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HomeMy WebLinkAbout48824-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#: 48824 Date: 1/31/2023 Permission is hereby granted to: Levine,.. Noah 360 Central Park W Apt 12E New York NY 10025 To: construct accessory in-ground swimming pool as applied for per DEC Non-Jurisdiction letter and Trustees approval. The pool equipment must be located a minimum of 15' from all property lines. At premises located at: 4790 Blue Horizon Bluffs Peconic SCTM # 473889 Sec/Block/Lot# 74.-1-35.56 Pursuant to application dated 8/25/2022 and approved by the Building Inspector. To expire on 8/1/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: $300.00 4 _1-1 Building Inspector as rY� V TOWN OF SOUTHOLD—BUILDING DEPARTI Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,N 71-0959 Telephone (631) 765-1802 Fax (631) 765-9502 l tl l pisoi.�tl d l ? °` ", IRLIILDOiG, Date eki APPLICATION FOR BUILDING PERMIT For Office Use Only �a � ti�J �i' �I lia PERMIT NO., d✓ Building Inspector: Fp mm��� �� Applications and forms must be filled out in their entirety.Incomplete applications will not be accepted. Where the Applicant is not the owner,an BUILDOt�� Owner's Authorization form(Page 2)shall be completed. �OUW N OF SOUT HOI°I~) Date: OWNER(S)OF PROPERTY: Name:Jonathan Rebell/Noah Levine scTM#ZDOC)4-01-35.56 Project Address:4790 Blue Horizon Bluffs, Peconic, NY Phone#: Email:tom@hfswanson.com Mailing Addres660 C pLu (qPr 1 a& New York, NY 10C 2.,� CONTACT PERSON: Name:John David Rose Architect P.0 AIA 6� Mailing Address:596 Hampton Road Unit 1 , Southampton, NY 11968 Phone#:(631)283-2051 Email:admin@jdrarchitect.com DESIGN PROFESSIONAL INFORMATION: Name:John David Rose Architect P.C. AIA Mailing Address:596 Hampton Road Unit 1, Southampton, NY 11968 Phone.#:(631)283-2051 Email:admin@jdrarchitect.com CONTRACTOR INFORMATION: Name:HF Swanson Construction & Associates LLC Mailing Address:P.O. Box 1897 East Hampton, NY 11937 Phone#:(631)324-6905Email: DESCRIPTION OF PROPOSED CONSTRUCTION ®New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated cost of Project: ❑Other a� A t ?vex, $%Je) ) Will the lot be re-graded? DYes El No Will excess fill be removed from premises? ❑Yes BNo 1 PROPERTY INFORMATION Existing use of property:Residential Intended use of property:Residential Zone or use district in which premises is situated, Are there any covenants and restrictions with respect to RR/R-40 this property? ❑Yes 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. 7ct hvid Rose Architect P.C.AIA Application SubrrlBAuthorized Agent ❑Owner Signature of AppI. i t 2� Date:s11,5rA ?-Z STATE OF NEW YORK) SS: COUNTY OF 'LC,1 ) John David Rose Architect P.C. AIA being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the Agent (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 Iday of r 20 Notary Public IN PARE Pumc,sute of Now York No.Cil P16366547 PROPERTY OWNER AUTHORIZATION Ouelffied In Stiflolk CommWakin Expires fit (Where the applicant is not the owner) Noah Levine/Jonathan Rebell residing at 133 W 22nd Street Apt 89, New York, NY do hereby authorize John David Rose Architect P.C. AIA to apply on my behalf to the Town of Southold Building Department for approval as described herein. Owner's Signature Date Print Owner's Name 2 Glenn Goldsmith,President � ��� � �� ��(�� � Town Hall Anne " �rratuiP r 54375 Route 25 A.Nicholas Krupski,Vice President P.O, fox 11.79 EY'1C SepE'llOSkl Southold,New York 119;1. Liz GilloolyZ Telephone(631) 765-1892 Elizabeth Peeples �� �� �w�i ' � � � >�° Fax(637) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10193A Date of Receipt of Application: July 11, 2022 Applicant: Jonathan Rebell & Noah Levine SCTM#: 1000-74-1-35.56 Project Location: 4790 Blue Horizon Bluffs, Peconic Date of Resolution/Issuance: August 17, 2022 Date of Expiration: August 17, 2024 Reviewed by: Elizabeth Peeples, Trustee Project Description: Conduct construction activity within 100' from the landward edge of wetlands for the construction of a new 1,786sq.ft. two-story frame dwelling with a 241sq.ft. screen porch, a 497sq.ft. deck with trellis and 69sq.ft. stairs to ground, a 255sq.ft. side porch with 121 sq.ft. stairs to ground, an 800sq.ft. swimming pool; one (1) 8' dia. by 10' effect. Depth discharge drywell for the pool, new IIA sanitary system and removal of existing conventional sewage disposal system. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the survey prepared by Howard W. Young, NYSLS, last dated May 16, 2022, and stamped approved on August 17, 2022. Special Conditions: Installation of gutters to leaders to drywells to contain roof run-off to be installed more than 100 feet from the top of the bluff. Inspections: Final Inspection, If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This i b not a deter F ination.fro li ny other agency. M Glenn Goldsmith, President Board of Trustees y Glenn Goldsmith, President � �n�� ti �'�� � "I°owra 1-Ir,ll Annex w A %;t' 54375 l o Lite`5) ":�ic.hol;�.:1Crti�l�ski, ,`ace President �� of 9�fr � � R0. Box 1179 Eric tie�enoski d Southold, New York 11971 Liz Gillooly �� r �t r l�.hlione (631) 765-.11892 ll;lzz�l�eth Peeples ��, ` 'r °'r�h /f��� "` ' rf Fax (631.) '7615.6641 4", BOARD BOARD OF TOWN TRUSTEES TOWN OF'SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 15t day of construction % constructed When project complete, call for compliance inspection; 4 I II i coo:) 4A 0 01 coo SEMMES= z LL VOM Q1 us 0 * '7 . Lo cil lu now 0 �I .. M a J W H w LU CA 10 Ed 0 Li z , ' w C= C002 Town Hall Annex Glenn Goldsmith,President." � . 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillools= CATelephone(631) 765-1892 Elizabeth Peeples + Fax(631) 765-6641 COUNVw" � BOARD OF TO TRUSTE] TOW OF SOUTH0.11...D ., Storm Water Runoff With recent heavy rainfalls, we are reminded once again of the problems Southold Town has with storm water runoff. With over 100 road ends terminating at creeks, bays, inlets,or Long Island Sound,as well as all of the lawns and homes lining our miles of shoreline, 100's of thousands of gallons of storm water runoff enters our wetlands-every year. Carrying sediment that prevents sunlight from reaching aquatic plants,nutrients from animal waste and lawn fertilizers that promote algae blooms detrimental to shellfish;and bacteria and other biologicals that in high doses can be harmful to swimmers, storm water runoff is one of the Trustees main public safety concerns. So important, in fact,that Southold has a Storm Water Management Code. Southold Town's Chapter 236 provides an outline for how people need to deal with storm water runoff from their properties. For example,new construction or renovation is required to contain any potential runoff to the wetlands from the construction by installing hay bales and silt fencing_ This acts as a barrier and keeps our wetlands clean. Another example in Chapter 236 is that every building must have provisions to collect and disperse, ON-SITE,at least a 2 inch.rainfall. This is usually handled by installing gutters, leaders and drywells to the home. The Trustees also have a standing policy of requiring pervious non-turf buffers along bulkheads and at tops of bluffs that help keep run off from entering the wetlands and prevents erosion to bluffs. These are important measures to keep our wetlands safe and clean! Before deciding to renovate or build, the Town Trustees urge you to check our website and the other department's websites to make sure what you are planning to do meet the Town's Code. These codes have been developed for the good of all citizens. ,And the wildlife all around us too! m New York State Department of Environmental Conservation Division of Environmental Permits, Region 1 Am& SUNY @ Stony Brook MOW 50 Circle Road, Stony Brook, NY 11790-3409 Phone: (631)444-0365 • Fax: (631)444-0360 Website:YwAwMw.1 LETTER OF NO JURISDICTION TIDAL WETLANDS ACT July 19, 2018 Jonathan Rebell Noah