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HomeMy WebLinkAbout51417-Z 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#: 51417 Date: 11/26/2024 Permission is hereby granted to: MedaliaAA&BogardU Jt Re Tr 1 Southgate Apt 3C Bronxville, NY 10708 To: install roof-mounted solar panels to existing single-family dwelling as applied for. Premises Located at: 1705 Trumans Path, East Marion, NY 11939 SCTM#31.-13-5 Pursuant to application dated 10/07/2024 and approved by the Building Inspector. To expire on 11/26/2026. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total $325.00 B d� Inspector TOWN OF SOUTHOLD —BUILDING DEPARTMENT 41 Town Hall Annex 54375 Main Road P. ®. Box 1179 Southold, NY 11971-0959 Telephone (6�1) 765-1802 Fax (631) 765-9502 ��� Date Received APPLICATION FOR BUILDINGPERMIT For Office Use Only PERMIT No. Building Inspector: Applications and forms must be filled out in their entirety.Incomplete Building OPPOTIMIen applications will not be accepted. Where the Applicant is not the owner,an Town outh ld Owner's Authorization form(Page 2)shall be completed. Date: ( 0 8/, I OWNER(S)OF PROPERTY: Name: LD` a, �o � SCTM# 1000- U 3 1 .Can -o L 3 o Project Address:/_7 0 S !rarn o,,u In Y I/ 9 3 9 Phone#: (�3 I _ � � g . -7 O'-I J Email: Co 0'�,�5 �S C.o � Mailing Address: [ 0 5 T � �✓l Ul'2 ��;1, [ �:� CONTACT PERSON: Name: L0 r'r&,I ne —b 1 pe-�#' - Mailing Address: -7 41 o SoLAAd 6100 Ko--+-�) Phone#: (D a I O g �-)`OLI / Email: pie,rrril 45 f, S f DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: Mailing Address: 141 _V Q L Ad 0 VO MA,44)`PVCr, IV .I 4 ' I C 5 Phone#: 3 . 3 g '1 D Lh Email: 61 I4 (2, C9,s cS , corn DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther I n5 X-0 �S� )ar Q V a ,� $ - v-a Will the lot be re-graded? ❑Yes;KNo Will excess fill be removed from premises? ❑Yes to 1 1 PROPERTY INFORMATION Existing use of property: Intended use of property: Zone o use district in which premises is situated: Are there an is d restrictions ct. ons with respect to this propertY IF YES, PROVIDE A COPY. t ock Box After Readll ng: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by 236 of the Town Code. APPLICATION 15 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 z10.45 of the New York State Penal Law. Application Submitted By(print name):Lorraine DiPenta ®Authorized Agent ❑Owner Signature of Applicant: Date: U `Q I g I l 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 ZU 9 day of S Zt — 6AotagKublic PROPERTY OWNER AUTI�10RIZATION (Where the applicant is not the owner) I, a c,Jf C✓�G e '04.0,14 residing at 00 S Tr tomminow do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein. X �Av2cz owns s Si aiitur jr j� Louis j Ro Date pub,a ,; , ate of " 1. Mr. ua"►ft dilR0 31 ,v, e 'Yor, Print Owner's Name o 's`sion P Suffolk O PirestPc�vember 17� K� BUILDING DEPARTMENT-Electrical Inspector 2a � TOWN OF SOUTHOLD T 'Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 � , d h southoldtokwn oar—sea nd southoldtownn ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: C O a_.l Company Name: El f mw+ L L Lf-. Electrician's Name: j n n l License No.: ja 9_1-( Elec. email: (me_V-rA; - C� Elec. Phone No: b3 t.,­7-7R.?c)cl Z request an email copy of Certificate of Compliance Elec. Address.: -1 q-7 o So;._r1,4_ Q V ►-� �.{+ "tuLIC `�, l 1 19 a JOB SITE INFORMATION (All Information Required) Name: L*_Lotf A-r- Address-11 b Cross Street: (Y "n . Phone No.: 0 _ (Q SJ o f-o Bldg.Permit#: email: Perm a G e.aS S,. Wn Tax Map District: 1000 Section: I.00 Block: 13. o o Lot: C9 0 0 Q BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly):. =n s+'e -t a -P t LA-5 �-A r'o 0 � 1'Yl 0 LA_n.-k-� 601 66 f' PS-1 S j�S4, ray Square Footage: Circle All That Apply: Is job ready for inspection?: YES N NO 0 Rough In Final Do you need a Temp Certificate?: YES F_� NO Issued On Temp Information: (All information required) Service Size 01 Ph 3 Ph Size: A # Meters,...... Old Meter# ❑New service[:]Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION px DATE(MM CERTIFICATE OF LIABILITY INSURANCE 7/ IDD/YYYY 16/20�4 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: SUOGIf the certlficate holcl,er is an ADDITIONAL INSURED, the policy(ie5)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 ri trots to the certificate holder in lieu of such erldor^sement(s). PRODUCER NTAC ROBERT S. FED E INSURANCE AGENCY NAME: PHDEWE 3 T 3S5=T7faCl A 23 GREEN STREET, SUITE 102 EaLrg ITM __ mmIT Inc W HUNTINGTON, NY 11743 Ar— ESS INSURANCE IT ^NIsuRsp AFes CE COMPANYa 24856c INSURER A ADM INSURANCE C ROBERT S FEDE."SURANmm INSURED ..., ..... ..... .......—.,,_._ ......._ ...... ....... ADMIRAL IN IN UlJh Element Energy LLCM" RELTE�CITIT"I MNTY� — .�.�......�_... DBA ELEMENT ENERGY SYSTEMS gEERC M NAOE.M �.... . 7470 SOUND AVENUE .. MATTITUCK, NY 11952 INSURER E CD"!II"ERAGES CERTIFICATE NUMBER., BELOW HAVE BEEER F.INSUR THIS IS TO C RTIFY THAT THE OR MAYTANDING ANY REQUIREMENT, TERM O REVISION NUMBER: THIS IS TO CERTIFY THAT ThiE POLICIES OF INSURANCE LISTEDN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD MAY R CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IIN.'CI'�� TYP........—,.....�ITI ,.—...........— E OF INSURANCE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID—pa"CLAIMS, �mm.". " COMMERCIAL GENERAL �""��"�®.�_.."" _ �... ._ �_/yD�L�s if NOnr�I�V ro d Z;1 r LIMITS ._. .. —.. _.... LIABILITY POt.1CY NUMB ER. ITS LITY D CONDITIONS OF SUCH POLICIES A CLAIMS MADE "' X X CA00005380701 7/14/2024 7/14/2025,,EACH OCCURRENCE g 1,000,000 OCCUR �_. �R �aa�ulav � 300,000 """" IMA389203C MED ExP s y one P±,,�S n) $ 5000 7/19/2024 7/19/2025 "" " PERSONAL a ADv NNJu RY 1000000 X — __ IPOUC`Y AGGREGATEPROTAP' PI-r"�'. G.ENEP AL AGGREGATE I LOC "J 2 D00 OOI (( .....— - .._. JECT j V PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY 4 _ $ I CN( IPILOSIN�u LIMIT !OWNED SCHEDULED ®fit accaeP,ed' $ ... .. ...... ANY AUTO IE tk •_ " ODILY INJURY(Per person) $ j AUTOS ONLY AUTOS } HIRED BODILY INJURY(Per accident $ NON-�OW"u`NE'.0 .,.... ....» ......�_.....�.........�........ AUTOS ONLY AUTOS ONLY ROd'"' R 1, A,.GE. ..._�Cadtln;E, _ $ UMBRELLA LIAB OCCUR UR $ .... _.. EACH COCURRE�NOE $EXCESS LIAR EACH C:EL" .. �RETEI'�VTAON'.�r FhGC"rRd"""•rhTE`._.............. F$ �....."....�..._..,.,—,...... QRKERS COMPENSATION I S ITmm mm M uaBIUTY 124494445 PE a OTTs. I NY P OPMETN PAMNERIE ECUTIVr YIN 7/13/2024 7/13/2025 ��TATu�rE FR E1 CFFICER/IIulEMMER EXCLUDED? . � N/a E.L.EACH ACCIDENT $ m 1 1�900.000 H es, ar+cetiNse under E.L D4SR..ASE. EA EMPq.OYE. S� DI SCRfPTION OF OPERATIONS below „"�'._ -.E.L.DISEASE.POLICY LIMIT $ NY State DBL DBL567527 1/01/2024 12/31/2025 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED- CERTIFICATE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITH THE POLICY'PROVISIONS. AUTHOORIIIZEED�REPRESENTATIVE Rob ©1988-2015 ACORD CORPORATION. All rights reserved. 4CORD 25(2016103) The ACORD name and logo are registered marks of ACORD " t workers' CERTIFICATE OF INSURANCE COVERAGE sr4r� 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 carrie 1 a. Legal Name&Address of Insured(use street address only) 1 b. Business Telephone Number of Insured ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 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) 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 Company TOWN OF SOUTHOLD 54375 MAIN STREET 3b.Policy Number of Entity Listed in Box"1 a" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01101/2024 to 12/31/2025 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. S.Only the following class or classes of employer's employees: Under penalty of perjury I certify That I am an authorized representative or Ilcensed agent of the Insurancee carrier referenced above and Fthat the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 7/10/2024 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516�-529 100 Name and Title LDS,tOD Welsh 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 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.gcv 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 cr 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 employes. 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 caniers are authorized to issue Form DB-120,1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) 11111IP1111°°1°2111�°1°��°11�°2°11°11°�IIIIIII Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in Box I for disability and/or Paid Family Leave benefits under the NYS Disability and Paid Family Leave Benefits.Law.. The insurance carrier or its licensed agent will send this Certificate of Insurance Coverage(Certificate)to the entity listed 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 cancelled 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 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 NYS disability and/or Paid Family Leave benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or Paid Family Leave benefits 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 Insurance Coverage for NYS disability and/ or Paid Family Leave Benefits or other authorized proof that the business is complying with the mandatory coverage requirements of the NYS Disability and Maid Family Leave Benefits Law. NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand and twenty-one, the payment cf family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (12-21)Reverse /7--"NIN6141 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 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 962287 07/13/2024 TO 07/13/2025 7/11/2024 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2449 444-5, 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 HTTPS:NWWW.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 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 AND/OR 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 ST/ T SUR NCE FUND �/ DIRECTOR,INSU NCE FUND UNDERWRITING VALIDATION NUMBER: 743799006