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HomeMy WebLinkAbout47075-Z y 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#: 47075 Date: 11/4/2021 Permission is hereby granted to: Owens, Mark 21 Devon St Malverne, NY 11565 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 2550 Reeve Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 100.-1-10 Pursuant to application dated 10/21/2021 and approved by the Building Inspector. To expire on 5/6/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 I Building Inspector F4 TOWN OF SOUT OLD-BUILDING DEPARTMENT Town epho el(63I)Annex 54375 {�3}P.0 9 021179 Southold,NY 11971-0959 - -- _ Date Received APPLITION CAI M PE _R _ 1 n For Office Use Only _e t. 41 PERMIT NO, Building Inspector- I L= U BUILDING Applications and forms must be filled out in their entirety.Incomplete TOWN OP SOU" IOL=: applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization farm(Page 2)shall be completed. Date: 10/19/2021 i OWNER(S)OF PROPERTY: #' L — Name: MARK OWENS SCTM#1000- ! I Project Address: 2550 REEVE RD MATTITUCK,NY 11952 Phone#: 5162636318 Email: markowens173@yahoo.com Mailing Address: 2550 REEVE RD MATTITUCK,NY 11952 CONTACT PERSON: Sung Lee Name: Momentum Solar Mailing Address: 45 Fairchild Avenue,Plainview NY 11803 Phone#: 5162185824 Email:permitsli@momentumsolar.com DESIGN PROFESSIONAL INFORMATION: ( Name: Mina A.Makar - I Mailing Address:30968 Hamilton BLVD,South Plainfield NJ 07080 r Phone#: 7329026224 Email: mmakar@momentumsolar.com i CONTRACTOR INFORMATION: , t Name: Momentum Solar(Sung Lee) Mailing Address: 45 Fairchild Avenue,Plainview NY 11803 Phone#: 5162185824 Email:permitsli@momentumsolar.com DESCRIPTION OF PROPOSED CONSTRUCTION a ❑New Structure ❑Addition ®Alteration ❑Repair ❑Demolition Estimated Cost of Project: ®Other Solar Panels $ 21,000 Will the lot be re-graded? ❑Yes G'No Will excess fill be removed from premises? ❑Yes ❑No j r f r S Building IIartmt AIIIilatin AUTHORIZATION (Where the Applicant is not the Owner) I� MARK OWENS residing at 2550 REEVE RD MATTITUCK, NY 11952 (Print property owner's name) (Mailing Address) do hereby authorize Sung Lee (Agent) to apply on my behalf to the Southold Building Department. 10/19/2021 (Owner's Signature) (Date) MARK OWENS (Print Owner's Name) tA saw ui co LO 1 0 J2 saw 0 • � J2 X - - o 4.0 75 c 6 dam c. } a�a US tin m CN 41 LIU �Q! LLAL ZZ f- Qwj 1 WAg 122, AT EE s V ensatio . mCERTIFICATE OF INSURANCE COVERAGE Top Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.Tobe 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 PRO CUSTOM SOLAR LLC DBA MOMENTUM SOLAR 3096 HAMILTON BOULEVARD (732) 902-6224 SOUTH PLAINFIELD,NJ 07060 i Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 27-1242539 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier I (Entity Being Listed as the Certificate Holder) First Unum Life Insurance Company I 'TOWN OF SOUTHOLD 154375 ROUTE 25 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD , NY 11971 955431 3c.Policy effective period 11/01/2020 to 11/01/2021 4. Policy provides the following benefits: ❑X A.Both disability and paid family leave benefits. B.Disability benefits only. F C.Paid family leave benefits only. I 5. Policy covers: QX 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: I I 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 10/29/2020 By KBSBy Brad (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 207-575-1519 Name and Title DBL Specialist '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 5B 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 (10-17) 1 ! II I I Ilillll (10-17) II lil I I III 111Pi =120.1 Additional Instructions for Form 1313-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Craw,The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed 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 cancelled 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 coverage indicated on this Certificate. (These notices my 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 Folder. 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note, Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the b usiness continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate bolder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17)Reverse ` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)04/15/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or he endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER otarcT Lisa MacDonald AAI CISR Brown&Brown Insurance of Delaware Valley PHONE {732)504-2001 FAX (7321504-2011 lA/C Na Ext): No): 2000 Midlantic Dr,Suite 440 ADORESS, Imacdonald@bbdvins.com I INSURER(S)AFFORDING COVERAGE € NAIC# Mt Laurel NJ 08054 = INsuRERA: Colony Insurance Company 39993 INSURED INSURER B: Zurich American Insurance Company 16535 Pro Custom Solar LLC dba Momentum Solar INSURER c: Evanston Insurance Company 35378 Momentum Home Services Holdings LLC dba Momentum Home INSURER D 45 Fairchild Ave,Suite B INSURER E Plainview NY 11803 INSURER F COVERAGES CERTIFICATE NUMBER: 21-22 NY Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSRAUUL POL CY F POLICY EXP LTR TYPE OF INSURANCE IN >?YVO' POLICY NUMBER iMMIDO/YYYYI MiI1.�D LIMfrS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 CLAIMS-MADEJ OCCUR PREMISES IEa c 4>� $ 250,D00 MED EXP(Anv one person) $ 10,000 A ] PACES4257993 s 04121/2021 04/2112022 PERSONAL&ADV INJURY $ 1,000,000 I GEN'LAGGREGATE LIMITAPPLIES PER: ; j GENERAL AGGREGATE $ 2,000,000 POLICY PRO PRODUCTS AGG $ —� JECT LOC 2,000,000 I OTHER: I Professional Liability $ 1,000,000 AUTOMOBILE LIABILITY j ) [ i COL B.tEO ILE:.tR}i $ 2,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED r AUTOS ONLY AUTOS I BAP 1873088-02 04/21/2021 ` 04/21/2022 BODILY INJURY(Per accident) $ S HIRED NON-OWNED { AUTOS ONLY AUTOS ONLY t € PROS DAMAGE � {Por 2, d&Ela I $ UMBRELLA OCCUR ) EACH OCCURRENCE _$ 5,000,000 C EXCESS LIAB MKLV4EFX102983 04/21/2021 04/2112022 AGGREGATE I$ 5,000,000 CLAIMS-MADE i DED RETENTION$ € $ WORKERS COMPENSATION i PER 0TH- ` AND EMPLOYERS'LIABILITY STATUTE ERY/N ) ANY PROPRIETOR/PARTNER/EXECUTIVE [ OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L,DISEASE-EA EMPLOYEE $ If yes,describe under _._._._.... DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Excess Limits Clarification CGL$5M xs$1 M LC MKLV4EFX102983 04/21/2021 04/21/2022 Auto$4M xs$2M I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Middle Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds Momentum ��_-r�cea Power YY. Power � ted® M=4�ntum Roofina and Solar, `'o-en um >-onfiLLo OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC NES W r s �_m CERTIFICATE F ATr Com s NYS R COMPE COVERAGE Board � g e .- —R&Aad .a_= -- ed.c=z!�U�aC =y Illy €a � si es= fiumbw off rsrrec - - dba Mow rl Cs-=r 30-0 Har 1 r NYS une'r-moyment insurance Em-1110�r RegisilliM !Ner:.tucs u!&20' at N, -War cr ao i Id sevwi 7_y ais ,r New e on.Sri_ 6,c ?o- 4evi Town of Southold 53095 Middle Road Southold, NY 11971 lo NJI LV C"_ € e pe,Q ?,E fine =roar r,[ 0nw r--R ot 7x vc C�Nl rs are 91 F KK IU6_d IN WrE111 parfrcrsjofficers exr1,,.-_c. I' c,e€`i es tI at the 1 -=�r<5���r,�r di_,a.er abo-e in box"3`at?�4:���Pt3�!�a�i��a�r�t��r�r i�� �a In box"ea=`terwo—kers' rnprm,ixia,i under t1e Now York Stag 110crke-s`Corn,_—_nswio1 Pw,{To us_a this forinr New York(NY"must be Bated und4r€Le.,m un the WORMA71 N PAGE of the w ke s'comp-ensittion 1naLs ncaolivt). _e Insurarca C <=r or iii 1.c-cn_-_ad a� Wil I scid this pri f caia al nsu-jnLe to i e en i., €et-_�d3 above as the f atm`r-older n fox .l .,o II z�-V_ A!_— �.<i�€ -`' 1,i:days or 2 policy ba �cance Iled'or ion-a-wrier'•••.; c3 pm.mi ti m n :L thin 'rl;;y.s if <g '€7`-r-_ tasc _ l- _ t=,: s ooh r4°7i €-rtllrS _t `�=if7°i '� r I I �: a maim;L.-lif >e¢r'sor ie.the and ul -. ?`E„curIbIrS ;o is€=scow m a q gtle_,o1 in rrrn ;gin o0y a d confers w r<ghis upon the ced ficate holdler-This ceridle-ale does-.ze _ enj .- R t'„nc mFir€F e Plovwarae afforced by Me Micy fismd,nor doeS •t corgt=ar ariv i€` is or to rSib«r[W-s be o.fo those rueinc r�eien ed o-oi cv, -Ns c@ it 'ate-a—�3e uspdl, s fwiririnre,of n'0;or#.fir_q'Comnen t n cuss*md of instirance oniv wh?l>. the underlyingRohe`°e rr el!ecs. Please etas n r-ancu-11a#on of the worke.--s'co€ Pens1 n llcy indicated on this form,if the business coati"u"to b2 nw-rod on a par€ it,lin ea or conimet rszued by a corgificam hot r:th a business must proiiiide that ceftificato holder with a stew,'Ce .gicnte of Workers'a?v C-P_ s-3tHn Coverage or other authorized proof that the business 1b com-plying with the mandatory covara e requirernents of the New York Srata orhefs'Compensation Law. 1.fnrinf prngz y of perjLlry=I gentIfy that 1 am an atuthonzad re ro§ nt ttve or licensed a t of the hisurance carrier reforenced abo-c and th3t the garner insured hat;she coverage im tkipicted on,h;s%rest. ,_., >� e_ ���;��� �.��tit' �:r _ej .- l-U_ O a., - A >. {,. 4/8/2021 hI.-: �.c urr_- xmcer[Vie Tnjop one I}sur ibmr. of cL ttr:rized r e=r esenM-tivd a ?icax.sed agenI est Irisur ice canis" 32-504-e 0031 Please -ter Only insurance carriers and their licensed agents are authorIzed to issue Form C-105.2.Insur-InCo brokers are NQT authorized to issue 4 jai F-_(9-15 1