Levine 360 Central Park West Apt 12E New York, NY 10025 Re: NYSDEC ID#1-0738-04611/00001 Rebell Property 4790 Blue Horizon Bluffs Peconic, NY 11958 Dear Mr. Rebell: Based on the information you submitted, the Department of Environmental Conservation has determined that the portion of the above referenced property shown landward of the'Crest of Bluff'as evidenced on the survey prepared by Howard W.Young, last revised July 09, 2018 is beyond Tidal Wetlands Act(Article 25)jurisdiction. Therefore, in accordance with the current"tidal Wetlands Land Use Regulations (6NYCRR Part 661)no permit is required for project activity proposed landward of the `Crest of Bluff'. Be advised, no construction, sedimentation,'or disturbance of any kind may take place seaward' of the tidal wetlands jurisdictional boundary, as indicated above,without a permit. It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or disturbance within Article 25 jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the jurisdictional boundary and your project(i.e. a 15'wide construction area)or erecting a temporary fence, barrier, or hale bay berm. This letter shall remain valid unless site conditions change. Please note that this letter does not relieve yo of the res sibility of obt f7ny necessary permits or approvals from other agencies or local m AcipalitieS' cerel r n end ep a tMAdministrat r cc: Thomas Wolpert NYSDEC -TW File Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) l/We,. CA L4vi Ike_ owners of the property identified as SCTM# 1000 in the town of � _e-. � : New York, herebyauthorizes r v X.) �S to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. ,XA Property Owner's Signature P operty Owner's Signature SWORN TO BEFORE ME THIS DAY OF � Notary Public SUSAN G VONwlsAi"N"t HELD Notary PUbli ,Mate of New York NO.01 V06366547 aalilied in Suffolkcounty cr iaaion xpires 1C�ol�01 & u. Board of Trustees Application AFFIDAVIT O _t O EING DULY SWORN DEPOSES AND AIS"F"IRM S TH .T HEfS:;BE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND.ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S)OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO:INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner S" tuare of Property Owner p SWORN TO BEFORE ME THIS DAY OF � ,20 a SUSAN VONSAMNEW ptoic,Mater of NowYolk Public No.oto 08366547 Notary �atd In SOO*� CmwNssion 050re 1 « 9 APPLICANUAGENURE-PRE,SEN ',, T VE TRANSACTIONAL DISCLOSURE FORM aeTrh�!It r la "s ari ot"3itx�(c -lribits confticks rrf itt a ra tl e ar c7 t ra n oClwc_ ccr n a� o e s l tic paw+f art �i _ sL aar collo w i4 t� akc va+aat int actia `; tlrisf r v'de" frsriah:srionta ri l canal: the a f i 1" fli rofitrterrr I_31t YOUR NAME: L`Q�I Ile Cl + e p 0 .y fk4 _L (Last name hist name,4liddle initial, "loss you are lin rat the,namc.of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Tt istee Change ofZone Coastal Erosion Approval of plat Mooring Exemption from plat or official snap Planning �. Other (If"Other,name the activity_) leo yogi personally(or throaugh your oomparuy"spopst,sibling,parentt,or clailcf)have°.a relatr"onslrrli wtith any officer or employee " oftlt:To rr cif SootCi'iald? ""gelatios�ip"�Includes by blued +� 1; or ssiM s i test *` us w s ia�c r rnpnssas Isosino s including;a ormership,iut which the town offic cr or employe':has;even a pirttat tr t�Itip of(or eanployitrcnt' y)a corporation. in Which the town officer or employee owns mai tliaul %of theshiaes. YES NO Ifyou answered"YES",complete the balance of this form and date and sign where:indicated. Name ofpers wemployed by the Town of Southold Title or position of that person, ascribe(l„ae relationship betwecn yourktf,(the appl&cant/ag t/roprescntadve)and the town officer or employee.Either check the approp ate,line A)through,D)andfor dsodlle in the space pt Vided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)`th,e'owner^617greater than^of the shares of the corporate stock of the applicpnt (What the aplit .utt Is a corporation}, B)the legal or n4cial owW of any interest in a non-corporate entity(whey the applicant is not It Corporation); C) an officer,director,partner,or employee of the applicant;or D)the actual applicant: DESCRIPTION OF RELATIONSHIP Submitted this S day of 10 . Signaturo Print Name ` �l ('(G Form TS 1 P° Y% NW Nv ,v✓'`� ''m^x�' &'Nr �^�`�G➢ e✓�"'„:'." 