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HomeMy WebLinkAbout46471-Z V o f�t'�CIO Town of Southold 3/26/2022 P.O.Box 1179 53095 Main Rd oy 0.1 Southold,New York 11971 4Jpl � �•b CERTIFICATE OF OCCUPANCY No: 42955 Date: 3/26/2022 THIS CERTIFIES that the building GENERATOR Location of Property: 105 Bittersweet Ln., Cutchogue SCTM#: 473889 See/Block/Lot: 104.-2-3.2 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/16/2021 pursuant to which Building Permit No. 46471 dated 6/23/2021 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 Klein,Jeremy&Malick,Marissa of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 46471 3/23/2022 PLUMBERS CERTIFICATION DATED t or Signature — TOWN OF SOUTHOLD �o suFEoc` BUILDING DEPARTMENT y x 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#: 46471 Date: 6/23/2021 Permission is hereby granted to: 105 Bittersweet LLC PO BOX 162 S Jamesport, NY 11970 To: Install accessory generator at existing single family dwelling as applied for. At premises located at: 105 Bittersweet Ln., Cutchogue SCTM # 473889 Sec/Block/Lot# 104.-2-3.2 Pursuant to application dated 6/16/2021 and approved by the Building Inspector. To expire on 12/23/2022. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CO-ADDITION TO DWELLING $50.00 Total: $235.00 Building Inspector SOUr�®l - 0 Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q sean.devlinCa-)town.southold.ny.us Southold,NY 11971-0959 ® • �® lyc®UNTY,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Jeremy Klein Address: 105 Bittersweet Ln city:Cutchogue st: NY zip: 11935 Building Permit#: 46471 Section: 104 Block: 2 Lot: 3.2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Universal Electrical Services License No: 54018ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1 st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Generator X INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan [I Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: 20kW Briggs & Stratton Generator-w/200A Whole House Transfer Switch Notes: Generator Inspector Signature: Date: March 23, 2022 S. Devlin-Cert Electrical Compliance Form laf so '9,taq`7 9-- Wee 6 5_u;7L3Dll N)G aDri-A. TOWN OF SOUTHOLD B 765-1802 INSPECTION FOUNDATION 1 ST ROUGH PLBG. FOUNDATION 2ND INSULATIOWCAULKING FRAMING/STRAPPING FINAL FIREPLACE & CHIMNEY FIRE SAFETY INSPECTION FIRE�RESISTANT CONSTRUCTION TIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) O&LECTRICAL (FINAL) CODE VIOLATION PRE C/O REMARKS: �A L AL I V A4 f! .14 -1.-K&ms-vpK .4�_ewo_vr . DATE INSPECTOR i `C l OF 50Ujy�� * TOWN OF SOUTHOLD BUILDING DEPT. �yComm, 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] SUL'ATIOWCAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: DATE [0 INSPECTOR I l I L, ,.n v1 FIELD INSPECTION REPORT DATE COMMENTS • FOUNDATION(IST) N ------------------------------------ • C FOUNDATION(2ND) to • � O ROUGH FRAMING& PLUMBING y k _ 1 INSULATION PER N.Y. y STATE ENERGY CODE Ira on 10 1 '(� i FINAL ADDITIONAL COMMENTS 0 z rn z x d . ro 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) 765-9502 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only + PERMIT N0. Building Inspector: 1 6 2021 - JUN � a7 s ' � ra r - /lpplicatnsandforms must betted out rn the�rent�rety;Incomplete „�< a ppl►catians witi got be acr epted There the Applrcant�s not the owner an Y C3wner'$Author tion farm(Page Z)shill be camp'-f ted Date:June 11, 2021 OWNERS}Ok�1ROPiWRTY77 77 �.-.m .... . . . ..� . _... ... �.�_ z A NameJeremy Klein SCTM#1000-104-2-3.2 Project Address: Bittersweet Lane Cutchogue Ny 11935 Phone#:845-664-5696 Email:tand11022@9mail.com Mailing Address: Box 162 South Jamesport NY 11970 �q CflNTACr PERSCIIVh Name:Sean ONeill Mailing Address PO Box 64 Jamesport NY 11947 Phone#:631-722-3595 Email:onellloutdoor ower hotmall com pESIGIV PftO�ESSIONAL INFC�RMATIt)N '. '� Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMAT10hl Name: Mailing Address: Phone#: Email: DESCRfPT10N QF PROPOSED CONSTtUCTICNa ` `�. .. & �.. .. • x ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project [i]Other Generator $12,000.00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes ®No 1 x5 0 F PROPERTY INfORMATIIDN Q v ' fi of property: Existing use property:..�.. _...�.. ..ResidentalIntended use of prope �...._ r.:. .. .�_ .�...:.._� . .__. Residential . �.�..___. Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes ®No IF YES, PROVIDE A COPY. Check>3Osc After R `ding The owner/contractor/design professional Wrespansibleafor all drainage acrd storm Hiater Isspes as prairided by hapte?236 Of tfie;rewn Code��4I�FlIC'TION IS HE Egg T' 'Meta the 8uddrng oepartment#arthe rssuanc of Buiiding Perrt iE pursuant tathe E4ui►ding Ttine ordrnance of the Town of sojiodld„5lr6i,County;�fo"rk' d”her applicable iaa's;Ordinances or ReguTatrons far rite eonstructian of buddrngsr= aiidition5,"ai erations o far remoual cr leinalitian as heCetn described Ti a applicant agrees to carnp1 wnt6 aliappTicabTe taws;ordinan�e��l�ulit[in a ode, housing lode and regulat[orrsanrto admrt autfiorrzed inspectors an premises and rn buildings)#or necessary rnspectrans False statements made fierein are Ep ? 7 n, Application Submitted By(print name):Sean O'Neill ®Authorized Agent El Owner Signature of Applicant: Date: 6/11/2021 STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Sean O'Neill being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Agent (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� I Z� a4 L tary Public TRACE L DWYER NOTARY PUBLIC, TE OF NEW YOR PROPERTY OWNER AUTHORIZATION NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY (Where the applicant is not the owner) COMMISSION EXPIRES JUNE 30,2-& I, Jeremy Klein residing at 105 Bittersweet Lane Cutchogue NY 11935 do hereby authorize Sean O'Neill to apply on my behal o the Town of So old Building Department for approval as described herein. June 11 12021 Owner' igna a Date Y Jerem Kln Print Owner's Name 2 eQ � BUILDING DEPARTMENT- Electricalinspector TOWN OFSOUTHOLD " Town Hall Annex .54375 Main Road - PO.Box 1179. Southold; New York.11971.-0959 z Telephone (631) 765-180.2 FAX (631) 765"95027 rogerr southoldtownny ciov �.seandCa�southoldtownny gov APPLICATION FOR:ELECTRICAL.INSPECTION`: ._ ELECTRICIAN INFORMATION (An Information Required} Company,Name.,-: Name: x1n.. ... .eM ne.// _ _ L�cen$e No;: f 5' of email Address; ........... Phone No. _. ..: JOB. SITE INFORMATION (Affinformation Required) Name:_ Address Cross Street: .... .... Phone NO. Bldg:Permit# / errtatlft //Uo P . Tax Map Distnct.. . 1 Q4Q, . coon° ..fO Block ;--. ....... BRIE`D SCRIPTI.ON:C1I=V t RI Pteacae:.Pr nt Claarlj) - .. - _. l_ ��7�..' C rcla All T....Appy, Is job ready for Inspection? YES°/ NO Rough:-ln Fi.nal Do o,u h6ed a Temp Certlfi...... YES t NO Y. Issued'On.. Temp Information: (All information:required) Seruice Si2e 1 Ph 3 Ph =Size ,. ....._ _..__A: #deters Old Meter# NewService. Fire:Reconnect- Flood Reconnect-Service:Reconnected-:Underground :Overhead: #Underground Laterals 1 -2 H Frame Pole Worf�done on Service? Y N _. . .- .. _-.._. :..:_. ........ _. ------------ ...... .... Additional Ihf variation _ PAYMENT IDUE WITH APPLICATION Reguesffor Inspection ForthAs V PERMIT# Address: Switches Outlets G FI's Surface Sconces H H's UC Lts Fans: .. Fridge HW Exhaust Oven W/D Smokes DW Mini. Carbon Micro. - G:enerator. Combo,.:. :... Cooktop Transfer ..:^�...,..,. .-':r,.:,'.. .s rn�:}v ...ut-u..•:...s.e _s....�.., ...,...�:h.. ...�9,_�.. .....:a...:.;. ..,.. .... a ....,.. � � _ , .r � .. a .. ..e yr ....x. ...�... AC. AH Hood Service Amps Have Used Special; ; n Comments: L CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD"YYY) 09/23/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditbns 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 CCT Carol Losquadro Roy H Reeve Agency,Inc. PHONE (631)298-4700 (631)298-3850 PO Box 54 F--MA"t°.Exth AIC,No ADDRESS: coosquadro@royreeve.com 13400 Main Road _. INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: Maxum Ind Co 26743 INSURED INSURERS: Eastern LI Gas Services LLC INSURER C: PO BOX 1134 INSURER D: INSURER E: Mattituck NY 11952 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2092313140 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AUDL 5U5R POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MMIDD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE OCCURPREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 A BDG0082594-07 09/18/2020 09/18/2021 EERSONALBADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑jECT F1 LOC PRODUCTS-COMP/OP AGG $ 11000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED - PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILI Y Y/N STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ (Mandatoryfyes,dln and E.L.DISEASE-EA EMPLOYEE $ 0 yes,describe under , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE 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. 53095 Main RD PO BOX 1179 AUTHORIZED REPRESENTATIVE r Southold NY 11971 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD .1. NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE %L;AAAAAA 463076153 EASTERN LI GAS SERVICES LLC PO BOX 1134MATTITUCK NY 11952 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SMITH DRIVE NORTH EASTERN LI GAS SERVICES LLC TOWN OF SOUTHOLD PO BOX 1134 53095 RT,25 MATTITUCK NY 11952 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12344620-6 1 622886 09/24/2020 TO 09/24/2021 9/25/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2344620-6, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. BY CAUSING THIS CERTIFICATE TO BE ISSUED TO THE CERTIFICATE HOLDER, THE POLICYHOLDER UNDERTAKES TO PROVIDE THE CERTIFICATE HOLDER 10 CALENDAR DAYS' NOTICE OF ANY CANCELLATION OF THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:863999430 U-26.3 �. r w Suffolk,County dept.of � y Labor,Licensing&Consumer Affairs .f' MASTER>ELECTRICAL LICENSE Name, ANTHONY J SEMONELLA Business Name This certifies that'the. UNIVERSAL ELECTRICAL SERVICES LLC bearer is duly licensed by the County of.seolk License Number:ME-54018 Rosalie Drago issued: 08128!2014 Commissioner Expires: 08/01/2022 NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,2ND FLR,MELVILLE,NEW YORK 11747-3166 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^"^ 471592478 UNIVERSAL ELECTRICAL SERVICES,LLC 151 FIRST AVENUE MASSAPEQUA PARK NY 11762 Role SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER UNIVERSAL ELECTRICAL SERVICES,LLC SOUTHOLD BUILDING DEPARTMENT 151 FIRST AVENUE 54375 MAIN ROAD MASSAPEQUA PARK NY 11762 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2449 563-2 622522 07/16/2020 TO 07/16/2021 9/25/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 563-2, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER-THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU.WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH:NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 1037062088 U-26.3 �e � I voa uSTATE workers' CERTIFICATE OF INSURANCE COVERAGE COR1pEnSdt10A Bawd 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 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured UNIVERSAL ELECTRICAL SERVICES LLC 516-850-7776 151 1ST AVENUE MASSAPEQUA PARK,NY 11762 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 471592478 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Southold Building Department 54375 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL537882 3c.Policy effective period 07/09!2019 to. 07/08/2021 - 4. Policy provides the following benefits: 0 A.Both disability and paid family leave benefits. E] B.Disability benefits only. F] C.Paid family leave benefits only. 5. Policy covers: © 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 described above. Date Signed 6/17/2020 By Udd (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer 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 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 NYS Workers'Compensation Board(only if Box 4C or 513 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 canners 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-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 111 1111a11111111111 III I I CONTRACTORS SPECIAL POLICY DECLARATIONS PAGE Renewal Declaration UTICA FIRST INSURANCE COMPANY CONSTITUTED IN OHIO AS UTICA FIRST INSURANCE COMPANY(MUTUAL) Direct Billed - Insured Home Office-5981 Airport Road,Oriskany NY 13424 Mail Address-P.O.Box 851,Utica,NY 13503-0851 Policy Number: ART 5057878 06 Renewal of Number: NAMED INSURED AND MAILING ADDRESS Number State,Z Code City. County, P Agent 3128000 UNIVERSAL ELECTRICAL NATHAN BUTWIN CO INC SERVICES LLC 60 CUTTER MILL RD STE 414 151 FIRST AVE GREAT NECK, NY 11021 MASSAPEQUA PARK NY 11762 POLICY PERIOD:12:01 A.M.Standard Time at the Location of Designated Premises. 08/20/20 08/20/21 From To Item Prot. Rate Const . and Location Number Class Group . of Property Covered 1 PP 04 F Description: ELECTRIC WORK-NO BUR Location: 151 FIRST AVE MASSAPEQUA PARK, NY 11762 County: NASSAU AGREEMENT In return for your payment of the required premium, we provide the insurance described in this policy. LIABILITY INSURANCE COVERAGE LIMITS ANNUAL PREMIUM Each Occurrence Limit $ 1,000,000 /per occurrence Medical Payment Limit $ 1,000 /per person General Aggregate Limit (other than Products/Completed Work) $ 2,000,000 Aggregate Limit (Products/Completed Work) $ 2,000,000 Fire Legal Liability $ 50,000 /per occurrence Personal and Advertising Injury $ 1,000,000 /per occurrence Property Damage Deductible $ 1000 Included PROPERTY INSURANCE COVERAGE DEDUCTIBLE LIMIT AUTOMATIC REPLACEMENT ACV PROTECTIVE ANNUAL INCREASE% COST DEVICES PREMIUM Building Business Personal Property Loss of Income Business Personal Property- Off Premises FORMS AND ENDORSEMENTS SEE FORMS INVENTORY PAGE ANNUAL FORM NUMBER DESCRIPTION PREMIUM BAI-1 Blanket Additional Insured (Contractors) Included $150 Minimum Retained Premium ANNUAL Name and Address SUB TOTAL $3,224.00 of Mortgagee: NYS Fire Fee $ 0.00 POLICY TOTAL $3,224.00 Our Authorized Representative Countersignature Date 06/17/20 APDEC(01 1'#) INSURED COPY S.0 T.M. NO. DISTRICT: 1000 SECTION:10.4 BLOCK!:2 LOT($),,a2 TW=L OM ELL DR659 56Cnom (CONC,PRFCAST CONPONENIS) .VITffit�N,{ ml �x.�k3uTM& .C'Mfly:®MtLf� CIGb _ �CiQD •SAM FU NAFUM TO 1E asw mm A+rJ'=VMLOmLm' awamc aavlsD' DSR, r.. LAND N/F OF LAND 1410 OF I.AND N/F QF RICHARD JERNI.CK KELLY DANS <.... .ti. .E.P10 LOT 57 700.00'6622'50' _ 503.E . .•.-.•.:!Ipc: LC .. WDOD RAJL FENCE 1.2'74 � - ma: EL 2C0 EL 24.Q ...... .nor:cq-Amz. L%Cah4AN9 f,Y>SA:Lh fkFn(s1 83.8' Awmw sz v QcCM D'�r71Jtx6... �o Kw era r0 r LAND N/F DF .e 'I S'pOWS'CF.1P ' LAURA WAHL j LAND NIF OF . H.P/°L6i'S? t... PATRICK MORIARTY &E DN (Vas) P16 LOT S7 1:. P/0 LOT 57 1 ILT FEND OIDR m h S.a^'y�.:; _. PAMmrMw pq t P.0 LOT 56' a _ f P/o"a 56 P/o AT ss 7DhNDAT0 .+IOY42}Na Al 1„^Oy675EW.?A.M t FNIRANCE--FOUNDifleN OF COYPACIID ,'2�!'2-' 011 SfiNE C t]i7 LTi N Y.STAFF D.O.T.APPROYm R4s) CA DRY YFIl.(T <TLL TO 18'04h)AEQYE':dX�W WADE FOR.DR4104E,. B'DNxS'DEEP. ;1 d E', Ei V.24. OLWW'UMU'.-1 EX?TRam i?: "�y' .DRAINAGE CALCU'LA77ONS. 4 BEDRODw O ,Cmr aJ, PL42f9 }#SiS4iL ( p I a6D cu sr. 60.0 s e Af OUP nv �—2S' {7)e'MAxi2'DLEi?LP '{?)SbN x S'D¢P 1WlWFl1.•M2d.PRN70ED PALE PROPOSED '.�q 5 . 4 )3` e)Q.RAWWAY.t IIS SOFT.. WL a 4TYN SEVINO ARFA 1,1iS-;.e.ibl tLSCf'fffD... . SIM}V�ORYRELL–Mal PAoinm PA r .. � PRIM V MON. SOD,DD' '2Ae fl'9'AtS'DEEIA.,...�t � 'W. , .502 i'f`OWN LC S'66o22!SD,'W' SP .FINE 70 11. _ NFSuiee - FRPP05.5D ASPRAL7! ^'��. --•. sP ,.E:J ' JN.01.2016'_f7'NO WATER, r _ 'END EJe5I1NG PAVED MAeYt6'f. ZONED R-40- NON—'CONFORMING FRONT YARD: 50'MIN THE WATER SUPPLY, WELLS,DRYWELLS AND•CE'SSPOOL REAR YARD`. 35' MIN (25' TOTAL}MIN LOCA77ONS SHOWN.ARF FROM'•RELD OBSERVATIONS SIDE YARD: 10'M IN NOV. 4, 2020 AND OR DATA OBTAINED FROM OTHERS,' EL£VATTQN DATUM: NAVD88 .4,REA:i4;999.8fi•S{1.FT, of O.46 ACRES ... UNAUTHORIZED ALTERA77ON OR ADDITION TO THIS SURVEY IS A WOLARON OF SECTION7204 OF THE NEW YORK STATE EDUCATION LAW, COPIES OF THIS SURVEY MAP NOT'BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED To BE A VALID•TRUE'COPY. GUARANTEES,INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE'SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING'INS77W77ON LISTED HEREON, AND 70 THE ASSIGNEES OF 774E LENDING INSTITUTION,:GUARANTEES ARE-NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM 774E PROPERTY LINES TO THE S7RUCTURES ARE FOR A.SPECIFIC PURPOSE AND.USE'THEREFORE-THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADDI77ONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS ANDIOR,SUBSURFACE STR(ICTLTR£S'RFCORDEO,OR UNRECORDED ARE.NOT GUARANTEED UNLESS PHYSIOALL.YENDENT,ON INE PREMISES AT THE TIME;OF SURVEY SURVEY OF: P/R LOT 58 & 57 tyCL. 'CERTIFIED TO. 105:BITTERSWEET LLC; MAP OF:NASSAU FARMS STEWART TITLE INSURANCE;:COMPANY; FILED,MARCH 28, 1935 NoA 179 RESOLUTION SITUATED AT:CUTCHOGUE .. -_ .. .... . ._ .... TOWN,dF:'SOUTHOLD ;KENNETH'M.11 P O0fmUK•L&Rn SURyEYIXd' PLLC SUFFOLK COUNTY, NEW YORK Professional Land'Surveying LandDesign ' P P:O. Box 159 Aquabogue, New York 11931 FIVE 220-67 SON.-E:1'=30' DATE:JULY 14, 2024 ----�--- PHONE'(031)280 laea FAX(681)298-1588 N.Y.S LISC. NO. 050882 mointaftd s th.r m"o oE'Robat 7.6—miy at Xemmn&Y,lrnycQnk'" 0+4-� OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE APPROVED AS NOTED OF OCCUPANCY DATE: 13.P.# FEE:el�a3- 7 oy BY:!= NOTIFY .BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE COMPLY WITH ALL CODES Or 2. ROUGH —FRAMING & PLUMBING NEW YORK STATE & TOWN CODES 3. INSULATION AS REQUIRED AND CONDITIONS OF 4. FINAL - CONSTRUCTION,MUST BE COMPLETE FOR C.O. SOUTHOLD TOWN ZBA ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW SOUTHOLD TOWN PLANNING BOAR[ YORK STATE. NOT RESPONSIBLE FOR SOUTHOLD TOWN TRUSTEES DESIGN OR CONSTRUCTION ERRORS. N.Y.S.DEC m=MCALVW=Cffi MUD •• • B R I;G G S:&STRATI'O N: ... .. .............. ...'... < . '4A " it r ter, XE ,. FORTRESS � � Nv 16.09 ueing our dealer1exciustve line: ��. AvaPlable atyour locarlggs&Straton 1..VO V. wltE1 these�r� #eatures p@?t l abar TravetNo ' C til edC UL IIS 7Alarran Q .::::: X� X. Corrosion Resistant Enclosure& Base Symphony II PoWoK.Ma'taget tent Rust resistant aluminum and a stainless steel base • Customizable to your home's needs to protect the generator from the elements. Robust • Automatically balances the power of your home's electrical protection against damage from the elements caused load including high wattage items like air conditioning units by strong winds,high humidity and salt air and electric ovens • Powder-coated paint for years of protection against • Offers whole house power with a more affordable chips and.abrasions home generator • Certified to withstand hurricane-force winds up to 175 mphs Quality Clean Power Unique Airflow Technology • Ensures your electronics are safely powered Making.these models 50%quieter than most Flexible Placement portable generators • The unique design pushes engine exhaust out the • Approved for installation as close as 18"to a building2 front,directly away from your home Briggs&Stratton®Full Synthetic Generator Oil Commercial-Grade Vanguard®Engine • Shields the engine from low temperature sludge buildup • Powerful v-Twin OHV engine and high temperature deposits • Easy conversion between natural gas(NG)and liquid Reduces engine wear,scuffing and abrasion propane gas(LP)during installation Enhanced cold weather start-up protection to-20•F r Liquid Propane Vapor Natural Gas Limited Warranty' Model Enclosure Voltage Phase' Hz Circuit LPV kWt LPV Amps NG kW' NG Amps Parts,Labor,Travel Type Breaker Amps 040547 Galvanneal 120/240 1 60 100 20 83.3 18 75 6 Year 040573 Aluminum 120/240 1 60 100 20 83.3 18. 75 6 Year 040592 Aluminum 120/240 1 60 100 20 83.3 18 75 10 Year 'This generator is certified in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C22.2 No.100-14(motors and generators). 'The installation manual contains specific instructions related to generator placement in addition to NFPA 37,including the requirement that carbon monoxide detectors be installed and maintained in your home. 'Single phase units are rated at 1.0 power factor and three phase units are rated at 0.8 power factor. 'See operator's manual or BRIGGSandSTRATTON.com for complete warranty details. 'When installed in accordance with the installation manual BRIGGS—'.AT GN 20M' Fortress"Standby Generator ���� s G W �y ,.✓ 2 "�" �a`'a�' �.v� �"wa^,s,a � .. � � '� �x� :' �"��"'m'.L'�.��� ti.:u.. r ,_. '�w& '.a.�E...... 'i�a e ,3*�..:.;v:u. _ ",".'`"�aw�`�.*" �.a.�.'�`a. � •:tea .�.... " ,3,-^a�� Engine Brand Vanguard® Oil Capacity(oz) 79 Engine Speed(RPM) 3600 Lubrication System Full Pressure Engine Fuel Liquid Propane Vapor(LPV)or Recommended Oil 5W30 Full Synthetic Natural Gas(NG) Y Engine Cylinder Configuration OHV Low Oil Pressure Sensor Yes Number of Cylinders 2 1 ern o acs Displacement(cc) 993 Manufacturer Briggs&Stratton Compression Ratio 8.51 Type Self-Excited,Rotation Field Governor Type Electronic Voltage Regulator Automatic Frequency Regulation +/-1% Insulation Class F Valves OHV with Hardened Seats itlrofler t�lreit i max= MRsv ,� Ignition System Fixed Timing Magnetron® Hour Meter Yes Starter Motor Rating Voltage 12 Volt LED Digital Display Yes Battery Required 12 Volt,Group 26R,540 CCA Minimum Fault Code Display Yes Weekly Exerciser Yes .� ! 4, s O 'itlMl� aiN ' ���� s a � a �. Full Load 1/2 Load No Load 64 dBA^ BTU/hr NG-260,000 NG-187,000 NG-99,000 LPV-337,500 LPV-207,500 LPV-100,000 ft'/hr NG-260 NG-187 NG-99 LPV-135 LPV-83 LPV-40 m'/hr NG-7.36 NG-5.30 NG-2.80 LPV-3.82 LPV-2.35 LPV-1.13 Parts • Labor•Travel Unlike other standby generator manufacturers, Limited our warranty covers parts, labor AND travel for the Warranty' full length of the warranty with no start-up costs! I' 'This generator is certified in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C222 No.100-14(motors and generators). :Fuel consumption rates are estimated based on normal operating conditions at Vz load.Generator operation may be greatly affected by elevation and the cycling operation of multiple electrical appliances-fuel flow rates may vary depending on these factors. 'See operator's manual or BRIGGSandSTRATTON.com for complete warranty details. 4 Lowest no-load measurement per ISO 3744.Sound level measurement at other locations around generator may be different depending upon installation configuration. 2 1aRlc©`sssSRAironl 20M' Fortress"Standby Generator SIR— Enclosure Galvanneal Steel or Aluminum Material with Corrosion Resistant Paint CARB Compliant Yes` Overcrank Protection Yes NFPA Approved Yes Engine Warm Up(sec) 20 or 50 Automatic Transfer cUL Listed to CSA 22.2 No.100-04 Yes Switch Controlled Engine CoolDown,(min) 1 NEMACompliant Yes Response Time(sac) 26 or 56 Automatic Transfer EPA Certified Fuel System Yes Switch Controlled _ Monitoring Options Basic Wireless MonitorA►►►$))8b8C8SSOltes �e InfoHub-Monitor ? Continuous Maintenance Kit 6035 Battery Charging Yes Cold Weather Kit a 6404 Galvanneal-601/273 Basic Wireless Monitor 6176 Assembled Weight(Iba/kg) Aluminum-440/200 InfoHub 6517 Overall Dimensions(in/mm) 49.2 x 31.7 x 30.6/1250 x 805 x 777 Packaged Weight(lbs/kg) . Galvanneal-626/ Remote Status Monitor 6144 Aluminum-5757 26161 Packaged Dimensions(in/mm) 68.1 x 41 x 39.5/1730 x 1041 x.1003 49.2 in(1250 mm) 31.7 in(805 mm) ::.. . :.. ��f I 30.6 in (777 mm) �....:.'.............. i 48.1 in(1222 mm) 29.6 in(752 mm) •CARB does not regulate emergency standby generators outputting less than 50 HP.Only the EPA standards apply. 'This generator is certified in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C22.2 No.100-14(motors and generators). 3 BRIccS6STRA7LON 20W' Fortress Standby Generator , u�� r a i a �:, �" ��` a, 4V)�y •X .[Y/M�,(��}�. Ik� " F �fix`�z �.0 "wm. 1/2"pipe capacity 3/4"pipe capacity 1"pipe capacity 1-1/4"pipe capacity 1-1/2"pipe capacity 2"pipe capacity 20'Length2 118 247 466 957 1,430 2,760 40'Length2 81 170 320 657 985 1,900 80'Length2 65 137 257 528 791 1,520 80'Length2 56 117 220 452 677 1,300 100'Length2 50 104 195 400 600 1,160 1/2"pipe capacity 3/4"pipe capacity 1"pipe capacity 1-1/4"pipe capacity 1-1/2"pipe capacity 2"pipe capacity 20'Length2 200 418 788 1,617 2,423 4,666 40'Length2 137 287 541 1,111 1,665 3,207 80'Length2 110 231 435 892 1,337 2,575 80'Length2 94 198 372 764 1,144 2,204 1100"Length" 84 175 330 677 1,014 1,954 e • 'This generator is certified in accordance with UL(Underwriters Laboratories)2200(stationary engine generator assemblies)and CSA(Canadian Standards Association)standard C22.2 No.100-14(motors and generators). z Total length of piping from outlet of regulator to appliance farthest away, BRIGGS&STRATTON CORPORATION Briggs.&Stratton has a policy of continuous product improvement and reserves the right to modify POST OFFICE BOX 702 BRIGGS&STRA7 its specifications at any time and without prior notice. MILWAUKEE,WI 53201 USA Not for Prime Power or use where standby systems are legally required,for serious life safety or health hazards,or where lack of power hampers rescue of fire-fighting operations. BS1155-8r18 Copyright©201B.All rights reserved. YOU.POWERE[Y.