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HomeMy WebLinkAbout49122-Z 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#: 49122 Date: 4/13/2023 Permission is hereby granted to: Paul, Neena 401 Atlantic Ave Greenport, NY 11944 To install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 35 Atlantic Ave, Greenport SCTM # 473889 Sec/Block/Lot# 34.-3-56 Pursuant to application dated 3/15/2023 and approved by the Building Inspector. To expire on 10/12/2024. Fees: SOLAR PANELS $50.00 ELECTRIC $100.00 CO-ALTERATION TO DWELLING $50.00 Total: $200.00 Building Inspector Zoho Sign Document ID:2A768FFA-ODLUBUUVZHITXXRWKUYLUFUC)JC;VWC:UZXZIDEKTUUKDC: 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 lett ://N w",.soutlioldto iiii .!,Iov Date Received APPLICATION FOR BUILDING PERMIT For Office Use OnlyL I MAR 15 2073 PERMIT N0. Building Inspector. Applications and forms must be filled out in their entirety. Incomplete T'0VVN OF SMI"1""OLD applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: 3 113 .3 OWNER(S) OF PROPERTY: Name: S j e v e,) L-u b t r2— SCTM# 1000- 1000-034.000-03.00-056.000 Project Address: 401 Atlantic Ave.,Greenport, NY 11944 Phone#: 631-466-4933 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#: 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 6.4kw $ 44,864.00 Will the lot be re-graded? ❑Yes ✓No Will excess fill be removed from premises? ❑Yes ✓ No 1 Zoho Sign Document ID:2A768FFA-ODLUBUUVZHITXXRWKUYLUFUUJUVWUC)ZXZIDEKTUUKDU 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 15 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: Mar 08 2023 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 his day of 20 Not ry PU lic NOTARY PUBLIC,STATE OF NEW YORK PROPERTY O,WNIER I 1jJR1ZAfl0fdSistrationNo.OISE6012697 (Where the applicant is not t' e owner) QualifiedinSuffotr My C'omniission Expires I, reUew ,�J b%'T_ residing at 401 Atlantic Ave.,Greenport, NY 11944 do hereby authorize Element Energy LLC to apply on my behalf to the Town of Southold Building Department for approval as described herein. Mar 08 2023 Owner's Signature Date Steven Lubitz Print Owner's Name 2 Zoho Sign Document ID:2A768FFA-ODLUBUUVZHITXXRWKUYLUFUUJC:VWC;UZXZIDEKTLC;KDC; BUILDING DEPARTMENT- Electrical Inspector CIO, TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Ze Southold, New York 11971-0959 Telephone (631) 765-1802 FAX (631) 765-9502 ro err southoldtownn ov seand southioId Itownny,gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Mar 08 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 (AII Information Required) Name: S/eu(fA) Address: 401 Atlantic Ave.,Greenport,NY 11944 Cross Street: Phone No.: 631-466-4933 Bldg.Permit#: .. email: Tax Map District: 1000 Section: 034.000 Block: 03.00 Lot: 056.000 BRIEF DESCRIPTION OF WORK (Please Print Clearly) 6.4Kw roof mounted solar PV system consistinq of 16 En base micro inverters model 18PLUS-72-2-US and 16 QCELL solar PV modules model Q.PEAK DUO BLK ML-G10+400 Circle All That Apply: Is job ready for inspection?, t / 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.xis Suffolk County Dept of Labor,Licensing&Consumer Affairs l HOME IMPROVEMENT LICENSE Name MICHAEL LAWTON Business Name TMs s Ow the. bearer is duly licensed Element Energy LLC DBA by the COunty Of suffOlk License Number:HI-67461 Rosalie Drago Issued: 09/02/2022 C°mrrussioner Expires: 09/01/2024 Suffolk County Dept.of Labor,Licensing$Consumer Affairs ti MASTER ELECTRICAL LICENSE Name JAMIE J MINNICK Business Name This- .tiros that ti e bearer is duly licensed ELEMENT ENERGY LLC by the County of Suffolk License Number:ME-52689 Rosalie Drago Issued: 12111/2013 Commissioner Expires: 12/01/2023 aI workers' CERTIFICATE OF INSURANCE COVERAGE of srAve 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"1 a" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01/01/2022 to 12/31/2023 4. Policy provides the following benefits: n A.Both disability and paid family leave benefits. E] B.Disability benefits only. n C.Paid family leave benefits only. 5. Policy covers: 0 A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. E] 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. 7/20/2022 g A 'r 4f Date Signed y (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 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. D13-120.1 (12-21) III 1111111°1°°1°11111111°°111°11°11°lIII I11 DB-120.1 (12-21) Additional Instructions for Form 1313-120.1 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 NYS Disability and Paid Family Leave Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage (Certificate)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 may 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 NYS 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Paid Family Leave Benefits Law. NYS 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. 1313-120.1 (12-21) Reverse DATE . +"R" CERTIFICATE OF LIABILITY INSURANCE (MMCDD7/21/PVY2Y02 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). CONTACT PRODUCER (AI'C 0'HONN a b FAX 631 385 1766 ROBERTS, FED"INSURANCE AGENCY PE 631-385--1760" .._.. _ NAM 23 GREEN STREET,SUITE 102 E MAYI. HUNTINGTON, NY 11743 D ESQ ROBERTS. FEDE INSURANCEINSURER(S�AFFORDING COVERAGE t NAIL# ._ ...,AAAA, ...... ...... , INSURER A:ATLANTIC CASUALTY INS.CO 524210 INSURED INSURER B: STATE INSURANCE FUND 52330 Element Energy LLC INSURE --SHELTER-F'0INT F'0INT ' ­ Si4'34 ELEMENT ENERGY SYSTEMS GENERALUSTAR MANACEI�"ENT CO— .....INSURERD,. ....... ......... ... ._ - , 7470 SOUND AVENUEINSURERt ... ."............. .. _. _,,.P,,...,. .. .. 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. a i� ............ TYPE GENERAL LIABILITY f Y MM/ O�IVVYX E 3,000,000 Nu l COMMERCI OF INSURANCE I'�UBA. POLICY NU CL002752 iR j POLICY E'O 1 POLICY EXP LIMITS I � MBER MMIDDIVYY CLAIMS-MADE � occuR 04 7/14/2022 7/14/2023 rlFD S LEI $ 100 000 X X M ED EXP5000 -...... #D IMA389203A .PERSONAL&yADV INJURY $ X � Contractual Lia 7/14/2022 7/14/2023 3000000 GEN'L AGGREGATE TI=LIMIT APPS PER. GENERAL pRODUCTS�COMP®P AGO $ 3 � (� � POLICY Ji I E LOC I AU. OI"HER'. 1 f O .. I ?. I COMBINED SINGLE M MOBILE $ ... . . .. ANY AUTO BODILY (Perper.s.on) $ . OWNED SCHEDULED AUTOS ONLY AUTOS I B ent? HDNON-OWNED AGF""' $AUTOS ONLY .... AUTOS ONLY .......,., $ UMBRELLA LIAB OCCUR EACH OCCURRENCE <$ I I EXCESS LIAB CLAIMS-MADE I AGGREGATE„ AND EMPLOYERS Y/N DED RETENTION$ $ - WOREMPLOY RS'LIA ILITY N/A 124494445 7/13/2022 7/13/2023 STAn1TF SRH B OFFICEKERS COMPENSATION R/MEMBER ER EXRTNER/EXECUTIVE X E.L EACH A $ 1,000,000 EMPLOYERS'LIABILITY (Mandatory in NH) ❑ E,L SE.-__-E-A EMPLOYEE, $ 1,.OQ��. 'Da If yes,describe under f DESCRIPTION OF OPERATIONS below I 1, E ..DISEASE-POLICY LIMIT $ 1 000,000 NY State DBL t �DBL567527 1/01/2022 1 1/01/2023 Statutory DESCRIPTION OF OPERATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 MAIN ROAD 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 SIF New York State Insurance Fund PO Box 66699,Albany, NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE Rill A^A^^ 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 HUNTINGTON NY 11743 I 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 I 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