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HomeMy WebLinkAbout50303-Z Of souryolo Town of Southold * * P.O. Box 1179 �0 53095 Main Rd UNV, - Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45764 Date: 11/19/2024 THIS CERTIFIES that the building ALTERATION Location of Property: 1350 Woodcliff Dr Mattituck, NY 11952 Sec/Block/Lot: 107.-8-1 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 01/05/2024 Pursuant to which Building Permit No. 50303 and dated: 02/06/2024 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: Interior alterations to an existing single-family dwelling as applied for. The certificate is issued to: Brad Piecuch,Kathryn Piecuch Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 50303 09/26/2024 PLUMBERS CERTIFICATION: Brad Piecuch 09/13/2024 OA th rjzd Signature r �oSufFn���o TOWN OF SOUTHOLD o. aye BUILDING DEPARTMENT y TOWN CLERK'S OFFICE oy • o� 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#: 50303 Date: 2/6/2024 Permission is hereby granted to: Piecuch, Brad 1350 Woodcliff Dr Mattituck, NY 11962 To: Interior alterations to an existing single-family dwelling as applied for. At premises located at: 1350 Woodcliff Dr, Mattituck SCTM #473889 Sec/Bldck/Lot# 107.-8-1 Pursuant to application dated 1/5/2024 and approved by the Building Inspector. To expire on 8/7/2025. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $500.00 CO-ALTERATION TO DWELLING $100.00 Total: $600.00 Building Inspector OF SOUT�oI � o Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 G Q Southold,NY 11971-0959 sear.devlinCa�town.southold.ny.us OWN, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Brad Piecuch Address: 1350 Woodcliff Dr City:Mattituck St: NY zip: 11952 Building Permit#: 50303 Section: 107 Block: $ Lot: 1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Electrician: Peconic Power Systems License No: 45056ME SITE DETAILS Office Use Only Residential X Indoor X Basement X Service X Commerical Outdoor X 1st Floor X Pool New X Renovation X 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph X Heat Duplec Recpt 21 Ceiling Fixtures 9 Bath Exhaust Fan Service 3 ph Hot Water GaSX2 GFCI Recpt 2 Wall Fixtures 3 Smoke Detectors 3 Main Panel 200A A/C Condenser 1 Single Recpt Recessed Fixtures 15 CO Detectors Sub Panel 100A A/C Blower 1 Range Recpt 50A Ceiling Fan 1 Combo Smoke/CO 2 Transfer Switch UC Lights 18' Dryer Recpt Gas Emergency Strobe Heat Detectors 1 Disconnect 1 Switches 15 4'LED Exit Fixtures Sump Pump Other Equipment: Fridge, Mini Fridge, DW, Double Oven, Gas Cooktop, Hood, W/D, Icemaker, Dehumi( 100A Sub 24 Circuit/ 17 Used Notes: Service, Kitchen, Laundry, HVAC Inspector Signature: ate: September 26, 2024 Copy ns�,ax: . osuFFocx' mvn Hall Annex Telephone{631}765-18 54375 Main Road CD ' P.-0.Sox 1179 . 5oumold,NY 11971-0959 . • BUILDING DEPARTMENT D� DTOVM OF SOUTHOLD S E P 2 0 2024 PU.BING DEPT. CERTIFICATION TOWN r bP SOUTH01 Pate: A Building Permit No. 03 D 7) ► y Owner: (Please print) Plumber.