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HomeMy WebLinkAbout41929-Z Tl NN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL:(631)765-1802 Planning Board approval FAX:(631)765-9502 "° j ,. Survey ... SoutholdTown.NorthForLnet PERMIT NO. Cheek Septic Form N.Y.S.D.E.C. Trustees_ C.O.Application Flood Permit Examined _...,,....,20 ...._ Single&Separate _,......_..__ Storm-Water Assessment Form Contact: Approved �........ 20,I Mail to:1 �.~h w : .v1 l' Q_ Disapproved alc C)" C, w_ 7,. 3 _.... . Phan �s-,� � ;a��[� ��, Expiration 20 utldng I eetor UG 23 ,'0 APPLICATION FOR BUILDING PERMIT '7 l BUILDING DEP"L INSTRUCTIONS Date—;//,/ ,20 TOWN OF SOUTHOLD a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans,accurate plot 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 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 permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. £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 Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,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 necessary inspections. ✓ app icant or name,if a corporation) ( , (N,ailing,address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises ,e - (As on the tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. 234(0 Other Trade's License No. 1. Loc-tion o and on,wh4ch propo ed work w"gl beton , U t_ House Number Street Hamlet County Tax Map No. 1000 Section '"l '( p) " t Lotk' m w Subdivision Filed Map No.­ Lot Z. State existing use and occupancy of premises and i.nten4rA use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occup cy 3. Nature of work(check which applicable):New I uildin Addition Alteration Repair Renmval_ Dernohtion_�_Other,Work (Description) 4. Estimated Cosh Fee � (To be paid on filing this application) 5. If dwelling,number of dwelling unit �_ Nur bcr of dwelling imiias on each floor ........ If garage, number of cars 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if y:Front_ Rear _ Depth Height Number of Stories Dimensions of same structure with alterations or Iditlons: Front sear Depth _Height ----_j .. Number of Stories 8. Dimensions of entire new construction:l rout lteae Deptlt Height_ umber of Stories 9. Size of lot:Front ear Depth 1 d.Date of Purchase Name of Forme Owner 11.Zone or use district in which premises are s' ted 12.Does proposed construction violate any zoningdance d law,or r regulation? . .^SNfD_ t 13.Will lot be re-graded? S NO"',,, Will excess tl lne removed from premises?YES NO— L ' Ad rzss ( S-Cc d l I 0&2- 14.Names of Owner of premises Ali Phone No. Name of ArchitectPhone No Name of Contractor r 1 aC _Ad '`rss C PhoneNo.trr l �`D 15 a.Is this property within 100 feet of a ti wetland or evuafer'wetland?*YES NO *IF S,SOUTIIOL TO TRUSTEES D.E C. QUI b.Is this property within 300 feet of a ti e ?* S NO *IF YES,D.E.C.PERMI TS MAY BE REQU][RED. { 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,prsvide topographical data on survey. 18.Are there any covenants and restrictions with respect tol this property?*YES__-____.NO'___--_ *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF rr � being d ily swore,deposes and says that(s)he is the applicant (Name of individual signing contras:)above named, (S)He is the �1 (Contractor,Agent,Corporates '.iii rr',etc.) of said owner or owners,and is duly authorized to perform or lnr eribrmed the said work and to matte and file this application; that all statements contained in this application are a to the bc,ya po9 iris knowledge and belief,and that the work will be performed in the manner set forth in the application filed there° t r. 1 Sworn to before me this r , .day of _...