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HomeMy WebLinkAbout45481-Z �O�g�FFQ(k 1o�' Town of Southold 12/21/2020 y� P.O.Box 1179 0 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 41703 Date: 12/21/2020 THIS CERTIFIES that the building GENERATOR Location of Property: 24850 Route 25, Orient SCTM#: 473889 Sec/Block/Lot: 18.-6-5.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/10/2020 pursuant to which Building Permit No. 45481 dated 11/23/2020 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 Stevenson,Thomas&Ors. of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 45481 12/8/2020 PLUMBERS CERTIFICATION DATED -�I-N �)�� Authorize Signature S��Fnc�r TOWN OF SOUTHOLD BUILDING DEPARTMENT c A TOWN CLERK'S OFFICE o • 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#: 45481 Date: 11/23/2020 Permission is hereby granted to: Stevenson, Thomas 24850 Route 25 Orient, NY 11957 To: install generator as applied for. At premises located at: 24850 Route 25, Orient SCTM # 473889 Sec/Block/Lot# 18.-6-5.1 Pursuant to application dated 11/10/2020 and approved by the Building Inspector. To expire on 5/25/2022. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $235.00 kileing I ector o��pF SO(/l�ol Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Southold,NY 11971-0959 0� ® i0 sea n.devlin(c�town.south old.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To. Thomas Stevenson Address: 24850 Route 25 city,Orient st: NY zip: 11957 Budding Permit# 45481 Section: 18 Block 6 Lot: 5.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Shore Power Elec. Cont. License No. 42536ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service X Commerical Outdoor X 1st Floor Generator X New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel 200A A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer SwitchUC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED El Exit Fixtures F1 Pump Other Equipment: 22kWGenerac Generator w/ 200A Whole House Transfer Switch Notes* Generator Inspector Signature: �� Date: December 8, 2020 S.Devlin-Cert Electrical Compliance Form As i 55 Z � pE SOGIy�� # # TOWN OF SOUTHOLD BUILDING DEPT. Ioo765-1802 INSPECTION [ ] FOUNDATION 1ST [ ]- ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ -] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION �] PRE C/O REMARKS: NOAjAite C211 AIUMIAV� - g- 0A DATE INSPECTOR TOWN OF SOUTHOLD–BUILDING DEPARTMENT Ca Gy= Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 �y�• aQ�� Telephone(631) 765-1802 Fax(631) 765-9502 hgps://www.southoldtomm..gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only � PERMIT NO. q6q�J— Building Inspector:_ ector. ' �t, - NOV 1 0 2020 Applications-and forms must be`filled out iri their entirety.,)ricomplete' applications"will',not,be accepted. Wher`e,thd�Applicant isnot the owner;an 4 awneei'Authorizattdri form_ (Page 2)'shall be completed: '� � ° ' 0 v �7�r4�iy riT IOLD Date: Rooto O1IVNER(5)OF'PROPERTY: Name: SCTM#1000- Physical Address: — - ,*iJN—R-0AJ 046,15N_ -=N Y 1/75- Phone /95Phone# Mailing Address: CONTACT PERSON: ' Name: Mailing Address: �-� AJa� W E<<N = o - �.� -9,-Cr-c.As 111 r.—/_L _3!� �0,3/—SAX_6 73 C1. Email L� Phone#: -, DESIGNrPROFESSIONAL INFORMATION: ; Name: C Mailing Address: _ Phone#:4. 3tF— ttpAc� Email:k� wCRI�/eGTh?+�c.-GoK CONTRACTOR INFORMATION: Name: Mali ftg Address: Phone Email.-.#_�e3.1-395^�toot�n /a, amER�leC-7Ric - DE CRIPTION OF-PROPOSED CONSTRUCTION_ El New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: %Otherso-F oUKw Sht Y g,FVLR&� $ ��84> • �o Will the lot be re-graded? ❑Yes E4AIO Will excess fill be removed from premises? ❑Yes ANo 1 PROPERTY11NIFORMATION Existing use of property: Intended use of property: e- -- -br �- Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes WNo IF YES, PROVIDE A COPY. ❑,Che&,Box After Reading:11 owner/contract f/deign professional is responsible for all drainagiand`storm water issues as proidded by Chapter 236 of the Town Code: APPLICATION IS HEREBY MADE to the Building Department�for_the issuance of a BuildingaPermifpursuant to the Building Zone, Ordinance of thaTowri of Southold;suffolk;`County,New York and other'applicable laws,Ordinances or Regula"tions;fog the construction`of'buildings; additions;aiteration's or for removal ordemolitiorias herein desciibed.`The-applicant agrees to'comply With all'applicable laws,�ordiiiances;building coder' housing code and regulations',and to admit authorized inspectors on premises and in buildiing(s)for necessaryinspections.False statements,rriade herein are =punishebl"e as"aClass A misdemeanor pursuant to section 230:45 of the Neuf York State Penal Application Submitted By(pri name : /.pu,ji-fS RS(Authorized Agent ❑Owner Signature of Applicant: Date: lr—Q-24 ZO STATE OF NEW YORK) IVY COUNTY OF LacA4.S Dr-S ,y`!S being duly sworn,deposes and says that Ohe is the applicant (Name of individual signing contract) )aabove named, As 4)he is the sig7 (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/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of / V tw V- . 209-0 Notary Public q',f blee$1210 Of rwyw 0'o01640594kSd/oikc PROPERTY OWNER AUTHORIZATION _Cama�Exsioo Expires MarcA 20� (Where the applicant�is not the owner) Ptd A 4P os 440, residing atAgjT0 H i�(RJ., Qgf:&i4 j Iy /�QS7 do hereby authorize koas to apply on my be a f tote own of Southold Bu ilding Department for approval as described herein. 006-<V� /I-?- Owner' ignature Date Print Owner's Name 2 + q�FFftt � BUILDING DEPARTMENT-Electrical Inspector ,:S QG TOWN OF SOUTHOLD 01*4 Town Hall Annex- 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631),765-9502 „roaerrCa�southoldtownny.gov sea nd0-southoldtownny-gov. ~ ` •- -- - APPLICATION FOR ELECTRICAL- INSPECTION. ELECTRICIAN INFORMATION (All Information Required)' Date: 8-020 Company Name:- S ho AE ._Pa wm G/P_c Ai C,+1 C°o w7�RACokq .Z_ ',!C• - - Name: N i r h-aLts D '�M�C0 License No.: df A 536 M E email: N ir,K@ SIIoRe co�RE c i s . co/►� Address: wr—f v 9A-A-u#4;*-A, C Rmoacchaz 14 117.5* Phone No.: JOB SITE INFORMATION (All Information Required) Name: - Address: �Lt S,j`o /�/�tiw a,g,cl OAS,eW •j / _ S 7_ Cross Street: Phone No.: 3/-3a 3 Bldg.Permit#: L4 ex(20 email: A Tax Map-District: 100 Section: I_ __ _---Block: (o ,_ Lot: S. BRIEF DESCRIPTION OF WORK (Please Print Clearly) ,4//i4ou a.� ,KW E1JElekC .G`ENP_RAfoR Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES NO issued-On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: __ , A #Meters - Old Meter# New Service_ Fire Reconnect- Flood Reconnect-Service Reconnected- Underground-Overhead #Underground Lateral's 1 2 H Frame - Pole Work done-on Service? Y N Additional Information:. PAYMENT,DUE WITH APPLICATION-- Request for Inspection FormAs ��` EW YORK Workers' CERTIFICATE OF INSURANCE COVERAGE 1'1;'* Board 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 108 FROWEIN RD-#2 6313954029 CENTER MORICHES,NY 11934 Work Location of Insured(Only required if coverage is specifically limited to 1 c Federal Employer Identification Number of Insured certain locations in New York State,r e.,Wrap-Up Policy) or Social Security Number 20-4999885 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold � tY P Y Town Hall Annex 3b.Policy Number of Entity Listed in Box"1 a" 54375 Route 25 79516-00 Southold, NY 11971 3c Policy effective period 1/1/2018 to 11/8/2021 4. Policy provides the following benefits Fol A.Both disability and paid family leave benefits ❑ B.Disability benefits only. C.Paid family leave benefits only 5 Policy covers: no A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B.Only the following class or classes of 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 and/or Paid Family Leave Benefits insurance coverage as descr6,ed above. F Date Signed 11/9/2020 By Y'' zY r '-' °f (9gnature of insurance carder's authorjz;d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/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 413, 4C or 5B is 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 NYSWorkerd Compensation Board(only if Bnx4Cor 5Bof Part 1 hasbeen 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 (9gnature of Authonzed NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note: Only insurance carvers 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-120.9. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) III�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIIIIIIIII NEW Workers' CERTIFICATE OF RK STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only 1 b.Business Telephone Number of Insured 631-395-4029 Shore Power Electrical Contracting,Inc. 108 Frowein Road,#2 1c.NYS Unemployment Insurance Employer Registration Number of Insured Center Moriches,NY 11934 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up 1 d.Federal Employer Identification Number of Insured or Social Security Policy) Number 20-4999885 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Hartford Casualty Insurance Company Town of Southold Town Hall Annex 3b.Policy Number of Entity Listed in Box"1 a" 54375 Route 25 12WECABSPSI Southold,NY 11971 3c.Policy effective period 07/20/2020 to 07/20/2021 3d.The Proprietor,Partners or Executive Officers are Included.(only check box if'all partners/officers included) X 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 mall.) 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 Workers'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: Shannon Carlson (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 1�k44terL Caen 11/09/2020 (Signature) (Date) Title: Certificate Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier: 631-567-1011 Ext 352 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(9-17) www wcb.ny.gov SHORE-4 OP ID:SPC Acosz® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/0912020 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 Hometown Insurance of LI,Inc NAME: Anna Olmedo Weber Agency A/CONNo Ext:631-567-1011 FAX No):631-589-4207 5 Orville Drive,Suite 400 n DRESS :A01medo@Hometownlnsurance.com Bohemia,NY 11716 James Small INSURERS AFFORDING COVERAGE NAIC# INSURER A:The Ohio Casualty Ins.Co. INSURED Shore Power Electrical INSURER B:Hartford Casualty Ins CO 29424 Contracting,Inc. INSURERC: 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 ADDL SUB POLICY EFF POLICY EXP LTR NSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ® (OCCUR BKO 21 57918685 07/17/2020 07/17/2021 DAMAGE TO RENTED) PREMISES Ea occurrence 300000$ s 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 a CT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSIJAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 12WECABBPSI 07/20/2020 07/20/2021 E L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y❑ NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is requlmd) Proof of Insurance. CERTIFICATE HOLDER CANCELLATION 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 Hall Annex 54375 Route 25. AUTHORIZED REPRESENTATIVE Southold,NY 11971 AA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD LiwdA A-pos+'4L- 024 82 okisk+, NY J[gS'7 S�cIS � ALK Io- �t�� Ip �'' I -/v C?crte� �s-�s-4v LR It a - � w :,t4 �• --oma: W Y d ! ' t7i Z!� f03V eU M co a Cl f ! a 1'+1 n g Ya P.O.B. S 48'411400"i 1 S 48*49'UO"W kRCEL 4 18,3.07° - .c '''� 129.' 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