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HomeMy WebLinkAbout47573-Z k�t 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 #: 47573 Date: 3/21/2022 Permission is hereby granted to: Vilardi ..F.ra.n.k.......... ........ ............... _..._._.__ a. ............................................... ...................... _.........._.. 2145 Havwaters Rd Cutchogue, NY 11935 To: Install roof mount solar on existing sinlge family dwelling as applied for. Disconnects must be located on the exterior, labeled and readily accessible as per code. At premises located at: 2145 Haywaters Rd., Cutcho ue SCTM....#....47,3$$9 y.......................__....._ww_______ .............. Sec/Block/Lot# 111.-7-3 Pursuant to application dated 2/17/2022 and approved by the Building Inspector. To expire on 9/20/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-RESIDENTIAL $50.00 Total: $200.00 . ..............A------------......................................................................................... Building Inspector a waw TOWN OF SOUTHOLD —BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 g frp Telephone (631) 765-1802 Fax (631) 765-9502 htt w Eldv m rN sout io Idt.owl,ii ,j,,L)y Date Received APPLICATI0111Y FOR BUILDING KIM I For Office Use Only I NO PERMIT NO. Building Inspector.............. ..._ ��} w�._ ............... Applications and forms must be filled out in their entirety.Incomplete BUILINL` G DEPT. applications will not be accepted. Where the Applicant is not the owner,an °'FOWN OF SOU"I"HOLD Owner's Authorization form(Page 2)shall be completed. Date: � '.. OWNER(S)OF PROPERTY: Name. 111 �� v'/� .moi SCTM # 1000- / �� �v�L,�0',: _ 0 ,. Project Address: Anl ell' Phone#: C, 3 SOV Email: Mailing Address: „ � CONTACT PERSON: Name: . l�eC�,dGfii Mailing Address°, Al'�"' � �--- Phone#: / 7/e/ .� G:-3 Email: / .. �a DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Z_ 6-C Mailing Address: Phone#: Email: 7/,� 1�llCs .�, . F DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther riL $ " e��..~~___ Will the lot be re-graded? ❑Yes Ji I No Will excess fill be removed from premises? ❑Yes f 1 Zoho Sign Document ID:987VWBXVVEUU--XI FUBPMA6AAZNLT87VB0NLW3FJJ6l PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covena is and restrictions with respect to this property? ❑Yes o IF YES, PROVIDE A COPY. s as provided by iapctw�' er e i eow r/c r/ gnp L aIle ibleforalld [ a rI 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 buNdings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all appNeable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and In buildings)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 220AS of the New York State Penal law. Application Submitted By(print nam ): ' '/e Authorized Agent El Owner Signature of Applicant: Date: -02-fi6l,2- Z STATE OF NEW YORK) q SS CO U NTY O F ` ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the ' (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 Ply.........._d a of JL.DEBRA A Notary Public N&01 °( OWNER � °� My ComRsdssiam Expite.s `- i �W re the applicant is not the owner) p. residing a do hereby authorize ll� a' to apply on my behalf to the Town of Southold Building Department for approval as described herein. v�,t,,, Feb 16 2022 _................. .......... ......e .......... m ��_. .p Owner's Signature Date ..................................... " �.................... .M. w_..__..� Print Owner's Name 2 ZI ILDING DEPARTMENT- Electrical Inspector N1 , TOWN OF SOUTHOLD a tTo all Annex - 54375 Main Road - PO Box 1179 aTelephone (6311) 765-1802 k FAX (6310 765-9502 4V r g rr southoldto n . w a nq@,so uL lt wn APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Electrician's Name: " License No.: ���" � Elec. email', 20.1 L, r s Elec. Phone No: iLil 7.2 " I request an email copy of Certificate of Compliance Elec. Address.. ,u� � JOB SITE INFORMATION (AII Information Required) Name: ,.. Address: "l t' Cross Street: Phone No.: Bldg.Permit#: " � � email: Tax Map District: 1000 Section: //0 Block: � Lot: % � BRIEF DESCRIPTION OF WOR%, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: � YES P NO Issued On Temp Information: (AII information required) Service Size 1 Ph F]3 Ph Size: _..._—A # Meters w Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground verhead #Underground Laterals 1 n2 R H Frame Pole Work done on Service? F Y ON Additional Information: PAYMENT DUE WITH APPLICATION Ir: Compensation NEW r rs• s�rrCERTIFICATE OF INSURANCE COVERAGE --.,w Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Uce..n......s....e..M.Md.M.M.MI.nM.M.sM.Mu.....mr_am..n.._c...,e Agent of that Ca.r....r...'.e._rmmm_. 1a.Legal Name&Address of Insured(use street addressonly) 1b.Business Telephone lephonee Number of Insured N �-mm^ ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e., Wrap-Up Policy) 823336604 2. Name and Address of Entity'Requesting Proof of Coverage -.M...w. 3a. Name of Insurancearrierriemmmmmmm�mm r (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 54375 Main Rd 3b,Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL567527 3c. Policy effective period 91/01/2021 to 12/31/2022 4. Policy provides the following benefits: WJ A. Both disability and paid family leave benefits. El B. Disability benefits only. F] 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 penury, I certify that i am an authorized representative or licensed agent of the insurance carrier referenced above and that t............ n e named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/15/2021 By ................w. " �i (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) p 516-829-8100to Chief Executive„ fficer___.�.. Tele hone Number ,,,.......w. ..... .µ,µ„ Name and Title ..Richard _hl ._. ... . ........ 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 ( f Box or 56 of Part 1 has been the.........ww.,._wwwwwww_. p Only ichecked) 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 _._._... ......................... ______.........__,�.. ........m __. .---- (Signature,,. .,_... _....___ ....,.... of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title . _w�r�w�� Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed.'.'.'_M.....v. ce ea e b ed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. t DB-120.1 (10-17) 1�� III � I III II III I III DB 120. 1 (10-17) +V DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 7/15/2021 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 have ADDITIONAL INSURED provisions or 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). PRODUCERONTA T NAME ROBERTS.FEDE INSURANCE AGENCY 0466& 631-385 1760 FAX -631-3854765 $II&JI .y..r€ .....____ www........ ... ............... Ai Ca ......... ---------- 23 GREEN STREET,SUITE 102 E HUNTINGTON,NY 11743 ADDRESS: __." __"_ ROBERTS.FERE INSURANCE ,,. INSURER(S AFFORDING COVERAGE NAIC# ATLANTIC CA0AL'TY"INS.-CO: —52421 INSURER A _ INSURED .... .SSE INANCE UNCSJJC� IN INSURERB: Element Ener LLC SHELTER POINT"POINT 81434 9Y INSURER C: ELEMENT ENERGY SYSTEMS INSURER D: 7470 SOUND AVENUE INSURER E: MATTITUCK, NY 11952 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 LTR ,... X XBRi ..,.. ,,,,,., .......POLICY EFF POLICY EXP 1....., ..., .. LIMITS COMMERCIAL GENERAL LIE POLICY NUMBER Mt._.I.,I, ? .�I, MMI D INSR ABILITY ADt3L SU � EACH OCCURRENCE $ TYPE OF INSURANCE� � X � occuR CL00275204 7/14/2021 7/14/2022f� ��i �,a, �El�� t,t ) 3,000,000 -- 1 CLAIMS-MADE E it ,. mtarrt r $ 100,000 A MED EXP(Any one person) $ 500I 'll0 IMA389203 7/14/2021 7/14/2022 PERSONAL&ADV INJURY $ 3000000 GEN'L AGGREGATE LIMIT APP LIES PER: GENERAL AGGREGATE $ 3,000,000 F��,0.T ... COMP/OP L0071L111CF111 EI LOC PRODUCTS COM P AGG $ ,3000000 : $ 3 AUTOMOBILE LIABILITY $ COMBINEDSINGLELflMfT ... ANYAUTO ! BODILY ......... ....... ,.,,, ,,, ..... INJURY(Per person.) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ ..,_.,_.,... AUTOS ONLY , AUTOS RRCTrc'"ER.''T'1"I:riP,fAF,O'E '. $.. ...... ........ . .... NON-OWNED HIRED AUTOS ONLY AUTOS ONLY .......... UMBRELLA LIAB OCCUR EACH OCCURRENCE $ ee EXCESS LIAR 7CLAIMS-MADE 1....AGGf@ELATE DFD RFTENTION$ $ PER OTH- WORKERS COMPENSATION 124494445 X ,STATUTE.,. ,.FR AND EMPLOYERS'LIABILITY y/N 7/13/2021 7/13/2022 " ANY PROPRIETOR/PARTNER/EXECUTIVE "" EL EACH ACCIDENT $ 1,000.000 B OFFICER/MEMBER EXCLUDED? x N I p` I (Mandatory in NH) EL DISEASE-EA EMPLOYEEI $ 1,000.Q-00,If yes,dascnbo under DESCRY"PiOtd OF OPERATIONS belowE L DISEASE-POLICY LIMIT $ (� NY State DBL DBL567527 1/01/2021 1/01/2022 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED CERTIFICATE:HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold NY11971 AUTHORIZED REPRESENTATIVE ZC ber 1.S. Ft'. , ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AMI-1-�N\ NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) ^^"^^ 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 r l . HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD DBA ELEMENT ENERGY SYSTEMS 54375 MAIN ROAD 7470 SOUND AVENUE SOUTHOLD NY 11971 MATTITUCK NY 11952 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449444-5 706281 07/13/2021 TO 07/13/2022 7/15/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 444-5, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY, THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:438572026