HomeMy WebLinkAbout51256-Z "�oF soulyo`o Town of Southold
* * P.O. Box 1179
o� 53095 Main Rd
"ai��nuxrr.� .� Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 45784 Date: 11/21/2024
THIS CERTIFIES that the building OTHER
Location of Property: 415 Grange Rd Southold, NY 11971
Sec/Block/Lot: 78.4-6
Conforms substantially to the Application for Building Permit heretofore,filed in this office dated: 08/19/2024
Pursuant to which Building Permit No. 51256 and dated: 10/08/2024
Was issued, and conforms to all of the requirements of the applicable provisions of the law.
The occupancy for which this certificate is issued is:
gas heat to an existing single-family dwelling as applied for.
The certificate is issued to: Nancy de Conciliis ,Marina de Conciliis
Of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL:
ELECTRICAL CERTIFICATE:
PLUMBERS CERTIFICATION:
Akhorad Signature
�aofSouryo 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#: 51256 Date: 10/08/2024
Permission is hereby granted to:
Nancy E de Conciliis
415 Grange Rd
Southold, NY 11971
To:
Install a combination-boiler to convert oil to gas in an existing single-family dwelling as
applied for per manufacturers specifications.
Premises Located at:
415 Grange Rd, Southold, NY 11971
SCTIVI#78.4-6
Pursuant to application dated 08/19/2024 and approved by the Building Inspector.
To expire on 10/08/2026.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Alteration $250.00
CO-RESIDENTIAL $100.00
Total $350.00
�'Igh
Building Inspector
OE SOGTyo� -- —
�/a . # "TOWN OF SOUTHOLD BUILDING DEPT.-
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loo ,0 631-765-1802
INSPECTION
[ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN ULATIOWCAULKING
[ " ] -FRAMING /STRAPPING [ FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY'INSPECTION
[ ] "FIRE RESISTANT CONSTRUCTION j ] FIRE RESISTANT PENETRATION
[ J. ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
] CODE VIOLATION [ ] PRE C/O [ -"] RENTAL
REMARKS: �OKA �0c
DATE INSPECTOR
MELD INSPECTION REPORT DATE COMMENTS
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INSULATION PER N.Y.
STATE ENERGY CODE
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FINAL
ADDITIONAL COMMENTS
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4A., r, 7{11','C)�r:I f,y f c�6;`>>; � , ... {';i'i aCiCi1 ; . ,;; ; _ Date Received
-APPLICATION-FOR- BUILDING-PERMIT-
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�o!PERMITN0. Building Inspector AU:G_ .:_:2024__c.Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant is not;the•owner,an.;-:<^; �,.i BUILDING DEPT.
Oviner'§'Authoriiatiori'formtPage 2)shall be completed.
Date: "
OWNER(S)OF PROPERTY:
Name: Marina DeConciliis SUM#1000-78-1-6
Project Address:415 Grange Road h
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Phone# 631'8758152 '• � [��{' �:'Y r' �,��. 'EmaiL•_marina@_kdcarchitec_ture.com_-..-
Mailing Address:415 Grange Road, Southold NY 11971
-CONTACT PERSON:-
Name M�rin�,DeConciliis,
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Mailing`Addres� [ 3- r:,�tf.{ . zl'ia r{ �_ {{r '.a., :.��-, r;2•�iw'�r �� , . .{1' ,,�'. -..i! ,
•415'Grange Road, Southol ��NY 11971
Phone#:6318758152 Email:marina@kdcarchitecture.com
DESIGN PROFESSIONAL INFORMATION:Y+w - - _ - 5'`
Name: Marina DeConciliis
MailingAddress:-
Hro
.260' rto64"Lane, Southold NY 11971
-
Phone#:,6314778736 Email: marina@kdcarchitecture.com
CONTRACTOR INFORMATION:
Name: North Fork Woodworks
Mailing Address:810 Traveler Street, Southold NY 11971
Phone#: - Email:SCo_tt@nfw00d,*w'
6312987900 _
DESCRIPTION-OF-PROPOSED CONSTRUCTION -
❑NewStructure ❑Addition rBAltbeationz ;r Repairr r Demolition,7rCI `s �,-,iiof:;'is.,u I,Estimated)Cost)of--Pcoject:-::,`I
El Other Oil to gas conversion $�-`2Lo 0
Will the lot be re-graded? l]Yes,BNo - Will excess fill be removed from;ppemses?,;[]Yes; No
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PROPERTY INFORMATION
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Existing use of property: residential `".ta ' Interideomse of..prope.r*,residential;'i~•.y
Zone,o.r.use,d-istrict,in,wliich.premises is.situated:.", « ,. Are.,these.any..covenants_and restrictions_with.respect to,.:..
