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48805-Z
° TOWN OF SOUTHOLD ttr �rblpl BUILDING DEPARTMENT TOWN CLERKS OFFICE ee 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 #: 48805 Date: 1/25/2023 Permission is hereby granted to Estrada, o n . .. . ! ! ......................................................... 2350 Deep Hole Dr Mattituck, 11952 To: Construct additions and alterations to an existing single family dwelling and legalize existing trellis and raised walkway as applied for per SCHD, Trustees and DEC approvals. Flood permit required. At premises located at: 2350 Deep Hole Dr, Mattituck SCTM # 473889 Sec/Block/Lot# 123.4-7 Pursuant to application dated 11/7/2022 and approved by the Building Inspector. To expire on 7/26/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $1,576.40 AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $291.20 CO-ADDITION TO DWELLING $50.00 Flood Permit $100.00 Total: _........$2 ,017.60 Building Inspector ARTMEN a TOWN OF SOUTHOLD BUILDINGD SoutholdNY 1��1971-0959 Town Hall Annex 54375 Main Road P. O. Box Telephone (631) 765-1802 Fax (631) 765-9502__.p �'V ,, lw .+ontho)dto r ran ' o , ur Date Received APPLICATION FOR BUILDING PERMIT For Office Use Only (1�1 �L:. 0 PER N0. Building ItisPekrz21 J lications and forms must be filled out in their"''entirety,Incomplete Apphcant is not the owner,an applications will not be accepted.. Where the App Owner's Authorization form(Page 2)shall be completed. Date:10/26/22 OWNER(S)OF PROPERTY: 000-123-4-7 Name:Koryn Estrada (aka Kori Estrada) scTM#1 Project Address:2350 Deep Hole Drive Mattituck NY 11952 Phone#:646-415-2450 Email:koriestrada@gmail.com Mailing Address:2350 Deep Hole Drive Mattituck NY 11952 CONTACT PERSON: Name;Agena Rigdon DKR SHORES INC Mailing Address:235 Trout Brook Lane Riverhead NY 11901 Phone#:631-566-6016 Email:dkrshorescorp@gmail.com DESIGN PROFESSIONAL INFORMATION: Name:FOLEY FIORE ARCHITECTURE Mailing Address: g 141 316 Cambridge St Cambridge MA 02 Email:estrada2021 @foleyfiore.com Phone#:617-547-8002 CONTRACTOR INFORMATION: Mark Boeckman .. Boeckman Building Construction Corp. Name: Mailing Address: P.O. Box 1453 Mattituck NY 11952 Email:mark@boeckmanconstruction.com Phone#:631-298-5319 DESCRIPTION OF PROPOSED CONSTRUCTION EstimateerOsr of Drniart: ❑New Structure NAddition ❑Alteration ❑Repair []Demolition $ []other d? ❑Yes ®No Will excess fill be removed from premises? ❑Yes Ig No Will the lot be re-grade 1 PROPERTY INFORMATION Existing use of property: S'rD Intended use of property: �5F Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes a No IF YES, PROVIDE A COPY. Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. Application Submitted By(print name):Koryn Estrada (aka Kori Estrada) Authorized Agent i@Owner Signature of Applicant: / Date: 10/28/2022 Texas STATE OF NM" SS: COUNTY OF Kerr ) Koryn Gatta Estrada being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the N/A(ownet-) (Contractor, Agen ,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 28th day of October 20 22 Notarized online using audio-video communication Notary Public MW r� ��p IIIIII III��'� �ry�' j #10'. 0pe, Heather Cook PROPERTY OWNERAU III RIZ W ID NUMBER '.. }I,, . ��..- }} 128853007 (Wher(Where he applicant IS not the owner) �r2 e2� COMMISSION EXPIRES e l J Jan—y 19,2024 Koryn Estrada (aka Kori Estrada) residing at 2350 Deep Hole Drive I, Mattituck NY 11952 do hereby authorize Agena Rigdon DKR SHORES INC to apply on my behalf to the Town of Southold Building Department for approval as described herein. Vk _ 10/28/2022 Owner's Signature Date Koryn Estrada (aka Kori Estrada) Print Owner's Name 2 tm TOWN 4I' tIUTIh@LD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Rad P. O.Box 1179 Southol ,NY 11971-0959 Yl, 0v Tleheane{ 1)765-1802 lett : wwa. etutlolcltwnn Floodplain Development Permit Application p SCTM#1000-123-4-7 FIRM Panel: PROPERTY INFORMATION: Flood Zone:Ie& � Address:2350 Deep Hole Drive zip:11952 City:NlattltUCk Phone#:631-566-6016 CONTACT PERSON: Name:Agena Ri9don DKR SHORES INC Mailing Address:235 Trout Brook Lane Riverhead NY 11901 PROJECT DESCRIPTION: �21 ��r l , SECTION A:STRUCTURAL DEVELOPME'l��" CHECK ALL THAT APPLY) . Type of Activity Type of Structure El New structure Q Residential 0 to 4 families) ❑Demolition of existing structure ❑Residential(more than 4 families) ❑Replacement of existing structure ❑ Combined use ❑Relocation of existing structure ❑Non-residential [..Addition to existing structure ❑ Elevated ❑ Alteration to existing structure ❑ Flood proofed(attach certification) ❑ Other: ❑Manufactured Home ❑Located on individual lot ❑Located in manufactured home park SECTION B:OTHER DEVELOPMENT(CHECK ALL THAT APPLY) [I Drilling ❑ Dredging ❑ Mining ❑ Grading ❑Clearing of trees,vegetation or debris ❑ Paving ❑ Placement of fill material ❑Connection to public utilities or services ❑Roadway or bridge construction ❑ Drainage improvement(including culvert work) ❑Watercourse alteration (attach description) ❑Fence or wall constructionecif El Excavation (not related to a structured development) ❑Other development not listed(specify); the terms and conditions of this permit and certify to the best of ssued The permi information contained conditions may be revoked if any By signing below l agree topied in this application is true and accurate.I understand that no work may start until a permit Is lop ent shal not be used or occu false statements are made herein.If revoked,all work must cease until permit mencedswithin one yearlof sualriceions .Other permits may be until a Cert.of Compliance is issued.The permit will expire if no work is required to fulfill regulatory requirements.Applicant gives consent to local authority or representative o make reasonable inspect to verify compliance. - ada (aka Kori Estrada) Owner, Application Submitted By(print name):Ko n Estr ... Date: Signature of Applicant: i Building Department Application AUTHORIZATION (Where the Applicant is not the Owner) I, n Estrada aka Kori Estrada residing at 2350 Deep Hie Drive (Print property owner's name) (Mailing Address) Mattituck, NY 11952 do hereby authorize Agena Riqdon (Agent) DKR SHORES INC to apply on my behalf to the Southold Building Department. -RP 10 �. 28 ?,c (Owner's Signature) Date Ko n Estrada aka Kori Estrada (Print Owner's Name) N SITE DATA 400 O Vadw Ave ve,RNwhood,Nen Y11K 11401 631.12T�305"'631 T:-0144 AREA=40,183 SQ.FT. mnYr9-9—gr,eery 9— EXISTING LOT COVERAGE PROPOSED LOT COVERAGE •DATUM =NGVD INSdytO��ltrt ' '1 25TORY HOUSE 66ARAKE =4184 SQ Fr. I STORY HOUSE a GARAGE =4-184 SQ FT. _ DEPTH To 6ROUNbWATER =5FT WOOD LANDING =1050 FT. WOODIANDING =10 SQ PT _-< - -d W Young Lord SAvoyor WOOD DECK =10645Q Fi. WOODDECK -IUfi45Q.FT. - NUMBER OF BEDROOMS(DESIGN EQUIVALENT) =B Tipmm G.Pblper'Prolea•Imiol Gglrow INfm"D POOL �330 5Q.FT IN6RouwD POOL -330 SQ FT MINIMUM REQUIRED L/A OWTS CAPACTf =8B06AL i Douglas E Adam Proloaawrol Errglrow HOT TUB -77.Q.FT HOT TIB =]SQ FT. sI z� ,�. STORAGE SHED =165Q.FT. STORA6E SHED =15 SQ.Fr. - - PROVIDED VA OWTS CAPACITY =10006AL PRoberlt TaW.4rchl[oct `TOTAL - --- =5ABI SQ FT 'TOTAL _- =5 MR SQ.FT LEA[ W SYSTEM REQUIRED =550 SFSWA Rooert 9:rormkl.4chltect =14.1% :1411 3 _ -- E£ SY'?F M.T Ee:ytx2 •5835FSWA -.. _ HEALTH DEPARTMENT USE EXISTING ADJACENT PROPOSED ADJACENT S " AREA LOT COVERAGE AREA LOT COVERAGE ADJACENT AREA=34.oD9 SQ FT ADJACENT AREA=34.009 SQ FT �=-aa..i •``"'�"1 - �l SSTORYHOUSE&GARAR T4.1045Q FT. 25TORY HOUSE 6 GARAGE =415450.FT. r - `y # " ':�'•. 4' _ j ,._.>- .-,4m WOODLAMING =10 SQ FT. WOOD LANDING =105Q..FT. '\ -- - �O _ <1,064 SQ.FT, WOOD DECK =I45Q FT. '. ., 06 - -330 SQ,FT. INSRORMD POOL =330 Sp.FT. Te '. '•�" - _n SQ.FT. HOT TUB =1]5%FT, - _A6FSHED =16SQFT. STORAGE SHED =16 SQ FT. J _„- WAS[ =2415p.FT. WOOD WALL a 241 SQ FT. - WALK. =TD SQ,FT. MASONRY WALK =]D Sp FT. _; ([Mellon•rM I £.1I _ .. `� ----_ �r..T3NAL =599054.FT 'TOTAL 599B SQ FT. '. - - •" _. >d a 11 6% =ITA% \jP.j�.-y s��--`-EkO RAI 11�nf' - • �a C_ 3 g Or. �_ 6 '� FNS aBRYLo -' a 'i -" � _'4R'P '" ENGINEER'S CERTIFICATION (b 3- / +�+ .,� 3=r - <41 RY Tg#•Y"TTT'WAiEA? Y€ij :,s'VtAstbISPOSAL NOTE CWT AMAEMObELCE6110MANUFAMN DDYFIJICLEANU5A s' s g r CONSTRULTI T K T _ DE5IC3H FUTHvtP54R9�s#,s`::A'IVS IRFXTv: � _ ONS A2�iA �3--S PZ€ErT 451� '1I3 R{ S€HEAT[Vf$g#AES1 'i: T?S'aT�LAATL(€iff Tei uAhTt �A� g. £ "`. `. ice#TOT ' SYSTEM AWROVAL tRfJM JIF= I+ GAC ¢ 5 `za - ; l� §€ .� mrsuaa•rwr �.F 1 9S"1TEA4STADT towty,6c'P LR44[R THE DIILECT x vru - ' 4iAf�FIt=. A3ix5A g' .TATA l � L WOCK F.G tT € B9/.�'. NYS �tT ,F £ PROPOSED SECOND ML OR HOWARD W YOUNG N 6/ - i t fs� ADDITION WITHIN EITSTIN6 THOMAS C WOLPERTPE N044B3 4 � KY4l;TPt.RA# 36A�C4JTReY' f4 4£ d V.L.« TPVWM4.R s �$..TCT}$ rw - FODTPR[N" DOUGLAS E.AbAM5,NY5 PE NO WB9) + fiT a f?AkT td'4`tg' 'F`a€YIr"atiiFLDH#7PRi Tla F 'i (32%SQ FT) �__. -: H t�`t¢;`CA3-i4'T �n++-�c�v a�t�;.€�!S lrt• -� � < �.; ...�. tt-`�' `p WET4 ARnmf nor n'E s € ITY SA'TT, - _ f 5 :..•,sem SV€YOR'S C�RTI'fICATIO Ra -WE HEREBY Cf FTIFYTO KGRI G.ESY . F T PROJECT DESCRIPTION _ F - WAS PREPARED IN ACCORDANCE WITH THE C+ ' -- MOOSED2nc ._"^ nsv F SURVEYS ADOPTED BY TIE NEW YORK STATE 15KIRB L$ Preporatl bit de t ddro 3.2365E wer an enMmg 41845E 5 [CONY � `� PROFESSIONAL LAND SURVEVOR5 msden-e loratW 3B.5f I h d•I•nlmM basdmy. }p <.a� _ _ •� ira§gdyq[ fh"�A*at13]_405F bcandabore lheaMrg wnnrn 3 rgp�aa.� xa I< -t_ tistidN.eHmdbavdory ..a,.Wwa. n��:, � .,7. 3m. �rWsn✓Let/ `r._-�-�. � �' Pro'.d' Mib Duk(SbMy)67.!0SF 1•caretl ah•ue rhe ulsing lust}locr weer.or uazarsTu. Hr _ - a 'I - 1'mng room andlocRxd 610}eeifrom ihi.tidal uerlmdb Jury rnAAer..iswNrAax sur+F - p - -, 3 - HOWARD YOU 'nYY CS kYt, r3 - rf<��xru.vnurArTravnr g¢ P `ef'R, �' ?t g=a r- — ,as En sing Trell,s 1115E IPcetW ab-tM e.isurg rirsY llPRr DedMlorcxd 601 E� _ , tut Irom the 1 dal wnlard haus'lory SURVEY FOR Enutirg Woad WWR 247SF ra be rtploced In klMdtff ds6rg mtil - sbvciv'ea haK bun removed and/RraGnmrrd � �'°' s I• -Propoxd zvntlary sysrem lamlodlO191eer from the 11m•e0ud bwdS - � . -. �q ORI G. E$ ADA Tlrr still be ro Nwease to proposed lot coversge from wsrirg for cover�e of _ __,_ ;` - �<r Q} � Dttituck,t M Town of Southold 5.6815F -ThexshRllberoiriae�exproposeamp�eArloteaKr�ermmerrinlago.�laeenr �` , TEST HOLE Suffolk County,New York .<.— lnrc•vaageaf5,99esF BUILDING PERMIT SURVEY I LEGEND ' ' - c �Z ( [oRnh ran Map 1000 sT.r, 123 mor 04 7 3 BBC s.8EI6IANBLOCICOIPB - s` 3. £?sem lwy FIELD SURVEY COMPLETED 71ME21.2022 CH =CHIMNEY u - <� .its. MAP PREPARED JUNE 24,2022 CMF W.G3.iMrE34TF "� i 3z CMS =CONCRETE MONUN �� DATE INAIENTSET ut'sJ,? t a AS �, R Record Of Revisions CSW =CONCRETE SIDEWALK � F ' DI =DRA6E INLET n EOP =CD6E OF PAVEMENT OCCLSp ¢<< `&, +g•3 y"" A t'3 _` IPF =IRON PIPE FOUND _ C �P� �. `tT• R- _ OL =ON PROPERTY LINE j A] P'HEWER PPF =POST05 OUT�IIL FENCE RD =ROOF OVER C�c C w WIF =WIRE FENCE _ `. WOF = WOOD FENCE W. =WOOD STAKE FOUND 9 a9 b BD 120 W55 WOOD STAKE SET �. =UTILITY POLE I-= t. rfP�Lsr LuresLR Scale:V= 40' - • =END OF DIRECTIOWDISTANCE _ uwa•nrlkr 1 JOB N0.2022-0113 _WEn ANOFIAG DW6.2022_0113_bp 1OF2 Telephone(631)765-1802 Town Hall Annex 54375 Main Road x ', Fax(631)765-9502 P.O.Box 1179 Southold, NY 11971-0959 �g s BUILDING DEPARTMENT NOTICE OF UTILIZATION OF TRUSS TYPE CONSTRUCTION, PRE-ENGINEERED WOOD CONSTRUCTION AND/OR TIMBER C�ONSTEU TIO Date: Owner: Location of Property: Please take notice that the (check applicable line): New commercial or residential structure Addition to existing commercial or residential structure Rehabilitation to an existing commercial or residential structure to be constructed or performed at the subject property reference above will utilize (check applicable line): Truss type construction (TT) Pre-engineered wood construction (PW) Timber construction (TC) in the following location(s) (check applicable line): Floor framing, including girders and beams (F) Roof framing (R) Floor and roof framing (FR) Signature: Name (person submitting this form): Capacity(check applicable line): Owner t-� Owner representative TrussRegMdocx Effective 1/1/2015 NEW Y0111"O'K 5 'AT E DEPARTMEN'I' OF ENVIRONMENTAL CONSERVATION MW110an oil I(AyhonsIA0111A p0mlits,Raglon'l 13 SUWo Slony Qraok50 COde Road,Stony Orook,NY 0790 R,(01)444,03651 R U01)40-0160 vy*W,6- nykjov 10117/2022 Koryn Estrada 2350 Deep Hole Dr Mattituck, NY 11952 Re.- Application #11-4738-00606100007 Estrada Property 2360 Deep Hole Dr SCTM# 100-123-4-7 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, EOL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit for the referenced activity. Please carefully read all permit conditions and special permit conditions contained in the permit to ensure compliance during the term of the permit. If you are unable to comply with any conditions please contact us at the above address. Enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather and a Notice of Commencement/Completion of Construction. Rianna Scanlon Environmental Analyst Trainee Cc: Y® DKR Shores Inc. it ti NEW YORK STATE, DEPARTMENT Ole ENVIR N E TA1,CONS RVA,rION Facility DEC I t 1-4738-00606 PERMIT w._.._. . ..._ ... Under the Environniental Conservallion Lam � Perwittee and Facility Information Permit Issued To: Facility: KORYN ESvj}1 ADA E TRADA1 OPE- 'rY 2350 L FEP i-1OLE DR 2350 C?E71313-HOLE D SC,T # 1000-123-4-7 MAT rITTJC K, NY 11952 MA114TUCK, NY 11952 FacilityLocation: in SOUTHOLD in L1FI` LK COUNTY Facility Principal f r neePoint.