—h y' (Please print) I certify that the solder used in the water supply system contains less than 2/10 of 1%lead. (Plumbers Signature) t� Sworn to before Ime this , \ day of e"- F�` f 20 Notary Public. //� County SU&N A.R=O Notary Pubric.State of Ne*yo* No.01RISIB3459 Qualified in Suffolk.County► Commission Expires March 17,WZ jr - I OE SOUT,Solo TOWN OF SOUTHOLD BUILDING DEPT. `y^ou 631.765-1802 INSPECTION [ ] FOUNDATION 1ST [v]40UGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: &P-&k �y 5�w All( sf?.,v(�Aia /�x� i` toss vr�e, /des DATE INSPECTOR #�OF SOGTy�# 6 ! �� ���� TOWN OSOUTHOLD BUILDING DEPT. . `ycou 631-765-1802 INSPECTION ' [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] .FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ,.LZVELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: / -4— &Z2 -4- 4a 24-y DATE " INSPECTOR OP SOUIyOIo # TOWN OF SOUTHOLD BUILDING DEPT. courm, 631.765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] R GH PLBG. [ ] FOUNDATION 2ND [ INSULATION/CAULKING [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE 31 20 INSPECTOR OE SOUtyO� - - * # ' TOWN OF SOUTHOLD BUILDING DEPT. 631-765-1802 INSPECTION [ ] FOUNDATION 1ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] "ULATION/CAULKING [ ] FRAMING/STRAPPING [ FINAL [. ] FIREPLACE .& CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS. 1 A� DATE INSPECTO y TOWN OF 9OUTHOLD BUILDING DEPT. o ,� 631-765-1802 INSPECTION . [ ] FOUNDATION 1 ST,/ REBAR [ ] .ROUGH PLBG. [ ], FOUNDATION 2ND [ ]- INSULATION/CAULKING [ ] FRAMING /.STRAPPING [ ] FINAL { ] FIREPLACE &CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION . [ ] FIRE RESISTANT PENETRATION { ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE.C/O [ ] RENTAL REMARKS: �A DATE INSPECT (� ] Qp � yv.cay� he4t dr�ec�; "(aG TIeivL� 1350 WCCdLt%-+f ► 4:t},+Vc� I Ny �I�lSZ PLTURE-S fOr elCCkt(Lal 6v,l A,-n) Qecmi fi '# 5C30j o a S E P e 2024 BUILDING DEPT. T OWN:T S M-m—o? f t MdOmbkk 6.uervo-j cl� - sm�r;e dz fcc�cf 41 .� � /y . ` 7 1 .N t; 4 _ ,��� n ` .... M � e ( `• � •}} � 1 � i t.,1 � '� ", , ��, Ili ±� .'`yl "RF 1�. .�{,��r_i` f„ _, � �- 1 LL'c/ i' :s r �,„q� R �`� �kith •'® •�.. .. - •1 t�n .f,�6e� t{ ! 7. � M' -. _._ � , ,r, .zt.� 9� 1�. �, '� � � ,� r. FIELD INSPECTION REPORT I DATE COMMENTS ro FOUNDATION (1ST) ------------------------------------ �c FOUNDATION (2ND) o 1 z Inlvi 4,- - H ROUGH FRAMING& v ��~ 5Su✓lC /�.ics �vv �C,ll a,�. PLUMBING r INSULATION PER N.Y. STATE ENERGY CODE jR FINAL ADDITIONAL COMMENTS 7`a �1• 0. 2 c� �� re '� nS 4 � � • 2 �• 2� V� i S Z lO-lI- 2 q. /OO �l c 1Vl• #eLG • Q CD J O - x r� Z � r x � d b a�oSvfFoc,r�o TOWN OF SOUTHOLD—BUILDING DEPARTMENT y Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631) 765-1802 Fax (631) 765-9502 httys://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT �� , ��...:L C For Office Use Only PERMIT NO. So �)03 Building Inspector: JAN 5 2024 Applications and„forms must be filled out in their.entirety. Incomplete I U. ,D17"i, Etr 1'. applications will not,be accepfed Where the A'pphcant is not'the owner,an- IrC.0 W N '1', iZ>e 7zc': Owner's Authorization form(Page 2)'shall be completed: Date:01.05.24 OWNER(S)OF PROPERTY Name:Brad Piecuch sCTM#1000-107-8-1` Project