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HomeMy WebLinkAbout48671-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT r TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 48671 Date: 12/29/2022 Permission is hereby granted to:. 1663 Brid a LLC C/O Donald P Brennan Jr 26 Remsen St Brooklyn, NY 11201 To: Construct attached raised masonry patios, swimming pool and attached lower level pool house at existing single family dwelling as applied for, with SCHD and per Trustees # 10175 approvals. At premises located at: 1663 Brid a Ln, Cutcho ue SCTM # 473889 Sec/Block/Lot# 118.-2-4.2 Pursuant to application dated 11/4/2022 and approved by the Building Inspector. To expire on 6/29/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $598.40 CO- SWIMMING POOL $50.00 Total: $898.40 Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 � . Telephone (631) 765-1802 Fax (631) 765-9502 )itt°i ,//w'r wr southoldtowz�.Zov. Date Received APPLICATION FOR BUILDING IT For Office Use Only u PERMIT NO., "Jj- Building Inspector: ,i Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,ank' Owner's Authorization form(Page 2)shall be completed. Date:November 2, 2022 OWNER(S)OF PROPERTY: Name:1663 Bridge, LLC SCTM # 1000-118-2-4.2 Project Address:1663 Bridge Lane, Cutchogue, NY 11935 Phone#:917-568-6525 1 Email:donald@brennanre.com Mailing Address:26 Remsen Street, Brooklyn, NY 11201 CONTACT PERSON: Name: Fred Seifert/ Seifert Construction Corp. Mailing Address: P.O. Box 1407, Mattituck, N.Y. 11952 Phone#: (631) 298-1036 Email: office@seifertconstruction.com DESIGN PROFESSIONAL INFORMATION: Name: Jeffrey T. Butler Mailing Address: P.O. Box 634, Shoreham, N.Y. 11786 Phone#: (631) 208-8850 Email: CONTRACTOR INFORMATION: Name: Seifert Construction Corp. Mailing Address: P.O. Box 1407, Mattituck, N.Y. 11952 Phone#: (631) 298-1036 Email: office@seifertconstruction.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑■ New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other $700,000.00 Will the lot be re-graded? ❑Yes ❑■ No Will excess fill be removed from premises? ❑Yes A No 1 PROPERTY INFORMATION Existing use of property: Residential Intended use of property: Same Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R4O this property? ❑Yes XNo IF YES, PROVIDE A COPY. ❑ C"('tee* Box After Re dh1g: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 230AS of the New York State Penal Law. Application Submitted By ifs naris M LlAuthorized Agent ❑Owner Signature of Applicant: Date: i/lv STATE OF NEW YORK) SS: COUNTY OF ) Fred Seifert being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he S he is the (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this w f r 4 , -5 da ��� , �� Y of . 20 ... 0 ary*l5ii lic EVE L,GATZ-SCHWMMBORN NOTARY PUBLIC.STATE OF NEW YORK R P IIIA!"° I II nRegistration No.OIGA6274028 ,�,�.. .�� mrv..........._� Qualified to Sui`9:olit County (Where the applicant is not the owner) cotnmissioru��tir ot�.24,20 } Donald Brennan, Jr. 26 Remsen Street, Brooklyn, NY 11201 I residing at do hereby authorize Fred Seifert to apply on my behalf to the Town of Southold Building Department for approval as described herein.. - , November 2, 2022 Owner's Signature Date Donald Brennan Jr/1663 Bridge LLC Print Owner's Name 2 .,, M� , 'Ynw,;, art,.�. m � n .„ ��,,�" r� yw„ w � 'wya '�i, ; '' ,.✓`a^' "' � mr ,�"ki yu"w�b i m � r i mi no n Y f a � v � , rr v .v ei.y iv u. '45 i iwv P� Jfta. 1 i r�rom r �w,ir, avvi r, � i f i � i� r n,� aim n�nv haNN�r aNi� rnaruJrmwti Prat r�i� Irma i7i i i,l �mv nn �ti i �m � n � ,' 1�Yti�m�.JO>'hYJr Wn�HI.,@� �' Ou�'D�� m' 9 l: 9 1 `m f� ,'J,. ➢ ,�. � Dy d BOARD OF SOUTHOLD TOWN TRUSTEES "A SOUTHOLD,NEW YORK PERMIT NO. 10175 DATE: JUNE 15,2022 ISSUED TO: 1663 BRIDGE LLC c/o DONALD P.BRENNAN JR. 'MANAGING MEMBER � PROPERTY ADDRESS: 1663 BRIDGE LANE,CUTCHOGUE SCTM#: 1000-118-2-4.2 AUTHORIZATION a° Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in , r, accordance with the Resolution of the Board of Trustees adopted at the meeting held on June 15,2022, and in consideration of application fee in the sum of$250.00 paid by 1663 Bri4ge,Bridge, LLC and subject to the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits the following: ° Wetland Permit to construct a 19'x41' swimming pool surrounded by a 1,625sq.ft. raised,bi-level masonry patio with 1)access ramps,steps and landings,2)cloth canopy above,and 3)pool equipment, l , half-bath, laundry/storage space beneath; remove existing two-system conventional septic system and w, install a new two-system I/A OWTS sanitary system more than 100' from wetlands; install stormwater drainage system and pool drywell; modify existing grade by±12"using excavated on-site material; and to establish and perpetually maintain a 15'wide,approximately 2,700sq.ft.non-turf buffer area adjacent to the wetland boundary to northeast("Bridge Lane"); and as depicted on the site plan prepared by Jeffrey T. Butler,P.E.,P.C.,dated December 17,2021,and stamped approved on June 15,2022. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,and these presents to be subscribed by a majority of the said Board as of the year and day first above written. ,Soa'f F04 " v„ ri r If r� h � Glenn Goldsmith, President ,� � � ,, " �.ti Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President r P.O. Box 1179 Eric Sepenoski l `' Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth PeeplesM Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 21, 2022 Robert E. Herrmann En-Consultants 1319 North Sea Road Southampton, NY 11968 RE. 1663 BRIDGE, LLC c/o DONALD P. BRENNAN, JR., MANAGING MEMBER 1663 BRIDGE LANE, CUTCHOGUE SCTM# 1000-118-2-4.2 Dear Mr. Herrmann: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, June 15, 2022 regarding the above matter: WHEREAS, En-Consultants on behalf of 1663 BRIDGE, LLC c/o DONALD P. BRENNAN, JR., MANAGING MEMBER applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated May 2, 2022, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on June 15, 2022, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, 2 WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of 1663 BRIDGE, LLC c/o DONALD P. BRENNAN, JR., MANAGING MEMBER to construct a 19'x41' swimming pool surrounded by a 1,625sq.ft. raised, bi-level masonry patio with 1) access ramps, steps and landings, 2) cloth canopy above, and 3) pool equipment, half-bath, laundry/storage space beneath; remove existing two-system conventional septic system and install a new two-system I/A OWTS sanitary system more than 100' from wetlands; install stormwater drainage system and pool drywell; modify existing grade by ±12" using excavated on-site material; and to establish and perpetually maintain a 15' wide, approximately 2,700sq.ft. non-turf buffer area adjacent to the wetland boundary to northeast ("Bridge Lane"); and as depicted on the site plan prepared by Jeffrey T. Butler, P.E., P.C., dated December 17, 2021, and stamped approved on June 15, 2022. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$50.00 per inspection. (See attached schedule.) Fees: $50.00 V ly your � 7 1 vo&�4,-A Glenn Goldsmith President, Board of Trustees GG/dd NEW YORK STATE DIEPAR"rimIENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region I SUNY A-.Stony Brook,50 Circle Road,Stony Brook,NY 11790 P:(631)444-0365 1 F:(631)444 0360 wvvw.dpc.ny.gov TIDAL WETLAND LETTER OF NON-JURISDICTION September 16, 2022 1663 BRIDGE LLC C/O DONALD BRENNAN 26 REMSEN ST BROOKLYN, NY 11201 Re'. 1663 BRIDGE LLC 1663 BRIDGE LN SCTIVI# 1000-118-2-4.2 CUITCHOGUE, NY 11935 DEC ID: 1-4738-02619/00014 Dear Applicant: Based on the information you have submitted, the New York State Department of Environmental Conservation has determined that: The portion of the referenced property landward of the elevation contour line of 10 feet above mean sea level, as shown on the survey by Kenneth M. Woychuk, LS, dated June 30, 2021, is beyond Article 25 (Tidal Wetland)jurisdiction. Therefore, in accordance with the current Tidal Wetlands Land Use ReguIations'(6NYCRR Part 661), no permit is required under the Tidal Wetlands Act to conduct regulated activities landward of that line. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetland jurisdictional boundaries, as indicated above, without a permit. This includes the buffer labeled as 'non-turf' as shown on the plans by Jeffrey T. Butler, last revised May 2, 2022; this buffer is to no longer be mowed, fertilized, or otherwise maintained,without a permit, and will be allowed to passively revert to a naturally vegetated area. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundaries and your project (i.e. a 15' to 20' wide construction area) and/or erecting a temporary fence, barrier, or hay bale berm. Please be further advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Sincerely, t��d� (_1 1�Cl:_ -1 I-aura -. Star Deputy Permit Administrator cc: En-Consultants BMHP-TW t'd%VVMTHK [)�?pa-vl[merkt of File Environmenmli ConservaUan Client#:4923 SEIFCON ACORD. CERTIFICATE OF LIABILITY' INSURANCE DATE127/2DIY2 10 12 712 0 2 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may r"'uire an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONANAME,c Commercial Support Edgewood Partners Ins.Center P1-390-9700 A� Nro...._ ...... _._....__..,. 63 I x_ ) 631 390-9790 40 Marcus Drive E-MAtL ADDRES .. S Nl�cert6ficates@ep)cbrokers.corn 3rdFloor ._��__��.... ..............�w .. ...__. Melville, NY 11747 INSURERA:Southwest Marine&General In_s Co GE 1 NAIC# m. .�._ 2294 INSURED ............................._...................... .. INSURER B.....Merchants Preferred Insurance Co. .... _ 12901 Seifert Construction Corp. iNsuRER. _...�__ _�_..�.� y. ....................... ........... ,. POBox 1407 _.................mw... _._.._. _._......�.......n...._. _... _ ...._ ...._...�__. INSURER D:. Mattituck, NY 11952 u•.- INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. TYPE OF INSURANCE NUMBER MMIDDIYYYY) AMM � - LTR INSR WVD POLICY^ ILOICDY EXP LIMITS )_,I /NSR ADDL UBR POLICY EFF PO A X LIABILITY E $1,000,000 CLAIMS-MADE ( Y GL2022LH600298 0811012022 08/10/202 EACH _.. COMMERCIAL GENERAL OCCUR IEI� ' w accurcac $1 000,000 0 u one person) SmSrOOO ti�� BI1PD Ded:2,50 MED EXP(Any m_. GEN'L AGGREGATE LIMIT APPLIES_ GERSONAL&ADV INJURY $1,000,000 P PER: GENERAL AGGREGATE $2x000,000 PRO- PRODUCTS-COMP $2 OOO OOO ..�._ POLICY I!�I JECG LOC $ OTHER: __ B AUTOMOBILE LIABILITY CAP9115710 � 5/11/2022 05/11/20 �`OMBIN�D SINGLE a Ir�roT OMOB.......IABI ............. .......... . 1 000 000 1202 ( accddaxnt� .+ . . ._....__,. X ANY AUTO BODILY INJURY(Per person) $ BODILY INJURY Per accident m OWNED SCHEDULED ( ) $ AUTOS ONLY AUTOS ._ x HIRED NON-OWNED PROPERTY IyA7M1'Ai $ AUTOS ONLY _X, AUTOS ONLY $ EXCESS LIA .... _...- _.. ._..... A _ ... A UMBRELLA LIAB X OCCUR EX2022LHB00085 8/10/2022 08/10/202 EACH OCCURRENCE $3,000 000 X 9 .....ro_ ... CLAIMS-MADE AGGREGATE mm _ $3 000,000 DED „� RETENTION$ _- _ $ WORKERS COMPENSATION -.__�.. _.. T41 — uwi- �--._... AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT $ OFNCr,R)MEMDER EXCLUDED? N I A (Mandatory In NH) E.L_DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Donald and Patricia Brennan are included as additional insureds for general liability coverage as required by written contract. CERTIFICATE HOLDEN, CANCELLATION Donald and Patricia Brennan SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1663 Bridge Lane ACCORDANCE WITH THE POLICY PROVISIONS. Cutchogue, NY 11935 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S4353781/M4265859 ICA01 17091\Nl� NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE D AAA^^A 113425746 SEIFERT CONSTRUCTION CORP PO BOX 1407 MATTITUCK NY 11952 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SEIFERT CONSTRUCTION CORP TOWN OF SOUTHOLD BUILDING DEPT PO BOX 1407 54375 NY-25 MATTITUCK NY 11952 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 1300 444-5 440846 06/29/2022 TO 06/29/2023 111312022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1300 444-5, 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:IIWWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. FREDERICK G SEIFERT PRES JOHN G SEIFERT V PRES OF SEIFERT CONSTRUCTION CORP 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 STAT S4 71*1 NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 578129590 Workers' CERTIFICATE OF INSURANCE COVERAGE ,rr YORK,,TATc Com ensateon Board NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW .W.................................. ............. _. -_.............. ......_ �...._...... ,.. _ PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrie ..... ... ... .......... 1 a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured SEIFERT CONSTRUCTION CORP 631-298-1036 ATTN: FRED PO BOX 1407 MATTITUCK,NY 11952 1 c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Onlyrequired ifcoverage is specifically limited to certain locations in New York State,I.e.,Wrap-Up Policy) 113425746 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoinY Life Insurance Company Town of Southold Building Department 54375-NY-25 31b.Policy Number of Entity Listed in Box"1 a" Southold, NY 11971 DBL115282 3c.Policy effective period 05/11/2022 to 05/10/2024 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. B.Disability benefits only. C.Paid family leave benefits only. 5, Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 12/212022 By �Ir � _.,...... (Signature of insurance carrier's authorized representative or NYS Licensed Insuranceg Agent afthat 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 carriers authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box 413,4C or 56 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 emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board,Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4B,4c or sB have 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(Article 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By _ -._.............. (Signature of Authorized NYS Workers'Compensation Board Employee) e) Telephone Number Name and Title Please Note:Only insuran..c.e carriers licensed to write NYS disability and paid family_y_.leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (12-21) III IIIIDIIII�����II�IIIII��(�IININf��llllllll " U z LOT 110 -- 4�f s f asp, 3 St00 � O T EXISTING EXISTING "la ✓� i EM MARSH -9,rl MARSH GVb I Ex PAT E: f6w ms`s 2 5T r F1 DWELL IN, N eCDRh o, d� C� x `�r ILr� SON �" j fl FFI. EXISTING 4R 5F J :I FrL e.0 i yPl0 E MARSHt4 SAN. + x pum I` & l � �4 i13 �� TIDAL WETLAND �s oX Ai a to PAPP 4hFBJ ltt V 14 Ia fv g�4r s G AFS ,EX, ,! AS �LL*EAD ° ANDON 7 X C_ u Fv� p Ns ry�t ll 1 qv-t, NED B1 TO BE ti r \ ABANDON@?IN PLACE PER ti EN-60 r s as 1 I XWE 21 02 THI r 16 Ts 5EEBQkID 40.21 NITy„ 1 r�j ,x,13 � ._...�• r uNC� �; � d A , �� PJfwSTING � F/ �p� .6NL46E 1' aP4.14 J � 1 1 � c° � PRC7.IEG1"I IMITINts „rr- �'�ry ,aha II TAa SILTBAR1RfH2, r,u i`F / j 1 APPROxIIF1ATE tEN6TRIR 9,64 LR � u -'�}� r 4 Ex 1 . 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SYSTE 'B' r_ N SYSTEM o v a dD �4 a J Z a U- 1-RUC w `$ W WA5TT BY REMOVAL 6RAPNI1 SCALE30 LL U, H I-4'0 PR ARY SYSTEM'C' 1"=s0%0� �' o UJ ` 0 2-4'En SITE W457E WATER TREA7ME�{T () 0i a '? a 7 v w w LL, TION�LEALHIN6 COMPOpgI75 — "- w w.d g el ycrr cn t `'; 0 oe arT AND REtIRWrS Notor^i/�4��V CI Y ' / �I.VIVtt�t1IV www Ii811cm C t x 51TEPLAN aromerstates) u O E SANITARY SYSTEM, , 800-272-4480 1611 - W 'E6 O*-PO�DETAILS Lu [3y laver,txsaro 6a s and cu t.aslora a kmg in CL LD R Y SYSTEM the 5va Wroeghs of Naw York For Safaty a Sana,homepwaa s arc aVangly ° ,° (n �� and SfffoiN CGua6ae an.LGng Island � u eneaurag d t call as w:erp han planning any '- ITE WASTE WAT82 TREATMENT contact')NN-1 1 apo-272-44ao 811;anaast ypa nr dr�gtng o d air pr©perry. e ' o JN AND LEACHIN$ 48 haom but o rn re than 10 wake tla a Nn usavna a can santaal us dlrecd et F LL1 1-a0a 272,-0480 or by sa111, s N5 COMPONENT'S !e aludmg waakanda Bred!agave harts ysJ pear y „' Q q 811,the I p" LLI DDtG to bagarvning y--cpn nized dig,,., nada aI sall We' ysu dig nunybar.Fw Y.I. of 1T ANI T Gawauan wsrk fn naara end gg g or ex avausn wmrk cpm ac ed on Tw Q Q REf7UIREN�tTS e a marked Fxsavam s and om c aB car pap y,rt Is the ongraGln r'aw 6� G' 'SITE PLAN alsp submit IPCaIe requagts o line.through reap°slbduty-- Lu NOT Iha ha eawner'a--ia 3W SANITARY�, ITIC,If you do not currently us IT,'t tuna' W-In-t 019Net.Having lil ty line-markad m111-8 U0.5.24-76©3 for more lntam P4 0.to di . ..-.._.�� r-- W AWOL't ggeng Is Ire -!'charge, ........_.:..-._.. ... 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