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HomeMy WebLinkAbout50972-Z s 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#: 50972 Date: 7/22/2024 Permission is hereby granted to: Batuello, Clifford 1725 Alvahs Ln Cutchogue, NY 11935 To: install roof-mounted solar panels to existing single-family dwelling as applied for. At premises located at: Alvahs Ln, Cutcho ue SCTM #473889 Sec/Block/Lot# 109.-1-24.3 Pursuant to application dated 4/26/2024 and approved by the Building Inspector. To expire on 1/21/2026. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CERTIFICATE OF OCCUPANCY $100.00 Total: $325.00 Building Inspector TOWN OF SOU'TDOLD—BUILDING DEPARTMENT -72 B/i-TT_ • _.,wn Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone(631)765-1802 Fax(631) 765-9502 h%%L/1'WWW.S Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only �k l PERMIT NO. Building lnspecton APR 2 6 ?024 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. .w' M w Date: - ' OWNER(S)OF PROPERTY: Name. SCTM#1000- OL '0 02 y Project Zclress � Phone#: Email: Mailing Address: f A—~ 3y � I° CONTACT PERSON: /1*1 r Name: LZILPI Mailing Address: LZZ2Z7_aa1_1,e Phone#: � Email: DESIGN PROFESSIONAL INFORMATION: Name: , . EPhone ddress: Email: , p�al CONTRAgplit INFORMATION: Name: f F Mailing Address: " „!w Email: Phone#: _ ilk DESCRIPTION OF PROPPSIM CONSTRUCTION ❑N Stru Addition ❑Alteration ❑Repair ❑Demolition Estima Cos' f Prale� Cher ,,�..,...—.. Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? ❑Yes No 1 i P"E Y 1 flog "f11O N property; In nded use of property: L4 Zone or use district in which premises is situated: Are there any covenants a rtctions with respect to this property" ❑Yes G3Wo IF YES,PROVIDE A COPY. tractor mlessional is responsible for aB dralnap and storm water Issues w provided by The owner wn eain . /design+p Check Box After / Chapter 236 of the Town Code.APPLICATION IS REVIEW 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 applkabk laws,ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as heroin described.The applicant agrees to comply with all applkabie laws,ordinances,building code, housing code and regulations and to admit authorized Inspectors on Prembes and In buildingls)for necessary Inspections.false statements made heroin are punishable as a glass A misdemeanor pursuant to Section 210AS of the New York State Penal law. Application Submitted By(print name): / S% �� thori:ed Agent C +lwner Signature of,Ap t: Date; STATE OF NEW YORK) S COUNTY OF I Y " 1 being duly sworn,deposes and says that(s)he is the applicant came of individual signing contract)above named, P Mhe is the " (Contract fr,Agent,C rporate Officer,etc.) of said owner or owners,and is duly authorized 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 Ime thi day of ,' 20 otary Pub c � V 7 (Where the applicant is not the owner) p residing ante do hereby authorize n' alf' o the To of Sou hold Bui ding.Department for approval as described herein,. er's Signa ure s Date o � e �M nt Owner's Name SUNRINC-02 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmYY)9/1/2023 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 pollcy(les)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 License#OC36861 CAO W CT Walter Tanner Alliant Insurance Services,Inc. PHONE _ FAX 560 Mission St 6th FI JC,No,E�Vr,_ __ (Afc Nrs) _. ._........ •••••••••• San Francisco,CA 94105 Walter Tal tnel alliant.com INSURERS)AFFORDING COVERAGE NAIC# INSURERA..Evanston Insurance Company,_,_,. 35378 .. INSURED _.._.__._ ...... w►NSURERBZurlch American Insurance Company 16535 Sunrun Installation Services,Inc N_pyRERp AmericanITZurich Insurance Company 401422 775 Fiero Lane,Suite 200 Ph#805-540-7643 SURER D IN San Luis Obispo,CA 93401 INSURER E:..,,,,-,.w____ INSURERF: CO CERTIFICATE NUMBER:: SON 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. INSLTRR TYPE OF INSURANCE ADDLSUBFk ....... F """LICY.. ---------------------------- VJVn POLICY NUMBER fimDaPOLICY EFF POLICY m LIMITS A X COMMERCIAL GENERAL LIABILITY EACH 9CCVRRENCE 2,000,000 _. DAMAGE TO RENTED .. .... .. ...... 1,000,000 CLAIMS-MADE l X occuR MKLVSENV104332 10/1/2023 10/1/2024 �,� � 5,000 ..... -- -.........W.......................... .................m...... ,MEGP.A!.N 4n,e.;persan.�..,,.,-,......�.._ .... PERSONAL&ADV INS RY 2,000,000 PRO- 2,000,000 _99 LIMIT L GEMERALAGGREGATE� X PO _X P RO- .. 2,000,000 i LOC PRODUCTS-COMP/OPAGG w OTHER Retention:$200,000 Per Project Agg $ 5,000,000 _B AUTOMOBILE LIABILITY COMMNEO SINGLE.LIMIT $mm - 2,000,000 X ANY AUTO BAP614287702 10/1/2023 10/1/2024 BODILY INJURY Parperson AUTOS ONLY SCHEDULED BODILY INJURY,IP,er accident, � �O1%Nag, P � M .E AMR ONLY X XI.•Net Covered Liability Ded .... .. _..._�L......._.............�1.,.0�.0_.0.�,000........ UMBRELLA LUIB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE. AGGRE...� DED RETENTION$ C WORKERS D EMPLOYERS COMPENSATION Y L N X °,"-,,,,• E L CH 0-STATUTE WC614287602 10/1/2023 10/1/2024 HACOIDENT � 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE _ OFFICER/MEM EXCLUDED? N N/A 1,000,000 (Mandatory m NH) ITE;Lm DISEASE,„,-EA EMPLOYE ,,w„-.............._ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATION$I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation Policy WC614287601 Deductible:$1,000,000 (Evidence of Insurance CERTIFICATE HOLDER I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 53095 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 Rix workers' CERTIFICATE OF INSURANCE COVERAGE TATNE 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 carrier la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Sunrun Installation Services Inc. 202 Commerce Dr., Ste. 7 Moorestown, NJ 08057 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 77-0471407 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 53095 Route 25 3b.Policy Number of Entity Listed in Box 1 a Southold, NY 11971 CG-52830-NY 3c.Policy Effective Period 1/1/2024 To 12/31/2_024 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 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 described a Vie. Date Signed January 02, 2024 By r �" (Signature of insurance carrier's authorized representative or NYS licensed 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 completed by the NYS Workers'Compensation Board(only if Box 413,4C 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 fonn. DB-120.1 (12-21) 1�1 11 111iiiiiiiiiiiiiiiiiiiiiii1iiiiiiiiiiiiiiiiilllll 9EWRIK Workers' CERTIFICATE OF sTA E Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Sunrun Installation Services Inc. (415)946-7500 225 Bush Street Suite 1400 1 c.NYS Unemployment Insurance Employer Registration Number of San Francisco,CA 94104 Insured 50-86426 4 Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e., 1 d.Federal Employer Identification Number of Insured or Social Security a Wrap-Up Policy) Number 77-0471407 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a.Name of Insurance Carrier Being Listed as the Certificate Holder) AMERICAN ZURICH INSURANCE COMPANY Town of Southold Town Hall Annex Building 3b.Policy Number of Entity Listed in Box"1 a" 54375 Route 25 P.O.Box 1179 WC 6142876-02 Southold,NY 11971 3c.Policy effective period 10101/2023 to 10/01/2024 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"3"insures the business referenced above in box 1 a"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 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: Mark Albi (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ��� }G 10-01-2023 (Signature) (Date) Title: VP/Underwriter Telephone Number of authorized representative or licensed agent of insurance carrier: (415)946-7500 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