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HomeMy WebLinkAbout47206-Z SUFfat rtt �o�o COGZ< Town of Southold 4/8/2022 o - P.O.Box 1179 o 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42979 Date: 4/8/2022 THIS CERTIFIES that the building SOLAR PANEL Location of Property: 1305 Rosewood Dr.,Mattituck SCTM#: 473889 Sec/Block/Lot: 113.-2-3 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 11/18/2021 pursuant to which Building Permit No. 47206 dated 12/9/2021 was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: roof-mounted solar panels to existing single-family dwelling as applied for. The certificate is issued to Schmitt,Philip&Suzanne of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 47206 2/8/2022 PLUMBERS CERTIFICATION DATED / d Authorized Signature �o�SOFFot�coTOWN OF SOUTHOLD ay BUILDING DEPARTMENT y 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#: 47206 Date: 12/9/2021 Permission is hereby granted to: Schmitt, Philip 1305 Rosewood Dr Mattituck, NY 11952 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 1305 Rosewood Dr., Mattituck SCTM # 473889 Sec/Block/Lot# 113.-2-3 Pursuant to application dated 11/18/2021 and approved by the Building Inspector. To expire on 6/10/2023. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 uilding Inspector pf SUU��® Town Hall Annex Telephone(631)765-1802 54375 Main Road P.O.Box 1179 sean.deviine-town.southold.ny.us Southold,NY 11971-0959 COUIII�,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Philip Schmitt Address: 1305 Rosewood Dr city:Mattituck st: NY zip: 11952 Building Permit#: 47206 Section: 113 Block: 2 Lot: 3 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Sunrun Installation Sery License No: 33878ME SITE DETAILS Office Use Only Residential X Indoor X Basement Solar X Commerical Outdoor X 1st Floor Pool New X Renovation 2nd Floor Hot Tub Addition Survey X Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser - Single Recpt Recessed Fixtures CO2 Detectors Sub Panel A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks Disconnect 60Ax2 Switches 4'LED Exit Fixtures Pump 11 Other Equipment: 12.920M PV Solar Energy System w/ (38) JAM60S10-340/MR Modules, (2) 60A- AC Disconnects, Combiner Panel , PV Rapid Shutdownx2 Notes: Solar Inspector Signature: Date: February 8, 2022 S.Devlin-Cert Electrical Compliance Form OF SOUTyo6 L4 7 Zb S * # TOWN'OF SOUTHOLD .BUILDING DEPT. • io 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING . [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE &.CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION_ [ ] .FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) ELECTRICAL (FINAL) [ ] CODE VIOLATION ] PRE C/O REMARKS: O (� DATE INSPECTOR pF SOUTyOIo * # TOWN OF SOUTHOLD BUILDING DEPT. cou765-1802 INSPECTION `[ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION/CAULKING [ ] FRAMING /STRAPPING FINAL S01&`- [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [. ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: f ot DATE Z INSPECTOR kllj4(4V' ` 1 Doo Bunch, Connie From: Jen Maher <jen.maher@sunrun.com> Sent: Wednesday, March 23, 2022 12:34 PM To: Bunch, Connie Subject: 1305 Rosewood Dr Mattituck 11952 Photos Hi Connie, Thank you so much for allowing us to submit the electrical failure fix via email. If you don't mind emailing me the electrical certificate once the inspector signs off on it/types it up that would be great, many thanks f - }}i 7� s 1 �R a A ti. t x Jen Maher Solar Technician, Inspections P 631-305-0516 0 [at [2- Fz] Fz] ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 2 av(, V4 EEC [ o FEB BUIt�lPdG DEPT. _ : January 23, 2022 TOW structure ENGINEM Subject: Post Installation Approval Letter . Job:Number:216R-305SCHM Client: Philip Schmitt Address: 1305 Rosewood Dr, Mattituck, NY, 11952 Attn:To Whom It May Concern The purpose of the review was to verify the installation is in conformance with the permitted plan 'set and that any potential modifications from those plans meet the intent of the permitted plan set. The PV.racking system's attachments have been observed to be installed in conformance with-the. . permitted plan set.The installation complies with the code provisions.listed below. -i:2020 NYS Code Books w/2018 IRC/IBC/IEBC,ASCE 7-16, NDS 2018 • Basic Wind:Speed V= 128 mph, Exposure: C •Ground Snow Load=25 psf OF N ►�, E Paul Zacher,P-E. c o ZA.C�,•O,n Professional Engineer T:916:961.3960_x101 . ... . email: paul@pzse.comw XP P0913652 _ - _ R�FESSIONP FIELD.INSPEC�'IC►IYrI +P(!)t�T 'SATE.: CONT�VL NTS FOUNDATION-.(AST)' . FOUNDATION:(2N))): . z. IA ROUGH FILMING& '. y1 PLUMBING. . • O INSULATION ftlk'N 'Y H. STATE ENERGY CODE; , FINAL ADDITIONAL�� 1;NT�' � ILL ;0 05 4 b • , z , � gUFFO("" TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold,NY 11971-0959 oy • o�> Telephone (631) 765-1802 Fax(631) 765-9502 https://www.southoldtomm.gov Date Received APPLICATION-FOR BUILDING PERMIT For Office Use Only PERMIT NO.' 4 1A Building Inspector: NOV 1 8 20L211 Applications and forms must be filled out in their entirety. Incomplete BUILDING DEPT. applications will not be accepted. Where the Applicant is not the owner,an TOWN OF SOUTHOLD Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: SCTM#.1-00.0.- Pr oject 1000-Project Address: Phone#: 3 i �' (o I Email: S Ind Mailing Address: CONTACT PERSON: Name: l� r ,J�rw�uK�v Mailing Address:- t'7-1. Cau��r k Zed weAbv,-`^l t-3`'l 115q.jD Phone#: S 1kL f,.o l U -?Vim( Email:: L;:P�vnns k s��uvc„,,in.eol DESIGN PROFESSIONAL INFORMATION: Name: . _. Mailing Address: >47,65� CA.lxsutp. i- Phone#: C1 ila -`lu 1 - 751(o 0 Email: vq- tE i?uv le p2se.cn CONTRACTOR INFORMATION: Name: S�,.v.rk 1,nS�ctllx�'a� 5e,ruiceS .. Mailing Address: i 5`0 Phone#: (o�� ���®� Email: -Per ts .SuV\ruVS-w . DESCRIPTION OF PROPOSED CONSTRUCTION El New Structure -❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: KPther .,,z -Jy Sa\,,✓ $ ..314a yob Will the lot be re-graded? ❑Yes Po Will excess fill be removed from premises? ❑Yes ❑No �pU P SDt v^GcAul�� 1Z,9ZotZ �kvy►. . . . 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district.in-which premises is situated: Are there any covenants nd restrictions with:respect to this property? ❑Yes o IF YES, PROVIDE A COPY. Check 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 buildings):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(print name): CoVeu vtn� thorized Agent ❑Owner y�,y�.� Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF (A�2.-G•'a �wt✓ being duly sworn, deposes,and says that(s)he is the applicant (Name of individual signing contract) above named,- - (S)he.is the (�'r e✓L� 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 day of: .20 _. Notary. i C5\0 E GIF/ i' P Y R0 % PROPERTY.OWNER AUTHORIZATION -1- No.01oE6338933:• G _. QUALIFIED4N (Where the applicant is not the owner) . _ NASSAI�CONTY: c dy .I, : �J U Z�'l��r� �/h INL U L"C residing at . J I ��t�CO� (Q AFF�NEI\``����` ydo hereby authorize . Ut '2 to apply on mybe If to the Town;of Southold Building:Department for approval as desc ibed herein. wner's Signature TI Date NIC LE IORG T - .. O G E tt- Notary-Public, State of New York - "l � i No. 01616292933 Qualified in:Suffolk County Print Owner's Name Commission Expires November 12,20 _ . 2 .. - c� frEDI' BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 , i Southold, New York 11971-0959 : Telephone (631) 765-1802 - FAX (631) 765-9502 ` rogerrCo)southoldtownny.gov sea ndiu'�southoldfownny.Qov APPLICATION FOR ELECTRICAL INSPECTION' ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Sunrun Installation Services Electrician's Name: Samy Mounas License No.: ME-33878 Elec. email:LiPermits@sunrun.com Elec. Phone No: 5166147891 El I request.an email copy of Certificate of Compliance Elec. Address.: 177 Cantiague Rock Rd Westbury NY 11590 JOB SITE INFORMATION (All Information Required) Name: Philip Schmitt Address: 1305 Rosewood Dr Mattituck Cross Street: Phone No.: 6312985161. BIdg.Permit#: 47206 email:suzannespals@optonline.net Tax Map District: 1000 Section:113.00 Block: 02.00 Lot:003.000 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE(Please Print Clearly): , . Installation of roof-mount solar (38) modules; 12.920kW system. G� Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES ❑V NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES ❑� NO Issued On Temp Information: (All information required) Service Size 1-11 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION dAO (nT116t. r_e,16 Rf Z�S Pf Z Z� soiw �� 6 �j � 1� ISS BUILDING DEPARTMENT- Electrical Inspector 4 � s 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 rogerr .southoldtownny.gov — seand(@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Company Name: Sunrun Installation Services Electrician's Name: Samy Mounas License No.: ME-33878 Elec. email:LiPermits@sunrun.com Elec. Phone No: 5166147891 01 request an email copy of Certificate of Compliance Elec. Address.: 177 Cantiague Rock Rd Westbury NY 11590 JOB SITE INFORMATION (All Information Required) Name: Philip Schmitt Address: 1305 Rosewood Dr Mattituck Cross Street: Phone No.: 6312985161 Bldg.Permit#: 47206 email:suzannespals@optonline.net Tax Map District: 1000 Section:113.00 Block: 02.00 Lot:003.000 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Installation of roof-mount solar (38) modules; 12.920kW system. Square Footage: Circle All That Apply: Is job ready for inspection?: ❑ YES 0 NO ❑Rough In ❑ Final Do you need a Temp Certificate?: ❑ YES NO Issued On Temp Information: (All information required) Service Size❑1 PhF—]3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION ,i �, su urs cQvi c IRIA 'n AR7rM T - DATE ;r the sewage disposal and Wter supplT. "• -:fse les -fnr thin. location have been' inspected by thi depart at dad found , to be'satisfacto�ry.VIE r ,� .. : .. Chief�of.Gener �l Enig3neerit� , se :ceS. / 67 irp s ` . i yox ` - , bra► .. c ( WWII .'..• { , !V Y qJ0{ + s hhhVVs - .- may. .:-.':�. ....-. .... f11►k �. :- � ... - J ... � , s.. -... f N :s. 6 r�'_r�.�� gra" �tj:' . . ���.•�'� �'' . . ... UNAEIEHORItEO ALTERATION OR:ADDITION • .,: 1O;THIS SURVEY IS A VIS)1A710N Of. _ SECTION 7109 OF THE-NEW.N .... ...... /� ,� t E E . A-/,A:S•-(r^l fi��.�� .,dam'fl ` EDUCATION LAW::. COPIES:OF THIS SURVEY MAP NOT BEA THE LAND SURVEYOR'S.INKED,SEAL OR RING EMBOSSED SEAL SHALL,NOi BE.CONSIDERED ID TRUE COPY. r r' •' ,�'��'I r l I! ''��C y�J � �f /. T�PANTfESLINDICATED HEREON SHALL RUN; 7 �• € ti r .T 6I HeLa fMM a4 HIS HALF TOETHERY£ AL AGENCY Y iERE C010.'PAS:Y,u^OYiRithiENi . Af ff//1 _)^/ /� ! 44T11%guam LOTED H.REON,MV -I. C Ji .i �'� 1®71�d►�!S,BrBFS;`•F TISE�k�lG MISTL- . .. - .. ._.. 11UY:Om�ADE iwv irm"T+lfx"TUME, Rea"O R -.. .: .. ...... -. .. 7fO��YIiSQYIIUYT� swafficifim ...... / V t j -1-c- :r W CAC-. 1�5+/��li e d I'%0 ry/l e t/l�l e Ca of f' tf f''j►rg' b'i ft ..¢..�Y` •/,�f �1{�u1(,••.(:•r �.'• f ' ,,, :� t i r J'yG! Q' t , met �l f4.7 C.�'S�/!"1t;.]r:o�% �'.'�,gi-fl� 41 (Fi/f 1 f-!� �..fd.. i^• �" PJ1'`�:f r j.S .t r" ...... f �yr +�'ra .{_ -7,1 L(1r1 ` 12's 81 U - o-i. .. ' .� :.l.. YI _ ,!• .. .. a �.� )..i1...�.G< .8t.5.. .s.JAS%.t s. 3. � .®mnw.e�e�--.+�-...-.....,..�.1 . ... NIW Workers' YORK CERTIFICATE OF sTATe Compensation Board -NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured{use street address only) .. 1b.Business Telephone Number of Insured Sunrun Installation Services Inc. (415)946-7500 . .. . .• 225 Bush Street,Suite 1400 1c.NYS Unemployment Insurance Employer Registration Number of -- San Francisco,GA 94104 Insured : .: 50-86426 4 •: . Work Location of Insured(Only required if coverage is specificafy.limited to id.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.;a;Wrap-Up Policy) Number . 77-0471407 2.Name 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 .3b.:Policy Number of Entity.Listed in Box"1 a" . _- Town Hall Annex Building .. 54375 Route 25 : WC 6142876-00 P O Box 1179 Southold,NY 11971 3c.Policy effective period . 10/0112021 to 10/01/2022-,:' 3d.The Proprietor,Partners or Executive.Officers are X❑ .included.(only check box if all partners/officers included) 0 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"1a"'for workers'-- compensation under the New York State Workers'Compensation Law.(To use this form, New York(NY).must be listed under Item 3 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: Uponcancellation 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: Samantha Furlan (Print name of authorized representative or licensed agent of insurance carrier) Approved by: :Y 2Z-2021. (Signature) - - - (Date)_ - Title: Underwriter .. . Telephone Number of authorized representative or licensed agent.of insurance carrier: (415)538-7125 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.ny.gov SUNRINC-02 TWANG ACO/ [ DATE(MM/DD/YYYY) CERTIFICATE OF LIAB.ILITY.INSURANCE 9/10/2021 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(les)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). PRODUCER CONTACT Walter Tanner NAME: Alliant Insurance Services,Inc. PHONE FAX 575 Market St Ste 3600 A/C,No,Ext): A/C,No San Francisco,CA 94105 EI RIE ,Walter.Tanner@alliant.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Navi ators Specialty Insurance Company 36056 INSURED INSURER B:Zurich American Insurance Company 16535 Sunrun Installation Services,Inc INSURERC:American Zurich Insurance Company40142 775 Fiero Lane,Suite 200 Ph#805-540-7643 INSURER D: San Luis Obispo,CA 93401 INSURER E 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE ]OCCUR LA21 CGL230321 IC 10/1/2021 10/1/2022 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 5'000 PERSONAL 8 ADV INJURY $ 2,000,000 GEN-L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY Fx�JECT F—] LOGPRODUCTS-COMP/OP AGG $ 2,000,000 X OTHER:Retention:-$1001000 Per Project Agg 10,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 Ea accident. $ X ANY AUTO BAP614287700 10/1/2021 10/1/2022 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident $ X Foe,Ded.: X Con.:Not Covered Liability Ded.: 250,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED F7RETENTION$ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ERH X WC614287600 10/1/2021 10/1/2022 1,000,000 ANY PROPRIETORIPXCLUDEEXECUTIVE E.L.EACH ACCIDENT $ (Mandatorylln NH)EXCLUDED? ® N/A 1,000,000 E.L.DISEASE-EA EMPLOYEE $ If Yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L:DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation Policy WC614287600 Deductible:$1,000,000. Evidence of insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED'POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED,REPRESENTATIV E ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks.of ACORD uric Workers' CERTIFICATE OF INSURANCE:COVERAGE STATE Compensation Board: UNDER THE NYS DISABILITY BENEFITS LAW PART 1:, To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone:Number of Insured Siinrun Installation Services Inc 8457268-2595 595 Market Street,29th Floor 1c.NYS Unemployment Insurance Employer Registration Number of San Francisco,CA 94105 Insured WO'rk Location of Insured_(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) Id..Federal Employer Identification Number of Insured or Social Security . Number 15 Charlotte Ave- 77-0471407 Hicksville,NY 11801 2.Name-and Address of Entity Requesting Proof of Coverage 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 Route 25 C&52830-NY P.O.Box 1179 Southold,NY 11 971 3c.Policy effective period 01/01/2018 to 12/31/2020 4.Policy covers:. ® A.All of the employer's employees eligible under the New York Disability Benefits Law E] 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 Benefits insurance coverage as described above. Date Signed January 26,2018 By (Signature of insurancecairices autiiorized repiesentative or NYS Licensed Insurance Agent of diat insurance carrier). Telephone Number 973-548-6389 Title Statutory Disability Coordinator IMPORTANT: If Box"4a"is 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"is checked,this certificate is NOT COMPLETE for purposes of Section,220,,Subd.8 of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance'Unit,328 State Street;$chdhdctady,NY 12305 PART 2.To be completed by the NYS Miker-s'Compensation Board(Only if Box"4b"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 Benefits Law with respect to all of his/her employees. Date Signed pBy Signature of NYS Workers'Compensation Board Employee) Telephone Number Title Please Note. Only insurance carriers licensed to write NYS disability 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 (9-15) �`,".+,\ r" . v ,\ :.-,-' �•--•.^:"`..,- ,:` 1:" t;:r. ..a"+{.;,A�. :i%',ter"'.'- al`» �:...,^``'ri„"�.'"• .i�^-r..•,f;>-`t -.`,7'+a\ - ^.•.�- a:• .. �+,'r�t,.a%M1i,:„•,t� �'a)f,19�,�±?.. 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J.t t Consumer Affairs >>i VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 !� ` ' I;I t DATE ISSUED: 10/1/2003 No: 33878-ME 1•, �' '`9.��ri i' E+}P%1,��< drat SUFFOLK COUNTY ,fir<t � rl baster Electrician .license , 11 This is to certify that SAMY A MOUNAS � doing business as t ;! SUNRUN INSTALLATION SERVICES INC ll Navineven satisfactory evidence of com etenc is hereby licensed as MASTER'ELECTRICIAN in accordance i" i sli with and� subject to the provisions of applicable:laws,rules and regulations of t � ' the County of Suffolk,=State of New York. E 1 s ' Additional Businesses NOT VALID WITHOUT ! -' I � t /J�^ ,' DEPARTMENTAL SEAL �la) E AND A CURRENT )�}trM ti1ly t' CONSUMER AFFAIRS ID CARDt �j. x. 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