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HomeMy WebLinkAbout51018-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE m 'g X ,tN SOUTHOLD, NY �Y� i kryV 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 #: 51018 Date: 8/1/2024 Permission is hereby granted to: VNP Properties Inc 4248 Grand Ave Mattituck, NY 11952 To: Install roof mount solar to existing single family dwelling as applied for. Disconnects must be located on the exterior, labeled, and readily accessible. At premises located at: 3600 Pe uash Ave, Cutcho ue SCTM # 473889 Sec/Block/Lot# 103.-14-2 Pursuant to application dated 6/18/2024 and approved by the Building Inspector. To expire on 1/31/2026. Fees: SOLAR PANELS $100.00 ELECTRIC $125.00 CO-RESIDENTIAL $100.00 Total: $325.00 Building Inspector TOWN OF SOUTHOLD -BUILDING DEPARTMENT j 'Town Hall Annex 54375 Main road P. 0. Box 1179 Southold, NY 1 1 97 1-0959 a Telephone (631) 765-1802 Fax (631) 765-9502 i Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ' , I 20 PERMIT NO. Building Inspector:, w Applications and forms must be filled out in their entirety.Incomplete pp � P applications will not be accepted. Where the Applicant is not the owner,an Owner's.Authorization form(Page 2)shall be completed. Date: (0 Jgla y :A OWNER(S) OF PROPERTY: Name: Re 6f� rn,-V+Iin SCTM# soon- p 00 - 00 7 02.00o Q Project Address: 34 0 0 A- �laS� C)---+Ch 0 /19.35 Phone#:: B_ 2 , -7 C)Lf Email: 9-C Co fl Mailing Address: ?)(o O O CONTACT PERSON: Name: L0 r-rA-7 n< ba 1 Mailing Address: -7 411® U oLtA J-++1 Phone#: (-v 3 Q 3 9 2 „-7 0 q Email: full 4,5 e, if,�� s DESIGN PROFESSIONAL INFORMATION'. Name: Mailing Address:. Phone#: Email: CONYT OR INFORMA'IfI'ON: Name: c 1 C.(y)e-11+ 5 1)f-r Mailing Address: 14 q ;S® d. 4y-; o- CK III,5 Phone#: �� s �� g ,� D Email: �tPil �� � `S b Urn DESCRIPTION OF PROPOSED CONSTRUCTION []New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: 'EJAQthen j n5-4-aL- i .So )A-,- Pv 6 z>±V-►''> $ 5ZP1 1 Will the lot be re-graded? ❑YesANO Will excess fill be removed from premises? ❑Yes)2AO k 1 PROPERTY INFORMATION Existing use of property: + 1.0 Intended use of property: Zone or use district in which premises is situated:. Are there any cove is restrictions with respect to this proper. s d IF YES, PROVIDE A COPY. sec' 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).Lorraine DiPenta 'Authorized Agent []Owner Signature of Applicant: La.1� Date: STATE OF NEW YORK) SS: COUNTY OF Suffolk Lorraine DiPenta 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 aday of Mc,-/ 2Q�y Notary Public LOUIS J ROMEO Notary Public,State of New York No.01 R06314813 PROPERTY OWNER AUTHORIZATION Qualified in Suffolk County Commission Expires November 17,20.Z& (Where the applicant is not the owner) I, W. ,(,—,4 N61LY'1);X 7_. residing at co ,I do hereby authorize - 4� to apply on my behalf to o of So old Building Department for approval as described herein. x , Owner's Signature LOUIS J Rto OMEO Notary Public,State of New York No.01 R06314813 Qualified in Suffolk County Print Owner's Name Commission Expires November 17,20<G 2 BUILDING DEPARTMENT l rl6l inspector TOWN WHO"LD aw Town Hall Annex - 5437 in R ��� 1179 Southold, New 11 -0959 "ant � ,d � a Telephone (631) 765-18 FAX (631) 66- ��2 ro err southoldtownn . o _. .6 °,�6Idto` r In ors seared APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: Ig Company Name: P l r, - En L-L-C. Electrician's Name:J"m e n K License No.: _ � Elec. email: Perm o}512, C a,Sb C0 Elec. Phone No: LZI request an email copy of Certificate of Compliance Elec. Address.: -1 &J-7 m 11SIO Vul ,,, JOB SITE INFORMATION (All Information Required) Name: RLo � Address: CA Cross Street: h-( vn ►�( Phone No.: 0 Bldg.Permit #: email: P Tax Map District: 1000 Section: Block: Lot: BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): r) M , ,d� S o i®.yr P V Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: L_jYES NO Issued On Temp Information: (All information required) Service Size1 Ph"3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect[—]Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 F1 H Frame M Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION tyORKr,Ar workers' CERTIFICATE OF INSURANCE COVERAGE ATE Corn Workers' ion 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 ._........... .� 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured ELEMENT ENERGY LL.0 7470 SOUND AVE MATTITUCK,NY 11952 1c.Federal Employer Identification Number of Insured Work Location of Insured fOnlyregidred ifcoverage is speorikaliyktnited to or Social Security Number cedain locations in New York State,i.e.,Wrap-Up Policy) 823336604 �.... ----------------- _...--. 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 Cornpww TOWN OF SOUTHOLD 54375 MAIN ROAD 3b.Policy Number of Entity Listed in Box"1a" SOUTHOLD,NY 11971 DBL567527 3c.Policy effective period 01/0112023 to 12/31/2024 4. Policy provides the following benefits: ® A-Both disability and paid family leave benefits. B.Disability benefits only. IUD 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. 0 B.Only the following class or classes of employers employees: Under penalty of perjury,I certify that I am an authorized representative or limed agent of the insurance carriw refer,above and VuV ft named insured has NYS Disability andior Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/10/2023 (W, t 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 Execit iive 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 carer,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 4B,4C or 513 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 PAUGwcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 6200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only If Box 48,4C 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 iSignature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Onfy 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 farm. i DB-120.1 (12-21) L�! CERTIFICATE OF LIABILITY INSURANCE M 7t12120IDOfYYYY3 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(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 ROBERT S. FEDE INSURANCE AGENCY N NN�EE"""""" FAx 23 GREEN STREET,SUITE 102 ,�""' """'. """"' "..... '1 ""�'° HUNTINGTON,NY 11743 48f :: ....... .... _._.........m............... ROBERT S_FEDE INSURANCE INsu AFFORDING COVERAGE _NAIC 0 INSURER A,ATLANTIC CASUALTY INS.CO. 524214 INSURED 01SUR ,, ••M.•M•,•.... . Element Energy LLC INSUIME:c: DBA ELEMENT ENERGY SYSTEMS 2""" '.....tNSiAtER D 7470 SOUND AVENUE 0ISU t11S11RER E MATTITUCK,NY 11952 asu P 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. TYPE OF INSURANCE .... .. .... ""°"""""'°- ._° - - LTFk POLICY NUMBER ��"� °, LIMITS A COMMECLAIMRCIAL GENERAL ADE LIABILITY X x S 3,000,000 'L1480038873 7/14/2023 7/1412024 EACH OCCURRENCE COMMERCIAL GENERAL �� ..,., OCCUR Fiva .La aaow renrom s 100,000 ...... MED EXP An acre n S _ 5000. X Contractual Lia 7/19/2022 711WO24 PERSONALaADSIMAMY s 3000000 GEN CTAPP PER: �E m3,0 O OOUC K PRODUUCTSOA S OTHER', s AUTOMOBILE INBN IiY I f 252i -,1.. . ___ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Pa accdenq f HIRED AUTOS ONLY AUTOS ,_ ,,,,,_,,, .'. DA9w1'Af'E 3 AUTOS ONLY AUTOS ONLLYY E'R 7 a m , UMBRELLA LIAB... 00CUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE .AGGREGATE 5 DED REfEN11CN.3. S WORKERS COMPENSATION 124494445 PER OTH- ARD EMPLOYERTLIABLJTY Yin 7/13/2023 7/1312024 A ER '.ANY PROPRIETOMPARTNERIEXECUTIVE NIA EACH ACCIDENT S 11,0 00DW $ OFFICERA�MBEREXCLUDED? � -EL_°-°°. (Mandatory In NH) EL DISEASE-EA EMPLOYE SNo Ifyes, under .................................. ..._......_ .........._ DESCRIPTION. PF.,RATIO belaw EL DISEASE-POLICY LIMIT i I Map NY State DBL DBL507527 1/01/2023 12131/2024 Statutory DESCRIPTION OF OPERATIONS 1 LOCATIONS r VEHICLES ACORD 101 Additional Remarks secheedule may be attaebad Y mare a Is red { Y Pas re9� t CERTIFICATE HOLDER IS ADDITIONAL INSURED Certticate holder and Property Owners are hereby named as additional insured(using CG 2010 and CG 2037)(Blanket)on a non contributory basis including completeted operations on GL Waiver of subrogation is applicable to General Liability_ 30 day notice of cancellation applies. CERTIFICATE iHOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 4375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WNLL BE DELIVERED IN 5 Southold in 119T1 ACCORDANCE WNTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE RQbea s. Feder ©1988-2015 ACORD CORPORATION. All rights reserved. Atlr%pn 19 a"A4410l1 Tk-ernon....... ...a I.... ,. . .:a. . .r—..L,--4 Amon NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysifcom CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) A A"AAA 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 HUNTINGTON NY 11743 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER ELEMENT ENERGY LLC TOWN OF SOUTHOLD DBA ELEMENT ENERGY SYSTEMS 54375 MAIN ROAD 7470 SOUND AVENUE SOUTHOLD NY 11971 MATTITUCK NY 11952 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12449 444-5 369075 07/13/2023 TO 07/13/2024 711112023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449444-5, 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 NTTPS:IIINWW.NYSIF.COM/CERTICERTVAL.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 AND10R 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 1� U ICE FUND 4 DIRECTOR,INSUENCE FUND UNDERWRITING