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HomeMy WebLinkAbout47947-Z �uFFac ,o�Os kCpG. Town of Southold 10/20/2022 y� P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 43 520 Date: 10/20/2022 THIS CERTIFIES that the building GENERATOR Location of Property: 1905 Fairway Dr., Cutchogue SCTM#: 473889 Sec/Block/Lot: 109.-5-14.20 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/11/2022 pursuant to which Building Permit No. 47947 dated 6/10/2022 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 Weber Jr,Robert&Patricia of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47947 7/22/2022 PLUMBERS CERTIFICATION DATED A o 0ized nature TOWN OF SOUTHOLD �S�yFfOiX�, o C�ay� BUILDING DEPARTMENT y TOWN CLERK'S OFFICE WOy • �r 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#: 47947 Date: 6/10/2022 Permission is hereby granted to: Weber Jr, Robert 24 Sunset Dr Manhasset, NY 11030 To: Install accessory stand-by generator at existing single family dwelling as applied for. At premises located at: 1905 Fairway Dr., Cutchogue SCTM # 473889 Sec/Block/Lot# 109.-5-14.20 Pursuant to application dated 5/11/2022 and approved by the Building Inspector. To expire on 12/10/2023. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CO-RESIDENTIAL $50.00 Total: $235.00 Building Inspector pE SO�jyol � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 Q sean.devlin(cD-town.southold.ny.us Southold,NY 11971-0959 �I�CpUNTV,N� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Robert Weber Jr Address: 1905 Fairway Dr city:Cutchogue st: NY zip: 11935 Building Permit#: 47947 Section: 109 Block: 5 Lot: 14..2 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Landi Electrical Serv. License No: 39160ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Surrey Attic Generator X INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 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 Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect Switches 4'LED Exit Fixtures Pump Other Equipment: Kohler 20kW Generator w/200A Whole House Transfer Switch Notes: Generator Inspector Signature: - Date: July 22, 2022 S. Devlin-Cert Electrical Compliance Form o�aaf SOUIyo a L47 Iqo ,5 # * TOWN OF SOUTHOLD BUILDING DEPT'. cou631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [. ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: JI/ f2 ci DATE /42, /2-2--INSIPECTOR 4� UE SOUlyolo # # TOWN OF SOUTHOLD BUILDING DEPT. "courmN�'' 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] NSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL &M&4fn� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: �- fc' (4-9-- 049� `� �► Slnr �� v�� DATE41 'YO��/ INSPECTOR .•r ' a!• + r�r '_ k ��i t�i by�r4' �� �J+'` �y�y [yi•• _ d`°'ti ? ./1 � .��� t {Hr 'yr-�., ?. '7r � :Cy*.i •. 71 ^�,� `t• .k t�'� �t ��`. 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( i ! ` - .. �> '.# 1 .- \1 y i `\i LF y� ,�.I .\ � - �I 1 r�� 't,`'1 >, '1 - \ � •k"* �� r 1 J ke� a l�Wll�lllllll t j AATTENTION ' — w*lnrvnrE nowln wuinc vurnei¢_s*•Nonv �... 1 rte.. -.- "�'•C• OErvtnM1iDD ON IT[rui9l9 A ATTENTION e� ' nurnf sound Dr roun•Nr oicnoNiaE 4trnnnnun win xnc A ATENC16N „ orreM�ceroxwfrvrtu*ENNn nianoNia.e. ooN o!lwFnaw CIA EN EL P11EC10 j� i GFN[MiDn iDCn110N. _ Y FNptnCCMFNr DD DEQ >r _ U&4•cpN Dfl4[MEn,l py DEC -j1'1X�//'N "'�•• .M1 a11p{ ` �5�r epn Via)��t+llil !qp aE•rq N ,1 rE sr -s A� n ,�. w m 1�iRfYJ�Ir SHUTDOWN (PRIME MOVER) FIELD INSPECTION REPORT DATE COMMENTS • b FOUNDATION(1ST) S y ------------------------------------ LD FOUNDATION(2ND) 3 t� co c H �t ROUGH FRAMING& , v PLUMBING Q® J O .7 , r INSULATION PER N.Y. y STATE ENERGY CODE G 56k 09MAW lkQ FINAL ADDITIONAL COMMENTS f'b 11157 MOL 101-L000l cc c- 7 7d Z rn C � b 0 i z d CrJ ' b H -` �sufFot too TOWN OF SOUTHOLD-BUILDING DEPARTMENT G Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 httpsJhvww.southoldtownny.iaov Date Received APPLICATION FOR BUILDING PERMIT 471 For Office Use Only EC^U7En � ���U1nPERMIT NO. Building Inspector: ® I� III MAY 1 1 2022 Applications and'forms`must be filled out in their entirety.Incomplete ;.applications will not be-accepted.­'Where the Applicant is not the owner,an BUILDING DEPT. TOWN OF SOUTHOLD Owner's Authorization form.(Page,2)shall be completed: Date: OWNER(S)OF PROPERTY: R - D 4P }Ga Name: SCTM#1000- o i� = - Project Add re ss: NO iT- ct. Dry @ Crlfi6we, /,)o Phone#: I ` 7—8?a.- Email: Mailing Address: ,90 ;CLAW /U y&9 '.CONTACT PERSON: ' Name: Xh &Iidt� Mailing Address: T ca ko!^ (-- Phone#: Email: 'A 6 C O DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: - Mailing Address: fall 5_ ae o y 11769 . Phone#: _ Email: DESCRIPTION OF PROPOSED CONSTRUCTION.,, ❑New Str„„un�cture ❑Addition. ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: d0therd 4 6 e hr '44Lt? 1 Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes No 1 Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants nd restrictions with respect to this property? ❑Yes No IF YES, PROVIDE A COPY. Check`Box After'Reading: The owner/contractor/design professional is.responsible for all drainage and stohn.waier issuis as'provided.by' Chapter 2S6 of the Cade: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-xonstruction of buildings, I dditions,alterations.or for removal_or;demolition as'herein described:The applicant agrees to comply with all applicablOinus,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in-building(s)for'necessary mspectldhi 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): /-I/) /�L WAuthorized Agent []Owner Signature of Applicant: Date: mr STATE OF NEW YORK) r/ COUNTY OF Jv l� ) / // � � p llq '4!! �-Eti81 +1 � -0A11 eing duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the - �C' r ct ontrao 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 P,k D. FO�-fo i / day of 20," l .� '�� •pl'''.O'I ��� Nota P ic O`er:=o� Gc"�J`,4 No• 00"V& _ mgj2% PROPERTY OWNER AUTHORIZATION %1, u'ti •'Q (Where the applicant is not the owner) �A AR OF N ```�� residing at Q(�5 rW��'�►lS W�CL� � �y. do hereby authorize ALT I-&2�� ft6. (moi L' &lo apply on my behalf to the Town of Southold Building Department for approval as described herein. zj 2Z O er's Signatur D to Ro.5e1Z!-1 \-4j 1:-:�a� Print Owner's Name 2 g�tapC 1 2�2� U ING DEPARTMENT-Electrical Inspector �0 MAI 1 TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 o TOWN OF SOUTHOLD Southold, New York 11971-0959 *A 0�T Telephone (631) 765-1802 - FAX (631) 765-9502 rogerrasoutholdtownnv.gov a seand(a�southoidtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: L „ ; )Ca Electrician's Name: 41; a.^ch License No.: 14 E -3m o Elec. email: Elec. Phone No: bI request an email copy of Certificate_of Compliance Elec. Address.: ,2q JOB JOB SITE INFORMATION (All Information Required) Name: r Address: g05 Cross Street: �cpd Phone No.: 1-417— Bldg.Permit 417_Bldg.Permit#: email: Tax Map District: 1000 Section: /09 Block: r' Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): P ,5V Square Footage: Circle All That Apply: Is job ready for inspection?: YES �NO F�Rough In F] 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 Reconnect[]Underground[]Overhead # Underground Laterals 1 2 F1 H Frame M Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION ®�uf�Oj 7? U LI ING DEPARTMENT- Electrical Inspector N �V TOWN OF SOUTHOLD N BuI DIS DEP ocwn Hall Annex - 54375 Main Road - PO Box 1179 TOWN Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 .gi v APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: Company Name: Electrician's Name: /,r License No.: P F 39 jElec. email: ? J Elec. Phone No: 63143Jj- (a) ti request an email copy of CertificaieV Compliance Elec. Address.: `�q JOB SITE INFORMATION (All Information Required) Name: Rr + k, bet- Address: • dS n // ,5 Cross Street: Phone No.. /4/7_S Bldg.Permit#: 4-7 9 tl-? email: Tax Map District: 1000 Section: /09 Block: G' Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage--T- Circle