__ZO—I,_.L.._ NICOLE Tri �nk ' d'� ubPublic,1I62929 l Si atur pp licantPfi In Suffolk County missionComEvolma Nowarnhor 12_ i CONSENT TO INSPECTION a the undersigned,do(es)hereby state: Owner(s)Narne(s) That the undersigned(is) are)the pwner(s)of the Arena! the To of Southold,located at A G, --2 which is shown and designated on the Suffolk County Tax Map as District 1000, Section .Block Lot That the undersigned(has)(have)filed,or cause to be filed,an application in the Southold Town wilding Inspector's Office for the following: That the undersigned do(es)hereby give consent to the Building Inspectors of the To of Southold to enter upon the above described property,including any and all buildings located thereon,to conduct such inspections as they may deem necessary with respect to the aforesaid application,including inspections to determine that said premises comply with all of the laws,ordinances,rules and regulations of the To of Southold. The undersigned,in consenting to such inspections,do(es)so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws,ordinances,rules or regulations of the Town of Southold. Dated: -7-- 7—- ---- Ngna�ure) (Print Name) (Signature) MCOLEGORGEFIN Notary PuUic,State of NeVftrk No.01G6292933 (Print Name) Quafified en Suffok County Commission Expilres Noveaber 12,2017 ,7e F®r No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN ALL, 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: 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 I%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, 957)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 I. 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$50.00,Businesses$50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy-Residential$15.00, Commercial$15.00 Date. New Construction: Old or Pre-existing Building- —(check­one)­­................................ 0 M o- (tv Location of PropertyCl( j P- .. ................................ House No. Street Hamlet Owner or Owners of Property: C-V1 C 6' Vk 0- ...... Suffolk County Tax Map No 1000, Section................... Block Lot Subdivision -—------- FiledMap. Lot: ------ Pen-nit No. Date of Permit........ ............ Applicant: Health Dept. Approval: .,, Approval ........................... Planning Board Approval: Request for: Temporary Certificate Final Certificate: ...... ......... (check orae) Fee Submitted: ............ ..............---.............................................. .......... Applicam Signature n a �s � l a� w_ Er ` cc WAS OE�•,EEL,�o_ UUn 41 l+ 01 ui t. z2 z a v z Q a y z Q m m ISO �m�j6 ni m 0 DATE(INIARDIDNYYY) ACC>R"' CERTIFICATE OF LIABILITY INSURANCE 08/21/2017 .. ............ F THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsement(s). PRODUCER CONTACT MARSI USA INC PHONE FAX 1225 l 7n STREET,SVJITE1300 ................................ A��N�),' —----------------- ................. DENVER,CO 80202 5534 E-MAIL Alla.Deinveu.CertIRcqupsl@irnalsli.com Fax:212 948,4381 ........... ..... ...................... ..... ---................ ...................... ..... ..... INSURER ff)_AFFORDING COVERAGENAIL 9 ...... ...................... ...... .............................. INSURER A:Axis Specialty Euppe.... ..... ........... ..... ................ ...................... ........................ INSURED INSURER S 7 Zurich Arnedca insura C 116535 VivintSolar,Inc. ................................................................... ...I I.—n-1,11 nc� �1------ --------------- Vivint Solar Developer LUC INSURER C 7 AmNican Zurich Ir e Co 140142 ... .................... .......... 1800 W Ashton Blvd. SURER iD�NIA NIA Lehi,LIT 84043 -M�..................................................... ------------------ ------ INSURER F COVERAGES CERTIFICATE NUMBER: SEA-003174062-16 REVISION NUMBER. 2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .............. .... .............. ............................... ....................... INSP POUCYEFF POLICY EXP LTR TYPE OF INSURANCE INSP,wVD POLICY NUMBER (MMIDDWYY) D/YYYY) LIMIT'S A X COMMERCLAL GENERAL LIABILITY 3776500117EN 0112912W7 1110112018 EACH OCCURRENCE 1,0U)'000 --- i------------------ CLAIMS-MADE OCCUR _PREPASES E orA'xrre2M Is 1,000,00o M -LA— -—---------------------- I0,000 ME PERSONAL&ADV INJURY 1$ 000,000 ------------------------------------------T-----------—,GE ENuL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE. 1$ 2,000,000 POLICY[�]PRO. LL