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HomeMy WebLinkAbout51670-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#: 51670 Date: 02/21/2025 Permission is hereby granted to: David Lewis 295 Mockingbird Ln Southold, NY 11971 To: install an EV charger in the attached garage of an existing single-family dwelling as applied for. Premises Located at: 295 Mockingbird Ln, Southold, NY 11971 SCTM# 55.-6-15.59 Pursuant to application dated 01/10/2025 and approved by the Building Inspector. To expire on 02/21/2027. Contractors: Required Inspections: Fees. EV Charger $125.00 ELECTRIC -Residential $100.00 CO- E IDENTIAL $100.00 01 Total $325.00 -- _ Bu ing Inspector TOWN OF SOUTHOLD-BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 w. Telephone (631) 765-1802 Fax (631) 765-9502 htti)s://www,soutlioldtowlinv.gov Date Received APPLICATION FOR BUILDING PERMIT L� I= iJ For Office Use Only 2���, PERMIT NO. Building Ins�sectore-& JM IN N � �.:"')" Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: 0Ali ip lVIS Z -OUI5r , SCTM#1000- 5-� t r Cq Project Address: eta 5'17. Email: Q a C Phone#: Pir' i Mailing Address: CONTACT PERSON: Name: PAVIp �I:(,AI7S Mailing Address: Ci -I +' G Al-. S490-r[401-b , /V y 0271 Phone#: 11 966 Email: t A�, O -O G0 DESIGN PROFESSIONAL INFORMATION: Name: A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: , oWv- Is]-A/vp 47-c : s15 A10, /tJr 6 q a 1� Mailing Address: ,7y n " L l vq&vhv 95' A/y 11 73" Phone#: 631 - �27 - 07o, Email: IRQA16-i S LA /J O E - 1 l )L . Cl7/tC DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: %Other___6V _I�k LA'TI 1 0 Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes jZNo . 1 PROPERTY INFORMATION Existing use of property: �S i p i:-�—Al Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Ati this property? ❑Yes ONO IF YES, PROVIDE A COPY.. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by hapter 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 210.4S of the New York State Penal Law. Application Submitted By(print name): I p I, ❑Authorized Agent pOwner Signature of Applicant: Date: . STATE OF NEW YORK) SS: COUNTY OF �) V L,; _1S 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 day of 0 r , Notary Public FSHAM—ECCA ANDREWS.( ublic-State of New YorkPROPERTY OWNER o.01AN6290108 (Where the applicant is not the owner) fied in Kings Countymission Exp. 10/07/2025 I residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 efl, ,{ a BUILDING DEPARTMENT- Electrical Inspector y , TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 co x Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 'ameah aoutholdtownn ov —,,,seand@sou,tholdtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Electrician's Name.- License No.: Elec. email: Elec. Phone No„ ❑I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: David Lewis Address: 295 Mockingbird Lane, Southold, NY 11971 Cross Street: Tuthill Road Ext. Phone No.: 718 866 6583 Bldg.Permit#: 0 email:pipeace@aol.com Tax Map District: 1000 Section: 55 Block: 6 Lot: 15.59 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Installation of electric vehicle charger in attached garage. Approx 40' run from panel. Square Footage: Circle Alll That Apply: Is job ready for inspection?: El YES R NO Rough In Final Do you need a Temp Certificate?: F� YES NO Issued On Temp Information: (All information required) Service Size Ill Ph 3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 0 1 n2 H Frame Pole Work done on Service? Ely ✓ N Additional Information PAYMENT DUE WITH APPLICATION now or formerly Francis a Patricia O'Malley EDGE OF WETLA�* ' N.88G56 132°E. 173.39' ' EL%97;1 M �CONSERV4TfpN RM I. e4sf Ad d MFNr TES7 HOLE I "�"� DATE: 9-9-98 4 '"". rn•,�"ca°"" EL=19 1 ..............�....... 0.0' I' AT DARK BROWN b L 0 t 5,3 �'".. C DAVE,LOAM 26 Are,=3p F� BROWN FINE Lot 54 y 640 S.f, To S ,COARSE SAND 7 7• (DWELLING) With Public 14hter WATER IN BROWN FINETO T COARSE SAND I AIL•agR "'.y� O WATER nq f L D IN GREYISH TV 0 BROWN 6A NOY yLU tA,dy CLAY AND CCJC,AT"TS Ea CLAYEY SAND O ram'. Z1p NOUN Rl X a + „ J BROWN VINE TO 1'� COARSE SANG N O y,.R'054" ELz,EO.B aRB� . Z Kr230.O0 3O V A R Ax:. �'.., , ,, ELA2A.I MpCK NAB \ ft, �A rD B W}DWJOU6 C WDler • '~�� HOUSE FINISH ONAOE FF, 237Z E Ito •••••••.� '.IE=19Z AW6"'i%r VV A1.4��irl�y7 MR 7°,d RY SYSTEMR CEO DE9B'I++OOL'T IODO OAL. {,H 4 PJ"M ■ y�•R. SEPTIC TANK L E CTA n] eTR MP ..._..V.--�.�_.:._. EL•N.a SEWAGE DISP05AL (USE(3) POOL SYSTEM) SUMIX COtWNDEPARIMENTOPMALTHSERVICES SURVEY FOR D.B.M. COMPANY FSRMIT FOR APPROVAL OFOONSTRUCnON FOR A LQT NO.53,°HIGHPOINT MEADOWS,SECTION THREE" SECT is;li991 O FAMMY RMBECH ONLY AT SOUTHOLD DATE: NOV. 29,1991 DATE HS RAPrNO. �) TOWN,OF SOUTHOLD SCALE; 1":40' APPAOVIM (F`FOLK COUNTY, NEW YORK No. 91- 1036 RA pEEO ALTENATNON'OR ADd FIE +tatiae+'NE 11 4 STATE TATPON 9OF hA4 PON...7209 OF Y"I 9A CERTIFIED 70 " FORMA)aMWOF D.B.M.COMPANY #COPIES Or THIS SUM TCY Or EI:ARYRo THE LINO BRIDGEHAMPTON NATIONAL BANK VMMM TR IMYEARSPRO v ROVAL SUR VE koAS INwED StAL ORTMNOSSEO SEAL SHALL #OT�EE CONt 10ERtO 6O NE',AYAL O TNUt COPY TICOR TITLE GUARANTEE AOUANANTttE MEDICATED WEIREON SHALL. R4RN'ORLY TO HENLTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUC•T.. Teo CIN WSsPOP ROA I,PArM" THE TITLE C M 11E GOVERN- : �uY AND pe W4t to*ALT 1M THE TITLE COMPANY,DovrRR- N PEANttT WARN lAIkNNI w9"'ASOURCt OF WATER'FRIMITE_PUBLIC_ MENTAL AGENCY AND LEROINA P.ST9TUrION LM$TEO �,y�, w e�F DO TARIAEw ANAtY� .tt0TYON.SS_ALOCN LOT ALAS HENEOR,AND TO TWE ASSIONEEA OF FHE LENDING 5 W• NTNIENE ARNE PO BWtLLOON WITNRN 100 FEET OF THIS NNOPERTY URiS Tt PnyTIOIR DL4AR RR TEE$AMC NOT TNAw$F RAN9.E. .. oYNitR THAN YNOtt lilNOWfNF HENtON TO AOOM T4ONAL IR579rUTION1 OR $1,14se 1E T . R.'FMt WATER COMPLY Amig,004E WSFOSu SYE'TEM FOR'THIN RE140ENLL OWNER$ Iff"CWFORU To THE STAN'OANpt or T'NE SARFFOux CORATYY'OEPANTPEN'T T DISTANCE! STREW HEREON FROM PROPERTY SPECIFIC LINES TURPOSTIME STRUCTURESETT AE USE A SI Of NI¢RIL TN'.ttEM NOEt.. PURPOSE AND NNE NOT TO BE ERECTION TOOFFC ESTABLISH AFwA•1CFMY, '"� PROPERTY LINE! OR FOR THE ERECTION OF FENCE! YOUNG .a YOUN R R AVENUE F r ✓ TEL �1MRlC . NOTE: )�OOR9i'UAdR,) SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF ALOEN WYOUNG,PROFESSIONAL ENGINEER Suf"',County AND LAND SURVEYOR NYS LICENSE NO,12845 *,SUFFPLK COUNTY ON MARCH 19,1990 AS FILE NO.6912. HOWARD W.YOUNG, LAND SURVEYOR SEP 23 1998 o W"XHE LOE,AflOko dF w11tILEYW), wFRE"GANN#1T7IE ttawoLEfol waFN N[ACOM I' N.Y.S.LICENSE NO.45893 AMPS MOM IMSLA OEWINARYNARE APO ON DATA OETAANEB FARIM OTHER! r` �xt,lh SeNICAT BAAPO9S 4 SONS$XNC'. a"•.r..rr r*«�� "• 0 DATE(MMIDDIYYYY) a4CCMa CERTIFICATE OF LIABILITY INSURANCE 1/8/2025 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 endorsements . PRODUCER NA.MONiTE ..CaSSi+: BUrkeww Suite 200 Arthur J.Gallagher Risk Management Services,LLCnss ChB8-2738155 ... N 9 Xt) 88 856 273 3683 4000 Midlantic Drive EwL rr H 11.8 D Cert 1�A 6G com Mount Laurel NJ 08054 INSURERIS AFFORDING COVERAGE NAIC# 6608 INSURER A:New York Marine And General Insurance Com an 16608 Strong Island Electric LLC HEENER-05 INSURER C.EnduranceornP... 12831 75 Linden Street � � B State„ Amencanmminsurance Com art mmmmm �� mmWUWWmmm� T National Insurance Com an Inc ._— T � P...� 10641 INSURED INSURER Lindenhurst, NY 11757 INSURER D:Allied„World Assurance Co U.S. Inc. 19489 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:113504452 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. _ ....m._...,.., ...... LIMITS .u....._ ......... try ILTR ... ,. . TYPE OF INSURANCE At1 L ......_ POLICY NUMBER NPVOLDDtYYyYY .EFF 5.11 EXP A X COMMERCIAL GENERAL LIABILITY PK202400022009 10/1/2024 10/1/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE m OCCUR RFp�iE¢�rgaLgm(ropwa $100 000 P one son) $5,000 MED EX.m...(Any �.................. PERSONAL&ADV INJURY $2,000,000 .•.•. .......... ...... ._ .. ...- GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: 2.000,000 X POLICY „ ]J LOC PRODUCTS COMP!OP AGG $2 000 000 A AUTOMOBILE LIABILITY AU202400018088 10/1/2024 10/1/2025 L� SINEDtIN L UM'ITL $„1,000^,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ X-„ AUTOS ONLY AUTOS HIRED NON-OWNED $ PRCNPCR.._.fY OAriAAGE AUTOS ONLY AUTOS ONLY Par aalI:rl �•• A X UMBRELLA LIAB OCCUR EX202400001655 10/1/2024 10/1/2025 EACH OCCURRENCE $25 000,000 mm l C - EXC30045527801 10/1/2024 10/1/2025 D X EXCESS LIAR CLAIMS-MADE 0312-0403 10/1/2024 10/1/2025 AGGREGATEmmmm $25 000 000 DED RETENTION B WORKERS COMPENSATION SK00014401 10/1/2024 10/1/2025 X T AND EMPLOYERS'LIABILITY YIN EACH ACCIDENT ER $1,000,00 .... ... StNYPROPRIETOWPARTNIEMEXF-CUTNE. NIA E.L.E. .^.EACH ACCIDENT 0.......".",". OF FICER1MEMSER EXCLUDED i (Mandatory In NH), E.L.DISEASE EA EMPLOYEE $1 000 000 It ss.describe under E.L.DISEASE-POLICY LIMIT $1.000,000 DESCRIPTION OF OPERATIONS b Aowr DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Evidence of insurance CERTIFICATE FOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 54375 Route 25 AUTHORIZED REPRESENTATIVE. Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YO K Workers' CERTIFICATE OF TATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Strong Island Electric LLC 6314805803 75 Linden Street 1 c.NYS Unemployment Insurance Employer Registration Number of Lindenhurst,NY 11757 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 83-0820693 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) State National Insurance Company,Inc Town of Southold 3b.Policy Number of Entity Listed in Box"I a" 54375 Route 25 SK00014401 Southold NY 11971 3c.Policy effective period 10/1/2024 to 1011/2025 3d.The Proprietor,Partners or Executive Officers are 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 09l1't..-JA_ 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"T. 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 farm 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: Catherine Burke (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title:Associate Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier: 856-675-2348 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 NEW workers'Yor�rt CERTIFICATE OF INSURANCE COVERAGE STATIE 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured STRONG ISLAND ELECTRIC LLC 75 LINDEN STREET 6314805803 LINDENHURST,NY 11757 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 83-0820693 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Lasted as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 54375 Route 25 3b.Policy Number of Entity Listed in Box I Southold, NY 11971 82668-00 3c.Policy Effective Period 10/17/2018 to 1/7/2026 4. Policy provides the following benefits: ❑X A.Both disability and Paid Family Leave benefits. ❑ B.Disability benefits only. ❑ C.Paid Family Leave benefits only. 5. Policy covers: Q 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 descr d above. Date Signed 1/8/2025 By (Signature of insurance carrier's authori d representati a or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR—DBL/POLICY SERVICES IMPORTANT:lf 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 Box 4B,4C or 5B of Part 1 has 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. DB-120.1 (12-21) J�l �11111 III Jill