All That Apply: Is job ready for inspection?: ❑ YES [�NO ❑Rough In ❑ Final Do you need a Temp Certificate?. ❑ YES MN,O Issued On Temp Information: (All information required) Service Size71 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground Doverhead # Underground Laterals 1 2 H Frame D Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION PERMIT# Address: Switches Outlets G FI's Surface Sconces H H's LIC Lts Fans Fridge HW Exhaust Oven Dryer Smokes DW Service Carbon Micro Generator Co In bo Cookto p Tra nsfe r AC AH Mini Special: Comments: ce� 0..4- {�_•_ '.ems __ �N;`r�'=.•_ -- _ - _ - -- -_ - -_ _ „� N R SURVEY OF: LOT 20 w' `LQT'20 AS SHONN OWA CERTAIN MAP ENTITIED°FAIRWAY.FARNS ,' f, FILED FffiJARYJ 5;(974.A5 MAP NO,6066 SITUATE: CUTCf1OG _ t _ TOWN'- 'S�O,UTh _ , ., - : . r.. _ _ OLD - ::�� s.• 3e �n N Y.; ; k °OUN Tl' �5U ;FOLK'C ,�' . . An - 5URVEYED 07-15-2004 :k`' '✓ UPDATE 08-26=2004' y.. ~�dn � �r• A, '+i M r,` 'SUFFOLK'COIJtJT-Y TAX'# •%� `;: 'j "° ,,<. -a,,, � 1000 109 `5-'14 CERTIFIED10i - 4 ;,PATRICIA;WEBER' ROBERT WEBER: FAf a"splialtroadway. 8 8• F 8 0 E:A' .j.,j'a le a^ .b: =1� 2 _ .. �� V, 4,_ , = I R t�l -- - Q• i_ - - _ y ;- Sit •�STONe.�,._ - yi eGe, .-- -_ Nb�z. _ - ;'COVERED a ':�, - /' 'SLATE PAV WAM'x - `•, S . � F' 6i5 T F -. -r^FRAME NOUSE_l - -�•� - -_ _ _ .6 GARAGE: •t 1G p, 21:9' e\i `— ^:'.%i5:6'; "•'05'. r. 'Pc I p our eauw. _LOT PA00, 1,2:0W. . iO.PAVeRWAIxa..- JI f r r I' fv 1 .:r Oi •2 2 'o P — (� •'I ,.o o_. . t V) Alcll { f' N89,°;h 21' _ . Q0:00 LOT.25 0:. a•r I n , uv T PN F' ovl, -�h� ivernl.Fa>x �` JOt1GV�:C�.:�E t1LERS LAND SURVEYOR 6 EAST.MAIM S - rear ti, :ad ,� 7REET 3 N,Y.5,LIC.-NO.5.02_0 {'' , •,°s�`°` °"" ' :°°�} A r 943 of;cres ft RIVCRItEAp N Y"I)9Q1 369-8258 ._ a� S y' ye4 - "YYY a., longislanclland591veyoe Gom I r^ _..._.__,s_"'_°'"".'"-• .,•`-,._..'O4 CA �>;�. •i ti.ra;-�"�,� "���,. ,iia - A� - E�SUi��L;,,,aa��,.•,�+C'��' �_ � , - - _ Suffolk County Dept.of Labor,Licensing&Consumer Affairs s� '. MASTER ELECTRICAL-LICENSE Name ALI LANDI Business Name This certifies that the LANDI ELECTRICAL SERVICE INC bearer is duly licensed by the County of suffolk License Number:ME-39160 Fraw.k,Narde.U.v Issued: 01/04/2006°, Commissioner Expires: 01/01/2022 t ' NEW Workers' YORK TATE 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 LANDI ELECTRICAL SERVICE INC 1c.NYS Unemployment Insurance Employer 129 SCUDDER PL Registration Number of Insured NORTHPORT NY 11768 1d. Federal Employer Identification Number of Insured or Work Location of Insured(Only required if coverage is specifically Social Security Number limited to certain locations in New York State,i.e. a Wrap-Up Policy) 20-4149782 2. Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Property and Casualty Insurance Company of Town of Southhold Building Department Hartford Town Hall Annex 34690 54375 MAIN RD 3b. Policy Number of Entity Listed in Box"1a": PO Box 1179 12 WEC ZH4995 SOUTHOLD NY 11971-0959 3c. Policy effective period: 03/11/2022 to 03/11/2023 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 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: 04/26/2022 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (866)467-8730 C-106.2(9-17) Form WC 88 3121 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 LANDELE-01 CCONSIDINE ACORO" CERTIFICATE OF LIABILITY INSURANCE E 412YYI(J 4/25/12022022 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 CTACT ON Grillo 8 Associates,Inc. PHONE FAX ri Broadway aC,No,Ext:(516)798-0320 (AIC,No):(516)798-2032 AIL Massapequa,NY 11768 E ADDRESS, INSURERS AFFORDING COVERAGE NAIC# INSURER A:MERCHANTS MUTUAL INSURANCE COMPANY 23329 INSURED INSURER B: Landi Electrical Service Inc. INSURERC: 129 Scudder Place INSURER 0: Northport,NY 11768 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 SUBINSD DR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRIDUMOM (MMI OR= A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 7 OCCUR