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HomeMy WebLinkAbout51430-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#: 51430 Date: 12/04/2024 Permission is hereby granted to: Lorraine Zito 3600 Deep Hole Dr Mattituck, NY 11952 To: install roof-mounted solar panels to existing single-family dwelling as applied for,. Premises Located at: 3600 Deep Hole Dr, Mattituck, NY 11952 SCTM# 115.-17-8 Pursuant to application dated 10/10/2024 and approved by the Building Inspector. To expire on 12/04/2026. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total 325.00 .8 Inspector ITD TOWN OF SOUTHOLD—BUILDING DEPARTMENT ' 4 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959 14 Telephone(631) 765-1802 Fax (631) 765-9502 h : 'wwrw.sutholdto r APPLICATION FOR BUILDING PERMIT' Date Received For Office Use Only 1YP,/k PERMIT NO. Building lnspect:or. G � Applications and forms must be filled out in their entirety. incomplete lid VAVOTtrrent applications will not be accepted. Where the Applicant Is not the owner,an owners Authorization form(Page 2)shall be completed. Date: Z�� ' OWNER(S)OF OP RTY: Ud' >;7. 00 o y• dbo Name: Sam# 1000- s. a 7• Gb .0037- � , Project Address: Email: Phone#: �. Mailing Address: 3 to St' CONTACT PERSON: — Name: w Mailing Address: ' 7-7/ Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name: �L Mailing Address: Phone#: . Email: OM/ aW, � CONTRACTOR INFORMATION: Name: Mailing Address: II Phone#: Email DES 70N OF PROPOSED CONSTRUCTION Str 1 ddition ❑Alteration ❑Repair ❑Demolition Estimated Cost of P ect: ether � Will the lot be re-graded? ❑Yes 0 Will excess fill be removed from premises? ❑Yes d PROPERTY INFORMATION `Existing use of property: Intended use of property: Zone or use district in whichWpremises : Are there any covenantssaa d restrictions with respect to this property? ❑YesV�No IF YES, PROVIDE A COPY. Check AfterReading: The owner/contractor/design professional Is responslbk for ap drsi�e and storm wow bum as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the building Department for the issuance of a Buodkrg Permit pursrwnt to the erdldft Zone ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordbmrces or Regulations,for the construction of buUM, additions,alterations or for removal or demolition as heroin described.The applicant agrees to comply with all appocAk lags,ordinances,bulklim code, housing code and regulations and to admit authorized Inspectors on premises and In bulding(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 Submi ed B Tint nam,,ri�or" �f� Authorized Agent ❑Owner App Y(P r� Signature of Applicant: ��, Date: STATE OF NEW YORK) S� COUNTY OF being duly sworn,deposes and says that(s)he is the applicant (Name of individual .signing contract)above named, (S)he is the . (Contra or�Agent, orporate Officer, etc,) of said owner or owners, and is duly authorized oor 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 rage this E8 , c day of / p Notary Publi I ON �J (Where the appfiirant is'not the owner) residing ati 10,DIU P )a A41L/r Lky--do hereby authorize _ ��Ljr,�,p a my eha f to the Town of So Id g ilding Department for approval as described herein. 9- 2L- 2tl Owner's Signature Date Print Owner's Name -11 2 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 "a mesh @southoldtownn . ov—seand @southoldtownn . av APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN IN ORMATION (All Information Required) Date: oLL2 tz Company Name: . C-/J Electrician's Name: License No.: Elec. ail ✓ ' Elec. Phone No: C request an eniail copy of certficate of Compliance Elec. Address.: JOB SITE INFORMATION (All Information Required) Name: Address: Cross Street: Phone No.: Bldg.Permit#: � email: r, �� Tax Map District: 1000 Section: Block: �7 Lot: BRIEF DESCRIPTION OF W RK, INC DE SQUA 'E F OTA � (Ple se Print Cl arly 5�7 arse s. 5,336 ted J-Vi-)e/n Footage:_ Circle All That Apply: Is job ready for inspection?: YES O Rough In Final Do you need a Temp Certificate?: YES O Issued On Temp Information: (All information required) Service Size Ill Ph L3 Ph Size: A # Meters Old Meter# ❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead # Underground Laterals M 1 M2 H Frame Pole Work done on Service? Y Ll N Additional Information: PAYMENT CLUE WITH APPLICATION YOWorkers' R CERTIFICATE OF YCO ft1C STATF Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured unrun Installation Services,Inc 415-946-7500 75 Fiero Lane,Suite 200 Ph#805-540-7643 San Luis Obispo,CA 93401 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 50-86426 4 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i,e.,a Wrap-Up Policy) Number 77-0471407 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 3095 Route 25 outhold,NY 11971 WC 6142876-03 3c.Policy effective period 10/01/2024 to 10/01/2025 3d.The Proprietor,Partners or Executive Officers are ❑Included.(Only check box if all partners/officers included)all ®excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'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 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 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 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 Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers'compensation 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 Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. 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 the coverage as depicted on this form. Approved by: Susan B. Kendziora (Print rnarno of authorized refry sesntative or licensed agent of insurance carrier) ^� clj�,Approved by: e. 1120? (Signature) (Date) Title:Vice President-Operations Services Telephone Number of authorized representative or licensed agent of insurance carrier:800-382-2 50 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 qWorkers' CERTIFICATE OF INSURANCE COVERAGE ATE 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. ___._.. _...�. ..W.__._� .....�. ........_ Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Sunrun Installation Services Inc. 202 Commerce Dr., Ste. 7 Moorestown, NJ 08057 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) 77-0471407 .... ._.___..... 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Prudential Insurance Company of America Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box 1 a Southold, NY 11971 CG-52830-NY 3c.Policy Effective Period 1/1/2024 To 12/31/2024 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 employers 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 descn ecl a ¢eve, Date Signed January 02, 2024 By (Signature of insurance carrier's authorized representative or NYS Ncensed insurance agent of that insurance carrier) Telephone Number 215-658-7318 Name and Title Carolynn Smith - VP Contracts 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 413,4C 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 46,4C 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. DB-120.1 (12-21) 111 IIIIPiiiuiuiiiiiuiiiiiiiiiiiiuiiiuiiiiiiiill�l�l ­__81N SUNRINC-02 ..... A G' A�� CERTIFICATE OF LIABILITY INSURANCE 9/912024 ) °A 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 endorsements) PRODUCER License'#O'C36861 c TACT Walter Tanner _ PHONE .. .. A/ — ... AIIIanit Insurance Services,Inc. IAac No. _ San 560 Flrancis oission f CA 94105 6DO.RI SS Nml� E. AIL Taflfter alllant com VlNalter ___� .............. ffAaE _ .... panc a — ... ..... !NURE ,_.._ ... 35378+nran Insurant �CO - -- — _ INSURED INSURE!„e Zurich American Insurance Company 16535 Sunrun Installation Services,Inc INSURER Amerlcan,Zurich Insurance Company ......, 40142 ............._ 775 Fiero Lane,Suite 200 Ph#805-540-7643 INSURER D San Luis Obispo,CA 93401 INSURER E.�.�..... ....._. INSURER F ......... .............. .........._ ... ..__._......... _._.. OVERAGES CERTIFICATE NUMBER: _... REVISIII N_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 MSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CON CLAIMS A XXUCOMMERCIALGENERALLIABpm --- -... ... I11!llkSl.la/YYYYI IMM(,I�YEXP ...... LIMITS 2�� . T � LITY ADDL SUBR. .._---- POLICY EFF POLI .. t _ DITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEE TYPINS E OF INSURANCE POLICY NUMBER CLAIMS-MADE X EACH OCCURRENCE 5 � a ��OCCUR MKLV5ENV104843 10/1/2024 10/1/2025 MADE TO RENTED E tr�ra���� $ 1,00 000 ��p� ----- ?. D EXP IAny one person) ... 2000,000 M GENL AGGREGATE LIMIT ERSONAL&ADV INJURY $ m .. T APPLIES PER: PRODUCTS N$ ..„, � 000 000 2, X POLICY C'� "'.]JECT ........... .... ., COMP/QP AGG M$ 2,000,000, -X POLICY, .,�., Retention:$200,000 Per Project Agg $ 5,000,000, PR .....". COMBINED SINGLE LIMIT ..... 2,000,000........ B AUTOMOBILE LIABILITY ...�FI#. aa9 .......�..�..$.m.m,_,_ ......... ..... ..... ]X- ANY AUTO BAP614287703 10/1/2024 10/1/2025 BODILY IN)uRY,(Perperson)__OWNED SCHEDULEDAUTOS ONLY AUTOS ,BODILY INJURyffm qr accident)ryry ..__ N �Dp P'tfPi:RTYDAMACE HtA�'ONLY AA08N ' �_er a�ccueffiemwll.� . . -- $ ........A Ded. X Con,:Not Covered Liability Ded.: 1,000„000 Fewelb, -7 UMBRELLA LIAB .....00CUR E,A,f H OCCURRENCE �$—=,=. ..- ....., EXCESS LIAB CLAIMS MADE AGGREGATE_ .............. DED RETENTION$ FAH $ ,...... mm C WPER OREMPLOKERS COMPENSATION 1NC614287603 10/1/2024 10/1/2025 E(L.EACH ACCIDENT _ $ 1' ANY PROPRIETOR/P RBTI ER/EXECUTIVE YIN ,.L DISEASE 000 OO , ..OFFICER/MEMBER EXCLUDED N Q N I A 1,000,000 (Mandato in NH) .........„...I ._._.._......... E,LDISEASE-POLICY LIMIT E.$ ... DESCRIPTION OF OPERATIONS below E s,describe under 1,000 000 ..... If ye ...._ DESCRIPTION OF OPERATIONS C LOCATIONS I V HICLES�I;ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation Policy WC614207603 Deductible:'$1„000,000. Evidence of insurance ...... ........ ............. ...... ......................................... CERTIFICATE HOLDER_ _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 Southold,NY 11971 -•• AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) _... ©1988 20 _. 15 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD