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HomeMy WebLinkAbout4832 Youngs Ave ` Perndit No. TOWN OF SOUTHOLD ����4VFFi}2 HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 (631)765-31401 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or regulations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws, ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized inspectors to make necessary inspections of the job site. Print or Type / Cal— 3 -Wo76 4L1CY6 060 06C '1+R® ou i l-OOL101J.�, ame�f Applicant Phone Numbfr Address of Applicant ,r 2 - G 6, 1 Cv - J sG �� ��AGE Name of Contractor C Phone Number A dress of Contractor 7 3. �R.Q YviE-P-7— �S� (&04 d S L4gt9 6 o4:D ��ae"`�to ��, � es�Tta�i✓0 K q, Name of Property Owner Requesting Service(if applicable) Address of Owner `` � G t� 4. C' �/¢��► f�l� FC3� L'l�c--r—e t C_ l_l N d= V 10 QerL vow Cos Ay � � `� 4 7 Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,other Town permits may be required. ' r NOTE: All information requested by this Signature of Applica Application/Permit Form is Required for a complete application! Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of all site and pavement restoration work. (b) Attach all other necessary permits and licenses for this project. (c) Work covered by this application may not commence before issuance of a Highway Excavation Permit by the Town Clerk. 6. Tax Map No.: District 1000 , Section Block 21- , Lot f 7. Starting Date: pt Completion Date: ,�11 8. Work Schedule: Phase Completion Date Excavation 0-0 Work Schedule Facility Installation bz d C `t Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. .3N 9. Under which authority is application being made: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work: $ 11. Remarks: D-39 1 of 5 0 1 N 12. Insurance Coverage:(Attach Co ) (a) Insurance Company: rhM I LY CA514 _[/VC. Go • e=)Ekk— C,-s U P.cr4 q7tJ S Gp (b) Policy#: 3 to X (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended to the Town: Any Loss including Bodily injury,property or commercial injury caused by or ibutable to the work performed: $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a)Surety Bond or Certified Check provided in the total Amount of$ (b)Maintenance Bond provided: 2 years or 3 years. 14. Fees for Applications and permits: Basic Application Fee for Each Project Location - $500.00x A Project Location would include each Bell Hole and/or every road opening or excavation within any 50'Radius whether or not they may be inter-connected by open trench or directional boring. The total number of Project Locations shall be subject to the approval of the Highway Superintendent. Al. /Service Connections excavations @$50.00 $ No. A2. /Additional Excavations same service @$20.00 $ No. B. Trench Excavations 18"in depth or less Total Lineal Footage of Excavation; L.F.@$10.00 $ C. Trench Excavations 18"in depth to 5'in depth 63Cad"P Total Lineal Footage of Excavation; -7$ L.F.@$30.00 $ a 3 4z:) D. Trench Excavations 5'in depth and over f Total Lineal Footage of Excavation; L.F.@$50.00 $ i E. Utility Repair Excavations @$1,000.00/Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. TOTAL$ - © � c" F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit. Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: Wattach ith this application and subject to the"General Conditions"and"Special Conditions"of permit o. SUPERINTE STOWN OF S U V ncen .Orlando Date Date Received by the Town Clerk .!� (� 1 Date Permit Issued S(901.( Permit No. 131 NOTE: Permit expires one(1)year from date of issuance. No work to start without 24 hour notice to Superintendent of Highways. Permit must be available at all times for inspection,on site,during construction. D-39 2 of S Copy Distribution: J z ' !x Permit# J'[ Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified i st 2nd 3 rd 4th (To Permit Clerk) REMARKS CODE IB Improper Barricades IL Improper Lights ST Sunken Trench or Excavation UTM Unable to Measure(due to backfilling) BUC Building Under Construction WIP Work In Progress DB Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of S GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Complv with Permit Requirements: The Permittee is responsible for informing its independent contractors, employees,agents and assigns of their responsibility to comply with this permit, including all special/site specific and general conditions imposed by the Highway Superintendent while acting as the permittee's agent with respect to the permitted activities,and such persons shall be required to comply with all permit requirements. 2. No Right to Trespass or Interfere with Private Property Rights: This permit does not convey to the permittee any right to trespass upon the lands of adjacent property owners in order to perform the permitted work nor does it authorize the impairment of any rights,title, or interest in real or personal property held or vested in a person not a party to the permit. 3. Protection of the Highway and Future Highway Maintenance: If future operations or highway maintenance projects by the Town of Southold require an alteration in the position of the utility, structure or work herein authorized,or if,in the opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health, safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility, structure,fill,excavation,or other modification of the highway hereby authorized shall not be completed. Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and conditions of the permit or Chapter 237 of the Town Code. 4. Revocation of the Permit by the Highway Superintendent: If the Highway Superintendent deems it necessary to revoke this permit and the project hereby authorized has not been completed,the applicant shall,without expense to the Town and to such extent and in such time and manner as the Superintendent may require,remove all or any portion of the uncompleted utility,structure or fill and restore the site to its former condition. 5. Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or contractor shall notify the Town Highway Department in writing that they are fully aware of and understand all terms and project conditions of this permit. Upon completion of the work,the contractor shall provide photographs of the completed work to the Town Highway Department and request a Final inspection. 6. Storage of Equipment&Materials: The storage of construction equipment and/or materials shall be confined within the project work area and/or adjacent areas where permission/legal access has been obtained in a manner that does not interfere with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the responsibility of the contractor and shall be repaired at the contractor's expense. 8. Road Closures: All scheduled road closures must first receive written permission from the Southold Town Board prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway Superintendent. This item will included but not be limited to the installation of appropriate signage and flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen emergencies require immediate notification of the Highway Department and shall be limited to immediate and/or expedited restoration of the Work Zone. 9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job site on a daily basis. All stockpiled soil as well as all other project materials that will be staged within the Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements of the NYS DOT Construction Standards. `t of GENERAL CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR (Continued) 10. Install,Maintain Erosion Controls: Required Erosion Control Measures(i.e.silt fencing)is to be placed on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any disturbance of the ground occurs and is to be maintained in good functional condition until thick vegetative cover is established. 11. Clean Fill Only: All project back-fill shall consist of clean sand, gravel or soil (NOT asphalt, slag,flyash, broken concrete or demolition debris). All unsuitable soils excavated at the site(i.e. Clay,Bog, etc.)are to be removed from the site and not used to backfill any excavation within a Town Highway. 12. All Areas of Soil Disturbance: All areas of soil disturbance resulting from the approved project shall be stabilized to the satisfaction of the Highway Superintendent immediately following project completion. If the project site remains inactive for more than 48 hours or planting is impractical due to the season,then the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor germination. 13. ]Backfill&Compaction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall be placed in maximum lifts of twelve(12")inches thick and shall be mechanically compacted to a Ninety- five(95%)percent maximum dry density. Suitable hydraulic compaction by water jetting at three-foot intervals will also be permitted subject to a project specific approval by the Highway Superintendent. 14. Restoration of the Road Shoulder Area: All man-made improvements located within existing road shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to driveway&private road aprons,mail boxes, sprinkler systems,trees and ornamental plantings. Excavations through driveways and private road pavements must be reconstructed to meet all requirements of Southold Town Highway Specifications. All pre-existing road shoulder improvements that have been disturbed during construction must be replaced or repaired by the contractor to the satisfaction of the Highway Superintendent.' 15. Schematic Plans with all Technical information and Scone of Work: To reasonably and adequately describe the proposed work,accurate"schematic site plans must be provided to show or indicate all proposed construction activity required under this permit. All Pavement surfaces scheduled for excavation must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width of trenching must be indicated by dimension or labeling. This schematic site plan must provide details on all restoration required to meet the requirements of these General Conditions and requirements found in the Southold Town Highway Specifications. 16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner; (Note-When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintendent) a) Complete all back-fill &soil compaction work as needed to provide a suitable sub-base; b) Over-cut existing asphalt bell hole or trench by twelve(12")inches on all sides; c) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification); d) Install a two and one half(2.5") inch compacted lift of Asphalt Base Course; e) Install a one and one half(1.5")inch of Asphalt(Type 6)Wearing Course. (Provide AC at all joints) All work listed herein must meet the minimum requirements of the Southold Town Highway Specifications. 17. TrenchinLy of Pavement Surfaces Exceeding One Hundred(1001)Feet in Length: All trenching of pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item # 16 as noted above. Once all pavement reconstruction is completed to the satisfaction of the Highway Superintendent,the entire road section and/or width of road over the entire length of trench shall be repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical,shoulder to shoulder). (del, aJI8) ® DATE(MM/DD/YYYY) ACCMo CERTIFICATE OF LIABILITY INSURANCE 05/15/2019 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 CONTACT Lon McBride NAME: Roy H Reeve Agency,Inc A/CNN Ext (631)298-4700 A/c,No; (631)298-3850 PO Box 54 E-MAIL Imcbride@royreeve com ADDRESS: 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattituck NY 11952 INSURERA: General Casualty Co of Wisconsin(0310761) 24414 INSURED INSURER B: Regent Ins.Co (0310761) 24449 K L Dickerson Excavating Corp INSURER C: 2120 Skunk Lane INSURER D: INSURER E: Cutchogue NY 11935 INSURER F. COVERAGES CERTIFICATE NUMBER: CL191909656 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS INSD WVD POLICY NUMBER MM/DD/YYYY MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A CCX0392798 06/29/2018 06/29/2019 PERSONAL aADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE $ 2,000,000 POLICY❑PRO F-12,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER - —FORTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER 100,000 B ANYPROPRIETORIPARTNER/EXECUTIVE N/A CWC1336590 01/31/2019 01/31/2020 EL EACH ACCIDENT $ OFFICER/MEMBER F�CCLUDED? 100,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ If yes,descnbe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER Is Included as Additional Insured with respect to General Liability as per the terms and conditions of Form CX00030711- Contractors Policy,as required by written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Main Road PO BOX 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 �Oba ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD eACo I CERTIFICATE OF LIABILITY INSURANCE °A'E`""'°°"""" 16 . 05/15/2019 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 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). Iaol►cER CONTACTEILEEN CUSHMAN RYAN KUHN P1{ONE 631-722-1100 IFAAMXNot:631-7224500 1116 MAIN ROAD SUITE A2 E•MAIL P.O.BOX 2336 INSURERS AFFORDING COVERAGE MAIC• AQUEBOGUE,NY 11931 INSURER A-FARM FAMILY CASUALTY INS.CO. BURRO INSURE=R B TOM GRATTAN LAWN CARE LLC INBURERC: POB 465 INSURER D: PECONIC,NY 11958 INSURER E: INSURER F.* OVERAGES CERTIFICATE NUMBER: 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 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. IR TYPE OF INSURANCE POLICY NUMBHR LIC EFF Y BXP LIMITS XXI COMMERCIAL GENERAL LIABILITY 3101X8012 04/12/2019 04/12/2020 EACH OCCURRENCE S 1.000.000 7 CLAIMS-MADE D OCCUR ��— S 10,000 MED EXP(Any one person) S 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2.0 0 000 XX POLICY ECT ❑LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER 5 AUTOM°BILELIABtLTYNED SINGLE u I $ Ea sed ant ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per acudecn) S AUTOS AUTOS � WNED ROPERAMAGE HIR DAUTOS ASa S UMBRELLAUAB OCCUR EACH OCCURRENCE S EXC6$S�® HCLAIMS-MADE AGGREGATE S DED I RETENTIONS S WORKERSCOMPENSATION AND EUPLOYERB'LIABILITY YIN STAT E ER ANY PROPRIETORIPARTNEWEXECUTIVE E.L EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? 17 NIA (Mandatory In NH) E L DISEASE-EA EMPLOYEE S I1 yes.desafbe order DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S ISCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddtOonal Ramadm Saheill"may be attached Kmoro spas Is mgLdmd) ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF SOUTHOLD ACCORDANCE WITH THE POLICY PROVISIONS. P.O.BOX 1179 SOUTHOLD NY 11971 AUTHORIZE REPRESENTATIVE O 1988-2014 ACORD CORPORATION. All rights reserved. CORD 25120141011 The ACORD name and loco are realstered marks of ACORD Workers' T� =nsatlon CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured TOM GRATTAN LAWN CARE LLC POB 465 PECONIC,NY 11958 1c.NYS Unemployment Insurance Employer Registration Number of Insured Work location of Insured(Only required if coverage is speciflce*limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations In New York State,Le.,a Wrap-Up Poky) Number 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) FARM FAMILY CASUALTY INS CO TiNON SOUTHOLD POB 117979 3b.Policy Number of Entity Listed in Box"1a"SOUTHOLi],NY 11971 3103W7247 30.Policy effective period 04112/2019 to 0411212020 3d.The Proprietor,Partners or Executive Officers are included.(Only chw*box it a0 partnerstoffscers included) ❑x all excluded or certain partnersiofficers excluded. This certifies that the insurance carrier indicated above in box'Y insures the business referenced above in box"16'for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Rom 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 7'. W111 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 pedod? AYES []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: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 1 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: RYAN KUHN (Print name d;7 f a orited representathro or licensed agent of insurance Cartier) Approved by: / (signature) L (Date) Title:AGENT Telephone Number of authorized representative or licensed agent of insurance carrier. 631-722-4100 Please Note:Only insurance carrlem and their licensed agents are authorized to Issue Form C405.2.Insurance brokers are NQI authorized to Issue It. C405.2(946) www.wcb.ny.gov 1 I I I w oeK 6" co 2.• N � � f I r,5 z 2