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HomeMy WebLinkAbout48911-Z TOWN OF SOUTHOLD VA BUILDING DEPARTMENT 49 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#: 48911 Date: 2/15/2023 Permission is hereby granted to: Perry, Matthew 360 E 72nd St Apt 131701 New York, NY 10021 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 3200 Camp Mineola Rd, Mattituck SCTM # 473889 Sec/Block/Lot# 123.-5-36.2 Pursuant to application dated 1/31/2023 and approved by the Building Inspector. To expire on 8/16/2024. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 Building Inspector Zoho Sign Document ID:2A768FFA-3WJUJUNOKVUZWV(3WBm,E1JYRB3UTFU-XVNRYNST7ZUXY Drax 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 https://www.soutti,olcitoNvnn,y.Lov Date Received APPLICATION FOR BUILDINGPERMIT 4�q � � For Office Use Only PERMIT NO. Building Inspector: ector; t,, Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUILDING DEPT: Owner's Authorization form(Page 2)shall be completed. TOWN OFSOUTHOLD Date: 4 Z—/I,/' J OWNER(S)OF PROPERTY: Name: Mathew Perry E!:M:#:1:000- 1000-123.00-05.00-036.200 Project Address: 3200 Camp Mineola Road, Mattituck, NY 11952 Phone#: 631-786-4892 Email:ma 7 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#: Email: 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 ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ✓Other 10.4 $ 36,688.00 Will the lot be re-graded? ❑Yes ✓No Will excess fill be removed from premises? ❑Yes ✓ No 1 Zoho Sign Document ID:2A768FFA-3WJUJUNOKVUZWVGWB,„_,EIJYRB3GTFU-XVNRYNST7ZUXY wn BUILDING DEPARTMENT- Electrical Inspector TOWN OF SOUTHOLD r'p Town Hall Annex - 54375 Main Road - PO Box 1179 d y. - Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 ro err southobdtowrn ov seand southoldtownn oar APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Jan 27 2023 Company Name: Element Energy LLC Name: Jamie Minnick License No.: 52689-ME email: permits@e2sys.com Address: 7470 Sound Ave., Mattituck, NY 11952 Phone No.: 631-861-5920 JOB SITE INFORMATION (All Information Required) Name: Mathew Perry Address: �- Cross Street: Phone No.: 631-786-4892 Bldg.Permit#: email:ji,4 e4,)rDe�s r 7�,0�) �o,, / Tax Map District: 1000 Section: 123.00 Block: 05.00 Lo(: 036.200 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Roof mounted solar PV astern consisting of 26 Enphase 18PLUS-72-2-US Micro Inverters 26 Solar PV panels QCELL.QPEAK DUO BLK ML-G10+400 Circle All That Apply: Is job ready for inspection?: / NO Rough In Final Do you need a Temp Certificate?: ” - / 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 INE"W workers' CERTIFICATE OF INSURANCE COVERAGE ATE 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 1a,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 Ifcoverage 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"l a" SOUTHOLD, NY 11971 DBL567527 3c. Policy effective period 01/01/2022 to 12/31/2023 4. Policy provides the following benefits: 21 A. Both disability and paid family leave benefits. ® B.Disability benefits only. 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 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 i i hard,Whj'(O 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 413,4C or 56 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 iIII lll DB-120. 1 (12-21) DATE(MMIfSIDFYYYY CC>R " CERTIFICATE OF LIABILITY INSURANCE 7/21 2012 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 CONTACT ROBERT S. FEDE INSURANCE AGENCY ,PHONE "631 385 1766 .............._ F 631-385.1766'--' .. 23 GREEN STREET,SUITE 102 E-MAIL HUNTINGTON, NY 11743 ADPB ------ ROBERTS. FEDE INSURANCE INSURER@)AFFORDING COVERAGE NAIC# ® .. --- -------- _ INSURER A:ATLANTIC CASUALTY INS.CO. 524210 INSURED INSURERS: STATE IN$URANO' FUND , 523930 Element Energy LLC INSURER C':"S"HEL'TER.P"OIN OI'NT 81434 .. ELEMENT ENERGY SYSTEMS INSURER D: GENERAL ST4R IViANAOEf�EI CO, 7470 SOUND AVENUE �.. .,, INSUREE RE 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. ILSR�...,,., , .,.... .. .......,........... ".ADOL:SUBR= ... ....,., POLICY EFF ...POLICY EXP TR, TYPE OF INSURANCE #INSp WVp POLICY NUMBER MMIDD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY 7/14/2022 7/14/2023 . a oco $ _ 100,000����� X X CL00275204 EACH OCCURRENCE $ 3,000,000 A , X DAMAGE rCJ~RENfED ®r claims MADE occuR � P��EMI��;�.[�.. . ..... #D IMA389203A HIED EXP(Anp ane person} _ �$ 5000 X Contractual Lia 7/14/2022 7/14/2023 PERSONAL&ADV INJURY $® 3000000 I ................... N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 PRO-POLICY® J I LOC y,PRODUCTS-COP .0000000 E OTHER AUTOMOBILE LIABILITY %I COMBINED SINGLE LIMIT $ (Ea,p;;0eu!�. ..... .. ...... ANY AUT BODILY INJURY(Per person) Is _ . AUTOS ONLY AUTOS I .......m OWNED SCHEDULED � BODILYINJURY(Peracadent) $ HIRED NON-OWNED PROP'ERTYdAMAGE.„ .. ..�...$..... ..-; AUTOS ONLY ,,..„„„ AUTOS ONLY (-Pprac dtm.w). I [ UMBRELLA LIAS OCCUR EACH OCCURRENCE I$ _.___ . EXCESS LIABCLAIMS-MADE - I I AGGREGATE $ - Y LIED RETENTION$ ASV RKERS COMPENSATION `124494445 r I PER � 0TH B �OFFCE O YX N 7I13I2O22 7/13/2023L EACHIACIDENT R $ 1^000 000AND , , ,E EAEMPLOYEE' $RRMW'MBER ELLYOE,D?' N/A (Mandalor�r iron NH) 1 EL DISEAS If yes,describe under , E,L DISEASE i'"� i DESCRIPTION OF OPERATIONS below I E POLICY LIMIT I $ NY State DBL j DBL567527 1/01/2022 1/01/2023 Statutory I 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 ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SOUTHOLD, NY 11971 AUTHORIZED REPRESENTATIVE ROBERT'S FEDE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 14?--00N-,N� NYSIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A^^A 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 go]FI *A2 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 95991 07/13/2022 TO 07/13/2023 7/19/2022 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 STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 126776733