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HomeMy WebLinkAbout34739-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 5/16/2012 CERTIFICATE OF OCCUPANCY No: 35651 Date: 5/16/2012 THIS CERTIFIES that the building ALTERATION Location of Property: SCTM #: 473889 Subdivision: 32005 MAIN RD CUTCHOGUE, Sec/Block/Lot: 97.-5-8 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 5/21/2009 pursuant to which Building Permit No. 34739 dated 6/2/2009 was issued, and conforms to all of the requirements of the applicable provisions of thc law. The occupancy for which this certificate is issued is: TANK REPLACEMENT FOR AN EXISTING SUN SERVICE STATION AS APPLIED FOR. The certificate is issued to Sayan & Kocan, Inc (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED -AuhriSignat~-rr: FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEP~LRTMENT Town Hall Southold, N.Y. BUII/)ING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 34739 Z Date JUNE 2, 2009 Permission is hereby granted to: SAY~/g & KOCD/g, INC. 32005 MAIN CUTCHOGUE,NY 11935 for : TANK REPLACEMENT FOR AN EXISTING SUN SERVICE STATION AS APPLIED FOR at premises located at 32005 MAIN RD CUTCHOGUE County Tax Map.No. 473889 Section 097 Block 0005 Lot No. 008 pursuant to application dated MAY 21, 2009 and approved by the Building Inspector to expire on DECEMBER 2, 2010. Fee $ 250.00 Authorized Signature ORIGINAL Rev. 5/8/02 Form No. 6 TOW OF SO mOL BUILDINGOEPARTMENT · ... Ill I 765-1~2 APPLICATION FOR CERTIFICATE OF OCCUPAnt0 j ~fis appli~tion must ~ filled m by ~pewfiter or ~ ~d submi.~ to ~e Buil~g De~ent wi~ ~e following: A. For new building or new u~: 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). 3. Approval of electrieal installation from Board of Fire Underwriters. 4. Sworn statement from plumber ce~t~, lng that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installahons, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-cxisting' land u~s: 1. Accurate survey of property showing all proper~y lines, streets~ building and anusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicanL If a Certificate of Occupancy is denie& the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00. Alterations to dwelling $25.00~ Swimming pool $25.00, Accessory. building $25.00, Additions to accessory building $25.00, 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 Property.: ~3 ;1, ~ O / /v~ ~ t ~-~ t~ b~ House No. Street Owner or Owners of Property: ~.~Y I/--~ ['~ O r,_,~ t--t Suffolk County Tax Map No 1000. Section ~ "7 Block (check one) Hamlet Lot Subdivision Permit No. I~o ¢ 3,4 '] 3 ~, Health Dept. Approval: Date of Permit. Filed Map. Lot: - I o Applicant: ,,~"/r~£ F_,-c,~t~d5 Underwriters Approval: Planning Board Approval: Request for: Temporary_ Certificate Fee Submitted: $ Final Certificate: ~ (check one) Applicant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY I 1971-0959 Telephone (631 ) 765-1802 Fax (631) 765-9502 ro.qer, richert~,town.southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Tevflnk Kocan Address: 32005 Main Road City: Cutchogue St: NY Zip: 1193." Building Permit #: 34739 Section: Block: Lot: WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: as built DBA: License No: SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI 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 R[~ HID Fixtures Wall Fixtures II Smoke Detectors Recessed Fixtures CO Detectors Fluorescent Fixtures~~ Pumps Emergency Fixture Time Clocks Exit Fixtures ~ TVSS installation of electricle power and control systems for permanently mounted fire extinguisher system to cover gasoline pumps at commercial location Notes: Inspector Signature: Date: Dec 7 2011 81-Cert Electrical Compliance Form TOWN OF SOUTHOLD765.1802BUILDING DEPT. '~~~~0(~ INSPECTION [ ] FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ~ECTRICAL (FINAL) REMARKS: DATE _INSPECTO~ Fire Guard of Long Island, Inc. Glenn Kamm - NYC Master Fire Suppression Piping Contractor - Class CLic. No. 0266 40-8 Butt Drive, Deer Park, NY 11729 (631 )242-5315 Fax (631 )242-4945 83 Jewett Ave., Staten Island, NY 10302 (718)981-7872 Email-fireguar dli~optimum.net April 8, 2010 Town of Southold Building Department Town Hall Southold, NY 11971 Attention: Bob Fisher RE: SUN GAS STATION 32001 Main Road Cutchogue, NY BP 34739 Dear Mr. Fisher, Please be advised that Fire Guard has completed the installation of the fueling area fire suppression system as shown on approved plans. The system was tested, tagged, and placed into operation on April 6, 2010. Said system was designed and installed in accordance with NFPA 17, "UL 1254" and the manufacturer's UL listed manual. Sincerely, FIRE GUARD OF LONG ISLAND, INC. BY: ~~ Suffolk County Lic. l17A LORRAINE ABRUZZO Fire Suppression S~stgms-Closcd Circuit ~ Syst~s-Fim B~in~ish~ ~' State M N~ Y~ FIELD INSPECTION REPORT [ DATE I COMMENTS FOUNDATION (1ST) FOUNDATION (2ND) ROUGH F1L~aMI~G & PL~G ~S~ATION PER N. Y. STATE E~RGY CODE ~DITION~ CO~ENTS TOW~ OF ~OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined $[~ , 20 0~ Approved ~ (~ , 20~ Disapproved a/c 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: Expiration '~/ ~, 20 [D ~)~ ~ ~ ~ I'~1 Building Inspector ---t~m~nmtn ! INSTRUCTIONS ds applic ' 'filled in by typewriter or in ink and submitted o Io*o~ to the Building Inspector with 4 sets of plan: ~ ..... ::: ~,~{ p~ to scale. Fee according to schedule. b. Plot plan showing location of lot ~d of buildings on premises, relationship to adjoining premises or public streets or are~, and wate~ays. c. The work covered by this application may not be commenced before issuance of Building Pe~it. d. Upon approval of this application, the Building Inspector will issue a Building Pe~it to the applicant. Such a pe~it shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in p~ for any pu~ose what so ever until the Building Inspector issues a Ce~ificate of Occupancy. f. Eve~ building pe~it shall expire if the work authorized hm not commenced within 12 months a~er the date of issuance or h~ not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the prope~ have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the pe~it for an addition six months. Therea~er, a new pe~it shall be required. APPLICATION IS HEREBY MADE to the Building Depa~ment for the issuance of a Building Pe~it pu~uant to the Building Zone Ordinance of the Town of Southold, Suffolk Count, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition ~ herein described. The applic~t agrees to comply with all applicable laws, ordinates, building code, housing code, ~d regulations, and to ~mit authorized inspectors on premises and in building for necessa~ inspections. (Signature of applicant or name, ifa co~ormion) (Mailing address of applio~t) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bu lder Nameofownerofpremises ~--~r~C~ INC. 4~3 'T'~_~ X7'~-_ (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders LicenseNo. Plumbers LicenseNo. Electricians License No. Other Trade's License No. Location of land on which proB.o~ed work will be done:. . House Number -- Street x County Tax Map No. 1000 Section q ~[ Block Subdivision ~ Hamlet ~ Lot Filed Map No. Lot 2. 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 Removal Demolition 4. Estimated Cost ~,'~.,~--,~ /0~0 f. If dwelling, number of dwelling units If garage, number of cars Fee Addition Alteration Other Work 'T'/~O~-, (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height. Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Depth Height. Number of Stories Rear 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 law, ordinance or regulation? YES __ NO__ 13. Will lot be re-graded? YES NO__Will excess fill be removed from premises? YES __ NO __ 14. Names ofOwnerofpremises ~c~.t?~:x;~& ~e~-Address32'r~ca'~ Z~g, '-'-' PhoneNo.~~o Name of Architect ~ ~~ Address ~/~ ~ ~o ~ Phone No Name ofContractor~,~ ~ Address'3~. ~m~3 ~ ~ne No.[~ 15 a. ls this propeay within 100 feet ufa tidal wetland or a freshwater wetland? *YES NO~ * IF YES, SOUTHOLD TO~ TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this prope~y within 300 feet ufa tidal wetland? * YES~ NO * 1F YEStD.~. PERMITS MAY_BE REQUIRED. 16. Provi& su~ey, t6 scale, with ~ate undation plan and distances to prope~y lines. 17. If ele~ati0n at ~y point on pmpe~ ~ 10 feet or below, must provide topographical data on sumey. 18. Are there any ;covenants and restrictions with respect to this prope~? * YES NO~ * IF YES, PROVIDE A cOPM. STATE OF NEW YORK) ['-~%J'~--<, ~ being duly swum, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to._before me thifi, / .., ~ Notary Public Signature of Applicant No. 01 CA5061595 · Qualified in Suffolk County Commission Expires June 10,20/O PERMIT TO CONSTRUCT Toxic and/or Hazardous Material Storage Facility Suffolk County Department of Health Services Humayun J. Chaudhry, DO, MS Commissioner SCHDS REFERENCE g 13600 SCHDS REGISTRATION # 10-0028 SCHDS PLAN # HM06-093RI Date of Issuance: March 13, 2009 Permit expires one year from the Date of Issuance FACILITY NAME & ADDRESS: Fenerbahce Inc. 32001 Main Road Cutchogue, NY 11935 Your Application for Permit to Construct a Toxic or Hazardous Material Storage Facilities for the above referenced site has been reviewed for compliance with Articles 7 & 12 of the Suffolk County Sanitary Code. The application has been approved. The items listed below and on the back of this Permit are conditions of this Permit and have to be observed during construction: A copy of the appr?ved plan must be kept at the construction site. A copy of this permit must be kept on display at the facility during construction. Safe construction practices must be followed during the installation of the storage facility(s). The storage facility(s) must be constructed in accordance with the approved plan. Any changes in design, materials or use requires prior written consent of both the design professionaI and the Office of Pollution Control. The changes have to be submitted in a form that is acceptable to the Office of Pollution Control. The contractor and/or design professional is required to inform the owner that the changes are being made. The Office of Pollution Control has the right to inspect this installation at any time to verify its being constracted in compliance with this permit. The Office of Pollution Control must be contacted at 854-2523 at least ~ business days prior to commencement of any work to arrange for the required construction inspections. Contact the local building department and/or fire safety enforcement office for any additional requirements that may apply to your project. The storage facility cannot be placed into service until the Office of Pollution Control performs all required installation inspections and issues an interim permit to operate. The Office of Pollution Control reserves the right to revoke this permit as allowable by law. ISSUED BY: Chris Wong Bureau of Environmental Engineering Office of Pollution Control Division of Environmental Quality See the back for exceptions DEPARTMENT OF HEALTH SERVICES STEVE LEVY SUFFOLK COUNTY EXECUTIVE HUMAYUN J. CHAUDHRY, DO, MS Commissioner BUREAU OF ENVIRONMENTAL ENGINEERING APPROVAL NOTICE March 13, 2009 Graham Associates 1981 Union Blvd Bayshore, NY 11706 Attn.: Michael Dunn Re: SCDHS Job No. : SCDHS Fac. ID. No.: SCDHS File Ref. No.: Dear Mr. Dunn, HM06-093R1 10-0028 13600 Your application for a permit to construct a project at Fenerbahce Inc. 32001 Main Road, Cutchogue, NY 11935 has been reviewed for compliance with Article 12 of the Suffolk County Sanitary Code. The application has been approved. Enclosed you will find the Permit to Construct. This permit has to be posted at the construction site during the construction. If you have any questions regarding the review