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HomeMy WebLinkAbout51022-Z N TOWN OF SOUTHOLD spew 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#: 51022 Date: 8/1/2024 Permission is hereby granted to: Goerler Jr, Ronald 3175 Cox Ln PO BOX 629 Cutcho ue NY 119350629 To: Install roof mount solar to existing accessory garage (front garage) as applied for. Disconnects must be located on the exterior, labeled, and readily accessible. At premises located at: 3175 Cox Ln, Cutcho ue SCTM #473889 Sec/Block/Lot# 96.-3-4.5 Pursuant to application dated 8/1/2024 and approved by the Building Inspector,. To expire on 1131/2026. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CO-RESIDENTIAL $100.00 Total: $325.00 Building 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) 765-9502 litt s:/ rvww.soLtt ioldtowiiii ,goy Date Receive For Office Use Only PERMIT NO. �/ Q�a- Building inspector. n 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: 6/7/2024 OWNER(S)OF PROPERTY: Name: Ronald Goerler SCTM# 1000- 3� Project Address: 3175 Cox Ln Cutchogue, NY 11935 Phone#: (631) 839-8329 Email: jamesportwines@gmail.com Mailing Address: 3175 Cox Ln Cutchogue, NY 11935 CONTACT PERSON: Name:Tyler Moston Mailing Address: 275 Marcus Blvd, Hauppauge NY 11788 Phone#: 631-203-1019 ; u a 0ol Email: permitting@surFcleanenergy.com DESIGN PROFESSIONAL INFORMATIO N: Name: Tom Petersen Mailing Address. 6 Country Ln Howell New Jersey 07731 Phone#: 732-730-1763 Email: petersen8@optonline.net CONTRACTOR INFORMATION: Name:Surf Clean Energy Mailing Address: 275 Marcus Blvd, Hauppauge NY 11788 Phone#: 631-203-1019 Email: permitting@surfcleanenergy.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alterati ❑ pair ❑Demolition Estimated Cost of Project: VOther Roof mounted solar panels ° ', $26,200 Will the lot be re-graded? ❑Yes VNo Will excess fill be removed from premises? ❑Yes o 1 PROPERTY INFORMATION Existing use of property: Single Family Residential Intended use of property: Single Family Residential Zone or use district in which premises is situated: Are there any covenants/and restrictions with respect to 1000-0 this property? ❑Yes Q[INo IF YES, PROVIDE A COPY. ❑ Check Box A' !er eadjr%Z' The owner/contractor/design professional Is responsible for all drainage and storm water issues a$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 b Class A misdemeanor pursuant to Section 230.4S of the New York State Penal Law. Application Submitted By(print name): Tyler Moston ®Authorized Agent ❑Owner Signature of Applicant: Date: 6/7/2024 STATE OF NEW YORK) SS: COUNTY OF Suffolk Tyler Moston being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, ( ) Contractor S he is the (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. oE4 Sworn before me this . . OF NEIN YORK June 7th day of 02024 Notary Pu PROPERTY OW E M)"THORIZATION (Where the applicant is not the owner) I, Ronald Goerler residing at 3175 Cox Ln Cutchogue, NY 11935 I do hereby authorize Tyler Moston to apply on my behalf to the Town of Southold Building Department for approval as described herein. 6/7/2024 Owner's Signature Date Ronald Goerler 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 ' m,esh southoldtownn o , - FAX (631) 765-9502 a Telephone 631 765-1802 seand@southoldtownny.gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All information Required) Date: 6/7/2024 Company Name: V and V Electrical Contracting Electrician's Name: Vincent Polizzi License No.: ME-43825 Elec. email: p1959optonline.net Elec. Phone No: +19176821974 Nf I request an email copy of Certificate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: Ronald Goerler Address: 3175 Cox Ln Cutcho ue, NY 11935 Cross Street: Phone No.: 6318398329 Bldg.Permit#: -5 1 Zk email: jamesportwines@gmail.com Tax Map District: 1000 Section: 96 Block: 3 Lot: 4.005 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Interconnection of roof mounted solar panels Square Footage:: 647 Circle All That Apply: Is job ready for inspection?: YES 0 NO Rough In El Final Do you need a Temp Certificate?: YES © NO Issued On "Temp Information: (All information required) Service Sizel1 Ph 3 Ph Size: A # Meters Old Meter# VNew Service[:]Fire Reconnect[:]Flood Reconnect❑Service Reconnect[:]underground❑Overhead # Underground Laterals 1 M2 H Frame LJ Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION Suffolk County Dept.of Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name TYLER MOSTON Business Name SURF CLEAN ENERGY INC This certifies that the bearer is duly licensed License Number HI-62275 by the County of suffolk Issued: 5/30/2019 Rosalie,Drago- Expires: 05/01/2025 Commissioner T(ry L 7 Q l6 V G r O m N O ro w N Z �c 0 V W ma Opmm aim CL N !0 C 2 m J r a a m C« c � N N N QO a m G DATE(MM/DD/YYYY) ACC->RV CERTIFICATE OF LIABILITY INSURANCE �Aft� 1 06/07/2024 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 516-277-4480 NAM .TE' T Thomas J Batista AC Risk Management, Inc PH° ,wa516NE -277-4480 racy •••�• � 1800 Walt Whitman Road A DR tbatista@acriskmana ement.com INSURER AFFORDING COVERAGE NAIC# S _ .� Melville NY 11747 INSURERA:Sout hwest Marine& General Insurance Coi 12294 INSURED 866-631-7873 INSURER B: Merchant Mutual Insurance Com an 23329 Surf Clean Energy Inc. INSURERC: 1 Cross Island Plaza INSURERD: INSURER E: Rosedale NY 11422 INSURERF: 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. ....... INSR TYPE OF INSURANCE _-__-__ JINSD O POLICY NUMBER MMIDDNY'Y MMfDDfY YY LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 A CLAIMS-MADE W OCCUR P I MI E Ea occurrence $ 100,000 GL202300014850 11/22/2023 11/22/2024 MED EXP(An one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY F`✓�JPROµ LOC PRODUCTS-COMP/OP AGG $4,000,000 I ❑CT OTHER: Per-Project Agg $5,000,000 AUTOMOBILE LIABILITY Ea aBINED ISIN LE t GM6T $ 1,000,000 B / ANY AUTO CAP1084751 07/28/2023 07/28/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED (Pe. -ci ent) AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per a d n) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB 1 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ---- ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/M EMBER EXCLUDED? NIA -""""""-""mm....®� (Mandatory $ Mandato in NH) E.L.DISEASE-EA EMPLOYE _ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ A Errors&Omissions Liab GL202300014850 11/22/2023 11/22/2024 Each Occurrence $1,000,000 A Contractor Pollution Liab GL202300014850 11/22/2023 11/22/2024 Each Occ/Aggregate $1mm/$2mm DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is included as an additional insured, as required by written and executed contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 54375 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORIZED REPRESENTATIVE � v{�bC�iN,r W: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YoftK NEW Workers' CERTIFICATE OF STATECompensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured (866)631-7873 Surf Clean Energy Inc 1c. NYS Unemployment Insurance Employer Registration Number of 1 Cross Island Plaza Rosedale,NY 11422 Insured Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 825438387 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 Town of Southold 3b. Policy Number of Entity Listed in Box 1 a" 54375 Main Road WC518-00229-024-SZ Southold,NY 11971 3c.Policy effective period 06/01/2024 to 06/01/2025 3d.The Proprietor,Partners or Executive Officers are 0 included.(Only check box if all partners/officers included) E] 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: Alicia Christiansen (Print name of authorized representative or licensed agent of insurance carrier) Approved by: ,rQE 06/07/2024 (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 A++ Workers' CERTIFICATE OF INSURANCE COVERAGE 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 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured SURF CLEAN ENERGY INC 631-848-7093 1 Cross Island Plaza Rosedale,NY 11422 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) 825438387 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 Main Road 3b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL659910 3c.Policy effective period 03/03/2023 to 03/02/2025 4. Policy provides the following benefits: A. Both disability and paid family leave benefits. B.Disability benefits only. C] 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 above. Date Signed 03/03/2024 By �Jjl 4f (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 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 form. D13-120.1 (12-21) �IIIIIP1°°°1°20°11°1°°12�"-21°°I�I�I