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HomeMy WebLinkAbout37258-ZTown of Southold Annex P.O. Box 1179 54375 Main Road Southold, New York 11971 CERTIFICATE OF OCCUPANCY 7/9/2012 No: 35806 Date: 7/9/2012 THIS CERTIFIES that the building Location of Property: SCTM #: 473889 Subdivision: SOLAR PANEL 680 HALLS CREEK DR MATTITUCK, Sec/Block/Lot: 115.-17-17.22 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 3/3/2010 pursuant to which Building Permit No. 37258 dated 5/30/2012 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: solar panel system on an existing one family dwelling as applied for. The certificate is issued to JOHN& ALICE KELLY (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 12720 4/9/10 Authorized Signature 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 #: 37258 Date: 5/30/2012 Permission is hereby granted to: JOHN & ALICE KELLY 680 HALLS CREEK DRIVE MATTITUCK, NY 11952-2646 To: INSTALLATION OF AN ELECTRIC SOLAR PANEL SYSTEM TO A DWELLING AS APPLIED FOR. REPLACES EXPIRED B.P. 35408 At premises located at: 680 HALLS CREEK DR MATTITUCK SCTM # 473889 Sec/Block/Lot # 115.-17-17.22 Pursuant to application dated 3/3/2010 To expire on 11/3012013. Fees: and approved by the Building Inspector. PERMIT RENEWAL Total: $100.00 $I00.00 Building Inspector FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUII/)ING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 35408 Z Date MARCH 23, 2010 Permission is hereby granted to: JOHN & ALICE KELLY 680 HALLS CREEK DR MATTITUCK,NY 11952 for : INSTALLATION OF AN ELECTRIC SOLAR PANEL SYSTEM TO A DWELLING AS APPLIED FOR at premises located at 680 HALLS CREEK DR MATTITUCK County Tax Map No. 473889 Section 115 Block 0017 Lot No. 017.022 pursuant to application dated MARCH 3, 2010-and approved by the Building Inspector to expire on SEPTEMBER 23, 2011. ,~ Fee $ .200.00 Authorized Signature COPY Rev. 5/8/02 Form No. 6 TOWN Ob' $OUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OccUPANcy This application must be filled in by typewriter or ink and submitted to the Building Depaganent with the follq3ving: A. For new building or uew use: I. Final survey ofproporty with aceurateiocation of all buildings, property lines; streets, and unusual natural or topographic featur6s. 2. Final Approval from Health Dept- of water supply and seweroge, disposal (S_9 form). 3, Approval ' ' - of electrical tnstallatton from Board 6fFire Underwriters. 4. '.g~om statement from plumier certifying that the ~Ider used in system contains less than 2/I0 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code ComPliance-from architect or engineer reapon,sible for the building: 6. Subroit Planning Board Approval of coropleted site plan requirements. B, For existing buildings (prior to April 9, 1957) ~ion~conforming us~s, or buildings and "pre-existing- land uses: I. Accurate survey of property showing all property lines,'streets, building and unusuM natural or topographic features. 2. A properly q~mpleted application and Consent to inspect signed by the ppbcant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. (2. Fees 1. Certifieaie of Occupancy - New dwelling $50.00, Additions to dwelling $50.00, Alterations to dwelling 550.00; Swiromi~g PO01 $50.00, AdceSsory building $50.00, Additions to accessory building $50.00, Businesses $50.00, ~. Certificate of Occupancy on Pre-existing ]Building - 5100.00 3. Copy &Certificate ofO~copancy ~ 5_25 · 4_ Updated CertificateofOCcupancy_ 550.00 ' 5. Tymporary Certificate 0fOccupancy _ Residential 515.00, Commercial 515.00 Date. New Construction: Old or Pre-existing Building: Location of Property: __ '~-' ~-~--~' House No. Street ~tmit No. ~Z,~ Imming Boant Approval: ~lUe~t for: Temporary Certificate (check one) Hamlet Juffoik .County Tar Map No 1000, SectiOn lubdivisibn Date of Permit. Block __ Filed Map. Applicaae Undetwri~ Approval:_.. Lot: ~eSubmi~ted:$ ~-~, ~~- _ Final· Certificate: (check one) 08/01/2012 10:26 FAX 18317793344 GO 30LAR INC 001/001 ,JUN - 1 2012 BLDG. O£PT, TOWN OF saUl'HOLD 40 Nottingham Drive, Mi~ldle lale~d, NY 11953 Telephone: 631 4958136 * Fax: 631 9806455 · E-Mail: SBEIG$~gmail.com CERTIFICATE OF ELECTRICAL COMPLIANCE Applicant: Rough In :~nspection Date: Application No,: L[PA Solar App No.: County Tax Hap No.: GO SOLAR Znc. Certificate No.: 12720 Final Inspection Date: Apr 09, 2010 12720 Building Permit No.: 35408 4831 This Certificate of Electrical Comp~i~lnce Is limited to the inspection and compliance of electrical equipment and/or work described below, installed by the applicant, named above, located at the premise of and not after the final inspection date above: Owner: John Kelly Site Location: Kelly, 680 Hills Creek Drive, Hattltuck, NY 11952 Owner's Address (if different): [~ Residential I: hndoo~ [::.}Basement ['::.1 Service [:':]Shed I.':] Commercial [:~:1 Outdoor ]'.'-] First Floor [:~ Pool ~'~ Hottub LJ New ~J Renovation [..~r Second Floor [_'.'] Attic ['~J Garage L .J Addition LJ Survey Other: photovoltaic system INVENTORY Othm Equipment; B,820 wpt~ ~lar electnc system wKh 42 KyoCe~ 210 wa[~ module8 and I Fronlus IGc 7.~ Inve~ar The electrical work and/or equipment described above were inspected and appear to be in compliance with local, state and national electrical code requirements and this office. Applicant: GO SOLAR Inc. Inspected By: Roger Rlchert License NO,; Date Of Certificate: Apr 23,2010 Signature: -, TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSULATION ~FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE ~--- ~ ~- / ~ INSPECTOR Pacifico Engineering PC PO Box 1448 Sayville, NY 11782 www.pacificoengineering.com Engineering Consulting Ph: 631-988-0000 Fax: 631-382-8236 engineer@pacificoengineering.com 6/4/1012 Town of Southold Building Department 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Subject: Solar Energy Installation for John Kelly 680 Halls Creek Drive Mattituck, NY 11952 I have reviewed the solar energy system installation at the subject address. The units have been installed in accordance with the manufacturer's installation instructions and the approved construction drawing. I have determined that the installation meets the requirements of the 2007 NYS Building Code, and ASCE7-05. To my best belief and knowledge, the work in this document is accurate, conforms with the governing codes applicable at the time of submission, conforms with reasonable standards of practice, with the view to the safeguarding of life, health, property and public welfare Regards, Ralph Pacifico, PE Professional Engineer ,.~;r,~ INSPECTION REPORT DATE COM[lVIENTS ~o~r~ATIO~ (~s~ ~,~' FOUNDATION (2~) , RO~ ~G & PL~G ~A~ON PER N. Y. STATE E~R~ CODE , ~ON~ CO~TS TOWN OF SOUTHOLD BUILDING ,DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Exmnined 3//,7 .~ , 2(~0 Approved 3/2 3 ,20 /O Disapproved a/c Expiration 9/~-~> , 20 I/ PERMIT NO. ~SZ/'~gg'' BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survez Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Stom~-Water Assessment Form Contact: Buildi~or APPLICATION FOR BUILDING PERMIT :ompletely filled in by typewriter in ink and submitted the or to Building Inspector with 4 s ale. 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 waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a pen]nit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pan for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Depart~nent 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, 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 lbr necessary inspections. \ _ ~ (~ignature ofapplicant or name, ifa corporation) ' (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name ofowner ofpremises hn /< ~. / (As on the tax roll est deed) If applic~ co¢oration, si~ature