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" ➢,~x' ^P.r:m.l" � ,,,. .� ,":. �;,r"aG y -,x�(F l„ r, a..�r�vr . � I ,�. u ,rr "4G ,,,:r,; I �%r;,, �,�,u� a ,,.�o G`P,Ur„ Gf �, e.,; �.,.,m�..art��J fr yp J"�G 2�°"' �.m;w,, of r, �(f�.�'",7 ro"• vi","' �,,ir,vl�� xa r„d lr re�,r6(l( m✓,:,,, N Nvr°-;.. `",w.,%t!r`, ,,.,6� //' .G'; � �^ ,�✓' r+'”, end KNm;, rw"nld.k'n :., ,,rP G ,,,, ;,Grv' G,, drr r ''"'r i,a, my"'i ✓, F'n ,y ,. .«"'xw Y� �',�/a� � Gd � i� � `"`w„ � ; VJ "aw�ar✓ww�i.:�vi��d'�,"�^„gid, "r� �'��mR"'�,x,",^nc�° "^0 "�w 17--%11111 NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A A A A 113791393 H F SWANSON CONSTRUCTION ASSOCIATES LLC r PO BOX 1897 EAST HAMPTON NY 11937 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER H F SWANSON CONSTRUCTION ASSOCIATES JONATHAN REBELL&NOAH LEVINE LLC 4790 BLUE HORIZON BLUFFS PO BOX 1897 PECONIC NY 11958 EAST HAMPTON NY 11937 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE 11464751-5 781453 09/08/2021 TO 09/08/2022 4/5/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1464 751-5, 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://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 POLICY DOES NOT COVER THE SOLE PROPRIETOR, PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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 STATEI SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 145892933 DATE(MM/DDIYYYY) C"R" CERTIFICATE OF LIABILITY INSURANCE 04/05/2022 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 Y 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 prvwisions 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). CONTACT Barbara Dammers PRODUCER 'NAME. Roy H Reeve Agency,Inc. PHONE (631)298-4700 CAPC Nb: (631)298-3850 AJC o Ext PO Box 54 A bdammers@royreeve.com ADDRESS: 13400 Main Road INSURE, S)AFFORDING COVERAGE' MAIC# Mattituck NY 11952 INSLIRERA,: Southwest Marine and General Insurance Compa INSURED Merchants Preferred Ins Co 12901 INSURER B HF Swanson Construction Assoc.LLC INsuRERc: PO Box 1897 INSURER D: INSURER E East Hampton NY 11937 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2110715460 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. INSRAM sm FU CY E POLI EXP LIMITS LTR TYPE OF INSURANCE S D POLICY NUMBER MIJIVDI�dYYYY MMtDD"1YYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X E 100,000 CLAIMS-MADE ❑X OCCUR _MMISE' rnce X Contractual Liability MED EXP 4Any one person 5,000 A GL202OLHB00450 10/12/2021 10/12/2022 PERSONAL&ADVINJURY $, 1,000,000 GENE'RALAGGREGATE $ 2,000,000 I"aEN'LAGGREGATE�LIMIT APPLIES PER: 2,000,000 POLICY PRO ❑LOC PRODUCTS-COMPlr1PAGG $ JECT OTHER COMBIfdEO tlNGLE LIMtlT' AUTOMOBILE LIABILITY Ea ncldnl $ 1,000,000 BODILY INJURY(Per person) $ ANY AUTO B OWNED SCHEDULED CAP1067708 11/16/2021 11/16/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED ^�,r...NON-OWNED PeraGlsditer�tl $ AUTOS ONLY d^w AUTOS ONLY UMBRELLA LIAB OCCUR EAOH OCCtJRRENCE $ 5,000,000 A EXCESS EX202OLHB00123 10/12/2021 10/12/2022 AGGREGATE $ 5,000,000 OLAIMS•MADE MPORKERS COMP RETENTION$ 0 $ DED a COMPENSATION STATUTE EOR AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOMPARTNER)EXECUtIVE. E L EACH ACCIDENT OFFICEp�aIMEMBER EXCLUDED? E N/A (Mandatory in NH) E L.DISEASE-EA EMPLOYEE pl eta,describe under E L DISEASE-POLICY LIMIT D SCRIPTION OF OPERATIONS bWow ESCRIPT10NOF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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. Jonathan Rebell&Noah Levine 4790 Blue Horizon Bluffs AUTHORIZED REPRESENTATIVE Peconic NY 11958 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD