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HomeMy WebLinkAbout49019-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE "o � 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#: 49019 Date: 3/13/2023 Permission is hereby granted to: Dorman Mary 306 W 19th St Ste 902 New York, NY 10011 To: install generator as applied for. At premises located at: 300 Cedar Birch Rd, Orient SCTM # 473889 Sec/Block/Lot# 15.-8-25 Pursuant to application dated 3/6/2023 and approved by the Building Inspector,. To expire on 9/11/2024. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $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 htC s l/°www.south ldtown o 44, Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMITNO. Building Inspector, Applications and forms must be filled out in their entirety.Incomplete I!,,.tbiNG p)E-1�P+ applications will not be accepted. Where the Applicant is not the owner,an GWN OFS0011-40k-[l Owners Authorization form(Page 2)shall be completed. Date:2/24/2023 OWNER(S)OF PROPERTY: Name:Mary D. Dorman SCTM#1000-15-08-25 Project Address:300 Cedar Birch Lane, Orient, NY 11957 Phone#:917-805-6139 Email:maryddorman@gmail.com Mailing Address: CONTACT PERSON: Name: See above Mailing Address: Phone#: Eaail: DESIGN PROFESSIONAL INFORMATION: Name:see above Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Peconic Power Systems Mailing Address:POBox 512, Cutcogue, NY 11935 Phone#:631-734-5026 Email:peconicpowersys@gmail.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other generator installation $ !0,500 Will the lot be re-graded? ❑Yes WNo Will excess fill be removed from premises? ❑Yes WNo 1 PROPERTY INFORMATION Existing use of property:reSldentlal Intended use of property:no Change Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ltw o IF YES, PROVIDE A COPY. ig 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 210AS of the New York State Penal Law. Application Submitted By Tint name Dorman ❑Authorized Agent IROWner Signature of Applicant: Date: W-73 STATE OF NEW YORK) SS: COUNTY OF Suffolk Mary D. Dorman being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract)above named, (S)he is the Owner (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 thkrewith Sworn before me this I / day of Q 20 �3 c DIANAFRANIQ: NOTARY PUBLIC,STATE OF NEW YORK Registration No.05FA6288M PROPERTY OWNER AUTHORIZATION Clualft in Suffolk County (Where the applicant is not the owner) my Wwriber0%M= 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 2 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o- Town Hall Annex- 54375 Main Road - PO Box 1179 P Southold, New York 11971-0959 y,, Telephone (631) 765-1802 - FAX (631) 765-9502 f ro err souths ldtow n . ov seand southoldtownny ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 31.3 Company Name: Oc Electrician's Name: fo License No.: AA s Sb �, Elec. email: Elec. Phone No: I }q- 1 q I ❑I request an email copy of bertifkate of Compliance Elec. Address.: - ) 3ax b � JOB SITE INFORMATION (All Information Required) Name: Address: 3 co 0n- AA) I10 -7 Cross Street: Phone No.: r 7 - q - 6 t Bldg.Permit#: O email: Tax flap District: 1000 Section: Block: Lo : `" BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Foota e: Circle All That Apply:. Is job ready for inspection?: YES O LJ Rough In Final Do you need a Temp Certificate?: YES R-NO Issued On Temp Information: (All information required) Service Size 1 Ph F]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION DATE(MM/DD/YYYY) ACCORV CERTIFICATE OF LIABILITY INSURANCE 01, 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(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 confer rlhts to the certificate holder in lieu of such endorsements. CONTAPRODUCER ; Josh Mitchell Freedom CorpCoverage rp17dNE 631 709 2777 i OXC,w AX 80 Orville Dr Suite 100 � � ) .E-MAIL A N f ,,..,...Ipsh reedo Covera ISew.�czm , Bohemia, NY 11716 _mm INSURER(S AFFORDING COVERAGE 1 _r�nIc* _ _ INsuRERA: 4M .�p_��?!.!�fl1ity1�11 �_ ...11. �. INSURE ., r D INSURER B:_ �es?lf1l .�f. *!!Ql17Pall - Peconlc Power Systems LLC INSURERC: � 315 Commerce Rd INI;uRER D Cutchogue, NY 11935 -INSURER E• INSURER F COVERAGES CERTIFICATE NUMBER: 00000166-0 REVISION NUMBER: 7 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. IRR TYPE OF INSURANCE FBF POL CY E7tRn INSO WVn POLICY NUMBER LIMITS A X EACH OCCURRENCE MLAIMS-MADEGENERAL �AoccuR GLP1092481 05126/2o2z o5/26/2oz3 �l� l � ��w_ $ WW1m�OwOQ;O00 0 0 m_ PERSONAL 8 ADV INJURY $ 1000000 N AGGREGATE APPLIES L : GENERAL POLICYEECTEOC PRODSCOMP/OP AGG $ 2000, 00 OTHER: $ AUTOMOBILE LIABILITY comeNN O SINGL $ - ANY AUTO BODILY INJURY(Per Person) $ i OWNED SCHEDULED BODILY INJURY(Per accident) $ a AUTOS ONLY AUTOS HIRED NON-OWNED gxFCFTTYe. $ AUTOS ONLY AUTOS ONLY IPar s d�LngL $ GGREDUMBRELLA LU1B OCCUR EXCESS LIAR CLAIMS MADE AGGREGATE--.- DED ED I RETENTION$ $ B WORKERS COMPENSATION R O I+ AND EMPLOYERS'LIABILITYNIA 12WECAT7UBP 09/02/2022 0910212023 X .. STATUTE Eft_.. ANY PROPRIETOR/PARTNERIEXECUTIVE YIN, EL EACH ACCIDENT $ 1 OOO OOO (Mandatory In NH)EXCLUDED? E.L.DISEASE-EA EMPLOY E $ 11000,000 If yyes,deeccdbo under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached M more apace Is required) As pertains to insureds operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold Building Department THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall Annex 54375 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. P.O. BOX 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971 JCM ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by JCM on 01/18/2023 at 11:04AM AJJ MAIN R° _ SURVEY OF 1 AT ORI. TOWN OF St SUFFOLK COL R'll 1000-15—( SCALE. 1 FEB. 18, Zo 14-,;, NN loco F �. 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