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HomeMy WebLinkAbout51902-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#: 51902 Date: 05/07/2025 Permission is hereby granted to: Paul Kesicki 1210 Ashamomaque Ave Southold, NY 11971 To: install EV charger on exterior wall of single-family dwelling as applied for. Protection from vehicular impact must be installed. Premises Located at: 1210 Arshamomaque Ave, Southold, NY 11971 SCTM#66.-2-28 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 S325.00 13ua ding Inspector 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 li,ttps://www.,,;outtioldtownn _ ov Date Received APPLICATION, FOR BUILDING PERMIT For Office Use Only E C E OWE IDI PERMIT NO. Building Inspector. --j-/ MAR 2 8 )rv� Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Building Department Owner's Authorization form(Page 2)shall be completed. Town of Southold Date:03/14/2025 OWNER(S)OF PROPERTY: Name:Paul Kesicki SUM#1000- Project Address:1210 Arshamomaque Ave, Southold, NY 11971 Phone#:631-492-0507 1Email:KESICKIPAUL@GMAIL.COM Mailing Address:1210 Arshamomaque Ave, Southold, NY 11971 CONTACT PERSON: Name:John Felbinger Mailing Address:20 Clark St East Rockaway, NY 11518 Phone#:516-887-4876 Email:jackjr@jffelectdc.com DESIGN PROFESSIONAL INFORMATION: Name:N/A Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:John Felbinger Mailing Address:20 Clark St East Rockaway, NY 11518 Phone#:516-887-+4876 Email:jackjr@jffelectdc.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: 0 Other EV Charging Station 3920 Will the lot be re-graded? ❑Yes IiiNo Will excess fill be removed from premises? ❑Yes RNo 1 I PROPERTY INFORMATION Existing use of property:Residential Intended use of property:Residential/Single Family Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes ❑No IF YES,PROVIDE A COPY. IN Checks BOX After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter er 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 210AS of the New York State Penal Law. Application Submitted By(p 'nt name):­50�1(\ �Q,��D:� � Authorized Agent ❑Owner Signature of Applicant: Date: 1 ( i( STATE OF NEW YORK) SS: COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing co 'tract)above named, (S)he is the C (\ (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 clay of !r 'at't�iyl 20 LKAX-t -1 A 91 Notary Public YNTHIA LABIA Notary Public,Slate OI Newu York No.OI LA6l 1011 OUalified in Nassau COuntyjAxlq— PROPERTY OWNER ��:AUTHORIZ ' IOC ommission xpiresA1 ust . (Where the applicant is not the owner) I, `cs.:n 1 1 1=S� residing at + ( -nof4� "Sc, A-A i V do hereby authorize - TC= to apply on my behalf o tcuvn of d old Building Department for approval as described herein. Own g er s Signature r e Date Print Owner's Name 2 pft ' BUILDING DEPARTMENT-Electrical Inspector xrd TOWN OF SOUTHOLD Town Hall Annex- 54375 Main Road - PO Box 1179 , . Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 $'$ jamesh@southoldtownny.gov— seand southoldtownrl . ov APPLICATION FOR ELECTRICAL INSPECT10N ELECTRICIAN INFORMATION (Ail Information Required) Date: 03/14/2025 Company Name: JFF Electric, Inc. Electrician's Name: John Felbinger License No.: ME49343 Elec. email:jack@jffelectric.com Elec. Phone No: 516-887-4876 [D I request an email copy of Certificate of Compliance Elec. Address.: 20 Clark Street, East Rockaway, NY 11518 .SOB SITE INFORMATION (All Information Required) Name: Paul Kesicki Address: 1210 Arshamomaque Ave, Southold, NY 11971 Cross Street: Phone No.: 631-492-0507 Bldg.Permit#: email: KESICKIPAUL@GMAIL.COM Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly). Install dedicated 100-amp 240v circuit for electric vehicle charging station protected by 100-amp circuit breaker&disconnect.Charger will be mounted on exterior wall of house. square Footage: 24w0 Circle All That Apply: Is job ready for inspection?: ElY€S Z✓ NO [—]Rough In Final Do you need a Temp Certificate?: YES R]NO Issued On Temp Information: (AII information required) Service Size❑1 Ph '3 Ph Size: A #Meters Old Meter# ❑New Service[]Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground averhead #Underground Laterals LJ 1 H Frame 0,Pole Work done on Service? Y N Additional Information: N/A PAYMENT DIRE WITH APPLICATION YNEw R Workers' CERTIFICATE OF 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 JFF Electric, Inc. 516-887-4876 20 Clark Street 1c.NYS Unemployment Insurance Employer Registration Number of East Rockaway, NY 11518 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 45-3353350 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold AmGuard Insurance Company 53095 NY-25 3b.Policy Number of Entity Listed in Box"I a" Southold, NY 11971 JFWC505069 3c.Policy effective period 04/16/2024 to 04/16/2025 3d.The Proprietor,Partners or Executive Officers are included.(Only check box if aN partnerstofficers 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"l 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 mast 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,)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: Jeffrey Greenfield (Print name of authorized representative or licensed agent of insurance carrier) Approved by: WM 41 3/14/2025 ( steers) V (Date) Tale: Managing Member p p g Telephone Number of authorized representative or licensed agent of insurance carrier 516-599-1100 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(947) www.wGb.ny.gov JFFELEC-01 N " CERTIFICATE OF LIABILITY INSURANCE DATE(Mililo "N) 3/1412025 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 endorsemen s. C PRODUCER C NGL Group LLC , i516 599 2968599-1100 a� Noiww516 1'12 Merrick Road Lynbrook,NY 11563 MA � 9 AFFOING CO _ R1 I ....n..RD COVERAGE ..... ..._. .. NAIL# INSURER A:Utica First Insurance Company—,—.—.. 15326 INSURED lNsuRER B AmGUARD Insurance CJI ._... 42390 ...., JFF Electric,Inc. INSURER C: u_.... ....... . __ � .. 20 Clark Street INSURER D:_ �6.._ .. _.� ....�.� .........,...... _ East Rockaway,NY 11518 ._ INSURER-. .............,. ........_�_. __.........m. ...,,.__ ... .�......... .... .................. _. INSURER F COVERAGES CERTII ICATE NIIMEE 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, _.............. ... m REDUCED BY PAID CLAIMS. EXCLUSIONS ANDCONDITIONS OF SUCH V"npoucY NUMBER �.. .... �IIIIII,IIIIO �A X aoMNeR...._...FN POLICIES. �IUBR LIMITS SHOWN MAY HAVE BEEN REPOLICY EFF POLICY EXP UNITS ITR mom INSR CULL GENERAL LUWUTY A _ _ d PE OF INSURANCE EACH OCCURRENCE CLAIMS-MADE X OCCUR ART3000192900 4/24/2024 4/24/2025 DAMAGE TO RENTED _^S m 100 000 a_ ....... 6 X 5,000 00 1,000,000 _ &ADV INJURY '..;........... ...._.....�._...PERSONAL_IT„m, 2,000,000 „BEN%AGGREGATE,LIMITAPPLIESPER. _GE RAL.AGGREGATE „1,.,.... .,. z,000,00 POLICY : .JE OT LOC PRODUCTS COMP/„OP AGG, S B AuroNoelL-LIABILITY, COMBINED SINGLE uMrr 1^^ 1,000,000 ANY AUTO JFAU592180 7/25/2024 7/25/2025 BODILY INJURY Per. rson , OWNED SCHEDULED AUTOS ONLY X AUTOS BODILYINJURYLPeracddent)'_5,,,,, H X.... NIIT N��p PROPERTY AMAGE X AUTOS ONLY A 0 L"W ,..(� _,_ ...5.. ... ....... UMBRELLA LIABH- -00—;Cl—U---- ON$ R EACH OCCURRENCEYe, $ _, �„ EXCESS LIAB S-MADE AGGREGATE . $ WORKERS COMPENSATION PER OT1-F AND EMPLOYERS'LUU31LI Y Y/N T 3T1 �R ANY PROPRIETO�RRIPARTNER/EXECUTWE ❑ N/A ,.E L EACH ACCIDENT OaFtlCE FNH)EXCLUDED? - ... 4UM' EL DISEASE EAFMPLQYE 5 yyeess,descnh under DESCRIPTION OF OPERATIONS below L.DISEASE POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Electrical Contractor Certificate holder is included as Additional Insureds CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southhold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 NY-25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Workers' CERTIFICATE OF INSURANCE COVERAGE STATE Con 1pensation Bolyd 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 onty) 1 b.Business Telephone Number of Insured JFF ELECTRIC, INC. 20 CLARK STREET 516-887-4876 EAST ROCKAWAY, NY 11518 Work Location of Insured(only required if coverage is specirwally 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 45-3353350 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Bein Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 54375 NY-25 3b.Policy Number of Entity Listed in Box 1a Southhold, NY 11971 R94668-002 3c.Policy Effective Period 1/1/2014 to 3/13/2026 4. Policy provides the following benefits: Q A.Both disability and Paid Family Leave benefits. B.Disability benefits only. ❑ C.Paid Family Leave benefits only.. 5. Policy covers: ❑X 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: I 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 describe abo Date Signed 3/14/2025 By (Signature of insurance carrhu's auth iza r'presenta't'ava or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title TALIN CONTI/MGR. 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 sox 46,4C or 56 of Part 1 has been checked) State of New York Workers' Compensation Board. e 'on Board the ab ove-named employer has com lied S Workers' Compensation P'o maintained b the NY W According to informati n A g y P 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) IIIII'DB-1w0 1iiii(12i � �i�l� ti Su Is cum ", Labor,Liewming&CO"sul`/Y uirst MASTER ELECTRICAL LICENSE " Name JOHN FELBINCM Businmm Name This c"ries thatthe JFF ELECTRIC INC beambyOv o ormdr,& Lkense r ME-19343 Issued- la%l/lg% Ros"it,VMS,, Eatp M: 1WO 2025 COMN " r r a� Dk-eLLINS-PURLII.HATER DHELUNl,9=PUBLIC WATER } .�Y N 26°14'00" W 111.25' FY LINE ` � W ! 6UBJEGT Y .� *,w z r - -- ri►«...r.xw�..m..w. P ! qr IPM TMw.POf.C�1.11.eMb.IR• fawsaug�iceP ���Nry//� 0 (({ P .4 ae396wri r� PATIO w�Fsp Ne rtb� � - jjf -OiY pS.#t TOTAE iOT -- X .ki# �a.raa w aascar ""T 9-OTORT 7iTORY WOOD P - B€ki F WOOD PRAM®MOM W FRAMm ADDITION PROPOSW ADDITION P (4 BROOM) sip. TIAe@B1T a:14.' �.�� ,,,. -�- , ----N - _, �.. _ _. _ a�#,I:cess.aeR a •. —_ RAF ! ' t ' - .s� I TAW W 4° 4 U e ae WmArw we - ....+w� g absrr.o i:. -' #�a7nA� _ wn.rRrr#mx - tu ya..cwrr.ww. -. a.+c r � .a w,mss�- I gym► eT. ..� rw�lnm r.r rrr e+"w rw,.e N" > 8 - ( t � . 'sI $ � � i`o°'+►a°4 r "Y.I'l _ ! ,b.�Y Yrr..'�ii. .` �� � � louo�►rl ` �Lj s o N ati;err ww.r."aYnr S ' ' � ti I '_` PROPOSPD SEPTIC SYSTEM DETAIL 2FIR -- --- .I.rr. KESIC ,Z �� RESIDE . w =OLK COUNTY HEALTH DEPARTMENT APPROVAL .a l210 ARSHAM AR5HAMOMAWE AVENUE Mar Pp0P08! SITE SPA