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HomeMy WebLinkAbout51468-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#: 51468 Date: 12/11/2024 Permission is hereby granted to: William S Clark 595 Kerwin Blvd Greenport, NY 11944 To; Install HVAC system to an existing single-family dwelling as applied for per manufacturers specifications. Premises Located at: 595 Kerwin Blvd, Greenport, NY 11944 SCTM# 53.-3-17.4 Pursuant to application dated 10/18/2024 and approved by the Building Inspector. To expire on 12/11/2026. Contractors: Required Inspections: ELECTRICAL-ROUGH, PLUMBING, ELECTRICAL-FINAL, FINAL, Fees: HVAC $250.00 CO-RESIDENTIAL $100.00 ELECTRIC -Residential $100.00 Total $450.00 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 httl) ://www. OL[tholdtownny,&Yov w Date Received APPLICATION FOR BUILDING PERMIT � � C I 'd For Office Use Only PERMIT NO. 1+� Building Inspector: j; 0Cl' 1 8 202 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Bta'1 'n Department Owner's Authorization form(Page 2)shall be completed. Town "''"`''=Wholcl Date: a OWNER(S)OF PROPERTY: Name: - - r ISCTM# 1000- 01S3 � 00 - 03,0-0 -01-? ,614 Project Address; Phone#: �3 ( Email: Mailing Address: �S'a�yYUo� CONTACT PERSON: Name: Lcy—y--) Pu�ili, Mailing Address: 1!`-141 0 S 0"d, Ot NO-) v)/1 s-4 8 U l Phone#: 65 J_ 5 g p _ '77 O LP I Email: �Y'�1 5 S A S qS _ c0 M DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: E Mailing Address: r7 q r7 v 1/b Mil UL 4) 1,4CK. J� Il - J`JoZ Phone#: l� 7 - =mail- .Y" "#j7 yy) DESCRIPTION OF PROPOSED CONSTRUCTION [--]New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: then U C.• 6ce1l l G. 10 Will the lot be re-graded? Dyes WO Will excess fill be removed from premises? ❑Yes o 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 tQ , _ this property? Eyes 6NO o IF YES, PROVIDE A COPY. ;ntfleck Bozo 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. c horized Agent ❑Owner Application Submitted By(prin name): LO I�YZL1 rie. I> 1 Ptj/u � g Signature of Applicant: � Date: STATE OF NEW YORK) SS: COUNTY OF&IUF f-o L k-- ) Lo`-rvtT1Q� -I, being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (Contractor,4gent,Corporate Officer,etc.) of said owner or owners,and is duly auth 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 ,'24 day of 20 Nota ublic LOUIS J ROMEO Notary Public,State of New York No.01 R06314613 Qualified in Suffolk County Where the I Tu Commission Expires November 17,2 � ' applicant is not the owner) I, C D -�-� C l �r� residing at 5 l k V,o` U Y) t ) q !l q�do hereby authorize �YYI� to apply on my behalf to the Town of Southold Building Department for approval as described herein. �. a La � Owner's Signature LOUIS J ROMEO Date I Notary Public,State of New York co C No.01 R06314813 Print Owner's Name Qualified in Suffolk County Commission Expires November 17,20 6 2 ovir BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 » � Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 amesh soutluoldtow,vnn ov - seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/26/24 Company Name: Glemenk- C" .c lam, Electrician's Name: c71.-1'Y1 t' I'Y1,1 License No.: Jra 8�_ I�6 Elec. email: JPe rm 4 S Is. co r✓1 Elec. Phone No: VII(V1 C 0I request an email copy of Certificald of Compliance Elec. Address.:1 4 q b S Vn _ aft.) m At :Ih. < iV 06 JOB SITE INFORMATION (All Information Required) Name: Scott Clark Address: 595 Kerwin Blvd, Greenport, NY 11944 Cross Street: Main Road Phone No.: 631-831-4177 Bldg.Permit#: 5 1 q email: Tax Map District: 1000 Section: 053.00 Block: 03.00 Lot: 017.004 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Install HVAC system Square Footage: Circle All That Apply: Is job ready for inspection?: � YES NO ��Rough In � Final Do you need a Temp Certificate?: YES NO Issued On Temp Information: (All information required) Service Size[11 PhD Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION ABC 0 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/16/2024 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER RTACNAME T ROBERT S. FEDE INSURANCE AGENCY i�H °ray ITITIT6� ' 7 PAX .4 23 GREEN STREET,SUITE 102 """"""""""""""" E-MApL HUNTINGTON, NY 11743 AVDRES$: ROBERTS.FEDE INSURANCE INSURERS)AFFORDINGCOVERAGE NAIC# INSURER A:ADMIRAL INSURANCE COMPANY 24856 INSURED INSURERS: IN LI-RANZP UN�I_ - 5239 Element Energy LLC LTL=1 PCB"iNTP TT _.................................................. INSURER C DBA ELEMENT ENERGY SYSTEMS INSURER D R"AL�A 0._MANAGSM[ENT .......................... 7470 2 ND AVENUE INSURERE: MATTITUCK, NY 11952 .-............................ ... 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 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. ......... .... -. TYPE............................... .. .., ... ...... - _ .... ..._..P_- INSR OF INSURANCE ASD B' POLCCY EFF POLICY EXP WW LIMITS LTR I POLICY NUMBER MMIDD/WYY.. MMIDD/YYYY ................................... .....-._._.....-_..........................a.-,.�w COM MERCIAL GENERAL LIABILITY CA00005380701 EACH OCCURRENCE NTED $ 1,000,000 A X X 7/14/2024 7/14/2025 CLAIMS-MADE occuR "AWt"�r 999 ._ PREn.�YS tEa ec�z�MM8 $ 300,000. MED EXP(,Any one person) $ 5000 IMA389203C ®®®-®®®®®® - 7/19/2024 7/19/2025 PERSONAL&ADV INJURY $ 1000000 T LOG PRODUCTS-COMP/OP AGG.........................................................._.... GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000 000 �Y PRO ... .... 'POLICY❑.JEu ❑ $ aQQQG1rQQ OTHER AUTOMOBILE LIABILITY GOMBYNEO"kC�dGLE LIMI $ _&a aocldenl: ............ I ANY AUTO BODILY INJURY(Per person) $ I OWNED SCHEDULED .. ... ........................... ...................-._...... p AUTOS AUTOS BODILY INJURY(Per accident) $ . (HIRED NON-OWNED PROPERTY DAMAGE ...... AUTOS ONLY AUTOS ONLY Per atrsden9),._ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ .. ..-,.- �p.p. .L.......- DED ( RETENTION$ -W. ..... ..,., $ WORKERS COMPENSATION 124494445 PER OTH AND ANYjkla PRO in NH) ......._, B OFF"CEWMEMB REXCLUDED?ECU ix I OOO TIVE N/A E.L.EACH ACCIDENT $ 1OOO EMPLOYERS'LIABILITY Y I N 7/13/2024 7/13/2025 STATUTE ER E„L DISEASE-EAEMPLOYE $ (� �. If yy� s,describe under ..................._ __ OESCRIPTION OF OPERATTiONS kreRowr E.L.DISEASE-POLICY LIMIT $ NY State DBL OBL567527 1/01/2024 12/31/2025 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED- CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED �REPRESENTATIVE I 'Rcbew L S. Fade, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers'A�r� Compensation CERTIFICATE OF INSURANCE COVERAGE sr Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability'and Paid Family Leave benefits carrier or licensed insurance agent of that carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 823336604 ............... .. ...... _ 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 54375 MAIN STREET 3b. Policy Number of Entity Listed in Box"la" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01/01/2024 to 12/31/2025 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. E] 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 employers 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 Signed 7/10/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title LeSton 1 elsh Chief Executive Officer 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 emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if sox 4B,4C or 58 have been checked) 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(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. p DB-120.1 (12-21) 111 jIIII ( III I III YSF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) ^^^^^^ 823336604 11 TAX ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD DBA ELEMENT ENERGY SYSTEMS 54375 MAIN ROAD 7470 SOUND AVENUE SOUTHOLD NY 11971 MATTITUCK NY 11952 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449 444-5 962287 07/13/2024 TO 07/13/2025 7/11/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 444-5, 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:/M/WW.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, THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. 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 STATE S4 71*4 NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799006