HomeMy WebLinkAbout50775-Z r � 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#: 50775 Date: 6/3/2024
Permission is hereby granted to:
Duran, Rita
1145 Smith Dr S
Southold, NY 11971
To: Legalize "as built" HVAC system to an existing single-family dwelling as applied for per
manufacturers specifications.
At premises located at:
1145 Smith Dr S, Southold
SCTM #473889
Sec/Block/Lot# 76.-2-33
Pursuant to application dated 4/24/2024 and approved by the Building Inspector.
To expire on 12/3/2025.
Fees:
AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $500.00
CERTIFICATE OF OCCUPANCY $100.00
ELECTRIC $200.00
Total: $800.00
.._ .....
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) 765-95021i ://ww� .southo9fltcrwa�ap. aY
Date Received
APPLICATION FUR BUILDING I IIIT
For Office Use Only
P
4 E i
q!
PERMIT NO. 50`71 Building Ins actor: G FT � 1
A
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:
OWNER(S)OF PROPERTY:
Name:Estate Of Duran scTM#so00-76-2-33
Project Address:1145 Smith Drive South, Southold NY
Phone#: Email:
Mailing Address:
CONTACT PERSON:
Name:Jerry Cibulski
Mailing Address:PO Box 598, Southold NY 11971
Phone#:631-404-2507 Email::
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
00therCentral Air pre existing
Will the lot be re-graded? ❑Yes ❑No Will excess fill be removed from premises? ❑Yes ❑No
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 ENO IF YES, PROVIDE A COPY.
Milli Check Box After Readin& The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. APPLICATION 15 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):Jerry Cibulski NAuthorized Agent ❑Owner
Signature of Applicant: Date:4-19-2024
CONNIE D.BUNCH
STATE OF NEW YORK) Notary Public,State of New York
SS: No.01 BU6186050
Qualified In Suffolk County ' G
COUNTY OF
Commission Expires April 14, 2 a d�
Jerry Cibulski
being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the 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
day of; 20
Notary Public
PROPER I'Y OWNERAu,,,n,,,i IRIII ATIG
(Where the applicant is not the owner)
Denis Stahl, as executor residing at,1145 Smith Dr S, Southold
I, .
do hereby authorize Jerry Cibulski, to apply on
nmbehafff to the Town of Southold Building Department for approval as described herein.
t7dj 4-19-2024
Owner's Signature Date
Denis Stahl as executor
Print Owner's Name
2
wft BUILDING DEPARTMENT- Electrical Inspector
"I TOWN OF SOUTHOLD
Town Hall Annex - 54375 Main Road - PO Box 1179
µ Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 765-9502
arnesh@southoldtownny.gov— seand@southoldtownny,.gov
APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date:4-19-2024
Company Name;.
Electrician's Name:.
License No.: Elec. email:
Elec. Phone No. ❑I request an email copy of Certificate of Compliance
Elec. Address.:
JOB SITE INFORMATION (All Information Required)
Name:
Address: 1145 Smith Drive South, Southold NY
Cross Street: Terry Place
Phone No.:
Bldg.Permit#: S 095 email:
Tax Map District: 1000 Section:76 Block:2 Lot:33
BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly):
CO for pre existing central air A5 n ,
UA- square Footage:
Circle All That Apply:
Is job ready for inspection?: Z YES ❑ NO 0 Rough In Final
Do you need a Temp Certificate?: ❑ YES [Z NO Issued On
Temp Information: (All information required)
Service SizeF_11 Ph❑3 Ph Size: A # Meters Old Meter#
El New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead '
# Underground Laterals 1 2 H Frame Pole Work done on Service? Y MN
Additional Information:
PAYMENT DUE WITH APPLICATION
-Bp* san{7s, �55r,-Sofs
AATTENTION/CAUTIONHIGH PRESSURE,
� .
+ REFRIGERANT 1,
ri� esSure.may Fxceed limit -of
�2 service
equipment,limite 1.
REFRIGERANT R-410A
SOUS HAUTE PRESSION
• • •- de service R-22
SERVICE AD
u L
"use only R-410A Refrigerant and POE i :
compressor oil
.refri gran# -4110A et de
tiliser ue�du -
nu _
9
Thuile POE-pour compresseur
92-22203-09.04
( .. ".t'-- - -- _ -. . �?ai"„iW+�zm�rt:.� +°_°•M�IMOg_ 'G , f;.i:�.
_ HAZARDOUS VOLTAGE,.
Tl o
'i's`syst qi i c + < tains�.�=4 -,Xi Of 9 ;
5 r
:erantrn� ;P0 =orl:: Refer'to :prOCIUC-t CAN CAUSE SEVERE PERSONAL
INJURY`OR DEATH.
l ate ra u.rP.`:be,f o re;-i n sta l l i n g o rs s e ryl_P 1g. TURN OFF ELECTRICAL POWER BEFORE REMOVIN T IIS
PANEL SERVICE MUST BE PERFORMED BY.A.QUAfIFIkD
S unit: - . :. 1 SERVICE PERSON4.
..
.i' f"r l�tiirFrrr
a - s,
OTICE
Ce systems f:contien;t du refrigerant ' A
6t .�
sr"X '4a1.0A e#.6t;1e,,I,h:Uile PO,E. Sb•:repdrter ;v Mum owTHEIN,SrALwTroNArv�oPERAn�tc-
1,. N Q PROVIDED W TH THIS'UNIT FAILURE TQ
AA{do ur e�n'tation`'du,p;roduit_;0Vi an J , Do guy RESULT W IMPROPER INSTAl1ATfON,r '
° ADJUSUfW,SC�tdVtCFANDMAMI1`ENANCE,'A0&IBLY .
nsaller cett� ;unity`ou. d.'Intervenlr fv cAUSItY�FJRE,ELI:CfRIGSHrjCCK,PERSONAL INJURY OR. w'
+' a ;` ::? ,, ' PROPERTY DAMAGE.FOR SERVICE AND MAINTENANCE;,' C
S S u S e' 'f 02,i;"Q 194:01;08 CONSULT A IXIAUFIED SERVKE C OMPAM! .�:_ ^ cum
2-22�04-23-OS COM
o RJ�I L—OVA FMFD , , ,
MODELS°. 60091
N .
SERIAL 11.11 - -O DOR USY
INN DE 3011E 7842W140900666 LIWE EXTE M R
VOLTS . -.206/230 PHASE_ . '. 1 HERTZ 60
.,COMPREtSOR%
COMPRESSEUR R L:..A: 21.8/21..8: L.R.A. 117 .
[r UT OOR' '.FAN MOTOR/
F.L..A.. 1.2 HK 1/5
- fiE1R { NTI L. EXT.
t
r SURPlY CIRCUIT. Ai�IPACITY/
.:,,... 29/29 AMP
CaURANT.ADMIt,SBLE D ALIM. -MI.N. -
: lAX: fU tE 0R.
At MAX, :DE :FU$lBLE/D*lSJ* :.5,0150 AMP
`AI N :F .E- OR. CKT`. UK, 'SIZE*
Aitti- LAMP
SAL: DE' FUSIBLE./D:IS�* -
D.ES`I-G10,::PRESSURE 'HI GH/.
475! PS1:G/3275::._kPa
i . PRE'SION NOMINALE `HAUTE , .
DESIGN :PRESSURE* 'LOWS 250. PS�IG/1724 kPa.
PRESSlO -NOMNI NALE BASSE
OUTDOOR": N_ITS FACTORY CHARGE/
• = 132 Oz/3742g R410A.
CHARGE U,M �D,UN_IT�S� -EXT.
TOTALIS", CHARGE/
QHARGE mw.,^E SY:STEME , R410A
►EE INSTRUCTIDNS I NSTDE ACCESS PANEL.
VO_IR JWROCTIONS, DAMS LE PANNEM D ACCES
RHEEM AIR. CONDITIONING DIV-1$164
ORT 'SMITH, *"SAS
9 --220* 7
_*HACR TYPE BKAKER FOR U.S..A. /
01SJONcTE.UR ,gJ.,FF'ERENTIEt, ASSEMOLED IN MEXICO