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HomeMy WebLinkAbout51418-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#: 51418 Date: 11/26/2024 Permission is hereby granted to: MedaliaAA&BogardU Jt Re Tr 1 Southgate Apt 3C Bronxville, NY 10708 To: install energy storage system in accessory boat house 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 Accessory $100.00 Total S325.00 Auiii'd--in"g Inspector � 'TOWN OF SOUTHOLD —BUILDING DEPARTMENT Town Hall Annex 54375 Main road P. ®. Box 1179 Southold, NCI 1 1 97 1-0959 Telephone (631) 765-1802 Fax (631) 765-9502 htttis. Date Received APPLICATION FOBUILDING I `1111MIT i For o ice use on,, PERMIT NO. Building Inspector. Applications and forms must be filled out in their entirety.Incomplete Building Department Town of Southold applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. ®ate o a OWNER(S)OF PROPERTY: M b 0 — ,0 00 _ c� Name: LGI.�Y' � SCTM#1000- 3 I 0 Q!3 � _ � Project Address: 3 Phone#: 8 7 o Lf Email: pe�ra►I�-S �, s c $1 i v Mailing Address: 1 -7 0 l ✓(.Cm/lt"� iQ h krkOn CONTACT PERSON: Name: Lp Irra,'ne b11 �1 Mailing Address: -7 4 1 o v OLAA , 6.Vti Mju+-�1 , I L� Phone#: (D 3 I 3 9 2 �-7 0`f / Email: P r; l+,5 e, t,Q.. DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone CONTRACTOR INFORMATION: Dame: de.men-d- r �Le, Mailing Address: '� >� �o l� 1 ► IQ�'1' "f CK IV .J Phone#: W b I . 15 s - ) 4 Email: � � e,,4,S cS , Corn DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ther )n,5+�O �So )-Lc Q V z: 1 $ � �-' d9 Will the lot be re-graded? ❑YesXNo Will excess fill be removed from premises? ❑YesNj;eNo 1 PROPERTY INFORMATION Existing use of property: KuIntended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes�Vo IF YES, PROVIDE A COPY. r C Boss After Reading. The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by 36 of the Town Code. APPUCATION 15 HEREBY MADE to the Building Department for the issuance of a Building permit pursuant to the Building Zone e of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, ode and regulations and to admit authorized inspectors on premises and in building(s)for necessary Inspections.False statements made herein are e as a Class A misdemeanor pursuant to Section Z30.45 of the New York State Penal taw. Application Submitted By(print name):Lorraine DiPenta BAuthoriz A nt ❑Owner Signature of Applicant: Da$e: 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 day of 20 ' . 6Aota,4fublic PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) �t e residing at i -7 0 i A-asT' VY10..►�1 o r� CrC a � f..., . :,Pcn..&- to n.f�_ do hereby authorize t apply on my behalf to the Town of Southold Building Department for approval as described herein. Owne s Si ature LO(JIS Date Notary Iq oti�sty o N !� , AID w York , Print Owner's Name �Iion Ipin a Pt co 8 ove Un r nie,t7� 2 13t BUILDING DEPARTMENT- Electrical Inspector + « ,� TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1802 - FAX (631) 765-9502 .amesi sotholdtownn o seared sowtfto(downn ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: ` O � ol.. Company Name: El f_,MeyI+ CR l. L ,— Electrician's Name: ICI' l" jl I License No.: q-t-t i5 Elec. email: Pe-v-rn i C &ate s9 "1 0) Elec. Phone No: q65 t-^7 7Q..'2 g c13 91 request an email copy of Certificate of Compliance Elec. Address.: '1 q-1 o .Sc,Lx-►naL Q J e- H &_-#+J +Ltc, I `J. l I 5 JOB SITE INFORMATION (All Information Required) Name: w Yv./1 o oi 4rA Address: -7 0 YnkM" E_ MA,.,''t bl [q 3 Cross Street: fy A Phone No. v2pf- Bldg.Permit#: femail. P"a r m e .aS S to Tax Map District: 1000 Section: c�0 Block: 3. 00 Lot: ,0 () BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): ^ ' '" Square Footage: Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do you need a Temp Certificate?: 11 YES NO Issued On Temp Information: (All information required) Service Size 1 PhE]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 CERTIFICATE OF LIABILITY INSURANCE DATE`MM��16284 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(e-s)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 CONTACT IT... .-.�. t. ROBERT S. FEDE INSURANCE AGENCY E M Lo E Aac Na 23 GREEN STREET,SUITE 102 —PRONE -°` --IT---6i�1�11776iT— =_Faze°mm�) HUNTINGTON,NY 11743 ADDRESSr ............ ROBERTS.FEDE INSURANCE ",,, INSURER(S1AFFORDINGCOVERAGE NAIC# INSURERA:ADMIRAL INSURANCE COMPANY 24856 INSURED ...,..... _ I'NS0I 'N 23: O..._. INSURER B Element Energy LLC -_SFELTER"P'0TNTp-0 """""""- INSURER C: DBA ELEMENT ENERGY SYSTEMS INSURER D- T7I=I "�°l�"TV C� mm""""" '"'""""" 7470 SOUND AVENUE °" """" _----- _ MATTITUCK, NY 11952 INSURER E: �'�"'uu ----mm�� ••--•••• INSURER F: 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 LINIII NDICATED. 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, XCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'Y '"" w ...— ....�..�. �,.., RiBR' ^^^^POLICY NUMBER LIMITS 7I .._ .....TYPE OFINSURANCE LICY EXP"MM/DO"•�/X.XYX h dWk/D C PY"9f"Y"N IT.. COMMERCIAL GENERAL LIABILITY CA001705380701 pEACH"MlaC $ 1 3001000 A X X 7/14/2024 7/14/2025 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5000 X 7/19/2024 7/19/2025 PERSONAL&ADV INJURY $ 1000000 � - GENERAL AGGREGATEmmmmmw n$ 12, 0�00 GEN°L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- ❑JwECT ❑LOC PRODUCTS-COMP/OP AGG $ _ O'THE�. $ AUTOMOBILE LIABILITY COM81INFO 91NOL.5uMITjLa $ BODILYINJURY ........ ........ BODI ANY AUTO (Per person) $ ........ OWNED SCHEDULED BODILY INJURY Per accident $ HIRED AUTOS ONLY AUTOS ( ) NON-OWNED PFdOPER'TY D�AMAGE AUTOS ONLY AUTOS ONLY Psr indent $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N 124494445 srAT TE "ER •••• ANY PROPRIETOR/PARTNER/EXECUTIVE 7/13/2024 7/13/2025 """"""'" "' B OFFICER/MEMBER EXCLUDED? 7 N/A E.L.EACH ACCIDENT $ 1.000,000 (Mandatory in NH) ESL..DISEASE-EA EMPLOYE $ mes„dosribo under SCRIPT&ON OF CPERArONS below E.L.DISEASE-POLICY LIMIT 1 $ NY State DBL DBL567527 1/01/2024 12/31/2025 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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. AUTHORIZED �REPRESENTATIVE ( I � be*1.,S. FadR., 01988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers' ,�re Compensation CERTIFICATE OF INSURANCE COVERAGE sr 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 1 c. 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"I a" SOUTHOLD, NY 11971 DBL567527 3c.Policy effective period 01/01/2024 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. 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 7/10/2024 By 'IA=t4� (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Leston 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 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 4B,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. DB-120.1 (12-21) 111111 1111111111111111111111111111111111111111111111111 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 Paid 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 of 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 YSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) "A A^A A 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:I/INWW.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 STAT 'SU N'OE FUND T */ DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799006 1 I_'7F 4