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HomeMy WebLinkAbout51369-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#: 51369 Date: 11/12/2024 Permission is hereby granted to: Osprey Dominion Co PO BOX 198 Peconic, NY 11958 To: Install(2) electric vehicle chargers with bollard protection as applied for per manufacturer specifications and conditions. Premises Located at: 44075 Route 25, Peconic, NY 11958 SCTM#75.4-20.1 Pursuant to application dated 07/10/2024 and approved by the Building Inspector. To expire on 11/12/2026. Contractors: Required Inspections: Fees• EV Charger $125.00 Electrical-Commercial $100.00 CO Commercial $100.00 Total S32S.00 Building Inspector F 'act TOWN OF SOUTHOLD—BUILDING DEPARTMENT 84 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 Mitt) ://www.SouthoMdtowm M.Gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. w15 I �)W l------www_, Building Inspector: �4—A---K)—...—. o Applications and forms must be filled out in their entirety.Incomplete 0Co applications will not be accepted. Where the Applicant is not the owner,an ON, fq Owner's Authorization form(Page 2)shall be completed. Date:June 7, 2024 OWNER(S) OF PROPERTY: Name:Osprey Dominion SCTM# 1000-075.00-01 .00-020.001 Project Address:44075 Main Road, Southold, NY, 11971 Phone#: Email: Mailing Address:44075 Main Road, Southold, NY, 11971 CONTACT PERSON: Name:NA Mailing Address:NA Phone#:NA Email:NA DESIGN PROFESSIONAL INFORMATION: Name:NA Mailing Address:NA Phone#:NA Email:NA CONTRACTOR INFORMATION: Name:Del Core Electric & HVAC Inc. Mailing Address:35 Corbin Ave A, Bay Shore, NY 11706 Phone#:631-835-7272 Email:Istewart@lynkwell.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition BAlteration ❑Repair ❑Demolition Estimated Cost of Project: HI Other DCFC(1-3)Charging Station $13,000 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ®Yes ❑No 1 PROPERTY INFORMATION _......... ... ....... _....._.. Existing use of property:Commercial Intended use of property.No Change Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Commercial this property? ❑Yes BNo IF YES,PROVIDE A COPY. ❑Check After : nee owner/ter/design wolesslOnal 8 responslia for as drainage and storm vistar ksm as prori&d by �p r��»APAlt AiION IS IEREBy MADE to tlw Butte D�ertment for the ysueCe Of a BLMdVg Permit puraont to the Buildbfg zone fMwil nwe o1N E tt►aw�azr �nn Cowrty,New York a�other applicable laws,Ordinances orRegulatimm for the anuftucWn of buildings, additions.afteratiwn; �a� ro/gnogdon as herein described nr appl(ont 0117—to C—Ply-n all applicable bvf%adYw=M WUdft code, ha4s6�o and g �x a tkw a t aatlrodsad kispccDors on pranises and in buildirg(s)for neausmy inspections.Pays smLnnaft made tMeln are rb��'le,y.Ciapss ow��rn9k to 21D 45 of the New York State Peril law. Application Subml ed Bit° ` nt name) "";o y14 /e ❑Authorized Agent ),�wner Signature of Applicant: ,� Date: STATE OF NEW YORK) COUNTY OF -)DkA Kam,I G11- 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 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 dayof June &&/w _�www�a 0-4 Notary Pub PROPERTY OWNER (why this li st i t AUTHORIZATION th oWn r , ubii,StR1 r w .r Not No 09 A Ir4UFMPN BARBA rk Kip �LA6084233 . 'W u i ualiiied In Sidi I'Coun I, John Kohler residing at 44075 Main Road, r�talJion Expires Lir o , � do hereby authorize Del Core Electric and HVAC to apply I on nmbeh4 Nothe wn of Southold Building Department for approval as described herein. /n ure Dat Print Owner's Name 2 SITE PLAN USE DETE t`ll(; 3 n lr�ml f RMINATION _ Southold T eau»°e Planning Board Initial Determination --8 / 3 D - ��� � Date:� a a , o t Date Sent: Project Name; Project Address:, �.'� �+.. _ _.. ., �_�.._....._�... ...-.�,,.__..._ Suffolk County Tax Map No.: 1000- -�_-o • Zoning District: Request: t (Note:Copy of Building Permit Application and supporting documentation as to proposed use or uses should be submitted.) Initial Determination as to whether use is permitted: Initial Determination as to whether site plan is required: —-- -- - Signature wilding Inspector ___—_____ __--_--___—___—_—_.._—_—.----_—_..___--_--___—_.. --- Planning Department(P.D.) Referrals i P.D. Date Received:��� Date of Comment: ; �Comments: `tt : t �g . S,� c.c Z : _ Signature of Planning D Staff Reviewer Final Determinaflon Date: Decision: Signature of Building Inspector �,J 0�� .., 11 r m t_ . . FOR INTERNAL USE ONLY SITE PLAN USE DETERMINATION Initial Determinatio--,,n�,��1 ��_ Date Sent: 3 0 2`� Date: Project Name: - Project Address: Suffolk County Tax Map No.: 1000- -�_-a0. Zoning District: Request: _ � LD (Note: Copy of Building Permit Application and supporting documentation as to proposed use or uses should be submitted.) Initial Determination as to whether use is permitted: Initial Determination as to whether site plan is required. Signature uilding Inspector Planning Department (P.D.) Referral: P.D. Date Received: �_J Date of Comment: Co m m e Signature of Planning Dept. Staff Reviewer Final Determination Date: Decision: Signature of Building Inspector Workers` CERTIFICATE OF INSURANCE COVERAGE sTATE Compensation under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW d�uawa rti .ART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance of that Carrier._........._._w w_ ........................—. _...........................M.. w----............... _w.wwww---........._ ta.Lgeal NameA5ofhtsnrre#e ............ tb.BusinessTelephone .,_........ww-_....... Number of Insured DEL CORE ELECTRIC&HVAC INC 31 LANIER LN 631-704-9383 to.Federal Employer Identification Number of Insured or Social Security BAY SHORE NY 11706 Nurabor Work Location of Insured 832587281 (0n1y mqui ed if ro-9,is sp®cillca/ly Ilmlled W�M locadops ip New York S—,i.e.,Wl up ftfi y) ........._.... ....._......................1.,...... -www ._ -.........w............�....mm w- rasa ofatgttyfrtfttestdng Proof of a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY TOWN OF SOUTHOLD 53095 ROUTE 25 3b Policy Number of Entity Listed in Box"la" SOUTHOLD,NY 11971 LNY-792142 Policy effective period 10/01/2023 to 09/30/2024 ....................�,�,..._._ ... ........................_------.,,,.,_,..______. .....,.................................,,...-,....._..._.�..�,.,.....�.........,..._............. ..............._..,.,. Ik Policy provides the following benefits: El A.Both disability and paid family leave benefits. ❑B.Disability benefits only. ❑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 and/or Paid Family Leave Benefits insurance coverage as described above. Date S1 nand 06/24/2024 Mff e YL/i re ,. .. .._.... . ..................._.................... .... ,. ...�„�.., .,_ .._.. ,. "4kan�tlu�mun wrjzmxewa�a aawwlirer^�m'aiint6n"ead�za"rq�pnu�waauprrgwn or n .irrrk�maaw mn�raraui�r auy�na"iTi�An 6nswoaaurocp asvwrgrrp Telephone Number(212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,StatutoryServices ....M.�,....,..........__.............. ......................___..,......,,......._._. .... .........,.,..._........,,.,,�....�_......_,._�.......... ......._..._.,,..�........._..�....................... IMPORTANT: If Boxes 4A and 5A are 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,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. ®...... y .........„ .......................�,..-._..P.,... o ..............(On y if Box 4 ................... �has been checked) PART 2 To be completed b the NYS Workers'Compensation Board(Only If Box 4C or 5B of Part t State of New York Workers'Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of hislher employees. DateSinned www.www...............................wwwwwww-.._..�www...ww...�_._._............m...,._____ QSignalum of Authorized NYS Workers'Compensation Board Employee) Tefe hone Numbor Name and Title . _....,.___., ................................................._.........__........................... _.........._......._.-,,,..........._._.__.�..—.--.—.....__._.._...........I-,,--..,..._..�___�...._.........................'. Please Note:Onlyinsurance tamers licensed to writ w. ,...ilit..._-_......,_._,. ..,.feav�.�..._....efit..-n µYµYµNNYMYY�W1_.�_.............................dins...... write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB420.1. Insurance brokers are NOT authorized to issue this form. DB-120.1(9-M 1111111011111111110MH Additional Instructions for Form D13-120.1 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"1 a"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 my 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 mandatory 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 benefits 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 for all employees has been secured as provided by this article. DB-120.1(9-17)Reverse AC CERTIFICATE OF LIABILITY INSURANCE D 06/19/2024) 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 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 NAMF Chr.S D AmIGD rAAG State Farm-Chris D'Amlco,Agent PHONE 567 1485 UL 1213 Montauk Highway ��Ko,AM s31 ss7 327s 9v Nnv--- weFarm Oakdale, NY 11769 Art ° damico rc l @, m ...................... ....,631-567-FARM (3276) State Farm Fire and Casualty COERAGE 25143 Chris f8 state arm co INSURERS AFFORDING COV ...... ..... „ .... .....- INSURER A Y mpany ,.,. INSURED Delcore Electric and HVAC Inc INSURFR,B7 31 Lanier Lane INSURERC: Bay shore, NY 11706 INSURER.D _ ......... INSURER,E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S 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, .....7 00'Cisu'dit1,,.-,,.. ...- ......... ..,..,.....00LWYENVY �..PULI UP I ......... ...... .-- ....... LIMI...TS ........... ..... .,,,,....., Y i TYPE OF INSURANCE 1 POLICY NUMBER � A X COMMERCIAL GENERAL LIABILITY Y 92-C8-K601-7 F 0311912024 1 03/19/2025 1 EACH OCCURRENCE $ 1,000,000 ...., DAMAfi e yo" AttdfN'C'. ..._ 1 �CLAIMS-MADE 1 X OCCUR , PRF'&dVP f"dd 500,000 MED EXP(Any one person) :$ 5 000 ...,..-..--...... .... , .,.........._ PERSONAL&ADV INJURY $ 1,000,000 F L N G.Prfro.GREC»AtE.LIMIT APPLIES PER: : GENERAL AGGREGATE $ 2,000,000 ,, ... YYYYY Y,.. 'PRO- 2,000,000 X" "� JECT 1 ?LOC = PRODUCTS COMP/OP AGG $ a ,. .,.,.,... ........... ....... ti -„- ..,,,,,,..- ..... 07 HER, $ J BODILY I $ AUTOMOBILE LIABILITY 265 5936-C29-32A 0312912024%03/29/2025' a,r r u tall a .. NJURY(Per person) S 1 000 000 ANY AUTO .., ..- ... .... ALL OWNED II SCHEDULED BODILY INJURY(Per acc dent) S 1 oo0 000 !AUTOS 7AUTOS _ P _.. NON OWNED { F'FC /�"s"cNtY G.I`AheA"Iv', ,..0 HIRED AUTOS � € ' � S 1 000 000 fi Auros ( J II�t1.a�r4t4. ......, Comp/Coll($1000 Ded) s A 5 ; RELLA LIAB I OCCUR 92-CP-M200-6 07/17/2024 1 07/17/2025 EACH OCCURRENCE s 2,000,000 UMBESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 I EXCESS .............. ,... .. .,. DED I X I RETENTION$ S WORKERS COMPENSATION : J I PER STATU7E OI AND EMPLOYERS'LIABILITY YIN[ rr ANY PROPRIETOR/PARTNER/EXECUTIVE "" > > = t I E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E)N I A - tMandatory in NH) f 1 E L DISEASE EA EMPLOYEE S If yes,describe under 1 iI �...... .... .. ....... ..' -.... m..W DESCRIPTION OF OPERATIONS below f E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(AC ORD 101,Additional Remarks Schedule,may be attached if more space is required) Description of Operations:electrical Additional insured: Town of Southold 53095 Route Southold,NY 11971 CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold,NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849 9 02-04-2014 6/28/24,9:29 AM Certificate of NYS Workers'Compensation Insurance Coverage CERTIFICATE OF kRK Workers' NYS WORKERS' COMPENSATION INSURANCE COVERAGE sTAT Compensation Board Insured Detail Ia.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of insured DEL CORE ELECTRIC&HVAC INC 631-704-9383 31 Lanier Ln Bay Shore,NY 11706 Ic.NYS Unemployment Insurance Employer Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to 832587281 certain location in Neha YorkStaie,i.e. a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company,Inc. Town of Southold 53095 Rt 25 3b.Policy Number of entity listed in box"la": Southold,NY 11971 TWC4426543 3c.Policy effective period: 5/16/2024 to 5/16/2025 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) 0 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"la"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: Matt Zender (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 6/28/2024 (S ignatw e) (Date) Title: Senior Vice President https://wc.amtrustgroup.com/ANAWC/PolicyNYCertificateOfWclns.aspx?lndexld=498077&Instance Id=159dbOI 5-42fd-4762-84aa-58ecb5dc4l 59 1/2 6/28/24,9:29 AM Certificate of NYS Workers'Compensation Insurance Coverage Telephone Number of authorized representative or licensed agent of insurance carrier:877-528-7878 Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it G105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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 so employed. 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 https://wc.amtrustgroup.com/ANAWC/PolicyNYCertificateOfWclns.aspx?lndexld=498077&lnstanceld=l59db015-42fd-4762-84aa-58ecb5dc4159 2/2 0 Suffolk County department of Labor, Licensing & ilz. Consumer Affairs 11 WW VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 DATE ISSUED: 09/30/2020 No, ME-64247 SUFFOLK COUNTY Master Electrician License This is to certify that Sebastian Del Core doing business as Del Core Electric&HVAC Inc having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws,rules and regulations of the County of Suffolk, State of New York. ' NOT VALID WITHOUT Additional Businesses DEPARTMENTAL SEAL AND A CURRENT CONSUMER AFFAIRS ID CARD 11 �F 11L Rosalie Drago Commissioner SPUD Addendum EV Charging Stations @ Osprey Dominion The following items are intended to be included and enforced in the permitting process through the Building Department: 1. Prohibit the installation or use of any LED Banner/screens; including any audio,music, speakers,etc.,on or near proposed charging units 2. Provide sufficient evergreen screening of the equipment proposed in the area of the new 800 amp power service connection.These units must be sufficiently screened from view, as this proposed point of connection is located within feet of NYS Route 25,a designated Scenic Byway. 3. No exterior light fixtures were reviewed as part of this application.Any proposed light fixture shall be verified to be in compliance with Chapter 172.This Department can aid in the review of any proposed light fixtures. 4. All signage must comply with Chapter 280-80 and shall not be internally lit. r CompLy Yid ryTH ALL,CODES OF DE APPROVED AS NOTED NEW YORK STATE &TOWN AS REQUIRED CONDMONS OF DATE: ��"I 'd B.P. MWIMIRMBIM WOMOMM FL B NOTIFY BUILDING DEPARTMENT AT ILUDEG 631-765-1802 8AM TO 4PM FOR THE FOLLOWING INSPECTIONS. FOUNDATION-TWO REOUIRED 4 FOR POURED CONCRETE ROUGH-FRAMING&PLUMBING IINSULATION ! I� ELECTRICAL FINAL-CONSTRUCTION MUST INSPECTION REQUIRED BE COMPLETE FOR C.O. ALL CONITION SMALL MFFT T14E I FOUfflEM NTS OF TFIE CODES OF NEW YORK STA1`E. NOT RESPONSIBLE FOR DESIGN OR CONSTRICT ORS 11 WE a.. .. PROJECT NAME AND ADDRESS PROJECT APPROVAL Hondius-44075 Main Rd Liuingst e ntatiue signature: Site contact signature: 44075 Main Rd, Southold, NY 11971 � Name/Title:Ni oyeney/Senior PM Name Title: NoperLy Manager Date:2/29/2024 Date: PROJECT INFORMATION GENERAL NOTES Electrical Information: `/ �] 1- ALL ELECTRICAL MATERIAL SHALL BE NEW AND LISTED BY RECOGNIZED ELECTRICAL TESTING LABORATORY. New 800amp 277/480V Jphase Service, 2, CUSTOM MADE EQUIPMENT SHALL HAVE COMPLETE TEST DATA SUBMITTED BY THE MANUFACTURER ATTESTING TO ITS SAFETY. 3. ALL METALLIC EQU I PM ENT SHALL BE GROUNDED_ 4. ALL SPECIFIC WIRING IS BASED ON THE USE OF COPPER CONTRACTOR SHALL OBTAIN ELECTRICAL PERMITS PRIOR TO INSTALLATION AND SHALL COORDINATE ALL INSPECTIONS,TESTING,COMMISSIONING AND ACCEPTANCE WITH THE CLIENT,UTILITY COMPANY AND CITY INSPECTORS AS NEEDED. Vehicle {., Charger THE ELECTRICAL CONTRACTOR SHALL VERIFY THE EXACT LOCATIONS OF SERVICE POINTS AND SERVICE SIZES WITH THE SERVING UTILITY COMPANY AND COMPLY WITH V Electric ehicle Charger Information: ALL UTILITY COMPANY REQUIREMENTS. (2) LCP-SK200 Units. 6 DRAWING DIAGRAMMATIC ONLY;ROUTING OF RACEWAYS SHALL BE OPTION OF THE CONTRACTOR UNLESS OTHERWISE NOTED AND SHALL BE COORDINATED WITH OTHER TRADES ({ into IF THE DISTANCES FOR CABLE RUNS ARE DIFFERENT THAN SHOWN,THE CONTRACTOR SHALL NOTIFY THE ELECTRICAL ENGINEER TO VALIDATE THE WIRE SIZE.FINAL Assembled into dual port Stations. DRAWINGS WILL BE RED-LINED AND UPDATED AS APPROPRIATE. Total of 4 ports. 8 WHENEVER A DISCREPANCY IN QUALITY OF EQUIPMENT ARISES ON THE DRAWING OR SPECIFICATIONS,THE CONTRACTOR SHALL BE RESPONSIBLE FOR PROVIDING AND INSTALLING ALL MATERIAL AND SERVICES REQUIRED BY THE STRICTEST CONDITIONS NOTED ON THE DRAWINGS OR IN THE SPECIFICATIONS TO ENSURE COMPLETE COMPLIANCE AND LONGEVITY OF THE OPERABLE SYSTEM REQUIRED BY THE ARCHITECTJENGWEERS. 9. ALL BROCHURES,OPERATION MANUALS,CATALOGS,SHOP DRAWINGS,ETC_SHALL BE HANDED OVER TO Owner's REPRESENTATIVE AT THE COMPLETION OF WORK. VICINITY MAP UTILITY AND AHJ INFORMATION CONTRACTOR • UTILITY COMPANY: PSEG • PUBLIC OR PRIVATE LOCATION: Public LIVINGSTON ENERGY GROUP LLC 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY, 12308 www.solution.energy SHEET INDEX Lj5 LIVINGSTON ENERGY GROUP 1.TITLE SHEET 2. SITE PLAN 3. SITE LOCATION(S) COPYRIGHT 02024 Sheet Na bh l LIVINGSTON ENERGY GROUP LLC 4. CHARGER SPEC SHEET ALL RIGHTS RESERVED ERVED THIS DRAWING AND ALL THE INFORMATION CONTAINED HEREIN IS S. SCOPE OF WORK AUTHORIZED FOR USE ONLY BY THE PARTY FOR WHOM THE WORK WAS CONTRACTED OR TO WHOM IT IS CERTIFIED,THIS DRAWING MAY NOT BE COPIED,REUSED,DISCLOSED,DISTRIBUTED OR RELIED UPON FOR ANY OTHER PURP05E WITHOUT THE EXPRESS WRITTEN CONSENT OF LIVINGSTON ENERGY GROUP LLC. NVId 311S :31111133HS qz ,q—N­S f , 14066 - uni a.IIAA alewlxoid 80TSb'ZL-'LLbbO'Tb 'Z `su011elS 6ul6aegO n] aql aaMod bOiSb'ZL-'£LbbO'Tb 'T of aolAaas dwe00 mou to uolleoo- S31VNIOIJ003 Sd9 HIE)IIVH3 A3 TL6TT AN 'ploglnos 'PH uleA SLOi7b PH ulew SLObb-snlpuOH shod tb)to lelol 1N311J °spaelloq pue a6eu6ls q11 suollels laod lenp olul polgwassV dnoa9 A9a3N3 si!un mO Ns-dm (Z)jouolleoo-1 NOISJNI/lIl Agiaua u01]nj05-MMM 805ZT'AN A(IVID3N3HOS 'T 3iins'1x3 OVO8 NOXVA Sb£Z all dnoil9 A9213N3 NOISONIAIl MO1:)d211NOJ CONTRACTOR LIVINGSTON ENERGY GROUP LLC _ 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY,12308 www,solu[ion..energy LIVINGSTON E NERGY GROUP CLIENT Hondius-44075 Main Rd 44075 Main Rd, Southold, NY 11971 2 t 2S Sh—N,,b,, SHEET TITLE: SITE LOCATION(S) 3 s ° ^ f C y' �` ry e .., WY� . F C' K' Ik: I rv��arr w N ✓Ayiir e, Lo n N r D m o N N Z p Ll Z z o z Z O �j , m el n z C m Q- � � r � o MR n Z o. D 7J D o Z cl N : Q LDD Q W O O w m v r L oo v � o O e' C rDrD O Os n n a Oe ~ ►.CD ('D O in ¢ ��' C rn' cn VQ p ¢ (b r* O O O En O rD � O rD n O y CD ¢ O rD cn in. O cCD CD G ¢ O Q ¢• O CD 0 O O rD v* W O n 7 CDCD Z7 r1 r• Q. CD o O CD ¢' t 7 rD rD rn cn rD nrD n C O O O o 0• O `t to C� W n CD r0•r 'd n aq rD �. �• O En cn cn C. rb O f1 SD n Q UQ a O O C O O n L _ O rD rD UQ r) n � CD tTj ¢ rs' CCD n o 0 w � O C• � � o o✓ r)N CD rD rD rrDD f1 C1 rDCD '"r• 'C3 G r�D UQ �:r t' '< p rD cn CD n � CD o r) �• CD O A� O a rD M n0 N = c m m m O z �' ci Q n � in f•1 -n sow zr ZX0 O o z Z p V f7 '^< o ^ z m r Q E q p m 7p O m m L)z � gaz D A a Z { an < { u, O obi ` C: c roe V OO v ... F-� C P1 Q I 3 Assc-s sor�z-s ao ,S SPUD Addendum EV Charging Stations @ Osprey Dominion I< y The following items are intended to be included and enforced in the permitting process through the Building Department: 1. Prohibit the installation or use of any LED Banner/screens;including any audio,music, speakers,etc.,on or near proposed charging units 2. Provide sufficient evergreen screening of the equipment proposed in the area of the new 800 amp power service connection.These units must be sufficiently screened from view,as this proposed point of connection is located within feet of NYS Route 25,a designated Scenic Byway. 3. No exterior light fixtures were reviewed as part of this application.Any proposed light fixture shall be verified to be in compliance with Chapter 172.This Department can aid in the review of any proposed light fixtures. 4. All signage must comply with Chapter 280-80 and shall not be internally lit. j P P I i t i 1 1 -- PROJECT NAME AND ADDRESS PROJECT APPROVAL Hondius-44075 Main Rd Livingst a ntative signature: Site contact signature: 44075 Main Rd, Southold, NY 11971 Name/Title:Ni oveney/Senior PM Name/Title: PropertyManager 2/29/2024 Date: Date: PROJECT INFORMATION GENERAL NOTES Electrical Information: 1. ALL ELECTRICAL MATERIAL SHALL BE NEW AND LISTED BY RECOGNIZED ELECTRICAL TESTING LABORATORY. New 800amp 277/480V 3phaSe Service. 2. CUSTOM MADE EQUIPMENT SHALL HAVE COMPLETE TEST DATA SUBMITTED BY THE MANUFACTURER ATTESTING TO ITS SAFETY, 3. ALL METALLIC EQUIPMENT SHALL BE GROUNDED. 4. ALL SPECIFIC WIRING IS BASED ON THE USE OF COPPER CONTRACTOR SHALL OBTAIN ELECTRICAL PERMITS PRIOR TO INSTALLATION AND SHALL COORDINATE ALL INSPECTIONS,TESTING,COMMISSIONING AND ACCEPTANCE WITH THE CLIENT,UTILITY COMPANY AND CITY INSPECTORS AS NEEDED. 5. THE ELECTRICAL CONTRACTOR SHALL VERIFY THE EXACT LOCATIONS OF SERVICE POINTS AND SERVICE SIZES WITH THE SERVING UTILITY COMPANY AND COMPLY WITH Electric Vehicle Charger Information. ALL UTILITY COMPANY REQUIREMENTS. (2) LC r-S f\200 Units. TRADES 6 DRAWING DIAGRAMMATIC ONLY;ROUTING OF RACEWAYS SHALL BE OPTION OF THE CONTRACTOR UNLESS OTHERWISE NOTED AND SHALL BE COORDINATED WITH 7. IF THE DISTANCES FOR CABLE RUNS ARE DIFFERENT THAN SHOWN,THE CONTRACTOR SHALL NOTIFY THE ELECTRICAL ENGINEER TO VALIDATE THE WIRE SIZE.FINAL Assembled Into dual port Stations. DRAWINGS WILL BE RED-LINED AND UPDATED AS APPROPRIATE. 8. WHENEVER A DISCREPANCY IN QUALITY OF EQUIPMENT ARISES ON THE DRAWING OR SPECIFICATIONS,THE CONTRACTOR SHALL BE RESPONSIBLE FOR PROVIDING AND Total Of 4 ports. INSTALLING ALL MATERIAL AND SERVICES REQUIRED BY THE STRICTEST CONDITIONS NOTED ON THE DRAWINGS OR IN THE SPECIFICATIONS TO ENSURE COMPLETE COMPLIANCE AND LONGEVITY OF THE OPERABLE SYSTEM REQUIRED BY THE ARCHITECT/ENGINEERS. 9. ALL BROCHURES,OPERATION MANUALS,CATALOGS,SHOP DRAWINGS,ETC.SHALL BE HANDED OVER TO Owner's REPRESENTATIVE AT THE COMPLETION OF WORK, VICINITY MAP UTILITY AND AHJ INFORMATION CONTRACTOR • UTILITY COMPANY:PSEG • PUBLIC OR PRIVATE LOCATION:Public LIVINGSTON ENERGY GROUP LLC 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY,12308 www.solution.energy SHEET INDEX Lf LIVINGSTON ENERGY GROUP 1.TITLE SHEET ` 2. SITE PLAN 3. SITE LOCATION(S) COPYRIGHT©2024 Sheet Number ON ENERGY 4. CHARGER SPEC SHEET LIVINALLRGHTS RES RVEEDP LLC S. SCOPE OF WORK THIS HORRID FORRAWING USE ALL THE INFORMATIONTHEPRTYFOR WHOMDHE EINWO IS AUTHORIZED FOR USE ONLY BY THE PARTY FOR WHOM THE WORK WAS CONTRACTED OR TO WHOM IT IS CERTIFIED.THIS DRAWING MAY 4l i NOT BE COPIED,REUSED,DISCLOSED,DISTRIBUTED OR RELIED UPON �7 FOR ANY OTHER PURPOSE WITHOUT THE EXPRESS WRITTEN CONSENT OF LIVINGSTON ENERGY GROUP U.C. CONTRACTOR LIVINGSTON ENERGY GROUP LLC 2345 MAXON ROAD EXT,SUITE 1, _ SCHENECTADY NY,12308 www.solution.energy LIVINGSTON LOCatIOn Of(Z) LCP-SKZOO UnItS. EN E R G Y GROU P Assembled into dual to stations with signage and bollards. CLIENT Total of(4) Ports Hondius-44075 Main Rd 44075 Main Rd, Southold, NY 11971 d' EV CHARGER GPS COORDINATES + Location of new 800amp service to 1. 