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HomeMy WebLinkAbout48793-Z TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 48793 Date: 1/24/2023 Permission is hereby granted to: 40200 Main LLC c/o RWN Mana ement LLC 712 Fifth Ave FI 30 New York NY 10019 To: Remove old and install new underground fuel tank at existing commercial marina as applied for, with flood permit, Trustees #10262, SCHD approval, and architect's letter for FEMA compliance & DEC no jurisdiction. At premises located at: 40200 Route 25, Orient SCTM #473889 Sec/Block/Lot# 15.-9-8.1 Pursuant to application dated 12/2/2022 and approved by the Building Inspector. To expire on 7/25/2024. Fees: NEW COMMERCIAL, ALTERATION OR ADDITIONS $200.00 CO-COMMERCIAL $50.00 Flood Permit $100.00 Total: $350.00 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 https://www.southoldtowtiny.szov Date Received APPLICATION FOR BUILDING PERMIT �Qm For Office Use Only 022 PERMIT NO, ff M Building Inspector. "/ 1, OpLlt�lo^�C3��i wF�'1� Applications and forms must be filled out in their entirety. Incomplete I NOF S01-Tft„1011) applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:11/29/22 OWNER(S)OF PROPERTY: Name:40200 Main LLC c/o Marc Rowan SCTM #1000-15-9-8.1 Project Address:40200 Main Road, Orient, NY 11957 Phone#:212-920-3131 Email:mharada@rwnmgmt.com Mailing Address:RWN Management LLC, 66 E. 55th St. 31st Floor, NY, NY 10022 CONTACT PERSON: Name:Graham Associates c/o Glenn Graham Mailing Address:256 Orinoco Drive, Suite A, Brightwaters, NY 11718 Phone#:6316659619 Email:Glenn@GrahamAssociatesNY.com DESIGN PROFESSIONAL INFORMATION: Name:Graham Associates c/o Michael Dunn, RA Mailing Address:256 Orinoco Drive, Suite A, Brightwaters, NY 11718 Phone#:6316659619 Email:Glenn@GrahamAssociatesNY.com CONTRACTOR INFORMATION: Name:Service Station Installations c/o Henry lorizzo Mailing Address:655 Orinoco Drive, Bay Shore, NY 11706 Phone#:516-523-0560 LIE—mail:gaspumprebuilder@aol.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ElAlteration ❑Repai•_ LODemulliitwn Estimated Cost of P--jest: DOther Fuel tank replacement $245,000.00 Will the lot be re-graded? ❑Yes ®'No Will excess fill be removed from premises? liiYes ❑No 1 PROPERTY INFORMATION Existing use of property:Marina & Restaurant Intended use of property:Marina & Restaurant Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Commercial M I I this property? Dyes iRNo IF YES, PROVIDE A COPY. Check Box After Reading:. The owner/contractor desi� �.-�.. / gn professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and In building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210,,45 of the New York State Penal Law. Application Submitted By(prina e . len ham @Authorized Agent ❑Owner Signature of Applicant: Date: 12, t 2':1- STATE 1-STATE OF NEW YORK) SS: COUNTY OF Suffolk ) Glenn Graham being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)he is the Agent for Owner (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 int iFti . Ewa CRCIM{ sC ary public-State of New rk Sworn before me this No.atc164a5314 ofi� Cek Cr, aty of GC V V o(� s n� z .�..._ ��daY � 2� F" Not ay Cnss 7'S' afu Notary Public PROPERTY OWNER AUTHORIZATION (Where the applicant is not the owner) Marc Rowan residing at 81 Vyut ft[Low ZC"M�i C-f DWO do hereby authorize Glenn Graham to apply on my behalf to the Town of Southold Building Department for approval a5 described herein. �I24 X22 Owner's Signature Date Marc Rowan Print Owner's Name 2 '- r>v '777— .......... l,rJ,,,lll',^'",Nid/JIMKft.,-rYy'i l6r,IL1TFY.,,,:r ,IT1l f.h l5f,.:��'///,"rr/N/,N///1V%„yflr') ,IAFWtY!„/l4 k lrlr MJrP.