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HomeMy WebLinkAbout50220-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 #: 50220 Date: 1/16/2024 Permission is hereby granted to", Stack, John 7825 Nassau�Point .R.d PO BOXg ........ -..- _...........___ _w .. .. . ............................................................................................................ ........_ . u. ........ 1.. .............................�....m,,.mm,�.mmm_.......................................... __......._.._...._ _..... oqueNY....... 1.9.3.5, _. _..� -..._ To: Construct a new single-family dwelling to include HVAC system and rear deck as applied for per SCHD approval. At premises located at: 7650 Nassau Point Rd, Cutchogue SCTM # 473889 Sec/Block/Lot# 118.-3-4.1 Pursuant to application dated 12/4/2023 . and approved by the Building Inspector.. To expire on 7/17/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $3,699.00 CO-NEW DWELLING $100.00 Total: $3,799.00 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 htt) :Ywww. ogtholdtow°nn . yov P wG v Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT N0. 5O , Building Inspector: nn^�% CFC ,.o r ����!��:r Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:11/2/2023 OWNER(S) OF PROPERTY: Name:John Stack & Patricia Stack SCTM #1000-118-3-4.001 Project Address:7650 Nassau Point Road, Cutchogue, NY 11935 Phone#:(646) 519-1093 Email:jackstacknyc@gmail.com Mailing Address:7650 Nassau Point Road, Cutchogue, NY 11935 CONTACT PERSON: Name:William Barba Mailing Address:PO BOX 90, Blue Point, NY 11715 Phone#:(631) 560-7908 Email:wbarba@bardarch.com DESIGN PROFESSIONAL INFORMATION: Name:William Barba - Barba Archtiectural Design, PLLC Mailing Address:PO BOX 90, Blue Point, NY 11715 Phone#:(631) 560-7908 Email:wbarba@bardarch.com CONTRACTOR INFORMATION: Name:Thomas Downing - Coastal Management, LLC Mailing Address:26 Old Riverhead Road, Westhampton Beach, NY 11978 Phone#:(631) 288-1226 Email:tom@buildcoastal.com DESCRIPTION OF PROPOSED CONSTRUCTION RNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other 850,000 Will the lot be re-graded? *Yes El No Will excess fill be removed from premises? ❑Yes *No 1 PROPERTY INFORMATION Intended use of property:Sin le Family Residers Existing use of property:Single Family Resider g y Zone or Use district in which premises is situated: Are there any covenants and restrictions with respect to R-4� this property? []Yes�iNO 1F YES,PROVIDE A COPY. W 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 210.45 of the New York State Penal Law. Application Submitted By(pifTj rint name):W)''lli a, AIA @Authorized Agent []owner Signature of Applicant: s"L, Date: 11/9!2023 CONNIE D.BUNCH Notary Public,State of New York STATE OF NEW YORK) No.01BU6185050 Qualified in Suffolk County 1-4 COUNTY OF Suffolk SS ) Commission Expires April 14, 2 , William Barba being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the Architect/Agent �,. (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 a day of Notary Public IROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I John J Stack & Patricia M residing at 7650 Nassau Point road, Cut( do hereby authorize William Barba to apply on my behalf to the Town of Southold Building Department for approval as described herein. &a / Com` CSV U-- r)' er"s Signature at Patricia M. Stack & John J Stack ....... .._.................... Print Owner's Name 2 N u Generated by REScheck-WebSoftware Compliance Certificate Project 7650 Nassau Point Road Energy Code: 2018 IECC Location: Cutchogue, New York Construction Type: Single-family Project Type: New Construction Conditioned Floor Area: 3,693 ft2 Glazing Area 21% Climate Zone: 4 (5572 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 7650 Nassau Point Road Cutchogue, NY 11935 0 • Compliance: 0.3%Better Than Code Maximum UA: 701 Your UA: 699 Maximum SHGC: 0.40 Your SHGC: 0.40 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. Slab-on-grade tradeoffs are no longer considered in the UA or performance compliance path in REScheck. Each slab-on-grade assembly in the specified climate zone must meet the minimum energy code insulation R-value and depth requirements, Envelope lues, Prop.Gross Area Cavity Cont. Hotroof Ceiling:Cathedral Ceiling 1,670 30.0 0.0 0.034 0.026 57 43 Vaulted Ceiling: Cathedral Ceiling 1,020 30.0 0.0 0.034 0.026 35 27 Above Grade Walls: Wood Frame, 16" o.c. 4,475 21.0 0.0 0.057 0.060 199 209 Front Door:Solid Door(under 50%glazing) 27 0.200 0.320 5 9 Side Door: Solid Door(under 50%glazing) 24 0.200 0.320 5 8 Above Grade Windows:Wood Frame 933 0.320 0.320 299 299 SHGC: 0.40 Floor Above Basement:All-Wood joist/Truss 2,252 21.0 0.0 0.044 0.047 99 106 Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2018 IECC requirements In REScheck Version : REScheck-Web and to comply with the mandatory requirements listed In the REScheck Inspection Checklist,. Gerson Rubio, P.E. 11/22/2023 Name-Title Signature Date Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Pagel of9 tl A REScheck Software Version : REScheck-Web Inspection Checklist Energy Code: 2018 IECC Requirements: 100.0% were addressed directly in the REScheck software Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. Section Plans Verified Field Verified # Pre-Inspection/Plan Review Value Value Complies? Comments/Assumptions & Re .ID 103.1, ;Construction drawings and ❑Complies Requirement will be met. 103.2 documentation demonstrate r❑Does Not ; [PR1]1 :energy code compliance for the ❑Not Observable 41 building envelope.Thermal envelope represented on ❑Not Applicable :construction documents. g ,®+Complies Requirement will be met. 103.1 'Construction drawings and o 103.2 documentation demonstrate ❑Does Not 403.7 ;energy code compliance for [PR3]1 lighting and mechanical systems. ❑Not Observable f PSystems serving multiple ❑NotA pplicable fidwelling units must demonstrate ;compliance with the IECC Commercial Provisions. 302.1, Heating and cooling equipment is Heating:mm Heating: ❑Complies ;Requirement will be met. 403.7 sized per ACCA Manual S based Btu/hr Btu/hr �❑Does Not [PR2]2 on loads calculated per ACCA ' Cooling: g Cooling: G❑Not Observable Manual J or other methods : Btu/hr Btu/hr approved by the code official. 9 ❑Not Applicable ; � R r Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 9 Data filename: Page 2 section # Foundation Inspection Complies? Comments/Assumptions & RecID p s imus of 6 in. below ,� pies Exception:Requirement is not applicable. and ex protective exposed exterior insulation ❑Do s Not p �FO1t) protecmmm $D3 2.1 to rot le. 14 grade.tend a mm UNot Observable ❑Not Applicable 403.9 Snow-and ice-melting system controls,❑Compiies Exception: Requirement is not applicable. [FO1212 installed. ;❑Does Not ,❑Not Observable, ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Page 3 of 9 Section Plans Verified Field Verified # Framing/ Rough-In Inspection Value Value complies? Comments/Assumptions & Re .ID _ 1402.3.4 Door U-factor„ U .. m.. - U flCom.., p❑DoespliesNot `table for Envelope Assemblies m values. [FR1]1 ] ❑Not Observable ;❑Not Applicable average). g U p❑Do plies $See the Envelope Assemblies 402.1.1, , GlazingU-factor(area-weighted U- ❑Cn 402.3.1, ° es Not table for values. 