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HomeMy WebLinkAbout51244-Z ho�aof souryO!° Town of Southold * P.O. Box 1179 ,0 53095 Main Rd UNTCN� Southold, New York 11971 CERTIFICATE OF OCCUPANCY No: 45834 Date: 12/15/2024 THIS CERTIFIES that the building HVAC Location of Property: 455 Knapp PI Greenport, NY 11944 Sec/Block/Lot: 34.-2-14 Conforms substantially to the Application for Building Permit heretofore, filed in this office dated: 08/15/2024 Pursuant to which Building Permit No. 51244 and dated: 10/04/2024 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: HVAC Mini-Split to existing single family dwelling as applied for. The certificate is issued to: Brigitte Amiri David Mendelsohn Of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL: ELECTRICAL CERTIFICATE: 51244 12/02/2024 PLUMBERS CERTIFICATION: ut riUedignature j oFsa�T 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#: 51244 Date: 10/04/2024 Permission is hereby granted to: Brigitte Amiri 410 2nd St#1 Brooklyn, NY 11215 To: construct alterations(oil to electric conversion)to existing single-family dwelling as applied fo r. Premises Located at: 455 Knapp PI, Greenport, NY 11944 SCTM#34.-2-14 Pursuant to application dated 08/15/2024 and approved by the Building Inspector. To expire on 10/05/2026. Contractors: Required Inspections: ELECTRICAL-ROUGH, PLUMBING, ELECTRICAL-FINAL, FINAL, Fees: Single Family Dwelling- Alteration $250.00 CO-RESIDENTIAL $100.00 Total S350.00 Building Inspector OF SOUr��l � o Town Hall Annex Telephone(631)765-1802 54375 Main Road CAP.O.Box 1179 Q Southold,NY 11971-0959 Jamesh -southoldtownny.gov OUNTY, BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Dave Mendelsohn Address: 455 Knapp Place city:Greenport st: New York zip: 11944 Building Permit#: 51244 Section: 34 Block: 2 Lot: 14 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: Alan Hubbard Electrical Electrician: Alan Hubbard License No: 4285-ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transfer Switch UC Lights Dryer Recpt Emergency Strobe Heat Detectors Disconnect Switches 4'LED Exit Fixtures Sump Pump Other Equipment: 1 blower head, 1 condenser Notes: HVAC MINI SPLIT Inspector Signature: 103V, , Date: December 2, 2024 455 knapp place �o�aOE SOUIyo� L 1 y J 71 jAe— '* * TOWN OF SOUTHOLD BUILDING DEPT coutm, 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: G DATE a INSPECTOR OF S0(/l�O� # TOWN OF.SOUTHOLD BUILDING DEPT. o►��a� 631-765-1802 INSPECTION [ ] FOUNDATION 1 ST/ REBAR [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ �FINAL LATION/CAULKING FRAMING /STRAPPING [ .] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT CONSTRUCTION [= ] FIRE-RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O [ ] RENTAL REMARKS: DATE INSPECTOR TELD INSPECTION REPORT DATE COMMENTS to FOUNDATION (1ST) ---- .� -------------------------------- FOUNDATION (2ND) WJ z o U1 ROUGH FRAMING& a PLUMBING . I � r INSULATION PER N.Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS 10 - a k r� � 2 — 0 - 2 rn � r a b O z ---- x d r� b tsa 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 https://www.southoldtownny.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only �,� PERMIT NO. Inspector: . . ` old; Applications and rety.In�qmOfebp of n`9",baccepted.I W ibre t e A -.-,n6tt6,,- �Opji�ptlpp&will V.e ,. 5owner,an ,!��r,s A066 1) completed e:�ia 46i Date:July 26, 2024 OVpNER(S)OF PROPERTY V Name David Mendelsohn & Brigitte Amiri T,SCTM-11# 1,000-034-02-014-111-11.11-11-11---.