- NY`TM-E: 709,554 NYTM-N: 4540.338 L atitu u: 40'59443" Longitude: 7230`32.1 Authorized Activity: Install neer IA O TSS Sanitary System. All activities authorized by this permit must be in strut conformance with the approved plans submitted by the: applicant or applicant's agent as part ofthe permit application. Such approved playas were prepared by 'rhomas C. Wolpert,Licensed Land Surveyor, last revised 09/03/2022, stamped NYSDEC approved 10/1792021 _ ....._.._._.w Permit Authorizations Tidal Wetlands- Under Article 25 Permit ID 1-4738-00606/00007 Now T erttabt l`wFt°eukive Date-, 10l1712022 Expiration Date: l0/10/;10/2027 NYSDEC Approval By acceptance oft is permit,the permittee agrees that the permit is contingent upon strict compliancewith the ECL,all applicable regulations,and all conditions included as part of this permit. Permit Administrator-,SUSAN AC" ACJ, Regional Permit Adra,Mistratror Address: N Y`SDEC Region I Headquarters SUNY ( ,,S e)oy irook50 Circle Rd Stony llroo 'w IN 1790-3409 Authorized Si naturep � .r. Mate (2/,,\ /1 �%.I.. Page I of NEW YORK SCATE DEPAWFMENT OF ENVIRONMENTAL CONSERVKFION Facility DEC to 1-4738-00606 Perntit Coluponents NATURAL Rrk,SOURCF,PERMITCONDITIONS GL-',NF,RAL CONDITIONS, ARPLY J'0 ALL. Aurl-IORVED PERN41TS TY)TIFICATION OF OTIJER PERmrri-EE OBLAGA,noNs ......— . -kl&6�11--.--.. IT 60011PIANS - Apply to the Following t. Stute able Vor ally dullinge or Not 1AMAC On Dautagenlu:Watc o j,Nc�,V y k,v�,1,ttil it, rj�,s cabe 1i irrjury to the Structure �:)r whbh array lay camed Lase,orrcstllt fi-0111 �lrtkwe jhc atAr or i IT)Provenjeqt of navigation,or R)r Other opmathns Weankerr by the sr;ltv� Corlpcilsalion s;onscryhaU accrAle f"01n, any such, dalnagce ptwpwws,and no clain" or Q1 LO con X, hjuintain Erosion Cowrtrols AH ctosiosi control deAcs Anil be maintained in good and fundimull conctilron 11nol the prqject has becli con,i) � een stabilized. , jejed and tile �,jrc�j lavas b 3,, Contain Exposed,Stockpiled Soils AH disturbed areas Mae" H I br,junpunwHy smsed or stockpiled t`(V 1011ge"than 48 hows MwH be owained by a copdnuous Unc al swked haybaWspo/ silt curtains (A),,other 'NYSI)EC approveki devices) f0aced on dw seaward skle between Lhe Fill am! I` wum and ur protected buffer aro-3, Tarps are thith0l'1zed to aMplernem these approved IlletbOds- 4Treatillerit Systelits�J/A , ManitCHIMCCOf(list"'led 'I ntjt)vadvWA BM OW,,,,S) jjje (lei-111iltee nisrsi nutintain, sen,Nice and IW.Cpail-the ijlst,,jjjc(1 I/A OWTS in decOrda"c with neilt of I'lealth,so-Vices('SCIM-1s) tilt,i:nanjLejja nec scheduic,set t,(a.(tj in to SuMAk CouMy DePM permit issued for the sYstem, 5, Auttint-ized lii,n(tv;itivcll,+kiter-lititive ()Ilsitc Systerris(1/A OWel'" wh"l TS)SePtiC Systeals , Pet,l,jr it Z,nthol-iZes the i nstal I ati on 01 1 any wduls oH/,A OWTS scW,ic syst11�1" reccivcd tile approval of,the suffolk Ccaiuoty Dllodels durielmOrnerst of I jealth Services (SCI)HS)-M, l ` orthese Ing,111C term of*this perinit, .,C,t`S(wi1 I no 11)1'lS0119er rewinds its ;lpproval ofolic or MON of I/A OWTS ,Ystems 111 11�'lvv '11)I)rOvat try all)rove new juslaHations of that moderl.The Ut c (3ur NVater- plomcowner section at" SCTMIS are knind on qlc,SutTolk CountY Websij� under the Reclairn f p,,jw0najjy ,Npproved 1echnoiogics. I Driveway and parking areas shall be constructed of 6. DrivewaytParking Area of Pervious Materia W SDEC-approved pervitlus nmwHals. 7. EMMbUst, Nlegptaled Buffer 1,0 ,,t,,t thew alues til`the tidal %yetknids, a permaadnentcw j0pagvegetated hy bullar zone shW1 be astakoishednhere AM be no,d'isturbance to than, twtmvl vegeton rap wkhk an aa mx(ending 2(,) ho air feet landward of be W weAnd boundary. page 2 ol 6 CONSERVATION� M1'W.,.K9 8'�rj, PA �ad"�p® O .�'VIKO'{ �°e 8, NIe rrwt, °<�+ bales orouter rtt 1 rdtrt NVo0 rnd�s A mvs o staked sura per t � lrrbales rrl ill l�l.��rwp i,alrrr�vr r1 ttlrrrrt,"l alevWes shrdl b " placed tit the landwar(l edge r tr6 Nltu,brrl l r r prior irtr°tri a arrt'rrrrr ria t rtt rrt rrN"""Yrt�prrllrtrr"i activities art rcstabilized �ailize d lvvithace a�vevegetation. N"1t�ar t���r�t:11 �����r4atn��r� Un it t,110 p"*Ct is a�aarrtN N tctl and A, dt�strrr°bt�d �ra.�r�,� aret 9m No UnakithOrizt-ti heft No fill or backlill is auth.riwedcby this permit with0lt further Written approval frtrrtt the department(perrti4 niodrlrcr to. tnrrt rrf l?quipme"t, Materials The storage cif cormr rrc�titrn equipment and rrt;rtc�rittl4r shall be l corrti`rrwd vvltl°rirr the project+rva°rr'k tri°,rr rt,tdlor rrlrlttrrr:l areas grcrrter tlrrrrr 75 lrtararr Nrret than tidal wetland boundaryA t to or t�t�®stul,b►t�nr' to ,Veg"anted °I idal Wetlantis Ther d all be o disturbance to vegetated tide! vmdands car' pnaeocd barller arc0s as a result 0011c p r 12. mater-iris Disposed at t.Nl,tIalul Me Any denwlitir°rrrt debrat Vis,dr«»excess ess Co ryr uction ll�ratlarrrmrrri�'l crla+l�l�r�r c�t is r; etrvatcd rntr rials sNarr�ll It , rr�rart r�dirrtr ly and t°r.arr p excel, el, Management llta lity "1'lrr say, rrrtrt r rtrls shrill be stritr bo sttthiNi cd, its rtrrt tri ra-enter r arty v�rrta,r l-wttdyN vvtYurtr,l or vvaTMtlartat rttllrrrr,arrt,lrrrwa, cent Aren ris r excess IlInterial from 13. Not,onstructi rrr Debris in ' ''rdUand nr tl,�tta�rlv�d hion the rat jalr�rttrtlrr a (upland) gird rQ111oved to cnnstruaian of this pr°gWc�t shall be r�rrtl'rl�t�l� 1 ° is prrtitcteetlr °rrls rttltrpatttyctrrbuffer areas. r �lartd arra lr+r alisposal, No debris an aahrrr c sh c vvtshrn��s lrttr°rr� ready mix d crAI d�tar .rtt ���r�lrtm rrr" rtstr�rictia�rr„ r'rat ver t a�rrCreslr rrrrrat�r.or lr<rrNrgrt� sNr�all tt� allowed 14. retc setrltr intra �rrryP vvt..tlaltds or writers ail New yor°kr state,nor . ," �� or trucks. mixers.ear°other alevre s be ;allowed to cnte arrell rat.rt l r t� trra.dr,-Iny wetland r tr displ�,ac Twat jjy wid ntth� Wins. tttrl�r^unl�l�trrs slr�t�rll l� used. '' t r.rtrtur�ta. nel cernent prk��Cct,the t3. NsNa tl a ret rrrratarar rareatrant t Mom llt larttrrrnaum lof tN"re en t,°lars�dt�ot ficatiararltlwrnn rwongVrn thatrth y ttnd Urrrrta•trmr�AnO slgrr raid r"trrarrn'hu LOP peep ter°c l'arNly ,asvltrta ail rrrrd arnalcr°strartd till tr�rnis and t„a:rratlatrrsr�tt Is of t trrrNis pra ttrr�nct gala rtN lwith plrtrto N mats of rrll'pr(rject, than bnttrrrl'r �l°ar�r°ticrt�t rel" ire Urn 1�naast�alstr etc ,.r dw a.Jtrrttoded work.. i6° �t Pernit in The permit sign+rraelrrsc�tl with this pert-nit shall be posted in 4 c;ranspierlcru5 location on the worksite and adequatety pr'rat"ta d firorra the weather, page 3 of 6 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVA,rION Fovility DEC 11) 1-4738-00606 17® State May Order Removal or Alteration of Work I f future operations by the State of New York require sin alteration in the position of the structure or work herein authorized, or if, in the opinion of the DePar(incrit of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destrUU1011 01"the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, the owners,shal I, without expense tothe State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion ofthe uncompleted structure or fill and restore to its rormer condition the navigable and floor d capacity of the watercourse. No claim shall be made against the State of New York on UCCOUnt of any such removal or alterations ttt® State May Require Site Restoration If upon the expiration or revocation of this perinit, the reject ject hereby authorized has not been completed,the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Env iron menta I Conservation may lawfully require, remove all or any portion ofthe uncompleted structure or Fill and restore the site to its former condition, No claim shall be made against the State of New York on account of any such removal or alteration, 1% Conformance With Plaits All activities authorized by this permit must be in strict conformance with teapproved plans submitted by the applicant or applicant's agent its part orthe permit application, Such approved plants were prepared by "rhomas C. Wolpert, Licensed Land Surveyor, last revised 08/03/2022, stamped YS ESC approved 10/17/2022, 20. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project, GENERAL CONDITIONS - Apply to ALL Authorized Permits: L---1----.—-. ............—' 1-----1-11-11 .1 11-11-1 1, Facility Inspection by The Department The pert-pitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Departrnentt)to determine whether the permittce is complying with this permit and the ECL Stich representative may order the work suspended pursuant to 1--,CL, 71®0301 and Si' 401(3). The permittee shall provide a person to accompany the Department's representative during ar,inspection to the permit area when requested by the Department. A copy oaf this permit, including all referenced maps, drawings ands eciaal conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy or the permit upon request by a Depanment representative is a violation of this, permit. Page 4 of 6 NEW VORKSTATE DVPARI'MPN,r OF EAVIRONWNTAL CONSERVATION p$,V,iIjty otil(AD 147,38-011606 tU'lless 2. ileia,innsifil) rf Ibis pe .Frklit tn()tiler J)cpartnlell. III( SlIperse(je or rescind �Iny tirder pl,(Ivided fol' ley tile DCfw0"file fit, issuallice ofthis pelvit, does not or determilV16011 PrOviollslY issued by the Deplirtroclit ov.any ofille terms, conditions or req iL. t ill soch order or delk-rillination, 'I'hel)erniittecinustSUI')I�)iLa .4. Applications For pertnit RelmWals, 01. 1'ent 1permit renewai, niodor transfer separalc wrift"i kIlTlicati0f) 1-11,1or stipplen,1C,111al iIfk)1.rflificationati0Il tlic,J)cparfi"nellofthiSrequires, , licit,ijill rnigst, includc.ai y l. I)epai'MIC11t,niust be in WrifilIg. Sub"lisqiOn Of arty renewill, n10(fill'Catioll of, 9-11111ted 11�� tile to he submitted to: applications fior Permit renew al, modiliulli(ln or transl'el' Regional Permit Administrator NYSDEC Region I Headquartcrs SUNY @ Stony 13rookJ50 Circle Rd Stony Brook,NY 11790-3409 4, Sit bill ission, of Renewal Application The pern)ittec Innst sobinit a renewal application at least 30 days before llefqnit expiration for the following per1liq at,allorizations: 'ridal Wetlands, Permit M.dificatif,101,4,Suspensions and Revocations by the Departuient I'lle Demritil errt resetws the rif.,,dit to exercise all available authority to Modify, suspend or revoke this permit, The grounds for modification, Suspension or revocation include: a, materially false or inaccurate statements in the permit application or supporting papers-, b. failure by the permittee to comply with any terms or conditions of the permit; c. exceeding the scope of the project as described in the permit application; de ilewly discovered material illf6rination or a niaterial charIge in environmental conditions, relevant techslologY oriliplicable law or regulations since the issuance of"01C existing Permit; 111011collipliince with pr-eviously issued permit conditions,orders of"the COV"olission", "fly isms f tile f,rivironn'lental Conservati(Al I-Aw Or regulations(It,,tile 1)cpa rt tile f,1,related to tile permitted aclivilye 6. Permit"I ransfer P0111lits are transferrable unlos speciticallY prollibited by sattte, regillatiOn or another pertlift condition, Applivalions for permit transi'er sliould be subtuitted pritortosac%jal transfer of Ownership, Page 5 of 6 0 l F Vo ttj(,Sw SJ'ATV A V EPAR*Por EN'te OF E NVI l'9 4`a NTAL Cs.F S B AXIN FlIVtttty 1)+X Ila 1.,>4138-00606 NOTIL FICATION OF OTHER PERMITTEE OBLIGATIONS ICUAOU siwlity es tO evintir ttca ,a l caaaaattav a cccpts t,cfaml 4craal aacmac t car r c, to indcr anal "I'd 1101(l haarrn'lless [Ile ,,,I ccclatara Slaw, or iaad 1�epaaatG��wca�0l 9 $1virowataaa nt�al cons ry atwaaaa gal.t4aa State 11 raaa�a�a;�t� the cxtontv York. its �aitri baat�able taa�tl�e�laa�a a�, and agent" wml 1. +^�w fbr all clraaaaas, writs, actions, and � lar aaaaittcc°parr is t0 tarrars*�ra)ras rrr rmartaacctr�ara "° ia�tlamra �<��a llltla by the a�laatlaba��taaa it:h.Or rrt�craaticaaa aracl raaarratcaa aacc of" the facr c:abmpliaaracc or raot ill a aaroph anee with (he terins,atad ww�c�,wtiolls a� tai Oa 'tl.r tllc claatrrin Voaall�lsrt "slr a aabb�a doa)dt Nes' carat cstcaacl to aara Claims, srratsPo ctaolvS,or rlarra�raatcs to t1 iaateaaticaaraal acts or aara'ars;aitaras,,�ar tcaaaarr a,laairrm , stai ,rral 1aala��1,�araaart�ir�atr�a»wral:,aaattM t° arising urlde" Article "alt rat'tlrc New 0rk Civil l rr cticc l..atws�t araadcr federal or state laws- Item W llcrmmaittcca's Contractors to Comply mall's Prn'lut The acrma"rrttcc is responsible for ill 1,16r illi g its independent Caspecial acciaalaa;car�conditions while aa�ctimaag as the assigns aaP l their responsibility to comply pl with this crraatt� iracltadrrr 1 .lthe learrralttctaaap agent rat with respect to flee 1aarraartta-clt, activit anscr tiiiaraml.,wNaas tlab:as-s�se prescribed C reel tile Pet tccc st'voctia.baas fear %dolaatararrs O d1c,;1' ir•caramaacaatarl ltcmaa C.' a Obtaining bt inn Oth.er iterluirccl taUits tra �tamfif -of talcl'cobtaining<aaaY other aennit` prvlls, lands, casements ase and rights l°lalwaitcc is rasparasrtlraaactrvrtrc taataata r cthis waa tlaaat m be rccaircd ti calTY Out - Mta rte lt: N'() ltea "l'a cslatmss arm°interfere Zvi i a+ri�xrr t -tere With This verimait c.oes wacat Convey tea tlac liven rraitlec any r right ta* l twtbrl�r c�rrclr� spon lit atartl�aaa a�r�a;atha riaaalaaa raaa�ghtstile tight t Of vilaaariaart rights rat'othersgra order to peel'arta theper mart aara rights 1,title, ra interest it) real atr°Personal properly held car Vested in as person,rta'bt as Part to the permit. page 6 of co 0 c ED cd o co E cn nn �wmm0AC13 W- of mm " cn .WWI cc CLmn� Ab .W.- 111�IW8 .niw�BrRR Umm as co 0 LL cd Co 4-0 cn 4-0 4--A C (0) C: E 4— , �@W A �>' muuWUR ® ,] m 6„u I. z I 4), � •M ��wl.mwwl'" �CX 4-4 � o a CL ro cd CL LU �m RETURN THIS C a ts�M� u��uq prof �Mouu.. N W -Mail-d m.RIMI-W BES ori c.ny� YSDEC Skjj4y at Stony Brook 'uyde Road M torly Brook, NY '11790-3409 PERMIT NUMBER. ........................ ............ ........... _ PERM ITTEE NAME& P J ..W.ADDRES& ���...., ...�. CONTRACTOR NAME&ADDRESS'. Dem, DEC � othat thkiuWtruzM a)GWwq WuMM�auup*uaP W pauuurD Mcu the special omiMWuoas o���u Wupu uMNireferenced rrniiD and arr)v d Mrv,mW f 0y uudes1aud " qc�� that kw �uu bed in the u WNgM ru u!u ijauve M�fisper„W buu W u aju M ul ��ud uuuuaMuN aM WNuua projectqaacuu MWu a°n cu"TNue WAruuu�it WDu uuuWMj uu� ajaW q mje M uW all q��e. and u.�au� with M�,r„rf"iM and rare depicted Ovo MM�ie j,,)proved WaN� ,ur6. O the site(or cart do so uuinspectionq gNun acc daf j� MDDu CleneraMuC�q � (MMkuon 1 (Both erin'iil si9l,iron aaaWaDafOve"3 pwiis will be available a cONTRACqR. .�... W ..._�.adTO RETURN THIS NOTICE, TF SS AT LEAST TWO DAyS PRIOR TO COMMENCEMENT GN, OR HAVE PWA 'rIVITIES, FAILURE R THE DURATION OF FHE PROJECT MAY SUEVECT TP 1E ANAPPROVED W 4 IT O W & 9TD 7FIE LF?M FE- IO CCNrRACTO T W �OpE-NAWTW FOR NON-COM PERMIT CONDITIONS, Q1"g,owNo -K-, Or Fax tW 631 4-0272 RETUR "TTI 'FORM PtA C� � 16M: � W � W�4�'� � ��� -gov 59 C ocl Road M'um13f(�)oka MAY 11790- EXPiRAflONATE" ,....._.. �.. 14UMBERI- PERM17TEE NAME P O J C..I ADDRESS �.�._ CONTRACTOR ME&ADDRESS: o... r .... ,._..� Puau a am to0; a6 conditions of WWF referenced .. .,..,� ...... �. � permit,you re hereby nMa�Vial the u�gq�uau� �uu�u�DuY�a� �D3ua�N�w �uaatiau+'���„�.0 M .. ruuu' d We Wu f�MMy mou�'uMM M4W� tus and cuotWuamtG a��Wn pd^u'owW ajaM a� ` ... .........�......... D W -....m. .._e. _. MDDAT _. 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BOARD OF SOUTHOLD TOWN TRUSTEES ' SOUTHOLD,NEW YORK , y i PERMIT NO. 10237 DATE: OCTOBER 19,2022 '✓ ISSUED TO: KORYN' ESTRADA PROPERTY ADDRESS: 2:350 DEEB”HOLE DRIVE MATTITUC�E SCTM#1000-123-4-7 AUTHORIZATION 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 QctobetI9 2022,„ and in consideration of application fee in the sum of$250,90 paid by Rn Estrada and subject to the Terms and w i Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits the ,I following: Wetland Permit to construct a 3,236sq.fL second story addition onto existing permitted 4,184sq.ft.dwelling; construct a 137.40sq.IL second floor balcony on seaward side;construct a : w 67.50sq.ft.second floor deck on seaward side; for the as-built 1 I lsq.ft.trellis on first floor seaward deck; existing 247sq.ft.wood walkway on landward side to be replaced in-kind; ' abandon existing sanitary system and install a new UA OWTS system landward of dwelling, r ; and as depicted on the revised survey prepared by Howard M.Young,last dated October 25, 'p^ 2022,and stamped approved on October 28,2022. 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 day and year first above written. a ° ap r r II 11 „�>ili w / ✓ � a r 7 J tl I `IJ>aer�'n�v� '1!Y!/Y�,.i '�'w�ilslmuu?�rlfrn;.,, �'�i�rwmi+l 'r�yy�;„:,,„. /��;')rlird��YJ'�✓���J`''' �1�ervlrrf;^?7Yr.✓1,.. 1',�11''P'Pr 7r r1 ;'7 �,� / � K \ > S ° ) k j \ 2 ƒ\ ƒ\ � \ / K ■ @ > & \ �\» ° «\ I \ ƒ ! DATE(MMIDDN YYY) ACCOREP CERTIFICATE OF LIABILITY INSURANCE 10/27/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 VIN Lauren Murphy Roy H Reeve Agency,Inc. PHONE (631)298-4700 (631)298-3850 At N E�xq.. . AIC No PO Box 54 ,E-MAIL s: Imurphy@royreeve.com 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC B Mattituck NY 11952 INSURERA; Southwest Marine and General Insurance Company INSURED INSURERS Boeckman Building Construction Corp INSURERC: PO Box 1453 INSURER D: INSURER E: Mattituck NY 11952 INSURER F: COVERAGES CERTIFICATE NUMBER.- CL22102717994 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 OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 Sp POLICYNUMBER MIDD MER LIMITS X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000,000 CLAIMS-WOE ❑X OCCUR PRE SES Eaooaurenoe $. 100,000 Contractual Liability MED EYP Any one erson) $ 5,000 A GL2022LHB00351 10/16/2022 10/1612023 PERSONAL&ADV INJURY $ 1.000,000 GC UL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY ''PERo- FILOC PRODUCTS-COMP/OPAGG $ 2,000,000 ..... $ eNMt AUTOMOBILE LIABILITY n, ANYAUTO BODILY INJURY(Per person) S OWNED SCHEDULED 1 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPER ANINGE $ AUTOS ONLY AUTOS ONLY Poracctdcnr $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITYSTATUTE ImR ANYPROPRIETORIPARTNERIE(ECUTIVE YIN', H/A E.LEACH ACCIDENT $ OFFICERIMEMCIER.EXCLUDED? (ManvdatorylnNH) EJ_DISEASE-EA EMPLOYEE S IV yea,desrAce evader DESCRIPTION Of OPERAT'GO�NS botbw 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) Town of Southold is included as Additional Insured with respect to General Liability as required by written contract per the terms and conditions of form CG2012B 0413-Additional Insured-State or Governmental Agency or Subdivision or Political Subdivision-Permits orAuthorizations-Blanket. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 AUTHORED REPRESENTATIVE Southold NY 11971 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ,�p�Y �YdrW+rr NYSIF lMemi lfaark State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 112778528 ; ROY H REEVE AGENCY INC 13400 MAIN RD PO BOX 54 MATTITUCK NY 11952 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER BOECKMAN BUILDING CONSTRUCTION CORP TOWN OF SOUTHOLD PO BOX 1453 PO BOX 1179 MATTITUCK NY 11952 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 12261405-1 423188 03/06/2022 TO 03/06/2023 10/27/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2261405-1, 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_ IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS://WWW.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 STAT NSUR NCE FUND 4/ DIRECTOR,:INSURANCE FUND UNDERWRITING VALIDATION NUMBER:315699788 U-26.3 SHELTERPOINT LIFE INSURANCE COMPANY BOECKMAN BUILDING CONSTRUCTION CORP.. STATE OF NEW YORK WORKERS'COMPENSATION BOARD NOTICE OF COMPLIANCE New York State Disability Benefits Disability Benefits For Employees 1. If you are unable to work because of an illness or injury, not work-related, you may be entitled to receive weekly benefits from your employer,his or her insurance carrier,or from the Special Fund for Disability Benefits. 2. To claim benefits you must file a claim form within 30 days from the first date of your disability,but in no event more than 26 weeks from such date. 3. Complete claim form DB-450(Notice and Proof of Claim for Disability Benefits) You may obtain the form from your�employer, his or her insurance carrier, your health provider, any Unemployment Insurance Office,the Workers'Compensation Board's website(www.wcb.ny.gov)or any office of the Board. IMPORTANT: Before filing your claim,your health provider must complete the"Health Care Provider's Statement"on the form showing your period of disability. • If you are employed,or have been unemployed for four weeks or less when your disability begins,send the completed form to your employer or the insurance carrier named below. • If you have been unemployed more than four weeks when your disability begins, send the completed form to the Workers'Compensation Board, Disability Benefits Bureau, 328 State Street, Schenectady, New York 12305. 4. You are entitled to be treated by any physician,chiropractor,dentist, nurse-midwife,podiatrist or psychologist of your choice. However, unlike workers'compensation,your medical bills will not be paid unless your employer and/or union provide for the payment of such bills under a Disability Benefits Plan orAgreement. 5. If you are ill or injured during the time you are receiving Unemployment Insurance Benefits,file a claim for Disability Benefits as soon as you sustain the injury or illness, by following the instructions outlined above. 6. If you are out of work in excess of seven days, your employer is required to send you a Disability Benefits Statement of Rights (Form DB-271S). 7. You may not take disability benefits at the same time as paid family leave benefits.The total amount of disability and paid family leave in a 52 week period cannot exceed 26 weeks. 8. Other information about disability benefits may be obtained by writing or calling the Workers'Compensation Board. SHELTERPOINT LIFE INSURANCE COMPANY 1225 FRANKLIN AVENUE,STE 475 GARDEN CITY, NY 11530 PHONE:800-365-4999 Policy ff: DBL35442 Effective From: 1/1/2022 To: 12/31/2022 []Statutory ®Under a Plan or Agreement Class es of Employees Covered: All Employees Eligible Under New York State Disability Benefits Law NYS Workers'Compensation Board Customer Service:(877)632-4996 www.wcb.nygov PRESCRIBED BY THE CHAIR,WORKERS'COMPENSATION BOARD THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND ABOUT THE EMPLOYER'S PLACE OR PLACES OF BUSINESS. Employers must post DB-120 so that all classes of their employees know who will pay their benefits. DB-120(11-17) THE WORKERS'COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION