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Home My WebLink About43788-Z i �o S�fF�t'�co Town of Southold 7/19/2019 P.O.Box 1179 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 40514 Date: 7/19/2019 THIS CERTIFIES that the building ELECTRICAL Location of Property: 160 Rambler Rd, Southold SCTM#: 473889 Sec/Block/Lot: 88.-5-35 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 5/23/2019 pursuant to which Building Permit No. 43788 dated 5/23/2019 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: Tesla Wall Connector The certificate is issued to Snow,Margaret of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 43788 7/19/2019 PLUMBERS CERTIFICATION DATED Authorized Signature ��sU Qty TOWN OF SOUTHOLD °may BUILDING DEPARTMENT TOWN CLERK'S OFFICE Nt 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#: 43788 Date: 5/23/2019 Permission is hereby granted to: Snow, Margaret PO BOX 1662 Southold, NY 11971 To: Tesla Wall Connector At premises located at: 160 Rambler Rd, Southold SCTM # 473889 Sec/Block/Lot# 88.-5-35 Pursuant to application dated 5/23/2019 and approved by the Building Inspector. To expire on 11/21/2020. Fees: ELECTRIC $90.00 Total: $90.00 Bt i ding Inspector �®'*pF SOU��®l Town Hall Annex Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 Q Southold,NY 11971-0959 ® • �® roger.riche rt(W-town.south old.ny.us BUELDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Michael Burlingham (Snow) Address: 160 Rambler Rd City: Southold St: New York Zip: 11971 Building Permit* 43788 Section: $$ Block: 5 Lot: 35 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: DBA: Tesla Energy Operations License No: 51331-ME SITE DETAILS Office Use Only Residential X Indoor X Basement Service Only Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage X INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks Disconnect Switches Twist Lock Exit Fixtures TVSS Other Equipment 60a "TESLA" car charging station Notes. Inspector Signature: Date: June 10 2019 81-Cert Electrical Compliance Form xis OF SOUTholo # TOWN OF SOUTHOLD BUILDING-DEPT. `ycoum, 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) [�j ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: 1p roo DATE G 10 ) INSPECTOR J4a of S -6,- id o- S f04 BUILDING DEPARTMENT-Electrical Inspector 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 roger.richertatown.southold.ny.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Jason Kane Date: 5/21/19 Company Name: Tesla Energy Operations Inc. Name: Jason Kane License No.: ME-51331 email: jkane@tesia.com Address: 15 Grumman Rd West Suite 400 Bethpage, NY 11714 Phone No.: 516-306-0126 JOB SITE INFORMATION: (All Information Required) Name: Michael Burlingham Address: 160 Rambler Ct Southold NY 11971 Cross Street: Phone No.: 914-826-11 Bldg.Permit -7 email: mburlingha@aol.com Tax Map District: 1000 Section: 85 Block: Lot: BRIEF DESCRIPTION OF WORK(Please Print Clearly) Install 1 Tesla Wall Connector Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: YES/ NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: .A #Meters Old Meter# New Service- Fire Reconnect- Flood Reconnect-Service Reconnected -Underground -Overhead #Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION "'�` �I 82-Request for Inspection Formals r` t YORK workers' CERTIFICATE OF Are Compensation Board NYS WORKERS, COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(Use street address only) 1b.Business Telephone Number of Insured 650-963-5100 Tesla Energy Operations,Inc. 6800 Dumbarton Circle 1c.NYS Unemployment Insurance Employer Registration Fremont,CA 94555 Number of Insured 49-892777 Work Location of Insured(Onlyrequired if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 02-0781046 2.Name and Address of the Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company 3b.Policy Number of entity listed in box"la" Town of Southold WC 1074583-01 54375 Main Road Southold,NY 11971-0959 3c. Policy effective period 10/31/2018 to 10/31/2019 3d. The Proprietor,Partners or Executive Officers are ® included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2" The Insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel-the policy or eliminate the insured from the coverage indicated on this Certificate (These notices may be sent by regular mail.)Otherwise, this Certificate is valid for one year after this form is approved by the insurance 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 the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Kelly Cada (Print name of authorized representative or licensed agent of insurance carrier) Approved by: fG�d 10/31/2018 (Signature) (Date) Title: Vice President-Enterprise Support Operations Telephone Number of authorized representative or licensed agent of insurance carrier: ' 800-382-2150 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. , f _ NEW Workers' ' n� compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) lb Business Telephone Number of Insured Tesla Energy Operations, Inc. 6800 Dumbarton Circle Fremont, CA 94555 1c Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,r a,Wrap-Up Policy) 02-0781046 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Prudential Insurance Company of America Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 54375 Main Road Southold, NY 11971-0959 CG-51526-NY 3c Policy effective period 01/01/2019 to 12/31/2020 4 Policy provides the following benefits ( ❑X 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 Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above Date Signed December 01, 2018 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 215-658-5178 Name and Title H. Richard Brummett-Statutory Disability Coordinator IMPORTANT- If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE Mail it directly to the certificate holder. If Box 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 mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200,Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 513 of Part 1 has been checked) State of New York Workers' Compensation Board According to information-maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her 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. D13-120.1 (10-17) �IIIII�°11°1°20°�1°1(110�°117)°IIIII� Suffolk County Dept.of a Labor,Licensing&Consumer Affairs MASTER ELECTRICAL LICENSE ' Name JASON KANE `. Business Name TESLA ENERGY OPERATIONS INC `;az This certifles that the bearer isduly licensed License Number ME-51331 by the County of Suffolk Jssued-. 03/1912013 Comr` ter Expires: 03!0112021 Commisi ssioner , % a • r 4} r ` t 6 t • 3 t S f Y , ` Suffolk County Dept of Labor,Licensing&Consumer Affairs HOME-IMPROVEMENT LICENSE Name WILLIAM CAMPBELL ' Business Name TESLA ENERGY OPERATIONS INC This certifies that the bearer is-duty licensed License Number HI-61305 by the County of Suffolk Issued: 11/08/2018 _ c missio Expires: 1110112020 r� A V U • r . I TESLA WALL CONNECTOR 1 r 15, (380 mm) •. T,SLn i 6.3" e-16 5° + (160 mm) (140 mm) ss(, 140mm) 7 5�� f ; A� 4I' t'I 4 I 1 Dascrjptiopecifications Voltage and Wiring 208V or 240V AC single-phase: Ll, L2, and earth Current Maximum output:80A, 72A, 64A, 56A, 48A, 40A, 36A, 32A, 28A, 24A, 20A,16A,12A Frequency 50 to 60 Hz Cable Length 8.5' (2.6 m) and 24' (7.4 m) Wall Connector Dimensions Height: 15.0" (380 mm) Width: 6.3" (160 mm) Depth: 5.5" (140 mm) Top Entry Bracket Dimensions Height: 10.8" (275 mm) Width: 5.1 " (130 mm) Depth: 2.0" (50 mm) Weight (including bracket) 20 Ib (9 kg) Operating Temperature -22°F to 122°F (-30°C to 50°C) Storage Temperature -40°F to 185°F (-40°C to 85°C) Enclosure Rating Type 3R Agency Approvals cULus listed for United States and Canada under file number E354307, FCC Part 15. Ventilation Not Required TESLA WALL CONNECTOR (380 mm) SMC c r1 6.3�- e-15 5" " (160 mm) (140 mm) L 4 ; 55'(140mm) 75'(190mm) is i .r V ` 4— Description' Specifications Voltage and Wiring 208V or 240V AC single-phase: Ll, L2, and earth Current Maximum output: 80A, 72A, 64A, 56A, 48A, 40A, 36A, 32A,28A, 24A,20A,16A,12A Frequency 50 to 60 Hz Cable Length 8.5' (2.6 m) and 24' (7.4 m) Wall Connector Dimensions Height: 15.0" (380 mm) Width: 6.3" (160 mm) Depth: 5.5" (140 mm) Top Entry Bracket Dimensions Height:10.8" (275 mm) Width: 5.1 " (130 mm) Depth: 2.0" (50 mm) Weight (including bracket) 20 ib (9 kg) Operating Temperature -22°F to 122°F (-30°C to 50*C) Storage Temperature -40°F to 185°F (-40°C to 85°C) Enclosure Rating Type 3R Agency Approvals cULus listed for United States and Canada under file number E354307, FCC Part 15. Ventilation Not Required TESLA WALL CONNECTOR (380 mm) N r t •. Fi rJ 63'r 55" (160 mm) (140 mm) 55'(140mm) 7 5'(1BDmm) �t„a• G Description Specifications Voltage and Wiring 208V or 240V AC single-phase: Ll, L2, and earth Current Maximum output: 80A, 72A, 64A, 56A, 48A,40A, 36A, 32A, 28A,24A,20A,16A,12A Frequency 50 to 60 Hz Cable Length 8.5' (2.6 m) and 24' (7.4 m) Wall Connector Dimensions Height: 15.0" (380 mm) Width: 6.3" (160 mm) Depth: 5.5" (140 mm) Top Entry Bracket Dimensions Height:10.8" (275 mm) Width: 5.1 " (130 mm) Depth: 2.0" (50 mm) Weight(including bracket) 20 Ib (9 kg) Operating Temperature -22°F to 122°F (-300C to 50°C) Storage Temperature -40°F to 185°F (-40°C to 85°C) Enclosure Rating Type 3R Agency Approvals cULus listed for United States and Canada under file number E354307, FCC Part 15. Ventilation Not Required TESLA WALL CONNECTOR 9 A:5 �`t �• 15 (380 mm) '.5 L C� 6 3" ti 5 6 ' (160 mm) (140 mm) +.;tc 55'(740mm) 76'(190mm)� s, Description Voltage and Wiring 208V or 240V AC single-phase: Ll, L2, and earth Current Maximum output: 80A, 72A, 64A, 56A, 48A,40A, 36A, 32A, 28A, 24A,20A,16A,12A Frequency 50 to 60 Hz Cable Length 8.5' (2.6 m) and 24' (7.4 m) Wall Connector Dimensions Height: 15.0" (380 mm) Width: 6.3" (160 mm) Depth: 5.5" (140 mm) Top Entry Bracket Dimensions Height: 10.8" (275 mm) Width: 5.1 " (130 mm) Depth: 2.0" (50 mm) Weight (including bracket) 20 Ib (9 kg) Operating Temperature -22°F to 122°F (-30°C to 50°C) Storage Temperature -40°F to 185°F (-40°C to 85°C) Enclosure Rating Type 3R Agency Approvals cULus listed for United States and Canada under file number E354307, FCC Part 15. Ventilation Not Required