-l-l -I.-IlI Project Address:455 Knapp Pt Greenport,NY 11944 Phone 91117-74 1-5795 Email:davemendelsohn@yaho o.com Address:410 2nd Street,, P J, Brooklyn, NY 11215 CONTACT CT PERSON:,,,,.%, Name:David Mendelsohn --——------ Mailing Address:410 2nd Street, Apt. 1, Brooklvn, NY 11215 wuLL Phone#:917-741-5795 J Email:davemendelsohT1@yqNq,-C;On1 OFE' S S k-INFORMAT DESIGN�,Pk IONv- Name: ............ Mailing Address: Phone#: CONTRACTOR INFORMATION Name:Kolb Heating & Coolinq Mailing Address: 11500 Old Sound Ave,--PO,BOX 106, Mattituck,-NY 11952 —---------- Phone#:631-298-5527 EmallwJzurawski@kolbmechanical.com &-kolbmechanical.com : f- PCISEDCONSTRU&1614-�,'�,DESCRIPTION. El New Structure ElAddition ElAlteration EIRepair ElDemolition Estimated Cost of Project: El Other HVAC:replace oil furnace and oil tank with new electric heat pump.Insulate existing ducts $12,750 Will the lot be re-graded? E]Yes ®No Will excess fill be removed from premises? E]Yes ®No F. PROPERTY INFORMATION Existing use of property: 1 fam. residence Intended use of property:1 fam. residence (no change) Zone or use district in which premises is situated: Are there 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/designiprofessional is responsible for all drainage andstorm water issues as provided by , Chapter 236 of the Town Code ;APPLICATION IS HEREBY MADE to the.Building.Department for the jssuance of a Building Permit pursuant to the BuiIdmg Zone Qrdlnance of,the Town of Southold,Suffolk County,New York and other applicable Laws;Ordinances or Regulations,for;, a construction of buildings, ' '. additions,,alterations orfor removal or demolition:asherein--:described The applicant,agrees to comply with,all applicable laws;ordinances;building code,. "housing code.and reguiations and Yo admit authorised inspectors on.premises and in buiiding(s)for necessary inspections.false statements made herein are. `punishable as a Class A misdemeanor pursuant to Section 210.45 ofthe New York State Renal Law: Application Submitted By(print name):David Mendelsohn ❑Authorized Agent BOwner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF 14-%04S ) v►G C1ee,�sol�+n 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 D day of CS 20 Z O� y�N,A VP Notary lic o ,o PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) �i/ZtSfrI021,``��� 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 6 (S p Town Hall Annex �4.;1 i. Telephone(631)765-1802 54375 Main Road � � ,ax(631)7,65-gg5pp22 P.O.Box 1179 Gr @ rogenrichert .T0 n.soufg5o .ny.us Southold,NY 11971-0959 I• BUILDING DEPARTMENT TOWN OF SOUTHOLD !� APPLICATION FOR ELECTRICAL INSPECTION I REQUESTED BY: ' . / , � �v.�6���7. Date: � 20 2y i p Y l a,A 14 u��i- i REQUESTED an Name: Name: /I License No.: Address: v �'U D� 2 g 31 i . Phone No.: Co31 "� 1 -7/< 1 . JOBSITE INFORMATION: (*Indicates required information) *Name: *Address: L/5-15 dL tQ-C-o— *Cross Street: _5�1 02w L;-�C— *Phone No.: 17 _/9 7 l Permit No.: '� Tax Map District: 9000 Section: Block: Lot: _ ' *BRIEF DESCRIPTION OF WORK(Please Print Clearly) �y 1 (Please Circle All That Apply) *Is job ready for inspection: YES/ NO. Rough In Final *Do-you need a Temp Certificate: YES Temp Information(If needed) i *Service Size: 1 Phase 3Phase 100 150 200 300 350 . 