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HomeMy WebLinkAbout51900-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#: 51900 Date: 05/07/2025 Permission is hereby granted to: John T Gardner PO BOX 727 Cutchogue, NY 11935 To: install EV charger in accessory garage as applied for. Protection from vehicular impact must be installed. Premises Located at: 4115 Stillwater Ave, Cutchogue, NY 11935 SCTM# 137.4-9 Pursuant to application dated 03/28/2025 and approved by the Building Inspector. To expire on 05/07/2027. Contractors: Required Inspections: Fees: EV Charger $125.00 ELECTRIC -Residential $100.00 CO-RESIDENTIAL $100.00 Total $325.00 Building Inspector � TOWN OF SOUTHOLD—BUILDING DEPARTMENT � a4 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631) 765-9502 I ttns://www.sioutii,o,.Idtowiiiiv.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only MAR 2 8 2025 g PERMIT NO. � w Building Inspector- :. "A 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: March 17, 2025 OWNER(S)OF PROPERTY: Name: Erin Gardner SCTM#1000- Project Address: 4115 Stillwater Ave, Cutchogue, NY 11935 Phone#: 917-754-6065 Email: erin.gardner@astrazenca.com Mailing Address: 4115 Stillwater Ave, Cutchogue, NY 11935 CONTACT PERSON: Name. Absolute Electrical Contracting and Des ign n Mailing Address: 1200 Shames Dr, Unit A, Westbury, NY 115901 Phone#: 516-586-3050 Email: information@absolutec-d.com DESIGN PROFESSIONAL INFORMATION: Name: Absolute Electrical Contracting and Design Mailing Address: 1200 Shames Dr, Unit A, Westbury, NY 115901 Phone#: 516-586-3050 Email: information@absolutec-d.com CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email: DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition MAlteration ❑Repair ❑Demolition Estimated Cost of Project: Mother Char a oint EV Char er installation and 300a OH se $7. 325.00 Will the lot be re-graded? ❑Yes 9 No Will excess fill be removed from premises? ❑Yes ❑■No i PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes IENo IF YES,PROVIDE A COPY. 0 Check Box After Reacting: The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffbk 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 220.45 of the New York State Penal Law. Dominic Chizzoniti Application Submitted 13 (print name): NAuthorized Agent ❑Owner Signature of Applicant: Date: 3/17/2024 STATE OF NEW YORK) SS: COUNTY OF Nassau ) Dominic Chizzoniti being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, Master Electrician (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 `^ 20oZ5 Notary Public Jillian Rose Brunner Notary Public,State of New Yor PROPERTY OWNER AUTHORIZATION Reg. Nei. 01BROO24633 Qualified in Nassau County Where the applicant is not the owner) Commission Expires May 13, 2C Erin Gardner residing at 4115 Stillwater Ave I Cutchogue Absolute Electrical Contracting and Design do hereby authorize, to apply on my behalf to the can of South, Building Department for approval as described herein. 3/18/2025 Owner's Signature Date Erin Gardner Print Owner's Name 2 off ' BUILDING DEPARTMENT-Electrical Inspector gar TOWN OF SOUTHOLD p' Town Hall Annex- 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 ° . Telephone (631) 765-1802 - FAX (631) 765-9502 � :�� aroesh southoldtownn . orseand southoldtownn . ov � , APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail Information Required) Date: 3/17/2025 Company Name: Absolute Electrical Contracting and Design Electrician's Name: Dominic Chizzoniti License No.: ME-62784 Elec. email:information@absolutec-d-com Elec. Phone No: 516-586-3050 01 request an email copy of Certificate of Compliance Elec. Address.: 1200 Shames Dr, Unit A, Westbury, NY 11590 ,JOB SITE INFORMATION (All Information Required) Name: Erin Gardner Address: 4115 Stillwater Ave, Cutchogue, NY 11935 Cross Street: NY-25 Phone No.: 917-754-6065 Bldg.Permit#: email: Tax Ma District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORD, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Chargepoint EV Charger installation and 300a OH service upgrade Square Footage: Circle All That App'Iy. Is job ready for inspection?: YES 0 NO _ Rough In 0 Final Do you need a Temp Certificate?: YES❑✓ NO Issued On Temp Information: (All information required) Service SizeF�1 Ph[-]3 Ph Size: A #Meters Old Meter# ❑New Service❑Fire Reconnect[]Flood Reconnect❑Service Reconnect❑Underground❑Overhead #Underground Laterals 1 2 0 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION w.� � �EAE le 7-1 FLOOD zq%r Ur Z ~' r'1 bd �, � r uNo " }" a N N1.0 � 6 o IS.cc tr) � C N m ZEti CL IQ vn. b +� �co 2 , co Z M ! 4 a O Li M �}�• r �w✓ Suffolk County Dept of Labor,Licensing&Consumer Affairs MASTER ELECTRICAL LICENSE Name DOMINIC CHIZZONITI Business Name ABSOLUTE ELECTRICAL This certifies that the CONTRACTING&DESIGN LLC bearer is duty licensed — by the Cowry of suff k License Number ME-62784 Issued: 01/21/2020 Commissioner Expires. 01/01/2026 This license is the property of Suffolk County Department of Labor,Ucensing&Consumer Affairs. Posmsion of fiats Icanse does not guarantee its validity. Additional Swinesa Name License Category AC4ORa CERTIFICATE OF LIABILITY INSURANCE DATEDIYYYY) 05/10/2/10/2024 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 pollcy(le-s)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 ri hts to the certificate holder in lieu of such endomsement(s). CT PRODUCER Nl1ME:. Camille M.Rizzo C.Quick Insurance Agency,Inc. rPH' E (845)497-1119 7012 A 402 Main Street ADDRESS,. CamilleR@cquickinsurance.com INSURMS1 AFFORDING COVERAGE NAIC# Port Jefferson NY 11777 INSURERA. Hartford Underwriters Insurance Company 30104 INSURED INSURER S: Hartford Insurance Company of Illinois 38288 Absolute Electrical Contracting and Design LLC INSURER C: Hartford Casualty Insurance Company 29424 1200 Shames Dr Unit A INSURERD: INSURER E: Westbury NY 11590 INSURER F s COVERAGES CERTIFICATE NUMBER: CI.24590643,9 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 MAYBE 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. LTR TYPE OF INSURANCE POLICY NUMBER Itmanna LIMITS COMMERCIAL GENERAL LIABILITY EACHOCOURRENCE $ 1,000,000 CLAIMS-MADE Fx—] PRIP,I OCCUR so=nlance $ 1 000,000 MEDEXP An one neon) S 10,000 A Y 16SBABK7EYY 09/01/2024 09/01/2025 PERSONAL&ADV INJURY $ 1,000,000 GELAG�G'REGATE UMITAPPUES PER: GENERAL AGGREGATE $, 2,000„p00 N' ❑/ PRO- ❑ PRODUCTS- $ 2,000,000 POLICY X JECT Loc OTHER:' AUTOMOBILE LIABILITY G a dsY�t I $ 1,000,000 ,.,... X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED �- TOS AUTOS ONLY AUTOS ONLY E E Y 16UECGE7260 O5/09/2024 OS/09/2025 BODILY INJURY(Per $ ED NON-OWNED PRO $ UMBRELLALlAB OCCUR EACH OCCURRENCE ,$ 3,000,000 A EXCESS LIAR CIAIMS•MADE Y 16SBABK7EYY 09/01/2024 09/01/2025 AGGREGATE $ 3,000,000 DEO I X RETENTION S 10,000 WORKERS COMPENSATION PER OR AN PROPRIETORER(MEMBER Exc ILITY Y/N C ANYPROPRIETRS La LUDERo EC IVE E.L FACHAGC9['.I T $ 500,000 (Ma, NIA 16WBCBF4EF0 05/0912024 05l09l2025 500,000 AND 1ldatorylnNH) ELDISEASE-EA EMPLOYEE $ 11 yes,describe under 500 000 DESCRIPTtONOOF OPERATIONS t El.DI'SEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addrdonal Remarks Schedule,maybe attached rr more space Is required) XXXX is an Additional Insured,if required by written contract,on a primary and non-contributory basis,including Waiver of Subrogation,per the attached SL3024 101 S.SL3036 1018,SL0000 1018,HA 9917 1221 and S00002 1018 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 AUTHORIZED REPRESENTATIVE PO Box 1179 Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers' CERTIFICATE OF NEW Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE TA E Board 1 a. Legal Name&Address of Insured(Use street address only) 1 b.Business Telephone Number of Insured Absolute Electrical Contracting and Design LLC 516-586-3050 Work Location of Insured(Only required if coverage is specifically limited to 1 c.NYS Unemployment Insurance Employer Registration Number of Insured certain locations in New York State,i.e a Wrap-Up Policy) 1 d.Federal Employer Identification Number of Insured or Social Security Number 461609385 2.Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold 3b.Policy Number of entity listed in box"1 a": 53095 Route 25 PO BOX 1179 3c. Policy effective period: Southold,NY 11971 05/09/2024 to 05/09/2025 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"Y insures the business referenced above in box"la"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 carver 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 insuE2g has the coverage as depicted on this fo . Approved by: Jason Quick (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 3/24/2025 (Signature) (Date) Title: Authorized Signature Telephone Number of authorized representative or licensed agent of insurance carrier.845-497-1119 Please Note:Only insurance carvers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov "NEW workers' O CERTIFICATE OF INSURANCE COVERAGE � 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ABSOLUTE ELECTRICAL CONTRACTING&DESIGNS,LLC 1200 SHAMES DR, UNIT A WESTBURY,NY 11590 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) 461609385 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southhold 53095 Route 25 3b.Policy Number of Entity Listed in Box"1 a" PO BOX 1179 DBL576825 Southhold, NY 11971 3c.Policy effective period 01/01/2025 to 12/31/2025 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: © A.All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Law. ❑ B.Only the following class or classes of employers employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent Of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 3/24/2025 By 14=trz�x— (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 46,4C 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 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 issue this form. ry D13-120.1 (12-21) 11111 N Ij III