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Home My WebLink About51797-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#: 51797 Date: 04/01/2025 Permission is hereby granted to: Kathleen E Walas 60 W 57th St Apt 10-B New York, NY 10019 To: install roof-mounted solar panels and energy storage system (outdoors)to existing single-family dwelling as applied for with flood permit. All battery/electric systems shall be installed at elevation 9' or higher. Premises Located at: 750 Brooks Rd, Greenport, NY 11944 SCTM# 51-1-16 Pursuant to application dated 02/24/2025 and approved by the Building Inspector, To expire on 04/01/2027. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Flood Permit $150.00 Total $475.00 Building Inspector �� yrra 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 Date Recerve APPLICATION FOR BUILDING PERMIT For Office Use Only q]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,anK4I Owners Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name:- k SCTM#1000-053•CO -OI • U 0 - O I 1p • 000 Project Address: -75C) ` I NeCY- 126 Circanport , W h q 4 Phone#: -732 . 55Q . � ZZ-] Email:SQl-QkC� ��r� IC I Corn Mailing Address:,15 I"(Y S ranocyt, T CONTACT PERSON: Name: ftutLch 5 1 I n c Mailing Address: Phone#: Lo 31 , ,CIS` e (II 1..0 Email C loa .. DESIGN PROFESSIONAL INFORMATION: Name:. N&Ifs U Mailing Address: I - r1 s ly "' W ' Phone#: 6 ® (PZ(? • LPZ.9 Email..Ali h t CONTRACTOR INFORMATION: Name: ' tic trl C Mailing Address: U A NA Eh) Phone#: 5 S D X 11 Email: 0 DESCRIPTION OF PROPOSED CONSTRUCTION vother,�' Q�0,r ew Structure ❑Addition (❑Alteration ❑Repair ®Demolition Estimated Cost of Project; l ........... " - $ Will the lot be re-graded? ❑Yes ;RNo Will excess fill be removed from premises? ❑Yes LNo 1 PROPERTY INFORMATION Existing use of property:51 fou1 l( Intended use of property: Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes RNo IF YES, PROVIDE A COPY. Check BOx Aftelr Reading: The owner/contractor/design professional i 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(print name): T►rko rh y E-F(DL,.5-)--o SAAuthorized Agent ❑Owner Signature of Applicant: �' Date: 2 "1 — ZU 2 S STATE OF NEW YORK) SS: COUNTY OF 0 ; rnth being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (Contractor,ment,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 off k. Z Notary PhWIt SANDRA MELISSA DISTEFANO CRUZ NOTARY PUBLIC-STATE OF NEW YORK OWNER�f � �� No.01 D16391205 (Where the applicant is not the owner) Qualified in Suffolk County My Commission Expires 04-29-2027 I " residing at � A.r � VD I ado hereby authorize to apply Y on -p alf to the T rl of Southold Building D artment for pproval as described herein. ' row, r.� , Owner's Signature Date VJ' 2 AIYIA.4 Print Owner's Name 2 �b AC V 12106/2024 Y) CERTIFICATE OF LIABILITY INSURANCE DATE(MM2024 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 endorsement(s). PRODUCER CONTACT NONE: Danielle Polonczyk Brown&Brown Metro,LLC PHHOONNE (856)552-6330 rAC Na. (856)840-8484 10 Lake Center Drive Danlelle,Polonczyk@bbrown.com ADDRESS: Suite 310 INSURER(S)AFFORDING COVERAGE NAIC# Marlton NJ 08053 INSURER A: Southwest Marine and General Insurance Company 12294 INSURED INSURERB, Merchants National Insurance Company 12775 Hytech Solar Inc INSURER C: 6 Washington Avenue INSURER D: INSURER E Bayshore NY 11706 INSURER F: COVERAGES CERTIFICATE NUMBER: 24-25 NY MASTER(no REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW PAVE 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. INSR LTR TYPE OF INSURANCE '.IN p AUVL-yyyD POLICY NUMBER MM/DD/YYYY MMID vwdyww— Policy UP LIMITS X,.COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ETO RENTED CLAIMS-MADE 7 OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 6,000 A PK202400015171 12/11/2024 12/11/2025 PERSONAL&ADV INJURY $ 2000,000 GLN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 4,000,000 POLICY PRO-] JE LOC PRODUCTS-COMP/OPAGG $ 4,000,000 O T HER $ AUTOMOBILE LIABILITY M PN LE 1M)T $ Ea arodankp ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPEW7 DAMAGE $ AUTOS ONLY AUTOS ONLY PeM acxldernt $ X UMBRELLALIAB X'..00CUR EACH OCCURRENCE $ 2,000,000 B EXCESSLIAB CLAIMS-MADE EXL0003762 12/11/2024 12/11/2025 AGGREGATE $ 2,000,000 DEpL_J RETENTION$ i I I I $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STA U T E ERTr ANY PROPRIETORMARTNERIEXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E,L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 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. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref# I Description Coverage Code Form No. Edition Date Errors&Omissions I PK202400015171 1 12/11/2024-12/11/2025 Limit 1 Limit 2 Limit 3 2=unt Deductible Type Premium 1,000,000 Ref# I Description Coverage Code Form No. Edition Date Contractor's Pollution PK202400015171 1 12/11/2024-12/11/2025 Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 c: Ref# Description I Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Aft2 ductible Type Premium FoFADTLCV Copyright 2001,AMS Services,Inc. Uocusign Envelope ID:F99A0056-BD61-485B-BC63-6F46032AF92E r NTEW Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Hytech Solar Inc. 631-595-5500 6 Washington Avenue Bayshore,NY 11706 1 c.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identificatlon Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New Jersey Manufacturers Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1a" W42088-5-24 PO Box 1179 Southold NY 11971 3c.Policy effective period 12/11/2024 to 12/11/2025 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: Danielle Polonczyk (Print name of authorized representative or licensed agent of insurance carrier) DocuSlgned by: Approved by: [ V }hod 12/6/2024 6A66erts200 natu ) (Date) Title: Insurance Broker Telephone Number of authorized representative or licensed agent of insurance carrier: 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 Building Department ApOication AUTHORIZATION (Where the Applicant is not the Owner) "�✓ V,41,A.5 I, " siding at (Print property owner's name) (Mailing Address) do hereby authorize Agent) to apply on my behalf to the Southold Building Department. (Owner's Signature) (Date) (Print Owner's Name)