JECT LOC i PRODUCTS-GOMP/OP AGO 'I$ 1,000,000 .......... .......... ... .............................. I OTHER is B i AUTOMOBILE LIABILITY BAP509601502 110112016 1110112017 COVISINED SINGA.E 1.1M'rF I1,0(n,wo IE--,Aarrj�)................................11...................... !.................................................... X ANY AUTO I BODILY INJURY(Per per s ..................... OWNED j SCHEDULED BODILY INJURY(Per arcident)i AUTOS ONLY --`AUTOS HIRED NON-OWNED X X �s AUTOS ONLY —7�AUTOS ONLY qFffl ... .......................................... ComplColl Ded uroo UMBRELLALIAB _ OCCUR ............................ CLAIMS EXCESS LIAB ... .CLAIMS-MADE! GATE .......................... .. .. ..................... DE. 1;TENON C WORKERS COMPENSATION WC509601302(AOS) 1 1101i2l)16 1110112.017 X I�Ell I OTH- AND EMPLOYERS'LIABLJr[Y ER ................................... B YIN W('509601402(MA) l/0��,2016 1 Vol 12.017 1,000,000 ANYPROPRIETORIPARTNERIEXECUTYVE F�-J�, E.L EACH ACCIDENT is ...................— OFFICER/MEMBER EXCLUDED? /A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE: S ,...I OQ311aIDQ0 If yes,descnbe under l000'000 DESCRIPI[ON OF OPERATIONS below E.L.DISEASE POLICY LIMIT is DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION Fown of Southod SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53905 Maln Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SouftA,NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M.Parsloe 'qxe�7/r. @)19 8-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I Illy"" o NEWRK Y YWorkers' CERTIFICATE OF ST S TATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Vivint Solar Developer,LLC 801-377-9111 1800 W Ashton Blvd. 1c.NYS Unemployment Insurance Employer Registration Number of Lehi,UT 84043 Insured Work Location of Insured(Only required if coverage is specifically limited to 1 d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 80-0756438 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) American Zurich Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"I a" 53095 Route 25 WC509601302 Southold,NY 11971 3c.Policy effective period 11/1/16 to 11/1/17 3d.The Proprietor,Partners or Executive Officers are included.(only check box if all partners/officers included) all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box"I a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? ZYES [:]NO This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note: on cancellation of the workers'compensation policy indicated on this form, if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation L . Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: MARK ELIAS (Print name of authorized representative or licensed agent of insurance carrier) Approved by: U111a, ext.; 08/08/2017 (Signature) (Date) Title: SR Vice President Telephone Number of authorized representative or licensed agent of insurance carrier: 212 225 7000 Please of Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-15) www.wcb.ny.gov Y YoK Workers' CERTIFICATE OF INSURANCE COVE TA1E Compensation U THE Y DISABILITY FIT LAW Board PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured VIVINT SOLAR DEVELOPER,LLC 6317503235 1565 OCEAN AVE BOHEMIA,NY 11716 1c.NYS Unemployment Insurance Employer Registration Number of Insured PENDING Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 80-0756438 ..................... �((Entity Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"l a" Southold,NY 11971 D95556-002 3c.Policy effective period 6/10/2013 to 8/21/2018 4.Policy covers: A.All of the employer's employees eligible under the New York Disability Benefits Law B.Only the following class or Gasses of employer's employees: 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. Date Signed 8/22/2017 B . 9 y.