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HomeMy WebLinkAbout49023-Z o�SUFF01�-coG Town of Southold 8/16/2023 a y� P.O.Box 1179 53095 Main Rd oy�j� aoriSouthold,New York 11971 CERTIFICATE OF OCCUPANCY No: 44436 Date: 8/16/2023 THIS CERTIFIES that the building GENERATOR Location of Property: 550 Birch Ln, Cutchogue Cutchogue SCTM#: 473889 Sec/Block/Lot: 83.-1-24 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/1/2023 pursuant to which Building Permit No. 49023 dated 3/13/2023 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: accessoly generator as applied for. The certificate is issued to Lark,Richard of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 49023 7/7/2023 PLUMBERS CERTIFICATION DATED I ut ori ignature � TOWN OF SOUTHOLD SUFRkIr ao aye, BUILDING DEPARTMENT y x 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#: 49023 Date: 3/13/2023 Permission is hereby granted to: Lark, Richard 550 Birch Ln PO BOX 1241 Cutchogue, NY 11935 To: install generator as applied for. At premises located at: 550 Birch Ln, Cutchogue SCTM #473889 Sec/Block/Lot# 83.-1-24 Pursuant to application dated 3/1/2023 and approved by the Building Inspector. To expire on 9/11/2024. Fees: ACCESSORY $100.00 ELECTRIC $85.00 CERTIFICATE OF OCCUPANCY $50.00 Aal: $235.00 Building ector SOUlyol 0 Town Hall An Telephone(631)765-1802 54375 Main Road P.O.Box 1179 Q sean.deviin(D-town.southold.ny.us Southold,NY 11971-0959 'Q �y00UNT`I,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Richard Lark Address: 550 Birch Ln city:Cutchogue st: ny zip: 11935 Building Permit#: 49023 section: 83 Block: 1 Lot: 24 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Standard Electric Corp License No: 43098ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1 st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Generator X INVENTORY Service 1 ph X 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 Transfer Switch 200A UC Lights Dryer Recpt Emergency StrobeHeat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 20kW Kohler Generator w/200A Whole House Transfer Switch Notes: Generator Inspector Signature: Date: July 7, 2023 S.Devlin-Cert Electrical Compliance Form OF50Ulyo� # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 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: • I(% 6,r-k aA e l �/'ev� f !^ -Jrjc&C J-Wl 1A���t • Aj (-sjj Vc, ci' PA C,e 06n e c jit�. r��seer w► v OA Ll DATE 3 INSPECTOR I �� �y O ho��OE SOUIyO� ' * # TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] R UGH PLBG. [ ] FOUNDATION 2ND [ ] NSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL &WJM6�� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: _ -0 ,� 64VIV66 t Yv b�z gohl('i -puk l DATE INSPECTOR S. jut _ 2023j To l. DING DEPT V-I !s 631 �' � l %i£✓ 3 N SUR SERNGf%nC( NORMAI AN ADD DISCO2 READILY THE ALT UNLESS i •<q,' SOURCE L14 ACCESS AND GAC SHUT OC 01 _ t� aP' C 4 a .. F��i`d�tt e aT' ' � r q CCA t� y x �3 rrr\\\`1YYYyyy1' \.1 1 t ti WHAT ?' 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Building Inspector: MAR 0 1 2023 cK=:'Y AppficatiQn�aridarsmheilrertfir�ty,lrreorrtplete � T/�^'t33L®lhIGLIEPT ;r,,:.e>•r:;: ,� s;£ s., x .� r< �.; ",� 5'.� >is 1 ilS F SOU applicaionsaiuilt:not;baa'ccepted _Where. e:Applieanf<is�n_otttre ouvnes an_ri;-:r& �0 �-fO6 p :Q�iaiei's���hbrizatioe��forni>:�.Pa a=2Ykfhal[:6e..com`;'leted;r�'��:>���.:::<`"�= - ,':g:E '..£h'. =9:1.°:•,;tom _ _ Date: February 27, 2023 :OWNEr �.OF'�PROPE - R RTII' ,?t;z -., .�:: ,.•�'->:��-_ Y f>'� .:'�^�: ,L`. :•lie'•"•="i:"�`-,!:i; Name: Richard Lark SCTM#1000- 83-1-24 Physical Address: 550 Birchlane Cutchogue, NY 11935 Phone#: (631)734-6225 Email: attys@larkandfolts.com MailingAddress: P.O. Box 973, Cutchog4e,_.NY,_11935_ _:•,� ,:,:. ���•�. :tom - ..t �yyss =ir fi4 Name: _......:..,.__..,..._Richard..__F-..._Lark. .,.__,._ ...._.-,.w...,_�...__,_.....__�:w_.._,.".__....,-_•_..._.._._.__.....�.._._..�._:..._,.___._..._•e_....._..._-.._...�__.._...-.:___..,...���_....__.,_,_.. Mailing Address: P.0. Box 973, Cutchogue, NY 11935 Phone.