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Home My WebLink AboutMoores Drain Daylighting Project - Construction Consultants RESOLUTION 2021-684 ADOPTED DOC ID: 17301 A THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2021-684 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON SEPTEMBER 7, 2021: RESOLVED that the Town Board of the Town of Southold hereby accepts the bid from Construction Consultants/LI, Inc. in the total amount of$74,000.00 for the Moores Drain Daylighting Project at Skipper Horton Park, all in accordance with the Town Attorney and be it further RESOLVED that the Town Board hereby authorizes and directs Supervisor Scott A. Russell to sign a contract with Construction Consultants/LI, Inc. for same, subject to the approval of the Town Attorney. Elizabeth A.Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Sarah E.Nappa, Councilwoman SECONDER:Jill Doherty, Councilwoman AYES: Nappa, Doherty, Ghosio, Evans,Russell ABSENT: James Dinizio Jr TI1 Document G702 - 1992 y Application and Certificate for Payment TO OWNER: Town of Southold PROJECT: APPLICATION ISO' 4 Distribution to: P O Box 1179 Moores'Drain Daylighting PERIOD TO: 12/31/22 OWNER ❑ 53095 Main Road Skipper Horton Park Southold NY 11791 CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DATE: CONTRACTOR ❑ Construction Consultants/L.I., Inc. PROJECT NOS: FIELD El East 2nd Street Riverhead, NY 11901 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance AIA Document G703TM,Continuation Sheet,is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and 1.ORIGINAL CONTRACT SUM................................................. $ 74,000.00 that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS.............................. $ 0.00 CONTRACTOR: Construction Consultants/ Inc. 3.CONTRACT SUM TO DATE(Line 1 f 2) $ Z4 nnn nn B Date: ..................................... 4.TOTAL COMPLETED&STORED TO DATE(Cohrmn G on G703) ...... $ inn(10State of: ` 5.RETAINAGE: County of: YOUNG a, 0.0 %of Completed Work SUSAN t Subscribed and sworn to before State of New York (Cohrmns D+E on G703) $ nnn me this —7-1-A day of Pr o2FJY Pu01Y06209293 b. 0.0 %of Stored Material Q Qualified in Suffolk County (Column F on G703) $ n nn Notary Public: X1C t—Qd�dU T (/ Term Expires: 7/27/20 9. My commission expires: Total Retainage(Lines Sa+Sb, or Total in Column I of G703)...... $ 0.00 6.TOTAL EARNED LESS RETAINAGE .................................... $ 74,000 n ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 minus Line 5 Total) In accordance with the Contract Documents,based on on-site observations and the data comprising 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT...................... $ this application,the Architect certifies to the Owner that to the best of the Architect's knowledge, u1,300 00 information and belief the Work has progressed as indicated, the quality of the Work is in (Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to payment of the 8.CURRENT PAYMENT DUE ............................................. $ 3 AMOUNT CERTIFIED. 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED ............................................................................. $ (Line 3 minus Line 6) $ 0.00 (Attach explanation if amount certified differs from the amount applied.Initial all figures on this Application and on the Continuation Sheet that are changed to conform with the amount certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: Total changes approved in previous months by Owner $ 0.00 $ 0.00 By: Date: Total approved this.month $ 0.00 $ 0 This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the Contractor TOTAL $ 0.00 $ 0.00 named herein.Issuance,payment and acceptance of payment are without prejudice to any rights of T CHANGES b Change Order $ 0.00 the Owner or Contractor under this Contract. INECAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G702Tm—1992.Copyright @ 1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA® Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA® Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 010711ACD44 I TMR Document 6703 — 1992 o_ Continuation Sheet Page 2 of 2 AIA Document G702Th1--1992,Application and Certificate for Payment,or G732,rm--2009, APPLICATION NO: 4 Application and Certificate for Payment,Construction Manager as Adviser Edition, APPLICATION DATE: containing Contractor's signed certification is attached. 12/31/22 In tabulations below,amPERIOD T0:ounts are in US dollars. 12/31/22 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE TO ITEM SCHEDULED PRESENTLY COMPLETED AND % RETAINAGE DESCRIPTION OF WORK FROM PREVIOUS FINISH N0. VALUE pppLICATION THIS PERIOD STORED STORED TO DATE (G=C) (C_G) (If variable rale) (D+E) (Not in D or E) (D+E+F) 1 Insurance& Mobilization 3,000.00 3,000.00 0.00 0.00 3,000.00 100 0.00 0.00 2 Site Demolition & Earthwork 32,800.00 32,800.00 0.00 0.00 32,800.00 100 0.00 0.00 3 Asphalt Paving 3,800.00 3,800.00 0.00 0.00 3,800.00 100 0.00 0.00 4 Concrete 13,000.00 13,000.00 0.00 0.00 13,000.00 100 0.00 0.00 5 Aluminum Pedestrian Bridge 21,400.00 21,400.00 0.00 0.00 21,400.00 .100 0.00 0.00 GRAND TOTAL 74,000.00 74,000.00 0.00 0.00 74,000.00 100 0.00 0.00 CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G703 TM—1992.Copyright @ 1963,1965,1966,1967,1970,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this Ale Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal 101210ACD44 counsel,copyright@aia.org. AIA Document G706TM ® 1994 Contractor's Affidavit of Payment ®f Debts and Claims PROJECT:(Name and address) ARCHITECT'S PROJECT NUMBER: OWNER❑ Shinnecock Canal Maritime Park GL C1-99-H110-00-6212-0000 CONTRACT FOR: General Construction ARCHITECT❑ CONTRACTOR❑ TO OWNER: (Name and address) CONTRACT DATED: March 14,2022 SURETY❑ Town of Southold PO Box 1179 OTHER El Main Road Southold,NY11791 STATE OF: New York COUNTY OF: Suffolk The undersigned hereby certifies that,except as listed below,payment has been made in full and all obligations have otherwise been satisfied for all materials and equipment furnished,for all work,labor,and services performed,and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or Owner's property might in any way be held responsible or encumbered. EXCEPTIONS: Regarding Application#4 Only SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR: (Name and address) 1. Consent of Surety to Final Payment. Whenever Construction Consultants/L.I., Inc. Sure is involved,Consent of Sure is required. Riverhead, East 2nd Street Surety Surety q Riverhead,NY 11901 AIA Document G707TM,Consent of Surety to Final Payment,may be used for this purpose. Indicate attachment: ❑ Yes El No BY: The following supporting documents should be attached (Signature of authori d representative) hereto if required by the Owner: Eric Baumack,President 1. Contractor's Release or Waiver of Liens, (Printed name and title) conditional upon receipt of final payment 2. Separate Releases or Waivers of Liens from Subscribed and sworn to before me on this date: Subcontractors and material and equipment suppliers,to the extent required by the Owner, T_L Notary Public: S accompanied by a list thereof USAN I. Y DUNG Notary Public, State of New York 3. Contractor's Affidavit of Release of Liens My Commission Expires: 01Y06209293 (AIA Document G706ATM) Qualified in Suffolk County Term Expires: 7/ 7 ?_0 5 . CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures t�af changes will not be obscured. AIA Document G706TM—1994.Copyright @ 1970 and 1994 by The American Institute of Architects.All rights reserved.WARNING:This AIA" Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA't'Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 07o ACA 2 CONTRACTOR'S AFFIDAVIT OF OkVNER RELEASE OF LIENS ARC H ITECT CONTItACTOR AIA I)ocitniew (7706A (III.Stl-LIC601I1 on OTHER Town of Southold TO OWNER: PO Box 1179 ARCI-11TFC-I"S PROJECT NO.: 53095 Main Road Southold,NY 11791 CONTRACT FOR: General Construction PROJECT: Moores'Drain Daylighting CONTRACT DATED: March ff,2022 Skipper Horton Park STATE OF: New York COLWIYOF: Suffolk The undersigned hereby certifies that to the best Of"the undursigned's knowlcdge, information and helief. except as listed below, the K(�.Iuascs Or Waivers of Lien aRaChUd IICI-CIO ilICILKIC III(:COIIH-ao.101%all SUb01I1[1_aCt0 (_S,all SLIj)j)IiV1-s OfMatClialS aIId U(JUil)IIIent.a11(1 all purfornwrs ol'Work,IahOr orscl-vicus who have or 111:1%'11:1XV hells()I-U11CLI III lWal ICes or the light to as."ell liens(ir encumbrances against alIV propozny Of the()\V ner ariSillg In-,tll\'111ani)(21-OLI(Ofthe I)CI_foI_IIIa1ICC Of(Ile C'O1It1'JL'l I'k:l.CI'CI1CCd ah(we. EXCEPTIONS: Regarding Application#4 Only SUPPORTING DOCUINIENTS A17ACHED 11ERETO: CONTitAcrOR: Construction Consultants/L.I.,Inc. 36 East 2nd Street 1. CoI)(r.IcIO1`.s Release or of Liens, COI)dilit)11:11 LII)OI1 Riverhead,NY 11901 receipt of Final paymem. 2. Separate Relcascs Or W.fix-crs Of Liens from Suhcontraclon, and 11MICI-i2l ;Ind t!(jL1il)IIIC1II SI-11)[IliCI-S. to the exient I-Cquirud by tile 0\vller.accompallied hya list thurcor. BY: 0qmlllljv"fal v; Eric Baumack,President (Pr hel"d 11,11at"Imt fillv) SUITS(TibWal)d S\\'()I-I)to before ilic on this date: Notary Public:.T.YUUIVG Notary Public, State of New Yorl, Nly Conlil)ission Expires: 01Y06209293 Qualified in Suffolk Countv CAUTION- You should sign an original AIA document that has this caL4Lqfh PROW. t92F;90()A original assures that changes will not be obscured as may occur when documents are reproduce - See Instruction-Sheet for Limited License for Reproduction of this document. AIA DOCUMENT G706A - (JIVI"RACIOR S AFFIDAVI I OF RELEAsi-,01: 1.117Ny - 1991 1:1)[110E, - AlA - F,1991 - THE A.\II:Rl(,A.N INSTITI TE OF AWIIITEC*I>. 1-3i NEW)ORK AVHNIT. NV.WAM 11\GTON, DA:.200(in-5292 - WARNING: Unlicensed photocopying G706A-1994 Violates U.S.copyright laws and will subject the violator to legal prosecution. Vendor No. Check No. Town of Southold, New York - Payment Voucher 3555 Vendor Tax ID Number or Social Security Number Vendor Address Entered by 36 East 2nd Street Vendor Name Riverhead, NY 11901 Audit Date Construction Consultants/L.I., Inc. Vendor Telephone Number (631) 727-6604 Town Clerk Vendor Contact Lauralynn Moore Invoice Invoice Invoice Net Purchase Order Number Date Total Discount j Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 4 12/31/2022 3,700.00 3,700.00 TBR 21-684 Moore's Drain H.1989.2.500.10O i Daylighting I i I 3,700.00 Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and payment is approved. Signature Title Signature / i Company Name Date Title)t1 t» 17 e .d Date—,q"'m SOUTHOLD DPW MIXTURE -J Pure Seed VARIETY GERM% 29.04% PAMER III PER RYEGRASS 90 19.66% METOLIUS PER. RYEGRASS 90 19.86% AMITY TALL FESCUE 90 14.65% SIMMONS CREEPING FESCUE 85 14.90% TRIBUTE TALL FESCUE 90 1.29% Inert 0.57% Crop 0.02% Weed r' LOT: G-22021 NET WEIGHT 25 LBS SELL BY 02/23 TEST 02/22 Long Island Cauliflower Assoc. 139 Marcy Ave.Riverhead,NY 11901 ALL SEED SALES ARE FINAL IVV IIVC Vf VVIV•1�1 G1�.+�rr�.,�, Vr �.v••v RETURN THIS FORM TO-COMPLIANCE Or Fax to 6311144-0297 Bureau of Marine Habitat Protection-NYSDEC 50 Circle Road Stony Brook, NY 11790-3409 8/13/2022 'ERMIT NUMBER 1-4738-04540 EXPIRATION DATE: DERM17TEE NAME&PROJECT ADDRESS Town of Southold Skipper Horton Park, Rt.48 Greenport NY 11944 CONTRACTOR NAME&ADDRESS: Construction Consultants/LI,Inc.,36 E 2nd St.Riverhead NY 11901 TELEPHONE: 631-727-6604 )ear Sir: 'ursuant to the special conditions of the referenced permit,you are hereby notified that the authorized activity shall commence on 3/21/2022 We certify that we have read the referenced permit and approved plans and fully understand the authorized project and all permit conditions. Ne have inspected the project site and can complete the project as described in the permit and as depicted on the approved plans. We can. Jo so in full compliance with all plan notes and permit conditions.The permit,permit sign,and approved plans will be available at the site for nspection in accordance with General Condition No 1 (Both signatures required) 1 1 --3 J,-7 1 17, PERMITEE: /!�l%1!��Ld�IL� �pV DATE T" - CONTRACTOR: DATE 3/21/2022 THIS NOTICE MUST BE SENT TO THE ABOVE ADDRESS AT LEAST TWO DAYS PRIOR TO COMMENCEMENT OF THE PROJECT 4ND/OR ANY ASSOCIATED ACTIVITIES. FAILURE TO RETURN THIS-NOTICE, POST THE PERMIT SIGN, OR HAVE THE-PERMIT AND 4PPROVED PLANS AVAILABLE AT THE'WORK SITE FOR THE DURATION OF THE PROJECT MAY SUBJECT THE PERMITTEE 4ND/OR CONTRACTOR TO APPLICABLE SANCTIONS AND PENALTIES FOR NON-COMPLIANCE WITH PERMIT CONDITIONS. ;,ut along this line X X X X X X X NOTICE OF COMPLETION OF CONSTRUCTION RETURN THIS FORM TO:COMPLIANCE Or Fax to: 631 444-0297 Bureau of Marine Habilat:Protection-NYSDEC 50 Circle Rd. Stony Brook,NY 11790-3409 '1 1I f K[jo�� HERMIT NUMBER: 1 - W73 9 - 04 5 4(-) EXPIRATION DATE: _ 'ERMITTEE NAME&PROJECT ADDRESS:. TD 0j1U CF &LLT?-fU I--L, SVi PPE_i" I4QET6fJ /1T. )49 - ;ONTRACTOR NAME&•ADDRESS: ('r7� ��.rtv�Tlca C0fQSC FALLS k-1 l PIC 3Lo TELEPHONE: In J�(- �a�— �•L�U�I" ?ursuant to special conditions of the referenced per it,you are hereby notified that the authorized activity was completed on We have fully complied with the terms and conditi s of the permit and approved pians.(Both signatures re uired) PERMITEE: DATE CONTRACTOR: DATE Z-� L2-3 THIS NOTICE, WITH PHOTOGRAPHS OF THE COMPLETED WORK AND/OR A COMPLETED SURVEY,AS APPROPRIATE, MUST BE SENT TO THE ABOVE ADDRESS WITHIN 30 DAYS OF COMPLETION OF THE PROJECT. '�1 _ � !" •/ sit; Tt - i • i {q, r I _ i-. 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' ! va�r HIM R 1\ 4 """�'�i"10 :r Construction Consultants LI,Inc. Project:Moores'Drain Daylighting Project at Skipper Horton ` -;r 36 East 2nd Street Park Riverhead,New York 11901 - P:(631)727-6604 F:(631)727-6605 Transmittal #2 - Payment Application # 1 To Michael Collins, PE(Town of Southold) From Lauralynn Moore(CCLI) 53095 Main Road,PO Box 1179 36 East 2nd Street Southold,New York 11971 Riverhead,New York 11901 Date Created Apr 26,2022 Copies To Transmit Sent Via Submitted For Approval Action As Noted Transmittal Items Format Description # Date i Copies { Document Application for Payment#1 AIA G702 View Mar 31,2022 1 Document Schedule of Values AIA G703#1 View Mar 31,2022 1 Document Application for Payment#1 Approved Pencil Copy View Mar 31,2022 1 ' ---___.--------__. Document Certified Payroll Reports w/OSHA Card Copies View Mar 31,2022 1 I Document Affidavit/Release of Liens AIA G706A-Subcontractor View Mar 31,2022 1 Document Partial Release&Partial Waiver of Lien CCLI View Mar 31,2022 1 —� j Document Affidavit of Payment of Debts&Claims AIA G706-CCLI View - - - Mar 31,2022u -1 Document -- — y - Affidavit of Release of Liens AIA G706A-CCLI View _— -—Mar 31,2022--— 1 i Comments Construction Consultants LI,Inc. Page 1 of 1 Printed On:Apr 26,2022 04:14 PM EDT &AIADocument G702TM ® 1992 Application and Certificate for Payment TO 0 PROJECLoores'Drain Da II htin APPLICATION NO: Distribution to: OBox 1179 y 9 9 PERIOD TO: 3/31/22 OWNER 'El Main Road Skipper Horton Park Southold NY 11791 CONTRACT FOR: ARCHITECT ❑ FRO�onntfuct�I nTCo sultants/L l.-Inc. VIA ARCHITECT: CONTRACT DATE: CONTRACTOR ❑ 36 East 2nd Street PROJECT NOS: / / FIELD ❑ Riverhead, NY 11901 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance AIA Document G703 TM,Continuation Sheet,is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for 74,000.00 Which previous Certificates for Payment were issued and payments received from the Owner,and 1.ORIGINAL CONTRACT SUM................................................. $ that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS.............................. $ CONTRACTOR: Construction Consultants/L.I., Inc. 3.CONTRACT SUM TO DATE(Line I t 2) ..................................... $ 74,000.00 By: Date: N Iu2,2./�.,2a 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) ...... $ 38,860.00 State of.`/amu L tk 5.RETAINVE: County of: SUSAN'T.'YOUNG a. %of Completed Work Subscribed and sworn to before Notary Public, State of New York 1,943.00 � O1Y06209293 (C l mns D+E on G703) $ me this ��,�( day of `9 ified in Suffolk County b. %of Stored Material 'T tpwj Term Expires: 7/27/20 )S (Column:F on G703) $ 0.00 Notary Public. ion, , 1,943.00 My commission expires: Total Retainage(Lines 5a+5b,or Total in Column 1 of G703)...... $ 6.TOTAL EARNED LESS RETAINAGE .................................... $ 36,917.00 ARCHITECT'S CERTIFICATE FOR PAYMENT (Lime 4 minus Line 5 Total) In accordance with the Contract Documents,based on on-site observations and the data comprising 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT...................... $ 0.00 this application,the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in (Line 6 frozn prior Certificate) accordance with the 96Nract D c and the Contractor is entitled to payment of the 8.CURRENT PAYMENT DUE ............................................. $ 36,917.00 AMOUNT CERTI BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIE ....:. ....... .. .............................................. $ S 3/7- 9. 2- 37,083.00 Attach ez lanati i i mount certified di ers om the amount a lied.Initial all ures on this (Line 3 minus Line 6) $ ( P f .ff JS' PP • .fig Applicationand n ze Continuation Sheet that are changed to con:forn with the amazirzt certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: l Total1 j changes approved in previous months by Owner $ $ By: 1� Total approved this month $ $ This Certificate is not negotiable.The AMOUNT CERTIFIED.is payable only to the Contractor UU TOTAL $ $ named herein.Issuance,payment and acceptance of payment are without prejudice to any rights of T CHANGES by Change Order $ the Owner or Contractor under this Contract. CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G702Tm—1992.Copyright @ 1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA®Document is protected by U.S.Copyright Law and international Treaties.Unauthorized reproduction or distribution of this AIA° Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 010711ACD44 Document 6703 - 1992 Continuation Sheet Page 2 .of 2 AIA Document G702T°'-1992,Application and Certificate for Payment,or G732TI-2009, APPLICATION NO: 1 Application and Certificate for Payment,Construction Manager as Adviser Edition, APPLICATION DATE: containing Contractor's signed certification is attached. 3/1/22 In tabulations below,amounts are in US dollars. PERIOD TO: 3/28722 Use Column I on Contracts where variable retainage for Iine items may apply. ARCHITECT'S PROJECT NO: A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE TO ITEM DESCRIPTION OF WORK FROM PREVIOUS SCHEDULED PRESENTLY COMPLETED AND % FINISH RETAINAGE NO. VALUE APPLICATION THIS PERIOD STORED STORED TO DATE (G+C) (C_G) (If variable rate) (D+E) (Not in D or E) (D+E+F) 1 Insurance& Mobilization 3,000.0 0.00 3,000.00 0.00 3,000.00 100 0.00 150.00 2 Site Demolition & Earthwork 32,800.0 0.00 14,760.00 0.00 14,760.00 45 18,040.00 738.00 3 Asphalt Paving 3,800.0 0.00 0.00 0.00 0.00 0 3,800.00 0.00 4 Concrete 13,000.0 0.00 13,000.00 0.00 13,000.00 100 0.00 650.00 5 Aluminum Pedestrian Bridge 21,400.0 0.00 8,100.00 0.00 8,100.00 38 13,300.00 '405.00 GRAND TOTAL 74,000.00 0.00 38,860.00 0.00 1 38,860.00 1 53 1 35,140.00 1 1,943.00 CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G703 rm—1992.Copyright©1963,1965,1966,1967,1970,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA®Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. IM210AOD44 Vendor No. Check No. Town of Southold, New York - Payment Voucher 3555 Vendor Tax ID Number or Social Security Number Vendor Address Entered by 36 East 2nd Street Vendor Name Riverhead, NY 11901 Audit Date Construction Cons ultants/L.I., Inc. Vendor Telephone Number (631)727-6604 .Town Clerk Vendor Contact Lauralynn Moore Invoice Invoice Invoice Net Purchase Order Number Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 1 3/31/2022 36,917.00 36,917.00 TBR 21-684 Moore's Drain H.1989.2.500.100 Da li htin 36,917.00 Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and payment is approved. Signature Title Signature'd �l Company Name Date Title W /, -J N CJ�Date /o Z U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and}-Tour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec 2008 NAME OF CONTRACTOR ❑ OR SUBCONTRACTOR O ADDRESS OMB No.: 1235-0008 Century Concrete Corp. 2375 Raynor Street Ronkonkoma, NY 11779 Expires: 07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECTAND LOCATION PROJECT OR CONTRACT NO. 1 03/2212022 Moores Drain Daylighting Project Moores Drain Daylighting Project (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (8) (9) NAME AND INDIVIDUAL O We Th Fr Sa Su Mo Tu DEDUCTIONS IDENTIFYING NUMBER T GROSS NET WAGES (e.g.,LAST FOUR DIGITS OF # or 03116 03117103/18 03119 03/20 03/21 03122 TOTAL RATE AMOUNT WITH- SOCIAL SECURITY NUMBER) Ex WORK S HOURS OF EARNED HOLDING STATE LOCAL TOTAL PAID FOR OF WORKER CLASSIFICATION T HOURS WORKED EACH DAYPAY PROJECT/ALL FICA TAX TAX TAX OTHER DED. WEEK Edwin Hutzler Laborer O 0 0 0 0 0 0 0 0 62.48 312.38 23 N.Howell Point Road Bellport,NY 11713 160.53 77.04 41.57 0.00 4.64 183.78 607.57 XXX-xx-6911 S 0 0 0 0 0 0 7.5 7.5 41.65 791.35 Edwin Hutzler Laborer 0 0 0 0 0 0 0 0 0 45.69 228.45 23 N.Howell Point Road Bellport,NY 11713 1 44.27 39.55 24.41 0.00 2.96 111.19 467.55 xxx-xx-6911 S 0 0 0 0 0 0 7.5 7.5 30.46 578.74 Israel Bautista Laborer 0 0 0 0 0 0 0 0 0 92.94 540.83 62 Robinson Avenue Medford,NY 11763 D 135.16 285.98 91.20 0.00 9.63 521.97 1244.73 xxx-xx-1977 S 0 0 0 0 0 0 7.5 7.5 72.11 1766.70 Silvestre Cano Laborer 0 0 0 0 0 0 0 0 0 92.94 540.83 62 Robinson Avenue Medford,NY 11763 0 135.16 285.98 91.20 0.00 9.63 521.97 1244.73 XXX-xx-9812 S 0 0 0 0 0 0 7.5 7.5 72.11 1766.70 Wilmer Rodriguez Laborer 0 0 0 0 0 0 0 0 0 92.94 540.83 36 Dow Street Central Islip,NY 11722 1 135.16 267.79 90.00 0.00 9.63 502.58 1264.12 xxx-xx-4966 IS 0 0 0 0 0 0 7.5 7.5 72.11 1766.70 Juan Carlos Lopez Laborer 0 0 0 0 0 0 0 0 92.94 540.83 36 Dow Street Central Islip,NY 11722 6 93.78 83.50 53.66 0.00 6.86 237.80 988.07 xxx-xx-3314 0 0 0 0 0 0 7.5 7.5 72.11 1225.87 Jose Lopez Laborer 0 0 0 0 0 0 0 0 0 92.94 540.83 121 Berkshire Drive Farmingville,NY 11738 4 93.78 69.51 54.17 0.00 6.86 224.32 1001.55 xxx-xX-1238 IS 0 0 0 0 0 0 7.5 7.5 72.11 1225.87 0 S +.- While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a). The Copeland Act(40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week."U.S. Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that it will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210. 5 Date 03/22/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I, Edwin R.Hutzler President WA -Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed (1)That I pay or supervise the payment of the persons employed by in the contract,except as noted in section 4(c)below. on the (Contractor or Subcontractor) (c)EXCEPTIONS Moores Drain Daylighting Project that during the payroll period commencing (Building or Work) EXCEPTION(CRAFT) EXPLANATION on the 16 day of March 2022 , and ending the 22 day of March 2022 , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said from the (Contractor or Subcontractor) full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations, Part 3(29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended(48 Stat.948,63 Stat. 108,72 Stat.967; 76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination Incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor,or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. NAME AND TITLE SIGNATURE (4)That: Edwin R.Hutzler (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS President E -In addition to the basic hourly wage rates paid to each laborer or mechanic listed in THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRA OR OR the above referenced payroll,payments of fringe benefits as listed in the contract SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND TION 231 have been or will be made to appropriate programs for the benefit of such OF TITLE 31 OF THE UNITED STATES CODE. employees,except as noted in section 4(c)below. U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and)dour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec 2008 NAME OF CONTRACTOR u OR SUBCONTRACTOR ADDRESS OMB No.: 1235-0008 Century Concrete Corp. 2375 Raynor Street Ronkonkoma, NY 11779 Expires: 07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 2 03/29/2022 Moores Drain Daylighting Project Moores Drain Daylighting Project (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (8) (9) NAME AND INDIVIDUAL We Th Fr Sa Su Mo Tu DEDUCTIONS IDENTIFYING NUMBER GROSS NET WAGES (e.g.,LAST FOUR DIGITS OF # or 03/23 03/24 03/25 03/26 03/27 03/28 03/29 TOTAL RATE AMOUNT WITH- PAID FOR WORK S EARNED HOLDING STATE LOCAL TOTAL SOCIAL SECURITY NUMBER) Ex CLASSIFICATION T HOURS OF FICA TAX TAX TAX OTHER DED. WEEK OF WORKER HOURS WORKED EACH DAY PAY PROJECT/ALL Israel Bautista Laborer 0 0 0 0 0 0 0 0 0 92.94 144.22 62 Robinson Avenue Medford,NY 11763 0 135.14 285.98 91.20 0.00 9.63 521.95 1244.75 XxX-xX-1977 S 2 0 0 0 0 0 0 2 72.11 1766.70 Wilmer Rodriguez Laborer o 0 0 0 0 0 0 0 0 92.94 144.22 36 Dow Street Central Islip,NY 11722 1 135.16 267.79 90.00 0.00 9.63 502.58 1264.12 xxx-xx-4966 S 2 0 0 0 0 0 0 2 72.11 1766.70 O S 0 S 0 S 0 S 0 S O S While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a). The Copeland Act(40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week."U.S. Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that it will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210. Date 03/29/2022 (b)WHERE FRINGE BENEFI'T'S ARE PAID IN CASH I, Edwin R.Hutzler President 0 -Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed (1)That I pay or supervise the payment of the persons employed by in the contract,except as noted in section 4(c)below. Century Concrete Corp. on the (Contractor or Subcontractor) (c)EXCEPTIONS Moores Drain Daylighting Project that during the payroll period commencing (Building or Work) EXCEPTION(CRAFT) EXPLANATION on the 23 day of March 2022 , and ending the 29 day of March 2022 , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Century Concrete Corp. from the (Contractor or Subcontractor) full weekly wages earned by any person and that no deductions have been made either _ directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations, Part 3(29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948,63 Stat. 108,72 Stat.967; 76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination Incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. NAME AND TITLE SIGNATURE (4)That: Edwin R.Hutzler (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS President -In addition to the basic hourly wage rates paid to each laborer or mechanic listed in THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACT the above referenced payroll,payments of fringe benefits as listed in the contract SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SFS, ON 231 OF TITLE 31 OF THE UNITED STATES CODE. have been or will be made to appropriate programs for the benefit of such employees,except as noted in section 4(c)below. rill' MORRO, P� v RRWr 10. g W if v? I $,X 00 "go "s -;-V "314 M e, V.9 gtreo on n U t g5tZ -QUI Ml- '0 !�@,i ifoii, R 41'1)- M 1. S Asr. ,cr "a M g�, • .41 OF lix, 'w"TO,C2 SV Wgr. ggm DOW V '15 a g --Ls gg N AM.? 'ON Oil 1 01111, 1-4 OSM 12-00611,6692 VMSM..Pu...150ay LAW This card sck-10Vs 1W the recipi-I h.successfully couipleled: .Ong, tikl*�Miryl R . attr.Occupp. ga "."goo, id ff g i BArtetion if�ty .Z. .:V x This card issued to: Juan Carlos Lopez Juan Gomez 02/25/2018 M Trainer Name Date of issue 12,0(16116690 12406009088 This cud ncknowludgus lhal llic rocipivol 11.3 sUMISSMI)l 1—picl— This cud acknowledges tha(the incipient his successfully COMPICIM: d Healffi, -10-hour Constrik"tiol—S Y. aifety' an • This card issued to: This card issued to: Silve%re Can Jose Godofredo Lopez 02/25/20.18 Lonqy Davis Juan Gomez 04/08/2016 Date OfIsshic Trainer Name Date of Issue U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wageand Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec.2008 NAME OF CONTRACTOR❑,/ OR SUBCONTRACTOR ❑ ADDRESS OMB No.:1235-0008 36 East 2nd Street,Riverhead,Ny 11901 T Construction Cons ultants/L.I., Inc. Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 01 03/26/2022 Moores'Drain Daylighting Skipper Horton Park (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (9) o Z N S M T W T F S DEDUCTIONS NET NAME AND INDIVIDUAL IDENTIFYING NUMBER LL 0 a GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY 0 F w WORK o 20 21 22 23 24 25 26 TOTALI RATE AMOUNT HOLDING TOTAL PAID NUMBER)OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Julio DeJesus Diaz-Oliva Laborer 0 $72.11 $576.88 0 3214 $220.65 $714.43 $7.61 $942.69 $1,941.71 s N.1)11 8.00 72.11 2,884.40 Michael H.Schwarz Laborer 0 $72.11 $1,370.09 5859 1 $148.14 $284.96 $8.15 $441.25 $1,495.17 s 8.00 8.00 3.00 19.00 72.11 $1,936.42 Alejandro M.Ramos Silva Operator o $105.83 $846.64 7533 Class B p $323.84 $1,38590 $7.61 $1,717.35 $2,505.85 s N1111 8.00 105.83 $4 223.20 Howard Sexton Operator 0 $109.39 $2'078A 9565 0 Class A $334.52 $1,423.54 $7.61 $1,765.67 $2,609.93 s 8.00 x.111 3111) 19.00 119.39 $4,375.60 0 s 0 S 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 Date 03/30/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller 0 — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores' Drain Daylighting ;that during the payroll period commencing on the (Building,or Work) 20th day of March 2022 and ending the 26th day of March 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made eitherdirectly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. _ from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SI AT Lauralynn Moore — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJ CT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. NOR 04 Flewl ilv qTAL;WO 81 tA S RP WIMOO —o-42om too- M Or go mpq? %q,Wrfvomq, vp4 -4P Z',�A XW Ja" fp CO. 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I will document this class to my OSHA Authorizing Training Organization.Upon successful review of my documentation, I will provide each student their completion card within 90 days of the end of the class. OSHA Authorized Provider: IINIVLRSI,ry or SOUTH FLORIDA 1�,f�/ ,% .r✓{}• Certificate#:00702541 .j .�•�i�%r(.�i,'a �j,°+$�,\� •,' .iii i��'A!r/.. ✓ _ _ :T•: :r1-*.Y:' -x:•rT :r,- -u-:- -I:v- _ __ --'"c. ;V.: ,,p• s 'r F; f f;..r•. it `r4: k: ..�• 1. r! \J 26-607298535' lbs=d acknmledees tha the rmpiew has succcssiWlp c plmd: h� - :i,°``-,x'. '.;{•i.;:: - �k3i' ry t...r_-..t -,5�,3rf.":•_r 5�'i^i3t�...Pz...i�4i".....a�`"ar-.,.:•.,. ��:uv.,,s�r.:a.✓.:rK....�,». r_:�L.:�:_.sr�.:....x.............::.b.:tea'M.i.u.. 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'rr t �t �IliS> Mrt � nr�ivDz Safel `e�nr1C`�rk_ :yam � :� .4, O• t •.,� � �. � ;=a�cl:> �ick�:�.Firid ��,C�r��fied��F.�cc s c ,. - <.; ca�ciit:,card�sfou(cf�faY s:w tl`s`ac: (. va eorictuct ri i + ..o fn ,5 y'. t: Y r ' Y +A i ' je v Ma ,'t- ls _ j aV ✓ ..{y..` �fi r 7�' •`.fie.. a '.;;"• :,�::� `,�- - _ _ ;fir' '�� - �•�- . ..a >r .' y 't��<t$f'4 ry>ip`-,S^,".. "h'.:,,:..� a.�,.:� ..r. _.:J".f,,,-.. a.J.:Y"�•;' -- .y R-a- ..Z;,�%'�:2=K,..,w.3:::�?�fii!t%:::*_.`_-'.`'.`�'."j-.•:,6i.:ws-4%:.aa':::c�±",-},,A'M1.'�`�"=.�� '". 3 5, uo CONTRACTOR'S AFFIDAVIT OF 0\\'NER RELEASE OF LIENS ARCHITECT ALA Doci nten[G706A CONTRACTOR SURF'n" (InsU`uCtions on rec'ersc sicic) OTHER TO O\t'``ER: Town of Southold PO Box 1179 ARCHITECT'S PRQJFCT NO.: a�'11urrrrrvindrGY.<cr 53095 Main Road Southold,NY 11791 CONTRACT FOR: General Construction PROJECT: Moores'Drain Daylighting CONTRACT DATED: March il,2022 6X,here•(11111 culdiv-)Skipper Horton Park STATE OF: New York COUNTY OF: Suffolk The:undersigned heretic•certifies that to the best of the undClsigneel's knowledge,information and belief,except as listed below.the Releases or V.-ricers of lien aaachcd hereto inClucle the Contractor,all SLII)CO11n-ACR)r5,all suppliers of nurterialS;111(1 equipment,and all performer:~of\Vorl<.labor or services who hac•e or may have liens or encumbrances or the right to assert liens or encumbrances against any property of the Owner arising in any manner out of the performance of the Contract referenced above EXCEPTIONS: Requisitions through 03/31/2022 SUPPORTING DOCUMENTS ATTACHED HERETO: COITRACTOR: Century Concrete Corp. rA'rmrc•rrNrr nrldrrsa 2375 Raynor Street 1. Conu-actor's Release or waic•er of Lien.~, condition:d upon Ronkonkoma,NY 11779 receipt of final payment. Separate Releases or Waivers of Liens from 5uhc011u-actors ;Incl material and equipment suppliers, to the euent required h) the Owner,accompanied b\•a list thereof. HY,_ i.17;¢rltlllllY n/:rRll,.g7:rd I i/n iKrulnllr'CI EANN HYWELL Edwin R. Hutzler, President ublic,State of New York rFrifned 11,11ne rued 6110 o.01 HY6342755 ied in Suffolk County ��[n Expires May 31,201Y t Subscribed and sc 11111 ur hcfure nu on this(late: April 26, 2022 Notary Public: ,\-Ix,Commission E.pires: May 31, 2024 CAUTION: You should sign an original AIA document that has this caution printed in red. An I 1 original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. pAIA DOCUMENT G706A • CONTRA(:'roR'S AFFIDAVIT Or• IMIYASE OF LIENS • 119+ EDITION • ':U:\ 19!1-I THE ANll:N1(:AN IN\I'I I't IF.(rF AIWHITE(A'S. 1'3i.NB%. YORK WENT R.NW,UASH1Nc1T0N,n C2000(,-i292 • WARNING: Unlicensed photocopying G706A-1994 r.:� violates U.S.copyright laws and will subject the violator to legal prosecution. t. PARTIAL RELEASE AND PARTIAL WAIVER OF LIEN The undersigned (hereinafter the "SUBCONTRACTOR") represents that it has furnished labor, services, equipment, supplies and/or material to CONSTRUCTION CONSULTANTS/L.I., INC.(hereinafter the "CONTRACTOR")and/or the construction project known as Town of Southold of which is the"Owner".Now, therefore, SUBCONTRACTOR, for and in consideration of a payment to be made by the Contractor to the Subcontractor in the sum of Thirty Sig Thousand Nine Hundred Seventeen and 00/100 Dollars($36,917.00), for itself,its successors,heirs and assigns,hereby states,affirms and agrees that,with respect to all of such work performed through March 31, 2022: 1. All labor employed thereon or in connection therewith and all payroll taxes and charges (such as withholding taxes, social security taxes and worker's compensation, disability and unemployment taxes and/or insurance premiums)have been paid in full;and 2. All materials,tools, equipment, supplies and services furnished and used upon or in connection with said work have been paid in full, and all sales,use, excise and similar taxes on or in connection with the same have been fully paid; and 3. all subcontractors and suppliers have been paid in full; and 4. This document is effective to release and forever discharge the CONTRACTOR,the CONTRACTOR'S bonding company and the OWNER and their respective officers, directors, agents, servants and employees,the funds due or to become due from the OWNER and/or from the CONTRACTOR,and all lands, improvements,chattels,and other real and personal property connected with or a part of said project from any and all claims, causes of action, demands, liens and claims of lien whatsoever arising our of or in connection with the project and all work performed through the aforementioned date,which it has or hereafter 5. might or could have. SUBCONTRACTOR warrants that it has completed all work performed through the aforementioned date as required and that it has complied with all the terms and conditions of its contract. Dated this ,U ay of ,2022. �- By: �`E �— Eric Baumac President STATE OF New York) . ss.. COUNTY OF Suffolk ) On ^l�� , 2022,before me,the undersigned,personally appeared _&f'rd n a y 'A) -'personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity,and that by his signature on the instrument,the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SUSAN T. YOUNG Notary Public, State of New York 01Y06209293 Qualified in Suffolk County Tor"n Expires: 7/27/20-2 AIATM Document 6706 _ 1994 Contractor's Affidavit ®f Payment ®f Debts and Claims PROJECT:(Name and address) ARCHITECT'S PROJECT NUMBER: OWNER❑ Shinnecock Canal Maritime Park GL C1-99-H110-00-6212-0000 CONTRACT FOR: General Construction ARCHITECT❑ CONTRACTOR❑ TO OWNER: (Name and address) CONTRACT DATED: March 14,2022 SURETY ❑ Town of Southold PO Box 1179 53095 Main Road OTHER 1:1 Southold, NY11791 STATE OF: New York COUNTY OF: Suffolk The undersigned hereby certifies that,except as listed below,payment has been made in full and all obligations have otherwise been satisfied for all materials and equipment furnished,for all work,labor,and services performed,and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or Owner's property might in any way be held responsible or encumbered. EXCEPTIONS: Regarding Application#'f Only SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR: (Name and address) 1. Consent of Surety to Final Payment.Whenever Construction Consultants/L.I.,Inc. Consent of Surety is required. Riverhead, East 2nd Street Surety is involved, Y q Riverhead,NY 11901 AIA Document G707TM,Consent of Surety to Final Payment,may be used for this purpose. Indicate attachment: ❑ Yes D No BY: �—_— The following supporting documents should be attached (Signature of authorized representative) hereto if required by the Owner: Eric Baumack,President 1. Contractor's Release or Waiver of Liens, (Printed name and title) conditional upon receipt of final payment 2. . Separate Releases or Waivers of Liens from Subscribed and sworn to before me on this date: X41dZ14,-;Z Subcontractors and material and equipment _ suppliers,to the extent required by the Owner, �� I V" accompanied by a list thereof Notary Public: SUSAN T. YOUNG Nar3. Contractor's Affidavit of Release of Liens My Commission Exp es01 : Public, State of New York (AIA Document G706ATM) Y06209293 Qualified in Suffol CAUTION:You should sign an original AIA Contract Document,on which this text appears in F'D IAr±-pfji� d a s�t��go mS changes will not be obscured. AIA Document G706TM –1994.Copyright©1970 and 1994 by The American Institute of Architects.All rights reserved.WARNING:This Al Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this Ale Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects'legal counsel,copyright@aia.org. on—Accu CONTRACTOR'S AFFIDAVIT OF 0%VN F R RELEASE OF LIENS AW:HITECT CONTIt.\GIUR .-VA I)ocitineiv (;706A (Illst ruct ions()I I ruverse Side) OTHER Town of Southold TO O%X'N E R: PO Box 1179 AW-1-11TECT-S PROJECT NO.: ,waaar-, 53095 Main Road Southold,NY 11791 CONTRA(:]'FOR: General Construction PROJF(:I-: Moores'Drain Daylighting CONTRACTDATED: March ri,2022 Skipper Horton Park STATE OF: New York COUNTYOF: Suffolk The undcl-sigricd 11cl-chy certifies that to Chu hest of the undersigned's knowludgc. information wl(l hdier.except as Ii-,led t)el()%v, the Rulcascs or W*aiver,of Lien;I I tacl led hereto i I icl Lide tote Corl 1 :111 S UhCorl I MCUWS.!it I SLI I)[fliCl-S of materials ZIIS UI Id(21,11-]i 1)11142111.J il(I a11 perti,mu•(:,of\\4,rk,Ichor or senriics�(•ho ha(c or m;n•bane liens or cn('umhranc(•s or the ri,rht to:Esser[ liens or cniumhr;In(•es at;:Iinst :111v propertyy of the Owner arisilIg in allyIII:11 I EICI-01-it of the pert orl na 1)(C of 11C Contract referellcudah(lvu. EX(,E.PTIONS: Regarding Application# I Only SUPPORTING DOCUNIENTS A'I-I*ACFfED HEREM: CONTRACTOR: Construction Consultants/L.I., Inc. 36 East 2nd Street 1. Contracu,r"ti Release or Waiver or Licris. con(litioll.11 upon Riverhead,NY 11901 I.VcCipt of rn-nI payllient. 2. Separate Rule-ascs or Waiven, of Liens from Subcontractors and marc-ri;il and equipment .1;LlI)I)IjCrS. To HIC UXICIM I-L!tILliI_(2LI hV IIIC OWIICT,aLVOIIIJXIIIiCd ll%':i It-,;(Illul-Cof- By: Eric Baumack,President Subscribed and warn to before Ili(:on dli.,;date: /-I L44-n A Notary Public:IC: - YOUNG Notartubgl ic,tate of New York NI v Commission Expires: 01Y06209293 Qualified in Suffolk County A CAUTION: You should sign an original AIA document that has this c - n original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. AIA DOCUMENT G706A - (*()\rRA(JoP', UTMAVI I of 1,1:'I.I:ASE k)l LIENS - 19l)i EJ)HION - -\Jk - "119, I l I F \MFRI(AN 1.\SI'1'1'1'11:ol:ARCI I 1-3i NIN )()I?K A\!I-'N I [: W . N . ON. 1,C. 2000f, 29 -� 2 - WARNING: Unlicensed photocopying —1994 violates U.S.copyright laws and will subject the violator to legal prosecution. G706A oi- Construction Consultants LI,Inc. Project:Moores'Drain Daylighting Project at Skipper Horton C yi C36 East 2nd Street Park i` Riverhead,New York 11901 P:(631)727-6604 F:(631)727-6605 Transmittal #3 - Payment Application # 2 To Michael Collins,PE(Town of Southold) From Lauralynn Moore(CCLI) 53095 Main Road,PO Box 1179 36 East 2nd Street Southold,New York 11971 Riverhead,New York 11901 Date Created May 26,2022 Copies To Transmit Attached Sent Via Attached Submitted For Approval Action As Noted Transmittal Items Format Description Date Copies j Document Application for Payment#2 AIA G702 View Apr 30,2022 1 Document Schedule of Values#2 AIA G703 View Apr 30,2022 1 i i Document Application for Payment#2 Approved Pencil Copy View Apr 30,2022 1 .i Document Certified Payroll Reports w/OSHA Card Copies ViewApr 30,2022 �1 Document -� Partial Release&Partial Waiver of Lien-CCLI View �!- Apr 30,2022 1 'Document Affidavit of Payment of Debts&Claims AIA G706-CCLI View Apr 30,2022 1 i Document-`y _-' �- Affidavit of Release of Liens AIA G706A-CCLI View-� +_y - Apr 30,2022 -�_1 Comments Construction Consultants LI,Inc. Page 1 of 1 Printed On:May 26,2022 01:16 PM EDT it"Pit TM AIA 4 Document 6702 ® 1992 OD® Application and Certificate for Payment TO OWNER: Town of SoutEold PROJECT APPLICATION NO: Distribution to: P O Box 1179 Moores'Drain Daylighting 4/30/22 53095 Main Road Skipper Horton Park PERIOD T0: OWNER El Southold NY 11791 CONTRACT, FOR: ARCHITECT ❑ FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DATE: CONTRACTOR ❑ Construction Consultants/L.I., Inc. 36 East 2nd Street PROJECT NOS: / / FIELD ❑ Riverhead, NY 11901 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance AIA Document G703 TM,Continuation Sheet,is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for 7400000 Which previous Certificates for Payment were issued and payments received from the Owner,and , . 1.ORIGINAL CONTRACT SUM................................................I $ that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS.............................. $ 0.00 CONTRACTOR: Construction Cons ultants/L.I., Inc. 3.CONTRACT SUM TO DATE(Line 1±2) ..................................... $ 74,000.00 By: ,,.� Date: 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703)...... $ . 55,780.00 State of: 5.RETAINAGE: County of. �U�3�b f 5.0 SUSAN T. YOUNG a. %of Completed Work Subscribed and sworn to before Notary Public,State of New York (Columns D+E on G703) $ 2,789.00 me this I"1A day of�n ;' ot:a 01Y06209293 b. 0 %of Stored Material Qualified in Suffolk Count (Column F on G703) $ 0.00 Notary Public: _ALC. -) �, "b �� Term Expires: 7/27/20" 2,789.00 My commission expires: ColumnTotal Retainage(Lines Sa+Sb,or Total in Column I of G703)...... $ 6.TOTAL EARNED LESS RETAINAGE .................................... $ 52,991.00 ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 minus Line S Total) In accordance with the Contract Documents,based on on-site observations and the data comprising 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT...................... $ 36,917.00 this application,the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in (Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to payment of the 8.CURRENT PAYMENT DUE ............................................. $ 16,074.00 1 AMOUNT CERTIFIED. 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED 5rZ.i!<..gfi+V�! �D�edev�y at2.� $ ! Q (Line 3 minus Line 6) $ 21,009.00 (Attach explanation if amount certified differs from the amount applied.Initial all ftgures bn this Application on the Co 'nuation Sheet that are changed to conform with the"amount certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITE Total changes approved in previous months by Owner $ 0.00 $ 0.00 By: _ Date J 3/ ZZ Total approved this month $ 0.00 $ 0.00 This ert" icate is not negotiable.The AMOUNT CERTIFIED is payable only to the Contractor TOTAL 1$ 0.00 $ 0.00 nam erein.Issuance,payment and acceptance of paymerit are without prejudice to any rights of T CHANGES by Change Order $ 0.00 the ner or Contractor under this Contract. , CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G702Tm—1992.Copyright ©1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA' Document is protected by U.B.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA® Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 010711AGD44 \� �J r '� TM ops Document 6703 — 1992 Continuation Sheet Page 2 of 2 AIA Document G702T11-1992,Application and Certificate for Payment,or G732TI-2009, APPLICATION NO: 2 Application and Certificate for Payment,Construction Manager.as Adviser Edition, APPLICATION DATE: 4/30/22 containing Contractor's signed certification is attached. In tabulations below,amounts are in US dollars. PERIOD TO: 4/30/22 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE TO ITEM DESCRIPTION OF WORK FROM PREVIOUS FINISH SCHEDULED PRESENTLY COMPLETED AND % RETAINAGE NO. VALUE APPLICATION THIS PERIOD STORED STORED TO DATE (C_C) (C—G) (If variable rate) (D+E) (Not in D or E) (D+E+F) 1 Insurance &Mobilization 3,000-OC 3,000.00 0.00 0.00 3,000.00 100 0.00 150.00 2 Site Demolition & Earthwork 32,800.0 14,760.00 13,120.00 0.00 27,880.00 85 4,920.00 1,394.00 3 Asphalt Paving 3,800.00 0.00 3,800.00 0.00 3,800.00 100 0.00 190.00 4 Concrete 13,000.00 13,000.00 0.00 0.00 13,000.00 100 0.00 650.00 5 Aluminum Pedestrian Bridge 21,400.00 8,100.00 0.00 0.00 8,100.00 38 13,300.00 405.00 GRAND TOTAL 74,000.0 38,860.0 16,920.00 0.00 55,780.00 .75 18,220.00 1 2,789.00 CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. - AIA Document G703TM11—1992.Copyright©1963,1965,1966,1967,1970,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA®Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 101210ACD44 Vendor No. Check No. Town of Southold, New York - Payment Voucher 3555 Vendor Tax ID Number or Social Security Number Vendor Address Entered by 36 East 2nd Street Vendor Name Riverhead, NY 11901 Audit Date Construction Consultants/L.I., Inc. Vendor Telephone Number (631) 727-6604 Town Clerk Vendor Contact Lauralynn Moore Invoice Invoice Invoice Net Purchase Order Number Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 2 4/30/2022 16,074.00 16,074.00 TBR 21-684 Moore's Drain H.1989.2.50O.10O Daylighting 16,074.00 Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and payment is approved. Signature Title Signature A'0U,\ 91 Company Name Date Title 1'1e(-/- Date J U.S. Department of Labor PAYROLL WHO Wage and Hour Division For Contractor's h l d i I Optional Use;See Instructions at www.dol.govlwhdiforms/wh347instr.htm)P 9 ) U.S.Nage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 - NAME OF CONTRACTOR m OR SUBCONTRACTOR ❑ ADDRESS OMB No.:1235-0008 Construction Consultants/L.I.,Inc. 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 02 04/02/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (6) (9) s= N S M T W T �FS DEDUCTIONS ° ¢ NET NAME AND INDIVIDUAL IDENTIFYING NUMBER a°a ° GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY ° w WORK p 27 2S 2I 30 31 02 TOTALI RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z�`w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll ° s 0 s 0 s 0 s 0 s c s 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"fumish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 04/02/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller Name r l Hata Pe Title © — Each laborer or mechanic listed in the above referenced payroll has been paid, ( Signatory m') (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 27th day of March 2022 and ending the 02nd day of April 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat. 108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIG AT Lauralynn Moore — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted in section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL WHO Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 - NAME OF CONTRACTOR m OR SUBCONTRACTOR E] ADDRESS OMB No.:1235-0008 Construction Consultants/L.I.,Inc. 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 03 04/09/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (8) (9) H o S M T W T F S DEDUCTIONS NET NAME AND INDIVIDUAL IDENTIFYING NUMBER o 0 ff 03 O4 OS 06 07 OH OJ GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY o F WORK o TOTALI RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll o s 0 s 0 s 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work an Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rale for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 04/09/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH Lauralynn Moore Controller I, m — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 3rd day of April 2022 , and ending the 09th day of April 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below. REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS NAME AND TITLE GNATU Lauralynn Moore in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed In the contract THE WILLFUL FALSIFICATION OF ANY OF 5NTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL MHO Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 - NAME OF CONTRACTOR m OR SUBCONTRACTOR ❑ ADDRESS OMB No.:1235-0008 Construction Consultants/L.I.,Inc. 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 04 04/16/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) z N S M T W T F S DEDUCTIONS 0 0 NET NAME AND INDIVIDUAL IDENTIFYING NUMBER o=� 10 11 12 13 14 IS 16 GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY w WORK o TOTALI RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Julio Diaz-Oliva Laborer 0 576.88 3214 $148.94 $428.60 $7.51 $585.05 $1,361.92 0 s s.00 8.00 72.11 1,946.97 Howard Sexton Operator 0 875.12 9565 0 Class A $296.89 $1,242 $7.51 $1,546.40 $2,336.95 s s.ao $,00 109.39 $3,883.35 0 s 0 S 0 s 0 s 0 s 0 IZ S While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to'Yumish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 04/16/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH Lauralynn Moore Controller Name of Signatory Pa Title m — Each laborer or mechanic listed in the above referenced payroll has been paid, ( 9 ry rty) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores' Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 10th day of April 2022 , and ending the 16th day of April 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below. REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE s c A Lauralynn Moore El — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE MENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour DivisionMHO (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR ADDRESS OMB No.:1235-0008 Construction Consultants/L.I.,Inc. 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 05 04/23/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (6) (9) Z,o S M T W T F S DEDUCTIONS NET NAME AND INDIVIDUAL IDENTIFYING NUMBER 0°x a ° GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY o 17 18 19 20 21 22 23 �w WORK O TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll ° s 0 s 0 s 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional,it Is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 04/23/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller Name r l Hato Pe Title — Each laborer or mechanic listed in the above referenced payroll has been paid, ( Signatory �) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 17th day of April 2022 , and ending the 23rd day of April 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS NAME AND TITLE SIGNATU Lauralynn Moore El — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller �p the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. K:f,�;�ez'�'y`r',., '..i; �,.' a,,> ".,,,,N•:,-•��.-?-'4•".�y�{. ".�,•s i' 7�,�� y"��rs>,�'°r'�"-a'1 �+Yi°�� _ .�' -_ g"�'•�;a-�,'��:.'�`-. -• ty�y",� � -"�"�cyc.�: -aFP• ! a,�.tf. � yxY': .� �':Fvnt ��'r-3t�;T�z•'a.. 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Va'` .. � S`'Eii•.'. l,:3:rf '3., ...9s '�'.:,r�.7,,.,��r,:„r:L;�;w'Fry.” ,st'�•%:.. t.:�'•'' �js;::,i;: .•?_. .2..rwfy:.�.,!,..AZ�..`�'-"gt _ ..'..i,e.S :,;J„�.� vJ,'•I..w't'L;:._s.:-._ _.,.,1 „{`+J -f - ✓fit am,.�1' ;b.>...r•_r�aa. ,;: - .� - - Intl' :-r<.:�ii�.'`�- Tom•_+-#-r,�- �:t* _ ';i, - ';'� - •-!. .+L'<,Y;.y'•Y,. .,�'Ti'.n'.i - .�'?s> _ _ :'�`S• �}i�'.]r�.( Q,`':'w_L t3�:.r•� x:i'. - �S.;rca, wrq.,. ,�r.�ut7.-- ^:`x'�, �r � - - a- .a'a ,�.`�"'S.,L+(rF«�;`v�;•� ..k-r-{::." =%ei•_ 'w-;_; ,..w':._4 s+'�:e�z;��.t:;' -'.x.. .`tr�::t� .,rti?:>•c_> ''_ _.. .Ii;-s. .:�i�':L.,, .-I K. a3'.,. »�^�:�':c�r.. -�w=s:w; :zt�'�,.a"'.-''L+�r:-�y�tir,(:;;- ';3': A'':�'•" r=T,x<`�;.r„'•�- _ "�`�.<i..z+,,�'� -'};=�r''rt•.,��,�>. �.u,,��>atr•F,: ;vzb`'�-;-d`:,ry-•y i''''v'3.•. ��}•�: ,.I�3+. .Xc�{•�� ..,�+_1.� pt_�;,,.:�;.�.-�`f<y-� .•s'i.. s�-`'.+''�.jF'v 7�Y'�! `��';.,,L-;"d7?':x;b5t`:�y- - .x y�'L - �-. b.�•�e.,zz+214�'iy�,�R,�j:' ar',-'-�'_:, 'T'F�."� �'� S-�.:.-'"ir_":_a> �P'�C,. Y„'n..ri'u�`•' Hx � 'ar=''-'�+^� \ r 5 vii J Air! IRlIq 11 4 itfi*Oft-4 r AK tivkllws•lll ROO Nlm.vm� FIpwRrd 5t.-xion V TA_ Px"wl 'RD Old J1. wo MIX, Asp �V�y_ .. ........ m-wi MID' It', ........ ...... Ntl PARTIAL RELEASE AND PARTIAL WAIVER OF LIEN The undersigned (hereinafter the "SUBCONTRACTOR") represents that it has furnished labor, services, equipment, supplies and/or material to CONSTRUCTION CONSULTANTS/L.I., INC.(hereinafter the "CONTRACTOR")and/or the construction project known as Town of Southold of which is the"Owner".Now, therefore, SUBCONTRACTOR, for and in consideration of a payment to be made by the Contractor to the Subcontractor in the sum of Sixteen Thousand Seventy-four and 00/100 Dollars ($16,074.00), for itself, its successors,heirs and assigns,hereby states, affirms and agrees that, with respect to all of such work performed through April 30,2022: 1. All labor employed thereon or in connection therewith and all payroll taxes and charges(such as withholding taxes, social security taxes and worker's compensation, disability and unemployment taxes and/or insurance premiums)have been paid in full;and 2. All materials,tools, equipment, supplies and services furnished and used upon or in connection with said work have been paid in full,and all sales, use, excise and similar taxes on or in connection with the same have been fully paid; and 3. all subcontractors and suppliers have been paid in full; and 4. This document is effective to release and forever discharge the CONTRACTOR,the CONTRACTOR'S bonding company and the OWNER and their respective officers, directors,agents,servants and employees,the funds due or to become due from the OWNER and/or from the CONTRACTOR,and all lands,improvements,chattels, and other real and personal property connected with or a part of said project from any and all claims, causes of action,demands, liens and claims of lien whatsoever arising our of or in connection with the project and all work performed through the aforementioned date,which it has or hereafter 5. might or could have. SUBCONTRACTOR warrants that it has completed all work performed through the aforementioned date as required and that it has complied with all the terms and conditions of its contract. Dated this r 7 day of )In 2022. By: Eric Baum ck/President STATE OF New York) . ss.. COUNTY OF Suffolk ) On ' _ 2022, before me,the undersigned,personally appeared --PAX'e-, .8 hj_L .�,C- J ,personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument,the individual,or the person upon behalf of which the individual acted, executed the instrument. Notary Pub14 SUSAN T. YOUNG Notary Public, State of New York 01Y06209293 Qualified in Suffolk County Term Expires: 7/27/20_,;� TM Document 6706 - 1994 Contractor's Affidavit®f Payment®f Debts and Claims PROJECT:(Name and address) ARCHITECT'S PROJECT NUMBER: OWNER❑ Shinnecock Canal Maritime Park GL C1-99-H110-00-6212-0000 CONTRACT FOR: General Construction ARCHITECT❑ CONTRACTOR❑ TO OWNER: (Name and address) CONTRACT DATED: March 14,2022 SURETY ❑ Town of Southold PO Box 1179 OTHER El Main Road Southold,NY11791 STATE OF: New York COUNTY OF: Suffolk The undersigned hereby certifies that,except as listed below,payment has been made in full and all obligations have otherwise been satisfied for all materials and equipment furnished,for all work,labor,and services performed,and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or Owner's property might in any way be held responsible or encumbered. EXCEPTIONS: Regarding Application#2 Only SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR: (Name and address) 1. Consent of Surety to Final Payment.Whenever Construction Consultants/L.I.,Inc. Sure is involved,Consent of Suret is required. Riverhead, East 2nd Street Surety Surety, 9 Riverhead,NY 11901 AIA Document G707Tn1,Consent of Surety to Final Payment,may be used for this purpose. Indicate attachment: ❑ Yes El No BY: The following supporting documents should be attached (Signature of aut rorized representative) hereto if required by the Owner: Eric Baumack,President 1. Contractor's Release or Waiver of Liens, (Printed name and title) conditional upon receipt of final payment 2. . Separate Releases or Waivers of Liens from Subscribed and sworn to before me on this date:5 I 1`7 Iia Subcontractors and material and equipment suppliers,to the extent required by the Owner, accompanied by a list thereof Notary Public: SUN T, NG Notary Public,State of New York 3. Contractor's Affidavit of Release of Liens My Commission Expires: 01Y06209293 (AIA Document G706ATM) Qualified in Suffolk County CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED��rr rginal assures that 20 / changes will not be obscured. AIA Document G706TM—1994.Copyright©1970 and 1994 by The American Institute of Architects.All rights reserved.WARNING:This AIAe Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA*Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects'legal counsel,copyright@aia.org. opo Cc 2 CONTRACTOR'S AFFIDAVIT OF RELEASE OF LIENS ARCII f ITECT VA 1)ocumunl C700A CONTRACT0R sl'RETY (III IVV(2I-.1;C SOU) I THP .R Town of Southold TO OWNER: PO Box 1179 ARCI I[TECT'S PROJECT NO.: 53095 Main Road Southold,NY 11791 CONTR;\CT FOR: General Construction PROJECT: Moores'Drain Daylighting CONTRACT f)ATEl): March ff,2022 I Skipper Horton Park STATE OF: New York C0I'NT`I OF: Suffolk Thc tIII(ICI-siglic-d that 10 IIIC IX',1 (dIhC LI1IdCI-.',111IICds kno\0(2dgC. information and helicif.except a, lislvd hckm, III(: Rcluases or Waiver,()I,Lien aM:WhCd hICILId(2 the ColItt".1CIol'.all • o1*1II:IL(!I-i;I1.1,and C(IL1iJ)iIIC1II.and all pci-f(irincrs of Work,hh(w i(,-(:s,.vj10 11;Iv(!c)r 111a v have IiCIIS()I-L:I)CL11I1h1-:III(CS or the right III:I.S,C11 lien (W VIICLII1IhI_!IIIC(::S .111V pJ-()pC1-(V oftheOwnur ]IMMICI-(MI(401C Of'(IIL: EXCEPTIONS: Regarding Application#2 Only Sf:1113ORTING DOCI!.NIENTS A'I-I'AC.1 IED I IERETO: CONTI-MTOR: Construction Consultants/L.I., Inc. r 36 East 2nd Street 1. Con[rlwlor,, Re](21I.sc or\V�liVC]' of'LiCIIN, C011dilioll.11 L1I)oII Riverhead,NY 11901 rcccip(of F111al paynICIII. 2. Scparatv k6cciNcs ()I- %X'aivurs of Liclis rnm) 5llhc()11[ractor� :III([ IIIJIL-I-Ld :111d C(ItJij)III(!I)t I() the L'XICIII I_CCIUiR!d hV the 0%VIIUI-.:WC01111),111iU(I!)\':I li.,,[ (11cl-L,of. BY: Inve) Eric Baumack, President SUSAN T.YOUNG Notary public, State ofNew yQ0,- olY062()9293 SLIhSCI_ih(:d ands\�orn to hvforc me on this elate2-2- • Qualified in Suffolk COW% Term Expires: 7/27/2044& Notary I'LlNiC T Com III ission Expires: CAUTION: You should sign an original AIA document that has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. AIA DOCUMENT G7116A - S AlTll)A\I I or RELEASE OF IJFN, - 1991 1:1)11,10%, - NIA - t:10I)i - THE \XIER KA N I\.,;'IITt TE of AI?(J I I 1*1:(.I`,. 1-F5 \'E:\\ )ORK A\'[-'.\I F. \A \\,\S II,,(; 1)C. 2(00(,-5291 - WARNING: Unlicensed photocopying G706A-1994 Violates U.S.copyright laws and will subject the violator to legal prosecution. Construction Consultants LI,Inc. Project:Moores'Drain Daylighting Project at Skipper Horton cd 36 East 2nd Street Park Riverhead,New York 11901 P:(631)727-6604 F�- I F:(631)727-6605 Transmittal #4 - Payment Application # 3 To Michael Collins,PE(Town of Southold) From Lauralynn Moore(CCLI) 53095 Main Road,PO Box 1179 36 East 2nd Street Southold,New York 11971 Riverhead,New York 11901 Date Created �Jul 29,2022 Copies To Transmit Attached Sent Via Attached Submitted For Approval Action As Noted Transmittal Items Format Description Date Copies Document Application for Payment#3 AIA G702 View Jun 30,2022 1 Document Scheulde of Values#3 AIA G703 View Jun 30,2022 1 Document Application for Payment#3 Approved Pencil Copy View Jun 30,2022 1 Document Certified Payroll Reports w/OSHA Card Copies View Jun 30,2022 1 Document Partial Release&Partial Waiver of Lien-CCLI View Jun 30,2022 1 Document Affidavit of Payment of Debts&Claims AIA G706-CCLI View Jun 30,2022 1 Document Affidavit of Release of Liens AIA G706A-CCLI View Jun 30,2022 1 Comments Construction Consultants LI,Inc. Page 1 of 1 Printed On:Jul 29,2022 03:20 PM EDT Al 111-40 TM :s ® Document 6702 1992 . Application and Certificate for Payment TO OWNER: Town ofSouthold' PROJECT: APPLICATION NO.',, 3 Distribution to: P 0 Box 1,179 Moores'Drain Daylighting PERIOD TO: 6/30/22 OWNER ❑ 53095 Main Road Skipper Horton Park Southold NY 11791 CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DATE: CONTRACTOR ❑ Construction Consultants/L.I., Inc. 36 East 2nd Street PROJECT NOS: FIELD ❑ Riverhead, NY 11901 - OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance AIA Document G703TM,Continuation Sheet,is attached. with'the Contract Documents, that all amounts have been paid by-the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner,and i.ORIGINAL CONTRACT SUM................................................. $ 74,000.00 that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS.............................. $ 0.00 CONTRACTOR: Construction Consultants/L.I., Inc. 3.CONTRACT SUM TO DATE(Line I f 2) :....:............................... $ 74,000.00 By: Date: 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) ...... $ 74,000.00 State of: L(_. 5.RETAINAGE: County of: 404_, tq_� SUSAN T. YOUNG a. 5.0%of Completed Work Subscribed and sworn to before try Publlt,State of New York (Columns D+E on G703) $ 3.700.00 me this ;Z�i> day ofa,�(�Qc/t ' 01Y06209293 b. 5.0%of Stored Material UU Qualified in Suffolk County (Column F on G703) $ 0.00 Notary Public: 'Y'," � t1&Lt1A Term Expires: 7/27/20 i My commission expires: (� Total Retainage(Lines 5a+5b,or Total in Column 1 of G703)...... $ 3,700.00 6.TOTAL EARNED LESS RETAINAGE .................................... $ 70,300.00 ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 minus Line 5 Total) In accordance with the Contract Documents,based on on-site observations and the data comprising 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT...................... $ 52,991.00 this application,the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in (Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to payment of the 8.CURRENT PAYMENT DUE ............................................. $ 17,309.00 AMOUNT CERTIFIED. �(� 1 S ' Aos?�� IJ�Q��IIA!c'$ 1�J 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED... ..'........ �..... ` ..................J. / / (Line 3 minus Line 6) $ 3,700.00 (Attach explagation if amount certified differs from the amount applied.Initial all figures on this Applicatibn a d o7th ont• ati n Sheet that are changed to conform with the amount certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECTy &/16-12 c Total changes approved in previous months by Owner $ 0.00 $ 0.00 By: Date: p (5 Z 2-. otal approved this month $ 0.00 $ 0.00 This C tficate is not negotiable.The AMOUNT CERTIFIED is payable only to the Contractor TOTAL $ 0.00 tte� $ 0.00 naa9herein.Issuance,payment and acceptance of payment are without prejudice to any rights of ET CHANGES by Change Order $ 0.00 th&Owner or Contractor under this Contract. CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G702TM11—1992.Copyright ©1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA® Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 010711Aco44 TM Iryi-11-AIADocument 6703 _ 1992 Continuation Sheet Page 2 of 2 AIA Document G702TM-1992,Application and Certificate for Payment,or G732Tm-2009, APPLICATION N0: 3 Application and Certificate for Payment,Construction Manager as Adviser Edition, APPLICATION DATE: containing Contractor's signed certification is attached. 6/30/22 In tabulations below,amounts are in US dollars. PERIOD TO: 6/30/22 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE TO ITEM DESCRIPTION OF WORK FROM PREVIOUS SCHEDULED 'PRESENTLY COMPLETED AND % FINISH RETAINAGE NO. VALUE APPLICATION THIS'PERIOD STORED STORED TO DATE (G_C) (C—G) (If variable rate) (D+E) (Not in D or E) (D+E+F) 1 Insurance& Mobilization 3,000.00 3,000.00 0.00 0.00 3,000.00 100 0.00 150.00 2 Site Demolition & Earthwork 32,800.00 27,880.00 4,920.00 0.00 32,800.00 100 0.00 1,640.00 3 Asphalt Paving 3,800.00 3,800.00 0.00 0.00 3,800.00 100 0.00 190.00 4 Concrete 13,000.00 13,000.00 0.00 0.00 13,000.00 100 0.00 650.00 5 Aluminum Pedestrian Bridge 21,400:00 8,100.00 13,300.00 0.00 21,400.00 100 0.00 1,070.00 j GRAND TOTAL 74,000.00 55,780.00 18,220.00 .0.00 74,000.00 100 0.00 3,700.00 CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G703TM'—1992.Copyright @ 1963,1965,1966,1967,1970,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This Ale Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this Ale Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 101210ACD44 --m r Vendor No. Check No. Town of Southold, New York - Payment Voucher 3555 Vendor Tax ID Number or Social Security Number Vendor Address Entered by 36 East 2nd Street Vendor Name Riverhead, IVY 11901 Audit Date Construction Consultants/L.1., Inc. Vendor Telephone Number (631)727-6604 Town Clerk Vendor Contact Lauralynn Moore Invoice Invoice Invoice Net Purchase Order Number Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 3 6/30/2022 17,309.00 17,309.00' TBR 21-684 Moore's Drain H.1989.2.5OO.10O Daylighting 17,309.00 Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and payment is approved. Signature Title Signature 1 t'l- Company Name Date Title 1�1 W'7 r-7 -7 f f Date U.S. Department of Labor PAYROLL Wage and Hour Division WHO (For Contractor's tlonase• eensruconsawww. o.www.dol.gov/whd/forms/wh347instr.htm) U.S.Wnge and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR [:] ADDRESS OMB No.:1235-0008 Construction Consultants/L.I.,Inc. 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 06 04/30/2022 Moores'Drain Dayllghtng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) 0 0 S M T W T F S DEDUCTIONS NET NAME AND INDIVIDUAL IDENTIFYING NUMBER a o a O GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY o F w WORK o 24 25 26 27 28 29 30 TOTALI RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3X CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Michael Schwarz Laborer 0 7$673.44 2 5859 0 $51.51 $59.22 $3.44 $114.17 $559.27 s 2.00 2.00 72.11 Howard Sexton Operator 0 $875.12 9565 0 Class A $296.88 $1,242 $7.51 $1,546.39 $2,336.96 s 8.00 8,00 109.39 $3,883.35 0 s 0 s a s 0 s 0 s 0 s Whilecompletion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing Pork on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 04/30/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller m — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 24th day of April 2022 and ending the 30th day of April 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages eamed by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below. REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE ' Lauralynn Moore — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted in section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour DivisionWHO (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Mage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR ❑ ADDRESS OMB No.:1235-0008 36 East Second Street,Riverhead,NY 11719 Expires:07/31/2024 Construction Consultants/L.I.,Inc, p PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECTOR CONTRACT NO. 07 05/07/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) Z S M T W T F S DEDUCTIONS NET 0 NAME AND INDIVIDUAL IDENTIFYING NUMBER aia 0 I GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY o F X WORK o 01 02 03 04 OS 06 07 TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURS1 OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Michael Schwarz Laborer o $721.10 5859 1 $79.99 $124.99 $5.34 $210.32 $835.28 s 8.00 2.00 10.0( 72.11 1,045.60 Howard Sexton Operator 0 $1,093.90 9565 0 Class A $296.89 $1,242 $7.51 $1,546.40 $2,336.95 S 8.0o z.o0 1 Q,Q 109.39 $3,883.35 Julio Diaz-Oliva Laborer 0 $576.88 3214 0 $215.14 $691.84 $7.51 $914.49 $1,897.80 s s.ao 8.00 7211 $2 812.29 0 S 0 s 0 S 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained In 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to'furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502.200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 05/07/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH - I Lauralynn Moore Controller Each n paid, (Name of Signatory Party) (Title) as dicatedron heor p as roll,nic an amount of less than the um of he applicable ed in the above referenced payroll has e payroll, do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 01 St day of May 2022 , and ending the 07th day of May 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations, Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat. 108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) MHO U.S.Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR [] ADDRESS 36 East Second Street,Riverhead,NY 11719 OMB No 07131/2024 713 0 Construction Consultants/L.I.,Inc. Expires:07/31//202424 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 08 05/14/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (g) 6 o 0 N S M T W T F S DEDUCTIONS _o NET NAME AND INDIVIDUAL IDENTIFYING NUMBER o Or- GROSS WITH- WAGES e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY 0 2 08 09 10 11 12 13 14 ( w WORK a TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z w CLASSIFICATION HOURS WORKED EACH DAY HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll 0 s 0 s 0 S 0 s 0 s 0 s 0 S 0 s 11 .71 1 1 1 1 1 V I I I I I I While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to'Yumish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 05/14/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller (Name of Signatory Party) (Title) © — Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by Construction Consultants/L.I., Inc. (c)EXCEPTIONS on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 08th day of May 2022 , and ending the 14th day of May 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below. REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS,OR PROGRAMS NAME AND TITLE SIGNAT R Lauralynn Moore ❑ — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. I TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour DivisionaNNO (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR E] ADDRESS O 36 East Second Street,Riverhead,NY 11719 MB No 07/31/2024 7/3 0 Construction Consultants/L.I.,Inc. Expires:07/31//202424 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 09 05/21/2022 Moores'Drain Daylightng Skipper horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) sZ N S M T W T F S DEDUCTIONS 0 NAME AND INDIVIDUAL IDENTIFYING NUMBER o F o NET LLxa I GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY ° y� WORK o 15 16 17 18 ]9 20 21 TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER °z 3 CLASSIFICATION HOURS WORKED EACH DAY HOURS OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll 0 s 0 s 0 s 0 s 0 s 0 a 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator.Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 05/21/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller m — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc. on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain Daylighting Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 15th day of May , 2022 , and ending the 21 St day of May 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat. 108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore '� Controller in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS 9AY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Laborr PAYROLL MHO Wage and Hour Division (For Contractors Optional Use;See Instructions at www.dol.gov/whd/forms/wh347instr.htm) U.S.\Vn[;c and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR r,_11 OR SUBCONTRACTOR[] ADDRESS 36 East Second Street,Riverhead,NY 11901 OMB No.:1235-0008 Construction Cons ultants/L.I.,Inc Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 11 06/04/2022 Moores'Drain Daylighting Skipper Holton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) z z N S M T W T }' S DEDUCTIONS 0 NET NAME AND INDIVIDUAL IDENTIFYING NUMBER LL a a o I GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY �.w WORK o 29 30 31 U I 02 03 04 TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURS OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll 0 s 0 s 0 s 0 S 0 S 0 s 0 s 0 F7 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained In 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(11)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this Information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room 53502,200 Constitution Avenue,N.W. Washington.D.C.20210 (over) Date 06/0412022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller ❑✓ — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain daylighting/Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 29th day of May 202204thand ending the day of dune 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS. (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore ❑ Controller — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In section 4(C)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347!nstr.htm) U.S.\VaQe and Honr Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR OR SUBCONTRACTOR [:] ADDRESS 36 East Second Street,Riverhead,NY 11901 OMB No-1235-0008 Construction Consultants/L.I.,Inc Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. Moores'Drain Daylighting 12 06/11/2022 Skipper Holton Park (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (9) Z Z N S M T W T H S DEDUCTIONS CI 0NET NAME AND INDIVIDUAL IDENTIFYING NUMBER -o' GROSS WITH- WAGES (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY D T,w WORK o ()S 30G �� ()$ Qy I I I TOTALI RATE AMOUNT HOLDING I TOTAL PAID NUMBER)OF WORKER z 3 w CLASSIFICATION HOURS WOJ DURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK No Payroll 0 s 0 s 0 s 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week."U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(11)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"Indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this Information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will lake an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room 53502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 06/11/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller ❑✓ — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS Construction Consultants/L.I., Inc on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain daylighting/Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 05th day of June 2022 , and ending the 11 th day of June 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Cons ultants/L.I., Inc from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore ❑ Controller — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In Section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL MHO Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.gov/whd/forms/wh347!nstr.htm) U.S.\Uagc:md Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR OR SUBCONTRACTOR E] ADDRESS 36 East Second Street,Riverhead,NY 11901 OMB No.:1235-0008 Construction Consultants/L.I.,Inc Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 1306/18!2022 Moores'Drain Daylighting Skipper Horton Park (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (9) Z, m S M T W T }' S DEDUCTIONS 0 NAME AND INDIVIDUAL IDENTIFYING NUMBER 2, o NET (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY o � 12 13 14 15 1617 I8 GROSS WITH- WAGES r w WORK o TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER OF WORKER z 3 w CLASSIFICATION HOURS WORKED EACH DAY HOURS OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK James R.Pavelchack Laborer 0 5144.22 3261 p $176.53 $543.33 $8.15 5728.01 $1,579.51 5 _iro 2.00 72.11 2,307.52 Michael Schwarz Laborer 0 S288.44 5859 1 $176.53 $391.83 58.15 5576.51 S1,731.01 s lrx 4.00 72.11 52,307.52 0 s 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3.5.5(a).The Copeland Act (40 U.S.G.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington.D.C.20210 (over) Date 06118/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller ❑✓ — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by Construction Consultants/L.I., Inc (c)EXCEPTIONS on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain daylighting/Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 12th day of June 2022 and ending the 18th day of June 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore ❑ Controller — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed In the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF except as noted In Section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347!nstr.htm) MOD i Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev.Dec.2008 NAME OF CONTRACTOR ✓❑ OR SUBCONTRACTOR R ADDRESS 36 East Second Street,Riverhead,NY 11901 OMB No.:1235-0008 Construction Consultants/L.I.,Inc Expires:07/31/2024 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 14 06/25/2022 Moores'Drain Daylighting Skipper Horton Park (1) (2) (3) (4)DAY AND DATE (5) I (6) (7) (9) Z Z � S M T W T }' S DEDUCTIONS 90 NAME AND INDIVIDUAL IDENTIFYING NUMBER o o NET =a GROSS WITH- WAGES 19 20 21 22 23 24 25 (e.g.,LAST FOUR DIGITS OF SOCIAL SECURITY ° w WORK o TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER)OF WORKER z w CLASSIFICATION HOURS WORKED EACH DAY HOURS OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Michael Schwarz Laborer ° S144.22 58590 $175.72 $389.03 $8.15 5572.90 $1,724.07 s IN 2.()0 72.11 2?96.97 0 s 0 s 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional,it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week."U.S.Department of Labor(DOL)regulations at 29 C.F.R.§5.5(a)(3)(ii)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed"Statement of Compliance'indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing Instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,.U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 06/25/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Lauralynn Moore Controller �✓ — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by Construction Consultants/L.I., Inc (c)EXCEPTIONS on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Moores'Drain daylighting/Skipper Horton Park ;that during the payroll period commencing on the (Building or Work) 19th day of June 202225thand ending the day of June 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Construction Consultants/L.I., Inc from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE Lauralynn Moore El — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Controller the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 1B AND SECTION 3729 OF except as noted In section 4(c)below. TITLE 31 OF THE UNITED STATES CODE. - 'S'I':�t't�`ilr:l'r�tl,�lrlf,;af i7': t1t j+' 1�1`; .h. 1i•� il�q\):1'.1'+'�;:;��1{�1 .:,ri;i e;.P�,r{„ ((i.lis, LLi.� I'��,r� .:1• ;��`l }'��;. f•,l!y„ �G�;;:'r' 1 'I1 ( . \• •.1.1 .S:' "4'•.�`:... •:t) l'':1 ,S:' A \ °.1 '1' . t 'T 1 4. Af = ? MICHAEL H SCHWARZ has successfully completed the following course: OSHA 30-Hr Outreach Training for the Construction Industry 0/18/2021 ©avid Couch OSHA Authorized Trainer Construction#:20-0106090 General#:20-00791354 ' I As an OSHA Outreach trainer,l verify that l have cvnducred this OSHA Outreach training class in accordance with OSHA Ouheach Training F7rograrn requiiements. 1 will document this class to my OSHA Authoriziny Draining Organization.Upon succes.sfial review of any docuarnentation, 1 will provide each student their completion caul within 90 days of the end of the ciass. I OSI IA Authorized Provider: J UNIVERSITY or {':.-': I 4��s SOIIIH FLRRlilli %'`.;/•' ,%';a' Certificate#'00702541 •r' t; .r 1r V, '7 3r',� err„S. 1, v "h . . •. •.., ,;);:,�; rrlr•!/i3 t' I '1tt�\hhj 111' • ,1,'.\::,fir�;ij i'{�1�t��,•:;I' '� jf\'0.+•..'}1 76"�Y }s1:3. p '�'i!yl•', s • T'��+r ar V f"i�,.•.r .yo-'r 'iy^ •�,+` 1 yl 1 ?•;', { '1.4 :7'.' 1•1: 1 e) , u�-i .F'.,+�r.-. 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Y �•- .s ��. � '9 0 9 E � i t i1 �� s� ��`�L2 t,�p-��G��'" wf. - `` fi �K1 5 a' �'r 1 5 6 f�"•�'t4a ji(�•-� - ��' �i�.}'at A t'q t- -, > � yam,~ �� '~ r-�<.� 4'1 ^:, y1'• ® to ® �`'p.` s .t Y y,r'• ti S A t %" r.�\ .-,+a �J`f�Sk•�`}�t*+'i-• - T ��•,..�{ Si c n• � r 4 f� •` T:.`F � ,'�•��.•s - �*.",� A' "'• tiyy� �. ash, Z.a�r"�!� � �'•� �•t•� �4��fs4��'xt,'�'y t�.u.>`�`�'r.� :.1 �'��:'V'..` p•� w'E+o"S�"J''�.`'- ��-."�^ rr d :c•�*t7`�,yx =WHOU.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.gov/whdKorms/wh3471nstr.htm) a c.Watt:and Floor Division Persons are not required to respond to the collection of information unfess it displays a currently valid OMB control number. Rev.Dec.2008 NA OF CONTRACTOR OR SUBCONTRACTOR® ADDRESS 1981 Montauk Highway Brookhaven 10MlNo.:1235-0006 r;,n G ires: 01/31/2015 3 PAYROLL NO. FOR WEEK ENDI G PROJECT AND LOCATION PROJECT OR CONTRACT NO. 05!08/2022 Skipper Horton Park Town of South Hold 15C-002 I (1) (2) (3) (4)DAY AND DATE (5) (B) (7) tel (9) ~ S M T W TH F SA DEDUCTIONS o � NET NAME AND INDIVIDUAL IDENTIFYING NUMBER a 3 2 3 4 5 6 ? GROSS WITH- I I WAGES (e.g..LAST FOUR DIGITS OF SOCIAL SECURITY °2E$ WORK o TOTAL RATE AMOUNT HOLDING TOTAL PAID NUMBER)OF WORKER z°3 CLASSIFICATION HOURS WORKED EACH DAY OUR OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Patrick W Tew Class A op o 5312.1 S 76 Hedges Ave 0 S242.80 S56.78 5718.25 5219.25 5420.61 $1,657.69 $2,258.51 East Patchogue NY 11772 s 300 3.00 104.05 3,916.20 Jeffrey Tew Class A op o $312'1 310 Gazzola Drive 0 5242,80 $56.78 S718.25 5219,25 5420.61 51,657,69 $2,258.51 East Patchogue NY 11772 s S.oa 3.00 104.05 53,916.20 Mario Olguln Rubio Laborer o 5246.87 12 David Overton Road 0 $123.66 528.92 $340.07 5105.45 510,79 5608.89 $1,385,69 Coram,NY 11727 s 1.00 3.00 9229 S 1,994.58 Patrick J Tew Laborer/Driver o S792.40 76 Hedges Ave 0 5138.85 $32.48 5374.89 S115.98 S112.04 S774.24 $1,465.41 East Patchogue,NY 11772 6 6.e0 8,00 99-05 52,239.65 o , i 6 ' O s 0 s 0 i F 6 While completion of Form WH-347 is optlonal.It is mandatory tar covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the Information collection contained in 29 C.F.R.§§3,3,5.5(a).The Copeland Act ( (40 U.S.C.§3145)contractors and subcontractors performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S.Department of Labor(DOL)regulations al 29 C.F.R.§5,5(a)(3)(II)require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project,accompanied by a signed'Statement of Compliance"indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-B000n prevailing wage rate for the work performed.DOL and federal contracting agendas receiving this information review the Information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement i We estimate that Is will lake an average of 55 minutes to complete this collection,including time for reviewing Instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of Information.If you have any comments regarding mese estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Dlvisian,U.S.Department of Labor,Room S3502,200 Constitution Avenue,N.W. Washington,D.C.20210 (over) Date 5/10/2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH I Colleen Tew Office Manager Name of ll nate Part m — Each laborer or mechanic listed in the above referenced payroll has been paid, ( Signatory y) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract,except as noted in section 4(c)below. (1)That I pay or supervise the payment of the persons employed by (c)EXCEPTIONS on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Skipper Horton Park Town of Southold ;that during the payroll period commencing on the (Building or Work) 2 day of 05 2022 , and ending the 08 day of 05 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat,967;76 Stat.357;40 U.S.C.§3145),and described below: REMARKS: (2)That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;that the wage rates for laborers or mechanics contalned therein are not less than the applicable wage rates contained In any wage determination incorporated into the Contract;that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered s with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAMEANDTITLE IGATU Colleen Tew Office Manger �� in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE S CODE, except as noted in section 4(c)below. 31 OF THE UNITED STATEI 1 i t ~ _ 11-0,04,121170 OSHA 26-607292663 IM NWU,,W,wbbVNb� This card acknowledges trial 1Ke,,.recipient-rias successiuliy completed a n,;,«,d k,-vi dg.mu 6--i*l su+--Tony a—pmud. 10ahour oceupatit nal§afety,aitd=Flea(thTraining Course in _i lgilHeaifh 5 4 hour Cos ructio5.0 4and I ea"lth, �S Pa-t-r i c k Dw i This card issued to: JEFFREY TEW William Campbell 7/7/13 Curtis Chambers 041202020 (Trainer name-print or type) (Course end date) Trainer Name Date of Issue ..« _ Yz r.. Y� ty{� � .:.,�. �.'!'+,i...'.'�� i+�.,,,; .l,ii:.,rj:jfj.,5+�',•+l 4 � _ _ ';hi'•.\._ j`r. � �O,i,ystJlz,itrr�:. , t' - .-�-.�- .'l,•}r•:':: gr..(: i �}= 1Wts�-\bW►�: �.x +Ie .t +r•l: s�,.�,.,. ..•�•.., �Jl',' °' v;L'. '�1 1 I - f. ,r t• r'- M , r,'r`�,� t[�n v1. s Iia he.'reci enCh'as ticc„ssfyll` ori"'e ..t.. P i�:c t.pl tea 7, A •ho '� •�o-c -fici ''y� l l� GU l Ofia I�;"- O a i 1 Satet�'andcPieattfi,'r alnlii t Courah i i"i`tinN'as'sticcsSsftily'iSit ,., t? _ f. r �--- n- r }. ?hfsccil�i�7eogea°4Ytata'racp h b.• �.. '�•'- "" `d' te7rn3n(n9Cours_ y :4 ConstrucfidnvSafetySari "Hemth<<- a; - wY0rhalsr.Ot�upaCtonalSaetyl� :a.'g- tFuction Safe ,and =Cons _t1! •a _ - ,,.. ?y. .r: 7• s3r.' .:i! :.tv .J' �'•r L; ..i-�"A Nom'"•: v. .t� ''?, 4:C+�:`'� Yr '! ..i�.war:.w...,-.,�_.,-._��_.✓w R_..�._- r.1• _ .�,. t• t _ 1 .n rR-i F. -_#: ,'Ir �'J,ra r^.N• :ti• 1r.r++ - 'sf.. f• i2 r1� y� j •�'�. tt.!pe)'i: :' (Courses d:dele' « e't�"t�f-fio '�e.. _ .�,�..�,f,�.� wy{ �,:i.w '�'.�•..�x�: 'C u 'and' L. - r� - €:«,�rafnor;rmma��=P.n �SH- /-� 26-007291052 0SM 12-602312598 �.. .u.aew,,:n..�. _ Pus cud xt wr•kd�n Thu the nCi7uml tu,avewsfully c.nupkted: lThis c2N uknuwtedgn that d�raip(cnitu mccnafullycemplcuxt: 1 ';y,: �V� (i!u' 1';CdnS41%�1,cllonx'il ale --1w _�..�,-,.:�. •tyanclP�ealf}i�;�, It '•a ,Z:,-ai�ifqp�>-':il`"' ,'..'-"�,::�+:.t.,'n �.«*r!C;�!""`t'^;�wC s�:..,._�-:: �i_.._r.._��r-.,..: -_..._+`.. '' `a�"•• _ - !4�'`. --sbio>rConstcu+e - � I w�•� tion QSafe This card issued to: this card issued to:FRANKLIN VERGARA Tew, Patrick Curtis Chambers 04/06/2020 Ignazio Di Magro 02/14/2021 Trainer Name fate orlssue Trainer Name Dute of Issue -" -- OSFU .�aN..nnr 26-607292114 OJ11ti 26-007290492 IWNlYrnbJ�u�,b, nus wd udmosrkdg-Thu the rxiprmt r-axtaslbllp_placd: llSl'l1£tlo c, nuc�laeln nxtdgc tial d,rtcp rnll usuet,muye®pM�1 3:0-bou'r lSot ane'altli ��<�_�� ,.,;>, TA=liq;gr��CQ;nstriiictiozsafe� an�l�roHealthr'�" This card issued to: PATRICK TEW This card issued to: Curtis Chambers 0411.812020 MARIO OL UIN RU131O Trainer Name Date of issue Curtis Chambers 04/05/2020 Trainer Nante Datc of Issue d PARTIAL RELEASE AND PARTIAL WAIVER OF LIEN The undersigned (hereinafter the "SUBCONTRACTOR") represents that it has furnished labor, services, equipment, supplies and/or material to CONSTRUCTION CONSULTANTS/L.I., INC.(hereinafter the "CONTRACTOR")and/or the construction project known as Town of Southold of which is the"Owner".Now, therefore, SUBCONTRACTOR, for and in consideration of a payment to be made by the Contractor to the Subcontractor in the sum of Seventeen Thousand Three Hundred Nine and 00/100 Dollars($17,309.00),for itself, its successors, heirs and assigns, hereby states, affirms and agrees that, with respect to all of such work performed through June 30,2022: 1. All labor employed thereon or in connection therewith and all payroll taxes and charges(such as withholding taxes, social security taxes and worker's compensation, disability and unemployment taxes and/or insurance premiums)have been paid in full;and 2. All materials,tools, equipment, supplies and services furnished and used upon or in connection with said work have been paid in full,and all sales, use, excise and similar taxes on or in connection with the same have been fully paid; and 3. all subcontractors and suppliers have been paid in full; and 4. This document is effective to release and forever discharge the CONTRACTOR,the CONTRACTOR'S bonding company and the OWNER and their respective officers, directors, agents, servants and employees,the funds due or to become due from the OWNER and/or from the CONTRACTOR,and all lands, improvements, chattels, and other real and personal property connected with or a part of said project from any and all claims,causes of action, demands, liens and claims of lien whatsoever arising our of or in connection with the project and all work performed through the aforementioned date,which it has or hereafter 5. might or could have. SUBCONTRACTOR warrants that it has completed all work performed through the aforementioned date as required and that it has complied with all the terms and conditions of its contract. Dated this�day of 92022. By: Eric Bau ack/President STATE OF New York) : ss.: COUNTY OF Suffolk ) On -2 -1 ,2022,before me,the undersigned,personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument,the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SUS Notary Public, to eo YOUNG eW York 01Y06209293 Qualified in Suffolk County Term Expires: 7/27/20--2,5 TM AIA Document G706 — 1994 Contractor's Affidavit of Payment of Debts and Claims PROJECT:(Name.and address) ARCHITECT'S PROJECT NUMBER: OWNER❑ Shinnecock Canal Maritime Park GL C1-99-H110-00-6212-0000 CONTRACT FOR: General Construction ARCHITECT❑ CONTRACTOR❑ TO OWNER:(Name and address) CONTRACT DATED: March 14,2022 SURETY❑ Town of Southold PO Box 1179 OTHER El Main Road Southold,NY11791 STATE OF: New York COUNTY OF: Suffolk The undersigned hereby certifies that,except as listed below,payment has been made in full and all obligations have otherwise been satisfied for all materials and equipment furnished,for all work,labor,and services performed,and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or Owner's property might in any way be held responsible or encumbered. EXCEPTIONS: Regarding Application#3 Only SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR: (Name and address) 1. Consent of Surety to Final Payment.Whenever Construction ConsultantstL.l.,Inc. Sure is involved,Consent of Sure is required. Riverhead, East 2nd Street Surety Surety 9 Riverhead,NY 11901 AIA Document G707TM.Consent of Surety to Final Payment,may be used for this purpose. Indicate attachment: ❑ Yes El No BY: The following supporting documents should be attached (Signature of authorized representative) hereto if required by the Owner: Eric Baumack,President 1. Contractor's Release or Waiver of Liens, (Printed name and title) conditional upon receipt of fmal payment 2. Separate Releases or Waivers of Liens from Subscribed and sworn to before me on this date: Subcontractors and material and equipment f a suppliers,to the extent required by the Owner, �� l Notary Public: accompanied by a list thereof SUSAN T. YOUNG 3. Contractor's Affidavit of Release of Liens My Commission Expires:Notary Public, State of New York (AIA Document G706ATM) 01Y06209293 Qualified in Suffolk Count CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.Kltrdflg5xafliptgur)a" y changes will not be obscured. --a_,� AIA Document G706Tm—1994.Copyright @ 1970 and 1994 by The American Institute of Architects.All rights reserved.WARNING:This AIA Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA®Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects'legal counsel,copyright@aia.org. wo3aancoaz CONTRACTOR'S AFFIDAVIT OF OWNF',R RELEASE OF LIENS ARCHFITCA' CONTRACTOR 11 1 I)ocitmeni G700A (Instructions on rcvcnse sid(2) OTHER Town of Southold TO O\VNER: PC Box 1179 A-RCl-lI'FEC1S PROJECT NO.: \,vll,rola,,,.., 53095 Main Road Southold,NY 11791 CONTRA(:-1-FOR: General Construction PRO,J EC-F: Moores'Drain Daylighting ('ON-l"RA(71'DA'l'ED: March rt,2022 Skipper Horton Park STATE OF: New York CO[ N'FYOF: Suffolk iicrchv C121-tifics(11-at to the hest of the 1-111(ici-signud's knoWICLI'lle. Mfol-111;10011 2;ld bell&,exCCI)l li-SIC(I b6OW. the Rulo.-.Jses or Waivers of Hen aml(J)Cd IIC:I-(!LO il)CILKIC dh:Contr;wror.all Suhremtrtcttrcti,all stlpplicrs uCnruerials'.111(I eCluipment.Mid-III pozi-fornicrs of%Vork,labor or scl-vices who have or l)I;IVh:I%V IiUITS[)I-CIICLI III hI-;II WeS or 11112 right to assets liClIN or encumbrances mynin"I :Ili propci-tv of the Owner arising in anvIMIlIIICI-out of Ihv of the Contract refs rvlicud ahovc. EXCEPTIONS: Regarding Application#3 Only SUPPORTING DOCUNIFNTS A1-lACf[ED IJERETO: CONTRACTOR: Construction Consultants/L.I., Inc. 36 East 2nd Street 1. Comrictor'.s Rclease or NVaivt:r of Liens, condiliolleIl Upon Riverhead,NY 11901 receipt of r1lial pigment. 2. Separate Releases ()I- of LiCIIS fl'orn SLIhCoI1II-:I(-I0I-S .Md II)d C(illil)MCIII SLII)IiIiCI-,S. to III(' L-MCIII I-U(11-lite(I I)v the Owner.accompanied hya list thereof. BY: Eric Baumack,President SUSAN T. Y0LING Notary Public, state of NeW York 01Y06209293 Qualified in Suffolk County Notar,'PuNic: Term Expires: 7/27/202,1�-_ NIv Commission Expires: CAUTION: You should sign an original AIA document that has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. AIA DOCUMENT G706A , CoNT11"1(*'1'1111`� -11:1111,11TI OF III'LFASE 1)1: LIFNs * 11111, FIA HON - AIA - D19AN 91 - I HE IFRI(AN INSTI 1*1'11:F,of F'AS NBV MRK -N\\ 1)(. 20011(,-�;21)2 - WARNING: Unlicensed A\FNI F. p hotocopying G706A-1994 Violates U.S.copyright laws and will subject the violator to legal prosecution. a y� RECEIVED o n o ® OCT 1 4 2021 y Southold Town Clerk Office of the Town Attorney Town of Southold Town Hall Annex, 54375 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone : 631-765-1939 Facsimile: 631-765-6639 MEMORANDUM To: Ms. Elizabeth A. Neville, Town Clerk From: Missy Mirabelli Secretary to the Town Attorney Date: October 13, 2021 Subject: Moores' Drain Daylighting Project Agreement With respect to the above-referenced matter, I am enclosing an original, fully executed Agreement for your records. If you have any questions regarding the enclosed, please do not hesitate to call me. Thank you. Cc: Accounting /mm Enclosures .y RECEIVE® OCT 1 4 2021 AGREEMENT Southold Town Clerk THIS AGREEMENT, entered into this Q day of 2021, by and between the Town of Southold,New York ("the Town"), a municipal corporation organized and existing under the laws of the State of New York with offices at 53095 Main Road, Southold, New York, and Construction Consultants/LI Inc. (the"Contractor"), with an address of 36 E 2°a Street,Riverhead,NY 11901; WITNESSETH, that the Town and the Contractor, for the consideration hereinafter named, agree as follows: ARTICLE 1. WORK TO BE DONE AND CONSIDERATION THEREFOR The Contractor shall perform the Moores' Drain Daylighting Project at Skipper Horton Park and all work necessary for completion thereof as set forth in the proposal and bid of contractor opened August 5, 2021 (see Exhibit A attached). The Contractor will furnish all labor, materials, supplies, equipment and other similar items necessary or proper for, or incidental to, the work contemplated by this Contract, as required by, and in strict accordance with the above drawings, and in strict accordance with such changes as are ordered and approved pursuant to this Contract. ARTICLE 2. TIME OF COMPLETION The services to be rendered under this Contract shall be completed no later than thirty(30) days from the date the contract is signed by all parties. Time of performance is of the essence of this Agreement. ARTICLE 3. ACCEPTANCE AND FINAL PAYMENT Upon receipt of written notice that the Contract has been fully performed and an inspection by the Town Engineer to certify that the work has been completed to the satisfaction of the Town, the Contractor shall file with the Town Comptroller an itemized voucher and the Town will pay the Contractor $74,000.00. Payments will be made on the basis of the actual work completed in accordance with the Contract. Contractor will be paid the total Contract amount after the project is completed and there will be no partial payments. The Town shall pay the Contractor upon the submission of a voucher at the conclusion of the contemplated project. Such voucher shall be due and payable within 45 days after receipt of such voucher, but such sum shall not be due and payable by the Town until the Town Board of the Town has received such a voucher and has audited and approved for payment the voucher to be submitted by Contractor in connection therewith. The Town Board shall process any voucher received from Contractor as expeditiously as possible. In the event that the Town disputes or objects to any portion of any voucher submitted by Contractor pursuant to this paragraph, the Town shall,within 30 days of the receipt of such voucher, notify Contractor in writing of such dispute or objection. Contractor acknowledges that Contractor is familiar with the requirements of section 118 of the Town Law which, in effect, prohibit payment f '1 1 of any of Contractor's claims against the Town unless an itemized voucher therefore shall have been presented to the Town Board or Town'Comptroller and shall have been audited and allowed by the Town Board or Town Comptroller. The acceptance by the Contractor of the final payment shall be, and shall operate as a release to the Town from all claims and all liabilities to the Contractor for all the things done or furnished in connection with this work and for every act and neglect of the Town and others relating to or arising out of, this Contract, except Contractor's claims for interest upon the final payment, if this payment be improperly delayed. No payment, however final or otherwise, shall operate to release the Contractor or its sureties from any obligations under this Contract. ARTICLE 4. CHANGES TO THE CONTRACT AND EXTRA WORK (a) The Town may at times, without notice to the Contractor's surety and without invalidating the Contract, order extra work or make changes by altering, adding to, or deducting from the work contemplated herein and may adjust the Contract price accordingly, pursuant to Paragraph (b) below. The Contractor shall not deviate from, add to, delete from, or make changes in the Work required to be performed hereunder unless so directed by a written Change Order. If the Contractor is directed by the Town to perform extra work prior to an agreement on costs or time, the Contractor shall promptly comply with the Change Order of the Town. No claim for extra work or any change in the work shall be allowed or made unless such extra work or change is ordered by a written Change Order from the Town. (b) The amount of compensation to be paid to the Contractor for any extra work, as so ordered, shall be determined as follows: 1. By a lump sum mutually agreed upon by the Town and the Contractor; or 2. Using the applicable price or prices within the Contract and/or Bid and approved by the Town and the Contractor. (c) Regardless of the method used by the Town in determining the value of a Change Order, the Contractor shall submit to the Town a detailed payment breakdown of the Contractor's estimate of the value of the omitted or extra work. (d) Unless otherwise specifically provided for in a Change Order, the agreed compensation specified therein for extra work includes full payment for extra work covered thereby, and the Contractor waives all rights to any other compensation for such extra work, damage or expense, including claims for delay, damage or expense. (e) The Contractor shall and hereby agrees to produce any and all data the Town may request, including but not limited to, time sheets, certified payrolls, foreman's reports, daily reports, bills and vouchers of Subcontractors, receiving documents, freight and trucking receipts, etc. (f) All change orders shall be processed, executed and approved in the following manner: r a s (i) if the estimated cost of the extra work is less than $1,000 in the aggregate, a Change Order Form must be processed and executed by the Supervising Department Head; (ii) if the estimated cost of the extra work is greater than $1,000, then a Change Order Form must be executed by the Supervising Department Head and submitted to the Town Board for consideration and approval by resolution. The Contractor must submit a detailed explanation of why the Change Order is needed and must also be submitted to the Town Board prior to its approval. The Change Order must also be approved by the Town Comptroller and the Town Attorney. Once this procedure is completed,the Contractor may proceed with the extra work. The Town will not accept any alteration to this form and no payment for Extra Work shall be due the Contractor unless it executes a Change Order on this Form. (g) If the Contractor claims that any work which the