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Home My WebLink About49504-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE �} b 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#: 49504 Date: 7/21/2023 Permission is hereby granted to: Ackerly Pond Ln LLC 62 Main St .��............................_ PO BOX 3163 Sag Harbor, NY 11963 To: Install roof mounted solar panels to an existing single-family dwelling as applied for and according to manufacturers specifications. At premises located at: 1635 Akerly Pond Ln,_Southold SCTM # 473889 Sec/Block/Lot# 69.-5-8 Pursuant to application dated 6/14/2023 and approved by the Building Inspector. To expire on 1/19/2025. Fees: SOLAR PANELS $50.00 CO-RESIDENTIAL $50.00 ELECTRIC $100.00 Total: $200.00 Building Inspector r TOWN OF SOUTHOLD -BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 htt,i)s://,ArwNv.southoldto"iiliygov Date Received APPLICATION FOR BUILDING PERMIT Foe Office Use Only ,5 0 A PERMIT NO, �®„ Building Inspector:. "• JUN Applications and forms must be filled out in their entirety. Incomplete` n° applications will not be accepted. Where the Applicant is not the owner,an y -: Owner's Authorization form(Page 2)shall be completed. Date: U12 OWNER(S)011PROPERTY: Name: NAC hme l Cb V-vt,�- SCTM #1000- a � „ C)® ' �� C�� - 00$ , Project Address:\0,65 (JW I Pend UnC SC�IC\0,�a qY j q--1 Phone#: Lo3\" Ltv55_`l-I 5 5 1 Emai1:yy)thmC+(,zv ham' C>23 Z)' M (,(� Mailing Address: 1 X035 nCe ly Porld �Y,C So AVA()�Ck, �Jy �1 q-( CONTACT PERSON: Name: k\ Mailing Address:a4G rWk"f) M %iVc 4M PIaIgv�t\jv ,, Phone#: b 11-�(i i- I I)O I Emai1: i t 1(n c-.h 6) n"yu,v`+ r -Or I DESIGN PROFESSIONAL INFORMATION: Name: -Puy 7MOYl CS�LCCgY�dIC�1'1 O.K1 Mailing Address: 11 Phone#: q _ 3, I_ 5 3 8 Email:IPUy M0(-\,.-ESk.0ad QA*CLn S«Y)?werC0p, CONTRACTOR INFORMATION: Name: Suh `),�e ��'�vo�on .. v Mailing Address: a4c: N�A-wvwn -LA - Sw{--e L-00 pkwn\�ltu' Phone#: 3 R-qC1 t- k v?J G E (1. Y-X\q @ atyl QOVlicv C&-p • co M DESCRIPTION OF PROPOSED CONSTRUCTION ❑NeWStructure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other pa" -) s lao 0 0 Will the lot be re-graded? ❑Yes XLNo Will excess fill be removed from premises? ❑Yes lkNo 1 DocuSign Envelope ID:4C6CDD07-8270-4BBO-8COF-OCDFOF41 1 CC5 PROPERTY INFORMATION Existing use of property: Sly 1;CX 1i iq Q Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes>L o IF YES, PROVIDE A COPY. 4Check 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 210AS of the New York State Penal Law. Application Submitted By(print name): 146MV) to 1 VAuthorized Agent ❑Owner Signature of Appiica � Date: STATE OF NEW YORK) SS:_ COUNTY OF 5, C ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is thee-�� ----- (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 applicill NICHOLAS GLOGOWSKI Commission#50068578 Sworn before me this Notary Public, State 0i" Sr-rs My Commission Expires September 21, � day of j _��20m Notary Public F"ROPERITY OWNER ) Z ION (Where the applicant is not the owner) I, NN NII h rne''i, � ht� residing at ,l�V do hereby authorize ` 1`� to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date tEf u Print Owner's Name 2 � tBUILDING DEPARTMENT- Electrical Inspector 44 TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 w ro err southoldtownn . ov— seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION IAII Information Required) Date: tol Company Name:' SCOW eXar�� Name: oO"w Wd E 6 CSC License No.: (VIE � �1 � email: .(saoandG) cue ,C Address:a l t �V�� ,'ifs YDft , NY 100 Phone No.: JOB SITE INFORMATION (All Information Required) Name: Me' ;met Ctt j ht� (_ Address: U35, n6 LckLt Cross Street: Phone No.: �23 _ X51-1`15 Bldg.Permit#: y email: Q�)aCj . Tax Flap District: 1000 Section: 0(oq , 00 Block: 05 ,Oo Lot: OO .,,_op BRIEF DESCRIPTION OF WORK (Please Print Clearly) Circle All That Apply: Is job ready for inspection?: YES / 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: PAYMENT DUE WITH APPLICATION Request for Inspection Formals Buildin , De oartrnent Application AUTHORIZATION (Where the Applicant is not the Owner) residing at (Print property owner's name) (Mailing Address) s ., .. v1 . �_. do hereby authorize �vyn-4—d (Agent) to apply on my behalf to the Southold Building Department. W a3 (Owners Signature) (Date) (Print Owner's Name) y" It workers' CERTIFICATE OF INSURANCE COVERAGE S r Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disabilityand Paid Family Leave benefits carrier or licensed insurance r y ...._... agent of that carrier 1 a. Legal Name&Address of Insured(use street address only) 1 b B...._._..._ ...er of_............. ............�— Business Telephone Number of Insured SunPower Corporation 3939 North First Street San Jose, CA 95134 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 94-3008969 2.Name and Address of Entity Requesting Proof°........... ......._._ �......_........—.. ..._- ........�- ............_.-.- ........___......... of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Prudential Insurance Company of America Town of Southold Town Hall 3b.Policy Number of Entity Listed in Box 1a 53095 Route 25 CG-50122-NY P.O. Box 1179 3c.Policy Effective Period Southold, NY 11971 01/01/2023 to 12/31/2023 4. Policy provides the following benefits: DE A.Both disability and Paid Family Leave benefits. F] 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 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 insuranro rnvarnna ac rlacrriharl -rh,nvo Date Signed May 19, 2023 By Alm �' . , (Signature of„w�. r~ a.�,,,..,,..,,�.,,�,.,.�.",. _.�.., ��.dnsed insurance agent of that insurance carrier) Telephone Number 215-658-7318 Name and Title Carolynn Smith - VP Contracts 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 co ......_., - ......W mpleted by the NYS Workers' Compensation Board (only if sox 4B,4C or 5B 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 benefits insurance policies and NYS licensed insurance y y y p 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 (12-21) DB-120.1 (12-21) DATE /YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/19/2023/2023 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, 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 AME; Marsh Risk&Insurance Services .... Marsh Risk&Insurance Services _ FAX 1735 Technology Drive,Suite 790 Exgm Attn:SanJose.CertRe uest marsh.com;F:212-9484335 c DREAILSanCerts@marsh com CA 95110 Franasco San Jose, AODaREsS ................. ... m _ INSURERS AFFORDING COVERAGE NAIC# CN 1 02680983-STND-GAW-23-24 INSURER A:Aspen W.. mmm S ectal 10717 Insurance Compan INSURED INSURER B N/A N/A SunPower Corporation SunPower Corporation,Systems INSURER C.Trumbull Insurance Company �44 LL 27120 1414 Harbour Way South,Suite 1901 INSURER D: Richmond,CA 94804 _...�...... .. _�_ -............_............... .... INSURER E INSURER F.. COVERAGES CERTIFICATE NUMBER: SEA-003920550-01 REVISION NUMBER: 3 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. f h` TYPE OF INSURANCE POLICY NUMBER � MOLIC F POLI... INg�" ADOL uIJ�B�I POLICY EFF POLICY EXP LIMITS LTR DD A X COMMERCIAL GENERAL LIABILITY CROOQF123 04/01/2023 04101/2024 EACH OCCURRENCE $ 2,000,000 I 1 ,000,000 CLAIMS-MADE X OCCUR PREMR,7MS((✓e roc r�rren�c �..$.�. .. ....._1 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES �7 PER: TE $ 4,000,000 GENERALAGGREGA ..mm _"" ........... X �PRO- 4,000,000 POLICY - 1:1 LOC PRODU - _/OP'AcG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE L8Iti,6tr $ (.Ea aIdenG ..._-m�_.- .....� ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ ". .... - PRe03�EN�TY DA�JgA'��GE� A HIRED NON-OWNED I* accYt9ert ....................... AUTOS ONLY AUTOS ONLY (......�� $ UMBRELLA LIAB OCCUR _EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION 57 WV WQ0015 4 04101/2024 X PER O1 H- Y 1 L.EACH R 1,000,ODO i AND EMPLOYERS'LIABILITY STATUTE '""�' E ANYPROPRIETOR/PARTNER/EXECUTIVE N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE ASEEA EMPLOYEE"$ � �� If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Installation of a 12.62 kW Grid-Tied,Roof-Mounted Solar System at 1635 Akerly Pond Lane,Southold,NY 11971,Installing a total of 29 Solar Panels. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD IN'S* Workers' 1r1 Compensation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a. Legal Name and address of Insured use street _ 1b. Business Tel of In --- g .... ( ephone Number of Insured address only) 888-249-8550 SUNPOWER CORPORATION, SYSTEMS 1c. NYS Unemployment Insurance Employer Registration 1414 HARBOUR WAY SOUTH #1901 Number of Insured RICHMOND CA 94804 Work Location of Insured (Only required if coverage is 1d. Federal Employer Identification Number of Insured or specifically limited to certain locations in New York State, Social Security Number i.e., a Wrap-Up Policy) 94-3008969 _ 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage (Entity Being Listed as the Certificate Holder) HARTFORD ACCIDENT AND INDEMNITY COMP 3b. Policy Number of Entity Listed in Box 1a": 57 WV WQ0015 3c. Policy effective period: TOWN OF SOUTHOLD TOWN HALL 04/01/23 to 04/01/24 53095 ROUTE 25 3d. The Proprietor, Partners or Executive Officers are PO BOX 1179 Included. (Only check box if all partners/officers included) SOUTHOLD, NY 11971 Dall excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" 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". 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 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 Worker's 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 depicted on this form. Approved by: Danielle Clausen ndintnm05 lg carrier) Approved by �1„�.:.�,_c �� e of authorized representative or licensed agent of insurance 0 2 3 (Signature) (Date) Title: Operations Manage - Telephone anage -Telephone Number of authorized representative or licensed agent of insurance carrier: (877) 853-2582 - 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) Form WC 88 31 21 F Printed in U.S.A. www.web.ny.gov Page 1 of 2 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter, and notwithstanding 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 compensation for all employees has been secured as provided by this chapter. 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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter, 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 compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE www.wcb.ny.gov Form WC 88 31 21 F Printed in U.S.A. Page 2 of 2 e 002 SK � w Labor, Licensing sn lk Coon Department g RN � _ Consumer Ajjairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 No. HI-66354 1M 0 DATE ISSUED: 02/25/202 - - A 1 WESUFFOLK COUNTY31 Q14 ,dome Improvement Contractor License This is to certify that Donald E Garland Jr. - - Sunpower Corporation Systems Inc . "F doing business as F having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York is hereby licensed to conduct ilk business as a HOME IMPROVEMENT CONTRACTOR, in the County of Suffolk. :. NOT VALID WITHOUT Restrictions Additional-Businesses. DEPARTMENTAL SEAL -4,HI l-Solar AND A CURRENT � CONSUMER AFFAIRSSuffolk County Dept.of ID CARD Labor,Licensing&Consumer Affairs ' HOME IMPROVEMENT LICENSE L �, Name DONALD E GARLAND JR, Business Name4 IF g-_ s certifies that the mgr is duly pcensetl Sunpower Corporation Systems Inc Rosalie Drago �,e Courty o,su�olk License Number:HI-66354 5 Commissioner Rosalie Drago Issued: 02J2512022 , Comn iss,oner Expires: 02/0112024 AN- 00 �E P IN IMP l' b a r - \..s-, :' =a �..- _ € 3`S vim' ti � vT �s . ,. �_ ..... :.g-h-. _a.�.. __: �..� --- - _ s -.:tip € ,� _ � � c kYJ z _ `MY - . , . \ Suffolk County Department of Lab fir, License Consumer Affairs � VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 1178 DATE ISSUED: 10/04/2021 No. ME-64678 SUFFOLK COUNTY3 Master Electrician License 7 , t This is to certify that Donald Garland JR. - SunPower Corporation, Systems doing business as - having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions o applicable laws, rules and regulations of the County of . I - 3 Suffolk, State of New York. W �21 � 2 \ NOT VALID WITIiOUT Additional Businesses DEPARTMENTAL SEAL AND A CURRENTIN CONSUMER AFFAIRS ID CARD All Rosalie Drago N-W�M Commissioner - g e _ � _ 'i =: - - _ -.:,- - t *sy �- ., _ `.. - , ��' �� -' ,,,-moi, ,.�=� - �•.� =