#: 631=734-6807 Email: attys@larkandfolts.com - -- - -- - — - c_r;,• _ ..•fib,'.'" -:j,:: "•M1�'. - ES G U �3..P_ S N R 1f1i0 - ,:t'+:ui-': w '.:.'a:`.>�.,P: :art" .f�,�: :3: :"N! ;;:+�'"+ 'FB+rrr`.!.., :"�)-:�'�4.ifu..;.'_k... )� .•k ,J�c.:?-�:�"�t,::�.`j"_�"''�r�rY.ta.hx."c::dr' Name: Mailing Address: Phone#: Email: f - ':'�:L-v`i'.i.Yom::.._i.•._...:.v-..__.,..., -.,,.-..�,,,ice.. .".:�._ _ - ;:CONTRACT R�INFORMA N. - 5. Name:Commander Power Systems- .... Mailing'Address: 285 Pulaski Street Riwerhead, NY 11901 Phone#: 631-765-6400 Email: ctyndall@commanderpowersystems.com is}^; -ciiT'`�` r:yr. S:DE SC.R"IP: ",PR .... �PR "CTOP4SED` NS �r r ..r. :_�:v � .1.: .,+..l.I::-{-, .-:'.::. .hl" I,• �.�.."Y'i.'rt..+',�'a.��•'�ir�. ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: {Other Install new Kohler 20 KW emergency standby generator(LP) $10,900.00 Will the lotbe re-graded? ❑Yes ONO Will excess fill be removed from premises? ❑Yes 2No 1 , P R 0 ERTY INMR Existing use of property:residential — intended use of property:residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to F�40 this property? E]Yes E3No IF YES, PROVIDE A COPY. 48,Check-Box.Aftbr;:Reaclihg`,The_oWheUcofitraito sign picifessionhi,ii and is' riri-iAiater ktuesas provided "O! ,respon�ibjc to 'Chiptdi,236 of the Town Code. APPLICATION IS HEREBY MADEAd,the Building Diipaiirribnt for the-Issuance of.a:Buildirfg.P.ei'rr�it"pursuant t..6 the Building.6 By, og Ordinance of of 6uildingi;. t,�ToWn of Sout o'Id,'S'u_ff*o'Ik,',C'ount -New and qt 'ilbiii Laws,6rdlAarfce's'or�kegulations,fort.-eji;qnstr h hqra 'Jlf� h construction County; PI u' O'idditiohtjalte,rations or for e' ­oV'al r'denol'itio'n'a'sherein described de�'ciibeil,The app'`Iapplicable Cc agrees;to comply with -' , - , I Ws,ordinances,building codej housing co q,andregu atiqfiS4n&to�adnk a thokzedj6p��tbrs6h premiseiand n,biildirg(s)for necessary inspections'False statements madebreinla,­re- ' uniiha0e a IassrA misdemeanor pursuant toSdetion210.4Softhe.Newybr StatePena Law, Application Submitted By(print.nt name):Richard F. Lark ElAuthorized Agent RiOwner 7L Signature of Applicant: � Date: February 27, 2023 Z_ STATE OF NEW YORK) SS: COUNTY OF SUFFOLK RICHARD F. LARK 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-qa4d-ewft-r-er-ewr*efs-, 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/flier knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this 27th day of February 2023 Notary Public BARBARA DIACHUN Notary Public, State of New York PROPERTY OWNER AUTHORIZATION NOOID146351,90-SuffolkGounty — COMMiselon Expires Oct.31,2036 (Where the applicant is not the owner) 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 Owners Name 2 oS�Efp��.c BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD o =` Town Hall Annex- 54375 Main Road - PO Box 1179 oy • Southold, New York 11971-0959 .h0 ap Telephone (631) 765-1802 - FAX (631) 765-9502 ro erra-southoldtownny.gov — seandasoutholdtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 2/27/23 Company Name: Standard Electric Corp. Electrician's Name: Calogero G. Brutto License No.: ME-43098 Elec. email:cbrutto@standardelectriccorp.com Elec. Phone No: (516) 819-8684 ®I request an email copy of Certificate of Compliance Elec. Address.: 6500 Jericho Tpke., Suite 22E Syosset, NY 11791 JOB SITE INFORMATION (All Information Required) Name: Richard Lark Address: 550 Birch Lane Cutchogue, NY 11935 Cross Street: DuckPondRoad Phone No.: 631-793-7722 Bldg.Permit#: email: attys@larkandfolts.com Tax Map District: 1000 Section: 83 Block: 1 Lot: 24 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Install new 20 KW Kohler (LP) generator with 200 Amp Automatic Transfer Switch Square Footage: 18 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 Size71 PhF—]3 Ph Size: 200 A # Meters Old Meter# ❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect[:]Underground❑✓Overhead # Underground Laterals 1 F12 M H Frame Pole Work done on Service? OY W/ N Additional Information: PAYMENT DUE WITH APPLICATION i i �gt1FF04 BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD co W