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HomeMy WebLinkAbout255 Ocean View Ave 09/14/2018 PRS 11:37 rAX 6317651750 ToWl-, Of Southold H-viy Dep Permit N'b- 7 -IGI-4WAY DEPART MF. Tcl -Peconic Lane Pecon ir.,New York 11958 (631)765-3140 APPLICATIQNIPURIMT EOR HIGHWAY EXCAVATION AND REPAIR A->PLICATION IS HEREBY made tothe Supel interidei.t.of Highways of the Town of Southold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town ofSowhold,Su6olk County.,New York,and other applicable laws,ordinances or regtilaLioiisfor eaciiiiidividiialcontiguotisexcavatioj)l)iolectliereiridr,scribed The applicant agrees to comply with all applicable laws ordinances,codes.and,rrgulations,the attached"Genera(Conditions of Permit"and"Special Conditions",if any and to permit author i7cd Ills per-lot s to make necessary inspections of the job site Plint.OLIYL�c 9.1-7 93 1---5?,5,15 C)CEW VJEA) A-V?—Mtjr- -.0 1 Ny Nanic of-A-661-ic'auil,— Phovie'Nuirz)el Addi css of Applicant C;-6SCib C/M All- Name 0fContractor Phone 11.1mr,-ici Address of Contractor E Name ofPiopcay Owncr Requesting Service(if-applicabic) Address of Owner 4 vlo' &HO Work Dusci ipt.ori and Location(Street Numbui,Ha:iiletl Cross Sti–A (a) Is construction located within 75 fist of tidal wetlands? *YesNo 'Ifyes,olliet Town peirnits may be required. NOTE All mforma(ion requested by this c;", Application/Permit Form is Required for complete application, C.70— 5 (a) Attached plot plan to ieasonahly and adequately desc6bethe proposed work Provide accurate schematic site,p larl showing she location of all proposed excavations and relationsilil,to adj[owing pi ernisci,public streets or areas-and aive P.detailed descl 11)(ioll 0.1 ail cite and pavement restoration work (b) A ulach at!orlic) necessary per nuts and license; clithis project (c) Wo,k covered by,this applica-t6mi may not commence befwc issumce of a Highway Exr-avition Petinit by the Town(71c,k Tax Map No bisti la 1000 Soction 0 FJor A o! 7 Staiutig late Com.picl foil Date A 3 Violl, Schedule Phase Com-oletion Date. Excavill loll ___ Wock Schedule Faillry Installation Must be Provided Backfill&Completion - ?-- for considej anon as P. Pavement Rcniaccrilen Ul'dwl wNcil author Ity Isapplication licnior made- 4cc'Fo%vn Cocle Chapter 2l7(F,)- of authoirLy fioni,the Unlity beina,modifted Ecoillated Cost ofPloposc(I Ntjorl,- 1 00 uJor tcg "C 09/14/2015 PRI 11:?S rA% 631?651750 Tnwz of Son+hold Hwy Dep tpjUU�/Ut15 ' 12. Insurance Coveraac (Attach Copy) (a) Insurance Companyrrvi. *- - �'- (b) Policy tt, - (c,)State whether policy of cei tification on file wirh the Highway Denai tmcnt: (d)Coverage iequued extended to the Town Any Loss including Bodily injury,property of,oriuneicial injury caused by m attributable to the work performed $1,000,000 pet Occurrence and$2,000,000 g(ne,al agg,egate 13 Secut rty (a)Surety Bond of Certified Che(l(- _provided in the total Amount of$ (b)Maintenance Bond provided:— 2 years of _ 3 years, 14. Fees for Applications and pei nnis Basic Application Fee for Each Proje(L Location - $500.00 A Project Location would include each Bell hole and/or e+,eiy road opening of excavation within any 50'Radius whether of not they may b, nitei-connected by open trench of directional boring The total number of Project Locations diall be subject to the approval of the Highway Supcuntendent. A] /Service Connections excavations tt,$50 00 $ Z No. A2 /Additional Excavations sane.service $20 00 B Trench Excavations 1S"in depth of ie:s Total Lineal Footage of rxcavatlon, ^—__L F a $t0 00 g _ C Trench Excavations 18"in depth to 5' in aenth Total Lineal Footage of Fxcavatioa, _ L.F,@S30.00 $ D Trench Excavations 5'in depth and ov--r Total Lineal Footage of)excavation, _^_L F-t $So 0() E _Utility Repair Excavat ons(k (:1,000 00!Each $ No Additional Repairs of Sante Service(_a:;$i00 00/Tach TOTAT, 09— >t--- F Official Notice to public utilities-pi o,,f iii List be provided and Shall be attached to this application pi for to issuance of pet nut Author vation is hereby gialited to the Town Ciei k(•f the l'own of Southold to issue a 1-iighway Excava- n permit to -----it ccotda e with this application and subject to the"Gcnei al Condiiions"and"Special Conditions"of permit(if an attac d hereto SUPERINTEND T TOWN OFSOt) iTUE ,N,}U 0, ' Vin nt M Ot Ian / ---- � Date Received by the Town CferDate �k � - Date Pcimit issued+(—R-6- Permit Na _—NIB NOTE Permit expires one(1)year from date r f issuance No work to start without 24 houi nohc•r to Supei uitcndcnt of 1-lrghways Pei nut must. be available at all tames fo. inspection,on site,dun ing construction- D-39 2 of y • 09/14/2018 PSI 11.37 PAX 6317651750 Town Of SouEhold Hwy Dep 0001/005 Permit No. �_ i OWN OF SOUTHOLD �pCFF02," 'P IG14WAY DEPARTMENT Pccnnic Lane on in.,New York 11958 0 s � (631)765-31411 ' APPLICATION/PERN41T FOR HIGHWAY EXCAVATION AND REPAIR A'PLiCATiON IS HEREBY made to the Supel uitendei�t of I-ligliways of tite Town of Soutliold for the issuance of an Excavation Permit pursuant to Chapter 237 of the Code of the Town of Sou hold,Suffolk County,New York,and other applicable laws,ordinances or regulations for each individual contiguous excavation ptnlect herein described The applicant agrees to comply with all applicable laws ordinances,codes and iegulations,the attached"General Conditions of Pct mit"and"Special Conditions",if any and to permit authorized inspector s to make necessary ulspcctions of the lob stic Punt 01 TvL I � � � � ^939-337T (f)C.EW t/lcvtW_�V�Il�l1l=, J Namc a,Applicant PhoncNun-,lei Arlditcss of Applicant fi3S 7±16 Cum enc. 1031-M-? S 5��� LQ _ s�xrs .TI eP-AIV 1 tante of Conti actor Phone Nuir'ici Addn,ss of Contractor 3 ttZt�bV E-C'lZf�4- _ass DCC /1 �._��>_��-+-��1?S�SI��� Name of Propcity Owner Requestingg Service(ti apap'plicabic) i Address of Owner ---- �AJork I?esaip[,on and Location(Sheet Number,Ha ulet,Cross Stled) — (a) Is construction located within 7` fr"ct of tida(wettan(l0 *Yes No *lfyes,other Town permits may lic rrcpmerl NOTE :,1!mfntmation tegttesierl by tills Signanme ofAppl cant a mit Fom is Required for-a complete application ate 5 fa) Attached plot plan to teasonahly and adequately dcsci the the pmposedi urork Provide accutatc schematic site plan showing file location of all proposed excavations and relationship to adjoining premises,public sticets or areas.and givea.detailed Mesa iption of all site and pavemc nt restoration work (b) Attach all other necessary permits and license; of this project (c) Woik covered by this application may not commence hefmc issuance of a Nighway Excavation Pei in by the Town(7,lelIC 6 Tax Mari No Disu ict 1000 S,retion_00?- F',lnck i Star[tnS Date completion Date, -- 3 Wroik Schedule Phase Completion Date F.xcavatioll __ WolkSchedule Facility Installation _ Must be pr mvided Backfill&,Completioo _ 0v—�0w---- foa consideration as a Pavement Replacement --— -- Cnmpiete Application. --- 9. U"flct which author ity is appircation bang made ,cc Town Code Chanter 217(F)-Provide Rcsolut;nn by.of authoi ay h oni,[lie Utility being modified— - -- - 10 Estimated Cosi of Proposed Work 500 ---- - I I Remarks u6Y y`�_ - �— - .