BOP1044969 1/6/2022 1/6/2023 DAMA IS TO RENTED $ 600,000 MED EXP(Any oneperson) $ 16,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEST �LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMaBIINEeD SINGLE LIMIT $ ANY AUTO BODILY INJURY Perperson) $ 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 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N IS A UTE ANY PROPRIETORIPARTNER/F>CECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If 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) CERT HOLDER LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southhold Building Department Town Hall Annex THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 64376 Main Road PO Box 1179 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Yo' Compensation Workers' STATE CERTIFICATE OF INSURANCE COVERAGE 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 LAND[ ELECTRICAL SERVICE INC. 129 SCUDDER PLACE 6314399027 NORTHPORT, NY 11768 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,i.e.,Wrap-Up Policy) or Social Security Number 20-4149782 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 Southhold Building Department tY p Y Town Hall Annex 3b.Policy Number of Entity Listed in Box"I a" 54375 Main Road PO Box 1179 R77287-000 SOUTHHOLD, NY 11971 3c.Policy effective period 3/11/2015 to 4/24/2023 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: ❑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: 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 descri ed above. y�/���' Date Signed 4/25/2022 By o d — (Signature of insurance carrier's authorizt: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.Mai(it directly to the certificate holder. If Box 4B,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 NYS Workers'Compensation Board(only if sox 4C or 513 of Part i 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-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) [II�IIP1°°°1°211°�111!�1'�0'°'17��!"I�I�I �J APPROVED AS NOTED OCCUPANCY OR DATE: 6'_.= B.P.# USE IS UNLAWFUL FEE•123= BY: WITHOUT CERTIFICATE NOT;02881AM TO - MPAR OEW AT FOR THE OF OCCUPANCY FOLLOWING INSPEC i IONS:. 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. COMPLY WITH ALL CO'; L, UF- ALL CONSTRUCTION SHALL MEET THE NEW YORK STATE & Tbv,iJ CODE` REQUIREMENTS OF THE CODES OF NEW AS REQUI D AND CONDITIONS C YORK STATE., NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. SOUTHOLD TOWN ZBA SOUTHOLD TOWN PLANNING BOA, SOUTHOLD TOW'S TRUSTE N.Y.S.DEC RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. 9 KOHLER Models: 20RCA(L) TOWN OF SOUTHOLD Multi-Fuel LPG/Natural Gas 09001 Standard Features 4 KOHLER. • RDC2 Controller NATIONALLY REGISTERED o One digital controller manages both the generator set and y4d transfer switch functions(with optional Model RXT). o Electronic speed control responds quickly to varying �I; t demand. o OnCue@ Plus Generator Management System for remote monitoring is included with the generator. a • Kohler Command PRO Engine Features o Kohler Command PRO@ OHV engine with hydraulic valve lifters for reliable performance without routine valve adjustment or lengthy break-in requirements. • Designed for Easy Installation o Sturdy aluminum base can be mounted on gravel or a concrete mounting pad. o Fuel and electrical connections through the enclosure wall The Kohler" Advantage eliminate the need for stub-ups through the base. o Customer connection terminal block located near the • High Quality Power controller allows easy access for field wiring. Kohler home generators provide advanced voltage and o Designed for outdoor installation only. frequency regulation along with ultra-low levels of • Certifications harmonic distortion for excellent generator power quality to protect your valuable electronics. o Meets emission regulations for U.S. Environmental Protection Agency(EPA)with both natural gas and LPG. • Extraordinary Reliability o UL 2200/cUL listed (60 Hz model). Kohler is