process or need assistance, feel free to contact this office at (631) 854-2388. Very truly yours, Chris Wong Assistant Public Health Engineer Bureau of Environmental Engineering Division of Environmental Quality - Office of Pollution Control - 15 Horseblock Place - Farmingville, NY 11738- 1220 Phone (631) $54~2388 Fax (631) 854 -2505 THIS PERMIT IS VALID FOR THE FOLLOWING STORAGE FACILITIES ONLY SCDHS # LOCATION VOLUME CONTENTS NOTE 12 Under / Out 6,000 Gals. Gasoline Compartmented 13 Under / Out 12,000 Gals. Gasoline Compartmented 14 Under / Out 6,000 Gals. Diesel Compartmented For up to ~'~i ,!:~x, after the Permit to Construct expires, the permit is renewable. The job file will remain open for that period. If the Office of Pollution Control does not receive a renewal application with the appropriate fees within the 90 days, the file will be closed and a new application for a Permit to Construct will have to be filed if the job is to be re-opened. All applicable filing fees will once again become due and payable. Issuance of this permit does not supersede any existing agreements with, or mandates by, the Office of Pollution Control or any other government agency. The construction period does not supersede any existing compliance dates agreed to, or mandated by, the Office of Pollution Control or any other government agency. Issuance of this permit does not authorize the use of the storage facility(s) that are in violation of the Suffolk County Sanitary Code or any other government code. Special Conditions: SUFFOLK COUNTY DEPARTMENT OF HEN.TH SERVICE TOXIC LIQUID STORAGE REGISTRATION FORM Principal Property T~Code D,st,,o, I~101 01~1 OFFICIAL USE ONLY J Fac. ,e,. ,o. I o1-1olo1 1 I section I 1'/17.1 I I sloc, ~ ,ct New Change Add Facility Name No. Street Community State Zip J Phone No. ~N~P._P-~-~CF.J_ ~.. ~zo-.-.-~ 7_5 z~ ~"/ iiq~$1'7;~4 - Tank Owner No. Street Community State Zip I Phone No. I Write mat'l, number in left column °- Designates cathodic protection SINGLE ~ WALLED WALLED OFFICIAL CAPACITY USE ONLY (GALLONS) Other Material (Specify) I certify that information on this application and all attachments have been reviewed and tha~, based on my inquiry of those Receipt believe that the information persons immediately responsible for obtaining the information contained in this application, I - is true, accurate, and complete. I understand that false statements made he~nishable as~3s~A misdemeanor Arr~j~o~ll~JO pursuant to Section 210.45 of the Penal Law. Date~ J Print Name , J Signat.r,~J ~ ~'~- HM,~, Io~ ~e~ ~'/ ~ 7, ~-, , .Z ~'/;' ,...~, , .......... Ila'Leg~NameandAddr~soflnsured ~se~em~&essonly) BUSINESS RESEARCH CONSULTANTS LTD 76 EAST HOFFMAN AVENUE LINDENHURST NY 11757 STATE OF .NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DIS.~BELITY BENEFITS LAW ~To be co--Disability Benefits Carrier or Licensed Insu fence A~ent of that Carrier I b. Business Telephone Number oflnsurea 631-587-D916 lc. NYS Unemployment Insurance Employer Rcs stration Nm-nbof~f Insured ' 2. NamemdAddressofthcEntiwR~uesti~pr~fof C°v~ge(EnfityBeingLi~ed~theCenifi~teHotder} TOWN OF SOUTHOLD P.O. BOX 1179 SOUTHOLD NY 11971 Id. Federal Employer identification Number of Insured o~ So,ia] Security Number __111-3198397 3a. Name ofI~surance Cazrier GUARDIAN LIFE INSURANCE 35. Policy Num her of entity listed in box "1 a"- 980119-001 3c. Policy effective period: 6/02/2008 Policy covers: a-~A °f the empl°yer's employees eligible under the New York Dtsability Benefit~ Law b. [] Only the following cla~s or classes of the employer's employees: to 6/02/2009 Under penaJty of perjury. ,. [ certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured ha~ NYS Disability Benefits inanranc~overage as d_eg, dhed above ! Dare Signed_ 3/31/2009 By.. Telep~oneNumber 631-366-2774. /itle'SecondVicePresident&Actuarv, Grouplnsurance, PART '~ To he .... ~ * ~ =- ~-'~'~ ~, --'" -~- ......... . ~ ...... az ~oaru ~_t_~.