41.04473,-72.45104 power the EV Charging Stations. 2. 41.04477,-72.45108 Approximate wire run - 190ft Briarcliff Lindscape s• tiq Sheet Number 25 SHEET TITLE: SITE PLAN2 CONTRACTOR LIVINGSTON ENERGY GROUP LLC 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY,12308 www.solution.energy i LIVINGSTON Dominion ENERGY GROUP o, CLIENT Hondius-44075 Main Rd S 44075 Main Rd, Southold, NY 11971 25 Briarcliff Landscape f• Sheet Number ' 25 SHEET TITLE: SITE LOCATION(S) 3 I LIVIi i,,. CONTRACTOR If LIVINGSTON ENERGY GROUP LLC 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY,12308 LCP-SK200 www.solution.energy Charger Station LIVINGSTON ENERGY GROUP Genorel enEatrnetiwt Model CLIENT r Ulr4`>sMl%;1> i 4VIVIvat cfD 13�IS�ir ][xLmrt'7l'A.arr�2,r�iGta>, PrLecbw„cal 5aa t,'N•J•14j With LED 0.--(ILO fi l,—'Dpa—a!} 7CYln•rn•iD.jmrn•2.3ilkrun W"htwt LLD fiel>— �(jnL�(iElul Hondius-4407S Main Rd WI�h LED®anncs(LED 44075 Main Rd,B.tnrt.^.r:C�r-amaf} 52tita(10(7I wgiza . Southold, NY 11971 9 AL.aFiOv'z FO`•6�.l1-SR,S TS e N F:"4-11ey .t&&D H, "Pat Pgwcr Fc ttr laY5j1ip1 m-(:urrrnt 27(LA vaipgc k4 q t 50 10Y7vdc Ot>;Pta Ctulent Raltge P.!,u s kK IDus CCS 1,1ODj Lieu.Pawrrr 2i edv 1150r\kry Type D�a'Ct37 CaGlc lzngln6nJ tm(17?iu - F.Irsc.k.,y .q%amo. tnen 420L WI Pm—Shwn q mrn-;Iw.01() nun-i00"t--100 .mn 103 {15t7nWI 0:nun-t50/m -75.mn-75 InC:reanenil Mi.Powur(l4vj 25k,1 Inp.1t(ta4 Ac 7(70 4W'v t_1(P.Ci PoAw Mrn.tll• 0"tp'4 Ndcj Of 150-10LGv PFC a 04S.:t a1ML PFC(11 \'dtage nt>5i15oi(:•vl Netermg Axurec) lrsi It:sn 1'2 N'L—A Car.r,..-nor. 4G,LT E N.W cm Cgf51T�lr>9!A't('fOtCGCI (xTe 1 61 Co— Sap 'xi"r) i<OCW Ili 1 r.nnrru,n Of>Jl,rryuesq Sheet Number SHEET TITLE: CHARGER CUT 4 SHEET • . •.. s . • .• • . C Civil and Electrical Scope of Work: CONTRACTOR 1. Furnish all trenching necessary for conduit runs. Backfilling in grass to be done with native soil unless otherwise noted. uvINGSTON ENERGY GROUP uc NOTE: If trenching occurs in blacktop surfaces,blacktop will be replaced in kind (no milling or seal coating of key way cut). 2345 MAXON ROAD EXT,SUITE 1, SCHENECTADY NY,12308 www.solution.energy 2. Furnish and Install all conduit necessary for completion of project (PVC,EMT, Rigid where applicable per NEC code) Lf LIVINGSTON 3. Furnish and install concrete bases (pedestal mount only) and bollards. E N E RGY G R o u P 4. Furnish and Install all electrical components for interconnection (wire,breakers). If a new service is applicable to the CLIENT project, panel(s), disconnect and meter sockets to be supplied and Installed per utility and NEC code. 5. Rake off all area(s) disturbed by trenching. Hondius-44075 Main Rd 44075 Main Rd, 6. Furnish and install grass seed and hay where trenching was completed (Watering and maintenance of new grass seed is the Southold, NY 11971 responsibility of the customer). 7. Installation, commissioning and testing of EV charging station(s) 8. Clean up and removal of all job-site debris. Exclusions and Clarifications: - Plan may be modified in the field based on site conditions and or utility requirements. If applicable, as built drawings to be delivered to customer at the end of project if necessary. - CIAC Costs not included - Inclusive of engineered stamped plans Sheet Number SHEET TITLE: SCOPE OF WORK Site contact initial: 5