Loading...
HomeMy WebLinkAboutCR 48 e/s of Depot Ln J I Permit No. � � j TOWN OF SOUTHOLD �o�guFFt1(�e. HIGHWAY DEPARTMENT Peconic Laney Peconic,New York 119550 (631)765-3140 �Al APPLICATION/PERi12IT,FOR HIGHAVA'Y ExcAVATION AND REPAIR APPLICATION 1S 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 inspector s to make necessary inspections of the job site. ROLT 22 Depot Ln Print or Tyne 1 CSC Holdings 631;846-5519 1111 Stewart Avenue, Bethpage NY 11714 Name of Applicant I Phone Number Address of Applicant 2. Eastern Utilities Contracting Corp. 631-874-2289 336 S Service Rd Melville, NY 11747 Name of Contractor j} Phone Number Address of Contractor 3. l Name.of Property Owner Requesting Service(if applicable) Address of Owner 4 Place U/G Conduit vaults&Fiber optic ROLT cabinet on the e/s of Depot Ln s/o Middle rd btw poles 43&45 Work Description and Location(Street Number,Hamlet,Cross Street) X (a) Is construction located within 75 feet of tidal wetlands? *Yes No *If yes,dth6r Town permits may be required. NOTE: All information requested by this S' iature of Applicant Application/Permit Form is Required for a complete application! 4/14/20 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 necessarypermits 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. 'i 6. Tax Map No.: District :1000 , Section Block Lot 7. Starting Dale: 5/4/20 ( 'Completion Date: 5/9/20 ii S. Work Schedule: Pliase Completion Date Excavation I S/5/20 Work Schedule Facility Installation S/6/2 9 Must be provided Backfill&Completion for consideration as a Pavement R placement Complete Application. 9. Under which authority is application being made: CATV See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. 10. Estimated Cost of Proposed Work. S_i 0,n o o 11. Remarks:Sonstructi nn'wi�l l he completed within rinyg of 2t;ar'-t; date 4 D-39 { 1 of 5 a i 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: see attached (b) Policy 4: see attached (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 i 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; 164 L.F.@$10.00 $ 1,640 C. Trench Excavations 18"in depth to 5'in depth Total Lineal Footagei 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. TOTAL$ 2,140 F. Official Notice to p#ic 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 Excav n permit to: CSC Holdings 12 Industrial Rd Port Jefferson Station NY 11776 i accordancewith this application and subject to the`,General Conditions"and"Special Conditions"of permit(if a )attac d hereto SUPERINTEN T I TOWN OF SO HO L W Y Vi cent M. �� Date 5f`1 Lv Date Received by the Town Clerk i l(�l Date Permit Issued Permit No. (S91 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. I D-39 2 of 5 I I Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk(Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified 1 St 2nd 3rd 01 (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 GENERAL CONDITIONS OF PERAUT 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 RijZht 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 Hij4hway 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 terns 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. � a-f� 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 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). (Fe1, al«) DATE(MMIDD/YYYY) ACCN?" CERTIFICATE OF LIABILITY INSURANCE 4/13/2020 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 ,NAME' Alliant Insurance Services, Inc PHONE FAX 333 Earle Ovington Blvd., Ste 700 A/C No); Uniondale NY 11553 ADDRESS. INSURERS AFFORDING COVERAGE NAIC# INSURER •Travelers Indemnity Company 25658 INSURED INSURER B:Travelers Property Casualty Company of America 25674 Eastern Utilities Services LLC INSURER C:Charter Oak Fire Insurance Company 25615 336 South Service Road Melville NY 11747 INSURER D.RSUI Indemnity Company 22314 INSURER E.Endurance American Ins.Co. 10641 INSURER F: Navigators Insurance Company 42307 COVERAGES CERTIFICATE NUMBER:2029218007 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 INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY Y Y VTC2K-CO-2E971115-IND-19 10/31/2019 10/31/2020 EACH OCCURRENCE $2,000,000 AMAGE TO RENTED SaCLAIMS-MADE F occurrence) $300,000 X Contractual Liab MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 POLICY 1K PRO- JECT F LOC PRODUCTS-COMP/OPAGG $4,000,000 ROTHER $ B AUTOMOBILE LIABILITY Y Y VTC2J-CAP-2E971127-TIL-19 10/31/2019 10/31/2020 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR Y Y CUP-2P395637-19-25 10/31/2019 10/31/2020 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED I I RETENTION$ $ C WORKERS COMPENSATION Y UB-5N4 9 624 9-1 9-25-K 10/31/2019 10/31/2020 X STATUTE ERH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE FN] NIA EL EACH ACCIDENT $1,000,000 OFFICER/MEM BER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 D Excess Liability Y Y NHA088033 10/31/2019 10/31/2020 Occ $5,000,000 Agg $5,000,000 E Excess Liability(Quota Share) EXC30000824201 10/31/2019 10/31/2020 Occ $7 5M p/o$15M Agg$7 5M p/o$15M F Excess Liability(Quote Share) NYI9EXC9439721V 10/31/2019 10/31/2020 Occ $7 5M p/o$15M Agg$7 5M p/o$15M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re Roll 23 Peconic Ave Town of Southold is Included as Additional Insured on a Primary and Non-Contributory basis as respects General Liability,Automobile Liability and Umbrella Liability as required by written contract.Waiver of Subrogation Is Included and applies In favor of the Additional Insureds as required by written contract. CERTIFICATE HOLDER CANCELLATION 30 Das Notice of 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. Highway Dept PeconicLane AUTHORIZED REPRESENTATIVE Peconic NY 11958 AC-1,4,— ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD EW YORK workers'STATE Compensation CERTIFICATE OF INSURANCE COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b Business Telephone Number of Insured EASTERN UTILITIES SERVICES LLC 336 SOUTH SERVICE ROAD 5153366720 MELVILLE, NY 11747 Work Location of Insured(Only required if coverage is specifically limited to 1 c Federal Employer Identification Number of Insured certain locations in New York State,i e,Wrap-Up Policy) or Social Security Number 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 Y p Y Highway Dept 3b Policy Number of Entity Listed in Box"1 a" Peconic Lane R23364-000 Peconic, NY 11958 3c Policy effective period 11/8/2019 to 12/10/2020 4 Policy provides the following benefits 0 A Both disability and paid family leave benefits B Disability benefits only. C Paid family leave benefits only. 5. Policy covers Qi A All of the employer's employees eligible under the NYS Disability and Paid Family Leave 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 and/or Paid Family Leave Benefits insurance coverage as desc' d above. Date Signed 4/13/2020 By (Signature of insurance carrier's authonz d representative or NYS Licensed insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT If 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 4B, 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 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 4C or 56 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 with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note: Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carvers are authorized to issue Form DB-120 1 Insurance brokers are NOT authorized to issue this form. 1313-120.1 (10-17) 111111111 !�I°!°°1101111°1°111°11°11°111°1111111 Additional Instructions for Form D13-120.1 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 and/or paid family leave benefits under the New York State Disability and Paid Family Leave 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. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is cancelled 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 coverage indicated on this Certificate. (These notices my 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 Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave 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 and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE 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 and after January first, two thousand and twenty-one, the payment of family leave 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 and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1 (10-17)Reverse YORK Workers' CERTIFICATE OF STATE Compensation Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured 516.336.6720 Eastern Utilities Service LLC 336 South Service Road 1 c.NYS Unemployment Insurance Employer Registration Number of Melville,NY 11747 Insured Work Location of Insured/Only required if coverage is specifically id.Federal Employer Identification Number of Insured or Social Security limited to certain locations in New York State;Ie,a Wrap-Up Policy) 2. Name and Address of Entity Requesting Proof of Coverage 3a.Name of insurance Carrier (Entity Being Listed as the Certificate Halder) Charter Oak Fire Insurance Company Town of Southold 3b.Policy Number of Entity Listed In Box"1 a" Highway Dept Peconic Lane UB-5N496249-19-25-K Peconic,NY 11958 3c.Policy effective period 10/31/2019 to 10/31/2020 3d.The Proprietor,Partners or Executive Officers are ® Included.(Only check box if all pariners/officers included) E] 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"1a"for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3,8 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 depicted on this form. Approved by: Philip Friel (Print name of authorized representative or licensed agent of insurance Ferrier) Approved by: 4�; 4/13/2020 (signature) (Dile) Title:Account Executive Telephone Number of authorized representative or licensed agent of insurance carrier, 516.414-8900 Please Note:Only insurance carriers and their licensed agents are authorized to Issue Form C-105.2.Insurance brokers are N01 authorized to issue It. C-105.2(9-17) www.wcb.ny.gov 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. ti C-105.2 (9-17)REVERSE