R-40 ` ` this property? ❑Yes ®No IF YES, PROVIDE A COPY. ;
.B,Check Box After Reading The owner/contractor/design professional is responsible forall drainage and storm water issues as provided by
Chapter?361%f the-Town Code APPLICATION IS HEREBY NAADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone
s Ordinance othaTown;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,ordinahm,,building code,
housing code and regulations'and to admit a4'oriaed inspectors on premises and In building(s)for necessary inspections.False statements made herein are
punishable'as a Class�Arpisdemeanornpi rsuarit to Section 210AS of the New York State knal Law:r, n,_A;_} � `'' {„ - ' •°r?_` a {
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- t Marina-DeConcilus' ,,,fi1s c;, �� s,<•� 3
Application'Submitted'By(print name) > _, 4 g��n•,;, as r,r, t`❑Authorized,Agent ,®Owner, r
a - a. ✓
Signature of Applicant: ate - -
r�rt9t
STATE OF..NEW.YORK)_.__._
SS: .�li., , ';lt, 7r' • '.! 1t , '`G r r r7 r ,
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COUNTYOF -Suffolk ____ �.� .. .._.__._._. . -. ___...__._..... .. . .._-•---.__._.___ ._� _ , t
=Marina-DeConciliis .--
i
t-;.,,•, G ;a- .'Yr ,,;'�: ,��Y t F;being duly sworn,deposes and says that_(s)he,i!F,the applicant
`(Name of individual-signing contract)-above named,-------'---- ---'-- t _
1' ht;!'?.- e^ t ( 1 -i r •t''r r ,S t r�V'!I. ,t.rl„ j rf
---Owner,- 1
3 l i 'f is
'(S)he is the r ,
------(Contractor,-Agent;-Corporate-Officer;-etc.)-
of said owner or owners,and is duly authorized to perform or have performed the said work and t&maW end file this
application;that all statements contained in this application are trued the best of his/her,knowledge nd,behe f,and;. . ,
that-the-work-will-be performed in the manner-setforth in-the-application-file-therewith. yy -- -- -•
."F_,... ,} 4,. i� t •tri�t'.• y,i'. 'Sla tS:.:: ? ! 1�.�9 r!I i.f. a ! 1 I ' i
Sworn before me this
day of .01 v • ' •' '
I- i wl Notary Public
I 1 ? S .v i, [' <3dyi_,l.j: �F; i.3 r ii .'.Y a+LYNDA':NI:aRUDDER.;t'0
Notary Public—State of NewYddt.---..._
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'.i1B frI lif.r,7: i QuarfecJinRSuffokLounty'` 91`7 '`a
-' - - - - - PROPERWOWNER AUTHORIZATION- Commission expires March.t3,20 d
_....._(Where-the-applicant•-is-not the-owner).
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do
hereby authorize
to:a I n
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my behalfto the.Towrf�of Southold;Building Department,for-ap 'oval.;asidescribed,herein.
µa'v Ow'nei's5ignafure -,
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/ NYSIF
New York State Insurance Fund PO Box 66699,Albany,NY 12206
1 nysif.com
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
0 �
11 A A A A n 272628352
AMWINS INSURANCE BROKERAGE LLC
200 ELWOOD DAVIS ROAD 0 . • f
00 2 E SUIT
LUTE 00 NY 13088 SCAN TO VALIDATE
AND SUBSCRIBE
POLICYHOLDER CERTIFICATE HOLDER
NORTH FORK WOOD WORKS INC MARINA DECONCILIIS
P O BOX 1407 415 GRANGE ROAD
SOUTHOLD NY 11971 SOUTHOLD NY 11971
POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE
Z2280 317-5 18439 05/01/2024 TO 05/01/2025 8/7/2024
THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2280 317-5, 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.
IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WESSITE AT HTTPSJNVWW.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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE
INSURED CORPORATION.
