Loading...
HomeMy WebLinkAbout49327-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#: 49327 Date: 6/1/2023 Permission is hereby granted to: Kasson, Allison .... ��� 145 Andover P� �... . ... ... ..�,..m_A.___. ..................................... WestHem stead, NY 11552_.... To: Construct an in-ground swimming pool to an existing single family dwelling as applied for. Pool and equipment require minimum setbacks of 10 feet. At premises located at: 5 Deep Hole Dr, Mattituck 3- ..aw__... .._ _ .. ._ .... ............... SCTM .... .# 473889 Sec/Block/Lot# 115.46-18 Pursuant to application dated 5/3/2023 and approved by the Building Inspector. To expire on 11/30/2024. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO- SWIMMING POOL $50.00 Total: -.... ..........��..�-$300.00 Building Inspector MA TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Fax (631) 765-9502 Ir Date Received APPLICATION FOR BUILDING PERMIT Use PERMIT NO, � J ForO Building Y lding Inspector: ul I . MAY 0 1 '10D s Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an P P "G,.��9R�i��;li iui��q•, nu r,r Owner's Authorization form(Page 2)shall be completed. Date: April 24, 2023 OWNER(S)OF PROPERTY: Name:Allison Kasson JS�m# 00- - 1 Q - $ Project Address:3495 Deep Hole Drive, Mattituck, New York 11952 Phone#:516-644-3482 1 Email:akasson@kpmg.com Mailing Address:145 Andover Place, West Hempstead, NY 11552 CONTACT PERSON: Name: Allison Kasson Mailing Address:145 Andover Place Phone#:516-644-3482 Email:akasson@kpmg.com DESIGN PROFESSIONAL INFORMATION: Name: Angelo Tuosto Designs Mailing Address:199 Hempstead Avenue, West Hempstead, NY 11552 Phone#:516-564-1066 Email:angelo@designgroupat.com CONTRACTOR INFORMATION: Name: Angelo Tuosto Designs Mailing Address:199 Hempstead Avenue, West Hempstead, NY 11552 Phone#:516-564-1066 Email:angelo@designgroupat.com DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project: DOther Inground Pool65,000 Will the lot be re-graded? WYes ONO, Will excess fill be removed from premises? WYes El No 1 PROPERTY INFORMATION Existing use of property: Second Home Intended use of property: Second Home Zone or use district in which premises is situated. Are there any covenants and restrictions with respect to this property? ❑Yes LRNo 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 Cade. 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 tint name): q I )OW " KR S5(YI ❑Authorized Agent (Owner Signature of Applicant: bP,&%q? Date: 413010 STATE OF NEW YORK) I SS: COUNTY OF � �'>>�-� ) being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)he is the ' (Contractor, Agent,Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of A P(d ,20 N�af � ll GEORGE PATRICK FORMONT Notary Public-State of New York NO. 01F06339228 PROPERTY OWNER AUTHORIZATION Qualified in Nassau County My Commission Expires Jun 27, 2024 (Where the applicant is not the owner) � rHwrMrPwww N, residing at do hereby authorize 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 so;oa.�iQ a2IdJ(H suivaa v'HaWaSN03 ,LNIaxafla v(INV zdas iviNiawiuvaaa .LIIOH.LIM QI'IVA.LORI sassauisng ieuoilippV .� �Iio S 30)ilunoO QR ut °-dO.LDV-d LN0D bLX3WaA0-dclWI ZKOH n sn ssouisnq Ionpuoo oI posuooti Agazau si xaoA moN jo olvIS `xiojjnS jo X4unoD a pjo suotlnpi2aa pun salt`snnni aignotiddn jo suoisiAo.Td a p oI IooCgns pun TVA aounpz000n ui glzoj las sluauuazmbai agl pagsmng SutAng cMO3 Sgd['JSQAIV'I V ARKOSVW OZSOILL V su ssouisng Suiop OZSOfLL oria9 v legl AJtluao of si srgs asuaairj .(ojavjjuo j 4udtuaaotduil atuoyy AIM103 XIOAXIS H-I1£9£ 'o.K b00Z/£vzl :mnsSI diva 88L I I XHOA TAUNT `HDflVddnVH AVAkHJIH �I�'RiOY�IEi�I SNH2Ia.La11 size ja nsuofo aaz saaz naax uno o n�� � .��0 .� � � AL1 �� S e — P [ 3 b NYSIF New York State Insurance Fund PO Box 66699 Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 208290411 COLSTAN&ASSOCIATES INC 512 SUNRISE HIGHWAY STE B WEST BABYLON NY 11704 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER A TUOSTO MASONRY AND TOWN OF SOUTHOLD LANDSCAPES CORP 53095 ROUTE 25 199 HEMPSTEAD AVENUE SOUTHOLD NY 11971 WEST HEMPSTEAD NY 11552 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H1356 787-0 259287 05121/2022 TO 05/21/2023 4/25/2023 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1356 787-0, 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 CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION. ANGELO TUOSTO A TUOSTO MASONRY&LANDSCAPES INC ONE PERSON CORP THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SURAANCEFUND D I RECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:344803569 U-26.3 , ^� CERTIFICATE LIABILITY DATE(MMIDDIYYYYI 04/25/2023 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 endorsement(s). PRODUCER CONTANAME:dalf Tyler Callaghan'7-f.a'anad"yr COlstan &Associates Inc. PHONE (AP.G �1� . 631)266 2800 dna.. 683-4423 512 Sunrise Highway,Suite B C-MAILs (erxArDPt kcplsmmt an.com West Babylon, NY 11704 INSURERLS)AFFORDING COVERAGE NAIC# A Tuosto Masonry 8r Landscape wsuRER„ chants Preferred Insurance Compan�r,,.., A Mer ....INSURED INSURE.,B,,: erchants Preferred Insurance Company 129 1 Landscapes Incorporated INSURER C Merchants --- - nce_ om ,an .m. ....23329 ........ DBA Angelo Tuosto Design Group p y 199 Hempstead Ave "NSURER D West Hempstead, NY 11552 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 00001149-1541689 REVISION NUMBER: 65 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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. INSRf `-U E "Abik�ubkl ._. POLICY EFF POLICY EXP ...., ., ......___m_..... ........_, ..._ µ,1 TR ITYPE OF INSURANCE PpLICY NUMBER MMIDDIXYYY MIDDm'YY LIMITS R . AI F IUIaI lvI rL... �00�000 " � COMMERCIALGENERAOLLIABILITY.I CTRI003517 01/11/2023 01/11/2024 E4.:At�H 414°CC°YDO�Y24 Y�dC Y S 1 0 .. L.AIM".°7AAlIY?. OCCUR V°rel MI MC" OO 000 ...... .,...�....... ......... ........ .,,.. MGD V=XP(Any one larw.,on).. ... ....... .., 5,000 m.. ,PERSONAL&ADV INJURY $ 1000,000 GENT. . ..........,. Y N4 RAI.AOGREG:,Arl POI ICY JEC f4Y�l'I j IOC aPlaOnua r G~callno IOP Ac z s 2,000 000 AUTOMOBILE LIABILITY COM SINGLE I,IPM'117` $ CAP1077948 01/27/2023 01/27/2024 t 1 ecad t) 9,000,OOQ„ ,.�ANYAUTO eW , 9 7)1Y II`.Ud((I'evcrroaro) . OWNED ' SCCIE DUIED 1G71IrIPJUFY(DeY'.6r16CN iy " JrOaWV " AUTOS ..,. CxiA'1�'4,Ng4991f. d AII.7D I-OS G]NI Y + _._ AU rOS C7IVILYIfu'"r'S1 tl _... UMBRELLA LIAB ... J......... 2,000,000 ...........C G�cC"UId CUP9151463 ov11/2oz3 01/11/2024 EACH OCCURRENCE S 2 EXCESS LIAB 1. C1 AIMS MADE �/�lC'l..l.�.EGArE �$.... 2,000,000 - ......_._. - ... �.... RTA DED RETENTION$ �...�. WORKERS COMPENSATION _...... PER Tu F �....... D_71a'17 � �.�. ...... AND ANY PROPRIETEOR/PARTNER/EXECUTIVE I:1 LACI I ACC ID N I' �$ RS'LIABILITY YIN OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) [1 "" -" .1 AS ASR E,A 7JN I'll C.1YI I ti If yes,describe under "" ""' ... - OES- IPT)ON OF PERATI2q below. FE- .I71.aI.AS P(x..Ecyi..wiir E A Equipment Floater CTRIO03517 01/11/2023 01/11/2024 219,500 DESCRIPTION OF OPERATIONS]LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe 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 Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route25 Southold, NY 11971 A17 THIO ED REPRESENTATIVE (TJC) (�1066-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by TJC on 04/25/2023 at 04:54PM NEW i c r �ati � CERTIFICATE OF INSURANCE COVERAGE 'iATBoard NYS DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by NYS disability and Paid Family Leave benefits carrier or licensed insurance agent of that carrier 1 a.Legal Name&Address of Insured(use street address only) 1 b.Business Telephone Number of Insured A TUOSTO MASONRY&LANDSCAPES CORP DBA ANGELO TUOSTO DESIGN GROUP 516-564-1066 199 HEMPSTEAD AVE. WEST HEMPSTEAD,NY 11552 1 c.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically limited to or Social Security Number certain locations in New York State,i.e.,Wrap-Up Policy) 208290411 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town of Southold 3b.Policy Number of Entity Listed in Box"1 a" 53095 Route 25 DBL199014 Southold, NY 11971 3c.Policy effective period 05/16/2022 to 05/15/2024 4. Policy provides the following benefits: A.Both disability and paid family leave benefits. E] B.Disability benefits only. 0 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. E] B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. i Flu Date Signed 4/25/2023 By (Signature of insurance carrier's authorized representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be emailed to PAU@wcb.ny.gov or it can be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 4B,4C or 513 have been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law(Artide 9 of the Workers'Compensation Law)with respect to all of their employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title ............ Please Note.Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1.Insurance brokers are NOT authorized to issue this form. 1313-120.1 (12-21) IIII!' 'm1ii2i0 (i12irNi Suffolk County Dept of Licensing VASTER ELECTRICAL LICENSEt \� Name 121 OF JONATHAN SMITH Business Name This certifies that the HARBOR SYSTEMS GROUP INC is l licensed oy the County of l License Number: a Issued.- CERTIFICATE OF NYS WORKERS'COMIPENSATION INSURANCE COVERAGE l.a.Legal Naine and addiress of Ilinsured(Use street address Ib.Business Telephone Number of Insured orally) 631-754-8050 I'larbor Systems Group,lirc. le.NYS Unemployment Insurance Employer 11 rr,,,,,halls a jCann rf Registration Number of Insured Fort.Salonga,NY 111763 Ich Federal Employer Indentification Number of Insured We 1-ocatiOn of Insured(Only reipWred V'coveroge it or Social Security Number specrficnl4y Ifmapd to certain locorOn in New Yoy*State,1.e a 201774963 97rap-(.p Policy) 2.Name and Address ofthe Entity Requesting Proofof 3a.Name of Insurance Carrier Coverage AmTrust Insurance Company of Kansas,Inc. (Entity Being Listed as the Certificate Holder) 3b.Policy Number of entity listed in box"la".- Town of Southold iKWC1298879 53095 Routc25 3c.Policy effective period: Southold,NY 11971 11/1/2022 to 11/1/2023 3d.The Proprietor,Partners or Executive Officers are: included(Only check box if all partners/officers included) all excluded or certain partnerstofficers excluded This certifies that the insurance carrier indicated above in box"3"insures the business referenced above in box "la"for workers'compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Its 3A on the INFORNUTION PAGE of the workers'compensation insurance policy).The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier mist notify the above certificate holder and the Workers'Conipensation Board within 10 days IF a policy is canceled due to nonpayment of prentiums or within 30 days IFthere are reasons other than nonpayinent of joreiniumis;that cancel the policy or eliminate the insured front the coverage indicated on this Certificate. (These notices may be sent by regular mail)Otherwise,this Certificate is valid for°oneyear after this form is approved by the insurance carrier or its licensed agent,or until thepolicy expiration date fisted in bo--c "3CH, whichever is earlier, This certificate is issued as a matter of information only and confers no rights upon the certificate holder.This certificate does nota end,extend or alter the coverage afforded byte 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 Workers' Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation 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 Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved By„ Horny C.Sibley (11rint name of authorized re.presentatise or licensed agent of insunnov camer) Approved lBy 1126/2023 (Signature) (Date) Title: Underwriting Manager Telephone Number of authorized representative or licensed agent of insurance carrier:CarrierPhone Please Node:Oniv insurance carriers aced their licensed agents are authorized to issue the G1012form.Insurance brokers are NOT authorized io issue it C-105.2(9-17) www.web.ny.gov STATE Ol, NEW YOU—, WORKERS'COMPENSATION B(--)A.RD CEWFIFICATE OF`INSURANCE COVERAGE UNDER THE NYS DISABILITYBENEFITS LIAM7 [P�T�ITo�hecojn�plcfcd 1Distibili itv Benefits Carrier or Licensed Insurance Agent of that Carrier I a.Legal Name and Address of Insured(Use street address only) 1b. Business Telephone Number ot'Insured 631-754..8050 Harbor Systems Group, Inc. I c.NYS Unemployment Insurance Employer Registration I Twin Hills Court Number of[nsurcd Fort Salogna, NY 11768 I d. Federa3 Employer.Identification Number of1risured or Social Security Number 201774963 2.Name and Address oftlic Entity Requesting Proof of 3a.Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate lJolder) Cardinal Disability Trust Town of Southold 3b. Policy N uniber of entity listed in box"I a": 53095 Route25 If.1311..E:.4007 Southold, NY 11971 3e.Policy effective period: 01/01/2023 to 01/01/2024 4. F)oficy covers: a. All of the employer's employees eligible under the New York-Disability Benefits Law b. 0 (onlv the following;class or classes of the employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced.above and. that the named insured has N)(S.Disability Benefits insurance coverage as described above. Date Signed 4/26/2023 13Y J-__/ (Signature of insurance carrier's authorized representative or NYS licensed Insurance Agent of that insurance cam er) Tel Number 518 213-1349 Title Trustee IMPORTANT:If box"4a"is checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed for allo"]RogrdDR Plans Accentance Unit,20 Park Street.Albany.New York 12207. .. ........ PART 2. To be completed by NYS Workers' Compensation Board(Only if box"4b"of Part I has been checked) State Of New York Workers' Compensation or According to information maintained by the NYS Workers'Compensation Board,the above.-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date (Signature of NYS Workers'Compensation Board Ernplo.yec) Telephone Nurnber—___."'............... Title-... ­___­­ — Please Note: Ofirli,insurance carriers licensed to write NYS disability benqj�hy insurance policies andNYS licensed insurance agents,of those insurance carn.ei,,5ai-ee.iii.lizot-izedloi.yyzte.Forii;..D.B.120.1. Insurairce brokers are NOTauthorized to isside this form, DB-IM 1 (5--06) DATE(MMIDD ) ACCORbr CERTIFICATE OF LIABILITY INSURANCE a4/26/za23 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 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 endorsement(s). [PRODUCER CON7AC1 Kathleen Bogdan NAME: SECUR-ALLAGENCY PHONE (516)576-0300 F'A•x_ (516)576-0310 (A1C.No Extj: A/C.Nss One Dupont Street E-MAIL kathee@secur-all.com ADDRESS:. Suite 209 INSURER(S)AFFORDING COVERAGE NAIC It Plainview NY 11803 Merchants Preferred Insurance Co 12901 INSURER A: .....— INSURED INSURER B: Harbor Systems Group Inc INSURER C 618 Bread and Cheese Hollow Rd INSURER D ......... ...... .......� .....-. INSURER E:. .........Y................................ w_ Northport NY 11768-2327 INSURER F COVERAGES CERTIFICATE NUMBER: 23/24 Master REVISION NUMBER: FIT,,,, fO CER f 11 Y FHAf r HE P(:)I....ICILS OF INSURANCE I.ISTI:.D I:)ELOIN I IAVI.13EI.::IV ISSIL :I.J TO fl il::::INSURED NAMI.DABOVI.:FOR I-I IE I:rC71....ICY PERIOD INDICA"FED NOi WI fI IS IANDING ANY RI::::OUIRI::::IVIE::NT"PERM OI2 CONI:LITION OFANY CONTE2A('"[OR O R IERIDOCUME.NT WIT[I R1:.::SPEC r FO VM 101 P IIS CER CIFIO6t,f f::: M61Y BE I;rtxlJl::::E)OR MAY frl::Ey FAIN, f1 IE IftISUIR"tIVC:LAFFORDED f::3Y fI IE C'AOLIC;If::S r..71::m"aG;RIf.:tf.:::1::)I II::::REIYV IS SIJ1::9J1:::::C;T'I"C}«LI... fl If.:::'fLIFMS, E::iXCI...l.JSIOIVSAI�D CONDI FIOIgS OI::SI..ICI I I::rOI....IC:IE:S I....IMI FS SHOWN MAY IIAVE:::.BE:::.I::::.N E:21::::C)U(::EI::)BY faAIID CLAIMS. 'II TR =V urm LI. . POLIO EXP TYPE OF INSURANCE V POLIC..Y NUMBER MMID (MMIDDfYYYY) _ LIMITS .-...... _... ._ ..0 .... .. ........ .......w. .... .........-.-.. �X COMMERCIAL GENERAL LIABILITYEACH OCC1&.LNCF � 1,000,000 _ _ 1 �t Tr 500,000 CLAIMS-MADE OCCUR f��I�I.MI..k.:,-.��aorrrarrersce1 $ Contractual Liability IVIED EXP(Anv one pemcL $ 5,000 A Y CTRIO07607 02/05/2023 02/05/2024 PERSONAL ADV INJURY $ 1,000,0"0 GFI,I LAGT,rvPRP1 XrE LIMITAPPB IES PER: GENERAL.AGGREGATE $ 2 000,000 JE C I' PC,11...IG:Y ,IEf.T'I" I..00 PRODUC;T�:>...COMP/O2,000,000 PAC3C $ CTq•i'Es Consultants Errors& $ AUTOMOBILE LIABILITY (461wF6.4MVLDISINGLE 1-11,01 IF Ea acddenk ANYAUT`0 BODLYINJURY(Per person) ....... 'S C}WNEC:7 SC HEI:YULED AUTOSONI..Y AUTOS f:3G)C]BLYIIVJUIP.Y(Per'accident) ';v I{Ildla:) NON-OWNED Prdl PERrYDAMAI $... AU TOS ONLY AU T'OS ONLYI Pcraccidlen rl UMBRELLA LAB OCCUR E`AC;IIOCC::URRENOE $ EXCESS LIAB CLAIMS-MAINE AGGREGATE $ �,.I.)E.D RETENTION$ $ WORKERS COMPENSATION PER U"IH- AND EMPLOYERS'LIABILITY Y/N ''.. STATIJY'EI FR ANY PROPRIETOR/PARTNER/EXECUTIVE NIA I::.I EAC HACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EDISE-ASE.EA I IAPI..OYF-.E $ If yes,describe under ---. .--_ DESCRIPTION OF OPERATIONS below E DISEASE :'01..ICY I IMI T' S; DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Town of Southold is named as an additional insured. 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. 53095 Route25 AUTHORIZED REPRESENTATIVE SouthholdNY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD