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Home My WebLink About48907-Z ;. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ' .� SOUTHOLD NY "t a. 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 #: 48907 Date: 2/14/2023 Permission is hereby granted to: Pec ionic Prop LLC Coastal .......... PO BOX 545 Southold, NY 11971 . .... �. ....._ ................... _ ......... To: Modification to existing wireless communication tower: Removal of Sprint tower equiptment and install T-Mobile / Crown Castle (9) new antennas, (6) RRH, and (3) hybrid cables, as applied for per Planning Board approval & conditions. At premises located at: 415 Elijahs Ln,mMattituck SCTM #473889 Sec/Block/Lot# 108.-4-11.3 Pursuant to application dated 12/22/2022 and approved by the Building Inspector. To expire on 8/15/2024._ n Fees: WIRELESS COMMUNICATIONS -MODIFICATIONS $500.00 CO-COMMERCIAL $50.00 Total: $550.00 Building Inspector TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval ww FAX:(631)765-9502 �i Survey—-— Southoldtownny.gov PERMIT NO. Q Check Septic Form N.Y.S.D.E.C.... ..................... Trustees C.O.Application_ Flood Permit Examined ,20 Single&Separate .. Truss Identification Form Storm-Water Assessment Form Contact: Atouea� .,,._ _... Pp __.20 Mail to; .... Disapproved a/c Phone:--- E _,20 :xaaraGY4?TI...�^y./ $yk -.._�`z. 1 4 ., �' Buildin nspector ULA; 49401 - LICATION FOR BUILDING PERMIT 1BUIING DWT Date — S 120 5C n tt t t^rQntr lf"l INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant.Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f Every building permit shall expire if the work authorized has not commenced within 12 months afler the data of issuance or has not been completed within 18 months fj,atn such('fate, if no zoning amendments or other regulations aMcting the property have been enacted in the interim„the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thercafler,a new permit shall be'required. 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,or 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 to building mg for necessary inspections, (Sigt store of Ala(:aa t�;name,if a co ration) 3500 Sunrise Hwy,Great River,NY 11739 (Mailing address of applicant) State whetber applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Applicant is Lessee Name of owner of premises_Qi (As on the tax toll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No._ Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 415 Elijah's Lane Mattituck House Number Street Hamlet County Tax Map No. 1000 SectionBlockLot . 04 11.3 los ,___ �,� Subdivision Filed Map No. .......... 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Telecommunications Facility ...... .............. b. Intended use and occupancy Telecommunications Facility Alteralaorer_. 3. Nature of work(check which applicable):New Building. ........Addition...... Repair Removal...........-.—Demolition---other Work upgiaide exWng telecommunications site (Description) 4. Estimated Cost $25,000 ........... .......... (To be paid on filing this application) 5. If dwelling,number of dwelling units NA Number of dwelling units on each floor NA If garage, number of cars NA 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. NA 7. Dimensions of existing structures,if any:Front NA Rear NA —..Depth......NA Height_....... NA Number of Stories NA Dimensions of same structure with alterations or additions: Front NA Rear NA Depth NA —Height NA Number of Stories NA 8. Dimensions of entire new construction:Front NA Rear NA Depth NA Height NA Number of Stories NA 9. Size of lot:Front NA RearNA Depth NA � 10.Date of Purchase NA Name of Fon-ner Owner NA ........... 11.Zone or use district in which premises are situated.............. 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO X 13.Will lot be re-graded?YES—NO X Will excess fill be removed from premises?YES No NA 14.Names of Owner of prcnjises G bill LLC Address 6915 SE Harbor Cir,Stuart,FI-Phone No. ......... .........._ Name of Architect Infinigy Engineers Address 500 W office Center or Phone No 518-690-0790 -TTWFsh4ngton, -17'03'%one No.531 Name of Contractor Comcell Contracting ...........__Address -t� _-Q.54-5915 t3fa , mAve— Holbrook,NY 11741 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO X •IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES—NO,,.-- •IF YES,D.E.C.PERMITS MAY BE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey, 18.Are there any covenants and restrictions with respect to this property?*YES—NO X *IF YES,PROVIDE A COPY. STATE OF NEW YORK) Ss COUNTYOF >6) being duly swom,deposes and says that(s)he is the applicant (Ninic ofindividual signinj contract)above named, (S)He is the ji Z�..1 —A Z M� ✓ 5 (Contractor"'Agent,Corporate Officer,c1c) 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 knowledge and belief,and that the work will be performed in the manner set forth in the application filed therewith. Swor o before me this day of "M 20 ay of Not Pub Jc chervr er ot, Public t mf Applicant ,w Notary Public,State of New York No.01 PF64006000 5n zb OFFICE LOCATION: MAILING ADDRESS: Town Hall Annex � � P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY � Telephone: 631 765-1938 www.southoldtowirmy.gov PLANNING BOARD OFFICE t ( ` TOWN OF SOUTHOLD FEB 13 2023 ' Ue ggI®��g 8= Pf lk' "�' MEMORANDUM TOWNOFSOUTHOLD To: Michael J. Verity, Chief Building Inspector From: Heather M. Lanza, AICP, Planning Director Date: February 13, 2023 Re: Planning Department Report T-Mobile at 415 Elijah's Lane SCTM#1000-108.4-11.3 415 Elijah's Lane, Mattituck The Planning Department has conducted a review of the proposed modifications pursuant to §280-74 B.(2), and has received a report from our Wireless-Technical Consultant, Cityscape, Inc. (see attached report). We have the following recommendations for this application: 1. The proposed T-Mobile modifications are in compliance with the General Requirements of§280-70, therefore, we recommend a Building Permit be issued for this application in accordance with the Structural Analysis Report, dated October 17, 2022, and the FCC RF Compliance Report, dated January 30, 2023. 2. All Hybrid cables shall be installed inside the monopole shaft.. Thank you for your cooperation.. �1t BUILDING DEPARTMENT- Electrical Inspector .� TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 " Southold, New York 11971-0959 ° Telephone (631) 765-1802 - FAX (631) 765-9502 Egger.richert tovyn.southoid.n ,us APPLICATION FOR EL.E(-,TRlCAL INSPECTION REQUESTED BY: Highlander Consultants, Inc. Date: 12-05-2022 Company Name: Electrician TBIJ Name: .... License No.: email: --- Address ,Phone No.: JOB SITE INFORMATION: (All Information Required) Name: Gobill LLC(property owner) Applicant:T-Mobile Northeast LLC c/o Highlander Consultants Inc. Address: 6915 SE Harbor Cir, Stuart, FI 155 Carleton Ave, E. Islip, NY 11730 Cross Street: Job location:415 Elijah's Lane, Mattituck - Phone No.: 516-810-1117 Bldg.Permit#: email: mrusso@highlanderinc.com 'Tax Map Ma District: 1000 Section. 108 Block: 04 Lot 11.3 BRIEF DESCRIPTION OF WORK(Please Print Clearly) Upgrade existing telecommunications facility site. Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp Certificate?: YES / NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A #MetersOld Meter# New Service- Fire Reconnect- Flood Reconnect- Service Reconnected -Underground - Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form As --r4llw "". Workers' CERTIFICATE OF INSURANCE COVERAGE . , STME compensation 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 COMCELL CONSTRUCTION CORP. 1373 LINCOLN AVENUE 631-654-5915 HOLBROOK, NY 11741 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 27-0807207 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 Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"1a" P.O. Box 1179 R90293-000 Southhold, NY 11971 3c.Policy effective period 1/1/2013 to 10/18/2023 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. B.Disability benefits only. F C.Paid family leave benefits only. 5. Policy covers: Q 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' ,nsured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as desr�mmmTy.d above. Date Signed10/19/20229i"'? (Signature of insurance earner`sakit.horla d oepr'e5er'iM1r NYS Licensed Insurance Agent of that insurance carrier) Telephone Number _(212) 355-4141 Name and Title SUPERVISOR-DBUPOLICY 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. Mail 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 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 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) 11111 IIIIII111111111111111111IIIIIIIIIIIIIIIIIII1111111 DB-120.1 (10-17) NYSIF PO Box 66699,Albany,NY 12206 New York State insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 270807207 MILLENNIUM ALLIANCE GROUP LLC 534 BROADHOLLOW RD STE 103 MELVILLE NY 11747 %9A. , SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER COMCELL CONSTRUCTION CORP TOWN OF SOUTHOLD 1373 LINCOLN AVENUE 53095 ROUT 25 HOLBROOK NY 11741 P.O.BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER �CERTIF�ICATEUMBERPOLICY PERIOD DATE 12108 505-5 08/0212022 TO 08/02/2023 07/08/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2108 505-5, 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. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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, ISURANCE FUND UNDERWRITING VALIDATION NUMBER: 75197434 II II1 IN I �100000Hill 1100�0100101110ill 511111 1ll 911111 Mill 1901140 1 N N III Form 1R'C-CERT-NOPRJNT Version 3(0$(2912019}[WC Policy-21095055] U-26.3 1855 [00000000000105919040][0001-000021085055][##1][15925-04][Cert_NnP-CERT_1][01-00001] COMCCON-01 _006RLEE CERTIFICATE OF LIABILITY INSURANCE DATE(MM2022YY) _]:::.. 61912022 r S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI ON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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 conferrI hts to the certificate holder In lieu of such endorsements ... . .._ PRODUCER License#BR-87'0302 c Neo EtI � Aslani ,Ext 161 � ,. �� FAX . . FA Millennium Alliance Group,LLC CO T a516n496-8004 161 IAA Nal: 534 Broadhollow Rd. Ste.103rl "ss,AslanistTta -insurance com Melville,NY 11747 lalsusge(S)AFFORDING COVERAGE e _ � � NAi,C,#,. _.. ® wNSUR p pA American Empire. urpI"Lines Insurance Co, 35351 a .. INSURED ... INSURERS;Merchants Preferred Insurance Company Comcell Construction Corp „MNSUaERp,?,R ui Inoemrtity irwsurence C+OrraParty ;_ 231 .. ... 1373 Lincoln Avenue INSURER D. rclh. pec-Wty 9Sgreu`wc0 C'p.._ 21, 199 Holbrook,NY 11741 INSURER E:Liberty Insurance Underwriters Inc _ 19917 MNSt1RER F: . ._� m COVERAGES CERTIFICATE CERTIFY THAT THE POLICIES IN URA �EELILISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMOED ABOVE ER THE H E 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. A X COMMERCIAL t 4V _ _ POLICYNUMBER ...e POLiC`AErr POLeCYEXP LIMITS _ LaLICY IEF bL 6M YiiP 1,000,000 RAL LIABILITY E,AgI-I O{CiIdR ENCIE _ DAMAGE TO RENTED 610,006 CLAIMS MADE X OCCUR PLE737843 7/8/2022 7/8/2023 pRFJAISE (Ea MED EXP lAnY,oricP6140lr)_. . $._ I - _ X 1,000,000 f ,... .. Pf RSONAL B(4:gyJN4LIRY.. ... 2,00000 G,NM AGGREGATE LIMIT All NII ES PER: GEr ERAL AG RL AtE ,,,,, a ,1I00 0 ql T' r Loc PRODUCTS COMPIOP AIG $ cTre�rR. POLICY AGGREAT 5,000,000 AU'_w _. _.... _ COMBINED SINGLE LIMIT � 1,000,000 OMOBILE LIABILITY (Ea,a"Idenl) ... ..„ { X ANY AUTO CAPI052866 7/8/2022 7/8/2023 $PPILY INJURY_0:=ev Ip�rson) r -OWNED I SCHEDULED - �a7 ; AUTOS ONLY I. .,1 ALTOS SO,PII Y IN,(tIR (Pur acod„d_ ) ..,;HbRUS ONLY ............... Aq.T7kJ Oh6 �' P O EIId p797A,@AGF I OCCUR AGGTEGATE 2,000,000 B;P� o qqC L9RRENCE X 2,000,000 :EXCESS [CLAIMS-MADE NHAO94791 7/8/2022 7/8/2023 .., ,w,„a C UMBRELLA LIAR X CCU „_, _ DED„J. RETENTION� $ �_.... ........ ........,.�..-. .._........... ....;..'".. ......... -.. .. WORMERS COMPENSATION `PEI ORI{ $TAT"DTF_ ER AND EMPLOYERS''S'LIABILITY IN A�R�MY PROP RIETOR(PARTNERR'XECOTIVE ,-(-rl..EACH ACCIDgN_T S (Man Y 1a MJ Ed LL10E{T N d A .. E,l,...:DIajFASE,,EA EMPLOYEE,SIt .., .,. ID es,SO describe under wo.__ D Ir CDCC/Per Agg tl.GM,6T $ RIPTION car OPEFdA'T'40NS cele, _ ....2023 P _..._.DISEASE _ E 0 ,Excess Liab. UXPt045284-00. 7f8f2022' 7181 gg 3,000,000 E 'Excess Liab. 1000352540-03 7/8/2022 7/8/2023 Per Occ/Per Agg 5,000,000 I �............_ ...................... DESCRIPTION OF OPERATtONS.d LOCATtONS I VEHICLES (ACORD tRN,Additional Remarks Schedule,may be attached If more space is required) Equipment Floater-Hartford Ins.Co.,Policy#12MSJE3032 9114/21--9114,122$250,000 limit for leased or rented equipment. Installation Floater-Hartford Ins.Co.Policy#12MSJE3032 9/14/21-9/14/22$1,000,000 limit. Pollution Liability-Markel Insurance Co.-Policy#MKLC1 ENV100512 2117/2022-2117/2023 $1,000,000 Condition Limit/2,000,000 Agg.Limit. Town of Southold,53095 Route 25,Southold,NY 11971 is included as an additional insured as required by written contract. .m ..., CERTIFICATE H'OLDP .._............ ................ CANCELLATiO 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 Route 25 P.O.Box 1179 .... ............. _ Southold,NY 11971 AUTHORIZED,REPRESENTATIVE P _. ..,...,_ __ .. .. ........ 1988-20 ACORD 25(2016/03) O 15 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD