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TOWN OF SOUTHOLD BUILDING DEPARTMENT 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 #: 49059 Date: 3/28/2023 Permission is hereby granted to: Woodard, Judith 1945 Village Ln PO BOX 402 Orient, NY 11957 To: install roof-mounted solar panels on existing accessory building as applied for per HPC approval with flood permit. At premises located at: 1945 Villa a Ln, Orient SCTM # 473889 Sec/Block/Lot# 25.-3-11 Pursuant to application dated 12/22/2022 and approved by the Building Inspector. To expire on 9/26/2024. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Flood Permit $100.00 Total: $300.00 —A // Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 'u Telephone(631) 765-1802 Fax(631) 765-9502 lits) ://'www. ouLliolcil ww tiii .g o v Date Received APPL I II _ w . For Office Use Only n PERMIT NO. Buildin Ins ector: I g I JUL 1 3 909 � Applications and forms must be filled out in their entirety.Incomplete P w applications will not be accepted. Where the Applicant is not the owner,an BUM...UNIGIf.:E.1:1'r' Owner's Authorization form(Page 2)shall be completed. fO�.°'�I OF SOU FH,'J:.D Date:06/30/2022 OWNER(S)OF PROPERTY: I�M::#:1000-25.-3-11Name.Judlth Woodard Physical Address: 1945 Village Lane., Orient, NY 11957 Phone#:917-592-0170 1 Email:jwoodard@nyc.rr.com Mailing Address: 1945 Village Lane., Orient, NY 11957 CONTACT PERSON: Name:Sue Estabrooke/Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:sue@longislandpowersolutions.com DESIGN PROFESSIONAL INFORMATION: Name:Pacifico Engineering, P.0 Mailing Address:700 Lakeland Avenue., Suite 2B., Bohemia, NY 117416 Phone#:631-988-0000 Email:Solar@pacificoengineering.com CONTRACTOR INFORMATION: Name:Michael Catizone/Long Island Power Solutions Mailing Address:2060 Ocean Ave., Ronkonkoma, NY 11779 Phone#:631-348-0001 Email:mike@longislandpowersolutions.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition R'Alteration ❑Repair ❑Demolition Estimated Cost of Project: iiiiiiProposed( 59 )panel roof mounted arra 21,240 )kW System 45,718.80 'Other y Will the lot be re-graded? ❑Yes 1No Will excess fill be removed from premises? Eyes RNo 1 PROPERTY INFORMATION Existing use of property:Single Family Dwelling Intended use of property:Single Family Dwelling Zone or use district in which premises is situated:.. Are there any covenants and restrictions with respect to o 'Nil 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. Catizone Electrical/Long Island Power Solutions Application Submitted By(print name: kA)o c P.}11 Authorized Agent ❑Owner Signature of Applicant: Date: Cg ( -3 I STATE OF NEW YORK) SS: COUNTY OF Suffolk Michael Catizonebeing duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Contractor (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 `nc 20 Notary Public ESCAYLIN CRISOL RIVERA RODRIGUEZ NOTARY PUBLIC-STATE OF NEW YORK No. 01816434031 Qualified in Suffolk County �� � n ( �"� OWNER �,,,,�� " ) ( " My Commission Expires 05-31-2026 (Where the applicant is not the owner) l, vl/ c�1_ residing at do hereby authorize PPY Michael Catizone/Long Island Power Solutions to apply on my behalf to the Town of Southold Building Department for approval as described herein. 2 v Owner's Signature Date -v,iv, �I o VZO Print Owner's Name 2 To search Licensed Contractors,dock"PTC. Home Etvwironmentat Ouallty Create an Application Record H-53562: Home Improvement License Record Status:Active Expiration Date:06/01/2024 Record Info Payments Custom Component � ® a 2060 OCEAN AVENUE,RONKONKOMA.NY 11779 Uxaflons— RENEEMENFEENEENEEM Applicant: Licensed Professional: MICHAEL J CATIZONE MICHAEL CATIZONE Birth Date:09/05/1979 LONG ISLAND POWER SOLUTIONS INC i g muuuoum 0 �pnr> Suffolk sCounty.Dept.of Labor,Licensing'n &Consumer Affairs � I MASTER ELECTRICAL LICENSE Name r MICHAEL CATIZONE Business Name This certifies that the LONG ISLAND POWER SOLUTIONS INC bearer is duty licensed by the County of Suffolk License Number:ME-53560 Rosalie Dra90 issued: 06/06/2014 Commissioner Expires: 06/01/2024 "myE IN " Labor,LsMl lasa9&Co� W Aftirs M1A7FMR ELE .CTRC.4 L%�18E Narm M CHAM J CAT=N K Business Name t*w wa-dar 4,x Nr camww Elsdrnotll �arvr itvactong Ntc tto `���uRat�r.Abltti"A�'. by It "Cwnly at somak erne Numbw:ME-316178 R'" lir oral* Issued; 1210IMN CanTimorw Exp1r .: 17JO112022 Client#: 83176 CATIELE ACORD., CI RTIFICATE OF LIABILITY INSURANCE DATD/YYYI� 6/227/207/2022 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CNAM ONT: Commercial Support Edgewood Partners Ins.Center 40 Marcus Drive E-MAIL NECer ificatesCe (Ar ADRN Est plcbrokers.com 3rd Floor INSURER(S)AFFORDING COVERAGE _NAIC# Melville,NY 11747-2647 INSURER A:Utica Mutual Insurance Company 25976 , ,.,.m,. " ........ . ............................... . ..........�....�...... ."........................�..._ .... ........_.._.._. INSURED INSURER B.Catizone Electrical Inc """""""""..°.°ITIT "'_.......... ....... 2060 Ocean Avenue INSURER C ........._.._.._ ............ ........ Ronkonkoma,NY 11779 INSURER D 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 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. --- r� ... LTR .. ..........._.,.�,�,,,. ADDU UBR YM VDDY EFF MPO ICDY'YYP LIMITS TYPE OF INSURANCE INP D POLIC NUMBER_ , __w_Y mmmIThITITG T COMMERCIAL R _PIS Ea oTa anee $1 00000 0... A X X CPP4784747 7/01/2022 07/01/202 EACH OCCURRENCE 51 _a ................................................................... ,.�.,. . M,E,D,,,,EXP(Any on,e.person) $.1__,a� 0.__..........................._... PERSONAL&ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000 000 PRO• PRODUCTS-COMP/OPAGG $2 000 000 POLICY❑JECT X ' ❑LOC OTHER: $ AUTOMOBILE LIABILITY CO BI D SINGLE LIMIT aacce ail . .... ...... ANY AUTO BODILY INJURY(Per person)_ $ OWNED SCHEDULED AUTOS ONLY AUTOS ONLY AUTOS ONLY BODILY ROPE INJURY(Per accident) AUTOS Pyr apcltda@) $ PROPERTY DAMAGE...." .. ....". UMBRELLA LIABOCCUR U, RRENCE $ EXCESS LIAB C IMS AE AGGREGATE $ . DED RETENTION$ $ A WORKERS COMPENSATION 4766763 7/01/2022 07/01/202 X AND EMPLOYERS'LIABILITY PER � DTH- n ANY PROPRIE'TO PA€3TNE1 EXECUTIVE YIN E.L.EACH ACCIDENT $5003000 OFPICER/hgE1�,REWPIRCLUDE07 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $500()00 DESCRIPTION OF OPERATIONS below M _ �."_d„„„„„„„„„„„...... DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Town of Southold is included as additional insured for general liability coverage as required by written contract. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S4115391/M4115046 KOS01 �NEw��e Workers' CERTIFICATE OF INSURANCE COVERAGE ....