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36040-Z
Town of Southold Annex 54375 Main Road Southoid, New York 11971 5/1/2011 CERTIFICATE OF OCCUPANCY No: 34920 THIS CERTIFIES that the building Location of Property: Date: 5/1/2011 SOLAR PANEL 9625 Main Bayview Rd, Southold, NY 11971, SCTM #: 473889 Sec/Block/Lot: 88.-3-23.1 Subdivision: Filed Map No. conforms substantially to thc Application for Building Permit heretofore 11/15/2010 pursuant to which Building Permit No. was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: accessory ground mount solar panels as applied for. Lot No. filed in this officed dated 36040 dated 11/19/2010 The certificate is issued to Homes Anew I Ltd (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 36040 4/11/11 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 36040 Z Date NOVEMBER 19, 2010 Permission is hereby granted to: HOMES for : ACCESSORY GROUND MOUNT ELECTRIC SOLAR PANEL AS APPLIED FOR at premises located at County Tax Map No. 473889 Section 088 purse, ant to application dated NOVEMBER Building Inspector to expire on MAY 9625 MAIN BAYVIEW RD SOUTHOLD Block 0003 Lot No. 023.001 15, 2010 and approved by the 19, 2012. Fee $ 100.00 Authorized Signature Rev. 5/8/02 ORIGINAL -- ~ Form No. 6 ~ C'~ x. ~ ~"~'*¥ / 765-1802 ~ ~' ~' APPLICATION FOR CERTIFICATE OF OCCUPA~NCY This application must be filled in by typewriter or ink and submitted to the Building Departmet A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 , 3. Copy of Certificate of Occupancy-$.25 ~x,j/,) J/ 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Old or Pre-existing Building: x/~ (check one) Street Hamlet Block OOo~ Lot 0~3,00 ) New Construction: Location of Property: House No. OwnerorOwnersofProperty: ~t~ [~g-l OL~c~ i- Suffolk County Tax Map No 1000, Section ~' Subdivision Filed Map. PermitNo. "~(,oqo DateofPermit. ttl~ff{l° Applicant: Lot: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ ~'o' C.oB Final Certificate: ~ (check one) - '~ p~ant Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone(631)765-1802 Fax(631)765-9502 rofler, riche~.town southo d ny us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION ssued To: Homes Anew LTD Address: 9625 Main Bayview Road City: Southold St: NY Zip: 11971 Building Permit #: 36040 Section: 88 Block: 3 Lot: 23.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Empower Solar LicenseNo: 47932-me SITE DETAILS Office Use Only Residential ~ Indoor ~ Basement ~ Service Only ~ Commedcal Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI Recpt Main Panel NC Condenser Single Recpt Sub Panel NC Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures ~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures ~.~ CO Detectors Fluorescent Fixture ~.~ Pumps Emergency Fixtures~.~ Time Clocks Exit Fixtures [~ TVSS photovoltaic system, 12.7 kw, 56 SER-228panels, 2 Sun Power 5000m and I Sun Power 3000m inverters Inspector Signature: Date: April 11 2011 81-Cert Electrical Compliance Form / INsPECTION [//]'FOUNDATION 1ST [ ] ROUGH PLBG. TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 [ ] FOUNDATION 2ND ] FRAMING / STRAPPING [ ] FIREPLACE & CHIMNEY [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIlI~RF. SlST4#TCO~b"IllUCTION [ ] RRERESST~WI'I~ENETRATI0# REMARKS~ INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) .~] ELECTRICAL (FINAL) \ REMARKS: DATE INSPECTOR~~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTIO/N [ ]FOUNDATION 15T [ ] R~OH PLBG. [ ]FOUNDATION 2ND [ ] iNSULATION [ ]FRAMING / STRAPPING [~/~FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION To: Town of Southold Page I of 1 221 Long Beach Rd,, Island Park, NY 11558 2011-04-18 19:18:57 (GMT) Gregory Sachs, PE From: David Schieren (516)-.509-39/2 sachsg@gmail.com Town of Southold Buildin§ Department 54375 Main Road P.O. Box 1179 ~outhold, New York 1&97:[-0959 APR 18 2011 BLDG. DEPT, TOWN OF SOUTHOLO April 14, 201:1 To Whom It May Concern: The Solar Electric installation at 9625 Main Bayview Road, (Section: 88 Block: 3, Lot: 23.1, Bldg Permit #36040) has been completed in compliance with structural engineer's requirements. The project is consistent with the specifications set forth in the perm,. ,~ su,cer~y,I ~/~ :-'~ 1- ~.~ \.~.'1.'-,~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALK" SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined [¢ ~, 20 / O Approved /ill c~ 20[0 Disapproved a/c Expiration PERMIT NO. ~ dO q/O BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey_ Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Fom~ Contact: Mail to: .~-~--'~~~F~ Building Inspector ~.~/ lq0~] '15 20~0 :I~L~}/ Date A~t43'~t ]~,. ,20'0 I ~ / INSTRUCTIONS -- I sp c or w th set~umt~lot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and wate~ays. c. The work covered by this application may not be commenced before issuance of Building Pemit. d. Upon approval of this application, the Building Inspector will issue a Building Pe~it to the applicant. Such a pemit shall be kept on the promises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pa~ for any pu¢ose what so ever until the Building Inspector issues a Ce~ificate of Occupancy. f. Evew building pe~it shall expire if the work authorized has not commenced within 12 months a~er the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other re~lations affecting the prope~y have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the pe~it for an addition six months. Thereafter, a new pe~it shall be required. ~PLICATION IS HEREBY M~E to the Building Depaament for the issuance ufa Building Pe~it pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordin~ces or Regulations, for the construction of buildings, additions, or 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 for necessaw inspections. (~na~e ~f applicant ~me, if a co¢oration) (Mailing add{ess of appli~ant~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name ofownerofpremises ~t~,,~)t ~l&~-~} ~-~w,,.~_ ,ZZ~e_~,/O (As on the tax roil or latest deed) If. applic,mit las a corlitoration, sign,a, ture of duly authoriz~i' officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. td'lq~2..- ~IE Other Trade's License No. Location of land on which proposed work will be done: House Number ~treet Hamlet County Tax Map No. 1000 Section Subdivision Block ~ Filed Map No. Lot 2. State existing use and occupancy of premises and intended.use and occupancy of proposed constru~t,ion: a. Existing use and occupancy {~ ~.,~t'cs ~J ~uj'ld, ~ b. Intended use and occupancy (./3 na mort'~ d ~Vd/dt .,~/ 3. Nature of work (check which applicable): New Building Repair Removal Demolition 4. Estimated Cost Fee Addition Alteration Other Work (Description) (To be paid on filing this application) 5. If dwelling, number of dwelling units If garage, number of cars Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Height. Number of Stories Dimensions of same structure with alterations or additions: Front Depth. Height Number of Stories Dimensions of entire new construction: Front Rear Height Number of Stories Depth Rear Depth Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated l 2. Does proposed construction violate any zoning law, ordinance or regulation? YES NO ~ 13. Will lot be re-graded? YES__ NO "~Will excess fill be removed from premises? YES NO'-/ 14. Names of Owner ofpremises ~q~'[~l ~Z{$1-h~e't~l Address/~[ ;v~t~-~[[0~?~'~o~bl?No.~~'~6 ~0 15' Name of Architect ~s~ ~c~ ~,~ Address I[~]~¢ ~ 5~hone No ~~ Name of Contractor ¢~ ~L~ Address~Phone No. g/~- X~q~ 15 a. Is this prope~y within 100 feet of a tidal wetland or a freshwater wetland. YES NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this prope~y within 300 feet of a tidal wetland? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES · IF YES, PROVIDE A COPY. NO STATE OF NEW YORK) SS: COUNTY OF ) J.~{,u4 ~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) a~ove named, '~ O of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application am true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this 01-24-11;20:33 ; 15167061789 Oompan:[;,.Name: Nar~:. APPLICATION FOR ELEO_TRICA£ INSPI~.OTi0N ,%, z$,/ '. Town Hall Annex 54375 Main Road P.O. Box 1179 Southold~ New York 11971-0959 Telephone (631 ) 765- 1802 Fax (631) 765-9502 BUILDING DEPARTMENT TOWN OF SOUTHOLD April 21, 2011 Homes Anew I Ltd 191 Sweet Hollow Road Old Bethpage, NY 11804-1314 RE: 9625 Main Bayview Rd, Southold TWO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: Application for Certificate of Occupancy. (Enclosed) Electrical Underwriters Certificate. A fee of 50.00. Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1184) __ Trustees Certificate of Compliance. (Town Trustees #765-1892) Final Planning Board Approval, Final Fire Inspection from Fire Marshall. __ Final Landmark Preservation approval. BUILDING PERMIT: 36040-Z ground mount solar panel OF DESCPISED PROPEHTY S~fUATED AT BAY'C2EW, TOWN OF SOUTHOLD SUFfOLE COUNTY, NE~ YOlkY S.C.~.M. NO. A~E4 = 41.552 S~. ~T. ~ ~' ~5 ~ ~ RO~, ~0~, N.~ RICHARD WILHELM ~ PROFESSIONAL LAN{) SURVEYORS 328A Main Street 41 Centre Street 3g O ~ ~ ~ Cen~er Moriches, NY 11934 ~lle, New Yo~ 11782 '%%%%~m ~'-~' ~z~~m' ~.~ ~) ~. ._ / (63U 878-0120 F~:(~I) 878-71~ (6JI) 567-4775 ~ NO, ~02 ~: l" = 30' DA~: 3/29/2~1 A oRb' CERTIFICATE OF LIABILITY INSURANCE I DATE,MM,OO 10 15/20 0 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATFER OF INFORMATION LoVulloAssociates, lnc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6450 Transit Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Depew, NY 14043 INSURERS AFFORDING COVERAGE NAIC # ~NSUREO EmPower CES, LLC iNSURER A: INTERSTATE FIRE & CASUALTY COMPANY 22829 dba EmPower Solar INSURER E: SCOTTSDALE INSURANCE COMPANY 41297 221 Long Beach Road INSURER C: Island Park, NY tt558 INSURER D: I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED· NOTVVlTHSTANDING 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ~,DD'L POUCY EFFECTIVE POUCY EXPIRATION GENERAL LIABILITY NGL1000581 05/04/2010 05/04/2011 E~CH OCCURRENCE $ 1,000,000 A -- DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES lEa occun~,flce) $ 50,000 I C~MSMADE [] OCCUR MEDEXPq~yo~e~,~o.) PERSONAL & ADV INJURY $ 1 ~000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS* COMP/DP AOG $ 2,000,000 PRO- · POLICY ~ ,J~T ~ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident} ALL OWNED AUTOS BODILY INJURY I SCHEDULED AUTOS (Per person ) $ HIRED AUTOS BODILY INJURY · NON_OWNED AUTOS (Per accident) $ (Per accident) $ GARAGE LIAalLITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY XLS0066841 05/04/2010 05/04/2011 EACH OCCURRENCE $ 3,000,000 B X~ OCCUR L~ CLAIMS MADE AGGREGATE $ 3,000,000 $ DEDUCTIBLE $ RETENTION $ $ AND EMPLOYERS' LIABILITY YiN ANY PROPRIETOR/PARTNER/EXECUTIVE CERTIFICATE HOLDER CANCELLATION TOWN OFSOUTHOLD 54375 ROUTE 25 PO BOX 1179 SOUTHOLD, NY 11971 SHOULD ANy OF THE ABOVE DESCRIBED POLICIES DE CANCELLED DEPORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL t 5 DAYS WRITTEN NOTICE TO TEE CERTIFICATE HOLDER NAMED TO THE LEFT, RUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR UABIUTY OF ANY KINO UPON THE iNSURER, iTS AGENTS OR REPRESENTAtiVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009101) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer dghts to the certificate holder in lieu of such endorsement(s). 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 dghts to the certificate holder in lieu of such endorsement(s). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009101) STATE OF NEW YOR. K WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name and address of lasured (Use street address only) Empowers CES LLC 221 Long Beach Road Island Park, NY 11558 Work Location of Insured (Only required if coverage is 679ecifically limited to certain locations in New York State, i e a Wrap- Up Po/icy) I b. Business Telephone Number of Insured 516 83%3459 lc. NYS Unemployment Insurance Employer Registration Number of Insured 47-472713 Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Town of Southold 54375 Route 25 PO Box 1179 Southold, NY 11971 I d. Federal Employer Ideutification Number of Insured 522407627 3a. Name of Insurance Carrier AIG Insurance Co. 3b. Policy Number of entity listed io box "ia": 007108313 3c. Policy effective period: 01/I 1/2010 to 01/I 1/2011 3d. The Proprietor, Partners or Executive Officers are: [] all excluded or certain partners/officers excluded. 3e. Demolition is: [--]included. [] excloded. (De. finition of Demolition o. Rever. s'e) This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" lbr workers' compensation under the New Ym'k Stale Workers' Compensation Law. The Insurance Carrier or its licensed agent will send this Ce~rificate of Insurance to the entity listed above as the certificate holder in box "2". The Imnrance Carrier will also nol(l~, the above cert(ficate holder withh? I 0 &O's IF a polio; iv canceled dz:e to nonpayment oJ¢Jremi#ms or within 30 days IF tho'e are reasons other than nonpayment ~f prenliunl,s that cancel the policy or eliminate the inst.'ed ft'om the cx)verage indicated on this Cert~ficate, (Tbese notices may be sent by regutar mail.) Otherwise, tht~ Certificate is vaIM for a moximum of one year after this form is approved by the insura, ce carrier or Its licensed age. t. Please Note: Upon the 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 Stale 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 insored has the coverage as depicted on this form. Approved by: /~(Prin~[ name of a~s~e or licensed agent of insura:lc~ carrier) Title: _ Telephone Number of authorized representative or licensed agent of insurance can'ier: Please Note: Only insurance cm'riers and Iheir lico~sed agents are aulhorized Ia ixs*~e the C- 105.2.form. Insurance brolo's are NOT C-105.2 (9-01) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. I. The head ora 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 a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue oFsuch permits, shall not issue such permit unless prooedtdy subscribed by an insurance carrier is produced in a Form satisfactory, lo the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the paK~ of such state or municipal department, board, commission or office to pay any compensation to a~y such employee irso employed. 2. The head ora state or iY~unicipal 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 o£emp)oyees in a hazardous employment dei'ined by this chapter, notwithstand any general or special statute requiring or authorizing ;any such contract, shall not enter into any such contract unless prooi"duly subscribed by an insm'ance carrier is produced in a form satisfacto~ to the chair, that compensation for all employees has been secured as provided by this chapter. Definition of Demolition (Box "3e." on the reverse side oftbis Form) A building wrecking or demolition is one where a building, chimney or steeple is razed, or where a floor, exterior wall or roof is removed. If the contract involves on my the removal of interior walls, partitions or the facing on ly of any exterior ,,,.,all, it is not considered demolition. C- 105.2 (9-0 I) Reverse STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier la. Legal Name and Address of Insured (Use street address only) EMPOWER CES LLC EBA EMPOWER SOLAR 221 LONG BEACH ROAD ISLAND PARK, NY 11558 lb. Business Telephone Number of Insured 917-620-9333 lc. NYS Unemployment Insurance Employer Registration Number of Insured 4747271 ld. Federal Employer Identification Number of Insured or Social Security Number 522407627 2. Name and Address of the Entity requesting Proof of Coverage (Entity being listed as the Certificate Holder) Town of Southold 3a. Name of Insurance Carrier The First Rehabilitation Life Insurance Company of America 54375 Route 25 PO Box 1179 Southold, NY 11971 3b. Policy Number of Enti~ listed in box "la": DBL252634 Policy effective period: 05/10/2010 to 05/09/2011 4. Policy covers: a. [] All of the employer's employees eligible under the New York Disability Benefits Law b.~] Only the followingclassorclassesoftheemployer'semployees: 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 Benefits insurance coverage as described above. (Signature of insurance CarTier's authorized representative or NYS Licensed Insurarw, e Agent of that insurance carrier) Telephone Number 516-829-8100 Title Chief Executive Officer IMPORTANT: If box "4a" is checked, and this fm'm is sigfled by the insurance ¢alTier's authorized representative or NY$ Licensed Insurance Agent PART 2. To be completed by NYS Worker"s Compensation Board (Only if box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board Date Signed By Telephone Number Title (Signature of NYS Workers Compensation Board Employee) Please Note: Only insurance carriers licensed to write NYS Disability 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 (5-06) Additional Instructions for Form DB-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 "la" for disability benefits under the New York State Disability Benefits Law. The insurance carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box "2". This cerUficate is valid for the earlier of one year after this form is approved by the insurance carrier or its licensed agent, or the policy expiration date listed in Box "3c". Please Note: Upon the cancellation of the disability 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 NYS Disability Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability Benefits Law. DISABILITY BENEFITS LAW Section 220. Subd. 8 (a) The head of state or municipal department, board, commission or office authorized or required by law to issue any perm it 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 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 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 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 for all employees has been secured as provided by this article. DB-120.1 (5-06) Reverse SPR3COOm INVERTER: 1 STRING OF 10 DWG 1 3000m & 4000m INVERTERS EXCEPTIONAL RELIABILITY AND PERFORMANCE The SunPower inverters 3000m and 4000m provide exceptional reliability combined with superior performance. Innovative design and advanced testing have been brought together to create a durable inverter that enables optimal system performance over the long term. Both models come with a standard 1 O-year warranty. www. sunpowercorp.com 3000m & 4000m INVERTERS EXCEPTIONAL RELIABILITY AND PERFORMANCE SPR-3OOOm SPR-4OOOm I00 95 75 SPRm Efficiency Curves 20% 30% 40% 50% ~0% 70% % of Rated Output Power www.sunpowercorp.com 3000m & 4000m INVERTERS EXCEPTIONAL RELIABILITY AND PERFOR/v~ANCE SPR-3OOOm SPR-4OOOm SPRm Efficiency Curves 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % Of Raled Output Power www,sunpowercorp,com 3000m & 4000m INVERTERS EXCEPTIONAL RELIABILITY AND PERFORMANCE The SunPower inverters 3000m and 4000m provide exceptional reliabilily combined wilh superior performance. Innovative design and advanced testing have been brought together to create a durable inverter that enables optimal system performance over the Long term. Both models come with a standard 1 O-year warranty. www.sunpowercorp.com E13 / 228 SOLAR PANEL SERIES Serengeti' Solar Panels deliver consistent Iong~ term performance. Rigorous quality assurance from SunPower Corporation ensures predictable output and proven reliability. C~lj s E13 / 228 SOLAR PANEL SER~228P Peak Power (+5~-3%) P.o.~ 228 W , , Rated Current i ImPP 770 A Power j P -045%/K Temperature ~ NOCT (+/-2° C j 45° C r~x 164W Rated Voltage Vmpp 266 V Rated Current i 6.15 A Temperature ] -40DF to +194°F (-40~C to +90~C) I 25 year limited power warranty Warranty 10 year limited product warranty Certificatlons UL1703, IEC 61215 Ed, 2, IEC 61730 (SCII) CAUT ON: REAl) SAFETY AND INSTALlaTION INS~RUCFIOP, i$ gEt:ORE USING THE PRODUCT 25" SUNPOWEH BER-228P P.V, PANELS ON UNTRAC SOLARMOUNT RAIL SYSTEM ALUMINUM SQUARE TUBE BRACING ANSI SCHEDULE 40 OD wi ~CAPSULEADHESIVE ANCHORAGE SYSTEM CONCRETE FOOllNG ~ ~ (300D PSI) . -- 3" CRUSHED 8TONE (or R.C.P.) aII SECTION 1 Scale: ~"= 1'-0" '- SOlAR.MOUNT HD RAIL -- 2"0 STEEL P PE ANSI SCHEDULE 40 {4) ~"~ SALVANIZED ROD w/ HILTI HVA CAPSULE ADHESIVE ,~ ANCHORAGE SYSTEM PENETRATION 75'.11'r 8UNPOWER s,r:R-228P P.V, PANELS ~ON UNIRAC SOLARMOUNT RAIL SYSTEM 6~4)'' 6'4)" 6'4)" 6'-0 6'-0" 6'4)" 6'~)" 6'-0" 6'-0" 6LO" 6'-0" 1'-11" LAYOUT PLAN Scale: ~" = 1'-0" ILO' DETAIL2 Scale: 1Y22" = 1'-0" 2r_10" / UNIRAC STEEL FLANGE (PART# 330004) THIS IS TO CERTIFY THAT WE HAVE CHECKED T'IE MOUNTING STRUCTURE FOR 125 MPH WIND, SNOW, UNBAU~NCED SNOW, LIVE AND DEADI LOADS BASED ON ASCE 7 AND FOR CONFORMANCE WITH THE 2007 NYS RESIDENTIAL CODE. THE MOUNTING BRACKETS & HARDWARE MEET OR EXCEED NYS CODE REQUIREMENTS. THE SYSTEM'S ATE\CHMENT TO THE RAILS TO IMEET OR EXCEED NYS CODE REQUIREMENTS. THIS MOUNTING STRUCTURE IS ADEQUATE TO SUPPORT THE PROPOSED LOADS. ' 'hlf_AWFUL CERTIFICATE APPROVED AS NOTED NOTIFY BUILDING DEPARTMENT AT 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS' FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2 ROUGH-FRAMING, PLUMBING, STRAPPING, ELECTRICAL & CAULKING 3 INSULATION 4~ FINAL-CONSTRUCTION&ELECTRICAL MUST SE COMPLETE FOR C,O. ALL CONSTRUCTION SHALL MEET THE REQUIREMFNTS OF THE CODES OF NEW YORK STATE NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION :R~oRS RETAIN STORM WATER RUiIOFF 1. PANELS SPACED 1" AFfA~SUANT TO OF THE TOWN 2, UNI-~C SOLAR-MOUNT RAILS 3. 3000 PSI CONCRETE 4. SYSTEM'S TOTAL POWER: 12.768kW F r C .RTIFICAT, SUNPBWER SERENGETI PHBTBVBLTAIC PANEL SPECS MUDEL # 56 65,35~ 38,98' 1,65" 4~,1~ Revisions: Prolect NO. 10174 ;t S-1