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HomeMy WebLinkAbout50242-Z TOWN OF SOUTHOLD r 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 #: 50242 Date: 1/23/2024 Permission is hereby granted to: Hoeltzel, Ma 213 Orchard Way Wayne, PA 19087 To: install roof-mounted solar panels on existing single-family dwelling as applied for. At premises located at: 6190 Great Peconic Bay Blvd, Laurel SCTM # 473889 Sec/Block/Lot# 128.-2-5 Pursuant to application dated 12/19/2023 and approved by the Building Inspector. To expire on 7/24/2025. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CO-ALTERATION TO DWELLING $100.00 Total: $325.00 _J'� , Building Inspector �r Yy TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 gl Ir Telephone (631) 765-1802 Fax(631) 765-9502 htt :r Fay. outholdtownn . ov "05 Date Received PERMITAPPLICATION FOR BUILDING E C E 0 W E For Office Use Only PERMIT NO. Building Inspector: S6 DEC1 9 2023 DI) Applications and forms must be filled out in their entirety.Incomplete e applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: I R 1 15-1 a3 OWNER(S)OF PROPERTY: Name:Mary Hoeltzel SCTM#1000-128-2-5 Project Address:6190 Peconic Bay Blvd, Laurel, NY 11948 Phone#:917-334-4111 1 Email:info@hallockbuilders.com Mailing Address:6190 Peconic Bay Blvd, Laurel, NY 11948 CONTACT PERSON: Name: Tammy Lea/Sunation Solar Systems Mailing Address: 171 Remington Blvd., Ronkonkoma, NY 11779 Phone#: 631-750-9454 x 3L-� I Email:permitting@sunation.com DESIGN PROFESSIONAL INFORMATION: Name:William Fisher Mailing Address:509 Sayville Blvd, Sayville, NY 11782 Phone#:631-786-4419 Email:bill@fisher-ny.com CONTRACTOR INFORMATION: Name:Scott Maskin/Sunation Solar Systems Mailing Address: 171 Remington Blvd., Ronkonkoma, NY 11779 Phone#: 631-750-9454 Email:permitting@sunation.com DESCRIPTION OF PROPOSED CONSTRUCTION [--]New Structure ❑Addition i�Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $ 61r 6M-T)S Will the lot be re-graded? ❑Yes igNo Will excess fill be removed from premises? ❑Yes R'No 1 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 this property? ❑Yes RNo 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. Application Submitted By(print name)a Scott Maskin BAuthorized Agent ❑Owner Signature of Applicant: Date: JQ115 f a3 STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Scott Maskin 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 �dayof 20 ' Cha Nota '"a ""Wi.(biic, State of N wYork ecg, stration #01V1506819-; Qualified in Suffolk r''PROPERTY OWNER y AUTHORIZATION IVIy Commission Expires (Where the applicant is not the owner) Mary Hoeltzel residing at 6190 Peconic Bay Blvd Laurel Scott Maskin do hereby authorize to apply on my behalf to the Town of S uthold ilding Department for approval as described herein. Owner's ignat r Date —,.-- .— Print dwner's Name 2 � IJ BUILDING DEPARTMENT- El+ ctrl I s e �� 20 TOWN OF SOUTHOLD " Town Hall Annex- 54375 Main Road - P& x,11 ' � ,In t „n Southold, New York 11971-0959 iCANJI N Telephone (631) 765-1802 - FAX (631) 765-9502 49 ro err southoldtownn : ov— seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: i Company Name: SUNation Solar Systems, Inc Name: Scott Maskin License No.: 33412-ME email: permitting@sunation.com Address: 171 Remington Blvd. Ronkonkoma, NY 11779 Phone No.: 631-750-9454 k ill JOB SITE INFORMATION (All Information Required) Name: MaEy Hoeltzel Address: Q190 EeQgnic Bay Blvd, Laurel, NY 11948 Cross Street: Phone No.: 917-334-4111 Bldg.Permit#: email: info hnallockbuilders.com Tax Map District: 1000 Section: 128 Block: 2 Lot: 5 BRIEF DESCRIPTION OF WORK (Please Print Clearly) ln!gallatim of sQlar planels =flat on roof 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, . PAYMENT DUE WITH APPLICATION Request for Inspection FormAs �'NIEW workers' CERTIFICATE OF INSURANCE COVERAGE YORK ATE Compensation Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrie 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured SUNATION SOLAR SYSTEMS 631-750-9454 171 REMINGTON BOULEVARD RONKONKOMA, NY 11779 1c.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) 753118816 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 Route 25 3b.Policy Number of Entity Listed in Box"1 all PO Box 1179 DBL631187 Southold, NY 11971 3c.Policy effective period 10/01/2022 to 09/30/2024 4. Policy provides the following benefits: © A.Both disability and paid family leave benefits. B.Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: © A.All of the employers 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 tfie named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. 440 Date Signed 9/26/2023 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that 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 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 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 sox 46,4C 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. DB-120.1 (12-21) 1111111111111111111111111111111111111111111111111111111111 AC R0 DATE[MMIDOIYYYY)CERTIFICATE OF LIABILITY INSURANCE !°` 2/9/2023 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,thepolicy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the olic ,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 C "' _ The Horton PHONE 10320 Orland Parkway E MAte cece s3 thehordr�n rou conA �) Orland Park IL 60467 R tl `.t g p ( . ....... ., _N_AIC0 ENSURER A:Evanston Insurance..Company 35378 .,...._... ,_� .. .........m...e_.,..._.m,,,., ,.,....... ..W. ,.......,�.. .........._....-�......... ...,... .. ......m.�........................ ... .._ Sy INsuRER 6 The .,ontinental InsuranceCo �arY.,._. � 35289.... _ INSURED SUrVA50L�.11 � SUNation Solar S stems, Inc. 171 Remington Blvd WSUAERC Axis Surplus Insurance o 26620 Ronkonkoma NY 11779 rNSVR,ERmU Travelers i ipa„rty CasLraltym r an o Arrert 2567 gNsuREsa E:Bums&Wilcox Ltd. IN9�IYRER�F..-_..._... ..... ............. ........... . COVERAGES CERTIF'I'CATE NUMBER:703220016 REMISIO'N 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. W__ .. ...... �.. .. .... .. _. ...��.,..... _. .. _. .. �wu........ POLICY EFF POUCr EXP ... _.�-...,_ m.�-...._...... LRP I POUCYNUMBER MMMD M TYPE OF INSURANCE �� LIMITS A X COMMERCIAL GENERAL XERAL LIABILITY Y Y 121 CTR 0212775-00 2/11/2023 2111/2024 I EACH OCCURRENCE s 1 000,00° CLAIMS­IMDE C OCCUR �,,EMWS (ba�eFr aJ 5300000 comm mmm mm_ MED EXP(Any one person/ S 10 000 , PERSONAL&ADV INJURY . ... S 1,000 00 GEN(.AGGREGATE LIMIT APPLIES PER LAGGREGATE $2,000.000 POLICY OPECT LOC PRODUCTS-COMPIOP AGG 5 2,000,9A0 OTHERW S v B AUTOMOBILELIABILnY Y Y 7018308202 2/11@COMBINED SINGLE LIMIT 023 2/11/2024 51,000,000 X ANY AUTO BODILY INJURY(Per person) S OWNED x ,SCHEOULED (Per ... ".,. AUTOS ONLY AUTOS R accident) S P BODILY aca ,,.�. cow_,.. �-„..�...._ HIRED NON-OWNED v_�OPERTYrYAMAOE S - AUTOS ONLY AUTOS ONLY 5 C JX UMBRELLALIAB XOCCUR Y Y P-001-00°795195-02 2/11/2023 2/11/2024 EACH OCCURRENCE S3,000,000 EXCESS LIAB CLAIMS..MapE, AGGREGATE S3.000.000 DED II RETENTION S S WORKERSCOMPENSA71ON ,..._�STATIfiE;_J! E ...._.....,, --...__ AND EMPLOYERS'LUU31LnY Y I N ANYPROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E._L EACH ACCIDENT S OFFICERIMEMBEREXCLUDED7 ”'""' (Mandatory In NH) I�`E.L.DISEASE-EA EMPLOYEE S U0descbe under SCRtP710N OF OPERATIONS beknw f E.L.DISEASE-POLICY LIMIT S D Builders Risk Y Y QT-030-2T010874-TIL-23 2/1112023 2/11/2024 Link 500,000 E Professi a/PolhAonLiablity 1000704865 2/11/2023 2111/2024 'omit: $1,000,000 D LbasedrRented Egwmprnant OT-630-2T010874-TIL-23 2/11/2023 2/11/2024 Urr t° $250,000 DESCAdditional Named PTION OF Insureds: UNatio SVEHICLES ervice Inc; UN10iation Electric Inc;SUNation Commercial if mom UN ti required) r martial InC;SUNation Cares Inc Additional Insured on a primary and non-contributory oasis Wtlh respect togenerW IiabH? Automobile and Pollution Liability coverage When required by Written contract.Waiver of subrogation applies to general'liability,Automobile and Pollution glabi 4y in favor of the stated additional insureds When required by Written contract.Excess follows form. Town of Southold is included as an additional insured as required by written contract and the CG 2012(State,Govemmental agency,or Political subdivision permits or authorization)is included on the policy. CERTIFICATE HOLDER CANC'ELLATI'ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Town of Southold 54375 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 , I :J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NY F PO Box 66699,Albany,NY 12206 New York State Insurance Fund I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A A 753118816 �. GCG RISK MANAGEMENT INC AN NFP COMPANY 100 CHURCH STREET-SUITE 810 NEW YORK NY 10007 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SUNATION SOLAR SYSTEMS INC TOWN OF SOUTHOLD 171 REMINGTON BOULEVARD 54375 ROUTE 25 RONKONKOMA NY 11779 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD =12/08/2022 Z 2160 670-2 598021 01/01/2023 TO 01/01/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2160 670-2, 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 STATE INSURANCE FUND 11� 4 DIRECTOR,I, SURANCE FUND UNDERWRITING VALIDATION NUMBER: 959308854 gillillillillill Hill Hill Hill HiHHnisiHill Hill HHHiHill oil unHill Hill HI � 00000000000110301221 Forrn WC-CERT-NOPRINT Version 3(08/29/2019)[WC Policy-216067021 U-26.3 64 [00000000000110301221][0001-0000216067@][##Z][16030-19][Cer NoP-CERT_1][01-00001] Y f It r'r Suffolk County Dept.of ou Labor,Licensing&Consumer Affairs l I � F. HOME IMPROVEMENT LICENSE Name SII SCOTT A MASKIN Business Name • s certifies that the icer is duly licensed SUNATION SOLAR SYSTEMS INC :he County of suFolk License Number:H44104 Rosalie Drago Issued: 03/06/2008 Commissioner Expires: 3/1/2024 r� II 3� p i '4 �y{ l )j b �4 l i 1 LL l Suffol!k County Dept. o o Labor, Licensing & Consumer Affairs MASTER ELECTRICAL LICENSE Name SCOTT A MASKI N Business Name SUNATION SOLAR SYSTEMS INC This certifies that the bearer is duly licensed License Number ME-33412 by the County of suffolk Issued: 06/24/2003 Prager- Expires: 06/01/2025 Commissioner