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Home My WebLink About48745-Z �" r TOWN OF SOUTHOLD �" nU BUILDING DEPARTMENT TOWN CLERK'S OFFICE N SOUTHOLD, NY ,w ,grok'' 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#: 48745 Date: 1/18/2023 Permission is hereby granted to: Luhrs Maryweld Rvc Trt c/o Margery Fields 600 Teepee Trl Southold NY 11971 To: Install roof mount solar to existing single family dwelling as applied for. Disconnects must be located on the exterior, labeled and readily accessible. At premises located at: 600 Tepee Trail, Southold SCTM # 473889 Sec/Block/Lot# 87.-2-24 Pursuant to application dated 12/5/2022 and approved by the Building Inspector. To expire on 7/19/2024. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-RESIDENTIAL $50.00 Total: $200.00 ` f 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) 765-9502 httj2s://w,wwsotitholdto,wntiy.gov Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only .w � PERMIT N0. � Building Inspector: Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an �l Owner's Authorization form(Page 2)shall be completed`. OFS OMD Date: 11/30/2022 OWNER(S)OF PROPERTY: Name: Margery Fields SCTM#1000- 087.00-02.00-024.000 Project Add11 ress: 600 Tepee Trail, Southold, NY 11971 Phone#: (610) 864-7705 Email: margeryfields@me.com Mailing Address: 600 Tepee Trail, Southold, NY 11971 CONTACT PERSON: Name: Ines Fernandez (EmPower CES, LLC.) Mailing Address: 4589 Austin Blvd., Island Park, NY 11558 ,o Phone#: (516)-544-4592 Email: permitting@empower-solar.com DESIGN PROFESSIONAL INFORMATION: Name: Gregory D. Sachs Mailing Address: 4589 Austin Blvd., Island Park, NY 11558 Phone#: (516)-544-4592 Email: permitting@empower-solar.com CONTRACTOR INFORMATION: Name: EmPower CES, LLC,. Mailing Address: 4589 Austin Blvd., Island Park, NY 11558 Phone#: (516)-544-4592 Email: permitting@empower-solar.com DESCRIPTION OF PROPOSED CONSTRUCTION El New Structure ❑Addition ❑Alteration ❑Repair [:]Demolition Estimated Cost of Project: CXOther Roof mounted solaranels $49,904.49 Will the lot be re-graded? ❑Yes 1XNo Will excess fill be removed from premises? ❑Yes ®No 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Residential 1 Family Residential 1 Family.. _ y Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑YesXNo IF YES, PROVIDE A COPY. Chet k''B x-Aft r Reading:, The ownec/contractor/designprofessional 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): Ines Fernandez MAuthorized Agent Owner Signature of Applicant: w�M��.. te: ' Ryan M.Moser NOTARY PUBLIC,STATE OF NEWYORK STATE OF NEW YORK) Registration No.01M064125M SS: Qualified in Nassau County COUNTY OF ) Commission Expires December 28,2024 Ines Fernandez being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the 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 a, day ofpnu�l 20 Notary Public P1l PIl..`Jll 1 Y OWNERALP rI°1IIIA"'P IN (Where the applicant is not the owner) Margery Fields residing at 600 Tepee Trail, Southold, NY 11971 do hereby authorize Ines Fernandez to apply on my behalf to the Town of old Building Department for approval as describ he;ein, ZZ Owner, "s Signa't a Date n r L� o- Prin ner's IName 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 , ro err southoldto rnnv. ov— seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Au information Required) Date: 11/30/2022 Company Name: EmPower CES, LLC, Name: Timothy Cirott License No.: ME-65990 email: p ermittin em owe solar.com i Address: 4589 Austin Blvd., Island Park, NY 11558 Phone No.: (516)-544-4592 JOB SITE INFORMATION (All Information Required) Name: Margery Fields Address: 600 Tepee Trail Southold NY 11971 Cross Street: Phone No.: (610)864-7705 Bldg.Permit#: email: _ marge!Aields@me.com Tax flap District:_ 1000 erection: 087.00 Block:02.00 Lot:.024.000 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Installation of roof mounted solar panels (32)SPR-415w ACPV modules 13.28kW totals stem size Circle All That Apply: Is job ready for inspection?: YES<j& 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.xls NI F PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nyilf'COm CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 622407627 �• " AMWINS BROKERAGE OF NEW YORK 200 ELWOOD DAVIS ROAD SUITE 200 ' LIVERPOOL NY 13088 SCAN M VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER EMPOWER CES LLC TOWN OF SOUTHOLD 4589 AUSTIN BLVD 54375 ROUTE 25 ISLAND PARK NY 11558 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE Z 2546 624-4 563452 05/01/2022 TO 05/01/2023 04/12/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2546 6244. 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. 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.COMICERTI CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY AFFORDS COVERAGE TO THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. DAVID SCHIEREN GREG SACHS EMPOWER CES LLC 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 moommomm AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,I SURANCE FUND UNDERWRITING VALIDATION NUMBER: 263370983 1111 � �1lnllwalr�lllwlllllr�l[ItrwN■I 0000000000010��I0013=3 318T5 87411111 Form WC.MT-NOPRETY V=d m 3(08292019)[WC Policy-254662441 U-26.3 163 MOWo103n&e4J[aooia0002s4662441*#II15M-79][cuLw-aw-iI i-mi] EMPOCES-01 ABELL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) n 5/612022 .............. ......... ........ --- 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. _._........... ww....................... 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 endorsements. PRODUCER License#0757776 CONTACT HUB International Insurance Services Inc. PHONE )568-5900_.._ �AAa�NSI Q310„�568.90 1600 Corporate Pointe CE-MA,No,Ext):(310 98 Suite 600 b POR �_ Culver City,CA 90230 —..____ INSURER(S).A—FFQRDING COVERAGE INSURER,A:Southwest Marine&General Insurance,Company 1.2294 _ . c INSURED INsuw; waa ,�a11�es River Insura..nCe,Gomn 12203 EmPower CES LLC c I D land Park,NY 11558 wE suRER _. . INSURER F: .................-.. ....._........ ........ COVERAGES CERTIFICATE NUMBERREVISION 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 CONTRACTOR 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. A X COMMERCIAL GENERAL -�. .... E INSR WOOL SUER POLICY EFF POLI .. .- TYPE OF INSURANCE POLICY N 1 �� T I yl UMBER / ICY EXP DA LIMITS EACH OCCURRENCE $ 500 000„ E ERAL LIABILITY EACH TO RENTED CLAIMS-MADE X OCCUR PK202200006109 514/2022 5/4/2023 $ XIh�FiE2�wlfl S Ged ....� ... _..._ 5.,,000 MED FX�Any one..P.erso,L�... Y_ _ PERSONAL&ADVINJURY $ 1,000000 % T--- LOC PRODUCTS COMP/GPA POLICY �i, , 00,000 EI�MLARE ATE LIMIT APPLIES PER: GNERALAGGRE $ E GATE GG $ 2,000,000 000 .__.........._._............__-1.11-......____.. ............. ..__.. ............. _ ., _..�.,..... ......... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ t5q ----- ANY AUTO BODILY INJURX OWNED SCHEDULED AUTOS ONLY AUTOS 9ODII.Y INJIJRY(Peraccidenk) S H RED NON-OWNED P OPERTY DAMAGE .m,,, C Ccwden� ,., __ ATOS ONLY AUTOS ONLY i �-.-- •• ...... $ B UMBRELLA LIAB X OCCUR EACH OCCURRENCE 000'000 __$ 11'._.__.. X EXCESS LIAB CLAIMS-MADE001306870 5/4/2022 5/412023 ,. _ 0,000 � � ac�PERnTF.._. - A_m$ 5,00 �� DED RETENTION$ WORKERS COMPENSATION oTH- AND EMPLOYERS'LIABILITY Y/N -m--__s_ T�J:�. .. � — - ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L,.EAGI"1�G,CIDE.N,T _$... ,,.,,,,-,,........................................., OFFICER/MEMBER EXCLUDED? (Mandatoryin NH) 171,DISEAS. F/ EM,P,LOYE $ ,.,_..... If yes,describe under DESCRIPTION OF OPERATIONS below __ _ E.L DISEASE-POLICY IT _L__...... 1: .. ...... .... ....... DESCRIPTION OF OPERATIONS f LOCATIONS i VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder IS listed as additional insured per attached endorsement#GL0202 0218. .................. ............... ............................. ......... 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 ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Route 25 Southold,NY 11971 ............................................... ....._.. ...................... AUTHORIZED REPRESENTATIVE ./” ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NEW workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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 carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured EMPOWER CES LLC DBA EMPOWER SOLAR 310-534-7994 4589 AUSTIN BOULEVARD ISLAND PARK,NY 11558 1c.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) 522407627 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 Route 25 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL252634 3c.Policy effective period 05/10/2021 to 05/09/2023 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: © 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 5/9/2022 By Via 4f (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that 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 46,4C or 513 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. DB-120.1 (12-21) 1�1IIII11 ° IIIIII DB 120.1 (12-21) n Cn( _\ $ , S ■ e &2 7 M g2 f o /i° X E kE ; 2 \m z 2 m � % @0 § 3 C \ % t rr ® ■ m k § S § z / w 0 o Cl ;o # Cl om f m Z. \ 2 m$ .J , > z � o \ 8 � 9 / @CD 8 ° En q 2� ) a� 7 / a Suffolk County Dept.of Labor,Licensing&Consumer Affairs MASTER ELECTRICAL LICENSE Name TIMOTHY M GROTTY Business Name This cedi es that the Empower CES LLC DBA 3earer is duly licensed �y the County of suffolk License Number:ME-65990 Rosalie Drago Issued: 11112/2021 Commissioner Expires: 11/0112023