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HomeMy WebLinkAbout37918-ZTown of Southold Annex 8/21/2013 P.O. Box 1179 54375 Main Road Southold, New York 11971 No: 36457 THIS CERTIFIES that the building SOLAR PANEL Location of Property: 71305 Route 25, Greenport, Date: 8/21 /2013 SCTM #: 473889 SecBlock/Lot: 45.-2-7.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 4/1/2013 pursuant to which Building Permit No. 37918 dated 4/8/2013 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: roof-mounted solar panels as anulied for. The certiScate is issued to CERTIFICATE OF OCCUPANCY St Peters Lutheran Church (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 37918 8/13/13 oriz Signa re 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 #: 37918 Permission is hereby granted to: St Peters Lutheran Church PO BOX 242 Greenaort. NY 11944 To: Installation of roof-mounted solar panels as applied for. At premises located at: 71305 Route 25, Greenport SCTM # 473889 Sec/Block/Lot # 45.-2-7.1 Pursuant to application dated To expire on 10/8/2014. Fees: 4/1/2013 and approved by the Building Inspector. SOLAR PANELS $50.00 CO-NEW CONSTRUCTION/ALTERATION/REPAIR $50.00 $100.00 t Date: 4/8/2013 Form No. 6 TOWN OF SOUTHOLD. BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFIC~ITE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new buBdipg 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 ©f Fire Underwriters. 4. Sworn statement from plumber certifying Utat the solder used in system contains less than 2110 of 1 % lead. . 5. Commercial building, industrial building, multiple residences and similaz buildings and installations, a certificate of Code Compliance'from architect or engineer responsible for the building. b. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings (prior to Apri19, 1957) non-conforming uses, or buildings and "pre-existing" land uses: I . Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly spmpleted 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 $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $SO.OQ, Businesses $50.00. 2. Certifteate of Occupancy on Pre-existing Building $100.00 3. Copy of Certificate of.Occupancy - $25 4. Updated Certificate of Occupancy - $50.00 S. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 New Construction: Location of Property: No. Street Hamlet Owner orOwnetsofProperty.~, /~oj.,~?S h,~~}~7/~,eAAs ~/7 'n~/~ Suffolk County Tax Map No 1000, Section L{5 Block a Lot Subdivision Filed Map. LoL• Permit No. ~ 7 ~~ / ~ Date of Permit. 1/ - fY -/ ~j Applicant: Health Dept. Approval: Planning Board Approval: Request for. Temporary Certificate Fee Submitted: $ jD` ~4,t~ Old or Pre-existing Building: Underwriters Approval: Final Certificate: V (check one) (check one) Applicant Signatwe Town Hall Annex 54375 Main Road P.O. Box I ] 79 Southold, NY 11971-0959 ,~;~Of SOUIyo~yy ~~ T ~ ~~~~ OI~CQU~,~~' Telephone (631)765-1802 Fax (631)765-9502 roger.richertCciltown.southold.ny.us BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: St Peters Lutheran Church Address: 71305 Route 25 City: Greenport St: NY Zip: 11944 Building Permit#: 37918 Section: 45 Block: 2 Lot: 7.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE contractor: osA: Sunation Solar Systems License No: 33412-me SITE DETAILS Office Use Only Residential Indoor X Basement Service Only Commerical X Outdoor X 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks Disconnect ~ Switches Twist Lock Exit Fixtures TVSS otner Eguipment: 26500W roof moun ted photovoltaic system to include, 100 Auo 260 watt pv pa nel; 2-Fronius IG 11.4 watt inverters Notes: Inspector Signature: ,rr-C ft Date: Aug 13 2013 81-Cert Electrical Compliance Form.xls o~,F,OF SOUTy~ #®~ ~~ ~ ~~~ ~~ TOWN OF SOUTNOLD BUILDING DEPT. ~' °N ~` 765.1802 B ~~ ~ 1 NSPECTION [ ]FOUNDATION 1ST [ [ ]FOUNDATION 2ND [ [ ]FRAMING /STRAPPING [ [ ]FIREPLACE & CHIMNEY [ [ ]FIRE RESISTANT CONSTRUCTION [ ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION ] FIRE RESISTANT PENETRATION [ ]ELECTRICAL (ROUGH) [ ]ELECTRICAL (FINAL) ,6 DATE o1 / 3 ~ ~ INSPECTOR Fisher Engineering Services, P.C. PO Box 30 • Oakdale • New York 11769 Phone: (631)563-9028 July 12, 2013 Building Department Subject: Engineer Statement for Solar Roof Installation St. Peter's Lutheran Church: 71305 Route 25 Greenport, New York 11944 Permit: 37918 I have verified the adequacy and structural integrity of the existing roof rafters for mounting the solar collector panels and their installation satisfies the structural roof framing design load requirements of the Residential Code of New York State. I have reviewed and certify that the manufacturer's guidelines and equipment for the photovoltaic equipment for the above residence meet the requirements for wind and snow load and that the roof structure is adequate to carry the new loads imposed by the System. For the installation of the solaz mounting, the rails aze securely anchored to the rafters utilizing lag screws that have been designed for wind speed criteria of 120 mph Exposure C and snow ground criteria of 20 psf. Wind loads will exceed seismic loads. Other climate and geo design criteria aze not applicable to this solaz installation. The solar collector system and the mounting assemblies comply with the applicable sections of the Residential Code of New York State- "Solar Systems" and loading requirements ofroof-mounted collectors. This system has been installed properly at the above referenced residence. The installation is in accordance with the minimum requirements certified by this letter. I hope that this letter serves and meets with the approval of the Building Department. ~~pF NEt4'r .