o~duly au~0zed Officer ;r co.orat o cer) '- " Build~rs License No. m mber Ucen e No. 3q qq - m p Electricians License No. ~q q ~ - ~ Other Trade's License No. Location of land on whiCh prQpose4 work will be done: County Tax Map No. 1000 Section //~ ~ oo~oqauz '~ : -Lot Subdivision Ftl'ed'Map N~5 ~e ~ Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction': a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work (check which applicable): New Building_ Repair Removal Demolition EstimatedCost~?hq! 0~/. OO If dwelling, number of dwelling units If garage, number of cars Fee Addition Alteration Other Work,q0'/a :r-~c-hax_/x'm.¢-~,~3 (Description) (To be paid on filing this application) 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 Depth ' Rear' 8. Dimensions of entire new construction: Front Rear ;. Depth Height Number of Stories :," 9. Size of lot: Front Rear Depth I 10. Date of Purchase Name of Former Owner 1 I. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO J 13. Will lot be re-graded? YES NO ~Will excess fill be removed from premises? YES NO 14. Names of Owner of premises.~ N ~llq Name of Architect Name of Contractor 90 .~O[Ct_a :~"r~£ 15 a. ls this property within 100 feet of a tidal wetland or a freshwater wetland? *YES__ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO 1,//'- * 1F YES, D.E.C. PERMITS MAY BE REQUIRED. Address(.oSO~czlls ff/~L Ir-Phone No. (oht-Zq~' Address Phone No Address o3"/o~ /'hot t~ ,~3~19 Phone No. (.0-~ '- 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: -. COt~qTY 6~F ) ,._~ t ~ ~ ~9~N~~ ~ being duly sworn, deposes and says that (s)he is the applicant (.N~,r~ o"-f i~ndividual signing~ntract) ab- ove named, (Cl~r~ctor, 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 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 /' I · ,,~ dayof ~]'~A,/'ffC/ 20//~ { ] '---. C' II Ntotary PuC[/ NO. 01VE6190831 · / Signature of Apphca Comrni~tofl ~pims 01/20/2013 ~ I [ ['~ - I.'-'[ -- !,9, '~.-Z~... TOWN OF $OUTHOLD PROPERTY RECORD CARD S'mE,'r ~ ~(~ WU. AGE D,S'r. SUB. ~_O'r owNeR " N E O,~AC., FORMER re~' ~I 0 ~. ~~-- earm . GOMM. ' / I I - , I . FRONTAGE ON WATER [ TI LLABLE FRONTAGE ON ROAD WOODLAND DEPTH MEADOWLAND BULKHEAD HOUSE/LOT TOTAL Exte~$tor~ Extension Patio Deck .~ Breezewa Garage Pool Foundation Basement Ext. Walls Fire Place Dormer Driveway COLOR TRIM Bath Ftoors Interior Finish Heat Wo~3dstove Attic Rooms 1st Floor qooms 2nd Floor Dinette Kit. L.R. D.R. BR. Fin. B. Southold Town Building Department P.O. Box 1179 54375 Main Road Southold, New York 11971 (631) 765-1802 Parcel ID: 115.-17-17.22 Permit #: 35408 Permit Date: 3/23/2010 Expiration Date: 9/23/2011 BUILDING PERMIT RENEWAL LETTER Dated: 5/24/2012 Applicant: Location: Work Description: JOHN & ALICE KELLY 680 HALLS CREEK DR MATTITUCK SOLAR PANEL INSTALLATION OF AN ELECTRIC SOLAR PANEL SYSTEM TO A DWELLING AS APPLIED FOR A FEE OF $100.00 IS REQUlRED TO RENEW THIS BUILDING PERMIT. Owner: Address: JOHN & ALICE KELLY 680 HALLS CREEK DRIVE MATTITUCK, NY 11952-2646 The permit listed above has expired. Please contact our office as soon as possible to begin the renewal process. All work on the project must stop on the expiration date. No work is permitted or authorized beyond the expiration date. THANK YOU, SOUTHOLD TOWN BUILDING DEPT. Town Hall Annex 54375 Main Road P.O. Box 1179 Southold. NY 11971-0959 Telephone (631 ) 765-1802 Fax (631) 765-9502 June 1, 2012 John Alice Kelly. 680 Halls Creek ¢~ ' Mattituck, NY 11952 BUILDING DEPARTMENT TOWN OF SOUTHOLD TO WHOM IT MAY CONCERN: The Following Items Are Needed To Complete Your Certificate of Occupancy: ~//Application for Certificate of Occupancy. (Enclosed) __ Electrical Underwriters Certificate. (contact your electrician) ~/ A fee of $50.00. __ Final Health Department Approval. Plumbers Solder Certificate. (All permits involving plumbing after 4/1/84) __ Trustees Certificate of Compliance. (Town Trustees # 765-1892) Final Planning Board Approval. (Planning # 765-1938) Final Fire Inspection from Fire Marshall. Final Landmark Preservation approval. BUILDING PERMIT: 37258 - Solar Panels New York State Insurance Fund Workers' Compensation & Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR, 3RD FLR, MELVILLE, NEW YORK 11747-3129 Phone: (631) 756~1300 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GO SOLARINC 272MAIN RD RIVERHEAD NY 11901 POLICYHOLDER CERTIFICATE HOLDER GO SOLAR INC TOWN OF SOUTHOLD 272 MAIN RD BUILDING DEPARMENT RIVERHEAD NY 11901 TOWN HALL SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER PERIOD COVERED BY THIS CERTIFICATE DATE I 1346 970-5 579480 02/09/2009 TO 02/09/2010 11/30/2009 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1346970-5 UNTIL 02/09/2010, 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 SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 02/09/2010 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. U-26.3 NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This cer[ificate can be validated on our web site at https://www.nysif.com/cerFcertval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 76580459 05/28/2009 11:57 FAX ~001/002 ACORD CERTIFICATE OF LIABILITY INSURANCEI 04,03=909 PRODUCER THIS CERTIFICATE IS ISSUED AB A MAI'rER 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 # INSURED GO Solar, Inc. INSURERA: SCOTTSDALE INSURANCE COMPANY 41297 cio Gary Minnick ~NSURER n: SCOTTSDALE IN SU RAN CE COMPANY 4~297 272 Main Road iNSURER C; Riverhead, NY 11901 iNSURER D; COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ~x~ss~uMsREL~ L~rrv EAC~ OCCUE~ENC~ OFFICE~BER ~CLUDED? CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 SH OU LD ANY OF THE ABOVE DESCRIBED POLICIES ~E CAN CELLED BEFORE TH E EXPIRATION IMPOSE NO O~LIGATION OR LIABILI~rY OF ANY KiND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD For more Information contact: Walter P Geoghan Agency Inc at 631-472-5000. IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A stalement on this certificate does not confer rights 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 rights 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 Ihe 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 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) GO SOLAR INC 272 MAIN ROAD RIVERHEAD, NY 11901 2. Name and Address of the Entity requesting Proof of Coverage (Entity being listed as the Certificate Holder) Town of Southold, Building Department Town Hall Southold, NY 11971 lb. Business Telephone Number of Insured 631-727-2224 lc. NYS Unemployment Insurance Employer Registration Number of Insured 4629719 ld. Federal Employer Identification Number of Insured or Social Security Number 300144659 3a. Name of Insurance Carrier The First Rehabilitation Life Insurance Company of America 3b. Policy Number of Entity listed in box "la": DBL176989 3c. Policy effective period: 02/05/2010 to 02/04/2011 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 per. jury, 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 carrier's authorized represe~ltedve or ~YS Lio~ Insurance Agent of that insurance carrier Telephone Number 516-829-8100 Title Sr. Vice President IU PORTANT:I f box "4a" is 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" is checked, this certificate is NOT COMPLETE for the purposes of Section 220, Subd. 8 of the Disability Benefits Law. It must be mailed for completion to the Worker's Compensation Board, DB Plans Acceptance Unit, 20 Park StreeL Albany, NY 12207. 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 According to information maintained by the NYS Worker's Conlpensation Board, the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By Telephone Number Title (Signature of NYS Worker's 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 certificate 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 NY$ Disability Benefits Coverage or other authorized proof that the business is complying with [he 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 permit 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 K IDr'ER;R 215 WATT HIGH EFFICIENCY MULTICRYSTAL PHOTOVOLTAIC MODULE KD215GX-LPU NEC 2008 Compliant UL1703, Class C IEC 61215 c(~us CUTrlNG EDGE TECHNOLOGY As a pioneer with 35 years in solar, Kyocera demonstrates leadership in the development of solar energy products, Kyocera's Kaizen Philosophy, commitment to continuous improvement, is shown by repeatedly achieving world record cell efficiencies. Kyocera Quality Built In: New frame technology allows for end mounting with 2400 Pa (50 psf) or wind speeds of 130 mph (ASTM E1830) and traditional mounting with 5400 Pa (113 psf) to support increased snow load UV stabilized, aesthetically pleasing black anodized frame Supported by major mounting structure manufacturers Easily accessible grounding points on all four corners for fast installation Proven junction box technology Quality locking plug-in connectors to provide safe & quick connections Kyocera manufactures and assembles solar cells and modules at its own worldwide production sites using a true vertical integration process. This superior approach gives Kyocera complete control over every step of the manufacturing process, producing modules with the industry's tightest power tolerance, promising high quality and efficiency. Superior Built-In Quality Proven Superior Field Performance Tight Power Tolerance 20 Year Warranty 5 Year Workmanship Warranty KD215GX-LPU ELECTRICAL CHARACTERISTICS Current-Voltage characteristics of Photovoltaic Module KD215GX-LPU at various cell temperatures Current-Voltage characteristics of Photovoltaic Module KD215GX-LPU at various irradiance levels SPECIFICATIONS · Physical Specifications Un,:mm(in.) 12.5 (0.Sin.) 965 (38.0in.) 12.5 (0.Sin.) 990 (39,0in.) 108 (4.25in.) 108 (4.25in.) · Specifications · Electrical performance under Standard Te~t Conditions (*STC) Maximum Power (Pmax) 215W (+sw/-ow) Maximum Power Voltage (Vmpp) 26.6V Maximum Power Current (Impp) 8.09A Open Circuit Voltage (voc) 33.2V Short Circuit Current (Isc) 8.78A Max System Voltage Temperature Coefficient of Voc Temperature Coefficient of Isc 600V -1,20x10-~ V/'C 5.27x10~ A/~ · Electrical Performance at 800Whn2, *NOCT. AMI .5 Maximum Power (Pmax) '~ 52W Maximum Power Voltage (Vmpp) 23.6V Maximum Power Current (Impp) 6.47A Open Cimuit Voltage (voc) 30.0V Short Cimuit Current (Isc) 7.12A ISO 9001and ISO 14001 Certified and Registered www. kyocerasolar, com 800-223-9580 toll free 800-523-2329 fax Number Per Module I 54 Length x Width x Depth 15~3T~5~lm)X99~T~39~}×48m~1~) Weight 18kg(39.71bs.) Cable (+)760mm{29.~n),(-}1840mm(72.4in) · Junction Box Charactetlaflc~ Length X Width X Depth IP Code I IP65 · Otha's *Operaltn~; Temperature I -40~C ~90'C Maximum Fuse I 15A K BEERa The Xantrex Grid Tie Solar Inverter (GT Series) is designed to convert photovoltaic (PV) electricity produced by solar modules into utility-grade power that can be used by the home or sold to the local electrical utility. Offering high efficiency (up to 96.0 %), clean aesthetics, high reliability, and a Iow installed cost, through ease of installation and integrated features, the GT Series is a proven, high-frequency design in a compact enclosure. The GT Series may be installed as a single inverter, for a single PV array, or in a multiple-inverter configuration for large PV arrays. Technology ~ An NEC compliant, integrated DC/AC disconnect, standard in the GT Series, eliminates the need for external DC (PV) disconnects, and in some jurisdictions, AC disconnects ~ Large heat-sink offers extraordinary heat dispersion without the need for a cooling fan · Liquid c~/stal display (LCD) provides instantaneous information - power level, daily and lifetime energy production, PV array voltage and current, utility voltage and frequency, time online "selling", fault messages, and installer-customized screens LCD vibration sensor allows the tap of a finger to turn backlight on and to cycle through display screens ~ Free PC software for remote monitoring and system troubleshooting available online Installation Flexible module selection and sizing due to wide PV input MPPT tracking voltage range Light,,veight and versatile mounting bracket Easy access DC (photovoltaic) and AC (utility) terminal block simplifies wiring Rugged NEMA 3R inverter enclosure allows reliable indoor and outdoor installations Performance ~ Best-in-class efficiency to maximize solar system return on investment ~ Accurate IvlPPT tracking ensures maximum energy harvest under any conditions , FCC Part B compliance provides less external electronic interference Serviceability ~ lO-year standard warranty ~ Sealed inverter enclosure can be quickly separated from the wiring box allowing DC/AC connections to remain intact in the unlikely event the inverter needs to be serviced Standard 10-year warranty Xantrex Technology Inc. Customer Service/Technical Support customerservice@xantrex.com Toll free: 1-800670-0707 www.xantrex,com Xantrex GT Series Grid Tie Solar Inverters Models GT5.0 GT4.0N GT3.3N GT2.8 Output 240V 208V 240V 208V 240v 208V 240V 208V Max. AC power output 5000 W 4500 W 4000 W 3800 W 3300 W 3100 W 2800 W 2700 W AC output voltage (nominal) 240 V 208 v 240 V 208 v 240 V 208 V 240 V 208 V AC output voltape range 211-264Vac 183-229 Vac 211-264Vac 183-229 Vac 211-264Vac 183-229Vac 211-264Vac 183-229 Vac AC frequency (nominal) 60 Hz AC frequency range 595 - 60.5 Hz Startup current 0 Aac Max. continuous output current 21 A 22 A 16.7 A 18.3 A 13.8 A 14.9 A 11.7 A 13.0 A Max. output over-current protec'don 30 A 25 A 20 A 15 A Max. output oveecurrent protection 30 Arms 25 Arms 20 Arms 20 Arms Max. utility bockfeed current 0 A Total harmonic distortion (THD) < 3 % < 5 % - Power factor > 0.99 % (at rated power), > 0.95 % (full power range) Utility monitoring, islanding protection UL1741-2005 ! IEEE 1547 Output characteristic~ Cu~ent Source Output current waveform True sine wave Max. array open-circuit voltage 60OVdc MPPT voltage range (CEC & CSA) 240 - 550 Vdc 240 - 480 Vdt 200 - 400 Vdt 195 - 550 Vdc MPPT operating range Low: 235 Vdt ! High: 550Vdc Low: 235 Vdt / High: 550 Vdc Low: 200 Vdc! High: 550 Vdt Vdc Low: lg3 Vdt / High: 550 Vdc Max. input current 22.0 Adc 20.0 Adc t 8.0 Adc 17.0 Adc 17.5 Adc t 6.5 Adc 15.4 Adc 14.9 Adc Max. array shart-circuit current 24.0 Adc Reverse-polarity protection Short<ticuit diode Ground-fault protection GF dete~ion, IDIF > 1 A Max. inverter efficiency 95.9% 95.5% 96.0% 95.7% 95.9% 95.6% 95.0% 94.6% CEC effidency 95,5% 95.0% 95.5% 95.0% 95.5% g5.0% 94.0% 93.5% Night-time power comumption 1 W Operating temperature range q 3°F to +149°F (-25°C to +65°C) Enclosure type NEMA 3 R (outdoor rated) Inverter weight 58.0 lb (25.8 kg) 58.0 lb (25.8 kg) 49.0 lb (22.2 kg) 49.0 lb (22.2 kg) Shipping weight 65.0 lb (272 kg) 65.0 lb (27.2 kg) 57.0 lb (25,9 kg) 57.0 lb (25.9 bg) Inverter dimensions (H x W x D) 28 1/2 x 16 x 5 3/4" (724 x 403 x 145 mm) Shipping dimensions (H x W x D) 34 x 20 1/2 x 10 5/16" (866 x 518 x 262 mm) Mounting Wall mount (mounting bracket included) Input and output terminal AC and DC terminals accept wires sizes of #14 to ~6 AWG PV ! UNIIty disconnect Eliminates need for external PV (DC) disconnect. Complies w~h NEC requirements Cooling Convection co~ed, fan not required Display 0acklit, twc-line, 16<haracter liquid c~stal display provides instantaneous power, dai)y and lifetime energy production, PV affay voltage and current, utilit~ voltage and frequency, Urae online "selling ', fault rr~ssages, and installer-oust omizable screens Communications Integrated R5232 and Xanbu$TM RJ4S communication ports Wiring box PV, utility, ground, and communications connections. Tr~ inve~er can be separated from the wiring box Warranty lO-year standard Model native (negative ground) GT5.0-NA-240/208 UL-05 GT4.0N-NA-240/208 Ub05 GT3.3N-NA-240/208 UL~)5 GT2.8-NA-240/208 UL~15 Part number (negative ground) 064-10C9 864-1 C08 864-1006 864-1001 Positive ground inverters are also available PV MODULE FRAMING AND MOUNTING SYSTEM FOR PITCHED ROOFS PV MODULE FRAMING AND MOUNTING SYSTEM FOR PITCHED ROOFS Module Compatibility Use SunFrame with PV modules from these major manufacturers: BP Solar, GE Ener~, Isofoton, Kyocera, Mitsubishi, Photowatt, RWE Schott, Sanyo, Sharp. Call UniRac or your PV dealer for manufacturers not listed. Code Compliance SunFrame is designed to comply with the Uniform and California building codes when installed according to SunFrame installation instructions. Call UniRac concerning status of International Building Code compliance. Components ' Inter-Module Rails support modules as little as 2.125 inches above the roof. Full Length Cap Strips secure modules and finish the array topside forming a gap-free frame. Serf- tapping screws at 16-inch intervals provide the holding power. Push-Fit End Caps neatly finish the rail ends. L-Feet attach directly to asphalt shingle roofs and support the rails one-haft to three-quarters of an inch above the roof snrface to provide convective ventilation. ~' Splices safely extend rails. ~,?~ Aluminum or Steel Standoffs (optional) in a range of heights sup- port L-feet above tile or shake roofs. UniRac offers appropriate flashings. Clear or dark finishes on all visible above-rouf components, from L-feet to screw heads, match the frames of your PV modules. Component Specifications Rails, cap strips, two-piece standoffs, splices, and L-feet: 6105-T5 aluminum extrusion. End caps: UV resistant plastic. One-piece standoffs: Service Condition 4 (very severe) zinc-plated welded steel. Fasteners: 304 stainless steel. See our Sun~ame page for complete information: pricing, installation instxuctons appropriate to your build- ing code, and minimum requirements for the number and type of modules you plan to mount. UniRae, Ine. 3201 University Boulevard SE, Suite 110 info@unirac.com Albuquerque NM 87106-5635 USA 505.242.6411 505.242.6412 Fax Pub 050206.1ds · February 2005 © 2005 UniRac, Inc. All rights reserved. GENERAL NOTES R~of Section A B mean roof height 14 ft 14 ft 1 CONTRACTOR SHALL CHE:CK AND V~=RIFY ALL CONDITIONS AT THE 11 THE OWNER SHALL SELECT ALL FINISH MATERIALS AND COLORS roof rafter 2x8 2x8 A'_L .. ~ , -. -" HIMSeLFW,TNTHEINIENTOFTHESEPLANSANOMAKEW~K REMAINTHEPROPER~OFTHEENO~EERWHETHERTHEPROJECT rafter spacing 16 in OC 16 in OC ME~T ~ AGREE WITH SAME FOR ~ICH THEY ~E UAOE I$ EXECUTEO OR NOT THEY ARE Reflected roof rafter span 13.5 ff 10.0 ff Ct:;:; c: .... PERMITS CERTIFICATESOF~CUPANCY. INSPECTI~ rills pROJECTEXCEPT~YAGREEMENT IN WRITING ANDWITH Table R802.5.1(1) max allowable 168 ff 16.8 ff 9. ANYOEVIATIONFROMTHESEP~SWITH~TTHEWRI~EN CON~C~S~KEEPS~F~E~STRUC~SRIS~DKE~PSI~F~L~ACCESS~LE ~~S~~~DET. 1 i TYPICAL RISER DIAGRAM REQUI~D,.~.~, . . - .~'.' : :F OF NEW. .. ,:,..~ ~PICAL CONNECTION To my best belief and information the work in this document is accurate, conforms with the ..~,.,on~ N.T.S. rRU~CT~.OR~X*CTSg~) governing codes appli~ble at the time of submission, conforms with reasonable standards Revis,on 3 ~PICAL CONNE~ION D~AIL ~ ALL ROOF PENE~ON5 ARE TO ~E SEALED of praxis, with the view to the saf~uarding of life, health, prope~ and public wel~re, R~,o. 2 ~ PANEL ~ 5i~FLEX 0~ EQUIVALENT 5EA~NT and is the responsibili~ of the license. ..~,.,on 1 as perASCE7, Method 1: X(f~2) 1.194 I (,able 6-1) 1 ~ PACtFICO EN INEERINO PC p.~ =AKztlpnet3o(eq6-2) K~(sec6.5.7) 1 Pn~30(fig ~3) ~7.9~~ ............. PO BOX ~4~g~ 5A~LLE~ NY ~7S~ CLIMACTIC AND Wind S~ed, Live load, ~ximim Tgi: ~35-q88-~ FAX: ~5~-~gA-gA3~ E~a[I: ¢~in¢¢r~aci~icogn~inecr[~.co~ GE~PHIC DESIGN Cat~o~ 3 ~c gust, pnet30 ~r load, lb spacing along JO~ ~ CRITERIA mph ASCE 7, psf mils, in ~ - Roof Section A C 120 58 572 5/16" die screw, 3-1/2" length 48 ~go Hall~ Creek Prlv¢, Ha~ituck, NY ,~e52 C ~ ~ B 31 306 5116" d iasc rew, 3-112" le ng th 48 ~~~ ~,.PRO ~.~POSED50 ~R EN ER~IN 5TA g~ ON ~ ~ENE~C NO~S, ~OF SE~ON, ~ATA, DETAILS AND SPECS /1/ PANEL: QTY: LENGTH: WIDTH: WATTS: PV Panel A Kyocera KD210 14 59.1 in 39 in 8820 ROOF LAYOUT B Kyocera KD210 28 59.1in 39in PO I~ox ::I.445, SAYV/LLE, NY ~-q~-o000 Fax: ~3~-3~2-~23~ John Kelly ~gO Halls ~r~ek Drive, Matt[tuck~ NY PROPOSED SOLAR ENEI~C4Y INSTALLATIOiq GENERAL NOTES, ROOF SECTION, DATA, DETAILS AND SPECS -2-.00 R~of Section A B GENERAL NOTES mean roof height 14 ft 14 ft ALL CONST pitch 4 1/2 in/12 7 1/4 in/12 .... - roof rafter 2x8 2x8 1. CONFRACrORSHALLCHECKANDVERIFyALLCONDIr~:)NSATTH~- 11 TNEOWNERSHALLSELECTALLFINISHMATERIALSANDCOLORS ,,, -r-~ SITE pRI~ TO STARTING TO WORK AND S~LL FAMII'~RiZ~ 12 THESE ~WINGS AS INSTRUMENTS OF SERVICE ARE A~ SHALL rafter spacing 16 in OC 16 in OC .... ~G.EE WITH SAME FO. ~IC. THEY ~E D~DE IS EXECUTED OR "eT ~'~W"E Reflected roof rafter span 13.5ff 10.0ff P~.MITS. CERTI~,CAT~S O~ OCCU"A.CY. INSP~OTI~ THIS P"O~CT EXCEPT "Y A~REEMENT ~ WRI11N~ ANO WITH Table R802.5.1(1 ) max allowable 16.8 ff 16.8 ff JURISDICTION T"ER~OF' JF REOUIRED' 13 C~ACT~ S~ ~OTEC' PATCH ~g REPAIR ALL EX~T~ WORK ~DJ~CENT TO H~S WOrK collar tie 2x4UNDERWR ~T: % CE ~IFICATE ALL RULES ~DREGU~TI~S OF THE RESP~SIBLE JURISTICTI~ 14 THESUBC~R~'~SSHALLmO~E~_EQ~PME~ T~S FENCES T~NS~RTATION~ collar tie spacing 48 in OC J' "* ' '" INVERTEF [NVERTE~ ' '¢ - TYPICAL RISER DIAG M ont< DETAIL [ ~ ~"~'A~J~ST~LE SU~ ~ R*VISI~ 5 ~PICAL CONNECTION To my ~st belief and information the work in this d~ument is accurate, conforms with the N.T,S. ,.u~ ~,~c,s~, governing codes appli~bie at the time of submission, conforms with reasonable s~ndards R..,~ 3 ~P/CAL CONNEXION D~AfL % A~ ROOF PENE~ONS ARE TO BE SEALED of practice, with the view to the safeguarding of life, health, pro~ and public welfare, R ..... 2 ~ PANEL wt~ ~I~FL~ OR E~UfVALENT ~EA~NT and is the res~nsibili~ of the minnie. as ~rASCE7, Method 1: i(fig6-2) 1.194 I (table 6-1) 1 'Fr*, PACIFICO ENGINEERINO PC P.et = A Kzt I p ~o (eq 6-2) K~ (sec 6.5.7) 1 Pna3O (fig ~3) ~7.9 ~"~ PO BOX %~ g. SA~ILLE. NY %% 7 S~ CLIMACTIC AND Wind Sp~d,: Live load, point pullout Fastener ty~ ~stener ;~.~,~ GEOG~PHIC DESIGN Catego~ 3 s~ gust, pnet30 per load, lb s~mng along JO~ CRITERIA mph ASCE 7, psf rails, in B 31 306 5/16" dia screw, 3-1/2" length 48 ~:72~ ,--,. P.OPOSEPSO..E.~.4YINSTAL..ON JO O~/~ A~ NOTE~ % OF 2 ROOF LAYOUT -~'~~ .... ~ Ij~C6E{~Z2_EN~/NEERI/q~ PC PV Panel //_~~.~\ PO ~ox ~8, SAWILLE, NY ~7B2 Kyocera Kyocera Jo~ Kell9 PANEL: KD210 KD210 LENGTH: 59.1 in 59.1 in PROPOSED SO~R ENERGY INSTAL~TION f~e ~fmount~ system The unimareto~ins~ll~ina~an~with the manufacturedsins~llation WIDTH: 39 in 39 JR ~ENE~L NOTES, ROOF SEXTON, PATA, ~ETAILS AND SPECS C~e, and ASCE7-05 ~en insal~ in a~r~n~ with the man~a~urer's ins~s. WA~S: 8820 o~/~oI AS NOTED HARBOR VIEW AT MATTITUCK FILE No. 8577 FILED AUGUST'21, 1987 SITUA TED A T MATTITUCK l.OWN OF- SOUI'HOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-115-17-17.22 SCALE 1"=50' SEPTEMBER 24, 1996 AREA = 40,906.52 sq. ff. 0.959 NOTES' 1, REFER TO FILED MAP FOR TEST HOLE DATA. 2. EXISTING ELEVATIONS SHOWN THUS: ~.0 ARE REFERENCED TO AN 5. MINIMUM SEPTIC TANK CAPACITIES FOR A 1 TO 4 BEDROOM HO 1 TANK; 8' LONG, 4'-5" WIDE, 6'-7" DEEP 4, MINIMUM LEACHING SYSTEM FOR A 1 TO 4 BEDROOM HOUSE IS 1 POOL; 12' DEEP, 8' die. TE,~ CERTIFIED TO: CHICAGO TITLE INSURANCE COMPANY TITLE No. 9708-00476 ALICE $. KELLY NYS. L[c No. 49668 Joseph Land PHONE (516)727-2090