Loading...
HomeMy WebLinkAbout49206-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#: 49206 Date: 5/3/2023 Permission is hereby granted to: Loeffler Henq J Irry Trust 535 Lupton Pt Rd Mattituck, NY 11952 To. install generator as applied for. At premises located at: 535 Lupton Pt Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 115.-11-2 Pursuant to application dated 4/3/2023 and approved by the Building Inspector. To expire on 11/1/2024. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Total: $235.00 Buil ng nspector ` 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 3 �s;// w . :iedc : ¢ Date Received p w For Office Use Only 4.J PERMIT NO. Building I pectora APR 0 3 2023 .pro Applications and forms must be filled out in their entirety.Incomplete 'I,BI applications will not be accepted. Where the Applicant is not the owner,an TOWN Owner's Authorization form(Page 2)shall be completed. Date: 4,P--il 3AJ Ac3 A� OWNER(S)OF PROPERTY: Name: NANCY d E Fly i.SSCTM#1000- //S- //- Z 6 L Project Address: Jr-.3s I t NS P0J;J Ro,,J. c Email: Phone#: 3 N#N c y1m 0 Ca - Bohr Mailing Address: G35 - CONTACT PERSON: I Name: k O Lk(`S b E Si4 S Mailing Address: Imo LO&i*4 00,AJ,,- 376 fi� M oleica,4 ° Phone#: 31-,5A S—(. 73 b Email:�l'c(1 owE,c' ICC17g,c. Cato DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: 1� v Iti•'? tom' E �Kc Mailing Address: /p,? �w�rK Phone#: 1p.31- 76 4,-7,0fA 3 Email 'cK�S -EleG4,eiC. CoM DESCRIPTION OF PROPOSED CONSTRUCTION New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other fa $ -To O- o0 Will the lot be re-graded? ❑Yes *0 Will excess fill be removed from premises? ❑Yes IONo 1 PROPERTY INFORMATION Existing use of property: R ESl dEN'� I h L Intended use of property: �Sl' 1_Ai 1�A Zone or use district in which premises is situated: Are there any covenants and restrictions/with respect to this property? ❑Yes ZNo IF YES,PROVIDE A COPY. ❑ C lheck B 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(grin ame)- u-( uthoriz+ed'Agent ❑Owner yj Signature of Applicant: ` Date: 3 STATE OF NEW YORK) SS: COUNTY OF, a UI S b E being duly sworn,deposes and says that Vhe is the applicant (Name of individual signing contract)above named, Ahe is the ,P- -� (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 (9 day of .20 Notary Public PROPERTY OWNER Al JTHORIZAT[ON (Where the applicant Is not the own I, /�l fid C O EF Gresiding at Ta NS siNf R0* A++;���do hereby authorize �U LA-I'S AG � N S to apply on my beh,,K to the Town of Southold Building Department for approval as described herein. ]t0w1n, Sigtla re Date NC Print Owner's Name 2 BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD m Town Hall Annex- 54375 Main Road - PO Box 1179 ZE Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 APPLICATIOL4 FOR ELE+ T1 IC& INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date:Awl a-, a as 3 Company Name: AE. (Z /64Air- I� ^ rKc.. Electrician's Name: LUCIJAS LABI'Co License No.: !� 9,53!6 C Elec. email: 1V isk. E Lws* E/Ec4A'c. CoA Elec. Phone No: L3 j.. -Z lela 911 request an email copy of Certificate of Compliance Elec. Address.: we - .3 JOB SITE INFORMATION (All Information Required) Name: I-oE Address: S-3f Ns 621al Ao,44 r'�c Cross Street: Phone No.: 1 Bldg.Permit#: email: Tax MaE District: 1000 Section: (Zs- Block: , Lot: dZ BRIEF DESCRIPTION OF'WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): .r N s fA 14-k-ON o I�f Kw Fir � .sf�H�f-l�r�,ca�,�►-f�,e Square Foota e: Circle All That Apply: Is job ready for inspection?: El YES NO ❑Rough In11Final Do you need a Temp Certificate?: El YES FX�NO Issued On Temp Information; (All information required) Service Size 1:11 Ph F13 Ph Size: A # Meters Old Meter# ❑New Service[]Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead #Underground Laterals M 1 H Frame LJ Pole Work done on Service? Y nN Additional Information: PAYMENT DYE WITH APPLIC TION ,A Awl A�,z-n aar..✓ xkmu a rw a�vo� v�..�:rm .,:�,,,,, o, ,,v„ � i J 1,, '� r„ �Vlr wk4w�um�urJr, ��� vM�u�m�aurmud ra�%� �i 4� Vr,�xb�',��a Nlur�+B Vrrxw>Trukam m �a 1h�(m�,� ' ✓ °�i%//i �;w 9l)'ff ���a�✓u �4h�i,�wr rnv�u�� #2r7 uv%� � , ! - y��%/o/i ,{i i,' �.wNa''�,I�Y tl�ino n✓viNrlr�F,ff � �i i I 41 / 1 /i✓i ✓I a���' - a ��� /v✓r Q✓ /1/// 1 m'N J i✓iii//' ' i�/�j%///, i * / /iiklm e// '17'77 / ) IN /ill i',/ v ,/ �'i� /i///, ✓ / �,,� � 4 01 fps ' r ,,,✓/;,, ✓i,,,Igrr,Afd7 v�Y�i,i/;�y1�l�G///il��l1 J,"✓p1,1r1�;�% f r ;'7 ,r -, ,.... ,, �, ,,,,, /""" l>.,;, ;lillhJi'/r//l; r M'�!//�I,� �!�JJ��%J ,�1��%/1�111�%vy�l/ry%l�1' �,�P JI 1.' l% % ! . /, , ,, ✓,,yr,r ,r, �� � r ,1 ,/�� l'v♦ ✓, flv;VOy ,,, 0 , wM� ` r 11414�� $ '�Nr9'✓A/y'�i �6�b ! ! r i l l 1, I /�/, 1 ✓ / /�J��k1l'%J��( �J' '^^ ;r^1�,r s G r,;�r✓r iI III i /i !�� ,'/✓f �i( � � / �%��f���/����///� / //iii , IMS''IOR . CERTIFICATE OF Y Workers CELT STATE K Compensation WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only 1b.8twinosss Telephone Number of Insured Shore Power ectrical631-3 Contraotirrg,Inc. b Ce fit IQ NYS Unemployment Caister Moriches,NY 11934 P yment Insurance Employer Registratiori Number of Insured Worts Location of insured(Ordy fiquked if e isknwW ty to in Afew York SW be.,a Up 1d.Federal Employer Identification Number of Insured or Social Seal rity AW) Number 6 2.Nairne and Addiess of Entity Requesting Proofof gage 3a.Name of Insurance Carrier (Entity Being Usted as the Ceilfflai to Ho Hartford Casualty Insurance Company Town of Southold 3b.Policy Number of Entity Usted in Box"1a" 64376 Route 26. 12WYECAB6PSI southow,NY 11971 3c.Policy offedive period 07/20/2022 to 97120MM 3d.The Proprietor,Partners or Executive Officers are included.IQ*duKk box it all par Xall excluded or certEdn partimstolficersmod , This certifies that the Insurance carrd;r-Indicated above In box"T Insures the business relbrenced above in box 01 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 worksiWoompensation 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 due to nonpayment of premiums or within 30 IF there are reasons than �IF a policy is canceled � nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. notices may be scent by regular snail.)COWnAfte,this Certificate Is valid for orre year after this form Is approved by fire insurance carrier or Its licensed agent,or until the policy explraftn date IMed In box.03c",whichever Is eariler. This certificate is issued as a matter of information only and confers no rights upon the certifimite holder.This cerMate does not amend, extend or alter the coverage afforded by the policy fisted,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 oontrad of insurance only while the underlying policy is in effect. Pleases Note:Upon cancellation of the warkeirW compensation policy Indicated an this form,If the business continues to be named on a fin%license or contrad Issued by a caffloate hotde#,the business must provide that Certificate holder with a new Certificate of Workers°COMPonwition Coverage or odw authorized proof that the business is complying with the mandatory coverage requirements of tlie New York State WorkeW Compensation Lm Under penalty of ury,1 certify that I am an authorized representative or licensed agent of the Insurance carrier referenced above andthat the named Insured has the coversoe as depicted on this form Approved by._ miclum MOW (Print name of auttwized mpreoontatWe or 11ceased agent of insiaance carrier) Approved by: 7X4��L;dPal&wl 8/31/2022 (Signature) (Date) Title: Certificate Coordinator Telephone Number of authorized representative or licensed agent of insurance carrier. 631-W--1011 EKt 317 P :Only Insurance carriers and their licensed agents are authorized to Issue Form C-106.2.Insurance brokers are NOT authorbsd to team It C406.2(9-17) www.wcb.ny_gov �"� CERTIFICATE OF LIABILITY INSURANCE ar�,rlo� THIS CERTIFICATE IS ISSUED AS A MATM OR F INpOWATION ONLY AND CONFERS No ROM UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE D068 NOT Y A % EXTEND OR ALTER THE COVERAGE AfFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT COMMUTE A CONTRACT BETWEEN THE ISSUING NSU S'h AUTH REPRESENTATIVE OR PRODUCER,AND THE CERTMATE HOLDER. WIIIORMNW: NOW is an A !DITIONAL INSURED,the POIIoT(Ies)mmsthm AIDD! AIA =u=T or b eondorsea If SUBROITA11ON IS WANED,subject to the terms and COrkdWarn of the pollay,owbdn poUoles nay require ane nt. A sbrhmwft on this wtiffeats does not ponhwooft t0 the In lkm of h,qrwcqSaMNM*81. s Hometown InSurlance of LI.,Inc. .5 0Mle Dr 631-58"100 Sft 400 WL 1 11T4 Bohemia,NY 11716 PlAFFORCUMOOVERAft MAWS' A.Ohio CaSUS W"fance Cc INIII�R I SHORPOWN a;Hard o slid' Shore Mmcting,Inc. Casualty 1(l8 l in RoaCenter Moriches,d C 11934 al IIL?ID: e; I— IMMMF; COMAGES POLICIES O " tON N CATV N 18'I7 INDICATED. NDICAED. MAY BE ISSUENG ANY D OR Ir1�wY�PERlAIN« NT, INSURANCE� O A TIIE NIRA F 3 R � � THE POLICY P�C� TMS IS TO CERTIFY THAT THE F INSURANCE LISTED HAVE B ISSUED TO THE INSURED, POU R ,CERTIFICATE A COIII;NTIONS E CFkI � WHICH THIS CF SUCH POLICIES,LIBMITS SFbCC7dUVVFM MAy HAV'BEEN R HEREIN IV IS SUBJECT TO ALL TERMS, TEI"BVI CR C�Ifi�ON ANY EI>IJCB3'D BY PAID LTR 11YPEOPINSURANCS VOL Sum --LwY!65M LAM A X 6EN6rAL IJABILRY Y BKO(23)5791888.5 7/17r422 71172M EACHOCCURRENCE $11000 q.ABrSMME FE OCCUR .. -WOMTOi Mow 8�� MED IDIP S 15,I1I�I _ Pi &ADVPINJ.IRY 1 ow OW I+I'W. C TE UMrr APPLIES PER OENEIINAI CRATE $2.11IIII.000 POLICY El jEC F LOC PR IOP AGO $ O I UQIB $ AUTOYDBLELLOAUTY S S ANY AUTO BODILY INJURY S _� Y AUTOS �D 80D4Y eLAIRY(P�r� S AUTOS ONLY AUTOSONLY S UMBRELe LJABLJ S OCCUR EACH OCCURRENCES EXCESSLUAB CLAS S S B ANDEINKANEWUABLFTY AY12WECAB5PS1 720=22 7220 X RrN�ECnu — ytiIIHINFIS Ei ILLHCCdENI Io11I00 VIdesaftomw E.L.DISEASE-EA S 1 000,011II oynom OF MO E..L..D Yumir S1/MIB Dg4 OESCROnMOFOPERATIOM * e�aayl,p Nom, Us The Town of Southold l all art add 10jB Insurfrl,as mgmu""d by wtftn Co CI_ ed to poky and ocnditlons. C I I+ A7E HO CANCIWATION SHOULD ANY OF THE ABOVE DESCRIBED POL K3Es BE CANCELLED BEFORE THE EXPIRATION DATE THERWF. NOTICE wLL BE DELIVERED N Town of Southold ACc C W1`M THIS P0u 54375 Route 25. Southold,NY 11971 AUTHORWEDREPRORWATNE RA"COW 0 ISW2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are ngistered marks of ACORD M' Workers' STAR Compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABIUTY AND PAID FAMILY LEAVE BENEFITS LAW 'PAW L To be completed by Disability and Paid Family Leave Benefits Carrier or Ucensed Insurance Agent of dint Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Nurnberof Insured SHORE POWER ELECTRICAL CONTRACTING, INC 108 FROWEIN RD.#2 6313954029 CENTER MORICHES,NY 11934 Work Location of Insured(oniymqukwif oavwwe r.sp M Med to 1c.Federal Employer Identification Number of insured certain Iocaffam In New York Slag Le.,Ktap-Up poffiW or social Security Number '20-4999885 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Beina Listed as the Certificate Holder) TOM Of Southold Standard Security Life Insurance Company of New York 54375 Route 25. 3b.Policy Number of Entity listed in Box"da" Southold, NY 11971 79516-00 3c.Policy effective period 1/1/2018 to 8/30/2023 4. Policy provides the following benefits: © A Both disability and paid familyy leave benefits. ❑ B.Didabifdy benefits only. ❑ C.Paid family leave benefits only. 15. Policy covers: © A-All of the employers employees eligible under the NYS Disability and Paid Family Leave Senefds Law. ❑ S.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 d7d above. Date Signed 8/31/2022 By SUPERVISO DBL/POLI oe �� Telephone Number 0212 1 Nameandrdle 355-414CY SERVICES IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carriers authorized representafte or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate hokler. 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 1116 W1fS Workers'CompenSation Board(only if Box 4C or 513 of Part 1 has been chedurd) State of Now York folk ' Compensation Board According to iMomdatiorr maintainedby the NYS MrkeWCOMPOnsaftn Board,the above-named employer has complied with the NYS Disability arra Pallid Fealty Leave Benefits Law whin respect to rail of his/her employees. Date Signed By APMre Of Authorked Mrs Workers'Comperr mon Board Employee) Telephone Number Name and Title Please Not&:Only orsurance carrier,kensed to write NYS disabAyy and paid family leave benefits lnwfarwe polies and NYS ficerlse d insurance agents of/hose insurance carrier;are authorized loIssue Foran DB-120.1. insurance brelkera arra NOreuakwhed to 111 nus thin lbnri DB-120.1 (10-1 i7 1111119,-1 S 1� ,, Suffolk County Dept,of Labor,Licensing&Consumer Affairs HOME:IMPROVEMENT LICENSE Name NICHOLAS IyAMICO Business Name This certifies that the bearer is duty licensed SHORE POWER ELECTRICAL by the County of suffcA CONTRACTING INC License Number.H-48269 Rosalie Drago Issued: 01/0612011 Commissioner Expires: 01/01/2023