Loading...
HomeMy WebLinkAbout46613-Z 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 #: 46613 „ __....w___........ Date: 7/23/2021 Permission is hereby granted to: . dings LLC 100 Bro w of e ara m .._ �����_.�...... _.....__..._..__ww.__�... _. ptPn Rd..... ._......... GNY 11530 arden C . �. .... To: construct an accessory in-ground swimming pool as applied for per Trustees approval &. Article 78 settlement. At premises located at: 1070The Strand, East Marion SCTM-_# 473889 _w. _w_www.......................�_........nnn �__.._... .. ______ __....... v..,,. Sec/Block/Lot# 30.-2-77 Pursuant to application dated ......7/15/2021 .... .. . and approved by the Building Inspector. v 2/2023. To expire on ,...........1./?.........___...................__. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 . Total: ..............................$300.00 �.... _ w(e,4' r� C pec r TORN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 ' Telephone(631) 765-1$02 Fax(631)765-9502 ti. lw r .s tboldto nn Date Received APPLICATION FOR BUILDING PE T D Fcsr Office Use Only "`"` ppppII g JD), PERMIT NO � ��° Building imsctrar:_ �" 21();211 Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an MILDING DETyr, Owners Authorization form(Page 2)shall be completed. 1.00 ° 0171101' Date:3/11/2021 OWNER(S)OF PROPERTY: Name:Lefkara Holdings LLC (Neofitos Stefanides) SCTM#1000-30-02-77 Project Address:1070 the strand East Marion NY Phone#:1-917-748-5178 Email:neostefanides@gmail.com Mailing Address:200 Hawkins Ave Suite366 Ronkonkoma NY 11779 CONTACTPERSON: _.._.,....�..._. � _.��..._.__..__....._._,......_....�._.._.__...�.._..,�..�. Name:Anabela Dix Mailing Address:2383 Motor Parkway Ronkonkoma NY 11779 Phone#:631-580-6090 Email:president2383@aol.com DESIGN PROFESSIONAL INFORMATION: ��„-- ����� Name:Pegasus Engineering Mailing Address:546 Blydenburgh Road Hauppauge NY 11788 Phone#:516-982-3439 Email:jtacefta@optonIine.net CONTRACTOR INFORMATION: Namelandscape Associates Inc. Mailing Address:2383 Motor Parkway Ronkonkoma NY 11779 Phone#:631-580-6090 Email:President2383@aol.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOtherGunite Swimming Pool 16'x42'Rectangle $50,000.00 Will the lot be re-graded? BYes ❑No Will excess fill be removed from premises? ❑Yes ..._.No 1 PROPERTY INFORMATION Existing use of property:Private home tome Intended use of property:Private home ome Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? Dyes BNo IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/deslign proliesslkwull Is responsiblie for all drainage and storm water Issues as provided by Chapter 236 of Hee Town Code. APPUCATIONis HERE13Y MADE to the Building Department for the Issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of , Ik,County,New York and other applicable laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or fax l or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorhied Inspectors on premises and In buildings)for necessary inspections.False statements made herein are punishable as a Class A m6demearwr pursuant to Section 210AS of the New York State Renal law. Application Submitted By(print name):AnabelaDix BAuthorized Agent ❑Owner I m Signature of Applicant: h �� � ��.., .a. Date: 3/11/2021 _a STATE OF NEW YORK) S : COUNTY OF Anabela Dix being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Contractor (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/her knowledge and belief,and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of 20LL _ ANITA KEIM GREEN Notary Public-State of New York N0.01GR4930806 PROPERTY OWNER T Rt (�e haled in xpirek County My Coau�krr7t�sion E�fatres May.4, 2022 (Where the applicant is not theer) eofitos Stefanides residing at 1070 The Strand East Marion , NY 11939 .............cow.. do hereby authorizeAnaDe1a Dix PPY to apply on my behalf to the Town of Southold Building Department for approval as described herein. 3/11/2021 Owner's Signature Date Print Owner's Name 2 Existing use Of propefty- Private �'T Intended use of property.Private home Zone r district inwhich � Premises is situate thereany coarenant and restrmetions with respect to s prop"? ❑Yes ..X o IF YES,PROVIDE A COPY. Check BOX After Reaadf / is Mf. *TOOM CWC APPUCAT1001IS 1*rur4r MME to howkq Comte ef a k Pvffic bw4,a cache maw aAd mra rl(MMUMMY kOVecdam Farce Avis mu made herein are Pim aaa a OAU A mhomwafow Pa N S00im 2'r �4s O(Ow Nm York state PrmnaM N a w. name)-Anabela DixligAuthorized Agentner SgnatureofApplicant- X oate: 3/11/2021 STATE OF NEW YORK) COUNTY O Anabela Dix in duly sworn,deposes ands says that(s)heis the applicant (Name f individual signing nwW o ct)above named, Mhe is theContractor (Contractor,Agent,Corporate Officer,etc,) of said owner or owners,and as 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 fest of his/her knowledge and Belief;and ` that the work will be performed in the manner,set forth in the application file therewith. Sworn before me this day Of 0 �..._ Notary Public ...�..`._, ._._.._.... PROPERTY OWNER AILITHORIgATION (Where the applicant is not theowner) I•�. 1 n Marion , 11939 residing at.�..__._._. ...mm._....�,.�.. .�.m.......��� ......�....�.�..�,..__,�........�.,... do hereby authorize 1411x' bola Dix apply on my belta"(f o the Town of Southold Building Department for approval as described herein. � 4 14 3/11/2021 ------------ Ohr's Signa re Date . Print Owner's Name 2 Mlwl�n Y//ya Y�l�,ri�51�/ry Jll'/" ,�,l�f� V,d;(,!'rx ! ;wV"'""r d":?^Ir�'AJa», �✓,',yia ✓, �� rlfx"M;!„..0 ,�/,, ;, fir., �i/nm a,Jir �y i,.; !N "grn,.a,n a r0-." s?�, rn/4 ,,x G �i,,r, %vw rd;,,�.v.,y.. ,../M a Mi �:rrx,i �d'i✓ .o,,;. 3 ,4 ,.. a,. 'e My ,,,.r I A np -n,;r y✓Nf ,i"„ms '1Mi `Ifa•., r nw,..°C! n ..x v,0-,,:. ! r c .. r,,,,. P N'kf ,,,,, •./ !�r,�� 'F� «'�v - ,�, �g.�,?.,,aa IJy- ,,�(J rid �M:,,,y�lrv) ,rR .:�I�) y�`�ri�l '���F ' ',w.�M w., r+,'�N,y�.�ro¢y�`ri i^ 'i,; n �i1.' r//s f�/I4A.:.. r"�„° � d^"v<;;;r,«.rv. .!,stir ,, r �mr� .rx�::, ,n,.i,,-,:drw`+%�'w !�y4�1�r v.w rx r n,�u/ 4�p�/�r�rH(m� :,.AaY /y(� &'1y;;J�r weµ^ I�;� 10--� R/,lCrd ;�'.J' �!l�'. r r.-✓a, 3'- rl> � .; �� a r .i”.�r' «� my i „"°,.:, <i,/«,. N4 �'"+A,m�,.',.,,�mGy,n ,.;?a �N^rmd ,,mvkrrar✓ ,r ,«-. "�':,�Vm"✓% f irr, �rn✓� ,�^.',�.� I' m I ,, ,�,/ �fY✓,1 � �r.'✓,. RM a u,, ,,,�'. f1 �n srmr6� rtr,, b w "mr.,,r ,�lr�,� r �y / ,radii rra�f� T�� � ��rN.,, r y I " ��„w:� ,, �'�;�` �{ ,, qm� f ,�.. ;� 'V,wi,� >i�;w�,,.�, �1� rr',P�;;,r�' ,q,,, r t r�'N lr„✓� ""✓F,'”.�TM,( «,.. �,r ,;J�r��,d � A,Fj y gp,�,;✓ I'� 6„n ,,.,liw,.., ! ,. '� ,.. r..N,l+.➢ � ,��:;: ��'.0„is/,: fv✓ �wd�a,�„ IIY��u�/,w,b r�� �� �k I„r� AJ' y � ,�j.M. ,p”" r ,.,, ,1 a Ar r ,rr r,of �Fa, �v It z,0-„xr..., ,,N ,,_..y ,,,,,'en ,, n rouxc:✓r fr,r meu<;, ,r, r c r.:. ,,,,,,,; /,d ,"ul�(l�((•. Jr±&ra,f.,�%A!Yrr�, ,>n,.,,, ..,,,, ll7Vl,�, id,,:xJ+m.oa� ,d/rli, ... / /I r,r ;...,. r..r m rro as /c, r rMn rr v�vm ✓n✓pro ni rra„m ru r c� «r �A� / "NV rro l BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD,NEW YORK est 9d ry, d('AX 1`/ PERMIT NO.9923 DATE: JUNE 16,2021 ^ �^ l ” r ” ISSUED TO: LEF ARA HOLDINGS,LLC c/o NEO "ITOS STEFANIDES �`0F«N/ tiro h �a rr r PROPERTY ADDRESS: :1070 THE STRAND E.AS,I 11A ON ^ �td r�� � 1 �",r✓� 'Vii' 9f'Xi4 SCTM#1000-30-2-77 AUTHORIZATION`' D Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in ' accordance with the Resolution of the Board of Trustees adopted at the meeting held on June 16,2021,and in P $ o« 4ir��rl,"�, of application fee in the sure ofd 0.41 paid by t aL491din LC and subject to the Terms consideration and Conditions as stated in the Resolution, the Southold 'Gown Board of Trustees authorizes and permits the ^° following: Wetland Permit to construct a pool 648sq. . outsidejurisdiction;within jurisdiction rl�4l� �r t remove invasive vegetation; restore with no mow fescue sod; install 70 linear feet by 63 linear feet by 70 linear feet of pool enclosure fencing with gates; with the condition that ray I f, E no activities will take place within 30 feet from the top of the bluff; and as depicted ona 11 ° the site plan prepared b Marshall Paetzel Landscape Architeciture received on June / F r a P P P Y SYI7,2021, and stamped approved on June 16,2021. / � f y '4 ^ rlg f r gydM�,>y Jf li �l j q IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,and these i presents to be subscribed by a majority of the said Board as of the 16th day of June,202 1. l MOOf✓ r I ♦ ', N j"{R,.'=e x ✓ / r � ` 4 � di r � a ,. :^www.._........ yIM 'rlr ✓« 9 'I r e I>! ,"� u'�ll,�r�r M br 4 fi r G013 Ir' ! r~ � tib ti .,`;x rrdr �«uA rr rax/ rrvru ii rrrr„m/bra s,firm r/i r ;7;r / ,;r, r`, f 1 ✓r -;e;r r0-., I;rNw�`t�4 n 4�,: rY,�dy ,�r ,,;:.iiy” V m.., �"" ar^'+�u""" "�„'.,. w I- �"M ,%l� ;.:' "NANNY I(j'or<,'r w r�r m''�, Y°lalPx„', ,�'" 'N„'1�i l+' '^"*.°Y;,.2,:�l r"`" S;'iN"r��:+� y r a ":,y, r w r „�'°„:rrXV /a :.re,.'ro ryd�(�I ama'n; rr ;•. ,,�, a' m, �,r„ r/,mmr,: „�,"a�,, I� ?�”, N, /wig-� � r'„�"�', ;/k�, ,,,,,,p � ,u"" +� '"'�' � f� ,rw.➢"�'„�,',"�„ �„ ',w4c hr ), ,. ;� m � ".. ;, v»'� y,,, y�' r I��7,, ,a , �� ��, �� ".;' xro„;, ,�j �r"�.i r`'�✓'"Y '�$', ,✓+"kV �il✓'^�,', 'MN� r fi',�Yl,r 4''"'m �,!m �;� �,,, ,4,.r, � �„ i .d.,,. Id¢.'�iM'r�? 64� rop Yu � � „w✓ ��IuA��:✓m✓ ,"d. n ,"'/w,;,„�,p,q, ���m°`N .:.,,.,. �/°✓ ""�'� � � ,r�°yll� �N:rM"�' � ,4�"",,, z :i �' � w;, yo � ,r„r, D ^r,. . ,e r� / ,,.�w�1 �� ;61� , �, ;� , �""��"d �ry,,,/%fir,rw ' MMMi,,���� �a,�;m"^- rG✓,�*' �r, � �,r,�ably �rl� ��v, �� �,Ir� ,-�x�,- ,,�;,.,.' r ��'„�a� 0-i^,„w �A���� vr” %,�/ " w ,nJM��>U'f�i��:�.rM'"",;,p;, LU 98 ® w � ani 14 UL .. °� ae AN ix a mm n hr r. , cl z 4 I"'d �n t .�n " 444 .w fl Wi' r " t r r e m ' `""v'+rr,„w.r.; ✓Y »d fi�,dry"'" �,r e ;:r"r w�N" r"� r �` ¢ � � p- � "'A ' A�'�r wed p'" "� d,�W"�,✓'�+ gym. �w"d�"� !a � �r u� Iy IM IN ,�,oda ,� ,� e ✓" ,� ✓^ p r. ate.„. .. w,._. s ;u RIO � J4 4 d _ ,.µ fl M LU No 01!10 w co LU .. __.... _.._ _ ........._. �_ ....._ _ w� www . . __. _.: Glenn Goldsmith,President p� "' Town Hall Annex A. Nicholas Krupski,Vice President �� " 54375 Route 25 John M. Bredemeyer III P.O.Box 1179 Southold,New York 11971 Michael J.Domino Telephone(631) 765-1892 Greg Williams ypyp{ q� Fax(631) 765-6641 BOARD OF TOYY1. TRUSTEES TOWN OF SOUTHOLD June 21, 2021 Patricia C. Moore, Esq. 51020 Main Road Southold, NY 11971 RE: LEFKARA HOLDINGS, LLC c/o NEOFITOS STEFANIDES 1070 THE STRAND, EAST MARION SCTM# 1000-30-2-77 Dear Mrs. Moore: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, June 16, 2021 regarding the above matter: WHEREAS, Patricia C. Moore, Esq. on behalf of LEFKARA HOLDINGS, LLC c/o NEOFITOS STEFANIDES applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated April 29, 2021, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on June 16, 2021, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, 2 WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of LEFKARA HOLDINGS, LLC c/o NEOFITOS STEFANIDES to construct a pool ( sq.ft.) outside jurisdiction; within jurisdiction remove invasive vegetation; restore with no mow fescue sod; install 70 linear feet by 63 linear feet by 70 linear feet of pool enclosure fencing with gates; with the condition that no activities will tape place within 30 feet from the top of the bluff; and as depicted on the site plan prepared by Marshall Paetzel, Landscape Architeciture, received on June 7, 2021„ and stamped approved on June 16, 2021.. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, M eL7 Y Glenn Goldsmith President, Board of Trustees GG/dd Glenn Goldsmith,President so Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 Michael J.Domino Telephone(631)765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOU, THOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction,'-hay bale lihe/silt-boom/silt curtain 1St day of construction- %constructed When project complete, call for compliance inspection; • �� NMNN� ` I�I�NVIININIro�u�ir����w.� ':�iMylll ,. Cl C � Cl) Y d N off -a �-� lit Q l- 4. of? LA pr Vi m o ' lith apa 116 1k, ., I , m tr 65,. V "P ,� Workers' CERTIFICATE OF INSURANCE COVE R AGE ear DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW p y ( ty ty)___a 1b.Business Telephone .,,—.___ �............. __ww Carrier PART 1 To be completed b Disability and Paid Family Leave~Benefrts�Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name S Address of Insured use street address on p Number of Insured _.v... LANDSCAPE ASSOCIATES INC. 2383 MOTOR PARKWAY 631-580-6090 RONKONKOMA,NY 11779 c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Orny required if covwage is Wedically umber limited to certain locations in Now York Slate,4e.„Wrap-Up Policy) 113520679 2»Name an ..__-and Address._ of-Entity . ...__ _st.._.in.g-Pr of ..__- .. _.M._a__......._. __ ..... ...�.. .... ....... _.. .________.w._ Coverage(Entity Being Listed as the Certificate Holder) Name of Insurance Carrier TOWN OF SOUTHOLD — BUILDING DEPARTMENT HARTFORD LIFE AND ACCIDENT Town Hall Annex 54375 Main Road P. O. Box 1179 3b Policy Number of Entity Listed in Box"1a" Southold, NY 11971-0959 LNY331043 Policy effective period 07-01-2020 to 06-30-2021 4.Policy provides the following benefits: ........�w__. ...M A.Both disability and paid family leave benefits. B.Disability benefits only. E]C.Paid family leave benefits only. 5.Policxcovarss i9 A.All of the employees employees eggl'ble under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employees 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. D03-11-2021 (Signaha> rgup- ate�irwswd,mmm w.... ............W.-. ._____._.mmmm,,,,_.............._....u...... ww._,,,.M._...... ..f Ins,--a"co. rized representative or NYS Ucim...._�_rd of_.....w�m__.........m.. 0 of irsihtlrar earr•Hsrt"s andiW� sed krsurarrce of rfraf Insurance carrier) Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory 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.R 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 b the NYS Workers Compensation Boarduu it Box has P wwmmmmm ....yw....._M.M.....• (Only if Box 4Cor5B 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. _. -- ..._-___ (Signature of Autirorized NYS workers'compensation Board Employee) Telephone Number Name and Title of masse Insurance insurance iers are ri ers I��iss Form DBi 120.ity and ....aid family leave benefits insurance 11111 v41 policies and NYS licensed ins.,.,......... _ w Please Note.Only insurance d pa insurance po sed insurance agents Insurance brokers are NOT a to issue this form. DB420.1 (10-17) kE ( bz) IH ACC>R& CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 03/11/2021 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(iss)must have ADDITIONAL INSURED provisions or be endorsed. ff 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 lhits to the certificate holder in lieu of such endorsement(s). PRODUCER CON A.CI Tango m Tango,Tango&Tango Inc. 1531 543-0500 � x t,31 938-0700 1139 JERICHO TPKE STE 5a1Ail - N") •-- �?8 ittanotangcrtang-cs com ._.. _. ....._.......LL_. . INsu ._s/AFFI171oING co�rE E NAIc COMMACK INSURED NY 11725-3000 IIRA COLONY INSURANCE COMPANY .. .. ___. INSIIRE'R B a TRAVELERS-COMPANY Y P INsul1 ... _ ..... �..._ Landscape Associates Inc.dba Pools b Landscape Associates EIa c 2383 MOTOR PKWY IlasuR ......... _............_ ...... ..... .. RD: _.. ., RONKONKOMA,NY 11779 . .. ........... ..- ,,,....._._. I'NSUR'ER E .....__..m.ry.. COVERAGES CERTIFICATE NUMBER: REVISION NUMBBR.,._.......— ._.... iNsuRER F 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, YdTR EXCLUSIONS AND ITIONS. _._ ..., stiiiii TYPE OF NSUAbu . .. _.... _. MS. OF SUCH POLICIES.LIMITS SHOWN MAY �. EN R POLibY F BY PAID APOLI _. .. .....w__.._,ry... .�uMfiS..__ INSURANCEAm I= POLICY NUMBEII P COMMERCIAL GENERAL LIABILITY _ EACH OCCURRENCE $ 1 000 00-0 CLAIMS-MADE �OCCUR .i'6�rm E ±� x 100.000 A — .15,000 X X WS303307 09/29/2020 09/29/2021 PERSONAL&ADV INJURY $ 4,600,000 GEN'L AGGREGATE LIMB APPLIES PER: GENERAL.AGGREGATE $ 2,000,000 ECa El LOC X POLICY El ....__ ....._._ ._._,,...... PTIODCO MPlOP AIxG $ 2,000,000 OTHER; $ AUTOMOBILE LIABILITY , MDINLO IaINGLE,LIMIT ANY AUTO £F u� �I�). __...... . . BODILY INJURY(Per person) $ ._ OWNED .._ SCHEDULED .... _ .. ..... .,.. __..,, ..., .....,,,,,.. . ....,, Per BODILY INJURY HIRED NON-OWNED PEWY AMAC E I( " ) $ AUTOS ONLY AUTOS E Ir+ _.. ., .,,.,.,.,. AUTOS ONLY AUTOS ONLY i$ UMBRELLA UAB _OCCURRENCE $ ..... __ OCCUR EACH O C C IXCESSLWB CIAIMMAOE I. CME ...... DEO RETCNTION PERM B OI Y PR LIABILITY' YIN E.L.F1ACH rH JamWORKERS COMPENSATION O AND EMPLOYERS' . LR ANY Pi1OfrI2ICIIIR4I AR'INE - I CI6'[IWE d EnNF'r�ExcLUDED. � NIA 009,1240198 09/15/2020 09/15/2021 A ID-INT _.. $_500000 -- - (Maredatory In and EL DISEASE EA EMPLOYEE II �w describe under " . , $ 5001,000 .._ DI SCRIPT`I IN IAF OPERATIONS t ow E.L.CIIS'LA a'E-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mare space is required) WITH RESPECT TO GENERAL LIABILITY THE CERTIFICATE HOLDER IS ALSO LISTED AS AN ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION TOWN OF SOUTHOLD BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hall Annex 54375 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971-0959 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTWICATE OF INSURANCE COVERAGE UNDER THE NYS DISABIELITY BENEnTS LAW PART 1.To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier la Legal Name and Address of Insured([Tse street address lb.Business Telephone Number of Insured only) 631-672-1266 Landscape Associates Inc. Ic.NYS Unemployment Insurance Employer dba Pools by Landscape Associates Registration Number of Insured 2383 MOTOR PKWY RONKONKOMA,NY 11779 1 d.Federal Employer Identification Number of Insured or Social Security Number 2.Name and Address of the Entity Requesting Proofof 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) TRAVELERS TOWN OF SOUTHOLD BUILDING DEPARTMENT 3b.Policy Number of entity listed in box 009J240198 Town Hail Annex 54375 Main Road 3c.Policy effective period: P.O. Box 1179 Southold,NY 11971-0959 9/15/2020 to 9/15/2021 4.Policy covers:"- a- ®All of the employee's employees eligible under the New York Disability Benefits Law b. ❑Only the following class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of tate insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed 10/16/201' w _By..�. (Signalme of insurance carr r"s saAarcmd w4mescalative or NYS Licensed h mane Agent of w_,_...w.._. Telephone Number 631-543-0500 Title Licensed Insurance Agent IMPORTANT:N "W Agent of . 's a tative or 5 ` that Mrder, to in COMPLETE Mail it dbwft to the Certificate hader. If box"4b"is eheck4 this certificate is NOT COMPLETE for purpom or section 220,Subd.8 or the Diabift Beneft Law. It mug be mailed for town Iction to the *Cara tion r¢' ItB I'isas A a t3 S Al sn orlc t PART 2.To be o checked) Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of hislher employee& Date (Signakm of NYS Workers'Compensation Board Employee)Telephone Title Pkase Note:Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT Aunco*qM p kndmid a#q ewjw_q sp Mir WInk Can*DepL of LAW.Limsing&emsmim PAMS HOME ONPROVEMauuCENSE Nwne auskless Nam r j s