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HomeMy WebLinkAbout47311-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 47311 Date: 1/10/2022 Permission is hereby granted to: Haag Jr, James PO BOX 28 Orient, NY 11957 To: install generator as applied for. At premises located at: 4725 Orchard St., Orient SCTM # 473889 Sec/Block/Lot# 27.-2-2.6 Pursuant to application dated 12/9/2021 and approved by the Building Inspector, To expire on 7/12/2023. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $235.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-95021ttp _' t. outlldtonv.tt Date Received APPLICATIONIPERMIT--= For Office Use Only t PERMIT N0. _ Building Inspector Applications and forms must be filled out in their entirety.Incomplete applications will not be"accepted. Where the Applicant Is not the owner,ars Owner's Authoriaation'form(Page 2)shall be completed. Date: t?UVNER(5)OF PROPERi'y Name:James Haag SCTM # 1000- 02 oZ Project Address:4725 Orchard St Orient, NY 11957 Phone#:631-902-6452 1Email:jamesfhaag@yahoo.com Mailing Address:4725 Orchard St Orient, NY 11957 CONTACT,PERSON: Name:Chris Tyndall Mailing Address:285 Pulaski Street Riverhead, NY 11901 Phone#:(631)831-8569 Email:ctyndall@commanderpowersystems.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Standard Electric Corp Mailing Address:6500 Jericho Tpke, Suite 22E Syosset, NY 11791 Phone#:(516) 499-7354 Email:cbrutto@standardelectriccorp.com DESCRIPTION OF PRPPOSED.CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: El Other Install new Kohler 20 KW standby generator(nat gas) $10,500.00 Will the lot be re-graded? ❑Yes @i No Will excess fill be removed from premises? Dyes No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES, PROVIDE A COPY. Chea-Rox After R (n . The owner/contractor/design professional 4-responsible for all drainage and storm water issues proulded by Chapter 236 of the Town Code.APPLICATION IS HEREBY MADE to the Building Department for the issuance of aBuIlding 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,alterations,or for renoital or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,budding code, i housing code and reulations and to admit authorized Inspectors on premises and in building(s)for necessary inspections.False statements made herein are + punishable as a Ctass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): V 2��� L�Authorized Agent ❑Owner Signature of Applicant: / Date: M STATE OF NEW YORK) SS: COUNTY OF ) (�tulbeing duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the (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 20 c�: Ric PIooTT vc- make o - or tav P 1P16166611 Qualified in Nassau County My commission Expires y 21, 2023 DROPERT tf� AUTHORIZATION (Where the applicant is not the owner) residing at � rI �` / `` - do hereby authorizeC&-,-4V1 to apply on my behalf o the Town of Southold Building Department for approval as described herein. OLr'sSignature j Datf Print Owner's Name 2 BUILDING DEPARTMENT- Electrical Irisector _ TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO B179 .' Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 roerr�so�tholdtownnv Dov seand�so�tholdtowrinov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: _ Name: LicenseNo.: - t-I _4g email: rrlt '' � Com Address: _ r �NC, `' ` Niq ilk Phone No.: g g Q JOB SITE INFORMATION (All Information Required) Name: Address: - Cross Street: -� /Vy // Phone No.: Bldg.Permit#: email: , co,✓t Tax Map District: 1000 Section: Block: -£ Lot: BRIEF DESCRIPTION OF WORK_(Please Print Clearly) Ln—S4g. .0 o LLA 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 SizeQ Phg 3 Ph Size: 00 A # Meters Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected - Underground - Overhead Underground Laterals(/--, 2 H Frame Pole Work done on Service? Y { Additional Information, PAYMENT DUE WITH APPLICATION Request for Inspection Formals T =rt =- �; _� _ IOT 450.00 fe _ -_-d s 3 _ - Z J . a Ain s =Y ye ACE 6= BULDWG L _ E i Workers' ST PK ATECompensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be comoleted by tai bitity and Paid Famiiy Leave Bene its Carrier or Licensed Insurance Agent or that Carver 1 a.Legal Name and Address of Insured tUse street address only) 1 b.Bus.ness Telephone Number of instar ed Standard Electric Corp ' (516)819-8684 Calogero Brutto 6500 Jericho Tpke 1c. Federal Employer Identification Number or Social Security I Syosset, NY 11791 Number 20-8322723 Work Location of Insured(Only required if specifically limited to certain locations in New York State,i.e,a Wrap-Up Policy) 2. Name and Address of Entity Requesting Proof of Coverage ` 3a.Name of Insurance Ca-ri r i (Entity Being Listed as Certificate Holder) Standard Security Life Town of Southold 3b.Policy Number of entity listed in box"1 a": 62310-00 Main Road POBox 1179 t 3c. Policy effective pedod:3126/2010 to 3126/2021 PO B i Southold. NY 11971 4. Policy provides the following benefits: X A. All for the employer's employees eligible under the New York Disability Law _B. Only the following class or classes of employer's employees: I —C. Paid family leave benefits only i 5. Policy covers: I X 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: I Under penalty of perjury, I certify that 1 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 November 23, 2020 : David M Boru (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone No. 631 673 7600 Name and Title: President IMPORTANT: If box 4a is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for