402.3.3, 402.5 UNot Observable d [FR2]1 Y F❑Not Applicable U i a ea 4 u F V b R Y V 303.1.3 ;U-factors of fenestration products; t❑Complies ;Requirement will be met. [FR4]1 (are determined in accordance ❑Does Not with the NFRC test procedure or taken from the default table. ❑Not Observable „k❑Not Applicable 402.4.1 installed per manufacturer's M ❑Doe shot Requirementwillbe met. 402.4 1 1 Air barrier and thermal barrier ❑Com lies i instructons. � ;�� � E❑Not Observable a ❑Not Applicable o ;402.4.3 'Fenestration that is not site built J, ❑Complies Requirement will be met. [FR20]1 is listed and labeled as meeting s❑Does Not AAMA/WDMA/CSA 101/I.S.2/A440 ❑Not Observable or has infiltration rates per NFRC , ( 400 that do not exceed code ` ;2❑Not Applicable y F limitS. 402.4.5 'IC-rated recessed lighting fixtures' ;' " ❑C'ornplies Requirement will be met. [FR16]2 sealed at housing/interior finish ❑Does Not and labeled to indicate s2.0 cfm l '[]Not Observable leakage at 75 Pa. r ❑Not Applicable ; 403.3.1 (Supply and return ducts in attics "❑Complies aRequirement will be met. [FR12]1 insulated >= R-8 where duct is 5❑Does Not >= 3 inches in diameter and >_ " R-6 where < 3 inches. Supply and; ` .,,,--;..,,�� ,..�- ,,,..�, �❑Not Observable I return ducts in other portions of ❑Not Applicable r ;the building insulated >= R-6 for ,; l diameter>= 3 inches and R-4.2 for< 3 inches in diameter. 403.3.2 1 Ducts, air handlers and filter j ❑Complies 'Requirement will be met. [FR13]1 I boxes are sealed with ❑Does Not �)oints/seams compliant with �❑Not Observable „ ;International Mechanical Code or ' EInternational Residential Code, as ❑Not Applicable 0 a Papldc 1 , „ W `'Requirement will be met. 403.3.5 Buildingcavities are not used as ❑Cornplies [FR15] ducts or plenums. t❑Does Not ❑Not Observable " ❑Not Applicable i ..w.............. .. 403.4 HVAC piping conveying fluids R- R (❑Complies „Requirement will be met. [FR17]2 above 105 °F or chilled fluids U ❑Does Not below 55°F are insulated to >R- ❑Not Observable x 3' E❑Not Applicable r o a 403.4.1 ,Protection of insulation on HVAC ,'[]Complies Requirement will be met. [FR24]1 piping. ❑Does Not 6 ❑Not Observable ",❑Not Applicable r 403.5.3 Hot water pipes are insulated to R- R- I❑Complies „Requirement will be met. [FR18]2 >_R-3 a +❑Does Not 8 ;[:]Not Observable l1 ❑Not Applicable l 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 4 of 9 Data filename: Section plans Verified Meld,'Verified tFraming /Rough-in Inspection omplies� Comments/Assumptions eID alud Value 3,,fi Automatic or rave dampers are _ .._ _... ❑Com Iles Requirement gravity p p will be met. (fit1;9)4 installed on all outdoor air J C1Does Not intakes and exhausts. 31 nNot observable u ;,E]Not Applicable Additional Comments/Assumptions: 1 High Impact('Tier 1) Medium Impact(Tier 2) 3 1 Low impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Page 5 of 9 Sectian Plans Verified Field Verified Insulation Inspection Value Value Complies? Comments/Assumptions Re I �.. �. ..... 303.1 All installed in._.._.� ..��....m.e-._.. sulation is labeled ❑Complies fiRequirement will be met. [IN13)2" 'or the installed R-values <`❑Does Not s provided. FiNot Observable ❑Rot Applicable 402.1.1, Floor insulation R-value. R- R ZIComplies 'See the Envelope Assemblies 402.2.6 E] Wood ;ElWood ;❑'Does Not ;table for values. [IN1)1 e❑ Steel ❑ Steel ;❑Not Observable ° i r❑Not Applicable " e " 303.2, €Floor insulation installed per ❑complies Requirement will be met. 1402.2.8 manufacturer's instructions and ❑Goes Not N211 ;in substantial contact with the ` ;®�9ot Observable [I ;underside of the subfloor,or floor , «framing cavity insulation is in ❑Not Applicable B contact with the top side of sheathing, or continuous insulation is installed on the =underside of floor framing and extends from the bottom to the stop of all perimeter floor framing t members. 402.1.1, ;Wall insulation R-value. If this is a R-Wood R �Dcomplies (See the Envelope Assemblies 402.2.5, � mass wall with at least 2 of the w Elo j� Wood ❑Does Not table for values. 402.2.6 bwall insulation on the wall ',❑ Mass Mass ,❑Not Observable [IN3)1 exterior,the exterior insulation ❑ Steel E] Steel ❑Not Applicable >requirement applies(FR10). k Y E o Y d 303.2 ;Wall insulation is installed per y ;❑complies Requirement will be met. [IN4)1 manufacturer's instructions. `❑Does Note ",[)Not Observable 9 []Not Applicable Additional Comments/Assumptions: 11 High Impact(Tier 1) a Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Page 6 of 9 Section Plans Verified Field Verified # Final Ingpection Provisions Value Value Complies. Comments/Assumptions & Re .113 _ 402.1.1, �Ceiling Insulation R-value. R- R „[]Compiles See the Envelope Assemblies 402.2.1, E] Wood [ Wood ❑Does Not table for values. 402.2.2, SteelSteel 402.2.6 © ❑Not Observable [FI1]1 a ❑Not Applicable 303.1 1.1, ;Ceiling insulation installed per � E]Com lies p "Requirement will be met. 303.2manufacturer's instructions. J ❑Does Not [F12]1 Blown insulation marked every ❑Not Observable °300 ft2. �T]Not Applicable 402.23 Vented attics with air permeable ,❑Complies n Requirement will be met. [F122]z insulation include baffle adjacent ❑Does Not to soffit and eave vents that 'extends over insulation. ❑Not Observable ; x❑Not Applicable l 402.2.4 ;Attic access hatch and door R- R- � ;❑Complies ;Requirement will be met. [1713]1 insulation >_R-value of theP❑Does Not N r i )adjacent assembly. N l❑Not Observable ° 4 f t❑Not Applicable 402.4.1.2 Blower door test @ 50 Pa. <=5 a ACH 50 = x ACH 50 = G❑Complies „Requirement will be met. [F117]1 ach in Climate Zones 1-2, and a❑Does Not <=3 ach in Climate Zones 3-8. u ❑ I u Not Observable , u o „❑Not Applicable ; 403.3.3 Ducts are pressure tested to ,' cfm/100 cfm/100 �,❑Complies Requirement will be met. [F127]1 ('determine air leakage with ft2 a ft2 a❑Does Not i either: Rough-in test:Total ;leakage measured with a i w❑Not Observable LI (pressure differential of 0.1 inch P ,❑Not Applicable g w.g. across the system including [ [ the manufacturer's air handler i r oenclosure if installed at time of n r ^test. Postconstruction test:Total n leakage measured with a x epressure differential of 0.1 inch p �w.g. across the entire system w , including the manufacturer's air Q handler enclosure. I I 403.3.14 Duct tightness test result of<=4 cfm/100 x cfm/100 �❑Cornpflies Requirement will be met. � (F14] cfm/100 ft2 across the system or 'I ft2 ftp ;❑Does Not n <=3 cfm/100 ft2 without air ; 1 ❑Not Observable handler @ 25 Pa. For rough-in tests,verification may need to ; ❑Not Applicable 9 occur during Framing p Inspection. 403.3.2.1 ',Air handler leakage designated `:®Complies sRequirement will be met. [17124]1 :by manufacturer at<=2%of %❑Does Not x design airflow. ❑Not Observable ❑Not Applicable 777— 403.1.1 Programmable thermostats °❑Complies Requirement will be met. [F19]2 installed for control of primary ,❑Does Not heating and cooling systems and initially set by manufacturer for❑Not Observable code specifications. ' ❑Not Applicable �.