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HomeMy WebLinkAbout23300 Route 25 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 10/10/19 Receipt#: 260659 Quantity Transactions Reference Subtotal 1 Excavation Permits 1356 $540.00 Total Paid: $540.00 Notes: 1 Payment Type Amount Paid By CK#4248 $540.00 American, Underground Utilities/Cablevi Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: LYNDAR Internal ID 1356 -Permit,No. 26 TOWN OF SOUTHOLD SUFFOIk HIGHWAY DEPARTMENT RECEIVE® Peconic Lane A Peconic,New York 11958 OCT 1 0 2019 0 , (631)765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVA'1 IOPA4010 Clerk 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 Amc-picAo l�votr� DUv� (JTlLtr,�-5 X4[7 r�D2T , A)Y 111?4 Name of Applicant Phone Number Address of Applicant 2. Name of Contractor Phone Number Address of Contractor 3. Dbzt97&>I Plt2E1)EP—, L-L1_—toa0e 1 ra1 K% 4-, OvLl e"� o Name of Property Owner Requesting Service(if applicable) Address of Owner 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. 7� l I -03 NOTE: All information requested by this Signature of Applic nt Application/Permit Form is Required for a complete application? IF C,c�L ;% Z®f 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 , Lot 7. Starting Date: l4 k�2 1! 1 Completion Date: ov 6,)L-y a 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. 9. Under which authority is application being made: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. � c7 10. Estimated Cost of Proposed Work: $ r 7 11. Remarks: L 6 0 ,_ �C—G i (� L`Y ZS Ti L-> C �''L L�V w Zr 20 e-P �.2 comic T D-39 1 of 3 12. Insurance Coverage: (Attach Copy) (a) Insurance Company: (b) Policy#: (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 attributable 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 - $500.00 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. cav A2. _A /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 Total Lineal Footage of Excavation; L.F.@$30.00 $ D. Trench Excavations 5'in depth and over Total Lineal Footage of Excavation; L.F.@$50.00 $ E. Utility Repair Excavations @$1,000.00/Each $ No. Additional Repairs of Same Service @$500.00/Each $ No. d G' TOTAL$ -� . F. Official Notice to public utilities-proof must be provided and Shall be attached to this application prior to issuance of permit.00 G L A�"� ! Z Y01 „rZ oL 1O Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to: i accordance with this application and subject to the"General Conditions"and"Special Conditions"of permit(if a )attaehedhe o. SUPERINTEND HI S TOWN OF SOU RK Vi cent a o f Date Date Received by the Town Clerk Date Permit Issued Permit No. 1 J I 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 3 Copy Distribution: l 3 5 Permit# l Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1 St 2nd 3rd 4`h (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 3 GENERAL, CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Comply 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. 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 Onlv: 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 Scope 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. Trenching 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). • v 3lit b!et, CERTIFICATE OF LIABILITY INSURANCE F,0/09/19DATE(MMMDNYYY) 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(ies) 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 Ileu of such endorsement(s). PRODUCER CONTACTMlchael Bonocore NAME• A. J. Bonocore Agency Inc. PHONE 631-234-5595 FAC No 631-234-5920 1797-48 Veterans Memorial Highway E-MIESS mbonocore@ajbonocore.com ADDR Islandia, NY 11749 INSURERISI AFFORDING COVERAGE NAIC# I SU American Southern Home Insurance Company INSURED American Underground Utilities Inc. INSURERB American Alternative Insurance Corp P.O. Box 900 INSURER C Ace American Insurance Company INSURERD Wesco Insurance Company Eastport, NY 11941 1 INSURER Hartford Life Insurance Co. INSURER F COVERAGES 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 BYPAID CLAIMS NSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER (MM/DDNYYYIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 OOO OOO CLAIMS-MADE D OCCUR PREMISES Ea occurrence) $ 100,000 88A6GL0000117 05/30/1905/30/20 MED EXP An onearson $ 5,000 A X Contractual PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2-,000,000 RPOLICY D PRJECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIM T T ANYAUT $ Ea accident) 1,000, 0 000 88A2CA1000747 05/30/1905/30/20 BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED $ AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS XNON-OWNED PROPERTY DAMAGE $ AUTOS Pe acrid nt X UMBRELLA LIAB X OCCUR N10839713 006 05/30/1905/30/20 EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ r /000 DED I X I RETENTION$ 10 000 WORKERS COMPENSATION X PER UTE ETH- AND EMPLOYERS'LIABILITY D ANY OFFICEROPRIISERExC UDED/EXECUTIVE Y N NIA EL EACH ACCIDENT $ 1,000,000 (Mandatory In NH) WWC3417404 06/16/1906/16/20 EL DISEASE-EA EMPLOYEE $ 11000,000 Ifyes,describe under 11000,000 DESCRIPTION O OPERATIONS belowE.L.DISEASE-POLICY LIMIT E DISABILITY LNY814925001 01/01/1912/31/19 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) The Certificate Holder is listed as the Additional Insured as their interest may appear. CERTIFICATE HOLD R CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O. Box 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold, NY 11971 ACCORDANCE WITHTHE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured(Use street address only) 1 b.Business Telephone Number of Insured 1-631-325-1797 American Underground,Inc. PO Box 900 1 c.NYS Unemployment Insurance Employer Registration Eastport,NY 11941 Number of Insured Work Location of Insured(Only required if coverage is specifically 1 d.Federal Employer Identification Number of Insured or limited to certain locations in New York State,i.e.a Wrap-Up Policy) Social Security Number 13-4337136 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Wesco Insurance Company Town of Southold 3b.Policy Number of entity listed in box"la": P.O.Box 1179 Southold,NY 11971 WWC3417404 3c. Policy effective period: 06/16/19 to 06/16/20 3d. The Proprietor,Partners or Executive Officers are: X included. (Only check box if all partners/officers included) ❑ all excluded or certain partners/officers excluded. 3e. Demolition is: (Definition of Demolition on Reverse) ❑ included. ❑ excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "la" 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"T'. The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums 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 a maximum of one year after this form is approved by the insurance carrier or its licensed agent. Please Note:Upon the 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 depicted on this form. Approved by: Michael A.Bonocore (Print name of authorized representative or licensed agent,of insurance carrier) Approved by: 10/09/19 10/09/19 (Signature) (Date) Title: Secretary/Treasurer Telephone Number of authorized representative or licensed agent of insurance carrier: (631)234-5595 Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form. Insurance brokers are NOT authorized to issue it. C-105.2(12-03) Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. 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 a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.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 compensation to any such employee if so employed. 2. 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 a hazardous employment defined by this chapter,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 compensation for all employees has been secured as provided by this chapter. Definition of Demolition(Box"3e."on the reverse side of this form) A building wrecking or demolition is one where a building,chimney or steeple is razed,or where a floor,exterior wall or roof is removed. If the contract involves only the removal of interior walls,partitions or the facing only of any exterior wall,it is not considered demolition. Out-of-State Companies Working in NYS--NYS Workers' Compensation and Disability Benefits Requirements for Permits, Licenses or Contracts issued by NYS Government Entities Generally,employers must have a workers'compensation policy or a combination of policies that cover each state in which they employ permanent employees to cover on-the-job accidents and disabilities. As you are probably aware,certain insurance carriers write policies that cover multiple states. "Riders"found under sections 3A and 3C on the Information Page of the policy specify the states of coverage. In addition,the operations covered in each state are identified in attachments to the policy. In addition to any other state's workers' compensation coverages, an out-of-state employer needs to be specifically covered for NYS workers' compensation insurance when there are "sufficient contacts" between that employer and the state. While there is no single determinative factor, any of the following criteria could be the basis for finding"sufficient contacts" requiring New York coverage: ♦ a physical location within New York State; ♦ $50,000 in payroll during a calendar year in New York State; ♦ one or more employees(including subcontractors)with a primary work location or hired within New York State;or ♦ employees(including subcontractors)working in New York State for more than 90 days during a calendar year. If an out-of-state employer meets any of the above criteria,it is required to carry a New York State workers'compensation policy. When New York is listed in Item 3A on the Information Page of an employer's workers'compensation insurance policy,the employer is fully covered under the NYS Workers'Compensation Law. If insured through a private insurance carrier,the out-of-state employer must file a C-105.2--Certificate of Workers'Compensation Insurance(the business'insurance carrier will send this form to the government entity upon request) PLEASE NOTE: The New York State Insurance Fund provides its own version of this form,the U-26.3.If the out-of-state employer is legally, fully self-insured in New York State, the out-of-state employer must file a SI-12 -- Certificate of Workers' Compensation Self-Insurance (the business calls the Board's Self-Insurance Office at 518-402-0247). If the out-of-state employer is participating in group self-insurance, the out-of-state employer must file a GSI-105.2 -- Certificate of Participation in Worker's Compensation Group Self-Insurance(the business'Group Self-Insurance Administrator will send this form to the government entity upon request). If an out-of-state employer does not meet any of the above criteria and has New York(NY)listed in Item 3C on the Information Page of its workers'compensation insurance policy(the Other States Insurance section),NYS specific coverage is not required and the employer may be able to use its own state's workers'compensation coverage by filing a WC/DB-101 form.[The out-of-state employer's employees will be covered under NY benefits when working in New York by having NY listed in Item 3C on the Information Page of the workers' compensation insurance policy(the Other States Insurance section).] C-105.2(12-03)Reverse STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a. Legal Name and Address of Insured(Use street address only) lb.Business Telephone Number of Insured 631325-1797 American Underground Inc. lc.NYS Unemployment Insurance Employer Registration P.O.Box 900 Number of Insured Eastport,NY 11941 1 d.Federal Employer Identification Number of Insured or Social Security Number 13-4337136 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Life Insurance Company Town of Southold 3b.Policy Number of entity listed in box"1 a": P.O.Box 1179 LNY814925001 Southold,NY 11971 3c. Policy effective period: 01/01/19 to 12/31/19 4.Policy covers: a.X All of the employer's employees eligible under the New York Disability Benefits Law b. ❑ Only the following class or classes of the 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-10/09/19 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 631234-5595 Title Secreta /Treasurer 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,20 Park Street,Albany,New York 12207. PART 2. To be completed by 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 (5-06) Additional Instructions for Form DB-120.1 By signing this form,the insurance carrier identified in box"3"on this form is certifying that it is insuring the business referenced in box "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". This Certificate is valid for the earlier ofone year after this form is approved by the insurance carrier or its licensed agent,or the policy expiration date listed in box"3c' Please Note:Upon the cancellation of the disability benefits policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of 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. DB-120.1 (5-06)Reverse