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HomeMy WebLinkAbout44971-Z �o�QSUFFOitx• Town of Southold 4/10/2023 P.O.Box 1179 o • .� 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 42013 Date: 5/7/2021 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 585 Donna Dr.,Mattituck SCTM#: 473889 Sec/Block/Lot: 115.-16-5 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 6/29/2020 pursuant to which Building Permit No. 44971 dated 7/10/2020 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: accessory in-ground swimming pool fenced to code as applied for. The certificate is issued to Oliver,Michael&Kristin of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 44971 9/28/2020 PLUMBERS CERTIFICATION DATED 0 v Au o ized ig tore TOWN OF SOUTHOLD FF01,�coGy BUILDING DEPARTMENT C* TOWN CLERK'S OFFICE "o • �,' 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#: 44971 Date: 7/10/2020 Permission is hereby granted to: Oliver, Michael 585 Donna Dr Mattituck, NY 11952 To: construct an in-ground swimming pool as applied for. At premises located at: 585 Donna Dr., Mattituck SCTM #473889 Sec/Block/Lot# 115.-16-5 Pursuant to application dated 6/29/2020 and approved by the Building Inspector. To expire on 1/9/2022. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 Building Inspector CONSENT TO INSPECTION 0�`v* r , the undersigned, do(es)hereby state: Owner(s)Name(s) That the undersi d(is) ( e) the owner(s) of the premis s in the Town of Southold, located at �j Hv►cr r �/r� l �/C , which is shown and designated on the Suffolk County Tax Map as District 1000, Section 1 ) Z�, Block 16 Lot 057 That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: That the undersigned do(es) hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon, to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances,rules and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances, rules or regulations of the Town of Southold. Dated: �O Z-Z12, /(Signature) -��!�t-7rf�/ G I�c•�r � (Print Name) (Signature) (Print Name) OF SO!/P�,®l Town Hall Annex ~ ® Telephone(631)765-1802 54375 Main Road Fax(631)765-9502 P.O.Box 1179 G sean.devlin(cD-town.southold.ny.us Southold,NY 11971-0959 • y® BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICAL COMPLIANCE SITE LOCATION Issued To: Michael Oliver Address: 585 Donna Dr city.Mattituck st: NY zip: 11952 Budding Permit#: 44971 Section: 115 Block. 16 Lot- 5 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: Bethel Electrical License No: 40557ME SITE DETAILS Office Use Only Residential X Indoor Basement Service Commerical Outdoor X 1st Floor Pool X New X Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures Bath Exhaust Fan Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures 1 Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO2 Detectors Sub Panel X A/C Blower Range Recpt Ceiling Fan Combo Smoke/CO Transformer UC Lights Dryer Recpt Emergency Fixtures Time Clocks 1 Disconnect Switches 4'LED Exit Fixtures Pump 1 Other Equipment: Intermatic Pool Panel, Pump on 220GFI, Salt Generator Notes, Date: September 28, 2020 Inspector Signature: S Devlin-Cert Electrical Compliance Form.xls 1� o�Oof SOUI�o # # TOWN OF SOUTHOLD BUILDING DEPT. ��`y�ourrn 765-1802 INSPECTION ' I FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND - [ ] INSULATIOWCAULKING [ ] FRAMING/STRAPPING [ ] FINAL [` ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ]' FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL ( INAL) [ ] CODE VIOLATION [ ] PRE C/O REM K e___ ;7, , - I W tq �/ DATE fTi7vv 7-v INSPECTOR so TOWN OF SOUTHOLD.BUILDING DEPT. ' co 765-1802 INSPECTION FOUNDATION 1ST- ROUGH PL13G. FOUNDATION 2ND rULATIOWCAULKING FRAMING /STRAPPING IV FINAI_fjvz� f-FIREPLACE & CHIMNEY FIRE SAFETY'INSPECTION FIRE--RESISTANT-CONSTRUCTION FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) ELECTRICAL (FINAL) CODE VIOLATION PRE C/O REMARKS: T_;4t DATE INSPECTOR i ` b-1 Arg 50UTyolo TOWN OF SOUTHOLD BUILDING DEPT.'" `ycou765.1802 v INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] NSULATION/CAULKING [ ] FRAMING /STRAPPING [ FINAL �ajt-� [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] PRE C/O REMARKS: Aaw\ � A DATE .INSPECTOR ^^^��2 � . ! " $/��\ \ » � , ��v y. . � � \ �� z \ � . : . �*�/� \ J�` � '�� « . � � ��?� \\« .¥. z� . � � � : �. �:� � � � ƒ�� . 4 � - : ,k�! &� . . � ,� �2. : y �\ �\��.\�\\\ � : \�.�z�: ,. a§ ' 3m �2 <wz ^ � , ��*y\\ . � \ � \% . ¥az : ~,\\������ � \\ % . «» - ��� »( / . , � � .22 r�2,� � � � }\ %�\ : ����` � ��2 _ \�� / \. �. , . �� . z � .. � , . � �e��w ,d. � -� � ' y � . ^ »� ��\t . � � � �. ...� � � r L � t`' .. '"; y 1� � Of __ _ ., .. u ,, • -- - -- -- _ ., _ _. p - ,� � _ - e_ �- � .. .� �� � � � , _. _ _ ., � __ +: ,_ ..�..�- r FIELD INSPECTION REPORT D TE COMM96S 49 FOUNDATION (1ST) ------------------------------------ ' FOUNDATION (2ND) � r ROUGH FRAMING& PLUMBING - 11� INSi:LATION PER N.Y. STATE ENERGY CODE 0-fa rr Yek K {I(Lp1,t, . � Sin/ fn. • FINAL on L-.1001 P ADDI$IONAL COMMENTS z x d H --1-- 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 Examined ,20 Single&Separate Truss Identification Form � m Storm-Water Assessment Form d 4 Contact: Approved ,20 Mail to: bvllif.le- Disapproved a/c �L k6 41:!"t ��✓��► r., Phone: 171 Co Expiration ,20 Lr JJL—LS C DuildingLInspp juN 2 9 2020APPLICATION FOR BUILDING PERMIT 1 7 ,�'.� "'' Date C� , 20 '2c --C INSTRUCTIONS 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. (Signature of ap licant or name,if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder 6 "her Name of owner of premises C,bq,z� 0l1'Ler— (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. q&5 r-7— Other Trade's License No. 1. Location of land on whi proposed w k will be done: House Number Street j Hamlet County Tax Map No. 1000 Section 11�5 Block / 6 Lot 0 ,57 �OS�fFOL,t,`O BUILDING DEPARTMENT- Electrical Inspector 0�0 Gym TOWN OF SOUTHOLD Town Hall Annex - 54375 Main Road - PO Box 1179 u' - Southold, New York 11971-0959 y p�� Telephone (631) 765-1802 - FAX (631) 765-9502 ��l rogerr(aDsoutholdtownny.gov - sea nd(a),southoldtownny.aov APPLICATION FOR ELECTRICAL INSPECTION ELECTRICIAN INFORMATION (Ail information Required) - Date: 2-a Z&- Company Name: 9VT"C-L nL-F—C--M- CAL CONT-RACTI N& L'TV Name: �:TC—Afz.-9, i U License No.: QQ� -� -. Nt , email: -P-L 0 IV/\ AeT, ;Address: = L1\A'Co1,,r,, v�mg— 74-1 Phone No.: JOB SITE INFORMATION (All Information Required) - Name: m Address: �5 Cross Street: 1- Phone No.: _7 -�BIdg:Permit#: �_1.�,Q � email: Tax Map District: 1000 : Section: 1 Block: - -)(a Lot: jg- BRIEF DESCRIPTION OF WORK (Please Print Clearly) POO 11`; Circle All That Apply: Is job ready for inspection?: YES NO Rough In Final Do,you need a Temp Certificate?: YES NO Issued On Temp Information: (All information required) Service Size 1 Ph 3 Ph Size: A # Meters Old Meter# New Service - Fire Reconnect - Flood Reconnect - Service Reconnected - Underground - Overhead # Underground Laterals 1 2 H Frame Pole Work done on Service? Y N A-dditionaldnformation: - Vas Z� Ca r, �R(L wi AA R a1N o r CCS. PAYMENT DUE WITH APPLICATION ,Q C� Request for Inspection Form.xls d G) z t 2?.0,0 NEW SUFFOLK A VE 0 Ld W LOT 69 S 87' 19' 20" E 182.0' �1 CID O 2.0' 2nd STORY O J7.8' OVERHANG I ESQ, O ;N 2 STORY N o WOOD TREX DECKING N Q W/ROOF OVER FRAME -_j I �0 woDS s LOT 50 Q RES. i K'/RAILIN LQ BLOCK 35 2PAVING O PA AO ASPHALT DW O W/BLOCK CURBING (GARAGE) 72 O O O d- 25 5' a rcF Ae p O O p VINYL To�' SHE N LOT 51 13 cf) N 87° 19' 20" W 182.0' - LOT 67 N SURVEY OF SURVEYED: 12 MARCH 2008 LOT 68 SCALE 1"=30' I IN AREA= 20,020 SF MAP OF DEEP HOLE ESTATES O 0,459ACRES SI TUA TE MA TTI TUCK, TOWN OF SOU THOLD SUFFOLK COUNTY, N. Y. SURVEYED FOR MARK PALLADINI EVEL YN PALLADINI TM 1000-115-16-05 FM#4256 SURVEYED FILED JAN. 28, 1965 GUARANTEES INDICATED HERE ON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY STANLEY J. I SAKSEN, JR. IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY, P.0. BOX 294 LENDING INSTITUTION, IF LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. NEW FFOLK, NY 56 GUARANTEES ARE NOT TRANSFERABLE TO 516- 34- 8 ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS. UNAU7HORIZED ALTERATION OR ADD177ON TO THIS GUARANTEED TO SURVEY IS A VIOLATION OF SECPON 7209 OF LI ENS LAND UR VE THE NEW YORK STATE EDUCATION LAW YS LIC. NO. 4 273 ' MARK PALLADINI EVELYN PALLADINI COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT.BE CONSIDERED TO BE A VALID TRUE OBR 1666 COPY DUNRI-1 OP ID-CH CERTIFICATE OF LIABILITY INSURANCE DATE ` 03//2727//220200201 I 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 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 845-783-2555 C,2NJACT Walter Rose Agency Inc Walter Rose Agency,Inc PHONE 845-783-2555 FAx 845-783-2425 8 Stage Road A/c No Ext: AIC No Monroe,NY,10950E-MAI lisa@walterroseagency.com INSURER(Si AFFORDING COVERAGE NAIC# INSURER A;Central Mutual 20230 1NSURED .Utica National of Texas 43478 Dunrite Manufacturing Corp Dunrite pools -INSURER C: 3510 Neferans Memorial Highway Bohemia,NY 11716 INSURER D -INSURER 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 j 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. ?LTRNSR r TYPEOFINSURANCE ADDLSUB J=wyn POLICYNUMBER POLICY EFF POUCYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY JL (MMfDDM= EACH OCCURRENCE 1,000,000 CLAIMS-MADE FX�OCCUR CLP 9791864 04/01/2020 04/01/2021 DAMAGETO RENTED 300,000 MISE PRE rMED EXP(Any one arson 5,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE 21000,000 X POLICY 0 TEC F-1 LOC PRODUCTS-COMP/OP AGG 2,000,000 1 OTHER* B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X ANYAUTO 4822099 12/31/2019 12/31/2020 BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY AUTOS SSW E BODILY INJURY Per accident PUS ONLY AUTOS ON YD PeOacEcR nDAMAGE i UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS MADE AGGREGATE DED I I RETENTION$ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LU\BILITY YYY III NNN ANY PROPRIETORIPARTNER/EXECUTIVE E L EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E L.DISEASE-EA EMPLOYE H yes,descnbe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Swimming Pools -Installation,Servicing Or Repair-Below Ground CERTIFICATE HOLDER CANCELLATION SOUTH02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 530950 Route 25 PO Box 1179 AUTHORIZED Southold,NY 11971 lC9REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD vo ears' Con"pertsatiaci CERTIFICATE OF INSURANCE COVERAGE Caim 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 1a.Legal Name&Address of Insured(use street address only) ib.Business Telephone Number of-insured DUNRITE MANUFACTURING CORP 3510 VETERANS MEML HGHWY BOHEMIA, NY 11716 ic. Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage Is specifically hm)fed to 112245133 certain locations in New York State,i.e.,Wrap-Up Policy) 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPolnt Life Insurance Company Town of Southold 530950 Route 25 3b Policy Number of Entity Listed in Box"1a" PO Box 1179 DBL593T30 Southold,NY 11971 3c.Policy effective period 01101/2020 to 12/31/2020 4. Policy provides the following benefits. © A. Both disability and paid family leave benefits. E] B.Disability benefits only. n C.Paid family leave benefits only. 5 Policy covers: © 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 described above. Date Signed 3/5/2020 By widge (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer 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 513 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 hislher 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 disabilityand paid family leave 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. DB-120.1 (10-17) �IIIIIP1°°°1°1°1°°1°1°t11°0�°�1�7°°�IIO NEw Workers' CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE STATE Compensation COVERAGE m Board 1a.Legal Name&Address of Insured(Use street address only) 1 b.Business Telephone Number of Insured 516-543-1616 Dunrite Manufacturing Corp 3510 Veterans Memorial Highway 1c.NYS Unemployment Insurance Employer Bohemia;NY 11716 Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e.,a 1d.Federal Employer Identification Number of Insured Wrap-up Policy) or Social Security Number 112245133 2.Name,and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) AmTrust Insurance Company of Kansas Inc Town of Southold 3b.Policy Number of entity listed in box"1a" 530950 Route 25 KWC1143762 PO Box 1179 Southold,NY 11971 36. Policy effective period 10/20/2019 to 10/20/2020 3d. The Proprietor,Partners or Executive Officers are x�Included.(Only check box If all partnerslofficers 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 "1a" 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". The Insurance Carrier will also notify the above certificate holder 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 carver 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 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 j 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: Kevin McDonough (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �G'— 3/5/2020 (Signature) (Date) Title: President of Walter Rose Agency,Inc Telephone Number of authorized representative or licensed agent of insurance carrier: 845-783-2555 _ 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(9-17) www_wcb.state.ny.us NOTVALID WITHOUT ' memo m9am mum MMMIM.EmCAM" m.�MGRUAW3 • momm - - - MEM mmmm= 9003 I i i.•.:{ z 1'nl:3.r x,b-,l ti •Ij -�I�' G I u` '� o I R7 `I 3 J° iG' ry3.rrYD Em MUM ® :111 _ �-.•. p-par�ar.-----4•-- _' 1 ,,..,-. 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HE GO E HE FOFPBollernja5 FN* ` If r r" - • 1 •1 •• '•• • '� � :�- • � � Qur'L—`'�c n�`_i. -t '- i '`.j_�i 1 i'�a,;_z: 1j ` r JAMES 1.'=1- __.,4 , 7.�K I ' ;` • 1. � .• • •. � `-� _ It 960 DEER DRIVE t MATTITUK,NEW YORK -� .�=e�=;rr:..--- s�:�>c�^.s�:�.e----"-' � .F�:-=-•= ;su-'"^.-.:,..:-ay.,--�.:r_cs-�^�.; �x: sa-- ��r..��-.•-- --�"--- ��...,x�_-��..��Q:�� --—�_x.�,...� _:..;�-s�s�:rr,.