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HomeMy WebLinkAbout46627-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 #: 46627 Date: 7/28/2021 Permission is hereby granted to: Dilollo, Patrick .._.., .......... ................................................ .... .. w 5 Washin ton Ave pay lle, NY_W 1...1..70.9a.w_... To: legalize "as built" HVAC system as applied for. At premises located at: 870 Inlet Ln., Greenport SCTM # 473889 Sec/Block/Lot# 43.-2-8.1 Pursuant to application dated 7/19/2021 and approved by the Building Inspector.. To expire on 1/27/2023. Fees: AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $400.00 CO-ALTERATION TO DWELLING $50.00 Total: $450.00 ...............w ww ... _:.. Bui g Inspector � s TOWN OF SOUTHOLD—BUILDING DEPARTMENT „ Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 v Telephone (631) 765-1802 Fax(631) 765-9502 https://www.southoldto)yppy,gqv Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only ��L2 �b '1 9 2021 PERMIT NO. Building InPtar,_ Applications and forms must be filled out in their entirety.Incomplete P 517.1' P� DEPT". �.�- applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:07/09/2021 OWNER(S)OF PROPERTY: Name:Patrick DiLollo scTM#1003-43-2-8.1 Project Address:870 Inlet Ln Greenport NY 11944 Phone#:516-993-8322 Email:pjdilollo@gmail.com Mailing Address:27 The Plaza Suite H Locust Valley NY 11560 CONTACT PERSON: Name:SAME AS ABOVE Mailing Address: Phone#: Email: DESIGN PROFESSIONAL INFORMATION: Name:SAME AS ABOVE Mailing Address: Phone#: Email: CONTRACTOR INFORMATION: Name:Empire Electric & Maintenance LLC Mailing Address:27 The Plaza Suite H Locust Valley NY 11560 Phone#:516-993-8322 FEMTII:pdilollo@empireelectric.co DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther HVAC as built $5000 Will the lot be re-graded? ❑Yes R No Will excess fill be removed from premises? ❑Yes RANo 1 __J PROPERTY INFORMATION Existing use of property:Resdlental Intended use of property:Residential Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R-40 this property? ❑Yes *No IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. 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,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(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name):Patrick— Lof Io ❑Authorized Agent @Owner g pp G/ao4 Signature of Applicant: "' ��°""" �� Date: 7/� LISA GIOIA STATE OF NEW YORK) " " - NOTARY PUBLIC-STATE OF NEW YORK SS: No.01616126405 COUNTY OF Ovelified in Nassau County u� + sla�io E�splf�o - 2 o y` Via.`c4c Q 0 being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the (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 thereWlfA GIOIA WbTAPY PUBLIC-STATE OF NEW YORK Sworn before me this No.01 G161 26405 QU®Ilfied in Nassau County day of c A 20 ` i IV Commission Expires 05.02.2W aGra' Notary Public ✓� PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) I, residing at do hereby authorize to apply on my behalf to the Town of Southold Building Department for approval as described herein,. Owner's Signature Date Print Owner's Name 2 NEW 'workers' CERTIFICATE OF INSURANCE COVERAGE ,. y1r tr Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Lice g Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured EMPIRE ELECTRIC& MAINTENANCE LLC #27 THE PLAZA, SUITE H 5169938322 LOCUST VALLEY, NY 11560 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e.,wrap-Up Policy) or Social Security Number 81-3277335 2.Name and Address of Entity*Requesting Proof of Coverage ........... 3a.Name Insurance __rrie______. ........................._..w._._....-w--w-w-... ..-..... of Insurance Carrier T6 WN eOF SOUTHOLing Listed as the ifDicate Holder) Standard Security Life Insurance Company of New York 53095 ROUTE 25 3b.Policy Number of Entity Listed in Box"1a" PO BOX 1179 R89377-001 SOUTHOLD, NY 11971 3c.Policy effective period 4/7/2017 to 7/8/2022 4. Policy provides the following benefits: Qo A. Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: no A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law, B.Only the following class or classes of employer's employees: Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as desc"' d above. Date Signed 7/9/2021 By pa aerat utww�r NYS Licensed.........w .... Signature of insurance carrier's aardhorae d r' . e Insurance Agent ofthat insurance carrier) .... M.M........_......w�w w ___ _�.... SERVICES Telephone Number X212.355-4141 Name and Title SUPERVISOR-DBUPOLICY S w 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.FTo be com....I_......____._....-_...�_......_...,,,m___ w._�..w-.�_... __-_ w__._..�................ ...........wwww...�,..._.._. .............__ w _.......wwww__�.....�.... ......M............ w ...,.w..._.... eted b the NYS ed) Workers Com,,,, pNMW F y Compensation Board(only if Box 4C or 56 of Part 1 has been check State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date SignedBy _ ......._..._ .................. w _..._ _ (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title agents of those insu insurance carriers are authorized to issue Form DB-11120.1.d Insurance leave benefits insurance policies brokers are NOT authorized toes and NYS often insurance disability p sed insurance issue this form. DB-120.1 (10-17) 111111111Duiiiiiiiiiiiiiiiiiiiiiiiiiiii:.:�iwiiiii11111 NEW Workers' CERTIFICATE OF YORK NYS WORKERS' COMPENSATION INSURANCE COVERAGE STATE Compensation O ( Insured Detail la,Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured EMPIRE ELECTRIC&MAINTENANCE 516-993-8322 27 The Plaza Suite H Locust Valley,NY 11560 lc.NYS Uttetnploytncut insurance Employer Registration Number of Insured DBA:EMPIRE LIGHTING ld.Federal Employer Identification Number of Insured or Social Security Number 813277335 Work Location of Insured(Ostirs required if coverage is specifically limited to rerlain location in Nets,York Sate,i.e,a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 38.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company,Inc. TOWN OF SOUTHOLD 53095 ROUTE 25 PO BOX 1179 3b.Policy Number of entity listed in box"la": SOUTHOLD,NY 11971 TWC3953390 3c.Policy effective period: 3/6/2021 to 3/6/2022 3d.The Proprietor,Partners or Executive Officers are: 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 bog"la"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"21'. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c';whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: HeM C.Sible (Print name of authorized representative or licensed agent of insurance carrier) Approved By: 7/9/2021 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 form.Insurance brokers are NOT authorized to issue it. C-105.2(9-17) www.web.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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(9-17)REVERSE ACCORL>I 0 DATE(MM/DDIYYYY)CERTIFICATE OF LIABILITY INSURANCE 7'/9/2021 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(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 CONTACT K BELL&ASSOCIATES PHONE, (041)0§9to FAX 67 9..w........_ 49 Main Street EMAIL b ll w so0ates o„tonli pµnet Cold Springs Harbor,NY 11724 INSURE, IAFfcrxglra ,cvGEw INSURER STANDARD SECURITY LIFE INSURANCE 69078 _.__... -. ---_� _________________ _.................,...... ......_.__ ..__ . . .. .....,, ... INSURED iNsuR.ERa. TECHNOLOGY INSURANCE CO 42376 EMPIRE ELECTRIC&MAINTENANCE LLC _.... INSURER C: MERCHANTS MUT . .. ......... .... _..... DBA EMPIRE LIGHTING INSURER D: __ ... 27 The Plaza,Suite H INSURER E LOCUST VALLEY NY 11560 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 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. .. ....... ._ . ............. . _____---___... IN812 ADDL,W60 POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM O D X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 X OCCUR PREMISES.(Fa AGCGIrrenr ) a c bAMAdE TO KgRTLIy 500000-- CLP,IMS-MADE CONTRACTUAL LIABILITY MED EXP(Ani one person) $ 15,000 C ...... ---- _ ................ X X BOP1083971 3/4/2021 3/4/2022 PERSONAL&ADV INJURY $ 1,000000 GEN A.,..... .... .......____._....._. ....... GGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ------------ 1POLICY X JECT RO, FLOC PRODUCTS COMP/OP AGG $ 2y000�O00 0114M. AUTOMOBILE LIABILITY COMBPNED SMA t LIMIT $___ 1,000,000 ., i� , �0. _...... --- ANY AUTO BODILY INJURY(Per person) $ OWNED _.. SCHEDULED BODILY INJURY(Per accident) $ C AUTOS ONLY X AUTOS X X CAP1069001 512612021 5/26/2022 XHIRED X NON-OWNED PROPERTY DAMAGE' $ AUTOS ONLY AUTOS ONLY (PPr Oc.tarlent� $ X UMBRELLA LIAR $X OCCUR EACH OCCURRENCE C CLAIMS5,000,000„m. EXCESS LIAR -MADE X X CUP9149369 3/412021 3/4/2022 AGGREGATE _ $ 5,000,000 i.. _ _.. ,.... DED i X' RETENTION$ 1 O OOO � $ WORKERS COMPENSATION V PER I OTH TATIJTf; l FR AND EMPLOYERS'LIABILITYN/A -------------------------------------------- ANY PROPRIETORIPARTNER/EXECUTIVE YIN ,E L EACH ACCIDENT $ 18000,000 B OFFICER/MEMBER EXCLUDED? t� X TWC3953390 3/6/2021 3/6/2022 (Mandatory In NH) E L DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 NYS DISABILITY A � R89377-001 11112021 12/3112021 NYS STAT LIMITS DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER IS NOTED AS ADDITIONAL INSURED PER WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 ROUTE 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 1179 AUTHORIZED REPRESENTATIV SOUTHOLD NY 11971 I � J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <NTE,K workersCERTIFICATE OF INSURANCE COVERAGE TE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier...._. ._..._ .. ..... _. --------- 1 a. Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured EMPIRE ELECTRIC& MAINTENANCE LLC #27 THE PLAZA, SUITE H 5169938322 LOCUST VALLEY, NY 11560 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i.e., Wrap-Up Policy) or Social Security Number 81-3277335 ............................................. __ .. _ _____.......w_.................................__._ ..._........ ...____—___...__- _ 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier TISityN Being Listed SOUTHOLifDicate Holder) W Standard Security Life Insurance Company of New York 53095 ROUTE 25 3b.Policy Number of Entity Listed in Box"1 a" PO BOX 1179 R89377-001 SOUTHOLD, NY 11971 3c.Policy effective period 4/7/2017 to 7/8/2022 4. Policy provides the following benefits: Rn A.Both disability and paid family leave benefits. F-] B. Disability benefits only. ❑ C.Paid family leave benefits only. 5. Policy covers: []i A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law,. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as desc d above. By .7/9/2.0�.21..M....ammm__a�w_�w_��._�.____._ Date Signed ___------..._...�w�.���_� �. _�. .__. �`:.......�..�.�.�.�.�.�.�.�.�._....�.�.......__..._________.__...w.w._.w_. (Signature of insurance carrier's autfwonz d represen Vve or NYS Licensed Insurance Agent of that insurance carrier) 5- E VISOR-D VICES Telephone Number (212) 355-4141 __. Name and Title ..S.IJ,,,,,,,,,,,,,,,, M....__���_._�w�w _....... 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. p y.....a NYS Workers Compensation Board(only if 4C or 5B of Part 1 has ee.....�... ..www._��_w�w__�������� PART 2.To be completed b the N.......w...�.,_,M..............._��w�w�w�......� ' n checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed �.......� By ........................._www _.� (Signature of Authorized NYS Workers Compensation Board Employee) Telephone Number Name and Title agents of Note: thosensu ante carriers are authorized to issue Form DB-1120.1Insurance nsu family brokers areNOT authorized rice policies and NYS ������ insurance disability p y insurance licensed insurance horized to issue this form. DB-120.1 (10-17) 111111111111111111111111111111IIIIUIII�I: 11111119 CERTIFICATE OF � NEW � � ss' NYS WORKERS'COMPENSATION INSURANCE COVERAGE STATE peg �wBoard Insured Detail la.Legal Name and address of Insured(Use street address only) lb.Business Telephone Number of Insured EMPIRE ELECTRIC&MAINTENANCE 516-993-8322 27 The Plaza Suite H 1c.NYS Unemployment Insurance Employer Locust Valley,NY 11560 Registration Number of Insured DBA:EMPIRE LIGHTING ld.Federal Employer IdentiRcation Number of Insured or Social Security Number 813277335 Work Location of Insured(Only required if coverage is specifically limited to certain location in New York State,i.e,a Wrap-Up Policy) 2.Name and Address of the Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Technology Insurance Company,Inc. TOWN OF SOUTHOLD 53095 ROUTE 25 3b.Policy Number of entity listed in box"la": PO BOX 1179 SOUTHOLD,NY 11971 TWC3953390 3c.Policy effective period: 3/6/2021 to 3/6/2022 3d.The Proprietor,Partners or Executive Officers are: 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"la"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 must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail)Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c';whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policy listed,nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By: Ilenry C.Sibk (Print name of authorized representative or licensed agent of insurance carrier) lx9 Approved By: 7/9/2021 (8iguww e) (]Date) Title: Underwriting Mana er Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Note:Only insurance carriers and their licensed agents are authorized to issue the C-105.2 farm.Insurance brokers are NOT authorized to issue it C-105.2(9-17) www.wcb.ny.gov Workers' Compensation Law Section 57.Restriction on issue of permits and the entering 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 (9-17)REVERSE ""� D/YYYI() [7�E(MM/D CERTIFICATE OF LIABILITY INSURANCE (MMID21 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 policy0es) 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 PHONE FAX A NRL ..,.( K BELL&ASSOCIATES AI AN9,F,�,_(631)659-3326 [(A 631 67 70"79 ... IL 49 Main Street AooR $s,,.bellassociatlinenet ---- ------------- Cold Springs Harbor, NY 11724 INSURER(S�AFFORDING COVERAGE NAIC# __J...�._...... _-....._. ___ _..... ._n ... ......... INSURER.A: STANDARD SECURITY LIFE INSURANCE_._. _ _._.. 69078..._ _... .. INSURED INSURER B TECHNOLOGY INSURANCE CO 42376 EMPIRE ELECTRIC&MAINTENANCE LLC INSURERC: MERCHANTS MUTUAL INSURANCE CO 23329 ........_ .,..... . ..... .. ..,.... ........._. - DBA EMPIRE LIGHTING INSURERD __,.,_.__. ..-..-...... -_-----------.... ..- ------ 27 ___27 The Plaza,Suite H INSURER E LOCUST VALLEY NY 11560 INSURER F: COVE GES 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 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _...__. ------ ....._._ _._.... ...... ..... .......... .. .... INSR TYPE OF INSURANCE HDLUFti POLICY EFF POLICY EXP LL _ LIMITS LTRPOLICY NUMBER M /D MM/DD ..�.. wawa _ X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE /� OCCUR PRE(U4YSE ,QFanr prcere) $ 500,000 -.-_I �..._._.� CONTRACTUAL LIABILITY MED EXP(Any one person) $ 15,000 ... C _ X X BOP1083971 3/4/2021 3/4/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 21000,000 PRO POLICY FX_1 JELT LOC PRODUCTS COMP/OPAGG $ 2 000,000 OTHER? $ AUTOMOBILE LIABILITY COMBINED SINGLE I IMI't $ 1 OOO OOO ( aq,atn(y w ... .... .._.__.._..w... .....,r.._...a_.._...... X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED C AUTOS ONLY AUTOS X X CAP1069001 5/26/2021 5126/2022 BODILY INJURY(Per accident) $ HIREDAUTOS ONLY AUTOS NLDY RCYPEFtPY DDAMAGELL X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5 000 Q0O C EXCESS LIAB CLAIMS-MADE X X CUP9149369 3/4/2021 3/4/2022 AGGREGATE $ 5000,000 DFD X RETENTION 10 000 $ WORKERS COMPENSATION PER OTH OFFICER/MEMBER R EXCLUDED? N/A X TW 3953390 3/612021 3/6/2022 X STATI,,,IT� ...,,..-€�Ii ..... . ....,.,. AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y --L EACH ACCIDENT $ 1 00tm_ 0 OOO B (Mandatory In NH) C E L DISEASE EA EMPLOYEE $ 1,000-,000 _...... .. .... If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A NYS DISABILITY R89377-001 1/1/2021 12/3112021 NYS STAT LIMITS DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER IS NOTED AS ADDITIONAL INSURED PER WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 ROUTE 25 ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 1179 AUTHORIZED REPRESENTATIV SOUTHOLD NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD V i y II !ii ,00000ii0000ii IIS t Ma Cwl r r„ v f rii r / 1 �r / v r / /r r r A�0 r r ; i