✓ur,lM Pf ff P�1<hfi.l,,,'1X/!,'mlirl.,.,1„ff/rzi'„Na.,.J✓/ 9,. „.lf.r,ki”. "nM,A,'n , ,./ ,J .,.N+ ,. r [ BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK r� s, PERMIT NO. 10262 DATE: NOVEMBER 16,202 �n ISSUED TO: 40200 MAIN, LLC J PROPERTY ADDRESS: 40200 MAIN ROAD, ORIENTf°'„ s 1 SCTM# 1000-15-9-8.1 AUTHORIZATIONI” Nl ✓ / Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on Novernbgr_1 T and in consideration of application fee in the sum of$250.00 paid by7 C1fD_6 aanb. LC and subject to the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits J the following: Wetland Permit to remove one (1) existing 1,000 gallon above ground diesel tank; install one (1) J y' 12,000 gallon double wall fiberglass tank split 8,000 diesel and 4,000 gas underground; install u new leak detection system, piping, alarms, and dispenser; and as depicted on the site plan w w prepared by Graham Associates, received on September 23, 2022 and stamped approved on k � November 16,2022. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, and theseg, presents to be subscribed by a majority of the said Board as of the day and year first above written.AL h � Y ?qry f ` �r 4 ?/ , "k 1f k4” N I✓r bK""' ! ,I., 1 k 1✓FF:: k4,rNF/', „✓.', /Jule,ld e(✓./,,,Y, ✓�.:/Ad D:A rMH,i, r f ,y n ,A4/ :ai/J,4:/ 7.1,fu,I: (4 IAIA Fr.r,: UN/Un,i».:,'l "1, .Nki ; f ��+ J „ � � �^�° " f� b� � z.�,� a � �',u., I �" �,v�'✓" �.'rr �k 7 ,W.. zo l� � Ew� dl i PERMIT TO CONSTRUCT Toxic and/or Hazardous Material Storage Facility Suffolk County Department of Health Services GREGSON PIGOTT, MD, MPH Commissioner PERMIT INFORMATION SCDHS Job No: T-HM-22-00192 Facility Name: Duryea's Orient by the Sea Restaurant and Marina Facility Address: 40200 Main Road,Orient,NY 11976 Site Record ID: SITE-11522-OPC File Ref. No: 11522 Issuance Date: August 30,2022 Expiration Date: August 30,2023 Your Application for Permit to Construct a Toxic or Hazardous Material Storage Facilities for the above referenced site has been reviewed for compliance with Articles 7, 12 and 18 of the Suffolk County Sanitary Code. The application has been approved. The items listed below and on the back of this Permit are conditions of this Permit and have to be observed during construction: 1. A copy of the approved plan must be kept at the construction site. A copy of this permit must be kept on display at the facility during construction. 2 Safe construction practices must be followed during the installation of the storage facility(s). 3 The storage facility(s) must be constructed in accordance with the approved plan. Any changes in design, materials or use require prior written consent of both the design professional and the Office of Pollution Control.The changes have to be submitted in a form that is acceptable to the Office of Pollution Control. The contractor and/or design professional are required to inform the owner that the changes are being made. 4. The Office of Pollution Control has the right to inspect this installation at any time to verify its being constructed in compliance with this permit. 5. The contractor/owner or agent of the owner must contact the Office of Pollution Control at least 2 business days prior to commencement of any work to arrange for the required construction inspections. The contact number to schedule required inspections is 631-854-2523.The storage facility cannot be placed into service until the Office of Pollution Control performs all required installation inspections and issues an interim permit to operate. 6. Contact the local building department and/or fire safety enforcement office for any additional requirements that may apply to your project. 7. The Office of Pollution Control reserves the right to revoke this permit as allowable by law. ISSUED BY: Alexander M. Santino,W.E. Principal Public Health Engineer Bureau of Environmental Engineering Division of Environmental Quality THIS PERMIT IS VALID FOR THE FOLLOWING STORAGE FACILITIES ONLY Table 1: The following storage facilities are approved for installation pursuant to this permit Tnk# Location amici"tY" oals Product Stored So a of Pro"ect 7 Under/Out 8,000 Diesel fuel Remove(1) 1,000 AST diked diesel tank. Install (1) DW FRP UST split compartment 8K Diesel, 8 Under/Out 4,00.0 Gasoline(PUL) 4K Premium. New DW piping, dispenser, sumps and alarms. NOTICE