HomeMy WebLinkAboutSleepy Hollow Ln Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/08/23 Receipt#: 314297
Quantity Transactions Reference Subtotal
1 Excavation Permits 1679 $550.00
Total Paid: $550.00
Notes: -
Payment Type Amount Paid By
CK#11719 $550.00 Center, Island Services Inc
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Center, Island Services Inc
67 Sycamore Street
Patchogue, NY 11772
Clerk ID: JENNIFER Internal ID: 1679
Permit No.
19
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958 0
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit
pursuant to Chapter 237 of the Code of the Town of Southold,Suffolk County,New York,and other applicable laws,ordinances or
regulations for each individual contiguous excavation project herein described. The applicant agrees to comply with all applicable laws,
ordinances,codes and regulations,the attached"General Conditions of Permit"and"Special Conditions",if any and to permit authorized
inspectors to make necessary inspections of the job site.
Print or Type
I. L\o J. au Vcboe c, (a31-47s-5(p oo c� o mor e
Name of Applicant Phone Number Address of Applicant
a(>-"f-,,�,k N k��
2. (,Slre 1c�S I rl C-. L-1'7 2-
Name
Name of Contractor Phone Number Address of Contractor
3. / q5-- 1395 9I eZP�A b:sA6V\) tJn. %),�hoA8
Name of Property Owner Requesting Service(if applicable) Address of Own r
4. 1C1C Q 21c�S` c 'eC_-I-1 ve C'a b1c 4roMI O9 13�i5 1 e�p�► Hv\�w Lin.
Work Description and Location(Street Number,Hamlet,Cross Street) S'ee— rct��
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes,other Town permits may be required.
NOTE: All information requested by this rature of Applicant
Application/Permit Form is
Required for a complete application! 1
Date
5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the
location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of
all site and pavement restoration work.
(b) Attach all other necessary permits and licenses for this project.
(c) Work covered by this application may not commences before issuance of a Highway Excavation Permit by the Town Clerk.
C�
6. Tax Map No.: District 1000 Section U , Block Lot
7. Starting Date: A '� — W�� �� [�1 y Completion Date: Seg irYLe— c a It
8. Work Schedule: Phase Completion Date
Excavation �N e,¢A.— 1 Work Schedule
Facility Installation �\\\ (�O rro,P\L�-C_ Gn Must be provided
Backfill&Completion for consideration as a
Pavement Replacement Complete Application.
9. Under which authority is application being made: 00 —t 1Y1 c�—` `�l Li2- ,
See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified.
10. Estimated Cost of Proposed Work: $ r 2 9 CSU o®
J v l
11. Remarks: 1 S5 L -- A le— t \ 00 S Ct nrLE S1C —Q CP (F.Ca6 In
D-39 J 1 of 3
12. insurance Coverage: (Attac Copy)
(a) Insurance Company: C1k'1 G G,�,o of`'
(b) Policy#: L- 30 2—O OO S— I
(c) State whether policy of certification on file with the Highway Department: C)n Q_
(d)Coverage required extended to the Town:
Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and$2,000,000 general aggregate.
13. Security: �p
(a)Surety Bond OR k& or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee for Each Project Location - $500.00
A Project Location would include each Bell Hole and/or every road opening or excavation within any
50'Radius whether or not they may be inter-connected by open trench or directional boring.
The total number of Project Locations shall be subject to the'approval of the Highway Superintendent.
Al. I Service Connections excavations @$50.00 $ 0 o oc)
No.
A2. /Additional Excavations same service @$20.00 $
No.
B. Trench Excavations 18"in depth or less
Total Lineal Footage of Excavation; L.F. @$10.00 $
C. Trench Excavations 18"in depth to 5' in depth
Total Lineal Footage of Excavation; L.F.@$30.00 $
D. Trench Excavations 5' in depth and over
Total Lineal Footage of Excavation; L.F.@$50.00 $
E. Utility Repair Excavations @$1,000.00/Each $
No.
Additional Repairs of Same Service @$500.00/Each $
No.
TOTAL$ter]�C�a U CU
F. Official Notice to public utilities-proof must be provided and
Shall be attached to this application prior to issuance of permit.
* * * * * * * * * * * * * *
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
in accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto.
SUPERINT ENT OF HIGHWAYS
TOWN ZS TOLD,EW YP
. 600OWN
^ 3 q ti ate
Date Received by the Townp. 7�jClerk Date Permit Issued i Z� Permit No. / 677
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 24 hour notice to Superintendent of Highways.
Permit must be available at all times for inspection,on site,during construction.
D-39 2 of 3
Copy Distribution: I / _ 7
Permit# l�
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1 St
2nd
3rd
4t'
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure(due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Improper Backfill(too high,not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
RFR Ready for Repair
D-39 3 of 3
y
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
1. Permittee's Contractors to Comply with Permit Requirements: The Perinittee is responsible for
informing its independent contractors, employees, agents and assigns of their responsibility to comply with
this pennit, including all special/site specific and general conditions imposed by the Highway
Superintendent while acting as the permittee's agent with respect to the permitted activities, and such
persons shall be required to comply with all permit requirements.
2. No Right to Trespass or Interfere with Private Property Rights: This permit does not convey to the
permittee any right to trespass upon the lands of adjacent properly owners in order to perform the permitted
work nor does it authorize the impairment of any rights,title, or interest in real or personal property held or
vested in a person not a party to the permit.
;. Protection of the Highway and Future Highway Maintenance: If future operations or highway
maintenance projects by the Town of Southold require an alteration in the position of the utility, structure
or work herein authorized,or if, in the opinion of the Highway Superintendent the work performed under
this permit shall cause unreasonable obstruction to required highway maintenance or endanger the health,
safety and/or welfare of vehicular or pedestrian traffic,this permit shall be revoked and the utility,
structure,ill,excavation,or other modification of the highway hereby authorized shall not be completed.
Additionally,the permit may be revoked if the Highway Superintendent finds that the issuance of the
permit was illegal or unauthorized or that the applicant failed to comply with any of the terms and
conditions of the permit or Chapter 237 of the Town Code.
4. Revocation of the Permit by the Highway Superintendent: If the Highway Superintendent deems it
necessary to revoke this permit and the project hereby authorized has not been completed,the applicant
shall,without expense to the Town and to such extent and in such time and manner as the Superintendent
may require,remove all or any portion of the uncompleted utility,structure or fill and restore the site to its
former condition.
5. Notice of Commencement: At least 24 hours prior to commencement of the project,the permittee and/or
contractor shall notify the Town Highway Department in writing that they are fully aware of and
understand all terms and project conditions of this permit. Upon completion of the work,the contractor
shall provide photographs of the completed work to the Town Highway Department and request a Final
inspection.
6. Storage of Equipment&Materials: The storage of construction equipment and/or materials shall be
confined within the project work area and/or adjacent areas where permission/legal access has been
obtained in a manner that does not interfere with normal highway traffic.
7. Utility Mark-Outs: The Applicant/Contractor shall be responsible for verification of all existing utility
mark-outs and shall take all precautions to protect same. Damage to existing utilities shall be the
responsibility of the contractor and shall be repaired at the contractor's expense.
8. Road Closures: All scheduled road closures must first receive written pennission from the Southold Town
Board prior to closing a road. Temporary lane closures may be permitted with the approval of the Highway
Superintendent. This item will included but not be limited to the installation of appropriate signage and
flag men to stop and start traffic to allow for single lane traffic. Road Closures due to unforeseen
emergencies require immediate notification of the Highway Department and shall be limited to immediate
and/or expedited restoration of the Work Zone.
9. No Construction Debris in Road Shoulder Area: All Construction Debris shall be removed from the job
site on a daily basis. All stockpiled soil as well as all other project materials that will be staged within the
Right-of Way must be delineated with reflective signage or other means to meet the minimum requirements
of the NYS DOT Construction Standards.
GENERAL CONDITIONS OF PERMIT
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
(Continued)
10. Install,Maintain Erosion Controls: Required Erosion Control Measures (i.e.silt fencing) is to be placed
on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any
disturbance of the ground occurs and is to be maintained in good functional condition until thick vegetative
cover is established. i
11. Clean Fill Only: All project back-fill shall consist of clean sand, gravel or soil (NOT asphalt,slag,flyash,
broken concrete or demolition debris). All unsuitable soils excavated at the site(i.e.Clay,Bog,etc.)are to
be removed from the site and not used to backfill any excavation within a Town Highway.
12. All Areas of Soil Disturbance : All areas of soil disturbance resulting from the approved project shall be
stabilized to the satisfaction of the Highway Superintendent immediately following project completion. If
the project site remains inactive for more than 48 hours or planting is impractical due to the season,then
the area shall be stabilized with straw,hay mulch and/or jute matting until weather conditions favor
germination.