~Q, ~\,~PM G. pis G~ Sincerely, 1t s'~ ~~p W William G. Fisher, P.E. iN b=,' Licensed Professional Engineer i9~ 074659 c`' ''' _ ~ -- - ~ ~r- -- li i ~~ ~. AOG ~t •. I~ ~, 92013 i,J ~itectural Design • Residential • Light Commercial Additions • Extensions • Conversions Cons[mction Estimates /Oversight • Expediting • Inspections f 1 - ~~I_C ~~ypATi014 (~T~ ,~~AS`YOPY (2NDl ~& RO ~~.~~ m~s~TrO~ r~ op~, ~A~ $N~gG'Y P2NA~ G ~ro4 II_~ ae 1~ d 2 O 1 ~ ~I fi ~~ ~ a ~~ .. d is r TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST ' ~ ~`~ $UILDING DEPARTMENT Do you have or need the following, before applying? TOWN HALL Board of Health SOUTHOLD, NY 11971 4 sets of Building Plare Yes TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey SoatholdTowo.NorthForknet PERMIT NO. Check Yes Septic Fortn N.Y.S.D.EC. Trustees Flood Perini[ Examined , 20 Storm-Water Assessment Fortn Contact: Approved , 20 Mail to: SUNation Solar Systems, Inc. Disapproved ak 121] ManWek Hwy., Oekeab, NV 11789 Phone~631-750-9454 Expiration 20 __.-__ _ Building Inspector ~~l I "'~ ~~ I,~ \I Iii APPLICATION FORBUILD[NGPERMIT ~ 1 ~ t3 I Date March 28 , 2013 2~ - ~ IN ~I R STRUCTIONS 'uI "F a. This applicazi S be completely filled m by typewriter or in ink and submitted to the Building Inspector with 4 L--setsefp~fi~ aq~urate plot plan to tale. Fee according to schedule. '~ „ . 'ti.,PI@hp~ ~rowin to n of lot and of buildings on premises, relationship to adjoining premises or public streets or c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, [he Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on [he premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part far 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 I S months from such daze. If no caning 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 [he Building Department for the issuance of a Building Permii pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the constmction 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 vt building for necessary inspections. r~CoSj})nepy2;~fgpp4c ro[me, ifa coryoretioLn) / ` /$/7f/~i~e7r J/~cu ,E_ /Tlr/y. ~6/F-C~rL4 (Mailing address of pl ant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Contractor Name of owner of premises Garret Johnson,_Pastor - St. Peters Lutheran Church (As on [he tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer Scott Maskin, President SUNation Solar Systems (Name and title of corporate officer) Builders License No. 44104-H Plumbers License No. N/A Electricians License No. 33412-ME Other Trade's License No. N/A 1. Location of land on which proposed work will be done: 71305 Rte. 25 Greenport House Number Street Hamlet Ny //969 County Tax Map No. 1000 Section 45 Block 2 Lo[ 7.1 Subdivision Filed Map No. Lot . n ~.. 2. S[a[e existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Church b. ln[ended use and occupancy Church 3. Nature of work (check which applicable): New Building Addition Alteration ~/ Repair Removal Demolition Other Work Solar Panels flat on roof (Description) 4. Es[imatedCost$80,500 Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, wmmercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or add'Rions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth I0. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any caning law, ordinance or regulation? YES_ NO~/ 13. Will lot be re-graded? YES_ NO~WiII excess fill be removed from premises? YES_ NO^/ 14. Names of Owner of premises~^""~°°^~"°v°~~^"a^w'Addresszt3o5Rte.25.creenpon phone No.~t~r/~s62 Name of Architect winiam G. Fisher Address ~ eo.3o, Oakdale mstphone No s3taae~tta Name of Contractor SUNation Solar systems, Inc Address i217 Montauk Hwy, OakdphOne No. 831-7509454 15 a. Is this property within 100 fee[ of a tidal wetland or a freshwater wetland? *YES NO IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY~REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. I6. Provide survey, to scale, with accurate foundation plan and distances [o property lines. 17. ]f elevation a[ any point on properly is at 10 feet or below, must provide topographical data on survey. l8. Are there any covenants and restrictions with respect to this property? *YES NO~ • IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Scott Meskin, SUNation Solar being duly sworn, deposes and says that (s)he is [he 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 [his application; that all statements contained in this application are tme to the best of his knowledge and belief, and that the work will be performed in the manner se[ forth in the application filed therewith. Sworn to before me this day of ~~'.-l~ a~ ..t NOFMYPUB ~A TO~NEW YORK Notary Public Si~ Applicant pFOLKGOYNTY ' L~C~e OtCR8TWp9 Town Hall Annex saws llaain Rozd P.O. Box 1179 Southold, NY 11971-0959 ~o~y~Of Sty~l;;~, ~ ~o#~ ~r' BUILDING DEPARTMENT TOWN OF SOUTIiOLD Telephone (63l) 765-1802 roaer.richert~'"o (6au 7u~io9d wn.so .nv.us APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: ~j <~~ Date: £S ~3 Company Name: J U A Y v IJ So bi~vYi Name: Lok1- 19SI(,~(V license No.: 33 12 - tYtF Address: i21-r ()1oN-rAu1F l~l(~~a„. Phone No.: 31- 750- R~5 JOBSITE INFORMATION: (*Indicates required information) 'Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: ~~! - 447 o~~a Lot: *BRIEF DESCRIPTION OF WORK (Please Print Clealiy) Sa~i~ r ~.Vte:Q- ~/ ) StQLlof~o/I X170- ~Q 2-(oD wabf P~neQ.t~ 2-f`f'JN~US 1Gf ~l.