� - - - 01/28/2014 01:38 6317885600 Z AND S PAGE 06 11/10/2020 TUB 19153 VZAX 631 765 1750 Igiuu��uua a9i t41201 to rxt )1•;38 r> 6:11?a-,i,Sa ^n�lt of ,nu;s��ln nwy, n�y1 fdJC /no s GahY f?istrihuli(m- I 2� Permit A rliglzu�ay r7E'l7ariyrr�nf Fn>?itt:ex(with page,3) A11p11r�11I 1`t�wn Cisrk (prigin�l) ,4�kY+C;.TQRIS RECORD' 1nsj=t3ojt Dare Findbitt (,Ase oode) Applicant Notified 2„d -------- rd ----nt __� _.W., - -- _•�._ —., -- --_ — �. ' � RISS • I can . • Itl Intl51'Aner fSAr+IGR[fCS it. Improper Lighis ST Slinken Treaah or Excavation Ll1'M Unahlc in NAe,tei,re(efue m flacltlllling) BGC, ali tdmS VudorGattsflliclinn WIP Wart;In Frog ur's Id hoproper tlaoltf;ll(tot)Pugh,not suf{'ias1Il) rras M"pecror Molding foi F uki Scku amax nrrxr-1v.1rim1 Rrx Reddy Rbr Repair D-34 of 5- t WJ004/000) GENERAL,CONDITIONS OF PERMIT APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR 1. Permittee's Contractors to Co inly with Permit Requirements: The Pet nutiee is responsible foi informing its independent contractors,employees,agents and assigns of theft responsibility to comply with this permit,including all special/site specific and general conditions imposed by the Highway Super intendent while acting as the peimrttec'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 pet mit does not convey lathe 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 peri lit. 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 o work herein authorized,or if,in the opinion of the Highway Superintendent the work performed under this permit shall cause unreasonable obsh•uctinn to requited highway maintenance or endanger the health, safety and/or welfare of vehicular o per esti ian 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 peunit was illegal of unauthorized or that the applicant failed to comply with any of the terms and conditions of the permit o Chaptei 237 ofthe Town Corte 4. Revocation of the Permit by the Highway Superintendent: if the Highway Supei intendeni deems it necessary to revoke this permit and the}nolect 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 requite,remove all of any portion cf the uncompleted utility,structure of fill and restore the site to its former condition. 5 Notice of Commencement: At least 24 houi s prior to commencement of the project,the permittee and/or conte actor shall notify the Town H,ghw»y 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 Penal inspection. 6 Storage of Equipment&Materials• 1 Ire storage of construction equipment and/or matet ials shall be confined within the project work area and/o adjacent areas where permission/legal access has been obtained in a manner that does not mterf tie with normal highway traffic. 7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for vet rtication of all existing utility mark-outs and shall take all precautions o protect same. Dannage to existing utilities shall be the i esponsibility of the contractor and shall he i epaired at the contractor's expense. 8 Road Closures: All scheduled toad C10'.1-Ires trust first receive written permission from the Southold Town Board prior to closing a road Teinpoi ai v 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 stair ttaffic to allow for single lane haf Fc. Road Closu,es due to unforeseen emergencies iequire immediate notification of the Highway Department and shall be limited to Immediate and/or expedited restoration of the Work 7_.ane 9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the joh site on a daily basis. All stockpiled soli:s well as all other pr0iect materials that will be staged with,,,tine Right-of Way must be delineated with reflective signage or other means of tto meet the minnnunn,equiicmcnts he NYS DOT Construction Standards V of; 09/14/2018 Fai 11: 38 Fiz�% 6317651750 Tow�I 01 nu`hold Ally Dep 0JO03/005 Copy Do ihution Pe nit 9 Highway Depaitmeni Engine (with page 3) Applicant Town Clerk([)t igmal) ;ti�SPECTOR'S RECORDS Inspection Datc Fundings(use code) Applicant Notified 1 Sl Znd 3rd —�-- —— —"' -- (To Pei ntt Clerk) REMARKS CODE IP, impiopet Bamcadcs IL impiopei Lights ST Sunken Trench or Excavation t_iTM Unable to Measure(due to backfilling) BUC Building Under Constriction WIP Woik In Piogices D3 Improper Backfill(too h gh,not suglicletti) H?S Inspector Holding foi Final Settlement of Fxr tvatron Rl•R Ready foi Repair D-3G 3 of 55- • 09/14/2016 FRI 11:39 FAX 6317651750 Town of Southnld Hwy pep 0005/005 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 disturber 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 aieas of soil disturbance resulting from the approved project shall be stabilized to the satisfaction of the Highway Superintendent ❑nmediately following project completion. if the project site remains inactive for mora than 48 hours of 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 gcl urination. 13 Backfill&Compaction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a well-defined moisture density relations}rip as determined to be in accordanee with ASTMD 698 Fill shall be placed in maximum lips oftwclve(I7_")inches thick and shall be mechanically compacted to a Ninety- five(95%)peicent maximum dry densit/. Suitable hydraulic compaction by water betting at three-foot intervals will also be petmitted sublecr t,,a project specific approval by the Highway Superintendent. 1/1 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 bcxes,sprinkler systems,trees and ornamental plantings, excavations through driveways and private road pavements must be teconsti ucted to meet all requirements of Southold Town Highway Specifications All pre-existing load shoulder improvements that have been distui bed during consti action must be;eplaced 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 scl emattc site plans must be provided to show of indicate all pioposed construction activity required Lildel this permit All Pavement surfaces scheduled foi 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 ditnen;,toti or labeling This schematic site plan must provide details on all restoration required to meet the requiiemcnts 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 mariner; (Note When Concrete Pavements are Present,Prase review Rcsloranon acquirements with the 1-1191tway 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(1211)inches oil all sides; c) Install a compacted lift of 4"thick Sto is Blend base ARCA 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(1.511)inch ol`Mphalt(Type 6)Wearing Course. (Provide AC at all_joints} All work listed herein must meet the nuni,num requirements of the Southold Town Highway Specifications 17. Trenching of Pavement Surfaces Exceeding One Hundred(1001)Feet in Lent?th All trenching of pavement surfaces exceeding 100,in lengih Must first be reconstructed to meet the requii erilents of Item rY 16 rJ ntendent, m noted above. Once all paveent rcConstrUctioll SUpel7is completed to the satisfaction of the Highway the entire road section ann/oi width of road ovei the entire length of trench shall be tepaved with a two(2")inch lift of Asphalt(Type 6)Wearing Course(Typical,shouldet to shoulder). 01/28/2014 01:38 6317885680 Z AND S PAGE 04 . ` OF eel qRoFrEffrjM LLC ENR & systm _qpm "silaw how- SYSTDA MWCIPA� WATER wA / � ` ` � ` 01/28/2014 01:38 6317885600 Z AND S PAGE 08 AC �' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11/10/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE T30ES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y 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 have ADDITIONAL INSURED provisions or be Ohdbrsed. If SU13ROGATION 1S 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 llau of such endorsement(s). PRoouceR 14AME Matthew Daley Matthew Daley A CN,r F639-744-3350 631-744-3383 mj, A/C Na Farm Family Insurance EMAIL matt.dele farm-famil .com ADDRESS: Y@ 85 Echo Avenue-Suite 2 INSURERS AFFORDING COVERAGE NAIL k Miller Place, Ny 11764 INSURERA Farm Family Casualty Insurance Co- 13803 INSURED INSURI F S 7-&S Contracting Inc INSURER P.O.Box 202 INSURER D Fishers Island NY 06390 INSURER r. COVERAGES CERTIFICATE NUMBER: REVISION NUMHI=R' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUI2IEnD 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 NER TR s aR POLICY EFFTYp6 DK INSURANCE g EXP POLICYNUMBER MMIDD MMbuNy" LIMITS 'A X COMMERCIAL GUNEkALLTARILITY 3152X2134 09/30/20 09/ 21 EACH OCCURRENCE S 1,000,000 C(AIMa-MADE 7 OCCUR PREMISK I rr S 100,000 MED EXP(Any eke psrson) 5 5,000 PERSONAL&ADVINJUkY $ 1,000,000 GENT AGGREGAYELIMITAPPLIESPEP, GENERAL AGGREGATE 5 2,000,000 X POLICY j80ST El LOC PRODUCTS-COMP/OP AGG '$ 1,000,000 1 OTHER- $ A I AUTOMO8ILEL(AB)y,ITY 315204692 09 30/20 09/30/21 COMBINED SINGLE LIMIT _$_1C)00', 000 Ea accident ANY AUTO BODILY INJURY(Per person) S OWNED X SCHEDULED BODILY INJURY P AUTOS ONLY ALIT ( or acdoenp S Ix HIRED x NON-oWNEo AUTOS ONLY AVTO5 ONLY PROPERTY DAMAGE $ Per accident M1 X UMtIRrLL,ALIABX OCCUR 3152E2431 09/30!20 09/30/21 EACH OCCURRENCE s 3,000,000 EXCrSs LIAa CLAIMS-MADE AQUREOATE 5 3,000,000 DED f2ETENTION S S WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPRO P RIETORIPARTNER/ExECUTIV E OFFICERIMEMBEREXCLUDED? NIA E L EACH ACCIDENT S (Mrndatoly In NH) If yes,deecrlbe under E L DISEASE-F11 EMPLOYEE $ DESCRIPTION OF OPERATIONS below E L DISEASE•POIJCY LIMIT $ I I DE80RIPTION OF OPPRATIONS/LOCATIONS I VEHICLES (ACORD 961,Add ltlonal Romar"SOwftle,may be attached,f more=pace In raqulrud) CARPENTRY CERTIFICATE HOLDER CANCELLATION 'Town of Southold 53095 Main Street SHOULD ANY OF THE ABOVE 058CRI[SED POLICIES BE CANCELLED BEFORE Southold, NY 11971 THE EXPIRATION DATE THEREOF, NOTICH WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHOR12E0 REPRESENTATIVE .r ©1988-2015 ACORD CORPORATION- All rights re-5erved. ACORD 25(2016/03) The ACORO name and logo ars registered marks of ACORD 01/28/2014 01:38 6317885600 Z AND S PAGE 09 NYSIF Nc York State Insurance Fund 199 CHURCH STREET,NEW YORK,N Y.10007-1100 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE lil - 5ri" Annnnn 061189187 a l ti. HAMOND SAFETY MANAGEMENT LLC 6800 JERICHO TURNPIKF � SUITE 105W SYOSSET NY 11791 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER Z&S CONTRACTING CORP TOWN OF SOUTHOLD 85 ECHO AVENUE 53095 MAIN STREET SUITE 2 SOUTHOLD NY 11971 MILLER PLACE NY 11764 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G1282 382-9 735311 � 01/01/2020 TO 01/01/2021 11/10/2020 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO, 1282 382,9, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATP THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS',/NVWW_NYSIF,COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND 1S NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THF CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOPUNSURANCE FUND UNDERWRITING VALIDATION NUMBER; 1038314353 U,26,3