400 Other I . f *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION .82=Request for Inspection Form C 4: `o�� ryol Town Hall Annexf l� Telephone(631)765-1802 �> 54375 Main Road cn� axW{637 OP.O.Box 1179 roger.richert nS0uggo1 .nV.us Southold,NY 11971-0959 Q �O IoOUa�� BUILDING DEPARTMENT TOWN OF SOUTHOLD i APPLICATION FOR ELECTRICAL INSPECTION I REQUESTED BY: /tq Ij A-P-D, Date: 0 20 2�I Company Name: A(CLA Name: C A 1�)to a�d License No.: S —.A-�e Address: Phone No.: &3 ( &_ ' 771 ! JOBSITE INFORMATION: (*Indicates required information) � i *Name: c VAC kA eA SOhn *Address: L j s 5- CQ *Cross Street: 5- E9 c— *Phone No.: c1 `-] '7 9 t — 157 7 cl E Permit No.: Tax-Map District: - 1000 Section:_ Block: Lot: *BRIEF DESCRIPTION OF WORK(Please Print Clearly) _ C f (Please Circle All That ply) j Is job ready for inspection: YES/ NO. Rough In Final *Do.you need a Temp Certificate: YES 00 I Temp Information (if needed) � *Service Size: 1 Phase 3Phase 100 150 200 300 350 . 400 Other I . *New Service: Re-conned Underground Number of Meters Change at Service Overhead . i Additional Information: PAYMENT DUE WITH APPLICATION i . -z1 .82=Request for Inspection Form PERMIT# Address:. Switches Outlets GFI's Surface v Sconces H H's UC Lts Fridge HW POOL Fans Mini Fr. WAD Panel Pump Exhaust Oven Sump Heater Trnsfmr Smokes DW Generator Salt Gen. Carbon Micro GrbDis Water Bond Lights Heat Pucks ERV Inst Hot DeHum Transfer HOT TUB/SPA Disc Combo Cooktop Minisplit Blower AC AH Hood Blower Service Amps Have Used Sub Amps Have Used Comments August 8, 2024 From: �+ 410 2nd Street, Apt. 1 0?4 AUG � 5 � Brooklyn, NY 11215 Bullding Department Town Of Southold To: Town of Southold - Building Department Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, RAY 11971-0959 To whom it may concern: Attached, please find the application for permit at 455 Knapp Place, Greenport. The woman I spoke with at the Building Department on 7/26/24 confirmed that for the scope of this project, this application and product brochure should be all that is needed, not a set of mechanical drawings. If this is incorrect, please let me know, and I'll hire an architect or engineer to do drawings. Kolb Mechanical, the contractor, notes that their Suffolk County License#is HI -66177, and it expires 05/01/2026. Their proof of insurance is included among the documents. The related electrical scope will be filed separately by the electrician. �Thank you, David Mendelsohn Owner, 455 Knapp Place, Greenport 917-741-5795 WSS Y—v)a 0 CT 1 0 2024 �1-j �1�\• Sit j t Luilding Department l'ovvn of Southold -09<Tl '4ec-�ZA 4'T �e�'n`1 `t�- S I'LLl`1, - ' F �k- SURVEY of PROPERTY P/O LOT54S&46 Map Of A.I1� `�itrtl vcY, IN, .7 ' SIXTY LOTS OF LAND BELONGING TO JOHN G.CHAMPLW Map Afm 337-Filed:ac-s3-i873 SITUATE �lD s-ath'Street GREENPORT,TOWN OF SOUTHOLD Efadeaharet,New York SUFFOLKCOUNTY,NEWYORK NJ9Deliae6mjolaadamvey,Cum - essi-os�-24ao Fesi-22e-z�on Suffolk Tax Map NO.:1000-034-02-014 iuA+eYCDenu i0B N0.535.8'i6 DATE SURYEYED:u13o1=5 DPAWNNYAG SCALE:x"=2a+ �;,t•IU Nj:' JC!:0,44S PARTP!F..•?S & PAVTELIS')Wk�GGLOU N73'45'35"E 50,220-UQ N74?3Wj0'E 50.00(OEM) UEDx Q)tOGLLY W NNE YWpp I4 E N O O CL ac' �•}N O rn r 'r• � 1'+t 5 C n A `n prax eeo �, v (i 10.4 PROPOSED 0 D LOCATION OF 1 OUTDOOR UNIT M - V• u rC•+ r,7 ri1 ({{ o 14.2 P V. 444.81 ,o,,m a S71P51,'44"W 52.16(�W ST 040V 50A0(0EE0) LOT AREA K N A P P PLACEF OF NEW 8,276.34' S.F �(�fr GUARANlEEDTO: BRfWTTEAfrRRlROA OMEIVDELSONN SPANOABSTRACT5ERWCECORA TWHO.SP34o3PS REVSS`4:...uPG41E^.+. CTTleA+vl;N.A. A=hs WESTCOR LAND TRiEJNSNRANCECOMPANY T aiTa DEscrswnoa: D•050 CNFrKMBF 1.50S�R�. (I) L1N-: l ll'IWD W b \(P fx8.9D Y I ,)„N.4 tKrl®Y.) •}�y/G 9': �-1PN 00,(tJ 196.E9LLttAgY p?