~_.~/ul OOX 4b' of Part 1 has been ' State Of New York Workers' Compensation Board : According t~ informal/on main~ned bv ~e NYS Wo~-~' r'____= ....... Disability Benefits Law respect to all ofhis~er Date Signed By. Telephone Numbor T{tle Please Note: Only insurance carrters licensed ro write Nt~ disabthty benefits insurance pohc~es anally ?S licensed insurance ~gents~ those in~urance carrierx are author~ed to ~x. ru~ Form DB l >O ! Insurance brokers are NOT aathorir, ed to ixsue thix form DB-120.1 (5-06) ACORD CERTIFICATE OF LIABILITY INSURANCE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Takach&Associates, lnc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 112 Terry Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Smithtown NY 11787 INSURERS AFFORDING COVERAGE NAIC # iNSURED BUSINESS RESEARCH CONSULTANTS LTD INSURER A: MARKEL 76 EAST HOFFMAN AVENUE iNSURER S: HARTFORD PERSONAL INSURANCE INSURER C: LINDENHURST NY 11757 [NSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVVITHSTANDING 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'I POLICY EFFECTIVE POLICY EXPIRATION GENERAL L~BILI~( EACH OCCURRENCE $ 1;000~000 X COMMERCIAL GENERAL LIABILITY 08PKGM00117 04/2512008 04/2512009 DAMAGE TO RENTED PRFM~.~F.~ ~E ....... ~ $ 50~000 I CLAIMSMADE [] OCCUR MED EXP (Any one person) $ 5r000 PERSONAL & ADV INJURY $ 110001000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/DP AG( $ 2,000,000 ~ POLICY ~]PRO-,IFK, T I~LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) SCHEDULED AUTOS (Per person) $ NONq3WNED AUTOS (Per accident) $ (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ ~ OCCUR [] CLAIMS MADE AGGREGATE $  DEDUCTIBLE $ RETENTION $ $ WC STATU* ANyEMPLOYERS'pRoPRIETOR/PARTNER/EXECUTIvELIABILITY ,I 12WECHO3815 0310312009 03103/2010 E.L. EACH ACCIDENT $ 100,000 CEKiiHCATE HOLDER CANCELLATION TOWN OF SOUTHOLD P.O. BOX 1179 SOUTHOLD, NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAJLURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, iTS AGENTS OR REPRESENTATIVES. AU THOR[ZE D REPRESE NTATIV~ ~41~ <JAB> ACORD 25 (2001108) © ACORD CORPORATION 1988 STATE OF NEW YORk ~ WORKERS' COMPENSATION BOARD UOBB CERTIFICATE OF NYS VVORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of Insured (Use street address only) BUSINESS RESEARCH CONSULTANTS LTD 74 E HOFFMAN AVE LINDENHURST NY 11757 Work Location of Insured (Or~lyrequiredifcoverege ia specifically limited to certain locations in New York State, i.e. a Wrap-Up Policy) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certifioate Holder) Town of Southhold PO BOX 1179 SOUTHOLD, NY 11971 lb. Business Telephone Numberoflnsured (516)523-6756 lc. NYS Unemployment Insurance Employer Registration Number of Insured ld. Federal Employer Identification Number of Insured or Social Security Number 113198397 3b. Policy Number of entity listed in box "la": 12 WEC HO3815 3c. Policy effective period: 03/03/2009 03/03/2010 ................ fo ............... 3d. The Proprietor, Partners or Executive Officers are: J~] included. (Only check box if all padners/officers included) ~lall or certain partners/officers excluded. excluded This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (TO use this rot'm, New Yod((NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Cartier 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 will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiurns 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 approwed by the insurance carrier or its licensed agent or until the policy expiration date listed in box '~c'; whichever is eattier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on s 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 requiraraente of the New York State Workers' Compensation Law. Under penalty of perjury, I cai'iffy 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: Kathi Golowski (Print name of authorized representative or licensed agent of insurance career) Approved by: ~3:-~(,,/~ _~_ C":9~'(?, i,E -3~ ......... 0 4~-_0_ l__2_O_Oa Title: __Operations M a_n~_e_r_ Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carders and their ficensed agents are authorized to issue the C- 105.2 form. Insurense brokers are NOT authorized to issue it. C-105.2 (9-07) www.wcb.state.ny.us Form WC 88 31 21 C Printed in U.S.A Page 1 of 2 GRAHAM ASSOCIATES Building Consultants & Expeditors 1981 Union Blvd. Bay Shore, NY 11706 63t.665.9619 Fax 631.969.0115 bayblueprint@aol.com LETTER OF TRANSMITTAL WE ARE SENDING YOU: Q Shop Drawings r~ Copy of Letter Attached ~ gnder Separate Cover via Prints r~ Plans C~ Samples Q Specifical~ons Change Order the following items: COPIES , DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: L.I For Approval r~ Approved as Submitted ~ Resubmit __ Q For Your Use Q Approved as Noted r~ Submit O As Requested O Returned for Corrections r~ Return Q For Review & Comment UI Q FOR BIDS DUE 20__ copies for approval __copies for dis1~ibotion __corrected pdnts PRINTS RETURNED AFTER LOAN TO US REMARKS: COPY TO: CONSENT TO INSPECTION Owner(s)Name(s) , the undersigned, do(es) hereby state: That the undersigned (is) (are) the owner(s) of the premises in the Town of Southold, located at 'g'P_cx>~ ~' ~,~/~ ~,..k)"fC~O(?dq: .v./N[ which is shown and designated on the Suffolk County' Tax Map as Di}trict'1000, Section ~q , Block ~ , Lot ~f' That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: ~ [~.'~ (e~O~'.3 That the undersigned do(es) hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon, to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances, rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances, rules or regulations of the Town of Southold. Dated: (Print Name) (Signature) (Print Name) TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER ,~ FOR~E~ OWNER A , RES. (3'Z- SEAS. LAND IMP. JSTREET '~ -~:~/'% ~ ,~ VILLAGE VL. FARM f/CO' '/WV~. ,., CB. MICS. TOTAL DATE REMARKS ~1 Mkt, D:j SUB. LOT, ACR. F ' t/~,.. ~'-Y-PE OF BUILDING AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE FARM Acre Tillable FRONTAGE ON WATER Woodland ~ FRONTAC-~ ON ROAD Meadowla~d DEPTH HOuse Plot BULKHEAD Value Per V~lue Acre DOCK ~tension ~-U ~ F J' ' ~tension Foundation ~ ~ Both ~ ~ Dinette Perch Basement ~ Floors ~~ K. ~t. Walls ~ /~ Interior Finish C ~ LR. Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631) 76&1802 ro~er r c h e r t (~_t~,°~.~ ~1~ ~. nv. us BUILDING DEPARTMENT TOWN OF SOUTHOI,B APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Company Name: Name: License No.: Date: Address: Phone No.: JOBSITE INFORMATION: (*Indicates required information) *Name: *Address': 3 *Cross Street: ' -- *Phone No.: Permit No.: Tax Map District: 1000 Section: Block: *BRIEF DESCRIPTION OF WORK (Please Print Cleady) Lot: (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 *New Service: Re-connect Additional Information: 100 Underground YES / NO Rough In YES / NO Final 82-Request for Inspection Form 150 200 300 350 400 Other Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION ~ lo~m 1 fall AnIwx 51373 Main P.O. Box ~oulll.ld, NY 11971-09,~9 Tdcphone (ti31) 71;.5-1802 Fax (631) 1½! !II,DIN(; I)EI'AI/TMENT TOWN OF SOUTHOLD April 26, 2010 Sayin & Kocan Inc 32005 Route 25 Cutchogue, NY 11935 RE: 1350 Sound Beach Dr, Mattituck TO WHOM IT MAY CONCERN: The following items are needed to complete your Certificate of Occupancy: __ Application of Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of $50.00 __ Final Health Department approval. __ Plumbers Solder Certificate. (All pem~its involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. __ Final Planning Board approval. __ Final Fire Inspection from Fire Marshal. __ Final Inspection from the Building Dept. __ Final Landmark Preservation approval. Building Permit: 34739-Z tank replacement Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY I 1971-0959 Telephone (631 ) 765-1802 Fax (631 ) 765-9502 November 9, 2011 BUILDING DEPARTMENT TOWN OF' SOUTIIOLD Sayin & Kocan 32001 Route 25 Cutchogue, NY 11935 Re: 32005 Route 25 TO WHOM IT MAY CONCERN: The Following Item(s) Are Needed To Complete Your Certificate of Occupancy: __ Application for Certificate of Occupancy. (Enclosed) ~"Electrical Underwriters Certificate. ~'~A fee of $50.00. ~Cr~I~Tc- D C[Jr ¢CtZ_ (~-rDc-t-~%C_D') __ Final Health Department Approval. __ Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) __ Final Planning Board Approval. Final Fire Inspection from Fire Marshall. - Bob Fisher Final Landmark Preservation approval. BUILDING PERMIT: 34739- Tank Replacement Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 Telephone (631 ) 765-1802 Fax (631) 765-9502 May11,2012 BUILDING DEPARTMENT TOWN OFSOUTHOLD Sayin & Kocan 32001 Route 25 Cutchogue, NY 11935 Re: 32005 Route 25, Cutchogue TO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: __ Application for Certificate of Occupancy. (Enclosed) ~A feCtrical Underwriters Certificate. (contact your electrician) e of $50 00 Outdated check a · . ( w s previously returned) Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __. Trustees Certificate of Compliance. (Town Trustees # 765-1892) Final Planning Board Approval. (Planning # 765-1938) __ Final Fire Inspection from Fire Marshall. __ Final Landmark Preservation approval. BUILDING PERMIT: 34739- Tank Replacement ,41 0,4 - "" PRO?OSP-P A,~,5, CONTROL5 tO B~ LOCATBP IN AfT~ND~P AkS'eA, BXISTIN~ PROPERTY tNB ~×lSqH6 IICH E×ISTIN~ FLBLINd t5LA~I)5 / W PRQPOSBP PIk:~ 5UPPBS551ON 5YSllSM, ( 5e~ PLAN VIeW ) MAN ROAP PARfAL 55 PLAN NOT TO 5CAL~ NOZZLU (TYP) MPP 75 LB CYLINI2UR ( TYPICAl. 51P U×I5TINid Ak~A LI~HI' POL~ (?Ye) MPP HBAT 12~$CTOR ( BLIf_-VATION PBTBCI'OR 5PACINd ?'¢ LD CYLINPBP. NOZZLE CbUSfeP. ( IO"On 225 ' HEAT PBFCCI'.OR ( IWP'~ -~ ~ BXI511N~ ~AS PI¢PBN~R ( 1M~)~'~- 7'-0 7'-e 0"10u NOZZLE 5PACIN~ PLAN VIBW KBY MAP N,T,5, APPROVAL5 IP?'__ + ~08" 4 el" IQ'tO BNP OF 15LANP AIM FrS, ('liP; PLAN VIBW MAIN I%ANt ~/d" CLOS~ HIPFL~ · N-All?NOZZLB / x ~/4" CLOS~ HPPLB ~ N-AI~ NQZZLB MAIN 15LANN NOZZLE CLLt51?R ~Nt? OP BLANP/ZONB NOZZb~ CbLI5FCR NOZZLB P?FAIL N,f,5, 5/4'* I,P,5, PlSCHAR. NB OUTI. BI' I/4" OP, COPPER TLIBINd PULL PiN PPA-P2 )~ACTUATOR AT[9-7S AT~-T5 e'-ok 0'-o ~xf e'-o MAIN 15LANP AIMIN& POINT5 ( BNN BLBVATION N,c5, I/2" CbOS~ NIPPLE I/2" 40' ELL PRY CHBMICAb CYI. INI2,UR5 PNBUMATIC ACTLIATION l~lf-l'AIb , 14"X H-"X 2" lO ~ 511~L COLLECTOR H~AI' COLLECTOR N~TAIL BLACK 5M-I?O 0 PUMP CONfAZQR 120 VAC NOTES WIRIN 5CHBMA'rlC 5,5, FEB 2} 2010 I. 5Y5TIf-M TO BP-- "PYR'.O-CHBM" ATTIf-N17ANT MO171~L, ATN-~5/75 AS APPROVBI2 IJNPBR "UL," STAR.AR17 1254 for lO MPPI WlN~ CONNITIOH5, 2, H~AT 17~lTcCTOR5 TO DP--"P~N-WAt" MOI::PNL 12-~27121 225' RATI~ ANTICIPATP-17, ~,ALL- PIJ~L' 1215PBNSP-R5 SHALL, 5HLiT 12OWN IJPON 5YSBM ACTIVATION, THERE SHALL, D~ NO MANUAl. RBSUT OP TH~ 1715P~MSINd 5YSTI~M AVAILAI::3LB, THN 1715PUNSUR5 SHALL, NOT DB CAPAf3L,U OP [31f-INl~ RIf-STAle. TUP IJNTIL' TIdE PIRB 5LIPPRB5510N 5YSTUM IS RIf-STOP. B17 TO OP~P-A,TiN~ CONPlTiON, ANY LINAIJTHORIZB17 ACTION TAKEN TO RP--STOR~ THU NiSPR-H- IN~ OPP. RATION WITHOUT PIRST HAVIN~ THIP- 5LJPPRU5510N 5YSTUM RIf-STORNP 5HALL, DP-- CONSIITBRIf-17 A VIOLATION OP THU NUW YORK 5TAT~ PIRIf- PRUVNHTIOH CON~, 4, ALL PIPIHG TO t3U 5CHN2LIL,B 4C) ~AL~VAHIZ~17 5TB~L, WITH ~00 LB CLASS dALVANIZUP MALL,BADL,P_- IRON PITTINg5, 5, 5YSTIf-M TO ~B 51NNLB ZONP- PI'.IBUMATIC RUL'UASB UTILIZINN I/4"0,17, RBPRINBR. ATION TUBING & I/4" 45.' PL,ARB TYPU PR.a,55 PITTING5 COHPORMINN TO 5AB dSl~c. ~, CYL~iN17P_-R5 ARB TO DB PIL~L,BP WITH MONO AMMONIUM PHOSPHAT~ ( ADC TYPE) CHAFe.~BI2 TO ~50 PSI~ WITH 17RY NITNO~P_-N, 7, NOZZL,B CAP5 ARB OPPICB. AN17 I:3U INST/CL'~17 APTP-R PINAL TR-STING P:OR THP. PIR~ FIREGUARD OF LONG 1~ 2. 40-8BURT DRIVE - DEER PARK, (631) 242-5315 FAX (631) 242-4945 REV DATE D~CRIPTI~N TI-LEPPBJFC= RE ~,'lSlLN~ PY'EO-CH~M MOt~BL "Al12-5~/7~" 5UN ~A'wN Sv %CA/E Lt 1254 PIRU 515°PFa55510N 5YSq~M ~200i ~VqN faF[( {/'q" ¢ I'-O C~TCHO~I~5, N,Y, DA-E HECKED BY %HF~ I NO i ~ i JOS NO TO I I I ~N ~O ~O~D~A~ 4. FINAL J J J J I} ~ II J ~TI~ ~X ~ 12"e 9~L mH~AVA YORK S] FAI~ILD [~-~= ~g= I )T R ~l t -9619 FAX gl ~ .................... · ~ .... 1~[ I i II HAT -- >l ROUTE 25~ (M,~IN R REVISION DESCRIPTION DATE '," !) 0P. .~,_ :7 :~¢',,.- "'"' :_- -~Y't...-~,.;~ ~ ,...--WiTN~'r ')Tlr,r, ,~ · 4 M ~-OR TH= ~,.,; ...... D UNN NY 1'1706 969-0115 EXPEDITERS NY 11706 969-0115 'PETROLEUM SPECIALISTS 'PERMIT EXPEDITING 52~1 ROUTE 25A (MAIN ROAD) IvlOTO~FL'~LSTO~AeETANASTO~E ~ ~ ~ ~ ~ ~ ~ L ~ TANK 5ITE PLAN SUFFOLK COUN~ DEPARTMENT OF H~LTH ~ERVICES BUR~U OF ENVIRONMENTAL ENGINEERING ~E ~Y~ ~U~~O~ON OF~ 7209~ and ~und to ~ in ~mpllian~ with $~o1~ expimson ~4g I G qnen ~ IN[ A55OCIATE 2/22/~ ~/ ~11TM I II I II I ~MTM II II II ~ II II I II ~ Il II ~1 I ~ II II II ~ ~ II 11 II II II II II II t~ '~ ~ ~ ............ ~. 1 ..... ~ ___ /~~,~ %x~ ..... ~''-"-~/~H~PL~X~ 1981 UNION BLVD BAY SHORE, NY 11706 T~mlC~k ~ET ~Mm E~UI~ENT mEAN ~0~ ~ m~EMIUM ~O~INE TAN~ PERMIT ACQUISITION AND EXPEDITERS 1981 UNION BLVD BAYSHORE, NY 11706 ~ODUGT PIPIN~ EN~RINO A TAN~ ~ 5HA~ BE I~EPlA~LY T~NSITION TO eALVANIZEO 5~L OR eONP 40 GAiN ~TEEL 'EN~RON~N~ 60MPU~OE 'P~RO~UM 8PEO~I~ FOR PlES~. CON~CTO~ ~ALL HINIHIZE EXPIRE OF F~P A5 USE PEA ¢~L O~ ¢~SHED 5TONE A5 ~IPIED IN ~GTIG~L~ P~SI~LE. T~ ~E5 INST~LATION HA~ AN~ OPE~TIN~ ~ ~JJ~ AH~N ~AL~ ~O~ ~ ~ 5T~o~ ti v~o~ ~Y~ T~N~ E~UI~E~T ~TE~: ~o~ ~ NO~ ~2~1 ~OUTE 25A (MAIN ~OAO) I. TANK TOP PIPIN¢ SUMP5 5HALL ~ FIBERCLA55, LIGUID TIGHT CUTCN~UE, TOP EDOE OF PIPLNO SUMP 5HALL TRiMliTE AT A POINT ~ ¢ ~ ~ ~ ~ FI~LA~ ~1~ ~ J · , ~ ' : THAT I~ HICHE~ THAN ~E MAN~Y 5KIlt A~ 5HALL MAINTAIN ', ~' ' " ~ - A HINIHUH OF 2" GLEA~NGE BET~EN THE HANDY ~IRT AND ............ Fe.~. ~ ~ PIPINe ~1~ ~i~N~FLEcTION ~I~E~ PORT PIPIN¢ ~HP, IR, MAN~A~ SKIRT ~ALL DE A MIN OF 4" IN ~IAHETER SUFFOLK COUN~ DEPAR~ENT OF H~TH ~RVICES I ' ~' ~~__,[ : _~[ ~ ~FE~O~O ~ ~ITION ~Ot LA~E~ THAN THAT OF THE PIPIN~ ~HP. BUREAU OF ENVIRONME~AL ENGINEERING II c~ = _~ ~ - c~ 5. A CONTAINMENT HANHOLE ~HALL BE P~VIPED AT ALL PILL PO~T5 ,'xPPROVAL ~ CONS~UCT SCDHS JOB N~~ 0 9 ~ITH A MIN OAPAOI~ OF 5 ~ALLONS. THE ~ONTAINMENT MANHOLE 22"~ HAZY ~ ' ~ ' ~ /~ '- 5HALL NOT ~E ATTACHE~ TO THE ~MP ACCE55 MAN~Y AND ~ALL ' : , ~ ? ~ ~ ~., DE OONTAINED HITHIN THE PIPIN¢ ~HP. ~EP HOLED A~ NOT PE~HITTE~. ~ Thee plans end sCec~caflon have been ~l~ed Sanitaw Code r~irements based upon ~ 0~ ~lO~ ~ IOt~=l~ ~ It5 CAPAOI~ 5HALL DE NO LE~ THAN 15 CALLO~ ANO A SECOND submlUed by ~li~t. approval to ~ns~ ~ ~%~ .~ MA~Y AND CONTAINMENT CO~ONENT5 5HALL BE ~FFOLK ExCretion Date DW6.~: MO~ THAN 2 INOHE5 A~ THE TANK. THE P~OBE MUST BE ~I~IDLY ,~S~ ~ DATE: SHE~ NOtE DAN~D DONE I::LEXIE LE E OOT NOT TO SCALE ENVIRON PEB-~"lS FO~ OONPUITS ENVIRON FEB-&2OO FOR 2" FRP NOT TO ~ALE FINISHED INDIANA SEA'~L- C. OHPAN¥ i'40~El ~l~.~ PIITH TEDT PORT FOR TESTIN5 OF SECONDARY GONTAINHENT. BA6KFILL ?¥~ICAL F=IF~INC~ TtRENCN DET,AII. GOPIF't~.ES~ION R. ING DANI: LINE INSIDE (;0NTAINHEh'T ~ I=LE×IE /E ENTRY l OOT ¥-¥ E"~LJ I~'"IENT LI~T DETAIL. SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES BUREAU OF ENVIRONMENTAL ENGINEERING These ptans and specifl~flon have been and found to be in ~mplian~ ~th Su~ Counly Senit~, Code requirements ~ u~n In--on ~bmitt~ by t~ti~. This approval ~ ~n~u~ expires~_ '""' '" Expiration Date I=H¥~,ICAI. ~.OOATION: REVISION DESCRIPTION DATE MICHAEL DUNN REGISTERED ARCHITECT 1981 UNION BLVD BAY SHORE, NY 11706 (631) 665-9619 FAX 969-0115 PERMIT ACQUISITION AND EXPEDITERS 1981 UNION BLVD BAYSHORE, NY 11706 (631) 665-9619 FAX 969-0115 'ENVIRONMNETAL COMPLIANCE *PETROLEUM SPECIALISTS 'COMMERCIAL SITE pLANNING 'PERMIT EXPEDITING FENEF NGE INC SUN SER,,vICE STATION 32¢¢1 I~OUTE 2D4, (MAIN CUTCH~UE, NY 11~SD PROJECT DE~CRIP~ON: ~ TAH~ SHEET DESCRIPTION: DETAILS