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HomeMy WebLinkAbout46635-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 #: 46635 Date: 7/28/2021 Permission is hereby granted to: Town of Southold ... .........._... ............................. __......__----- 53095 Route 25 SoutholdNY 11971 ............ . __..w__w_ .w.w. .. ._____.....�... l ..... _ �.. ..... �. ..... __ ._..... � _..._......... __.......... To: replace existing generator for Verizon Wireless Facility as applied for. At premises located at: 165 Peconic Ln,, Peconic SCTM # 473889nn Sec/Block/Lot# 75.-5-14.1 Pursuant to application dated pp /2/2021 and approved by the Building Inspector, 6 To expire on 1/27/2023.ww„ Fees: ACCESSORY $100.00 ELECTRIC $85.00 CO-COMMERCIAL $50.00 Total: $235.00 ail Inspector TOWN OF SOUT'IIOLD — BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1 179 Southold, NY 11971-0959 .._._._. .... l.,. .. ._,,.—, Telephone (631) 765-1802 Fax (631) 765-9502 htths //www.southoldtgwnny.r,�o}_ Date Received APPLICATION BUILDING PERMIT g For Office Use Only !r PERMIT NO Building Inspector, _.,. JUN 2021 ri ltcatro s arbcl f rnws ra st tae, upp qult tit tltetrw ea tlret r lnro tete �' aPaltcatrots wall not be accepted' Mier ttaeeP (tcn1 1 not tie orrnr�an PI' f T�f f,f )e:I'T'. Oane�" otl�ori��itlon form t�' e �` li�ill Ise c�irrtPCete ��- "� -�, �- ;F L. (,,,.moi' „d�o..' �.ffi,o ,//f � /i„n,/„E,m�,, ,. ;, f „` �� ✓.,,,/r r/ � t Date:6/1/2021 /-',yi(,/rl'�r(,/ri?q„irN,r�rl„F,i,l,y%ri„rr ,,,,,,: r +f„ r,' ,,;.! /.rff/� ! yrr/nrfi//inrJ�/i ` H r' 77, ,r .. / r! r /.Yrr�` , „ .Ie �0 / r.r/1L 15, / n �Jr/ ;• 1, � ,, r ,..� r.. ��.L�r, .a�,„a�G�r�r,..,, O lrO,r,' „! „L,,: ,'/,,pica✓oil/��//I/U�Grr✓/r/�,c„�,o9l�l,�rf��lr.ee Irl.l,c„,;� rr,.,r,%, r ,,..1�f;/ Name:Town of Southold scTM # 1000-075.00 - 05.00 - 014.001 Project Address:41450 Main Road, Peconic NY - _..-.- Phone #:,(631) 765-1802 Email: Mailing Address:54375 Main Road,l7r,v,�+l✓/l/,re.r.-,/,dw.rrl,u.r,/r... / Srorurttrc r1hov✓�,��m��lr/d N?,,/✓rrrnr,l�+,. ,iY 1i„.,,iw,r11i9..✓r///.�71 Yle'r� kln,dY�J&&' /�rrG,rr/,/r�,lr�//r:�./.,�•/rarr/JyO/r.1/,,,„.ir�„r��lw.,...���rrir w��(I,r r r,��r N i h;:,-/.,r�,,�” ,�d'�,DII„. Name: /�Jrrfl�r(//rrJ;rrr/r/��i.✓o./rr�,,1./:,,H���J/(oaN',�YN/r/A/>lrl/a.;.t..r�,.,t.Ni�('lr�/�,l1�,J�1�!ifr/1.,,I,m�/lrf��V/rl ,., '.. Matthew ,Zagelbaurn (attorney for New York SMSA Limited Partnership d/b/a Verizon Wireless) Mailing Address:c/o Amato Law Group, PLLC, 666 Old Country Road Suite 901 Garden City, NY 11530 Phone #: r5,,Y.�.ra.1, 6 +2y4/�,7.�2_ru"��R7;.y..,...-6.<3fl643 ,...T't0 r�,f.:/r.%./,„�,i/,tr,l�/r6r,�/.%//�/./,�orr�1li�r'1��✓'%.„rr,r/�.f,„,r�iI�r,a,;l,,,P//I//E,u`ma�././.ir/// m. z .✓''/;/lr�If,,',�„gr,r,„,�„plr,hr,rrau�mr lr lrda1f m�, ayl/l,t,r,r oflfirrrm/%�r/�r�,„✓i' .r,c�trrio�r/.rr1 r.mr �.,i.y ,r„,� b;.. 7 , uwuy,T r,r�r,,rr�,',`r�.,,r lr,tTif�,n,(urG,/�i/✓r,,,t�ri,,,,ifG�rrG,r,,,nl.,/hr ,(r ���1"l/I rr” f r r �/' h a 1 %'! r� �, r”u, � I! �% , � .ad / , ,�„ Name:APT Engineering Mailing Address:567 Vauxhall Street Extension - Suite 311 , Waterford, CT 06385 Phone #:-(860) 663 1697 Email smodonoughallrintstech.com r / y r r, y f r , ,N ,� p.y�ry«,,,!/,r r 1 r r � �//�r rl r �, �/r�i rrx' /.,,,,,// r r b ✓ „r ar, fH , r � / 1 , ✓r /r ,, .,r Name:AMP Communications LLC Mailing Address:32 Spruce Street Suite 13Oakland, NJ 07436 Phone # (201) 245-7852 Email Mgr n@ampc Iffl ommunlcatlons.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: OOther Replacement of existing diesel generator as depicted on construction drawings submitted herewith $25,000,00 Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from g � premises? ❑Yes BNo 1 PROPERTY INFORMATION .....�.._____. Existing use of property: Intended use of property: NO Change Zone or use district in which remises Is situated: Are there an covenants and restrictions with P Y respect to R-80 this property? ❑Yes �No IF YES, PROVIDE A COPY. R Clf Cif Boer rafter,,Rt�adln m`rhe cr wmer/r.ontrsrtior/desipn Profession I Is respbnsible for all drainage a.�m,w te____..._ ' � � "" and storntytirat+rrr lssocx as provided by Chanter„236 of the Toton Corte. APPLICATICIhi IS EpEtty MADE to the Building Department for bre Issuance ref a Building Pernift pursuant t6the Wilding Zone orrBirranrp of that Towrn of oaathoid,wr fuiir,county,EVevuYork at',qr ler�Ppifu 066biirnas ordinances or fCe ulatiori „for the corrstrrartioas o9 Izwbfkrfirsg s„. addtlons,alterations or for rc rnomal or dr rrrolfbon as herein,dr srrdlZad 11he rppiiqn aggrs a�to r"ornply with all applicable laws,ordina6j� 6o'lidhij code, h04p rods and reg uiatfon. Ifd to admit atrtraorbr d tnsppctoMir rr prernkes and;irr b6ilding(s)for ner�:siar I'spectioris,rape�taterot�n s osadr her fn ee frarrishabie a aSS, ons_emeanor ni r want tri ertfort A4f AS as ffmcs` tl vu prk state Pend Law. New York SMSA Limited Partnership d/b/a Verizon wireless Application Submitted By(print name): BAuthorized Agent ❑Owner Signature of Applicant: By: Date: 1012-1 Nam�obert C arni ..� / STATE OF NEW YORK) Title: Network EnginerrfMIg - Real Estate l SS: COUNTY OF O sS0.y ) a� " �j ,leif E� Ne,,v Y,,JcfAf4l,rm,W (ref)q.$4jp dlblp 14,1610,- lVi-4105 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 therewith; s�gttl4lililg//�/ w0 YATS r Sworn before me this : a j "'" rfy° iL y - .` t �''-da of �'�` '� 20 2...1 � rl� lf �AMff2� - �t'--00�l t TY Notary gc ,rtgs ill i3 PROPERTY OWNER AUTHORIZATIONgrOF NE' 0 (Where the applicant is not the owner) residing at . do hereby authorize _ ... . .. _ to apply on njy behalf to Town of Southold Building Department for approval as described herein... . eve .. .. ______________..... �.., _...... War's Signature Date Town of Southold Print Owner's Name 2 Workers' YORK CERTIFICATE OF Compensation -'- U Board NYS WORKERS" COMPENSATION INSURANCE COVERAGE ^ Ia.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured AMP Communications LLC 201-644-0808 32 Spruce St Oakland NJ 07436 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 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 45-3077002 3a.Name of Insurance Carrier 2.Name and Address of Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) Sirius America Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"I a" 53095 Route 25, WC67114 Southold, NY 11971 1 3c.Policy effective period 02/11/2021 to 02/11/2022 3d.The Proprietor,Partners or Executive Officers are E] included.(only check box if all partners/officers included) FxJ all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'insures the business referenced above in box"I 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". 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 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 carrier or its licensed agent,or until the policy expiration date listed inbox''ac''.whichever imearlier. 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 iscomplying 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 asdepicted onthis form. Approved by: /Nichue|Daw|i (Print name u/authorized representative orlicensed agent minsurance carrier) Approved by: 05/21/2021 (Signature) (Date) Title: Agent Telephone Number of authorized representative or licensed agent of insurance carrier: 201-487-8710 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are-NOT authorized toissue it. C'105.2 (9-17) w^ww.wcboy.Svv AMPCOMM-01 ------- ._..... ___'M.QAWATE M.IDDffYYY) .i CERTIFICATE OF LIABILITY INSURANCE ______ED0310/2021 w 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 w_.. ......... ovlsions 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 Iflcate does not confer rt hts t._.o the certificate holder in lieu of such olTdorsement's ..._ PRODUCER /"oNAMErAt T Michael Dawll All Poiret N Insurance Agency PHONE .............. 6r1G 224 Johnson Avenue 4? .E.No Ext) (201)487-8710 104 pait:,µ� _. MALL __ - ,.,....... Hackensack,NJ 07601 AMD$ mdawli glipoiiitlnsurance.com __..IN,LEReR(s ArFO RDIEaG covcrrAr L ...raAac a _.... .. ..... .. .___ .__ INSURER N'�at onwide. Mutual Insurance..Company -- .23787 ......... INSURED INSURER„B Harleysvllle,Insurance Company 23582 AMP Communications LLC INSURER :Westchester Fire Insurance Company 10030 32 Spruce St y Suite B INSURER D Sirius America Insurance Compannr 38776 Oakland,NJ 07436 INSURER E:The Hanover Insurance Company22292 COVERAGES, ....... .aR INSURER F:Tokio Marine Suecial insurance Company 23850 �,(�IIIC, TE NUM, ER: __.M..a_.. _.___w.....__CT�EVINON NUNUCEIC, .., .w....... 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. A X„COMMERCIAL GENERAL LIABILITY FF POLICY EXP INSR LIMITS 7 TYPE OF INSURANCE ALWI BL""UEEN POLICY NUMBER POLICY L��/� ���� XXX m m . � � r=aces OCcuRRENOE s 2,000,000 CLAIMS-MADE X OCCURDAMAt E 10 RENTED U 50 000 Y Y MPA00000070786Y 11/5/2020 11/5/2021 MED EXP(Any,one person)_ S 10,000 .. ........ --------------.._....__..__.. .. PERSONAL✓L ADV INJURY 2,000,000 LOC _ _— _.. r k Ck POLICY LIMIT JEC7 APPLIES PER: PRODUCTSREGATE $ 4,000,000 PRO- ._._... ..._........ _............. ._- _...,, COMP/OPAGG s 4,000,000 E sNERk 13 AUTOMOBILE LIABILITY COMINNEID;WELL LIMN" 1,000 000, X ANY AUTO Y Y BA 00000070787Y 11/5/2020 11/5/2021 BODILY INJURY(Ferperson), .._._.. OWNED .�..�. SCHEDULED �......_....... ... _._.....- - --.... ---------..... ......__ AUTOS ONLY ,...,,.,.,.,.'...AUTOppS BODILY INJURY(Per accident) S AUTOS ONLY _'AUTOS OONLDY fkM F N YnE Mu 6nL.,.,.,.,. 5.,.,...,. EXCESS LIAB CLAIMS-MADE ..,.._.......__._... _ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 10,O0-- 00-- MS-MADE.. Y Y N11071788001 11/5/2020 11/5/2021 AGGREGATE S 10,000 000 D WOR RETENTION 5 CU 00263 11/5/2021 AND EMPLOYERS'CO DED Y Y CUP0002633 11/5/2020 . WW^ _ S,_ _... LIABILITY .5TATI)7F f �_ER X PER O ANY PROPRIETOR/EXCLUDED N�A YIN Y WC67114 2/11/2021 2/11/2022 1,000,000 OFFICER/MEMBER EXCLUDED? E;L. EACH A--- CCIDENT S _ _ Y � (Mandatory in NH) ELDISEASE 1,000,000 I . . SE-EAEMPLOYEE 5 ____ If yes,describe under 1,000,000 DESCRIPTK)N OF OPERATIONS below E. DISEASE-POLICY LIMIT S E InstallationrrFloaterY Y IHYA82364506 _ 12/19/2020 12/19/2021� t .......Limit 1,000,000 F Professional&Pollution Liability Y Y PPK2094578 2/28/2021 2/2812022 Limit 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is named as a additional insured with respect to work done by the insured on their General Liability Policy _.__.............,.,.,..,.1v 1-_...____ .... ..__..__..__ ... _______________ ___......... _ ---------- CERTIFICATE HOLD :..._........_.. �..._ 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. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 1988-2015 ACORD CORPORATION. rights � ON. All rights resee rved.. The ACORD name and logo are registered marks of ACORD NEW workers' d=-- CERTIFICATE OF INSURANCE COVERAGE srCompensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW .. ..... PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed In surance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of Insured _____------ ww... AMP COMMUNICATIONS LLC (201)644-0808 32 Spruce St Oakland NJ 07436 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited or Social Security Number to certain locations in New York State,i.e.,Wrap-Up Policy) 45-3077002 2.Name and Address of Entity Requesting Proof of Coverage 3a. Name of Insurance Carrier SHELTERPOINT LIFE INSURANCE COMPANY Town of Southold 53095 Route 25, 3b.Policy Number of Entity Listed in Box"1 a" Southold,NY 11971 D376387 3c.Policy effective period 4/24/2021 to 4/23/2022 4. Policy provides the following benefits: ® A.Both disability and paid family leave benefits. B.Disability benefits only. ❑ 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. I 4� dil �, - Date Signed 3/25/2020 By (Signature of insurance carrier's authorized representative ..............S sed Insurance ranc.. at i_.._.ranc, er) tati or NY 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. ... .... ...................... .._ .....___—-...LL ---------------- __.._.. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 5B of Part i 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. Date Signed BY .......,.............._.,.__ ............. .._.....,..,,,........_,...._ S„ of Authorized NYS wor... (Signature Icees'(:`arnpensation Board En7plrgyee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and 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) I 111�111111111111111mlilll 11111111111111111111 Ill 11�1 DB 120.1 (10-17) " r""-111, 666 OLD COUNTRY ROAD, 9TH FLOOR AMA .1` GARDEN CITY, NY 11530 L A W G K c,, (J 11, 11 is 1,C TEL: 516.227.6363 FAX: 516.227.6367 June 1,2021 VIA FEDERAL EXPRESS JUN 2 2021 Town of Southold Building Department Town Hall Annex Building 54375 Route 25 PUTI 17' N Southold,NY 11971 0 V Re: Building Permit Application (the "Application") by New York SMSA Limited Partnership d/b/a Verizon Wireless ("Verizon Wireless")to the Town of Southold (the "Town") in connection with the replacement of the existing generator for the existing public utility communication facility (the "Communication Facility") located at 41450 Main Road, Peconic, New York, with Suffolk County Tax Map designation District 1000/ Section 75 /Block 5 /Lot 14.1 (the "Property") Verizon Wireless Ref.: Peco ic (GEN)/Our File No. 100-2186 .............. Dear Sir/Madam: In connection with Verizon Wireless' Application to the Town for the replacement of its existing generator for the existing Communication Facility at the Property, enclosed please find the following: I One (1) original Application for Building Permit, completed and executed by Verizon Wireless(we respectfully request that an authorized signatory of the Town, as Property owner, execute the Property Owner Authorization section on the second page); 2. One (1) original Owner's Authorization (we respectfully request that an authorized signatory of the Town, as Property owner, execute same); 3 Certificates of Worker's Compensation, Liability, and Disability Insurance; 4. Four(4) surveys of the Property; 5. Four (4) sets of construction drawings, prepared, signed, and sealed by APT Engineering, with a last revision date of May 18, 2021 (the "Construction Drawings"); and 6. Check payable to the "Town of Southold," in the amount of$235.00, representing the Application -filing fee. As depicted on the Construction Drawings, Verizon Wireless is proposing to replace its existing diesel fired generator and sub-base fuel tank located in the existing equipment shelter as part of the Communication Facility. 405 LEMNUI-ON AVI"NUE, � CHRYS�,ER BMLDINk 26` FLOOR � iNIDAI �010(,NY M'A �! 212A 85 6000 402,MA[N STRL]iY � SUITE?04 ! NIF-ITUCHEN,N 08840 � i�2 31/ 15H w. Please note that the Spectrum Act and the Federal Communications Commission Order' mandate an abbreviated, streamlined municipal application process for wireless communication facility applications which qualify as "eligible facilities requests," including a 60-day application review and approval timeframe. Verizon Wireless respectfully submits that this Application qualifies as an "eligible facilities request," which the Town "may not deny, and shall approve" within the required timeframe. Should you have any questions or concerns, please do not hesitate.to contact me. Thank you for your attention to this Application. Sincerely Matthew Zagelbaum Encls.. cc: Verizon Wireless (via e-mail,without enclosures) 'See 47 U.S.C. §1455 and FCC Report and Order No. 14-153,respectively. 2 NEw YORK Workers' CERTIFICATE OF Compensation STATE ..�� NYS WORKERS. COMPENSATION INSURANCE COVERAGE `k~ | Board 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured AMP Communications LLC 201-644-0808 32 Spruce St Oakland NJ 07436 1 c.NYS Unemployment Insurance Employer Registration Number of Insured 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 45-3077002 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Sirius America Insurance Company 3b.Policy Number of Entity Listed in Box 1 a" Town of Southold WC67114 53095 Route 25, Southold, NY 11971 3c.Policy effective period 02/11/2021 to 02/11/2022 3d.The Proprietor, Partners or Executive Officers are E] included.(Only check box if all partners/officers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box"T'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 nnthe INFORMATION PAGE nfthe workers'compensation insurance po|iuy). The Insurance Carrier orits 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 of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy o, 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 inbox^an''.whichever inearlier. 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 tnuo 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 iscomplying 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 asdepicted onthis form. Approved by: [Nichae| Davv|i (Print narne of authon7ed representative or licensed agent of insurance carrier) Approved by, _ /a/ _ 0�/�l/�02l________ (S/onam,e} (Dale) Title: Agent Te|ephoneNumberofamhohzedepesentabveo.licensedagcnLo|i^pumnnocanvc 20|187��10 ------------ Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized toissue it. C-105.2 9'17) www.vmb.ny.gov AMPCOMM-01 144c"MEY CERTIFICATE OF LIABILITY INSURANCE _. DAT3110/2021 , `.. _..._...... ..... 03110/2021,,, 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 endorsements) _____— " PRODUCER CONTACT Michael Dawll All Point Insurance Agency PHONE , .. FAX 224 Johnson Avenue6ArC +e,..� tlwOl)487-8710 104 IArc rstl Hackensack, NJ 07601 i l 61 mda..... llpotntinsurance com tkd URE_QL1 A FO,RtANG COV,ERA¢t tI 9# A"Nationwide Mutual Insurance Company 25787_ ._ ........ ...... ---..--___.._ ..... ,,,,..,,,, ,,,,.... _.-. ..... .. ,........-............ ...... _. .... .INSURER .... .. .. ....... .. ._ ...„..., INSURED INSURERB:HarleySVllle InSUranCe Company 11-111y 235812 AMP Communications LLC INSURER C.Westchester FireInsurance Company 10030 _ 32 Spruce St Suite B INSURER D:Sirius America Insurance Company"" 38776 Oakland,NJ 07436 INSUR,ERE 7 The Hanover lnsuraince Company INSURER F Tokio Marine Specialty In,Surance Company ,238$0„ ..... COVERAGES CERTIFICATE Nt.iME W..:....__....._w.... _ 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. tN,�td ......, ADUI #JB __ rr a #� wav{ t&/? #Y F 6IMM F% t ), ra ....... POLgCY FY Lt IMM Y w' EACH .a coal L#alar .. TYPE OF INSURANCE POLICY NUMBER I yY LIMITS A X COMMERCIAL GENERAL LIABILITY 2,000,000 pfCLAIMS-MADE X OCCUR Y Y MPA00000070786Y 11/5/2020 11/5/2021 I AMna.Y"a�allwtatP~t.�a 50,00() F/Lmno I. .ttAcr, +gnarl ». - 2,000,000 20"E^'1AY3V PC;,C;4'tE I 0 8'd� g .... M.E...�.,rpJfBPR,Ir�,..1t,AIjLAPPLIES R ......... w_w_,_. ......,..........,,,. w_ __.......... ... . _..... ........ „' ..,.4.000000,,00000 EMT POLICY PRO- PR' F` .. .. _ __ AUTOMOBILE LIABILITY . SMIISELSINGLE LIMIT 1"000,0000 .,. X ANY AUTO Y Y BA 00000070787Y 11/5/2020 11/5/2021 OWNED ".,........ SCHEDULED L�rL'Sk 744.Y OCa Y, r¢rtaK+� C AUTOS ONLY .AUTOS ... . ..,..,.#,1P'Y..IP.J..t4: ......... .. ....... HIRED PfOP ER,FY PAMAGE AUTOS ONLY ., AUTOS ONLY ,,,I+6 a 10,000,000 C X uMBREL071788001 11/5/2020 11/5/2021 nwG , FGATT' 10,000,000 EXCESS LIAR .. .: 6 I A... LA LIAR nro S nn4417P Y Y N11 C' I t ril4€scala., Y Y CLJP0002633 11/5/2020 11/5/2021 WORKERS COMPENSATION.. .,,,,,.-.._____ ....,.,,,,..�....,......._ ......... ...'.._,____w_........ .......... ..._........,.. ... .,,,,,,,, ........_ ........,..... ..,..,,,., .._.-,.,.. EL X a 1 a 4,ICM tPG`19 AND EMPLOYERS'LIABILITY R ANY PROPftIETOFtfPARTNF_R/EXECUTIVE YIN Y WC67114 2111/2021 2/11/2022 1, 000„000 ,�;}C G`FS Ii F�,C 4t I'CPlr OFFICERIMEMBER EXCLUDED? [Y N t A 1,CI00,000 (Mandatory in NH) Fw P. f41,t 4'r,';7i. L ra h.RSR"'dIL"'F r @_h E Ntr j ¢ro sr,u w OFOPERATIONS�ufw-xil t0Flwd ... ,._,. Y Y-.,IHYAB''2364506_,...._...__"� 12M912020 1211912021 Limit ��,xi s sa¢_it R.ul+rt 1,000,000 Ir t,ndel 000 000 r C IL"tli,Pt allation"” F Professional&Pollution Liability Y Y PPK2094578 2/28/2021 2/28/2022 Limit 5,000,000 CbY cate holderisnlame#d as a additional ....,.,"...... .."AT' __�- LES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Certificate insured with respect to work done by the insured on their General Liability Policy CERTIFICA'FE HOLDER CN _ .-. ...., _ 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. Southold,NY 11971 _ ------- AUTHORIZED REPRESENTATIVE ACORD _ --.-. _ ..._. ... „ .,-- ... _ _ _ ------- �....... ., 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NF.W Workers' YORK CERTIFICATE OF INSURANCE COVERAGE 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 ..............____........ --—-----__----------------------____...........___........................ ........---- 1a. Legal Name&Address of Insured(use street address only) 1b. Business Telephone Number of insured AMP COMMUNICATIONS LLC (201)644-0808 32 Spruce St Oakland NJ 07436 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) 45-3077002 .............. .....—-----_................... 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier SHELTERPOINT LIFE INSURANCE COMPANY Town of Southold 53095 Route 25, 3b.Policy Number of Entity Listed in Box"l a" Southold,NY 11971 D376387 3c.Policy effective period 4/2412021 to 4/23/2022 ...... ......................... 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5. Policy covers: Pfl A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law, E] 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. "Ju? Date Signed 3/25/2020 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance Carrier) Telephone Number 516-829-8100 Name and Title Ric-hard White- Chief Executive Officer _­­­­..................... 444 IMPORTANT: ..... ...........- -- 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. ........... ­­­- ---------- "I'll-�------------ ­­­­............_ -­111--­ ................ ............................- ---------- PART 2.To be completed by the NYS Workers' Compensation Board (only if Box 4C or 5B of Pa,rt­­1,has be_e_n. chec,ke_d.)___ ------------------------ ------ State of New York Workers' Compensation Board According to informahon rriaintained by the NYS Work(.,'rs' Compensation Board, the above-named employer has complied with the NYS Disability and Pand FanAy Leave Benefits Law with respect to all of his/her employees DateSigned ................. ......- By ........ ------------------................... ------------ .......... QSq'naalfe 0 Authowed Nys Telephone Number Name and Tifle Please Note:Only insurance carriers licensed to write NYS disability and 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) 11111111iiiiii111miiiliriiiiiiiii�iiiirioiiIII DB-120. 1 (10 17)