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HomeMy WebLinkAbout48714-Z . TOWN OF SOUTHOLD " � 'w;, BUILDING DEPARTMENT k TOWN CLERK'S OFFICE SOUTHOLD, NY u y 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#: 48714 Date: 1/10/2023 ITITITITITITITITITITITmmm Permission is hereby granted to: Hands, Venetia...������......._._.. .�........................... _.. _.........�...... �__....��..... _ PO BOX 398 57 Orient, NY 119.. ............. __. _.. .v.._. �.r ...... _.............._. To: Install roof mounted solar panels to a single family dwelling as applied for per manufacturers specifications. At premises located at: 255 S View Dr, Orient SCTM # 473889 Sec/Block/Lot# 13.-3-11.3 Pursuant to application dated 11/17/202 2 and approved by the Building Inspector. To expire on 7/11/2024.mmmmm Fees: SOLAR PANELS $50.00 CO- RESIDENTIAL $50.00 ELECTRIC $100.00 Total: X- mmmm ITITITITITIT $200.00 .. _ _-- Building Inspector Zoho Sign Document ID:DSUXUUVUXX7UREUS2UTBYU6IVWHNPKXHPNXWEFK4Z_8 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 htt :d'/ww-wv,. otbtholdto iii .,,(Z(°v "w,�q,srs atl Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only a LV "- PERMIT NO. 96 111 Building Inspector, Y -. F 1 7 "91� Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an mm, Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: Christine Novack SCTM#1000- 3 — Project Address: 255 South View Dr. Orient Point NY 11957 Phone#: 917-363-4445 Email:' Mailing Address: CONTACT PERSON: Name: Charles Jacabacci Mailing Address: 7470 Sound Ave.,Mattituck, NY 11952 Phone#: 631-388-7041 Email: charles.jacabacci@e2sys.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: =mail- CONTRACTOR INFORMATION: Name: Element Energy LLC Mailing Address: 7470 Sound Ave.,Mattituck, NY 11952 Phone#: 631-779-7993 Email: permits@e2sys.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure J71Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ✓Other 10.8 kw?,W mounted solar PV system (28) QCELL Q.PEAK DUO BLK $ 73,468.00 Will the lot be re-graded? ❑Yes ✓No Will excess fill be removed from premises? ❑Yes ✓ No 1 Zoho Sign Document ID:DSUXUUV(3XX7UREU52UTBYU6IVWHNPKXHPNXWEFK4Z_8 PROPERTY INFORMATION Existing use of property: Residential Intended use of property: Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Residential Zone AC this property? ❑Yes ✓No 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 building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name): Charles Jacabacci ✓Authorized Agent ❑Owner Signature of Applicant: Date: Oct 14 2022 STATE OF NEW YORK) SS: COUNTY OF Suffolk Charles Jacabacci 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 (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 Public PROPERTY OWNER AU1 110111-1111ZArliON (Where the applicant is not the owner) I, Christine Novack residing at Christine Novack do hereby authorize Element Energy LLC to apply on my behalf to the Town of Southold Building Department for approval as described herein. Oct 14 2022 Owner's Signature Date Christine Novack Print Owner's Name 2 YOP workers' CERTIFICATE OF INSURANCE COVERAGE s1tATt Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 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 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 54375 MAIN ROAD 3b. Policy Number of Entity Listed in Box"1a" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01/01/2022 to 12/31/2023 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. Date Signed 7/20/2022 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent ofthat insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer 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 emailed to PAU@wcb.ny.gov or it can 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 4B,4C or 5B have 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(Article 9 of the Workers'Compensation Law)with respect to all of their 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. D13-120.1 (12-21) I I 111111111111111111III I 1�1 DB-120. 