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HomeMy WebLinkAbout45474-Z �uFFocK TOWN OF SOUTHOLD BUILDING DEPARTMENT . . TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 45474 Date: 11/20/2020 Permission is hereby granted to: Indian Neck III LLC c/o Ernest Scalamandre 1350 Ave of Americas Ste 2300 New York, NY 10019 To: legalize "as built" deer fence as applied for per ZBA approval. At premises located at: 3123 Skunk Ln, Cutchogue SCTM # 473889 Sec/Block/Lot# 97.-9-10.4 Pursuant to application dated 10/8/2020 and approved by the Building Inspector. To expire on 5/20/2022. Fees: DEER FENCE $150.00 Total: $150.00 ui or TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey Southoldtownny.gov PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees C.O.Application Flood Permit ExaminedD ,20 (1 ® Single&Separate VVV\\\ Truss Identification Form F E B 1 9 2019 Storm-Water Assessment Form Contact: Approved ku20 AU 1�} .Di'I Du "-'j Mail to: 1A Disapproved a/c- 117 `� Phone-' ' — Expiration ,20 ect .rJ i' PLICATION FOR BUILDING PERMIT - 0 GT - 8 2020 Date — Z , 20Irl _ ,,,�;ao INSTRUCTIONS �v .r ... • `�,.-.�-tom a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application,the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within'18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize, in writing,the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County,New York, and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code,housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. oo A'e0KM1-6,A0"!X' A (Si of app cant name,if a corporation) 'u-555 & L-ij ULLE:l 1�4 (Mailing address of applicant) Lo-"oaul�-AW 1 lni State whether applicant is owner, les e, agent tect, engineer, general contractor, electrician, plumber or builder Name of owner of premises f 1 I 1 1--1--L (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer ame and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 131275 y 01�- LuTLJ r, (- House Number Street Hamlet County Tax Map No. 1000 Section- eTq Block Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and in ended use and occupancy of proposed construction: a. Existing use and occupancy VM4,h �C�LC��LZCJ� b. Intended use and occupancy V 3. Nature of work check which applicable):New Building Addition Alteration Repair Removal (Demolition Other Work (Description) 4. Estimated Cost Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units umber of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. �- r 7. Dimensions of existitomes, if any: Front �� Rear �� Depth Height Number of Stories^ Dimensions of same structure with alterations or additions: Front, Rear Depth Height �` Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of S ries 9. Size of lot: Front 3f- I Rear 253 Depth 194 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated A4= 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO 13. Will lot be re-graded? YES NO&Will excess fill be removed from premises? YES NO X 14. Names of Owner of premises , FA aln Address 6Lr 4 d,.lq 4L;& Phone No. Name of Architect Address i�� Phone No 7� Name of Contractor AddressPhone No. !-Z!tS -154 f 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO_)(__ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES NO-X— * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OFtQ� ) 4.j� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the / 6k,4l7T (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this � h day of rr,b ruDr 20 TRA EY L. DWYER NOTARY PUBLIC, OF NEWAY Notary Pub Uc QUALIFIED IN SUFFOLK COgnatur of pplicant COMMISSION EXPIRES JUNE 30,2— FORM NO. 3 NOTICE OF DISAPPROVAL DATE: March 5, 2019 TO: Bill Kelly(Indian Neck III LLC) 22355 Cox Lane LLC Cutchogue, NY 11935 Please take notice that your application dated February 19, 2019 For permit to construct an 8-foot deer fence at Location of property: 3123 Skunk Lane, Cutcho u County Tax Map No. 1000 - Section 97 Block 9 Lot 10.4 Is returned herewith and disapproved on the following grounds: The proposed fence is not permitted pursuant to Article XXII Section 280-105C, which states, "In residential and nonresidential zones except properties parcels engaged in bona fide agricultural production the installation of a deer exclusion fence maybe permitted by obtaining a building permit issued by the building inspector subject to the following criteria: The property is vacant and is not engaged in bona fide agricultural production. Authorized Signature Note to Applicant: Any change or deviation to the above referenced application, may require further review by the Southold Town Building Department. CC: file, Z.B.A. FORM NO. 3 NOTICE OF DISAPPROVAL DATE: March 5, 2019 RENEWED: November 13, 2019 TO: Bill Kelly(Indian Neck III LLC) 22355 Cox Lane LLC Cutchogue, NY 11935 Please take notice that your application dated February 19, 2019 For permit to construct an 8-foot deer fence at Location of property: 3123 Skunk Lane, Cutcho ugue, NY County Tax Map No. 1000 - Section 97 Block 9 Lot 10.4 Is returned herewith and disapproved on the following grounds: The proposed fence is not permitted pursuant to Article XXII Section 280-105C, which states, "In residential and nonresidential zones except properties parcels engaged in bona fide agricultural production the installation of a deer exclusion fence may be permitted by obtaining a building permit issued by the building inspector subject to the following criteria: The property is vacant and is not engaged in bona fide agricultural production. % Aut Si a e Note to Applicant: Any change or deviation to the above referenced application, may require further review by the Southold Town Building Department. CC: file, Z.B.A. FORM NO. 3 NOTICE OF DISAPPROVAL DATE: March 5, 2019 RENEWED: November 13,2019 RENEWED: January 13,2020 TO: Bill Kelly (Indian Neck III LLC) 22355 Cox Lane LLC Cutchogue,NY 11935 Please take notice that your application dated February 19, 2019 For permit to construct an 8-foot deer fence at Location of property: 3123 Skunk Lane, Cutcho ue,NY County Tax Map No. 1000 - Section 97 Block 9 Lot 10.4 Is returned herewith and disapproved on the following grounds: The proposed fence is not permitted pursuant to Article XXII Section 280-105C, which states, "In residential and nonresidential zones except properties parcels engaged in bona fide agricultural production the installation of a deer exclusion fence may be permitted by obtaining a building permit issued by the building inspector subject to the following criteria: e ro ert is v c and is not en a d in bona fide agricultural production. u ori igna e Note to Applicant: Any change or deviation to the above re need application, may require further review by the Southold Town Building Department. CC: file,Z.B.A. FORM NO. 3 NOTICE OF DISAPPROVAL DATE: March 5, 2019 RENEWED: November 13,2019 RENEWED: January 13,2020 AMENDED: February 24,2020 TO: Bill Kelly (Indian Neck III LLC) 22355 Cox Lane LLC Cutchogue,NY 11935 Please take notice that your application dated February 19, 2019 For permit to legalize an as built an 8-foot deer fence at Location of property: 3123 Skunk Lane, Cutchogue,NY County Tax Map No. 1000 - Section 97 Block 9 Lot 10.4 Is returned herewith and disapproved on the following grounds: The proposed fence is not permitted pursuant to Article XXII Section 280-105C, which states, "In residential and nonresidential zones except properties parcels engaged in bona fide agricultural production the installation of a deer exclusion fence mawpermitted by obtaining a building permit issued by the building inspector subject to the following criteria: The property is vacant and is not engaged in bona fide agricultural production. This Notice of Disapproval was amended on February 24, 2020, when it was brought to the building department's attention that the deer fence had been erected without the benefit of a buildingpermit. L7A-atH'o-'rnized ignature Note to Applicant: Any change or deviation to the above referenced application, may require further review by the Southold Town Building Department. CC: file, Z.B.A. BOARD MEMBERS OF SOOT Southold Town Hall Leslie Kanes Weisman,Chairperson ��� y�! 53095 Main Road-P.O.Box 1179 O Southold,NY 11971-0959 Patricia Acampora Office Location: Eric Dantes Town Annex/First Floor, Robert Lehnert,Jr. • �� 54375 Main Road(at Youngs Avenue) Nicholas Planamento liYCoUpm Southold,NY 11971 :1V http://southoldtownny.gov ZONING BOARD OF APPEALS ATOWN OF SOUTHOLDTel.(631)765-1809-Fax(631)765-9064SoutholdCler:- FINDINGS, DELIBERATIONS AND DETERMINATION MEETING OF AUGUST 20,2020 ZBA FILE: #7411 NAME OF APPLICANT: Indian Neck III,LLC PROPERTY LOCATION: 3123 Skunk Lane, Cutchogue,NY SCTM: 1000-97-9-10.4 SEORA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type H category of the State's List of Actions,without further steps under SEQRA. SUFFOLK COUNTY ADMINISTRATIVE CODE: This application was referred as required under the Suffolk County Administrative Code Sections A 14-14 to 23, and the Suffolk County Department of Planning issued its reply dated March 9, 2020 stating that this application is considered a matter for local determination as there appears to be no significant county-wide or inter-community impact. LWRP DETERMINATION: The relief, permit, or interpretation requested in this application is listed under the Minor Actions exempt list and is not subject to review under Chapter 268. PROPERTY FACTS/DESCRIPTION: The subject, conforming 9.936 acre, irregular shaped, landlocked, parcel, located in the AC Agricultural Zone,measures 221.98 feet behind a single family residence located on Skunk Lane then continues southwest 61 feet and northwest 99.6 feet behind the same residence, then runs northeast 1,386.69 feet behind several residences, part of the Bay Homes subdivision, then runs southeast 136.27 feet and continues 197.8 feet, before returning 1,445.97 feet back to the residence located on Skunk Lane. The subject parcel is improved with paddock fencing, a run-in shed and an `as-built' deer fence as shown on the survey prepared by Martin Alexander Read,Licensed Land Surveyor,Pinnacle Land Surveyors LLP and dated February 8,2018 BASIS OF APPLICATION: Request for a Variance from Article XXII, Section 280-105C and the Building Inspector's January 13, 2020, Amended February 24, 2020 Notice of Disapproval based on an application for a permit to legalize an "as built" 8 foot deer fence; at 1) not permitted on vacant parcel not engaged in bona fide agriculture production; located at: 3123 Skunk Lane, Cutchogue,NY. SCTM No. 1000-97-9-10.4. RELIEF REQUESTED: The applicant requests a variance to legalize an `as-built' eight-feet high deer fence, running along the perimeter of a separate lot,which is part of a larger"combined"farm parcel. The `as-built'fence is located on the eastside of Skunk Lane and along multiple neighboring residences,where the subject independent parcel is vacant and is not recognized as being engaged in bona fide agricultural production. Page 2,August 20,2020 r #7410,Indian Neck,III,LLC SCTM No. 1000-97-9-10.4 ADDITIONAL INFORMATION: The applicant owns several parcels of land, totaling approximately 133.48 acres,the bulk of which is actively farmed and receives and agricultural tax exemption from the Town of Southold and is engaged in bona fide agricultural activities. Development rights are intact. The combined parcels are operated collectively as "Indian Neck Farm". The applicant, in addition to the subject parcel, is requesting similar relief on two other, adjacent, parcels under application numbers: #7410 & #7411. The Zoning Board of Appeals opened all three applications at the same time during the public hearing on Thursday,August 6,2020. The applicant stated that the subject parcel has been in agricultural production and will continue to farm the property, planting a variety of crops including squash, which is sold locally. The property also is used to graze livestock. The Town of Southold issued a building permit for horse sheds on this parcel on June 28,2011. On August 5, 2020, the applicant provided the Board with a Resolution of the Suffolk County Agricultural and Farmland Protection Board recommending the inclusion of the subject parcel(s)into the Agricultural District No. 1. The Resolution is numbered 500-2020 of the Suffolk County Agricultural and Farmland Protection Board,pursuant to Section 303-B of Article 25-AA of the NYS Agriculture and Markets Law. Two residential neighbors, each with homes on Skunk Lane, spoke during the public hearing outlining their concerns over the proposed deer-fencing. The applicant offered to discuss their concerns privately and would work towards mitigating any issues brought up. Both neighbors stated that they preferred an active farm behind their home versus residential development. By right, an agricultural property is permitted deer fencing when engaged in bona fide agricultural operations. The applicant installed the `as-built' deer fencing well inside their property line along Skunk Lane and neighboring residences. The deer fence is well screened by existing vegetation and wooded areas. FINDINGS OF FACT/REASONS FOR BOARD ACTION: The Zoning Board of Appeals held a public hearing on this application on August 6,2020 at which time written and oral evidence were presented. Based upon all testimony, documentation,personal inspection of the property and surrounding neighborhood, and other evidence,the Zoning Board finds the following facts to be true and relevant and makes the following findings: 1. Town Law 4267-b(3)(b)(1). Grant of the variance will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. Skunk Lane is a well-developed residential community running along Mudd Creek and towards the Peconic Bay and the Nassau Point community. While developed primarily with single family residences, there are patches of woodlands, marsh areas and other open space, including the subject farm parcel. The `as-built' fencing is located behind existing vegetation and trees and is set well into the applicant's property. Passersby and residents will have difficulty discerning that the deer fence is there. The deer fencing will have little if any impact on the neighboring landowner's view shed and is essential for successful farming in the Town of Southold. Furthermore,the deer fencing that is visible to immediate neighbors is not located on the property line, as commonly installed, but rather set into the farm field, allowing the adjacent resident more visual space. 2. Town Law &267-b(3)(b)(2). The benefit sought by the applicant cannot be achieved by some method, feasible for the applicant to pursue, other than an area variance. Deer infestation is a recognized problem in the Town of Southold. There is no way to sustain agricultural production without deer fencing. If the fence is not allowed to remain,the crops will be decimated, and the land will be fallow. 3. Town Law §267-b(3)(b)(3). The variance granted herein is mathematically substantial, representing 100% relief from the code. However, the applicant has illustrated that the subject parcel is an integral part of a larger, f 6 Page 3,August 20,2020 #7410,Indian Neck,III,LLC SCTM No. 1000-97-9-10.4 combined agricultural operation and has shown evidence that the property is included in a Suffolk County recognized Agricultural District. 4. Town Law §267-b(3)(b)(4). No evidence has been submitted to suggest that a variance in this residential community will have an adverse impact on the physical or environmental conditions in the neighborhood. 5. Town Law 4267-b(3)(b)(5). The difficulty has been self-created. The applicant purchased the parcel after the Zoning Code was in effect and it is presumed that the applicant had actual or constructive knowledge of the limitations on the use of the parcel under the Zoning Code in effect prior to or at the time of purchase and the applicant should have established participation in bona fide agricultural activities prior to the installation of the deer fence. 6. Town Law $267-b. Grant of the requested relief is the minimum action necessary and adequate to enable the applicant to enjoy the benefit of a perimeter 8 feet high deer fence while preserving and protecting the character of the neighborhood and the health,safety and welfare of the community. RESOLUTION OF THE BOARD: In considering all of the above factors and applying the balancing test under New York Town Law 267-B, motion was offered by Member Dantes, seconded by Member Planamento, and duly carried,to GRANT the variance as applied for, and shown on the survey prepared by Martin Alexander Read,Licensed Land Surveyor, last revised April 10,2019. SUBJECT TO THE FOLLOWING CONDITIONS: 1. The applicant must apply to the Building Department for a building permit for the "as built" improvement(s)within 30 days of the date of this decision and submit same to the Office of the Zoning Board of Appeals,or submit a written request for an extension to the Board of Appeals setting forth the reason(s)why the applicant was unable to obtain a building permit in the time allotted. 2. The applicant must submit evidence of an approved Agricultural Exemption from the Town Assessors to further prove the parcel is engaged in a bona fide agricultural operation within three years. 3. At the discretion of the Board of Appeals,failure to comply with the above conditions may render this decision null and void Any deviation from the survey, site plan and/or architectural drawings cited in this decision will result in delays and/or a possible denial by the Building Department of a building permit, and may require a new application and public hearing before the Zoning Board of Appeals. Any deviation from the variance(s)granted herein as shown on the architectural drawings, site plan and/or survey cited above, such as alterations, extensions, or demolitions, are not authorized under this application when involving nonconformities under the zoning code. This action does not authorize or condone any current or future use, setback or other feature of the subject property that may violate the Zoning Code, other than such uses, setbacks and other features as are expressly addressed in this action. In the event that an approval is granted subject to conditions, the approval shall not be deemed effective until the required conditions have been met; and failure to comply therewith will render this approval null and void. The Board reserves the right to substitute a similar design that is de mininds in nature for an alteration that does not increase the degree of nonconformity. Page 4,August 20,2020 #7410,Indian Neck,III,LLC SCTM No. 1000-97-9-10.4 Pursuant to Chapter 280-146(B) of the Code of the Town of Southold any variance granted by the Board of Appeals shall become null and void where a Certificate of Occupancy has not been procured, and/or a subdivision map has not been filed with the Suffolk County Clerk,within three (3)years from the date such variance was granted. The Board of Appeals may, upon written request prior to the date of expiration, grant an extension not to exceed three (3) consecutive one (1)year terms. Vote of the Board: Ayes:Members Weisman(Chairperson)Acampora,Dantes,Lehnert, and Planamento(5-0). Leslie Kanes Weisman,Chairperson Approved for filing Fl� /2020 i BOARD MEMBERS Southold Town Hall Leslie Kanes Weisman,Chairperson o��0 SQUTy�,� 53095 Main Road-P.O.Box 1179 ti G► Southold,NY 11971-0959 Patricia Acampora Office Location: Eric Dantes Town Annex/First Floor, Robert Lehnert,Jr. • y0� 54375 Main Road(at Youngs Avenue) Nicholas Planamento l',f' •' Southold,NY 11971 http://southoldtownny.gov ZONING BOARD OF APPEALS TOWN OF SOUTHOLD Tel.(631)765-1809-Fax(631) 765-9064 November 10,2020 Martin Finnegan, Esq. Twomey, Latham,.Shea, Kelly, Et.AI 'P.O. Box 9398 Riverhead,NY 11901 RE: Request for Extension—30 Days Appeal No.7409,7410 and 7411 Indian Neck SCTM No. 1000-97-9-10.4, 1000-97-9-12, 1000-98-1-2.1 Dear Mr. Finnegan; I received your correspondence of October 19,2020,requesting an additional extension for thirty(30)days in order to comply with the Zoning Board's condition(#1)which requires that your client apply to the Building Department for a building permit for"as built'deer fence within 30 days from the date of the Zoning Board of Appeals' decision as cited above. According to the variance relief granted on August 20, 2020,the applicant was required to obtain and submit the building permits by September 20,2020. In your correspondence,you explained that although the Building Department staff is satisfied with your application submission,they have requested that you request an extension from the Zoning Board of Appeals. Based upon the circumstances described, the Board grants your request for an extension of thirty days (30) from the date of this resolution,November 5,2020,and to expire on December 5, 2020 to comply with the aforementioned Zoning Board of Appeals condition. Feel free to contact our office if you have any further questions or concerns. I will instruct the office to send a copy of this letter with your request to the Building Department. Sincerely, Leslie Kanes Weisman Chairperson cc: Michael Verity, Chief Building Inspector 3 -s ACD® DATE(MM/DD/YYYY) �- CERTIFICATE OF LIABILITY INSURANCE 09/21/2018 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(fes)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 d Aon Risk Services Central, Inc. NAME* O Chicago IL Office (ac No.Ext) (866) 283-7122 FAX No): (800) 363-0105 200 East Randolph E-MAIL Chicago IL 60601 USA ADDRESS' _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA• Zurich American Ins CO 16535 Morton Buildings, Inc. INSURER B. American Zurich Ins Co 40142 252 West Adams Street Morton IL 61550 USA INSURER Great American insurance Company of NY 22136 INSURER D INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: 570073159854 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 Limits shown areas requested A ID SUBR POLICY EFF POLICY EXP INS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIOD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE t2,000,000 CLAIMS-MADE OCCUR A $1,000,000 PREMISES Ea occurrence MED EXP(Any one person) $50,000 PERSONAL&ADV INJURY $2,000,000 't'nt GEN'LAGGREGATELIMITAPPLIESPERGENERAL AGGREGATE $10,000,000 w X POLICY �JECT LOC PRODUCTS Excluded OTHER o n A AUTOMOBILE LIABILITY BAP 9376314 15 10/01/2018 10/01/2019 COMBINED SINGLE LIMIT $2,000,000 n0 Ea accident X ANYAUTO BODILY INJURY(Per person) Z OWNED SCHEDULED BODILY INJURY(Per accident) d AUTOS ONLY AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY AUTOS ONLY Per accident V 111 C X UMBRELLA LIAB X OCCUR UMB2275621 10/01/2018 10/01/2019 EACH OCCURRENCE $2,000,000 ID EXCESS LIAB CLAIMS-MADE Umbrella Liability AGGREGATE $2,000,000 SIR applies per policy terns & condi ions DED X RETENTION B WORKERS COMPENSATION AND WC937631115 10/01/2018 10/01/2019 X PER OTH- EMPLOYERS'LIABILITY Y/N AOS STATUTE I ER ANY PROPRIETOR!PARTNERI EXECUTIVE EL EACH ACCIDENT $1,000,000 A OFFICER/MEMBEREXCLUDED? F9 NIA WC937631215 10/01/2018 10/01/2019 (Mandatory in NH) Retro MA,WI E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000— ill/= DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) rg� CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Town of Southold AUTHORIZED REPRESENTATIVE PO Box 962 Cutchogue NY 11935-1146 USA e��a � �'LdQ/G�s>G�aO �Pf iJ Baa. ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD YORK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured (309)263-7474 MORTON BUILDINGS,INC. 252 WEST ADAMS 200 PO BOX 399 1c.NYS Unemployment Insurance Employer Registration Number of MORTON IL 61550 Insured 1532342 Work Location of Insured(Only required if coverage is specifically limited to 1 d Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i e.,a Wrap-Up Policy), Number 37-0347310 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) AMERICAN ZURICH INSURANCE COMPANY Town of Southhold' 3b.Policy Number of Entity Listed in Box 1 a" 54375 Main Road WC 9376311-15 Southhold,NY, 11971 3c Policy effective period 10-01-2018 to 10-01-2019 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. This certifies that the insurance carrier indicated above in box"3"insures the business referenced above In box 1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form, New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". Will 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 period? Zx YES E]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 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: Kelly Cada (Print name of authorized representative or licensed agent of insurance carrier) Approved by: 09/14/2018 (Signature) (Date) Title- VP Underwriting Services Telephone Number of authorized representative or licensed agent of insurance carrier. (847)605-6914 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-15) 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. C-105.2 (9-15) REVERSE ��`ri��F y`Y.�� r; �,� � _.r• � _..:'y S fll�t •. Y� �c-��•�f°r it it t 'Jl�'.;, �' 't��„/7�'��.. it , -- � ko 5 j.liYr \i o•.''- SA t 1\ 5 Pli �• fes•' ````. / .. , rf1 Y? •-.'��"-1, ` `\ ��• � `` _` \„_•_, �`� .rte �'� ���YZ tt `\ � .pro. `'r � � '��`,; y yy'tt;�• , 5 �'y � ,� �L - f�,? t� q / rr , v � . +; t � _ a. •� % xnrucc..>.Aaw.x.rn.cu,u.Q,..,cv....>tia.,•. 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