-a Y O 8'S! XPF`.uSt.m! pIDt.R �� 1. 1)'1'K RVtI'.L�Ti S,RC W•DfI W+, �JttAtt(Plncit ]Y�'n\ T.IfISF�Tf)(TPP`Sft1TPt :l K�fatMrB.!0.:1. NYJ RID+V f R a�g!m 1"f;utowc' D iN?P]2YED1'm fM-0.6VHbR4 MST fF M+C X C(31 l.\'vA'1 f t v..N)p 1 d�:f:.Tt Y!� L.•r,. :,SnPM.tU •:1 PT..,l:h,!• r p r.,.: W 4 4.•.S-n•Artxta•rt D�clpslxa,n VG rF emr?W m.1 iR+...,P R i 'u' KOLBMEC-01 VGEORGE ACORO" DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 8/1/2024 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 CONTACT Neefus Ave.Agency (A//CC"N Exq:(631)722-3500 Aic,No):(631)722-3591 711 Unionon Av Aquebogue,NY 11931 E-f DAIE .info@nsainsure.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ohio Security Insurance Co 24082 INSURED INSURER B:Ohio Casualty 24074 Kolb Mechanical Corp and Kolb Service Corp INSURER C:Utica National Ins Co of Texas 43478 11500 Sound Ave Box 106 INSURER D: Mattituck,NY 11952 INSURER E 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 CONTRACTOR 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 INSURANCE AIDDp UB WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEOCCUR SE X BKS58512966 511/2024 511/2025 DAMAGE TORENTE occurrence) $ 100,000 X Contractual Liabilit MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X]YER& LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CO M(EaMINGLE LIMIT $ 1,000,000 X ANY AUTO BAS58512966 6/1/2024 5/1/2025 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-AWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accdent $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE US058512966 511/2024 511/2025 AGGREGATE $ DED I X I RETENTION$ 10,006 $ 1,000,000 C WORKERS COMPENSATION X PERTUT, OTH- AND EMPLOYERS'LIABILITY 5641120 5/112024 5/1/2025 1,000,000 OFFICER''rM ER EXCLUDED?ECUTIVE Y� N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1 00D,00� DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101 Additional Remarks Schedule,may be attached If more space Is required) David Mendelsohn and Brigitte Amid are included as Additional Insured with respect to general liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE David Mendelsohn and Brigitte Amiri THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 455 Knapp Place Greenport,NY 11944 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD rTATI workers' CERTIFICATE OF INSURANCE. COVERAGE srAre� 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 Carrie 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured KOLB MECHANICAL CORP 631-298-5527 ATTN:SHARON TUTHILL-FOHRKOLB PO BOX 106 MATTITUCK,NY 11952 1c.Federal Employer Identification Number of Insured or Social Security Number Work.Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e,,Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carver (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company David Mendelsohn and Brigitte Amid 3b.Policy Number of Entity Listed in Box"Ila" 455 Knapp Place DBL286735 Greenport, NY 11944 3c.Policy effective.period 11/01/2023 to 10/31/2025 4. Policy provides the following benefits: © 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 pequry,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. 8/7/2024 Date Signed By /15:4.:32292! (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 Welsh,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 6200, Binghamton, NY 13902-5200. PART 2.To.be completed by the NYS Workers'Compensation Board(only if sox 46,4C 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 I (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) IIIIIIIIIIIIIIIIIIIIIIoIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII r 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 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. 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. DB-120.1 (12-21)Reverse dad APP VED AS NOTED DATE• B.P.# 5 a� FEE�BY: NOTIFY BUILDING DEPARTMENT AT 631-765-1802 8AM TO 4PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION-TWO 11FOUIRIED FOR POURED CONGRE(E 2. ROUGH-FRAMING&PLUMBING 3. INSULATION 4 FINAL-CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTON ERRORS COMPLY WITH ALL CODES OF NEW YORK STATE&TOWN CODES AS REQUIRED AND CONDITIONS OF SOUTH LD TOWN ZBA SO LD TOWN PLANNING BOARD SO OLD TOWN TRUSTeES N,Y ,DEC SO OLD HPC S HD OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICAT OF OCCUPANCY ELECTRICAL INSPECTION REQUIRED SVZ-KP36NA 36,000 :TU/H MULTI-POSITION AIR HANDLER 111 OUTDOOR UNIT Job Name: System Reference: Date: Indoor Unit..............................................................................SVZ-KP36NA Outdoor Unit....................................................................SUZ-KA36NAHZ a ,ii tdUlHll1 out�lh � r Jffla m, B rI IN RE INDOOR UNIT FEATURES • Ducted air handler provides a solution to cool and heat large zones • Highly efficient totally enclosed ECM motor • Selectable external static pressure:0.30,0.50 and 0.80 in.WG with 3 fan speeds at each static setting • 1 inch R4.2 fiberglass free insulation reduces condensation and boosts efficiency • Positive pressure cabinet with air leakage of less than 2.0%at 1.0 In.WG(Tested perASHRAE Standard 193) • Unique blow through design allows simple coil cleaning when the blower is removed • Multi-position installation:horizontal(left or right),vertical(up or down) • Optional electric heat kit for additional heat capacity • Optional humidifier control and ERV control • Built-in humidifier control,ERV control and auxiliary heat control • Optional downflow kit • Multiple control options available: o kumo cloud®smart device app for remote access o Third-party interface options o Wired or wireless controllers OUTDOOR UNIT FEATURES • The outdoor unit powers the indoor unit,and should a power outage occur,the system is automatically restarted when power returns • INVERTER-driven compressor and LEV provide high efficiency and comfort while using only the energy needed to maintain maximum performance • Hyper-heating performance offers 100%heating capacity at 5'F • Hot-Start Technology:no cold air rush at equipment startup or when restarting after Defrost Cycle • Quiet operation • Built-in base pan heater • Innovative Joint Lap DC Motor leads to high efficiency and reliability • Pulse Amplitude Modulation technology Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. Maximum Capacity BTU/H 36,000 Rated Capacity BTU/H 36,000 Minimum Capacity BTU/H 14,200 Cooling at 95°F' Maximum Power Input W 3.760 Rated Power Input W 3,760 Moisture Removal Pints/h 8.4 Sensible Heat Factor 0.74 Power Factor[208V/230V] % 97.0/97.0 Maximum Capacity BTU/H 40,000 Rated Capacity BTU/H 37,000 Heating at 47°F2 Minimum Capacity BTU/H 13,800 Maximum Power Input W 4,160 Rated Power Input W 3,280 Power Factor[208V 1230V] % 98.0/98.0 Maximum Capacity _ BTU/H 37,000 Heating at 17°F' Rated Capacity BTU/H 32,800 Maximum Power Input W 5,800 Rated Power Input W 4.230 Heating at 5°F° Maximum Capacity BTU/H 37,000 Maximum Power Input _ W 6,590 Heating at-1 WF Maximum Capacity BTU/H 29,600 SEER]SEER2 16.01 16.0 EER']EER2' 9.519.5 HSPF[IV]1 HSPF2[IV] 9.019.0 Efficiency COP at 47°F' 3.3 COP at 17°F at Maximum Capacity' 1.8 COP at 5°F at Maximum Capacity° 1.6 ENERGY STAR®Certified No j Voltage,Phase,Frequency 208/230,1,60 li Guaranteed Voltage Range VAC 187-253 Voltage:Indoor-Outdoor,S1-S2 VAC 208/230 Electrical Voltage:Indoor-Outdoor,S2-S3 V DC 24 Short-circuit Current Rating[SCCR] kA 5 Recommended Fuse/Breaker Size(Oudoor) A 35 Recommended Wire Size[Indoor-Outdoor] AWG 14 Power Supply Indoor unit is powered by the outdoor unit MCA A 4.13 Fan Motor Full Load Amperage A 3.3 Fan Motor Type DC Motor Airflow Rate at Cooling,Dry CFM 767-910-910 Airflow Rate at Heating,Dry CFM 767-910-910 Sound Pressure Level[Cooling] dB[A] 35-40-42 Sound Pressure Level[Heating] dB[A] 35-40-42 Indoor Unit External Static Pressure in.WG 0.30-0.5-0.8 Drain Pipe Size In.[mm] 3/4[19.051 Coating on Heat Exchanger — External Finish Color Hot-dip coated steel(ZAM) Unit Dimensions W x D x H:In.(mm] 21 x 21-5/8 x 43-3/4[533 x 549 x 1,1111 Package Dimensions W x D x H:In.[mm] 21 x 283/4 x 483/8 1558 x 730 x 1,2281 Unit Weight Lbs.[kg] 119[54] Package Weight Lbs.[kg] 141(64] Indoor Unit Operating Temperature Cooling Intake Air Temp[Maximum/Minimum]` -F 90 DB,72 WB/68 DB,61 WB Range Heating Intake Air Temp[Maximum/Minimum] °F 77 DB!59 DB NOTES: AHRI Rated Conditions 'Cooling(Indoor/!Outdoor) °F 80 DB,67 WB//95 DB,75 WB (Rated data is determined at a fixed compressor speed) 'Heating at 470F(Indoor U Outdoor) OF 70 DB,60 WB 1147 DB,43 WB 'Heating at 170F(Indoor//Outdoor) °F 70 DB,60 WB!I 17 DB,15 WB Conditions °Heating at 5°F(Indoor p Outdoor) -F 70 DB,60 WB!/5 DB,4 WB 'Heating at-13°F(indoor//Outdoor) °F 70 DB,60 NB//-13 DB,-14 WB 'Indoor/Outdoor Unit Operating Temperature Range(Cooling Air Temp[Maximum/Minimum]): •Applications should be restricted to comfort cooling only;equipment cooling applications are not recommended for low ambient temperature conditions. "Outdoor Unit Operating Temperature Range(Cooling Thermal Lock-out!Re-start Temperatures;Heating Thermal Lock-out/Re-start Temperatures): •System cuts out in heating mode to avoid lhermistor error and automatically restarts at these temperatures. Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. MCA A 26.0 MOCP A 42 Fan Motor Output W 74 Airflow Rate[Cooling/Heating] CFM 590/680 Refrigerant Control LEV Defrost Method Reverse Cycle Sound Pressure Level,Cooling' dB(A) 52 Sound Pressure Level,Heating' dB(A) 53 Compressor Type Scroll Outdoor Unit Compressor Model ANB33FJMMT Compressor Rated Load Amps A 18 Compressor Locked Rotor Amps A 27.5 Compressor Oil[Type/1 Charge] oz. FV50S H 1.4,47 External Finish Color Ivory Munsell 3Y 7.811.1 Base Pan Heater Built-in Unit Dimensions W x D x H:In.[mm] 41-5116 x 14-3/16 x 52-11/16[1050 x 360 x 1338] Package Dimensions W x D x H:In.[mm] 43 x 18 x 57[1110 x 480 x 14401 Unit Weight Lbs.[kg] 261[118] T Package Weight _T Lbs.[kg] 285[1291 Cooling Air Temp[Maximum/Minimum]*- F 115 DB if 0 DB Outdoor Unit Operating Temperature Range Heating Air Temp[Maximum/Minimum] °F 75 DB,65 WB/-13 DB,-14 WB Heating Thermal Lockout/Re-start Temperatures- °F -221-13 Type R410A Refrigerant Maximum Charge Quantity Lbs,oz 11.0,7.0 Initial Charge Quantity Ft.[ml 100.0[30.0] Additional Refrigerant Charge PerAdditional Piping Length oz./Ft.[g/m] 0101 Gas Pipe Size O.D.[Flared] In.(mm] 5/8[15.88] Liquid Pipe Size O.D.[Flared] In.[mm] 3/8[9.52] Piping Maximum Piping Length Ft.[m] 245[75] Maximum Height Difference Ft.[m] 100[30] Maximum Number of Bends 15 NOTES: AHRI Rated Conditions 'Cooling(Indoor//Outdoor) °F 80 DB,67 WB 1195 DB,75 WB (Rated data is determined at a fixed compressor speed) =Heating at 47'F(Indoor//Outdoor) °F 70 DB,60 WB//47 DB,43 WB 'Heating at 17°F(Indoor!/Outdoor) •F 70 DB,60 WB//17 DB,15 WB Conditions 'Heating at 5°F(Indoor//Outdoor) °F 70 DB,60 WB//5 DB,4 WB rHeating at-13'F(Indoor//Outdoor) °F 70 DB,60 WB//-13 DB,-14 WB `Indoor/Outdoor Unit Operating Temperature Range(Cooling Air Temp[Maximum/Minimum]): •Applications should be restricted to comfort cooling only;equipment cooling applications are not recommended for low ambient temperature conditions. "Outdoor Unit Operating Temperature Range(Coaling Thermal Lockout/Re-start Temperatures;Heating Thermal Lockout/Re-start Temperatures); System cuts out in heating mode to avoid thennistor error and automatically restarts at these temperatures. Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. INDOOR UNIT ACCESSORIES: Airzone ZBS Wired Blueface Principal Controller White AZZBSBLUEFACECB Airzone ZBS Wired Blueface Principal Controller White AZZBSBLUEZEROCB Airzone ZBS Wired Lite Controller White AZZBSLITECB Airzone ZBS Wireless Lite Controller White AZZBSLITERB Airzone ZBS Wireless Think Controller White AZZBSTHINKRB BACnet°and Modbus"Interface PAC-UKPRC001-CN-1 Control Interface AY CN24 Relay Kit CN24REL -KIT-CM3 Connector cable for remote display _ PAC-SA88HA-EP IT Extender a PAC-WHS011E-E kumo station®for kumo cloud' PAC-WHS01 HC-E Remote Operation Adapter PAC-SF40RM-E Thermostat Interface PAC-US445CN-1 USNAP Adapter PAC-WHS01 UP-E Wireless Interface for kumo cloud® PAC-USWHS002-WF-2 Flush Mount Remote Temperature Sensor_ _ PAC-USSEN002-FM-1 Remote Sensor Flush Mount Temperature Sensor -- PAC-USSEN001-FM-1 Remote Temperature Sensor PAC-SE41TS-E Wireless temperature and humility sensor for kumo cloud% PAC-USWHS003-TH-1 Deluxe Wired MA Remote Controller* PAR-40MAAU Wired Remote Controller Simple MA Remote Controllers PAC-YT53CRAUJ Touch MA Controller* PAR-CT01_M_AU-SB ------------------------- ----- ------------------ kumo touch"RedLINK"Wireless Controller MHK2 Wireless Remote Controller Wireless MA Receiver PAR-FA32MA-W Wireless MA Remote Controller PAR-FL32MA-E Blue Diamond(Advanced)Mini Condensate Pump w/Reservoir&Sensor(208/230V)[recommended] X87-721 Condensate. Blue Diamond(MegaBlue Advanced)Condensate Pump w/Reservoir&Sensor X87-835 Blue Diamond Sensor Extension Cable—15 R. C13-103 Refco Condensate Pump(100-240 VAC)up to 120,000 BTU/H COMBI Control Wire 20/2PR,1 PR shielded+1 PR plenum wire for Airzone,100 ft reel CW2042S2-100 20/2PR,shielded+1 PR plenum wife for Airzone,500 ft reel CW2042S2-500 Disconnect Switch (30A/600V/UL)[fits 2"X 4"utility box]-Black TAZ-MS303 (30A/600V/UL)[fits 2"X 4"utility box]-White TAZ-MS303W Downflow Kit Downflow Kit DFK-M Electric Heat Lockout Electric Heat Lockout ETC 211020-MIT 10kW Electric Heater EHIOSVZ-M Electric Kit Heats 5kW Electric Heater EH05SVZ-M 8kW Electric Heater EH08SVZ-M 10'x 3/8"x 10'x 5/8"Lineset(Twin-Tube Insulation) MPLS385812T-10 100'x 3/8"x 100'x 5/8'Lineset(Twin-Tube Insulation) MPLS385812T-100 Lineset 16 x 318"x 15'x 5/8"Lineset(Twin-Tube Insulation) MPLS385812T-15 30'x 318"x 30'x 5/8""Lineset(Twin-Tube Insulation) MPL5385812TS0 50'x 318"x 50'x 5/8"Lineset(Twin-Tube Insulation) MPLS385812T50 65'x 3/8"x 65'x 5/8"Lineset(Twin-Tube Insulation) MPLS385812T-65 Terminal Block Separate Terminal Power Block, SPTB1 NOTES: =PAC-SF40RM-E(Unable to use with wireless remote controller) Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. OUTDOOR UNIT ACCESSORIES: Air Outlet Guide Air Outlet Guide(1 Piece) PAC-SH96SG-E(two pieces are required) Centralized Drain Pan Central Drain Pan PAC-SH97DP-E M-&P-Series Maintenance Tool Cable Set M21 EC0397 Control/Service Tool USB/UART Conversion Cable(Required for all laptop connection) M21 EC1397 Drain Socket Drain Socket PAC SH71DS-E Hail Guards Hail Guard HG-A2 14 Gauge,4 wire MiniSplit Cable-250 ft.roll S144-250 14 Gauge,4 wire MiniSplit Cable-50 ft,roll 5144 50 Mini-Split Wire 16 Gauge,4 wire MiniSplit Cable-250 ft.roll I S164-250 16 Gauge,4 wire MiniSplit Cable-50 ft.roll iS164S0 Mounting Pad Condensing Unit Mounting Pad:24"x 42"x 3' ULTRILITE2 16'Dual Fan Stand QSMS1802M Stand 24"Dual Fan Stand QSMS2402M Outdoor Unit Stand-12"High QSMS7202M Specifications are subject to change without notice. 0 2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. INDOOR UNIT DIMENSIONS: SVZ-KP36NA Tap Unit:mm(in.) view Note: Electrical entrance for SVZ located on both left and right side of the cabinet. m28 Knockout Hole see right or Left side view for knockout 026 Knockout Hole locations. for electrical heat wiring 2-04.6 Burring Holes for electricheat installation ( Refdgerant piping flare connedidn(gas) (DRefrigerant pipin Bare connection(quid) _ _ B(Duct) 28(1-3/161 (pdaryd 1 plpp 548 21-5/81 _ BEmergenc��mn 1 O 16(31 — ts.os(a/a}ara•Fppr Air inlet — a wew 116.8(4-5/8) 03l DUCT17/B1 P a y dra n pipe m e�mvnyy d � 19.05(3/4)3�4^FPT 43H /41 TO —(Hwimntal ten) 8(3/ Primary drain pipe 61(2-5/8) (Grav, drfn) b19.0((37a)374"FPT _ 8(3/81 43(1-314)_ (1-3116) 9613""" c- • • • Secondary drain plea • • • Secondary drain pipe (Ememeney drelning) 65.4 (Emergen4.dralrung) a19.05(3/4)3/4"FPT m m.05(3r4)314'FPT (H.rl—ma)Right) 026 Knockout Hole (indoor/Outdoor unit 026 Knockout Hole 55( -3/61 connection) (Indoor/Outdoor unit Primary drainplpe (Reole control er transmission) connection ravlttyy 14) (Remote connection) mntm of kansmisslon) 13La m19.05(374)3�4"FPT • • Control box FL (Remove Blower Panel) Oltom • • • Left side — QAir )nlet Rightside view A view Unit:mm(in.) Model Nominal Filter Size Duct Connection Bvlew SVZ-KP12NA - SVZ-KP18NA 508 x 406.4 x 25.4 376 x 402 SVZ-KP24NA (20 x 16 x 1) (14-13116 x 15-7/8) - SVZ-KP30NA 508 x 508 x 25.4 477 x 402 SVZ-KP36NA (20 x 20 x 1) (18-13/16 x 15-7/8) 36 11-I 21 Model A B C D E F G H J Gas Pipe Liquid pipe SVZ-KP12NA o 9.52 (3/8) a 6.35 SVZ-KP18NA 432 376 281 224 1,010.8 680 823 735.5 360 0 12 7(1/2) (1/4) SVZ-KP24NA (17) (14-13/16) (11-1/8) (8-7/8) (39-13/16) (26-13/16) (32-7/16) (29) (14-3/16) 015.88 o 9.52 SVZ-KP30NA 534 477 382.6 266.5 1,113.8 737 953.5 792 461 (5/8) (3/8) SVZ-KP36NA (21) (18-13/16) (15-1/8) (10-1/2) (43-7/8) (29-1/16) (37-9/16) (31-3/16) (18-3116) Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved. OUTDOOR UNIT DIMENSIONS: SUZ-KA36NAHZ Unit:mm<in> 10 a,9M14-[I�ff,4, 9 x � a� a r a a,929+R afAY'9L t9lEi Q SIILJI� o p N�a g a� z sa Er b s M1 s 101 r� N gig jI a9/�L, azEiy W C N s. oN .� � 'n g- 07 Y P ss Z a� �h > �9e ti Epp a1. o U H go Ul aS oJi y a 6 S; mM14-z.s .vin-t�a w o g s x 0 0 a �a 9,E2 a;1°vR uM1,.92 LLI 1340 Satellite Boulevard Suwanee,GA 30024 Toll Free:800-433-4822 www.mehvac.com CERTIFIED FORM#SVZ-KP36NA&SUZ-KA36NAHZ-202303 Intertek Specifications are subject to change without notice. ©2023 Mitsubishi Electric Trane HVAC US LLC.All rights reserved.