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HomeMy WebLinkAbout51565-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE a 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#: 51565 Date: 01/16/2025 Permission is hereby granted to: Gabriel Kochmer 13 Peacock Path East Quogue, NY 11942 To: Install roof mounted solar panels to an existing single-family dwelling as applied for per manufacturers specifications. Additional certification may be required. Premises Located at: 780 Legion Ave, Mattituck, NY 11952 SCTM# 142.-2-13.1 Pursuant to application dated 11/18/2024 and approved by the Building Inspector. To expire on 01/16/2027. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 CO-RESIDENTIAL $100.00 ELECTRIC -Residential $125.00 Total $325.00 Building Inspector 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 btt ://www.southoldtownny. e� Date Received APPLICATION FOR BUILDING PERMIT . r For Office Use Only PERMIT NO. Is 1 y s Building Inspector. AK Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,anp Owner's Authorization form(Page 2)shall be completed. " Date: OWNER(S)OF PROPERTY: Name: SCTM#1000- Project Address: -I F5b L.-. a Phone#: ?�1� $ - 4-0 S Email: el °L Mailing Address. -) , CONTACT PERSON: Name: ' k` Mailing Address: 2941 Sunrise Hwy, Islip Terrace, NY 11752 Phone#: (631) 647-3402 Email: hppermitting@harvestpower..net DESIGN PROFESSIONAL INFORMATION: Name: Michael Dunn, R.A. Mailing Address: 256 Orinoco Dr, Brihtwaters, NY 11718 Phone#: (631) 665-9619 --TEmail: Bayblueprint@aol. com CONTRACTOR INFORMATION: Name: Harvest Power LLC -7 Mailing Address: 2941 Sunrise Hwy, Islip Terrace, NY 11752 Phone#: (631) 647-3402 Email: hppermitting@harvestpower.net DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ®Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other 1 - � Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes jKNo 1 PROPERTY INFORMATION Existing use of property: Residence Intended use of property: (no change) 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 Box After Reading: 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 210.45 of the New York State Penal Law. Application Submitted By(pri t name): �( }e.1�n'Z�c'ce� 'Authorized Agent ❑Owner Signature of Applica Date: 1 A 4 STATE OF NEW YORK) SS: COUNTYOF a�A� KaAe--,�Lin �. being duly sworn,deposes and says that(s)he is the applicant (Name of individual Wing contract)above named, (S)he is the ontractor,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�2q NOTARY PUBLIC,Ca NA NSA BLIC,STATE OF NEW YORK Rerlislration N(-, 01 LA6034714 Oualfflod in Suffolk County PROPERTY OWNER AUTHORIZATIC N Commission Ex ire May 30„20 �wro�rim.� 1, l \ residing at . b 1 I do hereby authorize LLC to apply on me do my behalf To touthold Building Department for approval as described herein. Owner's figniature Date Print Owner's Name 2 ,d �y , Ty 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 nr 'amesh southoldtownn .1 ov Z seand southoldtownn . ov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: 11/12/2024 Company Name: Harvest Power LLC Electrician's Name: Carlo Lanza License No.: ME-68518 Elec. email: hppermifting@harvestpower.net Elec. Phone No: 631 647-3402 01 request an email copy of Certificate of Compliance Elec. Address.: 2941 Sunrise Highway, Islip Terrace, NY 11752 JOB SITE INFORMATION (All Information Required) Name: Gabriel Kochmer Address: 780 Legion Avenue, Mattituck, NY 11952 Cross Street: Pacific Street Phone No.: (312) 218-5599 Bldg.Permit#: rj j 5 email:gkochmer@gmail.com Tax Map District: 1000 Section: 142 Block: 2 Lot: 13.1 BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly): Installation of a 4.60 kW solar PV system with (10) REC460AA roof-mounted panels. Square Foota e: Circle All That Apply: Is job ready for inspection?: El YES R NO []Rough In ✓ Final Do you need a Temp Certificate?: Fv YES F] NO Issued On Temp Information: (All information required) Service Size1:11 Ph E3 Ph Size: 200 A #Meters 1 Old Meter# ❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑✓Overhead #Underground Laterals 1 2 H Frame Pole Work done on Service? Y nN Additional Information: PAYMENT DUE WITH APPLICATION Suffolk County Dept.01 Labor,Licensing&Consumer Affairs HOME IMPROVEMENT LICENSE Name CARLO LANZA Business Name Harvest Power LLC ThiS Ceitftes that the bearer is duty licensedLicense Number H-08165 by the County Of suttc§k issued: 1111 B12010 ROSWk Expires, 11/01/2026 Commissioner NEW Workers' CERTIFICATE OF s ATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured HARVEST POWER LLC 1c.NYS Unemployment Insurance Employer Registration Number of 2941 SUNRISE HWY Insured ISLIP TERRACE NY11752 28 22 Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 20-4214746 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America Town of Southold P.O.Box 970 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11964 C72358624 3c.Policy effective period 10/1/2024 lo 10/01/2025 3d.The Proprietor,Partners or Executive Officers are ❑X included.(Only check box if all partnerslofficers 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 1a"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: Lex Smith (Prf narne of authorized representative or licensed agent of insurance carrier) Approved by: 09/11/2024 (Signature) (Date) Title: ASSIStant Pro ram Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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 Acct#:2830004 Client#: 110076 HARVPOW . DATE(MMIDD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 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 endorse d. 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:ACT Commercial Support Edgewood Partners Ins.Center PHONE 631-390-9700 m AX— ................. .. iAl ,now E t1. -39 _......_ t�+C�.pei. 40 Marcus Drive 3rd Floor E-MAIL NEcertificates a Icbrokers.com Melville,NY 11747 . . .... � p ....... .... ..._ INSURER(S)AFFORDING COVERAGE NAIC it James River Insurance Company 1........... INSURER A: P Y 2203 '.........INSURED .. mmm._,.... ......................... ...... ,...,,-......,.,.,. INSURER B:Lloyd's Of.. ..._-..........- .. .....,._ .B London Harvest Power LLC,Friendly ...................................... _. INSEERUR S Construction Company Inc,EZ Flashing LLC NYRR�C n......... 2941 Sunrise Hwy INsuR _ _ . .. .... ................_ ...... Islip Terrace,NY 11752 INsuRRmEW: 4Y 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. UdA L...... � PO'LI% POLICY EXP LIMITS LTR - IA fS,, , !'.,(Y.. POLICY NUMBER (pd4MIO - (I (MM/DD/YYYY)TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY 1808 1411612024 0411612025 EACH OCCURRENCE $1,000 000 CLAIMS-MADE X OCCUR PREMI ES EaEaccnrMencz;) $501000 m . $Excluded ]� Contractual Liab. MEO EXP.(Any one person)......... ,__,.m ..... X $6,000 Ded. PERSONAL BADV INJURY $1,000 000 .. GEN'L AGGREGATE LIMIT APPLIES PER. - - - -------- �--- - GENERALAGGREGATE $2,000 OOO PRO- POLICY FXI ECTT LOC -PROD 11 UCTS ,COMP/OPAGG. $2,OO,O1000mm,,,,,,,mmmmmmmmmm OTHER: AUTOMOBILE LIABILITY .. .A,,...mm,. sBCOMBINED SINGLE LIMIT $ person) BODILY INJURY(Per P - -- ANY AUTO ) $ mm OWNED SCHEDULED BODILY INJURY(Peraccident) $ ....... ,,,,.. 1 ..m._.._. .�....,.,. AUTOS ONLY AUTOS ONLY ((�egO,,,mccac1, n4.?AlragAFaE�...�.�.......�,..,,m ... . .._,..........................__..,,... 1_9 $ .... CCUR MADE AGGREGATE EXCESS LIAB�( UMBRELLA LIAB OCCUR 000711797 4/15/2024 04/15/202 EACH OCCURRENCE DED RETENTION$ $ PER WORKERS COMPENSATION _ - --- OTH AND EMPLOYERS'LIAB'tLITY Y/N ANY PROPRIETORfPAR'TNERIE:X..ECUTIVE E,L EACH ACCIDENT $ (MandeRMEtery D _..... _ _._e ..... OFFICERCMEMBER EXCLUDED? NIA .L I EASE-EA EMPLOYEE $ NH) E._-...- _ ....... ...... ......... If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ _A._ Polluti.�.�.�.�.�.�..�.�lab. � � 000711808......................................��m __�.__ m_......._� .�.............., aaa�...... _..._ ..._, Pollution Li 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 4/15/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance 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 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold,NY 1 1 971-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497816/M6497588 RH002 Client#: 110076 HARVPOW DATE(MMIOD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 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 a p 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 any rights to the certificate holder in lieu of such endorsement(s), CO PRODUCER NAgJACTCommercial SutppOrt. ,,.A„ ..�,.. Edgewood Partners Ins.Center PHONE 631-390-9700 ........ 40 Marcus Drive 3rd Floor E-MAILE��Ecer(i�cates a icbrokers. mm immm mR ........ INSURER(S►AFFORDINGCOVERAGE WN Melville,NY 11747 Apt? ................ p ___._____......... _ Alca .�..., James Rl............... .. . ................� �_. �. _r __ .............. INSURER A: River Insurance Company 12203 INSURED INSURER B:Lloyd's of London Harvest Power LLC,Friendly _..................... .�� ..... .................. ...... INSURER C Construction Company Inc,EZ Flashing LLC INsuRERo: ........ �......... ....... _._. ............... 2941 Sunrise Hwy ....m..._ . _ _ ........ ..... Islip Terrace,NY 11752 INSURERE: 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 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 REDUCED BY PAID CLAIMS. SUCH O POLICIES. LIMITS SHOWN MAY HAVE BEEN _...........�......�................ I ) _�.. ......... ..... ........ INSR TYPE OF INSURANCE Ig ,p SyyDyp POLICY NUMBER MM/DDYIYYYY dtl t Y ., LIMITS LTR,.._. ww,,,,,.w,,,,. ...._---...................._ ,,.�, .__. .............. ............... .. ._,....- A X COMMERCIAL GENERAL LIABILITY 000711808 4/15/2024 04/15/202 mEACH OCCURRENCEmmmm $1 000,0100 _.... ....._. qM w- ... CLAIMS-MADE OCCUR DAM] R ME4T,Ea� nceJ, $5O OOO X Contractual Liab. MEDwEXP(Any one person) $Excluded�� 8 ADV INJURY $1 000 OOO X $5,000 Ded...... _. ......... .. PERSONAL m..... a.__...._ GEN'L AGGREGATE IR ITAPPLIESPER: GEwwRwww AL GmmGR�E„GA TE 2� a LOC PRODUCTS-COMP/OPAGG $2�000000,,0O000 TH LPOLIECFY JECT $ 0 mmm .,,., .....,�..... .... .............. ....m. w-. ... �,.......... .....,,,,..._.—. aa„ ......... ....m,,,.. AUTOMOBILE LIABILITY COMBINED-RGLE Dki Wu _.-. .L4 artx:dan ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJ URY(Per accident) $ AUTOS ONLY AUTOS P'ROPERTY.DAMAGE -$ ... HIRED NON-OWNED AUTOS ONLY AUTOS ONLY earcerderuk�_ ...-....._ ...-................... A X UMBRELLA LIAB ( OCCUR � �000711797 �4/15/2024 04/15/202� EACH OCCURRENCE s4�000,000 � EXCESS LIAB CLAIMS-MADE AGGREGATE s4 000,000 m. RET DED... mm COMPENSATION $ SE.A�,U. ....... !J l3�_..$ ..ENT .,.... -..aaa�.. ............ ...... ��,..,..,-.e,,. _ ....___ .-..,�..� WORKERS COMPENSATION AND EMPLOYERS"LIABILITY _ _ .. .... ANY PROP RIETOWPARTNERFEXECUTIVE YIN N E.L EACH ACCIDENT $ OF'FICER1MEMBER EXCLUDED"I NIA ................. ... .. (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $� If yes,describe under ��..._�.��..............EASE ... .......DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ �A Pollution Liab. 000711808 _...�........w __04/1�5/2024 04/15/20� MM Ea Ag9 2 $1MM Ea Claim/$1MM B Professional Liab HPL230064 4/15/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance 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 P.O.BOX 970 ACCORDANCE WITH THE POLICY PROVISIONS. South Hold,NY 11964-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497815/M6497588 RH002 Ytit� Workers'� Cclrnpensat)ffn CERTIFICATE OF INSURANCE COVERAGE rArts PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured HARVEST POWER LLC (631)647-3402 2941 SUNRISE HWY NEW YORK, NY 11752-2822 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically 2p-4214746 limited to certain locations in New York State,i.e.,Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a Name of Insurance Carrier Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Town of Southold b Policy Number of Entity Listed in Box"1a" 53095 Rte 25 Southold, NY 11971 LNY713777882 c Policy effective period 10/01/2024 TO 09/30/2025 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: I@ 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 S,i fled 09/30/2024 E r� (Signature of Insurance carders authoaitasd representative or NYS Licensed Insurance Agent of that Insurance canes) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services 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 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 4C or 5B of Part 1 has 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 with respect to all of his/her employees. Date Signed B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title DB-120.1(9-17) llil'Ilp!!111120MIIINIO1911-11971 IH Suffolk County Dept.of Labor,Licensing S Consumer Affairs 4W, MASTER ELECTRICAL LICENSE Name CARLO P LANZA Business Name Ms cedifes that the Harvest Power LLC bearer"a duly tiCensed License Number ME-68518 by the County Of suft'olk Issued: 11/30/2023 -/e*wvqv,r C4tiw e,, Expires: 11/01/2025 Commissioner NEW Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board la.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured HARVEST POWER LLC 1c.NYS Unemployment Insurance Employer Registration Number of 2941 SUNRISE HWY Insured ISLIP TERRACE,NY11752-2822 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 20-4214746 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Indemnity Insurance Co.of North America Town of Southold P.O.Box 970 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11964 C72358624 3c.Policy effective period 10/1/2024 to 10/01/2025 3d.The Proprietor,Partners or Executive Officers are ❑X 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"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 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: Lex Smith OM (Pri neane sf authorized representative or licensed agent of insurance carrier) Approved by: 09/11/2024 (Signature) (Date) Title: Assistant Program Manager Telephone Number of authorized representative or licensed agent of insurance carrier: 214-721-6248 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 Acct#:2830004 Client#: 110076 HARVPOW DATE jrHM/oorrrrv) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 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 pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. m.. ed. 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER H � Commercial Support Ed ewood Partners Ins.Center Ni P _ ._... _._.. y' 9 q �t, E 631 390-9700 � C 40 Marcus Drive 3rd Floor E-MAIL NEcertiticates plcbrokers com Melville,NY 11747 INSURERS)AFFORDING COVERAGE NAIC# INSURER A:James River Insurance Company 12203 ...INSURED......... .... �..,.,. .. .....-............ ... i INSURER B:Lloyd's Of London - Harvest Power LLC,Friendly I NSURERc.: �� ""�`" '"--"_________ . Construction Company Inc,EZ Flashing LLC '�"""""' ' INSURER D: Islip Terrace, NY 11762 2941 Sunrise Hwy .INSURER .E.m.... .., ,. -............._.......-. .-... .---..........................,-,,,mm'. 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 AODL UBR POLICY F POLICY EXP LIMITS :TR P --.............A .I R WVD. POLICY NUMBER 101_w_YOrY 0 i,mmigDdYY�M'1'q m.. ,-----_---- -. TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY OCCURRENCE $1 OOO OOO - A 000711808 4/15/2024 04/15/202 EACH CLAIMS-MADE X OCCUR PREMISESO RENTED DAMAGE T Ea occurrences $5O OOO Contractual Liab. EXP(Any one Person) X $5,000 Ded, PERSONAL B ADV INJURY $ „w 0 .0 mm GENLAGGREGA PRMOITA LIES PER: PRODUCTSGGREGATE $2�1'000,000 POLICY _ X JECT ryry LOC ,000,000 ........m.._,,,.0 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE[Wff - GcrttlsLa _... . $ ANY AUTO BODILY INJURY(Per person).. $ ...... ,BODILY INJURY(Per i ........... OWNED SCHEDULED .... accident) $ AUTOS ONLY .AUTOS HIRED NON-OWNED PROPER MAGE $ AUTOS ONLY AUTOS ONLY „,II?oc accitl ) ..„......mw�................... $ ._...........A OCCU .._......... 000711797 4/15/2024 04/15/202 EACH OCCUeRENC.E......___ ... $4,000 0..-0-_0 AIB RXUMBRELLA EXCESS LIAB CLAIMS-MADE GGREGAT $4 00O 000 ..... DED RETENTION.$ ��, $ ., ._.....�_....-. -.�.. m... .................. .... .,...... .... .. ,,,,,�. ... WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y/N _.__...... .....' ANY PROPRIETORIPARTNERIEXECUTIVE E,L EACH ACCIDENT $ OFFICERIIME'MBER EXC'LUDE07 N/A ........ (Mandatory I E $. E'�ndeko In NH E,L DISEASE-EA EMPLOYEE m,mmmm mmmmmmmmm,m,m,m,m„m,� .,,, If yes,describe under DESCRIPTION OF OPERATIONS b �. .—.w_�.,._........µ...._._. ._elow .... ,--.....,.,,_ .... .......... ..� ._-..... E.L DISEASE-POLICY LIMIT $.--..----.......... ...--.m.�. A Pollution Liab. 000711808 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 4/15/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance 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 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 11971-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497816/M6497588 RH002 Client#: 110076 HARVPOW DATE(MM/DDIYYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 4/16/2024 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 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 ns 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Commercial Support Edgewood Partners Ins.Center PHONE _. 637-390-9700 A/C,N Ext) 40 Marcus Drive 3rd Floor E"-MAtL DDREI N'I cBrl flcatl��°.`s@epicbroke s.com Melville,NY 11747 ..A..em. w........._........., .m.. �..._........ ..... ._ INSURERIS)AFFORDING COVERAGE NAIC# INSURER A:James River Insurance CompaD.. ��� ................ _ 2............ -. w .. ._. y 12203 INSURED INSURER B:Lloyds of London Harvest Power LLC,Friendly msuRERc: Construction Company Inc,EZ Flashing LLC ®' " ...... 2941 Sunrise Hwy JNSURERD: '.. RER ENSU Islip Terrace,NY 11752 INSU 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 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 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, N v TYPE OF INSURANCE AODL UOR POLICY EFF "POLICY EXP LIMITS POLICY NUMBER 'flNMIDDI4"fYY (,MM/DD/YYYY) ..._... ............... ... .,,,_, ......_ rI ... COMMERCIAL GENERAL LIABILITY ,000,000 A X 000711808 4/15/2024 04/15/202 EACHoccuRRENCE $1„m___ ED CLAIMS-MADE �m X]l OCCUR „PREMRES(Ea occurrence) $50 X Contractual Liab. MED EXP(Any one person) s EXcluded X $5,0.... 00 De(J, - PERSONAL 8 ADV INJU RY $1t000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2r000,OOO PR POLICY L-„.X JECaT ,_�LOC PRODUCTS-COMPIOPmAGG s2,000,000 THEIR: $ ................ ... AUTOMOBILE LIABILITY COMBINED'iNGLE IJMlT IE,acodd„Xa. ._.. s ..................... .-... ANY AUTO BODILY INJURY(Per person) $ ...... . .._.... OWNED - SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS •--••••• - ---- HIRED NON-OWNED PROPERTY DAMA�aE: $ AUTOS ONLY AUTOS ONLY A �( UMBRELITITITIT......-..... X I OCCUR 0007..�........................ -��..._.-.. ..........�..� .m.,,�. ._........._. lA LIAB 11797 4/15/2024 04/15/202 EACH OCCURRENCE s4 000,000 Www__ww__w ...-_ GATE $4 000 000 EXCESS LU1B �CLAIMS-MADE AGGRE .... DED RETENTION s WORK ......... ................ OTHERS COMPENSATION AND EMPLOYERS'LIABILITY ----- ANY PROPRIETORIPARTNERIEXECUTIVE Y/N E.,L..EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) w EMPLOYEE $E.,L..DISEASE EA E-..........-.._._ ...........__.. If yes,describe under DESCRIPTION OF OPERATIONS below E.L..DISEASE-POLICY $ A Pollution Liab. 000711808 4/15/2024 04/15/202 $1MM Ea Claim/$1MM Agg B Professional Liab HPL230064 4/16/2024 04/15/202 $2MM Ea Claim/$2MM Agg $10K Ded Ea Claim DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Evidence of Insurance 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 P.O.Box 970 ACCORDANCE WITH THE POLICY PROVISIONS. South Hold,NY 11964-0000 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6497815/M6497588 RH002 NEW workers' CERTIFICATE OF INSURANCE COVERAGE e s E cornpensation PART 1.To be completed by 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 HARVEST POWER LLC (631)647-3402 2941 SUNRISE HWY NEW YORK, NY 11752-2822 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically 20�214746 limited to certain locations in New York State,i.e., Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a Name of Insurance Carrier Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Town of Southold 3b Policy Number of Entity Listed in Box"1a" 3095 Rte 25 Southold, NY 11971 LNY713777882 c Policy effective period 10/01/2024 TO 09/30/2025 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 employers 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 09/30/2024 r (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services 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 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 4C or 5B of Part 1 has 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 with respect to all of his/her employees. Date Signed B (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title DBA20.1(9-17) IIIIIIID111111111°�1���0�9°17IIIIII IH r Ruildil1g,Department Agplication AUTHORIZATION (Where the Applicant is not the Owner) residing at " � (Print property owner's name) (Mailing Addret do hereby authorize necc� (Agent) Harvest Power LLC to apply on my behalf to the Southold Building Departrne (dwraer's Signattt ()ate) (Print Owner's.Name) n CONSENT TO INSPECTION L-Q�rc( ,the undersigned,do(es)hereby state: Owner(s)Name(s) wner(s)of premises in the Town of Southold, located at ( )( re the o I That the undersign is which is sho rid designated on the SuffolkCounty Tax �elap as [district 1000, Section , Block Q , Lot )S, I— That the undersigned(has)(have)filed,or cause to be filed,an application in the Southold Town Building Inspector's Office for the following, \ That the undersigned do(es)hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon,to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws,ordinances,rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections;do(es)so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws,ordinances,rules or regulations of the Town of Southold. Dated: gnatu�) Print Nam � t�nature) (Print Name)