Town Hall Annex-54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 rogerr(cDsoutholdtownny.aov - seanda-southoldtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 2/27/23 Company Name: Standard Electric Corp. Electrician's Name: Calogero G. Brutto License No.: ME-43098 Elec. email:cbrutto@standardelectriccorp.com Elec. Phone No: (516) 819-8684 ®I request an email copy of Certificate of Compliance Elec. Address.: 6500 Jericho Tpke., Suite 22E Syosset, NY 11791 JOB SITE INFORMATION (All Information Required) Name: Richard Lark Address: 550 Birch Lane Cutchogue, NY 11935 Cross Street: DuckPondRoad Phone No.: 631-793-7722 Bldg.Permit#: Ifa� email: attys@larkandfolts.com Tax Map District: 1000 Section: 83 Block: 1 Lot: 24 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Install new 20 KW Kohler (LP) generator with 200 Amp Automatic Transfer Switch Square Footage: s 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 SizeIV-(11 PhF-]3 Ph Size: 200 A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑✓Overhead # Underground Laterals 0 1 2 H Frame D Pole Work done on Service? MY ZN Additional Information: PAYMENT DUE WITH APPLICATION i 4 G r!>Ar�,. DATE(MM/DD/YYY1) CERTIFICATE OF LIABILITY INSURANCE 1/13/2023 . 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 pol(cy(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. CONTACT NAME: Sue George Borg$Borg Inc. PHONE 631-673-7600 FAX No:631-351-1700 148 East Main Street E-MAIL Huntington NY 11743. ADDRESS: cerfificates@bDrgins.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:.Merchants Mutual Insurance 23329 INSURED - STANELE-01 INSURER B:Twin City Fire Ins Co 29459 Standard Electric Corp INSURER C:Standard Security Life 69078 Calogero Brutto 6500 Jericho Tpke. INSURER D: Syosset NY 11791 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1508473797 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 SU D POLICY NUMBER MM/DDY EFF MM/DD EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY BOPIC63594 211/2021 2/1/2024 EACH OCCURRENCE $1,000,000 DAMAGE To_7RENTED CLAIMS-MADE �OCCUR PREM SES Ea occurrence) $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $Included -GEN'L AGGREGATE LIMITAPPLIES PER: - - GENERALAGGREGATE $2,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ _ A AUTOMOBILE LIABILITY CAP1075068 2/1/2023 2/1/2024 COMBINED SINGLE LIMIT $1,000,000' O accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ , AUTOS ONLY ' AUTOS ONLY Per accident UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ - $ B WORKERS COMPENSATION 12WECAJ5V6F 12/23/2022 12/23/2023 X PER - OTH- AND EMPLOYERS'LIABILITY YIN N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? NSA ' - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $1,000,000 C Disability 62310-00 3/26/2010 3/26/2024 Limits Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) 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 AUTHORIZED REPRESENTATIVE Southold NY.11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACO RD 25(2016/03) The ACORD name and logo are registered marks of ACORD' % wwt 1 4 � , .. CERTIFICATE F INSURANCE COVERAGE ' DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW _,� i���s�rd�¢ PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent or that Carrier 1 a.Legal Name and Address of Insured(Use,street address only) 1 b.Business Telephone Number of Insured Standard Electric Corp 516-499-7354 .65Q0 Jericho Tpke. Syosset, NY 11791 1 c. Federal Employer Identification Number or Social Security Number Work Location of Insured(Only required if specifically limited to 208322723 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 Carrier Standard Securitv (Entity Being Listed as Certificate Holder). 3b.Policy Number of entity listed in box"1a": 62310-00 Town of Southold 54375 Main Road . 3c.Policy effective period: Southold, NY 11971 03/26/2010 03/26/2024 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:' 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 Benefits insurance coverage as described above. 12/29/2022 Date Signed By: David M Bore (Signature of insurance carriers authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone No. 631 673 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 Disability Benefits Law. 'it must be mailed for completion to-the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street, Schenectady, New York 12305 - 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-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 Employee) 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 D13420.1. Insurance Brokers are not authorized to issue this form. DB120.1(10-17) ) Additional Instructions for Form DB-120.1 By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business referenced in box"la"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send-this Certificate of Insurance to the entity listed 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 cancelled 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 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 Disability.and/or Paid Family Leave Benefits-contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits 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 NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatoy coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW 220. Subd: 8 (a)The head'of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first, two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be,construed as creating any liability on the part"of such state or municipal department, board, commission or office to pay any disability benefts'to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,-that the payment of.disability benefits, and after January first,two thousand-eighteen,the payment of family leave benefits has been secured as provided be this article. DB120.1(10-17) Worked' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE- COVERAGE � s 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Standard Electric Corp 516-499-7354 6500 Jericho Tpke. Syosset, NY 11791 1 c.NYS Unemployment Insurance.Employer Registration Number of Insured Work Location of Insured(Ohiy required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 208322723 xx- 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Twin City Fire Ins Co Town of Southold 54375 Main Road 3b.Policy Number of Entity Listed in Box 1.1 a" Southold, NY 11971 " . 12WECAJ5V6F 3c.Policy effective period' 12/23/2022 12/23/2023 3d.The Proprietor,Partners or Executive Officers are included.(Only heck box ff all partners/officers included)all excluded or certain partners/officers exclude$. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"lei"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 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 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: Borg& Borg Inc.,"David M Borg President (Print name of authorized representative or licensed agent of insurance carrier) "Al 12/29/2022 Approved by: (Signature) " (Date) Title: Authorized Representative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-673-7600 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.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined.by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be. construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if soemployed. 2.' The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced.in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2(9-17)REVERSE SURVEY OF LOT 9 MAP OF BIRCH HILLS 0� FILE No. 4908 FILED JULY 19, 1967 c SITUATE CUTCHOGUE s TOWN OF SOUTHOLD loo S U W YORK �. FFOLK COUNTY,N TY, NE K � ro S.C. TAX No. 1000-83-01 -24 o'' SCALE 1 "-30' 40y tio'� // �, F O FEBRUARY 23, 2023 / / 1cP! AREA 22,000 sq. ft. 0.505 ac. G OR • V ��� �`f GOO. t, g. 6� �' �' !:,`'`CA: ''r` ' °'" PREPARED IN ACCORDANCE WITH THE MINIMUM • S. '.. ::•� ,. / � fi 9 'P :,,.�....'�,���.Y;,:;y. STANDARDS FOR TITLE SURVEYS AS ESTABLISHED • e•• '• 5 OQ �' O � �• BY THE LI.A.LS. AND APPROVED AND ADOPTED • '► c}1• F �••-• FOR SUCH USE BY THE NEW YORK STATE LAND .► ,,• , ••�•'o'r t } TITLE ASSOCIATION. _ ..