Diven, RobertFOR INTERNAL USE ONLY
Received by: Joseph P. Paoloni 1-1
Lynn O'Dell i'l
Cooper Leatherwood 1-1
"d �203'�
Date Received: G/7 l it
Serial #:
2021-05-13 JPP
Town of Wappinger
�,eceiv _Application for Hawkers
& Peddler's License
A�)R 17 Z025
C,
ifJ a p P I I'�l 9
J.
The undersigned does hereby apply to the Town of Wappinger Town Clerk for a
RENEWAL
TEMPORARY
(I weekend only)
License for Hawking and Peddling pursuant to Town of Wappinger Local Law No. 10 of 1992,
regulating Hawkers and Peddlers in the Town of Wappinger, and in con -
application, does state the following:
1) Applicant:
20
NAME: AGE: RO
CURRENT ADDRESS-.
- 6 of6u,-,,rck. L(\ k, � �
(St #) (Street) City) (State) (ZIP)
PHONE#
t (—CuiA, ) bq— q190
PERMANENT ADDRESS (if different):
(St #) (Street) (City) (State) (ZIP)
If Applicant is an Agent or Employer: Tape a 2"X 2"
Applicant's Employer TC kt\1-4. 5 OlAr color photo (less
Address of Employer -1) 'mM 'Ly - 4,,�Vf 0�' r4 than 60 days Old)
(St. #) (Street) (City) (State) (ZIP)
Proof of Employment (attach to gpplication) 00153
2) Nature of Business:
11 Motor Vehicle (circle one): car truck van
/On Foot &/or with vehicle drawn by hand or animal
Vehicle Info: Vehicle Make,ii4 Vehicle Model EkAfo,
License Plate # 1-5 '-42;7a State of Registration LlealorjC
Operator's License Number 6-2 U? 9qQ
1.1 Weights & Measures Certificate Certificate #
El Dutchess County Health Dept Permit Permit #
2021-05-13 JPP
3) Veteran Status
❑ Veteran Applicant - Exempt from license fee (attach certificate from Dutchess County)
Names of all other municipalities in which the applicant has been a vendor in the preceding 6
months:
4) Compliance
That the applicant, if the License requested hereby is granted, consents and agrees to/conduct the
aforesaid business or activity pursuant to all of the terms and regulations of the Local Law above
specified, and all other rules, regulations and Laws governing ones activities in the Town of
Wappinger as a Peddler or Hawker.'
fil
Dated: _ q/ � ? , 2075
Wappingers Falls, N.Y.
Sworn to before me this
day of G4it\ , 20 '�S
Notary Public
�&�
Signature of Applicant
Application must be accompanied by a fee of Two Hundred Dollars ($200.00) plus $50 for
each addition to the original license per year, payable to the Town of Wappinger. This is a
non-refundable fee.
Applicants possessing a valid Dutchess County Veterans Vendors License are exempt from
the $200.00 fee, provided that a copy of said license is attached to the application.
AC"R
ALJ Lj CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDlYYYY)
5i2812D24
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 endorsement(s).
PRODUCER
Arthur J. Gallagher Risk Management Services, LLC
300 Fellowship Road
Suite 200
CONTACT
NAME:
PHONE FAX
o Ext): 856-482-9900 A!C No): 856-482-1888
ADDRESS: CherryHill.BSD.CortM@AJG.com
INSURERS AFFORDING COVERAGE NAIC#
Mount laurel NJ 08054
INSURER A: Gotham Insurance Company 25569
GL202100013378
INSURED TRINHEA-03
Trinity Solar LLC
62 Leone Lane
INSURER B: National Union Fire Insurance Company of Pittsburg19445
INSURER C: Endurance American Specialty Ins Cc 41718
INSURER D: Liberty Insurance Underwriters Inc 19917
Chester, NY 10918
INSURER E: Columbia Casualty Company 31127
INSURER F :
COVERAGES CERTIFICATE NUMBER: 20B7486737 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT kOR 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
SUER
POLICY NUMBER
POLICY EFF
MMIDONYYY
POLICY EXP
MMIDD/YYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
Y
GL202100013378
6/1/2023
6/9/2025
EACH OCCURRENCE $2,000,060
CLAIMS -MADE OCCUR
PREMISES Ea occurri nca $100,000
MED EXP (Any one person) $ 0
PERSONAL &ADV INJURY $ 1,000,000
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,000
GEN'L
POLICY � jOT LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER:
B
AUTOMOBILE LIABILITY
CA 2960145
6/1/2024
6/1/2025
COMBINED SINGLE LIMIT $ 2,000,000
Ea accident
BCDILY INJURY (Per person) $
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per acddent) $
PROPER TY DAMAGE_ $
Per accident
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
A
D
E
X
UMBRELLALIAS
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
EX202300001871
ELD30006989102
1000231834-08
7039650582
6/1/2023
6!112024
6/1/2024
6/1/2624
6/112026
6/112025
6!1!2025
6/112025
EACH OCCURRENCE $5,000,000
AGGREGATE $ 5,000,000
DED RETENTION $
Limit x of $5,000,000 $19,000,000
g
WORKERS COMPENSATIONWC
AND EMPLOYERS' LIABILITY
ANYPROPRIETORIPARTNERlEXECUTIVE —1
013588107
6/1/2024
61112025
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 1,006,000
OFFICERIMEM BEREXCLUDED?
(Mandatory In NH)
NIA
E,L. DISEASE. EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
If yes, descrlbe under
DESCRIPTION OF OPERATIONS below
B
Automobile
CA 2960145
6/1/2024
611/2025
All Other Units $2501$500
Comp! Collusion Ded.
Truck -Tractors and
Seml-Trailers $2501$500
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder Is named as additional insured with respect to the above General Liability Policy, if required by written contract executed prior to services
performed.
CERTIFICATE HOLDER C:AI UtLL.AIIUIv
Town of Wappinger
20 Middlebush Road
Wappingers Falls NY 12590
USA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
(013Jdd-ZUI5 AL;UK1) UUKI-UKAI IUN. An rign[s reserves.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
NEW Workers'
YORK
sfAtr Compensation CERTIFICATE OF INSURANCE COVERAGE
"kr, Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW
PART 1. To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier
la. Legal Name & Address of Insured (use street address only)
1 b. Business Telephone Number of Insured
TRINITY SOLAR, LLC
62 LEONE LANE
8003733765
CHESTER, NY 10918
Work Location of insured (only required itcoverages specifically limited to
1c. Federal Employer Identification Number of Insured
certain locations in New York State, i.e,, Wrap -Up Policy)
or Social Security Number
22-32923244
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 Wappinger
20 Middlebush Road
3b. Policy Number of Entity Listed in Box la
Wappingers Falls, NY 12590
USA
871757-002
3c. Policy Effective Period
8/1/2017 to 6/1/2025
4. Policy provides the following benefits:
X A. Both disability and Paid Family Leave benefits.
® B. Disability benefits only.
L] C. Paid Family Leave benefits only.
5. Policy covers:
5c] A. All of the employer's employees eflgible under the NYS Disability and Paid Family Leave Benefits Law.
r] 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 carder referenced above and that the named
insured has NYS disability and/or Paid Family Leave benefits insurance coverage as desabove.
Date Signed 6/2/2024 By
jSignature of insurance carrier's authariled repiesentativeorNYS licensed insurance agent of thatirsurance carrier)
Telephone Number (212) 355-4141 Nate and Title SUPERVISOR-DBL/POLICY SERVICES
IMPORTANT:lf Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS
Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder.
If Box 46, 4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd. 8 of the NYS
Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for
completion to the Workers' Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200.
PART 2. To be completed by the NYS Workers' Compensation Board (Only if Box 413, 4C or 5B 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 and Paid Family Leave Benefits Law(Article 9 of the Workers' Compensation Law) with respect to all of
their employees.
Date Signed By
(Signature of Authorized NYS Workers'Compensatlon Board Employee)
Telephone Number Name and Title
Please Note.- Only insurance carriers ficensed to write NYS disability and Paid Family Leave benefits insurance policies and NYS licensed
insurance agents of those insurance carriers are authorized to issue Form DB -120.1. Insurance brokers are NOT authorized to issue this form.
13113-120.1 (12-21) III
I III III I 1�1
DB -120.1 (12-21)
qy-0tAW Workers'
TE Cvmporselr>Ir>
Board
CERTIFICATE OF
NYS WORKERS" COMPENSATION INSURANCE COVERAGE
1a. Legal Name & Address of Insured (use street address only)
1 b. Business Telephone Number of insured
Trinity Solar, LLC
631-319-7233
62 Leone Lane
Chester, NY 10918
1c. NYS Unemployment Insurance Employer Registration Number of
Insured
49-230977
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
22-3292324
2. Name and Address of Entity Requesting Proof of Coverage
3a. Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder)
National Union Fire Insurance Company
Town of Wappinger
3b. Policy Number of Entity Listed in Box "1 a"
20 Middlebush Road
Wappingers Falls, NY 12590
WC 013588107
USA
3c, Policy effective period
6/1/2024 to 611/2025
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 1 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".
The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled
due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or
eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this
Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy
expiration date listed in box "3c", whichever is earlier.
This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the
referenced policy.
This certificate may be used as evidence of a Workers' Compensation contract of insurance only while the underlying policy is in effect.
Please Note: Upon 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 Law.
Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced
above and that the named insured has the coverage as depleted on this form.
Approved by: Michael Price
(Print name of authorized representative or licensed agent of insurance carrier)
Approved by: ?i�i"�G£ 6i1i2D24
(Signature) (Date)
Title, C.E.O. North America
Telephone Number of authorized representative or licensed agent of insurance carrier:
Please Note: 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 (9-17) www.wcb.ny.gov
Form
(Rev. C
Depart
Interna
as
M
2
Will
Request for Taxpayer
Give Form to the
)rtober 2018)
Identification Number and Certification
requester. Do not
went of the Treasury
send to the IRS.
I Revenue Service
Il Go to www.irs.gov/FormWg for instructions and the latest information.
I Name (as shown on your income tax return). Name is required on this flne: do not leave this line blank,
Trinity Solar, LLC
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line t. Check only one of the
4 Exemptions (codes apply only to
following seven boxes,
certain, entities, not individuals; see
instructions on page 3):
El individual/sole proprietor or 0 C Corporation Ll S Corporation ❑ Partnership ❑s TrusUestale
single -member LLC
Exempt payee rode (if any)
Limited liability company. Enter the tax classil"cation (C=C corporation, S=S corporation, P=Partnership) ' P -_
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
code (if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes, Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
L] Other (see instructions)
5 Address (number, street, and apt or suite no.) See instructions.
Requester's name and address (optional)
2211 Allenwood Road
6 City. state, and ZIP code
Wall, NJ 07719
7 List account nomber(s) here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, far a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other = _M d
entities, It is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: if the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification nu -7b,,,=
Number To Give the requester for guidelines on whose number to enter. F—T-7 77-7-7-7-7—F7
MMMMMMMr
Under penalties of perjury, i certify that:
1. The number shown on this form is my correct taxpayer identification number (or f am waiting for a number to be issued to me)l and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that t am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. i am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide Your correct TIN. See the instructions for Part 11, later.
Sign Signature of
08/01/2023
Here U.S, person D- Date >
Section references .are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and Its Instructions, such as legislation enacted
after they were published, go to www.Jrs.gov/FormW9.
Purpose of Form
An knd'ividual or entity (Form VV -9 requester) Area is required to file an
.nformation return with the IRS must obtain your correct taxpayer
identification nurnber (TIN) which may be your social security number
(SSS), individual taxpayer'identification number OTIN), adoption
taxpayer ¢clentliftcatlon number (ATN), or employer identification nurnbor
(Ell\]), to report on an information return the amount paid to you, or other
annount reportable on an information return. Examples of iinformatioin
re-Lurris include, but are not limited to, the following,
Form 1099 -INT (interest earned or paid)
o Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
- Form 1099-MISC (various types of Income, prizes, awards, or gross
proceeds)
- Form 1099-8 (stock or mutual fund sales and certain other
transactions by brokers)
- F orrn 1.009--S (proceed from real estate transactions)
- Form, 1099-K (merchant card and third party network transactions)
- Form 1098 (home mortgage interest), 1098-E (student loan Intel
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (Including a resident
alien), to provide your correct TIN.
it you do nct return Form V1-9 to the requester with a 7-W, you rrgN
t,,p subject to backup withnofding, See What is backup withholding,
/a1er.
Cat No, 10231'X Form Y11-9 iRev 10-20
4y
SOLAR
*THIS INSTRUCTION SHEET IS FOR THE SA
Town of Wappinger,NY
Town Clerk
20 Middlebush Road
Wappingers Falls NY 12590
(845)297-5772
Application Location:
- Located in Packet.
Background Check/Fingerprinting Required? (instructions):
- Background check may be done through the town, though they did not mention
fingerprinting,
Special Notes About Towns hip/Applica�tion Process:
- The permit process could take up to a month to receive.
Salesperson is required to provide the following items:
- Valid Driver's License
Company ID
2 Passport Photos
All checks and documents provided in this packet, please complete application fully.
ONCE YOU TURN IN APPLICATION:
-Get the name of the person you are turning the application into and a contact phone
number. This is the information you will use to follow up on your permit/license.
-Make sure ALL the information is filled out completely on the application.
-If you are unsure about a question on the application, contact your DM or call the
town and ask. Do not leave it blank.
-If you find out the town is not accepting applications for any reason, please email
licensing and let them know. Include the name of the person who gave you this
information.
-Once you receive your permitlEcense, take a photo of it and email it to licensing.
-Anyone who does not send licensing a copy of their permit/license will be considered
non-compliant and managers will be notified.
Best of Luck!
L,icensin g_Utrinity-sola r. com
OLAR
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THANK YOU,
LiCENSING DEPARTMENT
Licensing �-tr
Lin i �t
v-,solar.com
loy'r 0""-""
NY/LI, Nassau County Home Improvement Contractor #H2409780000
IF/
r atty NY/LI, Suffolk County Home improvement Contractor #H-52821
SOLAR NY, jurisdictions, license or registration information furnished upon request.
For other jurisdictions, please visit: http://www.trinity-solar.com/about-us/Iocations-and-licenses
April 7', 20925
To Whom It May Concern:
Robert Diven is a Trinity Sales employee seeking approval to solicit in the Town of Wappinger,
NY. We are a local solar company specializing in residential financing options, and they are a part of the
division that generates leads by going door-to-door. The most prominent product we offer is a power
purchase agreement for homeowners to supplement their current utility bills by using solar energy
produced on their home.
Please contact me if you should have any questions,
Sincerely,
Maria Nuzlz,i
Maria Nuzzi
Licensing Administrator
Phone: (732)780-3779 ex 9809
Email: licensing@trinity-solar.com
Long Island, NY Office 1 -877 -SUN -SAVES
2180 Fifth Avenue, Unit 1 Ph: 631-319-7233
Ronkonkoma, New York 11779 Fax: 631-285-3428
www.trinity-solar.com