Contractor has been ordered to perform will be extra work, that the Contractor for any reason cannot comply with the terms and provisions of the Contract, or that any action or omission of the Town is contrary to the terms and provisions of the Contract and will require the Contractor to perform extra work,the contractor shall: 1. Promptly comply with the Town's direction to perform the work which the_ contractor claims will be extra work; and 2. Proceed diligently, pending and subsequent to the determination of the Town with respect to any said disputed matter, with the performance of the work in accordance with all the instructions of the Town. (h) No claim for extra work shall be allowed unless it was performed pursuant to change order duly approved by the Town Board. The Contractor's failure to comply with any part of this provision shall be deemed to be: 1. A conclusive and binding determination on the part of the Contractor that said change order, work, action or omission does not involve extra work and is not contrary to the terms and provisions of the Contract,and 2. A waiver by the Contractor of all claims for additional compensation, time or damages as a result of said change work, act or omission. (i) The value of claims for extra work, if allowed shall be determined methods described in the Contract including,but not limited to, section(b)immediately above. ARTICLE 5: CONTRACTOR'S OBLIGATIONS (a) The Contractor shall be responsible for the full and correct performance of the Work required-by this Contract within the time specified herein, including work of the Contractor's Subcontractors, and any errors therein shall be corrected at the Contractor's f ' � f own cost and expense. In addition, the Contractor shall indemnify the Town for any costs or expenses attributable to errors in performance by the Contractor or the Contractor's Subcontractors. (b) The Contractor agrees that the Contractor shall protect and shall be solely responsible for all labor and material provided for under this contract, whether or not the same may be erected in place, and for all its plans,tools, equipment, materials, tools of the Contractor's employees and agents, etc. for all adjoining private and public property, and all existing Work on the Project Site, which may be damaged by the Contractor's Work. In no event shall the Town be liable to the Contractor for loss of, pilferage, or damage to any of the same. In the event of said labor and materials, plant, tools or equipment, etc., are damaged, lost or destroyed by reason of fire, theft (irrespective of the negligence of the parties hereto or others), civil commotion, riot, insurrection, violence, war, acts of God, etc., the Contractor's responsibility therefore shall be absolute, and the Contractor shall replace, repair, rebuild, and make good any and all said damage or loss of any and all kinds whatsoever. (c) Contractor shall be responsible for securing all permits required to perform the Work and/or required by the applicable laws, regulations, ordinances, etc., and maintain the validity of all such permits throughout the contract duration, if any. ARTICLE 6. CONTRACTOR'S INSURANCE The Contractor shall not commence work under this Contract until it has obtained all insurance required under this paragraph and such insurance has been approved by the Town. (a) Compensation Insurance: The Contractor shall take out and maintain during the life of this Contract Workers' Compensation Insurance for its employees to be assigned to the work hereunder. (b) Insurance: The Contractor shall take out and maintain during the life of this Contract such general liability, property damage, and commercial auto liability insurance as shall protect it from claims for damages for personal injury, including accidental death, as well as from claims for property damage which may arise from operations under this Contract. The amounts of such insurance shall be as follows: General liability insurance in an amount not less than $1,000,000 for injuries, including wrongful death to any one person and subject to the same limit for each person, in an amount not less than$2,000,000 on account of any one occurrence. Property damage insurance in an amount not less than $300,000 for damage on account of all occurrences. Commercial auto liability insurance in an amount not less than $500,000 for damage on account of all occurrences. i The Contractor shall furnish'the above insurances to the Town and shall also name the Town as an additional named insured in said policies. (c) Any accident shall be reported to the office of the Town Clerk as soon as possible and not later than twenty-four (24) hours from the time of such accident. A detailed written report must be submitted to the Town as soon thereafter as possible and not later than three (3)days after the date of such accident. ARTICLE 7. REPRESENTATIONS OF CONTRACTOR The Contractor represents and warrants: (a) That it is financially solvent and that it is experienced in and competent to perform the type of work to be furnished by it; and (b) That it is familiar with all federal, state, municipal and department laws, ordinances and regulations which may in any way affect the work or those employed therein. ARTICLE 8. PERMITS AND REGULATIONS The Contractor shall comply with all permits issued to the Town in connection with the services furnished under this Agreement. ARTICLE 9. NO DAMAGES FOR DELAY The contractor agrees to make no claim for increased costs, charges, expenses or damages for delay in the performance of this Contract, or for any delays or hindrances from any cause whatsoever, and agrees that any such claim shall be fully compensated for by an extension in the time for substantial and/or final completion of the work. Should the Contractor be or anticipate being delayed or disputed in performing the work hereunder for any reason, it shall promptly, and in no even more than two (2) business days after the commencement of any condition which is causing or threatening to cause such a delay or disruption, notify the Town in writing of the effect of such condition stating why and in what respects the condition is causing or threatening to cause such delay or disruption. Failure strictly to comply with this notice requirement shall be sufficient cause to deny Contractor a change in Schedule and to require it to conform to the Schedule then in effect. ARTICLE 10. TOWN'S RIGHT TO STOP WORK OR TERMINATE CONTRACT The Town shall have the right to stop work or terminate the Contract if: (a) The Contractor is adjudged bankrupt or makes an assignment for the benefit of creditors; or (b) A receiver or liquidator is appointed for the Contractor or for any of its property and is not dismissed within 20 days after such appointment or the proceedings in connection therewith are not stayed on appeal within the said 20 days; or } y (c) The Contractor refuses or fails to prosecute the work or any part thereof with due diligence; or (d) The Contractor fails to make prompt payment to persons supplying labor for the work; or (e) The Contractor fails or refuses to comply with all applicable laws or ordinances; or (f) The Contractor is guilty of a substantial violation of any provision of this Contract; (g) The Town's execution and participation in this contract is found to be in violation of an existing collective bargaining agreement. (h) In any event, the Town, without prejudice to any other rights or remedy it may have, may, with our without cause, by seven (7) days' notice to the Contractor, terminate the employment of the Contractor and its right to proceed as to the work. In such case, the Contractor shall not be entitled to receive any further payment beyond what owed in quantum meruit. ARTICLE 11. DAMAGES It is hereby mutually covenanted and agreed that the relation of the Contractor to the work to be performed by it under this Contract shall be that of an independent contractor. As an independent contractor, it will be responsible for all damage, loss or injury to persons or property that may arise in or be incurred during the conduct and progress of said work,whether or not the Contractor, its agents, or employees have been negligent. The Contractor shall hold and keep the Town free and discharged of and from any and all responsibility and liability of any sort or kind. The Contractor shall assume all responsibility for risks or casualties of every description, for loss or injury to persons or property arising out of the nature of the work, from the action of the elements, or from any unforeseen or unusual difficulty. The Contractor shall make good any damages that may occur in consequence of the work or any part of it. The Contractor shall assume all blame, loss and responsibility of any nature by reason of neglect or violation of any federal, state, county or local laws, regulations or ordinances. ARTICLE 12. INDEMNITY AND SAVE HARMLESS AGREEMENT The Contractor agrees to indemnify and save the Town,its officers, agents and employees harmless from any liability imposed upon the Town, its officers, agents and/or employees arising from the negligence, active or passive, of the Contractor and from and against any damages, claims, or expenses, including reasonable attorney's fees, arising out of Contractor's breach of the Agreement or from Contractor's acts or omissions outside the scope of the Agreement or arising out of claims or actions by third parties against Contractor by virtue of its performance of this Agreement. ARTICLE 13. NO ASSIGNMENT In accordance with the provisions of section 109 of the General Municipal Law, the Contractor is hereby prohibited from assigning, transferring, conveying, subletting or otherwise disposing of this ■ , 1 Agreement, or of its right, title or interest in this Agreement, or its power to execute this Agreement, to any other person or corporation without the previous consent in writing of the Town. ARTICLE 14. REQUIRED PROVISIONS OF LAW Each and every provision of law and clause required by law to be inserted in this Contract shall be deemed to have been inserted herein. If any such provision is not inserted, through mistake or otherwise, then upon the application of either party, this Contract shall be physically amended forthwith to make such insertion. In particular,the Contractor shall, among other things, fully comply with: (a) Labor Law section 220-e and Executive Law sections 291-299 and the Civil Rights Law relating to prohibition against discrimination and providing equal opportunity. (b) Affirmative action as required by the Labor Law. (c) Prevention of dust hazard required by Labor Law section 222-a. (d) Preference in employment of persons required by Labor Law section 222. (e) Eight-hour workday as required by Labor Law section 220(2). ARTICLE 15. PREVAILING WAGE RATES REQUIRED BY LAW (a) The parties hereto, in accordance with the provisions of section 220(3) of the Labor Law, if applicable,hereby agree that there shall be paid each employee engaged in work under this Contract not less than the wage rate and supplements set opposite the trade or occupation in which he/she is engaged, which are the wage rates and supplements established as the prevailing rate of wages for the work covered by this Contract. (b) Labor classifications not appearing on the schedule of wages can be used only with the consent of the Owner and then the rate to be paid will be given by the Owner after being advised by the Department of Labor. (c) The Contractor shall post in a prominent and accessible place on the site of the work a legible statement of all wage rates and supplements, as specified in the Contract, for the various classes of mechanics,workingmen/women, or laborers employed on the work. ARTICLE 16. AUTHORITY FOR EXECUTION ON BEHALF OF THE TOWN The Supervisor has executed this Agreement pursuant to Resolution No. 2021-684 adopted by the Town Board of the Town of Southold, at a meeting thereof held on September 7, 2021. Scott A. Russell, Supervisor, whose signature appears hereafter, is duly authorized and empowered to execute this instrument and enter into such an Agreement on behalf of the Town. This instrument shall be executed in duplicate. At least one copy shall be permanently filed, after execution thereof, in the office of the Town Clerk, Elizabeth Neville. R ' 1 ARTICLE 17. NOTICES Any and all notices and payments required hereunder shall be addressed as follows, or to such other address as may hereafter be designated in writing by either party hereto: To Town: Elizabeth A.Neville,RMC, CMC Southold Town Clerk P.O. Box 1179 Southold,NY 11971-0959 With Copy To: Michael Collins,Town Engineer P.O. Box 1179 Southold,NY 11971-0959 To Contractor: Construction Consultants/LI Inc. Attn: Eric Baumack 36 E 2nd Street Riverhead,NY 11901 , ARTICLE 18. WAIVER No waiver of any breach of any condition of the Agreement shall be binding unless in writing and signed by the party waiving said breach. No such waiver shall in any way affect any other term or condition of this Agreement or constitute a cause or excuse for a repetition of such or any other breach unless the waiver shall include the same. ARTICLE 19. MODIFICATION This Agreement constitutes the complete understanding of the parties. No modification of any provisions thereof shall be valid unless in writing and signed by both parties. ARTICLE 20. APPLICABLE LAW This Agreement is governed by the laws of the State of New York. IN WITNESS WHEREOF, the Town of Southold has caused these presents to be signed by Scott A. Russell, its Supervisor, duly authorized to do so, and the Contractor has caused these presents to be signed by its President, the day and year first above written. Construction Consultants/LI Inc. Town of Southol By: By: Er a e, rN s a ►.,rr,(Name) %A T(Title) Scott-A ussell, Supe sor M ' � STATE OF NEW YORK) ) ss.: COUNTY OF S.�.pU,FFOLK) On this�� day of-Sept r in the year 2021 before me, the undersigned,personally appeared j2hc1j h (Name)the PALa � (title) and authorized agent of Construction Consultants/LI Inc.,personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument, the individual or the person upon whose behalf of which the individual acted, executed the instrument. tt"" I- Notary Publ' SUSAN T.YANG Notary Public, State of New York STATE OF NEW YORK) 01Y06209293 ) ss.: qualified in Suffolk county COUNTY OF SUFFOLK) Term Expires: 7/27/20-9=<- G On this[JA day of m the year 2021 before me,the undersigned,personally appeared SCOTT A. RUSSELL,personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument, the individual or the person upon whose behalf of which the individual acted, executed the instrument. Notary Public LAUREN M. STANDISH Notary Public-State of New York No.01 ST6164008 Qualified in Suffolk County Commission Expires April 9,2023 NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,3RD FLR,MELVILLE,NEW YORK 11747-3129 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE [oil#IA 0 ^^^"^ 112859961 CONSTRUCTION CONSULTANTS/L.I.iNC. 36 EAST 2ND STREET RIVERHEAD NY 11901 Imil SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER CONSTRUCTION CONSULTANTS/L.I. INC. TOWN OF SOUTHOLD 36 EAST 2ND STREET 53095 MAIN ROAD RIVERHEAD NY 11901 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11046035-0 978864 06/05/2021 TO 06/05/2022 9/30/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1046 035-0, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/lWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 1031075404 R' � YORK workers' Compensation CERTIFICATE OF INSURANCE COVERAGE STATE I 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 CONSTRUCTION CONSULTANTS/L I INC 631-727-6604 36 EAST 2ND STREET RIVERHEAD,NY 11901 1c Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i e,Wrap-Up Policy) 112859961 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) The Town of Southold ShelterPoint Life Insurance Company 53095 Main Rd 3b Policy Number of Entity Listed in Box"I a" Southold, NY 11971 DBL23270 3c.Policy effective period 09/15/2021 to 09/14/2022 4 Policy provides the following benefits: © A.Both disability and paid family leave benefits. B Disability benefits only F1 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 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 camer referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above Date Signed 10/1/2021 By r (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 TTo be completed by the NYS Workers'Compensation Board(only if Box 4C or 58 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 Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carvers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authonzed to issue Form DS-120.1 Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 1111111111111111111EIIIIIIIIIa��'1111111 ,4coR CERTIFICATE OF LIABILITY INSURANCE 7E(MM/DD1YYYY) /24/2021 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(les) must 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 NAME Sclrocco Group PHONE Ivonne Kraft FAX 777 Terrace Avenue A/c No E 201-727-0070 x205 [A/C No•201-727-0080 Hasbrouck Heights NJ 07604 A DRIESS (kraft sfirocco rou .com INSURERS AFFORDING COVERAGE NAIC# INSURERA The Travelers Indemnity Company of Connecticut 25682 INSURED CONST07 INSURER B The Travelers Indemnity Company of America 25666 Construction Consultants/LI Inc. INSURER C:The Travelers Indemnity Company 25674 36 East 2nd Street INSURER D The Travelers Indemnity Company 25658 Riverhead NY 11901 INSURER E:The Hanover Insurance Company 22292 INSURER F: COVERAGES CERTIFICATE NUMBER:927525739 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY Y DT-CO-1L800952-TCT-21 8/14/2021 8/14/2022 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence $300.000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 PRO- POLICY X JECT LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER $ B AUTOMOBILE LIABILITY BA-3N10651A-21-26-G 8/14/2021 8/14/2022 COMBINED SINGLE LIMIT Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per acadent $ C UMBRELLA LIAB X OCCUR CUP-11-954480-21-26 8/14/2021 8/14/2022 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED I X I RETENTION$10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N!A (Mandatory In NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ D Excess Liability EX-4S517832-21-NF 8/14/2021 8/14/2022 Occurrence/Aggregate $6,000,000 E RHY D666715 08 8/14/2021 8/14/2022 Leased/Rented Equip $300,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project:Moores Drain Daylighting Project at Skipper Horton Park. The Town of Southold as additional insured ATIMA as respects to work performed by the named insured as required by written contract and to the extent provided by the actual policy language of the Commercial General Liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Main Road Southold NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ' COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (Includes Products-Completed Operations If Required By Contract) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS (1) Any "bodily injury", "property damage" or The following is added to SECTION II— WHO IS AN "personal Injury" arising out of the providing, INSURED: or failure to provide, any professional Any person or organization that you agree in a architectural, engineering or surveying written contract or agreement to include as an services, including: additions! insured on this Coverage Part is an (a) The preparing, approving, or failing to Insured, but only: prepare or approve, maps, shop a. With respect to liability for "bodily injury" or drawings, opinions, reports, surveys, "property damage" that occurs, or for "personal field orders or change orders, or the injury" caused by an offense that is committed, preparing, approving, or failing to subsequent to the signing of that contract or prepare or approve, drawings and agreement and while that part of the contract or specifications; and agreement is in effect; and to the extent that, such inor (b) Supervisory, inspection, architectural or b. If, and only injury engineering activities. damage is caused by acts or omissions of you or your subcontractor in the performance of "your (2) Any "bodily injury" or "property damage" work" to which the written contract or agreement caused by "your work" and included in the applies. Such person or organization does not "products-completed operations hazard" qualify as an additional insured with respect to unless the written contract or agreement the independent acts or omissions of such specifically requires you to provide sucr person or organization. coverage for that additional insured during The insurance provided to such additional insured is the policy period. subject to the following provisions: c. The additional insured must comply with the a. If the Limits of Insurance of this Coverage Part following duties: shown in the Declarations exceed the minimum limits required by the written contract or (1) Give us written notice as soon as practicable agreement, the insurance provided to the of an "occurrence" or an offense which may additional insured will be limited to such result in a claim. To the extent possible, such minimum required limits. For the purposes of notice should include: determining whether this limitation applies, the (a) How, when and where the "occurrence" minimum limits required by the written contract or or offense took place; agreement will be considered to include the minimum limits of any Umbrella or Excess (b) The names and addresses of any injured liability coverage required for the additional persons and witnesses; and insured by that written contract or agreement. This provision will not increase the limits of (c) The nature and location of any injury or insurance described in Section III — Limits Of damage arising out of the "occurrence" Insurance. or offense. b. The insurance provided to such additional (2) If a claim is made or "suit" is brought against insured does not apply to: the additional insured: CG D2 46 0419 O 2018 The Travelers Indemnity Company.All rights reserved. Page 1 of 2 COMMERCIAL GENERAL LIABILITY (a) Immediately record the specifics of the (4) Tender the defense and indemnity of any claim or"suit" and the date received;and claim or "suit" to any provider of other (b) Notify us as soon as practicable and see insurance which would cover such additional to it that we receive written notice of the insured for a loss we cover_ However, this claim or"suit" as soon as practicable. condition does not affect whether the Insurance provided to such additional (3) Immediately send us copies of all legal insured is primary to other insurance papers received in connection with the claim available to such additional insured which or "suit", cooperate with us in the covers that person or organization as a investigation or settlement of the claim or named insured as described in Paragraph 4., defense against the "suit", and otherwise Other Insurance, of Section IV —Commercial comply with all policy conditions. General Liability Conditions. Page 2 of 2 0 2018 The Travelers Indemnity Company.All rights reserved. CG D2 46 04 19 ' COMMERCIAL GENERAL LIABILITY 9 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage.Read (1) The "bodily injury'or"property damage" is the entire policy carefully to determine rights, duties and caused by an"occurrencd'that takes place what is and is not covered. in the"coverage territory'; Throughout this policy the words "you"and "your"refer (2) The "bodily injury' or "property damage" to the Named Insured shown in the Declarations,and occurs during the policy period;and any other person or organization qualifying as a Named Insured under this policy. The words "we", "us" and (3) Prior to the policy period, no insured listed "our"refer to the company providing this insurance. under Paragraph 1. of Section If—Who Is An Insured and no "employee" authorized The word "insured" means any person or organization by you to give or receive notice of an qualifying as such under Section 11 — Who Is An "occurrencd' or claim knew that the"bodily Insured. injW' or"property damage" had occurred, Other words and phrases that appear in quotation in whole or in part If such a listed insured marks have special meaning. Refer to Section V — or authorized"employee" knew, prior to the Definitions. policy period, that the "bodily injury" or "property damage" occurred, then any SECTION I—COVERAGES continuation, change or resumption of such COVERAGE A—BODILY INJURY AND PROPERTY "bodily injury' or"property damage" during DAMAGE LIABILITY or after the policy period will be deemed to 1. Insuring Agreement have been known prior to the policy period. a. We will pay those sums that the insured c. "Bodily injury" or "property damage" which becomes legally obligated to pay as damages occurs during the policy period and was not, because of"bodily injury'or"property damage" prior to the policy period, known to have to which this insurance applies. We will have occurred by any insured listed under Paragraph the right and dutyto defend the insured against 1. of Section 11 — Who Is An Insured or any any "suit" seeking those damages. However, "�PI�''authorized by you to give or receive we will have no duty to defend the insured notice of an occurrencd or claim, includes any against any"suit' seeking damages for"bodily continuation, change or resumption of that "bodily injury"li or "property damage" after the injury' or "property damage" to which this of insurance does not apply. We may, at our end the policy period. discretion, investigate any "occurrences' and d. "Bodily injury' or "property damage" will be settle anyclaim or"suit"that may result.But: deemed to have been known to have occurred (1) The amount we will pay for damages is at the earliest tine when any insured listed limited as described in Section III —Limits under Paragraph 1. of Section II —Who Is An Of Insurance;and Insured or any"employee'authorized by you to give or receive notice of an "occurrencd' or (2) Our right and duty to defend end when we claim: have used up the applicable limit of (1) Reports all, or any part, of the "bodily insurance in the payment of judgments or injury" settbmenls under Coverages A or B or or "property damage!' to us or any medical a under Coverage C. other insurer; No other obligation�� or liabilityo to pay sums or (2) Receives a written or verbal demand or perform acts or services is covered unless clairn for damages because of the "bodilyinjury'or"propertydamage";or explicitly provided for under Supplementary Payments. (3) Becomes aware by any other means that b. This insurance applies to "bodily injury" and "bodily injury' or "property damage" has "property damage"only if occurred or has begun to occur. CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 1 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY e. Damages because of "bodily injury' include (3) Any statute,ordinance or regulation relating damages claimed by any person or organization to the sale, gift, distribution or use of for care, loss of services or death resulting at alcoholic beverages. anytime from the"bodily injury'. This a clusion applies only if you are in the 2. Exclusions business of manufacturing,distributing,selling, This insurance does not apply to: serving or furnishing alcoholic beverages. For a. Expected Or Intended Injury the purposes of this exclusion, permitting a person to bring alcoholic beverages on your "Bodily injury"or"property damage"expected or premises, for consumption on your premises, intended from the standpoint of the insured. whether or not a fee is charged or a license is This exclusion does not apply to"bodily injury' required for such activity, is not by itself or"property damage" resulting from the use of considered the business of selling, serving or reasonable force to protect persons or property. furnishing alcoholic beverages. b. Contractual Liability d. Workers'Compensation And Similar Laws "Bodily injury' or "property damage" for which Any obligation of the insured under a workers' the insured is obligated to pay damages by compensation, disability benefits or reason of the assumption of liability in a unemployment compensation law or any similar contract or agreement.This exclusion does not law. apply to liability for damages: e. Employer's Liability (1) That the insured would have in the absence "Bodily injury'to: of the contract or agreement; or (2) Assumed in a contract or agreement that is (1) An"employee"of the insured arising out of and in the course of- an fan "insured contract'; Provided that the "bodily injury'or"property damage"occurs (a) Employment by the insured;or subsequent to the execution of the contract (b) Performing duties related to the or agreement. Solely for the purposes of conduct of the insured's business; or liability assumed in an "insured contract", (2) The spouse, child, parent, brother or sister reasonable attorneys' fees and necessary of that "employee" as a consequence of litigation expenses incurred by or for a party Paragraph(1)above. other than an insured will be deemed to be damages because of "bodily injury' or This exclusion applies whether the insured may .'property damage", provided that: be liable as an employer or in any other capacity (a) Liability to such party for, or for the and to any obligation to share damages with or cost of, that party's defense has also repay someone else who must pay damages been assumed in the same "insured because of the injury. contract";and This exclusion does not apply to liability (b) Such attomeys' fees and litigation assumed by the insured under an "insured expenses are for defense of that party contract against a civil or alternative dispute f. Pollution resolution proceeding in which (1) "Bodily injury' or"property damage"arising damages to which this insurance out of the actual, alleged or threatened applies are alleged. discharge, dispersal, seepage, migration, c. Liquor Liability reuse or escape of"pollutants": "Bodily injury' or "property damage" for which (a) At or from any premises, site or any insured may be held liable by reason of location which is or was at any time owned or occupied by, or rented or (1) Causing or contributing to the intoxication loaned to, any insured. However, this of any person; subparagraph does not applyto: (2) The furnishing of alcoholic beverages to a (i) "Bodily injury' if sustained within a person under the legal drinldng age or building and caused by smoke, under the influence of alcohol; or fumes, vapor or soot produced by or originating from equipment that Page 2 of 21 ©2017 The Travelers,Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ' COMMERCIAL GENERAL LIABILITY is used to heat, cod or dehumidify to perform the normal electrical the building, or produced by or hydraulic or mechanical functions originating from equipment that is necessary for the operation of used to heat water for personal "mobile equipment' or its parts, if use by the building's occupants or such fuels, lubricants or other their guests; operating fluids escape from a (ii) "Bodily injury' or "property vehicle part designed to hold,store damage" for which you may be or receive them. This exception held liable, if you are a contractor does not apply if the"bodily injury" and the owner or lessee of such or"property darnaLge"arises out of premises, site or location has been the intentional discharge,dispersal added to your policy as an or release of the fuels, lubricants additional insured with respect to or other operating fluids,or if such your ongoing operations performed fuels, lubricants or other operating for that additional insured at that - fluids are brought on or to the premises, site or location and such premises, site or location with the premises, site or location is not intent that they be discharged, and never was owned or occupied dispersed or released as part of by, or rented or loaned to, any the operations being performed by insured, other than that additional such insured, contractor or insured;or subcontractor; (iii)"Bodily injury' or "property (ii) "Bodily injury' or "property damage" arising out of heat, dar>agd' sustained within a smoke or fumes from a "hostile building and caused by the release fire?'; of gases, fumes or vapors from (b) At or from any premises, site or materials brought into that building location which is or was at any time in connection with operations being used by or for any insured or others for performed by you or on your behalf the handling, storage, disposal, by a contractor or subcontractor;or processing or treatment of waste; (c) If such "pollt,rtants"are s were at any (iii) "Bodily injury' s "property damagd' arising out of heat, time transported, handled, stored, smoke or fumes from a "hostfle treated, disposed of, or processed as fire';or waste by or for: (Q Any insured;or (e) At or from any premises, site or (n) Any person or organization for location on which any insured or any whom you may be legally contractors or subcontractors worldng directly or indirectly on any insuredsresponsible; behalf are or were at any time (d) At or from any premises, site or performing operations to test for, location on which any insured or any monitor, clean up, remove, contain, cordractors or subcontractors woridng treat, detcDdfy or neutralize, or in any directly or indirectly on any insureds way respond to, or assess the effects behalf are performing operatics if the of,"pollutants". "pollutants" are brought on or to the premises, site or location in connection (2) Any loss, cost or expense arising out of with such operations by such insured, any contracts or subcontractor. However, (a) Request, demand,order or statutory or this subparagraph does not apply to: regulatory requirement that any insured {i) "Bodily injury' or "property or others test for, monitor, clean up, darnagd' arising out of the escape remove, contain, treat, deto)dfy or of fuels, lubricants or other neutralize, or in anyway respond to, or operating fluids which are needed assess the effects of,"pollutants';or CG Ti 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 3 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY (b) Claim or suit by or on behalf of any (b) The operation of any of the machinery governmental authority or any other or equipment listed in Paragraph f.(2) person or organization because of or f.(3) of the definition of "mobile testing for, monitoring, cleaning up, equipment'; or removing, containing, treating, (6) An aircraft that is: detoxifying or neutraliang, or in any way responding to, or assessing the (a) Chartered with a pilot to any insured; effects of,"pollutants". (b) Not owned by any insured;and g. Aircraft,Aub Or Watercraft (c) Not being used to cavy any person or "Bodily injury'or"property damage" arising out property for a charge. of the ownership, maintenance, use or h. Mobile Equipment entrustment to others of any aircraft, "auto" or "Bodily injury' or"property damage" arising out watercraft owned or operated by or rented or of. loaned to any insured Use includes operation and"loading or unloading" (1) The transportation of "mobile equipment" This exclusion applies evert if the claims by an "auto" owned or operated by or rented or loaned to any insured;or against any insured allege negligence or other wrongdoing in the supervision, hiring, (2) The use of"mobile equipment' in, or while employment, training or monitoring of others by in practice for, or while being prepared for, that insured, if the"occurrencd' which caused any prearranged racing,speed, demolition, the"bodily injury"or"property damage"involved or stunting activity the ownership, maintenance, use or i. War entrustment to others of any aircraft "auto" or "Bodily injury' or"property damage" arising out watercraft that is awned or operated by or of. rented or loaned to any insured. (1) War, including undeclared or c'nril war; This exclusion does not apply to: (2) Warlike action by a militaryforce, including (1) A watercraft white ashore on premises you action in hindering or defending against an . own or rent; actual or expected attack, by any (2) A watercraft you do not own that is: government, sovereign or other authority (a) 50 feet long or less;and using military personnel or other agents; or (b) Not being used to carry any person or (3) Insurrection, rebellion, revolution, usurped property for a charge; power, or action taken by governmental authority in hindering or defending against (3) Parking an "auto" on, or on the ways next any of thee. to, premises you own or rent, provided the "auto" is not owned by or rented or loaned J• Damage To Property to you or the insured; "Property damage"to: (4) Liability assumed under any "insured (1) Property you awn, rent, or occupy, contract'for the ownership,maintenance or including any costs or expenses incurred use of aircraft or watercraft; by you, or any other person, organization or (5) "Bodily injury'or"property damage"arising amity, for repair, replacement, out of: enhancement, restoration or maintenance (a) The operation of machinery or of such property for any reason, including equipment that is attached to, or part prevention of injury to a person or damage to another's property, of, a land vehicle that would qualify as "mobile equipment'under the definition (2) Premises you sell,give away or abandon,if of "mobile equipment' if such land the "property damage" arises out of any vehicle were not subject to a Part of those premises; compulsory or financial responsibility (3) Property loaned to you; law, or other motor vehicle insurance (4) Personal property in the care, custody or law, where it is licensed or principally controlof the insured; garaged,or Page of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ' COMMERCIAL GENERAL LIABILITY (5) That particular part of real property on accidental physical injury to "your product" or which you or any contractors or "your work"atter it has been put to its intended subcontractors working directly or indirectly use. on your behalf are performing operations, if n. Recall Of Products,Work Or Impaired the property damage arises out of those Property operations;or Damages claimed for any loss, cost or expense (6) That particular part of any property that incurred by you or others for the loss of use, must be restored, repaired or replaced withdrawal, recall, inspection, repair, because "your work!' was incorrectly replacement, adjustment, removal or disposal performed on it. Of Paragraphs(1),(3) and(4) of this exclusion do (1) "Your product' not apply to "premises damage'. A separate (2) "Your worm';or limit of insurance applies to"premises damage" as described in Paragraph 6. of Section IN — (3) "Impaired properly Limits Of Insurance. if such product,work, or property is withdrawn Paragraph(2)of this exclusion does not apply if or recalled from the market or from use by any the premises are "your work!' and were never pion or organization because of a known or occupied,rented or held for rental by you. suspected defect, deficiency, inadequacy or Paragraphs (3), (4), (5) and (6) of this dangerous condition in it. exclusion do not apply, to liability assumed o. Personal And Advertising Injury under a sidetrack agreement. "Bodily injury' arising out of "personal and Paragraph(6) of this exclusion does not apply advertising injury'. to"property damage"included in the"products- p. Electronic Data completed operations hazard'. Damages arising out of the loss of, loss of use k. Damage To Your Product of,damage to,corruption of, inability to access, "Property damage"to"your product"arising out or inability to manipulate"electronic data". of it or any part of ft- However, this exclusion does not apply to 1. Damage To Your Work liability for damages because of"bodily injury'. "Property damage"to"your worn' arising out of q. Unsolicited Communication it or any part of it and included in the"products- "Both injury' or r ' completed operations hazard" ty injN "property op�Y damage' arising out of any actual or alleged violation of any law that This exclusion does not apply if the damaged restricts or prohibits the sending, transmitting work or the work out of which the damage or distributing of"unsolicited communication". arises was performed on your behalf by a subcontractor- r. Access Or DisclosureOf Confidential Or Personal Information m, Damage To Impaired Property Or Property Not Physically Injured "Bodily injury' or"property damage" arising out of any access to or disclosure of any person's "Property damage' to "impaired property' or or organization's confidential or personal property that has not been physically injured, information arising out of. (1) A defect, deficiency, inadequacy or S. Asbestos dangerous condition in "your product" or (1) "Bodily injury'or"property damage" arising "your wcrK';or out of the actual or alleged presence or (2) A delay or failure by you or anyone acting actual, alleged or threatened dispersal of on your behalf to perform a contract or asbestos, asbestos fibers or products agreement in accordance with its terms. containing asbestos, provided that the "bodily injury" or "property damage" is This exclusion does not apply to the loss of use caused or contributed to by the hazardous of other property arising out of sudden and properties of asbestos. CG T1 00 0219 ©2017 The Travelers indemnity Company.All rights reserved. Page 5 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. 'COMMERCIAL GENERAL LIABILITY (2) "Bodily injury'or"property damage"arising employment-related practices described in out of the actual or alleged presence or Paragraph(a),(b), or(c)above is directed. actual, alleged or threatened dispersal of This exclusion applies whether the insured may any solid, liquid, gaseous or thermal irritant be liable as an employer or in any other capacity or contaminant, including smoke, vapors, and to any obligation to share damages with or soot, fumes, acids, alkalis, chemicals and repay someone else who must pay damages waste, and that are part of any claim or because of the"bodily injury'. "suit' which also alleges any"bodily injury' Exclusions c. through n. do not apply to "premises or "property damage" described in damage". A separate limit of insurance applies to Paragraph(1)above. "premises danxage"as described in Paragraph 6.of (3) Any loss, cost or expense arising out of Section III—Limits Of Insurance. any. COVERAGE B—PERSONAL AND ADVERTISING (a) Request, demand, order or statutory or INJURY LIABILRY regulatory requirement that any insured 1. Insuring Agreement or others test for, monitor, clean up, a. We will pay those sums that the insured remove, contain, treat, detoxify or becomes legally obligated to pay as damages neutralize, or in any way respond to, or because of"personal and advertising injury'to assess the effects of, asbestos, which this insurance applies. We will have the asbestos fibers or products containing right and dutyto defend the insured against any asbestos;or "suit'seeking those dams. However,we will (b) Claim or suit by or on behalf of any halve no duty to defend the insured against any gavernmental authority or any other "suit' seeking damages for "personal and person or organization because of advertising injury'to which this insurance does testing for, monitoring, cleaning up, not apply. We may, at our discretion remdvitig, containing, truing, investigate any offense and settle any claim or detoxifying or neutralizing, or in any "suit'that may result.But way responding to, or assessing the (1) The amount we will pay for damages is effects of,asbestos, asbestos fibers or limited as described in Section III —Limits products containing asbestos. Of Insurance;and t Employment-Related Practices (2) Our right and duty to defend end when we "Bodily injury"to: have used up the applicable limit of (1) A person arising out of any. insurance in the payment of judgments or (a) Refusal to employ that person; settlements under Coverages A or B or (b) Termination of that person's medical expenses under Coverage C. employrnent;or No other obligation or liability to pay sums or (c) Employment-related practice, policy, perform acts or services is covered unless act or omission, such as coercion, explicitly provided for under Supplementary demotion, evaluation, reassignment, Payments. discipline, failure to promote or b. This insurance applies to "personal and advance, harassment, humiliation, advertising injury' caused by an offense arising discrimination, libel, slander, violation out of your business but only if the offense was of the person's right of privacy, committed in the"coverage territory'during the malicious prosecution or false arrest, policy period. detention or imprisonment applied to or 2 Exclusions directed at that person, regardless of whether such practice, policy, act or This insurance does not apply to., omission occurs, is applied or is a. Knowing Violation Of Rights Of Another committed before, during or after the "personal and advertising injury' caused by or time of that person's employment;or at the direction of the insured with the (2) The spouse, child, parent, brother or sister knoMedge that the act would violate the rights of that person as a consequence of"bodily of another and would inflict "personal and injury' to that person at whom any of the advertising injury'. Page6 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG Tl 00 0219 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ' COMMERCIAL GENERAL LIABILITY This exclusion does not apply to "personal against a civil or alternative dispute injury"caused by malicious prosecution. resolution proceeding in which b. Material Published With Knowledge Of damages to which this insurance Falsity applies are alleged. "Personal and advertising injury' arising out of f. Breach Of Contract oral or written publication, including publication "Advertising injury' arising out of a breach of by electronic means,of material, if done by or at contract the direction of the insured with knowledge of g_ Quality Or Performance Of Goods—Failure its thls'ry. To Conform To Statements c. Material Published Or Used Prior To Policy "Advertising injury' arising out of the failure of Period goods, products or services to conform with (1) "Personal and advertising injury'arising out any statement of quality or performance made of oral or written publication, including in your"advertisement'. publication by electronic means,of material h. Wrong Description Of Prices whose first publication took place before the beginning of the policy period;or "Advertising injury' arising out of the wrong description of the price of goods, products or (2) "Advertising injury' arising out of services stated in your"advertisement'. infringement of copyright, "titV or"slogan" in your "advertisement' whose first i. Intellectual Property infringement in your "advertisement' was "Personal and advertising injury' arising out of committed before the beginning of the any actual or alleged infringement or violation of policy period. any of the following rights or laws, or any other d. Criminal Acts "personal and advertising injury' alleged in any claim or "suit' that also alleges any such "Personal and advertising injury'arising out of a infringement or violation: criminal act committed by or at the direction of (1) Copyright; the insured. e. Contractual Liability (2) Patent; "Personal and advertising injury'for which the (3) Trade dress; insured has assumed liability in a contractor (4) Trade name; agreement. This exclusion does not apply to (5) TradernarK liaUlityfor damages: (1) That the insured would have in the absence {6) Trade secret; or of the contract or agreement; or (7) Other intellectual properly rights or laws. (2) Because of "personal injury' assumed by This exclusion does not apply to, you in a contract or agreement that is an (1) "Advertising injury'arising out of any actual "insured contract", provided that the or alleged infringement or violation of "personal injury' is caused by an offense another's copyright, "title" or "slogan" in committed subsequent to the execution of your"advertisement;or the contract or agreement. Solely for the purposes of liability assumed by you in an (2) Any other "personal and advertising injury' "insured contract', reasonable attorneys' alleged in any claim or "suit' that also fees and necessary litigation expenses allegesant such infringement or violation incurred by or for a party other than an of another's copyright, "title" or"slogan" in insured will be deemed to be damages your"advertisement'. because of"personal injury',provided that: j, Insureds In Media And Internet Type (a) Liability to such party for, or for the Businesses cost of, that partys defense has also "Personal and advertising injury'caused by an been assumed by you in the same offense committed by an insured whose "insured contract";and business is: (b) Such attomeys' fees and litigation expenses are for defense of that party (1) Advertising,"broadcasting"or publishing; CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 7 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY (2) Designing or determining content of neutralizing,or in anyway responding to, or websites for others;or assessing the effects of, "pollutants". (3) An Internet search, access, content or o. War service provider. "Personal and advertising injury'arising out of: However, this exclusion does not apply to Paragraphs a.(1),(2) and(3)of the definition of (1) War, including undeclared or civil war; "personal injury'. (2) Warlike action by a military force, including For the purposes of this exclusion_ action in hindering or defending against an actual or e)pected attack, by any (1) Creating and producing correspondence govemment, sovereign or other authority written in the conduct of your business, using military personnel or other agents; or bulletins, financial or annual reports, or (3) Insurrection, rebellion, revolution, usurped newsletters about your goods, products or power, or action taken by governmental services will not be considered the authority in hindering or defending against business of publishing;and any of these. (2) The placing of frames, borders or links, or p. Unsolicited Communication advertising, for you or others anywhere on the Internet will not, by itself,be considered "Personal and advertising injury' arising out of the business of advertising, "broadcasting' any actual or alleged violation of any law that or publishing. restricts or prohibits the sending, transmitting or distributing of"unsolicited communication". k. Electronic Chatrooms Or Bulletin Boards q. Access Or Disclosure Of Confidential Or "Personal and advertising injury' arising out of Personal Information an electronic chatroom or bulletin board the "Personal and advertising injury' arising out of insured hosts or owns, or over which the any access to or disclosure of any person's or insured exercises control. organization's confidential or personal I. Unauthorized Use Of Another's Name Or information. Product r. Asbestos "Personal and advertising injury' arising out of (1) "Personal and advertising iryury'arising out the unauthorized use of another's name or product in your e-mail address,domain name or of the actual or alleged presence or actual, alleged or threatened dispersal of asbestos, metatag, or any other similar tactics to mislead another's potential customers. asbestos fibers or products containing asbestos, provided that the personal and m. Pollution advertising injury' is caused or contributed "Personal and advertising injury' arising out of to by the hazardous properties of asbestos. the actual, alleged or threatened discharge, (2) "Personal and advertising injury'arising out dispersal, seepage, migration, release or of the actual or alleged presence or actual, escape of"pollutants"at any times alleged or threatened dispersal of any solid, n. Pollution-Related liquid, gaseous or thermal irritant or contaminant, including smoke, vapors, Any loss,cost or expense arising out of any. soot, fumes, acids, alkalis, chemicals and (1) Request, demand, order or statutory or waste, and that are part of any claim or regulatory requirement that any insured or "suit'which also alleges any"personal and others test for, monitor, clean up, remove, advertising injury' described in Paragraph contain, treat, detoxify or neutralize, or in (1)above any way respond to, or assess the effects (3) Any loss, cost or expense arising out of of,"pollutants';or any. (2) Claim or suit by or on behalf of any (a) Request, demand, order or statutory or governmental authority or any other person regulatory requirement that any insured or organization because of testing for, or others test for, monitor, clean up, monitoring, cleaning up, removing, remove, contain, treat, detoxify or containing, treating, detodfying or neutralize, or in anyway respond to,or Paye 8 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T7 00 0219 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ' COMMERCIAL GENERAL LIABILITY assess the effects of, asbestos, (3) Because of your operations; asbestos fibers or products containing provided that: asbestos;or (a) The accident takes place in the "coverage (b) Claim or suit by or on behalf of any territory'and during the policy period; governmental authority or any other person or organization because of (b) The expenses are incurred and reported to Jesting for, monitoring, cleaning up, us within one year of the date of the removing, containing, treating, accident;and detoxifying or neutralizing, or in any (c) The injured person submits to examination, way responding to, or assessing the at our expense, by physicians of our choice effects of, asbestos, asbestos fibers or as often as we reasonably require. products containing asbestos. b. We will make thesepayments s. Em to menti-Relalied Practices fault. These regardless e p Y payments will not exceed the "Personal injury"to: applicable limit of insurance. We will pay (1) A person arising out of any. reasonable expenses for: a Refusal to em (1) First aid administered at the time of an ( ) employ person; accident; (b) Termination - of that person's (2) Necessary medical, surgical, X-ray and employment;or dental services, including prosthetic (c) Employment-related practice, policy, devices; and act or omission, such as coercion, (3) Necessary, ambulance, hospital, demotion, evaluation, reassignment, professional nursing and funeral services. discipline, failure to promote or 2. Exclusions advance, harassment, humiliation, discrimination, libel, slander, violation We will not pay expenses for"bodily injury': of the person's right of privacy, a. Any Insured malicious prosecution or false arrest, To any insured, except"volunteer workers". detention or imprisonment applied to or directed at that person, regardless of b. Hired Person whether such practice, policy, act or To a person hired to do work for or on behalf of omission occurs, is applied or is any insured or a tenant of any insured. committed before, during or after the c. Injury On Normally Occupied Premises time of that person's employment;or (2) The spouse, child, parent, brother or sister To a person injured on that part of premises you own or rent that the person normally of that person as a consequence of "personal injury' to that person at whom occupies. any of the employment related practices d. Workers'Compensation And Similar Laws described in Paragraph (a), (b), or (c) To a person, whether or not an "employee" of above is directed. any insured, if benefits for the"bodily injury'ane This exclusion applies whether the insured may payable or must be provided under a workers' be liable as an employer or in any other capacity compensation or disability benefits law or a and to any obligation to share damages with or similar law. repay someone else who must pay damages e. Athletics Activities because of the"personal injury'. To a person injured while practicing,instructing COVERAGE C—MEDICAL PAYMENTS or participating in any physical exercises or 1. Insuring Agreement games,sports, or athletic contests. a. We will pay medical expenses as described f. Products-Completed Operations Hazard below for"bodily injury'caused by an accident: Included within the "products-completed (1) On premises you own or rent; operations hazard". (2) On ways next to premises you own or rent; g. Coverage A Exclusions or Excluded under Coverage A. CG T1 00 0219 C 2017 The Travelers Indemnity Company.All rights reserved. Page 9 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY SUPPLEMENTARY PAYMENTS assumed by the insured in the same "insured 1. We willcontract'; pay, with respect to any claim we investigate or settle, or any"suit'against an insured d. The allegations in the"suit'and the information we defend: we know about the"occurrence"or offense are a. All expenses we incur. such that no conflict appears to exist between the interests of the insured and the interests of b. Up to$2,500 for the cost of bail bonds required the indemnitee; because of accidents or traffic law violations e. The indemnitee and the insured ask us to arising out of the use of any vehicle to which conduct and control the defense of that the Bodily Injury Liability Coverage applies. We indemnitee against such "suit" and agree that do not have to fumish these bonds. we can assign the same counsel to defend the G The cost of bonds to release attachments, but insured and the indemnitee; and only for bond amounts within the applicable limit f. The indemnitee: of insurance. We do not have to furnish these (1) Agrees in writing to: bonds. (a) Cooperate with us in the investigation, d. All reasonable expenses incurred by the settlement or defense of the"suit; insured at our request to assist us in the (b) Immediately send us copies of any investigation or defense of the claim or "suit', including actual loss of earnings up to $500 a demands, notices, summonses or legal day because of time off from work. Pis received in connection with the "suit"; e. All court costs taxed against the insured in the (C) Notify any other insurer whose "suit'. However, these payrnents do not include coverage is available to the indemnitee; attorneys' fees or attorne_ys' expenses taxed against the insured. and (d) Cooperate with us with respect to f. Prejudgment interest awarded against the coordinating other applicable insurance insured on that part of the judgment we pay. If available to the indemnitee;and we make an offer to pay the applicable limit of (2) Provides us with written authorization to: insurance, we will not pay any prejudgment interest based on that period of time after the (a) Obtain records and other information offer. related to the"suit';and g. All interest on the full amount of any judgment (b) Conduct and control the defense of the that accrues after entry of the judgment and indemnitee in such"suit'. before we have paid, offered to pay, or So long as the above conditions are met,attorneys' deposited in court the part of the judgment that fees incurred by us in the defense of that is within the applicable fimit of insurance. indemnitee, necessary litigation expenses incurred These payments will not reduce the limits of by us and necessary litigation expenses incurred by insurance the indemnitee at our request will be paid as Supplementary Payments. Notwithstanding the 2. If we defend an insured against a "suit' and an provisions of Paragraph 2.b.(2) of Section I — indemnitee of the insured is also named as a party Coverages — Coverage A — Bodily Injury And to the"suit', we will defend that indemnitee if all of Property Damage Liability or Paragraph 2.e. of the following conditions are met: Section I — Coverages — Coverage B — Personal a. The "suit' against the indemnitee seeks And Advertising Injury Liability, such payments will damages for which the insured has assumed not be deemed to be damages for "bodily injury', the liability of the indemnitee in a contract or "property damage" or"personal injury'', and will not agreement that is an"insured contract"; reduce the limits of insurance b. This insurance applies to such liability assumed Our obligation to defend an insured's indemnitee by the insured; and to pay for attorneys' fees and necessary c. The obligation to defend, or the cost of the litigation expenses as Supplementary Payments defense of, that indemnitee, has also been ends when. Page 10 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with its permission. " COMMERCIAL GENERAL LIABILITY a. We have used up the applicable remit of workers" while performing duties insurance in the payment of judgments, related to the conduct of your settlements or medical e>q)enses;or business; b. The conditions set forth above, or the terms of (b) To the spouse,child, parent,brother or the agreement described in Paragraph f. abate, sister of that co-"employee" or are no longer met. "volunteer worker" as a consequence SECTION II—WHO IS AN INSURED of Paragraph(I Xa)above; 1. If you are designated in the Declarations as: (c) For which there is any obligation to a. An individual, you and your spouse are share damages with or repay someone insureds, but only with respect to the conduct else who must pay damages because of a business of which you are the sole owner. of the injury described in Paragraph b. A partnership or joint venture, you are an (1)(a)or(b)above;or insured. Your members, your partners, and (d) Arising out of his or her providing or their spouses are also insureds, but only with failing to provide professional health respect to the conduct of your business. care services. C. A limited liability company, you are an insured_ Unless you are in the business or Your members are also insureds, but only with occupation of providing professional health respect to the conduct of your business. Your care services, Paragraphs (1)(a), (b), (c) managers are insureds, but only with respect to and(d)above do not apply to"bodily injury' their duties as your managers. arising out of providing or failing to provide first aid or Good Samaritan services!' by d. An organization other than a partnership, joint any of your "employees" or "volunteer venture or limited liability company, you are an workers", other than an employed or insured.Your"emcutive officers"and directors volunteer doctor.Any such "employees"or are insureds, but only with respect to their "volunteer workers" providing or failing to duties as your officers or directors Your provide first aid or "Good Samaritan stocidiolders are also insureds, but only with services" during their work hours for you respect to their liability as stockholders. will be deemed to be acting within the e. A trust, you are an insured. Your trustees are scope of their employment by you or also insureds, but only with respect to their performing duties related to the conduct of duties as trustees. your business. 2. Each of the following is also an insured (2) "Properiy damage"to property. a. Your"volunteer workers" only white performing (a) Owned,occupied or used by, duties related to the conduct of your business, (b) Rented to, in the care, custody or or your "employees", other than either- your control of, or over which physical "e motive officers" (if you are an organization control is being exercised for any other than a partnership,joint venture or lirnited purpose by, liability company)or your managers(if you are a you, any of your "employees", "volunteer limited liability compan)b, but only for acts workers", any partner or member(if you are within the scope of their employment by you or a partnership or joint venture), or any while performing duties related to the conduct member (if you are a limited liability of your business. However, none of these company). "employees" or "volunteer workers" are insureds for: b. Any person (other than your "employee" or "volunteer worker"), or any organization, while (1) 'Bodily injury'or"personal injury': acting as your real estate manager. (a) To you,to your partners or members(if c. Any person or organization having proper you are a partnership or joint venture), temporary custody of your property if you die, to your members (if you are a limited but only liability company), to a co-"employee" while in the course of his or her (1) With respect to liability arising out of the employment or performing duties maintenance or use of that property,and related to the conduct of your (2) Until your legal representative has been business, or to your other "volunteer appointed. CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 11 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. 'COMMERCIAL GENERAL LIABILITY d. Your legal reprove if you die, but only b. Arises out of the ownership, maintenance or with respect to duties as such. That use of that part of any premises leased to you. representative will have all your rights and The insurance provided to such premises owner, duties under this Coverage Part manager or lessor is subject to the following e. Any person or organization that, with your provisions: express or implied consent, either uses or is a. The limits of insurance provided to such responsible for the use of a watercraft that you premises owner, manager or lessor will be the do not own that is: minimum limits that you agreed to provide in the (1) 50 feet long or less; and written contract or agreement, or the limits (2) Not being used to carry any person or shown in the Declarations,whichever are less. property for a charge b. The insurance provided to such premises 3. Any organization you newly acquire or form, other awmer, manager or lessor does not apply to: than a partnership, joint venture or limited liability (1) Any "bodily injury' or "property damage" company, and of which you are the sole owner or in that occurs, or "personal and advertising which you maintain an ownership interest of more injury' caused by an offense that is than 50%, will qualify as a Named Insured if there is committed, after you cease to be a tenant in no other similar insurance available to that that premises;or organization. However: (2) Structural alterations, new construction or a. Coverage under this provision is afforded only demolition operations performed by or on until the 180th day after you acquire or form the behalf of such premises owner, manager or organization or the end of the policy period, lessor. whichever is earlier, 5. Any person or organization that is an equipment b. Coverage A does not apply to"bodily injury' or lessor and that you have agreed in a written contract "property damage" that Occurred before you or agreement to include as an additional insured on acquired or formed the organization;and this Coverage Part is an insured, but only with c. Co B does not respect to liability for "bodily injury', "property Coverage apply to personal and advertising injury' arising out of an offense damage', or"personal and advertising injury'that: committed before you acquired or formed the a. Is "bodily injury' or "property damage" that organization. occurs, or is "personal and advertising injury' For the purposes of Paragraph 1. of Section II — caused by an offense that is committed, Who Is An Insured, each such organization will be subsequent to the signing of that contract or agreement and deemed to be designated in the Declarations as: a. An organization, other than a partnership, Dint b. Is caused, in whole or in part, by your acts or p R 1 omissions in the maintenance, operation or use venture or limited liability company,or of equipment leased to you by such equipment b. A trust; lessor- as indicated in its name or the documents that The insurance provided to such equipment lessor is govern its structure. subject to the following provisions: 4. An a. The limits of insurance provided to such Any person or organization that is a premises equipment lessor will be the minimum limits that owner, manager or lessor and that you have agreed you agreed to provide in the written contract or in a written contract or agreement to include as an agreement, or the limits shown in the additional insured on this Coverage Part is an Declarations,whichever are less. insured, but only with respect to liability for"bodily injury', "property damage" or "personal and b. The insurance provided to such equipment advertising injury"that: lessor does not apply to any bodily injury' or "property damage" that occurs, or "personal a. Is "bodily injury' or "property damage" that and advertising injury' caused by an offense occurs, or is "personal and advertising injury' that is committed, after the equipment lease caused by an offense that is committed, expires. subsequent to the signing of that contract or No person or organization is an insured with respect to agreement; and the conduct of any current or past partnership, joint Page 12 of 21 C 2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 0219 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY venture or limited liability company that is not shown as a. The amount shown for the Damage To a Named Insured in the Declarations. This paragraph Premises Rented To You Limit in the does not apply to any such partnership,joint venture or Declarations of this Coverage Part; or limited liability company that otherwise qualifies as an b. $300,000 if no amount is shown for the insured under Section If—Who Is An Insured. Damage To Premises Rented To You Limit in SECTION III—LIMITS OF INSURANCE. the Declarations of this Coverage Part. 1. The Limits of Insurance shown in the Declarations 7. Subject to Paragraph 5. above, the Medical and the rules below fix the most we will pay Expense Limit is the most we will pay under regardless of the number of: Coverage C for all medical expenses because of a. Insureds; "bodily injury'sustained by anyone person. The Limits of Insurance of this Coverage Part apply b. Claims made or"suits"brought;or separately to each consecutive annual period and to any c. Persons or organizations malting claims or remaining period of less than 12 months, starting with bringing"suits'. the beginning of the policy period shown in the 2. The General Aggregate Limit is the most we will pay Declarations, unless the policy period is extended after for the sum of: issuance for an additional period of less than 12 months. In that case, the additional period will be a. Medical expenses under Coverage C; deemed part of the last preceding period for purposes of b. Damages under Coverage A, except damages determining the Limits of Insurance. because of"bodily injury'or"property damage" SECTION IV—COMMERCIAL GENERAL LIABILITY included in the"products-completed operations CONDITIONS hazard';and 1. Banivuptcy c. Damages under Coverage B. Bankruptcy or insolvency of the insured or of the 3. The Products-Completed Operations Aggregate insureds estate will not relieve us of our obligations Limit is the most we will pay under Coverage A-for under this Coverage Part. damages because of "bodily injury' and "property 2. Duties In The Event Of Occurrence,Offense, damage" included in the "products-complied Claim Or Suit operations hazard". 4. Subject to Paragraph 2. above, the Personal And a• You must see to it that we are notified as soon Advertising Injury Limit is the most we will pay as Practicable of an"occurrencd'or an offense which may result in a claim. To the event under Coverage B for the sum of all damages because of all "personal injury' and "advertising Passible, notice should include: injury'sustained by anyone person or organization. (1) How, when and where the"occurrence" or 5. Subject to Paragraph 2. or 3. above, whichever offense took place; applies, the Each Occurrence Limit is the most we (2) The names and addresses of any injured will pay for the sum of: persons and witnesses;and a. Damages under Coverage A;and (3) The nature and location of any injury or b. Medical expenses under Caverage C; damage arising out of the "occufrencd' or offense. because of all"bodily injury'and"property damage" arising out of any one"occurrence'. b. If a claim is made or "suit' is brought against For theu any insured,you must: p rposes of determining the applicable (1) Immediately record the specifics of the Each Occurrence Limit, all related acts or claim or"suit'and the date received;and omissions committed in providing or failing to provide first aid or "Good Samaritan services" to (2) Notify us as soon as practicable. any one person will be deemed to be one You must see to it that we receive written notice "occurrence". of the claim or"suit'as soon as practicable. 6. Subject to Paragraph 5. above, the Damage To c. You and any other involved insured must: Premises Rented To You Limit is the most we will pay under Coverage A for damages because of (1) Irrmediatety, send us copies of any "premises danced' to any one premises. The demands, notices, summonses or legal Damage To Premises Rented To You Limit will be: papers received in connection with the claim or"suit'; CG T1 00 0219 ©2017 The Travelers indemnity Company.All rights reserved. Page 13 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. 'COMMERCIAL GENERAL LIABILITY (2) Authorize us to obtain records and other (iii)An executive officer or director of information; any other organization;or (3) Cooperate with us in the investigation or (iv)A trustee of any trust; settlement of the claim or defense against that is your partner, joint venture the"suit';and member,manager or trustee,or (4) Assist us, upon our request, in the enforcement of any right against any (b) Any employee authorized by such partnership, joint venture, limited person or organization which may be liable to the insured because of injury or dame orgliability company, trust or other to which this insurance may also apply. "occu'rrenc ' r give notice of an occurrencd or offense. d. No insured will, except at that insureds own cost, voluntarily make a payment, assume any (3) Notice to us of such "occurrence" or obligation, or incur any expense, other than for offense will be deemed to be given as soon first aid,without our consent. as Practicable if it is given in good faith as soon as practicable to your workers' e. The following provisions apply to Paragraph a. compensation insurer. This applies only if above, but only for purposes of the insurance you subsequently give notice to us of the provided under this Coverage Part to you or any "occurrence" or offense as soon as insured listed in Paragraph 1.or 2. of Section II practicable after any of the persons —Who Is An Insured: described in Paragraph e.(1) or(2) above discovers that the "occurrence" or offense (1) Notice to us of such "occurrence" or may result in sums to which the insurance offense must, be givers as soon as provided under this Coverage Part may practicable only after the "occurrence" or apply. offense is known to you (if you are an individuan, any of Wu' partners or However, if this policy includes an endorsement members who is an individual (if you area that provides limited coverage for"bodily injury' partnership or joint venture), any of your or Property damage or pollution costs arising out of a discharge, release or escape of managers who is an individual (if you are a "pollutants" which contains a requirement that limited liability company), any of your the discharge, release or escape of"pollutants" "executive officers" or directors(if you are must be reported to us within a specific number an organization other than a partnership, of days after its abrupt commencement, this joint venture, or limited liability company), paragraph e.does not affect that requirement. any of your trustees who is an individual(if you are a trust) or any "employee" 3. Legal Action Against Us authorized by you to give notice of an No person or organization has a right under this "occurrencd'or offense. Coverage Part (2) If you are a partnership, joint venture, a. To join us as a party or otherwise bring us into limited liability company or trust, and none a"suit'asking for damages from an insured;or of your partners, joint venture members, b. To sue us on this Coverage Part unless all of managers or trustees are individuals,notioe its terms have been fully complied wift to us of such"oocurrence"or offense must A person or organization may sue us to recover on be given as soon as practicable only after an agreed settlement or on a final judgment against the"occurrence"or offense is known by. an insured; but we will not be liable for damages (a) Any individual who is: that are not payable under the terms of this Coverage Part or that are in excess of the (i) A partner or member of any applicable limit of insurance. An agreed settlement partnership or joint venture; means a settlement and release of liability signed by (ii) A manager of any limited IiabTty us, the insured, and the claimant or the claimants company, legal representative. Page 14 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 0219 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ` COMMERCIAL GENERAL LIABILITY 4. Other Insurance (ii) That is insurance for "premises If valid and collectible other insurance is available to damagC'; the insured for a loss we cover under Coverages A (iii) If the loss arises out of the or B of this Coverage Part, our obligations are maintenance or use of aircraft, limited as described in Paragraphs a.and b.below. "autos" or watercraft to the extent As used anywhere in this Coverage Part, other not subject to any exclusion in this insurance means insurance, or the funding of Coverage Part that applies to losses,that is provided by,through or on behalf of: aircraft,"autos"or watercraft; (tf Another insurance company, (iv) That is insurance available to a premises owner, manager or (ii) Us or any of our affiliated insurance companies, lessor that qualifies as an insured except when the Non cumulation of Each under Paragraph 4. of Section 11— Occurrence Limit provision of Paragraph 5. of Who Is An Insured, except when Section III — Limits Of Insurance or the Non Paragraph d. below applies;or cumulation of Personal and Advertising Injury (v) That is insurance available to an Limit provision of Paragraph 4. of Section III— Limits of Insurance applies because the equipment lessor that qualifies as an insured under Paragraph 5. of Amendment — Non Cumulation Of Each Section 11 — Who Is An Insured, Occurrence Limit Of Liability And Non except when Paragraph d. below Cumulation Of Personal And Advertising Injury applies Limit endorsement is included in this policy, (ill)Any risk retention group; or (b) Any of the other insurance, whether primary, excess, contingent or on any (iv)Any self-insurance method or program, in other basis, that is available to the which case the insured will be deemed to be insured when the insured is an the provider of other insurance. additional insured, or is any other Other insurance does not include umbrella insured that does not qualify as a insurance, or excess insurance, that was bought named insured, under such other specifically to apply in excess of the Limits of insurance. Insurance shown in the Declarations of this (2) When this insurance is excess, we will Coverage Part have no duty under Coverages A or B to As used anywhere in this Coverage Part, other defend the insured against any"suit'if any ' insurer means a provider of other insurance. As other insurer has a duty to defend the insured against that "suit'. If no other used in Paragraph c. below, insurer means a provider of insurance. insurer defends,we will undertake to do so, but we will be entitled to the insureds rights a. Primary Insurance against all those other insurers. This insurance is primary except when (3) When this insurance is excess aver other Paragraph b. below applies. If this insurance is insurance,we will pay only our share of the primary, our obligations are not affected unless amount of the loss, if any,that exceeds the any of the other insurance is also primary. sum of: Then,we will share with all that other insurance (a) The total amount that all such other by the method described in Paragraph c.below, insurance would pay for the loss in the except when Paragraph d. below applies. absence of this insurance;and b. Excess Insurance (b) The total of all deductible and self- insured amounts under all that other (1) This insurance is excess over: insurance. (a) Any of the other insurance, whether (4) We will share the remaining loss, if any, primary, excess, contingent or on any with any other insurance that is not other basis: described in this Excess insurance (i) That is Fire, Extended Coverage, provision and was not bought speaficallyto Builder's Risk, Installation Risk or apply in excess of the Limits of Insurance shown in the Declarations of this Coverage similar coverage for"your work"; Part CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 15 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ` tCOMMERCIAL GENERAL LIABILITY c. Method Of Sharing a. The statements in the Declarations are If all of the other insurance permits contribution accurate and complete; by equal shares, we will follow this method also. b. Those statements are based upon Under this approach each insurer contributes representations you made to us;and equal amounts until it has paid its applicable c. We have issued this policy in reliance upon limit of insurance or none of the loss remains, your representations. whichever comes first. The unintentional omission of, or unintentional error If any of the other insurance does not permit in, any information provided by you which we relied contribution by equal shares, we will contribute upon in issuing this policy will not prejudice your by limits. Under this method, each insurer's rights under this insurance. However,this provision share is based on the ratio of its applicable limit does not affect our right to collect additional of insurance to the total applicable limits of premium or to exercise our rights of cancellation or insurance of all insurers. nonrenewal in accordance with applicable insurance d. Primary And Non-Contributory Insurance If laws or regulations. Required By Written Contract 7. Separation Of Insureds If you specifically agree in a written contract or Except with respect to the Limits of Insurance,and agreement that the insurance afforded to an any rights or duties specifically assigned in this insured under-this Coverage Part must apply on Coverage Part to the first Named insured, this a primary basis, or a primary and non- insurance applies: contributory basis, this insurance is primary to a. As if each Named Insured were the only other insurance that is available tosuch insured Named Insured;and which covers such insured as a named insured, and we will not share with that other insurance, b. Separately to each insured against whom claim provided that: is made or"suit"is brought (1) The"bodily injury'or"property damage"for 8. Transfer Of Rights Of Recovery Against Others Mich coverage is sought occurs;and To Us (2) The "personal and advertising injury' for If the insured has rights to recover all or part of any which covereige is sought is caused by an payment we have made under this Coverage Part, offense that is committed; those rights are transferred to us.The insured must subsequent to the signing of that contract or do nothing after loss to impair them.At our request, agreement by you. the insured will brim "suit' or transfer those rights to us and help us enforce them. 5. Premium Audit 9. When We Do Not Renew a. We will compute all premiums for this Coverage If we decide not to renew this Coverage Part,we will Part in accordance with our rules and rates. mail or deliver to the first Named Insured shown in b. Premium shown in this Coverage Part as the Declarations written notice of the nonrenewal advance premium is a deposit premium only.At not less than 30 days before the expiration date. the close of each audit period we will compute If notice is mailed, proof of mailing will be sufficient the earned premium for that period and send notice to the first Named Insured.The due date proof of notice for audit and retrospective premiums is the date SECTION V—DEFINITIONS shown as the due date on the bill. If the sum of 1. "Advertisement"means a notice that is broadcast or the advance and audit premiums paid for the published to the general public or specific market policy period is greater than the earned segments about your goods, products or services premium, we will return the excess to the first for the purpose of attracting customers or Named Insured. supporters. For the purposes of this definition: c. The first Named Insured must keep records of a. Notices that are published include material the information we need for premium placed on the Internet or on similar electronic computation, and send us copies at such times means of communication;and as we may request, b. Regarding websites, only that part of a website 6. Representations that is about your goods, products or services By accepting this policy,you agree: for the purposes of attracting customers or supporters is considered an advertisement. Page 16 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with Its permission. COMMERCIAL GENERAL LIABILITY 2. "Advertising injury': b. In, by or with any other electronic means of a. Means injury caused by one or more of the communication, such as the Internet, if that following offenses: material is part of: (1) Oral or written publication, including (1) Radio or television programming being publication by electronic means, of material transmitted; in your "advertisement' that slanders or (2) Other entertainment, educational, libels a person or organization or instructional, music or news programming disparages a persons or organizations being transmitted;or goods, products or services, provided that the claim is made or the"suit'is brought by (3) Advertising transmitted with any of such a person or organization that claims to have programming. been slandered or libeled, or that claims to 6. "Coverage territory'means: have had its goods, products or services disparaged; a. The United States of America (including its (2) Oral or written publication, including territories and possessions), Puerto Rico and publication by electronic means, of material Canada; in your"aduerbsement'that: b. International waters or airspace, but only if the (a) Appropriates a person's name, voice, injury or damage occurs in the course of travel photograph or likeness; or or transportation between any places included (b) Unreasonably places a person in a in Paragraph a.above-,or false light;or c. All other parts of the world if the injury or (3) Infringement of copyright, "title"or"slogan" damage arises out of: in your "advertisement', provided that the (1) Goods or products made or sold by you in claim is-made or-the"suit' is brought'bya the territory "described in Paragraph a. person or organization that claims above, ownership of such copyright, "title" or (2) The activities of a person whose home is in "slogan,. the territory described in Paragraph a. b. Includes "bodily injury' caused by one or more above, but is away for a short time on your of the offenses described in Paragraph a. business;or above 3. "Autd'means: (3) "Personal and advertising injury' offenses that take place through the Internet or a. A land motor vehicle, trailer or semitrailer similar electronic means of communication; designed for travel on public roads, including provided the insureds responsibility to pay anyathached machineryor equipment; or damages is determined in a "suit' on the merits in b. Any other land vehicle that is subject to a the territory described in Paragraph a.above,or in a compulsory or financial responsibility law, or settternent we agree to. other motor vehicle insurance law, where it is licensed or principally garaged. 7. "Electronic datar' means information, tads or However, "auto" does not include "mobile programs stored as or on, created or used on, or equipment„ transmitted to or from computer software(including systems and applications software), hard or floppy 4L "Bodily injury'means: disks, CD-ROMs, tapes, dries, cells, data a. Physical harm, including sickness or disease, processing devices or any other media which are sustained by a person;or used with electronically controlled equipment. b. Mental anguish, injury_ or illness, or emotional S. "Employee" includes a"leased worker" "Employee' distress, resulting at any time from such does not include a"temporarywortker". physical harm,sickness or disease. 5. "Broadcasting" means transmitting an audio or 9. "Executive officer" mins a person holding any of visual material for an y the officer positions created by your charter, y 1u�: constitution, bylaws or any other similar gaverning a. By radio or television;or document. CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 17 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. ` 'COMMERCIAL GENERAL LIABILITY 10. "Good Samaritan services" means any emergency tracks, roadbeds, tunnel, underpass or medical services for which no compensation is crossing; demanded or received. (2) That indemnifies an architect, engineer or 11. "Hostile fine" means a fire which becomes surveyor for injury or damage arising out of: uncontrollable or breaks out from where it was (a) Preparing, approving, or failing to intended to be. prepare or approve, maps, shop 12. "Impaired property' means tangible property, other drawings, opinions, reports, surveys, than "your product' or "your work!', that cannot be field orders,change orders or drawings used or is less useful because: and specifications;or a. It incorporates "your product' or "your work!' (b) Giving directions or instructions, or that is known or thought to be defective, failing to give them, if that is the deficient, inadequate or dangerous; or primary cause of the injury or damage; b. You have failed to fulfill the terms of a contract or or agreement; (3) Under which the insured, if an architect, if such property can be restored to use by the engineer" or surveyor, assumes liability for repair, replacement, adjustment or removal of"your an injury or damage arising out of the product'or"your work'or your fulfilling the terms of insureds rendering or failure to render the contract or agreement. professional services, including those listed in Paragraph (2) above and supervisory, 13. "Insured contract'means: inspection, architectural or engineering a. A contract for a lease of premises. However, activities. that portion of the contract for a lease of 14. "Leased worker" means a person leased to you by a premises that indemnifies any person or labor Ding firm under an agreement between you organization for "premises damage" is.not an and the labor leasing firm,to perform duties related "insured contract'; to the conduct of your business. "Leased worker" b. A sidetrack agreement; does not include a"temporary worker". C. Any easement or license agreement, except in 15. "Loading or unloading" means the handling of connection with construction or demolition property: operations on or within 50 feet of a railroad; a. After it is moved from the place where it is d. An obligation, as required by ordinance, to accepted for movement into or onto an aircraft, indemnify a municipality, except in connection watercraft or"auto"; with work for a municipality, b. While it is in or on an aircraft, watercraft or e. An elevator maintenance agreement; "auto'';or f. That part of any other contract or agreement c. While it is being moved from an aircraft, pertaining to your business (including an watercraft or "auto" to the place where it is indemnification of a municipality in connection finally delivered; with work performed for a municipality) under but "loading or unloading' does not include the which you assume the tort liability of another movement of property by means of a mechanical party to pay for "bodily injury', "property device, other than a hand track,that is not attached damage" or"personal injury' to a third person to the aircraft,watercraft or"auto". or organization. Tort liability means a liability 16. "Mobile equipment" means any of the following that would be imposed by law in the absence of types of land vehicles, including any attached any contract or agreement. machinery or equipment: Paragraph f. does not include that part of any a. Bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public (1) That indemnifies a railroad for "bodily roads; injury' or "property damage" arising out of b. Vehicles maintained for use solely on or next to construction or demolition operations, premises you awn or rent; within 50 feet of any railroad property and c. Vehicles that travel on crawler treads; affecting any railroad bridge or trestle, i Page 18 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL GENERAL LIABILITY d. Vehicles, whether self-propelled or not, b. An act or omission committed in providing or maintained primarily to provide mobility to failing to provide first aid or "Good Samaritan permanently mounted: services" to a person, unless you are in the (1) Power cranes, shovels, loaders, diggers or business or occupation of providing drills; or professional health care services. (2) Road construction or resurfacing 18. "Personal and advertising injury' means "personal equipment such as graders, scrapers or injury'or"advertising injury'. rollers; 19. "Personal injury': e. Vehicles not described in Paragraph a., b., e. or d. above that are not self-propelled and are a. Means injury, other than "advertising injury', maintained primarily to provide mobility to caused by one or more of the following permanently attached equipment of the offenses: following types: (1) False arrest,detention or imprisonment; (1) Air compressors, pumps and generators, including spraying, welding, building (2) Malicious prosecution; cleaning, geophysical eploration, lighting (3) The wrongful eviction from, wrongful entry and well servicing equipment-,or into, or invasion of the right of private (2) Chevy pickers and similar devices used to occupancy of a room, dwelling or premises raise or lower workers; that a person occupies, provided that the f. Vehicles not described in Paragraph a., b., c. wrongful eviction,wrongful entryor invasion or d. above maintained primarily for purposes of the right of private occupancy is other than the transportation of persons or committed by or on behalf of the owner, cargo landlord or lessor of that room, dwelling or Howiver, self-propelled vehicles with the premises; following types of permanently attached (4) Oral or written publication, including equipment are not "mobile equipment' but will publication by electronic means, of material be considered"autos': that slanders or libels a person or (1) Equipment designed primarilyfor organization or disparages a person's or organization's goods, products or services, (a) Snow removal; provided that the claim is made or the"suit' (b) Road maintenance~ but not is brought by a person or organization that construction or resurWrig;or claims to have been slandered or libeled,or (c) Street cleaning; that claims to have had its goods, products (2) Chevy pickers and similar devices or services disparaged;or mounted on automobile or truck chassis (5) Oral or written publication, including and used to raise or lower workers;and publication by electronic means, of material (3) Air compressors, pumps and generators, that: including spraying, welding, building (a) Appropriates a person's name, voice, cleaning, geophysical e)ploration, lighting photograph or likeness; or and well servicing equipment However, "mobile equipment' does not include any (b) Unreasonably places a person in a land vehicle that is sut�ject to a compulsory or false fight. financial responsibility law, or other motor vehicle b. Includes "bodily injury' caused by one or more insurance law, where it is licensed or principally of the offenses described in Paragraph a. garaged. Such land vehicles are considered above. 20. "Pollutants" mean any solid, liquid, gaseous or 17. "Occurrence"means: thermal irritant or contaminant including smoke, a. An accident, including continuous or repeated vapor, soot, fumes, acids, alkalis, chemicals and exposure to substantially the same general waste. Waste includes materials to be recycled, harmful conditions;or reconditioned or reclaimed. CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 19 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission. "COMMERCIAL GENERAL LIABILITY 21. "Premises damage"means: contract calls for work at more than a. With respect to the first paragraph of the one lob site. exceptions in Exclusion j. of Section 1 — (c) When that part of the work done at a Coverage A — Bodily Injury And Property job site has been put to its intended Damage Liability, "property damage" to any use by any person or organization other premises while rented to you for a period of than another contractor or seven or fewer consecutive days, including the subcontractor worldng on the same contents of such premises;or project. b. With respect to the exception to Exclusions c. through n. in the last paragraph of Paragraph 2. Work that may need service, maintenance, of Section t — Coverage A—Bodily Injury And correction, repair or replacement,but which Property Damage Liability,"property damage"to comis otherwise complete, will be treated as any premises while rented to you for a period of more than seven consecutive days, or while b. Does not include "bodily injury' or "property temporarily occupied by you with permission of damage"arising out of: the owner, caused by. (1) The transportation of property, unless the (1) Fire; injury or damage arises out of a condition in or on a vehicle not owned or operated by (2) Explosion; you, and that condition was created by the (3) Lightning; "loading or unloading"of that vehicle by any (4) Smoke resulting from fire, explosion or insured; lightning;or (2) The existence of tools, uninstalled (5) Water. equipment or abandoned or unused But "premises damage" under this Paragraph materials;or b. does not include "property damage" to any (3) Products or operations for which the premises caused by. classification, listed in the Declarations or in a policy Schedule, states that products- (1) Rupture, bursting, or operation of pressure completed operations are subject to the relief devices; General Aggregate Limit (2) Rupture or bursting due to expansion or 23. "Property damage"means: swelling of the contents of any building or structure caused by or resulting from water; a. Physical injury to tangible property, including all or resulting loss of use of that property. All such loss of use will be deemed to occur at the time of (3) Explosion of steam boilers, steam pipes, the physical injury that caused it;or steam engines or steam turbines. b. Loss of use of tangible ible ro Ply that is not property 22. "Products-completed operations hazard": physically injured. All such loss of use will be a. Includes all "bodily injury' and "property deemed to occur at the time of the"occurrence" damage" occurring away from premises you that caused it own or rent and arising out of"your product"or For the purposes of this insurance,"electronic data" "your worK'except: is not tangible property. (1) Products that are still in your physical 24. "Slogan': possession;or a. Means a phrase that others use for the purpose (2) Work that has not yet been completed or of attracting attention in their advertising. abandoned. However, "your worK' will be b. Does not include a phrase used as, or in, the deemed completed at the earliest of the name of: following times: (1) Any person or organization, other than you; (a) When all of the work called for in your or contract has been completed. (2) Any business, or any of the premises, (b) When all of the work to be done at the goods, products, services or work, of any job site has been completed if your person or organization,other than you. Page 20 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office,Inc.with its permission. u , COMMERCIAL GENERAL LIABILITY 25. "Suit" means a civil proceeding in which damages (a) You; because of "bodily injury', "property damage" or (b) Others trading under your name;or "personal and advertising injury' to which this insurance applies are alleged."Suit'includes: (c) A person or organization whose business or assets you have acquired; a. An arbitration proceeding in which such and damages are claimed and to which the insured (2) Containers (other than vehicles), materials, must submit or does submit with our consent; parts or equipment furnished in connection or with such goods or products. b. Any other alternative dispute resolution b. Includes: proceeding in which such damages are claimed and to which the insured submits with our (1) Warranties or representations made at any consent time with respect to the fitness, quality, 26. 'Tem p durability, performance or use of "your 'Temporary worker' means a person who is product;and furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short (2) The providing of or failure to provide term workload conditions. warnings or instructions. 27. "Title"means a name of a literary or artistic work.' c. Does not include vending machines or other 28. "Unsolicited communication" means any property rented to or located for the use of others but not sold. communication, in any form, that the recipient of such communication did not specifically request to 31. "Your wort': receive. a. Means: 29. "Volunteer worker" means a person who is not your (1) Work or operations performed by you or on "employed', and who donates his or her work and your behalf;and ads at the direction of and within the scope of (2) Materials, parts or equipment furnished in duties determined by you, and is not paid a fee, connection with such worts or operations. salary or other compensation by you or anyone else for their work performed for you. b. Includes: 30. "Your product': (1) Warranties or representations made at any time with respect to the fitness, quality, a. Means: durabil' rty, performance or use of "your (1) Any goods or products, other than real work!';and property, manufactured, sold, handled, (2) The providing of or failure to provide distributed or disposed of by. warnings or instructions. CG T1 00 0219 ©2017 The Travelers Indemnity Company.All rights reserved. Page 21 of 21 Includes copyrighted material of Insurance Services Office,Inc.with its permission.