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Home My WebLink About47062-Z ria 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#: 47062 Date: 11/1/2021 Permission is hereby granted to: Bournis, Kyriakos 1300 Bay Haven Ln Southold, NY 11971 To: install roof-mounted solar panels & energy storage system to existing single-family dwelling as applied for. At premises located at: 1300 Bay Haven Ln, Southold SCTM # 473889 Sec/Block/Lot# 88.-4-17 Pursuant to application dated 10/18/2021 and approved by the Building Inspector. To expire on 5/3/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 Buil i sector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 <` Telephone (631) 765-1802 Fax(631) 765-9502 ' [t :., £, tlllt :10 _� Date Received APPLICATION IPERMIT For Office Use Only PERMIT NO. Building Inspector:: l i L Applications and forms must be filled out in their entirety.Incomplete BUILO:ke-�j_t' applications will not be accepted. Where the Applicant is not the owner,an TOWN Or BODY` L D Owner's Authorization form(Page 2)shall be completed. Date:10/13/2021 OWNER(S)OF PROPERTY: Name: Kyriakos Bournis SCTM#1000- Project Address: 1300 Bay Haven Lane Southold, NY 11971 Phone#: 718-362-0617 Email: kbournis@gmail.com Mailing Address: 3030 150th Street Flushing, NY 11354 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:Barun Corp./Yurianto Yurianto Mailing Address: 905 Chesterfield Drive Lower Gwynedd PA 19002 Phone#: 972-896-5373 Email: yuriy@barun-corp.com CONTRACTOR INFORMATION: Name:Tesla Energy Operations,lnc. Mailing Address: 15 Grumman Rd West Suite 400 Bethpage, NY 11714 Phone#: 631-406-9567 Email: anafernandez@tesla.com DESCRIPTION OF PROPOSED CONSTRUCTION Install(16)Roof Mount Solar Panels 6.8kw and(1)Tesla Energy Storage system 13.5kwh =flew Structure ❑Addition ❑Alteration ❑Re air ❑Demolition Estimated Cost of Project: I�stell(16) Roof Mount Solar Panels 6.8kw and(1)Tesla Energy Storage system 1k $ 15,864 Will the lot be re-graded? Dyes No Will excess fill be removed from premises? ❑Yes . No 1 Is 119 2-q PROPERTY INFORMATION Existing use of property: - Intended use of property: Lin Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes CGW'IF YES, PROVIDE A COPY. deck Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as 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 210AS of the New York State Penal Law. Application Submitted By ftint name): n de-7— Ol4uthorized Agent ❑Owner Signature of Applicant: �, Date: STATE OF NEW YORK) SS: COUNTYOF being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, - (S)he is the � l C-t&/` (Contractor,A ent,C rporate Officer, etc.) of said owner or owners, and is duly authorized to perform—for 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 day of AA 20clPA'vrRIZULLO Notary Public NOTARY PUBLIC-STATE OF NEW YORK No,01ZU6328662 Oualifled in Suffolk County � Ir-E My Commission Expires 08-03-20V'C (Where the applicant is not the owner) I, � i/c3-S f�`� residing at I � ��fyerl _()fha I C1 do hereby authorize to apply on my behalf to toe Town of Southold Building Department for approval as described h�rein. Jr 1 -� Owner's SignatureDate All Print Owner's Name 2 NEW Workers' YORK CERTIFICATE �-- STATE ! Compensation Y S' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use"street address only) 1 b.Business Telephone Number of Insured ] 650-963-5100 1 Tesla Energy Operations,Inc. 901 Page Avenue 1c.NYS Unemployment Insurance Employer Registration Numberof Fremont,CA 94538 Insured 49-892777 Work Location of Insured(Only required if coverage is specifically limitedto certain locations in New York State,i.e.,a Wrap-Up Policy) 1d•Federal Employer Identification Number of Insured or Social Security Number l 02-0781046 2.Nage and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Town of Southold Southold, NY 11971 3b.Policy Number of Entity Listed in Box"1 a" 3Main Road WC 1074583-03 3c.Policy effective period 10/31/2020 to 10/31/2021 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' 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 gate 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: _14cza„c cl:�-, � 1.0�31J200 (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. C-105.2(9-17) www.wcb.nv.aov INTERNAL USE ONLY NEW Workers' CERTIFICATE OF INSURANCE COVERAGE STA' Compensation iBoard 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) 1b.Business Telephone Number of Insured Tesla Energy Operations, Inc. 901 Page Avenue Fremont, CA 94538 `1c.Federal Employer Identification Number of Insured Work Location of Insured(only wir d if coverage is specifically limited to or Social Security Number certain br-afans in New York State,i.e_,Wra"p Policy= 02-0781046 12.Name and Address of Entity Requesting Proof of Coverage i 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 13c.Policy effective period 01/01/2021 to 12/31/2022 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. I Date Signed November 25, 2020 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 i Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 413,4C 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 56 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. DB-120.1 (10-77) M-1120.1 (10-17a°�IIII Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name CHARLES J PICARD Business Name rhis certifies that the �eerer is duly licensed TESLA ENERGY OPERATIONS INC :)y the County of suffolk License Number:HI-62558 Rosalie Drago Issued: 09/12/2019 Cammissloner Expires: 09/01/2023 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 MASTER ELECTRICAL LICENSE Name JASON KANE _ Business Name This certifies that the bearer is duty licensed JASON KANE INC by the County of suffoik License Number:ME-37295 Rosalie Drago Issued: 04/20/2005 Commissioner Expires: 04/01/2023