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Home My WebLink About47259-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 #: 47259 Date: 12/22/2021 Permission is hereby granted to: Tsoupros, David 129 Locust St Floral Park, NY 11001 To: Install roof mount solar to existing single family dwelling as applied for. At premises located at: 1860 N Bayview Road Ext., Southold SCTM # 473889 Sec/Block/Lot# 79.-6-3.4 Pursuant to application dated 12/2/2021 and approved by the Building Inspector. To expire on 6/23/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-RESIDENTIAL $50.00 Total: $200.00 Building Inspector 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) 765-9502hqPs: � wsoutholdtownov Date Received APPLICATIONIL IPERMIT For Office Use Only —, PERMIT NO.___ Z — Building Ins Sectora Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant Is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:11/17/21 OWNER(S)OF PROPERTY: Name:David Tsoupros scTM#1000- Project Address:1860 N Bayview Road Ext, Southold, NY 11971 Phone#:516-776-4224 1Email:david.tsoupros@gmaiI.com Mailing Address:1860 N Bayview Road Ext. Southold, NY 11971 CONTACT PERSON: Name:Reid Garton Mailing Address:385 W John St. Unit 100, Hicksville, NY 11801 Phone#:516-418-2131 Email:permitting@nystatesolar.com DESIGN PROFESSIONAL INFORMATION: Name:Naresh K. Mahangu Mailing Address:124-15 Metropolitan Ave. Kew Gardens, NY 11415 Phone#:646-626-6299 Email:filing@srsolardesign.com CONTRACTOR INFORMATION: Name:NY State Solar Mailing Address:385 W John St. Unit 100 Hicksville, NY 11801 Phone#:516-418-2131 1Email:permitting@nystatesolar.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑' OtherSOlarpanel installation $71,081 Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? ❑Yes ONO 1 PROPERTY INFORMATION Existing use of property: Intended use of property: � f Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes C7 No IF YES,PROVIDE A COPY. Checlf Box Afteredig: Thi onerjcontreetorJdeidrf psofesiol Is rnsllte for tlreae anistorm water Issues rovidd by C ranter i€3ri of the Town Code.WuCATION IS HERE11rMADEAo the Building-Department for the€ssua a of a buildini Permit;pursriant to the suilding zone ordinimce of the Town of sotithold,Suffolk,County,New York and other a pn 6le t aws,Ori>nanc s or Regulations,for the coristructi r}f hulidings, addittMsi ei !stints for moval Apr demolition as herein describe l h arft iitosfo"o m0ty Frith nil applInbte laws,ordmancesbulloing coo, housing code and regulations andto admit author kin drrpiu1640 46i rrecesiary lnspec iais.False steteritetits made herein are pdolshahle as a dass A misdemeapor pursuant toSectlon 210AS of tiro dew York State Penal Law. Application Submitted By(print name):P, � tl�Authorized Agent ❑Owner Signature of Applicant: _' Date3 STATE OF NEW YORK) SS: COUNTY OF ° km� being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the j z. (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 /-0- 1A 0 - `�_,e day of I Z :� Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) t : '1 _ residing at i do hereby authorize to apply on nyy behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date 4 Print Owner's Name 2 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 rocierrs sou nold£ownn- cv s and� cut oldto� l APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 12/22/2021 Company Name: Ny State Solar Name: Jamie Minnick License No.: ME-62692 email: permitting@nystatesolar.com Address: 385 W John St Unit 100 Hicksville, NY 11801 Phone No.: 516-418-2131 JOB SITE INFORMATION (All Information Required) Name: David Tsou ros Address: 1860 N Ba view Rd Extension Southold, NY 11971 Cross Street: Phone No.: 516-776-4224 Bldg.Permit#: Z 1email: permitting@nystatesolar.com Tax Map District: 1000 tion: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) 12.80kW Roof Mounted Solar Photovoltaic System Including 32 Q Peak DUO BLK ML G10+400 Panels w/32 Enphase IQ7+Microinverters. 60Amp Fused Service Disconnect.Fused at 60Amps. 1-Enphase Envoy IQ Combiner Box with 3 20Amp Breakers. 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 Request for Inspection Form.As NORTH BAYVIEW ROAD EXM S 73-40-W' E A" qs �t -NOW Av M Dom- mm__= POW"WES AR�IAI AM ap ` ngg A __RLA�U pe _��_,Ac _Oh 6ft ,- 'MM309 pff5av FW *,f 0 45 �WC�_ 1� A� v f�Lm�,� `Q-0,Aft . ..... ... - M, ��'g 4�— 6 rw��ffv?s %ff �v�n w Mcm rm R% AW U�w N_ Amff__ rzm%_ w WC, OR, E-i fmokk WP-, _�x CCX_,�T", NEVR !And sw�=m ma and Em—s— Be- aa mmuxtQc*� rm DO- 1 -0, m.-aim 60" MOM,v" I Workers' CERTIFI CATE OF EqYN(m)"T I I Compensation pard Y is.Legal Name&Address of insured(use street address only) tb,0hm T8190-oneT8190-one Number of Ing red NY State Solar LLC 516-419-2131 385 W John St,Unit 100 tri NYS UnOmPloirnwrd Insurance Employer Registralloin Number of Hicksville,NY 11801 InSured Work Location of Insured 1 requked If e is VeOwaffyNmfied to t d. I o ti n Number r of i tel rid In- Y ,Ia.a td Number 32-OS8007 2.Name and Address of Entity Requesting f of Coverage 3a.Name of Insurance Carder (Entity .ng Listed as the CertificateHolder) Indemnity Insurance Co.of North America Town of Southold 3b.Policy Number of Entity Listed In Box'la' 54375 Route 25 WLR 068959755 P.O.Box 1179 Southold,NY 11971 3c•Policy effective period 3/1/2021 to 3/1/2022 3d.The Proprietor,Partners or Executive Officers are ® Included.(Orgy check box if all partners/od9cens induded) 1- all excluded or certain partnersloificers excluded. This that Insurer carder indicated above in box`3"Insures businessreferenced ref abovein ax`1a-f workere compensation u New York State Work Compensation Law. Toa this form.Now Y (NY)must be listed under ft=3A on the INFORMATION PA of the workeW compensation insurance potion). The insurance Carder or its licensed agent will send the Certificate of Insurance to the entity listed above as Me certificate holder In lox*2#. The insurance ler must notify the above cartificato holder and the WorkeW Compensation rd wfthin 10 days IF a Policy is canceled due to nonpayment of premiums or within 30 days IF them are reasons other than nonpayment of premiums that n ;the policy or eliminate the insured from the coverage indicated this Certificate.(Those notices may be sent by regularmail.)Otherwise,thts Certificate Is valid for one year after this form is approved by the insurance carrier or Its licensed agient,or until the policy expindlon date listed In box'U",whichever Is earlier. This certificate is Issued as a matter of information only and confers no runts upon the cortiftate holder.This Certificated s 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. Ploase Note:Upon cancellation of the !vomponsaMon policy indicated on this form,It the business continuesto be naaned on a permit,license or contract Issued by a certificate holder,the business,most provide the certificate holklor with a now Certificate of Workers'Compensation Coverage or otherh d proof that the business Is complying with the mandatory coverage require the Now Yom State Workers'C n Law. Linder Penalty of Po4ury.I cerft that I am an authorized representative or licensed agent of the insurance carrier referenced a and that the owned Insured has the c a as depicted on this form. Approved by: Kevin Groves (Not nme of aulbodzed representative or licensed agent of insurance cartipr) 4Approved by: 11119/2021 (Signature) (pate) Title: Vice President Telephone Number of authorized representative or licensed agent of insurance carrier.469-445-3619 Please Note:Only Insurance carriers and their licensed agents are authlorlized to issue Form C-105.2.Insurance brokers are NOT authorized to Issue It. C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering Into contracts unless compensation Is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contrdct,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 compensation for all employees has been secured as provided by this chapter. C-105.2(947)REVERSE Worke-s' YORK CERTIFICATE OF INSURANCE COVERAGE STATE Compensation 13oa-d DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW . o eco late is iii a i fly Leave ane is Carrier r License Insurance ant oft a C rrir 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured NYSS LLC DBA.NY STATE SOLAR 385 W JOHN ST UNIT 100 5164182131 HICKSVILLE,NY 11801 Work Location of Insured(Only requiredif coverage is specificallylimited to 1c.Federal Employer Identification Number of Insured certain locations In New York State,Le.,Wrap-Up Policy) or Social Security Number 32-0580074 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of outhold Standard Security Life Insurance Company of New York 54375 Route 25 =3b.Policy Number of Entity Listed in Box"l a" P.O. Box 1179 T20186-000 Southold, NY 11971 3c.Policy effective period 1/7/2018 to 11/18/2022 4. Policy provides the following benefits: 7 A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: 7X A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. F-1 B.Only the following class or classes of employees 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 de-said above. Date Signed 11/19/2021 By (Signature of Insurance camer's aushoraid renesenmmvve or NYS''censed.nsurance Agent of zhm insurance Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES 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 carder,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 5B of Part I 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) I Telephone Number Name and Title I 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) Illll P°°�"1°1°0°°1°°t�1�N1°�1� °�IIII7) Additional Instructions for Form 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"la"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.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 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 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 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 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. D191-120.1 (10-17)Reverse R 11//1717/22021021 Y) CERTIFICATE OF LIABILITY INSURANCE DATE / THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 policy(ies)must be 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 Joseph Price Joseph P.Price Jr Insurance Brokerage Inc. PHONE Eft 631-509509 F : Priceagy.comE-MAIL Joseph@pdceagy.com P.O.BOX 171 INSURER(S)AFFORDING COVERAGE # NAIC# Mt.Sinai, NY 11766 INSURER A: Southwest Marine&General Insurance Company 12294 INSURED INSURERS: New York Marine&General Insurance Comany 16608 NYSS LLC. I_NSURERc: Southwest Marine&General Insurance Company 12294 DBA NY STATE SOLAR INSURER D: 385 W JOHN STREET INSURER E: HICKSVILLE,NY 11801 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. am ADOUSUOR I POLICY EFF POLICY EXP TYPE OF INSURANCE ; L _ _ i r I POLICY NUMBER ) LIMITS X COMMERCIAL GENERAL LIABILITY ( EACH OCCURRENCE $ 1,000,000 [( REN = CLAIMS-MADE �OCCUR 3 PF'iEA1ISEStF� S -$ 100,000 MED EXP(Any one person) _$ 5,000 A PK202100018285 07/01/2021 07/01/2022 pERsoNAL a ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY L jE T F-1LOG _: PRODUCTS-COMP/OPAGG ,S 2,000,000 [ ,$ Ip i i j AUTOMOBILE LIABILITY e_ W.EE LrMITIs 1,000,000 ANY AUTO BODILY INJURY(Per person) ;$ B ;ALL OWNED SCHEDULED 3 AU202100017053 07/01/2021 ',07/01/2022 BODILY INJURY(Per accident)j$ :AUTOS AUTOS NON-OWNED 1 - PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pawdentl $ UMBRELLA LU1B X_OCCUR EACH OCCURRENCE $ 3,000,000 C X EXCESS LIAB CLAIMS-MADE I EX202100001570 07/01/2021 107/01/2022_AGGREGATE 1$ 3,000,000 DED X I RETENTION$ 10,000 i Is WORKERS COMPENSATION _ `- `PER i AND EMPLOYERS'LIABILnY ,,/N .ANY PROPRIETOR/PARTNER/EXECUTIVE I - =E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? _N/A 3 = -_ (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEq$ If yes,describe under I DESCRIPTION OF OPERATIONS below - 'E.L.DISEASE-POLICY LIMIT j$ A Installation FloaterPK202100018285 07/01/2021 ,07/01/2022; Occurrence $50,000 , DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Description:Solar energy contractor,including operations,maintenance,and panel installation.Electrical work and oversight of subcontractors. Evidence of insurance. 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 Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 PO BOX 1179 AUTHORIZED REPRESENTATIVE Southhold NY 11971 Joseph Price @ 1988-2014 AC05IRWEORPOIRATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD vtt#fit#R"wUlicy LjC c.UI Labor,Licensing on u er Affairs NOME IF-PROVEFIENT LICENSE Name REID T GARTON .< Business Name chis Cert#fies that the ?eerer is duly lioensed NYSS LLC DSA )y the County of suffolk License plumber:FII-62273 Rosalie Drago Issued: 0610312019 Commissioner Expires: 0610112023 2#f = 7i\ N 2 � \\\ �Va\: \ }ƒ: m = c 7 - K S \ o} I