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Home My WebLink About48849-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT K; 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#: 48849 Date: 2/2/2023 Permission is hereby granted to: Way Back Inc The 1401 Main St Ste 6 Port Jefferson, NY 11777 To: install generator as applied for. At premises located at: 25675 Route 25 Cutcho ue SCTM #473889 Sec/Block/Lot# 109.-2-7 Pursuant to application dated 1/13/2023 and approved by the Building Inspector. To expire on 8/3/2024. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $235.00 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT 4 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax(631) 765-9502 lid i s://www,sotitholdtowi-ti. Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only r PERMIT NO. HgBuildingInspector: R JAN 1 3 20'2x3 Applications and forms must be filled out in their entirety. Incomplete EWILDINGDW. applications will not be accepted. Where the Applicant is not the owner,an TOWNOFSOUMM Owner's Authorization form(Page 2)shall be completed. Date: � OWNER(S)OF PROPERTY: Name: SCTM#1000- I / be Wa(A (3 Physical Address:a5 �S r i ai n9– K. _ -(-hogjUC0 NIV 11q 3's' Phone#: — _ Email: Mailing Address: ( ° ° w . M L CONTACT PERSON: Name: . . 2938 Mailing Address: Suite 212 Phone#: UZ?I- Email: DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Vow g�ra SeN I c Mailing Address: �cn ,\/ \-P ) - f Phone#: 31_ -70C) Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Est�'imaitst-of I',ra)ect: Vther $ Will the lot be re-graded? ❑Yes` eo Will excess fill be removed from premises? ❑Yes 1@0 1 PROPERTY INFORMATION Existing use of property: -1,r1. Intended use of property: sapL=2- 4L 4LYi Zone or use district in whicllh1plemises is situated Are there any covenants and restrictions with respect to this property? ❑Yes �& IF YES, PROVIDE A COPY. lt�heck Box After Reading: The owner/contractor/design professional Is irresponsible for all drainage and storm water Issues as provided by Chapter 236 of the Town Code. APPLICATION 15 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 Gass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(priT me): ❑Authorized ent 00Wner Signature of Applicant:+ Date: �2 / �� STATE OF NEW YORK) SS: COUNTY OF JUAFD( k ) �rm�ja5 being duly sworn,deposes and says that(s he s the applicant (Name of individual signing contract)above named, (Sr hh is the GX QC-e i \r-e— --D (Z (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 �.e �� day of 20 ... .� M � ' Notary Public DENISE R, LMSERG NOTARY Fl�l UC, AT' OF NEW YoRK PROPERTY OWNER AUTHORIZATION No otpAeo165,96 (Where the applicant is not the owner) Qualified!In Suffolk Courtly My' ootrhlisslori Expires 11-23,2026 ii I, e ) aQC ,.. residing at t, ..., / T " L � ��dca hereby authorize DOW Egaed&94to apply on my behaift own of Southold Building Department for approval as descri ed herein. 19- z Owner's Signature to Print ner's Name 2 µ Q AeCORe CERTIFICATE OF LIABILITY INSURANCE DATE`I1N,DD it)P1B12A2222 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 c9rtlfloate holder Is an ADDITIONAL tNSll'RED,the pollcy(fes)must.have ADDITIONAL INSURED provlslons or be endorsed. If SUBROGATION 18 WANED,subject to the torms and conditions of the poilcy,certain policies may require an endorsement. A statement on this Certificate does not confer rlgbts to the cortllicalo holder In lieu of oursomen s PRODUCER Borg&Borg Inc. 6316737600 AX Na:631.351.1700 148'east Main Street Huntington NY 11743 PNON or Ins°eo'In C3riI00IN b's'APPORDI96COVERAGE NAICq' INSURER A:Ohio SecurIj Insurance Co 24062 INSURED POMSER-11 +Nsumat a:Ohio Casusl Ins.Co. 24074 PowerRro Service Co.,Inc. INS c:West American Insurance CompAn 44383 608 Johnson Ave,Ste 6 70815 Bohemia NY 11716 untuaRD;Hartford Life And ACddent Ins ur REKRE; INSURER IF Cr,3VERAGfzS CERTIFICATE NUMBERI1333250851 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 OESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS. FR]CCLUSIONSANDE OP SCE OF SUCH POLICIES.LIMITS SHOWNP E BEEN REDUCCEO BY PAID CLAIMS.. sueal LrMrrs A X COMMERCIALGENERALUAB,LRY Y BKS59794035 6/7/2022 5/7/1023 EACHOC�CURRENCE '31,000,000 CSS" CLAIMSMADE OCCUR efjftmEs(Ed aadraancal 3300.040 X Canuaduel Uab SIEO EXP oma Ia 315,000„ PERSONAL&ADV1N4VRY S1.000,000 GENT.AGGREGATE