13. Backfill & Compaction of all Excavations: Back Fill shall consist of clean fill or soils which exhibit a
well-defined moisture density relationship as determined to be in accordance with ASTMD 698. Fill shall
be placed in maximum lifts of twelve(12")inches thick and shall be mechanically compacted to a Ninety-
five(95%)percent maximum dry density. Suitable hydraulic compaction by water jetting at three-foot
intervals will also be permitted subject to a project specific approval by the Highway Superintendent.
14. Restoration of the Road Shoulder Area: All man-made improvements located within existing road
shoulder areas must be protected to the greatest extent practical. Items would include but not be limited to
driveway&private road aprons, mail boxes,sprinkler systems,trees and ornamental plantings.
Excavations through driveways and private road pavements must be reconstructed to meet all requirements
of Southold Town Highway Specifications. All pre-existing road shoulder improvements that have been
disturbed during construction must be replaced or repaired by the contractor to the satisfaction of the
Highway Superintendent.
15. Schematic Plans with all Technical information and Scope of Work: To reasonably and adequately
describe the proposed work,accurate schematic site plans must be provided to show or indicate all
proposed construction activity required under this permit. All Pavement surfaces scheduled for excavation
must be saw cut to the full depth of asphalt and/or concrete pavements. Accurate size of bell holes or width
of trenching must be indicated by dimension or labeling. This schematic site plan must provide details on
all restoration required to meet the requirements of these General Conditions and requirements found in the
Southold Town Highway Specifications.
16. Pavement Reconstruction: All Pavement sections must be reconstructed in the following manner;
(Note:When Concrete Pavements are Present,Please review Restoration requirements with the Highway Superintendent)
a) Complete all back-fill &soil compaction work as needed to provide a suitable sub-base;
b) Over-cut existing asphalt bell hole or trench by twelve(12")inches on all sides;
c) Install a compacted lift of 4"thick Stone Blend base(RCA Blend must meet NYS DOT Specification);
d) Install a two and one half(2.5")inch compacted lift of Asphalt Base Course;
e) Install a one and one half(1.5")inch of Asphalt(Type 6)Wearing Course. (Provide AC at all joints)
All work listed herein must meet the minimum requirements of the Southold Town Highway
Specifications.
17. Trenching of Pavement Surfaces Exceeding One Hundred (100') Feet in Length: All trenching of
pavement surfaces exceeding 100' in length must first be reconstructed to meet the requirements of Item
# 16 as noted above. Once all pavement reconstruction is completed to the satisfaction of the Highway
Superintendent,the entire road section and/or width of road over the entire length of trench shall be
repaved with a two(2") inch lift of Asphalt(Type 6)Wearing Course(Typical, shoulder to shoulder).
OFF
(1�e1, all8)
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Referral Type DSTX Ticket DSTX00180943163
i
Dangerous SUmflon NO
Temp In Place YES
Facility Riverhead Refer To Construction
Corp 7839 Account# 365478-3 Census X9 112 Date 7/12/2023
Su 3 Address 1395 Sleepy Hollow Ln Amp# Supervisor Greene
Town Southold Ron Phone# 631 764-3769
XStreet Willow Pond cel Tech Henkel
Locati n of Fault Between 14 tap and term 7 tap Phone# 516-523-4026
IIiFC �
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Low Levels
i
Feeder Replacement UG 625 P3
290' 258' 30'
2 0NO
' I
NO NO NO
63 70 603 771
Le eta MER CU US Issue
Act7ve Active Active I Active
T p Tap TapHbn
Tap
rl 11 b3,
From output of 14 to near#1095 to in put of Term 7 Tap.Losingo er 10 the hi h frequencies.Ran tem
Crosses 2 drivewa s
I
F�TiTili
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IFhI�dlPa Information_
Clai #
PRG# 1800-259-8753
Techl-- Reg Hrs OT Hrs DT Hrs Miss
Tech 2 Reg We OT Hrs DT Hrs I Mise
7",c..P.r.y
Splice Shrink I
Comments
Address
I
Phone#
I
I
Service Node X9B112 ------
jj Bad Cable between 14 tap and Term 7 tap.
- - Health 98.9%(Past 3 days 98.7%) _-- _ - Service Node X913112_ i Crosses 2 driveways,290'625 p3 cable.
OIL
f. Health 98.9%(Past 3 days 98.7%) 4
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Center Island Services
67 Sycamore Street
Patchogue, NY 11772
Office: (631) 475-5600
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=-` Contact: Sal Cipo Ma
Cell: (631) 774-8599
Cablevision_Project-#;- koa-�5_3-_
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Center Island-Services —-- -J<<� -—
67S-y-c-amore_Street I
Patchogue, NY 11772 -- - -_
Officei l: (6131) 475=5600^
Fax: 631 -475-8830 - - —- � - - ---
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Cell: (631) ?7478509 - --
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DATE(MM/DD/YYYY)
ACORO® CERTIFICATE OF LIABILITY INSURANCE
1 08101/2023
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(les)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 CONTACT
NAME: Jennifer Heiser
Nicholas DeVito Agency, Inc. PHONE 631 FAX
A C No Exti: (631)509-6388 A/C No): (631)509-0099
449 Route 25A E-MAIL
ADDRESS: jennifer@devitoagency.com
Mount Sinai, NY 11766 INSURERS AFFORDING COVERAGE NAIC#
INSURERA: Atlantic Casualty Insurance Co. 42846
INSURED INSURER B: Merchants Mutual Insurance Co. 23329
Center Island Services Inc. INSURER C:
67 Sycamore Street INSURER D:
Patchogue, NY 11772-2874 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00020246-950551 REVISION NUMBER: 82
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.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY Y L302000845-1 10/03/2022 10/03/2023 EACH OCCURRENCE $ 5,000,000
DAMAGE TO RENTED
CLAIMS-MADE
X OCCUR PREMISES Ea occurrence)
ccurrence $ 50,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 51000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000
X POLICY PRO-
JECT
F—] LOC PRODUCTS-COMP/OP AGG $ 5,000,000
OTHER: MBINED
$
B AUTOMOBILE LIABILITY CAP1079949 10/03/2022 10/03/2023 (CEO,acc.id."'SINGLELIMIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY X AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
X AUTOS ONLY X AUTOS ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION PERTH
AND EMPLOYERS'LIABILITY YIN STATUTE OR
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Town of Southold is included as additional insured as required by written contract.
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Of Southold THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
275 Peconic Lane
Peconic, NY 11958 AUTHORIZED REPRESENTATIVE
J-H
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/031 The ACORD name and loao are reaistered marks of ACORD Printed by J-H on 08/01/2023 at 11:06AM
Yo
NEWT Workers' CERTIFICATE OF
STATE Compensation
Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE
B
1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured
Center Island Services Inc. 631-475-5600
67 Sycamore Street
Patchogue, NY 11772-2874 1c.NYS Unemployment Insurance Employer Registration Number of
Insured
Work Location of Insured(Only required if coverage Is speclflcallyllmited to 1d.Federal Employer Identification Number of Insured or Social Securit
certain.locations in New York State,i.e.,a Wrap-Up.Pollcy) Number y
11-3436332
2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier
(Entity Being Listed as the Certificate Holder) Property & Casualty Ins. Co. of Hartford
Town of Southold
275 Peconic Lane 3b.Policy Number of Entity Listed In Box"ia"
Peconic, NY 11958 12WECAK9DRY
3c.Policy effective period
03/21/2023 to 03/21/2024
3d.The Proprietor,Partners or Executive Officers are
included,(Only check box If all partnerslofficers Included)
® all excluded or certain partnerslofficers excluded.
This certifiesdhat the insurance carrier indicated above in box"3"insures the business referenced above,in box"1 a"for workers'
compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under item 3
on the INFORMATION 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 must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled
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 the coverage indicated on this Certffie e.(These notices may 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 listad 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-alterthe 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 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: Nicholas Devito
(Print name o rized presentative at licerl a of. surance carrier)
�l
Approved by:
(Signature) (Date)
Title: Authorized Representative
• 'Telephona Number of authorized representative or licensed agent of insurance carrier: 631-509-6388
Please Note:Only Insurance carriers and their licensed agentsare authorized to issue Form C-105.2.Insurance brokers areOTOT
authorized to Issue it.
C-105.2(9-17) www.wcb.ny,gov
yo
YORIK NEW workers' CERTIFICATE OF INSURANCE COVERAGE
STATE Compensation
Board 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
CENTER ISLAND SERVICES, INC. 631-475-5600
67 SYCAMORE STREET
PATCHOGUE, NY 11772
1c.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) 113436332
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
275 Peconic Lane 3b. Policy Number of Entity Listed in Box"1 a"
Peconic, NY 11958 DBL432480
3c.Policy effective period
01/01/2023 to 12/31/2024
4. Policy provides the following benefits:
[R1 A. Both disability and paid family leave benefits.
E] B.Disability benefits only.
❑ C.Paid family leave benefits only.
5. Policy covers:
[A 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.
Date Signed 8/1/2023 By Val, 4f
(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 sox 4B,4C or 5B 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(Article 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.
DB-120.1 (12-21) 1111111�]1°��°�°°11°111111111111°1°111°°��IIIIIII