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Home My WebLink About36118-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 6/1/2011 No: 34973 Date: 5/31/2011 Location of Property: SCTM #: 473889 Subdivision: THIS CERTIFIES that the building RESIDENTIAL ALTERATION 1900 MILL RD PECONIC, Sec/Block/Lot: 67.-7-13 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 12/23/2010 pursuant to which Building Permit No. 36118 dated 1/4/2011 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: interior alterations to an existing one family dwelling as applied for. The certificate is issued to 1900 Mill Ln LLC (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 5/9/11 36118 5/13/11 uertsand p!umbin~ ~orp tl~Sig~ature FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. (THIS BUILDING PERMIT PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 36118 Z Date JANUARY 4, 2011 Permission is hereby granted to: SONJA C STEIN P O BOX 815 PECONIC,NY for : INTERIOR ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR at premises located at 1900 County Tax Map No. 473889 Section 067 pursuant to application dated DECEMBER Building Inspector to expire on JULY MILL RD SOUTH/PEC Block 0007 Lot No. 013 23, 2010 and~approved by the 4, 2012. Fee $ 443.20 AuthOrized Signature ORIGINAL Rev. 5/8/02 Form No. 6 TOWN Ob' SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey °f ProPertY with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. ' 2. Final Appr°val from Health Dept. of water supply and sewerage-disposal (S_9 form). 3..Approval ofeleetrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contain~s less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. ·Submit PI.arming Board Approval of completed site plan requirements. B. F~ ex~sting bui~d~ngs (pri~r t~ Apri~ 9~ I957) n~n~e~nf~rming uses~ ~r bui~dings and "pre~existing~ land uses: 1. Accurate survey 0f pr0pertY showing all Preperty lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicaat. If a Certificate of Oocupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swinuning pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 Temporary Certificate of Occapancy - Residential $15.00, Commercial $15.00 Date. qew Construction: ~ Old or Pre-existing Building: (check one) Location of Preperty: · Suffolk County Tax Map No 1000, Section Lot: Subdi~sion Health Dept. Approval: Planning Board Approval: DateofPermit. Filed Map.. Applicant: Underwriters Approval: Request for: Temporary Certificate Fee Submitted: $ t~-O , j _ Final Certificate: _ __ (cheek one) Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York I 1971 0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 ro.qer, richort~town.southo d nv us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: 1900 Mill Lane LLC Address: 1900 Mill Lane City: Peconic St: NY Zip: 11958 Building Permit #: 36118 Section: 67 Block: 7 Lot: 13 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Cell Electrical Inc LicenseNo: 1022-e SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commedcal Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Servicelph ~ Heat ~ DuplecRecpt ~ Service 3 ph Hot Water GFCl Recpt Main Panel NC Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures ~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures ~ CO Detectors Fluorescent Fixtur~l~ Pumps Emergency Fixture Time Clocks Exit Fixtures ~ TVSS 1000 watt wall heater, heat pump-1 compressor & 2 wall units, 2 exhaust fans 1 paddle fan, 16 ft lighting track, 3 arc fault circuit breakers Notes: 2nd floor is open loft Inspector Signature: Date: Ma)/13 2011 81-Cert Electrical Compliance Form Town Hall, 53095 Main Road P.O Box 1179 Soulhold, New York 1197b0959 Fax (631) 765-9502 Telephone (631) 765 1802 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: Ma2~%~,_ 2011__ Buildi ag Pennit No. 4.~/t ~/ (Please print) Plumber: Bertsand Plumb±nc Corp. (Please print) I cel~if5, that the solder used in the water supply system contains less thinx 2/I0 o£ i% lead Sworn to before me this 9th davof__~ay ...... 20 11 NolaryPublic, Suffolk County IIIItm M, Rol;hl Notary Public, State of New York No. 4826942 Qualified in Suffolk County Gommisslon Expires January 31, 20~_~ (Plumbels Sigmature) }'OWN OF S0l]f~0[0 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION - / [ ~'RAMING / STRAPPING [ ] FINAL ] FIRE SAF..i ,f INSPECTION ] RRE RESISTANT PF,.NE'II~ATION FIREPLACE & CHIMNEY [ Frae RESISTANT (X)NSTRUCTX)N [ DATE INSPECTOR/" ~-~ ~i / TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] RRE RES~TAKrCONSTRUC110N [ ~ELECTRICAL (ROUGH) [ REMARKS: [ ] ROUGH PLBG. [ ]INSULATION [ ]FINAL [ ]FIRE SAFETY INSPECTION ]FIRE RESISTANT PENETRATION ]ELECTRICAL (FINAL) INSPECTOR~~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTI ION FOUNDATION 1ST [ ,,~]I:IOUGH PLBG. ] FOUNDATION 2ND [ ] INSULATION FRAMING / STRAPPING [ ] FINAL DATE INSPECTOR ~ ~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]l~l~l~"r/~IT~ [ ]FIRERESlSTANTI~IETRATION [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FOUNDATION 1ST [ ] ROU~.~.~.~.~.~.~.~.~ PLBG. [ ] FOUNDATION 2ND [,~-]"INSULATION TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ]R~GH PLBG. [ ] FOUNDATION 2ND [~/]~INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ] FOUNDATION 1ST ] FOUNDATION 2ND ] FRAMING / STRAPPING ] FIREPLACE & CHIMNEY ] m~~r~".~n~ REMARKS: [ ] ROUGH PLBG. [ ] INSULATION [ ~FINAL [ ] FIRE SAFETY INSPECTION [ ]FIRE RESISTANT ;T:HLrmATION DATE ~ / INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING / STRAPPING [ ]FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [~] ELECTRICAL (FINAL) REMARKS: DATE ~'/~//~/' r INSPECTOR~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INS~.LATION [ ] FRAMING / STRAPPING [,p~FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SA,-,-, f INSPECTION REMARKS: '- · DATE INSPECTOR~ PETER E. TOKAR ARCHITECT 3718 SOUND AVENUE, KIVERHEAD, NEW YORK 11901 (631) 208-4097 EMAIL: PTOKARAKCH@OPTONLINENET February 15, 2011 Town of Southold Building Departmem 54375 Route 25 P.O. Box 1179 Southold, NY 11971 Attn: Mr. Gary Fish Re : 1900 Mill Lane Peconic, NY Ken Tedaldi Dear Mr. Fish, Please be advised that we have reviewed the structural conditions at the above referenced project and have determined that the additional collar ties at removed ceiling location are not needed. Please feel fi~e to contact me if you have any further questions or concerns. Very Truly Yours, Kathy Albin <southernnights1969@yahoo.com> pics from southold the inspector wants March 14, 2011 7:21:26 PM EDT kwoliand @optonline.net 5 Attachments, 201 KB TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 76S-9502 SoutholdTown. NorthFork.net Examined ^pprovea /-- 7: ,20 // Expiration ~'~-- '~ .20 ]ff] BLOG. UEPT. IO¢iN OF SOUTHOL9 PERMIT NO. 9 ¢ ~ t ~ BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying'? Board of Health 4 sets of Building Plans Planning Board approval Survey Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Form Contact: Mail to: Phone: Building Inspector PPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS ,20 ,~. This appncatton MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. 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, Suflblk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and~egulations, and to admit authorized inspectors on premises and in building for necessary inspections. .~_i~ ~canY~me, ifa corporation) - - '(Ma~lin~addre~f~pplJcin{) ' ' State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises /9/)& /~ it{ ,~.. ~, .~-~---. .... (~s on the tax roll or latest deed) If applicant is a co¢or~n, signature ~ly authorized officer (Na~tl~~er) /' ' Builders License No. ~, _ Plumbers License No. ' ~ ~ ~ f ~ Electricians License No. '/0~ ~ ~ Other Trade's License No. 1. Location of land on which grpp, osed work will be done: !nno Lq, Hous umber Street ?n i (, Hamlet County Tax Map No. I000 Section Subdivision ?o!'~/ ~.Lt, k./ Block : Filed M No. Lot Lot 2. State existing use and occupancy of premises and inter~d use a,nd occupancy of proposed construction: a. Existing use and occupancy ~z:'/~/~/~ 'n/-,~/,,2o~~ A/ ~,.i.~ ~, . b. Intended use and occupancy_ [/ 3. Nature of work (check which applicable): New Building Repair ,L.~-'-- ' Removal Demolition 4. Estimated Cost ~ ~// 5. If dwelling, number of dwelling units If garage, number of cars A/~ Fee Addition Alteration Other Work Pea/~ /k27~/? .¢- ~ ~ ~C PW~hC ? ~,~/T (Description) (To be paid on filing this application) Number of dwelling units on each floor / If business, commercial or mixed occupancy, specify nature and extent of each type of use. Dimensions of existing structures, ii'any: Front~ //~ -~ Height /,/..// Number of Stories Rear Dimensions of same structure with alterations or additions: Front Depth Depth Height 8. Dimensions of entire new construction: F~d~f//~' Height Number of Stories / 9. Size of lot: Front ,~_~d~ ~/.-~/d) Rear /--/Z~ 10. Date of Purchase /'~¢-c [ / -//2 Name of Former Owner Number of Stories Rear Depth _Depth 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulatioi~? YES NO 13. Will lot be re-graded? YES NO ~ excess fill be removed from premises? YES 14. Names of Owner of pre~ses~z~_Address ~. NameofArchitect ~,~L-~,n '~'FO/~/~- Addres~ Name of Contractor~ ~ /1'/~' . Addr~ss~ Phone No. 15 a. Is this property within 100 feet ora tidal wetland or a freshwater wetland? *YES/,-~ NO * 1F YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED;/- b. Is this property within 300 feet of a tidal wetland? * YES NO__ /¥~ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate tbundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES__ NO ~ · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) 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 ~nake and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this day of 20__ Notary Public Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM ~ THE FOLLOWING ACTIONS MAY REQUtRE THE SUBMISSION OF A .S..TORM'WATERLG_?~DIN?_~ DRAINAGE AND ER(~SION CONTROL PLAN Dis~ct alock Lot GEk ~ irll:u BY A u~o,~n rKGFi$~iONAL IN THE STATE OF NEW YORK. scOPE OF WORK - PROPOSED CONSTRUCTION iTEM# / WORKA,.SSESSMENT '~' Yes No a. Wha! is the Total Ama of the Project Parcels? (Include Total Area of all Parcels located within /(/// 1Will this Pr°ject RetaIn AJI St°tm'Water Run-Off the Scope of Won~ for Proposed Construction) Gonemted by a Two (2') Inch Rainfall on Site? b. What is the Total Area of Land Cisadng ' ~ (S.F~'tA=m) (This item will Include all mn-off created by site clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed Site Improvements and the permanent creation of construction actM[y? impervious surfaces,) ~ (S.F. IAcres) PROVIDE BRIEF PRO. W, CT DF~C-,i~.i.iON ~r~d..~,~,~ ~.~.~ ,,. ~M,~ 2 O°es the Site Plan andl°r Survey Show,NI Proposed //~ r~ Drainage Structures Indicating Size & Location? This g//'~ Item shall include all Propesed Grade Changes and w s, s coof ,ng Surface Water F ow. tv ..~'y~ ~/.~,~ ~'~ // 3 D°es the Site Plan and/or SurveY describe the erosion ~L~ .~/ ~,7 /~ . sndaedimontesntralpracflcesthatwillbeesedtu A//; I I ....... c°ntrolsite erasion enristormwaterdischarges. This ~/ q(Y("~ I~l item must be maintained thmug~ut the Entire Construction Period. 4 Will this Project Require any Land Riling, Grading or Excavation where there is a change to the Natural r~ Existing Grade involving mom than 200 Cubic Yards of Mategal within any Pamel? 5 Will this Applicati°n Require Land Disturbin~ Activities [2] .~_k///.7~_,~ Encompassing an Area in Excess of Five Thousand (5,000 S.F,) Square Feet of Ground Surface? 6 ls there a Natural Water Course Running through the ~ Site? Is this Project wi0fln the Trustees jurisdiclion General DEC SWPpp Requirements: or within One Hundred (100') feet ota Wetland or Subm~slon of a SWPPP ts requ ~md for all Construction activities involving soil Beach? disturbances of o~e (1) or mom acres; including drsturbances of less ~an one acre that7 Will there be E;ita preparation o~ Existing Grade Slopes ~ are Pa~t of a isrger common plan that v*fll ultimately disturb one or mo~e ac~es of land; which Excesd Fift,e, en (15) fcet of Verticat Rise to ~ i Including CoflsthJcflon activities involving soii'dist urba nces of ~ than one (1) acre where' Or~e H, undred ( 100 ) of Horizontal Distance? the DEC has determined that a SPDES permit is required for storm w~ter dischalges. SWpPP'S Shall meet the Minimum Requirements of tbe SPOES General perm~ 8 Will Driveways, Parking Ames or other impervious I~qU[red. pe~t -consflt~ion Sfo~I water rnanager;~ent practises that va'il be used and~r Removal of Vegetation and/or the ConstmcOon of any ~ STATE OF NEW YORK, COUNTY OF ............................... SS 'hat I ....... ~.2~,~lm~ ...... .~-~ · ../. ............. .... bein~ duly ~wom, deposes and say~ that he./~he i~ the applicant for Owner and/or repre~enmve of the Owner or Owh~,, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements confined in this application are tree to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application fded herewith. Sworn to before me this;~ ............................................... day of ............................................ , ~0 ..... Notary Public: .......................................................................................... FORM - 06/10 BUILDING PERMIT EXAMINER CHECKI.IST Applicant: / ~00 /~ ~ a~ /--/~ ~ ~CTM# 1000- ~ r~_ 7' /~ Subdivision: PropertyAddr~s: /~C~ ~ ~ *Date Submitted: /a2-~-~-/O Date Reviewed: Owner: ~mated Co~ ~ ~/, ~o O , AC--Zone: Suilding Permits (Open/Expired): BP ~-o,TT__Z / C/0 z- 3P__-Z / C/0 Z- , Info: BP -Z / C/0 Z- j Info: lingle & Separate Search Required? Y o/(N. flDetermination: IBQ. Lot Size: ACT. Lot Size: Conforming? 71/:2-. Pre COs? ,Info: c'2.~.~, BP__-Z/C/OZ- ,Info: BP __-Z / CdO 7_.- , Info: _ REQ. Lot Coy. __ ACT: Lot Coy. IBQ. Front ACT. Front REQ Side ACT. Side REQ. Rear PROP. Rear IBQ. Height. ACT. Height t~ ~ ~. ~3,,~ SlO~5 ,ti CT__ · ~ '-~-v. . . _ ..o,.d--~- - ,~ 'd" ~ / ~ ./9 ~, ..-'~-CT'~ waterfront?~/or N? 6.~d ~ f~ ' ~ - - Iy~, water ~ody: .~~ ~ Panel~ Flood ~ne: Bul~ea~BluffDistance: [DDITIONAL APPROVALS REQUIRED Inffolk County Health: Yor~- If yes, *Bed#: *Date: / / *Permit#: - If no, certification required: Y or N Received: Y or N By: ~YS DEC: eRE-~C~n/7, Yor(N) Date: / / Permit #: louthold Trustees: Y 0rN~ Date: /__ __ louthold ZBA: Y or~7 Date: / louthold Planning: Y ore- Date: ['own Landmark C of A: Y or~,)DTE: / Permit #: Permit #: / Permit#: / / ~otes: Town Septic: Y or N or NJ Letter - Notes: - Notes: - Notes: Compliance (page 2)://~or N CODE L~ tee Structure: Calculation: :oundation: SF ~irst Floor: ¢ 6 ~ SF ',econd Floor: SF )then SF ~otal: SF bo ~ SFX $__.=$ + Initial Fee: $ + Addition.al Fee ( ): $. SF X $ =$ + Initial Fee: $ + Additional Fee ( ): $ blEW YORK STATE CODE COMPLIANCE CHECKLIST CLIMATIC/GEOGRAPHIC DESIGN CRITERIA: Gro~m(t Snow Load: 2.0. Wind Speed; I20MPH__ Seismic Design Category." B . Weathering: Severe__ .-Frost Depth: 36" __Termite: M-H' Decay: S-M Design Temp: 11 -Iee Shield Underlay: YES . Flood Hazai'ds: USE/OCCUPANCY CLASSIFICATION: HEIGIZlT/FIRE AR.BA: · TYPE OF CONSTRUCTION: DESIGN CRITERIA: ENGINEERED/pREscRIPTIVE FULL FRAMING DESIGN ELEMENTS: Y/lq ItEADERS: Y/N WALL sTUDs: YfN CEILING JOISTS: Y/N FLOOR JOISTS: LUi~vIBER SPECIES AND GRADE: YfN GLRDERS~ Y/N ROOF RAIVTERS: Y/IN WINDOW AND DOOR SCHEDULE! · MISSLE TEST ILEQUIREMENTS: Y/N EGRESS 5.7 S.F.: Y/N LIGHT 8%: Y/N 5rENT 4 %: NAILING/CONSTRUCTION SCHEDULE: Y/N MEANS OF EGP,~SS: YfN PLUMBING RISER DIAGRAM: Y/N LOCATION OF I~I]7.E PROTECTION EQUIPMENT: Y/N 'TRUSS DESIGN: Y/N CERTIFICATION: Y/N ENERGY CALCS: Y/N TOTAL COMPLIENCE? Y/N (RETURN TO PAGE ONE) TOWI~ OF SOUT~OLD APP.LICATION FOR ~LECTRICAL INSPECTION :Phone No.: JOBSI:'rE INFORMATION: (*.i'ndl~ates required information) *Cress Street: ] P~rmit No,: ~ ~p ~i~: ' .1000 8~on: ~EF DESCRIPTION OF WO~ (Plea~ Print *Bahia 81~:' 1 Phase. 3phase t00 160 . 200 30(~ 350 400 *New 8elMce: Re-connect Additional' I'~orma/Ion: O0'ter ndergmund Number of Me]era Change of Sen4ce Overhead PAYMENT DUE WITH'~PPLICA*IOH 03/30/2011 10:28 FAX 631 726 0519 LSM DEV CORP 0002/0003 C~y ff Surfak Eric A. Kopp 03/30/2011 10:28 FAX 631 726 0519 LS~ DEV CORP ~0003/0003 New York State Insurance Fund Workers' Compensation & Dlstttdlity Benefits Specialists Since 1914 $ CORPORATE CENTER DR, 3RD FI.R, MELVILLE, NEW YORK 11747-3129 phone: (631) 756~t300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 113051625 L S M DEVELOPMENT CORP CIO ANDREW S MENDELSON 5 BEAVER LANE WEST WESTHAMPTON NY 11977 POLICYHOLDER L S M DEVELOPMENT CORP C/O ANDREW $ MENDELSON 5 BEAVER LANE WEST WE:STHAMPTON NY 11977 CERTIFICATE HOLDER TOWN OF SOUTHOLD 54375 ROUTE 25 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATENUMBE~ I PERIODcovEREDB~THi~CERTiFiCATE I---DAT~-'- I 1230 138-8 ~ _ 477665 L 04/14/2010 TO 04/14/2011 J 3/30/2011 , THIS IS TO CERTIFY THAT THE POUCYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1230 138-8 UNTIL 04/14/2011. COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THESTATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WiTH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER~ REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 04/14/2011 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REO'JLAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND OOES NOT ASSUME ANY L.lABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MA']-rER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INBURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https:l/www.nysll'.com/cert/cen'val.asp or by calling (888) 875-5790 VALIDATION NUMBER: 103637002 F{ h [ UWING INSPECTIONS: 1 F~'~NDATION- ~ REQUI~D CO~ FU~ POURED CONCRE~ S r ~APPiNG, ELECTRICAL & CAULKi~ ' ~ FINAL - CONSTRUCTION & E~C~ICAL _ MUST BE COMPL~ FOR C 0 PLUMBING _ SOUTHOLO ALL CONSTRUCTION ~ ~ ~ ~LL P~M~ING WASTE REQU REMENTS OF THE CO~S OF NEW YORK STATE NOT ~ ~3c~ ~x,~,~ 5,-[,~'~Y, ~~~~ ,, ' ',! 0 0 ' II EXCEED~100F1%LEAD~ o'~" = EXIST'( r I ~' ~ ~,'*-]1 Ill i~__ ~~,,,,,, ~o~~ I~ I I BATH / / IJ ~ ~ , , '" '-' v.~,¢x~.~.. ~ ~ T ;-~ II FLOOR PLAN ~ ~e~~ ~ I I '1' II II 5tECTION