� 403.1.2 Heat pump thermostat installed '❑Complies Exception: Requirement is [FI 1012 on heat pumps. ;[]Does Not not applicable. '❑Not Observable '❑Not Applicable g � 3.5.1 'Circulating service hot water ❑Complies Requirement will be met. [FI11]2 systems have automatic or ❑Does Not ,accessible manual controls. ❑Not Observable R ,;" ❑Not Applicable a 1 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3Low Impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Page 7 of 9 Section Plans Verified Field Verified # Final Inspection Provisions Value Value Complies? Comments/Assumptions ­­ 403.6.1 'All Allns not mechanical tested system � � ,❑Com lies � b �_ ,.._ y p Requirement will be met. [F[25]2 p d and listed ❑Does Not g HVAC equipment meet efficacy ❑Not Observable t and airflow limits per Table R403.6.1, „ ❑Not Applicable x, 4 403.2 Hot water boilers supplying heat ❑ComP lies Requirement will be met, [FI26]2 through one-or two-pipe heating ❑Does Not systems have outdoor setback ❑Not Observable a control to lower boiler water ,temperature based on outdoor ❑Not Applicable temperature. 403.5.1.1 ;Heated water circulation systems " ❑Complies :Requirement will be met. [F128]2 have a circulation pump.The ❑Does Not system return pipe is a dedicated ' return pipe or a cold water supply ❑Not Apse vable ppipe. Gravity and thermos- F syphon circulation systems are not present. Controls for y; circulating hot water system pumps start the pump with signal; n for hot water demand within the occupancy. Controls automatically turn off the pump when water is in circulation loop o is at set-point temperature and no demand for hot water exists. o 403.5.1.2 'Electric heat trace systems ❑Complies ;Exception: Requirement is [FI29]2 'comply with IEEE 515.1 or UL ��❑Does Not snot applicable. X515. Controls automatically "' n adjust the energy input to the .�❑Not Observable 'heat tracing to maintain the .'❑Not Applicable desired water temperature in the o piping. 5.2 ;Demand recirculation water ,❑Complies ;Requirement will be met. [FI30]2 systems have controls that - ❑Does Not I manage operation of the pump ❑Nat Observable and limit the temperature of the M water entering the cold water ;❑Not Applicable w _W .. P P g to <= 104°F. w 403.5.4 "Drain �����,w .,-»� .a�rv,�����,..,,� water heat recovery units ❑C'omplies ;Exception: Requirement is [F131]2 tested in accordance with CSA ❑Does Not not applicable. B55.1. Potable water-side pressure loss of drain water heat ❑Not Observable recovery units< 3 psi for ;❑Not Applicable individual units connected to one or two showers. Potable water n =side pressure loss of drain water heat recovery units < 2 psi for y: individual units connected to three or more showers. 404.1 90% or more of have high rm nentlam s ❑Coesplies Not kRequirement will be met. [F1611 9 Y P " ❑Not Observable C ❑Not Applicable 404.1.1 Fuel gas lighting systems have ; Com lies Requirement will be met. [FI23]3 no continuous pilot light. %; ❑Does Not ❑Not Observable fl r Not Applicable e 401. 3 Compliance certificate posted, , � 'Complies Requirement will be met. [FI7]2 Does Not ';❑Not Observable %❑Not Applicable 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 7650 Nassau Point Road Report date: 11/22/23 Data filename: Page 8 of 9 ebtionu Plans"verified Field Verified, # Final Inspection provisions !False Va:lue Complies? CommentslAssumptions 3CY3.3 Manufacturer manuals 17-,.IC7r �CompiiesforRequirement will be met. CI1 )a mechanical and water heatingf}ees Not systems have been provided. R ",O'INot Observable CNot Applicable Additional Comments/Assumptions: 1 High impact(Tier 1) 2 Medium impact(Tier 2) 3 Low Impact M r 3) Project Title: 7650 Nassau Paint Road Report date: 11/22/23 Data filename: Page 9 of 9 C2018 IE,CC Energy Efficlency Certificate �J( Above-Grade Wall 21.00 Below-Grade Wall 0.00 Floor 21.00 Ceiling/ Roof 30.00 Ductwork(unconditioned spaces): M=. MMMMMIMM= Window 0.32 0.40 Door 0.20 MEMIM . . Heating System: Cooling System:, Water Heater MEN= EMEMEMEMMIMMEM Name: Date: Comments Town Hall Annex , Telephone(631)765-1802 54375 Main Road '� Fax(631)765-9502 �� P.O. Box 1179 Southold, NY 11971-0959 i e BUILDING DEPARTMENT NOTICE OF UTILIZATION OF TRUSS TYPE CONST CTIONPRE-ENGINEERED WOOD CONSTRUCTION AND/OR TIMBER CONSTRUCTION Dater 12/2/23 Owner: John J. Stack and Patricia M. Stack 7650 Nassau Point Road Cutc o Location of Property: gue, NY 1193 5 Please tike notice that the (check applicable line): New commercial or residential structure _ Addition to existing commercial or residential structure Rehabilitation to an existing commercial or residential structure to be constructed or performed at the subject property reference above will utilize (check applicable line): Truss type construction (TT) ow f Pre-engineered wood construction(PW) _m Timber construction (TC) in the following location(s)(check applicable line): m w Floor framing, including girders and beams (F) Roof framing (R) Floor and roof framing (FR) Signature: ,_ a Name (person submitting this form): William Barba, AIA Capacity(check applicable line): Owner �........... Owner representative TrussReg15.docx Effective 1/1/2015 Scott A. Russell �� STORMIWA\TIE]k SUPERVISOR MA\N ALEGrIEMIENT 5OUT110LD TOWN HALL-P.O.Box 1179 }}]]�� 53095 Main Road-SOLT HOLD,NEW YO K 11971 Town of Southold CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER, ) - - - - - - - -- - - - - - - - - - - - - -- - - — - - - - - - - - - - .APPLICANT: (Property Owner, Design Professional, Agent, Contractor, Other) NAME: 61"/&.A^ SA tZ r1.. i Date: j Qa 23 Contact Information: +$Mad 3 i'cicryf+prte Num&rl Pro erty Address f Location of Construction Site: S.C.T.M. #; 1000 District I S 3 y,vim/ Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT - - - - - — - - - - - - - - - - - - - - - -- - — - - - - - - - - — -- - - Area of Disturbance is less than 1 Acme. No S.P.D.E.S. Permit is Required! Project does Not Discharge to Waters of the State_ No ,1'I ,I S. Pe1'ailt is Ietitlrrell 1 0 Area of Disturbance is Greater than 1 Acre&Storm-water Runoff Discharges Directly to Waters of the State of New York. THE APPLICANT MUST OBTAIN a,S.P.D.L.S.Permit DIRLCrLY From N.Y S. D.C.C. Prior to Issuance of a Budding Permit. 0 - Area of Disturbance is{treater than I Acre&Storm-eater Runoff Flows Through Southold Towns MS4 Systems to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.C.Sm Perra°iit through the Southold'Town Eripirieeririg Department Prior to Issuance of a Building Permit, � �F 1 ii Reviewed i3 V: �' � D3t2: 1_`7(] 6 Fnpm x gmrP-'r _nrinhPv9014 1 i AP-04-kN11111 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 01 21 ^^^^^^ 202648957 COASTAL MANAGEMENT LLC 26 OLD RIVERHEAD ROAD WESTHAMPTON BEACH NY 11978 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER COASTAL MANAGEMENT LLC TOWN OF SOUTHOLD 26 OLD RIVERHEAD ROAD 54375 ROUTE 25 WESTHAMPTON BEACH NY 11978 P.O. BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z2120126-4 254493 04/01/2022 TO 04/01/2023 9/16/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2120126-4, 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:I/WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 639826224 U-26.3 Client#:9990 COASMAN ACORD. CERTIFICATE OF LIABILITY INSURANCE IJAT9/116/206/20D/YYYY) 22 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. IIrINPORTANT:1f the certificate holder Is an ADDITIONAL INSURED,the _musf 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 any rights to the certificate holder in lieu of such endorsement(s). DUCER C _commercial Support PROgONECom 390 9700 ..��,. C,No) 631 390 9790 Ed ewood Partners Ins.Center 40 Marcus Drive E-MAIL certificates@cookmaran.com ADDRESq.._...._ .._ ........_.. ............_ _......._.- 3rd Floor _ tIJSURERIS)AFFORDINGCOVE RA _._ _.GE NAIC# Melville, NY 11747 INSURER A:Southwest Marine&General Ins Co 12294 —.........�, _------....._.. ........... ... n...... ...., _n INSURED INSURER B:General Casualty Company of WI 24414 Coastal Management, LLC ...... _" INSURER C_. 26 Old Riverhead Rd. INSUSURER D. RE Westhampton Beach,NY 11978 _..... ._ _ INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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, _.........,. .°°°_.v. ...... __..._PAID CLAIMS. TYPE OF INSURANCE --- - AVE BEEN REDUCED BY S. LIMITS SHOWN MAY FN_SR -_- POLICY EFF' IPC City EXP EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. ADDL UBD .mm.. POLICY NUMBER 1MIMdDDR YYY MM/C0ffYYYI. LIMITS ...... LTR I-FI . D ��ryry W._. _. _ f�EV� �O(EaRrEr� m erare) $ ... .........G GL2021 LHB00393 10/13/2021 10/13/202 EACH OCCURRENCE 000J000 A ry OCCUR 1 000 000 COMMERCIAL GENERAL LIABILITY URRENCE CLAIMS-MADE �. X.�I ..,--�- ..., X BI/PD Ded:2,500 MED EXP(+ Y one porson) $5,000 PERSONAL&ADV INJURY $1 000 t'III''CI GE AG �..�.�. .� $2,000-000 N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ OTHICY F PRO- LOC WWWMP/OPAGG $2,CItpt1�0t1t) X JF O- PRODUCTS CO ER: .... ..._m.. .... ... __.. ...�........ ........�..... ......,. ,. ......._. .. ._.... COMBINED SiNC�i„E LIMIT B MOBILE LIABILITY BCA000551100mmmmm 10/13/2021 10/13/202 ,,,A ,�I _µµµµwww°mm 00,0100 ANY AUTO ...BODILY INJURY(Per person) $ . _ _........................ OWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS ONLY AUTOS �X AUTOS ONLY X AUTOS ONLY ROPERiff wIACam $ Prr�ecwdeI' $ -A LIAB X OCCMs•MAO EX2021LHB00119 10113/2�� EXCESS LIAB ... .._.. °°°°m .. ..,__ 021 10/13/202 EACH OCG�afzRr_NCE �00�0�0 .., G LAI AGGREGATE ___S4',q0%000 000 DED r fZETENTION$ .....__�.. ........�°..._.. �.....�................. ...�_. .....��.. _ _$.._. -„Y.....,. .... _. Pr WORKERS COMPENSATION ,... :f.Il ...�V 11 1H ITITITITIT, ,mm,mm AND EMPLOYERS'LIABILITY ANY PROPRIETOP PARTNERI:.XECUTIVE Y/N E L EA..4;9^i..ACCVDENT ... ,. ..�..._ OFFICEMMEMBERE:XCLUDED?r ❑ NIA m .m PE. DISEASE LA EMPLOYEE (Mandatory in NH) ......,..._. _.._.... .....If yes,describe under ,.... ,.IT.....,,, .9_..DISEASE wwwwPOLICY LIMIT '$.... ... ..... .. pJESGwROP"fBONOFOPERATIONS beltvurt..___. ........ �._ ... . � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S4285563/M3261846 RH002 LANDU N/FPRmosm unun wf£Ano 21P ZAP t LtL L-•, -„-s -'..''.,} „-_ y-AL`. ] OUFl+xrAo FLEciac sFRnCE _oven ,._ ,13 ExD 2Cr-�' 1 lw „v'. - _._ [BEVELO u—BLIL l'1 es OFMOusxm IXfSnNo SxED i0 �� 6D k N 80°43'c'3'E 309,64' �—' E PT=E,.—1 To IF F , u A aru_ I1 �'tl'rr f/. J R22 D989 f= A 9(29/22. �,u/4 P,/— Rcq:vll um OF IT ov ,_ \ AT SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES f !R kDAD2L I it QL Ex snNc z Rv Res DFNCE TO BE usxcD P1vO1O1EO RES TO-I eEDRo0RDA,(AS PER E`.HE) I 00 OOe 001 SHE p TDO ACHE O GENERAL NOTES 1. NO ENFBTAR__ e _ 4- an x of N_ +.x ENCLOsuaF i. 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