UMIT APPLIES PER GENCRAL AGGREGATE' $2,000, 00 POLICY' JECT LOC PRODUCTS•COMPIOPAGO 52.000.000 $ A AUTOMOBILE LU SUN BKS5979403S 9712022 5/7/2023 � aIPtEOISbNGL LIrA 51,000000 X ANY AUTO BODILY INJURY(Par panda) 3 OWNED SCHEDULED BODILY INJURY(Par sarrdana) S AUTOS ONLYAUTOS P HIRED NONlIWNED aua s AUTOS ONLY N AUTOS ONLY i B X UMBRELLAUAB OCCUR US059794036 51F12022 5/7/2023 EACHOCCURRENCE 56,000.000 EXCEIMI UAB I CLAIMS.NAOE AGGREGATE $5,000A00 DEO I X R 5 S C YMKER3COMPENSATION XWW59794035 517/2022 5/7/2023 X P ANOVAPLOYERV LIABILITY Y I N A'D#wAopairroFuPA;RTwER;axjecnwE ❑ NIA O,L,EACH�ACCrOEN"r $1.000.00'0 OFFICEAI4M0EREXCLUOE01 CL�DISEASE-EA EMPLOYE 51.000.000 ''.. q,MernGfa6ary IM NMI (Mandatory In aMI E.L.DISEASE'.»POLICY U4Irr 31000 000, D DIYbRYPTGON F OPEIRA IA�row utgr LNY811134 1/112014 12/3112023 NYS DBLUMH S I r31 DESCRWnDNCFOPERAVONSILOCAT1ONe1YENICUM(ACORO101,AddldOMIRemarbSchedule.meybealdchedIf more apaceurequlred) cerlificata holder is added as addlUonai Insured 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 AUnY K"ROUTATINS Southold NY 11971 1 7 1 4D 1BSS»2016 ACORO CORPORATION. All rights reserved. ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD h YORK Workers' CERTIFICATE OF TTe Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1POWerPfO SerViCeeCo f Ignored( address only) 1b.Business Teleph � __-- - - use street y) one Number of Insured 631-567-2700 608 Johnson Ave, Ste 6 Bohemia, NY 11716 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 113430118 d Address of Entity Requesting Proof of Coverage 3a,Name of Insurance Carrier 2.N. .an (Entity Being Listed as the Certificate Holder) West American Insurance Compan Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box"la" Southold, NY 11971 XWW59794035 3c.Policy effective period 05/07/2022 05/07/2023 3d.The Proprietor,Partners or Executive Officers are included,(Only .hock box if all partnerslofricers included)all excluded or certain partners/officers ximtuilr�i+rt, 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 certiifticate 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 dons 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 penury„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& Born�c David M_BoroPresident (Print name of authorized representative r licensed agent of insurance carrier) ��,,��y 10!20/2022 Approved by: (Signature) (Date} Title:,.-..,.....Authorized Telephone Number of authorized representative or licensed agent of insurance carrier: 31-673-1600 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 l"NEW K Workers' CERTIFICATE OF INSURANCE COVERAGE sxirr Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be, feted b Disablii and Paid Family Leave Bone Its Carrier or Licensed Insurance Aglent or that Carrier 1a,Legal'Name and Address of Insured(Use street address only) 1b. Business Telephone Number of Insured PowerPro Service Co., Inc. 631-567-2700 608 Johnson Ave, Ste 6 Bohemia, NY 11716 1 c. Federal Employer Identification Number or Social Security Number Work Location of Insured(Only required if specirically limited to 113430118 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 Caffiar Hartford Life And (Entity Being Listed as Certificate Holder) 3b.Policy Number of entity listed in box"1a"; LNY811134 Town of Southold 54375 Main Road 3c.Policy effective period: Southold, NY 11971 01/01!2014 12/31/2023 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: Underenalt of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced P Y above and that the named insured has NYS Disability Benefits insurance coverage as described above. ): Date Signed 10119/2022 B Dx vid i'A Bci y (Signature of insurance wrrier'e authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone No. 631673 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 Oisability Benefits Law. It must be mailed for completion to the Workers'Compensation Board„DB Plans Acceptance Unit, 328 Stage Street, Schenectady,New York 12305 PART 2.To be completed by the I!I''yS Workers Corn ensation Board(Only if Box 4C or 58 sof 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 t-n oloyce) 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. D11 120 1 00-6 7) SURVEYED FOR:- Aler LOCATED:4T 41� ;�s LOT tf ZQ!,000yw MAP OF AN„t'_ — err SURVI-AYED BY -WiLLiANI R, e z, EAS" ,. . 'r