-- . Ar 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 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured CATIZONE ELECTRICAL CONTRACTING, INC. 2060 OCEAN AVE 646-383-3599 RONKONKOMA, NY 11779 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i,e.,Wrap-Up Policy) or Social Security Number 45-5213112 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier TOnWN eOFLSOUTHOLas the D ate Holder) Standard Security Life Insurance Company of New York 53095 ROUTE 25 3b.Policy Number of Entity Listed in Box"l a" SOUTHOLD, NY 11971 R97483-000 3c.Policy effective period 1/1/2015 to 12/15/2022 4. Policy provides the following benefits: ri A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Fi 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 descoqed above. Date Signed 12/16/2021 By 44�& — (Signature of insurance carrier's xauthodz d representatuve or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number X212 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 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 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 i 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, p D13-120.1 (10-17) 11111111 1111111 Workers'Ym 'Compensation CERTIFICATE OF STATE oar NYS WORKERS COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Catizone Electrical Contracting Inc. 31348-0001 2060 Ocean Avenue - Ronkonkoma, NY 11779 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,a Wrap-Up Policy) 1d.Federal Employer Identification Number of Insured or Social Security Number 202241963 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier Being Listed as the Certificate Holder) Utica Mutual Insurance Company 3b.Policy Number of Entity Listed in Box"1 a" Town Southold 7 6763 53095 Route 25 3c.Policy effective period Southold,NY 11971 07/01/2022 to 07/01/2023 3d.The Proprietor,Partners or Executive Officers are ❑ inclu'de&(only check box if all partners/officers included) Ei all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box 1 a"for workers' 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 will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". T'he,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 snail..)Otherwise,this Certificate is valid for one year sifter 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: Upon cancellation 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 depleted on this form. Approved by: Leonard Scioscia (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 6/24/22. (Signature) (Date) Title: Authorized Re resentative Telephone Number of authorized representative or licensed agent of insurance carrier: 631-390-9700 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. -105.2(9-17) www.wcb.ny.gov Client#: 83393 LONGISL15 ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATz/07/207/2oD/YYYY) 22 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:µIf the certificate holder is an ADDITIONAL INSURED,the pollcyfles)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 any rights to the certificate holder in lieu of such endorsement( ). PRODUCER '01, T Commercial Support Edgewood Partners Ins.Center C " �°r E�lI 631-390-9700 qr emri.631 390-9790 40 Marcus Drive ADDRIESS NECe;rtificatesaepicbrokers com 3rd Floor � � INSURERS)AFFORDING COVERAGE MAIC# Melville, NY 11747-2647 ......_. _. INSURER A:Southwest Marine&General Ins Co 12294 INSURED INSURERB: _........___,�.-....,. _--... ................ Long Island Power Solutions,Inc. .. ------------ INSURERC: DBA New York Power Solutions INSURER D -- 2060 Ocean Avenue _..... INSURER E Ronkonkoma,NY 11779 —"�.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 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. r s¢, wvY COMMERCIAL GENERAL LIABILITY AOD6SdJ'86 1 PI�2�22oo�2ITIT� uIT�IMMI�ICS°ESP pOLICY EXd'� LIMITS , M, -....-,_-- �o1YY`Y. .�... ,. ._„-....,._._XJ .. ..... .,m. ...... A X 0693 2128120 Y MMYOo/YYYY TYPE OF INSURANCE N�dMBER dMMIOD/YY 22 02/28/2023 EACH OCCURRENCE S1,0100,00-0— ... 1,000,000 CLAIMS-MADE X,I OCCUR MED Eaaoc�iraM�nrr 4.._._ s300000 "AEO HENTED X PD Ded:5,000 Agcy one erup S 1n0�1 X Contractual Llai, &ADV INJURY 51,000/000 PERSONAL �„_, ,.,._ ... � . N „�.„ r 0 GEN'L AGGREGATE LIMIT APPLIES PER: l GENERAL AGGREGATE .2,000 OO POLICY�XI.JECTmm LOC I µmOPAGG s2 000 .._ , PRO- OTHE AUTOMOBILE LIABILITY - PK202200020693 2/28/2022 02/28/2023,PRODUdrT d COMPI lll4tll _.._...... .., ,._. A 1. 1,000,000 ...ru ( P BODILY INJURY Per erson) S ANY AUTO OWNED SCHEDULED BODILY INJURYPer accident)cciden[) S AUTOS ONLY .m, AUTOS j °• '" PY�'O�^w RTGAPo�tlAGE HIRED NON-OWNED S AUTOS ONLY X AUTOS ONLY ..CPer az idra0!),, X OCCUR "��", EX202200001789 2128/2022 02'./28/202 EACH OCC � A UMBRELLA LIAB � W EXCESS LIAB CLAIMS MADE,. ? �..AGGREGA.OCCURRENCE $5,000,000.. „ Iri .. D X !a NTIONS1000.0..... I I S _.� — _ a....... __. ... .._. _.. �xd. .. .._ J .._ WORKERS COMPENSATION ; ��� �I� C>7'H•, AND EMPLOYERS'LIABILITY Y .N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEMMEMBER EXCLUDED? N/A (Mandatory in NH) E L DISEASE E'A EMPb OYC.E S„ w ,_mm If yes,describe under I DESCRIPTION OF OPERATIONS blow EL.DISEASE POLICY LIMIT S „r I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Town of Southold is included as additional insured for general liability coverage as required by written contract. 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 REPRESENTATIVE i7 ©1988-2015 ACORD CORPORATION.All rights reserved. RD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S3438616/M3437780 LJACO �'Idvw Workers'STATE CERTIFICATE OF INSURANCE COVERAGE CO enSatlOn 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 la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured LONG ISLAND POWER SOLUTIONS INC DBA NEW YORK POWER SOLUTIONS 6313480001 2060 OCEAN AVE RONKONKOMA,NY 11779 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 27-1175107 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 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 R97411-000 3c.Policy effective period 1/1/2015 to 8/26/2022 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: RX 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 employers 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 desc` ci above, 14e Date Signed 8/27/2021 By SI nature of insurance carrier's authow ri r r¢•5rrr�waprrxr or NYS Licensed (Signature p 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. DB-120.1 (10-17) 11111111 1111111 /7-01kN11 , PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nySlf.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 271175107 " LOVELL SAFETY MGMT CO.,LLC 110 WILLIAM STREET 12TH FLR NEW YORK NY 10038 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER LONG ISLAND POWER SOLUTIONS INC TOWN OF SOUTHOLD 2060 OCEAN AVENUE 53095 ROUTE 25 RONKONKOMA NY 11779 SOUTHOLD NY 11971 POLICY NUMBER I CERTIFICATE NUMBER POLICY PERIOD DATE Z 2467 078-8 539135 04/01/2022 TO 04/01/2023 03/08/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2467 078-8, 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:IIWWW.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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT MICHAEL CATIZONE VICE PRESIDENT JOSEPH MILILLO TWO OF TWO OFFICERS LONG ISLAND POWER SOLUTIONS INC 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,I' SIJRANCE FUND UNDERWRITING VALIDATION NUMBER: 396794370 1111111000,000 O '0001.I21,0 1 Form WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-24670788] U-26.3 198 [00000000000102106564][0001-000024670708][##Z][15840-36][Cerl_NoP{ERT_3][01-00001] Mariella Ostroski, Chairperson our uni �� Town Hall Annex �, Anne Surchin, Vice Chair k , 54375 4 7Bo to 25 79 Allan Wexler Fabiola Santana "tom°'° " Southold,NY 11971 d OLD Tara Cubie �, Telephone: (631)765-1809 i� Y�b f ov southoldtownn g Jeri Woodhouse �� , r � kim@ Kim E. Fuentes, Coordinator Town of Southold Historic Preservation Commission Certificate o,f A1212roriateness DECEMBER 8, 2022 RESOLUTION #12.08.22.2 Owner: Judy Woodard RE: 1945 Village Lane, Orient,NY. SCTM# 1000-25-3-11 RESOLUTION: WHEREAS, 1945 Village Lane, Orient, NY, is on the Town of Southold Registry of Historic Landmarks; and WHEREAS, as set forth in Chapter 170 of the Town Code(Landmarks Preservation Code) of the Town of Southold, all proposals for material change/alteration must be reviewed and granted a Certificate of Appropriateness by the Southold Town Historic Preservation Commission prior to the issuance of a Building Permit; and WHEREAS, the applicant's representative, Sue Estabrooke of Long Island Power Solutions, submitted a proposal on October 6, 2022,to install solar panels on the roof of a single family dwelling and an accessory building/barn; and WHEREAS, the scope of work includes the installation of 59 black on black, anti-glare, anti- reflective panels solar panel on the roofs of the Main House and a rear yard Barn, facing south. Each panel will be installed with individual inverters with mounting to be adjustable and sitting three inches above the plane of the roof, and WHEREAS, the applicant's representative presented Commissioners with Engineered Plans(Site Plans, Elevations, Renderings) prepared by Ralph Pacifico, L.P.E., last June 17, 2022; and WHEREAS, during the Public Hearing on December 8, 2022,the applicant made a request to amend the application to limit the installation of the Solar Panels only to the roof of the Accessory Structure/Barn. NOW THEREFORE BE IT RESOLVED,that the Southold Town Historic Preservation Commission determines that the installation of Solar Panels upon the roof of an Accessory Structure/Barn in the above referenced application meets the criteria for approval under Section 170-8 (A)of the Southold Town Code; and Certificate of Appropriateness, HPC, Woodard, SCTM No. 1000-25-3-11 BE IT FURTHER RESOLVED,that the Commission approves the request for a Certificate of Appropriateness, subject to approvals by all involved agencies; and BE IT FURTHER RESOLVED,that a Building Permit may not issue until revised Engineering Plans depicting the approved installation of Solar Panels on the Barn Roof, only; and BE IT FURTHER RESOLVED,that this approval shall not be deemed effective until the required conditions have been met; and BE IT FURTHER RESOLVED,that any deviation from the approved plans referenced above may require further review from the commission. Motion made by: Commissioner Cubie Motion seconded by: Commissioner Santana VOTES: AYES: Commissioners Wexler, Santana, Cubie, and Woodhouse. NAYS: Chairperson Ostroski and Commissioner Surchin(4-2) RESULT: Passed Signed: Kim E. Fuentes Coordinator for the Historic Preservation Commission Date: December 8,2022 ! k ING DEPARTMENT..Electrical I or O, � m TOWN OF sOUTH®LD a .. ° own Fall Annex- 54376 Main Road - PO Box 111 ' C Southold, New York1197'1-0959 w�� a �9 , Telephone (031) 706-1802 - FAX (631) 7"06-9602 r Lr ou hp o to nn v ss and@souholdto nn.gy APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 06/30/2022 Company Name: Catizone Electrical/Long Island Power Solutions Name:Michael Catizone License No.: 36178-ME email: sue@longislandpowersolutions.com Address: 2060 Ocean Avenue,Ronkonkoma,NY 11779 Phone No.: 631-348-0001 JOB SITE INFORMATION (All Information Required) Name: Judith Woodard Address: 1945 Villa e Lane., Orient, NY 11957 Cross Street: Fletcher Street ........... - Phone No.: 917-592-0170 Bldg.Permit#: I email:j woodard@n c.rr.comm Tax Map District: 1000 Section: 25 Block: 3 Lot: 11 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Proposed( 59 )panel roof mounted array. ( 21,240 )kW System Circle All That Apply: Is job ready for inspection?: YES / NO 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: Modules 59 Hanwha Peak-Duo Inverters : 59 Enphase 19-Z Flus Support: Iron Ridge XR100 PAYMENT ITE WITH APPLICATION Request for Inspection FormAs '1w `gF TM f rz o.�r6• �.�.�y6� o PIQ--A:acwo 0OPk-)d ✓' 4spOWR .- sc SOLUTIQ N* 5 'NU 206"C6,111'AVNEY jl�t 3e 0 OIV. 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KO REASONS: 12MM KO ELEVATION' A-5 ELEVATION DATA BASED ON NAVD 88.DATUM OWER SOLUTIONS 2060 OCEAN AVENUE, RONKONKOMA., NY 11779 (631)348-0001 WOODARD RESIDENCE 1945 VILLAGE LANE ORIENT, NY 11957 917-592-0170 S:25 B:3 L: 11 -PROJECT"DATA:#225122 INVERTER:(35)ENPHASE IQ7PLUS-72-2-US MODULES:.M)'Q.PEAK DUO HLK,G10+36D PV MODULES RACIQN1;IRON RIDGE X11100 WATTAGE 12,600 :::i.a::::r.:i:4•r: t::;-::.-::ir: :-::::::_::: a::•r:. ..._............_ ....._.- .._...._._.._ :......._... ..........__.. ........._ ROOF TYPE COMPOS1710NSHINGLES .._._........•""-- _..._._-.... ...._........_._........... - c.........:v.a •:::•.:,r;e�:,:a�_..-•��._._.::z:cz•:: :::::::::x•:::•.•_c::•:::::•::^c._:a::-:-.• .....:.:........_ ..:::... ..r::-.- •:-::--.'... ::::-_:.:::.:r...__........ 'v.....:......�: -::: ;:::r.^-.:::.'::c_:•.r::c:.:::_.'::::.:sia�Y��:i:'_•--r:•i�:.iii`: .ice::::V.....-:::''s•:..:�::: ::':':: _...._........:..................._ . 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PV MODULES E LN• I GOO f� ! i 700 Lakeland Ave, Suite 2B Bohemia,NY 11716 I 1 l l Ph:631-988-0000 t I i I / ` I BFE+2 EL:8.0' solar@paciricoengineen-ng.com � ). I � � — t,vww.pacrricoenglneenng_com 1 if 1 I BFE EL:6.0' `.\'�l','j 1 \ \ ��\`/\ \/\�\/\ \\ \ DE EL:4.15 \ AVERAGE GRA %���{� `t�: /,\�1C>;\�/�!/� i�!``%\J�\��%`;��\f '��`��\`\/�C/,��✓lam /�ti/�\/��\'��% �\'ii"fey'/.�`fluff\'l� ��'/. \''✓. \�J�rl���it\%�Y/\�/�\�t\�h�/�\ \ �r'�' BARN NORTH ELEVATION NOT TO SCALE ALTEKATION OF THIS I)QCLIh1Ct3TEXCEPT BY A SE LICENSED P1tOFMtOVAL IS ILLEGAL C PAPER SIZE:11'x 17'(ANSI 8) Lo DATE: 6117(2022 DESIGN BY: MW CHECKED ft KO REVISIONS: 12lgre2 KO v 5n ELEVATION AJ ° ELEVATION DATA BASED ON NAVD-88.DATUM Ui � . 4p so?NER F ONS . RONKONKOMA, NY 11779( 2060 OCEAN AVENUE, WOODARD RESIDENCE 1946-MLLAGE LANE ORIENT, NY 11957 917-592-V 70 PROJECT DATA:.#225722 INVERTER-(35)ENIPHASE 107PLUS-72-2-US RACVJNG:IRON RIDGE XR100 FAST=-NEk'5116'Dk SSS LAGS Ph:631-988-0000 EJsolar@paciricoengineering-com TSFE+2 EL:8.9 www.pacificciengineering-com j411 (0o BARN WEST ELEVATION NOT TO SCALE b0tUNjE%,1r EXCEPT BY A LICENSED MOMS101MAL IS MLEGAL PAPER SIZE If'x 17*(ANSI I) 04 DE'SIGNS�. MW CHEKEDBY: KO REVISIONS: 1219122 KO ELEVATION A,8 5�1 EtVATION DATA BASED ON NAVD 88.DATUM � — ` \ — AERIAL OWE R sOLUT�ONs 2060 OCEAN AVENUE, F7 RONKONKOMA, NY 11779 !` (631)348-0001 WOODARD E - RESIDENCE 1945 VILLAGE LANE ORIENT, NY 11957 917-592-9170 R-5 S: 25 B: 3 L: 11 #MODULES(22) PROJECT DATA:#225722 PITCH: 17° AZIMUTH:271' 4z INVERTER(35)ENPHASE 107PLUS 72.2•US ~ MODULES:(35)O.PEAK DUO WWI 260 O *[ RAIJnNG:IRON RIDGE XR10D T SA�SjP . �- WATTAGE 12,600 SHEET INDEX:..:, ROOF TYPE:co�sPDsmoNSl�IrvGLEs r WAND LOAD:-54.6PSF @ 14MAPH O o S-1 SITE PLAN FASTENER: 116rDIA.6-SS LAGS S-2 DETAILS E-1 ELECTRICAL PLAN - LL'cc L-1 MOUNTING PLAN 1Gc 700 Lakeland Ave, Suite 2B 0 Bohemia, NY 11716 125 ! Ph:631-988-0000 36'ACCESS A7}IwgY solar@pacificoengFineering.com www.pac ificoengineenng-cam R-4 GENERAL NOTES MODULES(13) PITCH:32" -ENPHASE IQ7 PLUS MICRO INVERTER ' S AZIMUTH:91` LOCATED ON ROOF BEHIND EACH MODULE. oil -FIRST RESPONDER ACCESS MAINTAINED AND FROM ADJACENT ROOF. -WIRE RUN FROM ARRAY TO CONNECTION ISfr�." 49 FEET. ' ' 3 -COGEN DISCONNECT IS LOCATED ADJACENT TO UTILITY METER. ry -LAYOUT SUBJECT TO CHANGE BASED ON ALTERATION OFTf1AS_DOCLMM4TEXCEPT BYA SITE CONDITIONS AT DATE OF INSTALL LICFJQSPDPROFESS11,xirfONAIL(ANSI B)PAPER SUE,it'x 1T{ANSI BJ LEGEND _ - DATE: s/17i2a22 ry _ DESIGN 6Y: MW GROUND ACCESS POINT CHECKED BY: KO ® REVISIONS: 12/922 KO COGEN DISCONNECT ® UTILITY METER REPRESENTS ALL FIRE CLEARANCE FIRST RESPONDER ACCESS 2020 RESIDENTIAL CODE OF NEW YORK STATE,2020 ENERGY CONSERVATION CODE NEW YORK STATE, ��� INCLUDING ALTERNATIVE METHODS MINIMUM OF 36"UNOBSTRUCTED AS PER TOWN OF SOUTHOLD CODE,2017 NATK)NALELECTRIC CODE ASCE746. SITE PLAN THE 2020 RESIDENTIAL CODE OF NYS iri 4,- .IronRidge XR 100 Rail ADOWER VISOLUTIONS =;.:-•. %'� 2060 OCEAN AVENUE, RONKONKOMA, NY 11779 - 63 1' 348-0001 .�_ WOODARD Gap-- _ RESIDENCE Flashing 1945"LLAGE LANE r� Clcrnp ORIENT, NY 11957 = f 917-592-0170 S:25 B: 3 L 11 hwillichx X11 100 Rif t1 �� PROJECT DATA:#225722 ' 5/16" 5 Stainless INVERTER:'(35)ENP.RASE IOtPLUS 72-2-US r _IrmlRictgr XR 100 Rail • MODULES:(35)O.PEAK DUO SLK-G16+360 - - - - -- -- -- - Steel Lag Bolt RACK]NG:IRON RIDGE XR100 Solar Module - WATTAGE 12,660 ,3/8@16 x 3/4 HEX HERD SiOLT ROOF TYPECOMPOSITIONSHINGLES WIND LOAD:-54.6PSF g 140MPH FLANGE NUT 3�` /Q 11 l J J Q FASTENER:5'16"DIA S SS LAGS -- --- ------ - --- P 't, - E G.]'N, II�iC p GENERAL NOTES: GENERAL NOTES FOR ROOF R-4: 700 Lakeland Ave, Suite 2B -L FEET ARE SECURED TO ROOF RAFTERS @ 80" O.C. -L FEET ARE SECURED TO ROOF RAFTERS @ 48" O.C. Bohemia,NY 11716 USING 5116" x 5" STAINLESS STEEL LAG BOLTS. USING 5116" x 3" STAINLESS STEEL LAG BOLTS, Ph_631-988-0000 -SUBJECT ROOF HAS ONE LAYER. -SUBJECT ROOF HAS ONE LAYER. solar@p ifico oengineering vrww.pacficengin eering_cam ALL PENETRATIONS ARE SEALED AND FLASHED. -ALL PENETRATIONS ARE SEALED AND FLASHED. ROOF PITCH RIDGE RAFTERS LENGTH OVERHANG NOTES �q`l`, i '..:ice.., �•,. c O 11 11 11 11 11 1 11 R4 32 2 x6 TR 2x4 @24 O.C. g -8 0 } �- � - R5 17° 2''x8" 2"x6"@ 16"O.C. 12'-4" 12" ATE ICENSEA PR FO SID IONAL IS I�GALB�-a E Q PAPER SEZ 11'x 1T(ANSI S) N C4 DATE; 6/17/2022 DESIGN BY: MVV —' CHECKED BY: KO REVISIONS: IM/22 KO DESIGNED AS PER ASCE 710 2020 RESIDENTIAL CODE OF NEWYORKSTATE,202D ENERGY CONSERVATION CODE OF NEW YORK STATE, MODULES.WUNTED FLUSH TO ROOF TOWN OF$OUTHOLD GODS,2U17 NATIONAL ELECTRIC CODE A5CEfi16. DETAILS S•2_ NO HIGHER THAN 6"ABOVE ROOF SURFACE 44D alER BARN PHOTOVOLTAICS: so ONS (35)Q.PEAK DUO BLK-G10+360 2060 OCEAN AVENUE, RONKONKO MA, NY 11779 INVERTERS, (631)34MOOl (35) ENPHASE IQ7PLUS-72-2-US WOODARD CIRCUITS: (2)CIRCUITS OF(12)MODULES RESIDENCE NEMA311 (1)CIRCUIT OF(11) MODULES f945:VILLAGE LANE JUNCTION BOX ORIENT, NY 11957 BLACK-L1 917-592-0170 RED_ ENGAGE CABLE S:25 B: 3 L: 11 WHITE-NEUTRAL PROJECT DATA:#225722 GREEN-GROUND INVERTER:(35)ENPHASElQ7PLUS•72-2-US MODULES:(35)WEAK DUO'BLK G10+360 RACKING:IRON RIDGE XR100 WATTAGE:12.600 ROOF TYPE:COMPOSITION SHINGLES METER WIND LOAD:-54.6PSF @'I40LIPH MMMACOWnMV FASTENER:S11V DIA.S SS LAGS Oi 42.35 A - { �lC AOirjLTAGE 240 V0 f ---------------- E iiv G c PHOTOVOLTAIC j 2B LINE SIDE TAP 700 Lakeland Ave, Suite Bohemia, NY 11716 MAIN SOLAR SYSTEM Ph.-631-988-0000 125A LOAD CENTER AC DISCONNECT ATS �-A solar@pacificoengineering.com (1)-20A BREAKER www.pacifcoengineering.com PER CIRCUIT 60A FUSED SERVICE MAIN SERVICE RATED DISCONNECT 200A DISCONNECT �, � �- 60A FUSE ENVOY 'r WaVVV AR N I h1 iNyER7ER uTPUT CQN>'JECTION � DO NOT RELOCATE THIS �fi AWG THWN '#6 AWG THINK (1)LINE 1 (1)LINE 1 � - OVERCU RRE:NT DEVICE 1'}LINE 2 (1)LINE 2 ALTERATION OF THIS DOCUMENT EXCEPT BY A ( LICENSED PROFESSIONAL IS ILLFGAL (1.)NEUTRAL (1).NEUTRAL AC DISTRIBUTION=PANEL I (1)EGC PAPER SIZE 11'xtT(ANSIB) N (1)EGC OR.SUB PANEL IN 1}PVC CONDUIT (1)GEC DATE:_6/17(2022 N IN 1k PVC CONDUIT DESIGN BY: MW CHECKED BY: KO REVISIONS: 12M/22 Ko AC C.OM BIN ER: NOTE: 2020 RESIDENTIAL CODE OF NEW YORK STATE,2020-ENERGY CONSERVATION CODE OF NEW YORK STATE, 1-PHASE,MAIN LUG LOAD CENTER,125A ALL WIRING TO MEET THE 2017 NEC.AND 2020 ENERGY CODE TOWN OFSOUTHOLD CODE,2017 NATIONAL ELECTRIC CODEASCE7.16. ELECTRICAL PLAN E-160A'FLISED SERVICE RATED DISCONNECT IWA r SOLUTIONS t + W;? ',• �, 1''. z *•' � ; y. 2060 OCEAN AVENUE, ,�;, .f �; _' t 7_ .E i, r�.+".- � � •t RONKONKOMA, NY :k �a. �w -�,.� ",`,x . . ?'w• G 1 11779 . .3i< . ; - - c. (631)348-0001 _ j��(•, ~ice s y :� - WOODARD .✓- Z;• ° �, Y:'} .y �f�T�y, fy,�` `rig'-/` yt r # J :.� } r Irca a6 Li Tj �` , RESIDENCE 1945 VILLAGE LANE ''� •r!,S`' 3rd . ORIENT, NY 11957 �, 'k. 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