E---Requirement to Renew this Permit to Construct This permit is renewable for up to 90 days after the Permit to Construct expires. The job file will remain open for that period. If the Office of Pollution Control does not receive a renewal application within the 90 days, the file will be closed and a new application for a Permit to Construct will have to be filed. All applicable filing fees will become due and payable. Issuance of this permit does not supersede any existing agreements with, or mandates by, the Office of Pollution Control or any other government agency. The construction period does not supersede any existing compliance dates agreed to, or mandated by, the Office of Pollution Control or any other government agency. Issuance of this permit does not authorize the use of the storage facility(s) that are in violation of the Suffolk County Sanitary Code or any other government code. Special Conditions NOTICE: This tank installation will be a "wet-hole" type installation and will require a pre-construction meeting prior to the commencement of work. Contact this office to arrange the meeting. 1. All tank top piping sumps and under dispenser containment sumps shall be hydrostatically tested in accordance with SCDHS testing protocols to insure that they are liquid tight. 2. All underground piping shall be air tested in accordance with SCDHS testing protocols to ensure that piping joints are liquid tight. 3. The tank monitoring system consisting of the alarm control panel along with such associated equipment as leak detection sensors, liquid level indication probes, remote audible/visual overfill annunciator alarms shall be functional prior to the introduction of motor fuel product into any underground storage tank. 4. The high liquid level alarm shall be set at 90% of the working capacity of the tank on the liquid level indicating probe. 5. All work-in-progress tests shall be witnessed by a Public Health Sanitarian assigned to the Office of Pollution Control. It is the responsibility of the pump and tank contractor to schedule all work-in-progress tests to be witnessed by this Office. 6. No permit to operate will be issued until all tests are satisfactorily completed and the tank system monitoring equipment is fully functional. The new tanks cannot be filled until a permit to operate has been issued by this office. 7. A warning sign stating that when the alarm sounds the tank is full, do not overfill shall be posted near to or next to the remote audible/visible overfill annunciator alarm. 8. As-built plans and the tank installation checklist shall be submitted to this office at the completion of the tank installation project. The as built-plan shall conform to the requirements of§760-1802.1(4)(iii)of Article 18 of the Suffolk County Sanitary Code. 9. All work shall be conducted in a safe manner in accordance with OSHA regulations. The Public Health Sanitarian conducting the work-in-progress inspections may bring to the attention of the crew chief, clerk-of-the-works or superintendent if an unsafe work place condition is observed. Work on the project may be interrupted and delayed until such unsafe work condition is corrected. COUNTY OF SUFFOLK M M STEVEN BELLONE SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF HEALTH SERVICES GREGSON PIGOTT,MD,MPH Commissioner Graham Associates August 30, 2022 1981 Union Blvd. Bay Shore,N.Y. 11706 Attn: Michael K. Dunn, R.A. BUREAU OF ENVIRONMENTAL ENGINEERING APPROVAL NOTICE-APPLICATION FOR A PERMIT TO CONSTRUCT Site Information: SCDHS Job No: T-HM-22-00192 Facility Name: Duryea's Orient by the Sea Restaurant and Marina Facility Address: 40200 Main Road,Orient,NY 11976 Site Record ID: SITE-11522-OPC File Ref. No: 11522 Your application for a permit to construct to install, substantially modify or fabricate a project at the above referenced site has been reviewed for compliance with Articles 7, 12 and 18 of the Suffolk County Sanitary Code. The application is approved. The scope of work for this project includes the removal of one(1) 1,000 above ground diked diesel tank and the installation of one (1) 12,000 gallon DW FRP UST split compartment 8K diesel, 4K gasoline (PUL) with containment sumps.New double walled piping,one new dispenser, under dispenser containment sump and a complete tank monitoring system with liquid level indication and leak detection sensors shall also be installed. Enclosed you will find both the Permit to Construct and one set of stamped approved plans in .pdf format. This permit must be posted at the construction site and one copy of the approved plans must be kept on site while construction work is in progress. Read the permit conditions carefully. The contractor performing the installation work is responsible for scheduling the work-in-progress inspections. Contact the local building department and any fire safety enforcement office for additional requirements that may apply to your project. Very truly yours, A&yanrM. San tino. P.it. Principal Public Health Engineer Bureau of Environmental Engineering Division of Environmental Quality 10 DIMION OF ENVIRONMENTAL QUALITY •OFFICE OF POLLUTION CONTROL• 15 HORSEBLOCK PLACE • FARMINGVILLE,NY 11738 • Phone(631)854-2501 Fax(631) 854-2505 PJ'R'wd3pY PN9 muff.F',Pn.it.et.. W Scott A. � � 03,202 . , STOR �WWA T]ER tDEPT VA\NA\G]El�v[]EN]CSUPERVIFM SOUTHOLD TOWN HALL-P.O.Box 1179 " 53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold CRAFTER 236 - STORM' ATER MANAGEMENT REFERRAL FORM APPLICANT INF _.. (�..�� INFORMATION TO BE COMPLETED B �._ APPLICANT ORM Y THE .. ... . T.�..:.. _� k' ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) - - - - — - - - - - - - - - - - - - - --- - — - - - - - - - - —- — APPLICANT: (Property Owner Design 6 g Professional, Agent, Contractor, Other) NAME: 1' Q� ��� � � Date: � z�i�z�zz rl Contact Information: GrCliplom pBp 1 ��,I�`tlriy1MBM2� /) (G-Mad 8 Telephone Number) 1H I 1 � Proper Address / Location of Construction Site: til o-Z np V N` l s S.C.T.M. 1000 w District z d Se� Block Lot ,.. m ...� �.._.:� r... :.. .._.�........__ �,.�.�.... _ �.W� ....., a_... . . �_ ___ - .. .... .� .�._ __-�.�.e e......�__ m. I` �TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT l 1 - Area of �li ❑ - than I Acre. E1Required -mit is Required ! Project does Not Discharge toWatesof the State. No SP D ESPe li if ❑ - Area of Disturbance is Greater than I Acre & Storm-water Runoff Discharges Directly { to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit J? DIRECTLY From N.Y.S. D.E.C. Prior to Issuance of a Building Permit., � ❑ - Area of Disturbance is Greater than I Acre & Storm-4vater Runoff Flows Through Southold #(r Town's MS4 Systems to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit through the Southold Town EnRineering Department Prior to Issuance of a Building Permit. ` �. ate Rei iewBy. ed i �.- !R e c e"., e () i .... Graham Associates 256 Orinoco Drive, Suite A Bri twaters,NY 11718 Building Consultants &Expeditors (631)665-9619 January , 2022 Town of Southold Building Department- Annex Building Att: Ms. Nancy Dwyer 54375 Rt. 25 Southold, NY 11971 Re: Orient by the Sea (Seascape Partners) Fuel Tank Replacement 40200 Main Road Orient, NY Dear Ms. Dwyer, Please be advised that the proposed underground fuel tank at the above referenced facility have been fully designed to compensate for the effects of flooding in compliance with FEMA & ASCE 24-14 standards. The fills are watertight, the vents terminate 12' above grade and the tanks are anchored to prevent uplift due to buoyancy. I have also been advised by the property owner that the site has previous Non jurisdiction letter issued by the NYSDEC. The proposed underground storage tanks are behind the bulkhead ( a manmade structure greater then 100' length) and over 600' from a tidal wetland. If you have any further questions, do not hesitate to call. Sinc RC JA N 9 BUILDING DEPT "era®Re e%r-" a 9tl f'e Of DATE(MMIDDIYYYY) F CERTIFICATE OF LIABILITY INSURANCE 12101/2022 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 pollcy(ies)must have.ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NA : Maria Ptbarch LI Insurance Brokers LLC PHONE r. (516)249°5660 Arc Ne (516)249.6660 348 Main Street EMILmaiia@wbartonballen.com AODRES& P.O.Box 400 INSURER($)AFFORDING COVERAGE NAIL N Farmingdale NY 11735 INsuRERA: Hamilton Insurance Designated Activity Company INSURED INSURER 8: Service Station Installations of NY,Inc. INSURER C: 655 Orinoco Drive INSURER 0: INSURER E: Bay Shore NY 11706 INeuRER F COVERAGES CERTIFICATE NUMBER: CL2212139986 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 REOUIREMENT,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. —POLICY EXP TYPE OF INSURANCE POLICY NUMBER ''Md'D I)rYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S 1,000.000 WNIME CLAIMS-MADE ®OCCUR PREMI:r rW ` • MED EXP(Anyone pawn) 'S 5'.„000 A Y ENVPKGH1803226 09/07/2022 09/07/2023 PERSONAL&ADV INJURY S 11000,000 GE.N'LAGGREGATE'LIMITAPPUESPER, . GENERAL AGGREGATE S 2,000,000 POLICY El JECT LOC PRODUCTS-COMP/OPAGG S 2.000,000 OTHER. Pollution Llabllity-Each S 1,000,000 AUTOMOBILE LIABILITY a ANY AUTO BODILY INJURY(Par Person) WINS OWNED SCHEDULED ��� BODILY INJURY 5 AUTOS ONLY AUTOS HIRED NON-OWNED PPRr,PI tAAF,tlAGE S AUTOS ONLY AUTOS ONLY S UMBRELLA LLA& OCCUR EACHOCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DEO RETENTION S .. is (WORKERS COMPENSATION PSTATUTE Oq AND EMPLOYERS'LIABILITY Y I N 'ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA E-L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory M NEE) -L DISEASE-EA EMPLOYEE S T yes,desvibe under ,DESCRIPTION'OF OPERATIONS below E.L-DISEASE•POLICY LIMB 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101•Additional Remarks Schedule,may be attached If more space Is required) Town of Southold are included as additional insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of SDulhhold ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ®198'8.2041KCZORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD New York state Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE n e n A n n 833858101 ACRISURE LLC DBA WHARTON B ALLEN AGENCY 348 MAIN ST FARMINGDALE NY 11735 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SERVICE STATION TOWN OF SOUTHHOLD INSTALLATION OF LI INC P.0. BOX 1179 655 ORINOCO DRIVE SOUTHOLD NY 11971 BAYSHORE NY 11706 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12375708-1 562206 11/12/2022 TO 11/12/2023 1211/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2375708-1, 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. THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT HENRY IORIZZO EARTHWORKX 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. THIS POLICY IS CANCELLED EFFECTIVE 12/11/2022. NEW YORK STAT 'S7NCE FUND DI'RECTOR',INS'URANCE FUND UNDERWRITING VALIDATION NUMBER:804659676 U-26.3 <Nl,w workers' CERTIFICATE OF INSURANCE COVERAGE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured Service Station Installation of LI Inc (631)968-6915 655 Orinoco Drive Bay Shore NY 11706 1c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to certain locations in New York State,i.e.,Wrap-Up Policy) or Social Security Number 47-3446161 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) SHELTERPOINT LIFE INSURANCE COMPANY Town of Southhold 3b.Policy Number of Entity Listed in Box"la" D475521 P.O. Box 1179 SOUTHOLD, NY 11971 3c.Policy effective period 11/12/2022 to 11/11/2023 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: X❑ A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. R 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. �f7M/r Date Signed 12/1/2022 By (Wd, (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.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5113 of Part i has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) 1111111 11°°°1°°°°1°°1°°111° IIIIII DB 120.1 (10 17)