Loading...
HomeMy WebLinkAbout49275-Z � � t TOWN OF SOUTHOLD 41, BUILDING DEPARTMENT TOWN CLERK'S OFFICE 00 , 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 #: 49275 Date: 5/18/2023 Permission is hereby granted to: Bennett, Bepjw n _. p St ,160 AinslieApt 1.. .. _ _�... .._.... ..—--------- _ -� ,.. __ ._.......�..�. Brooklyn, NY 11211 To: Construct a single family dwelling with attached raised patio and inground pool as applied for per Trustees non jurisdiction, DEC non jurisdiction, Planning conditions, and SCHD approvals. At premises located at: 1220 Ninth St, Greenport SCTM # 473889 Sec/Block/Lot# 45.-6-9.2 Pursuant to application dated 3/22/2023 and approved by the Building Inspector.. To expire on .11/16/2024. Fees: SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $3,340.00 SWIMMING POOLS - IN-GROUND WITH FENCE ENCLOSURE $250.00 CO-NEW DWELLING $50.00 Total: ...........................................$3,640.00 ...........................................� �., . ,,,,.......� _........................................... Building Inspector TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 m Telephone (631) 765-1802 Fax(631) 765-9502 htt)s:L/www.soLitlioldtoNvii1 . oov Date Received APPLICATION FOR BUILDING PERMIT For Office Use OnlyDR F PERMIT NO. ✓ Building Inspector: MAR a 2023 Applications and forms must be filled out in their entirety.Incomplete SULDI � DEVI, applications will not be accepted. Where the Applicant is not the owner,an TOWN OFSOL11HOL Owner's Authorization form(Page 2)shall be completed. Date: OWNER(S)OF PROPERTY: Name:Ben and Carolyn Bennett sCTM# 1000-045.00-0600-009.002 Project Address: 1220 Ninth Street, Greenport, NY 11944 Phone#:917-442-9487 Email:benneb@gmail.com Mailing Address:160 Ainslie St, Apt 1, Brooklyn, NY 11211 CONTACT PERSON: Name:Peter DePasquale (architect) Mailing Address:370 Lexington Avenue, Suite 407, NY, NY 10017 Phone#:516-383-5341 Email:Pete@gdp.work DESIGN PROFESSIONAL INFORMATION: Name:Peter DePasquale (architect) Mailing Address:370 Lexington Avenue, Suite 407, NY, NY 10017 Phone#:516-383-5341 Email:Pete@gdp.work CONTRACTOR INFORMATION: Name:North Fork Woodworks, attn: Scott Edgett Mailing Address:810 Traveler St, Southold, NY Phone#:631-298-7900 Email:scott@nfwoodworks.com DESCRIPTION OF PROPOSED CONSTRUCTION New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: ❑Other 1,800,000 Will the lot be re-graded? ❑Yes �No Will excess fill be removed from premises? ❑Yes ®No 1 PROPERTY INFORMATION Existing use of property:None Intended use of property:One family residence Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to R40 this property? iiiYes 5RNo IF YES, PROVIDE A COPY. Ir ("heck I13ox A" :ells 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 n r DePasquale RAuthorized Agent ❑Owner Signature of Applicant: Date: g pp � • 'Z 1 Z� STATE OF NEW YORK) SS: COUNTY OF Manhattan Peter DePasquale 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 121 day of Atn,-�k ,20 a3 •� vap V,9n raas 4l3., Notary Public ARY PUBLIC, R 'GYg YORK O.OIV0643268 l QUALIFIED IN 8 � T TSMB ARX 2,2 6 �C ..... IEIIII C IIID ...., (Where the applicant is not the owner) Benjamin Bennett residing at 160 Ainslie St, Apt 1, Brooklyn, NY 11211 do hereby authorize Peter DePasquale to apply on my behalf to the Town of Southold Building Department for approval as described herein. 3/17/2023 wner's Signature Date Benjamin Bennett Print Owner's Name 2 l`rt � r Town Hall.Annex: Glenn Goldsmith, President 54375 Route 25 A. Nicholas l rupsk:i, Vice President r, a P.O lox 1179 y Eric `,epenou>ki Southold,New York. 1.1971 Liz Gillool Y `� � � �r- Telephone (631) 765-1892 Elizabeth Peeples 'VIA11� l)r � ° Fax (Hell) 765-6641 qu BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 3, 2023 Robert E. Herrmann En-Consultants 1319 North Sea Road Southampton, NY 11968 RE: BENJAMIN & CAROLYN BENNETT 1220 NINTH STREET, GREENPORT SCTM#: 1000-45-6-9.2 Dear Mr. Hermann: The Southold Town Board of Trustees reviewed your letter dated January 23, 2023, along with the survey prepared by Scalice Land Surveying, last dated January 20, 2023, and determined that the proposed construction of a single-family dwelling (to be connected to Greenport Sewer District), a swimming pool, and a tennis court on the captioned property are out of the Wetland jurisdiction under Chapter,275 of the Town Wetland Code and Chapter 111 of the Town Code. Therefore, in accordance with the current Wetlands Code (Chapter 275) and the Coastal Erosion Hazard ,area (Chapter 111) no permit is required. All mature trees should be protected durin construction activities. /any construction activity or disturbance seaward of the limit of Trustee jurisdiction will require an application for full permit. Additionally, any structure proposed seaward of the line of jurisdiction will require a permit as well. With any future permits it would be looped favorably upon if there was a plan for tree replacement and a non-turf buffer. Please be advised, however, that no clearing, no removal of vegetation, no cut Or fill of land or removal of sod, no construction, sedimentation, or disturbance of any kind may take place within 100' landward from the top of the bluff, or seaward of the tidal and/or freshwater wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, without further application to, 2 and written authorization from, the Southold Town Board of Trustees pursuant to Chapter 275 and/or Chapter 111 of the Town Code. 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 and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary fence, barrier, or hay bale berm. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Glenn Goldsmith, President Board of Trustees GG:dd Scott A. Russell -ISIJFrQ'r ST01KMWA\' IER. SUPERVISOR MA..NA�GJEM1ENT SOUTHOLD TOWN HALL-P.O.Box 1179 v' T ]A 53095 Main Road-SOUTHOLD,NEW YORK 11971 1 own o Southold CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL FORM FF7[F___ ( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) - - - - - - - - - - - - — - - — -- - - - - - - - - - - — - - - - - - - APPLICANT: (Property Owner, Design Professional, Agent, Contractor, Other) NAME: Peter DePasquale Date: 3/28/2023 Mint) (Signa I w e) Contact Information: Pete@gdp.work//516 383 5341 (E-Mad 8 Telephone Numher) Property Address / Location of Construction Site: 1220 Ninth Street, Greenport NY 11944 S.C.T.M. #: 1000 District 045.00 0600 009.002 Section Block Lot TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT R Area of Disturbance is less than 1 Acre. No S.P.D.E.S. Permit is Re uired! - Project does Not Discharge to Waters of the State. No S.P.D.E.S. Permit is E uired! - Area of Disturbance is Greater than 1 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 DIRECTLY From N.Y.S. D.E.C. Prior to Issuance of a Buildin Permit. - Area of Disturbance is Greater than 1 Acre&Storm-water Runoff Flows Through Southold 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 En ineerin De artment Prior to Issuance of a Buildin Permit, 7 Reviewed B.n y � Yl Date: 7 PORM # CMCP-T(1Q nrrnhar 7n i R NEW YORK s m'TE DEPARI TIENTOF ENVIRO�,HAEFJTAL CONSFRVAP[ON Diviskm ofF.:nvironimclnta�Peniflis,Reg4)s I `AJNY a i SU.pny Mook,50 Chdo Rload,Stony Rmok,NY 11790 R(6 31)444 0,365 1 F� 444 0'360 ny.gov LETTER OF NO JURISDICTION: TIDAL WETLANDS ACT & NOTIFICATION OF POSSIBLE ENDANGERED SPECIES ACT JURISDICTION March 14, 2023 Benjamin Bennett Carolyn Bennett 160 Ainslie St., Apt. 1 Brooklyn, NY 11211 Re: DEC# 1-4738-04937/00001 Bennett Property: 1220 Ninth Street SCTM# 1000-45-6-9.2 Dear Applicant: Based on the information you submitted the Department of Environmental Conservation has determined that the portion of the subject property landward of the line labeled "top of slope", as shown on the survey plan prepared by Scalice Land Surveying, last revised 1120/2023, is beyond the jurisdiction of Article 25 (Tidal Wetlands). Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6NYCRR Part 661) no permit is required under the Tidal Wetlands Act. Please be advised, however, that 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 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 boundary and your project (i.e. a 15' to 20' wide construction area) or erecting a temporary fence, barrier, or hay bale berm. Please be advised that DEC has documented the summer occurrence of the Northern Long Eared Bat (NLEB) (Myotis sep ten trio nalis), a species listed as "threatened" by both New York State and the US Fish & Wildlife Service, within 1.5 miles of the project location. We have determined that tree cutting at this location between March 1 and November 30 of any calendar year may result in the "take" of these endangered/threatened species or their habitat within the meaning of Environmental Conservation Law (ECL) §11-535. The term "take" is defined in part as the direct killing or injury of individual members of a protected species, interference with critical breeding, foraging, migratory or other essential behaviors, or the adverse modification of the species' habitat. The "take" of a species listed as endangered or threatened is prohibited in the absence of a permit from this Department issued Nk.WYORK of 1 OF L"[IV 1 r 0 1111-1 a 111 a pursuant to ECL §11-535. In order to avoid an Endangered Species "take," we recommend that no tree cutting activities be conducted at the project site between the dates of March 1 and November 30 of any calendar year. If you have questions about the presence of protected species on or near your property, the potential effects of activities on these species or your responsibilities as a landowner or project sponsor under the Endangered Species Regulations, please contact the Regional Wildlife Manager at (631) 444-0310. This letter shall remain valid unless site conditions change. Please note that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies or local municipalities. Sincerely, Kevin Kispert Permit Administrator cc: En-Consultants BMHP Wildlife file The Northern Long-Eared Bat Needs Your Help! r Please be advised that DEC has documented the summer occurrence of t`" y - the Northern Long Eared Bat (NLEB) (Myotis septentrionalis), a species listed as "threatened" by both New York State and the US Fish &Wildlife Service, within 1.5 miles of your property. A 98% decline in the �i abundance of NLEB has been observed since 2006. The Northern Long Eared Bat Story - Habitat and Decline Northern long-eared bats(NLEB), also known as northern Myotis, are primarily forest-dependent insectivores. Bats consume approximately 3,000 insects per day, including mosquitos and crop pests. They use a variety of forest habitats for roosting,foraging and raising young. In general, any tree large enough to have a cavity or that has loose bark may be used by the bats for roosting or rearing young. This species is listed as threatened because of a dramatic population decline throughout most of its range.This decline has been caused by white-nose syndrome (WNS) a disease caused by an invasive fungus that ultimately causes affected hibernating bats to starve to death over the winter. DEC has determined that tree cutting at your property between March 1 and November 30 of any calendar year may impact the bats in your area, and may result in the direct killing or injury of individual members of this protected species, interference with critical breeding, foraging, migratory or other essential behaviors, or adverse modification of the species' habitat (these activities are defined as a "take" by the Environmental Conservation Law). The "take"of a species listed as endangered or threatened is prohibited in the absence of a permit from this Department. In order to avoid the possibility of an Endangered Species"take," no tree cutting activities should be conducted at your project site between the dates of March 1 and November 30 of any calendar year. Depending on site conditions, it is possible that future projects on your property will not require adherence to this restricted timeframe. In some situations, an individual tree or very small trees may be cut at any time of the year without resulting in a "take" of endangered/threatened species or their habitat. If you have questions about the presence of protected species on or near your property,the potential effects of activities on these species or your responsibilities as a landowner or project sponsor under the Endangered Species Regulations, please contact the Regional Wildlife Manager at(631)444-0310. Please note that if you received a DEC Permit with this NOTICE,any new project on your property may require additional DEC permits. For information contact the DEC Division of Environmental Permits at(631)444-0355. For more information on the Northern Long-eared Bat, please visit: Lit p s: www. e , , pov an)rrts 1 06 11h,ir ll For more information on protective measures required for Northern Long-eared Bats when a project occurs within occupied habitat, please visit: Iitlp : www� ie n :mowa imisi Ob30 Ntrnl SYMBOL LEGEND s O s . O ' N _ r an � OI (FOR HEALTH DEPARTMENT USE ONLY) .Q) 0 J � d ISL D RAILROAD LONG AN VJ o Ti T - 564 99 a t' o i �I rAa:Imr -721 V CN rSqWj7L -114 O z o o yi a $ t€ rez rare I a.rOT o `` `1 ', e1 - x o - qq _ } io 3 - E ' N , 1pji € a - 1 i � O o§e s i :�3.. 599.56' r o 0 a§ta3axi C:(0.i.`r y1T1(tl�A'If I(f � y1 0� rAI 1�9.3 o �� O� :0:)3 Cow v J� lLZ i�i1 N p Z Iz DoWmaZI— OOVI¢oN0O of N U n a ' �ZL OY d ac maxcr rnarcmr LOTCOVERAGE o W L` - G Vof ',,... C7 GRAPHIC SCALE BUIUDAM LAND=ae4iee sF. w o w w NQ7E: _.Mix LOT Dawa.¢-9,W7s LOT AREA E"" 1 Pe0PFA11'510 9E ca+txam TO OREFIIPMI 10X,OF BULD —D )1.001 sF. W ""7�1E`71 awm asmar FOn warlxr SEw1cE oBPow. PaOPOfEu L.T 00w -d/se&F. ve]nc (Sy - nx OF MU•m F w D IN 1 1 h FE 40)N_ "ALL ELEVATIONS REFER TO NAVD88'DATUM - 1 /pi�� NYSIF New York state Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED) ISIR ^A A A A 272628352 AMWINS BROKERAGE OF NEW YORK 200 ELWOOD DAVIS ROAD SUITE 200 LIVERPOOL NY 130$8 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER NORTH FORK WOOD WORKS INC BENJAMIN&CAROLYN BENNETT P O BOX 1407 1220 9TH STREET SOUTHOLD NY 11971 GREENPORT NY 11944 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z2280 317-5 979232 05/01/2023 TO 05/01/2024 3!14/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2280 317-5, 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. 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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT SCOTT EDGETT NORTH FORK WOOD WORKS INC 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 - SU INCE FUND DIRECTOR,INSURANCI FUND UNDERWRITING VALIDATION NUMBER:840047504 IAF-0%111� NYSIF New York,state Nnsurauice If uund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AA A A A 272628352 AMWINS BROKERAGE OF NEW YORK 200 ELWOOD DAVIS ROAD SUITE 200 LIVERPOOL NY 13088 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER NORTH FORK WOOD WORKS INC BENJAMIN &CAROLYN BENNETT P O BOX 1407 1220 9TH STREET SOUTHOLD NY 11971 GREENPORT NY 11944 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE Z2280 317-5 979231 05/01/2022 TO 05/0112023 3/14/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2280 317-5, 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. 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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. PRESIDENT SCOTT EDGETT NORTH FORK WOOD WORKS INC 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 INCE FUND DIRECTOI�MSURANCE FUND UNDERWRITING VALIDATION NUMBER: 820364586 YO K Workers' CERTIFICATE OF INSURANCE COVERAGE 5TAT1 Compensation Board under the NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured NORTH FORK WOOD WORKS INC 810 TRAVELER STREET 631-298-7900 1c.Federal Employer Identification Number of Insured or Social Security SOUTHOLD NY 11971 Number Work Location of Insured 272628352 (only regolred Ircoverage Is speclticalty llmlfed to certain locations in New York State,I.e.,Wrap-Up Policy) 2,Name and.Address of Entity/Requesting Proof of 3a Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY BENJAMIN AND CAROLYN BENNETT 1220 9TH STREET 3b Policy Number of Entity Listed in Box"la" GREENPORT,NY 11944 LNY-628416 3c Policy effective period 04/01/2023 to 03/31/2024 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 employers employees: Under penalty of pedury,I certify that 1 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 03/16/2023 L= rPZl�?- �.. (Signature oi'iristinuice lmier"m aWbodzed representative w NYS Ire consadd Insurance Agent n1Fom 4nl waflen carder)... Telephone Number (212)553-8074 Name and Title:Elizabeth Tello—Assistant Director,Statutory Services 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 513 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 5B of Part 1 has been checked) ......_.............._.._.. ._ State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Si ned B (Signature of Authorized NYS Worker'Compensation Board Employee) Telephone Number Name and Title Please e insurance c / reNo� i and 1rerokrearInsurance agents of Mose carriers are authorized Form DS-120Insurance bers aNOauMarized to ssuethis form. DB-120.1(9-17) 111IDE 11111111111111101's2017IH Additional instructions for Form 13113-120.1 By signing this form,the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box 1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law.The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2. The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices my be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c,whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does not amend, extend or atter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the business continues to be named on a permit,license or contract Issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b) The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that the payment of disability benefits and after January first,two thousand eighteen,the payment of family leave benefits for all employees has been secured as provided by this article. DB-120.1(9-17)Reverse DATE(MMIDDNYYY) AC"C►A" "' CERTIFICATE OF LIABILITY INSURANCE 03/14/2023 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 require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME Commercial __,§ypp'p?Kt.. _-....W._. ... Edgewood Partners Insurance Center PHONE 40 Marcus Drive 3rd Floor ;_ Q631) 390 9700 1 631) 390-9790 E TAIL mstrlcert#t l e icbrokers.com Melville NY 11747 ' W� -- °- — INSURER(S)AFFORDING COVERAGE MAIC# INSURER A:SOUTHMST MARINE AND GENERAL I 12294 INSURED INSURER B:Merchants Bonding Co Mutual Gr 457 North Fork Woodworks Inc ""- INSURER C PO Box 1407 INSURER O: Southold NY 11971 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 13772 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. . POLICY/EFF POLICY EXP. LTR TYPE OF INSURANCE POLICYNUMBER MM LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 1:X1 � I� Afi �.- CLAIMS-MADE i" X OCCUR Y GL2022LBB00002 01/01/2023'01/01/2024 PREM (,IiP VLWp $ 100,000 MED EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 1,000,000 JEC ❑ r� ��EGATE $ 2,000,000 GFhTPAGCYEGXATE'LIMIT APPLIES OC' PRODUCTS-COMP/OP AGO $ 2,000,000 X OTHER& location $ AUTOMOBILELIABILITY COMBINED SINGLE LIM11' $ ANY AUTO BODILY INJURY(Per person) µ$ OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED S ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY rParacdda $ L $ A UMBRELLALLAB X OCCUR LIEX2022LHB00002 01/01/2023'01/01/2024 EACH OCCURRENCE $ 2,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE $ 2,000,000 DEA RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN ...... ANYPROPRIETOR/PARTNER/EXECUTNE E.L EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ N/A I (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE' $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Surety Bond MY6142329 01/13/2023 01/13/2024 Bond Limit $ 15,000 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Benjamin & Carolyn Bennett are included as additional insured for general liability coverage 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 Benjamin 6 Carolyn Bennett ACCORDANCE WITH THE POLICY PROVISIONS. 1220 9th Street AUTHORIZED REPRESENTATIVE Greenport NY 11944 wy� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD x�wf �o� ,m ,F bn++""' V LY j�o AV w 2/20/23 R-23-0146 � � �"� . �yrs � �.��.�,1�� �� �. gAl M� Urk,XIML-01A OF NA BEDROOMS A ISL 1 " ,. YEARS Vwd'" Hm`vnm Mr ry ,. m '2x O AP J {4w mm w bo N / / 230 LFT (3 LFT Cl + 227 LFT) 4 PVC SCH 40/D3034/SDR35 /" S=4 1 ' PER FT. 'i Vn ed � J ) � „�.. � � e;0. r r:::•'I CT PROPOSED 270,0' ) WOODED WATER LINE LOT CLEAN OUT C �5 0 NP 0 PT, LL -- 4T LOT 2 owe � I �, „ , � � � A L 1 �� �T 9 THE ME p OT �,�� , T � L � OT�J L fi. :r„�, d � �a� �u.,"1`a�� Pgi SET 1l Sly' CO),0° ) y1i 1� �o.re� p �'",N{�" ��/✓�• ,+,K'1 "..� .�. 1 W ^^-imirsed---..__warea..moo'e . <w an � 13 rd` M 4 I l \ , 2 ^¢,. 10 �� , 105.5' �� �I �.. TENNIS11 a7 � x � t 9 �� �, 9 I v �� COURT r �74,�4' ) � �"� � 4 ' °° v � III cru�y AT!D 222, f 7 TIVAJ-S_COal ': �' crLTA i a 100.0 u �'. SHED ry \ "p