1 (12-21) 47--qll\N� SIF New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE, NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE 111 w' . ^^^^^" 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 ° *rye ," HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF RIVERHEAD DBA ELEMENT ENERGY SYSTEMS 755 EAST MAIN STREET 7470 SOUND AVENUE RIVERHEAD NY 11901 MATTITUCK NY 11952 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449444-5 493712 07/13/2019 TO 07/13/2020 11/19/2019 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: 627860999 U-26.3 DATE(MMIDDNYYY) C"R131 CERTIFICATE OF LIABILITY INSURANCE 11/19/2019 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). PRODUCER NT`A' T NAME. ROBERTS,FEDE INSURANCE AGENCY PtaoNE '1534'a$54760 .... .....................................I4"WC -631-38'5-1766 �"............. P No Eredi 23 GREEN STREET,SUITE 102 E h1A(L S:ES HUNTINGTON,NY 11743 �A�"'""DOR �'_ """"" ROBERTS.FEDE INSURANCE INSURER(S)AFFORDING COVERAGE NAIC# -AC'CEPTANICE INDEMNITY INSURANCE ........ . ................ .... ........,. ....... .... ......... ,,,,. INSURER A: INSURED .............. INSURERS.STATE INSURANCE FUND................. ` Element Energy LLC INsuRERG:AMTIFS'UST'NORTRAMERI'C'A--- --- - ELEMENT ENERGY SYSTEMS INSURER D 7470 SOUND AVENUE INSURER E MATTITUCK, NY 11952 _._.....- ......... .... INSURERF: COVERAGES CERTIFICATE NUMBER: 112lu REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPEOFINSU ............. ,.�...�.� ... ��m""""""""""" I TRRR ................ INSURANCE pi)DLISUFSpi,J. """POLIGY N,,,....... .. .. .. ,.� POLICY EFF 1 POLICY EXP LIMITS UMBER MMI D MM09 BILITY .....COMMERCIALGENERAL LI ! l m1 A nOCCURRENCE s cG ncs) ±$ 1„0 00,000 XCL00275204 7/14/2019 7/14/2020 X �X DAMnGEY RENTED OCCUR 100,000 �...�....... A J 5000 -------_------ -MED EXP(Any one persan) $...... ............... ...,�00 _ ADV INJURY i$ 1000000 PERSONAL& GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE .. PROCOMPIOP AGG 2,-OOO O POLICY ..... ...-� LOC DUCTS............ ...- OO OTq-IER:. AUTOMOBILE LIABILITY COMBINED 9INGLE LIMIT 1 $ ANY AUTO BODILY INJURY(Per person) $ BODILY INJ.... ............................µ,�.... .......,.......,. OWNED SCHEDULED AUTOS r f URY(Peraccident) $ HIREDAUTOS ONLY '� AUTOS ONLY NON-OWNED ONLY PR R0PERT`"P DAM,h"iC3'1=.. ._ ...... _„„_,,,,_ { I AUTOS I I I IA X MBRELLA LIAR OCCURCLAIMS MADE EACH OCCU , , I XLOOOI 1240 7/14/2019 7/14/2020 AGGR GATERRENCE J $- 1 OOO OOO, EXCESS LIAB D... ED RETENTION$ ( i$ WORKERS COMPENSATIONAND EMPLOYERS'LIABILITY �24494445 7/14/2019 7/14/2020 - - �,X- ,,a.F ItJ:7E ( "�”F_RH 1 OO�,OQI) B fANY OFFICERER EXCLUDED ECUTIVE X N E.L EACH ACCIDEINT1111 $ /(Mandatory in NH) ❑ NIA X I EL DISEASE EAEMPLOYEE#'$ ...-.-,_.,.000,00.1. If yes,describe under DESCRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT $ NY State Disability WDLI0279340 7/14/2019 7/14/2020 statutory DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER LISTED IS AN ADDITIONAL INSURED CERTIFICATE HOLDER. CANCELLATION Town Of Riverhead SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 755 East Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Riverhead, NY 11901 AUTHORIZED REPRESENTATIVE Robs. FedeSr. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD