HomeMy WebLinkAbout50367-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
aro TOWN CLERKS 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 #: 50367 Date: 2/23/2024
Permission is hereby granted to:
Slavonik, Jose h
310 Old Shipyard Rd
Southold, NY 11971
To: construct alterations (gas conversion) to existing single-family dwelling as applied for.
At premises located at:
310 Old Shipyard Ln, Southold
SCTM # 473889
Sec/Block/Lot# 64.-2-49
Pursuant to application dated 1/23/2024 and approved by the Building Inspector.
To expire on 8/24/2025.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00
CO-ALTERATION TO DWELLING $100.00
Total: $350.00
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 littps://www.sotitholdtowniiv.20V
Date Received
APPLICATION FOR BUILDING PERMIT
0
WE
For Office Use Only
PERMIT NO. 6 � Building Inspector. 4N 2 3 2.0
Applications and forms must be filledqut in their entirety.,Incomplete
applications will not be accepted. ;Where the Applicant-is not the owner,an 8t'9�te11 `� ��rten�
Owner's Authorization form(Page 2)shall be completed. Town of Southold
ld
Date; 3
OWNERS)OF P" O AIYt .,
Name: 1 11 r SCTM#1000-
Project Address: 3 1 5- 1 —% m' �1 1 NM
M
Phone#: 5_1�)g 5� Email: L-fffrell Cam
Mailing Address:�/5 ki v veetd & V
CONTACT PERSON:
Name:
Mailing Address; 5-01 J yia&e, + V /(7
Phone#: ��� Email:
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email;
CONTRACTOR INFORMATION:
Name: . Ii110� � N � 'C
Mailing Address: �� 1t64orC �ct �'t LX'j
Phone#:6 N(7 11$Z Email: l�M�l✓ t er L1 ,C,o
M
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration DRepair ❑Demolition Estimated Cost of Project:.
Other c r" 0'V $ s OC121
Will the lot be re-graded? ❑Yes El No Will excess fill be removed from premises? ❑Yes ONO
1
PROPERTY INFORMATION
Existing use of property: Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes ❑No IF YES, PROVIDE A COPY.
❑ 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(print name): d� � C(-e Spo ❑Authorized Agent Owner
Signature of Applicant: ��- Date: p12-11
STATE OF NEW YORK)
SS:
COUNTY OF f�
being duly sworn, deposes and says that(s)he is the applicant
Name of individual signing contract) above named,
(S)he is the
(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
day of V 120
otary Public
NADINE FLEURANT
Notary Public-State of New York
No.oiFLezai�az 'ROP RT ° OWNER AUTHORIZATION
Qualified in Nassau County
My Commission Expires May 23, 2027 (Where the applicant is not the owner)
1, 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
Suffolk County Dept. of
Labor, Licensing & Consumer Affairs
MA
STER
TER PLUMBING
Name
WILLIAM BURGR EE N
Business Name
This certifies that the JIVIB Plumbing and Heating Inc
nearer is duly licensed
Y
the County of Suffolk
License Number: NIP-53534
Rosalie Drago Issued: 06/02/2014
Commissioner Expires: 06/01/2024
"EW
( Workers' CERTIFICATE OF
TATI BoardCompensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE
1a.Legal blame&,address of Insured(use street address only) 1 b.Business Telephone Number of Insured
JMB Plumbing 3 Heating Inc 516-417-1182
William Burgreen
33 Biltmore Blvd
Massapequa,NY 11758 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage is specifically limited to 11d.Federal Employer Identification Number of Insured or Social Security
certain locations in New York State,i.e.,a Wrap-Up Policy) Number
471396876
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) St.Paul's Insurance Co
Town of Southold
Po Box 1179
64375 Main Road 3b.Policy Number of Entity Listed in Box"I a"
Southold,NY 11971 1-163J331859
3c.Policy effective period
7/18/2023 to 7/18/2024
3d.The Proprietor,Partners or Executive Officers are
Included.(only check box if all partners/officers included)
X❑ all excluded or certain partners/officers excluded.
This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"1 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 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: Maurice Flannery
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: �".... •�,ri- t.
(Signature) ( le-)
Title:Vice President
Telephone Number of authorized representative or licensed agent of insurance carrier: 631-331-7700
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.wcb.ny.gov
C ERTIF
1s.L t,N JMB Plumbing
Address fh*101 8dI �i►Yi u. 6�tl 769 13r
534 Riverside Avenue
assapequa, NY 11758
ork Lord pn 6f iras r+ed ffodw4jpk fto—kftq.p JO Fsd WWrn r fir ur ;
47-1396876 "
k."iii�iwi;d'Addrsss of entlt�l�
( ti •'�s1a'v�llstbd a�•daw� did lrasirdM�rw.�"�ra��d�I�lr;�tr ' ta. '
Town of Southold Building Department
54375 Main Road 14;
Po Box 1179 928300-0000
Southold,' NY 11971 1
8cr.P`�11 !' %�ttar�praN'ltiud n
� 120,14 07 17 OF
4. PO pr wVII, Ahi f�Jtt>W t rr hts;,
efts,or*,
a,
�. Pdt�+ 'uecrap�rrr�t� 9
C]: .oo t f6tiow�� o r�s ��m s' i ity ena'.pa1d FamiN rr is t
i
Undbr"iraaalr rat Cie rj�trtr r,aeNf that 1 dha`saaEuect � h� "w9r sd' stnt air lh��nrara Gafrf®t.retsr en,sd ab.plia:arfd:th�tl�p,it4d
insarl a N r' l�ss�r911 !" dttRvr F�aitl FdrNl 'LOsaws ne8 (Cd 4rld ( r ,
r
t
Data$ignW anua 17 024 sy:
.--- .
THIephl7Rg:NUTd9f �'� ,) + �r�°t;St� 'N9m�aarp�°i'Ikl� � St�t�a�a�'
IMPS F, tat 1`tP Bo?tpa 4A Ond$ tkrsct, "that ra ls slrt b auttaarked rrlvgs:ctir N1�
UCO§hsed:thS.Urant p q of that*,6ddrj 1�cor0 "'C��'1 "*1 AT ,.,Malt it d d to t d opr onto,*t o'f,
T.s c s t rs is 1 Nt?X OWPLATff,Ibr purl d of tlw rti Q, 0d,40fth
a , ! r 6 7�a a .
"
00rn at1rto,tte Wo ; ryotope se#on oard,Pt::ntPo `Unn ,P.060."5 60 NOON' tonrN ft''044leted Vy The #" Nark W''t'0 "1 dh 1 1W46ANy If 8 4 0,,"4 rear bpi taavd b6aa 0*40, ,
aAOW "OW N
�or .1 � t1 rarattt�y °�
Work',: � wrrtrrti vcr+ .
1ia8 i11'ty era0 PA14t"a "J 00 new� , 10 0` �60rrtrtw�.ailfh rat �1N:tai tatNr A
Delia a3 4dd � tiq, G
"Telephoos NuMbe
r N aid TOM
• krr 'PANaso A1610 QrrA/Ir,op r:w dk&bN and NOPI. +N�'
agents. hoe errs r r as rs s s srl td tease�.Q t 2d « a�rrr � Ndh �r zed Ih�� ;
JMBPL-1
DATE(MMIDDIYYYYl
CERTIFICATE OF LIABILITY INSURANCE 01/1712024
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(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 endorsements.
PRODUCER 631-331-7700 c .cT
Lynda Rosasco
Coverage Concepp�is Inc PHONE FAX
4963 Nesconset Aighwray A c,No,E�rt;631-331-7700 A/c No):631-331-7790
Port Jefferson Sta,NY 11776 Lynda@cr Verage+concept.com -
INSURERIS)AFFORDING OVnE ACES NAIL
INSURER A:Travelers Indemnity Company
INSURED INSURER B:St. Paul Insurance Co./Travel 25623
JMB Plumbing S Heating Inc
William BLIr Teen . Nsup Ela Rc:Guardian Life Ins.Co. Of Amer 17779
33 Biltmorelvd
Massapequa, NY 11768 INSURER D:
INSURER E:
INSURER.F:
COVERAGESC REVISION
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,
EXCLU81ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN sit TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY dW.' P -. .. ... ..,...-.,... ..Xnmm LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 11000,000
SI�Gr11SE8-4EafL�ll�1 _ �
X CLAIMS-MADE OCCUR 68G-1 WS54328A-23 42 11/13/2 RENT
023 11/13/2024 DAMAGE TO RENTED 300,000'
X _ ................._._..._.._._ MEO EXP(AnY One person _1____......._....� ...'.._
Contractors Liabi _ 5 000
_. ........ _..... _ PERSONAL&A V 114JURY $ 1,000,000,
EN"L AGGREGATE LIMIT APPLIES PER: Q,ENERAL AGGREGA_Tg 2,0001000
X POLICY D JECT LOG PRODU S-COMP OP AGG 2,000,000
T R.
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
_(Ea as 'dent)
ANY AUTO A, OILYINJURY Per rso
OWNED SCHEDULED
AUTOS ONLY AUTOS qy 0i 9 S`Ifil 111P Y(I r ccC C)
VS ONLY A%STNO (Fo arEcbtlartR AP a
t _
UMBRELLA LIAB OCCUR EACH OQQURRENCE
LIAB CLAIMS-MADE AGGREGATE _�m
EXCESS. --. ._...._.._ ...,�....,.... ..-
DED RETENTION$
B WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY Y/N AT.0 ._ ER ,. -mm--
ANY PROPRIETBORIPARTNER/EXECUTIVE ❑ IIT E L.EACH ACCIDENT 500,000
N UB3J331869-23.42-G 07/18/2023 O7/18/2024
FIOER/MEM ER EXCLUDED? N I A E.L.DISEASE°EA.EMPLOYEE ..__..°-.._.�
andatory In H500,000
If yes,desorl under
DES RIPTI F P TIO I 500,000
C Disability 928300 07/18/2023 07/18/2024
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
CERTIFICATE LDE C
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
PO box 1179 AUTHORRED REPRESENTATIVE
54375 Main Road
Southold, NY 11971
V.p,
ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
NCB-240/130H ove,ie-L, I _QuickFacts I warranty. I Downloads I Accessories
Products>Combi Boilers>NCB-H Series>NCB-240/130H
ZI
N C B-240/ 1 3 0 H is I uj
HIGH EFFICIENCY CONDENSING COMBI—BOILER
7.
S Q NSF
* Smart controls LCD display,quick dial wheel &Setup Wizard
* Advanced stainless steel dual heat exchangers
* 15:1 DHW and up to 10:1 heating TDR
* Field convertible gas system (NG/LP) up to 10,100 ft.
* Capable of cascading up to 15 NPE water heaters
* Capable of common venting up to 7 NPE water heaters
* Built-in 3 zone pumps and 3 zone valves powered connections
* 2"venting up to 6 5'and 3"venting up to 150'
See nearby installers...
Credits&Rebates Finder
Find Sales Rep
1/9
Enter Zip Code
NCB-240/130 H ;)ve view 19uickFacts I Warranty- I Downloads I Accessories
Products>Combi Boilers>NCB-H Series>NCB-240/130H
' v &
UDD •-E "- 's' 3 °f P/'!�t,.i,r%; r^'S;rv�` Z'FQ : rS e"
fj
ON
2"PVC venting up to 65 feet including economical schedule 40 PVC.Vent Installation Detector(VID)for added safety.
Dual Venturi system creates better combustion control and turndown ratio and easy field gas conversions.
.I`;! ✓
t 'S
Durable dual condensing stainless steel heat exchangers recover extra heat for maximum efficiency.
2/9
•f f
;..•. t }pia
K r ,je'"'�j 4},r �l/,�6��YB�tliafi��p6t•� ' `y` 8lCFA
} ri
1�iii�;aR G� @b in73 Q,
s
i
( <••yC I 'Y,� �t
o ', - 164tun M C�ECPY �25 2W �•��
• �'.'�'r.`F �G lrl�l EarmJlNfl5MAlzaptpn �3008WTh
rIn
Pt
k � •�`y;[, � .-... y�mra_fesf�Na 76491FOdk111281i4 i•,p .}
- by Rr � �{ ¢i 1 �L.»•nH.-;..<.�...,�r.�,v.,n.•�.rr•Y��� ;vrY'�'! vy�' t�"' `�
;. �"ter �:�; _'`y• `" Ce
1� '�t 1• � ' ` � S��JTT.3`4 t.
- "• ��'_��l ` i�Iryil�y' yr' -
NCB-240/130H Qve;ylevi I guickFacts I Warranty I Downloads I Accessories
Products>Combi Boilers>NCB-H Series-NCB-240/130H
Advanced user interface with Setup Wizard is made easy with backlit panel,click-wheel control and intuitive text.
..............
1/2"gas pipe capability up to 24'(subject to local codes).Cuts installation time,no need to install new gas lines for retrofit applications.
ti
If I
bf
Easily accessible built-in DHW module includes integrated boiler pump,Flow adjustment valve,DHW stainless steel heat exchanger,mixing valve
and 3-way valve.
!M XI%4 ffl�x ol z:� -.I—
Dimensions
Certification Summary
DHW Flow Rates
4/9
i+ N1001lnn11 onu
NCB-240/130H I QuickFacts I Warranty, I Downloads I Accessories
Products>Combi Boilers>NCB-H Series>NCB-240/130H
Boiler weight 96 Ibs(43.5 kg)
Boiler Weight With Water 102lbs(46.3 kg)
Installation type Indoor wall-hung
Venting type Forced draft direct vent
Ignition Electronic ignition
Natural gas supply pressure(from source) 3.5"WC to 10.5"WC(0.87 Kpa to 2.61 Kpa)
Propane gas supply pressure(from source) 8"WC to 13.5"WC(1.99 Kpa to 3.36 Kpa)
Natural gas manifold pressure(min-max) -0.06"WC to-0.24"WC(-0.015 Kpa to-0.06 Kpa)
Propane gas manifold pressure(min-max) -0.06°WC to-0.26°WC(-0.015 Kpa to-0.065 Kpa)
Connection sizes Gas inlet
Power supply Main supply 120V AC,60Hz
Maximum power consumption Up to 15 amperes
Materials Casing Cold-rolled carbon steel
Heat exchanger stainless steel
Venting Exhaust 2"or 3"PVC,CPVC,approved polypropylene 2"or 3"special gas
vent type BH(Class III,A/B/C)2"or 3"stainless steel
Intake 2"or 3"PVC,CPVC,polypropylene 2"or 3"special gas vent type BH
(Class III,A/B/C)2"or 3"stainless steel
Vent clearances 0"to combustibles
Safety Devices Flame Rod,APS,Ignition operation detector,water temperature
high limit switch,exhaust temperature high limit sensor,water
pressure sensor,burner
Temperature setting range 86-140 T(30-60°C)(up to 0°F(°C)when setting the
parameter)
Navien reserves the right to change specifications at any time without prior notice.
6/9
K
t
R Model : NCB-24WI30H(RG)
II�I�II�IIIIIIIII�I�II��� • ��
�111�1��111111111�`Il 2184V2U2Wmm2
` ttltlttl1t�11I►►tlllAllll 8
84954 92164
t Federal Ydw P1°� '
i50K 14CS-2400
8odd NsEi4wioK Nei w
sow-lam Gas I
ti.
cod to,
i
E�aenCY
For orow 0.90V f
w� ,N ' �� .°ems„'"" :r, ,� ^, •
,► gW >Li'. a' 7. J.,,C,., 'h't � •�:i...,?#c.• 1. .,d,.l - +yi ?i�.Y3.s
,��� .9� �,+4°fir}"y..a'•*✓ •:a•� 'ytt'".'. ! � 'E. .4^ '-�'�� _
.'bra.. ..,�,aa; .1.Y.4. ..•�
K y'f r �'� ,'•R j!i,r
�.; It�• I �r i..