~f'f~td~Ef iNt~f[rS (Please Circle Ali Tfiat Apply) *Is job ready for inspection: YE / NO Rough In Final *Do you need a Temp Certificate: ES / NO Temp Ir~fonmation ( ,needed) ' *Service Sim: 1 Pha 3Phase 100 150 200 300 350 ,400 Other *New Service: Re-connect Underground Number of Meters Change of Service rhead Additional Information: PAYMENT DUE WITH APPLICATION }~c~ ~ loo. ~l~-1 82-Request for Inspection Form `~ C~ ~ }J New__York_State Insurance Fund Workers' Compensation & Disabilil0~ Benefits Specialists Since 1914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: lefis)ss7-38fi3 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE """""" 753118816 SUNATION ROOFING SERVICES INC 1217 MONTAUK HIGHWAY OAKDALE NY 11769 POLICYHOLDER SUNATION SOLAR SYSTEMS INC 1217 MONTAUK HIGHWAY ~, OAKDALE NY 11769 '. CERTIFICATE HOLDER '' TOWN OF SOUTHOLD 54375 ROUTE 25 ' SOUTHOLD NY 11971 POLICYNUMBER I. CERTIFICATE NUMBER Z 2160 670-2 775751 ', PERIOD COVERED BY THIS CERTIFICATE ~ DATE I 09/06/2011 TO01/Ot/2015 ~ 11/28/2012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2160670-2 UNTIL 01 /0 112 01 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, WfTH 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 01/01/2015 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 10 DAYS WRITTEN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BV 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 AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BV THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/ceNcertval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 587614295 u-26.3 484/CD45944-20/1198 STATE OF NEW YORK WORKER'S COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFffS LAW PART 1.To be completed by Disability Bene£tts Carrier or Licensed Insurance Agent of that Carrier ta. Legal Name and Address of Inwrad (Use street adflress only) tb. Business Telephone Ntartber of Insured SUNATION SOLAR SYSTEMS INC 631-737-sao4 le. NYS Unemploymerd Irwranee Employer Registration 1217 MONTAUK HIGHWAY Nutnbar of lrtwrad OAKDALE, NY 11769 td. Federal Employer Idemiflttation Number of Insured ar Social Security Number 753118816 2. Name and Addras of the Entity requesting Proof of Coverage 3a. Name of Insurance Carrie (EMity being listed a the CartiTca[e Holder) The First Rehabilitatbn Life Insltrartce Town of Southold Company ofAmenca 3b. Polity Number of Entity listed in boa "ta°: 54375 Route 25 DBL243442 Southold, NY 11971 3e. Polity enecliw period: 11/28/2012 ~ 1 1 /2712 01 3 4. Polity covers: a. ~ All of the employer's employees eligible under the Naw York Disability Bene£ds Law b. ~ Only the following class or classes of the employer's employees Under penalty of perjury, 1 certiry that 1 am an authorized represerartiva or lirorssev agent of the imwanra urriar refarertold above and that the ruined irtwred has NYS Disability Benefits irtwrance coverage as dasQihed above. 2/24!2013 __ By Date Signori (Sigrroae of irrstaance tamals sahorind reprmeNativs ar NYS Lkanted Irarartce Agora of tlut Irewaa:a orris) releprrone Number 516-829-8100 T;t,e Chief Executive Officer _ IMPORTANT: If lase •4' n e}asked, asst tlds farm is sigtrd try the imwaue terriers autlwdzM representa[IVe ar NYS Lkeraed Imsvase Agora d tlrY racier, this a"iFlYte is COMPLETE Mail k difeetty tO lrw Mrtifirab holdr. If twa'Po' h gwcWd, tlrbaxtifkata b NOT COIrWLETE far dp purpwes of Saedon t2Q Sulsd a ar Vra Disability Retrofire Law. It must be mallal for smtpkMOn totlre Wank/s Conpansnion Bovd, DB Plm Aueptxra Unl1, al Prk Sbaat, Aldany, NY 172W. 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 Aamrdirg ro information rroirealred by the NYS WarkeYS Coeputsatian 9oa4 the abwearsretl enploya has torrQlietl wkh drs NYS Disability Bamfits Law with napect to all of Nsaw empbyens Dale Signed By (Sigrwhre of NYS Worker's CanpwtsNian Boartl Enpkryae) Telephone Number Title Please Note: Only irtstrrtee carriers IiprtsW to write NYS Disability BertNlls irtstranca pollNas and NYS Licartsed Imurana Agxds of those imunnca carriers are atrdtorized b issue Form DB-120.1. Ireurance brokers are NOT autltwized m issue this form. DB-120.1 (5-06) RP-420-a/b-Rnw-II (9/08) NYS BOARD OF REAL PROPERTY SERVICES RENEWAL APPLICATION FOR REAL PROPERTY TAX EXEMPTION FOR NONPROFIT ORGANIZATIONS _ II -PROPERTY USE (See general information and instructions on back form) I a. I~~te ol:grgginiaation i ~y~~ r i_ C( d. I Jame o~ contact person 5( 1'Y-tPx S l ~,A lJ !JI Y1 j'~(. (~(l~rte h- YYl ~ ~~Y~~" b. M n add _`, U e. Telep one n . co tact person f~lJ7~ ~ 1~t-~-~7~ ~- Day 1 ening ( ) -~T(~.QJtI~CC~.~ ~ 151-T'1 41 ~ ^ ~ f S~ 1 ad~,ctr~ess (opn ~~ c. EmpioyerlDno. ` a ~19-4~~1. g. Property identification (see tax bill or assessment roll) Tax map nttmber or sec[ion/block/lot i~nG ~ Y_5-- a - ~ .~ 2. Have any of the following changes occurred since application for this property tax exemption was last filed? If any of the listed changes have occured, please give a detailed explanation of each change on the back of this form, check the appropriate line below, and'complete and sign the statement If none of the changes has occurred, please check the appropriate line below and complete and sign the statement. ^ a. A change has occurred in the ownership of all or part of the property. ^ b. A change has occurted in the use or uses of the property by the owner. ^ c. A change has occurred in that all or part of the property is now being offered for sale or lease. ^ d. All or part of the property is occupied by an organization other than the owner. the user organization(s) make payments for use of the prnperty,,and a change has occurred in (1) the proportion of the property so occupied, (2) the terms of the occupancy, or (3) the payments made by the occupant(s). ^ e. Physical changes in the property (such as construction, alterations, or demolition) have occurred. ^ f A change has occurred in the nature or schedule of planned construction of buildings or other improvements on an unimproved portion of the property. ^ g. One of the organization's purposes is hospital, and a change has occurred in the amount of space or time that the property is used for the private practice of staff members or others rather than for the direct hospital related activities. C] STATEMENT OF CHANGE I hereby certify Ilia[ all of the changes, as listed above, that have occurred since application for exemption was last Gled have been noted and the explanations of such charges are true and correct to [he best of my knowledge and belief ; ~' STA'PF.MENT OF NO CHANGE I here certi that none the changes listed above has occurred since application for exemption was last f e best y owledge and belief. 1-~b-13 `~~x' Signature Date Title FOR ASSESSOR'S USE Assessing unit County Cityffown Village School District ys - ~ ~ ~. J RP-azaaln-Rnwa (9roa> NYS BOARD OF REAL PROPERTY SER'YICES y RENEWAL APPLICATION FOR REAL PROPERTY TAX EXEMPTION FOR NONPROFIT ORGANIZATIONS I -ORGANIZATION PURPOSE - - (See general information and instructions on back form) Sl Yeters Lutheran Lnurcn PO Box 242 d. a of contact person Greenport, NY l 1944 ~ , ~9QiJ~t' m . Sp~'lY\gl7'1 e. Telephone no. o c~{a~ct~person Day 3~ t ~-11;vening ( ) p~~ p^y ~ f. E-mail address (ophto~) c 'Employer ID no. ,1Y ~\~./~Cl !"l SD1~ ±~1~'{~7~} (~ Have any of the following changes occurred since application for this property tax exemption was last filcd2 If any of the listed changes have occtrred, please give a detailed explanation of each change on the back of this form, check the appropriate line below, and complete and sign the statement If none oC the charges has occtured, please check the appropriate line below and complete and sign the statement. ^ a. A change has occurred in the purpose(s) of the organization. ^ b. A change has occurred in the organization as a result of action taken by one or more regulatory agencies (such as issuance, restriction, or withdrawal of an operating certificate, permit, charter, or similar authorization). ^ c. A change has occurred in the organization's status with regard to exemption from federal income taxes (such as exempt status has been recognized, denied, or revoked by the Internal Revenue Service, or the Internal Revenue Codc classification of exemption has been changed). - ^ STATEMENT OF CHANGE I hereby certify that all of the changes, as listed above, that have occurred since application for exemption was last filed have beery noted and the explanations of such changes are true and correct to the best of my knowledge and belief. - '~ STATEMENT OF NO CHANGE I h y c fy that none the changes listed above has occurred since application fox exemption was last filed to b my kn g and bell ~zS}c~ ~- lb-t Signature Title Date 3. Forms filed with [emal Revenue Service by the organization since application for property tax exemption was last filed {check all applicable lines): ^ Form 1023 (Application for Recognition of Exemption under Section 501 (c)(3) of the Internal Revemte Code) ^ Form 1024 (Application for Recognition of Exemption rmdtr Section 501 (a)). ^ Form 990 (Return of Organization Exempt from Income Taz under Section 501 (c) of the Internal Revenue Code) ^ Schedule A. Form 990 (Organizations Exempt under Section 501(c) (3)) ^ Form 990-PF (Return of Private Foundation Exempt fiom lncame Tax) ^ Form 990-AR (Annual Report of Private Foundation) ^ Form 990-T (Fatempt Organization Business Income Tax Return) ^ None of these (Note: Assessor may request a copy of forms filed) FOR ASSESSOR'S OSE Assessing unit County Schoo{ District SolarMount Technical Datasheet Pub 7t0818.1td V1.0 August 2011 SolarMount Module Connection Hardware ................................ Bottom Up Module Clip .............................................................. Mid Clamp ................................................................................. End Clamp ................................................................................. SolarMount Beam Connection Hardware ................................... L-Foot ........................................................................................ SolarMount Beams ....................................................................... ~*~l~rM~t+nt P~io~iule Cz^,nnec~ion Harc4tivare ~clarMoun($ottom Up Module Ciip =e-¢ aJc. 302000C Beam Y ~ _ _ *X .............1 .............2 .............2 .............3 .............3 .............4 Bottom Up Clip material: One of the following extruded aluminum alloys: 6005-T5, 6105-T5, 6061-T6 Ultimate tensile: 38ksi, Yield: 35 ksi Finish: Clear Anodized Bottom Up Clip weight: -0.031 Ibs (14g) Allowable and design loads are valid when components are assembled with SolarMount series beams according to authorized UNIRAC documents Assemble with one Y<"-20 ASTM F593 bolt, one Y<<"-20 ASTM F594 serrated flange nut, and one Y." flat washer Use anti-seize and tighten to 10 ft-Ibs of torque Resistance factors and safety factors are determined according to part 1 section 9 of the 2005 Aluminum Design Manual and third- party test results from an IAS accredited laboratory Module edge must be fully supported by the beam * NOTE ON WASHER: Install washer on bolt head side of assembly. DO NOT install washer under serrated flange nut Applied Load Direction Average Ultimate Ibs (N) Allowable Load Ibs (N) Safety Factor, FS Design Load Ibs (N) Resistance Factor, m Tension, Y+ 1566 (6967) 686 (3052) 2.28 1038 (4615) 0.662 Transverse, X± 1128(5019) 329(1463) 3.43 497(2213) 0.441 Sliding, Z± 66 (292) 27 (119) 2.44 41 (181) 0.619 Dimensions specified in inches unless noted Washer Bottom N,N (hidden..see ::~ ~~ Solar~lo~nt i1?id Cs~i;1p _' Pa c. 30219^, ~. 32101 ~, 3C2103C. 3t2'Gdv, 332105D. 302^.OSD Mid Clamp ~:m.,:;ruwe .x Dimensions specified in inches unless noted 5olarfvlounf End Clamp ?a ~rto 3caUOtr,so2oazr_,a02oo~D .30zo03r, 302CC3D, 302004C. 302CC4D, 302CCSC, 3020CSD. s:,2006C, 30200eD, 3020V7D, 302008C. 302008 D. CZCOSC. 3020040. 30201CC. 302011 C-302012C • Mid clamp material: One of the following extruded aluminum alloys: 6005-T5, 6105-T5, 6061-T6 • Ultimate tensile: 38ksi, Yeld: 35 ksi • Finish: Clear or Dark Anodized • Mid clamp weight: 0.0501bs (23g) • Allowable and design loads are valid when components are assembled according to authorized UNIRAC documents • Values represent the allowable and design load capacity of a single mid clamp assembly when used with a SolarMount series beam to retain a module in the direction indicated • Assemble mid clamp with one Unirac'/."-20 T-bolt and one Y."-20 ASTM F594 serrated Flange nut • Use anti-seize and tighten to 10 ft-Ibs of torque • Resistance factors and safety factors are determined according to part 1 section 9 of the 2005 Aluminum Design Manual and third- party test results from an IAS accredited laboratory Applied Load Direction Average Ultimate Ibs (N) Allowable Load Ibs (N) Safety Factor, FS Design Load Ibs (N) Resistance Factor, m Tension, Y+ 2020 (8987) 891 (3963) 2.27 1348 (5994) 0.667 Transverse, Z± 520 (2313) 229 (1017) 2.27 346 (1539) 0.665 Sliding, X± 1194 (5312) 490 (2179) 2.44 741 (3295) 0.620 golf v ~~'1' % ! End Clamp . ~-,. --Serrated Flange Nut .x Dimensions specified in inches unless noted • End clamp material: One of the following extruded aluminum alloys: 6005-T5, 6105-T5, 6061-T6 • Ultimate tensile: 38ksi, Yeld: 35 ksi • Finish: Clear or Dark Anodized • End clamp weight: varies based on height: -0.058 Ibs (26g) • Allowable and design loads are valid when components are assembled according to authorized UNIRAC documents • Values represent the allowable and design load capacity of a single end clamp assembly when used with a SolarMOUnt series beam to retain a module in the direction indicated • Assemble with one Unirac'/,"-20 T-bolt and one Y."-20 ASTM F594 serrated flange nut • Use anti-seize and tighten to 10 ft-Ibs of torque • Resistance factors and safety factors are determined according to part 1 section 9 of the 2005 Aluminum Design Manual and third- party test results from an IAS accredited laboratory • Modules must be installed at least 1.5 in from either end of a beam Applied Load Direction Average Ultimate Ibs (N) Allowable Load Ibs (N) Safety Factor, FS Design Loads Ibs (N) Resistance Factor, m Tension, Y+ 1321 (5876) 529 (2352) 2.50 800 (3557) 0.605 Transverse, Z± 63 (279) 14 (61) 4.58 21 (92) 0.330 Sliding, X± 142 (630) 52 (231) 2.72 79 (349) 0.555 4 r :7~8i~i~.s{1>>: ~"~ r., h I=J i t7~r,:.l'~'{c;Y~ .w: -~_ G i'3 [ d l ... .. Y -X Dimensions specified in inches unless noted • L-Foot material: One of the following extruded aluminum alloys: 6005- T5, 6105-T5, 6061-T6 • Ultimate tensile: 38ksi, Yield: 35 ksi • Finish: Clear or Dark Anodized • L-Foot weight: varies based on height: -0.215 Ibs (98g) • Allowable and design loads are valid when components are assembled with SolarMOUnt series beams according to authorized Bolt UNIRAC documents L-Foot For the beam to L-Foot connection: •Assemble with oneASTM F593'/a"-16 hex head screw and one ASTM F594'/;'serrated Flange nut • Use anti-seize and tighten to 30 ft-Ibs of torque • Resistance factors and safety factors are determined according to part 1 section 9 of the 2005 Aluminum Design Manual and third-party test results from an IAS accredited laboratory NOTE: Loads are given for the L-Foot to beam connection only; be sure to check load limits for standoff, lag screw, or other attachment method Applied Load Direction Average Ultimate Ibs (N) Allowable Load Ibs (N) Safety Factor, FS Design Load Ibs (N) Resistance Factor, m Sliding, Z± 1766 (7856) 755 (3356) 2.34 1141 (5077) 0.646 Tension, Y+ 1859 (8269) 707 (3144) 2.63 1069 (4755) 0.575 Compression, Y- 3258 (14492) 1325 (5893) 2.46 2004 (8913) 0.615 Traverse, X± 486 (2162) 213 (949) 228 323 (1436) 0.664 ~y '.1:. ~ ,. ... ~./.': ::®~~. °~olar~a~clltnt Beam ^. ,i pj ~... 's 1`,~~. 3iti'3GC-8, .i1 ii1 b5G; sft'a6$C-B ~ii'!e'o'.`~ 3^C2C8C,3''i;}CSC-S. "s1G240C.330240C-B.3102aCD 1 G1 a411 110 ifi3h1. 410204M. 410240M Properties Units SolarMount SolarMount HD Beam Height in 2.5 3.0 Approximate Weight (per linear ft) plf 0.811 1.271 Total Cross Sectional Area in' 0.676 1.059 Section Modulus (X-Axis) in' 0.353 0.898 Section Modulus (Y--Axis) in' 0.113 0.221 Moment of Inertia (X-Axis) in° 0.464 1.450 Moment of Inertia (Y-Axis) in° 0.044 0.267 Radius of Gyration (X-Axis) in 0.289 1.170 Radius of Gyration (Y-Axis) in 0.254 0.502 > ~", ~~ . _ x x. t~_ ~,_ try- ~~ ~ ~ , - ~«~ ._ ~.+', , ~~~~~`~~a .. ..- m SLOT FOR T-BOLT OR 1~" HEX HEAD SCREW 2X SLOT FOR ~ BOTTOM CLIP SLOT FOR- 3~" HEX BOLT .387 -~ .750 - Y 11 SLOT FOR T-BOLT OR 1/a" HEX HEAD SCREW SLOT FOR BOTTOM CLIP SLOT FOR 3~" HEX BOLT Y t ^X SolarMount Beam ~I 1.385 ~~ 1.875 -X SolarMount HD Beam Dimensions specified in inches unless noted http:/Iwww.wholesalesolar.conl/mverters.hhnl INPUT DATA Aoniue Ic Plue 9.0-i ur a.a-t ,~ 6.0-1 ,~ j 6.0-1 ,,, 7.6-1 ~ 10.0-1 ~ 11A-1 vA 11.4-8 oy 1z.0-a ysrm Recommended PV-POwer(Wp) 2500-3450 3200-4400 1 4250-5750 5100-6900 6350-8600 8500-11500 9700-13100 9700-13100 10200-13800 MPPT-Votage Range 230 ... 500 V DC Startup Vokage 245 V Max. Input Voltage (at loop Whn= 16°F (-1 O"CI In Cpen CirCWt Opplehpnl 6DD V Nominal Input Current 8.3 A 10.5 A 13.6 A 16.6 A 20.7 A 27.6 A 31.4 A 31.4 A 33.1 A Maz. usable Input Current 14.0 A 17.8 A 23.4 A 28.1 A 35.1 A 46.7 A 53.3 A 53.3 A ~ 56.1 A Admissible conductor Size (DCI No. 14 - 6 AWG Number of DC Input Terminals 6 Max. Current per OC Input Terminal 20 A; Bus bar available for higher input currents OUTPUT DATA Frmiua 10 Wua 8.0-i ixa 8.8-1 ua 6.0-1 un 8.0-1 ,w 7.6-1 ,w 10.0-1 ,a 11A-1 ,N 77°4-8 m tS"0-8 woman Nominal output power (P,,i,~ 3000 W 3800 W 5000 W '~. 6000 W 7500 W 9995 W 71400 W 11400 W 12000 W Max. continuous output power ''. i I i 104°F (40°C) 208 V / 240 V / 277 V 3000 W 3800 W 'I 5000 W 6000 W 7500 W 9995 W 11400 W 11400 W 12000 W Nominal AC output voltage 208 V / 240 V / 277 V 208 V / 240 V 277 V Operating AC votage range 208 V i 163 - 229 V (-12 /+10 %) (default) 240 V 211 - 264 V (-12 / +10 %) 277 V 244 - 305 V (-12 / +10 %) Max. continuous 208 V it 14.4 A 18.3 A ', 24.0 A 28.8 A j 36.1 A ~', 48.1 A 54.8 A 31.6 A' n.a. output current 240 V 125 A 15.8 A 20.8 A 25.0 A 31.3 A 'I 41.7 A I 47.5 A 27.4 A' n.a. 277VI 10.BA 73.7A ~~' iB.IA 21.7A _ 27.1A ~I. 3fi.1A dL2A n.a. 14.4 A" Admissible conductor size (AC) No. 14 - 4 AWG Max. continuous utility back teed current 0 A Nominal output frequency 60 Hz Operating frequency range 59.3 - 60.5 Hz Total harmonic distortion < 3 % Power factor 1 GENERAL DATA Franiua IG %ua a.0-i u. I 3.8.1 va 6.0.1 ur 6.0.1 uw TS-1 uN I 10.0-1 uw 1/A-1 11.4-a 11z.e-a Max. Efficiency 96.2 % CEC Efficiency 208 V 95.0 % 95.0 % 95.5 % 95.5 % I. 95.0 % 95.0 % 95.5 % 95.0 % n.a. 240 V 95.5 % ' 95.5 % 95.5 % '~ 96.0 % ! 95.5 % 95.5 % ~ 96.0 % 95.5 % n.a. 277VI 95.5 % I~ 95.5 % 96.0 % ~ 96.0 % 96.0 % I 96.0 % ~ 98.0 % n.a. 96.0 % Consumption in standby (night) < 1 W Consumption tlunng operation 8 W 15 W 22 W Cooling Controlled forced ventilation, variable tan speed Enclosure Type NEMA 3R Unit Dimensions (W x H x D) 17.1 x 24.8 x 9.6 in. 1].1 x 36.4 x 9.6 in. 17.1 x 48.1 x 9.6 in. Power Stack Weight 31 lbs. (14 kg) 571bs. (2fi kg) ' 821DS. (37 kg) Wiring Gompartmant Weight 24 lbs. (11 kg) 261bs. (12 kg) ' 261bs. (12 kg) Admissible ambient operating temperature -4 ... 122°F (-20 ... +50°C) GompNance '~I UL 1741-2005, IEEE 1547-2003, IEEE 1547.1, ANSIAEEE C62.41, FCC Part 15 Aa B, NEC Article 690, C?2.2 No. 107.1-01 (Sept. 2001) PROTECTION DEVICES Franiua lO Plus a.0-1 a.e-1 5.0-1 ~, 8.0-1 „- A6-7 ,,, 10.0-1 11A-1 I 11.4-8 120-8 Ground fauk protection Internal GFDI (Grountl Fault Detector/Interrupter); in accordance with UL 1741-2005 and NEC Art. 690 DC reverse polarity prprection Internal diode Islanding protection Internal; in accortlanca wkh UL 1741-2005, IEEE 1547-2003 entl NEC Over temperature Output power Berating /active cooling per Phase Fronfus USA LLC Solar Electronic Division 10421 Citation Drive, Suite 1100, Brighton, Michigan, 48116 E-Mail: pv-us~fronius.com wvrw.troniu6-usa.eom Mtp:!/www.wholesalesdar.owMnverters.lltrnl a jading force green power GreenTriplex PM25t}M00 Mono-crystaliine Photovoltaic Module Power Ran e o ww g o ~ MS265Wp $8~41<eLl ~ ~~14~etYGMl -Rghh Strengthe~red Design Modok complies vqh adwnad badYg hASm :~ ~'""~ O§M mrt anle~oair[pMfvmance . . j@ non s+oo ra regWrvnmh AC Photovdtait ~ UyMTrappingCapaMRty NRgrMed~aMioo~inre1Kr, Motile has '4C Myn~sbbkACpawaaplvlapanel Sperbperkmsance undarwnlrlgM MdMPP( scs rnnmlkn+surhu dawn, dirsk,anl do!N1Uays a ~!'~ ~,~ " V GreenTriplex I~M250M00 (245-265 Wp) ^ Electrical Data I-V curve vs dill. irradiance 9A ao 1000 W/m~. zo g ao _ 800 W!m? I SA ____ aA 500 W/ma - 3A _. _.. 400 W/m~ zo __..,:_... 1.0 200 W/m'. oA 0 5 10 15 ]0 IS 30 35 d0 village M aneraharage dmaaerlstks vMh aape~Mmce qn Mradlma and imduk tempenWrt. I-V Curve 245 Wp 250 Wp 255 Wp 260 Wp 265 Wp Typ. Moduke E(fkder7cy 14.70% 15.3096 15.6096 15.9096 16.2096 °n 30.76 30.82 30.86 30.90 30.95 Typ. NOltlinal Current Nn(+~ 8.09 8.22 8.34 8.46 8.58 37.80 37.86 37.92 37.98 36.09 . Typ. R1ertEYmlk Gurmrt ~c (A) 8.60 8.66 8.72 8.78 884 I I 0/+396 _ --- - J •Above dare are the effecUVx meazuremenl at StaMaM Teo Conditions (STCJ •Theghren electre4l data are mmwal values whrth acrounttw oavc meawremerns ano manwamnnq rwerairceswxmm, moan • STC'. irradiance 1000W1m+, spectral distribution AM 1.5, temperature 25 T 2° C, In attwdmce with EN 60904-3 the exceprwn W P•. the dassaicatimx is pedomud accwdiig b P. • 61ack backsheN is udlisd rw power range 145-160W; White bncksheet'a for 150.165W ^ Temperature Coefficient • NOCT Nomwl Operation Cell Tempemwre, meawrinq conditions: inadiance BOOW/m; PM 1.5, ar temperature 10° C, wind speed 1 m/s • Mechanical Characteristics 1657 x 942 x 40 mm (65.01 z 39.06 z 1.57 inches) t 19.3 kg (42.5Ibs) Hlgh Varnparent molar glass (tempered), 3.2 mm (0.13 inches) Ce8 60 monocrystalline solar cells, " " x6 ) 156 mmx156 mm (6 EVA BatkSh9Ph': Compositefilm, black/white y Aradized aluminum frarne, black iurlcda+8ox.:. function box with 3bypass diodes 1 z 4 mma (0.04 x 0.16 incha), . length: each 1.0 m (39.37 indtes) • Operating Conditions Maxbnum. Swface. toad Gapaclty -9o...+so° c loon v / 60o v IP 65 16A Tested up to 5400 Pa according [o IEC 61215 • Warranties and Certifications Maximum S years for material and workmanship Pedormmee Giuretltfe: Guaranteed output of 90°.6 far 10 years and 8046 for 25 years According to IEC 61215, IEC 61730 and UL 7703 guidelines • ___ _ .. `Please mnri~m other certaicadoniwiN AUO official dealers AU Optronics Corporation No. 1, Li-Hsin Rd. 2, Hsinchu Science Park, Hsinchu 30078, Taiwan ~ AUO Green Solutions rllxmo mx Tel:+886-3-500-8899 Email: solar@auo.com www.AUO.mm www.AUOsolaccom Panted wan soy wk SOA(INK, N_ew York State Insurance Fund Workers' Campensation & Disabiiily Benefrts Specialists Since 7914 199 CHURCH STREET, NEW YORK, N.Y. 10007-1100 Phone: (866)997-3663 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^^^^^^ 753118816 SUNATION ROOFING SERVICES INC 1217 MONTAUK HIGHWAY OAKDALE NY 11769 POLICYHOLDER SUNATION SOLAR SYSTEMS ING 1217 MONTAUK HIGHWAY OAKDALE NY 11769 CERTIFICATE HOLDER I TOWN OF SOUTHOLD 54375 ROUTE 25 SOUTHOLD NY 11971 i POLICY NUMBER ~ CERTIFICATE NUMBER ', PERIOD COVERED 8Y THIS CERTIFICATE I DATE Z 2160 670.2 775751 ~, 09/06/2011 TO 01/01/2015 ~ 11/26/2012 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY N0.2160670.2 UNTIL 01/0112015, 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, WRH 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 01/01Y1015 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 50 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 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 STATE INSURANCE FUND ~°',~~~ DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on our web site at https://www.nysif.com/ceNcertval.asp or by calling (888) 875-5790 VALIDATION NUMBER: 587614295 U-26.3 484lCD45944-20/1198 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 Berteftts Carrier or Licensed Insurance Agent of that Carrier ta. Legal Name and Address of Insured (Use street address only) ib. Business Telephone Ntmbtx of Inwred SUNATION SOLAR SYSTEMS INC 631-737-9404 tc. NYS Unemployment Irrssrartce Employer Registration 1217 MONTAUK HIGHWAY Number ofltatired OAKDALE, NY 11769 1d. Federal Employer Iderdifieation Number of Insrxed or Social SewrRy Ntrrtllu 753118816 2 Name and Address of the Entity requesting Proof of Coverage 3a. Name of Irtsurutce Carrie (Emity being listed as the Certificate Holder) The First Relmbilitatbn Life Insurance Town of Southold company °f A"te`;`a 3b. Polity Nunixr of Entity listed in boa "1a°: 54375 Route 25 DBL243442 Southold, NY 11971 x. Polity effective period: 11128/2012 ~ 11/27/2013 4. Polity covers: a. ~ All of the employer's employees eligible under the New York Disability Banerits Law b. ~ Only the following class or Gasses of the employer's employees: Under penalty of pxjury, l certify that I am an authorized represemative or licensed agent of the insurance carrier referenced above arW tlut the named inwred has NYS Disabilky Benefits insurance coverage o s d e sc rib ed ab o ve r ~ ~ ~ ~ ~/ ~j ~i ~ 2/24/2013 ~' ~ l lYr i/~ Date Signed (Stgnanae of krslaara:e curler's aumorizW represeraadve err NYS Lrcemad Imiearax<Agera of Usat hwaanre carrier) Telephone Number 516-829-8100 rue Chief Executive Officer IMPORTANT:If hox'q' h dsrrJSed and tlth form k signed a9l de krprurte cariu's asalsorlud reprasmtutive u NVS Licensed Irouruce Agra of thatmiw, Mta o"irxa! is COMPLETE. Mail h direCly m draeerdfkate hoMw. If boe'q° isctledsed.lAb ce"lficue h NOT COMPLETE ibrtln psapceesof SerBan y]D. Sand. a of drs Ditablllty Benefits Lsw. It msm be marled for twlgsktion m dw Wadcds Carnpera>tWrs Bowd DB Plus A Una, al Perk StreK, Albany, NY [1107. PART 2. To be completed by NYS Worker's Compensation Board (Only "d box "4b" of Part 1 has been checked) State of New York Worker's Compensation Board Aaording m infmrwdon makaairod by the NYS Workw's Cortpemrtlan Board the aboveasatled employer has celnpllM with Ne NYS DISWIIity BuaYlb Law wah rarpestb all of fdsllKr amplcycea Date Sigurd By (Sipsmae of NYS Wadtel's Carrquecebn Board Fmpbyee) Telephone Nurrlber Title Please Note: Only irtwrartce curlers lieertsed to vwite NYS Disability Benefits iraurertce polities and NYS Licensed Irtwrarrce Agems of those insurance curlers are atttharized to issw Form DB-720.1. Imvrartce brokers are NOT authorized to issue this form DB-120.1 (5-06) RP-4zo-alb-Rnw-n (grog) NYS BOARD OF REAL PROPERTY SERVICES RENEWAL APPLICATION FOR REAL PROPERTY TAX EXEMPTION FOR NONPROFIT ORGANIZATIONS _ H -PROPERTY USE (See general information and instructions on back form) 1 a. t~,~e o rg raation , ~ r t _ ~_ { d. T~e of contact person }F . ,Y S 1 ~.~11-Y`CYGt ~1"1.7tC Y1 ~(. (~Oo(`fP ~t- N'il - ~Y~~^ b. M~iljng addr ~, 1~ e. Telo3n1 n . o co tact tson Day ening j _~_ ~PJtlOcf~ ~'t ~~~------ --~- ` f. E-mail ad ress (oph c. Employer ID no. ~ `~ ~~ S~ 6~-ceCna>O Qo~ ~ C `~~ T g. Property identification (see tax bill or assessment roll) Tax map number or sectionlblock/lot 2. Have any of the following changes occurred since application for this_property tax exemption was last filed? If any of the listed change have occurred, please give a detailed explanation of each change on the back of this form, check the appropriate line below, and'complete and sign the statement If none of the changes has occurred, please check the appropriate line below and complete and sign the statement. ^ a. A change has occurred is the ownership of all or part of the.groperty_ ^ b. A change has occurred in the use or uses of the property by the owner. ^ c. A change has oceumed in that aIl ar part of the property is now being offered for sale or lease. ^ d. All or part of the property is occupied by an organization other than the owner. the user organiution{s) make payments for use of the pmperiy, .and a change has occurred in (I) the proportion of the piopery so occupied, (2) the teens of fhe occupancy, or (3) tfie payments made 6y the occupant(s). ^ e_ Physical changes in the property (such as wrrstmetion, alterations, or demolition) have occurred. ^ f A change has occurred in the nature or schedule of planned constaction of buildings or other improvements on an unimproved portion of the propery. ^ g. One of the orgatu2ation's prirposes is hospital, and a change has occurred in the amount of space or time that the property is used for the private practice of staff members or othr~s rather than for the direct hospital related activities. p STATEMENT OF CHANG$ I hereby certify that all of the changes, as listed above, that have occurred since application for exemption was last filed have been noted and the explanations of such charges are true and correct to the best of my knowledge and belief. ~' STATEMENT OF NO CHANGE I here c that none the changes listed above has occurred since application for exemption was last f e best y owledge and belief. 1-~b-13 `~s'roc' Signature Date Title FOR ASSESSOR'S USE Assessing unit County City/I'own Village School District RP-020-alaRnw-1 (9/DS) NYS BOARD OF REAL PROPERTY SERVICES RENEWAL APPLICATION FOR REAL PROPERTY TAX EXEMPTION FOR NONPROFIT ORGANIZATIONS I -ORGANIZATION PURPOSE ' (See general information and instructions on back form) St Yeters i.utneran l,nurcn PO Box 242 Greenport, NY 11944 d. a of contact person r. (sar~~r rn. ~'o1~+nga~ e. Telephone no. o c act-person Day 3~ ~vening ( ) _ 1~Y ~~-~~~ f. E-mail address (opLO ) c i~Employer ID no. ..> SO~CGYeffl(~"{ rQ `, 2 'Have any of the following changes occurred since application for this property tan exemption was last filed? If any of the listed changes have occurred, please give a detailed explanation of each change on the back of this form, check the appropriate line below, and complete and sign the statement. If none of the changes has occurred, please check the appropriate line below and complete and sign the statement. ^ a. A change has oeourred in the purpose(s) of the organization - ^ b. A change has oceurred in the organization as a result of action taken by one or more regulatory agencies (such as issuance, restriction, or withdrawal of an operating certificate, permit, charter, or similar authorisation). ^ c. A change has occurred in the organization's status with regazd to exemption from federal income taxes (such as exempt status has been recognized, denied, or revoked by the Internal Revenue Service, or the Internal Revenue Code classification of exemption has been changed). ^ STATEMENT OF CHANGE I hereby certify that all of the changes, as listed above, that have occurred since application for exemption was last filed have been noted and the explanations of such changes aze true and correct to the best of my knowledge and belief. - STATEMENT OF NO CHANGE I y fy that none ~ the changes listed above has occurred since application for exemption was last filed to my kn g and beli ~tS}cam 1- lb_ ~3 Signature Title Date 3. Forms filed with tht~tT ternal Revenue Service by the organization since ;application for property tax exemption was last filed (check all applicable lines): ^ Form 1023 (Application for Recognition of Exemption under Serrtion 501 (cx3) of the Internal Revenue Code) ^ Form 1024 (Application for Recognition of Exemption under Section 501 (a)). ^ Form 990 (Return of Organisation Exempt from Income Tax under Section 501 (c) of the Internal Revenue Code) ^ Schedule A. Form 990 (Organizations Exempt under Section 501 (c) (3)) ^ Form 990.PF (Return of Private Foundation Exempt from Income Tax) ^ Form 990.AR (Amual Report of Private Foundation) ^ Form 990.T (Exempt Organization Business Income Tax Return) ^ None of these (Note: Assessor may request a copy of forms filed) FOR ASSESSOR'S USE Assessing unit County City/town Village School District