PRESIDENT
SCOTT EDGETT
NORTH FORK WOOD WORKS INC
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 SU 0 ANCEFUND
DIRECTOR,INSURANCE FUND UNDERWRITING
VALIDATION NUMBER:323208999
AIC ® DATE 1YY
v CERTIFICATE OF LIABILITY INSURANCE os/07//o7/2024
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 NAME m T Co ercial Support
Edgewood Partners Insurance Center PHONE FAX
40 Marcus Drive 631 390-9700 (A/C.No: 631 390-9790
3rd Floor ADDRESS: NSHCortsCM@epicbrokers.com
Melville MY 11747
INSURE S AFFORDING COVERAGE NAICS
INSURERA:SOM2WEST MARINE AND GWWMAL I 12294
INSURED INSURER B:
North Fork Woodworks Inc
INSURER C:
PO Boz 1407 INSURERD:
Southold NY 11971 INSURERE:
INSURER F:
COVERAGES BN CERTIFICATE NUMBER:Cert ID 33893 (20) 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.
IL SR TYPE OF INSURANCEADD SUER POLICY EFF POLICY EXP
POLICYNUMBER IMMIDDIYYYYI 1MM1OD0YYYy) LIMITS
A Z COMMERCWLGENERALLIABIUTY EACH OCCURRENCE $ 2,000,000
-DAMAGE TO RENTED
CLAIMS-MADE F—x1 OCCUR Y OL2024LEB00012 01/01/2024 01/01/2025 PREMISES(Ea occurrence) $ 100,000
MED EXP Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY 1�1 jECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILELIABILITY COMBINED SINGLE 0 IT $
(Eaaccident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
A UMBRELLALIAB Z OCCUR EZ2024LBB00004 01/01/2024 01/01/2025 EACH OCCURRENCE $ 2,000,000
Z EXCESS LIAR CLAIMS-MADE AGGREGATE $ 2,000,000
DED I RETENTION$ $
WORKERS COMPENSATION STA TE ER
AND EMPLOYERS'LIABILnY Y/N
ANYPROPRIETORIPARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $
OFFICERIMEMBEREXCLUDED?
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE $
M yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may bo attached H more apace Is required)
Marina DeConciliis, is included as additional insured for general liability coverage as required by
written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Marina DeConciliis ACCORDANCE WITH THE POLICY PROVISIONS.
415 Grange Road AUTHoRIZED ENTATtVE
Southold MY 11971
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Danis 1 of 1
Road
APPROVED AS NOTED
o TE: I b-82q B.P# 5 125� COMPLY WITH ALL CODES OF
NEW YORK STATE&TOWN CODES
FE 3�' �� BY —� S REQUI ED AND CONDITIONS OF
NOTIFY BUILDING DEPARTMENT AT SBUttl 7owN Zm
631-765-1802 8AM TO 4PM FOR THE 90UtFI0lDTQWNRmG8m
FOLLOWING INSPECTIONS: m
pam
FOUNDATION-TWO REQUIRED UlDMi
FOR POURED CONCRETE swmHm
ROUGH-FRAMING&PLUMBING
INSULATION 'OD
FINAL-CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW ELECTRICAL
YORK STATE. NOT RESPONSIBLE FOR INSPECTION REQUIRED
DESIGN OR CONSTRUCTION ERRORS
P 7
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NuvieN
NCB-H High-Efficiency Condensing Combination Boiler
Submittal Sheet
❑ Model NCB-1901060H(60,000 Btu/hr. space heating and 160,000 Btu/hr. DHW)
❑ Model NCB-1901080H(80,000 Btu/hr. space heating and 160,000 Btu/hr. DHW)
Model NCB-240111OH(110,000 Btu/hr, space heating and 199,900 Btuthr. DHW)
❑ Model NCB 2401130H(130,000 Btu/hr, space heating and 199,900 Btuft. DHW)
❑ Model NCB-2501150H(150,000 Btu/hr. space heating and 210,000 Btu/hr. DHW)
Job Name: 15 G RA A61E_ rCAR 12
Location: !�O L D ..l'_-)
Engineer:
Wholesaler:
