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HomeMy WebLinkAbout50780-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE 111P 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#: 50780 Date: 6/4/2024 Permission is hereby granted to: Sun, Christina 615 E Gillette Dr East Marion, NY 11939 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: 615 E Gillette Dr East Marion SCTM # 473889 Sec/Block/Lot# 38.4-13 Pursuant to application dated 4/23/2024 and approved by the Building Inspector. To expire on 12/4/2025. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CO-ALTERATION TO DWELLING $100.00 Total: $325.00 Bui rig Inspector 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) 765-9502h s://www sotilI .)Idt _wiroii . Date Received IIII� III n I1I IIII,I IIII For Office Use Only PERMIT NO, Building Inspector: „p„ 0r Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name: l4J�w•t �r.w SCTM#1000- ................................................ " Project Address: Phone#: Email ✓ r' / / G 7' Mailing Address: �/ ✓� 3 ry y� CONTACT PERSON: Name: �� �,° ^ C T Mailing Address: Phone#: Email: / G � S 4 f! DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: dr "►' ' ", - °l Phone#r ��' Eml� �' � ! � CONTRACTOR INFORMATION: Name: Mailing Address: �, �� �� L-S , �� �°° Phone#: � 3 3 Email: yr L I ZUn I DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Stru; re Addition ❑Alteration ❑Re air ❑Demob ion Estimated Cost of Project: ❑Other ` " ° $ Will the lot be re-graded? ❑Yes &4 Will excess fill be removed from premises? ❑Yes ❑No 1 PROPERTY INFORMATION P w r Existing use of propr rl Intended use of property: ro ertY:. ij Zone or use district in,vvhich premises is situated: Are there any covenants and restrictions with respect to this property? Dyes o IF YES, PROVIDE A COPY. . .._......... .-..m. e u ,, , 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 tlg:,,Towo of 5outhold;Uffolk,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(p nt nam .. —1 l Authorized Agent ❑Owner Signature of Appliical Date: 4/� 4 STATE OF NEW YORK) SS: .. COUNTY OF ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, f � (S)he is the ......_... ,..__._.�_�.�..��___.._.___.._mm.._�........�„w. ....._. (Contractor, Agent, Cow � rate 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 kngJ�eAa8,qP( bf; and that the work will be performed in the manner set forth in the application file there"W&ARY PUBLIC-STATE OF NEW YORK No,01 GR8434884 Sworn b fore m this i Qualified in Suffolk County , rw y �- y or'rti l i Q / Notary Public m P i.��. ��i"Y��'R I�uu 11,/ m� i�, �"w I,4,,,.. i ),F,,i 7 JA i i:1;�i'k (Where the applicant is not the owner) � f residing at.-... �A.�°��� E I � _��r �� do hereby authorize °m ��"_. .. .�_ ...,° .. ..w_' __ _ o apply on my beha,f ;ee. Southold Building Department for approval as described herein. 43* er's g ure � -Date Print Owner's Name 2 _Suffolk County f Labor, _Licensing & Consumer it 70, ASTER ELECTRICAL LICENSE Name STEVEN LEGGIO -- Business Name This certifies that the nearer is duly licensed EMPIRE ELECTRIC & MAINTENANCE LLC Dy the County of suffolk License u_ : E-57024 Rosalie Da o Issued : 05/20/2010 Commissioner - x fires . 05/01 /2024 i ' w workers'Compensation CERTIFICATE OF INSURANCE COVERAGE Yo� stye 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 carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured EMPIRE ELECTRIC& MAINTENANCE LLC 1 SHORE RD, SUITE 903 5169938322 GLENWOOD LANDING, NY 11547 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 81-3277335 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Bein Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold, Department of Buidings Y P Y Town Hall Annex 3b.Policy Number of Entity Listed in Box 1a 54375 Route 25 R89377-001 Southold, NY 11971 3c.Policy Effective Period 4/7/2017 to 4/11/2025 4. Policy provides the following benefits: 0 A.Both disability and Paid Family Leave benefits. B.Disability benefits only. 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, 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 descri6od above. Date Signed 4/12/2024 By (59gnature of insurance carrier's anthori d representativp or NYS licensed insurance agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT:lf 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 46,4C 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 413,4C or 513 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(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. D113-120.1 (12-21) 1111111 1111111 —u NE CERTIFICATE OF YORK Workers' NYS WORKERS'COMPENSATION INSURANCE COVERAGE BoardSTATE Compensation Insured Detail In.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured EMPIRE ELECTRIC&MAINTENANCE 516-993-8322 1 Shore Rd Suite 903 Glenwood Landing,NY 11547 lc.NYS Unemployment Insurance Employer DBA:EMPIRE LIGHTING Registration Number of Insured Id.Federal Employer Identification Number of Insured or Social Security Number 813277335 Work Location of Insured(Only required if coverage is specifically limited to certain location in New York State,i.e.a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company,Inc. TOWN OF SOUTHOLD,DEPT OF BUILDINGS TOWN HALL ANNEX 3b.Policy Number of entity listed in box"la": 54375 ROUTE 25 SOUTHOLD,NY 11971 TWC4396269 3c.Policy effective period: 3/6/2024 to 3/6/2025 3d.The Proprietor,Partners or Executive Officers are: ❑included(Only check box if all partners/officers included) all excluded or certain partners/officers excluded This certifies that the insurance carrier indicated above in box 113"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 INT"ORMATION 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"21'. 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 113c';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 depicted on this form. Approved By: Matt Zender (Print name of authorized representative or licensed agent of insurance cagier) Approved By: 4/12/2024 (Signature) (Date) Title: Senior Vice President REA __000"Wi EMPIELE-04 KA D DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE _[ 4112M2024 _ 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 gA NTACT World Insurance Associates,LLC C PH/coNri E�i (631) 659 3326c �49 Main St. N) 'Cold Spring Harbor,NY 11724 [ANa insuranceIClaells soclates net INSl1,R,ER(SU AFFORDING COVERAGE, ,.� NAIC#,...,, 1715 INSURED 1 ... - .. misuRER_a Merchants Mutual Insurance Company_. ,„ 23529 Empire Electric$Maintenance LLC INSURERC Mt Hawley_Insurance Company 37974 1 Shore Rd,Suite 903 INsuRER D Technalo y'ttjsWqnce Co ..2376 Glenwood Landing,NY 11547 INSURER E_Standard Security Life Ins Co of 9 NY 0078r, INSURER F COVERA E a 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. INSR _ TYPE OF INSURANCE ..,... . .. _BRJ _ POLICY NUMBER. �.. .a, ..Y,.. ,.. . .., .. ... - _.r. .. ,m ... ....... ADDL SUBR POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE l 6 1,000,000 I DAMAGE TO RENTED 100,000 CLAIMS-MADE ['X"]OCCUR X CS NEC0000402-00 3/9/2024 ! 3/9/2025 ICI MI S I +rrlfr� } I 10.. 00 ___ ...... ...v _ ...... _... 6 000, PER ONAL&ADV NJURY $ 1, 000 POLICY X]JR�p - LOC ^PRODUCTS COMPATE c 2,000,000 GENLAGGREGATE PLIIMIITAPPLIES PER. GENERAL.AGGREG OPAGG C � 2,000 000 ECT 07HER: ; COMBINED SINGLE E LIMIT I 1,000,000 AUTOMOBILE LIABILITY M id'Q 0- y Au,. ANY AUTO CAP1069001 5/26/2023 5/26/2024 BODILY INJURY Per, ersan F OWNED xTl SCHEDULED AUTOS ONLY AUTOS �N B er0 cdgynURY Per„acaden[). X.. AUTOS ONLY X AIYTOONCOPERTY APWIAGE CCUR EACH E MXL0439895 3/9/2024 319/2025 AGGREGATE 000 OCCURRENCE $ 5,000, C X ExcEss Lu►BUMBRELLA AB � X�°LAIMs CLAIMS-MADE � 000 DED RETENTION$ ;( D WORKERS COMPENSATION XI PER AT�1TF OTH AND EMPLOYERS'LIABWTY Y/N TWC4396269 3/6/2024 3/6/202$ —STI, 1 000 000 ANY PROPRIIETO�RR/PARTNER/EXECUTIVE E L EACH ACCIDENTw WlFn atory In NH)EXCLUDED? Y J N!A E.L.DISEASE-EA EMPLOYF.I, S 1,000,000 _.,.., , .... . .- m .m .._._ , _ ..... ... If yes,desorlbe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT `F E Disability-Commerc R89377-001 1/1/2024 1/1/2025 'NYS STAT LIMITS DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The Certificate Heider is Included as an Additional Insured as required by written contract or agreement for General Liability with the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD,DEPT OF BUILDINGS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN HALL ANNEX ACCORDANCE WITH THE POLICY PROVISIONS. 54375 ROUTE 25 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Suffolk County Dept.of ". Labor,Licensing&Consumer Affairs HONE IMPROVEMENT LICENSE Name LORNE J BROUSSEAU Business Name HORIZON SOLAR LLC This certifies that the bearer is duly Ilcensed License Number H-46916 by the County of suffolk Issued: 06/16/2011 Ro:al I,>"& Expires: 06/01/2025 Commissioner New York State InsurancelFund All PO Box 66699, bany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 263420621 LOVELL SAFETY MGMT CO., LLC 22 CORTLANDT STREET 33RD FLR NEW YORK NY 10007 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER HORIZON SOLAR LLC TOWN OF SOUTHOLD 1087 FORT SALONGA ROAD 53095 ROUTE 25 NORTHPORT NY 11768 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z2232 489-1 1 654875 04/01/2024 TO 04/01/2025 4/02/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2232 489-1, 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://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 AFFORDS COVERAGE TO THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED(LIABILITY COMPANY. LORNE BROUSSEAU PARTNER, HORIZON SOLAR LLC 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 �/4 !i!i DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 643565512 U-26.3 A� ' CERTIFICATE OF LIABILIITY INSURANCE DATE4/0312D`YYY,' 04/03/2024 -_ - F 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 NAMCONTACYRaveena Malhotra Brown&Brown Metro,LLC PHONE (85 )552-6330 Ac Nr : (856)840-8484 C No t 10 Lake Center Drive E4AAIL s: Raveena.Mafhotra@bbrown.com ADDRES Suite 310 INSURERS)AFFORDING COVERAGE NAIC# Marlton NJ 08053 INSURERA: Southwest Marine and General Insurance Company 12294 INSURED INSURER B: Progressive Casualty Insurance Company 24260 Horizon Solar LLC INSURER C: 1087 Fort Salonga Road INSURER D: INSURER E: Northport NY 11768 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 Master REVISION NUMBER: THIS IS TO CERTIFYTHAT 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. TYPE OF INSURANCE POLICY NUMBER POLICY C EXP LIMITS LTR I MMlDOFY'YYY MM1DD!'YYYY Xli COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 AGE TO RENTED CLAIMS-MADE © OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) is 10,000 A PK202300027930 08/23/2023 108/23/2024 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATELIMITAPPL)ES PER,:, GENERAL AGGREGATE is 2,000,000 POLICY PRO` ILOC PRODUCTS-COMPIOP AGG is 2,000,000 JECT' OTHER: is CO AUTOMOBILE LIABILITY M INED SINGLE LIMIT ;s 1,000,000 Ea accidsni ANYAUTO BODILY INJURY(Per person) is B OWNED X SCHEDULED 00911166 09/30/2023 09/30/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPEkZTY DAMAGE $ AUTOS ONLY AUTOS ONLY Pecaxciden1 �ib X UMBRELLALIAB X OCCUR EACH OCCURRENCE is 2,000,000 A EXCESS LIAR CLAIMS-MADE EX202300002724 08/23/2023 08/23/2024 AGGREGATE is 2,000,000 DED I I RETENTION is 's WORKERS COMPENSATION STA OTH- AND EMPLOYERS'LIABILITY YIN, STATUTE J.ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT t$ OFFICER/MEMBER EXCLUDED? Li (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT .s I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD SEW, workers'Co CERTIFICATE OF INSURANCE COVERAGE �x mpensation 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 carrier' 1a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured HORIZON SOLAR LLC 631-871-1250 1087 FORT SALONGA ROAD NORTHPORT,NY 11768 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) 263420621 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 53095 RT 25 3b.Policy Number of Entity Listed in Box"1a" SOUTH HOLD, NY 11971 DBL427406 3c.Policy effective period 01/01/2024 to 12/31/2024 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 the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 4/15/2024 By (Udd hf a g (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 carriers 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 sox 46,4C 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 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. oB-120.1 (12-21) IIIIIIPiiimi1ii2i0iiii1i0iiiii1ii2i�-Niil�l� Buildip&lie partment Ap glication AUTHORIZATION (Where the Applicant is not the Owner) 10�1: residing at Z- 15 (Print property owner's name) (Mailing Address) �,e,t#L)h0 )? hj jj�'131 do hereby authorize (Agent) to apply on my behalf to the Southold Building Department. ag-xo J 2,kl (Dke) (Print Owner's Name) BUILDING DEPARTMENT- Electrical Inspector k TOWN OF SOUTHOLD Town Hall Annex 54375 Main Road - PO Box 1179 Southold, New York 1 1 971-0959 Telephone (631) 765-1802 - FAX (631) 765 9502 � 1 sh southioldtownn ov seated 6outholdto Lv APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 04-02-2024 Company Name: Ply " t L-t--27 Electrician's Name: ID License No.:MP— Elec. email: Elec. Phone No: request an email copy of Certificate of Compliaince Elec. Address.:I ar I 11 JOB SITE INFORMATION (All Information Required) Name: Christina Sun Address: 615 East Gillette Drive, East Marion NY 11939 Cross Street: Manor Place Phone No.: 631-333-2288 Bldg.Permit#: 150 email: christina@bowsprite.com Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Addition of 22 solar modules on roof of main house. Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: 1-1 YES NO Issued On Temp Information: (All information required) Service Size I J1 Ph❑3 Ph Size: A #Meters Old Meter# ❑New Service Fire ReconnectoFlood Reconnect QService Reconnect❑Underground Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y LJN Additional Information: PAYMENT DUE WITH APPLICATION - � ROOF PLAN GENERAL NOTES JOB NO.2024—S06866 � 1. SOLAR PANELS WILL BE ( 22 ) Q.CELL 410 WATT PV MODULES, AND (22) Q� ENPHASE IQ8M-72-2—US MICRO—INVERTERS. (f -^ 2. PROVIDE A.C. DISCONNECT: CUTLER HAMMER DG221VR6-30A GENERAL �) DUTY SAFETY SWITCH, NON FUSIBLE, 24OVAC, NEMA 3R. W 3. THE AC DISCONNECT WILL BE LABELED AS "UTILITY DISCONNECT AND 2 PHOTOVOLTAIC SYSTEM LOCK-OUT' LOCATED WITHIN VIEW OF THE ELECTRIC Z r UTILITY METER. O Z 4. IF IT IS NOT PRACTICAL TO LOCATE THE AC DISCONNECT WITHIN VIEW OF to to Lu THE UTILITY METER, THEN A WEATHERPROOF PLAQUE SHOWING THE LOCATION W Q Q OF THE SWITCH MUST BE INSTALLED WITHIN VIEW OF THE ELECTRIC UTILITY It a METER. 5. ALL WIRING TO MEET THE NATIONAL ELECTRICAL CODE, J I-Q- ���_-*r.�_ �. 6. THE RAFTERS AS INDICATED HAVE BEEN ANALYZED AND DEEMED SUFFICIENT N TO SUPPORT THE ADDED LOAD OF THE SOLAR PANELS AND CONNECTORS. Q W rr ll T 7. THE SOLAR PANELS MAY NOT BE INSTALLED ON AN EXISTING ROOF THAT N Q V "* HAS MORE THAN 1 LAYERS OF ASPHALT ROOF SHINGLES, UNLESS ADEQUATE W MEANS OF SUPPORT ARE PROVIDED AS PER THESE DRAWINGS. O Z ' o0 00 8. THE MAXIMUM SPACING BETWEEN THE STANDOFFS SHALL BE 64" O.C. v\ J W Q 9. THE SOLAR PANEL MOUNTING SYSTEM WILL BE BY IRON RIDGE XR100 WITH > ~ 00 t A 2 1/2" ALUMINUM BEAM lu 0000 p Q Q 0) Q cn ZONING INFORMATION U W o STREET ADDRESS: 615 EAST GILL.ETTE DRIVE, LZ W Q EAST MARION NY 11939 z SEC: 38 BLOCK: 4 LOT: 13 O J J (nWJZ z LINE DIAGRAM z O O _O Z �D STRING 1 ( CONNECTED TO PV MODULES ) O Q Q n O O =r: CC LL rl STRING 2 (CONNECTED TO PV MODULESLij ) L CO L of o � Q O o a. L.L_ (O W 0r W TJ ^fP" COMBINER MM EXISTING EXISTING NEMA 3R W ---- -- -- f• •z - UTILITY 200 AMP - - -Q M� -a � - - - - METER HOUSE IN 40 AMP LL W a- `/ [�i] BREAKER W O TOTAL SYSTEM SIZE: 9.02 KW Q V) Z w cv a O�Q 0Z WIND Q ZO (0 vaiQ ATTACHMENT D ETA I L Z N E_ SOLAR PANEL MODULE O O m T Q Z c _L ' ALUMINUM ALLOY L-FOOT ALUMINUM XR100 RAIL BY 1%I 111111j," IRON RIDGE \\\\ it, ASPHALT ROOF SHINGLE PV FLASHING ``�� •�..�� ' co . • EXISTING ROOF Oi 04 o i SHEATHING ul•cn •u-C 5/16' X 4 1/2' STAINLESS STEEL id.. ?Oe 0= EXISTING ROOF RAFTER LAG BOLTS INTO CENTER OF ROOF ���( RAFTER. MINIMUM 3' EMBEDMENT. wii�(p, •�. o* '','�w filif/f111111111 ``` PRI R TO CUTTING OR ORDERING OF MATERIAL JOB NO. OR PLACEMENT OF THE L-FOOT ATTACHMENT, 2024-SO6866 FIELD VERIFICATION OF EXACT RAFTER OUTLINE OF ROOF LOCATIONS ARE REQUIRE TO COMPENSATE FOR 36" GROUND 'PREEXISTING RAFTER IRREGULARITY THAT MAY ACCESS AREA EXIST. 1 36" MINIMUM— ROOF ACCESS Fr7- p W O i" THESE DRAWINGS COMPLY WITH THE 2018 IRC AND 2020 NEW YORK 18" MINIMUM STATE RESIDENTIAL BUILDING CODE. VENT AREA o I;/ V!� '> > u I cc ¢ a Q HATCHED AREA o ; ! NOTE: ALL ROOF MOUNTING INDICATES LOCATION �� r��� ,/. / ,BRACKETS SHALL BE PROPERLY Q OF SOLAR PANELS �% ��i lI ,1 o SECURED TO A ROOF RAFTER. % / o/_=!�r— -- ° THIS PROPERTY PRODUCES THE O Z W FROOF T \ 00 REQUIRED GROUND ACCESS TO THE 00� J W � ROOF ACCESS PATHWAYS AS DRAWN. HOUSE W > ,_, ! 00 10 W- Z � � x ao co THESE DRAWINGS HAVE BEEN DESIGNED IN U O to ACCORDANCE WITH THE (AF & PA) WOOD EAST GILLETTE DRIVE, !Y W � W o FRAME CONST.DWELLINGS. MANUAL FOR ONE AND TWO w W Z Lu FAMILY DWELLINGS. ROOF PLAN/PANEL LOCATION � O w SCALE 1/16"=1'-0" O W Z z z THE ACTUAL IN-FIELD ATTACHMENT TO o THE ROOF WILL MEET OR EXCEED NYS Z O IY O RESIDENTIAL CODE REQUIREMENTS W ~ Of Q z O �- O (n W O o GROUND ACCESS POINTS ARE NON-OBSTRUCTED Z 0- z PER 2018 IRC AND 2020 NEW YORK STATE O LLo (n W c RESIDENTIAL BUILDING CODE. w Q o 0- Li (O W V) 2" X 8" RIDGE Z 2"X4" COLLAR -O- - -Of 00- coo Q-CELL 410 TIES ® 48" O.C. q SOLAR MODULES 0 J 00 cy- IRONRIDGE FX SYSTEM cc O W C3 LAG BOLTED TO RAFTER --- -- _____ 2" X 6" ROOF Q (n I 6 } Cy RAFTER ® 16" O.C. W I-) C) Z cc ALUMINUM SUPPORT O x RAIL BY IRON RIDGE------,,, ATTIC z N n a ---- ---- cc o o 2 z EXISTING ASPHALT ROOF SHINGLES {\{{{ Illlfipl (MAX 1 LAYERS) ON 15# BUILDING /k� PAPER ON 1/2" PLYWOOD SHEATHING ••..•••��!����, O . tn��7>� �Qico cG�W� • Z= �Oi� p� ROOF CROSS SECTION a:`� o;o SCALE 1 4 =1 -0 �''.,%�'••......•• ���: 41111q{{{{ 44,-9" JOB NO. RIDGE LINE 2024•—SO6866 18" MIN -- -- - -- - _ VENT AREA OUTLINE OF ROOF Z O z Lu Q Q cc QCELL 410W a SOLAR MODULES r N J PROVIDE 2 1/2 Q ` ALUMINUM SUPPORT BEAM O PROVIDE ALUMINUM STANDOFF O Z00 LAG BOLTED TO RAFTER °O J W �' ti z ►� x00 o Q wco SYSTEM LENGTH = 37'-10 1/2" u 45'-1" z LLJ w � NOTE: THIS ROOF WILL HAVE (17) QCELL 410 WATT PV o w z MODULE PANELS WITH KW OUTPUT OF (6.97 KW ) AND O V) -J.I z (!) W — Z (17) ENPHASE IQ8M-72-2—US MICRO INVERTERS Z of 0 p O PANEL„CELL SIZE SOLAR PANEL LAYOUT ROOF # 1 Ld Z j Q g x SCALE 3/16"=1'-0" LINE OF HIP m O (� W J o Z F- Lli 74.0" O L Ln (n Z Ol) cFn OUTLINE OF ROOF � Q w o tl u- CO Lu 0- w Q - MODULE - TYPE/ --o- - a (0 T .� PANEL SIZE }` u. o oo w ui O Q W SCALE N.T.S. ,K. ` WELL 41OW Q (f} I N SOLAR MODULES a Z Z W PROVIDE 2 1/2" a J NOTE: WHENEVER POSSIBLE ALUMINUM SUPPORT BEAM cn O N x ; ��� .: ` � � N I a PLACE SMALLER SPAN BETWEEN ATTACHMENTS POINTS _ TO AN OUTSIDE EDGE OR LAG BOL ED MTo RAFTER 3 0 Q O r7 00 � OPENING IN A RUN. f o = o Z SYSTEM LENGTH = 13'-9 1/4" ,``tttt t t llll pl��i i J �' •3- NOTE: THIS ROOF WILL HAVE (5) QCELL 410 WATT PV "�'y °'W' o;z= SOLAR PANEL LAYOUT ROOF # 2 MODULE PANELS WITH KW OUTPUT OF (2.05 KW ) AND LW�N ice•cc % SCALE 3/16"=1'-O" (5) ENPHASE IQ8M-72-2-US MICRO INVERTERS ; P/" ••••••••••••,, ���lllnunntttt R ,� Rl..,e ct5 �i�tl�J�.�` i� � 5 J S n �i f ...�� IV 1. `1 t_ I ] ((" "� 11 �(1 la f llo �, r s 1 q�'y�-I U �t i.."-�� . �' .'\lJ r '�'1�'�1IIv1i7�?t'`:6�Cnh. LS�L-1..��?`lr )sV'_�II.�+J... .,`(3��" II1.�.(1 "F�r�; -� • � r � � •' ,�,sn�:� °'�tk\I;�7_�`.'�°C���G�i�;��;���`'��f�I" c:it`'!�• � �����i, — ■ n/ f 11 1 r 1 { , y • .t `�' 5llfn�I�l I t" 1.� r .•1 H�"" 7" j y /- J�1— II� • • ' , t � ' t1viJU�?�� �Jt� __u WARNING: DUAL POWER y •• . ,r- --r I SOURCE. MULTIPLE SOURCES OF 5:,,� • •� • • • • {`ram:11Cs:`_7 fal�'\y?� {i -jc�,•l ��� \.rp -- 1, •• _ p3 POWER UTILITY AND SOLAR ■ '• I • I W' •• •" • ' ' I j ELECTRIC SYSTEM ; • � •• -1 �"" `� J : MAX AG OPERATING CiJR�iENT: ®I A � - - ' • - - - __�, - .-- -- - NOMINAL OPERATING V :LTAGE t I V � � • NJ!hl' ��� ; TI RN OFF PHOTOVOLTAIC AC -� `- -- -' ." { � '�`I, ,�C-�t���S �� ,�•���/6'��) DISCONNECT PRIOR TO 1 • tAdORKING INSIDE PANEL N • r • ; ? WARNING - DUAL POWER SOURCE • DIVA D1' • • ` 1 ' �w ,i` {(��1I' Q1 !�(. (N;"It,in�� '�!\� °i- `� SECOND SOURCE XIS PV SYSTEM! • � ■ i I � - ' T, Ft N 1 N G A i � • • Al • , � 1 1 '1'` - � �`� tit ,^� 'Ip����'11r9 � I � a • � N I( 1:�� �: .t��ryS1157I-Iir-_i��t r r• r r • � • � ELECTRIC SHOCKiHAZARD - - • • I • i y�Y 'll-il�c�+'r�l U`�J,c�( l•`� r �i`� � M DO NOT TOUCH TERMINALS r !1�ii�l_C,nj,c,�����'��I�(�Sl(�{��I(���,.�v E I �' •• • � s r• � � TERMINALS ON BOTH LINE AND LOAD SIDES MAY BE;ENERGIZED 1 1 • '• IN ,THE OPEN POSITION • • 1.3 1 101 Irk.11,1' 1 • • �lf�'r'r1 io 1�?'ti�� it ■ _�_���11��.�11 • ° r { 15�r Yfcl_ILI 1J � l t`Il i� 'i'"� - i ' • r• , � � i' {�:,��-) «X'u.l I�(l Cti&W RJi7� 'R 5)RE a 19 r ' vvut-s.•u r pl��lil PROPERTY LINE Cn --d F— kVM]MJa -D I— 7 o om F9 -<I I ,-I m I 0 m z �;u m C I I�1 I I PROPERTY LINE 0 RA WINGS PREPARED FOR: DRAWN BY: J.N.S DATE: 4/0 2/2 4 REVISION NO. N �s•.• •. PROPOSED SOLAR PANEL INSTALL. HORIZON SOLAR For: SUN RESIDENCE i 615 EAST GILLETTE DRIVE (631 )-683-4898 O Ea EAST MARION NY 11939 rn 0216;:•�Q-`.``� 1087 FT. SALONGA ROAD PAGE NO. 00j „NEW;�.�` NORTHPORT NY 11768 PLOT PLAN rn 100 - 02 DAME S J. STOUT ARCHITECT 2 GREG LANE EAST NORTHPORT, NEW YORK (631) 858 9388 JOB NO. 2024—S06866 Q.PEQK DUO ML-G10+ v ENPHASE. ®® /IrIRONRIDGE Flush Mount System 1 SERIES citell3 395-415WP I211%Maxjmurn Module Efficiency I Q ' ,kooa;a>:du ouo w.c+a ' ., .'"�,�' O O �— Lu r � ITreaking the 21%efficiency barrier ou+rw ouozma.amr.a rooanaetmw t WmramPae,aFd!,wYWm}ni :- ;,., cc Q. 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I_J �~❑ #6 GEC Dedicated,PV Syste AC Combiner Panel 60A,240VAC Qcell Qpeak Duo Blk ML-1310+410 Specs MPP Voltage:37.64V [Account# wner ��� D C MPP Current: 10.89A g 3. Open Circuit Voltage:45.37V stina Sun ���� p� p g ^s Short Circuit Current:11.20A lette Drive FNorthport, Company Module Efficiency:20.9% n, NY 11939 ' �r ar Maximum System Voltage:1000V 9674059403 �t 1 �0 alonga Road Maximum Series Fuse Rating:20A 8385565 NY 11768