Loading...
HomeMy WebLinkAbout36911-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 2/3/2012 CERTIFICATE OF OCCUPANCY No: 35425 Date: 2/3/2012 THIS CERTIFIES that the building COMMERCIAL REPAIRS Location of Property: 10095 Route 25, Mattituck, SCTM #: 473889 Sec/Block/Lot: 142.-1-26 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in tins officed dated 12/28/2011 pursuant to which Building Permit No. 36911 dated 1/9/2012 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: Commercial Restaurant Repairs "as built." (Big City Burgers) The certificate is issued to Mattituck Plaza LLC (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 2/2/12 36911 1/19/12 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 #: 36911 Date: 1/9/2012 Permission is hereby granted to: Mattituck Plaza LLC PO BOX 77 Mattituck, NY 11952 To: Commercial Restaurant Repairs "as built" At premises located at: 10095 Route 25, Mattituck SCTM # 473889 Sec/Block/Lot # 142.-1-26 Pursuant to application dated To expire on 7/10/2913. Fees: 12/28/2011 and approved by the Building Inspector. NEW COMMERCIAL, ALTERATION OR ADDITIONS CO - COMMERCIAL Total: $500.00 $50.00 $550.00 Building Inspector Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971 0959 Telephone (631 ) 765-1802 Fax (631 ) 765~9502 ro.qer, richert~town.so uthold, nv. us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Big City Burgers Address: 10095 Main Rd City: Mattituck St: NY Zip: 11952 Building Permit#: 36911 Section: 142 Block: 1 Lot: 26 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Celi Electric Lighting Corp License No: SITE DETAILS Office Use Only Residential [~ Indoor ~ Basement ~ Service Only ~ Corn merical Outdoor 1 st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Servicelph ~ Heat ~ DuplecRecpt ~ Se~ice 3 ph Hot Water GFCl Recpt Main Panel A/C Condenser Single Recpt Sub Panel A/C Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: alteration to counter, move recpticles Ceiling Fixtures ~[~[E~ HID Fixtures Wall Fixtures I I Smoke Detectors Recessed Fixtures CO Detectors Fluorescent Fixtur~ ~,~ Pumps Emergency Fixture Time Clocks Exit Fixtures I I TVSS Notes: Inspector Signature: Date: Jan 19 2012 81-Cert Electrical Compliance Form Town Hall, 53095 Main Road P.O. Box I179 Southold, New York 11971-0959 Fax (631) 765 9502 Telephone (631) 765- 1802 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION I)ate:_ ~F~br_u~ 2012 Building Pmmit No. 36911 (Please print) Phunber: Aterts~nd _P~lumbirl~ COr~. ~ _ (Please prin0 ] certi£y thai the solde~ used iu the water supply system col~.tains less than 2/10 lead ~v,'ou~ lo belore me this 2l:Ld da),' of _F~e_~r~uar~y , 2(/12 (Plumbers Si~mhue) No(:ary Public, Suff, ml~ ..... County Notary Public, lltate of New York #o. 4828942 Co~nmQuallfled In Suffolk Coaaty Isslon Ex.ires January 31, 20~/ Form No. 6 TOWN OF 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 tile Building Departmeut with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of I% 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 Planning Board Approval of completed site plan requirelnents. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual uatural or topographic features. 2. A properly completed application and consent to inspect signed by the applicaut. [fa Certificate of Occupancy is denied, the Buildiug Inspector shall state tbe reasons therefor in writing to the applicant. I. Certificate of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming 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 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date. New Construction: Old or Pre-existing Building: Location of Propelly: \ I:D~) O~ ~' (253 ~J;~ ~'~'~ House No. Street Owner or Owners of Property: %~.,/~.~t~l~. ~'5~)l~.~ ~.~(2/~ ~ Suffolk County Tax Map No 1000, Section ] t-~2,, Block (check one) Hamlxet ( Lot SulSdivision Permit No.'~[:D~ \ \ Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ ~© - ~' Date of Permit. Filed Map. Applicant: Underwriters Approval: Lot: / Final Certificate: (check one) . fi' ,~"~1 icant S ig~at~re TOWN OF SOUTHOLD BUILDING DEPT. 765-18O2 INSPECTION FOUNDATION 1ST FOUNDATION 2ND FRAMING / STRAPPING FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE __ ~/7~~INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOU~ATION 1ST [ ] ROUGH PLBG. / [ ]/[~OUNDATION 2ND [ ] INSULATION / [/] FRAMING/STRAPPING [~] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (FINAL} 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 RRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ~J~ ELECTRICAL (ROUGH) [ ELECTRICAL (FINAL) REMARKS: DATE INSPECTO~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ FOUNDATION 1ST [~]"ROUGH PLBG. [ FOUNDATION 2ND [ FRAMING / STRAPPING [ FIREPLACE & CHIMNEY [ FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION REMARKS: DATE INSPECTOR /~~TOWN ~ OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ [ ] FIRE RESISTANT CONSllWCTION [ [ ] ELECTRICAL (ROUGH) REMARKS: [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION ~I~LECTRICAL (FINAL) DATE iNSPECTOR~~~~_~ ~ ..... TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN~.~I~-ATION [ ] FRAMING/STRAPPING [,*"] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] RRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) .[ ] ELECTRICAL (FINAL} REMARKS: ~ DATE~/~ INSPECTOR~/~~~ Action: CONT ~'v. Code(s): 12 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES FOOD INSPECTION NARRATIVE ....... Estab ID: 28663 Estab Class' 110 Estab Name' ']~-Htlt~ff/ Inspection Date: 1/25/12 Time of Inspection: 1:58 PM ' PART 1: RED CRITICAL ITEMS These items relate directly to factors which lead to foodborne illness and must receive immediate attention Code Section Deseriotion of Violation 760-1333.9 When food of animal origin is served raw or not cooked to temperatures prescribed by this Article, the consumer is to be notified by brochures, deli case or menu advisories, label statements, table tents, placards, or other effective written means of the significantly increased risk associated with certain especially vulnerable consumers eating such foods in raw or undercookad form; except, (a) Unmarinated beefsteaks that meet the definition of "whole-muscle, intact beef' may be served without a consumer advisory if cooked on the top and bottom to a surface temperatare of 145 degrees Fahrenheit (63 degrees Celsius) or above and a cooked color change is achieved on all external surfaces, if: (1) obtained packaged and labeled as "whole-muscle, intact beefsteaks" fi-om a food processing plant; or, (2) cut in the establishment from beef labeled at a food processing plant as meeting the definition of "whole-muscle, intact beef', prepared to remain intact, and individuaily packaged and labeled as "whole-muscle, intact beef steak". (b) Raw or undercooked food of aniraal origin shall not be served to a highly susceptible population. To Wit: CONSUMER MENU ADVISORY IS INADEQUATE IN THAT THE pRarNTED CONSUMER REMINDER STATEMENT ON THE MENU IS INCORRECT. 760-1352.2.a Corrective Acti0~l To Wit: CONSUMER ADVISOR' TO BE ADDED/CORRECTED The potable water system and equipment connected thereto shall be installed in such a manner as to preclude the possibility of backflow. THE SPRAY NOZZLE AT THE 3-COMPARTMENT SINK CAN HANG BELOW THE REPROCESSED FLOOD RIM OF THE SINK, AND THE POTABLE WATER SUPPLY IS NOT PROTECTED BY AN AIR GAP OR APPROVED ANTI-BACKFLOW DEVICE. PART 2: BLUE MAINTENANCE ITEMS These items relate to maintenance of the food service operation and cleanliness, correct as scheduled. Code Secti90 Descriotion of Violation 760-1303.2 Any person desiring to operate a food establishment shall make written application for a permit on forms provided by the deparanent. Such application shall include the applicant's full name and post office address and whether such applicant is an individual, firm or corporation, and if partnership, the names of the partners, together with their addresses; proof of the applicant's authority to collect sales tax in the State of New York; the location and thc type of food establishment; and the signature of the applicant or applicants. If the application is for a temporary food establishment, it shall also include the inclusive dates of the proposed operation. To Wit: THE OPERATOR FAILED TO SUBMIT PROOF OF AUTHORITY TO COLLECT SALES TAXES IN NEW YORK STATE. To Wit: THE OWNER/OPERATOR FAILED TO SUBMIT PROOF OF INCORPORATION OR VALID PROOF OF OWNERSHIP OF THE BUSINESS. To Wit: THE OPERATOR FAILED TO SUBMIT PROOF OF POSSESSION OF WORKER'S COMPENSATION AND DISABILITY INSURANCE. Correct By 2/8/2012 2/8/2012 2/8/2012 Person Receiving Report: Sanitarian: 808 KUEMMEL Page 1 of 2 AAc_tio_n:. CONT Estab. lD: 28663 Estab. Ciass: Il0 Estab'Narae:~l~Peh~t'A' SJG {~iTY gU~(~-~ ctiv. Code(s): 12 Inspection Date: 1/2S/12 Timeoflnspection: I:SSPM PART 2: BLUE MAINTENANCE ITEMS These items relate to maintennnee of the food service operation and cleanliness, correct as scheduled. Other No~s ESTABLISHMENT BUILT SUBSTANTIALLY ACCORDING TO APPROVED PLANS. OKAY TO ISSUE PERMIT ESTABLISHMENT MAY OPEN ONCE ALL FOOD CONTACT SURFACES HAVE BEEN THOROUGHLY WASHED, RlNSED AND SANITIZED. Thermometer Used: Cooper Min/Max 808 Inspection by Adam Kuemmel, g808 Suffolk County Department of Health Services Food Control Unit 360 Yaphank Avenue, Suite 2A Yaphank, NY 11980 Phone: (63 O 852-5999 Fax: (631) 852-5871 THE FOOD MANAGER'S COURSE IS AVAILABLE ONLINE To register for the Food Manager's course, please visit htlp://apps.suffolkcountyny.gov/health/foodmgttrain/or call (631) 852-5997 Person Receiving Report: Sanitarian: 808 KUEMMEL Page 2 of 2 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES FOOD ESTABLISHMENT INSPECTION SUMMARY REPORT Action:CONT Activ. Code(s): 12 Estab. ID: 28663 Estab. Cless: 110 Estab. Name: BIG CITY BURGERS Est,ab. Address: 10095 MAIN RD-STORE #15 Estab. City: MATTITUCK I Permit Restx: S Z Capacity: 16 Owner: GEORGE MALAMAS, MANA¢ Corp Name: BIG CITY BURGERS M~I Mgr. Cert. #1: SAFE: Corp. Address: 10095 MAIN RD.- STORE #15 Inspection Date: 1/25/12 I lnsp. Status(es): 06 Risk: 0 Corp. Zip: 11952 Time of Inspection: 1:58 PM I PART 1: RED CRITICAL ITEMS These items relate directly to factors which lead to foodborae illness and must receive immediate atlention Code Section Description of Violation Corrective Action 760-1333.9 760-1352.2.a CONSUMER MENU ADVISORY CROSS-CONNECTIONS CONSUMER ADVISORY TO BE ADDED/CORRECTED REPROCESSED PART 2: BLUE MAINTENANCE ITEMS These items relate to maintenance of the food service operation and cleanliness, correct as scheduled. Code Section Description of Violation Correct By 760-1303.2 FAILURE TO SUBMIT APPLICATION 2/8/2012 Signature of Person Receiving Report: _ Print Name: Sanitarian: 808 KUEMMEL Page I of 1 Joint Sanitarian: '~Tke items noted above are violationa of applicable laws, rules and regulations found during an inspection of the operation of the facilities in this establishment which must be corrected as indicated. Failure t~ comply may result in the initiation of legal action against this Csinblishment a~ provided for in Articles 2 and 13 of the Suffolk County Sanitary Code including a hearin~ p~nsible suspensiou of your food operation, and or the publication of tho violation and flne~" N. Y. S. DEPARTMENT OF STATE -- -'-'DIVISION OF CORPORATIONS AND STATE RECORDS ALBA/qY, NY 122~] 0,}~, FILING RECEIPT ENTITY NAME: BIG CITY BURGERS MATTITUCK LLC DOCUMENT TYPE: ARTICLES OF ORGANIZATION (DOM LLC) COUNTY: SUt FILED:12/19/2011 DURATION:********* CASH#:iII219000040 FILM %:1112190000 FILER: RICHARD T. HAEFELI, ESQ. 48F MAIN STREET WESTNAMPTON BEACH, NY 119V8 ADDRESS FOR PROCESS: THE LLC 130 JESSUP AVENUE QUOGUE, NY 11959 REGISTERED AGENT: P.O. BOX 815 EXIST DA'Pt iz/19/2o : SERVICE COMPANY: GERALD WEINBERG, P.C. 13 SERVICE CODE: FEES 225.00 PAYMENTS ...... CASH FILING 200.00 CHECK TAP{ 0.00 CHARGE ?ER%' 0.00 DRAWDOWIq _~COPIES 0.00 OPAL HANDLING 25.00 REFUND 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 76S-1802 FAX: (631) 765-9502 SoutholdTown. NorthFork. net Examined Approved Disapproved a/c ,20/2 ,20 / 2-- BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the lbllowing, before applying? Board of Health 4 sets of Building Plansi~'lt_~i',~ ~q Planning Board approval' } ' o Survey Check Septic Form N.Y.S.D.E.C. Trustees C.O. Application Flood Permit Single & Separate Storm-Water Assessment Form Contact: Mail to: Budding Inspector Phone: APPLICATION FOR BUILDING PERMIT Date /,,2 ~ ,2- ~ ,20 /?' INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink aud submitted to the Building Inspector witb 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 a4joining premises or public streets or arcas, and waterways. c. The work covered by this application may uot 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 fbr inspection throughout the work. e. No building shall be occupied or used in whole or in part lbr 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, tbe 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 ora Building Permit pursuant to the Building Zone Ordinance of the Town of Southold. Suftblk 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 regulations, and to admit authorized inspectors on premises and in building for uecessary inspections. (Signature of applicant or name, ifa corporation) (Mailing address of applicant) State whether applicant is o,~nel', lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Nameofownerofpremises /t'~,,r-/~('~cK ?~.42-/¢, Lf-~ (As on the tax roll or latest deed) I~applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. l ql frO{ tw t° Electricians License No. /O "~- :>-- - ~-~ Other Trade's License No. Location of land on which proposed work will be done: rooqs- M,t-/,o 5 Z?..ti_ lS'- House Number Street Hamlet County Tax Map No. 1000 Section /t'('2.- BLock / Lot 2-,~ Subdivision Filed Map No. Lot State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy Nature of work (check which applicable): New Building Repair I/~ Removal Demolition Estimated Cost 3, O 0 D Fee If dwelling, number of dwelling units If garage, number of cars Addition Alteration Other Work (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, if any: Front ! Height / 2- ' Number of Stories Dimensions of same structure with alterations or additions: Front Depth ~ y t Height / 2- / Depth /~/ Rear Number of Stories 8. Dimensions of entire new construction: Front Height Number of Stories Rear Depth 9. Size of lot: Front Rear .Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning la,v, ordinance or regulation? YES NO ~ 13. Will lot be re-graded? YES__ NO ~( Will excess fill be removed from premises? YES__ NO X 14. Names of Owner of premises Name of Architect Name of Contractor Address Phone No. Address Phone No Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES__ * IF 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. NO 16. Provide survey, to scale, with accurate foundation 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 ~5' · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) ~ ~4--(_,4~'~t,4'~ being duly sworn, deposes and say's that (s)he is the applicant (Name of individual signing contract) above named, CONNIE D. BUNCH Notary Public, State o~ New York (S)He is the No. 01BU6185050 (Contractor, Agent, Corporate Officer, etc.)Qua#fl~d in 8u~olk Count,/ Commission Expires April 14, 2 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 tbis application are tree to the best of his knowledge and belief; and that the work will be performed in tbe manner set forth in the application filed therewith. Sworn to before me this a c:~ &..~ d a y of4~ C.O~x.~..~ Notary Public 20 Il Signature of Applicant STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be comPlPted by Dlsabi ty Benefits Carr er or L censed nsdrance Agent of that Carrier la. Legal Name end Address of Inenmd (Use street eddrcsa only) BIG CITY BURGERS MATTITUCK LLC 10095 MAIN ROAD UNIT 15 MATTITUCK NY 11952 2. Name and Address of the Entity Requesting Proof of Coverage (Entity B~ing Listed as tt~ Certifieat~ Holder) I b. Busine~ Telephone Number of Invared 631 -31 5-5100 1 c. NYS Unemployment Inenrar~ Employer R. egistration Number of Inmr~l id. Feds'al Employer Identification Number of Insured or Social Security Number 45 - 41 021 91 3a. Name of Insurance Cartier / ANDARD LIFE INSURANCE CO. OF NEW Y 3b. Policy Number of entity listed in box "la": 49231 4 3c. Policy effective period: _~01_/23/2012 to 01/23/2013 Policy covers: a. ~[ All of the employer's employe~ eligible under th,e New Yo~k Disability Benefits Law ~b. [] Only the folloWing class or classes of the employer's employees: Under penalty o f pcrjury, I certify that I am an authorized representative or liccnsad agent of the iasurenen.carriar rct*erenced above and that the named insured has NYS Disability Benefits insurance covcriga as dcscrlbcd above. Date Si~ned i / q c~ /'~n ~ -~ By ,'J- ~' ~'"~ / ~g~--~ e ~. _-'ff~~ T¢lephoneNumbr 877-241-4361 Title DBL ADMINISTRATOR PART 2. To be completed by NYS Workers' Compensation Board (Or~ly if box"4b" of Part 1 has le~:qm checked) State Of New York Workers' Compensation Board According to inforraation maintained by thc NYS Workers' Compensation Board, the above-named employer has complied with thc NYS Disability B~aefit$ Law with respect to all of his/her employe~s. Date Signed By Telephone Number Title Pie. uae Note: Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS lizensad insurance agents of flloae insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120A (5-06) 12395 00 Town Hall Annex 54,375 M~ln Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 r ax (631) 7 5 o,q er. dchert(6,,~own.sou~.ny.us REQUESTED BY: Company Name: Name: BUI!.HING DF~P~ TOWN OF SOUTHOI',r~ APPLICATION FOR ELECTRICAL INSPECTION License No.: Address: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: ~/C_~ ~ ~ /'~-~/~ *Address: /o~?.(- ~/~ ~ ~~/~ *Cross Street: *Phone No.: Permit No.: "'-~2 ~' c~ / I Tax Map District: 1000 Section: / *BRIEF DESCRIPTION OF WORK (Please Print Clearly) Block: [ Lot: (Please Circle All That Apply) *Is job ready for inspectiOn: *Do you need a Temp Certificate: ~/NO YES / NO Rough In Final Temp Information (If. needed] *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82-1~quest for Inspect]on Form Town Hall ,~mex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 BUII ~HING DEPARTME/~ TOWN OF $OUTHOLD APPLICATION FOR ELECTRICAL INSPECTION Telephone (631) 765-1802 ax (681) 7 5 ro~ler, richert ~own.souru~l~5o(~.ny.u,s REQUESTED BY ~--~T-VO~--,~ /c'('~'/"~,1~f~--~ Date: Icompany Name: ~"~ 4;/ ~'~/~7-/f/C ~r'~----~7-,'~- ~, Name: License No.: Address: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: ~/~:- ~ ~' /~.,KL~c~-5 *Address: /°~?Jr /~I~/~ ~ ~,¢~c/~ *Cross Street: *Phone No.: Permit No.: Tax Map District: 1000 Section: / ~(,Z Block: 4' Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clearly) '~£P(~£ ~"~o v,<.,'-~-~ /'--t'~)v~ Ou"r'LCT~ 7-0 ~'5',4/ c%~.~,7-~.,e, R~,u ~',,~L[_ (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Temp Certificate: Temp Information (If needed} *Service Size: 1 Phase 3Phase 100 *New Service: Re-connect Underground Additienal Information: ~/NO YES / NO Final 82,4~uestforlnspecUon Form 150 200 300 350 400 Other Number of Meters Change of Service Overhe PAYMENT DUE WITH APPLICATION \ I ~ ~- ~ ~ ~11 i I ~/~ ~ I ~ V , ~ I I j ~1 L __~ I ~ ~ / I I // FLOOR PLAN GENERAL NOTEB I) ALL CONETRUCTION a) 4) lB TO CONFORM TO THE BUILDING CODE OF NEN YORK. DTATE AND LOCAL BUILDING CODED ALL PLUMBING ID TO CONFORM TO LOCAL AND COUNTY FIEALTM DEPARTMENT REQUIP. EMENTD. ALL ELECTRIC I$ TO CONFORM TO LOCAL~ N,E,C. AND ARCHITECTS STATEMENT I¢ PETER TOKAR - ARCNITECT~ STATE TIqAT TO THE BEST OF MT K.NOMLEOGE~ BELIEF AND PROFESSIONAL dUDGEMENT THAT THE PLANS AND EPECIFICATION5 CONTAINED P41THIN PETER TOKAR - ARCHITECT ,! S,N~ TOI LET  / 42"x~ ~ ,~kT~ TOP 5EATING L II I TO~ M/ ~¢ATING4,, L B FLOOP--. PLAN SCALE, ALL HALLS SMOI/qN AF~-.E EXISTING -HASTE LINE VENT (EXI,ST'G) (EXIST'G) FIXTURE KEY 74"x24" (B) COMPARTMENT SINK-EXISTING 12'xlG" HAND SiNK-EXISTING GO"xBO" PREP SINK-EXISTING ~F~ TO ~QLJIPMENT CUTS H'-o"x4'-$" EXMAU~T MOqD-EXI~TING 12" (2) BURNER 5TOVE-"NELL5 MANUFACTURING" MOOEL ~ MDM~-12~O~ REFER TO EQUIPMENT CUT5 46~ FLAT G~IDDLE-"APN ~YOTT~ MODEL ~ GGT-46M ~O"x30" LON EJOT-"TRAULSEN" MODEL ~ UMT-~O-LR FOUNTAIN SERVICE 5TATION-EX~STING SLOP SINK-EXISTING NATER ~EATER ABOVE-EXISTING ~ALK- IN ~EFRIG,- EXISTING REFER TO EQUIPMENT CUTS <: <: < PLUMBING, ALL PLUMBING WASTE & WATER LINES NEED TESTING BEFORE COVERING PL UMBER CERTIFICATION ON LEAD CONT~ENT BEFC, TE CERTIFICATE OF OCCUPANC Y SOLDER USED IN WA TER ~UP~L Y S¥ST, EM CANNOT EXCEED 2/I0 OF 1% LEAD. OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY APPROVED AS NOTED NOTi~'Y BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS' 1. FOUNDATION -TWO REQUIRED FOR POURED CONCRETE 2. ROUGH-FRAMING, PLUMBING, STRAPPING, ELECTRtGAL & CAULK'NO 3 INSULATION 4 FINAL. CONSTRUCTION & ELECTRF MUST BE COMPLETE FOR C 0 REQUIREMENTS OF THE C3D[, '· '~ORKSTATE NOT RESPuNSh: c ELECTRICAL INSPECTION REQUIRED FIRE INSPECTION REQUIRED BEFORE OPENING REVISIONS: DAli] TITLE DI:LAWING NO.: OF I SHEET