the purposes of Section 220,Sub.8 of the Disability Benefits Law. It must be mailed for completion to the Workers'Compensation Board, DB Plans Acceptance Unit,328 State Street, Schenectady, New York 12305 PART 2.To be com leted by the NYS Workers ComilLensation Board 0 ily if Box 4C or 5B of Part 1 has been checked I State of New York t Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named-insured employer has complied with the NYS Disability Benefits Law with respect to all or his/her employees. Date Signed By (Signature of NYS Workers'compensation Board Employee) Telephone No. Title: Please Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS license insurance agents of those insurance carriers are authorized to issue Form DS-120.1. Insurance Brokers are not authorized to issue this form. DB-120.1 (10-17) Additional Instructions for Form DB-120.1 By signing this form,the insurance camer identified in box"3"on this form is certifying that it is insuring the business ess referenced in box"la"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in box 7. The insurance `er must notify the above certificate holder and the Workers Compensation Board within 10 days IF a policy is cancelled 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 insuredfrom v indicated on this Certificate. (These nom 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 natter 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note.Upon the cancellation of the disability and/or paid family leave benefits policy indicated this form, N the business continues to be named on a permit,license or contract issued by a certificate holder,the business crust provide that certificate bolder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW 220. Subd. 8 (a)The head of a state or municipal department, board,commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board,commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits,and after January first, two thousand eighteen,the payment of family leave benefits has been secured as provided be this article. WWorkers' CERTIFICATE Yo STATE Compensation NYS WORKERS' COMPENSATION INSURANCE Board 11 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Standard Electric torp {516}519-6584 alogero Brutto 1 c.NYS Unemployment Insurance Employer Registration Number of 5001ericho Tpke ;Insured Syosset,NY 11791 i td.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 2 .3322723 I I certain locations in New York State,i.e.,a Wrap-Up Policy) 3 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier i (Entity Being Listed as the Certificate Holder) ( P&C Insurance Co of Hartford Town of Southold 13b.Policy Number of Entity Listed in Box"la" 154375 Main Road 12WECAC1771 PO Box 1179 l 3c.Policy effective period Southold,NY 11971 12/23/2020 to 12/23/2021 I The Proprietor,Partners or Executive Officers are included. (only chick Brox it all parinerslollficers included)all ❑ excluded or certain partnerstofficers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 a"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 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: Borg& Borg Inc., David M Borg President (Print name of authorized representative or licensed agent of insurance carrier) 114,23r2020 Approved by: (Signature) (Cate) Title:—Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-673-7600 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 ACCM CERTIFICATE OF LIABILITY INSURANCE DA Uff' DI 20 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. IMPORTANIT. If the certificate Wder is an ADDITIONAL D,the Ito s)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the P0.certain policies may require an endorsement A statement on this certificate does not confer tights to the certificate holder In lieu of such end- r1t(a PRODUCER Borg Inc. n 143 East Main Street ' •6311151-171 Huntington NY 11743 1 m 01311 APPOROM HMO A:Merchants Mutuat Inwanoo 23329 INSURED STAN-LE41 t a:P S C Iris Co of Ha ord 90 Standard I<leic Corp a and Sema Cal O Blottoumm 5500 Jericho Tpke. D Syosset NY 11751 INSUAW s: 1 F: CO CIES CERTIFICATE NUMBER:40014386 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. ISR TYPE OF INSURANCE _POt,ICY NUMBnangm= - LIMITS A X COMMERCMGEXERALUA81U Y BOP1063594 2/1/2020 2/112021 EACHOCCURRENCE 51,000,000 _ CLAIMSADE OCCUR 4M $500.000 MED EXP(Ag one person) $15.000 PERSONAL 15.000PERSONAL&ADV INJURY S Included GI N1 GAT! LIMIT APPLIES PER: I GENERAL AGGREGATE 52,000,000 POLICY !ECT LOC PRODUCTS-COMPICPAGO $2,000.000 S A AUTOMOBILELL48ILFTY CAP1075068 2/112020 21120210 S1,000,000 tea Sao-aLdj X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Peracddenl) S X HIRED X NON-OWNED AUTOS ONLY AUTOS ONLY S I S UMBRELLALUIBOCCUR ---- _ --_ EACH OCCURRENCE Is EXCESSLWII HCLAIMS-MADE AGGREGATE S DED RETENTIONS $ BWORKERS ORKERSC MP NSATION 12VMCAC1771 12/23/2016 12/23/2020 X IS-TA ANY EMPL ETO S'LIA NERIEXECUi1VE YIN 12WEGAC1771 12/23/2020 12!23/2021 - OFFICERWEMSEREXCLUDED7 E-1NIAE.L.EACH ACCIDENT S 1.000.000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 51,000.000 If yes.desaiba under - O SCRIPTION OF OPERATION$htdcw E.L.DISEASE-POLICY LIMIT S1.000.000 C NYS OW&W 2310-00 3/262010 312612021 NYS DBL Statutory DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addttlonsl Remarks Schedule,may be attached If more space Is mqutmd) CIERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Road PO Box 1179 � R R ESENTATIVE Southold NY 11971 /7 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD