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HomeMy WebLinkAbout51419-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#: 51419 Date: 11/26/2024 Permission is hereby granted to: Andrzej Kopala 675 Locust Ln Southold, NY 11971 To: install roof-mounted solar panels to existing single-family dwelling as applied for. Premises Located at: 675 Locust Ln, Southold, NY 11971 SCTM#62.-3-32 Pursuant to application dated 10/08/2024 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 - uilding Inspector r: 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 https:/Jww .soti holtltov�ov Date Received APPLICATION FOR BUILDING PERMIT n op . For Office Use Only f �G PERMIT NO ..� Building Inspector: Applications and forms must be filled out in their entirety. Incompletettn applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. fo Date: iUl I I Zc)-a-, OWNER(S) OF PROPERTY: Name: 4rdir?eIC-0 p I Q SCTM#1000- 070� r 3ooO '32u0 � Project Address: J Jam... , Phone#:R,-SLl_ 'i� -i e ZCGE Email: v--evq0-4n II Mailing Address: c9-?`�- Lcea +Lori e `"/)cy2c� CONTACT PERSON: Name: 'VL'C-+CJVt CL Cu-e (YiIVl S Mailing Address:1 71rchV101 Dli - F S-e+CkJC C - Phone#: ��i_S-�c�_�-7 L,f-7 1:Email: In t U �Q �P0. JQ.,•C DESIGN PROFESSIONAL INFORMATION: Name:-TQ A- Mailing Address: a C-1✓-2 Phone#: (�31_ gSg_cZ�� Email k.t-��/1u►3 cAwt-es S +Qf h CONTRACTOR INFORMATION: Name: �, h tom Mailing Address: Phone#: /-7 L/-7 Email: k&Ia, C DESCRIPTION OF PROPOSED CONSTRUCTION L�ther dd p '❑New Strticttrre ❑Aition ❑Alte t ( Pc-rr�' � .'� . $ f� ��� ration Re alr ❑Dem+ lition Estimated Cost of Project: � Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes ❑No 1 PROPERTY INFORMATION Existing use of property: reSiC.Q-e ri C-c- Intended use of property: RI SCCI e l C-c- Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes �No IF YES, PROVIDE A COPY. Check IBox After Read!ing: 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 210AS of the New York State Penal Law. Application Submitted By(print name): ❑Authorized Agent Owner Signature of Applicant: Date: IU[I 120z`'( STATE OF NEW YORK) S ' COUNTY OFSI ) AIr1CQw''�" e j� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the TACtA-e-o-c� V (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 lei day of Notary Public xia tc L SP PROPERTY OWNER AUTHORIZA Where the applicant ( pp nt Is not the owner) r I, r�� residingat U� tCcuS�- La ��rrirrr��a� do hereby authorize ✓•ee it to apply on my behalf to the Town of Southold Building Department for approval as described herein. oz Owner's Si nature Date C04 LEI 4*119Yt7-61 Print Owner's Name 2 BUILDING DEPARTMENT- Electrical Inspector off µ p TOWN OF SOUTHOLD mm Town Hall Annex - 54375 Main Road - PO Box 1179 Southold, New York 11971-0959 6 f �� Telephone (631) 765-1802 - FAX (631) 765-9502 N ro err southoldtownn . ov- seand@southoldtownny,gov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: I01. zo?,! Company Name: �-bQS QauDe �1C�lG�I LL Electrician's Name: jj_"V, c L License No.: �c.)? Z Elec. email: ( oA-� V, (-ec 5,CJCJ, -C C" Elec. Phone No: l co yto-�Z I request an email copy of Certificate of Compliance Elec. Address.: I( (ech yw o JOB SITE INFORMATION (All Information Required) Name.. ✓ 2� l Q Address: Cross Street:. Phone No.: R u -1�- Bld Permit #`" email:/-��2vlct- li�e•n�f g 5I Tax Map District: 1000 Section: (g2*h, Block: ' Lot: , BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): ��1C9-1 l✓1S�-ell l C C.)o ESquare Footage: Circle Al,l That Apply: Is job ready for inspection?: El YES NO []Rough In F] Final Do you need a Temp Certificate?: YES lr-V-,'['ICIO Issued On Temp Information: (All information required) Service Size 1 PhF�3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals 1 2 H Frame n Pole Work done on Service? Y N Additional Information: PAYMENT DUE WITH APPLICATION t,. a � 3 Suffolk County Department of.labor, Licensing & # Consumer Affairs fflwk- VETERANS MEMORIAL HIGHWAY * HAUPPAUGE,NEW YORK 11788 v E DATE ISSUED: 04/12/2024 No. ME-70212 SUFFOLK COUNTY Master Electrician License This is to certify that Eric E Mann doing business as Despaux Holdings LLC DBA 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. NOT VALID WITHOUT Additional Businesses DEPARTMENTAL SEAL } AND A CURRENT Greenleaf Solar _ CONSUMER AFFAIRS ID CARD ig �a Wayne T. Rogers Cgmm155101ier - i - e t Suffolk County Department of Labor, Licensing & Consumer Affairs VETERANS MEMORIAL HIGHWAY * HAUPPAUGE, NEW YORK 11788 1 7 DATE ISSUED: 04/19/2024 No. HI-70178 rep SUFFOLK COUNTY Home buprovement Contractor License This is to certify that William C Wei doing business as Despaux Holdings LLC DBA ✓ 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. NOT VALID WITHOUT Restrictions Additional Businesses 4 DEPARTMENTAL SEAL ;_ -" AND A CURRENT HI 1-Solar Greenleaf Solar r; CONSUMER AFFAIRS ID CARD � I Wayne T. Rogers Commissioner 3 _ Nil x _ ,aco CERTIFICATE OF LIABILITY INSURANCE F`MM/DD/YYY)024 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 endorsemen s . PRODUCER CONTACT Nicholas Zulkofske Brookhaven Agency,Inc. PHONE 631 941d113 FAX 631 941-4405 100 Oakland Avenue,Ste 1 E-MAIa. nick brookhaveoa, eftc .corn Port Jefferson NY11777 INSURER(S)AAFFORDING COVERAGE NAIL INSURER A. Maxum Indemnity Com an INSURED I1j§Uggjg . Utica Mutual Insurance Company Despaux Holdings,LLC dba Greenleaf Solar jbHgEgg Continental Indemni Company 11 Technology Drive INSUSER D.. Hartford Underwriters Insurance Company East Setauket NY 11733 IN-SURER 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 INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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 ADOLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000 000 10 A CLAIMS-MADE I^�occuR arx-rrnX X BDG-3074482-01 12I01/2023 12/01/2024 MED EXP'(Any o son) $50 0}000 PERSONAL.&.ADV INJURY $1 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 12,000,000 POLICY PE� LOC PRODUCTS COMP/OP AGG 12,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINE'C7 SINGLE LIMIT $1 000 000 B X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED X X 5612990 12/01/2023 112101/2024 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED BETE111ION S $ WORKERS COMPENSATION X PER I OTH- AND EMPLOYERS'LIABILITY C OFFICER/MEMBER EXCLUD FR ANY ED XECUTIVE Y N/A 46-860739-02-01 12/01/2023 11/16/2024 E L,EACH ACCIDENT $1,000 000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $1,00 000 If yes,describe under DESCRIPTIOa,QL,Q2gR6L12N.$_ w E.L,DISEASE-POLICY LIMIT $1,00000 D Installation Floater 12 SBA BB4RUS 12/01/2023 12/01/2024 $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 54375 Main Rd Southold,NY 11971 AUTHORIZED REPRESENTATIVE <1432> ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD d oW workers' CERTIFICATE OF INSURANCE COVERAGE STATE 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 1a. Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured DESPAUX HOLDINGS,LLC DBA GREENLEAF SOLAR 917-544-9306 11 TECHNOLOGY DRIVE EAST SETAUKET, NY 11733 1c, Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured (Only required ifcoverage is specificallylimited to certain locations in New York State,i.e., Wrap-Up Policy) 933707839 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 Town Hall Annex 54375 Main Road 3b. Policy Number of Entity Listed in Box"l a" Southold, NY 11971 DBL706197 3c.Policy effective period 12/01/2023 to 11/30/2025 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, Signed 8/2/2024 Date Si B 9 Y (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 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 (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) 111111111°°°1°°11°°1°1°111°°°11°1°°IIIIII 0 Additional Instructions for Form 1313-120.1 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 1 a 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. 1313-120.1 (12-21) Reverse 4y ,� Workers' CERTIFICATE OF A11 Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured 631-509-1747 GreenLeaf Solar,LLC 11 Technology Drive 1c.NYS Unemployment Insurance Employer Registration Number of East Setauket.'NY 11733 Insured Work Location of Insured(Only required If eavera, a is s� cillcall limited to( � fl 9 y 1d.Federal Employer Identification Number of insured or Social Security certain looatioss in New York,State,La.,a Wrap-Up P*y) Number 901035896 Entity Requesting a 3a.Name of Insurance Carrier 2.Name and Address of Enti R nesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Continental Indemnity Company Town of Southold Town Hall Annex 3b.Policy Number of Entity Listed in Box"1a" 54375 Main Road 46-860739-01-04 Southold,NY 11971 3c.Policy effective period ! R/9 to 4 3d.The Proprietor,Partners or Executive Officers are XO included.(Only check box If all partnerstofBcers included) 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 Rom on the INFORMATION PAGE of the workers'compensatlon 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 Harm 1�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 oonfers 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 an 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 Yolk State Workers'Compensation Law. Under penalty of perjury,)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: Nicholas Zulkofske (Print nerve orauth rued representative or licensed agent of insurance carder) Approved by: At- (Al I Z 3 n pp (Date) Title: Authorized Agent p p g Telephone Number of authorized representative or,licensed agent of insurance carrier: 631-941-4113 Please Note:Only Insurance carriers and their licensed agents are authorized to Issue Form C-105.2.Insurance brokers are N-0-Z authorized to issue it. C-105.2(9-17) www.wcb.ny.gov