model G007043-0(22 kW) • Intelligently manages up to four air conditioner loads with no No of Poles 2 additional hardware Current Rating(Amps) 200 Voltage Rating(VAC) 120/240,10 • Up to four more large(240 VAC)loads can be managed when used in Utility Voltage Monitor(Fixed)* conjunction with Smart Management Modules(SMMs). -Pick-up 80% • Electrically operated,mechanically-held contacts for fast,clean -Dropout 65% connections Return to Utility* approx 13 sec. • Rated for all classes of load,100%equipment rated,both inductive and Exercise weekly for 12 minutes* Standard resistive. UL Listed Standard Enclosure Type NEMA/UL 3R • Up to four more large(120/240 VAC)loads can be managed when used in ,Withstand Rating(Amps) 22,000 conjunction with 50 amp Power Management Modules(PMM**) Lug Range 250 MOM-#6 • 2 pole,250 VAC contactors *Function of Evolution Controller • Service equipment rated,dual coil design. • Rated for both aluminum and copper conductors w' • NEMA 3R aluminum outdoor enclosure allows for Indoor or outdoor mounting flexibility • Main contacts are silver plated or silver alloy to resist welding and sticking H2 H1 Dimensions 200 Amps 120/240,is Open Transition Service Rated Height Width Depth H1 H2 W1 W2 in 27 24 300 11.4 1 135 709 ° mm 692 0 1 7624 2890 1 3430 1 1800 DEPTH —w2--I GENERAC® 16/20/22 W available accessories Model# Product; Description Generac's Mobile Link allows you to check the status of your generator from anywhere that you have ; G006463-3 Moblle Link"" access to an Internet connection from a PC or any smart device. You will even be notified via e-mail or text message when a change In the generator's status occurs. Available in the U.S.only. G005819-0 ; 26R Wet Cell Battery Every standby generator requires a battery to start the system.Generac offers the recommended 26R wet cell battery for use with all air-cooled standby product(excluding PowerPact®). e G007101-0 Battery Pad Warmer The pad warmer rests under the battery.Recommended for use if the temperature regularly falls below 0°F.(Not necessary for use with AGM-style batteries). G007102-0 Oil Warmer Oil warmer slips directly over the oil filter.Recommended for use if the temperature regularly falls below 0°F. G007103-0 Breather Warmer The breather warmer is for use in extreme cold weather applications For use with Evolution controllers only in climates where heavy icing occurs. G005621 0 Auxiliary Transfer Switch Contact The auxiliary transfer switch contact kit allows the transfer switch to lock out a single large electrical Kit load you may not need.Not compatible with 50 amp pre-wired switches Fascia Base Wrap Kit The fascia base wrap snaps together around the bottom of the new air cooled generators.This offers G007027-0-Bisque (Standard on 22 kW) a sleek,contoured appearance as well as offering protection from rodents and insects by covering the lifting holes located in the base. If the generator enclosure is scratched or damaged,it is Important to touch-up the paint to protect G005703-0-Bisque Paint Kit from future corrosion The paint kit Includes the necessary paint to properly maintain or touch-up a generator enclosure. G006485-0-16,20& Generac's scheduled maintenance kits provide all the hardware necessary to perform complete 22 kW Scheduled Maintenance Kit routine maintenance on a Generac automatic standby generator. Smart Management Module ; Smart Management Modules are used in conjunction with the Automatic Transfer Switch to G006873-0 (50 Amps) Increase its power management capabilities.It provides additional power management flexibility not found in any other power management system. dimensions & UPCs Dimensions shown are approximate Refer to Installation manual for exact dimensions DO NOT USE THESE DIMENSIONS FOR INSTALLATION PURPOSES 6376 mm 1218 mm [25.1 In] 148 O In] — — --- Model UPC 0 G007035-0 696471070354 G007036-0 696471070361 G007037-0 696471070378 7272.. t21BIn] _ G007038-0 696471070385 G007039-0 696471070392 ® O o G007040-0 696471070408 KIM%��%%� / /:/%%/,��!/ %ii;' %' /i�/ G007042-0 696471070422 648 mm / /� //// /// G007043-0 696471070439 [25.5 In] 1282 mm (48 51try LEFT SIDE VIEW FRONT VIEW GENE RAC® Generac Power Systems,Inc. • S45 W29290 HWY..59, Waukesha,WI 53189 • generac.com 92016 Generac Power Systems,Inc All rights reserved All specifications are subject to change without notice Bulletin 10000000194-B 05/18/16