•'�.A. .),t• OjiAR �p��J�- v„•..�.�`n a•!•'..•,`, � :-+.��dr� � t ��. t •,. .••...: ,�•.+.1 tai•xVC aP 'Y t .. � ,t��. _ 4(i„ ,/ \\VV__ J• •S`,k..'�'I�j1.'.• �,` ,�'@� Com.• "'O' '. ��y/J •:' •..• : e.}• ,;�.,;.:.,,;..' ,+ ¢� "� a°`= s'%:^� 5 t ,�6``� ; N.Y.S. Lic. No. 50467 :::►..� �- °J�G.�°� �. 0 THIS SURVVEY IS ALTERATION OR OF Nathan Nathan Taft Corwin III SECTION 7209 OF THE NEW YORK STATE '' �• i EDUCATION LAW Land Surveyor COPIES OF THIS SURVEY MAP NOT BEARING 1`,:►. THE LAND SURVEYOR'S INKED SEAL OR B TOB E�A�VALID TRUSFAL E COPY.NOT BE CONSIDERED Successor To: Stanley J. Isaksen, Jr. LS. Joseph A. Ingegno LS. CERTIFICATIONS INDICATED HEREON SHALL RUN °•:: .• e ONLY TO THE PERSON FOR WHOM THE SURVEY Title Surveys — Subdivisions — Site Plans — Construction Layout IS PREPARED, AND ON HIS BEHALF TO THE OnP TITLE COMPANY, GOVERNMENTAL AGENCY AND FaX 727-1727 oG LENDING INSTITUTION LISTED HEREON, AND PHONE (631)727-2090 (631) TO THE ASSIGNEES OF THE LENDING INSTI- MAILING ADDRESS TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. OFFICES LOCATED AT 1586 Main Road P.O. Box 16 THE EXISTENCE OF RIGHT OF WAYS Jamesport, New York 11947 Jamesport, New York 11947 AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. E—Mail: NCorwin3®aol.com 43-037 LARK& FOLTS Attorneys at Law 28785 MAIN ROAD PO BOX 973 CUTCHOGUE,NEW YORK 11935 Tele.No.(631)734-6807 RICHARD F.LARK Fax No. (631)734-5651 MARY LOU FOLTS E-mail: Attys@larkandfolts.com February 27, 2023 Michael J. Verity, Building Inspector Town of Southold Building Department 54375 Main Road - P.O. Box 1179 Southold, NY 11971 RE: Richard F. Lark 550 Birch Lane, Cutchogue, New York SCTM #1000-83-1-24 Dear Mr. Verity: In regard to obtaining a permit for the installation of a standby generator, I am enclosing the following: 1 . Application for Building Permit 2 : Application for Electrical Inspection 3 . Survey prepared by Nathan Taft Corwin III Land Surveyor dated February 23, 2023 4 . Specifications of Kohler Multi-Fuel -LPG/Natural Gas (Model 20RCA(L) generator; and Kohler Automatic Transfer Switch (Model RXT) 5 . Certificate of Liability Insurance and Certificate of NYS Workers ' Compensation Insurance Coverage Very truly yours, Richard F. Lark RFL/bd Enclosures AP ROVED AS NOTED DATE: B.P.## FEE: 5,6� BY: NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO -4 PM FOR THE FOLLOWING.INSPECTIONS: Pro (/)`��1. FOUNDATION.- TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4r paptne, 4. FINAL - CONSTRUCTION MUST 1 BE COMPLETE FOR C.O. plK N���ALL CONSTRUCTION SHALL MEET THE asREQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR rep (Ktm e DESIGN OR CONSTRUCTION ERRORS. (� COMPLY WITH ALL CODES OF NEW YORK STATE & TOWN CODES AS REQUIRED AND CONDITIONS OF ^I'Tu111�T(1WN 7R6 7 .vI�ING BOARD RUSTEES .-j000PANCY OR JSE IS UNLAWFUL ,VITHOUT CERTIFICA"- 3F OCCUPANCY ELECTRICAL oNSPECTION REQUIRED R t S KOHLER. Models: 20RCA(L) Multi-Fuel LPG/Natural Gas 09001 Standard Features ILKOHLIIER. • RDC2 Controller NATIONALLY REGISTERED o One digital controller manages both the generator set and transfer switch functions (with optional Model RXf). o Electronic speed control responds quickly to varying demand. o OnCue®Plus Generator Management System for remote monitoring is included with the generator. 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§boost- technology provides excellent a Approved for stationary standby applications in locations starting power. served by a reliable utility source. . Aluminum Enclosure • 20RCAL models packaged with a Model RXT automatic o echv alumina tit enClos°°ure liiws installation transfer switch are available. See page 4 and the Model close as 18Vinches horn ourshome Ares II business # R)C f 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 +420/2401 V '�1 h181118 75 291201 4§J3 $109 120/208 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 at 1.0 power factor.The standby rating is applicable to variable loads with an average load factor of 80%for the duration of the power outage. No overload rapacity is specified at this rating. Ratings are in accordance with ISO-3046/1,BS5514,AS2789,and DIN 6271.GENERAL GUIDED NES FOR DERATING:ALTITUDE:Derate 4%per305 m(1000 ft.)elevation above 153 m(500 ft.).TEMPERATURE:Derate 2%per 5.5"C(10°F)temperature increase above 16°C(60'F). Availability is subjectto change without notice.The generator set manufacturer reservesthe rightto change the design or specifications without notice and without any obligation or liabilitywhatsoever. Contact your local Kohler Co.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. t 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) 9/19c ' Alternator Specifications Alternator Specifications Alternator Features Specifications Alternator • Compliance with NEMA, IEEE, and ANSI standards for Manufacturer Kohler temperature rise. Type 2-Pole,Rotating Field e Self-ventilated and dripproof construction. Leads,quantity 21`7 4 • 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 • 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 . 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 CHI 000 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 Type Full Pressure Compression ratio 8.8:1 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 8 (25) 1 3/4 Crankshaft material Heat Treated,Ductile Iron 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) 1 1/4 1 1/4 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) 9/19c 1 '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.H2O): • LCD display: Natural gas 0.9-2.7;33:5-11� 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 Propane,%by volume 1.0 max. 85 min. o Voltage and frequency Propene,%by volume(maximum) 0.1 max. 5.0 max. o Engine temperature o Oil pressure C4 and higher,%by volume ' 0.3 max. 2.5 max. Sulfur,ppm mass(maximum) 25 max. o Battery voltage Lower heating value, o Engine runtime hours MJ/m3(Btu/ftp),(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: t 1.0%RMS no-load to full-load Fuel Consumption,m3/hr.(cfh)@ 60Hz • Automatic start with programmed cranking cycle %Load Natural Gas LPG • Programmable exerciser can be set to start automatically on }� s.DO s2( 81) 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 KohlerO 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 64 dB(A) during weekly engine exercise and 69 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: parameters. o System voltage,frequency,and phase RDC2 Controller o Voltage adjustment o Measurement system, English or metric • ATS status (Model RXT ATS required): o Source availability voft�a,B: 2aov 0 o ATS position(normal/utility or emergency/generator) Freq: 60.OHz o Source voltage and frequency 0 0 0 • • ATS control (Model RXT ATS required): T 0 o Source voltage and frequency settings o Engine start time delay —aJ 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(active/inactive) 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) 9/19c 1 KOHLER CO.,Kohler,Wisconsin 53044 USA KOHLER, Phone 920-457-4441,nearestalesFax 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 management bo • Critical silencer ard❑ 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®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 UL 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 x 817 mm ❑ Emergency stop kit Generator Set Size,L x W x H: (47 x 26 2 x 32.2 in.) ❑ PowerSync®Automatic Paralleling Module (APM) (single phase only; parallel two 20kW residential generator Shipping Weights: sets with the RDC2 controller) 20RCA Generator Set: 252 kg (555 Ib.) 20RCAL with 100 A R)CF ATS w/L277 kg F-1Programmable interface module (PIM) 20RCAL with 200 A RXT SE ATS: 611 272 kg((6001lb.)) (provides 2 digital inputs and 6 relay outputs) L Fuel System Accessories ❑ Flexible fuel line(included on QS models) ❑ Carburetor heater, 120 VAC ❑ Carburetor heater,240 VAC H emmmp Carburetor heater is recommended for reliable starting 9=bFe2n,at temperatures below 0°C (32°F) Literature C] General maintenance literature kit I 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) ©2018,2019 by Kohler Co.All rights reserved. G4-272 (20RCA) 9/19c