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HomeMy WebLinkAbout48367-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#: 48367 Date: 10/4/2022 Permission is hereby granted to: Ber P 2021 APRT 2840 Stars Rd East Marion, NY 11939 To: Install accessory stand-by generator at existing single family dwelling as applied for. Must maintain a minimum of 105 feet from top of bluff to generator location. At premises located at: 2840 Stars Rd, East Marion SCTM # 473889 Sec/Block/Lot# 22.-3-1 Pursuant to application dated 9/30/2022 and approved by the Building Inspector. To expire on 4/4/2024. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CO-RESIDENTIAL $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) 765-9502 https://www.sotitholdt:L)wno Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector......... Applications and forms must be filled out in their entirety. Incompletes applications will not be accepted. Where the Applicant is not the owner,an µ Owners Authorization form(Page 2)shall be completed. Cu Date:9/19/22 OWNER(S)OF PROPERTY: Name:Paula Berry SCTM#1000-022-03-01 Project Address:2840 Stars Rd. East Marion NY 11939 Phone#:917-324-7215 Email:paulagberry@gmail.com Mailing Address: CONTACT PERSON. Name:Chris Tyndall (Commander Power Systems) Mailing Address:285 Pulaski Street Riverhead, NY 11901 Phone#:631-831-8569 Email:ctyndallQcommanderpowersystems.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: I Name: Standard Electric Corp. Mailing Address:6500 Jericho Tpke suite 22E Sysosset, NY Phone#:(516) 819-8684 Email:cbrufto@ standardelectriccorp.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: D Other Install new 20 KW Kohler(LP)generator $13,500.00 Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? ❑Yes W No PROPERTY INFORMATION Existing use of property:Single family residence Intended use of property:Single family residence Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R_80 this property? ❑Yes RiNo IF YES, PROVIDE A COPY. ❑ Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. 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,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(s)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name):Pau I a Berry 13Authorized Agent ROwner Date: Signature of Applicant: ,., .� ,. S � :2_ ,.� .. STATE OF NEW YORK) SS: COUNTY OF -Q (C......... being duly sworn,deR wd.1Ly61tlwt(s)he is the applicant (Name of individual signing contract)above named, Notary Public,State of New York No.01BU6185050 Qualified in Suffolk County (S)he is the Commission Ex ires A ril 14 2 b� (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 ofIse / , 20 Notary Public PROPERTY O ER AUS"I ! A BION (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein.. Owner's Signature Date Print Owner's Name NEW YOPK Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be com /sled b Iisabill and Paid Fami:ly Leave Benefits Carrier or Licensed Insurance A ent or that Carrier la_ Legal Name and Address of Insured(Use street address only) 1b_ Business Telephone Number of Insured Standard Electric Corp 516-499-7354 Calogero Brutto 6500 Jericho Tpke. 1c. Federal Employer Identification Number or Social Security Syosset, NY 11791 Number Work Location of Insured(Only required if specifically limited to 208322723 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 Carrier Standard Security (Entity Being Listed as Certificate Holder) 3b.Policy Number of entity listed in box"la": 62310-00 Town of Southold 54375 Main Road 3c. Policy effective period: Southold, NY 11971 1 03/26/2010 03/26/2023 4. Policy provides the following benefits: _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: _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 Benefits insurance coverage as described above. Date Signed 2/1/2022 By- fsvial Cvl lol° (Signature of insurance caraees authorized representative or KYS Licensed Instwance 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 carver,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 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-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 DB-120.1. Insurance Brokers are not authorized to issue this form. DB120.1(10-1 e) ., DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 21112022 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 have ADDITIONAL INSURED provisions or 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' 148 East Main Street ( N - Borg&Borg Inc. PHONE FAX) 63.-673-7800.. c Nn).63 6S 11780 ......._._ EWAIL Huntington NY 11743 ?QgRgss INSURERS AFFORDING COVERAGE NAIC# w INSURERA:Merchants Mutual Insurance 23329 Standard Electric Corp. ... .. ........ .. _.... INSURED STANELE-01 INSURER B CalogeroBrutto INSURER 6500 Jericho Tpke. INSURER D il Syosset NY 11791 INsuReR E INSURER F: COVERAGES CERTIFICATE NUMBER:440138992 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_ pp _ _................. .__..._ INS 9 TYPE OF INSURANCE &DDLj'l1i Rj POLICY NUMBER...... .,..�,.POLICY JMM �EFF MMIODYIYYYY �.,. LIMITS CH occuRNENCE ..�. A X �COMMERCIAL GENERAL �x1AUk�O ttEN1 [5..... 1 000000 _ ...,. CLAIMS-MADEX OCCUR BOP1063594 2 l { � 672022 ?1112023 PREMISES(Ea orcunence) $,500 000 MED EXP(My one person) S 15 000 _ PERSONAL&ADV INJURY $Included GEN1 AGGREGATE LIMIT APPLIES PER: I GENERAL,AGGREGATE „w�$2,000,000 POLICY�...X..,�PE6 X r LOC k t F PRODUCTS COMPIOPAGG., 52000,000 OTHER .._. X AUTOMOBILE LIABILITY {CAP1075068 2 112022 �. 2/1!2023 COMBaNLIJ SING&Iw.LglvklT `$1,000,000 _.,... _. ._._. A AU IE' mrmx �nur I ANY AUTO I f ILY INJURY(Per person) $ AUTOS SCHEDULED G 60DILYINJURY,Per.,, _....._: I ( accident) _X AUTOS ONLYf AUTOS f PP �'- ,,...$HIRED NON-Ow1JED r PGiOPLRTYOA,t�ihJ"F'V AUTOS ONLY �.„„X„I AUTOS ONLY 1 � � � ��.�I "ra,S" '' 16 ........, .. UMBRELLA LWB - EACH URR OCCUR I AGGREGATE ENCE �S CLAIMSMADE �.., m. ,_.,. _..... EXCESS LU�B � � � I OEO RETENTION S OFFICAND E PRIET WPA THE E 1 N/A S,F�,AH AC „�.OR� ..., WORKERS COMPENSATION ry' f EL DISEAACCIDENT S .(Mandato in YIN I SE EA EMPLOYEE!$._ ANYPROPRIETORlPARTNER/EXECUnVE �I E L EACH �If yes,describe under {{ EL DIS ..... DESCRIPTION OF OPERATIONS below k o EASE-POLICY LIMIT $ I � � I L DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) I CERTIFICATE HOLDER CANCELLATION, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 54375 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ._ N ©19BB-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD _J'NEW Workers7 CERTIFICATE OF � NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board ...1 -111111111111. ......._ ...... __... .. .. 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Standard Electric Corp 516-499-7354 Calogero Brutto 6500 Jericho Tpke. 1c.NYS Unemployment Insurance Employer Registration Number of Insured Syosset, NY 11791 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i_e.,a Wrap-Up Policy) Number 208322723 Xx- 2_Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Twin Citv Fire Ins Co Town of Southold 36.Policy Number of Entity Listed in Box"1a" 54375 Main Road Southold, NY 11971 12WECAJ5V6F 3c.Policy effective period 12/23/2021 12/23/2022 3d.The Proprietor,Partners or Executive Officers are included.(Only h"k box if all partnersloffem included)all excluded or certain partners/officers ...... 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~genii 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 14 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. (The-se 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. Borg& Borg Inc., David M Borg President (Print name of authorized representative or licensed agent of insurance carrier) 2/112022 Approved by: (Signature) (Date) Title:_Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-6:73-7600 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