Address:1350 Woodcliff Drive - Mattituck, NY 11952 Phone#:631.740.0417 Email:allpointseastplumbing@gmail.com Mailing Address:1350 Woodcliff Drive - Mattituck, NY 11952 cONTACT'PERSON Name:Zackery E. Nicholson, RA Mailing Address:1250,Evergreen Drivel Cutchogue, NY 11935 -- Phone#:631.513.6589 Email:ZENicholson.Arch@gmail.com DESIGN PROFESSIONAL INFORMATION: Name:Zackery E. Nicholson, RA Mailing Address:1250 Evergreen Drive - Cutchogue, NY 11935 Phone M 631.513.6589 Email:ZENicholson.Arch@gmail.com CONTRACTOR INFORMATION:: Name:Gabrielsen Builders LLC Mailing Address:PO Box 317 Jamesport, NY 11947 Phone#:516-322-1537 Email:Robb@gabrielsenbuilders.com DESCRIPTION OF PROPOSED.CONSTRUCTION ❑New Structure ❑Addition ®Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $100.000 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes ®No 1 PROPERTY INFORMATION' '. Existing use of property:Single Family_pWplliqg, Intended use of property:Single Family Dwelling Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes MNo IF YES,PROVIDE A COPY. B Check Box After Reading: The owner/contractor/design professional is responsible for alFdrainage acid 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 Buld'mg;Zone ordinance of the Town of,Southold,Suffolk,County,New Yorkand other applicible Laws,Ordrnances oe Regulations,for.the construction of buildings, additions,alterations of forreind"I or demolition as herein described.The applicant agrees to comply with all applicable leers;ordinance,building code, housing code and regrriations and to admit authorized inspectors on,premises'and in buildings)for necessary inspectior�.False statements made herein are Punishable as a Class A misdemeanor pursuant to Section 210.45 ofthe Neill York State,Penal Law. Application Submitted By(print name): 8r&J, P;ftvch ' " ' i Authorized'A/gent 00wner Signature of Applicant: Date: O'7-9 7 CONNIE D.BUNCH Notary Public,State of New York STATE OF NEW YORK) No.01BU6185050 (Qualified in Suffolk County COUNTY OF SS: Commission Expires April 14,2-1 Y 1 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 -LiPIday,of r / r Vl 202 Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I, Brad Piecuch residing at 1350 Woodcliff Drive- Maftituck, NY 11952 do hereby authorize Zackery E. Nicholson to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owne s Signature Date Brcia Net cuch Print Owner's Name 2 - uff BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD -�� Town Hall Annex- 54375 Main Road - PO Box 1179 o - Southotd, New York 11971-0959 ��0 ape Telephone (631) 765-1802 - FAX (631) 765-9502 1 'Y" iamesh southoldtownny. ov- seand southoldtownny.«ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 10/11/24 Company Name: Peconic Power Systems Electrician's Name: Robert Stanevich License No.: ME-45056- Elec. email:Peconicpowersys@gmail.com Elec. Phone No: 516-819-7191 ❑1 request an email copy of Certificate of Compliance Elec. Address.: PO Box 512 Cutchogue NY 11935 JOB SITE INFORMATION (All Information Required) Name: Brad Piecuch Address: 1350 Woodcliff Drive Mattituck 11952 Cross Street: Wickham/Grand ave Phone No.: 631-740-0417 Bldg.Permit#: 5 03 D 3 email:allpointseastplumbing@gmail Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): File existing service with PSEG. Existing 200 amp service was upgraded by previous electrical contractor and was never inspected or filed with PSEG Square Footage: Circle All That Apply: Is job ready for inspection?: 21 YES❑NO Rough In Final Do you need a Temp Certificate?: 0 YES O NO Issued On Temp Information: (All information required) Service SizeFv-I1 Ph O3 Ph Size: 200 A #Meters _Old Meter#oq 82g9X1J ❑New-ServiceOFire ReconnectOFlood Reconnect OService Reconnect OUndergroundE Overhead #Underground Laterals 1 02 H Frame Pole Work done on Service? n Y N Additional Information: -, 5-3 6 f PAYMENT DUE WITH APPLICATION too OCT 1 1 2024 V., BUI.LqJ DEPARTMENT-Electrical Inspector �o Gym FEB 2 2 2024 TOWN OF SOUTHOLD C* Town Hall Annex- 54375 Main Road - PO Box 1179 ce -M, , Pill Southold, New York 11971-0959 TO,; -N ,Oone (631) 765-1802 - FAX (631) 765-9502 —ia mesh 5-southoldtown ny.gov sea nd(@-southoldtown ny.90v APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: a Company Name: lIcon( 5�e--ti . Electrician's Name: License No.: Elec. email: Elec. Phone No: ED I request an email copy o(Certifrcate of Compliance Elec. Address.: a 66->< VL=e- /U/ 11q3-- JOB SITE INFORMATION (All Information Required) Name: er"A-j P1P-6L;��, Address: 13-5-6 Or /14Ak-J1t1-- Cross Street: tvcjc-�,, Phone No.: Bldg.Permit#: 563o 3 email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: -1 NO �ough In ❑ Final Is job ready for inspection?: 1EJ1*`YESF Do you need a Temp Certificate?: ❑ YESED40 issued On Temp Information: (All information required) Service SizeF-11 Ph❑3 Ph Size: A # Meters Old Meter# ElNew serviceFl Fire Reconnect E]Flood Reconnect Elservice Reconnect ElUnderground ElOverhead # Underground Laterals[]1 [—]2 [:] H Frame [:1 Pole Work done on Service? F1 y F-1N Additional Information: PAYMENT DUE WITH APPLICATION, �Z'�� �" 4 V',r- l b tp-7 - 3 60-0, 13 6 3 Si'0�01FFac�.t' BUILDI.Ny DEPARTMENT- Electrical Inspector FEB 2 ? 2024 TOWN OF SOUTHOLD o Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 ia mesh n-southoldtownnyr gov - seand a@southoldtownny.eov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: ! , Company Name: 4- �,� S�e� Electrician's Name: Q�� License No.: J A s-' &f r6r;S(, Elec. email: S s Elec. Phone No: "6_ t 1q� El request an email copy of Certifcate of Compliance Elec. Address.: a 13ex 0- JOB SITE INFORMATION (All Information Required) Name: 1260e-,� Address: J3>D L,,,J -Ar/ Ar Cross Street: Phone No.: Bldg.Permit#: 55D 3o email: Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: 970 Circle All That Apply: Is job ready for inspection?: ❑I"YES ❑ NO ©Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES -L-,KO Issued On Temp Information: (All information required) Service Size❑1 Ph❑3 Ph Size: A # Meters Old Meter# ❑New Service[:]Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground[-]Overhead # Underground Laterals al 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT'DUE WITH APPLICATION Yt c, p tp13 So g.p� s"b3 a 3 PERMIT 9 Address: Switches — Outlets i G FI's �\ Surface Sconces HH's 1 UC Lts Fans CJ Fridge HW cG f Exhaust Oven $ WAD Smokes DW I Mini -arbon Micro Generator -ombo Cooktop Transfer aC AH Hood Service Amps Have Usec -pecial ommments k ��si1FF0l,��® BUILDING DEPARTMENT-Electrical Inspector y x TOWN OF SOUTHOLD oy • �� Town Hall Annex-54375 Main Road-PO Box 1179-Southol;d, NY 11971-0959 ,O! c ' Telephone (631) 765-1802 Temporary Certificate # 1-7-7 9 Date_ IrD — 11 — 2024 Customer Name 'ES"MA MeLAAchElectrician Name Av6e Address 115,0 WobCte 1 (, hone 5 e-mail all of eakd- ►unv6f ' , e-mail .oc.cnie vjJ e� � Phone &j j. 'j p_ p License# rftp ^ S-p$(p Size ajCQ A Phase Overhead _Underground #of Meters 1 Remarks #of Underground Laterals 1 2 New "H" Frame or Pole H P Fire Reconnect Was work done on Service? Y/N Flood Reconnect Old Meter MolsService Reconnected Application for electrical service equipment is on file with the town of Southold.On the applicant's notification that this installation is complete,the town will conduct a premises inspection of the service equipment. This verification is valid for 90 days from the date ab e. r Authorized by , ,"'NEWK workers' CERTIFICATE OF INSURANCE COVERAGE STATE Compensation 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 carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured GABRIELSEN BUILDERS LLC 631-722-5130 P.O. BOX 317 JAMESPORT,NY 11947 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) Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Southold Building Dept 54375 NY-25 3b.Policy Number of Entity Listed in Box"1 a" f Southold, NY 11971. DBL244040 3c.Policy effective period 11/28/2023 to 11/27/2024 4. Policy provides the following benefits: 0 A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: 0 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 Signed 1/5/2024 By ��I_At (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, 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 413,4C or 513 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 Issuep this form. p I' DB-120.1 (12-21) IIIIIIIIIDII°III�IIIIIII IIII(IIIIII°III IIIIII�III Additional Instructions for Form 1313-120.1 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 NYS Disability and Paid Family Leave Benefits Law.The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage(Certificate)to the entity listed as the certificate holder in Box 2. S 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 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 NYS 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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. c DB-120.1 (12-21)Reverse PORK Workers' CERTIFICATE OF lf— STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Gabrielsen Builders LLC 631-722-5130 PO Box 317 1 c.NYS Unemployment Insurance Employer Registration Number of Jamesport, NY 11947 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Farm Family Casualty Insurance Company Southold Building Dept. 54375 NY-25 3b.Policy Number of Entity Listed in Box 1 a" Southold,NY 11971 3152W8527 3c.Policy effective period 11/28/2023 to 11/28/2024 3d.The Proprietor,Partners or Executive Officers are El included.(Only check box if all partners/officers included) ® 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: (Print name of authorized representative or licensed agent of insurance carrier) Approved by: '&_ /"L_ (Signature) (Date) Title: Telephone Number of authorized representative or licensed agent of insurance carrier: 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 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into 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. r C-105.2(9-17) REVERSE i DATE(MMIDDIYYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE � 01/05/2024 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 endorseinent(s). PRODUCER CONTACT NAME: Katie Jackson Brian Micena PHONE (631)821-2200 A/c No): 100 South Jersey Ave aI DRESS: katie.Jackson@american-national.com Unit 33 INSURERS AFFORDING COVERAGE NAIC# East Setauket, NY 11733 INSURERA: Farm Family Casualty Insurance Company 13803 INSURED INSURER B Gabrielsen Builders LLC INSURERC: PO Box 317 INSURER D:' INSURER E Jamesport NY 11947-0317 INSURERF: 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. ILT R TYPE OF INSURANCE AINSD WILD DDL SUBR POLICY NUMBER POLICY M/DI DY EFF/YYYY POLICY EXP LIMITS LTR A COMMERCIAL GENERAL LIABILITY 3152X2148 11/03/23 11/03/24 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE F OCCUR PREMISES Ea occurrence) $ 100,000 X Contractors Advantage MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ A AUTOMOBILE LIABILITY 3152C7227 02/06/23 02/06/25 COM�BIcINdEeDtSINGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNEDX AUTOS ONLY AUTOS ONLY l (Per RO ac d nDAMAGE $ A X UMBRELLA LIAB OCCUR 3101 E3010 12/18/202312/18/2024 EACH OCCURRENCE $ 1,000,000 4 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ 10,000 F $ A WORKERS COMPENSATION 3152W8527 11/28/23 11/28/24 X PER ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBEREXCLUDED? ❑Y N/A, (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under / DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/'LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if mare space Is required) Residential Carpentry CERTIFICATE HOLDER CANCELLATION Southold Building Dept. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 NY-25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. -� AUTHORIZED REPRESENTAT ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD MODEL NO./ MODELS N°RA1348AJINA MFD./FAR 10/2016 SERIAL NO./ N` DE SERIE W411634887 OUTDOOR USE/ UTILISATION EN EXTRIEURI COMPRESSOR CODE / CODES DE COMPRESSEUR 9047 VOLTS 208/230 PHASE. I HERTZ 60 COMPRESSOR/ COMPRESSEUR R.L.A. 21.8/21.8 L.R.A. 117 OUTDOOR FAN MOTOR/ MOTEUR VENTIL. EXT. F.L.A. 1 H.P. 1/6 MIN. SUPPLY CIRCUIT AMPACITY/ COURANT ADMISSABLE D'ALIM. MIN. 29/29 A - MAX. FUSE OR CKT. BKR. SIZE•/ CAL. MAX. DE FUSIBLE/DISJ• 50/50 A i MIN. FUSE OR CKT. BRK. SIZE'/ CAL. MIN. DE FUSIBLE/DISJ• 35/35 A - DESIGN PRESSURE HIGH/ PRESSION NOMINALE HAUTE 450 PSIG/3102 kPa DESIGN PRESSURE LOW/ 250 PSIG/1723 kPa PRESSION NOMINALE BASSE OUTDOOR UNITS FACTORY CHARGE/ R410A CHARGE US1NE D'UNITES EXTERIEUR 106 oz/30059 R410A TOTAL SYSTEM CHARGE/ CHARGE TOTALS OU SYSTEMS Eli SEE INSTRUCTIONS INSIDE ACCESS PANEL/ 610 YGIR LIS CHARGE INSTRUCTIONS A L'INTERIEUR DU PANMAU D'ACCf$ RHEEM SALES COMPANY FORT SMITH, ARKANSAS GISTALL PM111TED 11 SOUTNEAST AND SIUTNWEST ASSEMBLED IN •NNCR TYPE BREAKER FOR U.S.A./ MEXICO UISJDNCTEUR DIFFERENTIEL IPx4 I.s.om,'.m,ll 92-2205q-V Ac �c-Ua Q�ec�i,h �35c �1ccd�.l�ff br. llla}}E'fiv�?; 11N y AM 2 Amo-oaM2o} }c q-,y (T'r bvilF�ln�E �eEm; � in�}ulla�ic �1 C'� FCC SyS}tTY'1 t- t w,is r s4-11 ed BullA\n P�SM;t # Sc3d3 DD n S E P 2 6 2024 BUII,DING DEPT. TONS '-)I?SOI*TgOI F rll ts° AIR HANDLER ec�cT6�e�1N6 68,000 STUM 460 PSI FAIQEIIKNT: A410A VOLTAGE: 120V 60 lift i p6aca MOTOR: 316 HP 7.5 FLA 825 RPM CAPACITOR; 12.5 MFD MAX STATIC 8 .30 IN. Ht0 OU 200 F MAX SEE SPECS + 1160 1i 1140 N 065608155 M 15 AMP M 15 AMP C 718 M- TERMPERATORE—180 DEC M A>tI 6R PRESSURE—100 PSI. A-22 S must `knum copper conductors only ion I Mformation before Installing—t I SERIAL NUMBER �I' III IIIIIII���II�II'IIIIIIIIIIIIIII�III us yt. 7117A40062 Ac Evaeolra O( • 'Road APPROVED AS NOTED ,ATE: B.P. It 50 _E�( C)0'00 BY: DTIFY BUILDING DEPARTMENT AT 31-765-1802 8AM TO 4PM FOR THE ZEN DESIGN -OLLOWING INSPECTIONS: 1250 EVERGREEN DRIVE CUTCHOGUE,NY 11935 FOUNDATION-TWO REQUIRED PHONE:631513.6589 FOR POURED CONCRETE AREA OF PROPOSED WORK=s00 SF ROUGH-FRAMING&PLUMBING These INSULATIONpyrW plans ereaaidtectedanda rowersubjectm m2ortt pmtm Actman'A.as,rcturelwork'eunberea anal ko FlNAL-CONSTRUCTION MUST — — — — — — — — — — — — — — — — — caprtgldllC.d7u Works �>oD�°."'e„a as,Artkheatural Wade a lted BE COMPLETE FOR C.Q I Protection arra urdrwent an is ra oshlonof pa es and orm esweof D as the tion i kshei and m of gertnn tospe a and elements well design.Uatler such protection,unautkortswuss ottresa plain, —--—-----— I work or twne represented.can legmty result M tre cessation of ALL CONSTRUG"TiON SHALL MEET THE � caret urt6nr"Cushion to ing 201 eist N LIA maaeta r cmnpen98tbn ro iEN DESIGN I1G REQUIREMENTS OF THE CODES OF NEW EXISTING YORK STATE. NOT RESPONSIBLE FOR MASTER BATH I EXISTING I No. ISSUE DATE DESIGN OR CONSFRUGM ERRORSEXISTING I EXISTING LAUNDRY I 01 SCHEMATIC DESIGN 04.20.23 EXIST. EXISTING KITCHEN ROOM I 02 PERMIT SET OL05.24 MASTER BEDROOM PWDR. RM DINING PLUMBER CERTIFICATION ROOM ON LEAD CONTENT BEFORE _. CERTIFICATE OF OCCUPANCY ARC SOLDER USED IN WATER ExIST.w/1 1 I 5 E.Ni y'T SUPPLY SYSTEM CANNOT 1 CLOSEr_______; cs EXCEED 2110 OF 1% LEAD. I I N� °z EXISTING EXISTING I I 5 EXISTING LIVING 2 CAR I PLUMBINGEXISTING UP ROOM GARAGE i SUN ROOM GUEST 'S'T 04,447 LL PLUMdINf'WASTE BEDROOM I -9 T AO &WAT*ER LINES NEED I I F.OF rf TESTING BEFORE COVERING _ PIECUCH n FIRST FLOOR PLAN RESIDENCE ELECTRICAL `u a��` 1350 WOODCLIFF DRIVE INSPECTION REQUIRED MATTITUCK,NY 1.1952 1000-107-8-10 SCALE: 1/8"-1'-0" DATE: 0104.24 COMPLY WITH ALL CODES OF DRAWN BY: ZE.N. NEW YORK STATE&TOWN CODES AS REQUIRED AND CONDITIONS OF WROLD TOWN ZBA EXISTING FIRST SOUTHOLDTOWN PLANNING BOARD FLOOR PLAN SOUTHOLD TOM TRUSTEES N N.Y.S.DEC ry� SOUTHOLD HPC 0 10 20 Aml SCHD o• — — — — — — — — — — — — — — — — ZEN DESIGN 1250 EVERGREEN DRIVE CUTCHOGUE,NY IM5 — —— — —— — —— — / , / , r / / , / �r XX / / / NE:63L513.6589 / , 1 / / / / / ' / ' / I W II D I / REMOVE ALL KITCHEN I I �'_� 1 �T J a_r �, I I I I / WASHER&DRYER TO BE _ r lhesa Olsen am copyr�Med and are w^Jed m capyd@ft MILLWORK AS SHOWN I I �-----� �------J / RELOCATED �a A vllSa.Or�inandeddDDou-ber1199Waanddkn as Ard@e0«al Woda Copyright Protecdon Act of IMThe prom lion lndudaa but 6 not anted to the avenG farm aavM as fha anarrgernent and=npaeitbn of spa—and eWnens of designUndevsucl pnteedon,oneuduulred—of dress plain. bamempm-rded,can fegelly mutt fn the eessagon of aonstmdion a bu Mings being selmd and/«—tary EXISTING EXISTING ',��. c«npemmdan fo M C65MN L= DEMO WALLS AS SHOWN. KITCHEN LAUNDRY ROOM N0. ISSUE DATE , , DEMO CEILING AS REQUIRED TO / I ,/�/' 01 SCHEMATIC DESIGN 1 04.20.23 INSTALL NEW NON BEARING HEADER I I,��/' ( oz PERMIT SET oioa.za r , , REMOVE ALL LAUNDRY ROOM MILLWORK AS SHOWN -(EKED ARC 0 REMOVE EXISTING FLOORING \ \\ \\ \ \\ \\ \ \\ \\ \ \ \ \ \ \ Q T alp \ \ \\ \ \ \\ \ \ \ DEMO DROP CEILING TILES AND E OF N 'tj \ \\ \\ \ \\ \\ \ \\ \\ FRAMING AS REQUIRED TO \\ \ \ \\ \ \ \\ \ PREP FOR CATHEDRAL CEILING PIECUCH \ \ \\ \\ b \\ \\ \ RESIDENCE \ \\ \ \ \\ \ \ \\ \ 1350 WOODCLIFF DRIVE \ \ \ \ \ MATT(TUCY,NY 11952 \\ \\ \\ \\ \\ \\ \\ \\ \\ 1000-107-8-10 \ \ \ \\ \ \ \\ \ \ SCALE: 1/4"01!-W \ \ \ \\ \ \ \\ \ \ \ DATE: 01.04.24 LEGEND \ \ \ \ \ \ \ \ \ I DRAWN BY: ZE.N. \ \ \ \\ \ \ \\ \ \ EXISTING STUD WALL F,; T,%; -� I \\ \ \ \ \ \ \\ \ \ FIRST FLOOR --------------- ' t \ DEMO PLAN ------------------- DEMO'D WALL DEMO'D MILLWORK DEMO'D DROP CEILING A-2 0 5 10 <\ \Z-7 MEW n �v I ZEN DESIGN 1250 EVERGREEN DRIVE n ' CUTCHOGUE,NY U935 dl _ PHONE:631.513.6589 II =.n O O . II 000 \ � ,besePmrmaraeaPyr�tmaneareeabjectbmPy,i�t I 11 Pautertbn man'ertldtetiuralwork•under9ee.102ot the \ / Copyright Act,17US0.as amended December 199Dand known \\ // Protection o Artiontndat buts Wlinnted to then Aae/19n aswe s t eca-ngeuaes and composition mspe es and eb ants o I ll rm sig armngemmt end aampmttbn otapeoas and dements ar work wn.Under-p pmteotbn�rlegally result and Of these Warm, workarbornerepresented,caning se resultNthecessation of constnutbn or buildings being setstl and/or monetary I [A0 _ compensation m2EN DE91GN LLG NEW PILASTERS TO VISUA LY KITCHEN ` I N0. ISSUE DATE SUPPORT CASED OPENIN & I I 01 SCHEMATIC DESIGN 1 04.20.23 HEAD R I I I 02 PERMITSET 0104.24 II t 11 PANTRY \ PACK WALL OUT FLUSH 1 .��RED ARC p ---= i --- " �� E.NICKS' — i 1N i i. i � Q' V� l0 ��' I II I I N� Z I L------J L-----J ... . NEW CATHEDRAL CEILING WITH 46 .h NEW RADIANT FLOORING I EXPOSED COLLAR TIES. 444 THROUGHOUT :044a23 �O OF NEB ' LAUNDRY/ I PIECUCH MUDROOM RESIDENCE I 1 1350 WOODCLIFF DRIVE i MATTITUCK,NY 11952 I' 1000-107-8-10 I SCALE: 1,/4n-:V-W I I DATE: 01.04.24 LEGEND \\ DRAWN BY: ZE.N. GbiL�11 \ EXISTING STUD WALL ---------I I /'/ PROPOSED FIRST FLOOR PLAN i -— — — — —— - CEILING HIDDEN ABOVE I 00 NEW STUD WALLS NEW MILLWORK I� 0 5 10 A-3