�._ �&Snature ot"pig prance carver's r ufficTize repro,;Lotal u'or NYS Licensed Insurance Agent of ibutt insurance ccrmer) Telephone Number (212,)355.4141 Title SUPERVISOR-DBUPOLICY SERVICES IMPORTANT: If 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 purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 ....... PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box"4b"of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By ...wawa Signature of NYS Workers'CompensationBoard Employee) Telephone Number Title 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 (9-15) araa, au?,Pe,. ,..,.,� sff, „g... ...., :rte, ,7r„�. X, 7�.m raw, .�my* a�� _. � Additional By signing this form, the insurance carrier identified in box"3"on this form is certifying that it is insuring the business referenced in box"1 a"for disability 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". ............................................... Will the carrier notify the certificate holder within 10 days of a policy being cancelled for non-payment of premium or within 30 days if cancelled for any other reason or if the insured is otherwise eliminated from the coverage indicated on this certificate prior to the end of the policy effective period? ❑YES ®NO This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or after the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability Benefits contract of insurance only while the underlying policy is in effect. PleaseNote: 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 BenefitsCoverage 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 (a) The head of a state or municipal department, board, commission oroffice authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article. -120.1 ( -1 ) Reverse . ,� Luo,. , COON"00"or WCHAEL T MORS �� i SUFFOLK COUNTY DEPT OF LABOR, is LICENSING&CONSU1M ER AFFA RS HOME WROVEMEW i CONTRACTOR N 7 DANIEL T GARRITY i This If IeSdUty Bt theVIV INT SOLAR DEVELOPER LLC licensed by the County of Suffolk 1�"� 5- 8-H 03/01/2013 ""� '� 03/01/2019 a� i I f i i r y II i J fl i NEW YORK �ou�4ce1 " CERTIFICATE OF INSURANCE COVERAGE STATE Compensation.. BBoard . UNDER THE NYS DISABILITY BENEFITS LAW rbll,i Benet r or Licensed Insurance Agent of that Carrier e �� 1 � aI Neave Address p )p (use i§lreel ddt 1 b.Business Telephone Number of Insured 6317503235 BOHEMIA,NY 11716 1c.NYS Unemployment Insurance Employer Registration Number of Insured PENDING Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e_,a Wrap-Up Policy) Number 80-0756438 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Standard Security Life Insurance Company of New York Town of Southold 53095 Route 25 3b.Policy Number of Entity Listed in Box"l a" Southold,NY 11971 D95556-002 3c.Policy effective period 6/10/2013 to 8/7/2018 4.Policy covers: A.All of the employer's employees eligible under the New York Disability Benefits Law B.Only the following class or classes of employer's employees: 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. / Date Signed 8/8/2017 By "t~ ° (Signature of insurance carrier's auibohy.4 reprreseniat carr NYS Licensed Irnuaance Agent cftho in,suzarnee c=i r,) Telephone Number (212)355-4141 Title SUPERVISOR-DBUPOLICY SERVICES IMPORTANT: If 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 purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box"4b"of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By Signature of NYS Workers'Compensation Board Employee) Telephone Number Title 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. D13-120.1 (9-15) Additional Instructions for Form -120.1 By signing this form, the insurance carrier identi ix"3" is-form is,cert fying that it is insuring the business referenced in box"1a"for disability benefits-- — tffie N "owill" 46ility 'm" s-The Insur rrfdro w� , w ., � e t&bold :r in box,7„ licensed agent willsend this fcate of insurance to the entity ted as tt : rtific ,�,,,, GI rrn -cancel rage nt of - l" �' h"�� r9 g ay ed f�o� ra e p This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability Benefits contract of insurance only while the underlying policy is in effect. 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 §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits for all employees has been secured as provided by this article. 1313-120.1 (9-15)Reverse P �I uyi��ll yu°il III 1116 VIIV ���WWIII APPR RETAIN STORM WATER RUNOFF DAVE. B.P.# PURSUANT TO CHAPTER 236 F �w �,r�'Xr OF THE TOWN CODE. BY.N T FY BULLING ��: 765-1802 8 AM TO 4 PM FOR THE FOLLOWING INSPECT IONS: I. FOUNDATION m TWO REQUI ED FOR POUflED G v BETE; . HOUGH - FRA.WI`4G & PLUMBING E T I°,ilil!kL BE A„oolhf9 ALL N T SHALL MEET THE REQUIREMEN.S OF TI-1E CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. C(I°XIIolPL''lljll` 11T IIA I., I'I ODES (,''�) INIIJ IuI��F'�'F' ��.. ..II�' & Tm'VOIIIIN I�,.IDES ll! S I' ( IRED IIIV'" 11 �I`�U FIIIJDlTl�'�`NIS OF S()tMq0LD FOI"III �F ')D Mi().D 10W?l L1 P1NI (I"FU''AEF s(I)l (XD"F'U ........mww. t�"(�S.DEC �puC1p11 lull. Ipmull USE IS �iillllll IIIII , WITHOUT III 1111111 I T OFgull uum a° 11111 1°1111j11I111V llllll IIII 1 oll�u IIl I� III �l�\�� " i I � II��. <' - 1 ' 1800 WAshton 84043 Structural Group Jon P. Ward, SE,PE J.Alaffhear Walsh, Clint C. Karren, PE Structural Engineering Manager Senior Structural Engineering an r Structural Engineering Manager ion.wardpvivinfsoiar.com J Ish C&vi vin t of r.co m ctin rre n@-)vivin ts o1 r.co m July 18,2017 Re: Structural Engineering Services Gebbia Residence 665 Cardinal Dr, Mattituck, NY S-5689779; NY-02 To Whom It May Concern: We have reviewed the following information regarding solar panel installation on the roof of the above referenced home: 1. Site Visit/Verification Form prepared by a representative from our office under my supervision identifying specific site information including size and spacing of members for the existing roof structure. 2. Proposed layout of the system including connection details for the solar panels. 3. Photographs of the interior and exterior of the roof system identifying existing structural members and their conditions. Based on the above information,we have evaluated the structural capacity of the existing roof system to support the additional loads imposed by the solar panels and have the following comments related to our review and evaluation: A. Description of Residence: The existing residence is typical wood framing construction with a maximum of two layers of composite shingle. All wood material utilized for the roof system is assumed to be Hem-Fir(North)#2 or better with standard construction components and consists of the following: • Roof Section: Dimensional lumber - 2x8 at 16" on center and 2x4 collar ties at 48" on center. The attic space is unfinished and photos indicate that there was free access to visually inspect the size and condition of the roof members. • Roof Sections: Dimensional lumber-2x6 at 16" on center and 2x4 collar ties at 48" on center. The attic space is unfinished and photos indicate that there was free access to visually inspect the size and condition of the roof members. B. Loading Criteria 9.75 PSF= Dead Load (roofing/framing) 2.59 PSF= Dead Load (solar panels/mounting hardware) 12.34 PSF=Total Dead Load 30 PSF=Ground Snow Load (based on local requirements) Wind speed of 130 mph (based on Exposure Category B-the total area subject to wind uplift is calculated for the Interior, Edge, and Corner Zones of the dwelling.) C.Solar Panel Anchorage 1. The solar panels shall be mounted in accordance with the most recent "Unirac, Inc. Installation Manual", which can be found on the Unirac, Inc. website (www.unirac.com). If during solar panel installation, the roof framing members appear unstable or deflect non-uniformly, our office should be notified before proceeding with the installation. Page i of2 N j➢QN'' II' UrHv s Page 2of2 2. The solar panels are 11/2'thick and mounted 41/z" off the roof for a total height off the existing roof of 6". At no time will the panels be mounted higher than 6"above the existing plane of the roof. 3. Maximum allowable pullout per lag screw is 235 lbs/inch of penetration as identified in the National Design Specifications (NDS) of timber construction specifications for Hem-Fir (North). Based on our evaluation, the pullout value, utilizing a penetration depth of 21/2', is less than the maximum allowable per connection and therefore is adequate. 4. The maximum allowed spacing was calculated for the Wind Speed shown in paragraph A above, using the wind load uplift procedures of ASCE 7-10 and is specified below. The following values have been verified by in- house testing and the mounting hardware manufacturers' data, which are available upon request. Panel support connections shall be staggered to distribute load to adjacent members. Modules in Landscape Modules in Portrait Roof Zone Interior Ede Corner Interior Ede Corner Max Vertical S acin in 40 40 40 66 66 66 Max Horizontal S acin in 48 48 48 32 32 32 Max Uplift Load Ibs 174 113 63 293 191 107 D.Summary Based on the above evaluation,with appropriate panel anchors being utilized the roof system designed on will adequately support the additional loading imposed by the solar panels, if installed correctly.This evaluation is in conformance with the 2016 New York State Uniform Code Supplement,the 2015 IRC,the 2015 IBC,current industry standards and practice, and the information supplied to us at the time of this report. If there are any questions regarding the above, or if more information is required, please contact me. CP NPS Regards, �'" 0 Clint C. 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Z < :r",3 w . . w W- 0 a 0 Py c z ® >6 T Ian44 �� , U-BUILDER PROJECT REPORT VERSION:1.9.4 JUL 17,2017,09:45 PM PROJECT TITLE: NONE PROJECT ID:9F5DCF1F Designed by Name: None jacob.allred@vivintsolar.cwm Address: None SUNF.RAME MicroRail2.0 City,State: Mattituck,NY,11952 25-290 Watt Panels Module: Q-Cells Q.PEAK BLK-G4.1 290(32 mm) 3 ft2 290 Watts 72 kWs A PARTS AND ACCESSORIES Legend:r6 Base System 0 Part Accessory Part Suggested Unit Price Total List Number Part Type Description Quantity Quantity (USD) Price(USD) 230932B Micro Rail(9) SFM ATT SPLICE 9 32MM 4 4 36.27 145.08 240904D Roof Attachment SFM TRIM ROOF ATT ASSY HEX 10 10 14.20 142.00 008015S NS Wire Clip WIRE BND CLIP 9 9 2.77 24.93 004016D Flashing SFM FLAT FLASHING 56 56 13.91 778.96 030027C Lag Bolt HDW LAG BOLT,5/16 X 4 56 56 0.79 44.24 2401328 Trim SFM TRIMRAIL 66 32MM DRK 4 4 78.92 315.68 240232B Trim SFM TRIMRAIL 132 32MM DRK 2 2 155.36 310.72 240903D Trim Splice SFM TRIM SPLICE DRK 4 4 8.66 34:64. 2303328 Microrail(3) SFM MICRO RAIL 3 32MM 42 42 21.43 90U6 2301326 MicroRail Splice SFM SPLICE 9 32MM 12 12 22.78 273.36 0080099 Grounding Lug ILSCO LAY IN LUG(GBL4DBT) 1 1 8.40 8.40 BASE Sys"I 1::N ACZESSDIIES, TOTAL PRICE 1353.14 $1624.93 $2978.07 $0,187 PI.R.W I.I. V ,.",,,:Zl I R WA II.,.1.. $0.411 PER WATT This design is to be evaluated to the product appropriate Unirac Code Compliant Installation Manual which references International Building Code 2003,2006,2009,2012 and ASCE 7-02,ASCE 7-05,ASCE 7-10 and Califomia Building Code 2010.The installation of products related to this design is subject to requirements in the above mentioned installation manual. 2309326 SFM ATT SPLICE 9 32MM Micro Rail(9) TBD 4 240904D SFM TRIM ROOF ATT ASSY HEX Roof Attachment h, TBD 10 0060155 WIRE BND CLIP NS Wire Clip TBD 9 004016D SFM FLAT FLASHING Flashing Includes flashing,attached gasket,washer,and square aluminum washer only.(12"x 56 8").Lag bolt and rail attachment component sold separately.NOTE:about other flashing options 030027C HDW LAG BOLT,5116 X 4 Lag Bolt Zinc plated steel,3-1/2'length,2-1/2"threaded length,5/16"shoulder diameter. 56 Confirm that bolt strength and penetrating length can withstand the maximum loads of for your application. 2401328 SFM TRIMRAIL 66 32MM DRK Trim TBD 4 2402328 SFM TRIMRAIL 132 32MM DRK Trim TBD 2 �z 240903D SFM TRIM SPLICE DRK Trim Splice TBD 4 2303328 SFM MICRO RAIL 3 32MM Microrail(3) w ` TBD 42 r 230132B SFM SPLICE 9 32MM MicroRail Splice r, TBD 12 008009P ILSCO LAY IN LUG(GBL4DBT) Grounding Lug For electrical bonding of PV modules and rails.Accepts 4-14 AWG copper wires.Tin 1 plated copper body,1/4"stainless steel fasteners.NOTE:about other lug options ,'cn Yrs t 2. a w . 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