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HomeMy WebLinkAbout51279-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE czy - 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 #: 51279 Date: 10/11/2024 Permission is hereby granted to: ARAM Irry Trust 46 Stauderman Ave Lynbrook, NY 11563 To: Install ground mount solar to existing single family dwelling as applied for. Disconnects must be located on the exterior, labeled, and readily accessible. Minimum 15 feet setbacks are required between property lines and solar structure. Premises Located at: 1425 Orchard St, Orient, NY 11957 SCTM# 25.-2-22.1 Pursuant to application dated 08/23/2024 and approved by the Building Inspector. To expire on 10/11/2026. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC - Residential $125.00 CO - RESIDENTIAL $100.00 Total $325.00 Building Inspector oe- a F TOWN OF SOUTHOLD — BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1 179 Southold, NY 1 1 97 1-095 9 o Telephone (631) 765-1802 Fax (631) 765-9502 hMs://NvNyw-southoldtpwnny.g.0V Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only _ - PERMIT NO. Building Inspector: - AUG 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, 'S ! Z i OWNER(S) OF PROPERTY: �(r1rV IT•YLl S' Name: A A-f-f I o. - D-�V Q-'�- SCTM # 1000- 25-2-22.1 Project Address: 1425 Orchard Street, Orient, NY Phone #: c4 l S- 6 q O — c, Email: Gl r ► a C§L Q-"t 4-)-e-Q-0 yv� OL C - C-�b rv-% Mailing Address: t (o V-e-S b r o S S C S S-t- 4 .S %A b O 13 CONTACT PERSON: Name: Barbara - OreenLogic LLC Mailing Address: 97 North Sea Road, Southampton, NY 1 1968 Phone #: 631-771-5152 x1 17 Email: Barbara@Oreenlogic-corn DESIGN PROFESSIONAL INFORMATION Name: _ - �t C » Mailing Address: 2CI _ Phone #-. (Ej3�� � TJ�;-; -- 3 s r" Email: CONTRACTOR INFORMATION: Name: Green Logic LLC Mailing Address: 97 North Sea Road, Southampton, NY 1 1968 Phone #: 631-771-51 52 1 Email:AM@Greenlogic-corn DESCRIPTION OF PROPOSED CONSTRUCTION =New Structure =Addition SimlAlteration =Repair =Demolition Estimated Cost of Project. C]Other Solar Panels $ 80,000 Will the lot be re-graded? =Yes lW No Will excess fill be removed from premises? =Yes ®No 1 PROPERTY INFORMATION` Existing use of property: 1 Family Residence Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? =Yes I<No 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 Zane Ordinance of the Town of Southold,Suffolk,County,:New.York and other applicable Laws,Ordinances or Regulations,for the.construction of buildings, additions,alterations on 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 ZXO.45 of the New York State Penal Law_ Application Submitted By (print name): Green Logic LLC IRAuthorized Agent =Owner Signature of Applicant: Date: STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Nesim Albukrek .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 f day of 2 � Notary ultli ARBARA A CASCIOTTA ""My Public-State of New York MO.010A4894960 PROPERTY OWNER AUTHORIZATION ' ' "f0d in Suffolk 0ounty rrii #on(Where the applicant is not the owner) Eclair Ma Y-116 2027 I, iT�`dt � Un Cf � 2 Il. gs-7 do hereby authorize Green Logic LLC to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owners grta ure Date l -n a ne G A r l Print Owner's Name 2 BUILDING DEPARTMENT - Electrical Inspector TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1 179 Southold, New York 1 1 971-0959 Telephone (631 ) 765-1 802 - FAX (631 ) 765-9502 rooerr southoIdtownn 9ov — soandt sou'tholdto r l y gpv APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 8/21/2024 Company Name: GreenLogic LLC Name: Robert Skypala License No.: 43858-ME email: BarbaraG�G reen Logic.com Phone No: 631 -771 -51 52 request an email copy of Certificate of Compliance Address.: 97 North Sea Raid Southam tors NY 11968 JOB SITE INFORMATION (All Information Required) Name: Arad Irrevovable Trust Address: 1425 Orchard Street, Orient, NY 11957 Cross Street: Phone No.: Bldg.Permit #: Cj ( ,�q email: Tax Map District: 1000 Section: 25 Block: 2 Lot: 22A BRIEF DESCRIPTION OF WORK (Please Print Clearly) Ground mounted solar electric system (40) Sun Power SPR-X21 -335-BLK-E-AC panels Et (40) Enphsase IQ7XS micro inverters �(1 ) SunPower PVS6 monitor S stern Size: 13 40OKW Check All That Apply: Is job ready for inspection?: DYES = NO =Rough In Final Do you need a Temp Certificate?: YES ONO Issued On Temp Information: (All information required) Service Size =1 Ph =3 Ph Size: A # Meters Old Meter# New Service F-1 Service Reconnect = Underground = Overhead Underground Laterals =1 =2 =H Frame =Pale Work done on Service? [=Y =N Additional Information: PAYMENT DUE WITH APPLICATION Electrical Inspection Form 2020.xlsx <.G CEWTIFICATE C ILM131IL�ITY INSI ' CE DATE(MM/OD/YYYY) 01 t2r23 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 haeslder is an Af30ITlONA9_INSURED,the pOIiCV(ias)must have.MaDITIONAL INSURED pravisians 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 net Confer rights tO the Certificate holder in lieu of such andOrsernant(S)= PRODUCER CONTACT' Nich€slas Zulkafske---_. ----. Brookhaven Agency, Inc. PHONE 31 941-4413 FAI!' 1 941-4405 100 Oakland Ave, Ste 1 E aAl� CartifiCata;s ialChatrerl a. er1C Port Jefferson, NY 11777 tli*]UREft AFFOROINO COVEKA4GE r c I aN ttwea=_It A: Solt Vvest Marine S I--arteral Inv-11ranee Co. I INSUREn E. R B- Merchants Pr'r#avYt'Od Insurance Co. _ _ OreariLogIC, LLC INSURER c c First Rehab Life Insurance Cc3 97 North Sea Rd, Suite 3 Il2Su ER O. NationalUmbility-& Fire Insurance CO. Southampton NV 11968 Insurance CK3,- € INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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, 1lt5&t- SLiHRI POLjCY EFF POL.FGY liXF- [ TYPE OF INSURANCE [ PS]L£GY Nt1PaaBER - LIMITS I X COMMERCIAL GENERAL LIABILITY--- _ E ICI-€4 LIRF eNCCE.. $ 1 001).:000 I AI aA - T gal a tT=ra 1 CIO 800 A CLAIMS-MADE 1 X OCCUR I - X Contractual Liability X X. 1--L202300012922 04/31/2023 €0113112024 S 5,000 I fTERSONAL&Aa�V'NJURY s 1,000,000 _-3E14'L A<,s-REGA..TE.LIMIT APPLIES PER: SSNE=Rt-.a_ka sl_=sRE��A.T E 2,000 000 ----.--__. PRO- �r� rsUcrrs-COMP]�P AGG 2 000 000 1 POLICY X E „IECT LOC _ I - T a R_ [ E80 ]LIabill' $ 1,{It?[I-OiiO AUTOMOBILE LIABILITY _ ---COIF3II'+FEPa S.9N GLE'�3rIT $ 1,000,000 B � ANY AUTO E E BODILY INJURY tl' r parson) $ I OWNED SCHEDULED X ' BODILY INJURY(Per accident) $ __ AUTOS ONLY AUTOS X CAP1043565 06t'11/2022 08111/2023 ; HIRED I NON-OWNED PROPERTY DAA,MAO.E $ AUTOS ONLY X 7 AUTOS ONLY j $ UMBRELLA LIAB € OCCUR EAi;H D}"CUR'RE"ICE = ---- EXCESS LIAB 3] - CL�I.MS-Fv�AOE d I �DIED WORKERS COMPENSATION P p'1-=.T OTH- S AND EMPLOYERS'LIABILITY Y/N 7 MANY PROPRIETOR/PARTNER/EXECUTIVE E L_EACH,ACGIDE"€T [ 5 ---- OF a Ic Rar rl�a ExLUDED? N/a � see separate Certificate E_ OIS SE F � (M.-d.t.ry.in NH) _ [ - 3It Y...apse l un€1€r I€ -R _ d SC#2LPTit3N OF.C3PE.EAT.ION'S t> ruv E.L_fi3IS�A5E-e,OLICY L67�lSIT $ C NYS Disability D251202 04111/2022 04111/2023 Statutory Limits IE Installation Floater/Property SML93076366 04/I512022 10411512023 $300,000 E $2,500 Dad i I 1 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space ie required) Certificate holder is also named as Additional Insured. CERTIFICATE HOLDER CAMCELLATION - TOWN OF SOUTHOLD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 53095 ROUTE 25 SOUTHOLD. NY 11971 AUTHORIZED REPRESENTATIVE CNSZ> © 19BB-2015 ACORD CORPORATION. All rights reserved. ACORO 25 (2016/03) The ACORD name and logo are registered marks of ACIDR13 "^rorl«rs° CERTIFICATE OF INSURANCE COVERAGE Braatd 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 carrile 1a. Legal Name &Address of Insured (use street address only) 1b. Business Telephone Number of Insured I C_REENL{3G@G,LLC 631-941 -41 1 3 'LINCOIRTHEA ROAD,SUITC 3 ON,NY S 1she hhY 7 rasa1c. Federal Employer Identification Number of Insured or Social Security Number ion of Insured (Only required ifcoverage is specifically limited toons in New York State, i.e., Wrap-Up Policy) 203801194 . d Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier i (Entity Being Listed as the Certificate Holder ( Y 9 ) ShelterPoint Life Insurance Company Town of Southold Building Department " 3b. Policy Number of Entity Listed in Box"I a" D B L251 202 53095 Route 25 Southold, NY 1 1971 3c. Policy effective period 04/1 1/2022 to 04/1 0/2024 14. Policy provides the following benefits: A_ Both disability and paid family leave benefits. B. Disability benefits only. t 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 I insured has NYS [Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 4/4/2023 B Y (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) 'Telephone Number 51 6-829-81 9 Name and Title Richer 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 48, 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 4B,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. I 1 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 OB-120.1. Insurance brokers are NOT authorized to issue this form. DB_120.1 (12-21) 1111111P!IBuinii�iiuuu�ii�ii�iiiiiiuiii!�!��1111111 DocuSign Envelope iD:7BC1668A-3B38-462A-840B-39E28CE1 F002 Warkars' CERTIFICATE OF smaxt carnpensatic>n NYS WORKERS' COMPENSATION INSURANCE COVERAGE Berard 1 a_ Legal Name & Address of Insured (use street address only) 1 b_ Business Telephone Number of Insured = 631-771-5152 GREENLOGIC LLC 97 N SEA RD STE 3 1c. NYS Unemployment Insurance Employer Registration Number of SOUTHAMPTON, NY 11968 Insured Work Location of Insured (Only required if coverage is specifically limited to 1 d_ Federal Employer Identification Number of Insured or Social Security certain locations in New York State, i.a., a Wrap-Up Policy) Number 20-3801194 2. Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co_ of North America TOWN OF SOUTHOLD BUILDING DEPARTMENT 3b_ Policy Number of Entity Listed in Box"1a" 53095 ROUTE 25 C57207784 SOUTHOLD, NY 11971 3c_ Policy effective period 1213112023 to 1 2/3 1 1202 4 3d. The Proprietor, Partners or Executive Officers are QX included. (Only check box if all partnerstufficers included) 0 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 "I 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 frorn the coverage indicated can this Certificate_ (Theso no-tices may be sent by regular mail.) Qtlherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its lican5l.ed 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 warkors' cornpansation policy indicated on this form, if the bu-siness continues to be natmed «rr a permit, license or contract izf fed by a certificate hoider, the business must provide that certificate holder with a now Certificate-of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New Yark State Workers' Compensatian Law. Under penalty of perjury, 1 certify that I am an authorized representative or licensed agent of the insurance carrier referenced abi�ave and that the named insured has the coverage. as depicted on this form. Approved by: Lex Smith CxoF - of authorized representative or licensed agent of insurance carrier) 12/6/2023 Approved by: (Signature) (Date) Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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 Acct 4: 3031515 p d ti Suffolk CountyExecutive's ! ice o Consumer s. airs f a VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 m DATE ISSUED, 512512006 No. 40227-H SUFFOLK COUNTY Home Improvement Contractor License This is to certify that MARC A CLEAN doing business as GREEN LOGIC LLC having furnished the requirements set forth in accordance with and subject to the provisions of applicable laws,rules and regulations of the County of Suffolk,State of New York is hereby licensed to conduct business as a HOME IMPROVEMENT CONTRACTOR,in the County of Suffolk. ,v Additional Businesses NOT VALID WITHOUT DkPARTMENTAL SEAL AND A CURRENT CONSUNJU AFFAIRS ` ID CARD Director ecu ve'sOffice o Consun erAffairs su oIk �'oun x VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 DATE ISSUED. 1211 012007 No. 43858-ME SUFFOLK COUNTY Master Electrician License This is to certify that ROBERT d SKYPALA doing business as GREENLOGIC LLC having given satisfactory evidence of competency,is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws,rules and regulations of the County of Suffolk,State of New York. Additional Bg es es NOT VALID WITHOUT DEPARTMENTAL SEAL AND A CURRENT CONSUMER AFFAIRS III CARD Director i J., 1L61L :('N"O�C7Nt7d 's' l+'Fd.dNNd$Nr,Nrddr 3.�d1 rP" ' Y�T-9T anus kY''4�Avai O'r2N smy gaTo'T wo 33'�aOM ap3aAuaYas.'H,rxC'm sxd�a OVA sob kOO 'OS EOT'Y6 =V3lTV dwwr ws s 0 Y� s3 aura dwrr xMeal uxttrbw tstt—s9L(lr9)xv�O80s Yoe (arse 3 NI V, Y C 3:&TJ x rdasw 7. �elas sr{d3 3 N NON W $NJ F&k'N AG3wP 80/Od4Cd pw UY' 'J'd'S' A+4.3+1WS OINO,'7�-7d �ma Notuw';3ar Y, xa�Nras wrJ x a, as w do nwyx�wmc3a7r,xNw �Lssw O�r' 7�'�°,w' 3Nrr+n g v 1NvdmH m)0, y 37od Amon—`Q., ^�• m3N'nNon a fS 3Nr1S a Id Tam A3,N �.. w wrN of 030N3re3i3N sNaaLr.L3,3 O3l13LNnOJN3 Y3LYM ON-WON D d5 ONrS NnImJM Q!3NLf liN0H9 31rd .11 +YRM4 NwriIM4A' R xpM! 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