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Home My WebLink About46623-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 46623 Date: 7/27/2021 Permission is hereby granted to: Kubtm Jacob _... ...... .. ---11—..----------...-.--1 255 Knollwood Ln ........ _wwww............. _______. _.wwww____....... ._ _...., _.................... _.. _...._. Mattituck, NY 11952 To: install roof-mounted solar panels with energy storage system to existing single-family dwelling as applied for. At premises located at: 5 Knollwood Ln., Mattituck SCTM # 473889 Sec/Block/Lot# 107.-6-11 Pursuant to application dated 7/16/2021 and approved by the Building Inspector. To expire on 1/26/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $........................� 200.00 ilding Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall.Annex 54375 Main Road P. 0. Sox 1.179 Southold,NY 1.1971-0959 Telephone (631) 765-1802 hax (631) 765-9502 �g �://v , a�� haiaNaaaut ss�a Date Received I C. .� u LI I F BUII DI PES D ��a�-.:� � For Office Use Only a� PERMIT NO. .... � _ Building lnspe(tor. .. 2021 . ...,__ _..._.. Applications and forms must be filled out in their entirety.Incomplete 111'i[L1)VgG Hl. .1 applications will not be accepted. Where the Applicant is not the owner,an PP P PP Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: Jacob T. Kubetz SCTM#1000- Project Address: 255 Knollwood Lane Mattituck, NY 11952 i(0. 2 05 Phone#: 631-766-6397 Email: jacobkubetz@gmail.com Mailing Address: 255 Knollwood Lane Mattituck, NY 11952 CONTACT PERSON: Name:Tesla Energy Operations,lnc./Anais Fernandez Mailing Address: 15 Grumman Rd West Suite 400 Bethpage, NY 11714 Phone#: 631-406-9567 email: anafernandez@tesla.com DESIGN PROFESSIONAL INFORMATION: Name: Equilux Engineers LLC Mailing Address: 4129 Brittany Drive Ellicott City MD 21043 Phone#: 443-416-7800 Email: hkariuki@equiluxengineers.com CONTRACTOR INFORMATION: Name:Tesla Energy Operations,lnc./Anais Fernandez Mailing Address: 15 Grumman Rd West Suite 400 Bethpage, NY 11714 Phone#: 631-406-9567 J Email: anafernandez@tesla.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure E--]Addition 2Alteration ❑Repair ❑Demolition Estimated Cost of Project: 29,055 Will the lot be re-graded? ❑Yes E2No Will excess fill be removed from premises? ❑Yes V1No 1 PROPERTY INFORMATION Existing use of property: Residential Intended use of property: Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? []Yes ONO IF YES, PROVIDE A COPY. 12 Check Box After NReadin : The owner/contractor/design rofessional is res responsible for all drainage and storm water issues as li� P p g provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted B runt name): Anais Fernandez DAuthor'zed gent F—JOwner° Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF Nassau Anais Fernandez being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)he is the_mmm__..m_..... .._.._ _ contractor/agent _.. ... ...... ................_. ._ __ _......_m. (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this t day of r .n._...___ww...�420 Notary Public ZP�RQPIII��M-- _.......,... JTI�IIIII �� IIII 1 "ALEXuAND—SRW,, KOMAPOLWANY Ork (Where the applicant is not the owner) No.01KAM1991 , residing at hereby a u t h o r i ze.___.._..... M.....n. �......_. _._........_......_. ____,to apply on my behalf to the Town of Southold Building Department for approval as described herein. ................_mw_ Owner's Signature _._..__�... g Date Print Owner's Name 2 i muumwwam mouuo . G- 'i uil in a art ent A Ii ti�an AUTHORIZATION (Where the Applicant is not the Owner) I, � a�' residing at (print property owner's name) (Mailing Address) ma��nf�z do hereby authorize Tesla Energy Operations,Inc. (Agent) Anais Fernandez to apply on my behalf to the Southold Building Department. (Owner's Signature) (Date) (PrintOwner's e) M491m)G;McCoy"i,Em poria o:ac�a�sss, "UNA,t i �t` s' YORK CERTIFICATE OF STATE i NYS , COMPENSATION INSURANCE COVERAGE Board ............ address only) 1 a.Legal Name&Address of Insured(use street a s - - Telephone Number of Insured �..b....Business Tele ho ... ............"�___.w__._ ..._.._._.. ............�._-._w..�....__..... 650-963-5100 Tesla Energy Operations,Inc, 901 Page Avenue 1c.NYS Unemployment Insurance Employer Registration Number of Fremont,CA 94538 Insured 49-892777 Work Location of Insured(Only required if coverage is specifically limitedto 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 02-0781046 _...__.. ........................-..------- ......... _..._. 2.Name and Address of Entity Requesting Proof ofCoverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1a" 54375 Main Road WC 1074583-03 Southold, NY 11971 3c.Policy effective period 10/31/1,020 to 10/01/ Q21 ..._ 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 1 a"forworkers' _.._n._m,.. _,_..........._... compensation under the New York State Workers' Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business 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: Susan B. Kendziora (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title:Vice President-Enterprise Support Operations Telephone Number of authorized representative or licensed agent of insurance carrier:800-382-x2150__ Please Note:Onlyinsurance carriers and their licensed agents are authorized to issue Form C-105.2.Insura brokers m..... ' g Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.wcb.nv.qov INTERNAL USE ONLY i,, MW i.4W Workers' CERTIFICATE OF INSURANCE COVERAGE .. rATr i Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed b Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Age p_ Y Y Y _ ^„^........��.�.._.� _ _____._. nt of that Carrier 1 a.Legal Name&Address of Insured(use street address only) � 1b.Business Telephone Number of Insured..www_.......... ._www_.. Tesla Energy Operations, Inc. 901 Page Avenue Fremont, CA 94538 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required ifcoverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 02-0781046 2.Name and Address of Entity Requesting Proof of Co Y 4 9 0 overage 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"1a" 54375 Main Road CG-51526-NY Southold, NY 11971-0959 3c.Policy effective period 01/01/2021 to 12/31/2022 4. Policy provides the following benefits: Q A.Both disability and paid family leave benefits. ❑ B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: Q 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. November 25 2020 Date Signed ..w...... _..... ' 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. oCompensation �� PART 2.To be completed b the NYS Workers' Board(Onl ifBox4c or5B of Part l 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. ,Dale Signed By m _...(Signature of Authorized NYS Workers' .w..,w.w.....�,.....�_.__� ................. .. .. (Sin ur orkers'CompensaYon board Employee) Telephone Number Name and Title ........ ..... .... ......................_ ..... ..... ..w.....__._._. . _.__............................ Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 1111111�]1 1°1 °1°111 ° 1° 11°111111!" °° °°° °° Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name CHARLES J PICARD it Business Name This bearer is uly!'c 9w TESLA ENERGY OPERATIONS INC d by Lhe County of su'folt License Number:HI-62558 Frrr+k,Na4vW i, Issued: 9112/2019 Comn*sane• Expires: 9/1/2021 e y.. RECEIPT SUFFOLK COUNTY GOVERNMENT DEPARTMENT OF LABOR, LICENSING,AND CONSUMER AFFAIRS COMMISSIONER ROSALIE DRAGO P.O. BOX 6100, HAUPPAUGE, NY 11788 (631)853-4600 Today Date: 03/22/2021 Application: ME-37295 Application Type: Master Electrical License Receipt No. 421664 Payment Method Ref. Number Amount Paid Payment Date Cashier ID Comments Check 149 $400.00 03/22/2021 CHRIST11 Renewal Contact Info: JASON KANE INC JASON KANE 127 WEST BLVD EAST ROCKAWAY, NY 11518 Work Description: / Suffolk County Dept.of Labor,Licensing&Consumer Affairs e, MASTER ELECTRICAL LICENSE Name JASON KANE e Business Name This cerlIfles that the bearer is duly licensed JASON KANE INC by the County of suffolk License Number:ME-37295 Rosalie Drago Issued: 04/20/2005 Commissioner Expires: 04/01/2023