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HomeMy WebLinkAbout49320-Z }_ y e TOWN OF SOUTHOLD BUILDING DEPARTMENT -� TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDINO 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 #: 49320 Date: 5/31/2023 Permission is hereby granted to: Danek, Kelley 35 Semon Rd Huntington, NY 11743 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 3135 Mill Rd, Peconic SCTM # 473889 Sec/Slock/Lot # 67.-4-21.1 Pursuant to application dated 5/2/2023 and approved by the Building Inspector. To expire on 11/2912024._ Fees: SOLAR PANELS $50.00 CO - ALTERATION TO DWELLi1STG $50.00 ELECTRIC $100.00 Total: $200.00 4- -� Building Inspector - TOWN OF SOi7T1XO1L1[) — BUILDING DEPAlaTMENT j Town Hall Annex 54375 Main Road P. O. Box 1 179 Southold, NY 1 1971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 ltt �r/ outlecitwr�ts Date Received APPLICATICIN FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Insgecta�rs Applications and forms must be filled out in their entirety. Incomplete - applications will not be accepted_ Where the Applicant is rout the owner, an Owner's Authorization form (Page 2) shall be completed. Date:4/25/2025 OWNERS) OF PROPERTY: Dame: Kelley Danek scTM # 1000-g7-4-21 .1 Project Address: 3135 Mill Road, Peconic, NY 11958 Phone #: 631 -767-9759 - Sam I Email: Mailing Address:35 Semon Road, Huntington, NY 11743 CC13 TACT PERSON: Nara : Barbara - OraanLogic LLC Mailing Address:97 North See. Road, Southampton, NY 1 1968 Phone #: 631 -771 -5152 x1 17 Emaei: Barbar Cc-bire nll gic-com DESIGN PROFESSIONAL INFORMATION: Name: Pacifico Bngine lring P Mailing Address: 750 Lakeland Ave, Suite 2B, Bohemia, NY 1 1 71 6 Phone #: 631 -988-0000 Email:solar(s- pacificoengineering.com CONTRACTOR INFORMATION: Narne: r nl-ogic LLC Mailing Address: 97 North Sea Road, Southampton, NY 1 1968 Phone #: 631 -771 -5152 Email-Al(i� >Oreenlogic.cc im DESCRIPTION OF PROPOSED CONSTRUCTION =New Structure =Addition iWAlteration =Repair =Demolition Estimated Cost of Project: =other, Solar Electric System 64,000 Will the lot be re-graded? =Yes iiiiNci Will excess fill be removed from premises? =Yes F!!gNo 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? C]Yes NrNo IF YES, PROVIDE A COPY. Sax 3._ a - : 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 MAGE to the Building Mepartment 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, p ddlticros,alterations or for removal or demolition as herein described.The applicant agrees to comply With all applicable laws,ordinances,building code, housing code and rerguldtions and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are unishable as a Class A misdemeanor pursuant to Section 21Q.45 of the New York State Penal Law. Application Submitted By (print GreenLogic LLC , name): Aut1horized Agent OOwner Signature of Applicant: / v V,/ •� Date: �T l�SIz 3 STATE OF NEW YORK) V SS: COUNTY OF suif-1k } Nesim Albukrek being 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 � • ayof 20 V Notary Public BARBARA A CAB iOTTA Notary 1=ublic-State sf New y*rk No. 01-CA4S94-969 ARTY OWNER rLU—HQRl7AT1C1NOunlafied In Suffolk County COmrniss`st)rt Expires May I1,21 23 (Where the applicant Is not the owner) I, t �4residing at -3 %3s 1A; 1\ t Pe co...: C- do hereby authorize GreenLOgic LLC to apply on my behalf to the Town of Southold Building Department for approval as described herein_ _ Z LA Owner's Signature Date L-/-e-"4-,j Y'-)dL v. ¢.1 Print Owner's Name 2 BUILDING DEPARTMENT - Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 , c Telephone (631) 765-1802 - FAX (631) 765-9502 £ � rc oarr�sotstholdto srnny v — seandgQsoutholdtownny_ ov APPLICATION F<DR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 4/25/23 Company Name: Green Logic LLC Name: Robert SkypaLa License No.: 43858-ME email: Barba raCoGreenl.ogic.com Phone No: 631-771-5152 request an email copy of Certificate of Compliance Address_: _ 97 Forth Sea Road. Southampton, NY 11968 JOB SITE INFORMATION (All Information Required) Name: Kelley Danek Address: 3135 Mill Road, Peconic, NY 11958 Cross Street: Phone No.: 631-767-9759 Bldg.Permit#: gq_3AiE) email: Tax Map District: 1000 Section: 67 Block: 4 Lot: 21_1 BRIEF DESCRIPTION OF WORK (Please Print Clearly) Roof mounted solar electric system (36) SunPower SPR-M41 5-H-AC panels Et 36) €rephase 1 7HS micro inverters (1 ) SunPower PV56 monitor System Size: 14.94011 Check All That Apply: Is job ready for inspection?: DYES NO =Rough In Final Do you need a Temp Certificate?: YES =NO Issued On Ternp Information: (All information required) Service Size =1 Ph =3 Ph Size: A # Meters Old Meter# New Service Q Service Reconnect 0 Underground E]Overhead Underground Laterals 1 2 l-i Frame =Pole Work done on Service? DY =N Additional Information: PAYIVI=N-117 DDE WITH PP'LICATION Electrical Inspection Form 2020.x1sx CERTIFICATE OF M1L- TY NSU CE DATE(MM/DD,YYYY) 01/26!2023 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. IMPaUTANT: If the certiflaate holder Is an ADD[TtDtNAL INSURED,the poiicy(ies)must have ADDITIONAL INSURED provisions Or be endOw-nea- 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 andorsernent(s). PRODUCER CONT _HAMEA1rT I;I.ici'rOrlas Zu1KOfsKe PHONE Brookhaven Agency, Inc. 631 941-4413 F - f I1 941-4405 -_ 100 Oakland Ave, Ste 1 ERSS. Gerticates braokhavlrta enc — .cssm Port Jefferson, NY 11777 IIiS RER s AFFtF2€sINO cOVEAc rttc INSURER A. Southwest Marine & General Insurance Co. INSURED IN B. Merchants Preferred Insurance CO. Green Logic, LLC INSURER c e First Rehab Llife Insurance Co. 1 97 North Sea Rd, Suite 3 INnuppR D= National Liability 8. Fire insurance CO. _... Southampton NY 11968 INSURER-E- AGCS Marine Insurance Go. INSURER F t iE�A 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. -1NSR 'al\DOLI'SUK POLICY EFF POLICY EXP TYPE OF INSURANCE ; POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE --. $ 1000000 A CLAIMS-MAOE � OCCUR DAMAGE TO RENTED € $ ,100 000 XF Contractual Liability X i X GL202300012922 01f31/2023 :01/31/2024 mED ExF- Aon o., parson Iss.008 _PERSONAL�.AOV INJURY $ 1,000 000 GIt=N`L At';GllgI=t--ATE LIMIT APPLIES PER- [[` _ GERIERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT O LOC E 3 PRODUCTS COMP/OP ACR- ' $ 2.000,000 a [[[ t I p E&O Liability $ 1.000,000 AUTOMOBILE LIABILITY I [ CUMBINED SINGLE LIMIT $ 1.o00.000 B [_r _ ANY AUTO BOOILY INJURY(Par parson) IS OWNED SCHEDULED X X CAP1043565 08/11/2022 0$f11f2023 BOOILY INJURY(Paraocid—t) $ AUTOS ONLY AUTOS - _ HIRED NON-OWNED _ PRPEFTY C?i .AAE $ I c€ F , X AUTOS ONLY AUTOS ONLY , il i [ UMBRELLA LIAB '; OCCUR e I EACH OCCURRENCE ;is EXCESS 11-IA01 AGGREGATE S ----. I CLAIMS-MAd?E. g DED R TPNTI 14.. $ IWONKERS COMPENSATION € [ PErR OTH AND EMPLOYERS'LIABILITY y. H - ANY PROPRi.ETO AFIT IEPME-X l,3'1=•IVE� NlA E.L. EACH ACCIDENT S ----. OFFICER/MEMBER FXCLUDE0 see separate certificate I E L.DISEASE-EA EMPLOYEE S (Mandatory in NN) _ ------- If yyes describe under rlFSf:R IPTION OF OPERATIONS below F--L,DISEASE-POLICY LIMIT I $ C NYS Disability 0251202 04/11/2022 +04/11/2023 Statutory Limits E Installation Floater/Property t SML93076366 04/15/2022 3-04/15/2023 $300,000 $2,500 Ded 3 OESCRIPTiON OF OPERATIONS/LOCATIONS/VENICLES (ACORD 101,Additional Remarks Soh-1.1a,may be attaehatl if more space Is required) Certificate holder is also named as Additional Insured. CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 53095 ROUTE 25 SOUTHOLD, NY 11971 AUTHORIZED REPRESENTATIVE CNSZ> © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 3 Workers' CERTIFICATE OF INSURANCE COVERAGE sTATr Cotsepensation Surd 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 carlrie 1 a. Legal Name &Address of Insured (use street address only) 1 b. Business Telephone Number of Insured GREENLOGfc.LLG 631-941-4113 97 NORTH SEA ROAD,SUITE 3 SOUTHAMPTON.NY 15968 SOUTHAMPTON,NV 55988 I,-. 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) 203801194 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 ' Building Department 3b. Policy Number of Entity Listed in Box"1 a" DBL251 202 53095 Route 25 Southold, NY 1 1971 3c. Policy effective period 04/11/2022 to 04/10/2024 4. Policy provides the following benefits: A. Both disability and paid family leave benefits. _ Q 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 1 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. ff tet, ` 4/4/2023 Ii Date Signed By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 6'16-829-8100 Name and Title Richard Wf'lBte_ Chief Exk-_cutive OBCCf ; 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 513 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 Hoard 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. lnsurance brokers are NOT authorized to issue this form. DB-120_1 (12.21) 111411113 11111111mlmiiuiui�i«1°1����IIIIII SNI= workers' CERTIFICATE OF YCIl R K sT Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Boarld 1a. Legal Name &Address of Insured (use street address only) 1b_ Business Telephone Number of Insured Greenlogic LLC (631)771-5152 97 North Sea Rd 1 c. NYS Unemployment Insurance Employer Registration Number of Suite 3 Insured South Hampton, NY 11968 Work Location of Insured (Only required ifcoverage is specifically limited to 1d. Federal Employer Identification Number of Insured or Social Security certain locations in Neve York State, i.e., a Wrap-Up Policy) Number 203801194 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) United Wisconsin Insurance Company 3b. Policy Number of Entity Listed in Box"1a" TOWN OF SOUTHOLD WC605-00090-023-SZ BUILDING DEPARTMENT 53095 ROUTE 25 3c. Policy effective period SOUTHOLD, NY 11971 01/01/2023 to 01/01/2024 3d. The Proprietor, Partners or Executive Officers are Q included. (Only check box if all partners/officers included) 0 all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3" insures the business referenced above in box"1 a"for workers' compensation under the New"`Mork State Workers' Compensation Laves. (To use this form, New York (MY) must be listed under Metre AL on the INFORI411,A-171IONI PAOI- of the wartcew"s' compensation insurance pallicy). 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". 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 irtsured from the ccsverage indicated on this Certificate. (These notices may be sent by regular mail_) Otherwise, this Certificate is valid far€ne 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 tate 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 thopse 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 hoider, 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, 1 certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by. Alicia Christiansen (Print name of authorized representative or licensed agent of insurance carrier) Approved by: (Signature) (Date) Title: Director of Sales Operations Telephone Number of authorized representative or licensed agent of insurance carrier: 941-306-3077 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. C-105.2 (9-17) www.wcb.ny.gov w Suff"olk County Executive's Office o Consumer Affairs VETERANS MEMORIAL HIGHWAY HAUPPAUGE,NEW YORK 11788 DATE ISSUED; 512512006 No. 40227•H SUFFOLK COUNTY HomeImprovement C This is to certify that MARC A CLEAN doing business as GREEN LOGIC LLC having famished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules Fi and regulations of the County of Suffolk,State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR,in the County of Suffolk, Additional Bus aesses ' NOT VALID WITHOUT DFFARTMENTAL SEAL AND A CURRENT CONSOJER AFFAIRS ID CARD Director eV �._._. ... .w ....e ... _ . Suffolk Coun Executive's f Consumer Affairs ice o VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 DATE ISSUED: 1211012007 No. 43858-ME m SUFFOLK COUNTY "aster,electrician License This is to certify that ROBVVT J QN ALA doing business as G EINLO IC LLC having given satisfactory evidence of competency,is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws,rules and regulations of the county of Suffolk,State of New York. Ad��tional I3u�e` s NOT VALID WITHOUT DEPARTMENTAL SEAL AND W CURRENT CONSUMER AFFAIRS Ip CARD Y Director ELEV. 34.4 S C N, Uar SECT t :67 D-0c< 4 DR BROWN� OL LOAM 4, I BROWN SM LOAMY SAND BROWN 3.1' CLAYEY !-w- LA Sc SAND ea- Y,- �s A N BROWN 30+4 MEDIUM SID SAND 12.0' GRAVEL go's NO WATER h 2 17' JAN. 10, 2019 K. WOYCHUK LS 2ND AVENUE 6, -40. A6 N A z p aat F J- �' .o—_ _. ��az�x � ���� .. � � z aye ��- � �} !-JI j�- :2.3* ("pr R 1.11W Z 0 2r-- �z W �F4 ;zie 6- N,i� p V, Li - - ----- S 64'33'00"W 185-27' � VVA 4A p �s 0 30 60 PORC- C 5 2- S T. c 2 2 -RO�V 7 VA 0"N3 13 OBS! V", C4- 4 N, C C 2 A: o� Af5. -,R-S Z TEzRA DO OR ,-� SbPaiS ;V4i� CT IN �N T� NT�Te',P,, 4� V0- -RAAS�Aar C L S-uCTLIR�S ASE 7Ci�, A S�r �65-- 'AO USE T - LE 3,7 AjC-��R E.4SEMDVTS E;�E— 0- �-VCF� "1 0,44 1 -LD -5S ,,,SF�� f,31��i�, Jll��E,�GRO -V A--�j--- or NE4V K-- Al -A A CF. KENNETH M WOYCHUK LAND S UR®EkING, PLLC CO— S Professional Land Surveying esign P.O. Box 153 Aquebogue, New 11931 PHONE (631)298-1588 FAX (631) 298-1588 _CT ��C'S i maintaining the records of Robert J. Hennessy & Kenneth M.Woychuk