known for extraordinary reliability and o CSA certification available(60 Hz model). performance and backs that up with a premium 5-year or o Accepted by the Massachusetts Board of Registration of 2000 hour limited warranty. Plumbers and Gas Fitters. • Powerful Performance o Meets 181 mph wind rating. Exclusive Powe�rboost'"' technology provides excellent starting power. • Approved for stationary standby applications in locations • Aluminum Enclosure served by a reliable utility source.o Attractive aluminum enclosure allows installation business. • 20RCAL models packaged with a Model RXT automatic close as 18 inches from your home or small busine # transfer switch are available. See page 4 and the Model RXT ATS specification sheet. o Enclosure panels can be removed without tools to allow easy access for maintenance and service. • Warranty o 5-year/2000 hour limited warranty for on-grid (standby) applications in locations served by a reliable utility source. Generator Ratings Standby Ratings Line Circuit Natural Gas LPG Breaker Alternator Voltage Phase Hz kW/kVA Amps kW/kVA Amps Amps Poles 2F7 120/240 1 60 18/18 75 20/20 83 100 - 2 120/208 3 60 17/21 58 17/21 58 70 3 2G7 120/240 3 60 17/21 51 17/21 51 60 3 277/480 3 60 17/21 26 17/21 26 30 3 Note: The line circuit breaker is automatically selected based on the generator set model and voltage configuration. RATINGS:Standby ratings apply to installations served by a reliable utility source.All single-phase units are rated at1.0powerfactor.The standby rating is applicable to variable loads with an average load factor of 800/6 for the duration of the power outage. No overload capacity is specified at this rating. Ratings are in accordance with ISO-3046/1,BS5514,AS2789,and DIN 6271.GENERAL GUIDELINES FOR DERATING:ALTITUDE.Derate 4%per 305 m(1000 ft.)elevation above 153 m(500ft.).TEMPERATURE:Derate 2%per 5.5'C(10°F)temperature increase above 16°C(601F). Availabilityis subject to change without notice.The generator set manufacturer reserves the right to change the design or specifications without notice and without any obligation or liability whatsoever. Contact your local Kohler Go.generator distributor for availability. § Check the appliance manufacturer's specifications for actual power requirements.Consult a Kohlers Power Systems professional to calculate your exact residential power system requirements. 1' Meets NFPA guidelines for 18 inch clearance to combustible materials. Check state and local codes for minimum distance required from a structure. G4-272 (20RCA) 5/21d r � Alternator Specificationi' Alternator Specifications Alternator Features Specifications Alternator • Compliance with NEMA, IEEE, and ANSI standards for Manufacturer Kohler temperature rise. Type 2-Pole,Rotating Field Leads,quantity a Self-ventilated and dripproof construction. 2F7 4 e Windings are vacuum-impregnated with epoxy varnish for 2G7 12 dependability and long life. Voltage regulator Digital • Superior voltage waveform and minimum harmonic Insulation: NEMA MG1-1.66 distortion from skewed alternator construction. Material Class H e Digital voltage regulator with±1.0%no-load to full-load Temperature rise 130°C Standby RMS regulation. Bearing:quantity,type 1,Sealed a Rotating-field alternator with static exciter for excellent Coupling Direct load response. Amortisseur windings Full a Total harmonic distortion (THD)from no load to full load with Voltage regulation,no-load to full-load RMS ±1.0% a linear load is less than 5%. One-step load acceptance 100%of Rating Peak motor starting kVA: (35%dip for voltages below) 240 V,1 ph 2F7(4 lead) 41 (60 Hz) 240 or 480 V,3 ph 2G7(12 lead) 69(60 Hz) Application Data Engine Exhaust Engine Specifications Exhaust System Manufacturer Kohler Exhaust temperature exiting the Engine:model,type CH 1000 4-Cycle enclosure at rated kW,dry, °C(°F) 260(500) Cylinder arrangement V-2 Lubrication Displacement,cm3(cu.in.) 999(61) Bore and stroke,mm(in.) 90 x 78.5(3.54 x 3.1) Lubricating System Compression ratio 8.81 Type Full Pressure Main bearings:quantity,type 2,Heavy-Duty Sleeve Oil capacity(with filter),L(qt.)§ 1.9(2.0) Bearings Oil filter:quantity,type§ 1,Cartridge Rated RPM Oil cooler Integral 60 Hz 3600 § Kohler recommends the use of Kohler Genuine oil and filters. Max.engine power at rated rpm,kW(HP) LPG,60 Hz 23.0(30.9) Fuel Pipe Size Natural gas,60 Hz 20.2(27.1) Cylinder head material Aluminum Minimum Gas Pipe Size Recommendation,in.NPT Valve material Steel/Stellite® Pipe Length, Natural Gas LPG m(ft.) 281,000 Btu/hr. 340,000 Btu/hr. Piston type and material Aluminum Alloy Crankshaft material Heat Treated,Ductile Iron 8 (25) 1 3/4 Governor:type Electronic 15 (50) 1 1 Frequency regulation,no load to full load Isochronous 30 (100) 1 1/4 1 Frequency regulation,steady state ±0,5% 46 (150) 1 1/4 1 1/4 Air cleaner type Dry 61 (200) 11/4 11/4 Engine Electrical Engine Electrical System Ignition system Electronic, Capacitive Discharge Starter motor rated voltage(DC) 12 Battery(purchased separately): Ground Negative Volts(DC) 12 Battery quantity 1 Recommended cold cranking amps: (CCA)rating for-18°C(0°F) 500 Group size 51 G4-272 (20RCA) 5/21d L ti9 Fuel Requirements RDC2 Controller Features, Continued Fuel System • LED indicators for utility power and generator set source - Fuel types Natural Gas or LPG availability and ATS position (Model RXT transfer switch Fuel supply inlet 1/2 NPT required) Fuel supply pressure,kPa(in.'H20): • LCD display: Natural gas 0.9-2.7(3.5-11) o Two lines x 16 characters per line LP 1.7-2.7(7-11) o Backlit display with adjustable contrast for excellent Fuel Composition Limits* Nat.Gas LPG . visibility in all lighting conditions Methane,%by volume(minimum) 90 min. _ • Scrolling system status display: Ethane,%by volume(maximum) 4.0 max. - o Generator set status o Voltage and frequency Propane,.%by volume 1.0 max. 85 min. o Engine temperature Propene,%by volume(maximum) 0.1 max. 5.0 max. o Oil pressure C4.and higher,%by volume 0.3 max. 2.5 max. o Battery voltage Sulfur,ppm mass(maximum) 25 max. o Engine runtime hours Lower heatin value, MJ/m3(Btu/ft ),(minimum)- 33.2(890) 84.2(2260) • Date and time displays * Contact your local distributor for suitability and rating derates based • Smart engine cooldown senses engine temperature on fuel compositions outside these limits. • Digital isochronous governor maintains steady-state speed at all loads Operation Requirements • Digital voltage regulation: ±1.0% RMS no-load to full-load Fuel Consumption,m3/hr.(cfh)@ 6OHz • Automatic start with programmed cranking cycle %Load Natural Gas LPG • Programmable exerciser can be set to start automatically on 100 8.0 (281) 3.9 (136) any future day and time,and run every week or every two 75 6.9 (243) 3.1 (109) weeks 50 4.6 (161) 2.3 (82) • Exercise modes: 25 3.6 (127) 1.7 (59) o Unloaded weekly exercise with complete system Exercise 2.0 (71) 1.0 (35) diagnostics Nominal fuel rating: Natural gas: 37 MJ/m3(1000 Btu/ft.3) o Unloaded full-speed exercise LPG: 93 MJ/m3(2500 Btu/ft.3) o Loaded full-speed exercise(Model RXT ATS required) LPG conversion factors: 8.58 ft.3=1 Ib. • Front-access mini USB connector for SiteTech- or USB 0.535 m3=1 kg Utility connection 36.39 ft.3 =1 gal. • Integral Ethernet connector for Kohler®OnCue®Plus Generator Set Sound Data • Built-in 2.5 amp battery charger • Remote two-wire start/stop capability for optional connection Model 20RCA 8 point logarithmic average sound levels are of a Model RDT transfer switch 66 dB(A) during weekly engine exercise and 70 dB(A) during • Diagnostic messages: Displays diagnostic messages for the full-speed generator diagnostics and normal operation.* engine,generator, Model RXT transfer switch, programmable All sound levels are measured at 7 meters with no load. interface module (PIM), and load management device. • Maintenance reminders * Lowest of 8 points measured around the generator. Sound levels at other points around generator may vary depending on installation • System settings: I parameters. o System voltage,frequency, and phase o Voltage adjustment RDC2 Controller o Measurement system, English or metric ATS status(Model RXT ATS required): a o Source availability I o ATS position (normal/utility or emergency/generator)i 0 o Freq: 60.OHz O o Source voltage and frequency o®o a • ATS control (Model RXT ATS required): r 0 0 o Source voltage and frequency setting_s o Engine start time delay 0 -� o Transfer time delays } o Voltage calibration The RDC2 controller provides integrated control for the o Fixed pickup and dropout settings generator set, Kohler@ Model RXT transfer switch, • Programmable Interface Module (PIM)status displays: programmable interface module(PIM), and load shed kit. o Input status (activefinactive) o Output status (active/inactive) RDC2 Controller Features • Load control menus: • Membrane keypad: o Load status o OFF,AUTO, and RUN pushbuttons o Test function o Select and arrow buttons for access to system configuration and adjustment menus • LED indicators for OFF,AUTO,and RUN modes G4-272 (20RCA) 5/21d KOHLER, PhoneKOHL9 CO.,Kohler,Wisconsin 9-164 USA Phone 920-457-4441,Fax 920-459-1646 For the nearest sales and service outlet in the US and Canada,phone 1-800-544-2444 KOHLERPower.com Generator Set Standard Features Automatic Transfer Switches and Accessories • Battery cables ❑ Model RDT ATS • EPA certified fuel system ❑ Model RXT ATS • Aluminum sound enclosure ❑ Model RXT ATS with combined interface/load • Critical silencer management board [j Load shed kit for RXT or RDT • Field-connection terminal block ❑ Power relay modules (use up to 4 relay modules for • Fuel solenoid valve and secondary regulator each load management device) • Line circuit breaker ❑ Other Kohler@ ATS • Multi-fuel system, LPG/natural gas,field-convertible 20RCAL Model Packages • Oil drain extension with shutoff valve ❑ 20RCAL with 100 amp RXT with 16-space load center and • OnCue(D Plus Generator Management.System NEMA 1 steel enclosure for indoor installation • Premium 5-year limited warranty ❑ 20RCAL with 200 amp service entrance-rated Model RXT • RDC2 generator set/ATS controller with combined interface/load management board and • Rodent-resistant construction corrosion-resistant NEMA 3R aluminum enclosure • Sound-deadening,flame-retardant foam per LIL 94, Warranty class HF-1 ❑ 5-Year Comprehensive Limited Warranty ❑ Available Options 10-Year Comprehensive Limited Warranty Approvals and Listings ❑ CSA approval Concrete Mounting Pads ❑ Concrete mounting pad, 3 in.thick ❑ Concrete mounting pad, 4 in.thick (recommended for storm-prone areas) Electrical Accessories ❑ Battery ❑ Battery heater, 120VAC ❑ Battery heater, 240VAC ❑ Cold weather package, 120VAC Generator Set Dimensions and.Weights ❑ Cold weather package, 240VAC ❑ Emergency stop kit Generator Set Size,L x W x H: 1193 x 666 x 817 mm ❑ PowerSync@ Automatic Paralleling Module (APM) (47 x 26.2 x 32.2 in.) (single phase only; parallel two 20kW residential generator Shipping Weights: sets with the RDC2 controller) 20RCA Generator Set: 252 kg(555 Ib.) Programmable interface module PIM 20RCAL with 100 A RXT ATS w/LC 277 kg(611 lbs.) ❑ g (PIM) 20RCAL with 200 A RXT SE ATS: 272 kg(600 Ib.) (provides 2 digital inputs and 6 relay outputs) L Fuel System Accessories Ir r — ❑ Flexible fuel line(included on QS models) ❑ Carburetor heater, 120 VAC L) Carburetor heater, 240 VAC ®'� Carburetor heater is recommended for reliable starting H ®® at temperatures below 0°C(32'F) Literature ❑ General maintenance literature kit w ❑ Overhaul literature kit ❑ NOTE: Dimensions are provided for reference only and should not be used for planning Production literature kit installation.Contact your local distributor for more detailed information. Maintenance DISTRIBUTED BY- ❑ Maintenance kit(includes air filter, oil, oil filter, and spark plugs) ©2018 Kohler Co.All rights reserved. G4-272 (20RCA) 5/21d