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HomeMy WebLinkAbout48872-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT P 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#: 48872 Date: 2/7/2023 Permission is hereby granted to: Volinski, Mark 805 Theresa Dr Mattituck, NY 11952 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 805 Theresa Dr, Mattituck SCTM # 473889 Sec/Block/Lot# 115.-15-7 Pursuant to application dated 1/20/2023 and approved by the Building Inspector. To expire on _ 8/8/2024. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 Building Inspector J 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 hlWs://www.southoldtowmy, FAPPLICATION FOR BUILDING PERMIT Date Received For Office Use Only PERMIT NO. Building Inspector: �-2 ////iii Appl�a c�bs�t#tlfor`m�must be fll�e��fufi�irl therrer�tiret�+ lncotxrpfete �///rr ,,a i(ication�w fl t be actw� t � WI1er he,„ IM�a, '�f ��tr ;,.� Date: rrr rr 01AI11� S)/aF PROPEJ�TI / r Name: Mark Volinski =CTM#1000- Project Address: 805 Theresa Drive, Mattituck, NY 11952 Phone#: 516-658-7247 Email: mvolinski@aol.com Mailing Address: 805 Theresa Drive, Mattituck, NY 11952 ONTA'CT,PERSON� r Name:Reid Garton Mailing Address: 132 West 31st, New York, New York Suit 1300 Phone#: 516-418-2131 Email: permitting@nystatesolar.com r ......... DESIGN P //,ROFESSIONAL INFORMATION ,,,,,,,,rr;;;rrr,, Name:Robert Masone Mailing Address: 132 West 31st, New York, New York Suit 1300 Phone#: 516418-2131 Email: permitting@nystatesolar.com r rar„/: rro r/r' rri / ../Vii/ /i%,✓riir„ fi ri c. ioDi, lfiri,. r/i,,,,,,,,,;'///i/iruir,%//%// ,,,, V/iii/rug,,, „✓�,;,,,,��,,,,,,,,, i///////i ///i � E i rri/�����%///////%// Name:Reid Garton Mailing Address: 132 West 31st, New York, New York Suit 1300 11 P 11 hone#: 516418-213111, Email: permitting@nystatesolar.com r ri�r rri ri iri or%r III';: IP-r!0N OF PROPi�SED CONSTRUCTION 7,77/77 ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: E0 Other Solar Panel $ 32,@74.10 Will the lot be re-graded? ❑Yes CRNo Will excess fill be removed from premises? ❑Yes [:]No 1 "PR OPERTYJNFOitMATION Existing use of property: Sin lt� iviily ��S,cVnn Intended use of property: �Sin�le >^an � des jciQhtl Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes FX[No IF YES, PROVIDE A COPY. J05#66," ' er Reid! g The►swne�/contractor/design profess►onii rEspZOOnsiblefor all drainage end storW►+water issues as prded�►J� Cha�r}er 236 o!f the Tawn Code gPPtm [tCATIdN`I3`HEIi�BY'MAUE to the euildin epare r tho,�ssuance of a Building Permit pursttant to the ou►Id►ng Ione ,r r �Cf C ,%! , � i ,�/////„/,;//r tdi an of the Tawn'of S ethald,Suffolk;bounty Newyork and'ather a IiUalble l ews,0 dinars es;or Rosulatidhij or,tha construixion of buii , /r ,,,/„„ii rr ,% r ,,,,,, ,; ;: r,„/;r„ /„ io,,,.� ,,, ,6oi r, rori /,,,//:/ir,✓iiiiii,,,,, "W/1”r%/!/�/ adds ions'%'alterations,or for remo al''r,dernalitian as Here►n described Th a liwnt a tees t car►1piY wrkh all applica le laws,ordinances,b�ild►ng cct e, , ,/ ///f�/, 7/r %/%r///iiiiio „,,///„ �,,,,�//r, ,v„ ;eev,,';,,,',,; ,,, ,,,,///i i%%//fir✓�i%��,,,, :,,,ri0� rig,//�„/i ,ri ri ;,,, ,,,,, i, ;;, �;;yr/i ous►n code a�re Wations arrd to;adir►titi-authanzed Inspectors an rem►ses Bnd mbuildi�►g�)far rfecessa ,ms ec#ioos False statements made herein alfa o, "P un►shabld�as a Crass A mrsdem►!anorpursuant to Sect►an 210 45 oft he iVe►o=Dark Stata Penol� w ,,,,,,,,, pp Y(pname): ." .1 ,. ❑Owner Application Submitted B tint (]Authorized Agent� �. Signature of Applicant: � � Date: STATE OF NEW YORK) SS: COUNTY OF Reid Garton being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Reid Garton (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 - -� .. r ;''day of Notary Public NA THIC111,IS 1PROPERTY OWNEF1DTH ORl Tll' N (Where the applicant is not the owner) <c— 5 a 2075 I, Mark Volinski residing at 805 Theresa Drive Mattituck NY 11952 do hereby authorize Reid Garton to apply on my behalf tGGAo//.�•.the Town of Southold Building Department for approval as described herein. Mark �ski(Nov 21,2030 EST) Nov 21,2022 Owner's Signature Date Mark Volinski Print Owner's Name 2 BUILDING DEPARTMENT-Electrical Inspector TOWN OF SOUTHOLD � g Town Hall Annex - 54375 Main Road - PO Box 1179 4.` Southold, New York 11971-0959 71 k Telephone (631) 765-1802 - FAX (631) 765-9502 u ro err southoldtownn . ov seand sotholdtownn . ov w M APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail Information Required) Date: Company Name: NYSS Name: Jamie Minnick License No.: - (Q 1,&S Z email: permiffinganystatesolar.com Address: 13.2 West 31§t. New York New Y rk Suit 130+0 Phone No.: 516-418-2131 JOB SITE INFORMATION (All Information Required) Name: Mark Volinski Address: 805 Theresa Drive Mattituck NY 11952 Cross Street: Phone No.: 516_658-7247 Bldg.Permit#: Lfemail: mvolinsWi@aol.com 11 Tax Map District: 100!6 Section: Block: Lot: BRIEF DESCRIPTION OF WORK (Please Print Clearly) Grid tied fixed roof mount solar panel installation . i Circle All That Apply: Is job ready for inspection?: YES / NO Rough In Final Do you need a Temp Certificate?: YES N 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 # Under rSnd Laterals 1 u Promo Pula Work none on Service? Y N Additional Information: 4 w PAYMENT DUE WITH APPLICATION 7710 7W1 a.„ orrs' CERTIFICATE OF L0 F TATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE oar 1 a.Legal Name&Addressof Insured(use street address only) 1b.Business Telephone Numberof Insured 516-418-2131 NY State Solar LLC 1c.NYS Unemployment Insurance Employer Registration Numberof 385 W.John St.,Unit 100 Insured Hicksville,NY 11801 id.Federal Employer Identification Numberof Insured or Social Security Work Location of Insured(Onlymquiredifcoverage is specificallylinited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 32-0580074 2.Name and Addressof Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed asthe Certificate Holder) Indemnity Insurance Co.of North America 3b.Policy Numberof Entity Listed in Box"1 a" Town of Southold WLR C71145232 54375 Route 25 3c.Policy effective period P.O.Box 1179 3/1/2022 to 3/1/2023 Southold,NY 11971 3d.The Proprietor,Partnersor Executive Officersare ® included.(Only checkbox Wall partners/officers induded) ❑ all excluded orcertainpartners/officersexcluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box "1a"forworkers' compensation under the New York State Workers' Compensation Law.(To use this form,New York(NY) must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent w ill 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 bythe insurance carrier or its licensed agent,or until the po licy 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 after 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: Upon cancellation of the workers'compensation policy indicated on this form,if the business continuesto be named on a permit,license or contract issued bya certificate holder,the business must providethat certificate holderwith a new Certificate of Workers'Com pensation Coverage or other authorized proof that the business is com plying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certifythat I am an authorized representative or licensed agent of the insu rance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: • Lex Smith (Print name of authorized representative or licensed agent of insurance carrier) • 02/04/2022 Approved by: �c....�.....� (Dale) Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-777-4864 Please Note: Only insurance carriersand their licensed agents are authorized to issue Form C-105.2.Insurance brokersare NOT authorized to issue it. C-105.2(9-17) www.wcb.ny.gov Sit Workers' CERTIFICATE OF INSURANCE COVERAGE s"r�RA Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by 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 NYSS LLC DBA:NY STATE SOLAR 132 W 31ST ST,SUITE 1300 516-418-2131 NEW YORK,NY 10001 Work Location of Insured(Only required if coverage is specifically limited to 1c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,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) Standard Security Life Insurance Company of New York Town of Southold 53095 Route 25 PO Box 1179 3b.Policy Number of Entity Listed in Box"l a" Southold, NY 11791 T20186-001 3c.Policy effective period 7/1/2022 to 9/12/2023 4. Policy provides the following benefits: Q 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 des c d above. Date Signed 9/13/2022 By 14AIC12�t (Signature of insurance carrier's authorlr cl representative or NYS Licensed Insurance Agent of that insurance carrier) 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 carrier,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 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 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) 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 (10.17) Il�llD � ��r � � �( 0�N7)�� Illal Additional Instructions for Form D13-120.1 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"1 a"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. DB-120.1 (10-17)Reverse CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYY1f) 6/30/2022 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 endorsements. PRODUCER CONTACT NAME Marsh&McLennan 00 L bb a Mill East Boulevard LLC "� ,� 800-285-1778 Ne), 9 Suite 100 9 y ADDRESS. certificatesMarshMMA.Com Richmond VA 23230 __._._. INSURERS AFFORDING COVERAGE NAIC# INSURER A: Utica Mutual Insurance Com an 25976 INSURED NYSSLLC INSURER$:COIOn §p2ci-alty Insurance Company 36927 NYSS, LLC 132 W 31 st St Suite 1300 INSURER C:Southwest Marine&General Ins Co 12294 New York NY 10001 INSURER D: INSURER E: INSURERF. COVERAGES CERTIFICATE NUMBER:793398451 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. ......... .................. IR POLICY EFF POLICY EXP T, TYPE OF INSURANCE INA12POLICY NUMBER (MR/_D_P0= D LIMITS C X COMMERCIAL GENERAL LIABILITY Y Y PKG202100018285 7/1/2022 7/1/2023 EACH OCCURRENCE $2,000,000 - CLAIMS-MADE FRIOCCUR A AWY -NE1I �rvunaar_ w $100,000 ... ... MED EXP(Any one person) mm $5,000 PERSONAL&ADV INJURY $2,000,000 ............................ ................... _ X.. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL_A_G_GREGATE _ $4,000,000_...... POLICY F-1JECTT F1 LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 5521461 7/1/2022 7/1/2023 COMBINED SINGLE LIMIT $1,000,000 a ecciderdl u.............._ __.. ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED a X BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED "fi6PERT'Y'OAMAGE $ AUTOS ONLY AUTOS ONLY I?er acdmcrl)� B X UMBRELLALIAB X OCCUR Y Y EX04279465 7/1/2022 7/1/2023 EACH OCCURRENCE $3,000,000 EXCESS LWB CLAIMS-MADE AGGREGATE $3,000,000 DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ER H ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/M EM BER EXCLU DED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) 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 ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southoldd NY 11791 a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD wamok Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name REID T GARTON Business Name its certifies that the parer is duly licensed NYSS LLC DBA the County of Suffolk License Number:HI-62273 Rosalie Draijo Issued: 06103/2019 Commissioner Expires: 06/01/2023 Suffolk County Dept.of v yi Labor,Licensing 8 Consumer Affairs MASTER ELECTRICAL LICENSE Name JAMIE MINNICK Business Name T,-l,sel'A'eq k-M 7,,n NYSS LLC DBA bearer is doy i sensed by the COV14 o"""o"" License Number:ME-62692 Rosalie Drago Issued: 1111912019 Commissioner Expires: 1110112023