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HomeMy WebLinkAbout51814-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#: 51814 Date: 04/08/2025 Permission is hereby granted to: Alexander Warren 605 E Timber Branch Pkwy Alexandria,VA 22302 To: install roof-mounted solar panels and energy storage system(in garage)to existing single-family dwelling as applied for. Premises Located at: 2965 Marratooka Rd, Mattituck, NY 11952 SCTM# 123.-2-27 Pursuant to application dated 02/27/2025 and approved by the Building Inspector. To expire on 04/08/2027. Contractors: Required Inspections: Fees: SOLAR PANELS $100.00 ELECTRIC -Residential $125.00 CO-RESIDENTIAL $100.00 Total $325.00 Building Inspector TOWN OF SOUTHOLD —BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 1 1 97 1-0959 Telephone (631) 765-1802 Fax (631) 765-9502 9ltt), ://WN k°uSoLltlioldto,�vn]'IN".goy. Date Received APPLICATIONI For Office Use Only I I!.E E, E PERMIT NO. 50 Building Inspector. C I,,� "I pi r f r Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an Building Department Owner's Authorization form(Page 2)shall be completed. Town o, Southold Date. OWNER(S)OF PROPERTY: Name: �, 'An Jy SCTM#1000- �v23. OU � 0�'.�O - � ? , 000 Project Address: Phone#: G 3 1- 3 g 2 '7 O Lf I Email: ���✓ri�l-1 AZ 6.co F1 Mailing Address: Gl - o CONTACT PERSON: �h /� Name: Lo lrr#-, p� b)T'E D.- Mailin Address: g -7410 SvLAAd 6100 m4L44-► �, y. ILaS;L, Phone#: (D 3 `3 O 3 --7 0 L/ I Email: F)ie r j l TS cp� i�,- 02 S S , co Yr DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name: E�[ cry)cti V kit Mailing Address: 1 4 l ' .VCJ / ► A-4- Y'1AC0 Phone#: Ob Email: pt1 4. (z cos vs , c4p) DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑!Addition ❑Alteration ❑Repair 9❑Demolition Estimated Cost of Project: ther`Tm~1*-d & )a,- P V , Y«) + 7 qf3 kwVI A 9' 1.�(n 1 , r „V . Will the lot be re-graded? ❑YesXNo Will excess be rnorr d from premises? ❑Yes�Ao 3 r ant)I G454t inke J-Zt1 Ll Z's hr y )4 (.4'b PROPERTY INFORMATION Existing use of property: 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 No IF YES, PROVIDE A COPY. Check ox After Reading.-ing: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter z36 of the Town Code. APPUCAATION 15 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 Z1OAS of the New York State Penal Law. Application Submitted By(print name):Lorraine Di Penta 99 Authorized Agent ❑Owner Signature of Applicant: Date: 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 beforeme this day of 20 2S� . Not ublic PROPER ref OWNER AUTHIORIZA[ION (Where the applicant is not the owner) I, �►mE.Je 4 9) residing at X( ' M1 11/�uLh IQ— 1145� do hereby authorize IN' U►iYGcNt.s to apply on ! t my b e o e To of Southold Building Department for approval as described herein. Owiier's Signature.: Date LOUIS J ROMEO Notary Public,State of New York No.01 R06314813 Print Owner ame Qualified in Suffolk County Commission Expires November 17,20 2 . E C E fF BUILDING DEPARTMENT- Ele r all Ir @V�r7 2025 TOWN OF SOUTH Lb Town Hall Annex - 54375 Main Road Southold, New York 11971- M Telephone (631) 765-1802 - FAX (631) 765-9502 "arnesh southoldt nn m o seam' southoldtownn . cv APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (All Information Required) Date: p2 Iq Company Name: E en c .-�C.. Electrician's Name. j` /Yli nI�I License No.: z5��, 9 F-t 6 Elec. email: Pe-rrn i ,S e b�� Elec. Phone No: aG3 t--7-79-'-2 c1 request an email copy of Certificate of Compliance � I Elec. Address.: 1 L41 a 5o o-►104, 0.J e- F-1 &-++s+LtC -J. l ! 5 O-- JOB SITE INFORMATION (All Information Required) 'Name: �Y m Address: qto kr O o AJ Cross Street: Phone No.: -1l Bldg.Permit#: 5,1 SP4 email: PP—rm d+S Q, -e-Qsiscc Vn Tax Map District: 1000 Section:Jai. Block: 0 �, yap Lot:0.;LI, BRIEF DESCRIPTION OF WORK, 'INCLUDE SQUARE FOOTAGE (Please Print Clearly): 7-7 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 Size[I1 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? LJ Y N Additional Information: IA-� PV 4(,s sq..s I n 3CLYA PAYMENT DUE WI PPLI ATIO ✓'-�C 1® CERTIFICATE OF LIABILITY INSURANCE oATE(MM7/116YY!! 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 hales,4DDlT1+ONAI INSUREEI provisions or Ise 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 ri hts to the certificate holder in lieu of such endorsoment(s), PRODUCER ROBERTS, FEDE INSURANCE AGENCY NAME: PHONE 31� G7af1._. _� FAX 3 23 GREEN STREET;SUITE 102 AIC N-- - - HUNTINGTON,NY 11743 eta R?AIES ••• ROBERTS. FEDE INSURANCE INSURERS AFFOIRDING COVERAGE NAIC u INSURED oNSURERA:ADMIRAL INSURANCE COMPANY 24856 �"�'"""' Element Energy LLC INSURER I A IJ OBA ELEMENT ENERGY SYSTEMS INSURaRc; 7470 SOUND AVENUE INSt/REITo: - � MATTITUCK, NY 11952 INSLItaERE: COVERAGES INSLrRER 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 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. Nt Sq i ,JFD 'I'PI I TYPE OF INSURANCE I COMMERCIAL GENERAL POLICY NUMBER, POL Ck`EPF�T��L„!'Cy'EJfp % MM/DEVYYYY I MMvOOIYYY LIMITS... LIABILITY k A X X CA00005380701 7/14/2024 7/14/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR ¢ — r R Mt S a C urrencoi $ 31)0,000 �X II IMA389203C MED EXP(Any one person) $ 5000 GEN' 7/19/2024 7/19/2025 10 . PERSONAL&ADV INJURY S.. 00000 EN L AGGREGATE LIMITAPPLIES PER: POLICY E PRO- LOC '0'ENERA.L,AGGREGATE $ .2.u000,000 0THER PRODUCTS•COMPIOIP AGG $ AUTOMOBILE LIABILITY $ O BIN DSIN LE LIMI $ ANYAUTC a ; d rI, OWNED BODILY INJURY(Per person) $ w..�m AUTOS CNLY �AUTOSULED �...- HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY P'ROPE'RTY,pAMIAG,E� Lil $ Per aax, enl UMBRELLA LIAR $ OCCUR EXCESS LIAB CLAIMS-MADE AGGREGATE EACH OCCURRENCE. $. $ � DEO RETENTION S yIIORIt SC $ AND EMPLOYERS'LIABILITY 124494445 PER - ANY PR0PRIETORJPARTNER/EXEC,UTTVE Y/N EA �H 7/13/2024 7/13/2025 B CFFICERIMEMBER EXCLUOEO � N/A E.L.EACH ACCIDENT $ 1.000 000 (Mandatary in NH) dyAppeses,dcrl(;e udder E.L.DISEASE-EA EMPLOYE $ DESORIPTNC'DN OF OPERATIONS'Wow E.L.DISEASE-POLICY LIMIT S NY State DBL OBL567527 1/01/2024 12/31/2025 Statutory DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may he 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 ! �(TLlY.YL J. / ede, ©1988-2015 ACORD CORPORATION. All rights reserved. 4CORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Workers're ompensation CERTIFICATE OF INSURANCE COVERAGE sta C 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 carrie 1a.Legal Name&Address of Insured(use street address only) ib. Business Telephone Number of Insured ELEMENT ENERGY LLC 7470 SOUND AVE MATTITUCK, NY 11952 1 c.Federal Employer Identification Number of Insured Work Location Of Insured(Only required if coverage is specifically limited to 2.7Nameanddress of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier isted as the Certificate Holder) ShelterPoint Life Insurance Company TOUTHOLD 54 STREET 3b. Policy Number of Entity Listed in Box"1 a" 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 following class or classes of employer's employees: Under penatty of pequry,I certify that I am an authorized representative or licensed agent of the insurance carci r 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 /4a=4r— (5ignature of insurance carrier's authorized representative or NYS licensed Insurance Agent of that insurance carrier) Telephone Number .-ate 100 Name and Title Leston ' felsh 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 in 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) 111I 1°1�!°°1°1°1°11°�°°11!�°!�°�!°!°!��IIIIl11 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. DS-120.1 (12-21)Reverse YS I F New York State Insurance Fund PO Box 66699,Albany,NY 122C6 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) AAAAAA 823336604 ROBERT S FEDE INSURANCE AGENCY 23 GREEN ST STE 102 Fail 5' ' , 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:/NI/WW.NYSIF.COM/CERT/CERTVAL.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 STET S4 7*2 NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 743799C06 _�� z