Sales Rep:
Contractor:
Model: Gas Type(NG/LP):
Notes:
Boiler Standard Features Boiler Optional Accessories Controls
• SS Dual Heat Exchangers • SS Primary Manifold Kit • Smart Controls with LCD
• Cold-rolled Carbon Steel • Condensate Neutralizer Kit Display, Quick Dial Wheel and
Casing • Zone Controller Setup Wizard
• 95%AFUE • Universal Temperature Sensor • Built-in 3 zone pumps and 3
• DHW 15:1 TDR • NaviLink Control System zone valves powered
• Heating up to 11:1 TDR • Ready-Link Racking System connections
• 30 PSI ASME Relief Valve • NaviClean Magnetic Filter • Manual Reset LWCO
• Direct Spark Ignition • NaviCirc for Recirculation Manual Reset High Limit
• Variable Speed Blower • HotButton and Wall Plate • Freeze Protection
• Dual Venturi Mixing System • Outdoor Reset
• Negative Pressure Gas Valve Venting • Warm Weather Shutdown
• Cascaded with up to 15 NPEs - Direct Exhaust Sidewall or • Air Handler Interface
• Common Vented with up to 7 Roof Vent • 4 Circulator Outputs
NPEs • Direct Exhaust Inside Air • NaviLink Mobile Application
• Wall Mounting Bracket Venting
• High Altitude NG and LPG • 2" PVC, CPVC, PP, SS up to Warranties
Conversion Kits 65 ft. • 10 yrs. Residential HX
• Outlet& Inlet Temp Sensors • 3" PVC, CPVC, PP, SS up to Warranty
• Outdoor Temperature Sensor 150 ft. • 5 yrs. Residential Parts
• Flue gas Temperature Sensor • Vent Termination Caps Warranty
• Condensate Trap • Wall Flanges • 1 yr. Labor Warranty
• Mixing and Water Adjustment
Valves
20 Goodyear, Irvine, CA 92613 949.420.0420 949.420.0430 Navier:inc.com
2 NCB-H High-Efficiency Condensing Combination Boiler—Submittal Sheet
Overhead View
LLA
12 .5'(38 TM) 14.3"(364 mm)
d
el E
0 T
4.6'
_U
to i
7�1 4:1
Supply Connections
Supply Connections E
rao)—1�,o U(0
00 CC c
IDescription Diameter a
Pressure Relief Valve Adapter
A �F4 in cli ® 0 l I
B Air Intake
C Exhaust Gas Vent 2 in E_E�
D Heating Supply 1 in
E Domestic Hot V4 in cli
F Gas Connection 3/4 in
G I Domestic Cold 3/4 in 2.7"(68 mm) 3.5' 3 3" 2.9' 2.5"
H lAuto Feeder Inlet(Make-up Water_A in (88 min) (85 mm) (74 mm) (63 mm)
I Condensate Outlet A in i4 9.6"(244 Min) —
J Heating Return _]—Vin
17.3'(440 mm)
Navien Combination Boiler Other Specifications
Domestic Hot Water Ratings
Heating Input(BTU/H)
Water Minimum Flow Rate 770F DHW Supply DHW Return
Model NumberMin Max Pressure Flow Rate (4eC)Temp Rise Connection Size Connection Size
NCB-190/060H 10,700 160,000 3.7 GPM(14.0 L/m)
NC13-190/080H 10,700 160,000 0.5 GPM
NCB-240/110H 13,300 199,90 15-150 PSI (1.9 L/m) 4.7 GPM(17.8 L/m) 3/4"NPT 3/4"NP`r
NCB-240/130H 13,320 1 122�210
NCB-250/150H 1400
6 210,000 - i4.9 GPM(18.5 L/M)l I
C�. �71�, -
Navlen Condensing Boiler , - Y&
, " -i , other Specifications
UP,
Space Heating Ratings
Heatingin ut(BTU/H) Heating Net AHRI Water Water
Model Number Min Max Capacity Rating Water AFUE I%) Water Pressure Connection Size Volume
(MBI-f) (MBH) (Supply,Return)
NCB-190/060H 11 60 56 49 95.0
NCB-190/080H— 11 80 74 64 95.0
NCB-240/110H 13 110 102 89 95.0 12-30 psi V NPT 1.5 gallons
NCB-240/130H 13 130 120 104 95.0
NCB-2501150H 1 14 150 138_ 120 95.0
20 Goodyear, Irvine, CA 92618 949.420.0420 [EA 949.420.0430 N avieninc.com