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HomeMy WebLinkAbout51494-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#: 51494 Date: 12/18/2024 Permission is hereby granted to: Laurie Johnson PO BOX 72 Mattituck, NY 11952 To: install roof-mounted solar panels on existing single-family dwelling as applied for.. Premises Located at: 3005 Grand Ave, Mattituck, NY 11952 SCTM# 107.4-22 Pursuant to application dated 10/28/2024 and approved by the Building Inspector. To expire on 12/18/2026. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total $325.00 Building Inspector V MR 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 htt s:,//www.southoldtownn .f-,ov n -Da e�Received APPLICATION FOR BUILDING PERMIT For Office Use Only PERMIT NO. Building Inspector. � ` Applications and forms must be filled out in their entirety. Incomplete � ' applications will not be accepted. Where the Applicant is not the owner,an -fow f ou�old Owner's Authorization form(Page 2)shall be completed. 0 Date: 101 C;L Lf ja' OWNER(S)OF PROPERTY: Name: SCTM# 1000- 101 00 -n 1 ,00 Project Address: 30 O 5 Y w►LCtvi�. I n6L+4-4Ll.(A<— I I Q'5 d� Phone#: a p - 7 - s l-lQ Email: s G�►1LJ� l 0-� Q�'100 :e-&o Mailing Address: cSl>`-yri�J CONTACT PERSON: Name: LD Ir✓-tk f�V, Mailing Address: I Lf 2 0 0lWk CkVVM Cu+ +A Phone#: 3 l - D -7 Email: N° ) DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: .. G Mailing Address: Phone#: U,3 l.�7 ��Gl 9-3 Email: DESCRIPTION OF PROPOSED CONSTRUCTION E �fNelweStructure��❑�di�� �Altera�ti�o�n �Rlp�a�ir ❑D moiiton stimated Cost of Project: J-56t - ^'In $ 1 Will the lot be re-graded? ❑Ye N'o Will excess fill be removed from premises? ❑Yes + 1 PROPERTY INFORMATION Existing use of property: ku Intended use of property: Zone or use district in whit remises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes�mo IF YES, PROVIDE A COPY. mx,k Box After Reading: The owner/contractor/design professional b responsible for all draloage and vtorm water Issues as provided by Ater 236 of the Town Code.APPLICATION i51^HEREBY MADE to they Building Department for the Issumm of a Building Permit pursuant to the Building Zone ordinance of the Town of Southold,Suffolk,County,Newyork and other applicable laws,Ordinances or itegulations,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 buildingls)for necessary Inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section WAS of the New York State Penal taw. Application Submitted By(print name):Lorraine DiPenta RAuthorized Agent ❑Owner Signature of Applicant: Date: /'a 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 i ,20 Z'N ANota - aPubliic LOUIS J ROMEO Notary Public,State of New York No.01 R06314813 t '°1 'ilry I ITI GIU I IG Commission Expires Novembers 17 20 (Where the applicant ).��. Oualified in Suffolk County is not the owner O p �� I, La-u ru-. a h yi5Uv-7 residing at JDo f5 U �✓� t do hereby authorize r-1k L[�G Mb r�A to apply on Vj illy ehalf to the Town of Southold Building Department for approval as described herein. Owner'st9ignature Louis J ROEO Date Lac).-rile. 6 h��� Notary Public,Mete of niewo -� No,01 R06314813 Cluaiil'ied in Suffolk County Print Owner's Name Commission Expires November 17, 13i�g 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 " anesh sotholdtonn . ov^ seared aotholdtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: O 2'1-1 Company Name: El frnefi e L,L,C- Electrician's Name: CK I" /1'l rm` License No.:�� Cl_t- I5 Elec. email: Elec. Phone No: q 5 t_'-7 7Q_?c)�3 91 request an email copy of Certificate of Compliance Elec. Address.: -1 " o _Sc,Trial— Q J e— H &—+++ JOB SITE INFORMATION (All Information Required) Name LA_ L rl`+ U 0 h nson Address: 3 0 o 0 noyl 1r,4+1 t Cross Street: Phone No.: a'0 k - -7b l , 14 Bldg.Permit#: S/ �l y email: Penn G ef.a5 Tax Mafia District: 1000 Section: 101.00 Block: o100 Lot: 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?: YES NO Issued On Temp Information: (All information required) Service SizeF11 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 ° " ' CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDYYYY1 6/2024 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 AMENDu 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: It the certificate htal er is an ADDITIONAL INSURED,the polls -!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 0 ROBERT S. FEDE INSURANCE AGENCY NAME~ FANf -ram .._ 23 GREEN STREET,SUITE 102 PHONE HUNTINGTON, NY E-MAIL 11743 DDRsS � " ROBERTS. FEDE INSURANCE " INSURER S AFFORDING COVERAGE NAIC q. INSURED INSURER A:ADMIRAL INSURANCE COMPANY 24856-- Element Energy LLC INSURER B; A E 0 SHEDBA ELEMENT ENERGY SYSTEMS INSUezERc' T3 7470 SOUND AVENUE INSURER D: TKO. MATTITUCK, NY 11952 IN URERE' CDVERAOES INSURER F 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH PAOLICIE, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN„ p'NSP REDUCED BY PAID CLAIMS, LTR TYPE OF INSURANCE D� R,LIMITS SHOWN MAY HAVE BEEN PAY YEW— POLICY EXP PCLN�C'Y NV'�Ipp461=.;fiC. MMIDrAIYY'WY Y I�MBDDw"FP^YY uMlrs COMMERCIAL GENERAL LIABILITY A X 9 X CA00005380701 7/14/2024 7/14/2025 EACH OCCURRENCE $ 1,000,000 u CLAIMS-MADE 11 OCCUR „ .. _ PREANN Ea " ur: t, 300,000 IMA389203C ��GEN MED EXP(Arty one person) $ 5000, H 7/19/2024 7/19/2025 L AGGREGATE LIMIT APPLIES PER: a PERSONAL&ADV INJURY $ 1000000 POLICY K]JECT ELOC GENERALAGGREGAT-r. $ 2,000,000 OTHER; PRODUCTS-COMP/OP AGG $ 121��i0010'. � $ . I AUTOMOBILE LIABILITY MBINi_ SINGLE LIMIT a_..„. ANYAUTO Ea, dem'... $ ��... OWNED @@@ SCHEDULED BODILY INJURY(Per person) $ G AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ If HIRED '„ NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTYCAMAGE $ Per a en4.. UMBRELLA LIAB - $ OCCUR EXCE EACH OCCURRENCE.. $. SS LIAR - CLAIMS-MADE AGGRE"aATIE $ CEO RETEI+9"f%CIN'$.. WORKERS COMPENSATION POND EMPLOYERS'LIABILITY 7/13/2024' 711312025 E L EACH ACCIDENT ER TH­ AIJYPRPRNETCIRlPAR1'NERdE�IECUx1at�E. Y!N 124494445 . PER C 8 (mandatory in ER EXCLUDED? 0 N!A 1000,000 0405,descr Ire andNH) E If e�describe under L..DISEASE-EA EMPLOYE e� SCR WTION I:�F oPERATI(aN t--low 1 000 000 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. AUTHORIZED REPRESENTATIVE I2o�eI�tS. Fede, 11988-2015 ACORD CORPORATION. All rights reserved.. 4CORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NET� workers' CERTIFICATE OF INSURANCE COVERAGE , 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 ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1c.Federal Employer Identification Number of Insured Work LoCatfon Of Insured(Only require d ifcoverage 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"1a" 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 fallowing class or classes of employer's employees: Under penalty 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 (Signature of insurance carrier's authorized re resentative or NYS Licensed Insurance A ent of that insurance carri p er g ) Tefephone Number 516-829-8100 Name and Title Leston WeiSh 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. DIB-120.1 (12-21) 11 j Iiiiii—11 Aiuiiiiiisiiiiiiiiiluiviiuiiiiiuiillll ll 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 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. D13-120.1 (12-21)Reverse NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) "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:/IWWW.NYSIF.COM/CERTICERTVAL.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 NOE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799006